Minimal access surgery for rectal cancer: an update

Laparoscopic versus open surgery in obstructive colorectal cancer patients following stents placement: a comprehensive meta-analysis of cohort studies

BACKGROUND

Over the past decade, the use of stent placement as a bridge to surgery (BTS) has emerged as an alternative to emergency surgery for patients with (OCRC). However, the optimal surgical approach remains indeterminate. This study seeks to evaluate the safety and feasibility of a combined treatment modality involving stent placement and laparoscopic surgery for OCRC presenting with malignant obstruction.

METHODS

A comprehensive search of PubMed, Cochrane Library, EMBASE, Web of Science, and ClinicalTrials.gov was conducted until June 2023 to identify studies that compared laparoscopic to open surgery in patients with OCBC following stent insertion.

RESULTS

The meta-analysis incorporated 12 cohort studies, encompassing 933 patients. There was no statistically significant difference in the 30-day mortality rates between the two groups (relative risk [RR], 1.09; 95% confidence interval [CI] 0.26 to 4.48; P = 0.95). Compared to the laparoscopic approach group, the open approach group had a higher rate of overall postoperative complications (POCs) (RR 0.52; 95% CI 0.37 to 0.72, P < 0.0001). There was no significant variance in lymph node (LN) dissection number between the groups (mean differences [MD], 1.64; 95% CI - 1.51 to 4.78; P = 0.31). Notably, laparoscopic surgery resulted in less intraoperative blood loss (MD, - 25.84 ml; 95% CI - 52.16 to 0.49; P = 0.05) and a longer operation time (MD, 20.99 mins; 95% CI 2.31 to 39.44; P = 0.03). The laparoscopic approach was associated with a shorter length of hospital stay (LOS) (MD - 3.29 days; 95% CI - 5.27 to 1.31; P = 0.001). Conversely, the open approach group had a higher rate of postoperative surgical site infection (SSI) (RR 0.47; 95% CI 0.23 to 0.96, P = 0.04). Although the number of included studies was insufficient to conduct a meta-analysis, several of them imply that laparoscopic surgery may yield more favorable outcomes in terms of the 3-year overall survival rate (OS), 3-year disease-free survival rate (DFS), 5-year OS, and 5-year DFS when compared to open surgery. It is worth noting that these differences lack statistical significance.

CONCLUSION

In patients with OCRC subjected to stent insertion, laparoscopic surgery arguably presents a modest superiority over open surgery by diminishing the overall postoperative risk and potentially reducing the LOS.

Clinical Outcomes of Ileostomy Closure during versus after Adjuvant Chemotherapy in Patients with Rectal Cancer

Background

Protective ileostomy can effectively prevent severe anastomotic leakage after rectal cancer surgery; however, the optimal timing for ileostomy closure during adjuvant chemotherapy remains unclear. This study aimed to explore the safety and long-term outcomes of early ileostomy closure during adjuvant chemotherapy.

Method

Patients who underwent laparoscopic rectal cancer surgery combined with protective ileostomy and adjuvant chemotherapy between April 2017 and April 2021 were retrospectively evaluated. Patients were divided into an early closure group during chemotherapy (group A) and a late closure group after chemotherapy (group B).

Results

A total of 215 patients were included in this study, with 115 in group A and 100 in group B. There were no significant differences in demographic and clinical characteristics between the two groups. In group A, durations of stoma status (p < 0.001) and low anterior resection syndrome (LARS) (p < 0.001) were shorter, and rectal stenosis (p=0.036) and stoma-related complications (p=0.007), especially stoma stenosis (p=0.041), were less common. However, compliance with chemotherapy was worse (p=0.009). There were no significant differences in operative time, postoperative hospital stay, postoperative complications, incidence and severity of LARS, disease-free survival, or overall survival between groups.

Conclusion

Early ileostomy closure can effectively reduce the duration of stoma status, duration of LARS, rectal stenosis, and stoma-related complications while not affecting surgical complications and oncological outcomes. Ileostomy closure should not be delayed because of adjuvant chemotherapy. However, follow-up should be strengthened to increase compliance and integrity with chemotherapy.

Muscle quality, not quantity, is associated with outcome after colorectal cancer surgery

INTRODUCTION

Emerging evidence suggests that deconditioned patients benefit most from prehabilitation before colorectal cancer surgery. So far, selecting patients with poor muscle status and high perioperative risk remains challenging. Therefore, this study evaluates the potential of the CT-derived Skeletal Muscle Index (SMI), representing muscle mass, and of the Muscle Radiation Attenuation (MRA), a measure of muscle quality, for risk stratification in colorectal cancer patients.

METHODS

In this retrospective, single-center observational study, 207 patients with resection of colorectal adenocarcinoma between January 2016 and December 2020 were included. The Charlson comorbidity index (CCI), postoperative complications, length of hospital stay, and survival were recorded. Data were analyzed using multivariable linear, logistic, and Cox proportional hazards regression models adjusted for age, sex, BMI, CCI, neoadjuvant therapy, tumor stage, and surgery type.

