Oncologic results of laparoscopic versus conventional open surgery for stage II or III left-sided colon cancers: a randomized controlled trial

Surgical Outcomes and Utilization of Laparoscopic Versus Robotic Techniques for Elective Colectomy in Asian American and Native Hawaiian-Pacific Islanders (AAPI) Diagnosed With Colon Cancer

INTRODUCTION

Asian American and Native Hawaiian-Pacific Islanders (AAPI) are the fastest growing racial-ethnic group, with 18.9 million people in 2019, and is predicted to rise to 46 million by 2060. Colorectal cancer (CRC) is the most common cancer in AAPI men and the third most common in women. Treatment techniques like laparoscopic colectomy (LC) emerged as the standard of care for CRC resections; however, new robotic technologies can be advantageous. Few studies have compared clinical outcomes across minimally invasive approaches for AAPI patients with CRC. This study compares utilization and clinical outcomes of LC versus robotic colectomies (RCs) in AAPI patients.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database for elective RC and LC in AAPI patients from 2012 to 2020. Outcomes included unplanned conversion to open, operative time, complications, 30-d mortality, and length of stay. Multivariable logistic regression analyses assessed the association between outcomes and the operative approach.

RESULTS

Between 2012 and 2020, 83,841 patients underwent elective LC or RC. Four thousand six hundred fifty-eight AAPI patients underwent 3817 (82%) LCs and 841 (18%) RCs. In 2012, all procedures were performed laparoscopically; by 2020, 27% were robotic. Mean operative time was shorter in LC (192 versus 249 min, P < 0.001). On multivariable logistic regression, there was no difference in infection (odds ratio [OR] 0.8, 95% confidence interval [CI] 0.59-1.12), anastomotic leak (OR 0.97, 95% CI 0.59-1.61), or death (OR 0.9, 95% CI 0.31-2.61). Length of stay was shorter for RC (-0.44 d, 95% CI -0.71 to -0.18 d).

CONCLUSIONS

Overall, AAPI postoperative outcomes are similar between LC and RC. Future studies that evaluate costs and resource utilization can assist hospitals in determining whether implementing robotic-assisted technologies in their hospitals and communities will be appropriate.

Mid-term outcomes of laparoscopic vs open colectomy for pathological T4 and/or N2 colon cancer patients: Multicenter study using propensity score matched analysis

OBJECTIVES

We aimed to assess mid-term outcomes after laparoscopic surgery (LAP) vs open surgery (OP) for pathological T4 (pT4) and/or N2 (pN2) colon cancer.

METHODS

We retrospectively reviewed 255 primary tumor resections for pT4 and/or pN2 colon cancer performed from 2015 to 2020 at six hospitals, divided into LAP (n = 204) and OP groups (n = 51). After propensity score matching to minimize selection bias, 47 matched patients per group were assessed.

RESULTS

Before matching, the rate of males (53.9% vs. 37.3%, P = .042), left sided colon cancer (53.9% vs 37.3%, P = .042), D3 lymph node dissection (90.7% vs 68.6%, P < .001) and body mass index (kg/m2 ) (22.3 vs 21.8, P = .039) were significantly greater in the LAP group. The rate of pT4b (7.8% vs 40.4%, P < .001) was lower and pN2 was higher (57.4% vs 37.3%, P = .012) in the LAP group. After matching, preoperative characteristics and pathologic status were equivalent between the groups. The LAP and OP groups showed comparable overall survival (OS) (2-year OS, 84.5% vs 76.8%, P = .055) and recurrence-free survival (RFS) (2-year RFS, 73.9% vs 52.8%, P = .359). In the patients with pT4, OS (2-year OS, 79.4% vs 75.7%, P = .359) and RFS (2-year RFS, 71.3% vs 58.7%) were comparable. In the patients with pN2, OS (2-year OS, 83.4% vs 76.3%) and RFS (2-year RFS, 69.6% vs 36.2%) were also comparable.

CONCLUSIONS

LAP for pT4 and/or pN2 colon cancer showed comparable mid-term outcomes compared with OP. LAP was an acceptable surgical approach in this cohort.

Overall survival comparing laparoscopic to open surgery for right-sided colon cancer: propensity score inverse probability weighting population study

BACKGROUND

This retrospective cohort study reports on overall survival and short-term complications, comparing laparoscopic to open resection for right-sided colon cancers. It is one of the largest studies in the field with generalizable population-level results.

METHOD

This study on right sided colon cancers used prospectively collected administrative data linked to a death registry over 5 years from 2014 to 2018. Exclusion criteria were private patients, patients aged less than 10 years, synchronous and metachronous cancers. Propensity score weighting was used to balance cohorts and Cox proportional hazards regression was used to assess the hazard of death. In addition, logistic regression analysis was used to assess secondary outcomes. For completeness, unweighted data was similarly analysed.

RESULTS

There were 3603 patients identified for the analysis: 1729 open patients and 1874 laparoscopic patients. Cox proportional hazards regression analysis of the weighted data showed no evidence of a statistically significant effect of laparoscopic surgery compared to open surgery on overall survival for right-sided colon cancers (HR 0.86, 95% CI 0.71-1.04, P = 0.112). The weighted data showed lower odds of prolonged length of stay, return to theatre and discharge destination other than home in the laparoscopic cohort compared to the open cohort. There was no difference in inpatient mortality. Unweighted results were similar.

CONCLUSION

This study validates the use of laparoscopic surgery for right-sided colon cancer, showing similar long-term overall survival and inpatient mortality compared to open surgery. It is superior to open surgery for the short-term outcomes of LOS, return to theatre and discharge destination other than home.

Long-term oncological outcomes for minimally invasive surgery versus open surgery for colon cancer-a population-based nationwide study with a non-inferiority design

AIM

The study aimed to compare 5-year overall survival in a national cohort of patients undergoing curative abdominal resection for colon cancer by minimally invasive surgery (MIS) or by the open (OPEN) technique.

METHODS

All patients diagnosed between 2010 and 2016 in Sweden with pathological Union International Contre le Cancer Stages I-III colon cancer localized in the caecum, ascending colon, hepatic flexure or sigmoid colon and those who underwent curative right sided hemicolectomy, sigmoid resection or high anterior resection by MIS or OPEN were included. Patients were identified in the Swedish Colorectal Cancer Registry from which all data were retrieved. The analyses were performed as intention-to-treat and the relationship between surgical technique (MIS or OPEN) and overall mortality within 5 years was analysed. For the primary research question a non-inferiority hypothesis was assumed with a statistical power of 90%, a one-side type I error of 2.5% and a non-inferiority margin of 2%. For the secondary analyses, multilevel survival regression models with the patients matched by propensity scores were employed, adjusted for patient- and tumour-related variables.

RESULTS

A total of 11 605 pathological Union International Contre le Cancer Stages I-III patients were included with 3297 MIS (28.4%) and 8308 OPEN (71.6%) and were followed until 31 December 2020. The primary analysis demonstrated superiority for MIS compared to OPEN. The multilevel survival regression analyses confirmed that 5-year overall survival was higher in MIS with a hazard ratio of 0.874 (95% confidence interval 0.791-0.965), and if excluding pT4 the outcome was similar, with a hazard ratio of 0.847 (95% confidence interval 0.756-0.948).

CONCLUSION

This observational study demonstrated that MIS was favourable to OPEN with regard to 5-year overall survival. These results support the use of laparoscopic colon cancer surgery in routine practice.

