Laparoscopic Versus Open Resection for Colorectal Cancer: A Metaanalysis of Oncologic Outcomes

Colorectal resections for malignancy: A pilot study comparing conventional vs freehand robot-assisted laparoscopic colectomy

BACKGROUND

Laparoscopic colectomy is widely accepted as a safe operation for colorectal cancer, but we have experienced resistance to the introduction of the FreeHand® robotic camera holder to augment laparoscopic colorectal surgery.

AIM

To compare the initial results between conventional and FreeHand® robot-assisted laparoscopic colectomy in Trinidad and Tobago.

METHODS

This was a prospective study of outcomes from all laparoscopic colectomies performed for colorectal carcinoma from November 29, 2021 to May 30, 2022. The following data were recorded: Operating time, conversions, estimated blood loss, hospitalization, morbidity, surgical resection margins and number of nodes harvested. All data were entered into an excel database and the data were analyzed using SPSS ver 20.0.

RESULTS

There were 23 patients undergoing colectomies for malignant disease: 8 (35%) FreeHand®-assisted and 15 (65%) conventional laparoscopic colectomies. There were no conversions. Operating time was significantly lower in patients undergoing robot-assisted laparoscopic colectomy (95.13 ± 9.22 vs 105.67 ± 11.48 min; P = 0.045). Otherwise, there was no difference in estimated blood loss, nodal harvest, hospitalization, morbidity or mortality.

CONCLUSION

The FreeHand® robot for colectomies is safe, provides some advantages over conventional laparoscopy and does not compromise oncologic standards in the resource-poor Caribbean setting.

Clinicopathological Analysis of Complicated Colorectal Cancer: A Five-Year Retrospective Study from a Single Surgery Unit

Patients with primary colorectal cancer can present with obstructions, tumor bleeding, or perforations, which represent acute complications. This paper aimed to analyze and compare the clinical and pathological profiles of two patient groups: one with colorectal cancer and a related complication and another without any specific complication. We performed a five-year retrospective study on colorectal cancer patients admitted to a surgery unit and comparatively explored the main clinical and pathological features of the tumors belonging to the two groups. A total of 250 patients with colorectal cancer were included in the analysis. Of these, 117 (46.8%) had presented a type of complication. The comparative analysis that examined several clinical and pathological parameters showed a statistically significant difference for unfavorable prognosis factors in the group with complications. This was evident for features such as vascular and perineural invasion, lymph node involvement, pathological primary tumor stage, and TNM stage. Colorectal cancers with a related complication belonged to a group of tumors with a more aggressive histopathologic profile and more advanced stages. Furthermore, the comparable incidence of cases in the two groups of patients warrants further efforts to be made in terms of early detection and prognosis prediction of colorectal cancer.

Innovation in gastrointestinal surgery: the evolution of minimally invasive surgery-a narrative review

Background

Minimally invasive (MI) surgery has revolutionised surgery, becoming the standard of care in many countries around the globe. Observed benefits over traditional open surgery include reduced pain, shorter hospital stay, and decreased recovery time. Gastrointestinal surgery in particular was an early adaptor to both laparoscopic and robotic surgery. Within this review, we provide a comprehensive overview of the evolution of minimally invasive gastrointestinal surgery and a critical outlook on the evidence surrounding its effectiveness and safety.

Methods

A literature review was conducted to identify relevant articles for the topic of this review. The literature search was performed using Medical Subject Heading terms on PubMed. The methodology for evidence synthesis was in line with the four steps for narrative reviews outlined in current literature. The key words used were minimally invasive, robotic, laparoscopic colorectal, colon, rectal surgery.

Conclusion

The introduction of minimally surgery has revolutionised patient care. Despite the evidence supporting this technique in gastrointestinal surgery, several controversies remain. Here we discuss some of them; the lack of high level evidence regarding the oncological outcomes of TaTME and lack of supporting evidence for robotic colorectalrectal surgery and upper GI surgery. These controversies open pathways for future research opportunities with RCTs focusing on comparing robotic to laparoscopic with different primary outcomes including ergonomics and surgeon comfort.

Tumor extent impacts survival benefit in minimally invasive colectomy for T4 colon cancer: A propensity matched national cohort analysis

BACKGROUND

T4 colon cancers have been underrepresented in randomized trials comparing minimally invasive colectomy (MC) versus open colectomy (OC). Retrospective studies suggest improved survival with MC versus OC, but have not addressed the impact of tumor extent.

METHODS

Using the National Cancer Database (NCDB), we analyzed patients undergoing colectomy for T4 colon adenocarcinoma from 2010 to 2014. Propensity score matching was performed between MC and OC patients. Tumor extent was defined by zones based on adjacent organ involvement.

RESULTS

Of the 19 178 eligible patients, 6564 (34%) underwent MC. After matching, MC was associated with improved overall survival (hazard ratios: 0.71, 95% confidence interval: 0.67-0.76; median OS 59 vs. 42 months, p < 0.001). Compared to MC patients, those undergoing OC had: a higher margin positive rate (p = 0.009); lower median nodes examined (p < 0.001); a lower rate of adjuvant chemotherapy (p < 0.001); and a longer median time to chemotherapy (p < 0.001). Stratified survival analyses demonstrated that MC was associated with improved overall survival compared to OC in all zones except zone 3 and 4.

CONCLUSIONS

Compared to OC, MC for T4 colon cancer is associated with improved oncologic outcomes when performed for zone 0-2 tumors. For, zone 3 and 4 tumors MC and OC have similar oncologic outcomes and patients should be cautiously selected.

Laparoscopic vs. open colectomy for T4 colon cancer: A meta-analysis and trial sequential analysis of prospective observational studies

Background

To evaluate short- and long-term outcomes of laparoscopic colectomy (LC) vs. open colectomy (OC) in patients with T4 colon cancer.

Methods

Three authors independently searched PubMed, Web of Science, Embase, Cochrane Library, and Clinicaltrials.gov for articles before June 3, 2022 to compare the clinical outcomes of T4 colon cancer patients undergoing LC or OC.

Results

This meta-analysis included 7 articles with 1,635 cases. Compared with OC, LC had lesser blood loss, lesser perioperative transfusion, lesser complications, lesser wound infection, and shorter length of hospital stay. Moreover, there was no significant difference between the two groups in terms of 5-year overall survival (5y OS), and 5-year disease-free survival (5y DFS), R0 resection rate, positive resection margin, lymph nodes harvested ≥12, and recurrence. Trial Sequential Analysis (TSA) results suggested that the potential advantages of LC on perioperative transfusion and the comparable oncological outcomes in terms of 5y OS, 5y DFS, lymph nodes harvested ≥12, and R0 resection rate was reliable and no need of further study.

