A nationwide comparison of short-term outcomes after transanal, open, laparoscopic, and robot-assisted total mesorectal excision

Peri-operative, oncological and functional outcomes of robotic versus transanal total mesorectal excision in patients with rectal cancer: A systematic review and meta-analysis

BACKGROUND

Comparative outcomes of robotic low anterior resection (rTME) and trans-anal total mesorectal excision (TaTME) in patients with low rectal cancer were evaluated.

METHODS

A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov and Science Direct. Comparative studies of rTME versus TaTME for low rectal cancer were included. Primary outcomes were postoperative complications, including anastomotic leak, surgical site infection, and Clavien-Dindo complication rate. Total operative time, conversion to open surgery, intra-operative blood loss, intensive therapy unit (ITU) and total hospital length of stay (LOS), oncological outcomes and functional outcomes were the other evaluated outcome parameters.

RESULTS

A total of 12 studies with a total number of 3025 patients divided between rTME (n = 1881) and TaTME (n = 1144) groups were included. There was no significant difference between the two groups for total operative time (P = 0.39), conversion to open surgery (P = 0.29) and intra-operative blood loss (P = 0.62). Clavien-Dindo ≥ 3 complication rate (P = 0.47), anastomotic leak (P = 0.89), rates of re-operation (P = 0.62) and re-admission (P = 0.92), R0 resections (P = 0.52), ITU LOS (P = 0.63) and total hospital LOS (P = 0.30) also showed similar results between the two groups. However, the rTME group had higher rates of total harvested lymph nodes (P = 0.04) and complete total mesorectal excision (TME) resections (P = 0.05). Albeit with a limited dataset, the Wexner and low anterior resection syndrome (LARS) scores showed better functional results in the rTME group compared with the TaTME group (P = 0.0009 and P = 0.00001, respectively).

CONCLUSION

Compared with TaTME, rTME seems to provide better functional outcomes, higher lymph node yield and more complete TME resections with a similar post-operative complications profile.

Robotic-assisted low anterior resection for rectal cancer shows similar clinical efficacy to laparoscopic surgery: A propensity score matched study

BACKGROUND

Rectal cancer ranks as the second leading cause of cancer-related mortality worldwide, necessitating surgical resection as the sole treatment option. Over the years, there has been a growing adoption of minimally invasive surgical techniques such as robotic and laparoscopic approaches. Robotic surgery represents an innovative modality that effectively addresses the limitations associated with traditional laparoscopic techniques. While previous studies have reported favorable perioperative outcomes for robot-assisted radical resection in rectal cancer patients, further evidence regarding its oncological safety is still warranted.

AIM

To conduct a comparative analysis of perioperative and oncological outcomes between robot-assisted and laparoscopic-assisted low anterior resection (LALAR) procedures.

METHODS

The clinical data of 125 patients who underwent robot-assisted low anterior resection (RALAR) and 279 patients who underwent LALAR resection at Shandong Provincial Hospital Affiliated to Shandong First Medical University from December 2019 to November 2022 were retrospectively analyzed. After performing a 1:1 propensity score matching, the patients were divided into two groups: The RALAR group and the LALAR group (111 cases in each group). Subsequently, a comparison was made between the short-term outcomes within 30 d after surgery and the 3-year survival outcomes of these two groups.

RESULTS

Compared to the LALAR group, the RALAR group exhibited a significantly earlier time to first flatus [2 (2-2) d vs 3 (3-3) d, P = 0.000], as well as a shorter time to first fluid diet [4 (3-4) d vs 5 (4-6) d, P = 0.001]. Additionally, the RALAR group demonstrated reduced postoperative indwelling catheter time [2 (1-3) d vs 4 (3-5) d, P = 0.000] and decreased length of hospital stay after surgery [5 (5-7) d vs 7(6-8) d, P = 0.009]. Moreover, there was an observed increase in total cost of hospitalization for the RALAR group compared to the LALAR group [10777 (10780-11850) dollars vs 10550 (8766-11715) dollars, P = 0.012]. No significant differences were found in terms of conversion rate to laparotomy or incidence of postoperative complications between both groups. Furthermore, no significant disparities were noted regarding the 3-year overall survival rate and 3-year disease-free survival rate between both groups.

