Impact of conversion on surgical outcomes after laparoscopic operation for rectal carcinoma: a retrospective study of 1,073 patients

Evaluation of postoperative results after a presurgical optimisation programme

BACKGROUND

Presurgical optimisation programmes decrease the risk of postoperative complications, reduce hospital stays and speed up patient recovery. They usually involve a multidisciplinary team addressing physical, nutritional and psychosocial issues. The objective of this study was to assess the results of implementing a presurgical optimisation programme led by a liaison nurse in patients undergoing major surgery in a primary general hospital.

METHODS

An observational, retrospective, descriptive, cross-sectional, comparative study based on the revision of patients' health records undergoing major surgery between January 2019 and December 2022. Patients entering the presurgical optimisation programme (intervention group) were compared with patients receiving usual medical care (control group). The presurgical optimisation programme consisted of oral nutritional supplementation, physical exercise, strengthening of lung capacity and psychological and emotional support. Frequency (%) of surgery complications and use of healthcare resources (duration of hospitalisation, time spent in the intensive care unit (ICU), and readmission) at day 30 were recorded. Descriptive statistics were applied.

RESULTS

Two hundred eleven patients (58.5% men, mean age: 65.76 years (SD 11.5), 75.2%. non-smokers; mean body mass index (BMI): 28.32 (SD 5.38); mean Nutritional Risk Score (NRS) 3.71 (SD 1.35; oncology diagnosis: 88.6%) were included: 135 in the intervention group, and 76 in the control group. The average duration of the presurgical optimisation programme was 20 days (SD 5). Frequency of postoperative complications was 25% (n = 33) in the intervention group and 52.6% (n = 40) in the control group (p < 0.001) [odds ratio (OR) = 3.4; 95% confidence interval (CI) (1.8; 6.2)]. 14.5% (n = 19) of patients in the intervention group and 34.2% (n = 26) in the control group had remote postoperative complications [OR = 3.1; 95% CI (1.6; 6.2)]. Patients in the intervention group spent fewer days in the hospital [mean 8.34 (SD 6.70) vs 11.63 (SD 10.63)], and there were fewer readmissions at 30 days (7.6% vs 19.7%) compared with the control group.

CONCLUSIONS

A presurgical optimisation programme led by a liaison nurse decreases the rate of immediate and late surgical complications and reduces hospital stays and readmissions in patients undergoing major surgery.

Comparison of Early Clinical and Long-Term Oncological Outcomes of Laparoscopic Versus Converted Rectal Cancer Resection: A Retrospective Cohort Study

Aim The effects of conversion to open surgery during laparoscopic resection in rectal cancer on perioperative clinical and long-term oncological outcomes are still controversial. This study aimed to evaluate and compare the impact of conversion to laparoscopic resection for rectal cancer on perioperative and long-term oncological outcomes. Material and methods Between January 2019 and December 2023, 84 consecutive patients who underwent curative surgery for rectal cancer at a single academic center were evaluated retrospectively. Patients were classified and compared as the laparoscopic (LAP-G) and converted (CONV-G) groups. Perioperative, pathological, and long-term oncological outcomes were compared. Results Of the 84 consecutive patients included, 18 were converted to open surgery, leading to a 21.4% conversion rate. Intraoperative blood loss was higher in CONV-G (180 ml vs. 80 ml, p<0.001), but early clinical outcomes were similar in both groups. The median follow-up period was 23.5 (range 3-65) and 30.5 (range 6-61) months in the LAP-G and CONV-G, respectively, and recurrence occurred in 11 (16.7%) and 3 (16.6%) patients, respectively. Three-year overall survival was 96.9% and 89.4% (p=0.609) and 3-year disease-free survival was 92.4% and 83.3% (p=0.881) in LAP-G and CONV-G, respectively, and the results were similar. Conclusion Conversion from laparoscopic rectal resection to open surgery does not have a significant negative impact on morbidity and long-term oncological outcomes.

Impact of the endoscopic surgical skill qualification system on conversion to laparotomy after low anterior resection for rectal cancer in Japan (a secondary analysis of the EnSSURE study)

BACKGROUND AND AIMS

Conversion to laparotomy is among the serious intraoperative complications and carries an increased risk of postoperative complications. In this cohort study, we investigated whether or not the Endoscopic Surgical Skill Qualification System (ESSQS) affects the conversion rate among patients undergoing laparoscopic surgery for rectal cancer.

METHODS

We performed a retrospective secondary analysis of data collected from patients undergoing laparoscopic surgery for cStage II and III rectal cancer from 2014 to 2016 across 56 institutions affiliated with the Japan Society of Laparoscopic Colorectal Surgery. Data from the original EnSSURE study were analyzed to investigate risk factors for conversion to laparotomy by performing univariate and multivariate analyses based on the reason for conversion.

RESULTS

Data were collected for 3,168 cases, including 65 (2.1%) involving conversion to laparotomy. Indicated conversion accounted for 27 cases (0.9%), while technical conversion accounted for 35 cases (1.1%). The multivariate analysis identified the following independent risk factors for indicated conversion to laparotomy: tumor diameter [mm] (odds ratio [OR] 1.01, 95% confidence interval [CI] 1.01-1.05, p = 0.0002), combined resection of adjacent organs [+/-] (OR 7.92, 95% CI 3.14-19.97, p < 0.0001), and surgical participation of an ESSQS-certified physician [-/+] (OR 4.46, 95% CI 2.01-9.90, p = 0.0002). The multivariate analysis identified the following risk factors for technical conversion to laparotomy: registered case number of institution (OR 0.99, 95% CI 0.99-1.00, p = 0.0029), institution type [non-university/university hospital] (OR 3.52, 95% CI 1.54-8.04, p = 0.0028), combined resection of adjacent organs [+/-] (OR 5.96, 95% CI 2.15-16.53, p = 0.0006), and surgical participation of an ESSQS-certified physician [-/+] (OR 6.26, 95% CI 3.01-13.05, p < 0.0001).

CONCLUSIONS

Participation of ESSQS-certified physicians may reduce the risk of both indicated and technical conversion. Referral to specialized institutions, such as high-volume centers and university hospitals, especially for patients exhibiting relevant background risk factors, may reduce the risk of conversion to laparotomy and lead to better outcomes for patients.

TRIAL REGISTRATION

This study was registered with the Japanese Clinical Trials Registry as UMIN000040645.

A machine learning model to predict the need for conversion of operative approach in patients undergoing colectomy for neoplasm

BACKGROUND

Studies comparing conversion from laparoscopic to open approaches to colectomy have found an association between conversion and morbidity, mortality, and length of stay, suggesting that certain patients may benefit from an open approach "up-front."

AIM

The objective of this study was to use machine learning algorithms to develop a model enabling the prediction of which patients are likely to require conversion.