Conclusions

Laparoscopic surgery is safe and feasible in T4 colon cancer in terms of short- and long-term outcomes. TSA results suggested that future studies were not required to evaluate the 5y OS, 5y DFS, R0 resection rate, positive resection margin status, lymph nodes harvested ≥12 and perioperative transfusion differences between LC and OC.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022297792.

Laparoscopic natural orifice specimen extraction, a minimally invasive surgical technique for mid-rectal cancers: Retrospective single-center analysis and single-surgeon experience of selected patients

OBJECTIVE

To evaluate the feasibility, safety, and short-term outcomes of middle rectal resection followed by transanal specimen extraction.

METHODS

Forty-four patients with small mid-rectal tumors underwent laparoscopic rectal resection followed by transanal specimen extraction.

RESULTS

The procedure was successful in all patients without intraoperative conversion or additional access. The mean operation time was 182.7 minutes (range, 130-255 minutes), the mean blood loss was 26.5 mL (range, 5-120 mL), the mean postoperative exhaust time was 31.3 hours (range, 16-60 hours), and the mean length of hospital stay was 9.5 days (range, 8-19 days). One patient developed anastomotic leakage, which was treated by intravenous antibiotics and daily pelvic cavity flushes through the abdominal drainage tube. No infection-related complications or anal incontinence were observed. The mean tumor size was 2.1 cm (range, 1.6-3.2 cm), the mean number of harvested lymph nodes was 16.5 (range, 6-31), and the mean follow-up time was 8.5 months (range, 2-16 months). By the last follow-up, no signs of recurrence had been found in any patient.

CONCLUSION

The combination of standard laparoscopic proctectomy and transanal specimen extraction could become a well-established strategy for selected patients.

Freehand-robot-assisted laparoscopic colorectal surgery: Initial experience in the Trinidad and Tobago

BACKGROUND

Laparoscopic colorectal surgery is still developing in the Anglophone Caribbean, having been first performed in the region in the year 2011. We report the initial outcomes using a robot camera holder to assist in laparoscopic colorectal operations.

AIM

To report our initial experience using the FreeHand^® robotic camera holder (Freehand 2010 Ltd., Guildford, Surrey, United Kingdom) for laparoscopic colorectal surgery in Trinidad & Tobago.

METHODS

We retrospectively collected data from all patients who underwent laparoscopic colorectal resections using the Freehand^® (Freehand 2010 Ltd., Guildford, Surrey, United Kingdom) robotic camera holder between September 30, 2021 and April 30, 2022. The following data were recorded: patient demographics, robotic arm setup time, operating time, conversions to open surgery, conversions to a human camera operator, number and duration of intra-operative lens cleaning. At the termination of the operation, before operating notes were completed, the surgeons were administered a questionnaire recording information on ergonomics, user-difficulty, requirement to convert to a human camera operator and their ability to carry out effective movements to control the robot while operating.

RESULTS

Nine patients at a mean age of 58.9 ± 7.1 years underwent colorectal operations using the FreeHand robot: Right hemicolectomies (5), left hemicolectomy (1), sigmoid colectomies (2) and anterior resection (1). The mean robot docking time was 6.33 minutes (Median 6; Range 4-10; SD ± 1.8). The mean duration of operation was 122.33 ± 78.5 min and estimated blood loss was 113.33 ± 151.08 mL. There were no conversions to a human camera holder. The laparoscope was detached from the robot for lens cleaning/defogging an average of 2.6 ± 0.88 times per case, with cumulative mean interruption time of 4.2 ± 2.15 minutes per case. The mean duration of hospitalization was 3.2 ± 1.30 days and there were no complications recorded. When the surgeons were interviewed after operation, the surgeons reported that there were good ergonomics (100%), with no limitation on instrument movement (100%), stable image (100%) and better control of surgical field (100%).

CONCLUSION

Robot-assisted laparoscopic colorectal surgery is feasible and safe in the resource-poor Caribbean setting, once there is appropriate training.

Real-time vascular anatomical image navigation for laparoscopic surgery: experimental study

BACKGROUND

Recognition of the inferior mesenteric artery (IMA) during colorectal cancer surgery is crucial to avoid intraoperative hemorrhage and define the appropriate lymph node dissection line. This retrospective feasibility study aimed to develop an IMA anatomical recognition model for laparoscopic colorectal resection using deep learning, and to evaluate its recognition accuracy and real-time performance.

METHODS

A complete multi-institutional surgical video database, LapSig300 was used for this study. Intraoperative videos of 60 patients who underwent laparoscopic sigmoid colon resection or high anterior resection were randomly extracted from the database and included. Deep learning-based semantic segmentation accuracy and real-time performance of the developed IMA recognition model were evaluated using Dice similarity coefficient (DSC) and frames per second (FPS), respectively.

RESULTS

In a fivefold cross-validation conducted using 1200 annotated images for the IMA semantic segmentation task, the mean DSC value was 0.798 (± 0.0161 SD) and the maximum DSC was 0.816. The proposed deep learning model operated at a speed of over 12 FPS.

CONCLUSION

To the best of our knowledge, this is the first study to evaluate the feasibility of real-time vascular anatomical navigation during laparoscopic colorectal surgery using a deep learning-based semantic segmentation approach. This experimental study was conducted to confirm the feasibility of our model; therefore, its safety and usefulness were not verified in clinical practice. However, the proposed deep learning model demonstrated a relatively high accuracy in recognizing IMA in intraoperative images. The proposed approach has potential application in image navigation systems for unfixed soft tissues and organs during various laparoscopic surgeries.

Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach

A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.

Is newer always better?: comparing cost and short-term outcomes between laparoscopic and robotic right hemicolectomy

BACKGROUND

Enthusiasm is high for expansion of robotic assisted surgery into right hemicolectomy. But data on outcomes and cost is lacking. Our objective was to determine the association between surgical approach and cost for minimally invasive right hemicolectomy. We hypothesized that a robot approach would have increased costs (both economic and opportunity) while achieving similar short-term outcomes.

METHODS

We performed a retrospective cohort analysis with a simulation of operating room utilization at a quaternary care, academic institution. We enrolled patients undergoing minimally invasive right hemicolectomy from November 2017 to August 2019. Patients were categorized by the intended approach- laparoscopic or robotic. The primary outcome was the technical variable direct cost. Secondary outcomes included total cost, supply cost, operating room utilization, operative time, conversion, length of stay and 30-day post-operative outcomes.

RESULTS

79 patients were included in the study. A robotic approach was used in 22% of the cohort. The groups differed significantly only in etiology of surgery. Robotic surgery was associated with a 1.5 times increase in the technical variable direct cost (p < 0.001), increased supply cost (2.6 times; p < 0.001) and increased total cost (1.3 times; p < 0.001). Significant differences were observed in median room time (Robotic: 285 min vs. Laparoscopic: 170 min; p < 0.001) and procedure time (Robotic: 203 min vs. Laparoscopic: 118 min; p < 0.001). There were no differences observed in post-operative outcomes including length of stay or readmission. In a simulation of OR utilization, 45 laparoscopic right hemicolectomies could be performed in an OR in a month compared to 31 robotic cases.

