Long-term Outcomes of a Randomized Controlled Trial of Single-incision Versus Multi-port Laparoscopic Colectomy for Colon Cancer

Single-port laparoscopic surgery for cecum cancer with intussusception: a case report

BACKGROUND

Most adult cases of intussusception are caused by colorectal cancer, and emergency surgery is performed when symptoms such as abdominal pain and vomiting are present. The patient must customarily undergo both bowel decompression and radical surgery for colorectal cancer at the same time, and laparotomy is generally the procedure of choice.

CASE PRESENTATION

An 86-year-old woman presented to our hospital with diarrhea and bloody stools. Preoperative examination revealed the presence of a cancerous tumor in the advanced part of the transverse colon and bowel intussusception. Radical surgery was successfully performed using the laparoscopic single-port technique through a small incision at the umbilical site to treat intussusception caused by cecum cancer.

CONCLUSIONS

With only one wound site at the umbilicus, this single-port laparoscopic approach is much less invasive than endoscopic surgery that requires four to five incision wounds to perform the procedure. Furthermore, the patient was discharged without major complications and this surgical technique could be of great benefit if established as a standard procedure in the future.

Single-incision Laparoscopic Colonic Surgery: A Systemic Review, Meta-analysis, and Future Prospect

Although single-incision laparoscopic surgery (SILS) has gained some attention as a feasible alternative to conventional multiport laparoscopic surgery (MPLS) in colonic surgery, it became less prevalent than expected. Hence, we conducted this systematic review to evaluate the feasibility, safety, and oncological outcomes of single-incision laparoscopic colectomy (SILC) with meta-analysis and discussion of the future prospect of SILS. The search was conducted from September to October 2023 using PubMed and the Cochrane Central Register of Controlled Trials. Articles on colorectal cancer comparing SILC with multiport laparoscopic colectomy (MPLC) from all randomized controlled trials and comparative studies with 50 patients or more per arm were examined. The primary outcomes were the intra- and postoperative complication rates, and the secondary outcomes were the perioperative and oncological outcomes. The trends of the SILS number in Japan and the trends of the number of articles on SILS in PubMed were also reviewed. There were no significant differences in perioperative complication rates, operative factors, and oncological outcomes between SILC and MPLC, although heterogeneity was observed mainly in operative factors and the total length of the skin incision was significantly shorter in SILC. Therefore, SILC is technically and oncologically feasible and safe when performed by experienced laparoscopic surgeons. The case number of SILS was gradually increasing but the rate of SILS was decreasing in Japan. The number of articles on SILS was also decreasing. SILS has gained foothold to some extent but has plateaued. The emerging new robotic platform may reappraise the concept of SILS.

Long-term outcomes of single-incision laparoscopic colectomy for right-sided colon cancer utilising a craniocaudal approach

INTRODUCTION

This study aimed to evaluate the short- and long-term outcomes of single-incision laparoscopic colectomy (SILC) for right-sided colon cancer (CC) using a craniocaudal approach.

PATIENTS AND METHODS

The data of patients who underwent SILC for right-sided CC at our hospital between January 2013 and December 2022 were retrospectively collected. Surgery was performed using a craniocaudal approach. Short- and long-term operative outcomes were analysed.

RESULTS

In total, 269 patients (127 men, 142 women; median age 74 years) underwent SILC for right-sided CC. The cases included ileocaecal resection (n = 138) and right hemicolectomy (n = 131). The median operative time was 154 min, and the median operative blood loss was 0 ml. Twenty-seven cases (10.0%) required an additional laparoscopic trocar, and 9 (3.3%) were converted to open surgery. The Clavien-Dindo classification Grade III post-operative complications were detected in 7 (2.6%) cases. SILC was performed by 25 surgeons, including inexperienced surgeons, with a median age of 34 years. The 5-year cancer-specific survival (CSS) was 96.1% (95% confidence interval [CI] 91.3%-98.2%), and CSS per pathological disease stage was 100% for Stages 0-I and II and 86.2% (95% CI 71.3%-93.7%) for Stage III. The 5-year recurrence-free survival (RFS) was 90.6% (95% CI 85.7%-93.9%), and RFS per pathological disease stage was 100% for Stage 0-I, 91.7% (95% CI 80.5%-96.6%) for Stage II and 76.1% (95% CI 63.0%-85.1%) for Stage III.