The Senhance Surgical System in Colorectal Surgery: A Systematic Review

The Senhance Surgical System allows for infrared eye tracking, haptic feedback, and an adjustable upright seat allowing for improved ergonomics. This systematic review was designed with the aim of reviewing the current literature pertaining to the use of the Senhance Surgical System in colorectal surgery. Medline, EMBASE, and CENTRAL were searched. Articles were eligible for inclusion if they evaluated adults undergoing colorectal surgery with the Senhance Surgical System. The primary outcome was intraoperative efficacy; as defined by operative time, estimated blood loss (EBL), and conversion. A DerSimonian and Laird inverse variance random-effects meta-analysis was used to generate overall effect size estimates and narrative review was provided for each outcome. Six observational studies with 223 patients (mean age: 63.7, 41.2% female, mean BMI: 24.4 kg/m²) were included. The most common indication for surgery was colorectal cancer (n = 180, 80.7%) and the most common operation was anterior resection (n = 72, 32.3%). Meta-analyses demonstrated a pooled total operative time of 229.8 min (95% CI 189.3-270.4, I² = 0%), console time of 141.3 min (95% CI 106.5-176.1, I² = 0%), and docking time of 10.8 min (95% CI 6.4-15.2, I² = 0%). The pooled EBL was 37.0 mL (95% CI 24.7-49.2, I² = 20%). Overall, there were nine (4.0%) conversions to laparoscopy/laparotomy. The Senhance Surgical System has an acceptable safety profile, reasonable docking and console times, low conversion rates, and an affordable case cost across a variety of colorectal surgeries. Further prospective, comparative trials with other robotic surgical platforms are warranted.

Laparoscopic versus open left hemicolectomy for left-sided colon cancer: protocol for a systematic review and meta-analysis

INTRODUCTION

Laparoscopic colectomy has been widely used clinically due to its minimally invasive advantages, and many studies have also demonstrated its safety and efficacy. However, the efficacy of laparoscopic left hemicolectomy remains unclear due to the differences in pathogenesis and surgical details between left and right colon cancers. Therefore, we plan to conduct a systematic review and meta-analysis to investigate whether laparoscopic techniques can be safely used in left hemicolectomy.

METHOD AND ANALYSIS

This meta-analysis protocol will be completed and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. A systematic search was performed for all articles related to laparoscopic left hemicolectomy in PubMed, Web of Science, Medline, EMBASE and the Cochrane Library from inception to 5 November 2021. Article screening and data extraction were performed independently by two authors and cross-checked after completion. The literature to be included will use corresponding tools for bias risk assessment. Subgroup analyses and sensitivity analyses will be used to explore potential heterogeneity.

ETHICS AND DISSEMINATION

Because this systematic review is based on studies with published results and does not involve intervention in patients, no ethical review is required. The results of this study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022291526.

Comparison of Short-Term Results of Laparoscopic and Open Surgeries for Colorectal Cancer: A Single-Center Experience

OBJECTIVE

Although laparoscopic colon cancer surgeries have increased in recent years, their oncological competence is questioned. In our study, we aimed to evaluate oncological competence by comparing laparoscopic and open surgery.

METHOD

The study was planned retrospectively. A total of 94 patients were included in the study, 42 of whom underwent laparoscopy, and 52 patients underwent open surgery. Both groups were compared in terms of demographic characteristics, staging, number of benign/malignant lymph nodes, histological findings, and complications.

RESULT

The final pathology report of all patients was adenocarcinoma. The median number of dissected lymph nodes was 20.9 in the open group (8-34) and 19.46 in the laparoscopy group (7-31) (p = 0.639). The median number of dissected malignant lymph nodes was 1 (0-13) in the open surgery group and 3.1 (0-8) in the laparoscopy group (p = 0.216). The laparoscopy group exhibited a longer operation time (281.2 ± 54.2 and 221.0 ± 51.5 min, respectively; p = 0.036) than the open surgery group, but a shorter intensive care unit (ICU) discharge, quicker initiation oral feeding, and shorter length of hospital stay (4.0 ± 0.9 vs 5.7 ± 2.0 days, respectively; p < 0.001).

DISCUSSION

Laparoscopic surgery elicits many benefits such as less wound infection, lower requirement for blood transfusion, shorter hospitalization, quicker initiation of oral feeding, and mobilization. Our study has shown that laparoscopic surgery provides quite adequate lymph node dissection when compared to oncological surgery, which is viewed with suspicion in the light of these benefits of laparoscopy.

Long-term oncological outcomes in patients undergoing laparoscopic versus open surgery for colon cancer: A nationwide cohort study

AIM

To estimate the effect of laparoscopy versus laparotomy on recurrence status in patients undergoing intended curative resection for stage I-III colon cancer using nationwide data.

METHOD

A retrospective cohort study using prospectively collected nationwide quality assurance data on all patients undergoing elective, intended curative surgery for UICC stage I-III colon cancer in Denmark from 1 January 2010, through 31 December 2013. The association between laparoscopic versus open surgery and recurrence status was investigated using cause-specific hazard and subdistribution hazard models with death from any cause as a competing event.

RESULTS

In total, 4369 patients undergoing elective intended curative surgery for colon cancer were included in the analysis. Overall, 3243 (74.2%) patients underwent laparoscopic surgery. During a median follow-up time of 84 months, 1191 (27.2%) patients experienced recurrence, and 1304 (29.8%) patients died. The cause-specific hazard of recurrence following laparoscopic versus open surgery was HR_CS  = 1.08, 95% CI: 0.90-1.28, p = 0.422. The subdistribution hazard of recurrence following laparoscopic versus open surgery was HR_SD =0.99, 95% CI: 0.84-1.16, p = 0.880.

CONCLUSION

Elective laparoscopic resection for UICC stage I-III colon cancer is oncologically safe and comparable with open resection. These results confirm the external validity of previous RCTs in everyday clinical settings.

Robotic versus laparoscopic surgery for rectal cancer after neoadjuvant chemoradiotherapy: A propensity-score matching analysis

BACKGROUND

We aimed to investigate the advantages of robotic versus laparoscopic surgery for rectal cancer after neoadjuvant chemoradiotherapy as these remains unclear.

METHODS

We retrospectively recruited eligible patients with rectal cancer undergoing robotic or laparoscopic surgery following neoadjuvant chemoradiotherapy. We compared the surgical outcomes between patients undergoing either robotic surgery or laparoscopic surgery was based on the propensity-score matching analysis.

RESULTS

A total of 171 patients were recruited, including 76 who underwent robotic surgery and 95 who underwent laparoscopic surgery. There were no significant differences in clinical and pathological characteristics between the groups after propensity-score matching (56 matched pairs). Longer operation times (324.964 ± 83.435 vs. 246.232 ± 111.324 min, p < 0.001) and more blood loss (187.679 ± 176.615 vs. 98.214 ± 107.011, p < 0.001) were observed in the robotic group. The major complication rates were similar between the treatment groups after propensity matching (p = 0.086). There were no significant differences in disease-free survival rates (p = 0.205) and overall survival rates (p = 0.837) between the groups.

CONCLUSIONS

Robotic surgery is associated with similar technical safety and oncologic efficacy compared to laparoscopic surgery for the treatment of rectal cancer after neoadjuvant chemoradiotherapy; it is an acceptable option for patients requiring minimally invasive surgery. Nevertheless, the longer operation times and greater blood loss seen in the present study are a stark reminder that the convenience and surgical precision, on which the marketing of robotic surgery is rooted, are yet to be proven and require further investigation.

Laparoscopic versus Open Transverse-Incision Approach for Right Hemicolectomy: A Systematic Review and Meta-Analysis

Background and Objectives: There is general agreement on the benefits of laparoscopy for treatment of rectal and left colon cancers, whereas findings regarding the comparison of laparoscopic and open right colonic resections are discordant. The aim of this systematic review and meta-analysis was to assess the outcomes and advantages of laparoscopic versus transverse-incision open surgery for management of right colon cancer. Materials and Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Comparative studies evaluating the results of laparoscopic and transverse-incision open right hemicolectomies were analyzed. The measured outcomes were mean operative time, time to feeding, duration of hospital stay, and number of lymph nodes harvested. Results: A total of 5 studies including 318 patients met the inclusion criteria. Meta-analysis revealed no differences in time to resume oral feeding, hospital stay, and number of lymph nodes harvested in between groups, but mean length of surgery was significantly longer in the laparoscopic group. Conclusion: These data confirm that the preferred approach to right hemicolectomy is yet unclear. Laparoscopy has a longer operative time than transverse-incision open surgery, and no significant short-term benefits were observed for the studied parameters. Well-designed randomized control trials (RCTs) might help to identify the differences between these two techniques for the surgical treatment of right colon cancer.

