Laparoscopic resection for rectal cancer: a review

Implementation of robotic rectal cancer surgery: a cross-sectional nationwide study

AIM

An increasing number of centers have implemented a robotic surgical program for rectal cancer. Several randomized controls trials have shown similar oncological and postoperative outcomes compared to standard laparoscopic resections. While introducing a robot rectal resection program seems safe, there are no data regarding implementation on a nationwide scale. Since 2018 robot resections are separately registered in the mandatory Dutch Colorectal Audit. The present study aims to evaluate the trend in the implementation of robotic resections (RR) for rectal cancer relative to laparoscopic rectal resections (LRR) in the Netherlands between 2018 and 2020 and to compare the differences in outcomes between the operative approaches.

METHODS

Patients with rectal cancer who underwent surgical resection between 2018 and 2020 were selected from the Dutch Colorectal Audit. The data included patient characteristics, disease characteristics, surgical procedure details, postoperative outcomes. The outcomes included any complication within 90 days after surgery; data were categorized according to surgical approach.

RESULTS

Between 2018 and 2020, 6330 patients were included in the analyses. 1146 patients underwent a RR (18%), 3312 patients a LRR (51%), 526 (8%) an open rectal resection, 641 a TaTME (10%), and 705 had a local resection (11%). The proportion of males and distal tumors was higher in the RR compared to the LRR. Over time, the proportion of robotic procedures increased from 15% (95% confidence intervals (CI) 13-16%) in 2018 to 22% (95% CI 20-24%) in 2020. Conversion rate was lower in the robotic group [4% (95% CI 3-5%) versus 7% (95% CI 6-8%)]. Anastomotic leakage rate was similar with 16%. Defunctioning ileostomies were more common in the RR group [42% (95% CI 38-46%) versus 29% (95% CI 26-31%)].

CONCLUSION

Rectal resections are increasingly being performed through a robot-assisted approach in the Netherlands. The proportion of males and low rectal cancers was higher in RR compared to LRR. Overall outcomes were comparable, while conversion rate was lower in RR, the proportion of defunctioning ileostomies was higher compared to LRR.

Impact of obesity on morbidity and oncologic outcomes after total mesorectal excision for mid and low rectal cancer

BACKGROUND

A recent meta-analysis showed that obesity increased the conversion rate and postoperative morbidity of rectal cancer surgery, but did not influence pathological results. However, this meta-analysis included patients with cancer of the upper rectum and had many biases. The aim of the present retrospective study was to investigate the impact of obesity, defined as a body mass index (BMI) ≥ 30 kg/m², on postoperative morbidity and short- and long-term oncologic outcomes of total mesorectal excision for mid and low rectal cancer in consecutive patients.

METHODS

This study included all eligible patients who were operated on for mid and lower rectal cancer between 1999 and 2018 in our hospital. We compared 90-day postoperative morbidity and mortality, and short- and long-term oncologic outcomes between obese and non-obese patients.

RESULTS

Three hundred and ninety patients [280 males, mean age 65.7 ± 11.3 years, 59 obese individuals (15.1%)] were included. There was no difference in the 90-day mortality rate between obese and non-obese groups (p = 0.068). There was a difference in the overall 90-day morbidity rate between the obese and non-obese groups that disappeared after propensity score matching of the patients. There was no difference in short-term oncological parameters, with a median follow-up of 43 (20-84) months, and there were no significant differences in disease-free and overall survival between obese and non-obese patients (p = 0.42 and p = 0.11, respectively).

CONCLUSIONS

Obesity does not affect the 90-day morbidity rate, or short- and long-term oncologic results in patients operated on for mid and lower rectal cancer.

Is robotic da Vinci Xi® superior to the da Vinci Si® for sphincter-preserving total mesorectal excision? Outcomes in 150 mid-low rectal cancer patients

The aim of this study was to determine the superiority between the robotic da Vinci Si® (Si group) and da Vinci Xi® (Xi group) generation in patients with mid-low rectal cancer. Between December 2011 and December 2017, 88 patients with mid-low rectal cancer were operated on using the Si robotic system, from January 2018 to May 2021, 62 more patients with mid-low rectal cancer were operated on using the Xi robotic system. Perioperative and postoperative short-term outcomes were compared between the two groups. Univariate and multivariate Cox-regression analysis were performed to determine factors affecting operating time. A cumulative sum (CUSUM) analysis was also performed to determine the learning curve of the primary surgeon. All patients underwent sphincter saving total mesorectal excision (TME). The overall operating time was significantly shorter in the Xi group (181.3 ± 31.8 min in Si group vs 123.6 ± 25.7 min in the Xi group, p < 0.001). There were no significant differences in terms of conversion rates, mean hospital stays, complications and histopathologic data. CUSUM analysis show completion of learning curve in 44th case of Si group. Univariate and multivariate analysis demonstrated that the learning curve of the primary surgeon (p < 0.001) and the type of robotic system (Xi) are only two factors associated with operating time (OR, 95% CI p; 3.656, 0.665-9.339, p < 0.001). Our study found that the robotic da Vinci Xi systems provide significantly shorter operating time comparing with Si systems, when performing sphincter-preserving TME in mid-low rectal cancer patients. Surgical system (da Vinci Xi) and primary surgeon learning curve are two independent risk factors which associated shortened operating time. Postoperative complication rates and histopathologic outcomes are similar in both groups.

Sphincter-Saving Robotic Total Mesorectal Excision Provides Better Mesorectal Specimen and Good Oncological Local Control Compared with Laparoscopic Total Mesorectal Excision in Male Patients with Mid-Low Rectal Cancer

INTRODUCTION

Laparoscopic rectal resection with total mesorectal excision is a technically challenging procedure, and there are limitations in conventional laparoscopy. A surgical robotic system may help to overcome some of the limitations. The aim of our study was to compare long-term oncological outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision in male patients with mid-low rectal cancer.

MATERIALS AND METHODS

The study was conducted as a retrospective review of a prospectively maintained database. One-hundred-three robotic and 84 laparoscopic sphincter-saving total mesorectal excisions were performed by a single surgeon between January 2011 and January 2020. Patient characteristics, perioperative recovery, postoperative complications, pathology results, and oncological outcomes were compared between the two groups.

RESULTS

The patients' characteristics did not differ significantly between the two groups. Median operating time was longer in the robotic than in the laparoscopic group (180 minutes versus 140 minutes, p=0.033). Macroscopic grading of the specimen in the robotic group was complete in 96 (93.20%), near complete in four (3.88%) and incomplete in three (2.91%) patients. In the laparoscopic group, grading was complete in 37 (44.04%), near complete in 40 (47.61%) and incomplete in seven (8.33%) patients (p=0.03). The median length of follow up was 48 (9-102) months in the robotic, and 75.6 (11-113) months in the laparoscopic group. Overall, five-year survival was 87% in the robotic and 85.3% in the laparoscopic groups. Local recurrence rates were 3.8% and 7.14%, respectively, in the robotic and laparoscopic groups (p<0.05).