CONCLUSIONS

SILC for right-sided CC can be safely performed with a craniocaudal approach, with reasonable short- and long-term outcomes.

Long-term outcomes of single-incision plus one-port laparoscopic surgery versus conventional laparoscopic surgery for rectosigmoid cancer: a randomized controlled trial

BACKGROUND

Though our previous study has demonstrated that the single-incision plus one-port laparoscopic surgery (SILS + 1) is safe and feasible for sigmoid colon and upper rectal cancer and has better short-term outcomes compared with conventional laparoscopic surgery (CLS), the long-term outcomes of SILS + 1 remains uncertain and are needed to evaluated by an RCT.

METHODS

Patients with clinical stage T1-4aN0-2M0 rectosigmoid cancer were enrolled. The participants were randomly assigned to either SILS + 1 (n = 99) or CLS (n = 99). The 3-year DFS, 5-year OS, and recurrence patterns were analyzed.

RESULTS

Between April 2014 and July 2016, 198 patients were randomly assigned to either the SILS + 1 group (n = 99) or CLS group (n = 99). The median follow-up in the SILS + 1 group was 64.0 months and in CLS group was 65.0 months. The 3-year DFS was 87.8% (95% CI, 81.6-94.8%) in SILS + 1 group and 86.9% (95% CI, 81.3-94.5%) in CLS group (hazard ratio: 1.09 (95% CI, 0.48-2.47; P = 0.84)). The 5-year OS was 86.7% (95% CI,79.6-93.8%) in the SILS + 1 group and 80.5% (95% CI,72.5-88.5%) in the CLS group (hazard ratio: 1.53 (95% CI, 0.74-3.18; P = 0.25)). There were no significant differences in the recurrence patterns between the two groups.

CONCLUSIONS

We found no significant difference in 3-year DFS and 5-year OS of patients with sigmoid colon and upper rectal cancer treated with SILS + 1 vs. CLS. SILS + 1 is noninferior to CLS when performed by expert surgeons.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02117557 (registered on 21/04/2014).

Selection of surgical modality for massive splenomegaly in children

BACKGROUND

Laparoscopic splenectomy (LS), a treatment for both benign and malignant splenic diseases, can prove technically challenging in patients with massive splenomegaly. In particular, the optimal surgical modality for treating massive splenomegaly in children remains controversial.

METHODS

The clinicopathologic data of 289 pediatric patients undergoing splenectomy for massive splenomegaly were studied in a retrospective analysis. Accordingly, the patients were classified into the LS surgery group and open splenectomy (OS) surgery group. In the laparoscopy cohort, they were separated into two subgroups according to the method of surgery: the multi-incision laparoscopic splenectomy (MILS) and the single-incision laparoscopic splenectomy (SILS) surgery groups, respectively. Patient demographics, clinical data, surgery, complications, and postoperative recovery underwent analysis. Concurrently, we compared the risk of adverse laparoscopic splenectomy outcomes utilizing univariable and multivariable logistic regression.

RESULTS

The total operation time proved remarkably shorter in the OS group in contrast to the LS group (149.87 ± 61.44 versus 188.20 ± 52.51 min, P < 0.001). Relative to the OS group, the LS group exhibited lowered postoperative pain scores, bowel recovery time, and postoperative hospitalization time (P < 0.001). No remarkable difference existed in post-operation complications or mortality (P > 0.05). Nevertheless, the operation duration was remarkably longer in the SILS surgery group than in the MILS surgery group (200 ± 46.11 versus 171.39 ± 40.30 min, P = 0.02). Meanwhile, the operative duration of MILS and SILS displayed a remarkable positive association with splenic length. Moreover, the operative duration of SILS displayed a remarkable positive association with the age, weight, and height of the sick children. Splenic length proved an independent risk factor of adverse outcomes (P < 0.001, OR 1.378).

