Operative blood loss and use of blood products after full robotic and conventional low anterior resection with total mesorectal excision for treatment of rectal cancer

Association of omental pedicled flap with anastomotic leak following low anterior resection for rectal cancer

BACKGROUND AND OBJECTIVES

Anastomotic leak following colorectal anastomosis adversely impacts short-term, oncologic, and quality-of-life outcomes. This study aimed to assess the impact of omental pedicled flap (OPF) on anastomotic leak among patients undergoing low anastomotic resection (LAR) for rectal cancer using a multi-institutional database.

METHODS

Adult rectal cancer patients in the US Rectal Cancer Consortium, who underwent a LAR for stage I-III rectal cancer with or without an OPF were included. Patients with missing data for surgery type and OPF use were excluded from the analysis. The primary outcome was the development of anastomotic leaks. Multivariable logistic regression was used to determine the association.

RESULTS

A total of 853 patients met the inclusion criteria and OPF was used in 106 (12.4%) patients. There was no difference in age, sex, or tumor stage of patients who underwent OPF versus those who did not. OPF use was not associated with an anastomotic leak (p = 0.82), or operative blood loss (p = 0.54) but was associated with an increase in the operative duration [β = 21.42 (95% confidence interval = 1.16, 41.67) p = 0.04].

CONCLUSIONS

Among patients undergoing LAR for rectal cancer, OPF use was associated with an increase in operative duration without any impact on the rate of anastomotic leak.

Retrospective analysis of operative time and time to discharge for laparoscopic vs robotic approaches to appendectomy and cholecystectomy

Robotic-assisted appendectomies and cholecystectomies are believed to increase cost compared to the gold standard laparoscopic approach. Two equally qualified surgeons performed both approaches over 2 years to evaluate intraoperative duration, time to discharge, conversion to open procedure, and readmission within 30 days. 110 laparoscopic, 81 robotic-assisted appendectomies; and 105 laparoscopic and 165 robotic-assisted cholecystectomies were performed. Intraoperative time; laparoscopic appendectomy was 1.402 vs 1.3615 h for robotic-assisted (P value = 0.304); laparoscopic cholecystectomy was 1.692 vs 1.634 h for robotic-assisted (P value = 0.196). Time to discharge, was 38.26 for laparoscopic vs 28.349 h for robotic-assisted appendectomy (P value = 0.010), and 35.95 for laparoscopic vs 28.46 h for robotic-assisted cholecystectomy (P value = 0.002). Intraoperative conversion to open; only laparoscopic procedures were converted, one appendectomy and nine cholecystectomies. None in the robotic-assisted procedures. Readmissions, none in the appendectomy group and three in the cholecystectomy group. One laparoscopic and two robotic-assisted cholecystectomy patients were readmitted. Intraoperative times for robotic appendectomy and cholecystectomy were not longer than laparoscopic approach. Robotic approach shortened the time to discharge and the likelihood for conversion to open procedure.

Lower need for allogeneic blood transfusion after robotic low anterior resection compared with open low anterior resection: a propensity score-matched analysis

Robotic low anterior resection (R-LAR) for rectal cancer may decrease estimated blood loss compared with open low anterior resection (O-LAR). The aim of this study was to compare estimated blood loss and blood transfusion within 30 days after O-LAR and R-LAR. This was a retrospective matched cohort study based on prospectively registered data from Västmanland Hospital, Sweden. The first 52 patients operated on using R-LAR for rectal cancer at Västmanland Hospital were propensity score-matched 1:2 with patients who underwent O-LAR for age, sex, ASA (American Society of Anesthesiology physical classification system), and tumor distance from the anal verge. In total, 52 patients in the R-LAR group and 104 patients in the O-LAR group were included. Estimated blood loss was significantly higher in the O-LAR group compared with R-LAR: 582.7 ml (SD ± 489.2) vs. 86.1 ml (SD ± 67.7); p < 0.001. Within 30 days after surgery, 43.3% of patients who received O-LAR and 11.5% who received R-LAR were treated with blood transfusion (p < 0.001). As a secondary post hoc finding, multivariable analysis identified O-LAR and lower pre-operative hemoglobin level as risk factors for the need of blood transfusion within 30 days after surgery. Patients who underwent R-LAR had significantly lower estimated blood loss and a need for peri- and post-operative blood transfusion compared with O-LAR. Open surgery was shown to be associated with an increased need for blood transfusion within 30 days after low anterior resection for rectal cancer.