METHODS AND RESULTS

We used ACS NSQIP data to identify patients undergoing colectomy (2014-2019). We included patients undergoing elective colectomy for colorectal neoplasm via a minimally invasive approach or a converted approach. The outcome of interest was conversion. Variables were included in the model based on their correlation with conversion by logistic regression (p < .05). Two models were used: weighted logistic regression with regularization, and Random Forest classifier. The data was randomly split into training (70%) and test (30%) cohorts, and prediction performance was calculated. 24 327 cases were included (17 028 training, 7299 test). When applied to the test cohort, the models had an accuracy of 0.675 (range 0.65-0.70) in predicting conversion; c-index ranged from 0.62-0.63. This machine learning model achieved a moderate area under the curve and a high negative predictive value, but a low positive predictive value; therefore, this model can predict (with 95% accuracy) whether a colectomy for neoplasm can be successfully completed using a minimally invasive approach.

CONCLUSION

This model can be used to reassure surgeons of the appropriateness of a minimally invasive approach when planning for an elective colectomy.

Validation of a pelvic surgery difficulty risk model to predict difficult pelvic dissection and poor outcomes

BACKGROUND

We previously developed the Pelvic Surgery Difficulty Index for predicting intraoperative events and postoperative outcomes associated with rectal mobilization with or without proctectomy ("deep pelvic dissection"). The aim of this study was to validate the scoring system as a prognostic tool for outcomes of pelvic dissection, regardless of the cause of dissection.

METHODS

Consecutive patients who underwent elective deep pelvic dissection at our institution from 2009 to 2016 were reviewed. Pelvic Surgery Difficulty Index score (0-3) was calculated from the following parameters: male sex (+1), prior pelvic radiotherapy (+1), and linear distance from sacral promontory to pelvic floor >13 cm (+1). Patient outcomes stratified by Pelvic Surgery Difficulty Index score were compared. The outcomes assessed included operative blood loss, operative time, length of hospital stay, cost, and postoperative complications.

RESULTS

A total of 347 patients were included. Higher Pelvic Surgery Difficulty Index scores were associated with significantly more blood loss, operative time, postoperative complications, hospital costs, and hospital stay. The model achieved good discrimination with area under the curve ≥0.7 for most outcomes.

CONCLUSION

Preoperative prediction of the morbidity associated with difficult pelvic dissection is possible with an objective, feasible, and validated model. Such a tool may facilitate preoperative preparation and allow for better risk stratification and uniform quality control across centers.

Comparison of robotic vs laparoscopic left-sided colorectal cancer resections

Robotic assisted surgery (RAS) has become increasingly adopted in colorectal cancer surgery. This study aims to compare robotic and laparoscopic approaches to left sided colorectal resections in terms of surgical outcomeswith no formal enhanced recovery programme. All patients undergoing robotic or laparoscopic left sided or rectal (high and low anterior resection) cancer surgery at a single tertiary referral centre over 3 years were included.A total of 184 consecutive patients from July 2017 to December 2020 were included in this study, with 40.2% (n=74/184) undergoing RAS. The median age at time of surgery was 68 years (IQR 60-73 years). RAS had a significantly shorter length of median stay of 3 days, compared to 5 days in the conventional laparoscopic surgery (CLS) group (p<0.001). RAS had a significantly lower rate of conversion to open surgery (0% vs 16.4%, p<0.001). The median operative time was also shorter in RAS (308 minutes), compared to CLS (326 minutes, p=0.019). The overall rate of any complication was 16.8%, with the RAS experiencing a lower complication rate (12.2% vs 20.0%, p=0.041). There was no significant difference in anastomotic leak rates between the two groups (4.0% vs 5.5%, p=0.673), or in terms of complete resection (R0) (robotic 98.6%, laparoscopic 100%, p=0.095). Robotic left sided colorectal surgery delivers equivalent oncological resection compared to laparoscopic approaches, with the added benefits of reduced length of stay and lower rates of conversion to open surgery. This has both clinical and healthcare economic benefits.

Post-operative outcomes in patients with locally advanced colon cancer: a comparison of operative approach

INTRODUCTION

Surgeons may choose an open approach to locally advanced colon cancer (LACC) because of the elevated conversion rate (minimally invasive to open) in these patients (resulting in part from a judgment of the technical feasibility of a minimally invasive approach). Poorer outcomes have been suggested in those requiring conversion from a minimal access to an open approach; however, the influence of conversion has not been studied in LACC. We sought to compare perioperative outcomes in patients with T4aN2 colon cancer undergoing minimally invasive surgery (MIS), planned open (PO), and converted (CN) procedures to evaluate the influence of conversion in this subgroup.

METHODS

A retrospective cohort study was conducted using the NSQIP database. Patients with T4aN2 colon cancer undergoing elective resection were included; rectal/unknown tumor location, and T4b disease were excluded (to ensure homogeneity in surgical management). Patients were divided into cohorts based on approach: PO, MIS, and CN. Summary statistics were compared between groups. Multivariable analysis was conducted for mortality and morbidity outcomes.

RESULTS

1286 cases were included (313 PO, 842 MIS, 131 CN); 10.2% underwent conversion. Those undergoing MIS had a shorter length of stay than those undergoing PO or CN (p < 0.0001). On univariable analysis, CN resulted in increased rates of any complication (p < 0.0001). CN also had a greater rate of anastomotic leak (p = 0.0046) and death (p = 0.05). On multivariable analysis, significant predictors of any complication included age, ASA class, M stage, and approach; however, CN did not increase the risk of complication compared with MIS, whereas PO nearly doubled the risk of complication (OR = 1.98, p = 0.0083). The only significant predictor of mortality on multivariable analysis was age (HR = 1.09, p = 0.0002)-approach was not associated with mortality.

CONCLUSION

PO confers the greatest risk of suffering any complication. Surgical approach was not associated with death. Results of our study challenge the notion that conversion is associated with the worst perioperative outcomes and an MIS approach should be considered in patients with LACC.

Are oncological long-term outcomes equal after laproscopic completed and converted laparoscopic converted rectal resection for cancer?

BACKGROUND

The aim of this study was to compare long-term survival after laproscopic completed and laparoscopic converted rectal resection for cancer.

METHODS

All consecutive patients who underwent curative laparoscopic rectal surgery for cancer at our institution between January 2001 and December 2016 were included in a single-center retrospective study. Patients were divided into two groups: the converted (CONV) group and the totally laparoscopic (LAP) group. The primary outcomes were long-term oncologic outcomes including overall survival (OS) and disease-free survival (DFS), as well as local and distant recurrence (LR, DR). The secondary outcomes included postoperative mortality and morbidity as defined as death or any complication occurring within 90 days postoperatively.

RESULTS

Of 214 consecutive patients included, 57 were converted to open surgery (CONV group), leading to a 26.6% conversion rate. Mean length of follow-up was 68 ± 42 months in the LAP group and 70 ± 41 months in the CONV group. Five-year OS was significantly shorter in the CONV group compared to the LAP group (p = 0.0016). On multivariate analysis, rectal tumor location (middle and low) and conversion to open surgery were predictors of both OS and DFS.

CONCLUSIONS

This study suggests that conversion to open surgery after laparoscopic rectal resection appears to significantly reduce OS without having a significant impact on DFS and recurrence rates.

Open colectomy vs. laparoscopic colectomy in Japan: a retrospective study using real-world data from the diagnosis procedure combination database

PURPOSE

To compare the short-term outcomes of conventional open colectomy with those of laparoscopic colectomy for colon cancer.