CONCLUSIONS

For pediatric patients with massive splenomegaly who can tolerate prolonged anesthesia and operative procedures, LS surgery proves the optimal treatment regimen. SILS remains a novel surgery therapy which may be deemed a substitutional surgery approach for treating massive splenomegaly.

A 3 mm Port Reduces Postoperative Pain After Laparoscopic Colon Cancer Surgery: A Case-control Matched Study

BACKGROUND

Recently, smaller-size trocars and instruments have been developed for laparoscopic colon cancer surgery; however, their effectiveness and safety have not been elucidated. This study aimed to investigate whether 3 mm trocars and instruments have benefits compared with conventional trocars and instruments.

PATIENTS AND METHODS

Patients with colon cancer who underwent laparoscopic anterior resection or right hemicolectomy were included. Patients who underwent combined resections of other organs and those with conversion to open surgery were excluded. In the 3 mm group, three 5 mm trocars were replaced by 3 mm trocars. The numeric rating scale (NRS) immediately postoperatively at 24, 48, and 72 hours, respectively, after surgery and the use of additional analgesics and perioperative outcomes were analyzed. Case-control matched analysis was used to reduce bias according to the type of surgery.

RESULTS

A total of 207 patients (conventional: n = 158, 3 mm: n = 49) were included. Before matching, NRS 48 hours postoperatively ( P = 0.049), proportion of patients using additional intravenous (IV) analgesics ( P = 0.007), postoperative hospital stay ( P < 0.001), and blood loss ( P < 0.001) were lower in the 3 mm group. In multivariable analysis, trocar type significantly impacted the proportion of patients using additional IV analgesics (odds ratio: 0.330; 95% CI: 0.153-0.712; P = 0.005). After case-control matching, NRS immediately postoperatively ( P = 0.015) and 24 hours postsurgery ( P = 0.043), patients using additional IV analgesics ( P = 0.019), postoperative hospital stay ( P = 0.010), intraoperative blood loss ( P < 0.001), and postoperative complication rate ( P = 0.028) were significantly lower in the 3 mm group compared with the 5 mm group.

CONCLUSIONS

The use of 3 mm trocars and instruments in laparoscopic colon cancer surgery can effectively reduce postoperative pain while maintaining perioperative safety.

Disulfidptosis-associated long non-coding RNA signature predicts the prognosis, tumor microenvironment, and immunotherapy and chemotherapy options in colon adenocarcinoma

BACKGROUND

Disulfidptosis is independent of apoptosis, ferroptosis, and cuproptosis and is associated with cancer progression, treatment response, and prognosis. However, the predictive potential of disulfidptosis-associated lncRNAs in colon adenocarcinoma (COAD) and their features in the tumor immune microenvironment (TIME) require further elucidation.

METHODS

RNA transcriptome, clinical information, and mutation data of COAD samples were obtained from the TCGA database. The risk model was first constructed by co-expression analysis of disulfidptosis genes and lncRNAs, and prognostic lncRNAs were screened using Cox regression, followed by least absolute shrinkage and selection operator analysis. Enrichment analyses were performed to explore the underlying biological functions and signaling of model-associated differentially expressed genes (MADEGs). Moreover, TIME of MADEGs was analyzed to assess the immunotherapy. Finally, the expression levels of the lncRNAs were verified by taking specimens of patients with COAD from the Affiliated Hospital of Qingdao University.

RESULTS

We constructed a prognosis-related risk model based on four disulfidptosis-associated lncRNAs (ZEB1-AS1, SNHG16, SATB2-AS1, and ALMS1-IT1). By analyzing the survival of patients in the whole, training, and test groups, we found that patients with COAD in the low-risk group had better overall survival than those in the high-risk group. Validation of the model via Cox analysis and clinical indicators demonstrated that the model had a decent potential for predicting the prognosis of patients with COAD. Enrichment analyses revealed that the MADEGs were related to disulfidptosis-associated biological functions and cancer pathways. Furthermore, patients with COAD in the high-risk group had more positive responses to immune checkpoint inhibitors (ICIs) than those in the low-risk group, as confirmed by TIME analysis. ZEB1-AS1, SNHG16, and ALMS1-IT1 were expressed at higher levels in tumor samples than those in the corresponding paracancerous samples (p < 0.05), whereas SATB2-AS1 was upregulated in the paracancerous samples (p < 0.05).

