Results of laparoscopic anterior resection for rectal adenocarcinoma: retrospective analysis of 157 cases

Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going?

Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.

Anastomotic Leak Rate and Prolonged Postoperative Paralytic Ileus in Patients Undergoing Laparoscopic Surgery for Colo-Rectal Cancer After Placement of No-Coil Endoanal Tube

BACKGROUND

Colorectal cancer (CRC) is the second most common gastrointestinal tumor in men and the third in women. Left-hemicolectomy (LC) and low anterior resection (LAR) are considered the gold standard curative treatment. In this retrospective study, we evaluated the presence or absence of post-operative complications, in all patients who underwent Video-laparoscopic (VLS) LAR/LC with No Coil trans-anal tube positioning, and compared the data with the current literature on the topic.

METHODS

Thirty-nine patients diagnosed with CRC of the descending colon, splenic flexure, sigma, and rectum were recruited. LC was performed for sigmoid and descending colon cancers, while LAR was applied for tumors of the upper two-thirds of the rectum. The No Coil trans-anal tube (SapiMed Spa, Alessandria, Italy) was placed in all patients of the study at the end of surgical treatment.

RESULTS

Eighteen patients received a LAR-VLS (46%) and 21 patients received a LC-VLS (54%). The average length of hospital stay after surgery was 7 days. PPOI occurred in only one in 39 patients (2.6%) who had undergone LAR-VLS. As for complications, in no patient of the study did AL (0%) occur.

CONCLUSION

In patients undergoing LAR-VLS and LC-VLS, we performed colorectal anastomosis and in the same surgical operation we introduced the No-Coil device. Although this is a preliminary study and subject to further investigation, we believe that the No Coil tube positioning may reduce the time of presence of first flatus and feces and the risk of AL.

Prognosis Comparisons of Laparoscopy versus Open Surgery for Rectal Cancer Patients after Preoperative Chemoradiotherapy: A Meta-Analysis

AIM

We aimed to compare the oncological outcomes of laparoscopy and open resection for patients with rectal cancer following neoadjuvant chemoradiotherapy (NCRT).

METHODS

We searched the publications that compared the efficacy of laparoscopic surgery and open thoracotomy in treatment outcomes of rectal cancer after NCRT. All trials analyzed the summary hazard ratios of the endpoints of interest, including survival and individual postoperative complications.

RESULTS

Totally, 10 trials met our inclusion criteria. The pooled analysis of 3-year disease-free survival (OR 1.39, 95% CI 0.93-2.06; p = 0.11) and 3-year overall survival (OR 1.01, 95% CI 0.70-1.45; p = 0.97) showed that laparoscopic surgery did not achieve beneficial effects compared with open thoracotomy. The pooled result of duration of surgery indicated that laparoscopic surgery was associated with a trend for longer surgery time (SMD 27.53, 95% CI 1.34-53.72; p = 0.04), shorter hospital stay (SMD -1.64, 95% CI -2.70 to -0.58; p = 0.002), more postoperative complications (OR 0.77, 95% CI 0.60-0.99; p = 0.04), and decreased blood loss (SMD -49.87, 95% CI -80.61 to -19.14; p = 0.001). However, the number of removed lymph nodes, positive circumferential resection margin, as well as complications after surgery showed significant differences between the 2 groups.

CONCLUSIONS

We focused on current evidence and reviewed the studies indicating that similar oncological outcomes were associated with laparoscopic surgery following NCRT for patients with locally advanced lower rectal cancer in comparison with open surgery.

Relationship between anastomotic leakage and CT value of the mesorectum in laparoscopic anterior resection for rectal cancer

OBJECTIVE

This study aims to indicate whether the CT value of the mesorectum could be correlated with the incidence of anastomotic leakage (AL) in laparoscopic surgery for rectal cancer.

METHODS

The study subjects included 173 patients who underwent laparoscopic anterior resection (LAR) for rectal cancer from September 2005 to 2016 in our institution as well as reliable contrast-enhanced CT preoperatively. Univariate and multivariate analyses were performed to determine the correlation between surgical outcomes, including AL and CT value of the mesorectum.

RESULTS

AL was observed in 30 (17.3%) patients. Amongst short-term surgical outcomes, overall complication showed significant correlation with the CT value of the mesorectum (P = 0.003). In addition, AL was the only factor, which significantly correlated with the CT value of the mesorectum (P = 0.017). By plotting receiver operating characteristic curve, -75 HU was the threshold of the CT value of the mesorectum for predicting AL with an area under the curve of 0.772. Categorized into two groups as per the threshold, low group showed significantly higher incidence of AL (OR, 2.738; 95% CI, 1.105-6.788; P = 0.030) as well as whole complications (OR, 4.431; 95%CI, 1.912-10.266; P = 0.001).

CONCLUSION

The CT value of the mesorectum may be a helpful preoperative radiological biomarker to predict AL after LAR for rectal cancer.

Does conversion during laparoscopic rectal oncological surgery increases postoperative complications and anastomotic leakage rates? A meta-analysis

OBJECTIVE

To evaluate, regarding previous published studies, postoperative outcomes between patients undergoing rectal cancer resection performed by totally laparoscopic approach (LAP) compared to those who underwent peroperative conversion (CONV).

METHODS

Studies comparing LAP versus CONV for rectal cancer published until December 2017 were selected and submitted to a systematic review and meta-analysis. Articles were searched in Medline and Cochrane Trials Register Database. Meta-analysis was performed with Review Manager 5.0.

RESULTS

Twelve prospective and retrospective studies with a total of 4503 patients who underwent fully laparoscopic approach for rectal cancer and a total of 612 patients who underwent conversion were included. Meta-analysis did not show any significant difference on overall mortality between both approaches (OR=0.47, 95%CI=0.18-1.22, P=0.12). However, Meta-analysis showed that anastomotic leakage rate, wound abscess rate and postoperative morbidity rate were significantly decreased with totally laparoscopic approach (OR=0.37, 95%CI =0.24-0.58, P<0.0001; OR=0.29, 95%CI=0.19-0.45, P<0.00001; OR=0.56, 95%CI=0.46-0.67, P<0.00001 respectively).

CONCLUSION

This meta-analysis suggests that conversion increases anastomotic leakage, overall morbidity and wound abscess rates without increasing mortality rate for patients who underwent rectal resection for cancer.

Totally-laparoscopic versus laparoscopic-assisted low anterior resection for rectal cancer: are outcomes different?

BACKGROUND

Laparoscopic low anterior resection for rectal cancer has superior short-term benefits compared to open surgery. When operative conditions do not favour a totally-laparoscopic (TL) approach, a hybrid operation can be performed. In this laparoscopic-assisted (LA) approach, mobilization and vessel ligation are performed laparoscopically, with total mesorectal excision and distal transection performed either partially or totally in an extra-corporeal fashion. We compared short-term post-operative and oncological outcomes of both approaches.

METHODS

A prospectively collected database of patients who underwent laparoscopic low anterior resection for rectal cancer between January 2009 and December 2014 was retrospectively analysed. Demographics, post-operative and oncological outcomes were compared.

RESULTS

Of 174 patients, 97 were completed by TL, 62 by LA and the remaining 15 were converted to open. Baseline demographics were similar. LA group compared to TL group had bulkier rectal cancers (6.75 cm³ versus 4.50 cm³ , P = 0.04) which were lower (6 cm versus 7 cm from anal verge, P = 0.02). They were of a more advanced tumour grade and had greater incidence of lymphovascular invasion. Yet, post-operative outcomes such as time to diet, pain scores, hospitalization duration, wound-related and anastomotic complications, 30-day morbidity and mortality were similar. There was no difference in oncological adequacy, including circumferential resection margins, distal margins, lymph node harvest and 2-year local recurrence rates.