CONCLUSION

Sphincter-saving robotic total mesorectal excision is a safe and feasible tool, which provides good mesorectal integrity and better local control in male patients with mid-low rectal cancer.

The feasibility of laparoscopic TSME preserving the left colic artery and superior rectal artery for upper rectal cancer

Background

Laparoscopic tumor-specific mesorectal excision (TSME) preserving the left colic artery and superior rectal artery is still a technically challenging procedure. We conducted this study to demonstrate the feasibility of this procedure for upper rectal cancer.

Methods

A total of 184 patients with upper rectal cancer were retrospectively analyzed in our cancer center between April 2010 and April 2017. These patients were treated with either laparoscopic TSME (n = 46) or laparoscopic total mesorectal excision (TME) (n = 138). In the TSME group, the left colonic artery and superior rectal artery were preserved while they were not in the TME group.

Results

The operation time in the TSME group was longer than that in the TME group (218.56 ± 35.85 min vs. 201.13 ± 42.65 min, P = 0.004). Furthermore, the number of resected lymph nodes in the TSME group was greater than that in the TME group (19.43 ± 9.46 vs. 18.03 ± 7.43, P = 0.024). The blood loss between the TSME and TME groups was not significant. No mortality occurred in either the TSME or TME groups. One patient in the TME group underwent conversion to laparotomy. The total postoperative complication rates in the TSME and TME groups were 8.7% and 17.4%, respectively. There was no difference in severe complications between the two groups (anastomotic leakage and stenosis).

Conclusions

Laparoscopic TSME preserving the left colic artery and superior rectal artery can be safely conducted for upper rectal cancer.

The long-term oncological outcomes of the 140 robotic sphincter-saving total mesorectal excision for rectal cancer: a single surgeon experience

Robotic surgery became more popularly in the colorectal surgical field. The aim of the study was to evaluate of the oncological outcomes which patients who underwent the robotic total mesorectal excision for rectal cancer. A series of 140 consecutive patients who underwent robotic rectal surgery between January 2012 and June 2019 was analyzed retrospectively in terms of demographics, pathological data, and surgical and oncological outcomes. There were 104 (74.28%) male and 36 (25.71%) female patients. The tumor was located in the lower rectum in 84 (60%) cases, in the mid rectum in 38 (27.14%) cases, and in the upper rectum in 18 (12.85%) cases. Ninety-eight (70%) of the patients has received neoadjuvant chemoradiotherapy. All the patients underwent robotic sphincter-preserving surgery, 101 (72.14%) patients low-anterior resection, and 39 (27.85%) patients underwent intersphincteric resection with colo-anal anastomosis. There were no conversions. The circumferential resection margin was positive in five (3.57%) patients. The median distal resection margin of the operative specimen was 3.2 (0.2-7) cm. The median number of retrieved lymph nodes was 22 (16-42). TME quality in the in our study was rated as complete in 88.57% (n124) of patients, nearly complete in 7.14% (n10) of patients; and 4.28% (n6) of incomplete. The median hospital stay was 3.5 (3-12) days. In-hospital and 1-month mortality was zero. The median length of follow-up was 40 (2-80) months. The 5-year overall survival rate was 92.78%. The 5-year disease-free survival rate was 90%. Locally recurrence and distance recurrence rate was 3.57% (n5/140) and 2.85% (n4/140), respectively. Robotic rectal cancer surgery has a good oncological outcomes and feasible tool in the field of the rectal surgery, but required a steep learning curve.

Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of elective rectal resection for rectal cancer in adults by robotic surgery compared with conventional laparoscopic surgery.

SUMMARY OF BACKGROUND DATA

Technological advantages of robotic surgery favor precise dissection in narrow spaces. However, the evidence base driving recommendations for the use of robotic surgery in rectal cancer primarily hinges on observational data.

METHODS

We searched MEDLINE, Embase, and CENTRAL for randomized controlled trials (until August 2016) comparing robotic surgery versus conventional laparoscopic surgery. Data on the following endpoints were evaluated: circumferential margin status, mesorectal grade, number of lymph nodes harvested, rate of conversion to open surgery, postoperative complications, and operative time. Data were summarized as relative risks (RR) or weighted mean differences (WMDs) with 95% confidence intervals (95% CIs). Risk of bias of studies was assessed with standard methods.

RESULTS

Five trials were eligible, including 334 robotic and 337 laparoscopic surgery cases. Meta-analysis showed that RS was associated with lower conversion rate (7.3%; 4 studies, 544 participants, RR 0.58; 95% CI 0.35-0.97, P = 0.04, I = 0%) and longer operating time (MD 38.43 minutes, 95% CI 31.84-45.01: P < 0.00001) compared with laparoscopic surgery. Perioperative mortality, rate of circumferential margin involvement (2 studies, 489 participants, RR 0.82, 95% CI 0.39-1.73), and lymph nodes collected (mean 17.4 Lymph Nodes; 5 trials, 674 patients, MD -0.35, 95% CI -1.83 to 1.12) were similar. The quality of the evidence was moderate for most outcomes.

CONCLUSION

Evidence of moderate quality supports that robotic surgery for rectal cancer produces similar perioperative outcomes of oncologic procedure adequacy to conventional laparoscopic surgery. Robotic surgery portraits lower rate of conversion to open surgery, while operating time is significantly longer than by laparoscopic approach.

Totally-laparoscopic versus laparoscopic-assisted low anterior resection for rectal cancer: are outcomes different?

BACKGROUND

Laparoscopic low anterior resection for rectal cancer has superior short-term benefits compared to open surgery. When operative conditions do not favour a totally-laparoscopic (TL) approach, a hybrid operation can be performed. In this laparoscopic-assisted (LA) approach, mobilization and vessel ligation are performed laparoscopically, with total mesorectal excision and distal transection performed either partially or totally in an extra-corporeal fashion. We compared short-term post-operative and oncological outcomes of both approaches.

METHODS

A prospectively collected database of patients who underwent laparoscopic low anterior resection for rectal cancer between January 2009 and December 2014 was retrospectively analysed. Demographics, post-operative and oncological outcomes were compared.