CONCLUSION

Robotic surgery offers potential advantages in terms of accelerated recovery of gastrointestinal and urologic function compared to LALAR resection, while maintaining similar perioperative and 3-year oncological outcomes.

Conversion rate to open surgery during transanal total mesorectal excision (TaTME) for rectal cancer: a single-center experience

Minimally invasive techniques for rectal cancer have demonstrated considerable advantages in terms of faster recovery and less post-operative complications. However, due to the complex anatomy and a limited surgical field, conversion to open surgery is still sometimes required, with a negative impact on the short-and long-term outcomes. The purpose of this study was to analyse the conversion rate to open abdominal surgery during laparoscopic transanal total mesorectal excision (TaTME) procedures performed at a high-volume Italian referral center. All consecutive TaTME performed for mid-to-low rectal cancer between 2015 and 2023 were reviewed, independently if treated with a primary anastomosis (with/without a diverting ostomy) or an end stoma. All procedures were performed using a standardized approach by the same surgical team. Patients with benign diagnosis that underwent different-from rectal resection procedures and cases pre-operatively scheduled for open surgery were excluded. The primary outcome of interest was the rate of conversion, defined as an un-planned intraoperative switch to open surgery using a midline laparotomy. Secondary aims included the comparison of patients who had a longer vs shorter operative time. Out of 220 patients, 210 were selected. In 187 cases, a primary anastomosis was performed, while 23 patients received a terminal colostomy (1 in the converted group; 22 in the full MIS- TaTME group, 10.6%). A surgical approach modification occurred in two cases, with a conversion rate of 0.95%. Median operative time was 281 min. Reasons for conversions included intra-operative difficulties impairing the mini-invasive procedure without intra-operative complications in one case, and difficulties in the laparoscopic control of an intraoperative bleeding due to a splenic lesion in another patient. Male sex and a higher BMI were found to be statistically significantly associated to longer operative time (respectively: p = 0.001 and p = 0.0025). In a high-volume center, a standardized TaTME is associated to a low conversion rate to open abdominal surgery.

Robotic, transanal, and laparoscopic total mesorectal excision for locally advanced mid/low rectal cancer: European multicentre, propensity score-matched study

BACKGROUND

Total mesorectal excision (TME) is the standard surgery for low/mid locally advanced rectal cancer. The aim of this study was to compare three minimally invasive surgical approaches for TME with primary anastomosis (laparoscopic TME, robotic TME, and transanal TME).

METHODS

Records of patients undergoing laparoscopic TME, robotic TME, or transanal TME between 2013 and 2022 according to standardized techniques in expert centres contributing to the European MRI and Rectal Cancer Surgery III (EuMaRCS-III) database were analysed. Propensity score matching was applied to compare the three groups with respect to the complication rate (primary outcome), conversion rate, postoperative recovery, and survival.

RESULTS

A total of 468 patients (mean(s.d.) age of 64.1(11) years) were included; 190 (40.6%) patients underwent laparoscopic TME, 141 (30.1%) patients underwent robotic TME, and 137 (29.3%) patients underwent transanal TME. Comparative analyses after propensity score matching demonstrated a higher rate of postoperative complications for laparoscopic TME compared with both robotic TME (OR 1.80, 95% c.i. 1.11-2.91) and transanal TME (OR 2.87, 95% c.i. 1.72-4.80). Robotic TME was associated with a lower rate of grade A anastomotic leakage (2%) compared with both laparoscopic TME (8.8%) and transanal TME (8.1%) (P = 0.031). Robotic TME (1.4%) and transanal TME (0.7%) were both associated with a lower conversion rate to open surgery compared with laparoscopic TME (8.8%) (P < 0.001). Time to flatus and duration of hospital stay were shorter for patients treated with transanal TME (P = 0.003 and 0.001 respectively). There were no differences in operating time, intraoperative complications, blood loss, mortality, readmission, R0 resection, or survival.

CONCLUSION

In this multicentre, retrospective, propensity score-matched, cohort study of patients with locally advanced rectal cancer, newer minimally invasive approaches (robotic TME and transanal TME) demonstrated improved outcomes compared with laparoscopic TME.

