Japanese Evidences on Nerve-Preserving Lateral Pelvic Lymh Node Dissection for Rectal Cancer: Major Historical Milestones and Clinical Impact: The Past, Present and Future

Advancement of indocyanine green fluorescence imaging technology in laparoscopic surgery for rectal cancer

Indocyanine green fluorescence imaging technology has been increasingly utilized in rectal surgery in recent years. As a safe tracer, indocyanine green can facilitate lymph node tracing, assess the blood supply at anastomotic sites, and localize tumour lesions during laparoscopic surgery, thereby resulting in favourable outcomes. This technology helps surgeons to achieve more precise diagnoses and treatments in laparoscopic procedures, thus ultimately benefiting patients. However, the current application of indocyanine green fluorescence imaging technology still lacks standardized regulations, and certain effects remain contentious. This study provides a comprehensive review of the application of indocyanine green in laparoscopic surgery for rectal cancer based on the pertinent literature.

Extended pelvic lymphadenectomy and rectal cancer: An umbrella review

Extended pelvic lymph node dissection (EPLND) for rectal cancer is common in Asian countries to reduce local recurrence and improve survival. This umbrella review investigates the benefit of adding extended lymphadenectomy to the standard total mesorectal excision (TME) practice. We conducted a comprehensive search of PubMed, Scopus, and Web of Science to identify systematic reviews and meta-analyses examining the role of EPLND in rectal cancer surgery. Primary outcomes were local recurrence and overall survival; secondary outcomes included: operation time, blood loss, urinary dysfunction, and sexual dysfunction. Of the 953 articles screened, 12 met the inclusion criteria. The median follow-up time was 52 months. In terms of overall survival, 10 studies found no statistically significant difference in the EPLND group; only two showed a significant improvement in 5-year survival. Nine studies found no significant benefit of EPLND in preventing local recurrence, while two suggested benefits for patients with locally advanced cancer after neoadjuvant chemoradiotherapy. In most studies, operation time and blood loss were higher in the EPLND group. EPLND was associated with increased odds of urinary and sexual dysfunction, with four out of six studies reporting higher rates for both outcomes. Our analysis concludes that EPLND offers no additional benefit over TME alone in terms of local recurrence, overall survival, or secondary outcomes, including increased risks of urinary and sexual dysfunction, longer operation times, and greater blood loss.

Postoperative urinary dysfunction following lateral lymph node dissection for rectal cancer via minimally invasive surgery

BACKGROUND

Lateral lymph node dissection (LLND) for locally advanced rectal cancer (LARC) is performed widely since it reduces local recurrence. However, there are some disadvantages to LLND, including technical difficulties and association with postoperative urinary dysfunction. Procedures for LARC have also become more minimally invasive: laparoscopic surgery (LS) has become more common, and use of robot-assisted LS (RALS) is increasing. The purpose of this study is to assess differences in postoperative urinary dysfunction after LLND for LARC between LS and RALS, and to identify risk factors for postoperative urinary dysfunction.

METHODS

The subjects were 100 patients with LARC (≥ cT3) with the inferior border of the tumor reaching the peritoneal reflection who underwent LS or RALS with LLND between 2009 and 2023 at Juntendo University Hospital. After LLND, the urinary catheter was usually removed on or before postoperative day 5. The duration of urinary catheterization (DUC) was used to evaluate postoperative urinary dysfunction. The standard (S) and long-term (L) groups were defined as cases with urinary catheter removal at ≤ 5 and > 5 days, respectively. DUC was examined for LS vs. RALS and clinicopathological factors were identified that adversely affect DUC.

RESULTS

Of the 100 subjects, 72 underwent LS and 28 received RALS. LLND was bilateral in 65 cases and unilateral in 35 cases. The median DUC was 5 days, with 74 cases in group S and 26 in group L. The most frequent postoperative complication (Clavien-Dindo Grade 2 or higher) was urinary dysfunction, followed by ileus and surgical site infection (SSI), and none differed by procedure (LS vs. RALS). Univariate analysis showed significant differences in LLND laterality (p = 0.02) and SSI (p = 0.04) between groups S and L. In multivariate analysis, bilateral LLND (p < 0.01, HR 7.37) and SSI (p = 0.01, HR 15.36) were independent factors that worsened DUC.

CONCLUSIONS

There was no difference in urinary dysfunction after LLND between LS and RALS. Bilateral LLND and SSI were risk factors for lengthening DUC. Compared to bilateral LLND, unilateral LLND can reduce urinary dysfunction; therefore, selective LLND, which is overwhelmingly unilateral LLND, and prevention of perioperative SSI may be important for maintenance of urinary function.

The Learning Curve for Robotic Lateral Pelvic Lymph Node Dissection for Rectal Cancer: A View From the West

BACKGROUND

Lateral pelvic lymph node dissection is performed for selected patients with rectal cancer with persistent lateral nodal disease after neoadjuvant therapy. This technique has been slow to be adopted in the West because of concerns regarding technical difficulty. This is the first report on the learning curve for lateral pelvic lymph node dissection in the United States or Europe.