RESULTS

Of 174 patients, 97 were completed by TL, 62 by LA and the remaining 15 were converted to open. Baseline demographics were similar. LA group compared to TL group had bulkier rectal cancers (6.75 cm³ versus 4.50 cm³ , P = 0.04) which were lower (6 cm versus 7 cm from anal verge, P = 0.02). They were of a more advanced tumour grade and had greater incidence of lymphovascular invasion. Yet, post-operative outcomes such as time to diet, pain scores, hospitalization duration, wound-related and anastomotic complications, 30-day morbidity and mortality were similar. There was no difference in oncological adequacy, including circumferential resection margins, distal margins, lymph node harvest and 2-year local recurrence rates.

CONCLUSION

Laparoscopic-assisted low anterior resection enables minimally invasive rectal surgery to be performed despite unfavourable tumour factors and technical challenges; and compares favourably with TL approach in terms of short-term outcomes and oncological safety.

[Transanal mesorectumectomy for rectal cancer - is it optimal surgery for 'difficult' patients?]

AIM

To compare short-term outcomes after transanal total mesorectumectomy (Ta-TME) and laparoscopic (Lap-TME) procedure in 'difficult' patients.

MATERIAL AND METHODS

Prospective nonrandomized trial included patients with confirmed middle-/low rectum adenocarcinoma T1-4aN0-2M0 for the period November 2013 - September 2016. We identified 20 out of 55 in TA-TME and 14 out of 54 patients in Lap-TME group as those of 'difficult' subgroup: male, BMI ≥25 кг/м², previous chemoradiotherapy (CRT).

RESULTS

Time of surgery, blood loss, conversions rate, postoperative morbidity and length of hospital-stay were similar in both groups. Hardware anastomoses were more frequent in TA-TME compared with LAP-TME group (78.9% vs. 50%, p=0.086). Specimen quality was more favorable in TA-TME group: Grade I 10% in Ta-TME group vs. 28.6% in Lap-TME group; 'positive' CRM 5% vs. 14.3%, р=0.365. Within-group analysis did not reveal any differences between 'difficult' and 'typical' patients by surgical and pathomorphological characteristics in TA-TME group in contrast to Lap-TME group. Median of follow-up was 24.6 (IR 10.6-40.2) and 23.8 (IR 12.1-39.9) months for TA-TME and Lap-TME groups, respectively. Local recurrence occurred in 1 (1.8%) 'difficult' patient after Ta-TME. Distant metastases were observed in 1 (1.8%) patient of Ta-TME and 2 (3.7%) patients of Lap-TME group. Actuarial 3-years reccurence-free survival was 95.7% for Ta-TME and 93.9% for Lap-TME group, respectively (p=0.923).

CONCLUSION

TA-TME is advisable for 'difficult' patients. Further multicenter randomized trials are necessary to specify the effectiveness of TA-TME in these patients.

Laparoscopic treatment of rectal cancer and lateral pelvic lymph node dissection: are they obsolete?

Laparoscopic surgery for rectal cancer offers favorable short-term results without compromising long term oncological outcomes so far, according to the data from major trials. For this reason, it is currently considered as a standard option for rectal cancer surgery. The learning curve of laparoscopic rectal cancer surgery is generally longer compared to colon cancer. Appropriate standardization and training of laparoscopic rectal cancer surgery is required. Several RCTs suggested the potential negative effect on quality of resected specimen, which can increase local recurrence. The long-term outcomes - especially local recurrence rate - of these RCTs are awaited. Lateral pelvic lymph node dissection (LPLND) has a certain effect of reducing local recurrence of rectal cancer even after neoadjuvant radiotherapy. Since LPLND is associated with postoperative morbidity, we should carefully select the candidate to maximize the effect of LPLND and minimize the morbidity caused by LPLND. Recent advancements in imaging study such as CT and MRI enable us to find the suitable candidates for LPLND. The morbidity caused by LPLND could be reduced by minimally invasive surgeries such as laparoscopic surgery and robotic surgery. We have to improve oncological outcomes and reduce morbidity by the multidisciplinary strategy for rectal cancer including total mesorectal excision, neoadjuvant chemoradiotherapy and LPLND together with laparoscopic surgery.

Intestinal endometriosis combined with colorectal cancer: a case series

BACKGROUND

Intestinal endometriosis is a common benign disease among menstruating women that affects the intestinal tract.

CASE PRESENTATION

This case report presents seven Japanese cases of intestinal endometriosis with colorectal cancer treated by laparoscopic surgery. Five of the seven cases reported here are women presenting with bowel obstruction due to colorectal endometriosis with colorectal cancer. It can be confused with serious lesions such as advanced colorectal cancer with peritoneal involvement or invasion of adjacent organs (T4).

CONCLUSIONS

Therefore, we should consider the probability that the cause of bowel obstruction is not T4 but intestinal endometriosis. For surgical treatment, we recommend laparoscopic surgery for colorectal resection because of its benefits of differential diagnosis of T4, preserving fertility, and preventing excessive surgical stress. We performed laparoscopic resection in seven patients with intestinal endometriosis and colorectal cancer. These cases demonstrate the difficulty of establishing a differential diagnosis of intestinal endometriosis with colorectal cancer from T4.

Intestinal endometriosis combined with colorectal cancer: a case series

Background

Intestinal endometriosis is a common benign disease among menstruating women that affects the intestinal tract.

Case presentation

This case report presents seven Japanese cases of intestinal endometriosis with colorectal cancer treated by laparoscopic surgery. Five of the seven cases reported here are women presenting with bowel obstruction due to colorectal endometriosis with colorectal cancer. It can be confused with serious lesions such as advanced colorectal cancer with peritoneal involvement or invasion of adjacent organs (T4).

Conclusions

Therefore, we should consider the probability that the cause of bowel obstruction is not T4 but intestinal endometriosis. For surgical treatment, we recommend laparoscopic surgery for colorectal resection because of its benefits of differential diagnosis of T4, preserving fertility, and preventing excessive surgical stress. We performed laparoscopic resection in seven patients with intestinal endometriosis and colorectal cancer. These cases demonstrate the difficulty of establishing a differential diagnosis of intestinal endometriosis with colorectal cancer from T4.

Transanal TME - really needed?

In the last decade, thanks to natural orifice translumenal endoscopic surgery, the application of laparoscopy through the anus has gained interest from both research and clinical point of views. Therefore, an increased number of transanal procedures have been reported, from the resection of a large rectal polyp to total mesorectal excision, and for controlling perioperative complications like leak, bleeding, and stenosis. Currently, the most popular surgical trend remains transanal total mesorectal excision. In this article, the technique, advantages, and disadvantages are discussed.

Impact of Body Mass Index on Surgical and Oncological Outcomes in Laparoscopic Total Mesorectal Excision for Locally Advanced Rectal Cancer after Neoadjuvant 5-Fluorouracil-Based Chemoradiotherapy

Aims

To evaluate the impact of body mass index (BMI) on the surgical outcome of laparoscopic total mesorectal excision (laTME) for locally advanced rectal cancer (LARC, clinically staged as UICC stage II/III) after neoadjuvant chemoradiotherapy (nCRT).