Early Experience of Undertaking Robotic Assisted Total Mesorectal Excision in Rectal Resections, Avoiding a Diverting Stoma: Key eHancement of the Anastomosis for No Stoma Technique - A Case Series

Background. Anastomotic leak is a feared complication in rectal cancer surgery, and a proximal diverting stoma to protect the rectal anastomosis is used to minimize its impact. We evaluated a novel technique that uses the da Vinci® robotic platform (Intuitive Surgical) to reinforce the colorectal anastomosis and rectal staple line with sutures, and rectal resection and assessment of the anastomotic perfusion, using our Portsmouth protocol. Methods. During robotic rectal cancer surgery, we used indocyanine green to determine the level of transection and check the vascularity of the circular anastomosis. The distal transverse staple line and circular staple line of the colorectal anastomosis were reinforced with absorbable interrupted stitches (KHANS technique - Key enHancement of the Anastomosis for No Stoma). The integrity of the colorectal/anal anastomosis was also checked using the underwater air-water leak test, with concomitant flexible sigmoidoscopy to visualize the circular staple line. Results. Fifty patients underwent total mesorectal excision for cancer. Using the KHANS technique, we avoided a diverting stoma in all cases. One patient had a radiological leak, leading to a pelvic abscess. In 56% of cases, the anastomosis was within 5 cm of the anal verge. Median length of stay was 5 (3-34) days, with two 30-day readmissions. No 90-day mortality or 30-day reoperations were observed. Conclusion. The KHANS technique appears feasible, successful, and safe in decreasing the incidence of diverting stomas in rectal resections.

Early experience with the ARTISENTIAL® articulated instruments in laparoscopic low anterior resection with TME

Background

The notion of articulation in surgery has been largely synonymous with robotics. The ARTISENTIAL^® instruments aim at bringing advanced articulation to laparoscopy to overcome challenges in narrow anatomical spaces. In this paper, we present first single-center results of a series of low anterior resections, performed with ARTISENTIAL^®.

Methods

Between September 2020 and August 2021, at the Department of Surgery, St. Marienkrankenhaus Siegen, Siegen, Germany, patients with cancer of the mid- and low rectum were prospectively enrolled in a pilot feasibility study to evaluate the ARTISENTIAL^® articulated instruments in performing a laparoscopic low anterior resection. Perioperative and short-term postoperative data were analyzed.

Results

Seventeen patients (10 males/7 females) were enrolled in this study. The patients had a median age of 66 years (range 47–80 years) and a median body mass index of 28 kg/m² (range 23–33 kg/m²). The median time to rectal transection was 155 min (range 118–280 min) and the median total operative time was 276 min (range 192–458 min). The median estimated blood loss was 30 ml (range 5–70 ml) and there were no conversions to laparotomy. The median number of harvested lymph nodes was 15 (range 12–28). Total mesorectal excision (TME) quality was ‘good’ in all patients with no cases of circumferential resection margin involvement (R0 = 100%). The median length of stay was 9 days (range 7–14 days). There were no anastomotic leaks and the overall complication rate was 17.6%. There was one unrelated readmission with no mortality.

Conclusions

Low anterior resection with ARTISENTIAL^® is feasible and safe. All patients had a successful TME procedure with a good oncological outcome. We will now seek to evaluate the benefits of ARTISENTIAL^® in comparison with standard laparoscopic instruments through a larger study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02588-y.

Laparoscopic compared with open nephroureterectomy in upper urinary tract urothelial carcinoma: A systemic review and a meta-analysis

BACKGROUND

We performed a meta-analysis to evaluate the effects of open nephroureterectomy compared with laparoscopic nephroureterectomy on postoperative results in upper urinary tract urothelial carcinoma subjects.