Efficient and Safe Method for Splenic Flexure Mobilization in Laparoscopic Left Hemicolectomy: A Propensity Score-weighted Cohort Study

Supplemental Digital Content is available in the text.

Because methods of performing laparoscopic left hemicolectomy differ between surgeons, standardizing the procedure is crucial to reduce complications and secure good oncologic outcomes.

Robotics Total Mesorectal Excision Up To the Minute

Surgical techniques have evolved over the past few decades, and minimally invasive surgery has been rapidly adapted to become a preferred operative approach for treating colorectal diseases. However, many of the procedures remain a technical challenge for surgeons to perform laparoscopically, which has prompted the development of robotic platforms. Robotic surgery has been introduced as the latest advance in minimally invasive surgery. The present article provides an overview of robotic rectal surgery and describes many advances that have been made in the field over the past two decades. More specifically, the introduction of the robotic platform and its benefits, and the limitations of current robotic technology, are discussed. Although the main advantages of robotic surgery over conventional laparoscopy appear to be lower conversion rates and better surgical specimen quality, oncological and functional outcomes appear to be similar to those of other alternatives. Other potential benefits include earlier recovery of voiding and sexual function after robotic total mesorectal excision. Nevertheless, the costs and lack of haptic feedback remain the primary limitations to the widespread use of robotic technology in the field.

Applicability of minimally invasive surgery for clinically T4 colorectal cancer

The role of minimally invasive surgery (MIS) to treat clinically T4 (cT4) colorectal cancer (CRC) remains uncertain and deserves further investigation. A retrospective cohort study was conducted between September 2006 and March 2019 recruiting patients diagnosed as cT4 CRC and undergoing MIS at a university hospital and its branch. Patients’ demography, clinicopathology, surgical and oncological outcomes, and radicality were analyzed. A total of 128 patients were recruited with an average follow-up period of 33.8 months. The median time to soft diet was 6 days, and the median postoperative hospitalization periods was 11 days. The conversion and complication (Clavien–Dindo classification ≥ II) rates were 7.8% and 27.3%, respectively. The 30-day mortality was 0.78%. R0 resection rate was 92.2% for cT4M0 and 88.6% for pT4M0 patients. For cT4 CRC patients, the disease-free survival and 3-year overall survival were 86.1% and 86.8% for stage II, 54.1% and 57.9% for stage III, and 10.8% and 17.8% for stage IV. With acceptable conversion, complication and mortality rate, MIS may achieve satisfactory R0 resection rate and thus lead to good oncological outcomes for selected patients with cT4 CRC.

Recurrence Risk after Radical Colorectal Cancer Surgery-Less Than before, But How High Is It?

Simple Summary

Evidence indicates that recurrence risk after colon cancer today is less than it was when trials performed decades ago showed that adjuvant chemotherapy reduces the risk and prolong disease-free and overall survival. After rectal cancer surgery, local recurrence rates have decreased but it is unclear if systemic recurrences have. After a systematic review of available literature reporting recurrence risks after curative colorectal cancer surgery we report that the risks are lower today than they were in the past and that this risk reduction is not solely ascribed to the use of adjuvant therapy. Adjuvant therapy always means overtreatment of many patients, already cured by the surgery. Fewer recurrences mean that progress in the care of these patients has happened but also that the present guidelines giving recommendations based upon old data must be adjusted. The relative gains from adding chemotherapy are not altered, but the absolute number of patients gaining is less.

Abstract

Adjuvant chemotherapy aims at eradicating tumour cells sometimes present after radical surgery for a colorectal cancer (CRC) and thereby diminish the recurrence rate and prolong time to recurrence (TTR). Remaining tumour cells will lead to recurrent disease that is usually fatal. Adjuvant therapy is administered based upon the estimated recurrence risk, which in turn defines the need for this treatment. This systematic overview aims at describing whether the need has decreased since trials showing that adjuvant chemotherapy provides benefits in colon cancer were performed decades ago. Thanks to other improvements than the administration of adjuvant chemotherapy, such as better staging, improved surgery, the use of radiotherapy and more careful pathology, recurrence risks have decreased. Methodological difficulties including intertrial comparisons decades apart and the present selective use of adjuvant therapy prevent an accurate estimate of the magnitude of the decreased need. Furthermore, most trials do not report recurrence rates or TTR, only disease-free and overall survival (DFS/OS). Fewer colon cancer patients, particularly in stage II but also in stage III, today display a sufficient need for adjuvant treatment considering the burden of treatment, especially when oxaliplatin is added. In rectal cancer, neo-adjuvant treatment will be increasingly used, diminishing the need for adjuvant treatment.

Laparoscopic surgery for colon cancer

Background

To evaluate a new procedure in daily clinical practice, it might not be sufficient to rely exclusively on the findings of randomized clinical trials (RCTs). This is the first systematic review providing a synthesis of the most important RCTs and relevant retrospective cohort studies on short- and long-term outcomes of laparoscopic surgery in colon cancer patients.

Materials and methods

In a literature search, more than 1800 relevant publications on the topic were identified. Relevant RCTs and representative high-quality retrospective studies were selected based on the widely accepted Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria. Finally, 9 RCTs and 14 retrospective cohort studies were included.

Results

Laparoscopic surgery for colon cancer is associated with a slightly longer duration of surgery, but a variety of studies show an association with a lower rate of postoperative complications and a shorter duration of hospital stay. Particularly in older patients with more frequent comorbidities, laparoscopy seems to contribute to decreasing postoperative mortality. Concerning long-term oncologic outcomes, the laparoscopic and open techniques were shown to be at least equivalent.

Conclusion

The findings of the existing relevant RCTs on laparoscopic surgery for colon cancer are mostly confirmed by representative retrospective cohort studies based on real-world data; therefore, its further implementation into clinical practice can be recommended.

Comprehensive literature review of randomized clinical trials examining novel treatment advances in patients with colon cancer

The treatment of colon cancer has had numerous recent advances, in terms of surgical approach, adjuvant therapies, and more. In this review, the authors examine randomized clinical trials comparing open surgery to laparoscopic surgery (including total mesocolic excision), and also examine the role of robotic surgery. Novel surgical techniques including the no-touch technique, side-to-side anastomosis, suture technique, complete mesocolic excision (CME) with central vascular ligation (CVL), and natural orifice transluminal endoscopic surgery (NOTES) are outlined. The role of placing endoscopic self-expandable metal stents (SEMS) for colonic obstruction is compared and contrasted with the surgical approach, and the effect that the anti-VEGF inhibitor bevacizumab may have on this side effect profile is further explored. The role of the resection of the primary tumor in the setting of metastatic disease is examined with respect to survival benefit. Pathways of perioperative care which can accelerate post-surgical recovery, including enhanced recovery after surgery (ERAS) are examined. The role of adjuvant chemotherapy in patients with high-risk stage II and patients with stage III disease is examined, along with the role on circulating tumor DNA (ctDNA) as well as with the biologic targeted agents cetuximab and bevacizumab. Lastly, the authors detail the postoperative surveillance schedules after surgical resection with respect to survival outcomes.

Diffuse reflectance spectroscopy to monitor murine colorectal tumor progression and therapeutic response

SIGNIFICANCE

Many studies in colorectal cancer (CRC) use murine ectopic tumor models to determine response to treatment. However, these models do not replicate the tumor microenvironment of CRC. Physiological information of treatment response derived via diffuse reflectance spectroscopy (DRS) from murine primary CRC tumors provide a better understanding for the development of new drugs and dosing strategies in CRC.

AIM

Tumor response to chemotherapy in a primary CRC model was quantified via DRS to extract total hemoglobin content (tHb), oxygen saturation (StO2), oxyhemoglobin, and deoxyhemoglobin in tissue.

