Impact of the introduction and training of total mesorectal excision on recurrence and survival in rectal cancer in The Netherlands

Clinical application of eight-zone laparoscopic dissection strategy for rectal cancer: Experience and discussion

BACKGROUND

The incidence of rectal cancer is increasing worldwide, and surgery remains the primary treatment modality. With the advent of total mesorectal excision (TME) technique, the probability of tumor recurrence post-surgery has significantly decreased. Surgeons' focus has gradually shifted towards minimizing the impact of surgery on urinary and sexual functions. Among these concerns, the optimal dissection of the rectal lateral ligaments and preservation of the pelvic floor neurovascular bundle have become critical. To explore the optimal surgical technique for TME and establish a standardized surgical protocol to minimize the impact on urinary and sexual functions, we propose the eight-zone dissection strategy for pelvic floor anatomy.

AIM

To compare the differences in surgical specimen integrity and postoperative quality of life satisfaction between the traditional pelvic floor dissection strategy and the innovative eight-zone dissection strategy.

METHODS

We analyzed the perioperative data of patients who underwent laparoscopic radical resection of rectal cancer at Qilu Hospital of Shandong University between January 1, 2021 and December 1, 2023. This study included a total of 218 patients undergoing laparoscopic radical surgery for rectal cancer, among whom 109 patients underwent traditional pelvic floor dissection strategy, and 109 patients received the eight-zone dissection strategy.

RESULTS

There were no significant differences in general characteristics between the two groups. Patients in the eight-zone dissection group had higher postoperative specimen integrity (88.1% vs 78.0%, P = 0.047). At the 3-month follow-up, patients in the eight-zone surgery group had better scores in urinary issues (6.8 ± 3.3 vs 5.3 ± 2.5, P = 0.045) and male sexual desire (2.2 ± 0.6 vs 2.5 ± 0.5, P = 0.047) compared to the traditional surgery strategy group.

CONCLUSION

This study demonstrates that the eight-zone dissection strategy for laparoscopic lateral ligament dissection of rectal cancer is safe and effective. Compared with the traditional pelvic floor dissection strategy, this approach can reduce the risk of nerve injury and minimize the impact on urinary and sexual functions. Therefore, we recommend the clinical application of this strategy to better serve patients with rectal cancer.

Total mesorectal excision in MRI-defined low rectal cancer: multicentre study comparing oncological outcomes of robotic, laparoscopic and transanal total mesorectal excision in high-volume centres

BACKGROUND

The routine use of MRI in rectal cancer treatment allows the use of a strict definition for low rectal cancer. This study aimed to compare minimally invasive total mesorectal excision in MRI-defined low rectal cancer in expert laparoscopic, transanal and robotic high-volume centres.

METHODS

All MRI-defined low rectal cancer operated on between 2015 and 2017 in 11 Dutch centres were included. Primary outcomes were: R1 rate, total mesorectal excision quality and 3-year local recurrence and survivals (overall and disease free). Secondary outcomes included conversion rate, complications and whether there was a perioperative change in the preoperative treatment plan.

RESULTS

Of 1071 eligible rectal cancers, 633 patients with low rectal cancer were identified. Quality of the total mesorectal excision specimen (P = 0.337), R1 rate (P = 0.107), conversion (P = 0.344), anastomotic leakage rate (P = 0.942), local recurrence (P = 0.809), overall survival (P = 0.436) and disease-free survival (P = 0.347) were comparable among the centres. The laparoscopic centre group had the highest rate of perioperative change in the preoperative treatment plan (10.4%), compared with robotic expert centres (5.2%) and transanal centres (2.1%), P = 0.004. The main reason for this change was stapling difficulty (43%), followed by low tumour location (29%). Multivariable analysis showed that laparoscopic surgery was the only independent risk factor for a change in the preoperative planned procedure, P = 0.024.

CONCLUSION

Centres with expertise in all three minimally invasive total mesorectal excision techniques can achieve good oncological resection in the treatment of MRI-defined low rectal cancer. However, compared with robotic expert centres and transanal centres, patients treated in laparoscopic centres have an increased risk of a change in the preoperative intended procedure due to technical limitations.

Evolution of clinical nature, treatment and survival of locally recurrent rectal cancer: Comparative analysis of two national cross-sectional cohorts

BACKGROUND

In the Netherlands, use of neoadjuvant radiotherapy for rectal cancer declined after guideline revision in 2014. This decline is thought to affect the clinical nature and treatability of locally recurrent rectal cancer (LRRC). Therefore, this study compared two national cross-sectional cohorts before and after the guideline revision with the aim to determine the changes in treatment and survival of LRRC patients over time.

METHODS

Patients who underwent resection of primary rectal cancer in 2011 (n = 2094) and 2016 (n = 2855) from two nationwide cohorts with a 4-year follow up were included. Main outcomes included time to LRRC, synchronous metastases at time of LRRC diagnosis, intention of treatment and 2-year overall survival after LRRC.

RESULTS

Use of neoadjuvant (chemo)radiotherapy for the primary tumour decreased from 88.5% to 60.0% from 2011 to 2016. The 3-year LRRC rate was not significantly different with 5.1% in 2011 (n = 114, median time to LRRC 16 months) and 6.3% in 2016 (n = 202, median time to LRRC 16 months). Synchronous metastasis rate did not significantly differ (27.2% vs 33.7%, p = 0.257). Treatment intent of the LRRC shifted towards more curative treatment (30.4% vs. 47.0%, p = 0.009). In the curatively treated group, two-year overall survival after LRRC diagnoses increased from 47.5% to 78.7% (p = 0.013).

CONCLUSION

Primary rectal cancer patients in 2016 were treated less often with neoadjuvant (chemo)radiotherapy, while LRRC rates remained similar. Those who developed LRRC were more often candidate for curative intent treatment compared to the 2011 cohort, and survival after curative intent treatment also improved substantially.

Trends and Variation in the Use of Radiotherapy in Non-metastatic Rectal Cancer: a 14-year Nationwide Overview from the Netherlands

AIMS

This study describes nationwide primary radiotherapy utilisation trends for non-metastasised rectal cancer in the Netherlands between 2008 and 2021. In 2014, both colorectal cancer screening and a new guideline specifying prognostic risk groups for neoadjuvant treatment were implemented.

MATERIALS AND METHODS

Patients with non-metastasised rectal cancer in 2008-2021 (n = 37 510) were selected from the Netherlands Cancer Registry and classified into prognostic risk groups. Treatment was studied over time and age. Multilevel logistic regression analyses were carried out to identify factors associated with (i) radiotherapy versus chemoradiotherapy use for intermediate rectal cancer and (ii) chemoradiotherapy without versus with surgery for locally advanced rectal cancer.

RESULTS

For early rectal cancer, the use of neoadjuvant radiotherapy decreased (15% to 5% between 2008 and 2021), whereas the use of endoscopic resections increased (8% in 2015, 17% in 2021). In intermediate-risk rectal cancer, neoadjuvant chemoradiotherapy (43% until 2011, 25% in 2015) shifted to radiotherapy (42% in 2008, 50% in 2015), the latter being most often applied in older patients. In locally advanced rectal cancer, the use of chemoradiotherapy without surgery increased (2-4% in 2008-2013, 17% in 2019-2021). Both neoadjuvant treatment in intermediate disease and omission of surgery following chemoradiotherapy in locally advanced disease varied with increasing age (odds ratio>75vs<50: 2.17, 95% confidence interval 1.54-3.06) and treatment region (Southwest and Northwest odds ratio 0.63, 95% confidence interval 0.42-0.93 and odds ratio 0.65, 95% confidence interval 0.44-0.95, respectively, compared with the North).

CONCLUSION

Treatment patterns in non-metastasised rectal cancer significantly changed over time. Effects of both the national screening programme and the new treatment guideline were apparent, as well as a paradigm shift towards organ preservation (watch-and-wait). Observed regional variations may indicate adoption differences regarding new treatment strategies.

Perioperative and long-term oncological outcomes of robotic versus laparoscopic total mesorectal excision: a retrospective study of 672 patients

Although there's growing information about the long-term oncological effects of robotic surgery for rectal cancer, the procedure is still relatively new. This study aimed to assess the long-term oncological results of total mesorectal excision (TME) performed laparoscopically versus robotically in the setting of rectal cancer. Restrospective analysis of a prospectively maintained database. A total of 489 laparoscopic (L-TME) and 183 robotic total mesorectal excisions (R-TME) were carried out by a single surgeon between 2013 and 2023. The groups were compared in terms of perioperative and long-term oncological outcomes. In the R-TME and L-TME groups, male sex predominated (75.4% and 57.3%, respectively), although the robotic group was significantly greater (p = 0.008). There was no conversion in R-TME group, whereas three (0.6%) converted to open surgery in L-TME group. The R-TME group had a statistically significant higher number of distal rectal tumors (85%) compared to the L-TME group (54.6%). Only three (1.7%) patients in the R-TME group received abdomineperineal resection (APR); in contrast, 25 (5%) patients in the L-TME group received APR (p < 0.001). For R-TME, the mean follow-up was 70.7 months (range 18-138) and for L-TME, it was 60 months (range 14-140). Frequency of completed mesorectum was significantly greater in R-TME group (98.9% vs 94.2%, p < 0.001). The 5 year overall survival rates for R-TME and L-TME groups were 89.6% and 88.7%, respectively. The 5 year disease-free survival for R-TME and L-TME groups were 84.1% and 81.1%, respectively. The local recurrences rates were 7.6% and 6.3%, respectively in R-TME and L-TME groups (p = 0.274). R-TME is characterized by no conversion and improved mesorectal integrity. R-TME had longer operation time. The long-term oncological outcomes were comparable between groups.