RESULTS

An increase of the MRA was associated with fewer postoperative complications (anastomotic leakage and pneumonia) and lesser severity according to the Clavien-Dindo classification, shorter hospital stays, and prolonged survival (Hazard ratio: 0.63 [95%CI: 0.49-0.81], p < 0.001). No relevant associations were found between the SMI and postoperative complications, length of hospital stay, or survival.

CONCLUSION

The easy-to-raise MRA serves as a more reliable tool than the SMI for identifying high-risk patients with poor muscle status before colorectal surgery. Those patients may benefit most from prehabilitation, which has to be proven in future interventional trials.

Pitfalls and promises of bile duct alternatives: A narrative review

Biliodigestive anastomosis between the extrahepatic bile duct and the intestine for bile duct disease is a gastrointestinal reconstruction that abolishes duodenal papilla function and frequently causes retrograde cholangitis. This chronic inflammation can cause liver dysfunction, liver abscess, and even bile duct cancer. Although research has been conducted for over 100 years to directly repair bile duct defects with alternatives, no bile duct substitute (BDS) has been developed. This narrative review confirms our understanding of why bile duct alternatives have not been developed and explains the clinical applicability of BDSs in the near future. We searched the PubMed electronic database to identify studies conducted to develop BDSs until December 2021 and identified studies in English. Two independent reviewers reviewed studies on large animals with 8 or more cases. Four types of BDSs prevail: Autologous tissue, non-bioabsorbable material, bioabsorbable material, and others (decellularized tissue, 3D-printed structures, etc.). In most studies, BDSs failed due to obstruction of the lumen or stenosis of the anastomosis with the native bile duct. BDS has not been developed primarily because control of bile duct wound healing and regeneration has not been elucidated. A BDS expected to be clinically applied in the near future incorporates a bioabsorbable material that allows for regeneration of the bile duct outside the BDS.

PAI1 is a Marker of Bad Prognosis in Rectal Cancer but Predicts a Better Response to Treatment with PIM Inhibitor AZD1208

Colorectal cancer (CRC) is the third most common cancer worldwide. The standard treatment in locally advanced rectal cancer is preoperative radiation alone or in combination with chemotherapy, followed by adjuvant chemotherapy. Rectal cancer is highly lethal, with only 20% of patients showing a complete remission (by RECIST) after standard treatment, although they commonly show local or systemic relapse likely due to its late detection and high chemotherapy resistance, among other reasons. Here, we explored the role of PAI1 (Serpin E1) in rectal cancer through the analyses of public patient databases, our own cohort of locally advanced rectal cancer patients and a panel of CRC cell lines. We showed that PAI1 expression is upregulated in rectal tumors, which is associated with decreased overall survival and increased metastasis and invasion in advanced rectal tumors. Accordingly, PAI1 expression is correlated with the expression of (Epithelial-to-Mesenchymal Transition) EMT-associated genes and genes encoding drug targets, including the tyrosine kinases PDGFRb, PDGFRa and FYN, the serine/threonine kinase PIM1 and BRAF. In addition, we demonstrate that cells expressing PAI1 protein are more sensitive to the PIM inhibitor AZD1208, suggesting that PAI1 could be used to predict response to treatment with PIM inhibitors and to complement radiotherapy in rectal tumors.

Laparoscopic Complete Mesocolic Excision for Right-Sided Colon Cancer: Analysis of Feasibility and Safety from a Single Western Center

BACKGROUND

Colectomies performed according to complete mesocolic excision (CME) principles have demonstrated an improvement in the quality of surgical specimen and a potential improvement of long-term results. Laparoscopic CME right hemicolectomy is considered a demanding procedure and adopted in few centers from the West. The main purpose of this paper is to present a video showing our technique for laparoscopic CME right hemicolectomy and to analyze our short-term results to prove its safety.

METHODS

Data from 38 patients operated on at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, between September 2014 and February 2017, were included in the study.

RESULTS

In the present series, 37% of patients were ≥75 years old, 32% of patients were ASA class 3, 46% of patients had ≥2 comorbidities, 30% of patients had BMI >28 and 17% of patients had ≥2 previous abdominal surgeries. Despite these unfavorable clinic characteristics, no mortality was observed, Clavien-Dindo ≥3 complications occurred in 13.1% and redo surgery in 5.3%. Good quality specimens were obtained with a mean (SD) length of 34.5±7.5 cm, a proximal margin of 16.8±9.2 cm and a distal margin of 14.3±6.4 cm. The mean (SD) number of harvested lymph nodes was 24.3 (8.3).

CONCLUSIONS

When implemented in a Western center, laparoscopic CME right hemicolectomy is feasible and safe and allows obtaining good quality specimens.

Laparoscopic-Assisted Resection for Advanced Colorectal Cancer in Solid Organ Transplant Recipients

AIM

To evaluate the feasibility, short- and long-term outcomes, and safety of laparoscopic resection for advanced colorectal cancer (CRC) in solid organ transplant recipients.