METHODS

A systematic literature search up to January 2021 was done and 36 studies included 23 013 subjects with upper urinary tract urothelial carcinoma at the start of the study; 8178 of them were laparoscopic nephroureterectomy, and 14 835 of them were open nephroureterectomy. They were reporting relationships between the efficacy and safety of open nephroureterectomy compared with laparoscopic nephroureterectomy in the treatment of upper urinary tract urothelial carcinoma. We calculated the odds ratio (OR) or the mean difference (MD) with 95% confidence intervals (CIs) to assess the efficacy and safety of open nephroureterectomy compared with laparoscopic nephroureterectomy in the treatment of upper urinary tract urothelial carcinoma using the dichotomous or continuous method with a random or fixed-effect model.

RESULTS

Laparoscopic nephroureterectomy in subjects with upper urinary tract urothelial carcinoma was significantly related to longer operation time (MD, 43.90; 95% CI, 20.91-66.90, P < .001), shorter hospital stay (MD, -1.71; 95% CI, -2.42 to -1.00, P < .001), lower blood loss (MD, -133.82; 95% CI, -220.92 to -46.73, P = .003), lower transfusion need (OR, 0.56; 95% CI, 0.47-0.67, P < .001) and lower overall complication (OR, 0.79; 95% CI, 0.70-0.90, P < .001) compared with open nephroureterectomy. However, no significant difference was found between laparoscopic nephroureterectomy and open nephroureterectomy in subjects with upper urinary tract urothelial carcinoma in 2-5-years recurrence-free survival (OR, 0.90; 95% CI, 0.69-1.18, P = .46), 2-5-years cancer-specific survival (OR, 0.94; 95% CI, 0.69-1.28, P = .68) and 2-5-years overall survival (OR, 1.31; 95% CI, 0.91-1.87, P = .15).

CONCLUSIONS

Laparoscopic nephroureterectomy in subjects with upper urinary tract urothelial carcinoma may have a longer operation time, shorter hospital stay, lower blood loss, transfusion need and overall complication compared with open nephroureterectomy. Further studies are required to validate these findings.

A systematic review and meta-analysis of robotic-assisted transabdominal total mesorectal excision and transanal total mesorectal excision: which approach offers optimal short-term outcomes for mid-to-low rectal adenocarcinoma?

BACKGROUND

Resection of low rectal adenocarcinoma can be challenging in the narrow pelvis of male patients. Transanal total mesorectal excision (TaTME) appears to offer technical advantages for distal rectal tumours, and robotic-assisted transabdominal TME (rTME) was introduced in effort to improve operative precision and ergonomics. However, no study has comprehensively compared these approaches. The aim of the present study was to perform a systematic review of the literature to compare postoperative short-term outcomes in rTME and TaTME.

METHODS

A systematic online search (1974-July 2020) of MEDLINE, Embase, web of science and google scholar was conducted for trials, prospective or retrospective studies involving rTME, or TaTME for rectal cancer. Outcome variables included: hospital stay; operation duration, blood loss; resection margins; proportion of histologically complete resected specimens; lymph nodes; overall complications; anastomotic leak, and 30-day mortality.

RESULTS

Sixty-two articles met the inclusion criteria, including 37 studies (3835 patients) assessing rTME resection, 23 studies (1326 patients) involving TaTME and 2 comparing both (165 patients). Operating time was longer in rTME (309.2 min, 95% CI 285.5-332.8) than in TaTME studies (256.2 min, 95% CI 231.5-280.9) (p = 0.002). rTME resected specimens had a larger distal resection margin (2.62 cm, 95% CI 2.35-2.88) than in TaTME studies (2.10 cm, 95% CI 1.83-2.36) (p = 0.007). Other outcome variables did not significantly differ between the two techniques.

CONCLUSIONS

rTME provides similar pathological and short-term outcomes to TaTME and both are reasonable surgical approaches for patients with mid-to-low rectal cancer. To definitively answer the question of the optimal TME technique, we suggest a prospective trial comparing both techniques assessing long-term survival as a primary outcome.

Comparison of pathologic outcomes of robotic and open resections for rectal cancer: A systematic review and meta-analysis

Objective

The application of robotic surgery for rectal cancer is increasing steadily. The purpose of this meta-analysis is to compare pathologic outcomes among patients with rectal cancer who underwent open rectal surgery (ORS) versus robotic rectal surgery (RRS).