CONCLUSION

Laparoscopic-assisted low anterior resection enables minimally invasive rectal surgery to be performed despite unfavourable tumour factors and technical challenges; and compares favourably with TL approach in terms of short-term outcomes and oncological safety.

Predictive factors for anastomotic leakage after laparoscopic colorectal surgery

Every colorectal surgeon during his or her career is faced with anastomotic leakage (AL); one of the most dreaded complications following any type of gastrointestinal anastomosis due to increased risk of morbidity, mortality, overall impact on functional and oncologic outcome and drainage on hospital resources. In order to understand and give an overview of the AL risk factors in laparoscopic colorectal surgery, we carried out a careful review of the existing literature on this topic and found several different definitions of AL which leads us to believe that the lack of a consensual, standard definition can partly explain the considerable variations in reported rates of AL in clinical studies. Colorectal leak rates have been found to vary depending on the anatomic location of the anastomosis with reported incidence rates ranging from 0 to 20%, while the laparoscopic approach to colorectal resections has not yet been associated with a significant reduction in AL incidence. As well, numerous risk factors, though identified, lack unanimous recognition amongst researchers. For example, the majority of papers describe the risk factors for left-sided anastomosis, the principal risk being male sex and lower anastomosis, while little data exists defining AL risk factors in a right colectomy. Also, gut microbioma is gaining an emerging role as potential risk factor for leakage.

Conversion is a risk factor for postoperative anastomotic leak in rectal cancer patients - A retrospective cohort study

AIM

The impact of conversion from laparoscopic surgery to laparotomy on the development of anastomotic leak (AL) in rectal cancer patients following laparoscopic low anterior resection (LAR) with total mesorectal excision (TME) has not been evaluated. The aim of this study was to evaluate the impact of conversion on the risk of AL and develop a prediction nomogram for postoperative AL.

METHODS

All rectal cancer patients following laparoscopic LAR with TME from January 2010 to October 2014 were enrolled in the primary cohort. Comparisons of the postoperative anastomotic leak incidence rate between converted patients and non-converted patients were performed using both univariate and multivariate logistic regression analyses. The result of multivariable analysis was used to develop the predicting model and the performance of nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. An independent validation cohort containing 200 patients from November 2014 to October 2015 was assessed.

RESULTS

Of all patients enrolled (n=646), 592 (91.6%) patients underwent totally laparoscopic surgery, and 54 (8.4%) were converted from laparoscopic surgery to laparotomy. Converted group patients were more likely to have a higher body mass index (BMI), prolonged length of stay (LOS), increased overall postoperative complication rates and advanced clinical T stage (T3 or T4), pathological N stage (N1 or N2) and pathological TNM stage (III or IV). The percentage of patients who had preoperative radiotherapy for rectal cancer was higher in non-converted patients. Patients who underwent conversion to laparotomy (n=10, 18.5%) were more likely to suffer from postoperative AL than those undergoing totally laparoscopic surgery (n=38, 6.4%) (P=0.004). Multivariate logistic regression analyses confirmed the association between conversion and postoperative AL (Odds ratio [OR], 95% confidence interval [CI]: 2.71 [1.31-5.63], P=0.007). Conversion, gender, and clinical N stage incorporated in the individualized prediction nomogram showed good discrimination, with a C-index of 0.697 (C-index, 0.621 and 0.772 through internal validation), and good calibration. In the validation cohort, the main results were consistent with the findings of the primary cohort, with a C-index of 0.670 (C-index, 0.562 and 0.777 through internal validation). Decision curve analysis demonstrated that the prediction nomogram was clinically useful.

CONCLUSION

Conversion during laparoscopic LAR was found to be associated with an increased risk for the postoperative AL in RC patients. A nomogram model incorporating conversion, gender and patient's clinical N stage seems to offers a useful tool for predicting postoperative AL in these patients.

Transanal Inspection and Management of Low Colorectal Anastomosis Performed With a New Technique: the TICRANT Study

BACKGROUND

Anastomotic leakage is one of the most serious complications after rectal cancer surgery.

METHOD

A prospective multicenter interventional study to assess a newly described technique of creating the colorectal and coloanal anastomosis. The primary outcome was to access the safety and efficacy of this technique in the reduction of anastomotic leak.

RESULT

Fifty-three patients with rectal cancer who underwent low or ultra-low anterior resection were included in the study. There were 35 males and 18 females, with a median age of 68 years (range = 49-89 years). The median tumor distance from the anal verge was 8 cm (range = 4-12 cm), and the median body mass index was 24 kg/m² (range = 20-35 kg/m²). Thirty patients underwent open, 16 laparoscopic, and 7 robotic surgeries. Multiple firing (2-charges) was required in 30 patients to obtain a complete rectal division. Forty-five patients had colorectal anastomosis, and 8 patients had coloanal anastomosis. The protective ileostomy was created in 40 patients at the time of initial surgery. There was no mortality in the first 30 days postoperatively, and only 10 (19%) patients developed complications. There were 3 anastomotic leakages (6%); 2 of them were subclinical with ileostomy created at initial operation and both were treated conservatively with transanal drainage and intravenous antibiotics. One patient required reoperation and ileostomy. The median length of hospital stay was 10 days (range = 4-20 days).

CONCLUSION

Our technique is a safe and efficient method of creation of colorectal anastomosis. It is also a universal method that can be used in open, laparoscopic, and robotic surgeries.

An evidence-based medicine approach to the laparoscopic treatment of colorectal cancer

During the 1990s, laparoscopic resection was established as a treatment for gastrointestinal malignant tumors.　A number of randomized controlled trials comparing laparoscopic-assisted colorectal surgery with conventional open colorectal surgery for colon cancer have been conducted.　These trials have shown short-term benefits, and the vast majority demonstrated no significant difference in long-term outcomes.　Laparoscopic-assisted colorectal surgery is widely performed for the treatment of colon cancer, whereas laparoscopic-assisted colorectal surgery for rectal cancer is less commonly performed.　In recent years, there have been an increasing number of reports of laparoscopic-assisted colorectal surgery for rectal cancer, where improving short-term outcomes was shown, but no definitive effect on long-term survival has been shown to date.　Randomized controlled trials focusing on long-term survival are currently ongoing.

Long-Term Oncologic Outcomes of Laparoscopic versus Open Surgery for Middle and Lower Rectal Cancer

Background

Laparoscopic surgery for middle and lower rectal cancer remain controversial because anatomical and complex surgical procedures specifically influence oncologic outcomes. This study analyzes the long-term outcomes of laparoscopic versus open surgery for middle and lower rectal cancer.

Methods

Patients (laparoscopic: n = 129, open: n = 152) who underwent curative resection for middle and lower rectal cancer from 2003 to 2008 participated in the study. The same surgical team performed all operations. The mean follow up time of all patients was 74.3 months.

Results

No statistical difference in local recurrence rate (7.8% vs. 7.2%; log-rank = 0.024; P = 0.876) and distant recurrence rate (20.9% vs.16.4%; log-rank = 0.699; P = 0.403) between laparoscopic and open groups were observed within 5 years. The 5-year overall survival rates of the laparoscopic and open groups were 72.9% and 75.7%, respectively; no significant statistical difference was observed between them (log-rank = 0.163; P = 0.686). The 5-year survival rates between groups were not different between stages: Stage I (92.6% vs. 86.7%; log-rank = 0.533; P = 0.465); stage II (75.8% vs. 80.5%; log-rank = 0.212; P = 0.645); and Stage III (63.8% vs. 69.1%, log-rank = 0272;P = 0.602). However, significant statistical difference amongst different stages were observed (log-rank = 1.802; P = 0.003).

Conclusion

Laparoscopic and open surgery for middle and lower rectal cancer offer equivalent long-term oncologic outcomes. Laparoscopic surgery is feasible in these patients.