Methods

312 LARC patients undergoing laTME after nCRT were divided into nonobese (BMI < 25.0 kg/m², n = 249) and obese (BMI ≥ 25.0 kg/m², n = 63) groups. Preoperative radiotherapy was delivered in 45–50.4 Gy/25f, 5 days/week, and concurrent chemotherapy using FOLFOX or CapeOX. Technical feasibility, postoperative and oncological outcome were compared between groups.

Results

Obese patients had significantly longer operative time (P = 0.004). There was no significant difference regarding estimated blood loss, conversion, postoperative recovery, and morbidities. Multivariate analysis demonstrated that higher ASA score and abdominoperineal resection were risk factors for postoperative complications and diverting stoma was a protective factor. The length of resection margin, circumferential resection margin involvement, and number of lymph node retrieved were comparable. With a median follow-up time of 55 months (ranging 20–102 months), oncological outcome was comparable in terms of overall survival, local recurrence, and distant metastasis.

Conclusions

Obesity does not affect surgical or oncological outcome of laTME after nCRT. LaTME may be feasible and safe to obese LARC patients after nCRT in a specialized center.

Evolution of Surgical Treatment for Rectal Cancer: a Review

Surgery that produces an optimal total mesorectal excision (TME) resection specimen remains the cornerstone of curative rectal cancer management. In the modern era, despite the results of recent randomised trials, laparoscopic TME is a crucial technique in the TME surgery armamentarium. Laparoscopic surgery offers the benefit of magnified views that aid sharp and precise dissection. However operating in the confines of a narrow pelvis, particularly when the mesorectum is bulky, requires significant technical skill. This is compounded by limited angulation of laparoscopic instruments and staplers. The final challenge is to preserve the integrity of the mesorectum during delivery of the specimen. The principles of TME surgery, on which Bill Heald founded the Basingstoke Colorectal unit, can equally be applied to laparoscopic, transanal and robotic TME, but great care must be taken to preserve the key principle-that no steps are taken that have the potential to shed tumour cells or compromise the quality of the mesorectal specimen.

Is it right to ignore learning-curve patients? Laparoscopic colorectal trials

BACKGROUND

Increasingly complex, technically demanding surgical procedures utilizing emerging technologies have developed over recent decades and are recognized as having long 'learning curves'. This raises significant new issues. Ethically and scientifically, the outcome of a patient in the learning curve is as important as the outcome of a patient outside the learning curve. The aim of this study is to highlight just one aspect of our approach to learning-curve patients that should change.

METHODS

The protocols of multicentre, prospective, randomized trials of patients undergoing either traditional open or laparoscopic surgery for colorectal cancer were reviewed. The number of patients excluded from the published trial results because they were in surgeons' learning curves was calculated. The seven editorials accompanying these publications were also examined for any mention of these patients.

RESULTS

The eight studies identified had similar designs. All patients in the surgeons' laparoscopic learning curves, which were often several years long, were excluded from the actual trials. The total number of patients included in the trial publications was 5680. The number of patients excluded because they were in the surgeons' laparoscopic learning curves was >10 605. In none of the studies or accompanying editorials is there any mention of the total number of patients in the surgeons' learning curves, these patients' outcomes or how inclusion of their outcomes might have affected the overall results.

CONCLUSION

Learning curves are inescapable in modern medicine. Our recognition of patients in these curves should evolve, with more data about them included in trial publications.

Intraoperative Ultrasound as a Screening Modality for the Detection of Liver Metastases during Resection of Primary Colorectal Cancer - A Systematic Review

Colorectal cancer (CRC) is one of the most common cancer diseases worldwide. One in 4 patients with CRC will have a disseminated disease at the time of diagnosis and often in the form of synchronous liver metastases. Studies suggest that up to 30% of patients have non-recognized hepatic metastases during primary surgery for CRC. Intraoperative ultrasonography examination (IOUS) of the liver to detect liver metastases was considered the gold standard during open CRC surgery. Today laparoscopic surgery is the standard procedure, but laparoscopic ultrasound examination (LUS) is not performed routinely. Aim To perform a systematic review of the test performance of IOUS and LUS regarding the detection of synchronous liver metastases in patients undergoing surgery for primary CRC. Method The literature was systematically reviewed using the search engines: PubMed, Cochrane, Embase and Google. 21 studies were included in the review and the key words: intraoperative ultrasound, laparoscopic ultrasound, staging colon and rectum cancer. Results Intraoperative ultrasound showed a higher sensitivity, specificity, positive predictive value and overall accuracy for the detection liver metastases during surgery for primary CRC, compared to preoperative imaging modalities (ultrasound, computed tomography (CT) and contrast-enhanced computed tomography (CE-CT)). LUS showed a higher detection rate for liver metastases compared to CT, CE-CT and magnetic resonance imaging (MRI). Conclusion This systematic review found that both IOUS and LUS had a higher detection rate regarding liver metastases during primary CRC surgery, especially liver metastases<10 mm in diameter, when compared to US, CT, CE-CT and MRI.

Surgical Results and Oncologic Outcomes for Rectal Cancer with Tailored Mesorectal Excision over Two Decades

OBJECTIVE

This study aimed to compare the characteristics of the tumors, the management strategy, and oncologic outcomes of patients with rectal cancer surgery in these two periods: period 1 (1993-2001) and period 2 (2002-2011).

METHODS

All patients who underwent radical resection of rectal cancer from 1993 to 2011 were included. Comparisons of the patients' demographics, characteristics, operating results, and oncologic outcome between the two periods were undertaken.

RESULTS

Radical resection for rectal cancer was performed in 1611 patients (993 men). Patients were significantly older and more had comorbid medical diseases in period 2. More laparoscopic resections were performed and more patients had preoperative chemoradiation in period 2. The postoperative mortality was significantly lower and the hospital stay was significantly shorter in period 2. In those with non-metastatic cancer, the 5-year local recurrences of patients in period 1 and period 2 were 11.9 and 5.9 %, respectively. (p = 0.002) The patients in period 2 had significantly better 5-year overall (68.1 vs. 60.2 %, p = 0.003) and 5-year cancer-specific survival (76.1 vs. 69.4 %, p < 0.001) when compared with those treated in period 1. The improvement occurred mainly in patients with abdominoperineal resection and those with stage III diseases. In the multivariate analysis, among the other histological factors, operations performed in period 2 and laparoscopic surgery were independent factors associated with better overall survival.

CONCLUSIONS

Significant improvement in the surgical outcomes in terms of a lower recurrence rate and better survival was achieved in the recent years with the increase in neoadjuvant therapy and the application of laparoscopic surgery.