Comparing perioperative and oncological outcomes of transanal and laparoscopic total mesorectal excision for rectal cancer: a meta-analysis of randomized controlled trials and prospective studies

INTRODUCTION

Meta-analysis of the results of transanal total mesorectal excision (taTME) and laparoscopic TME (laTME) regarding perioperative and oncological outcomes have been conducted. Due to the lack of high-quality randomized controlled trials (RCTs) and prospective studies in the included literature, the conclusions are unreliable. This study included RCTs and prospective studies for analysis to obtain more reliable conclusions.

MATERIALS AND METHODS

Systematic searches of the PubMed, Embase, and Cochrane Library databases were conducted up to June 2023. To assess the quality, the Cochrane quality assessment tool and the Newcastle-Ottawa Scale were employed. The perioperative and oncological outcomes were then analyzed. The I2 statistic was used to evaluate statistical heterogeneity and sensitivity analyses was conducted.

RESULTS

A total of 22 studies, comprising 5056 patients, were included in the analysis, of which 6 were RCTs and 16 were prospective studies. The conversion rate in the taTME group was significantly lower than that in the laTME group (OR 0.14, 95% CI 0.09 to 0.22, P < 0.01), and the circumferential resection margin (CRM) was longer (MD 0.99 mm, 95% CI 0.66 to 1.32 mm, P < 0.01), with a lower rate of positive CRM involvement (OR 0.68, 95% CI 0.47 to 0.97, P = 0.03). No statistically significant differences were found in terms of the operation time, intraoperative blood loss, complications, anastomotic leakage, uroschesis, obstruction, secondary operation, hospital stay, urethral injury, readmission, mortality rate within 30 days, mesorectal resection quality, number of harvested lymph nodes, distal resection margin (DRM), positive DRM, local recurrence, and distance recurrence (P > 0.05).

CONCLUSION

According to the findings of this meta-analysis, which is based on RCTs and prospective studies, taTME appears to have an advantage over laTME in terms of conversion rate and CRM involvement.

Comparison of short-term outcomes between robot-assisted and laparoscopic rectal surgery for rectal cancer: A propensity score-matched analysis using the Japanese Nationwide diagnosis procedure combination database

Background

The use of robot-assisted surgery for rectal cancer is increasing, but its short-term results remain unclear. We compared the short-term outcomes of robot-assisted and laparoscopic surgery for rectal cancer using a nationwide inpatient database.

Methods

We analyzed patients registered in the Japanese Diagnosis Procedure Combination database who underwent robot-assisted or laparoscopic surgery for rectal cancer from April 2018 to March 2020. Postoperative complication rates, anesthesia time, length of hospital stay, and cost were compared using propensity score matching for low anterior resection (LAR), high anterior resection (HAR), and abdominoperineal resection (APR).

Results

Among 38 090 rectal cancer cases, 1992 LAR, 357 HAR, and 310 APR pairs were generated by propensity score matching and analyzed. Anesthesia time was longer for robot-assisted surgery compared with laparoscopic surgery (LAR: 388.6 vs. 452.8 min, p < 0.001; HAR: 300.9 vs. 393.5 min, p < 0.001; APR: 4478.5 vs. 533.5 min, p < 0.001). Robot-assisted surgery was associated with significantly shorter hospital stay for LAR (22.3 vs. 20.0 days, p < 0.001) and APR (29.2 vs. 25.9 days, p = 0.029). Total costs for LAR were significantly lower for robot-assisted surgery (2031511.6 vs. 1955216.6 JPY, p < 0.001). The complication rates for robot-assisted surgery tended to be fewer than laparoscopic surgery for all procedures, but the differences were not significant.

Conclusions

Although the anesthesia time was longer for robot-assisted surgery, the procedure resulted in shorter hospital stay for LAR and APR, and lower costs for LAR compared with laparoscopic surgery. Robot-assisted surgery can thus help to reduce costs and can be performed safely.

Feasibility of Perineal Defect Reconstruction with Simplified Fasciocutaneous Inferior Gluteal Artery Perforator (IGAP) Flaps after Tumor Resection of the Lower Rectum: Incidence and Outcome in an Interdisciplinary Approach

BACKGROUND

Extralevator abdominoperineal excision (ELAPE) is a relatively new surgical technique for low rectal cancers, enabling a more radical approach than conventional abdominoperineal excision (APE) with a potentially better oncological outcome. To date, no standard exists for reconstruction after extended or extralevator approaches of abdominoperineal (ELAPE) resection for lower gastrointestinal cancer or inflammatory tumors. In the recent literature, techniques with myocutaneous flaps, such as the VY gluteal flap, the pedicled gracilis flap, or the pedicled rectus abdominis flaps (VRAM) are primarily described. We propose a tailored concept with the use of bilateral adipo-fasciocutaneous inferior gluteal artery perforator (IGAP) advancement flaps in VY fashion after ELAPE surgery procedures. This retrospective cohort study analyzes the feasibility of this concept and is, to our knowledge, one of the largest published series of IGAP flaps in the context of primary closure after ELAPE procedures.