METHODS

We retrieved data between January 2014 and March 2016 from the Diagnosis Procedure Combination database. A total of 69,418 patients who underwent colectomy for colon cancer were analyzed from among 15,901,766 cases of colorectal cancer. We applied a multilevel logistic regression model using a 2-level structure of individuals nested from 1065 hospitals.

RESULTS

A total of 22,440 open colectomy and 46,978 laparoscopic colectomy procedures were performed. The in-hospital mortality rate was significantly lower in the laparoscopic group than in the open group (0.28% vs. 0.06%, odds ratio [OR] 0.40, p < 0.001). Similarly, the 30-day postoperative mortality rate (0.14% vs. 0.03%, OR 0.47, p = 0.019) and surgical morbidity rate (43.0% vs. 25.3%, OR 0.47, p < 0.001) were significantly lower in the laparoscopic group than in the open group. The postoperative length of stay was significantly longer in the open group (mean difference - 5.6 days, p < 0.001) than in the open group. The admission cost was significantly greater in the open group than in the laparoscopic group (mean difference - 95,080 yen, p < 0.001).

CONCLUSIONS

Laparoscopic colectomy is safe and effective in the short term.

What influences conversion to open surgery during laparoscopic colorectal resection?

INTRODUCTION

We analyzed the risk of morbidity and mortality in laparoscopic (Lap) conversion for colorectal surgery across a group of subspecialist surgeons with expertise in minimally invasive techniques.

METHODS

We reviewed prospective data patients who underwent abdominopelvic procedures from 7/1/2007 to 12/31/2016 at a tertiary care facility. We identified procedures that were converted from Lap to open (Lap converted). Lap converted procedures were matched to Lap completed and open procedures based on elective versus urgent and surgeon. We also abstracted patient demographics and outcomes at 30 days using the American College of Surgeons National Surgical Quality Improvement Program defined adverse event list. We analyzed outcomes across these groups (Lap converted, Lap completed, open procedures) with x² and t tests and used the Bonferroni Correction to account for multiple statistical testing.

RESULTS

From a database of 12,454 procedures, we identified 100 Lap converted procedures and matched them to 305 open procedures and 339 Lap completed procedures. In our dataset of abdominopelvic procedures, Lap techniques were attempted in 49 ± 1%. We noted a higher risk of aggerate morbidity following open procedures (33 ± 10) as compared to Lap converted (29 ± 17%) and the matched Lap completed procedures (18 ± 8%; p < 0.001). Converted cases had the longest operative time (222 ± 102 min), compared to lap completed (177 ± 110), and open procedures (183 ± 89). There were no differences in mortality, sepsis complications, anastomotic leaks, or unplanned returns to the operating room across the three operative groups.

CONCLUSIONS

Although aggregate morbidity of Lap converted procedures is higher than in Lap completed procedures, it remains less than in matched open procedures. Compared to Lap completed procedures, the additional morbidity of Lap converted procedures appears to be related to additional surgical site infection risk. Our data suggest that surgeons should not necessarily be influenced by additional complications associated with conversion when contemplating complex laparoscopic colorectal procedures.

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.

[Conversion of laparoscopic access in colorectal cancer surgery (in Russian only)]

AIM

To analyze the problem of access conversion in laparoscopic surgery for colorectal cancer.

MATERIAL AND METHODS

There were 876 procedures for colorectal cancer T14N01M0 performed at the Rostov Research Institute of Oncology in 2015-2017. Open and laparoscopic surgery was applied in 562 and 309 patients, respectively. Conversion of laparoscopic procedures was required in 35 (10.2%) patients.

RESULTS

Conversions were 2.7 times more frequent in men (p<0.05) (probably due to anatomical features - a narrow pelvis) and predominantly with rectosigmoid (22.2%, 2 patients) and rectal cancer (12%, 22 patients). Conversions in women were as well in right-sided colon cancer (9.7%, 3 cases) and sigmoid cancer (7.4%, 4 patients). Conversions were performed mostly due to locally advanced tumors (37.1%, 13 patients) which are especially baffling in case of narrow pelvis. Visceral obesity (20%, 7 patients) and abdominal adhesions (17.1%, 6 patients) were also important causes of conversions. Conversions did not affect time of surgery (256 min vs. 240 min in laparoscopic and 237 min in open surgery). Intraoperative blood loss (284 ml) was higher than in laparoscopy (240 ml) but did not exceed that in open surgery (291 ml).

CONCLUSION

It is necessary to assess risks and benefits of laparoscopy in patients with high probability of conversion in colorectal cancer surgery.

Influence of Conversion and Anastomotic Leakage on Survival in Rectal Cancer Surgery; Retrospective Cross-sectional Study

BACKGROUND

Conversion and anastomotic leakage in colorectal cancer surgery have been suggested to have a negative impact on long-term oncologic outcomes. The aim of this study in a large Dutch national cohort was to analyze the influence of conversion and anastomotic leakage on long-term oncologic outcome in rectal cancer surgery.

METHODS

Patients were selected from a retrospective cross-sectional snapshot study. Patients with a benign lesion, distant metastasis, or unknown tumor or metastasis status were excluded. Overall (OS) and disease-free survival (DFS) were compared between laparoscopic, converted, and open surgery as well as between patients with and without anastomotic leakage.

RESULTS

Out of a database of 2095 patients, 638 patients were eligible for inclusion in the laparoscopic, 752 in the open, and 107 in the conversion group. A total of 746 patients met the inclusion criteria and underwent low anterior resection with primary anastomosis, including 106 (14.2%) with anastomotic leakage. OS and DFS were significantly shorter in the conversion compared to the laparoscopic group (p = 0.025 and p = 0.001, respectively) as well as in anastomotic leakage compared to patients without anastomotic leakage (p = 0.002 and p = 0.024, respectively). In multivariable analysis, anastomotic leakage was an independent predictor of OS (hazard ratio 2.167, 95% confidence interval 1.322-3.551) and DFS (1.592, 1077-2.353). Conversion was an independent predictor of DFS (1.525, 1.071-2.172), but not of OS.

CONCLUSION

Technical difficulties during laparoscopic rectal cancer surgery, as reflected by conversion, as well as anastomotic leakage have a negative prognostic impact, underlining the need to improve both aspects in rectal cancer surgery.

Objective Preoperative Parameters Predict Difficult Pelvic Dissections and Clinical Outcomes

BACKGROUND

Objective criteria to predict difficult pelvic dissection with prognostic significance are lacking. Previous studies have focused on predicting intraoperative conversion and not evaluated factors specific to pelvic surgery. We aimed to develop an objective, prognostic, preoperative assessment to predict difficult pelvic dissections and clinical outcomes. Such a model is much needed, may facilitate objective comparisons between rectal cancer centers, or may serve as a stratification variable in clinical trials.

MATERIALS AND METHODS

Patients who underwent low anterior resection or abdominoperineal resection for rectal cancer within 10 cm of the anal verge (2009-2014) were retrospectively analyzed. Procedures were categorized into "routine" or "difficult" based on predefined criteria. All patients underwent 14 measurements on preoperative imaging. Outcomes were compared between the two groups. Stepwise multivariate logistic regression was used to develop the prediction model, which was validated in an independent data set.