Experience of a single academic institution with the National Accreditation Program for Rectal Cancer and the resulting improvement in care

AIM

The American College of Surgeons Committee on Cancer developed the National Accreditation Program for Rectal Cancer (NAPRC) to reduce variations in rectal cancer care, standardize clinical practice and encourage multidisciplinary approaches. The aim of this study was to analyse if accreditation achieved a higher quality of care at one hospital.

METHOD

The University of California Davis Medical Center was accredited in 2019. A retrospective review of rectal adenocarcinoma patients was performed between the years 2013 and 2018. Patients presenting from 2013 to 2015 were discussed at a gastrointestinal tumour board while patients in 2018 had an accredited rectal cancer tumour board. Patients from 2016 to 2017 were excluded as the programme was still developing. Compliance to the NAPRC standards was compared between the cohorts.

RESULTS

One hundred and thirty patients were evaluated, 88 (68%) in the prerectal tumour board cohort and 42 (32%) in the rectal tumour board cohort. The prerectal tumour board cohort often failed to meet attendance standards. All patients in the rectal tumour board cohort met all criteria. Similarly, clinical service compliance improved in the rectal tumour board cohort for 13 metrics, 10 of which were statistically significant. Although a high proportion of patients in both groups experienced quality surgery, i.e. complete total mesorectal excision and negative margins, the lack of complete pathological reporting in the prerectal tumour board cohort limited analysis.

CONCLUSION

Multidisciplinary rectal cancer tumour boards are associated with improved compliance with recommended care by the NAPRC. Patients discussed at a rectal cancer tumour board were more likely to receive appropriate staging, coordinated care and have better clinical documentation.

A retrospective study analyzing if lymph node ratio carbon nanoparticles predict stage III rectal cancer recurrence

Background

Lymph node ratio has garnered increasing attention as a prognostic marker for rectal cancer; however, few studies have investigated the relationship between lymph node ratio and rectal cancer recurrence. Additionally, Carbon Nanoparticle tracking is a safe and effective strategy for locating tumors and tracking lymph nodes. However, no studies have reported the relationship between Carbon Nanoparticles and rectal cancer recurrence.

Methods

Patients with stage III rectal cancer who underwent radical resection between January 2016 and 2020 were analyzed. The primary outcome was tumor recurrence. 269 patients with stage III rectal cancer were included in this study. The effects of lymph node ratio, Carbon Nanoparticles, and other clinicopathological factors on rectal cancer recurrence were assessed using univariate, multivariate analyses and the t-test.

Results

Univariate analysis determined tumor recurrence using cytokeratin 19 fragment, CA-199, CEA, N-stage, positive lymph nodes, total lymph nodes, and lymph node ratio(positive/total); with the lymph node ratio being the most relevant. Receiver operating characteristic (ROC) analysis determined lymph node ratio =0.38 as the optimal cutoff value. The analysis of lymph node ratio ≥0.38 and <0.38 showed statistical differences in three indicators: tumor recurrence, CEA, and use of Carbon Nanoparticles.

Conclusion

Lymph node ratio is a strong predictor of stage III rectal cancer recurrence and may be considered for inclusion in future tumor-node-metastasis staging and stage III rectal cancer stratification. In addition, we found that Carbon Nanoparticles use significantly increased total lymph nodes and decreased lymph node ratio.

A Space Expander of Laparoscopic Rectal Cancer Surgery for Overweight or Obese Patients

BACKGROUND/NEED

Laparoscopic rectal cancer surgery (LRCS) has become a preferred approach for its minimal invasion and fast postoperative recovery. But it is challenging for the tumors of the middle and lower rectum, especially for overweight or obese patients.

METHODOLOGY

We present a space expander of laparoscopic rectal cancer surgery, which is a simple tool to widen the perirectal space, as to facilitate the procedure of total mesorectal excision (TME) during the rectal cancer surgery. It has several advantages of lower demand for an assistant, less risk of surgical complications and good feasibility.

DEVICE DESCRIPTION

It is designed as a cylindrical shape, and it is the first invented device to help surgeons safely perform accurate TME on overweight or obese patients during LRCS. With this method, we are able to dissect the rectal wall circumferentially in a safe and quick way.

PRELIMINARY RESULTS

Our previous pig experiments indicated that the learning curve for this technique was as short as 10 minutes.

CURRENT STATUS

Further clinical trials will be conducted on its efficacy and safety in the future.

Meeting the New Commission on Cancer Operative Standards: Where Do We Stand Now?

INTRODUCTION

The 2020 Commission on Cancer accreditation standards 5.7 and 5.8 address total mesorectal excision for rectal cancer and lymph node sampling for lung cancer. The purpose of this review was to assess our institution's compliance with these operative standards, which will be required in 2022 and 2023, and provide recommendations to other military training facilities seeking to comply with these standards.

MATERIALS AND METHODS

A 2018-2020 single institution chart review was performed of operative and pathology reports. Identified deficits were addressed in meetings with colorectal and thoracic surgery leadership, and cases were followed to reassess compliance.

RESULTS

A total of 12 rectal and 48 lung cancer cases met the inclusion criteria and were examined. Pre-intervention compliance for standards 5.7 and 5.8 was 58% and 35%, respectively, because of inadequate synoptic reporting and lymph node sampling. After intervention, compliance was 100%.

CONCLUSIONS

Our institution requires changes to comply with new standards, including in areas of documentation and systematic pulmonary lymph node sampling. We provide lessons learned from our own institutional experience, including practical tips and recommendations to achieve compliance. All military training facilities performing lung and rectal oncologic resections should conduct an internal review of applicable cases in preparation for upcoming American College of Surgeons Commission on Cancer site visits.

Application and evaluation of transitory protective stoma in ovarian cancer surgery

Ovarian cancer is the most fatal of all female reproductive cancers. The fatality rate of OC is the highest among gynecological malignant tumors, and cytoreductive surgery is a common surgical procedure for patients with advanced ovarian cancer. To achieve satisfactory tumor reduction, intraoperative bowel surgery is often involved. Intestinal anastomosis is the traditional way to restore intestinal continuity, but the higher rate of postoperative complications still cannot be ignored. Transitory protective stoma can reduce the severity of postoperative complications and traumatic stress reaction and provide the opportunity for conservative treatment. But there are also many problems, such as stoma-related complications and the impact on social psychology. Therefore, it is essential to select appropriate patients according to the indications for the transitory protective stoma, and a customized postoperative care plan is needed specifically for the stoma population.

Implementation of robotic rectal cancer surgery: a cross-sectional nationwide study

AIM

An increasing number of centers have implemented a robotic surgical program for rectal cancer. Several randomized controls trials have shown similar oncological and postoperative outcomes compared to standard laparoscopic resections. While introducing a robot rectal resection program seems safe, there are no data regarding implementation on a nationwide scale. Since 2018 robot resections are separately registered in the mandatory Dutch Colorectal Audit. The present study aims to evaluate the trend in the implementation of robotic resections (RR) for rectal cancer relative to laparoscopic rectal resections (LRR) in the Netherlands between 2018 and 2020 and to compare the differences in outcomes between the operative approaches.

METHODS

Patients with rectal cancer who underwent surgical resection between 2018 and 2020 were selected from the Dutch Colorectal Audit. The data included patient characteristics, disease characteristics, surgical procedure details, postoperative outcomes. The outcomes included any complication within 90 days after surgery; data were categorized according to surgical approach.

RESULTS

Between 2018 and 2020, 6330 patients were included in the analyses. 1146 patients underwent a RR (18%), 3312 patients a LRR (51%), 526 (8%) an open rectal resection, 641 a TaTME (10%), and 705 had a local resection (11%). The proportion of males and distal tumors was higher in the RR compared to the LRR. Over time, the proportion of robotic procedures increased from 15% (95% confidence intervals (CI) 13-16%) in 2018 to 22% (95% CI 20-24%) in 2020. Conversion rate was lower in the robotic group [4% (95% CI 3-5%) versus 7% (95% CI 6-8%)]. Anastomotic leakage rate was similar with 16%. Defunctioning ileostomies were more common in the RR group [42% (95% CI 38-46%) versus 29% (95% CI 26-31%)].

CONCLUSION

Rectal resections are increasingly being performed through a robot-assisted approach in the Netherlands. The proportion of males and low rectal cancers was higher in RR compared to LRR. Overall outcomes were comparable, while conversion rate was lower in RR, the proportion of defunctioning ileostomies was higher compared to LRR.

