Robotic and laparoscopic sphincter-saving resections have similar peri-operative, oncological and functional outcomes in female patients with rectal cancer

Comparison of laparoscopic versus robot-assisted sugery for rectal cancer after neo-adjuvant therapy: a large volume single center experience

PURPOSE

This study aims to assess the short- and long-term outcomes of rectal cancer patients undergoing robotic versus laparoscopic surgery after receiving neo-adjuvant therapy. There is a lack of clarity on this topic, necessitating a comprehensive comparison.

METHOD

Between January 2017 and December 2021, consecutive patients who underwent laparoscopic and robotic rectal resection at a major public medical center were enrolled. All participants received neo-adjuvant chemoradiotherapy (nCRT) before surgery. The primary objective of this study was to assess the sphincter preservation rate and the rate of conversion to open surgery, using propensity score matching (PSM) analysis. Secondary endpoints included 5-year disease-free survival (DFS), 5-year overall survival (OS), short-term postoperative complications, long-term oncological prognosis, and the occurrence of low anterior resection syndrome (LARS).

RESULT

A total of 575 patients diagnosed with rectal cancer participated in the cohort study, with 183 individuals undergoing robotic surgery and 392 undergoing laparoscopic surgery. Patients in the robotic group tended to be younger and had higher ypT, cT, and cN stages, lower tumor locations, and higher rates of extramural vascular invasion (EMVI) and circumferential resection margin (CRM) positivity. PSM resulted in 183 patients in the robotic group and 187 in the laparoscopic group. We found a higher sphincter preservation rate in robotic group compared with laparoscopic group (92.9% vs. 86.1%, P = 0.033), with no significant difference in conversion to open surgery(P > 0.05). The robotic group had a higher incidence of postoperative chylous ascites (4.9% vs. 1.1%, P = 0.029) and potentially lower sepsis occurrence (0% vs. 1.6%, P = 0.085). No significant differences were observed in long-term oncological prognosis or 5-year survival rates (P > 0.05). The median survival time for each group was 34 months. Subgroup analysis of 76 rectal cancer patients who underwent intersphincteric resection (ISR) surgery indicated that those who selected robotic surgery had higher cN and cT stages. Furthermore, no statistically significant differences were observed in short-term and long-term clinical outcomes, LARS, OS time, and DFS time between the two surgical modalities. The primary outcomes of interest, specifically the rate of sphincter preservation and the rate of conversion to open laparotomy, showed no significant differences.

CONCLUSION

Robotic surgery for rectal cancer, following preoperative nCRT, demonstrates comparable technical safety and oncological outcomes to laparoscopic surgery. Further comprehensive studies are needed to to confirm the potential advantages of robotic surgical interventions.

The prognostic value of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in colorectal cancer and colorectal anastomotic leakage patients: a retrospective study

OBJECTIVE

The purpose of this study was to investigate the influence and predictive value of preoperative peripheral blood neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) index on the prognosis of colorectal anastomotic leakage (CAL) patients.

METHODS

This study retrospectively analyzed the clinical data of 1016 patients who underwent radical resection for colorectal cancer at a single center between January 1, 2007 and December 31, 2023. In this study, NLR and PLR were analyzed before surgery. Kaplan-Meier survival analysis was performed according to the postoperative survival status of the patients. Nomogram and calibration curve were established by proportional hazards model (COX) to verify its predictive value.

RESULTS

A total of 890 patients with colorectal cancer, 102 patients with CAL, and 788 patients with non- anastomotic leakage (AL) colorectal cancer were enrolled for a median follow-up of 96 months (quartile range 33-133). In this study, COX regression analysis showed that preoperative NLR and PLR could predict the prognosis of CAL patients, and the optimal cut-off points of NLR and PLR were 2.89 and 157.62, respectively. Kaplan-Meier survival curve results showed that 5-year overall survival (OS) and disease-free survival (DFS) in the low NLR and PLR group were significantly higher than those in the high NLR and PLR group. OS and DFS were divided into high, low NLR and PLR groups. Finally, based on COX model, a nomogram analysis was conducted to analyze the risk factors affecting OS and DFS, and the accuracy and practicality of the model were verified by calibration curve and decision curve.

CONCLUSION

Preoperative NLR and PLR can predict the long-term prognosis of colorectal cancer (CRC) and CAL patients, and patients with NLR ≥ 2.89 and PLR ≥ 157.62 have poor survival prognosis. Nomogram and calibration curve analysis will further improve the accuracy of OS and DFS prediction.

Robotic surgery versus laparoscopic surgery for rectal cancer: a comparative study on surgical safety and functional outcomes

BACKGROUNDS

This study aims to evaluate the clinical efficacy and functional outcomes of DA Vinci (Xi)-assisted surgery compared to conventional laparoscopic surgery for middle and low rectal cancer, focusing on oncologic cure and functional preservation.

