1
|
Use of a national registry to define a composite quality metric for rectal cancer. Am J Surg 2023; 225:514-518. [PMID: 36517277 DOI: 10.1016/j.amjsurg.2022.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 11/23/2022] [Accepted: 11/29/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Quality assessment in oncologic surgery has traditionally involved reporting discrete metrics that may be difficult for patients and referring providers to interpret. We define a composite quality metric (CQM) for resection in rectal cancer. METHODS We queried the National Cancer Database to identify patients undergoing low anterior resection for clinical stage II-III rectal adenocarcinoma between 2010 and 2017. CQM was defined as appropriate neoadjuvant therapy, margin-negative resection, appropriate lymph node assessment, postoperative length of stay (LOS) < 75th percentile, and no 30-day readmission or mortality. RESULTS 19,721 patients met inclusion criteria; 8,083 (41%) had a CQM. The most common reasons for failure to achieve CQM: inadequate node assessment (27%), prolonged LOS (26%). On Cox modeling, CQM (aHR 0.70, 95% CI [0.66, 0.75]) was associated with improved overall survival. CONCLUSION CQM is independently associated with improved survival in rectal cancer and may be an effective measure of quality.
Collapse
|
2
|
Oncological outcomes of open, laparoscopic and robotic colectomy in patients with transverse colon cancer. Tech Coloproctol 2022; 26:821-830. [PMID: 35804251 DOI: 10.1007/s10151-022-02650-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 05/25/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Literature concerning surgical management of transverse colon cancer is scarce, since many key trials excluded transverse colon cancer. The aim of this study was to evaluate clinical and oncological outcomes comparing open, laparoscopic and robotic transverse colon cancer resection. METHODS Consecutive patients who underwent elective surgery for transverse colon cancer between December 2005 and July 2021 were included. Data were kept in a prospective database approved by the institutional ethics committee. Primary outcome was overall and disease-free survival. Secondary outcomes included complications, operative time, length of stay and lymph node harvest. Statistical analysis was corrected for age and tumour localisation. RESULTS Two hundred and forty-six (38 robotic, 71 open and 137 laparoscopic resections) were recruited in this study. There were five conversions during laparoscopic procedures. Operative time was significantly shorter in robotic vs laparoscopic procedures (195 vs 238 min, p = 0.005) and length of stay was shorter in robotic vs laparoscopic and open group (7 vs 9 vs 15 days, p < 0.001). There was no difference in overall complications. R0 resections were similar. Lymph node harvest was highest in the robotic group vs. laparoscopic or open (32 vs. 29 vs. 21, p < 0.001). Overall survival was 97%, 85% and 60% (p < 0.001) and disease-free survival was 91%, 78% and 56% (p < 0.001) for the robotic, laparoscopic and open groups, respectively. CONCLUSIONS Minimally invasive surgery for transverse colon cancer is safe and offers good clinical and oncological outcomes. Robotic resection is associated with significantly shorter operating times, higher lymph node harvest, lower conversion rate and does not increase morbidity. Differences in disease-free and overall survival should be further explored in randomised controlled trials.
Collapse
|
3
|
Predictors and Outcomes of Minimally Invasive Surgery for Small Bowel Neuroendocrine Tumors : Minimally Invasive Surgery for SBNETs. J Gastrointest Surg 2022; 26:1252-1265. [PMID: 35132564 DOI: 10.1007/s11605-022-05264-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 01/22/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Open surgical resection with regional lymphadenectomy is the standard of care for small bowel neuroendocrine tumors (SBNETs). There is no consensus on the role of minimally invasive surgery (MIS). This study aims to evaluate the current national trends for MIS in treating SBNETs and its association with lymph node (LN) yield. METHODS The National Cancer Database was queried for patients with Stage I-III SBNETs who underwent surgery from 2010-2017. Time trends were examined using the Cochran-Armitage test. Chi-square tests, t test, and multivariable logistic regression assessed associations of surgical approach with patient, clinical, and facility characteristics. Kaplan-Meier curves and propensity score weighted Cox proportional hazards model were used to examine survival. RESULTS Of the 11,367 patients with Stage I-III SBNETs, 46.5% (N = 5,298) underwent MIS. From 2010-2017, the proportion of MIS increased from 35.6% to 57.7% (P < 0.001). Patients of Stage I disease (OR = 1.23), Caucasian race (OR = 1.18), private insurance (OR = 1.29), and higher volume centers (OR = 1.29) were more likely to undergo MIS (all P < 0.02). The average number of LN harvested in the MIS cohort was greater than in the open surgery cohort (13.3 vs 11.8 LN, P < 0.001). MIS patients had shorter length of stay by 2 days compared to open surgery (5.4 vs 7.6 days, P < 0.001). LN yield ≥ 8 was associated with better survival (HR = 0.77, P < 0.001). CONCLUSION The utilization of a MIS approach to treat Stage I-III SBNETs has increased, especially at higher volume centers. We did not observe an inferior LN harvest with the MIS cohort compared to the open surgery cohort.
Collapse
|
4
|
Simon HL, Reif de Paula T, Spigel ZA, Keller DS. National disparities in use of minimally invasive surgery for rectal cancer in older adults. J Am Geriatr Soc 2021; 70:126-135. [PMID: 34559891 DOI: 10.1111/jgs.17467] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/30/2021] [Accepted: 08/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) is safe and improves outcomes in older persons with rectal cancer but may be underutilized. As older persons are the largest surgical population, investigation of the current use and factors impacting MIS use is warranted. Our goal is to investigate the trends and disparities that affect utilization of MIS in older persons with rectal cancer. METHODS The National Cancer Database was reviewed for persons 65 years and older who underwent curative resection for rectal adenocarcinoma from 2010 to 2017. Cases were stratified by surgical approach (open or MIS [laparoscopic or robotic]). Univariate analysis compared patient and provider demographics across approaches. Multivariate analysis investigated variables associated with MIS use. Main outcome measures were trends and factors associated with MIS use in older persons. RESULTS Of 31,910 patients analyzed, 51.9% (n = 16,555) were open and 48.1% (n = 15,355) MIS. The MIS cohort was 66.7% (n = 10,236) laparoscopic and 33.3% (n = 5119) robotic. MIS increased from 29% in 2010 (n = 1197; 25% laparoscopic, 4% robotic) to 65% in 2017 (n = 2382; 35% laparoscopic, 30% robotic), likely from annual increases in robotics (OR 1.24/year, p < 0.0001). In the unadjusted analysis, there were significant differences in MIS use by age, race, comorbidity, socioeconomic status, and facility type. In multivariate analysis, patients with advancing age (OR 0.93, p < 0.001), major comorbidity (OR 0.75, p < 0.001), total proctectomy (OR0.78, p < 0.001), and advanced pathologic stage (OR 0.51, p < 0.001) were less likely to undergo MIS. CONCLUSION Nationwide, less than half of rectal cancer cases in older persons were performed with MIS, despite steady robotic growth. Patient and facility factors impacted MIS use. Further work on regionalizing rectal cancer care and ensuring equitable MIS access and training could improve utilization.