APPROACH

A multimodal DRS and imaging probe (0.78 mm outside diameter) was designed and validated to acquire diffuse spectra longitudinally-via endoscopic guidance-in developing colon tumors under 5-fluoruracil (5-FU) maximum-tolerated (MTD) and metronomic regimens. A filtering algorithm was developed to compensate for positional uncertainty in DRS measurements Results: A maximum increase in StO2 was observed in both MTD and metronomic chemotherapy-treated murine primary CRC tumors at week 4 of neoadjuvant chemotherapy, with 21  ±  6  %   and 17  ±  6  %   fold changes, respectively. No significant changes were observed in tHb.

CONCLUSION

Our study demonstrates the feasibility of DRS to quantify response to treatment in primary CRC models.

Robotic Colorectal Surgery

The role of robotics in colon and rectal surgery has been established as an important and effective tool for the surgeon. Its inherent technologies have provided for increased visualization and ease of dissection in the minimally invasive approach to surgery. The value of the robot is apparent in the more challenging aspects of colon and rectal procedures, including the intracorporeal anastomosis for right colectomies and the low pelvic dissection for benign and malignant diseases.

Rivaroxaban for extended antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer. Design of the PRO-LAPS II STUDY

BACKGROUND

The clinical benefit of extending prophylaxis for venous thromboembolism (VTE) beyond hospital discharge after laparoscopic surgery for cancer is undefined. Extended prophylaxis with rivaroxaban is effective in reducing post-operative VTE after major orthopedic surgery without safety concern.

METHODS

PROLAPS II is an investigator-initiated, randomized, double-blind study aimed at assessing the efficacy and safety of extended antithrombotic prophylaxis with rivaroxaban compared with placebo after laparoscopic surgery for colorectal cancer in patients who had received antithrombotic prophylaxis with low molecular-weight heparin for 7 ± 2 days (NCT03055026). Patients are randomized to receive rivaroxaban (10 mg once daily) or placebo for 3 weeks (up to day 28 ± 2 from surgery). The primary study outcome is a composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT or VTE-related death at 28 ± 2 days from laparoscopic surgery. The primary safety outcome is major bleeding defined according to the International Society of Thrombosis and Haemostasis. Symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT, major bleeding or death by day 28 ± 2 and by day 90 from surgery are secondary outcomes. Assuming an 8% event rate with placebo and 60% reduction in the primary study outcome with rivaroxaban, 323 patients per group are necessary to show a statistically significant difference between the study groups.

DISCUSSION

The PROLAPS II is the first study with an oral anti-Xa agent in cancer surgery. The study has the potential to improve clinical practice by answering the question on the clinical benefit of extending prophylaxis after laparoscopic surgery for colorectal cancer.

Essential advances in surgical and adjuvant therapies for colorectal cancer 2018-2019

Surgical resection and adjuvant chemotherapy are the only treatment modalities for localized colorectal cancer that can obtain a "cure." The goal in surgically treating primary colorectal cancer is complete tumor removal along with dissection of systematic D3 lymph nodes. Adjuvant treatment controls recurrence and improves the prognosis of patients after they undergo R0 resection. Various clinical studies have promoted the gradual spread and clinical use of new surgical approaches such as laparoscopic surgery, robotic surgery, and transanal total mesorectal excision (TaTME). Additionally, the significance of adjuvant chemotherapy has been established and it is now recommended in the JSCCR (the Japanese Society for Cancer of the Colon and Rectum) guideline as a standard treatment. Herein, we review and summarize current surgical treatment and adjuvant chemotherapy for localized colorectal cancer and discuss recent advances in personalized medicine related to adjuvant chemotherapy.

Multicenter phase III randomized trial comparing laparoscopy and laparotomy for colon cancer surgery in patients older than 75 years: the CELL study, a Fédération de Recherche en Chirurgie (FRENCH) trial

Background

Several multicenter randomized controlled trials comparing laparoscopy and conventional open surgery for colon cancer have demonstrated that laparoscopic approach achieved the same oncological results while improving significantly early postoperative outcomes. These trials included few elderly patients, with a median age not exceeding 71 years. However, colon cancer is a disease of the elderly. More than 65% of patients operated on for colon cancer belong to this age group, and this proportion may become more pronounced in the coming years. In current practice, laparoscopy is underused in this population.

Methods

The CELL (Colectomy for cancer in the Elderly by Laparoscopy or Laparotomy) trial is a multicenter, open-label randomized, 2-arm phase III superiority trial. Patients aged 75 years or older with uncomplicated colonic adenocarcinoma or endoscopically unresectable colonic polyp will be randomized to either colectomy by laparoscopy or laparotomy. The primary endpoint of the study is overall postoperative morbidity, defined as any complication classification occurring up to 30 days after surgery. The secondary endpoints are: 30-day and 90-day postoperative mortality, 30-day readmission rate, quality of surgical resection, health-related quality of life and evolution of geriatric assessment. A 35 to 20% overall postoperative morbidity rate reduction is expected for patients operated on by laparoscopy compared with those who underwent surgery by laparotomy. With a two-sided α risk of 5% and a power of 80% (β = 0.20), 276 patients will be required in total.

Discussion

To date, no dedicated randomized controlled trial has been conducted to evaluate morbidity after colon cancer surgery by laparoscopy or laparotomy in the elderly and the benefits of laparoscopy is still debated in this context. Thus, a prospective multicenter randomized trial evaluating postoperative outcomes specifically in elderly patients operated on for colon cancer by laparoscopy or laparotomy with curative intent is warranted. If significant, such a study might change the current surgical practices and allow a significant improvement in the surgical management of this population, which will be the vast majority of patients treated for colon cancer in the coming years.

Trial registration

ClinicalTrials.gov NCT03033719 (January 27, 2017).

Comparison of Oncologic Outcomes in Laparoscopic versus Open Surgery for Non-Metastatic Colorectal Cancer: Personal Experience in a Single Institution

The oncologic merits of the laparoscopic technique for colorectal cancer surgery remain debatable. Eligible patients with non-metastatic colorectal cancer who were scheduled for an elective resection by one surgeon in a medical institution were randomized to either laparoscopic or open surgery. During this period, a total of 188 patients received laparoscopic surgery and the other 163 patients received the open approach. The primary endpoint was cancer-free five-year survival after operative treatment, and the secondary endpoint was the tumor recurrence incidence. Besides, surgical complications were also compared. There was no statistically significant difference between open and laparoscopic groups regarding the average number of lymph nodes dissected, ileus, anastomosis leakage, overall mortality rate, cancer recurrence rate, or cancer-free five-year survival. Even though performing a laparoscopic approach used a significantly longer operation time, this technique was more effective for colorectal cancer treatment in terms of shorter hospital stay and less blood loss. Meanwhile, fewer patients receiving the laparoscopic approach developed postoperative urinary tract infection, wound infection, or pneumonia, which reached statistical significance. For non-metastatic colorectal cancer patients, laparoscopic surgery resulted in better short-term outcomes, whether in several surgical complications and intra-operative blood loss. Though there was no significant statistical difference in terms of cancer-free five-year survival and tumor recurrence, it is strongly recommended that patients undergo laparoscopic surgery if not contraindicated.

A meta-analysis of laparoscopic surgery versus conventional open surgery in the treatment of colorectal cancer

BACKGROUND

This meta-analysis aimed to explore the overall effect and safety of anterior laparoscopic surgery versus conventional open surgery for patients with colorectal cancer based on eligible randomized controlled trials (RCTs), especially the difference in the postoperative incidence of deep venous thrombosis (DVT).

METHODS

PubMed, Cochrane, and Embase were searched based on keywords to identify eligible studies before February 2018. Only RCTs were eligible. We analyzed the main outcomes using the relative risk (RR) or mean difference (MD) along with 95% confidence interval (95% CI).