Operative and Pathological Factors in Right-Sided Colon Cancers: How Can We Improve the Outcomes?

INTRODUCTION

Though the tumour-node-metastasis staging classification is the standard approach to risk stratification in patients with colorectal cancer, several other important variables including the presence of extramural venous invasion (EMVI), the tumour mismatch repair status, as well as surgical technique and its influence on lymph node yield all have an impact on long-term survival. This study aims to review both the impact of the type of operation on lymph node yield: complete mesocolic excision (CME) versus right hemicolectomy, and the impact of EMVI and microsatellite instability in predicting overall survival in patients undergoing a right hemicolectomy for colon cancer.

METHODS

Data of all patients who underwent an elective or emergency right hemicolectomy with curative intent for colon cancer between January 2013 and June 2022 (inclusive) was collected for this single-centre retrospective study. Kaplan-Meier survival curves were calculated using the Statistical Package for the Social Sciences (SPSS version 28, IBM Corp., Armonk, NY) software, and the log-rank (Mantel-Cox) test was used to compare survival distribution between different groups.

RESULTS

A total of 421 patients underwent a right hemicolectomy for colon cancer with curative intent during the study period. EMVI was present in 173 (41%) tumours. Survival analysis showed significantly reduced cancer-related survival in patients with EMVI-positive tumours (p < 0.001), with five-year survival rates of 70% in EMVI-positive groups versus 96% in EMVI-negative groups. Subgroup analysis showed a significant difference in survival between node-positive and node-negative tumours in cancers found to have EMVI (p < 0.001). Mean lymph node yield was significantly higher in the CME group versus the standard right hemicolectomy group (p < 0.001). We found no significant difference in survival between patients with microsatellite instability-high (MSI-H) tumours and microsatellite stable (MSS) tumours (p = 0.432).

CONCLUSION

Consideration of tumour biology and adopting the optimum surgical technique are factors that may influence long-term survival in patients with colorectal cancer. Extramural venous invasion is an important prognostic indicator of adverse outcomes in patients with right-sided colon cancer. Our study demonstrates a reduction in survival in patients with EMVI-positive tumours when undertaking subgroup analysis by the presence or absence of nodal disease. Further research needs to be undertaken to compare the relative efficacy of neoadjuvant versus adjuvant chemotherapy in right-sided cancers known to be EMVI-positive as some patients will fail to have adjuvant chemotherapy due to postoperative complications, thereby delaying recovery and missing the optimum window for treatment.

Do differences in surgical quality account for the higher rate of R1 margins to lymph node metastases in right- versus left-sided Stage III colon cancer: A retrospective cohort study

AIM

Microscopically positive (R1) margins to lymph node metastases (R1LNM) are associated with poorer oncological outcomes in patients with Stage III colon cancer. R1LNM margins are more common in right-sided cancer, although the cause of this phenomenon is unknown. We sought to investigate whether differences in surgical quality account for the higher rate of R1LNM in right-sided cancers.

METHOD

Patients treated for Stage III colon cancer from 1 January 2016 to 31 December 2018 were identified using the Danish national cancer registry. Indicators of surgical quality (mesocolic resection grade, median lymph node yield, and length to the distal colonic margin) were compared according to tumour site and margin status.

RESULTS

In all, 1765 patients were included, 981 (55.6%) with right-sided cancers. R1LNM margins were more common in right-sided cancers (14.4% vs. 6.1%, P < 0.001). All three surgical quality indicators were higher in patients with right-sided cancers (mesocolic resection planes 81.7% vs. 69.5%, P < 0.001; median lymph node yield 28 vs. 25, P < 0.001; ≥5 cm to the distal colon margin 81.2% vs. 53.6%, P < 0.001). When stratified according to margin status, no differences in mesocolic resection planes or resectate length were noted, whilst median lymph node yield was higher in patients with R1LNM margins (29 vs. 27, P = 0.009).

CONCLUSION

Surgical quality does not appear to be poorer in patients undergoing surgery for right-sided versus left-sided colon cancers in Denmark. Suboptimal surgery does not appear to be responsible for R1LNM margins, implying that these margins may be a surrogate for more aggressive biology.

A Narrative Review of the Usefulness of Indocyanine Green Fluorescence Angiography for Perfusion Assessment in Colorectal Surgery

Anastomotic leakage is one of the most dreaded complications of colorectal surgery and is strongly associated with tissue perfusion. Indocyanine green fluorescence angiography (ICG-FA) using indocyanine green and near-infrared systems is an innovative technique that allows the visualization of anastomotic perfusion. Based on this information on tissue perfusion status, surgeons will be able to clearly identify colorectal segments with good blood flow for safer colorectal anastomosis. The results of several clinical trials indicate that ICG-FA may reduce the risk of AL in colorectal resection; however, the level of evidence is not high, as several other studies have failed to demonstrate a reduction in the risk of AL. Several large-scale RCTs are currently underway, and their results will determine whether ICG-FA is, indeed, useful. The major limitation of the current ICG-FA evaluation method, however, is that it is subjective and based on visual assessment by the surgeon. To complement this, the utility of objective evaluation methods for fluorescence using quantitative parameters is being investigated. Promising results have been reported from several clinical trials, but all trials are preliminary owing to their small sample size and lack of standardized protocols for quantitative evaluation. Therefore, appropriately standardized, high-quality, large-scale studies are warranted.

Understanding the Philosophy, Anatomy, and Surgery of the Extra-TME Plane of Locally Advanced and Locally Recurrent Rectal Cancer; Single Institution Experience with International Benchmarking

Pelvic exenteration surgery has become a widely accepted procedure for treatment of locally advanced (LARC) and locally recurrent rectal cancer (LRRC). However, there is still unwarranted variation in peri-operative management and subsequently oncological outcome after this procedure. In this article we will elaborate on the various reasons for the observed differences based on benchmarking results of our own data to the data from the PelvEx collaborative as well as findings from 2 other benchmarking studies. Our main observation was a significant difference in extent of resection between exenteration units, with our unit performing more complete soft tissue exenterations, sacrectomies and extended lateral compartment resections than most other units, resulting in a higher R0 rate and longer overall survival. Secondly, current literature shows there is a tendency to use more neoadjuvant treatment such as re-irradiation and total neoadjuvant treatment and perform less radical surgery. However, peri-operative chemotherapy or radiotherapy should not be a substitute for adequate radical surgery and an R0 resection remains the gold standard. Finally, we describe our experiences with standardizing our surgical approaches to the various compartments and the achieved oncological and functional outcomes.

The "terminal line": a novel sign for the identification of distal mesorectum end during TME for rectal cancer

Background

Although the clinical importance of complete, intact total mesorectal excision (TME) is the widely accepted standard for decreasing local recurrence of rectal cancer, the residual mesorectum still represents a significant component of resection margin involvement. This study aimed to use a visible intraoperative sign to detect the distal mesorectal end to ensure complete inclusion of the mesorectum and avoid unnecessary over-dissection.

Methods

The distal mesorectum end was investigated retrospectively through a review of 124 operative videos at the Union Hospital of Fujian Medical University (Fujian, China) and Cleveland Clinic (Ohio, USA) by two independent surgeons who were blinded to each other. Furthermore, 28 cadavers and 44 post-operative specimens were prospectively examined by hematoxylin and eosin (H&E) staining and Masson's staining to validate and confirm the findings of the retrospective part. Univariate and multivariate analyses were carried out to detect the independent factors that can affect the visualization of the distal mesorectal end.

Results

The terminal line (TL) is the distal mesorectal end of the transabdominal and transanal TME (taTME) and appears as a remarkable pearly white fascial structure extending posteriorly from 2 to 10 o'clock. Histopathological examination revealed that the fascia propria of the rectum merges with the presacral fascia at the TL, beyond which the mesorectum ends, with no further downward extension. In the retrospective observation, the TL was seen in 56.6% of transabdominal TME and 56.0% of taTME operations. Surgical approach and tumor distance from the anal verge were the independent variables that directly influenced the detection of the TL (P = 0.03 and P = 0.01).

Conclusion

The TL is a visible sign where the transabdominal TME should end and the taTME should begin. Recognition of the mesorectal end may impact the certainty of complete mesorectum inclusion. Further clinical trials are needed to confirm the preliminary findings.

Training of radiology specialists in local staging of primary rectal cancer on MRI: a prospective intervention study exploring the impact of various educational elements on the interpretive performance

Background

MRI interpretation and accurate radiological staging are crucial to the important treatment decisions and a consequent successful patient outcome in rectal cancer.

Aims

To investigate the effect of intensive training on rectal cancer MRI staging performance of radiologists and the impact of different course elements on learning outcomes.