METHODS

Between December 2020 and June 2021, 102 patients with middle and low rectal cancer (tumour lower margin ≤10 cm) were enrolled at the affiliated Hospital of Xuzhou Medical University. Participants were divided into two groups: robot-assisted (n = 51) and laparoscopy-assisted (n = 51). Each group underwent a radical resection using their assigned method. Clinical and functional outcomes were analysed post-surgery.

RESULTS

Preoperative data did not differ significantly between groups (P > 0.05). All surgeries were successfully completed without conversion to open surgery. The robotic group experienced significantly less intraoperative blood loss (55.2 ± 29.8 mL vs. 109.5 ± 58.5 mL) and faster recovery in gastrointestinal function (35.1 ± 9.4 h vs. 40.7 ± 1.9 h), diet recovery (2.1 ± 0.8 days vs. 2.9 ± 0.4 days), and catheter removal (2.9 ± 2.7 days vs. 5.3 ± 2.1 days). The robotic group also dissected more lymph nodes (23 ± 6 vs. 15 ± 4). However, they had longer operative times (239.8 ± 29.6 min vs. 141.1 ± 18.5 min) and higher hospital costs. Satisfaction levels regarding defecation, voiding, and sexual functions were notably higher in the robotic group.

CONCLUSION

No significant differences in surgical safety or immediate postoperative outcomes were observed between robotic and laparoscopic approaches. However, robotic surgery demonstrated superior lymph node dissection, anal function preservation, and gastrointestinal recovery, enhancing overall functional outcomes.

Robotic surgery is associated with a decreased risk of circumferential resection margin positivity compared with conventional laparoscopic surgery in patients with rectal cancer undergoing mesorectal excision: A systematic review and meta-analysis

OBJECTIVE

To investigate whether robotic surgery (RS) decreases the risk of circumferential resection margin (CRM) positivity compared with conventional laparoscopic surgery (LS) in patients with rectal cancer (RC) undergoing mesorectal excision (ME).

BACKGROUND

Although it is well known that CRM positivity affects postoperative outcomes in patients with RC undergoing ME, few studies have investigated whether RS is superior to conventional LS for the risk of CRM positivity.

METHODS

We performed a comprehensive electronic search of the literature up to December 2022 to identify studies that compared the risk of CRM positivity between patients with RC undergoing robotic and conventional laparoscopic surgery. A meta-analysis was performed using random-effects models to calculate risk ratios (RRs) and 95 % confidence intervals (CIs), and heterogeneity was analyzed using I2 statistics.

RESULTS

Eighteen studies, consisting of 4 randomized controlled trials (RCTs) and 14 propensity score matching (PSM) studies, involved a total of 9203 patients with RC who underwent ME were included in this meta-analysis. The results demonstrated that RS decreased the overall risk of CRM positivity (RR, 0.82; 95 % CI, 0.73-0.92; P = 0.001; I2 = 0 %) compared with conventional LS. Results of a meta-analysis of the 4 selected RCTs also showed that RS decreased the risk of CRM positivity (RR, 0.62; 95 % CI, 0.43-0.91; P = 0.01; I2 = 0 %) compared with conventional LS.

CONCLUSIONS

This meta-analysis revealed that RS is associated with a decreased risk of CRM positivity compared with conventional LS in patients with RC undergoing ME.

A New Approach to Ultra-Low Anterior Resection-Intersphincteric Dissection With Total Hiatal Ligament Excision for Very Low Rectal Cancer Located in the Posterior Wall of the Rectum: A More Satisfactory Technique for Local Recurrence Control

BACKGROUND

The hiatal ligament, as the anatomical landmark for the completion of total mesorectal excision (TME) for ultra-low rectal cancer, represents a continuation of the longitudinal muscle of the rectum. It receives vascular supply from the median sacral artery and contains lymphatic vessels. In cases where ultra-low rectal cancer is located in the posterior rectal wall, the hiatal ligament may theoretically serve as an anatomical region susceptible to direct tumor cell spread or distant metastasis.

OBJECTIVE

To evaluate the effect of circumferential tumor location (CTL) on postoperative survival of low rectal cancer and to determine the effect of total hiatal ligament excision (THLE) on the prognosis of patients with posterior rectal cancer.

METHODS

Patients with ultra-low rectal cancer who underwent laparoscopic surgery between March 2014 and October 2021 were enrolled in this study. Propensity score matching (PSM) analysis was used to compare the clinicopathological characteristics and prognosis of patients in the posterior group and the non-posterior group. Prognostic factors were identified using COX regression. PSM analysis was also used in the posterior tumor subgroup to compare the clinicopathological characteristics and prognosis of patients in the hiatal ligament traditional transection (HLTT) and THLE groups.

RESULTS

After PSM, OS, and DFS were comparable between the posterior and non-posterior groups. Similarly, no difference was noted in the local recurrence rate between the two groups (p = 0.23). The prognosis of ultra-low rectal cancer was not affected by CTL. However, the local recurrence rate was significantly lower in the THLE group compared with the HLTT group (p = 0.023). Multivariate analysis of the posterior group identified CRM, TNM stage III, and HLTT as independent risk factors for local recurrence-free survival.