OBJECTIVE

This study aimed to analyze the learning curve associated with robotic lateral pelvic lymph node dissection.

DESIGN

Retrospective observational cohort.

SETTING

Tertiary academic cancer center.

PATIENTS

Consecutive patients from 2012 to 2021.

INTERVENTION

All patients underwent robotic lateral pelvic lymph node dissection.

MAIN OUTCOME MEASURES

The primary end points were the learning curves for the maximum number of nodes retrieved and urinary retention, which was evaluated with simple cumulative sum and 2-sided Bernoulli cumulative sum charts.

RESULTS

Fifty-four procedures were included. A single-surgeon learning curve (n = 35) and an institutional learning curve are presented in the analysis. In the single-surgeon learning curve, a turning point marking the end of a learning phase was detected at the 12th procedure for the number of retrieved nodes and at the 20th procedure for urinary retention. In the institutional learning curve analysis, 2 turning points were identified at the 13th procedure, indicating progressive improvements for the number of retrieved nodes, and at the 27th procedure for urinary retention. No sustained alarm signals were detected at any time point.

LIMITATIONS

The retrospective nature, small sample size, and the referral center nature of the reporting institution may limit generalizability.

CONCLUSIONS

In a setting of institutional experience with robotic colorectal surgery, including beyond total mesorectal excision resections, the learning curve for robotic lateral pelvic lymph node dissection is acceptably short. Our results demonstrate the feasibility of the acquisition of this technique in a controlled setting, with sufficient case volume and proctoring to optimize the learning curve. See Video Abstract.

LA CURVA DE APRENDIZAJE DE LA DISECCIN ROBTICA DE LOS GANGLIOS LINFTICOS PLVICOS LATERALES EN EL CNCER DE RECTO UNA VISIN DESDE OCCIDENTE

ANTECEDENTES:La disección lateral de los ganglios linfáticos pélvicos se realiza en pacientes seleccionados con cáncer de recto con enfermedad ganglionar lateral persistente tras el tratamiento neoadyuvante. La adopción de esta técnica en Occidente ha sido lenta debido a la preocupación por su dificultad técnica. Éste es el primer informe sobre la curva de aprendizaje de la disección de los ganglios linfáticos pélvicos laterales en EE.UU. o Europa.OBJETIVO:El objetivo de este estudio fue analizar la curva de aprendizaje asociada a la disección robótica de los ganglios linfáticos pélvicos laterales.DISEÑO:Cohorte observacional retrospectiva.LUGAR:Centro oncológico académico terciario.PACIENTES:Pacientes consecutivos desde 2012 al 2021.INTERVENCIÓN:Todos los pacientes fueron sometieron a disección robótica de ganglios linfáticos pélvicos laterales.PRINCIPALES MEDIDAS DE RESULTADO:Los criterios de valoración primarios fueron las curvas de aprendizaje tomando en cuenta el mayor número de ganglios recuperados y la retención urinaria que fueron evaluados con gráficos de suma acumulativa simple y de suma acumulativa de Bernoulli de dos caras.RESULTADOS:Fueron incluidos 54 procedimientos. En el análisis se presentan una curva de aprendizaje de un solo cirujano (n = 35) y una curva de aprendizaje institucional. En la curva de aprendizaje de un solo cirujano, se detectó un punto de inflexión que marcaba el final de una fase de aprendizaje en el duodécimo procedimiento para el número de ganglios extraídos y en el vigésimo para la retención urinaria. En el análisis de la curva de aprendizaje institucional, se identificaron dos puntos de inflexión en las intervenciones 13.ª y 26.ª, que indicaron mejoras progresivas en el número de ganglios extraídos, y en la 27.ª en la retención urinaria. No se detectaron señales de alarma sostenidas en ningún momento.LIMITACIONES:La naturaleza retrospectiva, el pequeño tamaño de la muestra y la naturaleza de centro de referencia de la institución informante que pueden limitar la capacidad de generalizarse.CONCLUSIONES:En un entorno de experiencia institucional con cirugía robótica colorrectal incluyendo más allá de las resecciones TME, la curva de aprendizaje para la disección robótica de ganglios linfáticos pélvicos laterales es aceptablemente corta. Nuestros resultados demuestran la viabilidad de la adquisición de esta técnica en un entorno controlado, con un volumen de casos suficiente y una supervisión que puede optimizar la curva de aprendizaje. (Traducción-Dr. Osvaldo Gauto ).