Methods

In this prospective intervention study, 17 radiology specialists and 1 radiology registrar participated in a training programme including a 6-hour imaging workshop, a 3-hour session of individual feedback and independent MRI readings of primary rectal cancer cases. Their rectal MRI interpretive performance was evaluated through repeated readings of 30 training cases before and after each course element and a time interval with no educational intervention. A proforma template for MRI staging of primary rectal cancer was used and the results were compared with a reference standard of an expert panel. Participants repeatedly reported on confidence scores and self-assessed learning outcome. Outcomes were analysed using mixed-effects models.

Results

At baseline the quality of rectal MRI assessment varied significantly, with a higher interpretive performance among participants with shorter radiological experience (10.2 years vs 19.9 years, p=0.02). The ability to perform correct treatment allocation improved from 72% to 82% (adjusted OR=2.36, 95% CI 1.64 to 3.39). The improvement was largely driven by the participants with lower performance at baseline and by prevention of overstaging. Individual feedback had a significant impact on the improved interpretive performance (adjusted OR=1.82, 95% CI 1.27 to 2.63), whereas no significant change was seen after workshop or case readings only. Confidence scores increased significantly during training.

Conclusions

Targeted and individualised training improves the rectal cancer MRI interpretive performance essential to successful patient treatment, especially among radiology specialists with lower performance at baseline.

Impact of circumferential tumor location of mid to low rectal cancer on oncologic outcomes after preoperative chemoradiotherapy

Purpose

Some studies have suggested that circumferential tumor location (CTL) of rectal cancer may affect oncological outcomes. However, studies after preoperative chemoradiotherapy (CRT) are rare. This study aimed to evaluate the impact of CTL on oncologic outcomes of patients with mid to low rectal cancer who received preoperative CRT.

Methods

Patients with mid to low rectal cancer who underwent total mesorectal excision after CRT from January 2013 to December 2018 were included in this retrospective study. The impact of CTL on the pathological circumferential resection margin (CRM) status, local recurrence-free survival (LRFS), disease-free survival (DFS), and overall survival (OS) was analyzed.

Results

Of the 381 patients, 98, 70, 127, and 86 patients were categorized into the anterior, posterior, lateral, and circumferential tumor groups, respectively. Tumor location was not significantly associated with the pathological CRM involvement (anterior, 12.2% vs. posterior, 14.3% vs. lateral, 11.0% vs. circumferential, 17.4%; P = 0.232). Univariate analyses revealed no correlation between CTL and 3-year LRFS (93.0% vs. 89.1% vs. 91.5% vs. 88%, P = 0.513), 3-year DFS (70.3% vs. 70.2% vs. 75.3% vs. 75.7%, P = 0.832), and 5-year OS (74.7% vs. 78.0% vs. 83.9% vs. 78.2%, P = 0.204). Multivariate analysis identified low rectal cancer and pathological CRM involvement as independent risk factors for all survival outcomes (all P < 0.05).

Conclusion

CTL of rectal cancer after preoperative CRT was not significantly associated with the pathological CRM status, recurrence, and survival.

Mesentery in Transanal TME

Oncological adequacy in rectal cancer surgery mandates not only a clear distal and circumferential resection margin but also resection of the entire ontogenetic mesorectal package. Incomplete removal of the mesentery is one of the commonest causes of local recurrences. The completeness of the resection is not only determined by tumor and patient related factors but also by the patient-tailored treatment selected by the multidisciplinary team. This is performed in the context of the technical ability and experience of the surgeon to ensure an optimal total mesorectal excision (TME). In TME, popularized by Professor Heald in the early 1980s as a sharp dissection through the avascular embryologic plane, the midline pedicle of tumor and mesorectum is separated from the surrounding, mostly paired structures of the retroperitoneum. Although TME significantly improved the oncological and functional results of rectal cancer surgery, the difficulty of the procedure is still mainly dependent on and determined by the dissection of the most distal part of the rectum and mesorectum. To overcome some of the limitations of working in the narrowest part of the pelvis, robotic and transanal surgery have been shown to improve the access and quality of resection in minimally invasive techniques. Whatever technique is chosen to perform a TME, embryologically derived planes and anatomical points of reference should be identified to guide the surgery. Standardization of the chosen technique, widespread education, and training of surgeons, as well as caseloads per surgeon, are important factors to optimize outcomes. In this article, we discuss the introduction of transanal TME, with emphasis on the mesentery, relevant anatomy, standard procedural steps, and importance of a training pathway.

Anatomical classification of middle rectal arteries regarding detailed vasculature patterns

This study aimed to clarify the anatomy of middle rectal artery and pelvic vasculature patterns, and to provide schematic information in a manner applicable to the total mesorectal excision. Forty sides of pelvis from 20 formalin-embalmed cadavers (10 male, 10 female) were dissected, and all the pelvic vasculatures from the internal iliac artery were investigated, focusing on the middle rectal artery. Middle rectal arteries were classified into major types depending on their vascular origins. Each type was subdivided into minor types according to variability of the pelvic vasculature. A middle rectal artery was identified in 18 out of 20 cadavers, and in 25 out of 40 pelvic sides. In most cases, the middle rectal artery originated from the internal pudendal artery or inferior gluteal artery. These two arteries arose directly from the anterior trunk of the internal iliac artery or were bifurcated from the gluteal-pudendal trunk. In rare cases, these arteries arose from the posterior trunk of the internal iliac artery. The other origins of the middle rectal artery included the gluteal pudendal trunk, inferior vesical artery, internal iliac artery, obturator artery, and the prostatic artery, and the pelvic vasculatures in these cases also presented variability. The detailed anatomical findings related to the middle rectal artery and pelvic vasculatures are noteworthy for their improved clinical applicability.

Transanal total mesorectal excision combined with intersphincteric resection has similar long-term oncological outcomes to laparoscopic abdominoperineal resection in low rectal cancer: a propensity score-matched cohort study

Background

Transanal total mesorectal excision (taTME) or intersphincteric resection (ISR) has recently proven to be a valid and safe surgical procedure for low rectal cancer. However, studies focusing on the combination of these two technologies are limited. This study aimed to evaluate perioperative results, long-term oncologic outcomes, and anorectal functions of patients with low rectal cancer undergoing taTME combined with ISR, by comparing with those of patients undergoing laparoscopic abdominoperineal resection (laAPR).

Methods

After 1:1 propensity score matching, 200 patients with low rectal cancer who underwent laAPR (n = 100) or taTME combined with ISR (n = 100) between September 2013 and November 2019 were included. Patient demographics, clinicopathological characteristics, oncological outcomes, and anal functional results were analysed.

Results

Patients in the taTME-combined-with-ISR group had less intraoperative blood loss (79.6 ± 72.6 vs 107.3 ± 65.1 mL, P = 0.005) and a lower rate of post-operative complications (22.0% vs 44.0%, P < 0.001) than those in the laAPR group. The overall local recurrence rates were 7.0% in both groups within 3 years after surgery. The 3-year disease-free survival rates were 86.3% in the taTME-combined-with-ISR group and 75.1% in the laAPR group (P = 0.056), while the 3-year overall survival rates were 96.7% and 94.2%, respectively (P = 0.319). There were 39 patients (45.3%) in the taTME-combined-with-ISR group who developed major low anterior resection syndrome, whereas 61 patients (70.9%) had good post-operative anal function (Wexner incontinence score ≤ 10).

Conclusion

We found similar long-term oncological outcomes for patients with low rectal cancer undergoing laAPR and those undergoing taTME combined with ISR. Patients receiving taTME combined with ISR had acceptable post-operative anorectal function.

A comparative examination of colorectal cancer burden in European Union, 1990-2019: Estimates from Global Burden of Disease 2019 Study

AIM

This study examines the burden of colorectal cancer (CRC) in European Union (EU) countries in the last 3 decades.

METHODS

The data pertaining to CRC burden were procured from the Global Burden of Disease 2019 Study for 28 EU countries (including United Kingdom) for the period 1990-2019. The age-standardized rates of CRC were utilized to compare the country-wise burden and joinpoint regression models were applied to examine the trends.

RESULTS

In EU, CRC incident cases increased by 70.2% from 261,306 to 444,872 and deaths increased by 36.8% from 155,823 to 213,174 between 1990 and 2019. The age-standardized incidence rate (ASIR) increased by 11.9% from 37.8/100,000 to 42.3/100,000 between 1990 and 2019; in contrast, the age-standardized mortality rate (ASMR) decreased by 16.9% (1990: 22.4/100,000; 2019: 18.6/100,000) and age-standardized DALYs rate (ASDALR) decreased by 18.6% (1990: 472.9/100,000; 2019: 385.1/100,000) in the study period. In 2019, Hungary was the leading country in terms of ASMR (28.6/100,000) and ASDALR (630.3/100,000), and Lithuania (29.2/100,000) had the lowest ASIR, whereas Finland had the lowest ASMR (12.3/100,000) and ASDALR (253.6/100,000) in 2019.

CONCLUSION

CRC incidence is increasing in EU and mortality rates, although decreasing, are still unacceptably high. CRC control efforts must be focused around early detection using screening and prevention through reduction of modifiable risk factors. Increasing CRC incidence rates in young adults in recent years requires more research to pinpoint risk factors, and there must be more awareness of this recent development among general public and clinicians.

