Intersphincteric resection for low rectal cancer: laparoscopic vs open surgery approach

Laparoscopy is non-inferior to open surgery for rectal cancer: A systematic review and meta-analysis

BACKGROUND

Laparoscopic surgery has been endorsed by clinical guidelines for colon cancer, but not for rectal cancer on account of unapproved oncologic equivalence with open surgery.

AIMS

We started this largest-to-date meta-analysis to comprehensively evaluate the safety and efficacy of laparoscopy in the treatment of rectal cancer compared with open surgery.

MATERIALS & METHODS

Both randomized and nonrandomized controlled trials comparing laparoscopic proctectomy and open surgery between January 1990 and March 2020 were searched in PubMed, Cochrane Library and Embase Databases (PROSPERO registration number CRD42020211718). The data of intraoperative, pathological, postoperative and survival outcomes were compared between two groups.

RESULTS

Twenty RCTs and 93 NRCTs including 216,615 patients fulfilled the inclusion criteria, with 48,888 patients received laparoscopic surgery and 167,727 patients underwent open surgery. Compared with open surgery, laparoscopic surgery group showed faster recovery, less complications and decreased mortality within 30 days. The positive rate of circumferential margin (RR = 0.79, 95% CI: 0.72 to 0.85, p < 0.0001) and distal margin (RR = 0.75, 95% CI: 0.66 to 0.85 p < 0.0001) was significantly reduced in the laparoscopic surgery group, but the completeness of total mesorectal excision showed no significant difference. The 3-year and 5-year local recurrence, disease-free survival and overall survival were all improved in the laparoscopic surgery group, while the distal recurrence did not differ significantly between the two approaches.

CONCLUSION

Laparoscopy is non-inferior to open surgery for rectal cancer with respect to oncological outcomes and long-term survival. Moreover, laparoscopic surgery provides short-term advantages, including faster recovery and less complications.

Robotic Intersphincteric Resection for Low Rectal Cancer: Technical Controversies and a Systematic Review on the Perioperative, Oncological, and Functional Outcomes

Intersphincteric resection (ISR) is the ultimate anus-sparing technique for low rectal cancer and is considered an oncologically safe alternative to abdominoperineal resection. The application of the robotic approach to ISR (RISR) has been described by few specialized surgical teams with several differences regarding approach and technique. This review aims to discuss the technical aspects of RISR by evaluating point by point each surgical controversy. Moreover, a systematic review was performed to report the perioperative, oncological, and functional outcomes of RISR. Postoperative morbidities after RISR are acceptable. RISR allows adequate surgical margins and adequate oncological outcomes. RISR may result in severe bowel and genitourinary dysfunction affecting the quality of life in a portion of patients.

Nomogram for Predicting the Probability of Permanent Stoma after Laparoscopic Intersphincteric Resection

PURPOSE

The purpose of this study was to determine the risk factors for the development of a permanent stoma in laparoscopic intersphincteric resection (LS-ISR) for ultralow rectal adenocarcinoma and to develop and validate a prediction model to predict the probability of permanent stoma after surgery.

METHODS

A primary cohort consisting of 301 consecutive patients who underwent LS-ISR was enrolled in this study. Multivariable logistic regression analysis was used to identify risk factors and develop the nomogram. The performance of the nomogram was assessed with respect to its calibration, discrimination, and clinical usefulness. An independent validation cohort contained 91 consecutive patients from January 2012 to January 2019.

RESULTS

The permanent stoma rate was 11.3% (34/301) in the primary cohort and 18.7% (17/91) in the validation cohort. Multivariable analysis revealed that nCRT (OR, 3.195; 95% CI, 1.169-8.733; P=0.024), ASA score of 3 (OR, 5.062; 95% CI, 1.877-13.646; P=0.001), distant metastasis (OR, 14.645; 95% CI, 3.186-67.315; P=0.001), and anastomotic leakage (OR, 11.308; 95% CI, 3.650-35.035; P<0.001) were independent risk factors for permanent stoma, and a nomogram was established. The AUCs of the nomogram were 0.842 and 0.858 in the primary and validation cohorts, respectively. The calibration curves showed good calibration in both cohorts. Decision curve analysis demonstrated that the nomogram was clinically useful.

CONCLUSION

We developed and validated a nomogram for ultralow rectal adenocarcinoma patients who underwent LS-ISR, and the nomogram could help surgeons identify which patients are at a higher risk of a permanent stoma after surgery.

Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection

The surgical management of low-lying rectal cancer, within 5 cm from the anal verge (AV), is challenging due to the possibility, or not, to preserve the anus with its sphincter muscles maintaining oncological safety. The standardization of total mesorectal excision, the adoption of neoadjuvant chemoradiotherapy, the implementation of rectal magnetic resonance imaging, and the evolution of mechanical staplers have increased the rate of anus-preserving surgeries. Moreover, extensive anatomy and physiology studies have increased the understanding of the complexity of the deep pelvis. Intersphincteric resection (ISR) was introduced nearly three decades ago as the ultimate anus-preserving surgery. The definition and indication of ISR have changed over time. The adoption of the robotic platform provides excellent perioperative results with no differences in oncological outcomes. Pushing the boundaries of anus-preserving surgeries has risen doubts on oncological safety in order to preserve function. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.

Minimally invasive versus open intersphincteric resection of low rectal cancer regardless of neoadjuvant chemoradiotherapy: long-term oncologic outcomes

Intersphincteric resection (ISR) is a surgical technique intended to avoid abdominoperineal resection (APR) in patients diagnosed with low-lying rectal cancer. However, the oncologic outcomes of minimally invasive ISR are still controversial. We analyzed the long-term oncologic outcomes of open and minimally invasive ISR. A total of 313 rectal cancer patients who underwent ISR between 2000 and 2014 were analyzed, including 147 in the open surgery group and 166 in the minimally invasive surgery (MIS) group. This study also analyzed 113 patients who received neoadjuvant chemoradiotherapy (nCRT) for advanced lower rectal cancer. Propensity score matching (PSM) was used to correct for differences between the two groups. 5-year disease-free survival (DFS) rate was the primary end point. The length of hospital stay was significantly shorter in the MIS group (9.6 vs. 11.8 days, p < 0.001). Differences in overall postoperative morbidity rates between the groups were not significant; however, the rate of surgical site infection was significantly lower in the MIS group (1.2 vs. 10.9%, p < 0.001). The 5-year DFS associated with all stages combined in the matched patients were not significantly different: 75.2% in the open group vs. 64.2% in the MIS group (p = 0.214). Similar results were found in matched patients treated with nCRT, with 72.0% in the open group and 61.3% in the MIS group (p = 0.078) showing DFS. Both minimally-invasive and open ISR for rectal cancer yielded similar 5-year oncologic outcomes. MIS showed statistically significant advantages in some postoperative outcomes such as reduced surgical site infection and shorter hospital stay, and similar long-term outcomes compared with open ISR. This study also suggests that MIS after nCRT for advanced rectal cancer represents a surgical option with similar oncological results.

Effects of needlescopic surgery on postoperative pain in intersphincteric or abdominoperineal resection

PURPOSE

Laparoscopic surgery allows minimally invasive treatment of rectal cancer, and needlescopic surgery (NS) offers even more minimally invasive operations beyond the scope of conventional laparoscopic surgery (CS). The aim of this study was to compare short-term outcomes of NS for intersphincteric resection (ISR) or abdominoperineal resection (APR) to treat anal or rectal cancer without an abdominal incision for specimen extraction and to measure abdominal wound pain compared to CS.