Laparoscopic Versus Open Surgery for Mid-Low Rectal Cancer: a Systematic Review and Meta-Analysis on Short- and Long-Term Outcomes

BACKGROUND

The safety of laparoscopic surgery for mid-low rectal cancer treatment has remained controversial, especially regarding the long-term outcomes. The aim of this study was to demonstrate whether the laparoscopic technique is feasible.

METHODS

We searched all of studies that compared the short- or long-term outcomes regarding laparoscopic and open rectal cancer surgeries (the tumour distance from anal verge within 10 cm). The data sources included PubMed, EMBASE, OVID, Web of Science and the Cochrane Library databases. The combined outcome of the dichotomous variables was expressed as an estimation of the odds ratios and continuous variables were presented in the form of weighted mean differences with 95% credible intervals. Subgroup, publication bias and sensitivity analyses were performed.

RESULTS

Thirteen studies met the final inclusion criteria (total n = 3,678). The pooled analyses showed, despite longer operation times, that there were significantly less blood loss, fewer transfusions, shorter times to bowel function recovery, resumed diet and hospital durations, and lower overall complication and wound infection rates. The compared results of the lymph node harvest number, distal resection margin, circumferential resection margin involvement, local and distant recurrences, disease-free survival and overall survival were similar between both groups.

CONCLUSIONS

This study suggests that the safety and feasibility of laparoscopic surgery appear to be equivalent to open surgery for treatment of mid- low rectal cancer, with the more favourable short-term benefits, fewer complications, comparable pathological outcomes and long-term outcomes.

Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: long-term results

The long-term role of laparoscopy in the treatment of rectal cancer is still controversial. The aim of the present study was to evaluate the safety, the feasibility, the perioperative outcome, and the long-term results of laparoscopic total mesorectal excision (TME) for extraperitoneal rectal cancer considering a single center series.

METHODS

Data about 186 unselected consecutive patients that underwent laparoscopic TME for middle and low rectal cancer between January 2001 and December 2011 were prospectively recorded and were included in the present study.

RESULTS

Distribution of TNM stage was 5 % T1, 37 % T2, 52.5 % T3, and 6 % T4. Fifty-one percent of patients have lymph node metastases. The average duration of surgery was 234 min. Fourteen patients required conversion (7.5 %). A complete microscopic excision was achieved in 169 patients (91 %). The mean hospital stay was 9 days. The overall postoperative morbidity rate was 24 %. Surgical-related complications were reported in 19 %. Overall mortality was 0.5 %. Sex, tumor level, and the presence of a stoma were the only statistically significant independent risk factors for anastomotic leakage. Median follow-up was 71 months. The 5-year overall survival rate was 77 %, with 89 % for stage 1, 81 % for stage 2, 43 % for stage 3, and 10 % for stage 4. The 5-year disease-free survival rate was 66 %. The 10-year survival rate was 54 %. Nine patients (4.8 %) experienced a pelvic recurrence. Late metastases developed in 31 patients (17.2 %).

CONCLUSIONS

The study confirms the oncological safety of laparoscopic TME in a long follow-up period.

Have early postoperative complications from laparoscopic rectal cancer surgery improved over the past 20 years?

AIM

Laparoscopic rectal cancer surgery has been increasingly used since 1991 following the publication of the first case series. Since then, several studies have confirmed that laparoscopic surgery for rectal cancer is challenging with associated morbidity and mortality. The aim of this study was to determine if the rates of early postoperative complications in laparoscopic rectal cancer surgery have improved over the past 20 years.

METHOD

A literature search of the EMBASE and MEDLINE databases between August 1991 and August 2011 was conducted using the keywords laparoscopy, rectal cancer and postoperative complications. Data were analysed using linear regression ANOVA performed in GNUMERICS software.

RESULTS

Ninety-seven studies were included for analysis. Over the last 20 years there has been no significant change in the rate of any early postoperative complications (anastomotic leak, conversion, sexual, urinary or faecal dysfunction, wound infection, overall morbidity or mortality). However, in the last 3 years, the rate of positive resection margins has decreased significantly (P = 0.01).

CONCLUSION

There was no evidence of a statistically significant change in early postoperative complications until 3 years ago. This may reflect the inherent morbidity associated with rectal surgery regardless of the approach used, the limitations of the current laparoscopic instrumentation or the relatively long learning curve. With increasing experience, a repeat analysis in the near future following the publication of ongoing randomized clinical trials might show improved outcomes.

Laparoscopy-assisted posterior low anterior resection of rectal cancer

Background

Laparoscopy-assisted low anterior resection (LAR) of colorectal cancer, using a posterior surgical approach, is a difficult and controversial procedure to perform. We report successful operations on 13 patients with clear surgical margins and no serious complications.

Methods

Thirteen patients [10 males and three females, age range: 48 to 69 years (median: 61 years)] with low adenocarcinoma confirmed by preoperative colonoscopic biopsy (four stage T1; nine stage T2) were resected. The distance from inferior edge of tumor to dentate line was 2 ~ 5 cm (average: 3.4 cm). Intraperitoneal laparoscopy was performed to isolate rectosigmoid and mesocolon moving toward distal end of the tumor. Perineal operation was performed in the prone clasp-knife position.

Results

The circumferential resection margin (CRM) was negative in all cases. No serious postoperative complications occurred. There were four cases of perineal wound infection, two cases with superficial perineal wound dehiscence, and two cases with persistent postoperative sacral pain. All 13 patients passed the Wexner continence test and had satisfactory anal function during a mean 18-month postoperative follow-up period.

Conclusion

Laparoscopic posterior LAR of colorectal cancer is a safe and reliable treatment for patients with low colorectal cancer, increasing the chance of anal functional recovery.

Trial registration

Chinese Clinical Trial Register ChiCTR-ONC-14005145. Registered 19 August 2014.

Seniors have a better learning curve for laparoscopic colorectal cancer resection

PURPOSE

This study was designed to evaluate the outcomes of laparoscopic colorectal resection in a period of learning curve completed by surgeons with different experience and aptitudes with a view to making clear whether seniors had a better learning curve compared with juniors.

METHODS

From May 2010 to August 2012, the first twenty patients underwent laparoscopic colorectal resection completed by each surgeon were selected for analysis retrospectively. A total of 240 patients treated by 5 seniors and 7 juniors were divided into the senior group (n=100) and the junior group (n=140). The short-term outcomes of laparoscopic surgery of the two groups were compared.

RESULTS

The mean numbers of lymph nodes harvested were 21.2 ± 11.0 in the senior group and 17.3 ± 11.5 in the junior group (p=0.010); The mean operative times were 187.9 ± 60.0 min as compared to 231.3 ± 55.7 min (p=0.006), and blood loss values were 177.0 ± 100.7 ml and 234.0 ± 185 ml, respectively (p=0.001); Conversion rate in the senior group was obviously lower than in the junior group (10.0% vs 20.7%, p=0.027) and the mean time to passing of first flatus were 3.3 ± 0.9 and 3.8 ± 0.9 days (p=0.001). For low rectal cancer, the sphincter preserving rates were 68.7% and 35.3% (p=0.027).

CONCLUSIONS

Seniors could perform laparoscopic colorectal resection with relatively better oncological outcomes and quicker recovery, and seniors could master the laparoscopic skill more easily and quickly. Seniors had a better learning curve for laparoscopic colorectal cancer resection compared to juniors.

Short-term outcomes of laparoscopically assisted surgery for rectal cancer following neoadjuvant chemoradiotherapy: a single-center experience

OBJECTIVE

The efficacy of laparoscopic treatment of rectal cancer remains unclear, and little is known about its effect on sphincter preservation. We compared short-term outcomes of laparoscopically assisted and open surgeries following neoadjuvant chemoradiotherapy (CRT) for mid and low rectal cancer.