RESULTS

In this meta-analysis, we analyzed a total of 24 studies with 4592 patients in the laparoscopic surgery group and 3865 patients in the open surgery group. The results indicated that compared with the open surgery, laparoscopic surgery significantly decreased estimated blood loss (SMD: -1.14, 95%CI: -1.70 to -0.57), hospital stay (SMD: -1.12, 95%CI: -1.76 to -0.47), postoperative mortality (RR: 0.60, 95%CI: 0.41-0.86) and postoperative complication (RR: 0.83, 95%CI: 0.72-0.95). However, the operative time (WMD: 40.46, 95%CI: 35.94-44.9) was statistically higher in the laparoscopic surgery group than the open surgery group, and there was no significant difference in the incidence of DVT between the 2 groups (RR: 0.96, 95%CI: 0.46-2.02).

CONCLUSION

Laparoscopic surgery is superior to open surgery for patients with colorectal cancer. But the 2 surgeries showed no significant difference in the incidence of DVT.

With widespread adoption of MIS colectomy for colon cancer, does hospital type matter?

BACKGROUND

Recent studies have shown that hospital type impacts patient outcomes, but no studies have examined hospital differences in outcomes for patients undergoing minimally invasive surgery (MIS) for segmental colectomies.

METHODS

The 2010-2014 National Cancer Data Base was queried for patients undergoing segmental colectomy for non-metastatic colon adenocarcinoma. Descriptive statistics characterized MIS utilization by hospital type. Multivariable models were used to examine the effect of hospital type on outcomes after MIS. Survival probability was plotted using the Kaplan-Meier method.

RESULTS

80,922 patients underwent MIS segmental colectomy for colon cancer from 2010 to 2014. From 2010 to 2014, the number of MIS segmental colectomies increased by 157% at academic hospitals, 151% at comprehensive hospitals, and 153% at community hospitals. Compared to academic hospitals, community and comprehensive hospitals had greater adjusted odds of positive margins (Community OR 1.525, 95% Confidence Interval 1.233-1.885; Comprehensive OR 1.216, 95% CI 1.041-1.42), incomplete number of lymph nodes analyzed (< 12 LNs) from surgery (Community OR 2.15, 95% CI 1.98-2.32; Comprehensive OR 1.42, 95% CI 1.34-1.51), and greater 30-day mortality (Community OR 1.43, 95% CI 1.14-1.78; Comprehensive OR 1.36, 95% CI 1.17-1.59). Patient survival probability was higher at academic hospitals at 5 years (Academic 69% vs. Comprehensive 66% vs. Community 63%, p < 0.001). Community hospitals and comprehensive hospitals had significantly higher risk of adjusted long-term mortality (Community HR 1.28; 95% CI 1.19-1.37; p < 0.001; Comprehensive HR 1.14; 95% CI 1.09-1.20; p < 0.001).

CONCLUSIONS

Despite widespread use of laparoscopic oncologic surgery, short- and long-term outcomes from MIS for segmental colectomy are superior at academic hospitals. This difference may be due to superior perioperative oncologic technique and surgical outcomes at academic hospitals. Our data provide important information for patients, referring physicians, and surgeons about the significance of hospital type in management of colon cancer.

Should Surgical Treatment Be Provided to Patients with Colorectal Cancer Who Are Aged 90 Years or Older?

PURPOSE

The number of patients aged ≥ 90 years is increasing worldwide; however, the treatment guidelines for colorectal cancer in elderly patients remain unclear. This study aimed to investigate the clinical outcomes of patients with primary colorectal cancer aged ≥ 90 years.

METHODS

We retrospectively reviewed the medical records of 100 patients (aged ≥ 90 years) with primary colorectal adenocarcinoma. Their demographic and clinical characteristics and surgical outcomes were assessed.

RESULTS

The patients who underwent tumor resections (n = 71) showed longer overall and cancer-specific survival than those who underwent non-operative treatments (n = 29) (median overall survival time: 23.92 months vs. 2.99 months, P < 0.0001). Age, body mass index, performance status, advanced cancer stage (stages 3 and 4), and treatment strategy were identified as risk factors, prognostic factors, and predictors of overall survival. No significant differences in the postoperative morbidity rate, in-hospital mortality rate, and survival time were found between the elective laparoscopic (n = 27) and elective open (n = 37) surgery subgroups. However, the in-hospital mortality rate was 6.25% (4/64) in the patients who underwent elective open surgeries and 42.9% (3/7) in those who underwent emergent open surgeries (p = 0.0179).

CONCLUSIONS

In clinical practice, surgical treatment should not be denied to patients with primary colorectal cancer aged ≥ 90 years. However, the high complication and mortality rates for emergency surgeries act as a deterrent. Further studies to eliminate the bias between operative and non-operative groups may be needed to validate our results.

Robotic surgery trends in general surgical oncology from the National Inpatient Sample

BACKGROUND

Robotic surgery is offered at most major medical institutions. The extent of its use within general surgical oncology, however, is poorly understood. We hypothesized that robotic surgery adoption in surgical oncology is increasing annually, that is occurring in all surgical sites, and all regions of the US.

STUDY DESIGN

We identified patients with site-specific malignancies treated with surgical resection from the National Inpatient Sample 2010-2014 databases. Operations were considered robotic if any ICD-9-CM robotic procedure code was used.

RESULTS

We identified 147,259 patients representing the following sites: esophageal (3%), stomach (5%), small bowel (5%), pancreas (7%), liver (5%), and colorectal (75%). Most operations were open (71%), followed by laparoscopic (26%), and robotic (3%). In 2010, only 1.1% of operations were robotic; over the 5-year study period, there was a 5.0-fold increase in robotic surgery, compared to 1.1-fold increase in laparoscopy and 1.2-fold decrease in open surgery (< 0.001). These trends were observed for all surgical sites and in all regions of the US, they were strongest for esophageal and colorectal operations, and in the Northeast. Adjusting for age and comorbidities, odds of having a robotic operation increased annually (5.6 times more likely by 2014), with similar length of stay (6.9 ± 6.5 vs 7.0 ± 6.5, p = 0.52) and rate of complications (OR 0.91, 95% CI 0.83-1.01, p = 0.08) compared to laparoscopy.

CONCLUSIONS

Robotic surgery as a platform for minimally invasive surgery is increasing over time for oncologic operations. The growing use of robotic surgery will affect surgical oncology practice in the future, warranting further study of its impact on cost, outcomes, and surgical training.

Effects of laparoscopic surgery on survival, quality of care and utilization in patients with colon cancer: a population-based study

OBJECTIVE

Laparoscopy is a safe and effective treatment for colon cancer. However, its effects on short- and long-term health outcomes and medical utilization are not fully elucidated. This study aimed to compare short- and long-term utilization and health outcomes of colon cancer patients who underwent either laparoscopic or open surgery in a population-based cohort.

METHODS

This study was conducted by linking data from Taiwan Cancer Registry, National Health Insurance claims and Death Registry. Patients aged 18 and older with colon cancer between 2009 and 2012 were included in the study. Propensity score matching was used to minimize selection bias between laparoscopic and open surgery groups. Cox proportional hazard regression and generalized linear mixed logistic regression were used to test hypotheses.

RESULTS

Among the 11,269 colon cancer patients who underwent colectomy, 3236 (28.72%) received laparoscopy and 8033 (71.28%) underwent open surgery. Patients who received laparoscopic surgery had better overall survival (HR = 0.82; 95% CI: 0.70-0.97). These patients also had lower 30 day mortality (0.44% vs. 0.91%), lower 1 year mortality (2.83% vs. 4.68%), lower overall occurrence of complications (6.16% vs. 8.77%), shorter mean length of stay (12.53 vs. 14.93 days) and lower cost for index hospitalization (US$4325.34 vs. US$4453.90). No significant differences were observed in medical utilization over a period of 365 days after the surgery.

CONCLUSIONS

Our results demonstrate that, in both the short- and long-term post-operation periods, laparoscopic surgery reduced the likelihood of postoperative complications, 30 day, and 1 year mortality while being no more expensive than open surgery for colon cancer.

Predictors of adequate lymph node harvest during colectomy for colon cancer

BACKGROUND

Consensus guidelines recommend a yield of 12 lymph nodes in resections for colon cancer. Factors affecting this yield are not well defined.