METHODS

Between September 2014 and December 2016, a total of 134 patients underwent laparoscopic ISR or APR. Of these, 26 patients underwent NS, and 108 patients underwent CS. Postoperative abdominal wound pain was estimated using the numerical rating scale. Short-term outcomes were compared between NS and CS.

RESULTS

No conversion to CS or open surgery was required. Median operation time was significantly shorter with NS (295 min) than with CS (331.5 min; p = 0.020). Median estimated blood loss was significantly lower with NS (30 ml) than with CS (50 ml; p = 0.011). Postoperative pain score on postoperative day (POD)5 was significantly lower with NS than with CS (p = 0.025), and frequencies of analgesic use were significantly lower with NS than with CS on POD0, POD2, and POD3 (p = 0.032, p = 0.017, p = 0.045, respectively). The postoperative complications occurred at similar frequencies between groups (p = 0.655).

CONCLUSION

NS for ISR or APR offers comparable short-term outcomes to CS, with better pain outcomes.

Latest Advances in Intersphincteric Resection for Low Rectal Cancer

Background

Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR.

Methods

A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR.

Results

Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients' quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter.

Conclusions

The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.

Laparoscopic Approach to Rectal Cancer-The New Standard?

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.

Study of anorectal dynamics in patients undergoing laparoscopic ultra-low resection and transanal intersphincteric resection for rectal cancer

BACKGROUND

Quite a few studies on anal functions after open total mesorectal excision combined with transanal intersphincteric resection (ISR) have been reported, but there is little literature on anal function after laparoscopic total mesorectal excision (LTME) combined with transanal ISR. The aim of this study was to explore the post-operative anorectal dynamic changes in ultra-low rectal cancer patients undergoing LTME combined with transanal ISR.

METHODS

The data of 26 ultra-low rectal cancer patients undergoing LTME + transanal ISR were analysed. A total of 30 patients undergoing laparoscopic low anterior resection by the same surgeons during the same period were randomly enrolled into the control group.

RESULTS

There were no differences in the preoperative anorectal manometry data and Wexner anal function scores between the observation group and the control group (P > 0.05). There were no significant differences in the mean operation time, the mean amount of bleeding and the mean post-operative hospital stay between the two groups (P > 0.05). The mean follow-up time was 16 months. No recurrence and metastasis were found in all cases. At 3 and 6 months after the operation, there were significant differences in the anorectal manometry data and Wexner anal function scores between the two groups (P < 0.05). However, at 1 year after the operation, there were no significant differences in the anorectal manometry data and Wexner anal function scores between the two groups (P > 0.05).

CONCLUSION

Laparoscopic ISR for ultra-low rectal cancer is technically feasible, but the surgical indications should be strictly defined.

Trends of robotic-assisted surgery for thyroid, colorectal, stomach and hepatopancreaticobiliary cancer: 10 year Korea trend investigation

BACKGROUND

The current position of robotic surgery in the field of minimally invasive surgery remains ambiguous. We evaluated long-term trends of robotic general surgery and the future direction of its development.

METHODS

Data on robotic cancer surgeries between 2005 and 2014 were retrospectively collected by volunteer institutions in the Republic of Korea. Spearman's correlation and logistic regression analyses were used to compare robotic and laparoscopic surgery trends in general surgery.

RESULTS

The odds that robotic surgery was performed instead of laparoscopic surgery significantly decreased in the fields of colorectal, stomach, and hepato-biliary-pancreatic surgery (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.93-0.97; OR: 0.90, 95% CI: 0.88-0.92; and OR: 0.71, 95% CI: 0.65-0.78, respectively), except for thyroid surgery (OR: 1.28, 95% CI: 1.25-1.30). Of the total numbers of each procedure, proportions of robotic intersphincteric resections, abdominoperineal resections, and pylorus-preserving surgery performed significantly increased (r = 0.98, P < .001; r = 0.78, P = .01; and r = 0.86, P = .007, respectively).

CONCLUSIONS

The use of robotic surgery failed to preponderate that of laparoscopic surgery, except for thyroid surgery. Robotic surgery is increasingly preferred for limited fields or complex surgeries, but the use of robotics in simple surgeries has decreased.

Early and Late Functional Outcomes of Anal SphincterSparing Procedures With Total Mesorectal Excision for Anorectal Adenocarcinoma

Purpose

The study aims to assess the functional outcome of anal sphincter-sparing procedures (SSP) with total mesorectal excision (TME) for anorectal adenocarcinoma.

Methods

In a multicentric, prospective, single-group study in the period between December 2012 and November 2017, 93 patients presented with anorectal adenocarcinoma were included in the study. Sixty-nine patients underwent SSP with TME. SSP included the combined approach of transabdominal TME with intersphincteric resection (ISR) or transanal transabdominal TME. Using the per anal examination scoring system (PASS), postoperative anal function was assessed after 1 year.

Results

Bowel motility time was 50±19 hours. The time needed for narcotic analgesia was 54±18.8 hours. Mean hospital stay was 15.4±10.25 days. Incidence of evident fecal incontinence after ISR is 10.6% (7 of 67 cases). The PASS findings of 69 cases are as follows: extremely hypotonic 8.6% (6 cases), slightly hypotonic 26.1% (18 cases), normal tone 58% (40 cases), slightly stenotic 3 cases (4.3%), or occluded 2.9% (2 cases). Urinary dysfunction occurred in 1 case (1.4%). Temporary diversion was performed in 61 patients (87.1%).

Conclusion

Sphincter preservation with TME for anorectal adenocarcinoma helps avoid permanent stoma and provides reasonable functional outcomes. PASS is a new application for postoperative assessment of anal function.

Needlescopic surgery for very low rectal cancer with no abdominal skin incision

INTRODUCTION

Needlescopic surgery (NS) is a minimally invasive operation beyond traditional laparoscopic surgery. This study aimed to describe NS for intersphincteric resection (ISR) and abdominoperineal resection (APR) for low rectal cancer without a small abdominal skin incision for extracting the specimen and to evaluate the safety and feasibility of the operation.

METHODS

From January 2011 to April 2016, 36 patients underwent NS for either ISR or APR. By definition, NS for ISR or APR at our institution uses three 3-mm ports and two 5-mm ports at the umbilicus and in the right lower quadrant. The specimen was extracted through the anus or the perineal wound. The feasibility of this operation was determined based on short-term outcomes and pathological findings.

RESULTS

No patients required conversion to open surgery. The mean operation time was 299 minutes, and the mean estimated blood loss was 30 mL. Postoperative complications higher than Clavien-Dindo grade III occurred in 2.8% of patients (n = 1). The median number of harvested lymph nodes was 16 (range, 0-30), and in no case was there a positive circumferential resection margin.

CONCLUSIONS

Needlescopic surgery for ISR or APR is technically safe and feasible for low rectal cancer based on the short-term outcomes and the oncological quality, particularly when compared to conventional laparoscopic surgery as described in previous reports.