RESULTS

Of the 280 patients analyzed, 80 fulfilled the inclusion criteria. Baseline characteristics were similar except for more males having a "difficult" pelvis. "Difficult" patients were significantly more likely to have a narrower pelvis, smaller pelvic volumes, a longer pelvis, more curved sacrum, and more acute anorectal angle. Difficult cases correlated significantly with higher blood loss, hospital costs, longer operative time, and length of stay. A practical model to predict difficult pelvic dissections was created and included male gender, previous radiation, and length from promontory to pelvic floor > 130 mm. Model validation was performed in 40 patients from an independent data set.

CONCLUSIONS

An objective, validated model that predicts a difficult pelvic dissection and associated worse clinical outcome is possible.

[Transanal mesorectumectomy for rectal cancer - is it optimal surgery for 'difficult' patients?]

AIM

To compare short-term outcomes after transanal total mesorectumectomy (Ta-TME) and laparoscopic (Lap-TME) procedure in 'difficult' patients.

MATERIAL AND METHODS

Prospective nonrandomized trial included patients with confirmed middle-/low rectum adenocarcinoma T1-4aN0-2M0 for the period November 2013 - September 2016. We identified 20 out of 55 in TA-TME and 14 out of 54 patients in Lap-TME group as those of 'difficult' subgroup: male, BMI ≥25 кг/м², previous chemoradiotherapy (CRT).

RESULTS

Time of surgery, blood loss, conversions rate, postoperative morbidity and length of hospital-stay were similar in both groups. Hardware anastomoses were more frequent in TA-TME compared with LAP-TME group (78.9% vs. 50%, p=0.086). Specimen quality was more favorable in TA-TME group: Grade I 10% in Ta-TME group vs. 28.6% in Lap-TME group; 'positive' CRM 5% vs. 14.3%, р=0.365. Within-group analysis did not reveal any differences between 'difficult' and 'typical' patients by surgical and pathomorphological characteristics in TA-TME group in contrast to Lap-TME group. Median of follow-up was 24.6 (IR 10.6-40.2) and 23.8 (IR 12.1-39.9) months for TA-TME and Lap-TME groups, respectively. Local recurrence occurred in 1 (1.8%) 'difficult' patient after Ta-TME. Distant metastases were observed in 1 (1.8%) patient of Ta-TME and 2 (3.7%) patients of Lap-TME group. Actuarial 3-years reccurence-free survival was 95.7% for Ta-TME and 93.9% for Lap-TME group, respectively (p=0.923).

CONCLUSION

TA-TME is advisable for 'difficult' patients. Further multicenter randomized trials are necessary to specify the effectiveness of TA-TME in these patients.

Laparoscopic treatment of rectal cancer and lateral pelvic lymph node dissection: are they obsolete?

Laparoscopic surgery for rectal cancer offers favorable short-term results without compromising long term oncological outcomes so far, according to the data from major trials. For this reason, it is currently considered as a standard option for rectal cancer surgery. The learning curve of laparoscopic rectal cancer surgery is generally longer compared to colon cancer. Appropriate standardization and training of laparoscopic rectal cancer surgery is required. Several RCTs suggested the potential negative effect on quality of resected specimen, which can increase local recurrence. The long-term outcomes - especially local recurrence rate - of these RCTs are awaited. Lateral pelvic lymph node dissection (LPLND) has a certain effect of reducing local recurrence of rectal cancer even after neoadjuvant radiotherapy. Since LPLND is associated with postoperative morbidity, we should carefully select the candidate to maximize the effect of LPLND and minimize the morbidity caused by LPLND. Recent advancements in imaging study such as CT and MRI enable us to find the suitable candidates for LPLND. The morbidity caused by LPLND could be reduced by minimally invasive surgeries such as laparoscopic surgery and robotic surgery. We have to improve oncological outcomes and reduce morbidity by the multidisciplinary strategy for rectal cancer including total mesorectal excision, neoadjuvant chemoradiotherapy and LPLND together with laparoscopic surgery.

Short-Term and Long-Term Outcomes of Laparoscopic Versus Open Surgery for Low Rectal Cancer

AIM

To compare the short-term and long-term outcomes of laparoscopic versus open surgery for low rectal cancer.

METHODS

Patients with low rectal cancer who underwent laparoscopic or open surgery at our department from January 2009 to December 2013 were enrolled in this retrospective study. The primary end points were 3-year local recurrence and overall and disease-free survival (DFS) rates. Secondary end points were intraoperative and postoperative outcomes.

RESULTS

Laparoscopic group had longer operative time (165.0 versus 140.0, P < .001), less blood loss (20.0 versus 40.0, P < .001), shorter length of incision (5.0 versus 18.0, P < .001), and more lymph node harvested (11.0 versus 9.0, P = .002). However, time to first flatus (P = .941), postoperative hospital stay (P = .095), postoperative complications (P = .155), and 30-day mortality (P = .683) was similar between two groups. With the median follow-up period of 65 months, the 3-year local recurrence rate was 4.3% in laparoscopic group and 7.5% in open group (P = .077); the 3-year overall and DFS rates were similar in two groups (85.9% versus 88.8%, P = .229 and 76.9% versus 79.2%, P = .448, respectively); and the overall and DFS curves were comparable between two groups (hazard ratio [HR] = 0.858, 95% confidence intervals [CI] 0.709-1.037, P = .112 and HR = 1.076, 95% CI 0.834-1.389, P = .275, respectively).

CONCLUSIONS

Laparoscopic surgery is safe and has equivalent long-term oncologic outcomes for low rectal cancer when compared to open surgery. Furthermore, large-scale, prospective randomized clinical trials are needed to confirm the present findings.

Open Versus Laparoscopic Surgery for Rectal Cancer: Single-Center Results of 587 Cases

PURPOSE

We aimed to compare the short-term and long-term results of laparoscopic and open rectal resections.

METHODS

A total of 587 rectal cancer patients were included. The main measures were demographic data, duration of surgery, early postoperative results, pathologic data, and long-term follow-up.

RESULTS

There were no significant differences in demographic data, morbidity rate, tumor location, and sphincter-preservation rates between the 2 groups. The duration of surgery (155 vs. 173 min, P<0.001), time to gas passage, defecation, and solid food intake and length of hospital stay were significantly shorter in the laparoscopic group than the open group (P<0.05). According to the univariate and multivariate analysis, laparoscopic surgery did not have an effect on local recurrence but had a favorable effect on survival rates.

CONCLUSIONS

Laparoscopic rectal surgery has advantages over open surgery with respect to short-term and long-term clinical results and when performed in high-volume centers.

Cancer recurrence following conversion during laparoscopic colorectal resections: a meta-analysis

INTRODUCTION

Evidence regarding long-term oncological outcomes following conversion to open surgery (COS) during laparoscopic colorectal resection (LCR) is controversial. The aim of this study is to assess the impact on cancer recurrence of a failed laparoscopic attempt.

METHODS

MEDLINE, Scopus and ISI Web of Knowledge databases were searched for articles reporting data on cancer recurrence in patients undergoing completed LCR and COS. Data were pooled by fixed or random effect modeling, according to the presence of heterogeneity. Primary outcomes were local recurrence (LR) and distance recurrence (DR).