CONCLUSIONS

This signature may guide prognosis, molecular mechanisms, and treatment strategies, including ICIs and chemotherapy, in patients with COAD.

A propensity score matching investigation of short-term results of single-incision laparoscopic low anterior rectal resection via ileostomy site

Aims

The study was performed to verify the results of single-incision laparoscopic surgery (SILS) through the ileostomy site for low rectal cancer compared with conventional laparoscopic surgery (CLS).

Materials and Methods

From January 2019 to November 2021, 133 patients with low rectal cancer underwent single-incision (n = 27) or conventional (n = 106) methods of low anterior rectal resection surgery with ileostomy. All patients were balanced by propensity score matching for basic information in a ratio of 1:2, resulting in 27 and 54 in SILS and CLS groups, respectively.

Results

Relative to the CLS group, the SILS group exhibited fewer leucocyte changes, shorter time to first exhaust and first bowel sounds, shorter length of hospital stay and lower Visual Analogue Score on post-operative days (POD2) and POD3. Intraoperative or post-operative complications or readmissions were comparable between the two groups. The oncologic results remained consistent between the two groups other than the number of lymph nodes dissected in group no. 253.

Conclusions

Single-incision laparoscopic low rectal resection surgery through the ileostomy site has advantages in terms of reduced post-operative pain, shorter post-operative exhaust time and length of hospital stay while also achieving oncologic outcomes similar to those of conventional laparoscopy. It can be an alternative procedure for patients with low rectal cancer who require ileostomy.

D3 lymph node dissection with versus without left colic artery preservation in single-incision laparoscopic surgery for sigmoid and rectosigmoid cancer: A propensity score-matched analysis

PURPOSE

In surgery for colorectal cancer, dissection of the lymph nodes and fatty tissue around the root of the inferior mesenteric artery is important from an oncologic point of view. However, it is debatable whether it is better to preserve or remove the left colic artery (LCA). This study aimed to compare D3 lymphadenectomy with versus without LCA preservation in single-incision laparoscopic surgery for sigmoid and rectosigmoid cancer.

METHODS

A total of 1138 patients underwent surgery for colorectal cancer between April 2011 and December 2018 at Fukui Prefectural Hospital. This propensity score-matched retrospective study analyzed the data of 163 patients: 42 patients with LCA preservation (group A) and 129 without LCA preservation (group B). Clinical and oncological outcomes were compared between the two groups.

RESULTS

There were no significant differences between groups A and B in patient characteristics, surgical outcomes, including the 5-year overall survival rate (75% vs. 64.2%, hazard ratio [HR] 1.34, 95% confidence interval [CI] 0.37-4.30), 5-year disease-free survival rate (85.7% vs. 85.7%, HR 0.99, 95% CI 0.24-4.22), and 5-year cancer-specific survival rate (92.8% vs. 89.3%, HR 1.50, 95% CI 0.25-11.4).

CONCLUSION

There were no significant differences in the short- and long-term outcomes of patients who underwent single-incision laparoscopic surgery with D3 lymphadenectomy with versus without LCA preservation. This suggests that LCA preservation is safe and feasible in single-incision laparoscopic surgery for sigmoid and rectosigmoid colon cancer.

Comparison of clinical efficacy of single-incision and traditional laparoscopic surgery for colorectal cancer: A meta-analysis of randomized controlled trials and propensity-score matched studies

Background

Single-incision laparoscopy surgery (SILS) is a new laparoscopic technique that has emerged in the past decade. Whether it has advantages over conventionl laparoscopy surgery (CLS) is inconclusive. This article aimed to compare the short- and long-term outcomes of single-incision laparoscopic surgery and conventional laparoscopic surgery for colorectal cancer through high-quality literature text mining and meta-analysis.

Methods

Relevant articles were searched on the PubMed, Embase, and Cochrane Library databases from January 2012 to November 2021. All data was from randomized controlled trials (RCTs) in order to increase the confidence of the analytical results.The main outcomes were intraoperative and postoperative complications.