Ultimate Functional Preservation With Intersphincteric Resection for Rectal Cancer

The proximity of the very low rectum rectal cancer to the anal sphincter raises a specific problem: how and until when can we preserve the anal continence without compromising the oncological result of the tumor resection? In this situation, intersphincteric resection (ISR) offers an excellent alternative to abdominoperineal resection (APR), but the selection of patients for this option must be extremely precise. This complex choice justifies the simultaneous consideration of an oncological approach with a functional approach in order to provide a full benefit to the patient. When a circumferential resection margin of at least 1 mm can be performed with a distal resection margin of at least 1 cm with or without preoperative radiotherapy, ISR ensures a safety choice. The oncological results of ISR reported in the literature when performed properly found a 5-year disease-free survival of 80.2% with a local recurrence rate of only 5.8%. In parallel to this oncological evaluation, the expected post-operative functional outcome and the resulting quality of life must be properly assessed pre-operatively, since partial or total resection of the internal sphincter impacts significantly on the functional outcome. Based on data from the literature, this work reports the essential anatomical considerations and then the oncological and functional elements indispensables when an anal continence preservation is evoked for a tumor of the very low rectum. Finally, the precise selection criteria and the major surgical principles are outlined in order to guarantee the safety of this modern choice for the patient.

Long Term Results of Modified Intersphincteric Resections for Low Rectal Cancer: A Single Center Experience

BACKGROUND AND OBJECTIVES

The objective of this article is to evaluate the long-term oncological and functional outcomes following modified intersphincteric resections (ISR) for low rectal cancer. The modified technique consisted of the abandonment of colonic J-pouches, transverse coloplasty, or defunctioning temporary stoma in favor of a direct handsewn coloanal anastomosis (CAA).

MATERIAL AND METHODS

Sixty consecutive patients with type II and III (juxta-anal or intra-anal) low rectal tumors underwent modified ISR by the same surgical team and were followed for a period of five years. Functional outcomes using the Wexner Score, postoperative complications, recurrence rates, morbidity, and mortality rates were assessed.

RESULTS

The five-year survival rate was 93.3% with a disease-free interval at three years of 98%. Morbidity was 15% (n = 9) consisting of intestinal wall necrosis (n = 6), stenosis (n = 2), and sacral metastasis (n = 1). The Wexner score values were, at 1 year, 8.5 (range, 4-13); at three years 7.2 (range, 2-11); and at 5 years 6.7 (range, 2-12). A second surgery was needed in only one case that showed postoperative transmural necrosis of the colonic wall.

CONCLUSIONS

In highly selected patients with type II or III low rectal tumors and proper preoperative imaging staging, ISR might be a viable alternative to other techniques such as abdominoperineal resection and low anterior resection, both from a functional and an oncological perspective.

Comparison of Clinical Efficacy and Complications Between Laparoscopic Versus Open Surgery for Low Rectal Cancer

Aim:

To compare the surgical outcomes of laparoscopic surgery for lower rectal cancer with open surgery.

Methods:

The multiple databases including PubMed, Springer, EMBASE, EMBASE, OVID were adopted to search for the relevant studies, and full-text articles involving the comparison of unilateral and bilateral PVP surgery were reviewed. Review Manager 5.0 was adopted to estimate the effects of the results among the selected articles. Forest plots, sensitivity analysis and bias analysis for the articles included were also conducted.

Results:

Finally, 1186 patients were included in the 10 studies, which eventually satisfied the eligibility criteria, and laparoscopic and open surgery group were 646 and 540, respectively. The meta-analysis suggested that there was no significant difference of the operation time between laparoscopic and open surgery group, while the time to solid intake, hospital stay time, blood loss and complication rate of laparoscopic group are much less than those of open surgery.

Conclusion:

Although both these two punctures provide similar operation time, we encourage the use of the laparoscopic surgery as the preferred surgical technique for treatment of lower rectal cancer due to less time to solid intake, hospital stay time, blood loss and lower complication rate.

Long-term results of intersphincteric resection for low rectal cancer in Japan

Intersphincteric resection (ISR) is the ultimate sphincter-preserving procedure for low rectal cancer. A questionnaire about the standardization of ISR was given to 2125 patients who underwent curative ISR for low rectal cancer between 2005 and 2012 at 127 affiliated institutions of the Japanese Society for Cancer of the Colon and Rectum (JSCCR), and the results were compared with the results of a systematic review. The findings revealed that although mortality and morbidity were relatively low and the survival rate after ISR was good, the rates of local recurrence and postoperative fecal incontinence were relatively high. The radicality of ISR was compared with that of abdominoperineal resection and low anterior resection using the propensity score matching prognosis analysis of patients in the JSCCR nationwide registry. The local recurrence rate was significantly higher after ISR, and especially high in patients with T3 (invasion into the external anal sphincter) and T4 disease. These results provide evidence about the factors related to fecal incontinence after ISR. As measures for the standardization of ISR, it is important to reconfirm that ISR is not indicated for patients with cT3 and cT4 disease and those with poor preoperative defecatory function, based on the ISR indication criteria.

A quest for sphincter-saving surgery in ultralow rectal tumours-a single-centre cohort study

INTRODUCTION

Despite the progress in the treatment of colorectal cancer, there is still no optimal strategy for tumours located adjacent to the anal sphincter. This study aims to evaluate oncological and functional results of surgery for rectal cancer in unfavourable locations in proximity to anal sphincters.

MATERIALS AND METHODS

Patients with rectal cancer, which was either initially infiltrating the anal sphincter or located in the close proximity of the sphincter, were included in the study. Patients were submitted to extralevator abdominoperineal resection (APR), intersphincteric resection, or transanal total mesorectal excision (TaTME). Primary outcomes were perioperative data: operative time, blood loss, complications, length of stay (LOS), and 30-day mortality. Secondary outcomes were pathological quality of the specimens and functional outcome 6 months after defunctioning ileostomy closure.

RESULTS

Among patients with cancer adjacent to the anal sphincter, 13 (25%) underwent APR, 14 (27%) patients were submitted to intersphincteric resection, and 25 (48%) patients were treated with the TaTME approach. Operative time was 240 (210-270 IQR) for APR, 212.5 (170-260 IQR) for intersphincteric resection, and 270 (240-330 IQR) for TaTME (p = 0.018). Perioperative morbidity was 31% for APR, 36% for intersphincteric resections, and 12% for the TaTME group (p = 0.181). Complete mesorectal excision was achieved in 92% of specimens in the TaTME group, 93% in intersphincteric resections, and 78% in the APR group (p = 0.72). Median circumferential resection margin in APR was 6 mm (4-7 IQR), in intersphincteric resections 7.5 mm (2.5-10 IQR), and in the TaTME group 4 mm (2.8-8 IQR). All patients after intersphincteric resections developed major low anterior resection syndrome (LARS). Four patients in the TaTME group developed minor LARS, and 21 had major LARS.

CONCLUSION

Sphincter-saving rectal resections are a feasible alternative to APR with good clinical, pathological, and oncological outcomes. Intersphincteric resections and TaTME seem to be equal in terms of clinicopathological results. The functional outcome is yet to be investigated.

TRIAL REGISTRATION

The study was retrospectively registered in Thai Clinical Trials Registry (23-07-2018, ID TCTR20180724001 ).

Intersphincteric Resection for Patients With Low-Lying Rectal Cancer: Oncological and Functional Outcomes

The aim of this review is to evaluate the outcomes after an intersphincteric resection (ISR) for patients with low-lying rectal cancer. Reports published in the literature regarding surgical, oncological, and functional outcomes of an ISR were reviewed. The morbidity after an ISR was 7.7%–32%, and anastomotic leakage was the most common adverse event. Local recurrence rates ranged from 0% to 12%, 5-year overall survival rates ranged from 62% to 92%, and rates of major incontinence ranged from 0% to 25.8% after an ISR. An ISR is a safe procedure for sphincter-saving rectal surgery in patients with very low rectal cancer; it does not compromise the oncological outcomes of the resection and is a valuable alternative to an abdominoperineal resection. While the functional outcomes after an ISR were found to be acceptable, the long-term functional outcome and quality of life still require careful investigation. ISRs have been performed with surgical and oncologic safety on patients with low-lying rectal cancer. However, patients must be selected very carefully for an ISR, considering the associated functional derangement and the limited extent of the resection.