CONCLUSIONS

Robotic right hemicolectomy was associated with increased costs with no improvement in post-operative outcomes. In a simulation of operating room efficiency, a robotic approach was associated with 14 fewer cases per month. Practitioners and administrators should be aware of the increased cost of a robotic approach.

Laparoscopic vs open surgery for colorectal cancer patients with high American Society of Anesthesiologists classes

INTRODUCTION

Laparoscopic surgery has become popular for colorectal cancer treatment in recent years. However, its success rate even among high-risk patients remains debatable. The present study aims to compare the short- and long-term outcomes between laparoscopic and open surgeries in the American Society of Anesthesiologists (ASA) classes 3 and 4 patients with colorectal cancer.

METHODS

This was a single-center, retrospective, cohort study performed at a university hospital, with 78 patients suffering from colorectal cancer who underwent surgery in ASA classes 3 and 4 as respondents. Patient and tumor characteristics, operative outcomes, and prognoses were factors compared between the open and laparoscopic groups.

RESULTS

Compared with the open group, laparoscopic group had longer operation time (median 287.5 vs 204.5 minutes, P = .001), less operative blood loss (median 40 vs 240 mL, P = .020), and fewer postoperative complications (24% vs 55%, P = .011). In addition, operative approach (open vs laparoscopic) served as an independent factor for the occurrence of postoperative complications [HR = 3.963 (1.344-12.269), P = .013]. In terms of overall survival and recurrence-free survival (P = .171 and .087, respectively), no significant difference was found between the two groups.

CONCLUSION

Laparoscopic surgery is thus associated with more favorable short-time outcomes and could be adopted as treatment even for colorectal cancer ASA class 3 and 4 patients.

The Comparison of Laparoscopic Colorectal Resection with Natural Orifice Specimen Extraction versus Mini-Laparotomy Specimen Extraction for Colorectal Tumours: A Systematic Review and Meta-Analysis of Short-Term Outcomes

Aim

The aims of this study were to compare the short-term outcomes of natural orifice specimen extraction surgery (NOSES) and conventional laparoscopic surgery (CLAPS) for colorectal tumours and to evaluate the safety and feasibility of NOSES in colorectal resection.

Methods

A literature review was performed on the PubMed, Cochrane Library, and Embase databases up to March 2019. Papers conforming to the inclusion criteria were used for further analysis. The short-term outcomes included intraoperative outcomes and postoperative recovery results. The weighted mean difference (WMD) was calculated for continuous outcomes and odds ratio (OR) for dichotomous results. Study quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS) or the 6-item Jadad scale.

Results

Eight studies comprising 686 patients met the inclusion criteria. Compared with CLAPS, NOSES had more advantages in terms of postoperative complications, postoperative pain, recovery of gastrointestinal function, duration of hospital stay, and cosmetic results. The lymph nodes harvested and intraoperative blood loss in NOSES were comparable with CLAPS; however, a prolonged operative time was observed in NOSES.

Conclusions

NOSES was shown to be a safe and viable alternative to CLAPS in colorectal oncology in terms of short-term results. Further long-term and randomized trials are required.

Premetastatic niches, exosomes and circulating tumor cells: Early mechanisms of tumor dissemination and the relation to surgery

The physiological stress response to surgery promotes wound healing and functional recovery and includes the activation of neural, inflammatory and proangiogenic signaling pathways. Paradoxically, the same pathways also promote metastatic spread and growth of residual cancer. Human and animal studies show that cancer surgery can increase survival, migration and proliferation of residual tumor cells. To secure the survival and growth of disseminated tumor cells, the formation of premetastatic niches in target organs involves a complex interplay between microenvironment, immune system, circulating tumor cells, as well as chemical mediators and exosomes secreted by the primary tumor. This review describes the current understanding of the early mechanisms of dissemination, as well as how surgery may facilitate disease progression.

Essential advances in surgical and adjuvant therapies for colorectal cancer 2018-2019

Surgical resection and adjuvant chemotherapy are the only treatment modalities for localized colorectal cancer that can obtain a "cure." The goal in surgically treating primary colorectal cancer is complete tumor removal along with dissection of systematic D3 lymph nodes. Adjuvant treatment controls recurrence and improves the prognosis of patients after they undergo R0 resection. Various clinical studies have promoted the gradual spread and clinical use of new surgical approaches such as laparoscopic surgery, robotic surgery, and transanal total mesorectal excision (TaTME). Additionally, the significance of adjuvant chemotherapy has been established and it is now recommended in the JSCCR (the Japanese Society for Cancer of the Colon and Rectum) guideline as a standard treatment. Herein, we review and summarize current surgical treatment and adjuvant chemotherapy for localized colorectal cancer and discuss recent advances in personalized medicine related to adjuvant chemotherapy.

Comparison of pressure- and volume-controlled ventilation during laparoscopic colectomy in patients with colorectal cancer

This study investigated the differences in airway mechanics and postoperative respiratory complications using two mechanical ventilation modalities and the relationship between biomarkers and postoperative respiratory complications in patients with colorectal cancer who underwent laparoscopic colectomy. Forty-six patients with colorectal cancer scheduled for laparoscopic colectomy were randomly allocated to receive mechanical ventilation using either volume-controlled ventilation (VCV) (n = 23) or pressure-controlled ventilation (PCV) (n = 23). Respiratory parameters were measured and plasma sRAGE and S100A12 were collected 20 minutes after the induction of anesthesia in the supine position without pneumoperitoneum (T1), 40 minutes after 30° Trendelenburg position with pneumoperitoneum (T2), at skin closure in the supine position (T3), and 24 hours after the operation (T4). The peak airway pressure (Ppeak) at T2 was lower in the PCV group than in the VCV group. The plateau airway pressures (Pplat) at T2 and T3 were higher in the VCV group than in the PCV group. Plasma levels of sRAGE at T2 and T3 were 1.6- and 1.4-fold higher in the VCV group than in the PCV group, while plasma S100A12 levels were 2.6- and 2.2-fold higher in the VCV group than in the PCV group, respectively. There were significant correlations between Ppeak and sRAGE, and between Ppeak and S100A12. There were also correlations between Pplat and sRAGE, and between Pplat and S100A12. sRAGE and S100A12 levels at T2 and T3 showed high sensitivity and specificity for postoperative respiratory complications. Postoperative respiratory complications were 3-fold higher in the VCV group than in the PCV group. In conclusion, during laparoscopic colectomy in patients with colorectal cancer, the peak airway pressure, the incidence of postoperative respiratory complications, and plasma sRAGE and S100A12 levels were lower in the PCV group than in the VCV group. Intra- and postoperative plasma sRAGE and S100A12 were useful for predicting the development of postoperative respiratory complications.