Collapse
Affiliation(s)
- Hillary L Simon
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Thais Reif de Paula
- Division of Colorectal Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Zachary A Spigel
- Department of Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Deborah S Keller
- Division of Colorectal Surgery, Department of Surgery, The University of California at Davis Medical Center, Sacramento, California, USA
| |
Collapse
|
5
|
Yellinek S, Krizzuk D, Gilshtein H, Moreno-Djadou T, de Sousa CAB, Qureshi S, Wexner SD. Early postoperative outcomes of diverting loop ileostomy closure surgery following laparoscopic versus open colorectal surgery. Surg Endosc 2021; 35:2509-2514. [PMID: 32458288 DOI: 10.1007/s00464-020-07662-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 05/20/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although diverting loop ileostomy (DLI) formation reduces the consequences of anastomotic leak and may also decrease the incidence of this severe complication, DLI closure can result in significant complications. The laparoscopic approach in colorectal surgery has numerous benefits, including reduced length of stay (LOS), less wound infection, and better cosmesis. The aim of this study was to determine whether a laparoscopic approach at the time of the ileostomy creation has a beneficial effect on the outcomes of ileostomy closure. METHODS A retrospective analysis of an IRB-approved prospective database was performed for all patients who underwent DLI closure between 2010 and 2017. Patients' demographics, operative reports, and postoperative course were reviewed. Statistical analyses were performed using SPSS software and included descriptive statistics, Chi-square for categorical variables, and Student's t tests for continuous variables. Skewed variables were compared using the non-parametric Mann-Whitney U test. Regression analysis for overall complications and LOS were preformed to further assess the impact of laparoscopy. RESULTS We identified 795 patients (363 females) who underwent DLI reversal surgery. The surgical approach in the index operation was laparoscopy in 65% of patients. Conversion to laparotomy at the ileostomy closure occurred in 6.1% of patients. The overall complication rate was lower and the LOS was shorter for patients who underwent DLI closure following laparoscopic surgery. Laparoscopy at the index operation was also associated with a lower incidence of postoperative ileus and a lower estimated blood loss (EBL) at the time of DLI reversal. Multivariate regression analysis found laparoscopy to have significant benefits compared to laparotomy for overall complications and for LOS. CONCLUSION Ileostomy closure following laparoscopic colorectal surgery offers benefits including reductions in LOS and overall complications.
Collapse
Affiliation(s)
- Shlomo Yellinek
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Dimitri Krizzuk
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Hayim Gilshtein
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Teresa Moreno-Djadou
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | | | - Sana Qureshi
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
| |
Collapse
|
6
|
Guidolin K, Spence RT, Chadi SA, Quereshy FA. Minimally Invasive Surgical Approaches Are Safe and Appropriate in N2 Colorectal Cancer. Dis Colon Rectum 2021; 64:293-300. [PMID: 33555709 DOI: 10.1097/dcr.0000000000001809] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is emerging evidence of the oncological safety of minimally invasive surgery in T4 colorectal cancer; however, such support is lacking in N2 disease. OBJECTIVE This study aimed to compare oncological and perioperative outcomes of surgical resection for N2 colorectal cancer using an open versus minimally invasive approach. DESIGN We conducted a retrospective cohort study using the National Surgical Quality Improvement Program's generic and targeted colectomy data sets. SETTINGS Data about surgery for N2 colorectal cancer were obtained regarding North American hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. PATIENTS All patients undergoing elective surgical resection for N2 colorectal cancer in participating hospitals between 2014 and 2018 were selected. INTERVENTIONS Surgical resection of N2 colorectal cancer was performed. MAIN OUTCOME MEASURES Our primary outcome was nodal yield. Secondary outcomes included perioperative complications and mortality. RESULTS A total of 1837 patients underwent open and 3907 patients underwent minimally invasive surgery colectomies for N2 colorectal cancer (n = 5744). Median nodal yield was 20 (interquartile range, 15-27) in the open group and 21 (interquartile range, 16-28) in the minimally invasive group (p < 0.0001); however, nodal harvest between the 2 groups was not significantly different on multivariate analysis. Perioperative complications were higher on univariate analysis in the open surgery group, with respect to key outcomes including anastomotic leak and death (p < 0.001). LIMITATIONS This study is limited by its retrospective design and by the fact that the staging data collected by the National Surgical Quality Improvement Program are pathological rather than clinical; however, prior studies found a 97% concordance between pathological and clinical N2 determination. CONCLUSIONS Minimally invasive surgery approaches to colorectal cancer with N2 disease result in equivalent nodal harvests compared with open approaches. Our group supports the use of a minimally invasive approach in advanced nodal stage colorectal cancer in the appropriately selected patient. See Video Abstract at http://links.lww.com/DCR/B417. LOS ABORDAJES QUIRRGICOS MNIMAMENTE INVASIVOS SON SEGUROS Y APROPIADOS EN EL CNCER COLORRECTAL N ANTECEDENTES:Existe evidencia emergente de la seguridad oncológica de la cirugía mínimamente invasiva en el cáncer colorrectal T4; sin embargo, semenjante apoyo falta en la enfermedad N2.OBJETIVO:comparar los resultados oncológicos y perioperatorios de la resección quirúrgica para el cáncer colorrectal N2 utilizando un abordaje abierto versus mínimamente invasivo.DISEÑO:Realizamos un estudio de cohorte retrospectivo utilizando los conjuntos de datos de colectomía genéricos y específicos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica.AJUSTE:Hospitales de Norte America que participan en el Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos.PACIENTES:Todos los pacientes sometidos a resección quirúrgica electiva por cáncer colorrectal N2 en los hospitales participantes entre 2014 y 2018.INTERVENCIONES:Resección quirúrgica de cáncer colorrectal N2.PRINCIPALES MEDIDAS DE VOLORACION:Nuestro resultado principal fue el rendimiento nodal. Los resultados secundarios incluyeron complicaciones perioperatorias y mortalidad.RESULTADOS:1837 pacientes fueron sometidos a cirugía abierta y 3907 pacientes fueron sometidos a colectomías de cirugía mínimamente invasiva por cáncer colorrectal N2 (n = 5744). La mediana del rendimiento nodal fue 20 (IQR 15-27) en el grupo abierto y 21 (IQR 16-28) en el grupo mínimamente invasivo (p <0,0001); sin embargo, el rendimiento nodal entre los dos grupos no fue significativamente diferente en el análisis multivariado. Las complicaciones perioperatorias fueron mayores en el análisis univariado en el grupo de cirugía abierta, con respecto a los resultados clave, incluida la fuga anastomótica y la muerte (p <0,001).LIMITACIONES:Este estudio está limitado por su diseño retrospectivo y por el hecho de que los datos de estadificación recopilados por NSQIP son patológicos más que clínicos; sin embargo, estudios previos encontraron una concordancia del 97% entre la determinación patológica y clínica de N2.CONCLUSIONES:Los enfoques de cirugía mínimamente invasiva para el cáncer colorrectal con enfermedad N2 dan rendimientos nodales equivalentes a abordajes abiertos. Nuestro grupo apoya el uso de abordaje mínimamente invasivo en el cáncer colorrectal avanzado en estadio ganglionar en el paciente adecuadamente seleccionado. Consulte Video Resumenhttp://links.lww.com/DCR/B417.