METHODS

In a retrospective cohort analysis, we evaluated all the consecutive patients with rectal resections from Jan 2017 to Sep 2021. All the patients with abdominoperineal resection were included in the study evaluation. The primary endpoint of the study was the proportion of plastic reconstruction and inpatient discharge.

RESULTS

Out of a total of 560 patients with rectal resections, 101 consecutive patients with ELAPE met the inclusion criteria and were included in the study evaluation. The primary direct defect closure was performed in 72 patients (71.3%). In 29 patients (28.7%), the defect was closed with primary unilateral or bilateral IGAP flaps in VY fashion. The patients' mean age was 59.4 years with a range of 25-85 years. In 84 patients, the indication of the operation was lower rectal cancer or anal cancer recurrence, and non-oncological resections were performed in 17 patients. Surgery was performed in a minimally invasive abdominal approach in combination with open perineal extralevatoric abdominoperineal resection (ELAPE) and immediate IGAP flap reconstruction. The rate of perineal early complications after plastic reconstruction was 19.0%, which needed local revision due to local infection. All these interventions were conducted under general anesthesia (Clavien-Dindo IIIb). The mean length of the hospital stay was 14.4 days after ELAPE, ranging from 3 to 53 days.

CONCLUSIONS

Since radical resection with a broad margin is the standard choice in primary, sphincter-infiltrating rectal cancer and recurrent anal cancer surgery in combination with ELAPE, the choice technique for pelvic floor reconstruction is under debate and there is no consensus. Using IGAP flaps is a reliable, technical, easy, and safe option, especially in wider defects on the pelvic floor with minimal donor site morbidity and an acceptable complication (no flap necrosis) rate. The data for hernia incidence in the long term are not known.

A systematic review and meta-analysis of minimally invasive total mesorectal excision versus transanal total mesorectal excision for mid and low rectal cancer

Background

Minimally invasive total mesorectal excision (MiTME) and transanal total mesorectal excision (TaTME) are popular trends in mid and low rectal cancer. However, there is currently no systematic comparison between MiTME and TaTME of mid and low-rectal cancer. Therefore, we systematically study the perioperative and pathological outcomes of MiTME and TaTME in mid and low rectal cancer.

Methods

We have searched the Embase, Cochrane Library, PubMed, Medline, and Web of Science for articles on MiTME (robotic or laparoscopic total mesorectal excision) and TaTME (transanal total mesorectal excision). We calculated pooled standard mean difference (SMD), relative risk (RR), and 95% confidence intervals (CIs). The protocol for this review has been registered on PROSPERO (CRD42022374141).

Results

There are 11010 patients including 39 articles. Compared with TaTME, patients who underwent MiTME had no statistical difference in operation time (SMD -0.14; CI -0.31 to 0.33; I²⁼84.7%, P=0.116), estimated blood loss (SMD 0.05; CI -0.05 to 0.14; I²⁼48%, P=0.338), postoperative hospital stay (RR 0.08; CI -0.07 to 0.22; I²⁼0%, P=0.308), over complications (RR 0.98; CI 0.88 to 1.08; I²⁼25.4%, P=0.644), intraoperative complications (RR 0.94; CI 0.69 to 1.29; I²⁼31.1%, P=0.712), postoperative complications (RR 0.98; CI 0.87 to 1.11; I²⁼16.1%, P=0.789), anastomotic stenosis (RR 0.85; CI 0.73 to 0.98; I²⁼7.4%, P=0.564), wound infection (RR 1.08; CI 0.65 to 1.81; I²⁼1.9%, P=0.755), circumferential resection margin (RR 1.10; CI 0.91 to 1.34; I²⁼0%, P=0.322), distal resection margin (RR 1.49; CI 0.73 to 3.05; I²⁼0%, P=0.272), major low anterior resection syndrome (RR 0.93; CI 0.79 to 1.10; I²⁼0%, P=0.386), lymph node yield (SMD 0.06; CI -0.04 to 0.17; I²⁼39.6%, P=0.249), 2-year DFS rate (RR 0.99; CI 0.88 to 1.11; I²⁼0%, P = 0.816), 2-year OS rate (RR 1.00; CI 0.90 to 1.11; I²⁼0%, P = 0.969), distant metastasis rate (RR 0.47; CI 0.17 to 1.29; I²⁼0%, P = 0.143), and local recurrence rate (RR 1.49; CI 0.75 to 2.97; I²⁼0%, P = 0.250). However, patients who underwent MiTME had fewer anastomotic leak rates (SMD -0.38; CI -0.59 to -0.17; I²⁼19.0%, P<0.0001).