Developing Laparoscopic Surgery on the Caribbean Island of St. Lucia: A Model for Public-Private Partnership

The first recorded laparoscopic operation in the Caribbean was a cholecystectomy performed in 1991. After a temporary peak in basic laparoscopic operations in subsequent years, the initial interest waned. While laparoscopic surgery was being popularized in the developed world, there was a stagnation in the Caribbean. There were many reasons for this stagnation, including a lack of surgical expertise, the negative attitudes of health-care workers, active opposition from surgical leaders, and equipment deficiencies, all exacerbated by the global financial recession in the early twenty-first century. A similar situation existed on the Caribbean island of St. Lucia, where laparoscopic surgery remained relatively dormant. After a strong desire by community surgeons to incorporate advanced laparoscopy into surgical practice, surgical leaders in St. Lucia engineered a public-private partnership to achieve this. This review article evaluates the available data, documents the obstacles encountered, and explains the mechanisms to overcome these obstacles to incorporate advanced laparoscopy in St. Lucia. This information is important because it can serve as a template for other developing Caribbean countries.

Short-Term Outcomes of Three-Port Laparoscopic Right Hemicolectomy Versus Five-Port Laparoscopic Right Hemicolectomy: With a Propensity Score Matching Analysis

Purpose: The aim of this study is to compare the short-term and pathological outcomes of TPLRC (Three-port laparoscopic right hemicolectomy) and FPLRC (Five-port laparoscopic right hemicolectomy), using propensity score matching analysis. Methods: One hundred and sixty-eight patients who accepted laparoscopic right hemicolectomy with either three ports or five ports from January 2013 to October 2017 were non-randomly selected and analyzed retrospectively. Propensity score matching model was used to eliminate the patients' selection bias between two groups. Results: A total of 168 patients were involved. After propensity score matching, 39 for each group were compared. The number of harvested lymph nodes was significantly larger in the TPLRC group than in the FPLRC group (18.36 ± 8.58 vs. 14.90 ± 6.63, p = 0.048). A lower mean operative time was observed in the TPLRC group (136.24 ± 26.78 vs. 168.64 ± 43.68 min, p < 0.001). A less blood loss in the TPLRC group (62.44 ± 55.17, 135.54 ± 139.11 ml, p = 0.003). No significant differences in the other short-term outcomes between the two groups. Conclusions: TPLRC is a safe and feasible surgical procedure with similar results of FPLRC in short-term clinical outcomes. TPLRC has the advantages of shorter operative time, less blood loss and larger number of harvested lymph nodes. A randomized prospective clinical trial of long-term outcomes of TPLRC is required to further prove the present results.

Novelties in treatment of locally advanced rectal cancer

Treatment of locally advanced rectal cancer is evolving through surgical innovation and paradigm shifts in neoadjuvant treatment. Whereas local recurrence was a significant concern before the systematic implementation of neoadjuvant chemoradiation therapy and surgery according to total mesorectal excision principles, distant relapse remains a major drawback. Hence, efforts in recent years have focused on delivering preoperative chemotherapy regimens to overcome compliance issues with adjuvant administration. In parallel, new surgical techniques, including transanal video-assisted total mesorectal excision and robot-assisted surgery, emerged to face the challenge to navigate in the deep and narrow spaces of the pelvis. Furthermore, patients experiencing a complete response after neoadjuvant treatment might even escape surgery within a close surveillance strategy. This novel "watch and wait" concept has gained interest to improve quality of life in highly selected patients. This review summarizes recent evidence and controversies and provides an overview on timely and innovative aspects in the treatment of locally advanced rectal cancer.

A randomized clinical trial comparing the initial vascular approach to the inferior mesenteric vein versus the inferior mesenteric artery in laparoscopic surgery of rectal cancer and sigmoid colon cancer

BACKGROUND

The inferior mesenteric artery approach with a selective lateral splenic flexure mobilization is the most widely used initial step in laparoscopic rectal and left colon surgery. Surgery started through the inferior mesenteric vein (IMV) with systematic medial mobilization (MM) has some theoretical advantages that have never been analyzed in a clinical trial. The aim of this study was to compare the two techniques with regards to surgical technique variables (conversion, surgical time, bleeding, morbidity, and mortality) and pathological outcomes.

METHODS

A single-blinded, randomized, controlled trial of patients operated electively by laparoscopic with curative intention for rectal or sigmoid cancer was performed at a single, specialized colorectal surgery department from April 2016 to October 2017.

RESULTS

49 patients were included in each group. There were no statistical differences in patient demographics between the two approaches. Pathological outcomes did not differ between the two groups. Intra-operative characteristics showed a higher conversion rate in patients in which the inferior mesenteric artery was dissected first (p = 0.031). The artery approach also increased intra-operative bleeding (p = 0.049), but there were no differences regarding operative time. On multivariate analysis, the artery approach was associated with a higher risk of conversion (OR 8.68; p = 0.050). Post-operatory complications did not differ between artery and vein dissection.

CONCLUSIONS

In our study, the initial approach by the IMV with a systematic MM of the splenic flexure has allowed us to reduce the conversion rate without increasing complications or the surgical time. No differences were observed in the pathological results. Both approaches seem to be safe and effective and well-trained laparoscopic surgeons should have the two techniques available to them for use as needed.

What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review

BACKGROUND

"Big data" refers to large amount of dataset. Those large databases are useful in many areas, including healthcare. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and the National Inpatient Sample (NIS) are big databases that were developed in the USA in order to record surgical outcomes. The aim of the present systematic review is to evaluate the type and clinical impact of the information retrieved through NISQP and NIS big database articles focused on laparoscopic colorectal surgery.

METHODS

A systematic review was conducted using The Meta-Analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The research was carried out on PubMed database and revealed 350 published papers. Outcomes of articles in which laparoscopic colorectal surgery was the primary aim were analyzed.

RESULTS

Fifty-five studies, published between 2007 and February 2017, were included. Articles included were categorized in groups according to the main topic as: outcomes related to surgical technique comparisons, morbidity and perioperatory results, specific disease-related outcomes, sociodemographic disparities, and academic training impact.

CONCLUSIONS

NSQIP and NIS databases are just the tip of the iceberg for the potential application of Big Data technology and analysis in MIS. Information obtained through big data is useful and could be considered as external validation in those situations where a significant evidence-based medicine exists; also, those databases establish benchmarks to measure the quality of patient care. Data retrieved helps to inform decision-making and improve healthcare delivery.

Patient-specific mental rehearsal with interactive visual aids: a path worth exploring?

Background

Surgeons of today are faced with unprecedented challenges; necessitating a novel approach to pre-operative preparation which takes into account the specific tests each case poses. In this study, we examine patient-specific mental rehearsal for pre-surgical practice and assess whether this method has an additional effect when compared to generic mental rehearsal.