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.

Comparison between the perioperative results of single-access and conventional laparoscopic surgery in rectal cancer

INTRODUCTION

Laparoscopic surgery for rectal cancer has low rates of morbidity and mortality and achieves comparable pathologic outcomes. With improved instruments and surgical techniques, many surgeons have recently begun using single-access laparoscopic surgery (SALS) to minimize scars and pain. Since 2011, most reports of SALS for rectal cancer have shown comparable pathologic outcomes to those of conventional laparoscopic surgery (CLS). However, SALS is said to be superior to CLS in reducing complications, producing less discomfort, and faster recovery rates. This study aimed to compare the technical feasibility and early postoperative outcomes of these approaches.

METHODS

From January 2011 to January 2014, 78 cases of adenocarcinoma of the rectum and anal canal were enrolled in the study. Anterior, low anterior, intersphincteric, and abdominoperineal resections were performed. Data collected included technical feasibility and outcomes of operation, such as morbidity, mortality, severity of pain, analgesic usage, and length of hospital stay.

RESULTS

SALS was performed on 35 patients, and CLS was performed in 36 cases. Demographic data, including age, sex, BMI, ASA classification and clinical staging, were similar between the groups. Operative time, blood loss, and conversion rate were similar (P > 0.05). Postoperatively, the only significant difference between the groups was pain score, which was significantly lower in the SALS group (P < 0.001).

CONCLUSION

SALS and CLS for rectal and anal cancer had the same intraoperative, pathologic, and early postoperative results. However, SALS patients had slightly better pain scores in the first 24 and 48 h postoperatively.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery?

AIM

The surgical technique used for transanal total mesorectal excision (TaTME) was reviewed including the oncological quality of resection and the peri-operative outcome.

METHOD

A literature search of MEDLINE, Embase, Science Citation Index Expanded and Cochrane was performed in order to identify studies reporting on TaTME.

RESULTS

Thirty-six studies (eight case reports, 24 case series and four comparative studies) were identified, reporting 510 patients who underwent TaTME. The mean age ranged from 43 to 80 years and the mean body mass index from 21.7 to 31.8 kg/m(2) . The mean distance of the tumour from the anal verge ranged from 4 to 9.7 cm. The mean operation time ranged from 143 to 450 min and mean operative blood loss from 22 to 225 ml. The ratio of hand-sewn coloanal to stapled anastomoses performed was 2:1. One death was reported and the peri-operative morbidity rate was 35%. The anastomotic leakage rate was 6.1% and the reoperation rate was 3.7%. The mean hospital stay ranged from 4.3 to 16.6 days. The mesorectal excision was described as complete in 88% cases, nearly complete in 6% and incomplete in 6%. The circumferential resection margin was negative in 95% of cases and the distal resection margin was negative in 99.7%.

CONCLUSION

TaTME is a feasible and reproducible technique, with good quality of oncological resection. Standardization of the technique is required with formal training. Clear indications for this procedure need to be defined and its safety further assessed in future trials.

Transanal total mesorectal excision: Towards standardization of technique

AIM: To describe the role of Transanal total mesorectal excision (TaTME) in minimally invasive rectal cancer surgery, to examine the differences in patient selection and in reported surgical techniques and their impacts on postoperative outcomes and to discuss the future of TaTME.

METHODS: MEDLINE (PubMed), EMBASE, and The Cochrane Library were systematically searched through the 1^st of March 2015 using a predefined search strategy.

RESULTS: A total of 20 studies with 323 patients were included. Most studies were single-arm prospective studies with fewer than 100 patients. Multiple transanal access platforms were used, and the laparoscopic approach was either multi- or single port. The procedure was initiated transanally or transabdominally. If a simultaneous approach with 2 operating surgeons was chosen, the operative time was significantly reduced.

CONCLUSION: TaTME was also associated with better TME specimens and a longer distal resection margin. TaTME is thus feasible in expert hands, but the learning curve and safety profile are not well defined. Long-term follow-up regarding anal function and oncological outcomes should be performed in the future.

Comparison of clinical outcome between laparoscopic and open right hemicolectomy: a nationwide study

Background

This study aimed to compare clinical outcome between laparoscopic and open right hemicolectomy.

Methods

The data were sourced from Taiwan’s National Health Insurance Research Database. This study included 14,320 and 1313 patients who underwent open and laparoscopic right hemicolectomies, respectively. The study outcome included “intensive care unit (ICU) admission,” “over 2 h of general anesthesia,” “use of mechanical ventilation,” “acute respiratory failure,” “in-hospital death,” and “hospitalization for pneumonia.” Separate conditional logistic regressions were performed for each clinical outcome.

Results

The results showed that patients who underwent an open right hemicolectomy had significantly higher likelihood of ICU admission (31.4 vs. 13.4 %, p < 0.001), acute respiratory failure (3.6 vs. 0.8 %, p < 0.001), mechanical ventilation (12.8 vs. 4.1 %, p < 0.001), in-hospital death (3.7 vs. 0.9 %, p < 0.001), over 2 h of general anesthesia (4.6 vs. 1.2 %, p < 0.001), and hospitalization for pneumonia (5.8 vs. 3.1 %, p < 0.001) than patients who underwent a laparoscopic right hemicolectomy. Adjusted conditional logistic regression analyses revealed that patients who underwent an open right hemicolectomy were 2.96, 4.98, 3.41, 4.01, 3.44, and 1.78 times more likely to be admitted to the ICU, to have acute respiratory failure, the use of mechanical ventilation, in-hospital death, over 2 h of general anesthesia, and hospitalization for pneumonia, respectively, than patients who underwent a laparoscopic right hemicolectomy.

Conclusions

Laparoscopic right hemicolectomy reduced risk of post-operative pulmonary complications.

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.

Outcome of tumor-specific mesorectal excision for rectal cancer: the impact of laparoscopic resection

OBJECTIVE

The study aimed to compare the outcomes of laparoscopic and open resection for rectal cancer in 1,063 consecutive cases in a single center.

METHODS

We performed an analysis of 11 years of experience in rectal cancer surgery and compared the outcome of laparoscopic and open surgery. Multivariate and subgroup analysis was performed to look at the effect of the level of tumor and stage of disease on short-term outcomes like conversion rate, anastomotic leak rate, length of stay, complication rate, 30-day mortality, and long-term outcomes like local recurrence and survival.