Vascular variants in laparoscopic extended right hemicolectomy with central vascular ligation for right colon cancer

PURPOSE

To evaluate the right colic vascularity, focusing on the confluences of veins.

METHODS

The subjects of this retrospective study were 100 patients who underwent laparoscopic extended right hemicolectomy (Lap-ERHC) between April 2015 and September 2020, at our hospitals. Veins draining into the superior mesenteric vein (SMV) included the ileocecal vein (ICV), the right colic vein (RCV), the middle colic vein (MCV), and the gastrocolic trunk of Henle (GCT). Veins draining into vessels other than the SMV were defined as accessory colic veins (aICV, aRCV or aMCV).

RESULTS

The GCT, aRCV, and aMCV were found in 86, 89, and 15 patients, respectively. In 66 patients with one aRCV, drainage was split as the anterior superior pancreaticoduodenal vein (ASPDV) in 12, the right gastroepiploic vein (RGEV) in 7, and the GCT in 47. In 23 patients with two aRCVs, drainage was split as the ASPDV in 4, the RGEV in 1, the GCT in 11, and the ASPDV and GCT in 7. In 14 patients with one aMCV, drainage was split as the GCT in 8, the splenic vein in 5, and the first jejunal vein (FJV) in 1. One patient had two aMCVs, draining into the GCT and the FJV.

CONCLUSIONS

The findings of our evaluation of vascular anatomy, focusing on confluences of the colic veins, provides useful information for colorectal surgeons.

Artificial Intelligence-Based Total Mesorectal Excision Plane Navigation in Laparoscopic Colorectal Surgery

BACKGROUND

Total mesorectal excision is the standard surgical procedure for rectal cancer because it is associated with low local recurrence rates. To the best of our knowledge, this is the first study to use an image-guided navigation system with total mesorectal excision.

IMPACT OF INNOVATION

The impact of innovation is the development of a deep learning-based image-guided navigation system for areolar tissue in the total mesorectal excision plane. Such a system might be helpful to surgeons because areolar tissue can be used as a landmark for the appropriate dissection plane.

TECHNOLOGY, MATERIALS, AND METHODS

This was a single-center experimental feasibility study involving 32 randomly selected patients who had undergone laparoscopic left-sided colorectal resection between 2015 and 2019. Deep learning-based semantic segmentation of areolar tissue in the total mesorectal excision plane was performed. Intraoperative images capturing the total mesorectal excision scene extracted from left colorectal laparoscopic resection videos were used as training data for the deep learning model. Six hundred annotation images were created from 32 videos, with 528 images in the training and 72 images in the test data sets. The experimental feasibility study was conducted at the Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba, Japan. Dice coefficient was used to evaluate semantic segmentation accuracy for areolar tissue.

PRELIMINARY RESULTS

The developed semantic segmentation model helped locate and highlight the areolar tissue area in the total mesorectal excision plane. The accuracy and generalization performance of deep learning models depend mainly on the quantity and quality of the training data. This study had only 600 images; thus, more images for training are necessary to improve the recognition accuracy.

CONCLUSION AND FUTURE DIRECTIONS

We successfully developed a total mesorectal excision plane image-guided navigation system based on an areolar tissue segmentation approach with high accuracy. This may aid surgeons in recognizing the total mesorectal excision plane for dissection.

A modified method for resected specimen processing in rectal cancer: Semi-opened with transverse slicing for measuring of the circumferential resection margin

Circumferential resection margin (CRM) is essential for oncological quality assessment in rectal cancer surgery. CRM represents a surrogate parameter for oncological outcomes and is important for stratifying treatment strategies in Western nations. In Japan, the mesentery is removed for specimen processing in order to extract as many lymph nodes (LNs) as possible; consequently, CRM cannot be measured. Given the diversification of treatment strategies for rectal cancer, the lack of measurement of CRM to assess surgical outcomes is a crucial issue that must be resolved. Therefore, it is necessary to establish a method enabling measurement of CRM while enjoying the advantages of the Japanese method. In the method we developed, the mesentery is removed from the rectum more than 2 cm away from the tumor, and the vicinity of the tumor is circularized. It is necessary to investigate the usefulness of this method prospectively in a multi-center study.

Identifying the long-term survival beneficiary of preoperative radiotherapy for rectal cancer in the TME era

This study was to verify the long-term survival efficacy of preoperative radiotherapy (preRT) for locally advanced rectal cancer (LARC) patients and identify potential long-term survival beneficiary. Using the Surveillance, Epidemiology, and End Results (SEER) database, 7582 LARC patients were eligible for this study between 2011 and 2015 including 6066 received preRT and 1516 received surgery alone. Initial results showed that preRT prolonged the median overall survival (OS) of LARC patients (HR 0.86, 95% CI 0.75-0.98, P < 0.05), and subgroup analysis revealed that patients with age > 65 years, stage III, T3, T4, N2, tumor size > 5 cm, tumor deposits, and lymph nodes dissection (LND) ≥ 12 would benefit more from preRT (all P < 0.05). A prognostic predicting nomogram was constructed using the independent risk factors of OS identified by multivariate Cox analysis (all P < 0.05), which exhibited better prediction of OS than the 8th American Joint Cancer Committee staging system on colorectal cancer. According to the current nomogram, patients in the high-risk subgroup had a shorter median OS than low-risk subgroup (HR 2.62, 95% CI 2.25-3.04, P < 0.001), and preRT could benefit more high-risk patients rather than low-risk patients. Hence, we concluded that preRT might bring long-term survival benefits to LARC patients, especially those with high risk.

Interactive Training Program Improves Surgeon and Pathologist Comfort Level With Total Mesorectal Excision Grading for Rectal Cancer

BACKGROUND

Total mesorectal excision for rectal cancer has been shown to decrease local recurrence and improve survival, and specimen grading is recommended as a best practice. However, specimen grading remains underutilized in the United States potentially because of the lack of surgeon and pathologist training in the technique.

OBJECTIVE

This study aimed to determine whether an interactive webinar improves physician comfort with mesorectal grading.

DESIGN

To test the effect of the program, participants completed a survey before and after participating.

SETTINGS

Twelve Michigan Surgical Quality Collaborative hospitals volunteered to participate in a Total Mesorectal Excision Project.

PARTICIPANTS

Total mesorectal excision grading training program participants were surgeons, surgery residents, pathologists, and pathology assistants from 12 hospitals.

MAIN OUTCOME MEASURES

Comfort with grading total mesorectal excision specimens was our main outcome measure. Prewebinar surveys also measured familiarity, previous experience, and training in grade assignment, as well as interest in the training program. Postwebinar surveys measured webinar relevance and effectiveness as well as participant intention to use content in practice.

RESULTS

A total of 34 participants completed the prewebinar survey and 28 participants completed the postwebinar survey. The postwebinar overall median comfort level with specimen grading of 3.64 was significantly higher than the prewebinar overall median comfort level of 2.94 (95% CI, 3.32-3.96 versus 95% CI 2.56-3.32; p = 0.007). When evaluated separately, both surgeons and pathologists reported significantly higher comfort levels with total mesorectal excision grading after the webinar.

LIMITATIONS

Six participants did not complete the postwebinar survey. Surgery residents and pathology assistants were analyzed with practicing surgeons and pathologists. The pre- and postwebinar surveys were deidentified, so paired analysis was not possible.

CONCLUSIONS

Our total mesorectal excision grading training program improved the comfort level of both surgeons and pathologists with specimen grading. Survey results also demonstrate that providers are interested in receiving training in rectal cancer specimen grading. See Video Abstract at http://links.lww.com/DCR/B766.PROGRAMA DE ENTRENAMIENTO INTERACTIVO MEJORA EL NIVEL DE COMODIDAD DEL CIRUJANO Y DEL PATÓLOGO CON LA CLASIFICACIÓN DE LA ESCISIÓN TOTAL DEL MESORRECTO PARA EL CÁNCER DE RECTO.

ANTECEDENTES

Se ha demostrado que la escisión total del mesorrecto para el cáncer de recto disminuye la recurrencia local y mejora la supervivencia, y se recomienda la clasificación de la muestra como buena práctica de rutina. Sin embargo, sigue siendo poco utilizado en los Estados Unidos debido principalmente a la falta de formación en la técnica de cirujanos y patólogos.

OBJETIVO

Determinar si un seminario interactivo en línea mejora la comodidad del médico con la clasificación mesorrectal.

DISEO

Para probar el efecto del programa, los participantes completaron una encuesta antes y después de haber participado de la misma.

MARCO

Doce hospitales en cooperación sobre la calidad quirúrgica de Michigan se ofrecieron como voluntarios para participar en el proyecto de Escisión Total de Mesorrecto.

PARTICIPANTES

Los participantes del programa de entrenamiento en la clasificación de escisión total de mesorrecto fueron cirujanos, residentes de cirugía, patólogos y asistentes de patología de doce hospitales.