Collapse
Affiliation(s)
- Keegan Guidolin
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Richard T Spence
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Sami A Chadi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Fayez A Quereshy
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Hsieh C, Cologne KG. Laparoscopic Approach to Rectal Cancer-The New Standard? Front Oncol 2020; 10:1239. [PMID: 32850374 PMCID: PMC7412716 DOI: 10.3389/fonc.2020.01239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/16/2020] [Indexed: 12/20/2022] Open
Abstract
Minimally invasive surgery has revolutionized the way surgeons perform colorectal surgery, and new technologies continually upend the way surgeons view and operate within the deep pelvis. Among other benefits, it is associated with decreased lengths of stay, wound and surgical site infections, pain scores, and has an overall lower complication rate vs. open surgery (1). Recently, however, the role of minimally invasive surgery has been called into question in the effective and safe treatment of rectal cancer. This manuscript will outline the history of minimally invasive rectal cancer surgery, examine evidence detailing its safety (compared with alternatives), and discuss important aspects of use, most notably the considerable learning curve required to achieve proficiency, the extent of its current use, and potential pitfalls. The current evidence suggests minimally invasive surgery is a very safe way to treat rectal cancer when performed by experienced and specialty trained surgeons.
Collapse
Affiliation(s)
- Christine Hsieh
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Kyle G Cologne
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
8
|
Evolution of minimally invasive surgery for rectal cancer: update from the national cancer database. Surg Endosc 2020; 35:275-290. [PMID: 32112255 DOI: 10.1007/s00464-020-07393-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND As the use of minimally invasive techniques in colorectal surgery has become increasingly prevalent, concerns remain about the oncologic effectiveness and long-term outcomes of minimally invasive low anterior resection (MI-LAR) for the treatment of rectal cancer. STUDY DESIGN The 2010-2015 National Cancer Database (NCDB) Participant Data Use File was queried for patients undergoing elective open LAR (OLAR) or MI-LAR for rectal adenocarcinoma. A 1:1 propensity match was performed on the basis of demographics, comorbidity, and tumor characteristics. Outcomes were compared between groups and Cox proportional hazard modeling was performed to identify independent predictors of mortality. A subset analysis was performed on high-volume academic centers. RESULTS 35,809 patients undergoing LAR were identified of whom 18,265 (51.0%) underwent MI-LAR. After propensity matching, patients receiving MI-LAR were less likely to have a positive circumferential radial margin (CRM) (5.5% vs. 6.6%, p = 0.0094) or a positive distal margin (3.6% vs. 4.6%, p = 0.0022) and had decreased 90-day all-cause mortality (2.0% vs. 2.6%, p = 0.0238). MI-LAR resulted in decreased hospital length of stay (5 vs. 6 days, p < 0.0001) but a greater rate of 30-day readmission (7.6% vs. 6.5%, p = 0.0054). Long-term overall survival was improved with MI-LAR (79% vs. 76%, p < 0.0001). Cox proportional hazard modeling demonstrated a decreased risk of mortality with MI-LAR (HR 0.859, 95% CI 0.788-0.937). CONCLUSION MI-LAR is associated with improvement in CRM clearance and long-term survival. In the hands of experienced surgeons with advanced laparoscopy skills, MI-LAR appears safe and effective technique for the management of rectal cancer.
Collapse
|
9
|
Oncologic and Perioperative Outcomes of Laparoscopic, Open, and Robotic Approaches for Rectal Cancer Resection: A Multicenter, Propensity Score-Weighted Cohort Study. Dis Colon Rectum 2020; 63:46-52. [PMID: 31764247 DOI: 10.1097/dcr.0000000000001534] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Minimally invasive approaches have been shown to reduce surgical site complications without compromising oncologic outcomes. OBJECTIVE The primary aim of this study is to evaluate the rates of successful oncologic resection and postoperative outcomes among laparoscopic, open, and robotic approaches to rectal cancer resection. DESIGN This is a multicenter, quasiexperimental cohort study using propensity score weighting. SETTINGS Interventions were performed in hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. PATIENTS Adult patients who underwent rectal cancer resection in 2016 were included. MAIN OUTCOME MEASURES The primary outcome was a composite variable indicating successful oncologic resection, defined as negative distal and radial margins with at least 12 lymph nodes evaluated. RESULTS Among 1028 rectal cancer resections, 206 (20%) were approached laparoscopically, 192 (18.7%) were approached robotically, and 630 (61.3%) were open. After propensity score weighting, there were no significant sociodemographic or preoperative clinical differences among subcohorts. Compared to the laparoscopic approach, open and robotic approaches were associated with a decreased likelihood of successful oncologic resection (ORadj = 0.64; 95% CI, 0.43-0.94 and ORadj = 0.60; 95% CI, 0.37-0.97), and the open approach was associated with an increased likelihood of surgical site complications (ORadj = 2.53; 95% CI, 1.61-3.959). Compared to the laparoscopic approach, the open approach was associated with longer length of stay (6.8 vs 8.6 days, p = 0.002). LIMITATIONS This was an observational cohort study using a preexisting clinical data set. Despite adjusted propensity score methodology, unmeasured confounding may contribute to our findings. CONCLUSIONS Resections that were approached laparoscopically were more likely to achieve oncologic success. Minimally invasive approaches did not lengthen operative times and provided benefits of reduced surgical site complications and decreased postoperative length of stay. Further studies are needed to clarify clinical outcomes and factors that influence the choice of approach. See Video Abstract at http://links.lww.com/DCR/B70. RESULTADOS ONCOLÓGICOS Y PERIOPERATORIOS DE LOS ABORDAJES LAPAROSCÓPICOS, ABIERTOS Y ROBÓTICOS PARA LA RESECCIÓN DEL CÁNCER RECTAL: UN ESTUDIO DE COHORTE MULTICÉNTRICO Y PONDERADO DEL PUNTAJE DE PROPENSIÓN: Se ha demostrado que los enfoques mínimamente invasivos reducen las complicaciones del sitio quirúrgico sin comprometer los resultados oncológicos.El objetivo principal de este estudio es evaluar las tasas de resección oncológica exitosa y los resultados postoperatorios entre los abordajes laparoscópico, abierto y robótico para la resección del cáncer rectal.Este es un estudio de cohorte cuasi-experimental multicéntrico que utiliza la ponderación de puntaje de propensión.Las intervenciones se realizaron en hospitales que participan en el Programa Nacional de Mejora de la Calidad Quirúrgica del Colegio Americano de Cirujanos.Se incluyeron pacientes adultos que se sometieron a resección de cáncer rectal en 2016.El resultado primario fue una variable compuesta que indicaba una resección oncológica exitosa, definida como márgenes negativos distales y radiales con al menos 12 ganglios linfáticos evaluados.Entre 1,028 resecciones de cáncer rectal, 206 (20%) fueron abordadas por vía laparoscópica, 192 (18.7%) robóticamente y 630 (61.3%) abiertas. Después de ponderar el puntaje de propensión, no hubo diferencias sociodemográficas o clínicas preoperatorias significativas entre las subcohortes. En comparación con el abordaje laparoscópico, los abordajes abiertos y robóticos se asociaron con una menor probabilidad de resección oncológica exitosa (ORadj = 0.64; IC 95%, 0.43-0.94 y ORadj = 0.60; IC 95%, 0.37-0.97), y el abordaje abierto se asoció con una mayor probabilidad de complicaciones del sitio quirúrgico (ORadj = 2.53; IC 95%, 1.61-3.959). En comparación con el abordaje laparoscópico, el abordaje abierto se asoció con una estadía más prolongada (6.8 frente a 8.6 días, p = 0.002).Este fue un estudio de cohorte observacional que utilizó un conjunto de datos clínicos preexistentes. A pesar de la metodología de puntuación de propensión ajustada, la confusión no medida puede contribuir a nuestros hallazgos.Las resecciones que se abordaron por vía laparoscópica tuvieron más probabilidades de lograr el éxito oncológico. Los enfoques mínimamente invasivos no alargaron los tiempos quirúrgicos y proporcionaron beneficios de la reducción de las complicaciones del sitio quirúrgico y la disminución de la duración de la estadía postoperatoria. Se necesitan más estudios para aclarar los resultados clínicos y los factores que influyen en la elección del enfoque. Vea video resumen en http://links.lww.com/DCR/B70.