METHODS

Retrospective study using the colectomy-targeted American College of Surgeons National Surgical Quality Improvement Program for years 2014-2016. Primary outcome was resection of at least 12 nodes. Univariate and multivariate analyses determined factors associated with ≥12 LN yield.

RESULTS

17,612 colectomies for colon cancer were extracted from the NSQIP database. 7.26% of cases did not reach a 12 LN harvest. Harvesting ≥12 LN was 74% more likely (p = 0.001) if the resection was laparoscopic and 72% more likely (p < 0.0001) if hand-assisted. Advanced T and N stage had a higher likelihood of reaching 12 LN harvest. Older age, female gender and smoking history decreased the likelihood of ≥12 LN harvest.

CONCLUSIONS

Laparoscopic and robotic colectomies were 1.5-2.5 times more likely to achieve adequate LN harvest compared to open surgery. Several non-modifiable patient and disease related factors may render adequate LN yield challenging.

Comparison of robot-assisted surgery, laparoscopic-assisted surgery, and open surgery for the treatment of colorectal cancer: A network meta-analysis

BACKGROUND

The aim of this study was to find the better treatment for colorectal cancer (CRC) by comparing robot-assisted colorectal surgery (RACS), laparoscopic-assisted colorectal surgery (LACS), and open surgery using network meta-analysis.

METHODS

A literature search updated to August 15, 2017 was performed. All the included literatures were evaluated according to the quality evaluation criteria of bias risk recommended by the Cochrane Collaboration. All data were comprehensively analyzed by ADDIS. Odds ratio (OR), mean difference (MD), and 95% confidence interval (CI) were used to show the effect index of all data. The degree of convergence of the model was evaluated by the Brooks-Gelman-Rubin method with the potential scale reduction factor (PSRF) as the evaluation indicator.

RESULTS

The PSRF values of operation time, estimated blood loss, length of hospital stay, complication, mortality, and anastomotic leakage ranged from 1.00 to 1.01, and those of wound infection, bleeding, and ileus ranged from 1.00 to 1.02. Open surgery had the shortest operation time compared with LACS and RACS. Furthermore, compared with LACS, the amount of blood loss, complication, mortality, bleeding rate, and ileus rate for RACS were the least, and the length of hospital stay for RACS was the shortest. The anastomotic leakage rate for LACS was the least, but there was no significant difference compared with those of RACS and open surgery. The wound infection rate for LACS was the least, but there was no significant difference compared with that of RACS.

CONCLUSION

RACS might be a better treatment for patients with CRC.

Laparoscopic right-sided colon resection for colon cancer-has the control group so far been chosen correctly?

Background

The treatment strategies for colorectal cancer located in the right side of the colon have changed dramatically during the last decade. Due to the introduction of complete mesocolic excision (CME) with central ligation of the vessels and systematic lymph node dissection, the long-term survival of affected patients has increased significantly. It has also been proposed that right-sided colon resection can be performed laparoscopically with the same extent of resection and equal long-term results.

Methods

A retrospective evaluation of a prospectively expanded database on right-sided colorectal cancer or adenoma treated at the University Hospital of Wuerzburg between 2009 and 2016 was performed. All patients underwent CME. This data was analyzed alone and in comparison to the published data describing laparoscopic right-sided colon resection for colon cancer.

Results

The database contains 279 patients, who underwent right-sided colon resection due to colorectal cancer or colorectal adenoma (255 open; 24 laparoscopic). Operation data (time, length of stay, time on ICU) was equal or superior to laparoscopy, which is comparable to the published results. Surprisingly, the surrogate parameter for correct CME (the number of removed lymph nodes) was significantly higher in the open group. In a subgroup analysis only including patients who were feasible for laparoscopic resection and had been operated with an open procedure by an experienced surgeon, operation time was significantly shorter and the number of removed lymph nodes is significantly higher in the open group.

Conclusion

So far, several studies demonstrate that laparoscopic right-sided colon resection is comparable to open resection. Our data suggests that a consequent CME during an open operation leads to significantly more removed lymph nodes than in laparoscopically resected patients and in several so far published data of open control groups from Europe. Further prospective randomized trials comparing the long-term outcome are urgently needed before laparoscopy for right-sided colon resection can be recommended ubiquitously.

Single port laparoscopic ileocaecal resection for Crohn's disease: a multicentre comparison with multi-port laparoscopy

AIM

Single port (SP) ileocaecal resection (ICR) is an established technique but there are no large studies comparing SP and multi-port (MP) laparoscopic surgery in Crohn's disease (CD). The aim of this study was to compare postoperative pain scores and analgesia requirements after SP and MP laparoscopic ICR for CD.

METHOD

This was a retrospective study of patients undergoing SP or MP ICR for CD in three tertiary referral centres from February 1999 to October 2014. Baseline characteristics (age, sex, body mass index and indication for surgery) were compared. Primary end-points were postoperative pain scores, analgesia requirements and short-term postoperative outcomes.

RESULTS

SP ICR (n = 101) and MP ICR (n = 156) patients were included in the study. Visual analogue scale scores were significantly lower after SP ICR on postoperative day 1 (P = 0.016) and day 2 (P = 0.04). Analgesia requirements were significantly reduced on postoperative day 2 in the SP group compared with the MP group (P = 0.007). Duration of surgery, conversion to open surgery and stoma rates were comparable between the two groups. Surgery was more complex in terms of additional procedures when MP was adopted (P = 0.001). There were no differences in postoperative complication rates, postoperative food intake, length of stay and readmissions.

CONCLUSION

These data suggest that in comparison to standard laparoscopic surgery SP ICR might be less painful and patients might require less opioid analgesia.

Laparoscopic vs open complete mesocolic excision with central vascular ligation for colon cancer: A systematic review and meta-analysis

AIM

To compare the effectiveness of laparoscopic complete mesocolic excision (CME) with central vascular ligation (L-CME) with its open (O-CME) counterpart.

METHODS

We conducted an electronic search of the PubMed/MEDLINE, Excerpta Medica Database, Web of Science Core Collection, Cochrane Center Register of Controlled Trails, Cochrane Database of Systematic Reviews, SciELO, and Korean Journal databases from their inception until May 2017. We considered randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that included patients with colonic cancer comparing L-CME and O-CME. Primary outcomes included the quality of the resected specimen (lymph nodes retrieved, complete mesocolic plane excision, tumor to arterial high tie, resected mesocolon surface). Secondary outcomes included the three-year and five-year overall and disease-free survival rates, recurrence of the disease, surgical data, and postoperative morbidity and mortality. Two authors of the review screened the methodological quality of the eligible trials and independently extracted data from individual studies.

RESULTS

A total of one RCT and eleven CCTs (four from Europe and seven from Asia) met the inclusion criteria for the current meta-analysis. These studies involved 1619 patients in L-CME and 1477 patients in O-CME. The L-CME was associated with the same quality of the resected specimen, with no differences regarding the retrieved lymphnodes (MD = -1.06, 95%CI: -3.65 to 1.53, P = 0.42), and tumor to high tie distance (MD = 14.26 cm, 95%CI: -4.30 to 32.82, P = 0.13); the surface of the resected mesocolon was higher in the L-CME group (MD = 11.75 cm², 95%CI: 9.50 to 13.99, P < 0.001). The L-CME was associated with a lower rate of blood transfusions (OR = 0.45, 95%CI: 0.27 to 0.75, P = 0.002), faster recovery of gastrointestinal function, and less postoperative overall complication rate. The L-CME approach was associated with a statistical significant better three-year overall (OR = 2.02, 95%CI: 1.31 to 3.12, P = 0.001, I² = 28%) and disease-free (OR = 1.45, 95% CI: 1.00 to 2.10, P = 0.05, I² = 0%) survival.

CONCLUSION

The laparoscopic approach offers the same quality of the resected specimen as the open approach in complete mesocolic excision with central vascular ligation for colon cancer. The laparoscopic complete mesocolic excision with central vascular ligation is superior in all perioperative results and at least non-inferior in long-term oncological outcomes.

