Trans-perineal minimally invasive approach during extralevator abdominoperineal excision for advanced low rectal cancer: A retrospective cohort study

Transperineal minimally invasive surgery during laparoscopic abdominoperineal resection for low rectal cancer could improve short-term outcomes: A single-institution retrospective cohort study

PURPOSE

Transperineal minimally invasive surgery (TpMIS) during laparoscopic abdominoperineal resection (APR) is an emerging approach that allows for the precise treatment of lower rectal cancer. However, evidence regarding the efficacy of TpMIS is insufficient. This study evaluated the efficacy of TpMIS during laparoscopic APR for patients with lower rectal cancer.

METHODS

Patients who underwent laparoscopic APR with TpMIS (TpMIS group; n = 12) and those who underwent conventional laparoscopic APR for low rectal cancer (conventional group; n = 13) were enrolled consecutively in this retrospective study. Standardized TpMIS was performed at our institution. Patient and tumor characteristics and intraoperative, postoperative, and pathological outcomes were compared between groups. The primary outcome was postoperative perineal wound infection.

RESULTS

No patients in the TpMIS group experienced postoperative perineal wound infection; however, five (38.5%) patients in the conventional group experienced postoperative perineal wound infection (significant difference; p = 0.016). The estimated blood loss (median, 81 mL vs. 463 mL) and incidence of postoperative urinary dysfunction (8.3% vs. 46.1%) were significantly lower in the TpMIS group than in the conventional group. The postoperative hospital stay (median, 13 vs. 20 days) of the TpMIS group was significantly shorter than that of the conventional group. Pathological outcomes did not differ between groups. The positive circumferential resection margin rates of the TpMIS and conventional groups were 8.3% and 15.4%, respectively.

CONCLUSION

TpMIS during laparoscopic APR was associated with significant improvements in the postoperative outcomes of patients with low rectal cancer.

The impact of short-course total neoadjuvant therapy, long-course chemoradiotherapy, and upfront surgery on the technical difficulty of total mesorectal excision: an observational study with an intraoperative perspective

PURPOSE

Total neoadjuvant therapy (TNT) is becoming the standard of care for locally advanced rectal cancer. However, surgery is deferred for months after completion, which may lead to fibrosis and increased surgical difficulty. The aim of this study was to assess whether TNT (TNT-RAPIDO) is associated with increased difficulty of total mesorectal excision (TME) compared with long-course chemoradiotherapy (LCRT) and upfront surgery.

METHODS

Twelve laparoscopic videos of low anterior resection with TME for rectal cancer were prospectively collected from January 2020 to October 2021, with 4 videos in each arm. Seven colorectal surgeons assessed the videos independently, graded the difficulty of TME using a visual analog scale and attempted to identify which category the videos belonged to.

RESULTS

The median age was 67 years, and 10 patients were male. The median interval to surgery from radiotherapy was 13 weeks in the LCRT group and 24 weeks in the TNT-RAPIDO group. There was no significant difference in the visual analog scale for difficulty in TME between the 3 groups (LCRT, 3.2; TNT-RAPIDO, 4.6; upfront, 4.1; P=0.12). A subgroup analysis showed similar difficulty between groups (LCRT 3.2 vs. TNT-RAPIDO 4.6, P=0.05; TNT-RAPIDO 4.6 vs. upfront 4.1, P=0.54). During video assessments, surgeons correctly identified the prior treatment modality in 42% of the cases. TNT-RAPIDO videos had the highest recognition rate (71%), significantly outperforming both LCRT (29%) and upfront surgery (25%, P=0.01).

CONCLUSION

TNT does not appear to increase the surgical difficulty of TME.

Transperineal minimally invasive abdominoperineal resection for low rectal cancer: standardized technique and clinical outcomes

BACKGROUND

Despite the increasing utilization of transanal total mesorectal excision as a promising approach for low rectal cancer, the feasibility and safety of transperineal minimally invasive abdominoperineal resection (tp-APR) remain unclear.

METHODS

In total, 25 patients who underwent tp-APR between April 2017 and May 2020 (tp-APR group) and 27 patients who underwent conventional laparoscopic APR between May 2009 and September 2016 (lap-APR group) for low rectal cancer were enrolled in this retrospective study. Clinical outcomes were compared between the groups before and after propensity score matching. The primary outcome was the incidence of the overall postoperative complications with Clavien-Dindo grade II or above. Standardized technique of tp-APR was also demonstrated.

RESULTS

On comparison, operative time, intraoperative blood loss, and overall postoperative complications with Clavien-Dindo grade II or above were significantly less in the tp-APR group both before and after propensity score matching. The rates of urinary disturbance and perineal wound infection were significantly less in the tp-APR group after matching. Further, postoperative hospital stay was significantly shorter in the tp-APR group both before and after matching. However, pathological outcomes did not differ between the groups before and after matching. There has been no local recurrence in the tp-APR group with a median follow-up period of 18 months.

CONCLUSION

Standardized tp-APR for low rectal cancer is feasible and seems superior to conventional laparoscopic APR in terms of short-term outcomes. Further larger-scale studies with a longer follow-up period are required to evaluate oncological outcomes.

Extralevator abdominoperineal excision for advanced low rectal cancer: Where to go

Since its introduction, extralevator abdominoperineal excision (ELAPE) in the prone position has gained significant attention and recognition as an important surgical procedure for the treatment of advanced low rectal cancer. Most studies suggest that because of adequate resection and precise anatomy, ELAPE could decrease the rate of positive circumferential resection margins, intraoperative perforation, and may further decrease local recurrence rate and improve survival. Some studies show that extensive resection of pelvic floor tissue may increase the incidence of wound complications and urogenital dysfunction. Laparoscopic/robotic ELAPE and trans-perineal minimally invasive approach allow patients to be operated in the lithotomy position, which has advantages of excellent operative view, precise dissection and reduced postoperative complications. Pelvic floor reconstruction with biological mesh could significantly reduce wound complications and the duration of hospitalization. The proposal of individualized ELAPE could further reduce the occurrence of postoperative urogenital dysfunction and chronic perianal pain. The ELAPE procedure emphasizes precise anatomy and conforms to the principle of radical resection of tumors, which is a milestone operation for the treatment of advanced low rectal cancer.