PRINCIPALES RESULTADOS MEDIDOS

La comodidad con la clasificación de las muestras de escisión total de mesorrecto fue nuestro principal resultado de medición. Las encuestas previas al seminario en línea también midieron la familiaridad, la experiencia y entrenamiento previo en la clasificación, así como el interés en el programa de entrenamiento. Las encuestas posteriores midieron la relevancia y la eficacia del seminario web, así como la intención de los participantes de utilizar en la practica el contenido.

RESULTADOS

Un total de 34 participantes completaron la encuesta previa, y 28 de ellos la completaron con posterioridad al seminario en línea.La mediana del nivel de comodidad general, posterior al seminario en línea, con respecto a la clasificación de la pieza de 3,64 fue significativamente mayor con respecto al valor de 2,94 previo al seminario (IC del 95%: 3,32 - 3,96 versus IC 2,56 - 3,32, respectivamente; valor de p = 0,007).Cuando fueron evaluados de manera separada, tanto los cirujanos como los patólogos reportaron niveles de comodidad significativamente más altos con la clasificación de escisión total de mesorrecto (TME) después del seminario en línea.

LIMITACIONES

Seis participantes no completaron la encuesta posterior al seminario en línea. Los residentes de cirugía y los asistentes de patología fueron analizados conjuntamente con los cirujanos y patólogos en ejercicio, respectivamente. Las encuestas previas y posteriores al seminario en línea fueron anónimas, anulándose la identificación, por lo que no fue posible realizar un análisis por pares.

CONCLUSIONES

Nuestro programa de entrenamiento en la clasificación de escisión total de mesorrecto mejoró el nivel de comodidad tanto de los cirujanos como de los patólogos con la clasificación de las muestras. Los resultados de la encuesta también demuestran que el personal involucrado está interesado en recibir capacitación en la clasificación de muestras de cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/B766. (Traducción-Dr Osvaldo Gauto).

The role of transanal total mesorectal excision

At inception, transanal total mesorectal excision (TaTME) was hypothesized to be a solution for several problems encountered in pelvic surgery, particularly for distal rectal cancer. The transanal part of the procedure is less hampered by patient related factors such as visceral obesity and a narrow bony pelvis and can thus overcome access and visualization problems encountered with a pure abdominal approach. Clearly, as for any new technique, a learning curve needs to be negotiated, ideally without unacceptable harm to patients. Once in experienced hands, TaTME might overcome challenges found in anatomically challenging rectal cancer patients as well as for other indications. The role of TaTME is not to replace, but rather complement its abdominal counterpart.

Postoperative MRI Findings Following Conventional and Extralevator Abdominoperineal Excision in Low Rectal Cancer

Aim: The disparity in outcomes for low rectal cancer may reflect differences in operative approach and quality. The extralevator abdominoperineal excision (ELAPE) was developed to reduce margin involvement in low rectal cancers by widening the excision of the conventional abdominoperineal excision (c-APE) to include the posterior pelvic diaphragm. This study aimed to determine the prevalence and localization of inadvertent residual pelvic diaphragm on postoperative MRI after intended ELAPE and c-APE. Methods: A total of 147 patients treated with c-APE or ELAPE for rectal cancer were included. Postoperative MRI was performed on 51% of the cohort (n = 75) and evaluated with regard to the residual pelvic diaphragm by a radiologist trained in pelvic MRI. Patient records, histopathological reports, and standardized photographs were assessed. Pathology and MRI findings were evaluated independently in a blinded fashion. Additionally, preoperative MRIs were evaluated for possible risk factors for margin involvement. Results: Magnetic resonance imaging-detected residual pelvic diaphragm was identified in 45 (75.4%) of 61 patients who underwent ELAPE and in 14 (100%) of 14 patients who underwent c-APE. An increased risk of margin involvement was observed in anteriorly oriented tumors with 16 (22%) of 73 anteriorly oriented tumors presenting with margin involvement vs. 7 (9%) of 74 non-anteriorly oriented tumors (p = 0.038). Conclusion: Residual pelvic diaphragm following abdominoperineal excision can be depicted by postoperative MRI. Inadvertent residual pelvic diaphragm (RPD) was commonly found in the series of patients treated with the ELAPE technique. Anterior tumor orientation was a risk factor for circumferential resection margin (CRM) involvement regardless of surgical approach.

Rectal cancer treatment and outcomes in elderly patients treated with curative intent

The elderly population comprises a significant proportion of patients diagnosed with rectal cancer. However, there is a lack of evidence to guide treatment decisions in this group. Thus, this multicentre study compares the histopathology, treatment patterns and outcomes between the elderly and young populations with non-metastatic rectal cancer. The present study reported on the clinicopathological variables, treatment modalities and survival outcomes in 736 patients diagnosed with non-metastatic rectal cancer between 2006 and 2015. Patients were divided into the following two groups, <70 and ≥70 years of age, which were compared using Chi-square and survival outcome analysis using Kaplan-Meier. Elderly patients made up nearly half of the cohort and were less likely to undergo trimodality therapy or be discussed in a multidisciplinary meeting. Surgery in the elderly patients was associated with increased mortality. Elderly patients had worse cancer-specific survival (75 vs. 85%), which was particularly evident in stage III disease (hazard ratio, 2.1). Elderly patients in this subgroup treated with trimodality therapy had similar survival outcomes to younger patients. Elderly patients with locally advanced rectal cancer comprise a large proportion of the patient cohort. Consideration should be given for trimodality therapy in this group, taking into account biological age, especially in the context of increasing life expectancy and improvement in the management of age-related comorbidities.

Minimal access rectal cancer surgery: an observational study of patient outcomes from a district general hospital with over a decade of experience with robotic rectal cancer surgery

AIM

Robotic surgery for colorectal cancer has become established more slowly than in other specialities. The aim of this study was to assess the risks and benefits of the use of robotic rectal cancer surgery in comparison with laparoscopic surgery within the confines of a subspecialist rectal cancer service in a district general hospital.

METHOD

Outcomes from consecutive patients undergoing minimal access rectal cancer surgery between July 2008 and January 2020 were analysed. Comparisons were made between short-term outcomes including conversion rates, anastomotic leakage and pathological outcomes as well as long-term survival and cancer recurrence.

RESULTS

A total of 337 patients were included in the analysis, 204 (60.5%) of whom underwent robotic surgery. Demographic characteristics and use of neoadjuvant chemoradiotherapy were similar between groups. However, patients having robotic surgery had significantly lower tumours than in the laparoscopic group (7.6 cm vs. 9.8 cm, p = 0.003). Conversion to open surgery in the robotic group was significantly less likely (9.8% vs. 22.6%, p = 0.001). Operative mortality, clinical leakage and major complications were similar between groups. While asymptomatic 'radiological' leaks were significantly more common following robotic surgery (13.7% vs. 5.3%, p = 0.017) this did not affect the long-term stoma closure rate. Pathological outcomes were similar with the exception of shorter mean distal resection margins (25.9 mm vs. 32.8 mm, p = 0.001) for the robotic group of patients. There was no statistical difference in 5-year survival between groups (78.7% robotic vs. 85.4% laparoscopic, p = 0.263) nor local recurrence (2.0% robotic vs. 3.8% laparoscopic, p = 0.253).

CONCLUSIONS

These results illustrate how the selective use of robotic surgery by a dedicated rectal cancer team can achieve low rates of cancer recurrence and low permanent stoma rates.

Snapshots of lymphatic pathways in colorectal cancer surgery using near-infrared fluorescence, in vivo and ex vivo

INTRODUCTION

Indocyanine green (ICG) fluorescence imaging has been used for blood flow assessment in anastomoses in the field of colorectal cancer surgery. However, whether ICG fluorescence is related to the presence of cancer cells in the lymph nodes is unclear. We explored the utilization of ICG fluorescence in colorectal cancer surgery.

MATERIALS AND METHODS

ICG was injected into the submucosa around the tumor before radical resection in colorectal cancer patients. Intraoperatively, near-infrared (NIR) fluorescence was used for lymphatic flow visualization. After specimen removal, harvested lymph nodes were classified as positive or negative based on the detection of fluorescence, followed by pathological examination. ICG distribution on a section of each lymph node was examined by fluorescence microscopy.

RESULTS

Overall, 155 patients underwent real-time NIR fluorescence imaging-guided surgery. Altogether, 1,017 lymph nodes were retrieved from these patients. Metastatic lymph nodes were present in 36 (5.8%) of 622 fluorescence-negative lymph nodes, which was significantly higher than 11 (2.8%) of 395 fluorescence-positive lymph nodes (odds ratio: 2.15, P = 0.03). Fluorescence microscopy of metastatic lymph nodes showed that ICG fluorescence was present in the normal structural region but not in the cancerous region of the lymph nodes. Furthermore, ICG fluorescence was observed in all metastatic lymph nodes, except those with cancer cells occupying >90% of the total area.

CONCLUSIONS

ICG fluorescence detected only the normal parts of the lymph node draining from the peritumoral area and not the cancer tissues. This finding is important for developing appropriate strategies for navigation surgery using NIR fluorescence.