Induced Bias Due to Crossover Within Randomized Controlled Trials in Surgical Oncology: A Meta-regression Analysis of Minimally Invasive versus Open Surgery for the Treatment of Gastrointestinal Cancer

BACKGROUND

Randomized controlled trials (RCTs) inform clinical practice and have provided the evidence base for introducing minimally invasive surgery (MIS) in surgical oncology. Crossover (unplanned intraoperative conversion of MIS to open surgery) may affect clinical outcomes and the effect size generated from RCTs with homogenization of randomized groups.

OBJECTIVES

Our aims were to identify modifiable factors associated with crossover and assess the impact of crossover on clinical endpoints.

METHODS

A systematic review was performed to identify all RCTs comparing MIS with open surgery for gastrointestinal cancer (1990-2017). Meta-regression analysis was performed to analyze factors associated with crossover and the influence of crossover on endpoints, including 30-day mortality, anastomotic leak rate, and early complications.

RESULTS

Forty RCTs were included, reporting on 11,625 patients from 320 centers. Crossover was shown to affect one in eight patients (mean 12.6%, range 0-45%) and increased with American Society of Anesthesiologists score (β = + 0.895; p = 0.050). Pretrial surgeon volume (β = - 2.344; p = 0.037), composite RCT quality score (β = - 7.594; p = 0.014), and site of tumor (β = - 12.031; p = 0.021, favoring lower over upper gastrointestinal tumors) showed an inverse relationship with crossover. Importantly, multivariate weighted linear regression revealed a statistically significant positive correlation between crossover and 30-day mortality (β = + 0.125; p = 0.033), anastomotic leak rate (β = + 0.550; p = 0.004), and early complications (β = + 1.255; p = 0.001), based on intention-to-treat analysis.

CONCLUSIONS

Crossover in trials was associated with an increase in 30-day mortality, anastomotic leak rate, and early complications within the MIS group based on intention-to-treat analysis, although our analysis did not assess causation. Credentialing surgeons by procedural volume and excluding high comorbidity patients from initial trials are important in minimizing crossover and optimizing RCT validity.

Effects of age after laparoscopic right colectomy for cancer: Are there any specific outcomes?

BACKGROUND

Laparoscopic approach in colorectal surgery has demonstrated to give advantages in terms of postoperative outcomes, particularly in high-risk patients. The aim was to assess the impact of patients' age on the short-term outcomes after laparoscopic right colectomy for cancer.

METHODS

From January 2004 to September 2014, all patients who underwent laparoscopic right colectomy for cancer in a single institution were divided into four groups (A: <64 years; B: 65-74 years; C: 75-84 years; D ≥85 years). Risk factors for postoperative complications were determined on multivariable analysis.

RESULTS

Laparoscopic right colectomy was performed in 507 patients, including 171 (33.7%) in A, 168 (33.1%) in B, 131 (25.8) in C and 37 (7.4%) in D. Patients in Group C and Group D had higher ASA score (p<0.0001) and presented more frequently with anaemia (20.6% and 29.7%, p=0.001). Stages III and IV were more frequently encountered in groups C and D. Overall morbidity was 27.5% without any difference in the four groups (24.5%, 29.1%, 7.5% and 18.4% respectively, p=0.58). The rate of minor complications (such as wound infection or postoperative ileus) was higher in Group D compared to other groups (p=0.05). The only independent variable correlated with postoperative morbidity was intraoperative blood transfusion (OR 2.82; CI 95% 1.05-4.59, p<0.0001).

CONCLUSIONS

The present series suggests that patient's age did not significantly jeopardize the postoperative outcomes after laparoscopic right colectomy for cancer.

[Laparoscopic colectomy versus colectomy performed via laparotomy in the treatment of non-metastatic colic adenocarcinomas]

INTRODUCTION

Laparoscopic colectomy is considered with increasing frequency the gold standard treatment for colorectal cancer. Our study aims to show that short-term results and the oncological safety of laparoscopy are at least equivalent to those of laparotomy in the treatment of non-metastatic colic adenocarcinomas. We also highlight the impact of the learning curve on outcomes after laparoscopy in patients with these cancers.

METHODS

We conducted a retrospective study of all patients undergoing surgery for resectable colic adenocarcinomas over a period of 6 years. The study population was divided into 2 groups based on the surgical procedure used initially. The group "OC" included 35 patients who underwent midline laparotomy and the group "LAC" included 30 patients who underwent laparoscopy. All data were analyzed using SPSS software version 19.0.

RESULTS

Our study showed that there was no significant difference in short-term outcomes between the 2 groups, namely intraoperative morbidity, hospital stay, intensive care unit stay as well as postoperative morbidity and mortality. Regarding the long-term outcomes, there was also no significant difference in the incidence of late complications, type of recurrence, overall survival and disease-free survival. Oncological safety based on the limits of resection and the number of lymph nodes removed was not significantly different between the two groups. Operative time was significantly longer in the laparoscopic group (p <0.001). Convertion rate was 33%. It went from 67% in the first 2 years of the study to 13% in the last 2 years. The conversion from laparoscopy to laparotomy had no significant impact neither on early postoperative outcomes nor on overall survival and disease-free survival.

CONCLUSION

Laparoscopy is a surgical procedure resulting in at least equivalent short and long term outcomes as laparotomy. The learning curve representing a "prerequisite" has no negative impact on the outcomes of laparoscopic treatment of non-metastatic colic cancers.

Network meta-analysis of protocol-driven care and laparoscopic surgery for colorectal cancer

BACKGROUND

Laparoscopic approaches and standardized recovery protocols have reduced morbidity following colorectal cancer surgery. As the optimal regimen remains inconclusive, a network meta-analysis was undertaken of treatments for the development of postoperative complications and mortality.

METHODS

MEDLINE, Embase, trial registries and related reviews were searched for randomized trials comparing laparoscopic and open surgery within protocol-driven or conventional perioperative care for colorectal cancer resection, with complications as a defined endpoint. Relative odds ratios (ORs) for postoperative complications and mortality were estimated for aggregated data.

RESULTS

Forty trials reporting on 11 516 randomized patients were included with the network. Open surgery within conventional perioperative care was the index for comparison. The OR relating to complications was 0·77 (95 per cent c.i. 0·65 to 0·91) for laparoscopic surgery within conventional care, 0·69 (0·48 to 0·99) for open surgery within protocol-driven care, and 0·43 (0·28 to 0·67) for laparoscopic surgery within protocol-driven care. Sensitivity analyses excluding trials of low rectal cancer and those with a high risk of bias did not affect the treatment estimates. Meta-analyses demonstrated that mortality risk was unaffected by perioperative strategy.

CONCLUSION

Laparoscopic surgery combined with protocol-driven care reduces colorectal cancer surgery complications, but not mortality. The reduction in complications with protocol-driven care is greater for open surgery than for laparoscopic approaches. Registration number: CRD42015017850 (https://www.crd.york.ac.uk/PROSPERO).

Future of Minimally Invasive Colorectal Surgery

Minimally invasive surgery is slowly taking over as the preferred operative approach for colorectal diseases. However, many of the procedures remain technically difficult. This article will give an overview of the state of minimally invasive surgery and the many advances that have been made over the last two decades. Specifically, we discuss the introduction of the robotic platform and some of its benefits and limitations. We also describe some newer techniques related to robotics.

Scope or scalpel? A matched study of the treatment of large colorectal polyps

BACKGROUND

Large colorectal polyps can be treated either endoscopically or by formal resection. The aim of this study was to clarify the relative advantages and disadvantages of surgical resection and colonoscopic snaring as means of treating large colorectal polyps.

METHODS

This is a matched cohort study, comparing cases of surgical resection of benign colorectal polyps with endoscopic resection. Cases drawn from pathology and endoscopy databases were matched for the size and site of polyps, and the groups were compared for the end points of complications, length of hospital stay and completeness of the removal of the polyp.