Laparoscopic intersphincteric resection versus an open approach for low rectal cancer: a meta-analysis

AIM

The aim of this study was to compare the short-term and mid-term effects of laparoscopic intersphincteric resection with the conventional open approach for patients with low rectal cancer through a meta-analysis.

METHODS

The PubMed, EMBASE, Cochrane, and Ovid databases were searched for eligible studies until March 2017. Operation time, blood loss, circumferential resection margin-positive rate, distal margin length, number of resected lymph nodes, diverting stoma rate, postoperative overall morbidity, anastomotic leakage, and hospital stay were the main short-term effect endpoints. We also examined disease-free survival, overall survival, local recurrence, and post-operational anal function as secondary outcomes to evaluate the mid-term effects of laparoscopic surgery.

RESULTS

Five studies involving 620 patients were included in the analyses. Compared with the open approach, the laparoscopic ISR had less blood loss (weighted mean difference [WMD] = - 214.65 ml, 95% CI [- 370.44, - 196.13], p < 0.01), less postoperative overall morbidity (OR = 0.58, 95% CI [0.40, 0.86], p < 0.01), and shorter duration of hospital stay (WMD = - 5.87 days, 95% CI [- 11.35, - 0.40], p < 0.05); however, the operation time was significantly longer in the laparoscopic group (WMD = 47.34 min, 95% CI [4.10, 90.58], p < 0.05). No other significant differences were observed.

CONCLUSION

Laparoscopic ISR for low rectal cancer offers fewer complications and faster recovery, with similar operation quality and mid-term oncological results than the conventional approach. Although this technique is comparatively more complex than the conventional approach and requires practice, laparoscopic ISR shows great potential as a surgical option and deserves further clinical study.

Long-Term Functional and Oncological Outcomes Following Intersphincteric Resection for Low Rectal Cancers

Surgery for low rectal cancer often involves a permanent stoma. Intersphincteric resection (ISR) with colo-anal anastomosis is a valuable sphincter sparing surgical procedure that avoids the need for permanent stoma in patients with low rectal cancer. The aim of this study was to analyze the long-term functional and oncological outcomes following ISR. This was a retrospective analysis of patients with low rectal cancer who underwent ISR with colo-anal anastomosis in our institution between 2007 and 2015. All patients had a diversion stoma. Bowel function outcomes were assessed prospectively using Wexner incontinence score, low anterior resection syndrome score (LARS), and the Cancer Institute Quality of Life (QoL) questionnaire. The histological reports were reviewed to assess the oncological adequacy of the surgery. Patterns of recurrence and survival were analyzed in this group of patients. Thirty-three patients who underwent an ISR were eligible for this study. Laparoscopic resection was performed in five patients. All the patients received neoadjuvant chemoradiation except the two who received short course radiation and one who did not receive any neoadjuvant treatment. The median distance from the anal verge to the distal edge of the tumor was 3 cm (range 1.5-5 cm). Distal resection margins and circumferential resection margins were negative in all the patients. The 30-day post-operative mortality rate was 3.03%. In 20 patients with a median follow-up of 48 months, the 3-year overall survival was 95%. One patient had recurrence in the para-aortic nodes. No patient had a local recurrence. Bowel function was assessed in 18 patients who had a minimum stoma free period of 1 year. After a median of 43 months following stoma closure, the median Wexner score was 3.56 (range 0-19), median LARS score was 4.78 (range 0-33), and the mean Cancer Institute QoL score was 151.56 ± 15.741. The QoL was average to very high with an overall acceptable quality of life. In this study, ISR was associated with acceptable long-term functional and oncological outcomes. It can be considered as a safe alternative to a permanent stoma in selected patients with low rectal cancer.

Functional outcomes after intersphincteric resection for ultralow rectal cancer

Anal function is one of the most important parameters for evaluating the efficacy of intersphincteric resection (ISR) for the treatment of ultralow rectal cancer (< 1 cm from the anal sphincter). Although there have been no results hitherto from randomized controlled trials to verify the clinical benefits of the ultimate sphincter-sparing technique, increasing evidence demonstrates that ISR significantly decreases the rate of permanent stoma and patients could acquire satisfied functional results after surgery. This review discusses the short-term and long-term functional outcomes, risk factors for anal incontinence, and surgical method and approach of ISR.

Novel anal sphincter saving procedure with partial excision of levator-ani muscle in rectal cancer invading ipsilateral pelvic floor

Purpose

Tumors at the level of the anorectal junction had required total levator-ani muscle excision to achieve an adequate resection margin. However, in the cases of tumor invading ipsilateral levator-ani muscle and intact external sphincter, en bloc resection of rectum with levator-ani muscle including tumor would be possible. This hemilevator excision (HLE) technique enables preserving the anal sphincter function while obtaining oncologic clearance and avoiding permanent colostomy in those patients. This study aimed to evaluate the surgical outcomes and feasibility of HLE.

Methods

Data on 13 consecutive patients who underwent HLE for pathologically proven low rectal cancer were retrospectively collected. All 13 patients presented low rectal cancer at the anorectal ring level that was suspected to invade or abut to the ipsilateral side of the levator-ani muscle.

Results

A secure resection margin was achieved in all cases, and anastomotic leakage occurred in 2 patients. During follow-up, 3 patients experienced tumor recurrence (2 systemic and 1 local). Among 6 patients who underwent diverting ileostomy closure after the index operation, 2 complained of fecal incontinence. The other 4 patients without fecal incontinence showed <10 times of bowel movement per day. Accessing their incontinence scale, mean Wexner score was 9.4.

Conclusion

HLE is a novel sphincter-preserving technique that can be a treatment option for low rectal cancer invading ipsilateral levator-ani muscle, which has been an indication for abdominoperineal resection (APR) or extralevator APR. However, the long-term oncologic and functional outcomes of this procedure still need to be assessed to confirm its validity.

Robot-assisted intersphincteric resection facilitates an efficient sphincter-saving in patients with low rectal cancer

PURPOSE

Few investigations of robot-assisted intersphincteric resection (ISR) are presently available to support this procedure as a safe and efficient procedure. We aimed to evaluate the utility of robot-assisted ISR by comparison between ISR and abdominoperineal resection (APR) using both robot-assisted and open approaches.

METHODS

The 558 patients with lower rectal cancer (LRC) who underwent curative operation was enrolled between July 2010 and June 2015 to perform either by robot-assisted (ISR vs. APR = 310 vs. 34) or open approaches (144 vs. 70). Perioperative and functional outcomes including urogenital and anorectal dysfunctions were measured. Recurrence and survival were examined in 216 patients in which >3 years had elapsed after the operation.

RESULTS

The robot-assisted approach was the most significant parameter to determine ISR achievement among potent parameters (OR = 3.467, 95% CI = 2.095-5.738, p < 0.001). Early surgical complications occurred more frequently in the open ISR group (16 vs. 7.7%, p = 0.01). The voiding and male sexual dysfunctions were significantly more frequent in the open ISR (p < 0.05). The fecal incontinence and lifestyle alteration score was greater in the open ISR than in the robot-assisted ISR at 12 and 24 months, respectively (p < 0.05). However, the 3-year cumulative rates of local recurrence and survival did not differ between the two groups.