Collapse
|
10
|
Zimmermann M, Merkel S, Weber K, Bruch HP, Hohenberger W, Keck T, Grützmann R. Laparoscopic surgery for rectal cancer reveals comparable oncological outcome even in context of worse short-term results-long-term analysis of nearly 500 patients from two high-volume centers. Int J Colorectal Dis 2019; 34:1541-1550. [PMID: 31309324 DOI: 10.1007/s00384-019-03350-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Large randomized controlled trials have investigated the oncological value of the laparoscopic approach to colorectal cancer. Mainly, non-inferiority for the laparoscopic approach regarding long-term survival could be shown. Nevertheless, some recent trials revealed inferiority especially due to histopathological quality of specimen or location of the tumor in the rectum. The main objective of this study was to compare two historical patient collectives of specialized centers for either the laparoscopic or the open resection approach, regarding long-term survival and disease progression of rectal cancer according to tumor localization in a retrospective propensity score-matched analysis. METHODS A retrospective analysis, based on two prospectively maintained institutional colorectal cancer databases, was performed. The database of the reference center in Erlangen maintained almost exclusively open operations whereas the database in Lübeck maintained to a vast majority laparoscopic operations. To adjust risk profiles, a 1:1 propensity score matching was performed. RESULTS Seven hundred fifty-five patients of both centers (Erlangen, n = 507, Lübeck n = 248) were included. Propensity score matching resulted in two equalized groups with 248 patients. Regarding the postoperative complications, advantages for the open approach were seen. Analyzing the survival data, no differences in disease-free as well as overall survival were shown. Also, no differences in the overall loco-regional recurrence and distant metastasis rate were detected. CONCLUSION In centers with adequate expertise, open and laparoscopic procedures result in equivalent oncologic long-term outcomes. Advantages for the open resected group concerning short-term results and complications were detected, due to remarkably low rates of anastomotic leakage.
Collapse
Affiliation(s)
- Markus Zimmermann
- Department of Surgery, Medical University Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Susanne Merkel
- Department of Surgery, University Hospital, Friedrich-Alexander-University Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Klaus Weber
- Department of Surgery, University Hospital, Friedrich-Alexander-University Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Hans-Peter Bruch
- Department of Surgery, Medical University Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Werner Hohenberger
- Department of Surgery, University Hospital, Friedrich-Alexander-University Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Tobias Keck
- Department of Surgery, Medical University Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Robert Grützmann
- Department of Surgery, University Hospital, Friedrich-Alexander-University Erlangen, Krankenhausstraße 12, 91054, Erlangen, Germany
| |
Collapse
|
11
|
Laparoscopic Versus Conventional Open Rectum Amputation: a Clinical, Intraoperative, and Short-term Outcome Comparative Study. JOURNAL OF INTERDISCIPLINARY MEDICINE 2018. [DOI: 10.2478/jim-2018-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective: To evaluate and compare laparoscopic and conventional open rectum amputation procedures using clinical, intraoperative, postoperative, and oncological criteria.
Methods: Fifty-nine patients with lower rectal and anorectal cancer were included in a retrospective study, conducted between 2014 and 2017. Patients underwent open or laparoscopic rectum amputation surgery and were divided into two groups: group 1 – laparoscopic amputation group (LAG) and group 2 – open amputation group (OAG). The clinical, intraoperative, and postoperative outcomes and oncological results were compared between the two groups.
Results: We found a significantly smaller intraoperative blood loss (325 mL vs. 538.29 mL, p = 0.0002), earlier return of bowel motility (2.41 days vs. 3.10 days, p = 0.036), shorter hospital stays (10.08 days vs. 12.66 days, p = 0.03), and a higher number of lymph nodes removed during surgery (12.33 nodes for LAG vs. 9.98 nodes for OAG, p = 0.049). In the open surgery group we found shorter durations of surgery (199.58 minutes for LAG vs. 157.87 minutes for OAG, p = 0.0046).
Conclusion: Laparoscopic rectum amputation is a technically demanding procedure. The present study demonstrates the benefits and disadvantages of this surgery, with comparable clinical, intraoperative, postoperative, and oncological results compared to the conventional open rectum amputation procedure.
Collapse
|
12
|
Cleary RK, Morris AM, Chang GJ, Halverson AL. Controversies in Surgical Oncology: Does the Minimally Invasive Approach for Rectal Cancer Provide Equivalent Oncologic Outcomes Compared with the Open Approach? Ann Surg Oncol 2018; 25:3587-3595. [DOI: 10.1245/s10434-018-6740-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Indexed: 12/15/2022]
|
13
|
Bustamante-Lopez LA, Nahas CSR, Nahas SC, Marques CFS, Pinto RA, Cotti GC, Imperiale AR, de Mello ES, Ribeiro U, Cecconello I. Pathologic complete response implies a fewer number of lymph nodes in specimen of rectal cancer patients treated by neoadjuvant therapy and total mesorectal excision. Int J Surg 2018; 56:283-287. [PMID: 29981939 DOI: 10.1016/j.ijsu.2018.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/30/2018] [Accepted: 07/02/2018] [Indexed: 12/26/2022]
Abstract
Studies have suggested that the use of neoadjuvant chemoradiation results in a lower lymph nodes yield in rectal cancer patients. OBJECTIVE To evaluate factors associated with less than 12 lymph nodes harvested on patients with rectal cancer treated with preoperative chemoradiotherapy followed by total mesorectal excision. PATIENTS This was a cohort/retrospective single cancer center study. Low and mid locally advanced rectal cancer or T2N0 under risk of sphincter resection underwent chemoradiotherapy followed by total mesorectal excision with curative intent. Chemotherapy consisted of 5-FU and leucovorin IV. Total dose of pelvic radiation was 5040 Gys. All patients were staged and restaged by digital rectal examination, proctoscopy, colonoscopy, CT of abdomen and chest, and MRI of the pelvis. Patients were stratified in two groups: ≥12 and < 12 L N retrieved. The possible factors affecting number of LN were analyzed. RESULTS 95 patients met the inclusion criteria. Mean LN harvest was 23.2 (3-67). 81 patients (85%) had ≥12 L N. Gender, age, tumor size, tumor stage, tumor location, length of specimen, presence of LN involvement, type of surgery, and surgical access showed no association with number of LN retrieved. Only pathological complete response showed a statistically significant association with <12 L N on univariate (p = 0.004) and multivariate analyses (p = 0.002). LIMITATIONS Data were collected retrospectively. The number of patients disparity between the two groups. CONCLUSIONS Complete pathologic response is associated with <12 L N harvested. Thus, the number of lymph nodes should not be used as a surrogate for oncologic adequacy of resection in patients with pathologic complete response.