Methods

We systematically searched the literature of EMBASE, PubMed, the Cochrane Library of randomized controlled trials (RCTs) and nonrandomized controlled trials (nRCTs) comparing ORS with RRS.

Results

Fourteen nRCTs, including 2711 patients met the predetermined inclusion criteria and were included in the meta-analysis. Circumferential resection margin (CRM) positivity (OR: 0.58, 95% CI, 0.29 to 1.16, P = 0.13), number of harvested lymph nodes (WMD: −0.31, 95% CI, −2.16 to 1.53, P = 0.74), complete total mesorectal excision (TME) rates (OR: 0.93, 95% CI, 0.48 to 1.78, P = 0.83) and the length of distal resection margins (DRM) (WMD: −0.01, 95% CI, −0.26 to 0.25, P = 0.96) did not differ significantly between the RRS and ORS groups.

Conclusion

Based on the current evidence, robotic resection for rectal cancer provided equivalent pathological outcomes to ORS in terms of CRM positivity, number of harvested lymph nodes and complete TME rates and DRM.

Understanding the Value of Both Laparoscopic and Robotic Approaches Compared to the Open Approach in Colorectal Surgery

INTRO

Although the use of laparoscopy has significantly increased in colorectal procedures, robotic surgery may enable additional cases to be performed using a minimally invasive approach. We separately evaluated the value of laparoscopic and robotic colorectal procedures compared to the open approach.

METHODS

Patients undergoing nonemergent colorectal operations from 2010 to 2013 with National Surgical Quality Improvement Project data were identified. Robotic and laparoscopic procedures were separately matched (1:1) to open cases. Outcomes included 30-day composite morbidity, length of stay, operative time, and inpatient costs. Frequently used intraoperative disposable items were categorized, and significant cost contributors were identified by surgical approach. Statistical differences were determined with Chi-square and Wilcoxon signed-rank tests.

RESULTS

Both laparoscopic (n = 67) and robotic (n = 45) approaches were associated with decreased composite morbidity compared to matched open cases (lap vs. open: 22.4% vs. 49.2%, P < .01; robotic vs. open: 6.7% vs. 33.3%, P < .01). Median length of stay was significantly shorter for both laparoscopic and robotic compared to open surgery (lap vs. open: 5 vs. 7 days, P < .01; robotic vs. open: 5 vs. 7 days, P < .01). Median hospital costs were similar between laparoscopic and open surgery ($13,319 vs. $14,039; P = .80) and robotic and open surgery ($13,778 vs. $13,629; P = .48).

CONCLUSION

These findings illustrate the value for both laparoscopic and robotic approaches to colorectal surgery compared to the open approach in terms of short-term outcomes and inpatient costs. Advanced intraoperative disposable items such as cutting staplers and energy devices are important targets for additional cost containment.

Robotic-assisted surgery versus open surgery in the treatment of rectal cancer: the current evidence

The aim of this meta-analysis was to comprehensively compare the safety and efficacy of robotic-assisted rectal cancer surgery (RRCS) and open rectal cancer surgery (ORCS). Electronic database (PubMed, EMBASE, Web of Knowledge, and the Cochrane Library) searches were conducted for all relevant studies that compared the short-term and long-term outcomes between RRCS and ORCS. Odds ratios (ORs), mean differences, and hazard ratios were calculated. Seven studies involving 1074 patients with rectal cancer were identified for this meta-analysis. Compared with ORCS, RRCS is associated with a lower estimated blood loss (mean difference [MD]: −139.98, 95% confidence interval [CI]: −159.11 to −120.86; P < 0.00001), shorter hospital stay length (MD: −2.10, 95% CI: −3.47 to −0.73; P = 0.003), lower intraoperative transfusion requirements (OR: 0.52, 95% CI: 0.28 to 0.99, P = 0.05), shorter time to flatus passage (MD: −0.97, 95% CI = −1.06 to −0.88, P < 0.00001), and shorter time to resume a normal diet (MD: −1.71.95% CI = −3.31 to −0.12, P = 0.04). There were no significant differences in surgery-related complications, oncologic clearance, disease-free survival, and overall survival between the two groups. However, RRCS was associated with a longer operative time. RRCS is safe and effective.