Methods

Sixteen medical students were trained how to perform a simulated laparoscopic cholecystectomy (SLC). After baseline assessments, they were randomised to two equal groups and asked to complete three SLCs involving different anatomical variants. Prior to each procedure, Group A practiced mental rehearsal with the use of a pre-prepared checklist and Group B mental rehearsal with the checklist combined with virtual models matching the anatomical variations of the SLCs. The performance of the two groups was compared using simulator provided metrics and competency assessment tool (CAT) scoring by two blinded assessors.

Results

The participants performed equally well when presented with a “straight-forward” anatomy [Group A vs. Group B—time sec: 445.5 vs. 496 p = 0.64—NOM: 437 vs. 413 p = 0.88—PL cm: 1317 vs. 1059 p = 0.32—per: 0.5 vs. 0 p = 0.22—NCB: 0 vs. 0 p = 0.71—DVS: 0 vs. 0 p = 0.2]; however, Group B performed significantly better [Group A vs. B Total CAT score—Short Cystic Duct (SCD): 20.5 vs. 26.31 p = 0.02 η² = 0.32—Double cystic Artery (DA): 24.75 vs. 30.5 p = 0.03 η² = 0.28] and committed less errors (Damage to Vital Structures—DVS, SCD: 4 vs. 0 p = 0.03 η²=0.34, DA: 0 vs. 1 p = 0.02 η² = 0.22). in the cases with more challenging anatomies.

Conclusion

These results suggest that patient-specific preparation with the combination of anatomical models and mental rehearsal may increase operative quality of complex procedures.

Learning curve in robotic rectal cancer surgery: current state of affairs

INTRODUCTION

Robotic-assisted rectal cancer surgery offers multiple advantages for surgeons, and it seems to yield the same clinical outcomes as regards the short-time follow-up of patients compared to conventional laparoscopy. This surgical approach emerges as a technique aiming at overcoming the limitations posed by rectal cancer and other surgical fields of difficult access, in order to obtain better outcomes and a shorter learning curve.

MATERIAL AND METHODS

A systematic review of the literature of robot-assisted rectal surgery was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was conducted in October 2015 in PubMed, MEDLINE and the Cochrane Central Register of Controlled Trials, for articles published in the last 10 years and pertaining the learning curve of robotic surgery for colorectal cancer. It consisted of the following key words: "rectal cancer/learning curve/robotic-assisted laparoscopic surgery".

RESULTS

A total of 34 references were identified, but only 9 full texts specifically addressed the analysis of the learning curve in robot-assisted rectal cancer surgery, 7 were case series and 2 were non-randomised case-comparison series. Eight papers used the cumulative sum (CUSUM) method, and only one author divided the series into two groups to compare both. The mean number of cases for phase I of the learning curve was calculated to be 29.7 patients; phase II corresponds to a mean number 37.4 patients. The mean number of cases required for the surgeon to be classed as an expert in robotic surgery was calculated to be 39 patients.

CONCLUSION

Robotic advantages could have an impact on learning curve for rectal cancer and lower the number of cases that are necessary for rectal resections.

Laparoscopic Right Colon Resection With Transvaginal Extraction: A Systematic Review of 90 Cases

BACKGROUND

Natural orifice specimen extraction is a laparoscopic technique that reduces the procedure's invasiveness.

OBJECTIVE

We aimed to examine all the available data for the transvaginal extraction of laparoscopic right-sided colonic resections.

DATA SOURCES

A systematic search was conducted using PubMed/MEDLINE, Cochrane, Google Scholar, EBSCO, clinicaltrials.gov, and congress abstract databases.

STUDY SELECTION

All case-control series, case series, and case reports were included, irrespective of age, region, race, obesity, comorbidities, or history of previous surgery. No restrictions were made in terms of language, country, or journal.

MAIN OUTCOME MEASURES

Patient selection criteria and results of the cumulative data.

RESULTS

The search identified 10 studies including 90 cases. Most patients were elderly (mean, 65.9; range, 29 to 87 y) and had comorbid diseases (96%). 33.8% had a history of abdominopelvic surgery. The mean body mass index was 25.7 kg/m (range, 18 to 50 kg/m). Most patients (83%) had malign or premalign (14%) diseases and required regular or extended right hemicolectomies (99%). The mean operating time and blood loss ranges were 193 (140 to 471) minutes and 62.4 (0 to 300) mL, respectively. Overall, morbidities were seen in 18 patients (20%), and 3 of them were related to the transvaginal extraction. There were no abdominal wound related early or late complications. When compared with laparoscopic colon resections with transabdominal extraction, the procedure seems to result in decreased postoperative pain and length of hospital stay.

LIMITATIONS

There are a limited number of comparative studies and an absence of randomized studies.

CONCLUSIONS

Laparoscopic resection and transvaginal specimen extraction is a promising technique for some right-sided colon pathologies. For patient selection, an accessible vaginal port (patient acceptance and a vagina that is not narrow) and an en-mass lesion of ≤8 cm were necessary. Malignancy, previous abdominopelvic surgery, obesity, and old age were not considered as contraindications.

Prospective study of patient satisfaction and postoperative quality of life after laparoscopic colectomy in Japan

INTRODUCTION

This prospective cohort study was designed to compare the short-term and intermediate health-related quality of life of Japanese patients after laparoscopic colectomy (LC) or open colectomy (OC) for colonic cancer.

METHODS

Seventeen hospitals participated, and 240 colonic cancer patients with T3 or T4 invasion that were estimated as curatively resected were enrolled. Three patients were excluded as ineligible, one patient died suddenly before operation, and one patient was not registered based on the doctor's decision. Therefore, analysis was done on 235 patients who underwent either LC (n = 165) or OC (n = 70) in accordance with their stated preference. The major outcome scale end-point was health-related quality of life as assessed by the 36-item Short Form Health Survey (Japanese version 2.0). Accessory end-points were feeling of satisfaction 1 month after operation and recovery time needed to perform normal activities after operation. Observations were performed on enrollment, postoperative day 3, postoperative day 7, discharge day or postoperative month 1, and postoperative month 6.

RESULTS

Defecation condition, wound pain score, and abdominal pain score were better in the LC group than in the OC group on postoperative day 7 and in postoperative month 1. Recovery time to normal daily activity took 30 days in the LC group, whereas the OC group needed 44 days.

CONCLUSION

Patients' subjective responses indicated that LC was more beneficial than OC for patients with stage II or III colonic cancer. LC's superiority was seen particularly in the following indicators: (i) health-related quality of life during early postoperative days; (ii) recovery to normal daily activities; and (iii) defecation after surgery.

Why have we embraced minimally invasive surgery and ignored enhanced recovery after surgery?