Collapse
Affiliation(s)
| | - Caio Sergio Rizkallah Nahas
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Sergio Carlos Nahas
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Rodrigo Ambar Pinto
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Guilherme Cutait Cotti
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Antonio Rocco Imperiale
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Evandro Sobroza de Mello
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, Surgical Division, University of São Paulo Medical School, São Paulo, Brazil
| |
Collapse
|
14
|
Chen CF, Lin YC, Tsai HL, Huang CW, Yeh YS, Ma CJ, Lu CY, Hu HM, Shih HY, Shih YL, Sun LC, Chiu HC, Wang JY. Short- and long-term outcomes of laparoscopic-assisted surgery, mini-laparotomy and conventional laparotomy in patients with Stage I-III colorectal cancer. J Minim Access Surg 2018; 14:321-334. [PMID: 29483373 PMCID: PMC6130178 DOI: 10.4103/jmas.jmas_155_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Three operative techniques have been used for colorectal cancer (CRC) resection: Conventional laparotomy (CL) and the mini-invasive techniques (MITs)– laparoscopic-assisted surgery (LAS) and mini-laparotomy (ML). The aim of the study was to compare the short- and long-term outcomes of patients undergoing the three surgical approaches for Stage I–III CRC resection. Patients and Methods: This study enrolled 688 patients with Stage I–III CRC undergoing curative resection. The primary endpoints were perioperative quality and outcomes. The secondary endpoints were oncological outcomes including disease-free survival (DFS), overall survival (OS) and local recurrence (LR). Results: Patients undergoing LAS had significantly less blood loss (P < 0.001), earlier first flatus (P = 0.002) and earlier resumption of normal diet (P = 0.025). Although post-operative complication rates were remarkably higher in patients undergoing CL than in those undergoing MITs (P = 0.002), no difference was observed in the post-operative mortality rate (P = 0.099) or 60-day re-intervention rate (P = 0.062). The quality of operation as assessed by the number of lymph nodes harvested and rates of R0 resection did not differ among the groups (all P > 0.05). During a median follow-up of 5.42 years, no significant difference was observed among the treatment groups in the rates of 3-year late morbidity, 3-year LR, 5-year LR, 5-year OS or 5-year DFS (all P > 0.05). Conclusions: Patients undergoing CL had higher post-operative morbidities. Moreover, the study findings confirm the favourable short-term and comparable long-term outcomes of LAS and ML for curative CRC resection. Therefore, both MITs may be feasible and safe alternatives to CL for Stage I-III CRC resection.
Collapse
Affiliation(s)
- Chin-Fan Chen
- Department of Surgery, Division of Trauma and Critical Care, Kaohsiung Medical University Hospital; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chieh Lin
- Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
| | - Hsiang-Lin Tsai
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital; Faculty of Medicine, College of Medicine; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ching-Wen Huang
- Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital; Faculty of Medicine, College of Medicine; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yung-Sung Yeh
- Department of Surgery, Division of Trauma and Critical Care; Division of Colorectal Surgery; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Cheng-Jen Ma
- Department of Surgery, Division of Colorectal Surgery; Division of General and Digestive Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Kaohsiung, Taiwan
| | - Chien-Yu Lu
- Department of Internal Medicine, Division of Gastroenterology, Kaohsiung Medical University Hospital; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Huang-Ming Hu
- Department of Internal Medicine, Division of Gastroenterology, Kaohsiung Medical University Hospital; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiang-Yao Shih
- Department of Internal Medicine, Division of Gastroenterology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ying-Ling Shih
- Department of Surgery, Nutrition Support Team; Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Chu Sun
- Department of Surgery, Nutrition Support Team; Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Herng-Chia Chiu
- Research Education and Epidemiology Centre, Changhua Christian Hospital, Changhua; Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jaw-Yuan Wang
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University; Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University; Department of Surgery, Division of General and Digestive Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University; Research Center for Environmental Medicine, Kaohsiung Medical University; Research Center for Natural Products and Drug Development, Kaohsiung Medical University, Kaohsiung, Taiwan
| |
Collapse
|
15
|
Koh YX, Goh BKP. Minimally invasive surgery for gastric gastrointestinal stromal tumors. Transl Gastroenterol Hepatol 2017; 2:108. [PMID: 29354765 DOI: 10.21037/tgh.2017.11.20] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 11/27/2017] [Indexed: 12/19/2022] Open
Abstract
Minimally invasive surgery has been increasingly performed for gastric gastrointestinal stromal tumors (GIST). In this review we discuss and summarize the current evidence on minimally invasive surgery for gastric GISTs. Laparoscopic resection for gastric GIST has been consistently shown to be associated with superior perioperative outcomes with no compromise in oncological outcomes when compared to open resection in numerous retrospective case-control studies. It has also been shown to be safe and feasible for large tumors or tumors located in unfavorable sites. However, to date, there remains a lack of level 1 evidence from prospective randomized control trials in support of laparoscopic resection.
Collapse
Affiliation(s)
- Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke NUS Medical School, Singapore, Singapore
| |
Collapse
|
16
|
Abstract
OBJECTIVE National examination of open proctectomy (OP), laparoscopic proctectomy (LP), and robotic proctectomy (RP) in pathological outcomes and overall survival (OS). BACKGROUND Surgical management for rectal adenocarcinoma is evolving towards utilization of LP and RP. However, the oncological impacts of a minimally invasive approach to rectal cancer have yet to be defined. METHODS Retrospective review of the National Cancer Database identified patients with nonmetastatic locally advanced rectal adenocarcinoma from 2010 to 2014, who underwent neoadjuvant chemoradiation, surgical resection, and adjuvant therapy. Cases were stratified by surgical approach. Multivariate analysis was used to compare pathological outcomes. Cox proportional-hazard modeling and Kaplan-Meier analyses were used to estimate long-term OS. RESULTS Of 6313 cases identified, 53.8% underwent OP, 31.8% underwent LP, and 14.3% underwent RP. Higher-volume academic/research and comprehensive community centers combined to perform 80% of laparoscopic cases and 83% of robotic cases. In an intent-to-treat model, multivariate analysis demonstrated superior circumferential margin negativity rates with LP compared with OP (odds ratio 1.34, 95% confidence interval 1.02-1.77, P = 0.036). Cox proportional-hazard modeling demonstrated a lower death hazard ratio for LP compared with OP (hazard ratio 0.81, 95% confidence interval 0.67-0.99, P = 0.037). Kaplan-Meier analysis demonstrated a 5-year OS of 81% in LP compared with 78% in RP and 76% in OP (P = 0.0198). CONCLUSION In the hands of experienced colorectal specialists treating selected patients, LP may be a valuable operative technique that is associated with oncological benefits. Further exploration of pathological outcomes and long-term survival by means of prospective randomized trials may offer more definitive conclusions regarding comparisons of open and minimally invasive technique.