RESULTS

Seven studies involving 2493 patients (completed LCR, n 2201 and COS, n 292) were included. The pooled analysis showed that COS resections have an higher risk of LR (OR 1.97, 95% CI 1.14-3.42, p = 0.1); no difference was found in DR (OR 1.09, 95% CI 0.67-1.77, p = 0.71). However, an higher rate of T4 tumor was present in the converted group (OR 2.62, 95% CI 1.71-4, p = 0.0). Subgroup analysis including studies with T stage matched populations showed no significant statistical difference in LR rate; however, a trend toward higher recurrence was still clear.

CONCLUSION

There is no consistent evidence that a failed laparoscopic attempt does not result in a poorer oncological outcome; therefore, a careful selection of patients for LCR for cancer is required.

Impact of Timing of Conversion to Open Surgery on Short-Term and Oncologic Outcomes in Patients Undergoing Minimally Invasive Surgery for Colorectal Cancer

To evaluate the influence of timing of open conversion on short-term and oncologic outcomes after minimally invasive surgery for colorectal cancer. Six hundred forty-six consecutive patients were enrolled. All patients converted to open surgery were classified into early (n = 10) or late (n = 67) groups based on conversion timing using a 60-minute cutoff. A comparison of early conversion and nonconverted groups showed that history of prior abdominal surgery and pT4 tumor was more common in the early conversion group. Mean operative time was longer in the early conversion group. Rates of 30-day postoperative complications (30% vs 27%), time to soft diet (5 days vs 5 days), and hospital stay (12 days vs 12 days) were not different. A comparison of the late and nonconverted groups showed that history of prior abdominal surgery was more common in the late conversion group. Mean operative time was longer in the late conversion. Rates of 30-day postoperative complications (42% vs 27%), Clavien–Dindo score ≥3 (22% vs 11%), intensive care unit care (31% vs 15%), and transfusion (37% vs 21%) were significantly higher in the late conversion group. Time to soft diet (6 days vs 5 days) and hospital stay (15 days vs 12 days, P = 0.037) were longer in the late conversion group. Cancer-specific and recurrence-free survival rates did not differ among the early, late conversion, and nonconverted groups. Decisions about open conversion need be made within 60 minutes of the beginning of surgery as early conversion does not worsen short-term and oncologic outcomes.

Conversions in laparoscopic surgery for rectal cancer

BACKGROUND

Laparoscopic surgery offers patients with rectal cancer short-term benefits and similar survival rates as open surgery. However, selecting patients who are suitable candidates for laparoscopic surgery is essential to prevent intra-operative conversion from laparoscopic to open surgery. Clinical and pathological variables were studied among patients who had converted laparoscopic surgeries within the COLOR II trial to improve patient selection for laparoscopic rectal cancer surgery.

METHODS

Between January 20, 2004, and May 4, 2010, 1044 patients with rectal cancer enrolled in the COLOR II trial and were randomized to either laparoscopic or open surgery. Of 693 patients who had laparoscopic surgery, 114 (16 %) were converted to open surgery. Predictive factors were studied using multivariate analyses, and morbidity and mortality rates were determined.

RESULTS

Factors correlating with conversion were as follows: age above 65 years (OR 1.9; 95 % CI 1.2-3.0: p = 0.003), BMI greater than 25 (OR 2.7; 95 % CI 1.7-4.3: p < 0.001), and tumor location more than 5 cm from the anal verge (OR 0.5; CI 0.3-0.9). Gender was not significantly related to conversion (p = 0.14). In the converted group, blood loss was greater (p < 0.001) and operating time was longer (p = 0.028) compared with the non-converted laparoscopies. Hospital stay did not differ (p = 0.06). Converted procedures were followed by more postoperative complications compared with laparoscopic or open surgery (p = 0.041 and p = 0.042, respectively). Mortality was similar in the laparoscopic and converted groups.

CONCLUSIONS

Age above 65 years, BMI greater than 25, and tumor location between 5 and 15 cm from the anal verge were risk factors for conversion of laparoscopic to open surgery in patients with rectal cancer.

Conversion of laparoscopic colorectal resection for cancer: What is the impact on short-term outcomes and survival?

Laparoscopic resection for colon and rectal cancer is associated with quicker return of bowel function, reduced postoperative morbidity rates and shorter length of hospital stay compared to open surgery, with no differences in long-term survival. Conversion to open surgery is reported in up to 30% of patients enrolled in randomized control trials comparing open and laparoscopic colorectal resection for cancer. In this review, reasons for conversion are anatomical-related factors, disease-related-factors and surgeon-related factors. Body mass index, local tumour extension and co-morbidities are independent predictors of conversion. The current evidence has shown that patients with converted resection for colon cancer have similar outcomes compared to patients undergoing a laparoscopic completed or open resection. The few studies that have assessed the outcomes after conversion of laparoscopic rectal resection reported significantly higher rates of complications and longer length of hospital stay in converted patients compared to laparoscopically treated patients. No definitive conclusions can be drawn when converted and open rectal resections are compared. Early and pre-emptive conversion appears to have more favourable outcomes than reactive conversion; however, further large studies are needed to better define the optimal timing of conversion. With regard to long-term oncologic outcome, overall and disease-free survival in the case of conversion in laparoscopic colorectal cancer surgery seems to be worse than those achieved in patients in whom resection was successfully completed by laparoscopy. Although a worse long-term oncologic outcome has been suggested, it remains difficult to draw a proper conclusion due to the heterogeneity of the long-term outcomes as well as the inclusion of both colon and rectal cancer patients in most of the studies. Therefore, we discuss the currently available evidence of the impact of conversion in laparoscopic resection for colon and rectal cancer on both short-term outcomes and long-term survival.

The influence of obesity and body mass index on the outcome of laparoscopic colorectal surgery: a systematic literature review

AIM

The relationship between obesity, body mass index (BMI) and laparoscopic colorectal resection is unclear. Our object was to assess systematically the available evidence to establish the influence of obesity and BMI on the outcome of laparoscopic colorectal resection.

METHOD

A search of PubMed/Medline databases was performed in May 2015 to identify all studies investigating the impact of BMI and obesity on elective laparoscopic colorectal resection performed for benign or malignant bowel disease. Clinical end-points examined included operation time, conversion rate to open surgery, postoperative complications including anastomotic leakage, length of hospital stay, readmission rate, reoperation rate and mortality. For patients who underwent an operation for cancer, the harvested number of lymph nodes and long-term oncological data were also examined.

RESULTS

Forty-five studies were analysed, the majority of which were level IV with only four level III (Oxford Centre for Evidence-based Medicine 2011) case-controlled studies. Thirty comparative studies containing 23 649 patients including 17 895 non-obese and 5754 obese showed no significant differences between the two groups with respect to intra-operative blood loss, overall postoperative morbidity, anastomotic leakage, reoperation rate, mortality and the number of retrieved lymph nodes in patients operated on for malignancy. Most studies, including 15 non-comparative studies, reported a longer operation time in patients who underwent a laparoscopic procedure with the BMI being an independent predictor in multivariate analyses for the operation time.

CONCLUSION

Laparoscopic colorectal resection is safe and technically and oncologically feasible in obese patients. These results, however, may vary outside of high volume centres of expertise.