METHODS

This study enrolled 137 patients with mid-low rectal cancer who underwent curative resection, 51 by laparoscopically assisted (Lap group) and 86 by conventional open (Open group) surgeries, following neoadjuvant CRT from July 2007 to July 2012. The clinical and surgical findings of the two groups of patients were prospectively collected and analyzed.

RESULTS

Three patients (5.9%) in the Lap group were converted to an open procedure. The mean operating times were similar in both groups. The Lap group had a significantly higher rate of sphincter preservation (62.7% versus 41.9%, P = 0.018) and significantly lower mean blood loss than the Open group. Mean times to first flatus, start of a normal diet, and overall postoperative hospitalization were longer for open surgery. The complication rate (11.8% versus 31.4%, P = 0.009) was significantly lower in the Lap group. Mean distal resection margin, involvement of the circumferential resection margin (2.0% versus 3.5%, P = 1.000), and mean lymph nodes harvested (12 versus 11; P = 0.242) were equivalent in the two groups.

CONCLUSIONS

Laparoscopically assisted surgery following neoadjuvant CRT is safe for patients with rectal cancer and provides favorable short-term benefits but without compromising oncologic outcomes. This sphincter-preserving procedure may be a treatment of choice for patients with lower rectal cancer.

Surgical margins and short-term results of laparoscopic total mesorectal excision for low rectal cancer

It is suggested that laparoscopic total mesorectal excision of low-lying rectal cancer has advantages over an open procedure with less blood loss, reduced hospital stay, and a shorter disability period. Complete macroscopic surgical resection appears to be aided by improved pelvic view offered by laparoscopy.

Background and Objectives:

The confines of the narrow bony pelvis make laparoscopic surgery more challenging in the treatment of low rectal cancer. Macroscopic evaluation of the completeness of the mesorectum provides detailed information about the quality of surgery. This study was performed to observe the short-term outcomes and evaluate the macroscopic quality of specimens acquired from laparoscopic total mesorectal excision versus open total mesorectal excision in patients with low rectal cancer.

Methods:

A total of 177 patients with low rectal cancer underwent total mesorectal excision by either a laparoscopic (n = 87) or open (n = 90) approach. In all cases the surgical time, blood loss, intraoperative and postoperative complications, postoperative bowel opening, and hospital stay were assessed. Special attention was given to the macroscopic judgment concerning the cut edge of peritoneal reflection, Denonvilliers fascia, completeness of the mesorectum, and bowel wall below the mesorectum.

Results:

The surgical time was 160 ± 40 minutes in the laparoscopic group. It was not significantly different from that in the open group (P = .782). The operative blood loss was 28 ± 5 mL in the group undergoing laparoscopic surgery and 80 ± 20 mL in the group undergoing open surgery (P < .01). Intraoperative injuries to the pelvic autonomic nervous system were recorded in 4 cases in the laparoscopic group compared with 12 cases in the open group (P < .05). The incidences of chest infection and anastomotic leakage were similar between the 2 approaches. The postoperative bowel opening time was 2.1 ± 1.5 days in the laparoscopic group and 3.5 ± 1.6 days in the open group (P < .01), whereas the hospital stay was 5.2 ± 1.8 days and 7.0 ± 2.1 days, respectively (P < .01). Intact Denonvilliers fascia and complete total mesorectal excision were more likely to be achieved by the laparoscopic approach than the open approach (P < .01). Colorectal anastomoses were located significantly lower in the laparoscopic group than in the open group (P < .01).

Conclusion:

Laparoscopic total mesorectal excision has consistent advantages over open total mesorectal excision, including similar surgical time, less blood loss, reduced hospital stay, and shorter disability period. A complete macroscopic specimen is more likely to be acquired by laparoscopy because of the better pelvic view offered by the approach.

Laparoscopic surgery for rectal cancer: outcomes in 513 patients

BACKGROUND

Few reports have demonstrated the feasibility and efficacy of laparoscopic resection in patients with rectal cancer (RC). The objective of the present study was to assess the effectiveness of laparoscopic resection for RC, with an emphasis on perioperative variables and long-term oncological outcomes.

METHODS

This prospective study was carried out between January 2005 and September 2010 and included 513 patients diagnosed with RC who underwent laparoscopic surgery. Patients with locally advanced RC (cT3/cT4 or N+) received neoadjuvant treatment. Adjuvant treatment was applied to patients with stage II/III disease or according to the neoadjuvant protocol. All patients were followed-up prospectively for the evaluation of complications and oncological outcome. Survival rate analysis was performed using the Kaplan-Meier method.

RESULTS

Sphincter-preserving surgery was performed on 389 patients, and the remaining 124 patients underwent abdominoperineal resection. Perioperative mortality occurred in only one patient (0.2 %), and 27 (5.3 %) intraoperative complications were recorded. The most common postoperative complication was anastomotic leakage (5.5 %). The conversion rate was 6.4 %. The mean number of harvested lymph nodes was 23.6 ± 13. The mean distance to the distal margin was 2.6 ± 1.9 (0-7) cm. Distal margin positivity was detected in 9 (1.7 %) patients. The circumferential margin was positive in 39 (7.6 %) cases. After a median follow-up period of 30 (1-78) months, recurrence occurred in a total of 59 patients (11.5 %). Local recurrence was detected in 16 patients (3.1 %), and both local and distant recurrence was found in 7 patients (1.4 %). Distant recurrence only was detected in 43 patients (8.4 %). The overall 5-year survival rate was 84 %, and the 5-year disease-free survival rate was 77.4 %. The local recurrence-free survival rate was 98.4 % at 2 years, 95.7 % at 3 years, and 94.3 % at 5 years.

CONCLUSIONS

Our results, together with the review of the literature, clearly demonstrate that laparoscopic resection for RC is a feasible method at specialized high-volume centers. The long-term outcomes are at least as good as those from open surgery as long as the principles of oncologic surgery are respected and faithfully performed.

Short-term results of laparoscopic surgery after preoperative chemoradiation for clinically staged T3 and T4 rectal cancer

INTRODUCTION

The feasibility of laparoscopic surgery for clinically staged T3 and T4 rectal cancer has not been clearly defined specifically in cases following preoperative chemoradiation therapy (CRT). Our aim was to investigate the feasibility of laparoscopic surgery after preoperative CRT for clinically staged T3 and T4 rectal cancer.

METHODS

Between May 2003 and June 2009, 57 patients (T3: n = 50, T4: n = 7) who underwent preoperative CRT for rectal cancer were identified. Forty-three patients with laparoscopic surgery (Lap group) were compared with 14 patients who underwent open surgery (Open group). Perioperative data including postoperative morbidity were assessed between the two groups.

RESULTS

All patients underwent complete laparoscopic operations, and none was converted to laparotomy. Operating time was longer in the Open group (331 vs 375 min, P < 0.01). Blood loss was lower in the Lap group (160 vs 316 mL, P < 0.01). Lymph node harvest and morbidity rate were similar in both groups. The distal tumor margin was negative in all patients. No patients had perioperative mortality associated with surgery after CRT.

CONCLUSION

Laparoscopic surgery after preoperative CRT is a feasible and a safe option for T3 and T4 rectal cancer compared to conventional open surgery.

Midterm outcomes of laparoscopic surgery for rectal cancer

In this study, the authors examine midterm survival and recurrence after laparoscopic and open surgery for rectal cancer. This is a retrospective review of a prospective database for rectal cancer surgeries performed at the authors' institution, with follow-up data obtained through chart review. In all, 74 patients in this study had open surgery, and 93 had laparoscopic surgery. The 5-year overall survival was 73.6% ± 12.0% in the open group and 80.0% ± 12.8% in the laparoscopic group (P = .159). Disease-free survival at 5 years was better in the laparoscopic group (71.0% ± 13.4%) than in the open group (50.3% ± 12.7%), with a P value of .01. Laparoscopic surgery remained an independent predictor of disease-free survival in the multivariate analysis. Results of prospective randomized trials are awaited, and the authors expect that the laparoscopic approach will be shown to be a safe and effective option for the management of rectal cancer.