RESULTS

A total of 1,063 patients underwent rectal resection with 470 (44.2%) patients undergoing the laparoscopic approach. Groups were comparable in terms of age, sex, or co-morbidities, and the operating time was longer in the laparoscopic group (210 vs. 150 min; p value < 0.001). A conversion rate of 6.8% was noted, with an anastomotic leak rate of 3.87% in the open group and 2.97% in the laparoscopic group. The laparoscopic group had a lower blood loss (100 vs. 350 ml; p < 0.001), lower complication rates, and shorter length of stay (6 vs. 9 days). The local recurrence rate was comparable, and the laparoscopic approach had better overall and cancer-specific survival, even after adjusting for stages. The laparoscopic approach was an independent factor associated with better overall and cancer-specific survival on multivariate analysis.

CONCLUSION

We confirmed the oncological safety of laparoscopic rectal cancer surgery. Laparoscopic surgery also showed superiority in the short-term and long-term outcomes of rectal cancer.

Multicenter Analysis of Long-Term Oncologic Impact of Anastomotic Leakage After Laparoscopic Total Mesorectal Excision: The Korean Laparoscopic Colorectal Surgery Study Group

This study aims to validate the oncologic outcomes of anastomotic leakage (AL) after laparoscopic total mesorectal excision (TME) in a large multicenter cohort. The impact of AL after laparoscopic TME for rectal cancer surgery has not yet been clearly described. This was a multicenter retrospective study of 1083 patients who underwent laparoscopic TME for nonmetastatic rectal cancer (stage 0-III). AL was defined as an anastomotic complication within 30 days of surgery irrespective of requiring a reoperation or interventional radiology. Estimated local recurrence (LR), disease-free survival (DFS), and overall survival (OS) were compared between the leakage group and the no leakage group using the log-rank method. Multivariate Cox-regression analysis was used to adjust confounding for survival. The incidence of AL was 6.4%. Mortality within 30 days of surgery occurred in 1 patient (1.4%) in the leakage group and 2 patients (0.2%) in the no leakage group. The leakage group showed a higher LR rate (6.4% vs 1.8%, P = 0.011). Five-year DFS and OS were significantly lower in the leakage group than the no leakage group (DFS 71.7% vs 82.1%, P = 0.016, OS 81.8% vs 93.5%, P = 0.007). Multivariate analysis showed that AL was an independent poor prognostic factor for DFS and OS (hazard ratio [HR] = 1.6; 95% confidence intervals [CI]: 1.0-2.6; P = 0.042, HR = 2.1; 95% CI: 1.0-4.2; P = 0.028, respectively). AL after laparoscopic TME was significantly associated with an increased rate of LR, systemic recurrence and poor OS.

Robotic versus laparoscopic surgery for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of short-term outcomes

The aim of our study was to compare short-term outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision (TME) in male patients with mid-low rectal cancer (RC) after neadjuvant chemoradiotherapy (NCRT). The study was conducted as a retrospective review of a prospectively maintained database, and we analyzed 14 robotic and 65 laparoscopic sphincter saving TME (R-TME and L-TME, respectively) performed by one surgeon between 2005 and 2013. Patient characteristics, perioperative recovery, postoperative complications and and pathology results were compared between the two groups. The patient characteristics did not differ significantly between the two groups. Median operating time was longer in the R-TME than in the L-TME group (182 min versus 140 min). Only two conversions occurred in the L-TME group. No difference was found between groups regarding perioperative recovery and postoperative complication rates. The median number of harvested lymph nodes was higher in the RTME than in the L-TME group (32 versus 23, p = 0.008). The median circumferential margin (CRM) was 10 mm in the R-TME group, 6.5 mm in the L-TME group (p = 0.047. The median distal resection margin (DRM) was 27.5 mm in the R-TME, 15 mm in the L-TME group (p = 0.014). Macroscopic grading of the specimen in the R-TME group was complete in all patients. In the L-TME group, grading was complete in 52 (80%) and incomplete in 13 (20%) cases (p = 0.109). R-TME is a safe and feasible procedure that facilitates performing of TME in male patients with mid-low RC after NCRT.

Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: long-term results

The long-term role of laparoscopy in the treatment of rectal cancer is still controversial. The aim of the present study was to evaluate the safety, the feasibility, the perioperative outcome, and the long-term results of laparoscopic total mesorectal excision (TME) for extraperitoneal rectal cancer considering a single center series.

METHODS

Data about 186 unselected consecutive patients that underwent laparoscopic TME for middle and low rectal cancer between January 2001 and December 2011 were prospectively recorded and were included in the present study.

RESULTS

Distribution of TNM stage was 5 % T1, 37 % T2, 52.5 % T3, and 6 % T4. Fifty-one percent of patients have lymph node metastases. The average duration of surgery was 234 min. Fourteen patients required conversion (7.5 %). A complete microscopic excision was achieved in 169 patients (91 %). The mean hospital stay was 9 days. The overall postoperative morbidity rate was 24 %. Surgical-related complications were reported in 19 %. Overall mortality was 0.5 %. Sex, tumor level, and the presence of a stoma were the only statistically significant independent risk factors for anastomotic leakage. Median follow-up was 71 months. The 5-year overall survival rate was 77 %, with 89 % for stage 1, 81 % for stage 2, 43 % for stage 3, and 10 % for stage 4. The 5-year disease-free survival rate was 66 %. The 10-year survival rate was 54 %. Nine patients (4.8 %) experienced a pelvic recurrence. Late metastases developed in 31 patients (17.2 %).

CONCLUSIONS

The study confirms the oncological safety of laparoscopic TME in a long follow-up period.

Clinical usefulness of laparoscopic surgery for clinical stage 0/I cancer in the rectum: a single-center experience in 137 patients

PURPOSE

Laparoscopic surgery has yet to achieve widespread acceptance for the treatment of rectal cancer because of technical difficulty caused by anatomical features and the lack of sufficient evidence supporting effectiveness. Consequently, the safety and long-term outcomes of laparoscopic surgery for rectal cancer remain to be established in Japan. We evaluated the feasibility, safety, and effectiveness of laparoscopic surgery in patients with up to clinical stage 0/I rectal cancer.

MATERIALS AND METHODS

From February 1998 through December 2010, we studied 137 patients with up to clinical stage 0/I rectal cancer treated by laparoscopic surgery. Surgical outcomes, invasiveness, safety, recurrence rates and patterns, and medium-term outcomes were examined. Four patients were converted to open surgery and excluded from analysis.

RESULTS

The median follow-up was 64 months (range, 9 to 156 mo), and the rate of conversion to open surgery was 2.8% (4/141). Postoperative complications occurred in 37 patients (27%) and included anastomotic leakage in 10 patients (10/125, 7.9%) and ileus in 10 patients (10/37, 7.3%). The recurrence rate was 6.6%. Lung metastasis and liver metastasis were frequent, but no patient had port-site recurrence. The 5-year disease-free survival rate and the cumulative survival rate were 94.2% and 96.9%, respectively, in patients with stage I disease and 80.2% and 94.7% in those with stage III disease.