Results

A total of 10 RCTs were included, involving 1609 patients. The quality of the included studies was generally high. No significant difference was found between SILS and CLS in the postoperative complications, operation time, postoperative hospital stay, number of lymph nodes removed, readmission, reoperation, complication level I- II, complication level IIIa, complication level IIIb, prolonged Ileus, blood loss, infection, anastomotic leakage and operation time. The results showed that SILS group had a higher rate of intraoperative complications, but it had lower incision length and better cosmetic effects.

Conclusion

These results indicate that SILS did not have a comprehensive and obvious advantage over the CLS. On the contrary, SILS has higher intraoperative complications, which may be related to the more difficulty of SILS operation, but SILS still has better cosmetic effects, which is in line with the concept of surgical development. Therefore, the SILS needs to be selected in patients with higher cosmetic requirements and performed by more experienced surgeons.

Oncologic outcomes of single-incision laparoscopic surgery versus conventional laparoscopic surgery for colorectal cancer (CSILS): study protocol for a multicentre, prospective, open-label, noninferiority, randomized controlled trial

Background

In most previous studies, single-incision laparoscopic surgery (SILS) for colorectal cancer (CRC) was feasible and safe in the short term. However, long-term oncologic outcomes remain uncertain, as only a few studies contained long-term survival data. SILS for CRC is still in the early stages of research. Further studies, particularly large-scale, prospective randomized controlled trials, are necessary to assess the value of SILS for CRC.

Methods

This study is a prospective, multicentre, open-label, noninferiority, parallel-group randomized controlled trial that investigates the long-term oncologic outcomes of SILS compared to conventional laparoscopic surgery (CLS) for CRC. A total of 710 eligible patients will be randomly assigned to the SILS group or the CLS group at a 1:1 ratio using a central, dynamic, and stratified block randomization method. Patients with ages ranging from 18 to 85 years old, of both sexes, with CRC above the peritoneal reflection diagnosed as cT1-4aN0-2M0 and a tumour size no larger than 5 cm will be considered for the study. The primary endpoint is 3-year disease-free survival (DFS). The secondary endpoints include: intraoperative outcomes, postoperative recovery, postoperative pain assessment, pathological outcomes, early morbidity and mortality rate, cosmetic effects, quality of life, 3-year overall survival (OS), incidence of incisional hernia, 5-year DFS and 5-year OS. The first two follow-up visits will be scheduled at one month and three months postoperatively, then every three months for the first two years and every six months for the next three years.

Discussion

Currently, no randomized controlled trials (RCTs) have been designed to investigate the long-term oncologic outcomes of SILS for CRC. This study is expected to provide clinical evidence of the oncologic outcomes of SILS compared to CLS for CRC to promote its widespread use.

Trial registration

ClinicalTrials.gov: NCT 04527861 (registered on August 27, 2020).

Da Vinci SP robotic approach to colorectal surgery: two specific indications and short-term results

BACKGROUND

Da Vinci® Single Port (dvSP) was recently developed. Its application in colorectal surgery is under investigation. The aim of this study was to explore the safety and feasibility of dvSP for intersphincteric (dvSP-ISR), right colectomy (dvSP-RC), and transverse colectomy (dvSP-TC). Surgical indication and short-term results were analyzed.

METHODS

All consecutive patients from a prospective database of patients who underwent dvSP-ISR, dvSP-RC, and dvSP-TC at Korea University Anam Hospital from November 2020 to December 2021, were analyzed. Perioperative, pathological, and oncological short-term outcomes were analyzed.