CONCLUSIONS

The current procedure of robot-assisted ISR replaced a significant portion of APR to achieve successful SSO via mostly transabdominal approach and double-stapled anastomosis. The robot-assisted ISR with minimal invasiveness might be a help to reduce anorectal and urogenital dysfunctions.

Insurance Status, Not Race, is Associated With Use of Minimally Invasive Surgical Approach for Rectal Cancer

OBJECTIVE

To determine the impact of race and insurance on use of minimally invasive (MIS) compared with open techniques for rectal cancer in the United States.

BACKGROUND

Race and socioeconomic status have been implicated in disparities of rectal cancer treatment.

METHODS

Adults undergoing MIS (laparoscopic or robotic) or open rectal resections for stage I to III rectal adenocarcinoma were included from the National Cancer Database (2010-2012). Multivariate analyses were employed to examine the adjusted association of race and insurance with use of MIS versus open surgery.

RESULTS

Among 23,274 patients, 39% underwent MIS and 61% open surgery. Overall, 86% were white, 8% black, and 3% Asian. Factors associated with use of open versus MIS were black race, Medicare/Medicaid insurance, and lack of insurance. However, after adjustment for patient demographic, clinical, and treatment characteristics, black race was not associated with use of MIS versus open surgery [odds ratio [OR] 0.90, P = 0.07). Compared with privately insured patients, uninsured patients (OR 0.52, P < 0.01) and those with Medicare/Medicaid (OR 0.79, P < 0.01) were less likely to receive minimally invasive resections. Lack of insurance was significantly associated with less use of MIS in black (OR 0.59, P = 0.02) or white patients (OR 0.51, P < 0.01). However, among uninsured patients, black race was not associated with lower use of MIS (OR 0.96, P = 0.59).

CONCLUSIONS

Insurance status, not race, is associated with utilization of minimally invasive techniques for oncologic rectal resections. Due to the short-term benefits and cost-effectiveness of minimally invasive techniques, hospitals may need to improve access to these techniques, especially for uninsured patients.

Intersphincteric resection for very low rectal cancer: A review of the updated literature

Intersphincteric resection (ISR) has rapidly increased worldwide including laparoscopic surgery. However, there are some concerns for the definition of ISR, surgical technique, oncological outcome, anal function, and quality of life (QoL). The aim of the present study is to evaluate those issues. A review of this surgical technique was carried out by searching English language literature of the PubMed online database and appropriate articles were identified. With regard to open‐ISR, the morbidity rate ranged from 7.5% to 38.3%, with lower mortality rates. Local recurrence rates varied widely from 0% to 22.7%, with a mean follow‐up duration of 40–94 months. Disease‐free and overall 5‐year survival rates were 68–86% and 76–97%, respectively. Those outcomes were equivalent to laparoscopic‐ISR. Surgical and oncological outcomes of ISR were generally acceptable. However, accurate evaluation of anal function and QoL was difficult because of a lack of standard assessment of various patient‐related factors. The surgical and oncological outcomes after ISR seem to be acceptable. The ISR technique seems to be valid as an alternative to abdominoperineal resection in selected patients with a very low rectal cancer. However, both necessity for ISR and expectations of QoL impairment as a result of functional disorder should be fully discussed with patients before surgery.

Laparoscopy for Rectal Cancer

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.

Clinical and functional results of laparoscopic intersphincteric resection for ultralow rectal cancer: is there a distinction between the three types of hand-sewn colo-anal anastomosis?

PURPOSE

The purpose of this study is to compare the clinical and functional outcomes of three types of hand-sewn colo-anal anastomosis (CAA) after laparoscopic intersphincteric resection (Lap-ISR) for patients with ultralow rectal cancer.

METHODS

A total of 79 consecutive patients treated by Lap-ISR for low-lying rectal cancer in an academic medical center from June 2011 to February 2016. According to the distal tumor margin and individualized anal length, the patients underwent three types of hand-sewn CAA including partial-ISR, subtotal-ISR, and total-ISR.

RESULTS

Of the 79 patients, 35.4% required partial-ISR, 43% adopted subtotal-ISR, and 21.5% underwent total-ISR. R0 resection was achieved in 78 patients (98.7%). In addition to distal resection margin, there were no significant differences in clinicopathological parameters and postoperative complications between the three groups. The type of hand-sewn CAA did not influence the 3-year disease-free survival (DFS) or local relapse-free survival (LFS). At 24-months follow-up, in spite of higher incontinence scores in total-ISR group, there were not statistically significant differences in functional outcomes including Wexner score or Kirwan grade between the groups. Nevertheless, patients with chronic anastomotic stricture showed worse anal function than those without the complication.

CONCLUSION

The type of hand-sewn CAA after Lap-ISR may not influence oncological and functional outcomes, but chronic stricture deteriorates continence status.

Intersphincteric resection for low rectal cancer

For low rectal cancer located < 5 cm from the anal verge, abdominoperineal resection (APR) with permanent sigmoid colostomy is usually used to ensure the R0 resection. Sphincter saving surgery has emerged in the last 20 years, and the introduction of intersphincteric resection (ISR) can successfully preserve the anal function and guarantee a radical tumor resection for patients with ultra-low lying tumors. Therefore, the use of APR has been consistently declining worldwide. Recently, a growing body of research on ISR has been reported. However, more evidence based results are needed to clarify some issues about ISR. In the current review, we discuss the indications for ISR and the oncological and functional outcomes following the procedure. Some technique issues of ISR are also discussed.

Short-term and Long-term Outcomes Regarding Laparoscopic Versus Open Surgery for Low Rectal Cancer: A Systematic Review and Meta-Analysis

PURPOSE

It is to disclose whether the laparoscopic technique is feasible or not in the treatment of low rectal cancer.

MATERIALS AND METHODS

We systematically searched PubMed, Embase, Ovid, Web of Science, Science Direct, SpringerLink, EBSCO, and the Cochrane Library databases for the eligible studies. Review Manager 5.2 was used to test the heterogeneity and to evaluate the overall test performance.

RESULTS

Twelve studies met the final inclusion criteria (total n=2973). The pooled analyses showed, despite longer operation times, that there were significantly less blood loss, fewer transfusions, shorter times to bowel function recovery, resumed diet and hospital durations, and lower overall complication and wound infection rates. The compared results of the lymph node harvest number, distal resection margin, circumferential resection margin involvement, local and distant recurrences, disease-free survival, and overall survival were similar between both the groups.

CONCLUSION

Laparoscopic surgery is safe and feasible for the treatment of low rectal cancer.

Laparoscopic intersphincteric resection: indications and results

Surgical treatment of distal rectal cancer has long been based only on abdominoperineal excision, resulting in a permanent stoma and not always offering a definitive local control. Sphincter saving surgery has emerged in the last 20 years and can be offered also to patients with low lying tumours, provided that the external sphincter is not involved by the disease. An intersphincteric resection (ISR) is based on the resection of the rectum with a distal dissection proceeding into the space between the internal and the external anal sphincter. Originally described as an open procedure, it has also been developed with the laparoscopic approach, and also this technically demanding procedure is inscribed among those offered to the patient by a minimally invasive surgery. Indications have to be strict and patient selection is crucial to obtain both oncological and functional optimal results. The level of distal dissection and the extent of internal sphincter resected are chosen according to the distal margin of the tumour and is based on MRI findings: accurate imaging is therefore mandatory to better define the surgical approach. We here present our actual indications for ISR, results in terms of operative time, median hospital stay for ISR in our experience and review the updated literature.