Meta-analysis of the risk for anastomotic leakage, the postoperative mortality caused by leakage in relation to the overall postoperative mortality

BACKGROUND

Availability of anastomotic leakage rates and mortality rates following anastomotic leakage is essential when informing patients with rectal cancer preoperatively. We performed a meta-analysis of studies describing anastomotic leakage and the subsequent postoperative mortality in relation to the overall postoperative mortality after low anterior resection for rectal cancer.

METHODS

A systematic search was performed of the published literature. Data on the definition and incidence rate of AL, postoperative mortality caused by AL, and overall postoperative mortality were extracted. Data were pooled and a meta-analysis was performed.

RESULTS

Twenty-two studies with 10,343 patients in total were analyzed. Meta-analysis of the data showed an average AL rate of 9%, postoperative mortality caused by leakage of 0.7% and overall postoperative mortality of 2%. The studies showed variation in incidence, definition and measurement of all outcomes.

CONCLUSION

We found a considerable overall AL rate and a large contribution of AL to the overall postoperative mortality. The variability of definitions and measurement of AL, postoperative mortality caused by leakage and overall postoperative mortality may hinder providing reliable risk information. Large-scale audit programs may provide accurate and valid risk information which can be used for preoperative decision making.

Three-port laparoscopy-assisted colectomy for colorectal cancer using external traction with suspension suture

BACKGROUND

Laparoscopy-assisted colectomy is accepted as a standard procedure for colorectal resection. There have been many attempts to minimize the invasiveness of the procedure by reducing the number of operating ports and changing the specimen retrieval windows. Indeed, the invasiveness of laparoscopy-assisted colectomy has been minimized with these attempts; however, the technical challenges have increased. The technical challenges are related to lack of retraction and triangulation, which is necessary to expose the appropriate surgical field for safe surgery. A new technique based on retraction and triangulation with suspension suture traction for laparoscopy-assisted colorectal surgery is presented.

METHODS

Between September and November 2009, 24 laparoscopy-assisted colorectal resections for adenocarcinoma were performed through 3 ports with external traction with suspension suture. The surgical technique is described herein, and the intraoperative and postoperative courses of the patients were assessed.

RESULT

There were no intraoperative complications, and no need to convert to open surgery. All the resection margins were clear and the mean distance of proximal and distal margins was 11.4 and 4.8 cm, respectively. The median number of lymph nodes examined was 20.7. There were 2 cases of postoperative bleeding, but no cases of leakage or strictures at the anastomosis site.

CONCLUSIONS

This new, simple technique is feasible and safe. External suspension suture traction can create an appropriate operative field, allowing balanced traction and countertraction and meeting the needs for oncologic surgery. In addition, this technique can be applied to other types of laparoscopic surgery and will contribute to reducing the number of ports.

Evaluation of diverting ileostomy in laparoscopic low anterior resection for rectal cancer

BACKGROUND

Diverting ileostomy is believed to mitigate the effects of anastomotic complications in low anterior resections (LAR) for rectal cancer. However, there are no data about the effects of diverting ileostomy on the outcomes of laparoscopic LAR METHODS: We retrospectively reviewed the medical records of 77 consecutive rectal cancer patients who had undergone laparoscopic LAR with (n = 23) or without (n = 54) diverting ileostomy. The patients' data were recorded and supplemented on short-term follow-up visits and included standard demographics, operative procedure, location of the cancer, and final pathologic diagnosis. We noted length of hospitalisation, complications, and time interval from ileostomy creation to closure. Morbidity and mortality were also included.

RESULTS

Surgical intervention requiring anastomotic leakage occurred in three patients who underwent laparoscopic LAR without diverting ileostomy. The anastomosis level of patients who underwent laparoscopic LAR with diverting ileostomy was significantly lower than that of patients who underwent laparoscopic LAR without diverting ileostomy (p < 0.05).

CONCLUSION

Anastomosis level and total mesorectal excision are the main factors for creation of diverting ileostomy in laparoscopic LAR Laparoscopic LAR without diverting ileostomy could be selectively performed. Our study provides a basis for further prospective randomised studies on the role of diverting ileostomy in LAR.

Laparoscopic surgery for rectal cancer: preoperative radiochemotherapy versus surgery alone

BACKGROUND

A few studies have suggested advantages of laparoscopic surgery for rectal cancer. However, the role of laparoscopy has not been clearly defined specifically in cases after neoadjuvant radiochemotherapy. This study aimed to assess the impact of preoperative radiotherapy on the feasibility of laparoscopic rectal excision with sphincter preservation for rectal cancer.

METHODS

From 1999 to 2010, the authors considered all patients treated by laparoscopic rectal excision with sphincter preservation for rectal cancer. Patients treated by long-course preoperative radiochemotherapy (45 Gy during 5 weeks) were compared with those treated by surgery alone. The end points of the study were mortality, conversion, and overall and surgical morbidity.

RESULTS

Among 422 patients treated by laparoscopic conservative rectal excision, 292 received preoperative radiotherapy, and 130 had surgery alone. The two groups were similar in sex, age, body mass index, and American Society of Anesthesiologists (ASA) score. The mortality rate was 0.3% in the radiotherapy group and 0.8% in the surgical group (P = 0.52). The two groups did not differ in terms of conversion (19 vs. 15%; P = 0.39), overall morbidity (37 vs. 29%; P = 0.14), surgical morbidity (20 vs. 18%; P = 0.60), or anastomotic leakage (13 vs. 11%; P = 0.54). Multivariate analysis showed male gender and synchronous metastasis as independent factors of surgical morbidity. The independent factors of conversion were male gender, obesity, tumor stage, and type of anastomosis. Preoperative radiotherapy influenced neither conversion nor surgical morbidity.

CONCLUSION

Long-course radiochemotherapy does not have an impact on the feasibility or short-term outcome of laparoscopic conservative rectal excision for rectal cancer.

Laparoscopic surgery for rectal cancer: review of published literature 2000-2009

We reviewed seven reports of laparoscopic low anterior resection (LAR) alone for rectal cancer and 18 reports of laparoscopic surgery, including LAR. We examined the length of surgery, blood loss during surgery, conversion rate to open surgery, incidence of anastomotic leakage, morbidity, mortality, and local recurrence, and the 5-year overall survival rates. The values were as follows (range): length of surgery, 107-540 min vs 23-780 min; blood loss, 0-600 ml vs 0-1800 ml; conversion to open surgery, 0%-14.0% vs 1.0%-21.9%; anastomotic leakage, 0%-23.0% vs 3.0%-17.0%; morbidity, 6.1%-38.6% vs 5.8%-40.0%; mortality, 0%-2.0% vs 05-5.8%; and local recurrence, 1.4%-6.8% vs 0.95%-20.8%, respectively, in the LAR alone vs laparoscopic surgery groups. The 5-year overall survival rates of patients with stage I, II, III, and IV disease were 92%-98%, 79%-81%, 67%-89%, and 0%-15%, respectively, in the LAR alone group versus 85.4%-100%, 61.7%-94.4%, 53.7%-78%, and 0%-44.6%, respectively, in the laparoscopic surgery group. Thus, we demonstrated the safety and efficacy of laparoscopic surgery for rectal cancer.