Robotic oncologic complexity score - a new tool for predicting complications in computer-enhanced oncologic surgery

BACKGROUND

While there is little doubt that robotic interventions have already opened new horizons in surgery due to its inherent complexity, there is still an unmet need for tools allowing center-to-center performance comparisons. A complexity score could be a valuable instrument for further research.

METHODS

The items of the robotic oncologic complexity score (ROCS) were based on risk factors identified in previous studies. We attempt to build the score and validate it on 400 consecutive cases of robotic oncologic surgery. The primary endpoint is to assess the value of ROCS in predicting major complications.

RESULTS

The mean ROCS in the group was 3.3(+/-1.4). Different correlations were calculated: the score and the complications (r=0.38), the major complications (r=0.42), Clavien grade (r=0.5), the operating time (r=0.35), and the length of stay (r=0.47). On the ROC-curve a score >4 has the best specificity and sensibility for predicting major complications (P<0.05).

CONCLUSION

ROCS has potential in predicting complications and hospital length of stay, as well as a role in classifying oncologic robotic surgical interventions. Copyright © 2015 John Wiley & Sons, Ltd.

Robotic Rectal Cancer Resection: A Retrospective Multicenter Analysis

BACKGROUND

Conventional laparoscopy has been applied to colorectal resections for more than 2 decades. However, laparoscopic rectal resection is technically demanding, especially when performing a tumor-specific mesorectal excision in a difficult pelvis. Robotic surgery is uniquely designed to overcome most of these technical limitations. The aim of this study was to confirm the feasibility of robotic rectal cancer surgery in a large multicenter study.

METHODS

Retrospective data of 425 patients who underwent robotic tumor-specific mesorectal excision for rectal lesions at seven institutions were collected. Outcome data were analyzed for the overall cohort and were stratified according to obese versus non-obese and low versus ultra-low resection patients.

RESULTS

Mean age was 60.9 years, and 57.9 % of patients were male. Overall, 51.3 % of patients underwent neoadjuvant therapy, while operative time was 240 min, mean blood loss 119 ml, and intraoperative complication rate 4.5 %. Mean number of lymph nodes was 17.4, with a positive circumferential margin rate of 0.9 %. Conversion rate to open was 5.9 %, anastomotic leak rate was 8.7 %, with a mean length of stay of 5.7 days. Operative times were significantly longer and re-admission rate higher for the obese population, with all other parameters comparable. Ultra-low resections also had longer operative times.

CONCLUSION

Robotic-assisted minimally invasive surgery for the treatment of rectal cancer is safe and can be performed according to current oncologic principles. BMI seems to play a minor role in influencing outcomes. Thus, robotics might be an excellent treatment option for the challenging patient undergoing resection for rectal cancer.

Total mesorectal excision: open, laparoscopic or robotic

Goals Total mesorectal excision (TME) is the gold standard technique for the surgical treatment of rectal cancer. Despite the benefits of minimally invasive surgery, laparoscopic TME (LTME) is a technically challenging procedure with a long learning curve. Robotic TME (RTME) has been advocated as an alternative to conventional LTME, but large studies supporting the efficacy or RTME are scarce. This work will review the current literature on minimally invasive surgery for rectal cancer and discuss future directions in the field. Methods A review of recent large single and multicenter studies on minimally invasive surgery for rectal cancer was conducted. Results Based on two large randomized clinical studies (CLASICC (Green et al. 2013) and COLOR II (van der Pas et al. 2013)). LTME is safe and feasible for the treatment of rectal cancer. Compared to open surgery, LTME has been shown to result in superior postoperative outcomes and similar oncologic results. However, the conversion rate of LTME is around 17 %. The literature supporting RTME is more limited. Robotic rectal resection appears to have similar postoperative and oncologic outcomes compared to LTME. RTME results in higher costs and possibly lower conversion rates. A large randomized clinical trial (ROLARR) comparing robotic to laparoscopic surgery for rectal cancer is underway. Conclusions Despite the technical challenges, current data supports the use of minimally invasive technique for rectal cancer surgery with superior short-term outcomes compared to an open approach. The use of robotic surgery is promising, but still limited and awaiting the conclusion of randomized clinical trials.