Impact of Conversion to Open Surgery on Early Postoperative Morbidity After Laparoscopic Resection for Rectal Adenocarcinoma: A Retrospective Study

BACKGROUND

The impact of conversion to open surgery after a laparoscopic resection for rectal adenocarcinoma on postoperative morbidity is still unclear. Most previous studies included colon and rectal carcinomas and produced conflicting results. The aim of this study was to investigate the impact of conversion to open surgery on early postoperative morbidity in patients who underwent a laparoscopic resection for rectal adenocarcinoma.

METHODS

This was a retrospective bicentric study. It included all consecutive patients who underwent a laparoscopic resection for nonmetastatic rectal adenocarcinoma between January 2005 and December 2013. The impact of conversion to open surgery on 30-day postoperative morbidity was analyzed by univariate and multivariate analyses. Risk factors for conversion were also investigated by univariate and multivariate analyses.

RESULTS

One hundred thirty-one patients were included. The conversion rate was 26.7%. The global 30-day morbidity rate was 31.3% (41 patients). The conversion to open surgery was associated with higher rates of postoperative complications, anastomotic leaks, and reoperations. It was also an independent predictive factor to postoperative morbidity in the multivariate analysis (P = .01; odds ratio 2.86; 95% confidence interval [CI] 1.23-6.63), in addition to T4 tumors (P = .04; odds ratio 3.92; 95% CI 1.05-14.61). Risk factors for conversion in the multivariate analysis were T4 tumors (P = .006; odds ratio 6.09; 95% CI 1.66-22.32) and the height of the tumor (P = .025; odds ratio 2.7; 95% CI 1.13-6.43).

CONCLUSIONS

This study showed that conversion to open surgery after laparoscopic proctectomy for rectal adenocarcinoma was associated with higher rates of early postoperative complications. It also showed that T4 tumors and the height of the tumor were independent factors associated with the conversion to open surgery. Reducing postoperative morbidity could be achieved by a better patient selection and a policy of early conversion.

Critical appraisal of laparoscopic vs open rectal cancer surgery

AIM: To evaluate the long-term clinical and oncological outcomes of laparoscopic rectal resection (LRR) and the impact of conversion in patients with rectal cancer.

METHODS: An analysis was performed on a prospective database of 633 consecutive patients with rectal cancer who underwent surgical resection. Patients were compared in three groups: Open surgery (OP), laparoscopic surgery, and converted laparoscopic surgery. Short-term outcomes, long-term outcomes, and survival analysis were compared.

RESULTS: Among 633 patients studied, 200 patients had successful laparoscopic resections with a conversion rate of 11.1% (25 out of 225). Factors predictive of survival on univariate analysis include the laparoscopic approach (P = 0.016), together with factors such as age, ASA status, stage of disease, tumor grade, presence of perineural invasion and vascular emboli, circumferential resection margin < 2 mm, and postoperative adjuvant chemotherapy. The survival benefit of laparoscopic surgery was no longer significant on multivariate analysis (P = 0.148). Neither 5-year overall survival (70.5% vs 61.8%, P = 0.217) nor 5-year cancer free survival (64.3% vs 66.6%, P = 0.854) were significantly different between the laparoscopic group and the converted group.

CONCLUSION: LRR has equivalent long-term oncologic outcomes when compared to OP. Laparoscopic conversion does not confer a worse prognosis.

Effect of Visceral Obesity on Surgical Outcomes of Patients Undergoing Laparoscopic Colorectal Surgery

BACKGROUND

Visceral obesity has been known to be more pathogenic than body mass index (BMI). There have been a few reports about the association between visceral obesity and surgical outcomes in laparoscopic surgery. The aim of this study was to evaluate the effect of visceral obesity on surgical outcomes undergoing laparoscopic colorectal surgery.

METHODS

Between January 2005 and December 2012, a total of 543 patients who underwent laparoscopic resection for colorectal cancer and had available computed tomography (CT) scans were included in this retrospective study. Visceral fat volumes (VFVs) were measured in preoperative CT scans from S1 to 12.5 cm above. Patients were divided into an obese group and a non-obese group according to VFV and BMI. Obesity was defined by VFV ≥1.92 dm(3) (75% value of VFV) or BMI ≥25 kg/m(2).

RESULTS

There were 136 (25.0%) and 150 (27.6%) obese patients according to VFV and BMI, respectively. The high VFV group had a longer operative times (165.2 ± 84.4 vs. 146.1 ± 58.9 min; P = 0.016), higher blood loss during surgery (132.5 ± 144.8 vs. 98.3 ± 109.6 ml; P = 0.012), more frequent conversion to laparotomy (5.9 vs. 1.5%; P = 0.010), and more frequent major complications (Dindo score ≥3; 11.0 vs. 4.7%; P = 0.008), whereas there was no significant difference between the high and low BMI groups. High VFV was a significant independent risk factor for open conversion (odds ratio 4.964, 95% confidence interval 1.336-18.438, P = 0.017).

CONCLUSIONS

Visceral obesity can be a more clinically useful predictor than BMI in predicting surgical outcomes for laparoscopic colorectal cancer surgery.

Conversion during laparoscopic colorectal resections: a complication or a drawback? A systematic review and meta-analysis of short-term outcomes

PURPOSE

Several studies compared the outcomes of laparoscopically completed colorectal resections (LCR) to those requiring conversion to open surgery (COS). However, a comparative analysis between COS patients and patients undergoing planned open surgery (POS) would be useful to clarify if the conversion can be considered a simple drawback or a complication, being cause of additional postoperative morbidity. The aim of this study is to perform a meta-analysis of current evidences comparing postoperative outcomes of COS patients to POS patients.

METHODS

A systematic search of Medline, ISI Web of Knowledge, and Scopus was performed to identify studies reporting short-term outcomes of COS and POS patients. Primary outcomes were 30-day overall morbidity and length of postoperative hospital stay. Data were analyzed with fixed-effect modeling, and sensitivity analyses were performed to test the robustness of the results.

RESULTS

Twenty studies involving 30,656 patients undergoing POS and 1935 COS patients were selected. The mean conversion rate was 0.17. Similar 30-day overall morbidity and length of postoperative hospital stay were found in COS and POS patients. Wound infection (OR 1.43, 95 % CI 1.12 to 1.83, p < 0.01) was higher in the COS group. Other results were robust. Outcomes were comparable for patients undergoing resection for different natures of the disease (benign vs. malignant) and at different sites (colon vs. rectum).

CONCLUSION

Conversions from laparoscopic to open procedure during colorectal resection are not associated with a poorer postoperative outcome compared to patients undergoing planned open surgery, except for a higher risk of wound infection.

Robotic versus conventional laparoscopic surgery for rectal cancer: systematic review and meta-analysis

PURPOSE

Robotic surgery (RS) overcomes the limitations of previous conventional laparoscopic surgery (CLS). Although meta-analyses have been published recently, our study evaluated the latest comparative surgical, urologic, and sexual results for rectal cancer and compares RS with CLS in patients with rectal cancer only.