DISCUSSION

Laparoscopic resection had good surgical outcomes, minimal invasiveness, high safety, and high rates of disease-free survival and overall survival in patients with up to clinical stage 0/I rectal cancer. These results suggest that laparoscopic surgery is a safe and effective procedure for the management of rectal cancer with clinical stage 0/I.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

Robotic-assisted versus laparoscopic colorectal surgery: a meta-analysis of four randomized controlled trials

Background

Robotic-assisted laparoscopy is popularly performed for colorectal disease. The objective of this meta-analysis was to compare the safety and efficacy of robotic-assisted colorectal surgery (RCS) and laparoscopic colorectal surgery (LCS) for colorectal disease based on randomized controlled trial studies.

Methods

Literature searches of electronic databases (Pubmed, Web of Science, and Cochrane Library) were performed to identify randomized controlled trial studies that compared the clinical or oncologic outcomes of RCS and LCS. This meta-analysis was performed using the Review Manager (RevMan) software (version 5.2) that is provided by the Cochrane Collaboration. The data used were mean differences and odds ratios for continuous and dichotomous variables, respectively. Fixed-effects or random-effects models were adopted according to heterogeneity.

Results

Four randomized controlled trial studies were identified for this meta-analysis. In total, 110 patients underwent RCS, and 116 patients underwent LCS. The results revealed that estimated blood losses (EBLs), conversion rates and times to the recovery of bowel function were significantly reduced following RCS compared with LCS. There were no significant differences in complication rates, lengths of hospital stays, proximal margins, distal margins or harvested lymph nodes between the two techniques.

Conclusions

RCS is a promising technique and is a safe and effective alternative to LCS for colorectal surgery. The advantages of RCS include reduced EBLs, lower conversion rates and shorter times to the recovery of bowel function. Further studies are required to define the financial effects of RCS and the effects of RCS on long-term oncologic outcomes.

Laparoscopic resection for rectal cancer: what is the evidence?

Laparoscopic colectomy for colon cancer is a well-established procedure supported by several well-conducted large-scale randomised controlled trials. Patients could now be conferred the benefits of the minimally invasive approach while retaining comparable oncologic outcomes to the open approach. However, the benefits of laparoscopic proctectomy for rectal cancer remained controversial. While the laparoscopic approach is more technically demanding, results from randomised controlled trials regarding long term oncologic outcomes are only beginning to be reported. The impacts of bladder and sexual functions following proctectomy are considerable and are important contributing factors to the patients' quality of life in the long-term. These issues present a delicate dilemma to the surgeon in his choice of operative approach in tackling rectal cancer. This is compounded further by the rapid proliferation of various laparoscopic techniques including the hand assisted, robotic assisted, and single port laparoscopy. This review article aims to draw on the significant studies which have been conducted to highlight the short- and long-term outcomes and evidence for laparoscopic resection for rectal cancer.

Laparoscopic versus open total mesorectal excision for rectal cancer

BACKGROUND

Colorectal cancer including rectal cancer is the third most common cause of cancer deaths in the western world. For colon carcinoma, laparoscopic surgery is proven to result in faster postoperative recovery, fewer complications and better cosmetic results with equal oncologic results. These short-term benefits are expected to be similar for laparoscopic rectal cancer surgery. However, the oncological safety of laparoscopic surgery for rectal cancer remained controversial due to the lack of definitive long-term results. Thus, the expected short-term benefits can only be of interest when oncological results are at least equal.

OBJECTIVES

To evaluate the differences in short- and long-term results after elective laparoscopic total mesorectal excision (LTME) for the resection of rectal cancer compared with open total mesorectal excision (OTME).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2013, Issue 2), MEDLINE (January 1990 to February 2013), EMBASE (January 1990 to February 2013), ClinicalTrials.gov (February 2013) and Current Controlled Trials (February 2013). We handsearched the reference lists of the included articles for missed studies.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) comparing LTME and OTME, reporting at least one of our outcome measures, was considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality according to the CONSORT statement, and resolved disagreements by discussion. We rated the quality of the evidence using GRADE methods.

MAIN RESULTS

We identified 45 references out of 953 search results, of which 14 studies met the inclusion criteria involving 3528 rectal cancer patients. We did not consider the risk of bias of the included studies to have impacted on the quality of the evidence. Data were analysed according to an intention-to-treat principle with a mean conversion rate of 14.5% (range 0% to 35%) in the laparoscopic group.There was moderate quality evidence that laparoscopic and open TME had similar effects on five-year disease-free survival (OR 1.02; 95% CI 0.76 to1.38, 4 studies, N = 943). The estimated effects of laparoscopic and open TME on local recurrence and overall survival were similar, although confidence intervals were wide, both with moderate quality evidence (local recurrence: OR 0.89; 95% CI 0.57 to1.39 and overall survival rate: OR 1.15; 95% CI 0.87 to1.52). There was moderate to high quality evidence that the number of resected lymph nodes and surgical margins were similar between the two groups.For the short-term results, length of hospital stay was reduced by two days (95% CI -3.22 to -1.10), moderate quality evidence), and the time to first defecation was shorter in the LTME group (-0.86 days; 95% CI -1.17 to -0.54). There was moderate quality evidence that 30 days morbidity were similar in both groups (OR 0.94; 95% CI 0.8 to 1.1). There were fewer wound infections (OR 0.68; 95% CI 0.50 to 0.93) and fewer bleeding complications (OR 0.30; 95% CI 0.10 to 0.93) in the LTME group.There was no clear evidence of any differences in quality of life after LTME or OTME regarding functional recovery, bladder and sexual function. The costs were higher for LTME with differences up to GBP 2000 for direct costs only.

AUTHORS' CONCLUSIONS

We have found moderate quality evidence that laparoscopic total mesorectal excision (TME) has similar effects to open TME on long term survival outcomes for the treatment of rectal cancer. The quality of the evidence was downgraded due to imprecision and further research could impact on our confidence in this result. There is moderate quality evidence that it leads to better short-term post-surgical outcomes in terms of recovery for non-locally advanced rectal cancer. Currently results are consistent in showing a similar disease-free survival and overall survival, and for recurrences after at least three years and up to 10 years, although due to imprecision we cannot rule out superiority of either approach. We await long-term data from a number of ongoing and recently completed studies to contribute to a more robust analysis of long-term disease free, overall survival and local recurrence.

Laparoscopic versus open surgery following neoadjuvant chemoradiotherapy for rectal cancer: a systematic review and meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the short-term and pathological outcomes of laparoscopic surgery (LS) versus open surgery (OS) following neoadjuvant chemoradiotherapy (NCRT) for rectal cancer.