Intraoperative neuromonitoring in rectal cancer surgery: a systematic review and meta-analysis

PURPOSE

The aim of this study is to evaluate the role of pelvic intraoperative neuromonitoring (pIONM) in rectal cancer surgery.

METHODS

A systematic review of the literature and a meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Overall, nine studies were identified. Quantitative analysis was performed only in three trials. Bilateral pIONM improved postoperative anorectal and urogenital functional outcomes. However, unilateral pIONM displayed a significant effect only on erectile function (p = 0.001).

CONCLUSIONS

Our findings suggest a positive effect of pIONM on postoperative functional outcomes and quality of life after rectal cancer surgery. Due to several limitations, further trials are required in order to elucidate the exact role of pIONM.

Preservation of the rectum is possible in early rectal cancer with neoadjuvant radiotherapy, delay and local excision-a 12-year single-centre experience of the evolution of early rectal cancer treatment

AIM

Treatment of early rectal cancer (ERC) is undergoing a revolution towards rectum preservation. Adjuvant and neoadjuvant therapy alongside local excision (LE) means that organ preservation is a real possibility for most patients and a viable alternative for frailer patients. This study presents our 12-year experience as a specialist regional ERC unit, evolving towards organ preservation.

METHOD

Data were collected prospectively between 2006 and 2018 for all patients referred to the regional ERC multidisciplinary team with suspected or confirmed ERC. Patients considered suitable for LE, or those declining radical surgery, were offered LE or neoadjuvant short-course radiotherapy (SCRT), delay and LE with subsequent rescue surgery or contact brachytherapy for unfavourable histopathology.

RESULTS

In all, 102 patients underwent LE. Ten patients were excluded (N = 92). 45 patients underwent LE directly and 47 patients received SCRT and LE. After SCRT and LE, a pathological complete response was achieved in 44.7%. This approach also resulted in a lower rate of lymphovascular invasion (22.2% vs. 6.4%), fewer distant recurrences (4.4% vs. 0%) and a better disease-specific mortality (11.1% vs. 0%) (P < 0.05). Although statistically insignificant, fewer patients required rescue surgery after SCRT (15.6% vs. 4.3%).

CONCLUSION

Organ preservation with a good oncological outcome is better achieved by neoadjuvant radiotherapy, delay and LE. To achieve this, careful patient selection, thorough preoperative investigation, experienced surgical technique and a deep appreciation of tumour biology managed via a dedicated ERC network is paramount.

Readiness of Graduating General Surgery Residents to Perform Colorectal Procedures

OBJECTIVE

In the United States, the majority of colorectal procedures are performed primarily by nonfellowship trained general surgeons. Given that surgical technique and experience affect patient outcomes, it is important that general surgeons are well-trained to perform colorectal surgery operations. In this study, we evaluated how prepared general surgery residents were to perform colorectal procedures upon graduating residency.

DESIGN

This was a retrospective observational cohort study. Attending ratings of residents' intraoperative performance were collected with the System for Improving and Measuring Procedural Learning application from 9/2015 to 9/2018. Descriptive analyses and Bayesian mixed models were used to determine a resident's probability of being deemed competent upon graduating residency, controlling for core vs. advanced procedure, case complexity, and rater and resident effects.

SETTING

Faculty and residents within 30 teaching institutions within the Procedural Learning and Safety Collaborative (PLSC).

PATIENTS

We sampled colorectal procedures and categorized them as core or advanced based on American Board of Surgery designations.

RESULTS

A total of 564 residents were rated after 2102 operations (82% core, 18% advanced). A resident in their fifth year of clinical training had a 93% (95% CI 85-97%) adjusted probability of competent performance after a core procedure and 75% (95% CI 55-89%) after an advanced procedure.

CONCLUSIONS

General surgery residents were not universally deemed competent to perform colorectal procedures even at the end of residency. These gaps were more pronounced for advanced colorectal procedures. Current graduation requirements should be carefully reviewed to ensure residents are appropriately trained to meet the needs of their communities. Additionally, advanced training remains a critical resource for surgeons who will perform complex colorectal procedures in practice.

Sphincter-Saving Robotic Total Mesorectal Excision Provides Better Mesorectal Specimen and Good Oncological Local Control Compared with Laparoscopic Total Mesorectal Excision in Male Patients with Mid-Low Rectal Cancer

INTRODUCTION

Laparoscopic rectal resection with total mesorectal excision is a technically challenging procedure, and there are limitations in conventional laparoscopy. A surgical robotic system may help to overcome some of the limitations. The aim of our study was to compare long-term oncological outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision in male patients with mid-low rectal cancer.

MATERIALS AND METHODS

The study was conducted as a retrospective review of a prospectively maintained database. One-hundred-three robotic and 84 laparoscopic sphincter-saving total mesorectal excisions were performed by a single surgeon between January 2011 and January 2020. Patient characteristics, perioperative recovery, postoperative complications, pathology results, and oncological outcomes were compared between the two groups.

RESULTS

The patients' characteristics did not differ significantly between the two groups. Median operating time was longer in the robotic than in the laparoscopic group (180 minutes versus 140 minutes, p=0.033). Macroscopic grading of the specimen in the robotic group was complete in 96 (93.20%), near complete in four (3.88%) and incomplete in three (2.91%) patients. In the laparoscopic group, grading was complete in 37 (44.04%), near complete in 40 (47.61%) and incomplete in seven (8.33%) patients (p=0.03). The median length of follow up was 48 (9-102) months in the robotic, and 75.6 (11-113) months in the laparoscopic group. Overall, five-year survival was 87% in the robotic and 85.3% in the laparoscopic groups. Local recurrence rates were 3.8% and 7.14%, respectively, in the robotic and laparoscopic groups (p<0.05).

CONCLUSION

Sphincter-saving robotic total mesorectal excision is a safe and feasible tool, which provides good mesorectal integrity and better local control in male patients with mid-low rectal cancer.

Magnetic resonance imaging as a predictor of surgical outcome in patients with local pelvic recurrence of colorectal cancer

INTRODUCTION

Pelvic local recurrence of colorectal cancer (PRCRC) may be cured if radical surgery is performed. Preoperative assessment normally includes magnetic resonance imaging (MRI). The aim of this study was to evaluate the influence of specific MRI-related findings on outcome of surgery of PRCRC.

MATERIALS AND METHODS

Clinical data from 95 consecutive patients, operated with a curative intent for PRCRC at Karolinska University Hospital during 2003-2013, were collected from medical records. Preoperative MRI examinations of the PRCRC were re-evaluated. The potential influence of clinical factors and specific MRI-findings (location, solid/mucinous, size, volume and border) on surgical resection margins (R0-R1) and survival were calculated with logistic and cox regression.

RESULTS

Eighty-seven patients had available MRI scans and were included in the study. Sixty-five patients (75%) had a R0 resection and 22 patients (25%) had a R1 resection of their PRCRC. In all, 47 patients (54%) had an involved lateral compartment. Lateral location was the only MRI finding associated with both an increased risk of R1 resection (OR 3.97, 95%CI: 1.31-12.04) and death (HR 1.94, 95%CI: 1.07-3.51). Lateral location entailed an increased risk of death also after R0 resection (HR2.09, 95%CI: 1.07-4.10). Five-year survival was 35% for all patients, 44% after R0 resection and 7% after R1 resection.

CONCLUSION

Tumour involvement of the lateral and posterior compartments on MRI was a predictor for R1 resection, but only lateral involvement was associated with an increased risk of death. An increased risk of death associated with lateral involvement was still present after R0 resection.

High-pressure CO2 insufflation is a risk factor for postoperative ileus in patients undergoing TaTME

The aim of this study is to evaluate the influence of high-pressure CO₂ insufflation during TaTME on the occurrence of postoperative ileus. All patients undergoing elective transanal total mesorectal excision (TaTME) between April 2015 and March 2019 were included in a prospective database. Eligible patients were adults with mid and low-level rectal cancer undergoing elective TaTME with colorectal anastomosis and diverting ileostomy, following a standardized ERAS pathway. Patients were divided into a low-pressure (LP) group, where surgery was performed with an intrabdominal CO₂ pressure of 12 mmHg, and a high-pressure (HP) group, where the intrabdominal pressure reached 15 mmHg of CO₂ once the two surgical fields were connected. Of 98 patients undergoing TaTME in the observed period, 74 met the inclusion criteria and were included in this study. There was no significant difference in postoperative complications between the LP and HP groups, except for postoperative ileus, which occurred in seven patients (13.2%) in the LP group and seven patients (33.3%) in the HP group (p value 0.046). The logistic multivariate analysis showed that a high intraabdominal CO₂ pressure (OR 7040, 95% CI 1591-31,164, p value 0.01) and male sex (OR 10,343, 95% CI 1078-99,256, p value 0.043) were significantly associated with postoperative ileus after TaTME. Intraabdominal CO₂ pressure should be carefully set, as it may represent a risk factor for postoperative ileus in patients undergoing TaTME.