RESULTS

There were 78 patients in each group, with mean ages of 65.6 years (colonoscopy) and 66.8 years (surgery). A total of 39 of the surgery group and 47 of the colonoscopy group were men. Mean polyp size was 34.1 mm (colonoscopy) and 32.1 mm (surgery). There was an exact match for polyp location. Complications occurred in eight colonoscopy patients (10.3%) and 42 surgery patients (56.0%) (P < 0.001, chi-square). Length of hospital stay was 0 days for colonoscopy patients and 7.3 ± 4.7 days for surgery (P < 0.001). The surgery group was separated into laparoscopic (n = 35) and open (n = 43) surgery. There was no difference in complication rates (42.4 versus 53.5%, respectively) but laparoscopic had shorter length of stay (5.8 days ± 4.9 SD versus 8.4 days ± 4.3 SD). Recurrence of surgically resected polyps was zero; at last follow-up 13% of snared polyps persisted.

CONCLUSION

Although resection is a more certain and absolute way of treating benign polyps, endoscopic polypectomy is preferable.

Laparoscopic caudal-to-cranial approach for radical lymph node dissection in right hemicolectomy

PURPOSE

The present study evaluated the safety and feasibility of this caudal-to-cranial laparoscopic dissection approach for the curative resection of right-sided colon cancer. To the best of our knowledge, no study has reported the caudal-to-cranial approach in the laparoscopic right colectomy with curative intent for colon cancer.

METHOD

The key procedure of the caudal-to-cranial approach is the commencement of the dissection at the mesentery root, thus entering into the Toldt's space before the mesenteric vessels are accessed. We retrospectively analyzed the data obtained from a prospectively established database on 80 consecutive patients who had undergone laparoscopic right hemicolectomy with caudally approached radical lymph node dissection for curable right-sided colon cancer between June 2014 and June 2015.

RESULTS

There were 38 male and 42 female patients, with a mean age of 72.5 years (range, 53-83) and a mean BMI of 22.1 kg/m(2) (16.5-35.2). All procedures were successful without any serious intraoperative complications or any conversion to open surgery. The mean operation time was 178.3 min (range, 150-215), and the mean blood loss was 81.6 ml (range, 50-200). The mean number of harvested lymph nodes was 19 (range, 12-25).

CONCLUSIONS

The findings indicate that laparoscopic caudal-to-cranial approach for radical lymph node dissection is a feasible and safe procedure for the treatment of curable right-sided colon cancer.

Meta-analysis of the risk of small bowel obstruction following open or laparoscopic colorectal surgery

Background

One of the potential advantages of laparoscopic compared with open colorectal surgery is a reduction in postoperative bowel obstruction events. Early reports support this proposal, but accumulated evidence is lacking.

Methods

A systematic review and meta-analysis was performed of randomized clinical trials and observational studies by searching the PubMed and Cochrane Library databases from 1990 to August 2015. The primary outcomes were early and late postoperative bowel obstruction following laparoscopic and open colorectal surgery. Both ileus and bowel obstruction were defined as a postoperative bowel obstruction. Subgroup and sensitivity analyses were performed, and a random-effects model was used to account for the heterogeneity among the studies.

Results

Twenty-four randomized clinical trials and 88 observational studies were included in the meta-analysis; 106 studies reported early outcome and 12 late outcome. Collectively, these studies reported on the outcomes of 148 392 patients, of whom 58 133 had laparoscopic surgery and 90 259 open surgery. Compared with open surgery, laparoscopic surgery was associated with reduced rates of early (odds ratio 0·62, 95 per cent c.i. 0·54 to 0·72; P &lt; 0·001) and late (odds ratio 0·61, 0·41 to 0·92; P = 0·019) postoperative bowel obstruction. Weighted mean values for early postoperative bowel obstruction were 8 (95 per cent c.i. 6 to 10) and 5 (3 to 7) per cent for open and laparoscopic surgery respectively, and for late bowel obstruction were 4 (2 to 6) and 3 (1 to 5) per cent respectively.

Conclusion

The reduction in postoperative bowel obstruction demonstrates an advantage of laparoscopic surgery in patients with colorectal disease.

Laparoscopic right hemicolectomy: short- and long-term outcomes of intracorporeal versus extracorporeal anastomosis

BACKGROUND

The use of laparoscopy for right hemicolectomy has gained popularity allowing the option of a totally laparoscopic intracorporeal anastomosis (IA) for intestinal reconstruction. This technique may alleviate some of the technical limitations that a surgeon faces with a laparoscopic-assisted extracorporeal anastomosis (EA).

METHODS

A retrospective chart review of 195 consecutive patients who underwent laparoscopic right hemicolectomy by four colorectal surgeons at three institutions from March 2005 to June 2014 was performed. Multivariate regression analysis was used to compare postoperative and oncologic outcomes.

RESULTS

A total of 195 patients underwent laparoscopic right hemicolectomy over the study period, with 86 (44 %) patients receiving IA and 109 (56 %) patients receiving an EA. The most common indication for surgery in both groups was cancer: 56 (65 %) of IA cases and 57 (52 %) of EA cases. IA had a significantly higher rate of minor complications but no difference in serious complications compared to EA. Conversion to open resection was higher in EA. Using multivariate analysis to compare IA versus EA, there was no significant difference in length of stay, return of bowel function, risk of anastomotic leak, risk of intraabdominal abscess or risk of wound complications. Amongst cancer resections, there was no significant difference in the median number of lymph nodes harvested (18 LNs in IA group vs. 19 LNs in EA group, P > 0.05). There was also no significant difference in overall survival and disease-free survival at 5.7 years between the two groups.

CONCLUSIONS

IA in laparoscopic right hemicolectomy is associated with similar postoperative and oncologic outcomes compared to EA. IA may possess advantages in terms of conversion and flexibility of specimen extraction, but this is counterbalanced by a higher incidence of minor complications. These findings suggest that IA represents a valid technique in the arsenal of the experienced colorectal surgeon without compromising outcomes.

Adoption of Laparoscopic Colorectal Surgery: It Was Quite a Journey

The adoption of laparoscopic colorectal surgery has been a slow but steady progress. The first adopters rapidly expanded the application of the technology to all colorectal pathology. Issues related to extraction and port site recurrence of cancer delayed widespread adoption until incontrovertible data from well-powered prospective randomized studies confirmed equipoise with open surgery. Since that time, the data has consistently demonstrated patient-care benefits related to reductions in both short- and long-term complications historically associated with open colectomy. The potential for further improvement related to single-port access, robotic assistance, and natural orifice access for both the surgery and/or extraction will await the test of time. However, it is clear now that laparoscopic colorectal surgery is the new standard of care and a key enabler of enhanced recovery programs.

Long-Term Oncologic Outcomes of Laparoscopic versus Open Surgery for Middle and Lower Rectal Cancer

Background

Laparoscopic surgery for middle and lower rectal cancer remain controversial because anatomical and complex surgical procedures specifically influence oncologic outcomes. This study analyzes the long-term outcomes of laparoscopic versus open surgery for middle and lower rectal cancer.

Methods

Patients (laparoscopic: n = 129, open: n = 152) who underwent curative resection for middle and lower rectal cancer from 2003 to 2008 participated in the study. The same surgical team performed all operations. The mean follow up time of all patients was 74.3 months.

Results

No statistical difference in local recurrence rate (7.8% vs. 7.2%; log-rank = 0.024; P = 0.876) and distant recurrence rate (20.9% vs.16.4%; log-rank = 0.699; P = 0.403) between laparoscopic and open groups were observed within 5 years. The 5-year overall survival rates of the laparoscopic and open groups were 72.9% and 75.7%, respectively; no significant statistical difference was observed between them (log-rank = 0.163; P = 0.686). The 5-year survival rates between groups were not different between stages: Stage I (92.6% vs. 86.7%; log-rank = 0.533; P = 0.465); stage II (75.8% vs. 80.5%; log-rank = 0.212; P = 0.645); and Stage III (63.8% vs. 69.1%, log-rank = 0272;P = 0.602). However, significant statistical difference amongst different stages were observed (log-rank = 1.802; P = 0.003).

Conclusion

Laparoscopic and open surgery for middle and lower rectal cancer offer equivalent long-term oncologic outcomes. Laparoscopic surgery is feasible in these patients.