METHODS

We searched three foreign databases (Ovid-MEDLINE, Ovid-Embase, and Cochrane Library) and five Korean databases (KoreaMed, KMbase, KISS, RISS, and KisTi) during July 2013. The Cochrane Risk of Bias and the Methodological Index for Non-Randomized were utilized to evaluate quality of study. Dichotomous variables were pooled using the risk ratio (RR), and continuous variables were pooled using the mean difference (MD). All meta-analyses were conducted with Review Manager, V. 5.3.

RESULTS

Seventeen studies involving 2,224 patients were included. RS was associated with a lower rate of intraoperative conversion than that of CLS (RR, 0.28; 95% confidence interval [CI], 0.15-0.54). Time to first flatus was short (MD, -0.13; 95% CI, -0.25 to -0.01). Operating time was longer for RS than that for CLS (MD, 49.97; 95% CI, 20.43-79.52, I(2) = 97%). International Prostate Symptom Score scores at 3 months better RS than CLS (MD, -2.90; 95% CI, -5.31 to -0.48, I(2) = 0%). International Index of Erectile Function scores showed better improvement at 3 months (MD, -2.82; 95% CI, -4.78 to -0.87, I(2) = 37%) and 6 months (MD, -2.15; 95% CI, -4.08 to -0.22, I(2) = 0%).

CONCLUSION

RS appears to be an effective alternative to CLS with a lower conversion rate to open surgery, a shorter time to first flatus and better recovery in voiding and sexual function. RS could enhance postoperative recovery in patients with rectal cancer.

Oncologic and Clinicopathologic Outcomes of Robot-Assisted Total Mesorectal Excision for Rectal Cancer

BACKGROUND

Minimally invasive rectal cancer surgery is challenging and technically difficult. Robotic technology offers a stable surgical platform with magnified 3-dimensional vision and endowristed instruments, which may facilitate the minimally invasive procedure. Data on short-term and long-term outcomes indicate results comparable to laparoscopic and open surgery.

OBJECTIVE

We assessed the perioperative, clinicopathologic, and oncologic outcomes of robotic surgery for rectal cancer.

DESIGN

This study was a review of a prospective database of patients over a 7-year period.

SETTINGS

Procedures took place in the colorectal division at a tertiary hospital.

PATIENTS

From August 2005 to October 2012, 101 patients with rectal cancer were operated on using the robotic approach. Rectal cancers were defined as tumors within 15 cm from the anal verge.

INTERVENTIONS

Patients received either a totally robotic or a hybrid laparoscopic-robotic operation with rectal dissection performed robotically.

MAIN OUTCOME MEASURES

Operative and perioperative data, pathologic outcomes, and disease-free and overall survival were examined.

RESULTS

There were 63 men (62.4%) and 38 women (37.6%) in the study; the mean age was 61.5 years. Mid rectal and low rectal cancers composed 74.2% of cases. Preoperative chemoradiation was given to 74.3% of patients. Four conversions to open surgery occurred. Circumferential margin positivity was 5%, and median lymph node yield was 15. At a mean follow-up of 34.9 months, the disease-free survival was 79.2% and overall survival 90.1%. The mean cost of robotic surgery was $22,640 versus $18,330 for the hand-assisted laparoscopic approach (p = 0.005).

LIMITATIONS

This was a single-institution study with no head-to-head comparative group.

CONCLUSIONS

Robotic surgery for rectal cancer extirpation is safe and feasible. It has a low conversion rate, satisfies all measures of pathologic adequacy, and offers acceptable oncologic outcomes. Robotic surgery is significantly more expensive than hand-assisted laparoscopic surgery. The absence of randomized data limits recommending it as the standard of care at present.

Laparoscopic intersphincteric resection and hand-sewn coloanal anastomosis: a natural orifice specimen extraction technique

The incidence of rectal cancer in India is on the rise, and unlike in the West, predominantly younger individuals are affected. Surgery for rectal cancer has evolved over the years with the ultimate goals of sphincter preservation and better quality of life, besides oncological safety. With the routine use of magnetic resonance imaging for local staging, intersphincteric resection has become a viable alternative to abdominoperineal resection. Similarly, there is enough evidence to consider laparoscopic surgery as feasible and oncologically safe for rectal cancer. Thus laparoscopic intersphincteric resection fulfills all the objectives of modern-day rectal cancer surgery. Here we describe the technical points while performing the surgery as well as short-term results of our own series.

The impact of laparoscopic converted to open colectomy on short-term and oncologic outcomes for colon cancer

PURPOSE

This study was designed to evaluate the impact of laparoscopic converted to open colectomy on short-term and oncologic outcomes and to identify risk factors for long-term survival in patients undergoing colectomy for non-metastatic colon cancer.

METHODS

A prospective database of consecutive operations for non-metastatic colon cancer was reviewed. Patients were grouped as conversion (CONV) group, completed laparoscopic resection (LAP) group, or open resection (OPEN) group. The clinical and perioperative parameters, pathologic features, and oncologic outcomes were collected. Univariate analysis was performed for comparing these data. Patients without evidence of recurrence at last follow-up or still alive at the end of study period were censored. Kaplan-Meier curves were utilized to analyze survival. A multivariate analysis was performed to identify predictors of poor disease-free survival (DFS) and overall survival (OS).

RESULTS

The conversion rate was 15.2 %. The most common reason for conversion was locally advanced cancer (45.5 %). Converted patients were associated with a longer operative time (188 ± 29.1 min, P < 0.001), greater blood loss (147 ± 14 mL, P < 0.001), and a higher rate of intra-operative complications (15.2 %, P = 0.042) compared to the completely laparoscopic or open patients. Days to flatus, early ambulation, and length of hospitalization were significantly shorter in completed laparoscopic resection (LAP) group (P < 0.001); however, the outcomes were comparable between conversion (CONV) and open resection (OPEN) groups. The incidence of wound infection was significantly higher in the OPEN group than in the LAP group (P = 0.005), whereas there were no significant differences observed between the CONV group and the OPEN group (P = 1.000) or between the LAP group and the CONV group (P = 0.073). The 5-year DFS in CONV patients (46.5 %) was comparable to LAP patients (55.5 %, P = 0.138) and OPEN patients (59.1 %, P = 0.113). Moreover, there were no significant differences noted in terms of the 5-year OS in the CONV group (56.7 %) compared to the LAP group (67.3 %, P = 0.317) or the OPEN group (66.3 %, P = 0.420). The multivariate analysis showed that pT3-4 cancer (P < 0.001) and poor differentiation (P < 0.001) were independent predictors of both lower OS and lower DFS, whereas leakage (P = 0.008) and lack of adjuvant chemotherapy (P = 0.023) were independent risk factors only of lower DFS.

CONCLUSION

Conversion to open colectomy from an initial laparoscopic approach does not worsen the long-term survival in patients with non-metastatic colon cancer.