There has been a lot of enthusiasm about minimally invasive surgery (MIS) in the surgical community in recent times. Some of the main reasons for this are an unmatched appeal to patients, doctors and healthcare systems alike. Push from the industry also serves as an important reason for its popularity. 'Enhanced recovery after surgery' (ERAS) is a programme of implementing multimodal interventions in the perioperative period to promote faster recovery. Even though MIS is an important component of ERAS protocols, the latter has not seen the reception the former has received. In this article, the authors present their personal viewpoint on the matter. The authors intend to highlight issues surrounding an increasing emphasis on MIS and to caution against the MIS operative technique superseding comprehensive perioperative care.

Cancer Recurrence and Regional Anesthesia: The Theories, the Data, and the Future in Outcomes

OBJECTIVE

More than one million people each year in the United States are diagnosed with cancer. Surgery is considered curative, but the perioperative phase represents a vulnerable period for residual disease to spread. Regional anesthesia has been proposed to reduce the incidence of recurrence by attenuating the sympathetic nervous system's response during surgery, reducing opioid requirements thus diminishing their immunosuppressant effects, and providing antitumor and anti-inflammatory effects directly through systemic local anesthetic action. In this article, we present a description of the perioperative period, a summary of the proposed hypotheses and available literature on the effects of regional anesthesia on cancer recurrence, and put regional anesthesia in context in regard to its potential role in reducing cancer recurrence during the perioperative period.

METHODS

A literature review was conducted through PubMed by examining the following topics: effects of surgery on tumor progression, roles of multiple perioperative variables (analgesics, hypothermia, blood transfusion, beta-blockade) in cancer recurrence, and available in vitro, animal, and human studies regarding the effects of regional anesthesia on cancer recurrence.

RESULTS

in vitro, animal and human retrospective studies suppport the hypothesis that in certain types of cancer, regional anesthesia may be associated with lower recurrence rates. A few well-planned human randomized clinical trials are currently under way that may provide more solid evidence to substantiate or refute the benefits of regional anesthesia in reducing cancer recurrence.

CONCLUSIONS

The benefits of regional anesthesia in reducing cancer recurrence have a sound theoretical basis and, in certain cancers, are supported by the existing body of literature. This article outlines the current state of our knowledge on the relationship between cancer progression and regional analgesia.

Single-Incision Laparoscopic Right Hemi-Colectomy: a Systematic Review

As surgeons became more adept with laparoscopic colon surgery, other less invasive procedures, such as single-incision laparoscopic right hemi-colectomy (SIL-RH), have been applied. The objective of this study was to evaluate the safety of SIL-RH as well as its intraoperative and postoperative outcomes for right-sided colon diseases. A detailed search in PubMed for citations that included SIL-RH from 2000 to 2014 revealed 21 studies fulfilling the criteria of the present review. A total of 684 patients were analyzed. Of the patients, 50.2 % were men. Mean patient age was 64.8 years. Of the patients, 36.1 % had already undergone an abdominal operation before the performance of SIL-RH, while 69 % of the patients underwent SIL-RH for colon cancer. Relatively low rates of overall morbidity (15 %) and mortality (0.75 %) were reported in the included studies. Mean length of postoperative hospital stay (LOS) was 5.5 days. Bowel motility return had a mean value of 2.8 days. Mean number of harvested lymph nodes (LN) was 19.2 LN. All resection margins were tumor-free. SIL-RH was a safe alternative to multiport laparoscopic right hemi-colectomy (ML-RH) in terms of morbidity and mortality, postoperative gastrointestinal function recovery, LOS, as well as oncological radicalness.

Laparoscopic combined resection of synchronous gastric and colorectal cancer

PURPOSE

The aim of this study was to examine the feasibility of performing combined laparoscopic resection in patients with synchronous gastric and colorectal cancer.

METHODS

Thirty-six consecutive patients with synchronous gastric and colorectal cancer who underwent simultaneous combined resection were enrolled in this retrospective study.

RESULTS

Six patients underwent laparoscopic combined resection (lap group), whereas the other 30 patients underwent conventional open combined surgery (open group). Although the operative time was longer in the lap group than in the open group, there were no differences in the amount of intraoperative bleeding. Although there were no differences in the rates of postoperative complications between the 2 groups, the postoperative hospital stay was significantly shorter in the lap group. During a mean follow-up of 35 months, all 6 patients who underwent laparoscopic combined resection survived without any signs of recurrence.

CONCLUSIONS

Simultaneous laparoscopic resection is a feasible procedure in patients with synchronous gastric and colorectal cancer.

Efficacy of perioperative synbiotics treatment for the prevention of surgical site infection after laparoscopic colorectal surgery: a randomized controlled trial

PURPOSE

The aim of this study was to assess the effect of perioperative oral administration of synbiotics on the surgical outcome in patients undergoing laparoscopic colorectal resection.

METHODS

In this single-center randomized, controlled trial, patients scheduled to undergo elective laparoscopic colorectal surgery were eligible to participate and randomly assigned to a synbiotics group or a control group. The primary study outcome was the development of infectious complications, particularly surgical site infection (SSI), within 30 days of surgery.

RESULTS

In this study, 379 patients were enrolled and randomly assigned (173 to the synbiotics group and 206 to the control group), of whom 362 patients (168 to the synbiotics group and 194 to the control group) were eligible for this study. SSI occurred in 29 (17.3%) patients in the synbiotics group and 44 (22.7%) patients in the control group (OR: 0.761, 95% CI 0.50-1.16; p = 0.20). Overall, the rate of postoperative complications, including anastomotic leakage, did not differ significantly between the two groups. Synbiotics treatment reversed the changes in fecal bacteria and organic acids after surgery and suppressed the increases in potentially pathogenic species, such as Clostridium difficile.

CONCLUSION

The efficacy of perioperative administration of synbiotics was not validated as a treatment for reducing the incidence of infectious complications after laparoscopic colorectal resection. However, the microbial imbalance, in addition to the reduction in organic acids, could be improved by perioperative synbiotics treatment.

Safety and feasibility of laparoscopic colo-rectal surgery for cancer at a tertiary center in a developing country: Egypt as an example

BACKGROUND

Laparoscopic colectomy has been shown to have significant short- and long-term benefits compared to open approach. The incorporation of laparoscopy in developing countries is challenging, due to the high costs of equipment and lack of expertise. The aim of this study was to evaluate the safety and feasibility of laparoscopic colorectal surgery for cancer that could be performed in developing countries under different circumstances in developed countries.

METHODS

Thirty-seven patients (23 males and 14 females) with colorectal cancer with a median age of 46 years (39-72) have been enrolled for laparoscopic colo-rectal surgery in a tertiary center in Egypt (South Egypt Cancer Institute) with the trend of reuse of some disposable laparoscopic instruments.

RESULTS

The median operative time was 130 min (95-195 min). The median estimated blood loss was 70 ml (30-90 ml). No major intra-operative complications have been encountered. Two cases (5.5%) have been converted because of local advancement (one case) and bleeding with unavailability of vessel sealing device at that time (one case). The median time for passing flatus after surgery was 36 h (12-72 h). The median hospital stay was 4.8 days (4-7 days). The peri-operative period passed without events. Pathologic outcome revealed that the median number of retrieved lymph nodes was 14 (range 9-23 lymph node) and all cases had free surgical margin.