Collapse
|
17
|
The positive impact of surgical quality control on adequate lymph node harvest by standardized laparoscopic surgery and national quality assessment program in colorectal cancer. Int J Colorectal Dis 2017; 32:975-982. [PMID: 28190102 DOI: 10.1007/s00384-017-2771-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE We aimed to present the factors associated with lymph node harvest (LNH) and seek whether surgical quality control measures can improve LNH. METHODS From a prospectively collected data at a single institution, 874 CRC patients who underwent curative surgery between 2004 and 2013 were included. Factor and survival analyses were performed regarding LNH. Subgroup analysis was performed according to LNH group (LNH ≥ 12 vs LNH < 12) and year of surgery (2004-2008, 2009-2011, and 2012-2013 group). RESULTS In the multivariate analysis, tumor location (OR 0.6, p < 0.001), stage (OR 1.95, p < 0.001), and year of surgery (OR 3.86, p < 0.001) showed an association with adequate LNH. In the subgroup analysis categorized by the year of surgery, surgical quality control measures by standardized laparoscopic surgery (OR 52.91, p < 0.001) showed notable association with adequate LNH. Comparing the 2009-2011 and 2012-2013 group, the national quality assessment program additionally improved adequate LNH percentage (83.9 vs 94.3%). In the survival analysis, disease-free survival (DFS) differed according to year of surgery, standardized laparoscopic surgery with high vascular ligation, and adequate LNH by stage. In the overall survival (OS) analysis, the LNH-related factors did not show significant difference. CONCLUSIONS Through standardized laparoscopic surgery with high vascular ligation and national quality assessment program, surgical quality control had a positive impact on the increase of adequate LNH. Improving the modifiable LNH factors resulted in the enhancement of adequate LNH and related DFS.
Collapse
|
18
|
Dhruva Rao PK, Peiris SPM, Arif SS, Davies RA, Masoud AG, Haray PN. Value of multi-disciplinary input into laparoscopic management of rectal cancer - An observational study. World J Gastrointest Surg 2017; 9:153-160. [PMID: 28690775 PMCID: PMC5483415 DOI: 10.4240/wjgs.v9.i6.153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 01/18/2017] [Accepted: 05/19/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the impact of multi-disciplinary teams (MDTs) management in optimising the outcome for rectal cancers.
METHODS We undertook a retrospective review of a prospectively maintained database of patients with rectal cancers (defined as tumours ≤ 15 cm from anal verge) discussed at our MDT between Jan 2008 and Jan 2011. The data was validated against the national database to ensure completeness of dataset. The clinical course and follow-up data was validated using the institution’s electronic patient records. The data was analysed in terms of frequencies and percentages. Significance of any differences were analysed using χ2 test. A Kaplan-Meier analysis was performed for overall survival and disease free survival.
RESULTS Following appropriate staging, one hundred and thirty-three patients were suitable for potentially curative resections. Seventy two (54%) were upper rectal cancer (URC) - tumour was > 6 cm from the anal verge and 61 (46%) were lower rectal cancers (LRC) - lower extent of the tumour was palpable ≤ 6 cm. Circumferential resection margin (CRM) appeared threatened on pre-operative MRI in 19/61 (31%) patients with LRC requiring neo-adjuvant therapy (NAT). Of the 133 resections, 118 (89%) were attempted laparoscopically (5% conversion rate). CRM was positive in 9 (6.7%) patients; Median lymph node harvest was 12 (2-37). Major complications occurred in 8 (6%) patients. Median follow-up was 53 mo (0-82). The 90-d mortality was 2 (1.5%). Over the follow-up period, disease related mortality was 11 (8.2%) and overall mortality was 39 (29.3%). Four (3%) patients had local recurrence and 22 (16.5%) patients had distant metastases.
CONCLUSION Management of rectal cancers can be optimized with multi-disciplinary input to attain acceptable long-term oncological outcomes even when incorporating a laparoscopic approach to rectal cancer resection.
Collapse
|
19
|
Bustamante-Lopez L, Nahas CS, Nahas SC, Ribeiro U, Marques CF, Cotti G, Rocco A, Cecconello I. Understanding the factors associated with reduction in the number of lymph nodes in rectal cancer patients treated by neoadjuvant treatment. Int J Colorectal Dis 2017; 32:925-927. [PMID: 28035459 DOI: 10.1007/s00384-016-2747-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Rectal cancer patients frequently present with locally advanced disease for which the standard of care includes neoadjuvant chemoradiotherapy followed by total mesorectal excision. Positive lymph nodes are one of the most powerful risk factors for recurrence and survival in colorectal cancer. In the absence of specific rectal guidelines, the literature recommends to the pathologist to optimize the number of rectal lymph nodes (LN) retrieved. We made a literature review in order to identify factors that could potentially affect the number of LN retrieved in specimens of patients with rectal cancer treated by chemoradiotherapy (CRT) followed by total mesorectal excision (TME). RESULTS Age did not have a significant effect on LN yield. The effect of sex on LN number is not consistent in the literature. Most of the papers did not find a relationship between lower LN obtained and gender. Laparoscopy for primary rectal cancer is associated with a greater number of LN as well as short-term benefits. Tumors in the upper rectum are associated with a higher number of LN than those in the mid and lower rectum. The type of surgery had no effect on lymph node yield either. Tumors with complete or almost complete pathologic regression were exactly the ones with lower number of lymph nodes detected. Approximately one-third of patients with neoadjuvant treatment had less than 12 LN yield. CONCLUSION The tumor regression grade is the most important factor for the decrease in the number of lymph nodes.
Collapse
Affiliation(s)
- L Bustamante-Lopez
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil.