RESULTS

A total of 7 dvSP-ISR, 5 dvSP-RC, and 1 dvSP-TC were performed. Median age was 56.0 (55.0-61.0) years for the dvSP-ISR and 54.0 (44.7-63.5) years for the dvSP-RC/TC. Median body mass index was 22.8 (17.1-24.8) kg/m² for the dvSP-ISR and 23.6 (20.8-26.9) kg/m² for the dvSP-RC/TC. All dvSP-ISR patients received neoadjuvant long-course chemoradiotherapy, including one patient with squamocellular carcinoma who was treated with 5-fluorouracil (5-FU)/mitomycin. All other patients, excluding one dvSP-RC patient with Crohn's disease, had an adenocarcinoma. Median operation time was 280 (240-370) minutes for the dvSP-ISR and 220 (201-270) minutes for the dvSP-RC/TC. Estimated blood loss was insignificant. No intraoperative complications or conversions to multiport/open surgery was reported. Median post-operative stay was 7.0 (6.0-10.0) days for the dvSP-ISR and 5.0 (4.0-6.7) days for the dvSP-RC/TC. Quality of mesorectum was complete for six patients, and nearly complete for one. Median number of retrieved lymph nodes were 21 (17-25) for the dvSP-ISR and 28 (24-49) for the dvSP-RC/TC. Proximal and distal resection margins were tumor free. Four patients experienced post-operative complications not related to the platform which were: ileus, voiding dysfunction, infected pelvic hematoma, and wound infection. Median follow-up was 9 (6-11) months and 11 (7-17) months for the dvSP-ISR and dvSP-RC/TC, respectively. Two patients had systemic recurrence; all others were tumor free.

CONCLUSIONS

The dvSP platform is safe and feasible for intersphincteric resection with right lower quadrant access, and right/transverse colectomy with suprapubic access. Further studies are needed to evaluate benefit differences compared to multiport robotic platform.

Short-Term Outcomes of Single-Incision Laparoscopic Surgery for Colorectal Cancer: A Single-Center, Open-Label, Non-Inferiority, Randomized Clinical Trial

Objective

To date, well-designed randomized controlled trials examining the safety, efficacy, and long-term outcomes of single-incision laparoscopic surgery (SILS) for colorectal cancer are scarce. The aim of the current study was to compare short-term outcomes of SILS for colorectal cancer with conventional laparoscopic surgery (CLS).

Methods

Between June 28, 2017, and June 29, 2019, a single-center, open-label, non-inferiority, randomized clinical trial was conducted at the Department of General Surgery, Ruijin Hospital (North), Shanghai Jiaotong University School of Medicine in Shanghai, China. In total, 200 patients diagnosed or suspected of colorectal cancer (cT_1-4aN_0-2M₀) were randomly assigned to either the SILS or CLS group in a 1:1 ratio. The primary outcome was early morbidity rate. Secondary outcomes included intraoperative outcomes, pain intensity, postoperative recovery, pathologic outcomes, and long-term outcomes.

Results

In total, 193 participants (SILS, 97; CLS, 96) were analyzed in the modified intention-to-treat (MITT) population. Among them, 48 underwent right hemicolectomy (SILS n = 23, 23.7% and MLS n = 25, 26%), 15 underwent left hemicolectomy (SILS n = 6, 6.2% and MLS n = 9, 9.4%), 1 underwent transverse colectomy (MLS n = 1, 1%), 57 underwent sigmoidectomy (SILS n = 32, 33% and MLS n = 25, 26%), and 72 underwent anterior resection (SILS n = 36, 37.1% and MLS n = 36, 37.5%). No significant differences were observed in the baseline characteristics. The intraoperative complication was comparable between the two groups [5 (5.2%) vs. 4 (4.2%); difference, 1%; 95% CI, -5.8% to 7.8%; p > 0.999) and so was postoperative complication rates [10 (10.3%) vs. 14 (14.6%); difference, -4.3%; 95% CI, -13.9% to 5.3%; p = 0.392]. The SILS group showed shorter incision length [median (IQR), 4 (3.5-5) vs. 6.6 (6-7.5), p < 0.001] and lower VAS scores on the first [median (IQR), 4 (3-5) vs. 4 (4-5), p = 0.002] and the second day [median (IQR), 2 (1.5-3) vs. 3 (2-4), p < 0.001] after surgery. No statistically significant difference was found in other measured outcomes.

Conclusions

Compared with CLS, SILS performed by experienced surgeons for selected colorectal cancer patients is non-inferior with good short-term safety and has the advantage of reducing postoperative pain.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT03151733.