CONCLUSIONS

CTL is not a prognostic risk factor for low rectal cancer. In posterior wall tumors, THLE significantly reduces the local recurrence rate for low rectal cancer.

Comparing total mesorectal excision with partial mesorectal excision for proximal rectal cancer: evaluating postoperative and long-term oncological outcomes

The treatment role of Total Mesorectal Excision (TME) in proximal rectal cancers (PRC) is still debated. Partial Mesorectal Excision (PME) can reduce morbidity in PRC patients. The purpose of this study was to compare short-term clinical and long-term oncological outcomes between the two groups. A total of 157 PRC patients were enrolled in this study (114 performed with PME and 43 with TME). The two groups were compared in terms of perioperative and long-term oncological outcomes. The overall postoperative complications rate was higher in TME group (18.4% vs. 32.5%, p < 0.05). The incidence of diverting ileostomy was also significantly higher in TME group (86.0% vs. 2.6%, p < 0.001). Overall survival rates for 3, 5, and 7 years in PME and TME group accordingly were: 94.6%, 89.3%, 81.5% and 93.2%, 87.6%, 78.4% (p = 0.324). Disease-free survival rates for 3, 5, and 7 years in PME and TME group were: 90.2%, 84.5%, 78.6% and 88.7%, 81.2%, 75.3% (p = 0.297), respectively. Local recurrence rates for 3, 5, and 7 years in PME and TME group were: 2.6%, 6.1%, 8.8% and 4.6%, 9.3%, 11.2% (p = 0.061), respectively. PME is feasible and can be safely performed in PRC patients with favorable oncological outcomes. TME is associated with increasing risk of surgical complications and requires a two-step surgery for stoma takedown.

Post recurrence survival in early versus late period and its prognostic factors in rectal cancer patients

To identify factors associated with post-recurrence survival (PRS), we examined our institutional recurrence patterns following definitive resection for rectal cancer. We reviewed all patients with rectal cancer diagnosed at three hospitals in the east of Iran from 2011 to 2020. The optimal cut-off value was determined by receiver operating characteristic (ROC) analysis to determine early recurrence. The effect of recurrence time was evaluated on PRS. 326 eligible patients with a mean ± SD age of 56 ± 12.8 years were included in this study. In a median (IQR: Inter-quartile range) follow-up time of 76 (62.2) months, 106 (32.5%) patients experienced at least any recurrence (locoregional or distant metastasis) following primary resection. The median (IQR) time from initial surgery to recurrence was 29.5 (31.2) months. Based on ROC analysis, early recurrence was specified at ≤ 29 months. However, for the patients who experienced only locoregional recurrence, 33 months was the cut-off to define early recurrence. Recurrence time and recurrence management were both significant variables on PRS. Moreover, TNM staging was significantly associated with early recurrence (P = 0.003). In this research, recurrence time, recurrence management and TNM staging were found to be correlated with PRS.

Perioperative and long-term oncological outcomes of robotic versus laparoscopic total mesorectal excision: a retrospective study of 672 patients

Although there's growing information about the long-term oncological effects of robotic surgery for rectal cancer, the procedure is still relatively new. This study aimed to assess the long-term oncological results of total mesorectal excision (TME) performed laparoscopically versus robotically in the setting of rectal cancer. Restrospective analysis of a prospectively maintained database. A total of 489 laparoscopic (L-TME) and 183 robotic total mesorectal excisions (R-TME) were carried out by a single surgeon between 2013 and 2023. The groups were compared in terms of perioperative and long-term oncological outcomes. In the R-TME and L-TME groups, male sex predominated (75.4% and 57.3%, respectively), although the robotic group was significantly greater (p = 0.008). There was no conversion in R-TME group, whereas three (0.6%) converted to open surgery in L-TME group. The R-TME group had a statistically significant higher number of distal rectal tumors (85%) compared to the L-TME group (54.6%). Only three (1.7%) patients in the R-TME group received abdomineperineal resection (APR); in contrast, 25 (5%) patients in the L-TME group received APR (p < 0.001). For R-TME, the mean follow-up was 70.7 months (range 18-138) and for L-TME, it was 60 months (range 14-140). Frequency of completed mesorectum was significantly greater in R-TME group (98.9% vs 94.2%, p < 0.001). The 5 year overall survival rates for R-TME and L-TME groups were 89.6% and 88.7%, respectively. The 5 year disease-free survival for R-TME and L-TME groups were 84.1% and 81.1%, respectively. The local recurrences rates were 7.6% and 6.3%, respectively in R-TME and L-TME groups (p = 0.274). R-TME is characterized by no conversion and improved mesorectal integrity. R-TME had longer operation time. The long-term oncological outcomes were comparable between groups.