METHODS

Between September 2001 and April 2016, five patients who underwent laparoscopic-assisted resection for CRC after solid organ transplantation were included in this study. Their clinical data were retrospectively analyzed with regard to patient demographics, immunosuppressive therapy, tumor characteristics, surgical outcomes, and follow-up data.

RESULTS

Four kidney and one heart transplant recipients were included. Laparoscopic-assisted low anterior resection was performed in four patients with rectal or rectosigmoid junction cancer, and sigmoidectomy was done in one with sigmoid colon cancer. One kidney transplant patient received a protective loop transverse colostomy. All resections achieved complete tumor removal with tumor-free margins and total mesorectal excision, with an average number of 14 lymph nodes harvested. Most tumors were in stage III (n = 3), one was in stage II, and one in stage IV. The mean duration of surgery, intraoperative blood loss, and postoperative hospital stay were 144 min, 105 mL, and 8.8 days, respectively. No major complications occurred and graft function stayed well. During a mean follow-up period of 62 months, two patients developed metastasis and died eventually.

CONCLUSION

Laparoscopic resection for advanced CRC in organ transplant recipients is technically feasible and therapeutically safe, and seems to have the advantages of few postoperative complications, short recovery time, and acceptable oncological outcomes.

The effect of surgical approach on short-term oncologic outcomes in rectal cancer surgery

BACKGROUND

Although evidence to support the use of laparoscopic and robotic approaches for the treatment of rectal cancer is limited, these approaches are being adopted broadly. We sought to investigate national practice patterns and compare short-term oncologic outcomes of different approaches for rectal cancer resections.

METHODS

The 2010 National Cancer Database was queried for operative cases of rectal cancer. Approach was classified as open, laparoscopic, or robotic. Patient, tumor, and hospital characteristics and surgical margin status were evaluated. Propensity score matching was used to compare outcomes across approaches.

RESULTS

We identified 8,712 patients. Laparoscopic and robotic approaches were more common in privately insured and wealthier patients at high-volume centers (P < .001). Open approaches were used for tumors with higher histologic grade and pathologic stage (P < .001). A minimally invasive approach was associated with fewer positive margins and shorter hospital stays. After propensity score matching, the laparoscopic approach was associated with a 2.0% lesser (P = .01) and robotic surgery with a 3.8% lesser (P = .004) incidence of positive margins compared with open surgery.

CONCLUSION

An open approach is often used in rectal cancers with higher pathologic stages. Matched patient analysis suggests minimally invasive approaches are associated with improved R0 resections.

Robotic right colectomy: A worthwhile procedure? Results of a meta-analysis of trials comparing robotic versus laparoscopic right colectomy

BACKGROUND:

Robotic right colectomy (RRC) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach is worthwhile in enhancing patient recovery and reducing post-operative complications, compared with laparoscopic right colectomy (LRC). Literature is still fragmented and no meta-analyses have been conducted to compare the two procedures. This work aims at reducing this gap in literature, in order to draw some preliminary conclusions on the differences and similarities between RRC and LRC, focusing on short-term outcomes.

MATERIALS AND METHODS:

A systematic literature review was conducted to identify studies comparing RRC and LRC, and meta-analysis was performed using a random-effects model. Peri-operative outcomes (e.g., morbidity, mortality, anastomotic leakage rates, blood loss, operative time) constituted the study end points.

RESULTS:

Six studies, including 168 patients undergoing RRC and 348 patients undergoing LRC were considered as suitable. The patients in the two groups were similar with respect to sex, body mass index, presence of malignant disease, previous abdominal surgery, and different with respect to age and American Society of Anesthesiologists score. There were no statistically significant differences between RRC and LRC regarding estimated blood loss, rate of conversion to open surgery, number of retrieved lymph nodes, development of anastomotic leakage and other complications, overall morbidity, rates of reoperation, overall mortality, hospital stays. RRC resulted in significantly longer operative time.

CONCLUSIONS:

The RRC procedure is feasible, safe, and effective in selected patients. However, operative times are longer comparing to LRC and no advantages in peri-operative and post-operative outcomes are demonstrated with the use of the robotic surgical system.

Laparoscopic and robotic total mesorectal excision in the treatment of rectal cancer. Brief review and personal remarks

The current standard treatment for rectal cancer is based on a multimodality approach with preoperative radiochemotherapy in advanced cases and complete surgical removal through total mesorectal excision (TME). The most frequent surgical approach is traditional open surgery, as laparoscopic TME requires high technical skill, a long learning curve, and is not widespread, still being confined to centers with great experience in minimally invasive techniques. Nevertheless, in several studies, the laparoscopic approach, when compared to open surgery, has shown some better short-term clinical outcomes and at least comparable oncologic results. Robotic surgery for the treatment of rectal cancer is an emerging technique, which could overcome some of the technical difficulties posed by standard laparoscopy, but evidence from the literature regarding its oncologic safety and clinical outcomes is still lacking. This brief review analyses the current status of minimally invasive surgery for rectal cancer therapy, focusing on oncologic safety and the new robotic approach.