Conclusion

This study comprehensively and systematically evaluated the safety and efficacy of MiTME and TaTME in the treatment of mid to low-rectal cancer through meta-analysis. There is no difference between the two except for patients with MiTME who have a lower anastomotic leakage rate, which provides some evidence-based reference for clinical practice. Of course, in the future, more scientific and rigorous conclusions need to be drawn from multi-center RCT research.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42022374141.

Incidence and Risk Factors of Surgical Complications and Anastomotic Leakage After Transanal Total Mesorectal Excision for Middle and Low Rectal Cancer

PURPOSE

Transanal total mesorectal excision (taTME) is a promising surgical procedure for middle and low rectal cancer; however, it is linked to significant morbidity. This study aimed to determine the incidence of postoperative surgical complications and anastomotic leakage following taTME and to identify their associated risk factors.

METHODS

The prospective clinical data of 114 patients, who underwent taTME and primary anastomosis for mid-low rectal cancer between November 2016 and June 2022, were retrospectively analyzed. Univariate and multivariate analyses were performed to identify clinical characteristics and risk factors for predicting surgical complications and anastomotic leakage.

RESULTS

Surgical complications occurred in 40 (35.1%) patients within the first 30 days following surgery. Based on the Clavien-Dindo classification, minor complications (Clavien-Dindo grades I + II) accounted for 30.7%, while major complications (Clavien-Dindo grades III + IV) accounted for only 4.4%. None of the patients died within 30 days. The incidence of anastomotic leakage was 15.8%: 4.4% as grade A (5 cases), 9.6% as grade B (11 cases), and 1.8% as grade C (2 cases). Preoperative T3-4 was identified as an independent risk factor for surgical complications (p = 0.031) by multivariate analysis. American Society of Anesthesiology score ≥ 3 (P = 0.021) and incomplete total mesorectal excision specimens (P = 0.030) were significantly associated with the risk of anastomotic leakage.

CONCLUSIONS

In this study, the incidence of surgical complications and anastomotic leakage in taTME aligned with previously reported rates. Preoperative T3-4 was significantly associated with surgical complications. American Society of Anesthesiology score ≥ 3 and incomplete TME specimens independently increased the risk of anastomotic leakage.

The taTME learning curve for mid-low rectal cancer: a single-center experience in China

Purpose

As transanal total mesorectal excision (taTME) is performed worldwide, the optimization of existing training and guidance programs to enhance new taTME learners’ competence in performing this procedure is warranted. This study aimed to evaluate the taTME learning curve in patients with mid-low rectal cancer.

Methods

Patients who underwent taTME for mid-low rectal cancer between October 2015 and August 2021 at a single center were included. A cumulative sum (CUSUM) learning curve analysis was performed with the total operation time as the study outcome. The learning curve was analyzed using risk-adjusted CUSUM analysis, with postoperative complications and anastomotic leakage (AL) as outcomes.

Results

In total, 104 consecutive patients were included in this study. The CUSUM learning curve for total operative time started declining after 42 cases (309.1 ± 84.4 vs. 220.2 ± 46.4, P < 0.001). The risk-adjusted CUSUM (RA-CUSUM) learning curve for postoperative complications fluctuated in cases 44–75 and declined significantly after case 75. The RA-CUSUM learning curve for AL declined after 68 cases.

Conclusions

taTME had learning curves of 42, 75, and 68 cases for total operative time, postoperative complications, and AL, respectively. A surgeon may require 42 and 75 cases to achieve “proficiency” and “mastery” in taTME procedures, respectively.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02763-3.