Hand-sewn coloanal anastomosis for low rectal cancer: technique and long-term outcome

AIM

This study compared the operative outcome and long-term survival of three types of hand-sewn coloanal anastomosis (CAA) for low rectal cancer.

METHOD

Patients presenting with low rectal cancer at a single centre between 2006 and 2014 were classified into three types of hand-sewn CAA: type 1 (supra-anal tumours undergoing transabdominal division of the rectum with transanal mucosectomy); type 2 (juxta-anal tumours, undergoing partial intersphincteric resection); and type 3 (intra-anal tumours, undergoing near-total intersphincteric resection with transanal mesorectal excision).

RESULTS

Seventy-one patients with low rectal cancer underwent CAA: 17 type 1; 39 type 2; and 15 type 3. The median age of patients was 61.6 years, with a male/female ratio of 2:1. Neoadjuvant therapy was given to 56 (79%) patients. R0 resection was achieved in 69 (97.2%) patients. Adverse events occurred in 25 (35.2%) of the 71 patients with a higher complication rate in type 1 vs type 2 vs type 3 (47.1% vs 38.5% vs 13.3%, respectively; P = 0.035). Anastomotic separation was identified in six (8.5%) patients and pelvic haematoma/seroma in five (7%); two (8.3%) female patients developed a recto-vaginal fistula. Ten (14.1%) patients were indefinitely diverted, with a trend towards higher long-term anastomotic failure in type 1 vs type 2 vs type 3 (17.6% vs 15.5% vs 6.7%). The type of anastomosis did not influence the overall or disease-free survival.

CONCLUSION

CAA is a safe technique in which anorectal continuity can be preserved either as a primary restorative option in elective cases of low rectal cancer or as a salvage procedure following a failed stapled anastomosis with a less successful outcome in the latter. CAA has acceptable morbidity with good long-term survival in carefully selected patients.

Multicentre study of robotic intersphincteric resection for low rectal cancer

BACKGROUND

There is a lack of information regarding the oncological safety of robotic intersphincteric resection (ISR) with coloanal anastomosis. The objective of this study was to compare the long-term feasibility of robotic compared with laparoscopic ISR.

METHODS

Between January 2008 and May 2011, consecutive patients who underwent robotic or laparoscopic ISR with coloanal anastomosis from seven institutions were included. Propensity score analyses were performed to compare outcomes for groups in a 1 : 1 case-matched cohort. The primary endpoint was 3-year disease-free survival.

RESULTS

A total of 334 patients underwent ISR with coloanal anastomosis, of whom 212 matched patients (106 in each group) formed the cohort for analysis. The overall rate of conversion to open surgery was 0.9 per cent in the robotic ISR group and 1.9 per cent in the laparoscopic ISR group. Nine patients (8.5 per cent) in the laparoscopic group and three (2.8 per cent) in the robotic ISR group still had a stoma at last follow-up (P = 0.075). Total mean hospital costs were significantly higher for robotic ISR (€ 12,757 versus € 9223 for laparoscopic ISR; P = 0.037). Overall 3-year local recurrence rates were similar in the two groups (6.7 per cent for robotic and 5.7 per cent for laparoscopic resection; P = 0.935). The combined 3-year disease-free survival rates were 89.6 (95 per cent c.i. 84.1 to 95.9) and 90.5 (85.4 to 96.6) per cent respectively (P = 0.298).

CONCLUSION

Robotic ISR with coloanal anastomosis for rectal cancer has reasonable oncological outcomes, but is currently too expensive with no short-term advantages.

Laparoscopic Versus Open Surgery for Mid-Low Rectal Cancer: a Systematic Review and Meta-Analysis on Short- and Long-Term Outcomes

BACKGROUND

The safety of laparoscopic surgery for mid-low rectal cancer treatment has remained controversial, especially regarding the long-term outcomes. The aim of this study was to demonstrate whether the laparoscopic technique is feasible.

METHODS

We searched all of studies that compared the short- or long-term outcomes regarding laparoscopic and open rectal cancer surgeries (the tumour distance from anal verge within 10 cm). The data sources included PubMed, EMBASE, OVID, Web of Science and the Cochrane Library databases. The combined outcome of the dichotomous variables was expressed as an estimation of the odds ratios and continuous variables were presented in the form of weighted mean differences with 95% credible intervals. Subgroup, publication bias and sensitivity analyses were performed.

RESULTS

Thirteen studies met the final inclusion criteria (total n = 3,678). The pooled analyses showed, despite longer operation times, that there were significantly less blood loss, fewer transfusions, shorter times to bowel function recovery, resumed diet and hospital durations, and lower overall complication and wound infection rates. The compared results of the lymph node harvest number, distal resection margin, circumferential resection margin involvement, local and distant recurrences, disease-free survival and overall survival were similar between both groups.

CONCLUSIONS

This study suggests that the safety and feasibility of laparoscopic surgery appear to be equivalent to open surgery for treatment of mid- low rectal cancer, with the more favourable short-term benefits, fewer complications, comparable pathological outcomes and long-term outcomes.

Laparoscopic intersphincteric resection and hand-sewn coloanal anastomosis: a natural orifice specimen extraction technique

The incidence of rectal cancer in India is on the rise, and unlike in the West, predominantly younger individuals are affected. Surgery for rectal cancer has evolved over the years with the ultimate goals of sphincter preservation and better quality of life, besides oncological safety. With the routine use of magnetic resonance imaging for local staging, intersphincteric resection has become a viable alternative to abdominoperineal resection. Similarly, there is enough evidence to consider laparoscopic surgery as feasible and oncologically safe for rectal cancer. Thus laparoscopic intersphincteric resection fulfills all the objectives of modern-day rectal cancer surgery. Here we describe the technical points while performing the surgery as well as short-term results of our own series.

Feasibility and oncological outcomes of laparoscopic rectal resection following neo-adjuvant chemo-radiotherapy: A systematic review

AIM: To study the feasibility and oncological outcomes following laparoscopic total mesorectal excision (LTME) in patients who have received Neo-adjuvant long course chemo-radiotherapy (LCRT).

METHODS: A protocol driven systematic review of published literature was undertaken to assess the feasibility and oncological outcomes following LTME in patients receiving LCRT. The feasibility was assessed using peri-operative outcomes and short term results. The oncological outcomes were assessed using local recurrence, disease free survival and overall survival.

RESULTS: Only 8 studies-1 randomized controlled trial, 4 Case Matched/Controlled Studies and 3 Case Series were identified matching the search criteria. The conversion rate was low (1.2% to 28.1%), anastomotic leak rates were similar to open total mesorectal excision (0%-4.1% vs 0%-8.3%). Only 3 studies reported on local recurrence rates (5.2%-7.6%) at median 34 mo follow-up. A single study described disease free survival and overall survival at 3 years as 78.8% and 92.1% respectively.

CONCLUSION: LTME following LCRT is feasible in experienced hands, with acceptable short term surgical outcomes and with the usual benefits associated with minimally invasive procedures. The long term oncological outcomes of LTME after LCRT appear to be comparable to open procedures but need further investigation.