Laparoscopic surgery for rectal cancer: a single-centre experience of 120 cases

INTRODUCTION

For colorectal surgeons, laparoscopic rectal cancer surgery poses a new challenge. The defence of the questionable oncological safety tempered by the impracticality of the long learning curve is rapidly fading. As a unit specialising in minimally invasive surgery, we have routinely undertaken rectal cancer surgery laparoscopically since 2005.

METHODS

Patients undergoing surgery for rectal cancer between June 2005 and February 2010 were retrospectively reviewed from a prospectively maintained colorectal cancer database.

RESULTS

One hundred and thirty patients underwent surgery for rectal cancer during the study period. One hundred and twenty patients had a laparoscopic resection, six were converted to open (conversion rate 5%) and 10 had a planned primary open procedure. Fifty four were low rectal tumours and 76 were upper rectal tumours. One hundred and thirteen patients had an anterior resection (87%), 17 patients an abdomino-perineal resection (13%) and 62 of the 130 patients (47.6%) had neoadjuvant radiotherapy. The median lymph node retrieval rate was 12 (9-14), five patients (3.8%) had a positive circumferential margin and the clinical anastomotic leak rate was 3.8% (n = 5 patients). There was no significant difference in the stated parameters for neoadjuvant versus non-neoadjuvant patients and for upper versus lower rectal tumours. Ninety three percent of mesorectal excision specimens were complete on pathological assessment.

CONCLUSIONS

During the study period, 92% of rectal cancers underwent a laparoscopic resection with low rates of morbidity and acceptable short-term oncological outcomes. This data supports the view that laparoscopic surgery for rectal cancer can be safely delivered in mid-volume centres by surgeons who have completed the learning curve for laparoscopic colorectal surgery.

Clinical impact of lymph node status in rectal cancer

Lymph node status at the time of diagnosis remains one of the principal indicators of prognosis in patients with rectal cancer. Involvement of loco-regional lymph nodes is relevant to surgical and clinical oncologists and continues to impact significantly upon local and systemic management strategies, in both neo-adjuvant and adjuvant settings. In this review, the clinical impact of lymph node status in the surgical management of rectal cancer is considered, with particular reference to the significance of lymphadenectomy and the potential implications for rectal tumours amenable to trans-anal excision. Current standards of care are reviewed and the extent to which the determination of lymph node status influences oncological decisions regarding neo-adjuvant and adjuvant therapies are discussed with areas of controversy highlighted.

Laparoscopic surgery for rectal cancer

Laparoscopic surgery for rectal cancer is much more challenging than that for colon cancer because of the confined space within the pelvis. Further, because of the tumor's location in the pelvis, maintenance of resection margins is of greater concern. Nonrandomized studies by groups experienced in laparoscopic surgery have shown both that it produces short-term outcomes equivalent to those for open surgery and that it can be performed safely from an oncologic perspective. Nonsurgical complications appear to be fewer, but conversion to open surgery may become a real issue. This review summarizes these findings by addressing technical considerations, early outcomes, late outcomes, costs, and complications.

Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline.

METHODS

An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference.

RESULTS

Laparoscopic surgery for extraperitoneal (mid- and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery.

CONCLUSIONS

Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.

Long-term outcomes of laparoscopic surgery versus open resection for middle and lower rectal cancer: an NTCLES study

BACKGROUND

Prognoses for treatment of middle and lower rectal cancer remain unclear because anatomical and complex surgical procedures specifically influence long-term outcomes. This study analyzes the long-term outcomes of laparoscopic versus open resection for middle and lower rectal cancer.

METHODS

Patients (laparoscopic, n = 113; open, n = 123) who underwent curative resection for middle and lower rectal cancer from 2000 to 2005 participated in the study. All operations were performed by the same surgical team with extensive experience in laparoscopic and open procedures. The mean follow-up time of all patients was 74.8 months.

RESULTS

No statistical differences in local recurrence rate (9.1% vs. 6.4%; log-rank = 0.432; p = 0.511) and in distant recurrence rate (19.7% vs. 15.5%; log-rank = 0.505; p = 0.477) between laparoscopic and open groups were observed within 5 years. The 5-year overall survival rates of the laparoscopic and open groups were 77.9 and 78.9%, respectively; no significant statistical difference was observed between them (log-rank = 0.012; p = 0.913). The 5-year survival rates between groups were not different between stages: stage I (91.7% vs. 92.0%; p = 0.950), stage II (82.8% vs. 79.4%; p = 0.643), and stage III (66.7% vs. 70.3%; p = 0.850). However, significant statistical differences between different stages were observed (log-rank = 11.156; p = 0.004).

CONCLUSION

Laparoscopic and open surgery for middle and lower rectal cancer offer similar long-term outcomes. The continued use of laparoscopic surgery in these patients can be supported.

Total mesorectal excision for rectal cancer: the potential advantage of robotic assistance

PURPOSE

The purpose of this study was to analyze the safety, feasibility, and efficacy of the da Vinci S HD robotic system in mesorectal excision for rectal adenocarcinoma, with the aim to identify areas of potential advantage for the robot in this procedure.

METHODS

This study was conducted as a retrospective review of a prospectively maintained database of 44 consecutive cases of robot-assisted mesorectal excision for rectal adenocarcinoma performed between August 2005 and February 2010. Patient demographics, perioperative outcomes, and complications were evaluated and compared with similar published reports and relevant literature.

RESULTS

There were 28 (63.6%) men and 16 (36.4%) women, with a mean age of 63 years. The majority of patients were either overweight or obese and 88.7% of lesions were in the mid or low rectum. We performed 36 low anterior resections (6 intersphincteric) and 8 abdominoperineal resections with a median blood loss of 150 mL (range, 50-1000), a median operative time of 347 minutes (range, 155-510), and a median length of stay of 5 days (range, 3-36). The median lymph node yield was 14 (range, 5-45) and the circumferential resection margin was negative in all patients. We had 1 distal margin positivity (2.7%), 2 anastomotic leaks (5.6%), 1 death (2.7%), and 2 conversions (4.5%) to the open approach. No robot-associated morbidity occurred in this series.

CONCLUSIONS

This series compares favorably with similar published reports with regard to the safety and feasibility of robotic assistance in total mesorectal excision for rectal cancer. The lower conversion rates reported for robotic rectal resection compared with laparoscopy require validation in large randomized trials.

Effects of surgical laparoscopic experience on the short-term postoperative outcome of rectal cancer: results of a high volume single center institution

PURPOSE

The purpose of the study was to assess the effects of the surgeon's learning curve on the short-term outcome of laparoscopic resections performed for rectal cancer.

METHODS

A total of 284 patients who underwent laparoscopic resection for rectal cancer performed by 3 different surgical teams between 2005 and 2008 were included in the study. The operative experience was represented by the team's previous surgical case numbers (frequency). Four skill levels were categorized as follows: Level 1: the first 60 cases, Level 2: 61 to 120 cases, Level 3: 121 to 180 cases, and Level 4:>180 cases. Characteristics of the patients, perioperative variables, and the experience levels of the surgeons were analyzed and compared. To investigate the learning curve, we used the following parameters: duration of operative time, conversion rates, general complications, anastomotic leak rates, and oncologic parameters.

RESULTS

Operative time gradually decreased with increasing experience. The mean operative times for Level 1, Level 2, and Level 3 were 195.0+/-46.7, 181.7+/-34.2, and 172.3+/-33.0 minutes, respectively, whereas the mean operative time for Level 4 was 151.3+/-27.7 minutes (P<0.05). With increased experience, conversion rates, complication rates, anastomotic leak rates, and hospitalization durations decreased (P<0.05). The resected specimen length was found to be longer with increased surgical experience (P<0.05). There were no significant differences among the groups with regard to tumor size, T stage, harvested lymph node count, lateral margin involvement, and R0 resections.