CONCLUSION

Laparoscopic colorectal surgery for cancer in developing countries could be safe and feasible. Safe reuse of disposable expensive parts of some laparoscopic instruments could help in propagation of this technique in developing countries.

Perioperative and Oncologic Outcomes of Single-incision Laparoscopy Compared with Conventional Laparoscopy for Colon Cancer: An Observational Propensity Score-matched Study

Single-incision laparoscopic (SIL) surgery is a recent advance in minimally invasive surgical techniques. From May 2011 to August 2012, 77 patients underwent primary SIL surgery for colon cancer by one colorectal surgeon. Among them, 61 patients were one-to-one-matched to control patients who had undergone conventional laparoscopic (CL) surgery with a propensity-matched score, and the outcomes were compared. Two hundred forty-seven patients with colon cancer underwent radical colectomy. Of these, 77 patients underwent SIL colectomy. After matching, there were no significant differences in the general characteristics between the patients undergoing the two types of surgery. Operation time was significantly longer in SIL surgery (139 vs 121 minutes, P = 0.001), but procedure time (107 vs 99 minutes, P = 0.069) was not significantly longer than CL surgery after eliminating closure time (31 vs 22 minutes, P < 0.001) from the operation time. There was no significant difference in postoperative complications between the two groups (3.3 vs 1.6%, P = 1.000). The mean number of harvested lymph nodes was 23 and 22 for SIL and CL surgery, respectively ( P = 0.332). The mean follow-up period was 15.7 for the SIL group and 21.4 months for the CL group ( P < 0.001) with two recurrences in the SIL group (3.3%) and three recurrences in the CL group (4.9%, P = 1.000). Disease-free survival at 20 months did not differ significantly between the two groups (93.3 vs 94.7%, P = 0.939). SIL for colonic malignancy can be safely applied for various types of operations and can provide equivalent oncologic resection and perioperative outcomes compared with CL surgery.

Incidence of minimally invasive colorectal cancer surgery at National Comprehensive Cancer Network centers

BACKGROUND

Laparoscopic colectomy has been shown to have equivalent oncologic outcomes to open colectomy for the management of colon cancer, but its adoption nationally has been slow. This study investigates the prevalence and factors associated with laparoscopic colorectal resection at National Comprehensive Cancer Network (NCCN) centers.

METHODS

Data on patients undergoing surgery for colon and rectal cancer at NCCN centers from 2005 to 2010 were obtained from chart review of medical records for the NCCN Outcomes Project and included information on socioeconomic status, insurance coverage, comorbidity, and physician-reported Eastern Cooperative Oncology Group (ECOG) performance status. Associations between receipt of minimally invasive surgery and patient and clinical variables were analyzed with univariate and multivariable logistic regression. All statistical tests were two-sided.

RESULTS

A total of 4032 patients, diagnosed between September 2005 and December 2010, underwent elective colon or rectal resection for cancer at NCCN centers. Median age of colon cancer patients was 62.6 years, and 49% were men. The percent of colon cancer patients treated with minimally invasive surgery (MIS) increased from 35% in 2006 to 51% in 2010 across all centers but varied statistically significantly between centers. On multivariable analysis, factors associated with minimally invasive surgery for colon cancer patients who had surgery at an NCCN institution were older age (P = .02), male sex (P = .006), fewer comorbidities (P ≤ .001), lower final T-stage (P < .001), median household income greater than or equal to $80000 (P < .001), ECOG performance status = 0 (P = .02), and NCCN institution (P ≤ .001).

CONCLUSIONS

The use of MIS increased at NCCN centers. However, there was statistically significant variation in adoption of MIS technique among centers.

Evolution and future of laparoscopic colorectal surgery

The advances of laparoscopic surgery since the early 1990s have caused one of the largest technical revolutions in medicine since the detection of antibiotics (1922, Flemming), the discovery of DNA structure (1953, Watson and Crick), and solid organ transplantation (1954, Murray). Perseverance through a rocky start and increased familiarity with the chop-stick surgery in conjunction with technical refinements has resulted in a rapid expansion of the indications for minimally invasive surgery. Procedure-related factors initially contributed to this success and included the improved postoperative recovery and cosmesis, fewer wound complications, lower risk for incisional hernias and for subsequent adhesion-related small bowel obstructions; the major breakthrough however came with favorable long-term outcomes data on oncological parameters. The future will have to determine the specific role of various technical approaches, define prognostic factors of success and true progress, and consider directing further innovation while potentially limiting approaches that do not add to patient outcomes.

Analysis of conversion factors in robotic-assisted rectal cancer surgery

BACKGROUND

Robotic surgical management of rectal cancer has a series of advantages which might facilitate the surgical approach to the pelvic cavity and reduce conversion rates. The aim of the present study is to identify independent factors for conversion during robotic rectal cancer surgery.

METHODS

A total of 67 patients underwent preoperative CT scan in order to obtain a three-dimensional image of the pelvis, the tumour and prostate. We measured maximum and minimum ilio-iliac, sacral promontory-pubis, coccyx-pubis diameters and maximum lateral axis. Further variables under consideration were age, BMI and use of neoadjuvant therapy. We recorded short-term follow-up outcomes of the resected tumour.

RESULTS

The present study included 67 patients (39 males) with an average age of 65.11 ± 10.30 years and a BMI of 27.70 ± 3.97 kg/m(2). Operative procedures included nine abdominoperineal resections and 58 low anterior resections. There were 15 (22.38 %) conversions. Mean operating time was 192.2 ± 42.73 min. Minimum ilio-iliac, maximum ilio-iliac, promontory-pubic and coccyx-pubis diameter as well as maximum lateral axis were 100.38 ± 7.65, 107.10 ± 10.01, 109.97 ± 9.20, 105.61 ± 9.27 and 129.01 ± 9.94 mm, respectively. Mean tumour volume was 37.06 ± 44.08 cc; mean prostate volume was 42.07 ± 17.49 cc. The univariate analysis of the variables showed a correlation between conversion and BMI and minimum ilio-iliac and coccyx-pubis diameters (p = 0.004, 0.047, 0.046). In the multivariate analysis, the only independent predictive factor for conversion was the BMI (p = 0.004).No correlation was found between conversion and sex, age, tumour volume or the rest of pelvic diameters.

CONCLUSION

BMI is an independent factor for conversion in robotic-assisted rectal cancer surgery.