Perineal transanal approach: a new standard for laparoscopic sphincter-saving resection in low rectal cancer, a randomized trial

BACKGROUND

Laparoscopic sphincter preservation for low rectal cancer is challenging because of the high risk of positive circumferential resection margin. We hypothesized that perineal dissection of the distal rectum may improve quality of surgery, compared with the conventional abdominal dissection.

METHODS

Between 2008 and 2012, 100 patients with low rectal cancer (< 6 cm from the anal verge) suitable for sphincter preservation were randomized between perineal and abdominal low rectal dissection. Surgery included laparoscopic mobilization of the left colon with high rectal dissection. Distal rectal dissection was performed laparoscopically in the abdominal group and transanally in the perineal group. The primary endpoint was quality of surgery (circumferential resection margin, mesorectum grade, and lymph nodes). Secondary end points were morbidity and conversion.

RESULTS

The rate of positive circumferential resection margin decreased significantly after perineal compared with abdominal low rectal dissection, 4% versus 18% (P = 0.025). The mesorectum grade and the number of lymph nodes analyzed did not differ between the 2 groups. There was no difference in surgical morbidity (12% vs 14%; P = 0.766) and conversion (4% vs 10%; P = 0.436) between perineal and abdominal rectal dissection. Multivariate analysis showed that abdominal rectal dissection was the only independent factor of positive circumferential resection margin (odds ratio = 5.25; 95% confidence interval: 1.03-26.70; P = 0.046).

CONCLUSIONS

Perineal rectal dissection reduces the risk of positive circumferential resection margin, as compared with the conventional abdominal dissection in low rectal cancer. This suggests the perineal rectal dissection as a new standard in laparoscopic sphincter-saving resection for low rectal cancer.

Intersphincteric resection and hand-sewn coloanal anastomosis for low rectal cancer: Short-term outcomes in the Indian setting

INTRODUCTION

The rectum remains a predominant subsite of colorectal cancer in the Indian population. Unique to the Indian setting are significant social repercussions associated with a permanent stoma. On account of this, many patients who are advised abdominal perineal excision of the rectum (APER) default treatment. Accurate demonstration of the intersphincteric plane with magnetic resonance imaging has made intersphincteric resection (ISR) a viable option. This study is aimed at determining the feasibility and oncological adequacy of ISR in the Indian scenario.

MATERIAL AND METHODS

All patients with low rectal cancer who underwent an ISR at the Tata Memorial Centre, from July 2013 to December 2013 were included. Patients with invasion of the external sphincter and suboptimal preoperative sphincter function were excluded. Following standard preoperative staging, patients with a threatened circumferential resection margin (CRM) and/or mesorectal nodes were given preoperative chemoradiotherapy. The oncological adequacy of the procedure was evaluated in terms of margin positivity (distal and CRMs) and lymph node yield. Short-term perioperative outcomes included 30-day mortality, postoperative morbidity, anastomotic leaks, and length of hospital stay.

RESULTS

Thirty-three patients with low rectal cancer and a median age of 38 years underwent ISR during the defined study period. Twenty-three patients (70 %) underwent open surgery whereas ten patients received a laparoscopic resection. The median blood loss and hospital stay was 300 mL and 7 days, respectively. Two patients had an involved CRM, but all distal margins were free of tumor. The quality of total mesorectal excision was satisfactory in all patients with a median lymph node yield of 9 nodes.

CONCLUSIONS

Intersphincteric resection is feasible and oncologically safe in selected patients with low rectal cancer. Long-term functional and oncological outcomes are essential before it can be considered a viable alternative to APER.

Current status of laparoscopy for the treatment of rectal cancer

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.

Laparoscopic intersphincteric resection using needlescopic instruments

Intersphincteric resection (ISR) is a procedure designed to preserve anal function in cases with very low rectal cancer. We report our clinical experience with laparoscopic ISR (Lap ISR) performed using needlescopic instruments. First, a camera port is created at the umbilicus. Two 5-mm ports are then inserted at the right upper and lower quadrants. Two needlescopic forceps (Endo-Relief^™ Hope Denshi Co., Chiba, Japan) are inserted at the left upper and lower quadrants. We then perform the following procedures; ligation of the inferior mesenteric artery and vein, total mesorectal excision and dissection of the intersphincteric space. After the transanal intersphincteric dissection, the specimen is extracted through the anus and a hand —sewn coloanal anastomosis is performed. The covering ileostomy is finally created at the right upper port. We performed Lap ISR using needlescopic forceps in two patients with very low rectal cancer. In both cases, we were able to perform this procedure without insertion of an additional port or to change the needlescopic forceps to conventional 5-mm forceps. Lap ISR with needlescopic instruments is a feasible procedure for minimally invasive surgery.

Robotic versus laparoscopic intersphincteric resection for low rectal cancer: comparison of the operative, oncological, and functional outcomes

BACKGROUND

Robotic surgery was developed to overcome the limitations of laparoscopic surgery and is increasingly used to treat low rectal cancer. In this study, we compared the operative, oncological, and functional outcomes of low rectal cancer patients who underwent robotic or laparoscopic intersphincteric resection (ISR).

METHODS

Prospectively collected data from low rectal cancer patients who underwent laparoscopic or robotic ISR between September 2006 and August 2011 were retrospectively compared. The functional outcomes of patients followed up for ≥ 12 months after ileostomy closure were evaluated via questionnaire.

RESULTS

Forty-four and 26 patients underwent robotic and laparoscopic ISR, respectively. The robotic group patients had a higher body mass index (BMI; 21.42 ± 3.13 vs. 24.13 ± 3.33 kg/m(2); p = 0.001), more advanced clinical N stage (p = 0.029), lower cancer location (3.71 ± 0.89 vs. 3.24 ± 0.78 cm; p = 0.023), more frequent chemoradiotherapy (26.9 vs. 54.5 %; p = 0.025), and longer operation time (286.77 ± 51.46 vs. 316.43 ± 65.11 min; p = 0.038). However, no intergroup differences were observed in the pathological details (except the number of retrieved lymph nodes), postoperative morbidity, 3-year overall survival, recurrence-free survival (RFS), local RFS, and functional outcomes.

CONCLUSIONS

Robotic and laparoscopic ISR yielded similar operative, oncological, and functional outcomes in patients with low rectal cancer, despite differences in unfavorable outcome-affecting factors, including BMI, clinical N stage, cancer location, and chemoradiotherapy frequency. A randomized trial will provide more solid methodology for investigating the potential benefits of robotic ISR.

Laparoscopic transabdominal approach partial intersphincteric resection for low rectal cancer: surgical feasibility and intermediate-term outcome

BACKGROUND

Traditionally, conventional intersphincteric resection requires a combined abdominal and perineal approach and a handsewn coloanal anastomosis procedure, which is difficult to accomplish via the perineal approach. A completely abdominal approach partial intersphincteric resection (APISR) with laparoscopy can simplify the anastomosis procedure. This study evaluated the intermediate-term oncological and functional results of laparoscopic versus open APISR for low rectal cancer.

METHODS

A total of 137 consecutive patients with low rectal cancer who underwent APISR from January 2006 to August 2013 were retrospectively evaluated. Patient groups were classified into as open surgery (OP, n = 48) group and laparoscopy (LAP, n = 89). The primary endpoint was 3-year disease-free survival and the Wexner score for anal function.