Management of Surgically Accessible Lymph Nodes Beyond Normal Resection Planes

This article discusses the management of isolated metastatic lymph nodes for colon and rectal cancer. There are traditionally significant differences in how certain regions of lymph nodes for colon and rectal cancer are managed in the East and West. This has led to the development of the lateral lymph node dissection for rectal cancer and extended lymphadenectomy techniques for colon cancer. This article will evaluate the literature on these techniques and what the surgical and oncological outcomes are at this time. In addition, colon and rectal cancers can occasionally have isolated distant lymph node metastases. These would traditionally be treated as systemic disease with chemotherapy. There is consideration though that these could be treated as similar to isolated liver or lung metastases which have been shown to be able to be treated surgically with good oncological results. The literature for these isolated distant lymph node metastases will be reviewed and treatment options available will be discussed.

Essential anatomy for lateral lymph node dissection

In Western countries, the gold-standard therapeutic strategy for rectal cancer is preoperative chemoradiotherapy (CRT) following total mesorectal excision (TME), without lateral lymph node dissection (LLND). However, preoperative CRT has recently been reported to be insufficient to control lateral lymph node recurrence in cases of enlarged lateral lymph nodes before CRT, and LLND is considered necessary in such cases. We performed a literature review on aspects of pelvic anatomy associated with rectal surgery and LLND, and then combined this information with our experience and knowledge of pelvic anatomy. In this review, drawing upon research using a 3-dimensional anatomical model and actual operative views, we aimed to clarify the essential anatomy for LLND. The LLND procedure was developed in Asian countries and can now be safely performed in terms of functional preservation. Nonetheless, the longer operative time, hemorrhage, and higher complication rates with TME accompanied by LLND than with TME alone indicate that LLND is still a challenging procedure. Laparoscopic or robotic LLND has been shown to be useful and is widely performed; however, without a sufficient understanding of anatomical landmarks, misrecognition of vessels and nerves often occurs. To perform safe and accurate LLND, understanding the landmarks of LLND is essential.

Transanally assisted lateral pelvic lymph node dissection for rectal cancer

BACKGROUND

Although lateral pelvic lymph node dissection (LLND) might be an effective approach for patients with rectal cancer with lateral lymph node metastasis, it is technically challenging because of the anatomical complexity and location of the deep pelvis. An assistance by transanal approach might be useful for a successful LLND.

METHODS

From September 2016 to May 2021, 39 patients with low rectal cancer underwent transanal total mesorectal excision with LLND. Among them, 18 patients underwent LLND using a conventional laparoscopic approach alone, while the remaining 21 underwent LLND using both conventional and transanal approaches. Their clinical outcomes were retrospectively compared.

RESULTS

The operation time for LLND on each side was significantly shorter in the transanal group (105 min vs. 54 min, P < 0.001). The intraoperative blood loss was also significantly less in the transanal group (40 g vs. 0 g, P = 0.031). The rate of overall postoperative complications ≥ grade II according to the Clavien-Dindo classification was significantly less in the transanal group (66.7% vs. 28.6%, odds ratio: 5.000, 95% confidence intervals: 1.313-19.047, P = 0.040). The number of harvested lateral lymph nodes in both groups was similar (8.5 vs. 8, P = 0.544).

CONCLUSION

The transanal approach for LLND reduced operative time, blood loss, and morbidity compared with the conventional approach alone in a cohort of patients with rectal cancer.

Aggressive Resection of Malignant Paraaortic and Pelvic Tumors Accompanied by Arterial Reconstruction with Synthetic Arterial Graft

BACKGROUND Advanced malignancies in the lower abdomen easily invade the retroperitoneal and pelvic space and often metastasize to the paraaortic and pelvic lymph nodes (LNs), resulting in paraaortic and/or pelvic tumor (PPT). CASE REPORT A total of 7 cases of aggressive malignant PPT resection and orthotopic replacement of the abdominal aorta and/or iliac arteries with synthetic arterial graft (SAG) were experienced during 16 years. We present our experience with aggressive resection of malignant PPTs accompanied by arterial reconstruction with SAG in detail. The primary diseases included 2 cases endometrial cancer and 2 cases of rectal cancer, and 1 case each of ovarian carcinosarcoma, vaginal malignant melanoma, and sigmoid cancer. Surgical procedures are described in detail. Briefly, the abdominal aorta and iliac arteries were anastomosed to the SAG by continuous running suture using unabsorbent polypropylene. Five Y-shaped and 2 I-shaped SAGs were used. This en bloc resection actually provided safe surgical margins, and tumor exposures were not pathologically observed in the cut surfaces. Graphical and surgical curability were obtained in all cases in which aggressive malignant PPT resections were performed. The short-term postoperative course of our patients was uneventful. From a vascular perspective, the SAGs remained patent over the long term after surgery, and long-term oncologic outcomes were satisfactory. CONCLUSIONS To our knowledge, this case series is the first report of aggressive malignant PPT resection accompanied by arterial reconstruction with SAG. This procedure is safe and feasible, shows curative potential, and may play a role in multidisciplinary management of malignant PPTs.