Postoperative respiratory complications and peak airway pressure during laparoscopic colectomy in patients with colorectal cancer

To determine whether the incidence of postoperative pulmonary complications increases in patients with high peak airway pressure (≥30 cm H2O) during laparoscopic colectomy, we investigated consecutive patients with colorectal cancer who had undergone laparoscopic colectomy. Of the 115 enrolled patients, 34 patients (30%) had peak airway pressure ≥30 cm H2O (an overload group). Compared with a nonoverload group (peak airway pressure <30 cm H2O), the overload group had a 5-fold greater incidence of postoperative respiratory complications and operations of longer duration, longer postanesthesia care unit stays, greater alveolar-arterial O2 differences, greater alveolar dead space-to-tidal volume ratios, and lower PaO2 measurements. Body mass index and preoperative alveolar-arterial O2 difference significantly affect higher peak airway pressure occurring during laparoscopic colectomy. Patients who had peak airway pressures ≥30 cm H2O during laparoscopic colectomy for colorectal cancer had higher incidence of postoperative respiratory complications than those whose peak airway pressures remained <30 cm H2O.

Uptake and outcomes of laparoscopically assisted resection for colon and rectal cancer in Australia: a population-based study

BACKGROUND

Meta-analyses of randomized controlled trials support the use of laparoscopically assisted resection for colon cancer. The evidence supporting its use in rectal cancer is weak.

OBJECTIVE

The purpose of this work was to investigate the uptake of laparoscopically assisted resection for colon and rectal cancer and to compare short- and long-term outcomes using population data.

DESIGN

This was a retrospective cohort study using linked administrative health data.

SETTINGS

The study encompassed all of the public and private hospitals in New South Wales, Australia, between 2000 and 2008.

PATIENTS

A total of 27,947 patients with colon or rectal cancer undergoing surgery with curative intent were included in the study.

MAIN OUTCOME MEASURES

We summarized the proportion of resections performed laparoscopically. Short-term outcomes were extended stay, 28-day readmission, 28-day emergency readmission, 30- and 90-day mortality, and 90-day readmission with pulmonary embolism or deep-vein thrombosis. Long-term outcomes were all-cause and cancer-specific death and admission with obstruction or incisional hernia repair.

RESULTS

Laparoscopic procedures increased between 2000 and 2008 for colon (1.5%-20.7%) and rectal cancer (0.6%-15.5%). Laparoscopic procedures reduced rates of extended stay (OR, 0.60; 95% CI, 0.49-0.72) and 28-day readmission (OR, 0.86; 95% CI, 0.74-0.99) for colon cancer. For rectal cancer, laparoscopic procedures had lower rates of 28-day readmission (OR, 0.58; 95% CI, 0.42-0.78) and 28-day emergency readmission (OR, 0.54; 95% CI, 0.34-0.85). Laparoscopic procedures improved cancer-specific survival for rectal cancer (HR, 0.71; 95% CI, 0.51-1.00). Survival benefits were observed for laparoscopically assisted colon resection in higher-caseload hospitals but not lower-caseload hospitals.

LIMITATIONS

It was not possible to identify laparoscopically assisted resections converted to open procedures because of the claims-based nature of the data.

CONCLUSIONS

Despite increases in laparoscopically assisted resections for colon and rectal cancer, the majority of resections are still treated by open procedures. Our data suggest that laparoscopic resection reduces the lengths of stay and rates of readmission and may result in improved cancer-specific survival for both colon and rectal resections.

Three ports laparoscopic resection for colorectal cancer: a step on refining of reduced port surgery

Background. Reduced port surgery (RPS) is becoming increasingly popular for some surgeries. However, the application of RPS to the field of colectomy is still underdeveloped. Patients and Methods. In this series, we evaluated the outcome of laparoscopic colorectal resection using 3 ports technique (10 mm umbilical port plus another two ports of either 5 or 10 mm) for twenty-four cases of colorectal cancer as a step for refining of RPS. Results. The mean estimated blood loss was 70 mL (40–90 mL). No major intraoperative complications have been encountered. The mean time for passing flatus after surgery was 36 hours (12–48 hrs). The mean time for oral fluid intake was 36 hours and for semisolid food was 48 hours. The mean hospital stay was 5 days (4–7 days). The perioperative period passed without events. All cases had free surgical margins. The mean number of retrieved lymph nodes was 14 lymph nodes (5–23). Conclusion. Three ports laparoscopy assisted colorectal surgeries looks to be safe, effective and has cosmetic advantages. The procedure could maintain the oncologic principles of cancer surgery. It's a step on the way of refining of reduced port surgery.

Long-term survival following laparoscopic and open colectomy for colon cancer: a meta-analysis of randomized controlled trials

AIM

Large randomized clinical trials comparing long-term survival after laparoscopic and open colectomy for large bowel cancer show equivalence, but meaningful analysis of data by stage has not been possible due to the small numbers of patients in individual trials. The aim of this meta-analysis was to improve statistical power by combining data to enable assessment of survival for individual stages.

METHOD

A systematic review and meta-analysis was conducted through a computerized search of all randomized controlled trials comparing open and laparoscopic surgery for large bowel cancer. Overall survival data were analysed and subgroup analysis was performed for cancer of Stages I-III.

RESULTS

Five trials (3152 patients) were included. Overall survival was equivalent (hazard ration 0.93; 95% confidence interval 0.80-1.07). With each of the cancer stages, I-III, there was no difference in 5-year survival. There was, however, a nonsignificant trend in favour of open surgery in the subgroup analysis of Stage II patients.

CONCLUSION

Laparoscopic-assisted surgery for colon cancer is equivalent to open surgery with respect to long-term survival although there may be a difference for Stage II cancer.

Evaluation of short-term outcomes after laparoscopically assisted abdominoperineal resection for low rectal cancer

BACKGROUND

To investigate the feasibility, safety and short-term efficacy of laparoscopic techniques applied in the abdominoperineal resection (APR) for low rectal cancer.

METHODS

The clinical data of 236 patients with APR from January 2010 to January 2012 were analysed retrospectively, including 100 patients underwent laparoscopically assisted APR (LAAPR group), 136 cases of open APR (OAPR group). The demographics, tumor and procedure-related parameters, perioperative results and short-term oncological outcomes were evaluated using t-test or χ(2) -test.

RESULTS

The demographic data of the two groups were comparable. Perioperative results were better after laparoscopic surgery, with less intraoperative blood loss (P = 0.017), earlier return of bowel function (P < 0.05) and lower complication rates (P = 0.015). No significant differences were detected between the two groups in operation time, tumor size, specimen length, the distance of tumor from the anal verge, lymph nodes removed and the status of circumferential resection margin (P > 0.05). During the follow-up period of 17-38 months (average, 26 months), the overall survival rates were not significantly different between the two groups [82.5% (80/97) versus 82.7% (110/133), P > 0.05]. The differences in recurrence and metastasis between the two groups were not statistically significant.

CONCLUSION

Laparoscopically assisted APR for low rectal cancer is safe and effective. It has the advantages of less bleeding, rapid postoperative recovery and fewer complications, without affecting the radical degree of the surgery. Further studies are needed to fully assess oncological outcomes in the future.