| | - C S Nahas
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - S C Nahas
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - U Ribeiro
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - C F Marques
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - G Cotti
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - A Rocco
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| | - I Cecconello
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - Instituto de Câncer do Estado de Sáo Paulo, Sao Paulo, Brazil
| |
Collapse
|
20
|
Saia M, Buja A, Mantoan D, Sartor G, Agresta F, Baldo V. Isolated rectal cancer surgery: a 2007-2014 population study based on a large administrative database. Updates Surg 2017; 69:367-373. [PMID: 28409441 DOI: 10.1007/s13304-017-0445-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 04/03/2017] [Indexed: 12/11/2022]
Abstract
Rectal resection is technically one of the most demanding laparoscopic procedures, requiring additional training and expertise of both surgeons and institutions. The literature has shown that laparoscopic procedures can be appropriate for the treatment of rectal cancer (RC), in terms of safety, outcome and efficiency, but results may not always be directly transferable to the general population. This study aimed to investigate the use of laparoscopic rectal cancer resections in a north-eastern Italian region (the Veneto) and to see how the characteristics of patients and hospitals are associated with the use of laparoscopy. This was a retrospective cohort study based on administrative data collected from 2007 to 2014 in the Veneto region (north-east Italy). In the period considered (2007-2014), 4953 rectal resections were performed for RC in Veneto hospitals, accounting for 35% of the total 14,243 surgical procedures involving the rectum, and resulting in 76,739 days in hospital [mean length of stay-post-operative (MLOS) 15.5 ± 11.1 days]. Patients were a mean 67.9 ± 11.7 years old (68 ± 12.7 for women, 67.9 ± 11 for men), while the subgroup of patients undergoing laparoscopic procedures was on average 2 years younger (66.5 ± 11.8 vs 68.8 ± 11.5; p < 0.05). The four main findings of this study are: (1) the increasing rates of laparoscopic procedures for RC resection at all the hospitals in our geographical area, rising up to 52% in 2014. This is probably related to not only to availability of better equipment but surely to a growing expertise of surgeons; (2) the esteem of proportion of laparoscopically treated RC; (3) the significant difference between the laparoscopic and open surgical approach in terms of mean length of hospital stay after RC resection, making the laparoscopic approach cost-effective generally speaking; and (4) the disparities in hospitals' use of laparoscopy by patients' age group: Laparoscopic surgery is safe also in the elderly population but it is not so widely offers in Veneto Region hospitals, and it's probably due to the lack of experience about this approach in frail/old patients.
Collapse
Affiliation(s)
- Mario Saia
- Veneto Region Health Directorate, Venice, Italy
| | - Alessandra Buja
- Department of Molecular Medicine, Laboratory of Public Health and Population StudiesUniversity of Padua, Padua, Italy
| | | | - Gino Sartor
- Department of Molecular Medicine, Laboratory of Public Health and Population StudiesUniversity of Padua, Padua, Italy
| | - Ferdinando Agresta
- Department of General Surgery, ULSS 5 Polesana del Veneto, Adria, RO, Italy.
| | - Vincenzo Baldo
- Department of Molecular Medicine, Laboratory of Public Health and Population StudiesUniversity of Padua, Padua, Italy
| |
Collapse
|
21
|
Abstract
It is evident that the use of laparoscopy in the management of rectal cancer has gained popularity in the last few years. It is still, however, not widely accepted as the standard of care. Multiple randomized trials have shown that short-term outcomes and perioperative morbidity and mortality of laparoscopic proctectomy are equivalent to open surgery. However, data regarding long-term oncologic outcomes are still scarce, with only a few randomized trials reporting similar outcomes in both laparoscopic and open group. A more recent trial failed to replicate those results in patients with locally advanced rectal cancer. In this article, we will look at the most recent evidence regarding the use of laparoscopy for patients with rectal cancer. We will also briefly discuss the different approaches and new minimally invasive techniques used in this field, and we will talk about the challenges facing the widespread adoption of laparoscopic surgery in the management of rectal cancer.
Collapse
Affiliation(s)
- Chady Atallah
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
22
|
Abu Gazala M, Wexner SD. Re-appraisal and consideration of minimally invasive surgery in colorectal cancer. Gastroenterol Rep (Oxf) 2017; 5:1-10. [PMID: 28567286 PMCID: PMC5444240 DOI: 10.1093/gastro/gox001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 12/13/2022] Open
Abstract
Throughout history, surgeons have been on a quest to refine the surgical treatment options for their patients and to minimize operative trauma. During the last three decades, there have been tremendous advances in the field of minimally invasive colorectal surgery, with an explosion of different technologies and approaches offered to treat well-known diseases. Laparoscopic surgery has been shown to be equal or superior to open surgery. The boundaries of laparoscopy have been pushed further, in the form of single-incision laparoscopy, natural-orifice transluminal endoscopic surgery and robotics. This paper critically reviews the pathway of development of minimally invasive surgery, and appraises the different minimally invasive colorectal surgical approaches available to date.
Collapse
Affiliation(s)
- Mahmoud Abu Gazala
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Steven D. Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| |
Collapse
|
23
|
Clark LA, Peters WR. Laparoscopic resection of rectal cancer in the elderly. Proc (Bayl Univ Med Cent) 2016; 29:436-438. [PMID: 28000800 DOI: 10.1080/08998280.2016.11929504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Recent published trials have failed to demonstrate that laparoscopic resection is not inferior to open resection of rectal cancer in terms of pathologic outcomes. However, there have been numerous studies showing the benefit of laparoscopic resection in terms of short-term complications and quality of life. Fewer complications and shorter hospital stays improve the chance of maintaining functional status, which is very important for the elderly population. Thus, laparoscopic resection of rectal cancer remains a viable option for the elderly.
Collapse
Affiliation(s)
- L August Clark
- Departments of Internal Medicine (Clark) and Colon and Rectal Surgery (Peters), Baylor University Medical Center at Dallas, Texas
| | - Walter R Peters
- Departments of Internal Medicine (Clark) and Colon and Rectal Surgery (Peters), Baylor University Medical Center at Dallas, Texas
| |
Collapse
|
24
|
Moon SY, Kim S, Lee SY, Han EC, Kang SB, Jeong SY, Park KJ, Oh JH. Laparoscopic surgery for patients with colorectal cancer produces better short-term outcomes with similar survival outcomes in elderly patients compared to open surgery. Cancer Med 2016; 5:1047-54. [PMID: 26923309 PMCID: PMC4924362 DOI: 10.1002/cam4.671] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 01/18/2016] [Accepted: 01/24/2016] [Indexed: 12/25/2022] Open
Abstract
The number of operations on elderly colorectal cancer (CRC) patients has increased with the aging of the population. The aim of this study was to evaluate surgical outcomes in elderly patients who underwent laparoscopic or open surgery for CRC. We analyzed the data of 280 patients aged 80 or over who underwent surgery for CRC between January 2001 and December 2010. Seventy-one pairs were selected after propensity score matching for laparoscopic or open surgery. Operative time, return to normal bowel function, length of hospital stay, postoperative complications, overall survival (OS), recurrence-free survival (RFS), and prognostic factors affecting survival were investigated. In matched cohorts, operative time in the laparoscopic group was longer than in the open group (P < 0.001). In the laparoscopic group, time to flatus passage (P < 0.001) and length of postoperative hospital stay (P = 0.037) were shorter than in the open group. The rate of operation-related morbidity was higher in the open group (P = 0.019). There was no difference in OS and RFS between two groups. This study suggests that laparoscopic surgery for CRC in elderly patients may be safe and feasible, with better short-term outcomes. OS and RFS, however, were not different in both groups.