Outcomes of robotic-assisted colorectal surgery compared with laparoscopic and open surgery: a systematic review

BACKGROUND

Robotic technology has been applied to colorectal surgery over the last decade. The aim of this review is to analyze the outcomes of robotic colorectal surgery systematically and to provide objective information to surgeons.

METHODS

Studies were searched and identified using PubMed and Google Scholar from Jan 2001 to Feb 2013 with the search terms "robot," "robotic," "colon," "rectum," "colorectal," and "colectomy." Appropriate data in the studies about the outcomes of robotic colorectal surgery were analyzed.

RESULTS

Sixty-nine publications were included in this review and composed of 39 case series, 29 comparative studies, and 1 randomized controlled trial. Most of the studies reported that robotic surgery showed a longer operation time, less estimated blood loss, shorter length of hospital stay, lower complication and conversion rates, and comparable oncologic outcomes compared to laparoscopic or open surgery.

CONCLUSION

Robotic colorectal surgery is a safe and feasible option. Robotic surgery showed comparable short-term outcomes compared to laparoscopic surgery or open surgery. However, the long operation time and high cost are the limitations of robotic surgery.

Robot-assisted low anterior resection in fifty-three consecutive patients: an Indian experience

From December 2005 to December 2009, we performed 150 laparoscopic colorectal procedures. Based on this experience, we started offering robot-assisted colorectal surgery from December 2009. This study is a prospective evaluation of consecutive patients in order to study the technical feasibility and oncological outcome of robot-assisted low anterior resection. This investigation was conducted at a single minimal access surgery institute. Between December 2009 and December 2011, 53 consecutive patients with rectal adenocarcinoma underwent a robot-assisted low anterior resection (LAR) or ultralow anterior resection (ULAR) with total mesorectal excision (TME), using the standard da Vinci 'S' model. Patient demographics, mean operative time, mean postoperative hospital stay, blood loss, days to first flatus, resumption of oral feeds, urinary incontinence, and sexual dysfunction were studied. Surgical and pathological outcomes such as quality of TME, free circumferential margins, and number of lymph nodes dissected were also evaluated. Robot docking and undocking times were noted. Of the 53 patients, 41 were men and 12 were women. Their mean age was 66.7 years (range 37-90 years). The ASA grades were distributed as follows: ASA I 15 (28.3 %), ASA II 25 (47.16 %), ASA III 12 (22.64 %), ASA IV 1 (1.88 %). The mean operative time was 180 min (150-230 min) and the mean blood loss was 101.6 ml (50-300 ml). The robot docking time was 10 min (15-25 min) and the undocking time was 5 min (3-10 min). The mean hospital stay was 8 days (7-15 days). None of the patients was converted to either laparoscopic or open procedure. The longitudinal and circumferential margins were negative in all patients. Histopathological reports of 45 patients showed complete TME while 8 patients showed nearly complete TME. No repositioning of the robot was needed for splenic flexure mobilization, thus decreasing the operative time. Along with TME, even the splenic flexure mobilization was achieved through the same robotic ports without undocking the robot. Robot-assisted LAR and ULAR is technically feasible, and a complete TME is possible.

Strategies to reduce the use of blood products: a US perspective

PURPOSE OF REVIEW

To describe the recent developments in the strategies to reduce allogeneic blood transfusions with emphasis on the impact on clinical outcomes.

RECENT FINDINGS

Concerns over the safety, efficacy, and supply of allogeneic blood continue to necessitate its judicious use as the standard of care. Patient blood management is emerging as a multidisciplinary, multimodality strategy to address anemia and decrease bleeding with the goal of reduced transfusions and improved patient outcomes. Common risk factors for transfusion include anemia, blood loss, and inappropriate transfusion decisions. Several approaches are available to mitigate these. Recent data continue to support the effectiveness of various hematinics, hemostatic agents and devices, as well as intermittent discontinuation of anticoagulant therapy. Use of autotransfusion techniques, particularly cell salvage, is the other strategy with accumulating data supporting its safety and efficacy. Finally, implementation of evidence-based transfusion guidelines will help to target allogeneic blood to those patients who are likely to benefit from it and thus reduce or eliminate unnecessary exposure to blood.

SUMMARY

Patient blood management is the timely use of safe and effective medical and surgical techniques designed to prevent anemia and decrease bleeding in an effort to improve patient outcome.