RESULTS

The LAP group had longer operating time, less intraoperative blood loss, and shorter hospital stay after surgery compared with the OP group. Median follow-up was 32.3 months. The local recurrence rates were similar in the two groups (LAP 3.2% vs. OP 6.1%; P = 0.652). The combined 3-year disease-free survival rate was 83.2% in the LAP group and 83.8% in the OP group (P = 0.857). Wexner scores were similar in the two groups (LAP 2.9 ± 4.5 vs. OP 3.1 ± 5.0). In the LAP group, 89.7% of patients had good continence compared with 91.4% in the OP group (P = 0.311).

CONCLUSIONS

Laparoscopic APISR can be performed safely and offers similar intermediate-term oncological and functional outcome compared with the open procedure. The oncological adequacy requires long-term follow-up data.

Feasibility of laparoscopic intersphincteric resection for patients with cT1-T2 low rectal cancer

AIMS

The purpose of this study was to assess the feasibility of laparoscopic intersphincteric resection (LAP-ISR) for rectal cancer in terms of morbidity, oncological outcomes, and functional results.

METHODS

Thirty-seven patients with primary low rectal cancer cT1-T2 underwent LAP-ISR. Surgical outcomes, pathological results, postoperative complications, oncological outcomes, and functional results were analyzed retrospectively.

RESULTS

Three patients (8.1%) had carcinoma in situ, 22 (59.5%) had pT1 tumor, and 11 (29.7%) had pT2 tumor. Eleven patients (29.7%) were diagnosed as being node positive, while 26 (70.3%) had node-negative disease. The median operative time was 315 min (range: 195-502). The median blood loss was 37 ml (range: 0-745). One case was converted to open surgery. Pathological complete resection was achieved in all cases. There was no surgical mortality. Postoperative complications of grade III-IV on the Clavien-Dindo classification were observed in 16.2% of the patients. The median follow-up period was 2.8 years (range: 187-2,241 days), and 3-year disease-free survival was 93.1%. No patient developed local recurrence. The functional result was objectively good.

CONCLUSION

LAP-ISR can be recommended as a feasible, ultimate sphincter-preserving procedure with acceptable functional and intermediate-term oncological outcomes in patients with cT1-T2 very low rectal cancer.

Single-port laparoscopic total mesorectal excision with transanal resection (transabdominal transanal resection) for low rectal cancer: initial experience with 22 cases

BACKGROUND

Total mesorectal excisions (TME) with transanal resection and coloanal anastomosis (CAA) represent one of the standard surgical treatments for low rectal cancers. We report our initial experiences with trans-abdominal trans-anal resections (TATAR) with TME, performed using a single-port laparoscopic surgeries (SPLS) approach for low rectal cancers.

METHODS

Between June 2009 and April 2011, 22 low rectal cancer patients underwent SPLS TATAR with TME. SPLS was performed transumbilically or through predetermined stoma sites. Conventional laparoscopic instruments were used, and the intracorporeal procedures and range of operation did not differ. After a full laparoscopic TME to the pelvic floor muscles, the specimen was pulled through the anus. CAA was completed with transanal hand sewn sutures. Patient and tumor characteristics and operative, pathologic, and postoperative outcomes were studied.

RESULTS

SPLS TATAR with TME was successful in all patients. No additional incisions for trocars or conversions to open surgery were performed. The median incision length, operative time, and postoperative length of stay were 2.0 cm (range: 1.5-2.5), 260 min (range: 190-380), and 6 days (range: 4-16), respectively. The median number of harvested lymph nodes was 22 (range: 9-42). The median distal margin from the tumor was 2.0 cm (range: 0.3-4.0). No intraoperative complications were noted.

CONCLUSIONS

SPLS TATAR with TME was safe and feasible. In addition to cosmetic advantages, oncologic requirements for specimens, including adequate margins and sufficient lymph node harvesting could be fulfilled entirely. However, the technique and oncologic safety warrant further evaluation and prospective randomized studies.

Laparoscopic versus open surgery for stage I rectal cancer: long-term oncologic outcomes

BACKGROUND

Laparoscopic resection is increasingly being performed for rectal cancer. However, few data are available to compare long-term outcomes after open versus laparoscopic surgery for early-stage rectal cancer.

METHODS

Included in this retrospective study were 160 patients who underwent surgery for stage I rectal cancer between 2001 and 2008. Perioperative outcomes, overall survival (OS), and disease-free survival (DFS) were compared for open versus laparoscopic surgery.

RESULTS

Altogether, 85 patients were treated using open surgery and 80 with laparoscopic surgery. Postoperative mortality (0 vs. 1.3%; p = 1.00), morbidity (31.3 vs. 25.0%; p = 0.38), and harvested lymph nodes (22.5 vs. 20.0; p = 0.84) were similar for the two groups. However, operating time was longer (183.8 vs. 221.0 min; p = 0.008), volume of intraoperative bleeding was less (200.0 vs. 150.0 ml; p = 0.03), time to first bowel movement was shorter (3.54 vs. 2.44 days; p < 0.001), rate of superficial surgical-site infection was lower (7.5 vs. 0%; p = 0.03), and postoperative hospital stay was shorter (11.0 vs. 8.0 days; p < 0.001) in the laparoscopy group than in the open surgery group. At 5 years, there was no difference in OS (98.6 vs. 97.1%; p = 0.41) or DFS (98.2 vs. 96.4%; p = 0.30) between the open and laparoscopy groups.

CONCLUSIONS

Long-term outcomes of laparoscopic surgery for stage I rectal cancer were comparable to those of open surgery. Laparoscopic surgery, however, produced more favourable short-term outcomes than open surgery.

A pilot study of natural orifice transanal endoscopic total mesorectal excision with laparoscopic assistance for rectal cancer

BACKGROUND

The objective of this pilot study was to evaluate the feasibility and safety of natural orifice endoscopic transanal total mesorectal excision (TME) with laparoscopic assistance in a cohort study of five patients with stage I and IIA rectal cancer.

METHODS

Five eligible patients with node-negative rectal cancer located 4-12 cm from the anal verge were enrolled in an IRB-approved pilot study. All patients underwent transanal endoscopic TME with laparoscopic assistance, hand-sewn coloanal anastomosis, and a diverting loop ileostomy. Primary and secondary end points included adequacy of the mesorectal excision and 30-day postoperative complications, respectively.

RESULTS

Between November 2011 and May 2012, three males and two females underwent transanal endoscopic TME with laparoscopic assistance. Patient mean age and BMI were 48.6 ± 9.8 years and 25.7 ± 2.3 kg/m(2), respectively. Tumors were located an average of 5.7 ± 2.4 cm from the anal verge and preoperatively staged as T1N0M0 (2), T2N0M0 (1), and T3N0M0 (2). Mean operative time was 274.6 ± 85.4 min with no intraoperative complications. Partial intersphincteric resection was performed in conjunction with transanal endoscopic TME in three patients. Pathologic examination of TME specimens demonstrated complete mesorectal excision in all cases with negative proximal, distal, and radial margins. Mean length of hospital stay was 5.2 ± 2.6 days and three minor complications occurred, including one ileus and two cases of transient urinary dysfunction. At a mean early follow-up of 5.4 ± 2.3 months, all patients remain disease-free.

CONCLUSIONS

In this pilot study of five patients with rectal cancer, transanal endoscopic TME with laparoscopic assistance is feasible and safe, and is a promising alternative to open and laparoscopic TME. Evaluation of long-term functional and oncologic outcomes of this approach is needed before widespread adoption can be recommended.