Collapse
Affiliation(s)
- Soo Yun Moon
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sohee Kim
- Biometric Research Branch, Research Institute, National Cancer Center, Goyang, Korea
| | - Soo Young Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eon Chul Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea
| | - Sung-Bum Kang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea.,Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.,Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | | |
Collapse
|
25
|
Evaluating quality across minimally invasive platforms in colorectal surgery. Surg Endosc 2015; 30:2207-16. [DOI: 10.1007/s00464-015-4479-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 07/28/2015] [Indexed: 12/14/2022]
|
26
|
Odermatt M, Flashman K, Khan J, Parvaiz A. Laparoscopic-assisted abdominoperineal resection for low rectal cancer provides a shorter length of hospital stay while not affecting the recurrence or survival: a propensity score-matched analysis. Surg Today 2015; 46:798-806. [DOI: 10.1007/s00595-015-1244-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 08/04/2015] [Indexed: 12/19/2022]
|
27
|
Laparoscopic surgery for radiation enteritis. J Surg Res 2015; 194:415-419. [DOI: 10.1016/j.jss.2014.11.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/30/2014] [Accepted: 11/14/2014] [Indexed: 11/18/2022]
|
28
|
Transanal total mesorectal excision of rectal carcinoma: evidence to learn and adopt the technique. Ann Surg 2015; 261:234-6. [PMID: 25565121 DOI: 10.1097/sla.0000000000000886] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
|
29
|
Campa-Thompson M, Weir R, Calcetera N, Quirke P, Carmack S. Pathologic processing of the total mesorectal excision. Clin Colon Rectal Surg 2015; 28:43-52. [PMID: 25733973 DOI: 10.1055/s-0035-1545069] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Total mesorectal excision (TME) is the current optimal surgical treatment for patients with rectal carcinoma. A complete TME is related to lower local recurrence rates and increased patient survival. Many confounding factors in the patient's anatomy and prior therapy can make it difficult to obtain a perfect plane, and thus a complete TME. The resection specimen can be thoroughly evaluated, grossly and microscopically, to identify substandard surgical outcomes and increased risk of local recurrence. Complete and accurate data reporting is critical for patient care and helps surgeons improve their technique.
Collapse
Affiliation(s)
- Molly Campa-Thompson
- Department of Pathology, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Robert Weir
- Department of Pathology, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Natalie Calcetera
- Department of Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Philip Quirke
- Department of Pathology and Tumor Biology, Leeds Institute of Cancer and Pathology, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Susanne Carmack
- Department of Pathology, Baylor University Medical Center at Dallas, Dallas, Texas
| |
Collapse
|
30
|
Ye F, Chen D, Wang D, Lin J, Zheng S. Use of Valtrac™-secured intracolonic bypass in laparoscopic rectal cancer resection. Medicine (Baltimore) 2014; 93:e224. [PMID: 25546660 PMCID: PMC4602602 DOI: 10.1097/md.0000000000000224] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The occurrence of anastomotic leakage (AL) remains a major concern in the early postoperative stage. Because of the relatively high morbidity and mortality of AL in patients with laparoscopic low rectal cancer who receive an anterior resection, a fecal diverting method is usually introduced. The Valtrac™-secured intracolonic bypass (VIB) was used in open rectal resection, and played a role of protecting the anastomotic site. This study was designed to assess the efficacy and safety of the VIB in protecting laparoscopic low rectal anastomosis and to compare the efficacy and complications of VIB with those of loop ileostomy (LI). Medical records of the 43 patients with rectal cancer who underwent elective laparoscopic low anterior resection and received VIB procedure or LI between May 2011 and May 2013 were retrospectively analyzed, including the patients' demographics, clinical features, and operative data. Twenty-four patients received a VIB and 19 patients a LI procedure. Most of the demographics and clinical features of the groups, including Dukes stages, were similar. However, the median distance of the tumor edge from the anus verge in the VIB group was significantly longer (7.5 cm; inter-quartile range [IQR] 7.0-9.5 cm) than that of the L1 group (6.0 cm; IQR 6.0-7.0 cm). None of the patients developed clinical AL. The comparisons between the LI and the VIB groups were adjusted for the significant differences in the tumor level of the groups. After adjustment, the LI group experienced longer overall postoperative hospital stay (14.0 days, IQR: 12.0, 16.0 days; P < 0.001) and incurred higher costs ($6300 (IQR: $5900, $6600)) than the VIB group (7.0 days, $4800; P < 0.05). Stoma-related complications in the ileostomy group included dermatitis (n = 2), stoma bleeding (n = 1), and wound infection after closure (n = 2). No BAR-related complications occurred. The mean time to Valtrac™ ring loosening was 14.1 ± 3.2 days. The VIB procedure, as a good partner with the laparoscopic rectal cancer resection, appears to be a safe and effective, but time-limited, diverting technique to protect an elective low colorectal anastomosis.
Collapse
Affiliation(s)
- Feng Ye
- From the Department of Colorectal Surgery (FY, DC, DW, JL); and Department of General Surgery, the First Affiliated Hospital, Zhejiang University, No. 79, Qinchun Road, Hangzhou, China (SZ)
| | | | | | | | | |
Collapse
|
31
|
Shussman N, Wexner SD. Current status of laparoscopy for the treatment of rectal cancer. World J Gastroenterol 2014; 20:15125-15134. [PMID: 25386061 PMCID: PMC4223246 DOI: 10.3748/wjg.v20.i41.15125] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 05/23/2014] [Accepted: 06/23/2014] [Indexed: 02/07/2023] Open
Abstract
Surgery for rectal cancer in complex and entails many challenges. While the laparoscopic approach in general and specific to colon cancer has been long proven to have short term benefits and to be oncologically safe, it is still a debatable topic for rectal cancer. The attempt to benefit rectal cancer patients with the known advantages of the laparoscopic approach while not compromising their oncologic outcome has led to the conduction of many studies during the past decade. Herein we describe our technique for laparoscopic proctectomy and assess the current literature dealing with short term outcomes, immediate oncologic measures (such as lymph node yield and specimen quality) and long term oncologic outcomes of laparoscopic rectal cancer surgery. We also briefly evaluate the evolving issues of robotic assisted rectal cancer surgery and the current innovations and trends in the minimally invasive approach to rectal cancer surgery.
Collapse
|
32
|
Wexner SD, Berho M. Transanal TAMIS total mesorectal excision (TME)--a work in progress. Tech Coloproctol 2014; 18:423-5. [PMID: 24682802 DOI: 10.1007/s10151-014-1141-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/15/2014] [Indexed: 01/16/2023]
Affiliation(s)
- S D Wexner
- Department of Pathology, Cleveland Clinic Florida, Weston, FL, USA,
| | | |
Collapse
|
33
|
Laparoscopic and converted approaches to rectal cancer resection have superior long-term outcomes: a comparative study by operative approach. Surg Endosc 2014; 28:1940-8. [PMID: 24515259 DOI: 10.1007/s00464-014-3419-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 01/04/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes. METHODS Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach. RESULTS Overall, 294 patients were analyzed-116 LAP (39.5%), 153 OPEN (52.0%), and 25 (8.5%) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1-20) LAP, 6 days (range 3-13) CONVERTED, and 8 days (range 1-35) OPEN (p < 0.01). More OPEN had postoperative complications (p < 0.01)-complication rates were 43.8% OPEN, 32.0% CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6% OPEN, 16.0% CONVERTED, 12.1% LAP). Overall 3-year disease-free survival (DFS) was 98.3%, and local recurrence rate was 2.0%. By approach, DFS was 100% CONVERTED, 93.1% LAP, and 87.6% OPEN (p = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1% LAP, and 97.4%. OPEN. Local recurrence was 0% CONVERTED, 2% OPEN, and 2.6% LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (p = 0.05), with comparable local recurrence (p = 0.07) and OS rates (0.43). CONCLUSIONS LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.
Collapse
|