Robotic taTME using the da Vinci SP: technical notes in a cadaveric model

Transanal total mesorectal excision (taTME) is an emerging albeit complex technique to treat rectal cancer. The aim of this proof-of-concept preclinical study was to determine the technical feasibility of robotic taTME using the da Vinci SP (_dVSP). Two fresh cadavers, one female (case 1) and one male (case 2), were used. Focus was given only to the transanal phase of the taTME. Two different clinical scenarios were simulated: in case 1, the tumor was hypothesized to be at 1 cm above the anorectal junction; in case 2, at > 4 cm. The GelPOINT Path was used as the transanal access platform through which the 2.5 cm single port robotic trocar and a 10 mm sleeve were inserted. A complete taTME was performed in both cases with a sleeve mucosectomy initiated at the level of the dentate line in case 1. In case 2, the purse-string was created and tightened robotically. At the completion of the procedure, the quality of the mesorectal dissection was verified showing an intact mesorectal fascia in both cases. Operation times were 124 and 106 min with a ~ 15 min of non-console time for robot positioning and docking. Robotic taTME with the _dVSP is technically feasible and might overcome the limits of the traditional laparoscopic approach.

Total mesorectal excision and sphincter preservation — the early steps of rectal cancer surgery

The treatment of rectal cancer has evolved significantly over the last 100 years. Standardization of total mesorectal excision and the development of techniques for sphincter preservation have resulted in significant improvements in the management of this disease. Still, local disease control and functional outcomes of sphincter preserving procedures remain a relevant issue. In this historical paper, the oncological and functional outcomes of patients with rectal cancer treated between 1960 and 1971 by a pioneer woman surgeon using a sphincter preserving approach and a technique resembling total mesorectal excision performed at that time are reported. The results reflect one of the earliest steps of partial intersphincteric resection and total mesorectal excision with good oncological outcomes (2% local recurrence) and acceptable functional outcomes in a highly selected group of patients.

Clinical translation and implementation of optical imaging agents for precision image-guided cancer surgery

INTRODUCTION

The field of tumor-specific fluorescence-guided surgery has seen a significant increase in the development of novel tumor-targeted imaging agents. Studying patient benefit using intraoperative fluorescence-guided imaging for cancer surgery is the final step needed for implementation in standard treatment protocols. Translation into phase III clinical trials can be challenging and time consuming. Recent studies have helped to identify certain waypoints in this transition phase between studying imaging agent efficacy (phase I-II) and proving patient benefit (phase III).

TRIAL INITIATION

Performing these trials outside centers of expertise, thus involving motivated clinicians, training them, and providing feedback on data quality, increases the translatability of imaging agents and the surgical technique. Furthermore, timely formation of a trial team which oversees the translational process is vital. They are responsible for establishing an imaging framework (camera system, imaging protocol, surgical workflow) and clinical framework (disease stage, procedure type, clinical research question) in which the trial is executed. Providing participating clinicians with well-defined protocols with the aim to answer clinically relevant research questions within the context of care is the pinnacle in gathering reliable trial data.

OUTLOOK

If all these aspects are taken into consideration, tumor-specific fluorescence-guided surgery is expected be of significant value when integrated into the diagnostic work-up, surgical procedure, and follow-up of cancer patients. It is only by involving and collaborating with all stakeholders involved in this process that successful clinical translation can occur.

AIM

Here, we discuss the challenges faced during this important translational phase and present potential solutions to enable final clinical translation and implementation of imaging agents for image-guided cancer surgery.

Prognostic Value of Surgical Site Infection in Patients After Radical Colorectal Cancer Resection

Background

This study aimed to evaluate the clinicopathological factors associated with surgical site infection (SSI) and the prognostic impact on patients after colorectal cancer (CRC) resection surgery.

Material/Methods

This retrospective study evaluated the relationships between SSI and various clinicopathological factors and prognostic outcomes in 326 consecutive patients with CRC who underwent radical resection surgery at Wuhan Union Hospital during April 2015–May 2017.

Results

Among the 326 patients who underwent radical CRC resection surgery, 65 had SSIs, and the incidence rates of incisional and organ/space SSI were 16.0% and 12.9%, respectively. Open surgery, chronic obstructive pulmonary disease (COPD), and a previous abdominal surgical history were identified as risk factors for incisional SSI. During a median follow-up of 40 months (range: 5–62 months), neither simple incisional nor simple organ/space SSI alone significantly affected disease-free survival (DFS) or overall survival (OS), whereas combined incisional and organ/space SSI had a significant negative impact on both the 3-year DFS and OS (P<0.001). A multivariate analysis identified that age ≥60 years, lymph node involvement, tumor depth (T3–T4), and incisional and organ/space SSI were independent predictors of 3-year DFS and OS. In addition, adjuvant chemotherapy and a carbohydrate antigen-125 concentration ≥37 ng/ml were also independent predictors of OS.

Conclusions

We have identified several clinicopathological factors associated with SSI, and identified incisional and organ/space SSI is an independent prognostic factor after CRC resection. Assessing the SSI classification may help to predict the prognosis of these patients and determine further treatment options.

Operative and long-term oncological outcomes in patients undergoing robotic versus laparoscopic surgery for rectal cancer

BACKGROUND

This study aimed to compare short- and long-term outcomes after robotic versus laparoscopic approach in patients undergoing curative surgery for rectal cancer.

METHODS

Patients undergoing elective robotic and laparoscopic resection for rectal cancer were included. Perioperative clinical characteristics, postoperative short- and long-term outcomes were compared between groups.

RESULTS

There were 72 and 44 patients in robotic (RG) and laparoscopic (LG) groups respectively. No differences were detected regarding patients' demographics, histopathologic outcomes, conversion rates and 30-day overall postoperative complication rates. Operative time was longer in the RG (341 ± 111.7 vs. 263 ± 97.5 min, p = 0.001) and length of stay was longer in the LG (4.4 ± 1.9 vs. 6.4 ± 2.9 days, p = 0.001). The 5-year overall and disease-free survival rates were similar (97.1% and 94.9%, p = 0.78; 86.2% and 82.7%, p = 0.72) between the groups.

CONCLUSION

This study showed both short and long-term outcomes of a limited number of included patients between the robotic and laparoscopic surgery were similar. However, future studies and randomized trials are necessary to establish these findings.

Do We Have to Treat All T3 Rectal Cancer the Same Way?

Chemoradiotherapy (CRT) followed by surgery is the recommended approach in the last years for stage II and III rectal cancer with the intention to decrease the risk of local recurrence. However, fewer patients benefit from this strategy in terms of overall survival and long-term adverse outcomes because T3 rectal cancer has a broad range of prognosis, as shown by recent publications. Many patients with cT3 rectal cancer have a substantial risk of overtreatment with long-term toxicity related to radiotherapy that could be avoided in a subset group of cT3 tumors with good prognosis. These findings raised the question of whether all cT3 rectal cancer should receive preoperative radiotherapy and if a selected cT3 subgroup could be treated by surgery alone. This review addresses the rationale of selecting good prognosis cT3 rectal cancer for surgery alone and analyzes the data to support this recommendation.

Optimising functional outcomes in rectal cancer surgery

Background

By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention.

Purpose

This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted.

Conclusion

Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.

Minimally invasive complete mesocolic excision and central vascular ligation (CME/CVL) for right colon cancer

Total mesorectal excision (TME) is the standard of care in rectal cancer surgery. Complete mesocolic excision and central vascular ligation (CME and CVL) are surgical concepts that are extrapolated from the principles of TME. Increasingly adopted by surgical units worldwide, laparoscopic CME/CVL for right sided colon cancer is a challenging procedure that requires meticulous dissection by the surgeon and detailed knowledge of the colonic vascular anatomy. This review article addresses the main issues pertaining to this surgical technique and also discusses steps on how to perform this operation safely.

Total Mesorectal Excision Technique-Past, Present, and Future

While the treatment of rectal cancer is multimodal, above all, a proper oncological resection is critical. The surgical management of rectal cancer has substantially evolved over the past 100 years, and continues to progress as we seek the best treatment. Rectal cancer was historically an unsurvivable disease, with poor understanding of the embryological planes, lymphatic drainage, and lack of standardized technique. Major improvements in recurrence, survival, and quality of life have resulted from advances in preoperative staging, pathologic assessment, the development and timing of multimodal therapies, and surgical technique. The most significant contribution in advancing rectal cancer care may be the standardization and widespread implementation of total mesorectal excision (TME). The TME, popularized by Professor Heald in the early 1980s as a sharp, meticulous dissection of the tumor and mesorectum with all associated lymph nodes through the avascular embryologic plane, has shown universal reproducible reductions in local recurrence and improvement in disease-free and overall survival. Widespread education and training of surgeons worldwide in the TME have significantly impact outcomes for rectal cancer surgery, and the procedure has become the gold standard for curative resection of rectal cancer. In this article, we discuss the evolution of the standard abdominal approach to the TME, with emphasis on the history, relevant anatomy, standard procedure steps, oncologic outcomes, and technical evolution.