CONCLUSIONS

The operative time is inversely proportional to the level of skill. Laparoscopic surgical procedures do not have any negative effects on short-term surgical outcome. With the strict application of surgical principles, the oncologic quality of the specimen is not influenced by the experience period. With increased experience, the surgeon feels more confident and performs more difficult and complex laparoscopic surgical interventions for rectal cancer.

Laparoscopic total mesorectal excision for rectal cancer: experience of a single center with a series of 174 patients

BACKGROUND

Laparoscopic total mesorectal excision for low rectal cancer is not considered a gold standard treatment due to the high conversion rate and the long operation time.

METHODS

A retrospective review examined a surgical series of 174 laparoscopic low rectal resections involving total mesorectal excision (1995-2006), with particular reference to technical points as well as surgical and oncologic outcomes. Miles operations and partial mesorectal excisions were excluded.

RESULTS

The cancer affected the low rectum in 110 cases and the medium rectum in 64 cases. A total of 68 patients were subjected to neoadjuvant radiochemotherapy. The anastomosis was mechanical for 83.3% of the cases and intersphinteric through the perineum for 16.6% of the cases. Protective ileostomy was performed in 112 cases. The conversion rate was 4.6%. The mesorectum remained intact in 91.6% of the cases and was partially interrupted in 15 of the cases. In no case was it totally discontinued. The postoperative morbidity rate was 16.7%, and the mortality rate was 0.57%. The incidence of anastomotic fistulas was 14.4%. The percentage was higher for males (18.6 vs 8.3%) and correlated with the low distance of the tumor from the anal verge (18.2 vs 7.8%) and the absence of a protection ileostomy (20.9 vs 10.7%). After an average follow-up period of 48.6 months (range, 24-149 months), six patients (3.44%) experienced a pelvic recurrence. The 5-year overall survival rate was 75.4%, and the disease-free survival rate was 61.9%.

CONCLUSION

Laparoscopic total mesorectal excision for low rectal cancer is safe and effective, allowing surgical and oncologic outcomes similar to those reported for open surgery.

Multicentric study on robotic tumor-specific mesorectal excision for the treatment of rectal cancer

BACKGROUND

Recently, traditional laparoscopic anterior resection has been used for rectal cancer, offering good functional results compared with open resection and resulting in better early postoperative outcomes. Few studies investigating the role of robot-assisted tumor-specific rectal surgery (RTSRS) have been carried out to show its feasibility. The aim of the study was to verify on a multicentric basis the perioperative and oncologic outcome of RTSRS.

METHODS

One hundred forty-three consecutive patients undergoing RTSR in three centers were reviewed. Pathologic data, and postoperative and oncologic outcome measures were prospectively collected and analyzed by an independent researcher.

RESULTS

A total of 112 restorative surgeries and 31 abdominoperineal resections were carried out. Conversion rate was 4.9%, mean blood loss was 283 ml, and mean operative time was 297 min. The number of harvested nodes (14.1 +/- 6.5) and margin status compared favorably with those of open series (mean distal margin 2.9 +/- 1.8 cm; negative radial margin in 142 cases). The 3-year overall survival rate was 97%, and no isolated local recurrences were found at mean follow-up of 17.4 months.

CONCLUSION

RTSRS is a safe and feasible procedure that may facilitate mesorectal excision. Randomized clinical trials and longer follow-up are needed to evaluate a possible influence of RTSRS on patient survival.

Short-term outcomes of laparoscopic total mesorectal excision following neoadjuvant chemoradiotherapy

OBJECTIVE

To investigate the feasibility of laparoscopic total mesorectal excision (TME) in mid and lower rectal cancers following neoadjuvant chemoradiation (nCRT).

BACKGROUND

The laparoscopic approach for colon cancer has been widely accepted. A few studies have shown that there are advantages of laparoscopic over open TME surgery for rectal cancer. However, the role of laparoscopy has not been clearly defined specifically in cases following nCRT.

METHODS

All patients with rectal cancer who underwent nCRT were identified; no operations for rectal carcinoma were performed laparoscopically between 1997 and 2005. The laparoscopic cases were matched to open cases based on gender, procedure, age, and body mass index (BMI). The medical records were reviewed and short-term outcome was compared between these two groups. Statistical analysis was performed using SPSS 15 software.

RESULTS

Between 2002 and 2008, 64 patients were identified, including 32 patients who underwent laparoscopic surgery and 32 who had a laparotomy. There was no difference between the two groups based on gender, procedure, age, BMI or American Society of Anesthesiologists (ASA) classification. The procedures performed within each group included 8 abdominoperineal resections and 24 anterior resections, which included 20 colonic J-pouch-anal anastomoses and 4 straight coloanal anastomoses. In the laparoscopic group, 12 patients underwent totally laparoscopic operations, 12 were either laparoscopic-assisted or hand-assisted procedures, and 8 were converted to laparotomy. The reasons for conversion included bleeding, splenic injury, and difficult anatomy. There were no differences in comorbidities, tumor location, tumor size, tumor stage or radiation dose between the two groups. Operative time was longer in the laparoscopic group (267 + or - 76 versus 205 + or - 49 min, p < 0.001). Operative blood loss, complication rate, and mortality rate were all similar between the two groups. However, the laparoscopic group benefited from shorter length of stay (6.1 + or - 2.4 versus 7.6 + or - 2.3 days, p = 0.012), earlier first bowel movement (1.9 + or - 1 versus 3.3 + or - 2.4 days, p = 0.006), and shorter time to regular diet (3.9 + or - 2.1 versus 5.8 + or - 2.5 days, p = 0.003). There was no difference in lymph node harvest (both positive node harvest and total lymph node harvest), distal margin or radial margin.

CONCLUSIONS

In our experience, laparoscopic TME for mid and lower rectal cancer is feasible and safe. Patients benefit from the short-term advantages of laparoscopy, including shorter length of hospital stay, time to tolerating a regular diet, and time to first bowel movement or stoma function. Although there were no short-term differences in oncologic parameters, the long-term oncologic outcome requires further investigation.

Randomized clinical trial comparing laparoscopic and open surgery in patients with rectal cancer

BACKGROUND

The laparoscopic treatment of rectal cancer is controversial. This study compared surgical outcomes after laparoscopic and open approaches for mid and low rectal cancers.

METHODS

Some 204 patients with mid and low rectal adenocarcinomas were allocated randomly to open (103) or laparoscopic (101) surgery. The surgical team was the same for both procedures. Most patients had stage II or III disease, and received neoadjuvant therapy with oral capecitabine and 50-54 Gy external beam radiotherapy.

RESULTS

Sphincter-preserving surgery was performed in 78.6 and 76.2 per cent of patients in the open and laparoscopic groups respectively. Blood loss was significantly greater for open surgery (P < 0.001) and operating time was significantly greater for laparoscopic surgery (P = 0.020), and return to diet and hospital stay were longer for open surgery. Complication rates, and involvement of circumferential and radial margins were similar for both procedures, but the number of isolated lymph nodes was greater in the laparoscopic group (mean 13.63 versus 11.57; P = 0.026). There were no differences in local recurrence, disease-free or overall survival.

CONCLUSION

Laparoscopic surgery for rectal cancer has a similar complication rate to open surgery, with less blood loss, rapid intestinal recovery, shorter hospital stay, and no compromise of oncological outcomes.

Laparoscopic resection for rectal cancer: a review

Despite increasing evidence on the success of laparoscopic resection in colorectal diseases, clinicians remain skeptical about the application of laparoscopic resection in rectal cancer, although it may benefit patients by resulting in early return of bowel function, reduced postoperative pain, and shorter hospital stay. Rectal cancer surgery has been regarded as a technically demanding procedure. Deviation from the oncologic principle of mesrectal dissection will lead to a higher local recurrence rate. Therefore, rectal cancer was not included in earlier studies on laparoscopic versus open resection for colorectal cancer. However, many colorectal surgeons who practice laparoscopic surgery soon appreciated that the improved optics of laparoscopy can provide a much better view of the pelvis, and the Heald principle of meticulous sharp dissection for total mesorectal excision could be performed without compromise. In recent years, there has been increasing number of reports on laparoscopic resection of rectal cancers. Apart from the issues on postoperative outcomes and long-term results, laparoscopic resection has generated interest in its impact on the preservation of sexual and bladder function. We summarize the current evidence on laparoscopic resection for rectal cancer.