Current status of robotic surgery for rectal cancer: A bird's eye view

Minimally invasive surgery for rectal cancer is now widely performed via the laparoscopic approach and has been validated in randomized controlled trials to be oncologically safe with better perioperative outcomes than open surgery including shorter length of stay, earlier return of bowel function, better cosmesis, and less analgesic requirement. Laparoscopic surgery, however, has inherent limitations due to two-dimensional vision, restricted instrument motion and a very long learning curve. Robotic surgery with its superb three-dimensional magnified optics, stable retraction platform and 7 degrees of freedom of instrument movement offers significant benefits during Total Mesorectal Excision (TME) including ease of operation, markedly lower conversion rates and better quality of the specimen in addition to shorter (steeper) learning curves. This review summarizes the current evidence for the adoption of robotic TME for rectal cancer with supporting data from the literature and from the authors' own experience. All relevant articles from PubMed using the search terms listed below and published between 2000 and 2014 including randomized trials, meta-analyses, prospective studies, and retrospective reviews with substantial numbers were included.

Short-term surgical outcomes from a randomized controlled trial to evaluate laparoscopic and open D3 dissection for stage II/III colon cancer: Japan Clinical Oncology Group Study JCOG 0404

OBJECTIVE

A randomized controlled trial to confirm the non-inferiority of laparoscopic surgery to open surgery in terms of overall survival was conducted, and short-term surgical outcomes are demonstrated.

BACKGROUND

The efficacy and safety outcome of laparoscopic surgery for clinical stages II/III colon cancer undergoing Japanese D3 dissection are still unclear.

METHODS

Eligibility criteria included colon cancer; tumor located in the cecum, ascending, sigmoid, or rectosigmoid colon; T3 or T4 without involvement of other organs; N0-2; and M0. Patients were randomized preoperatively and underwent tumor resection with D3 dissection. Safety analyses were conducted by per-protocol set.

RESULTS

A total of 1057 patients were randomized between October 2004 and March 2009. By per-protocol set, 524 patients who underwent open surgery and 533 patients who underwent laparoscopic surgery were analyzed. D3 dissection was performed in 521 (99.4%) patients in the open surgery arm and 529 (99.2%) patients in the laparoscopic surgery arm. Conversion to open surgery was needed for 29 (5.4%) patients. Patients assigned to laparoscopic surgery had less blood loss (P < 0.001), although laparoscopic surgery lasted 52 minutes longer (P < 0.001). Laparoscopic surgery was associated with a shorter time to pass first flatus, decreased use of analgesics after 5 postoperative days, and a shorter hospital stay. Morbidity [14.3% (76/533) vs 22.3% (117/524), P < 0.001] was lower in the laparoscopic surgery arm.

CONCLUSIONS

Short-term surgical safety and clinical benefits of laparoscopic D3 dissection were demonstrated. The primary endpoint will be reported after the primary analysis, planned for 2014.

Conversion in mini-invasive colorectal surgery: the effect of timing on short term outcome

INTRODUCTION

Different results have been reported about postoperative outcomes of conversion during laparoscopic colorectal surgery. We aimed to detect the effect of conversion on postoperative outcome and to identify features associated to better outcome after conversion.

METHODS

Two hundred-fourteen mini-invasive left colonic and rectal resections were retrospectively analysed. Two groups were identified: mini-invasive colorectal surgery (MI) that includes both laparoscopic and robotic resections, and conversion to open surgery.

RESULTS

Among 214 colorectal procedures, 189 were MI. Conversion rate was 11.7%. Operating time was shorter for MI at overall analysis (p 0.003) and sub-analysis of left colectomies (p 0.001). MI procedures had shorter hospital stay (p 0.000) both in left colectomy and rectal resection (p 0.008 and p 0.001 respectively). A shorter time to first flatus emission was detected in MI group in both overall analysis (p 0.003) and procedure's sub-analysis (left colectomy p 0.032; anterior rectal resection p 0.040). Oral feeding was resumed earlier after mini-invasive rectal resections (p 0.014). Converted procedures required more blood transfusions (p 0.000) and grade II complication rate was lower after MI procedures (p 0.013). Conversion presented higher anastomotic leakage and reoperation rates (p 0.035 and p 0.006 respectively). Conversion before 105 min (early conversion) had a significant lower number of blood transfusions (p 0.047).

CONCLUSIONS

Conversion is associated to higher rate of blood transfusions, grade II complication and slower recovery. Earlier conversion has better outcomes. Colorectal surgeons should identify any critical aspects that could avoid late conversion allowing reducing negative effects of conversion.

Laparoscopic surgery for rectal cancer: current status and future perspective

Although laparoscopic surgery for colon cancer is accepted in the treatment guidelines, the laparoscopic approach for rectal cancer is recommended only in clinical trials. Thus far, several trials have shown favorable short-term results such as early recovery and short hospital stay, but long-term results remain a critical concern for laparoscopic rectal cancer surgery. To date, no randomized control trials have shown an increased local recurrence after laparoscopic surgery for rectal cancer. Additionally, according to previous studies, open conversion, which is more frequent in laparoscopic rectal surgery than in laparoscopic colon surgery, may affect short-term and long-term survival. The evidence on male sexual function has been contradictory. Long-term results from ongoing multicenter trials will be available within several years. Based on accumulated evidence from well-organized clinical trials, laparoscopic surgery will likely be accepted as a treatment choice for rectal cancer. In the future, extended laparoscopic rectal surgery might be feasible for additional procedures such as laparoscopic lateral pelvic lymph node dissection and laparoscopic total pelvic exenteration for rectal cancer invading the adjacent pelvic organ.

Minimally invasive surgery for rectal cancer

Rectal cancer remains a common and complex surgical problem. There is growing evidence that minimally invasive surgery (MIS) can provide ideal care for patients with rectal cancer. This review examines the short- and long-term benefits to MIS for rectal cancer, as well as the current techniques available, and how wider adoption of these techniques may be performed.

Influence of conversion on the perioperative and oncologic outcomes of laparoscopic resection for rectal cancer compared with primarily open resection

BACKGROUND

This study aimed to evaluate the influence of conversion on perioperative and short- and long-term oncologic outcomes in laparoscopic resection for rectal cancer and to compare these with those for an open control group.

METHODS

The data of 276 consecutive patients who underwent surgery for rectal cancer between 2006 and 2010 at a single institution were prospectively collected. Of the 276 patients, 114 underwent primarily open surgery, and 162 underwent laparoscopic surgery (on an intention-to-treat basis). Of the 162 laparoscopic patients, 38 (23.5%) underwent conversion to open surgery. The three groups of patients were compared: the conversion surgery group, the open surgery group, and the completed laparoscopy surgery group.

RESULTS

The converted patients had more wound infections (18.4 vs 4.8%, p = 0.009), but the wound infection rate in the primarily open group also was significantly higher than in the laparoscopic resection group (p = 0.007). No further differences in perioperative morbidity, including anastomotic leakage, were found. The perioperative 30-day mortality rate was comparable between all the groups (0.6 vs 2.6 vs 2.6%, nonsignificant difference). The oncologic parameters such as number of harvested lymph nodes and rate of R0 resection were equal in all the groups. The completed laparoscopy group had a shorter hospital stay [12 vs 16 days in the primarily open group (p = 0.02) vs 15 days in the converted group (p = 0.03)]. The rates for survival, local recurrence (4.5 vs 3 vs 3%), and metachronous metastasis (10.1 vs 9.3 vs 9%) did not differ significantly between the three groups after a period of 3 years.

CONCLUSION

Conversion to open surgery in laparoscopic rectal resection has no negative effect on perioperative or long-term oncologic outcome.