Laparoscopic versus open surgery for rectal cancer: long-term oncologic results

OBJECTIVE

The goal was to assess long-term oncologic outcome after laparoscopic versus open surgery for rectal cancer and to evaluate the impact of conversion.

SUMMARY BACKGROUND DATA

Laparoscopic resection of rectal cancer is technically feasible, but there are no data to evaluate the long-term outcome between laparoscopic and open approach. Moreover, the long-term impact of conversion is not known.

METHODS

Between 1994 and 2006, patients treated by open (1994-1999) and laparoscopic (2000-2006) curative resection for rectal cancer were included in a retrospective comparative study. Patients with fixed tumors or metastatic disease were excluded. Those with T3-T4 or N+ disease received long course preoperative radiotherapy. Surgical technique and follow-up were standardized. Survival were analyzed by Kaplan Meier method and compared with the Log Rank test.

RESULTS

Some 471 patients had rectal excision for invasive rectal carcinoma: 238 were treated by laparoscopy and 233 by open procedure. Postoperative mortality (0.8% vs. 2.6%; P = 0.17), morbidity (22.7% vs. 20.2%; P = 0.51), and quality of surgery (92.0% vs. 94.8% R0 resection; P = 0.22) were similar in the 2 groups. At 5 years, there was no difference of local recurrence (3.9% vs. 5.5%; P = 0.371) and cancer-free survival (82% vs. 79%; P = 0.52) between laparoscopic and open surgery. Multivariate analysis confirmed that type of surgery did not influence cancer outcome. Conversion (36/238, 15%) had no negative impact on postoperative mortality, local recurrence, and survival.

CONCLUSIONS

The efficacy of laparoscopic surgery in a team specialized in rectal excision for cancer (open and laparoscopic surgery) is suggested with similar long-term local control and cancer-free survival than open surgery. Moreover, conversion had no negative impact on survival.

Laparoscopic or open surgery for the cancer of the middle and lower rectum short-term outcomes of a comparative non-randomised study

INTRODUCTION

The study compares the short-term results of the laparoscopic and open approach for the surgical treatment of rectal cancer. Consecutive cases with rectal cancer operated upon with laparoscopy from 2004 to 2007 were compared to open rectal cancer cases. Total mesorectal excision (TME) was attempted in all cases.

PATIENTS AND METHODS

Forty-two cases were included in the OPEN and 45 in the LAP group and were matched for age, gender, disease stage and operation type.

SURGICAL PROCEDURE

Duration of surgery was longer and blood transfusion requirements were less in the LAP group. Higher blood loss was observed in patients with neoadjuvant treatment in both groups. Patients with neoadjuvant treatment in the OPEN group had higher operation time, but that was not the case in the LAP group. There were three conversions (7%).

RESULTS

Overall morbidity was higher in the OPEN group. LAP group patients were found to recover faster. R0 resection was achieved in 88% in the OPEN and 94% in the LAP group.

DISCUSSION

Less morbidity and faster recovery is offered after laparoscopic TME. Quality of surgery assessed by histopathology is similar between the approaches. Neoadjuvant chemoradiation seems to have significant impact on blood loss but results in longer operation times of the OPEN group.

Multidimensional analysis of the learning curve for laparoscopic resection in rectal cancer

BACKGROUND

We attempted to assess the learning curve for laparoscopic resection for rectal cancer.

METHOD

We included 381 patients who underwent laparoscopic resection for rectal cancer between December 2002 and December 2007. The operative experience was divided into four periods according to numbers of operations and significant changes in main surgical results.

RESULTS

Operative time decreased significantly after 90 operations. The overall anastomotic leakage rate was 3.7%; 14.6% for the first 50 patients and 5.4% for the following 40 patients. The overall conversion rate was 2.9%, 4-6% during the first and second periods, but decreasing thereafter. The number of harvested lymph nodes and distal resection margin was within an acceptable range during the entire period. For the patients with stage I-III tumors, the local recurrence rate was 4.4% and the overall recurrence rate was 22.9%. The local recurrence rate was 8.9% initially and decreasing to 1.4% after the second period. The cumulative incidence of local recurrence decreased to less than 7% after 120 patients and to less than 5% after 180 cases.

CONCLUSION

The learning curve for laparoscopic surgery for rectal cancer changed over time. Moreover, the learning curve for oncological safety was longer than that for operative safety.

Laparoscopic-assisted anterior resection with double-stapling technique anastomosis: safe and feasible for lower rectal cancer?

BACKGROUND

Laparoscopic surgery for rectal cancer has been considered more demanding than laparoscopic colectomy due to its technical difficulties.

OBJECTIVE

The aim of this study was to show safety and feasibility of laparoscopic low anterior resection for lower rectal cancer reconstructed by double-stapling technique (DST).

METHODS

The present study reviewed 159 patients with rectal cancer undergoing laparoscopic anterior resection reconstructed by DST. They were subdivided into two groups: 98 patients with upper rectal cancer located between 75 and 150 mm from the anal verge (group A) and 61 with lower rectal cancer located within 75 mm from the anal verge (group B). Short-term results and pathological findings were compared between the two groups.

RESULTS

There was no conversion in both groups. Operating time and intraoperative blood loss were similar in the two groups. No mortality occurred in either group. Overall morbidity rate was 10.2% in group A and 11.5% in group B (p = 0.798). Anastomotic leak rate was similar in the two groups (2.0% in group A versus 3.3% in group B; p = 0.638). Pathological examination of resected specimen showed no involvement of distal resection margin or circumferential resection margin in both groups.

CONCLUSIONS

The present study shows that laparoscopic surgery is safe and feasible for lower rectal cancer in a very select group of patients.

Laparoscopic resection for rectal adenocarcinoma

AIMS

Laparoscopic surgery for rectal cancer is still under discussion, but there is evidence that minimal access surgery can be feasible and safe also in this field. The aim of this study was to confirm that laparoscopic resection for rectal cancer can afford good results in terms of recurrence rate and survival.

PATIENTS AND METHODS

Since June 1998 through December 2007 as many as 252 patients underwent laparoscopic resection for rectal cancer. Laparoscopic anterior resection (LAR) was performed in 209 and laparoscopic abdominoperineal resection (LAPR) in 43. Neoadjuvant radiochemotherapy (nCRT) was administered in 48 patients with mid-low rectal cancer stage II and III with evidence of nodal involvement in preoperative work up.

RESULTS

Patients who received nCRT showed a significant longer duration of surgery compared to patients who did not (p=0.004). Conversion to laparotomy was needed in 24 cases, (21 LAR and three LAPR) but no patient receiving nCRT needed conversion. Postoperative surgical complications occurred in 38 patients, 20 of which were represented by anastomotic leak after LAR. Six patients died postoperatively, in half the cases for surgery related causes. Downstaging after nCRT was seen in 40 patients, and complete histological response was observed in six cases. The mean number of lymph nodes harvested was 12, also in patients receiving nCRT. The mean follow-up was 48+/-33 months (range 0.1-120.4), and 10 patients experienced local recurrence. Cumulative 5 year survival was 73.7%.

CONCLUSION

Laparoscopic resection for rectal cancer is feasible and safe, with morbidity and long-term results quite acceptable also in patients receiving neoadjuvant treatment.