METHODS

PubMed, Embase, Web of Science, Cochrane Library, and Chinese Biomedicine Literature databases were searched for eligible studies published up to July 2013. The rates of postoperative complication, positive circumferential resection margin (CRM), and the number of lymph nodes harvested were evaluated.

RESULTS

Three randomized controlled trials (RCTs) and five non-RCTs enrolling 953 patients were included. Compared to OS, LS had similar rate of postoperative complication [odds ratio (OR) 0.86; 95% confidence interval (CI), 0.60 to 1.22], comparable rate of positive CRM (OR 0.41; 95% CI, 0.16 to 1.02), and smaller number of lymph nodes (weighted mean difference -0.8; 95% CI, -1.1 to -0.5). LS also had significantly less blood loss, faster bowel movement recovery, and shorter postoperative hospitalization than those of OS.

CONCLUSION

LS is associated with favorable short-term benefits, similar postoperative complication rate, and comparable pathological outcomes for rectal cancer after NCRT compared to OS despite a slight difference in the number of lymph nodes. Additional high-quality studies are needed to validate long-term outcomes of LS following NCRT.

Functional long-term results after rectal cancer surgery--technique of the athermal mesorectal excision

PURPOSE

The total mesorectal excision (TME), embedded in a multimodal therapeutic concept, is accepted as the standard therapy of the advanced adenocarcinoma of the middle and lower thirds. The thermal damages of the autonomous nerves in the little pelvis caused by dissection devices remains a large problem. For our patients, we use water-jet dissection (WJD)-aided TME with the intention to minimise the rate of bladder and sexual function disorders.

METHODS

From October 2001 until June 2010, we recorded 125 patients with an adenocarcinoma of the middle and lower third of the rectum. Ninety deep anterior rectum resections and 35 abdominoperineal rectum extirpations by WJD were performed. Of the patients, 27.2 % received neoadjuvant radiochemotherapy. Bladder and sexual function disorders were assessed by International Prostate Symptom Score and International Index of Erectile Function.

RESULTS

The median follow-up period was 46 (2-117) months. Considering a local recurrence rate of 9.6 %, the tumour-specific 5-year survival of the entire collective was 75.4 %. Long-term bladder function disorders showed in 6.0 % (4/64) and sexual function disorders in 25.0 % (9/36) of the male patients in the course of time.

CONCLUSION

The specific advantage of the WJD technique is not only the facilitated dissection between the mesorectal fascia and the surrounding nervous structures in the little pelvis but also a completely athermal TME. The rate of bladder and sexual function disorders is an excellent result compared to that of international centres. Due to the size of the patient collective and the retrospective character of the study, further studies are necessary to validate the presented results.

Integration of open and laparoscopic approaches for rectal cancer resection: oncologic and short-term outcomes

BACKGROUND

Laparoscopy is increasingly used for rectal cancer surgery. Laparoscopic surgery is not attempted for some suitable patients because of concerns for conversion or technical difficulty. This study aimed to evaluate oncologic and short-term outcomes for patients undergoing curative resection for rectal cancer via laparoscopic and open approaches.

METHODS

A prospective database was reviewed to identify rectal cancer resections from 2005 to 2011. Patients who had primary rectal cancer within 15 cm of the anal verge were included in the study. Those with recurrent or metastatic disease were excluded. Patients were assigned to laparoscopic or open approaches preoperatively based on clinical criteria and imaging. All patients underwent a standard total mesorectal excision and followed a standardized enhanced recovery pathway. The oncologic and clinical outcomes were evaluated by approach.

RESULTS

The analysis included 81 patients. The preoperative assignments consisted of 62 laparoscopic (77%) and 19 open (23%) procedures. Nine laparoscopic procedures (14.5%) were converted to open procedures. After a median follow-up period of 25 months, all oncologic outcomes were comparable. Three patients (two laparoscopic, one open) had a positive circumferential margin (≤1 mm). The laparoscopic and open groups were similar in terms of their 3-year disease-free periods (93.6 vs. 88.2%; P = 0.450) and overall survival periods (93.5 vs. 90.9%; P = 0.766). The local recurrence rate was 2.5%.

CONCLUSIONS

Laparoscopic resection for rectal cancer can be attempted for most patients. Conversion to open procedure does not compromise clinical or oncologic outcomes. In practice, combining laparoscopic and open surgery optimizes resource use and results in at least equivalent outcomes.

Laparoscopic rectal resection versus open rectal resection with minilaparotomy for invasive rectal cancer

BACKGROUND

The minilaparotomy approach is technically feasible for the resection of rectal cancer in selected patients with rapid postoperative recovery and small incision. The study aimed to compare the clinical and oncological outcomes of minilaparotomy and laparoscopic approaches in patients with rectal cancer.

METHODS

The 122 included patients with rectal cancer were assigned to either minilaparotomy group (n=65) or laparoscopic group (n=57) which ran from January 2005 to January 2008. Clinical characteristics, perioperative outcomes, postoperative and long-term complications, pathological results and survival rates were compared between the groups.

RESULTS

The demographic data of the two groups were similar. The time to normal diet (P=0.024) and the hospital stay (P=0.043) were less in the laparoscopic group than that in the minilaparotomy group. Compared with the minilaparotomy group, the mean operation time was significantly longer [low anterior resection (LAR), P=0.030; abdominoperineal resection (APR), P=0.048] and the direct costs higher for laparoscopic group (P<0.001). The morbidity and mortality were comparable between the two groups. Local recurrence was similar (5.3% laparoscopic, 1.5% minilaparotomy, P=0.520). The 5-year overall and disease-free survival rates were also similar (overall survival is 87.1% in laparoscopic group, and 82.5%in minilaparotomy group, P=0.425; disease-free survival is 74.2% in the laparoscopic group, and 71.4% in mini- laparotomy group, P=0.633).

CONCLUSIONS

The minilaparotomy approach was similarly safe and oncologically equivalent to laparoscopic approach for patients with rectal cancer. At the expense of a longer operative time and higher cost, laparoscopic surgery was associated with faster postoperative recovery.

Short-term efficacy of laparoscopic and open Dixon surgery for rectal cancer

AIM: To compare the short-term efficacy of laparoscopic and open Dixon surgery for rectal cancer.

METHODS: The clinical data for 109 patients who received Dixon surgery for rectal cancer at our hospital between June 2011 and June 2013 were reviewed retrospectively and perioperative results were compared. The patients were divided into two groups, a laparoscopy group (n = 48) and an open surgery group (n = 61).

RESULTS: The operation was successfully performed on all patients. The mean operation time for the laparoscopy group was significantly longer than that for the open surgery group (231.0 min ± 60.3 min vs 201.7 min ± 46.9 min, P < 0.05). The length of operative incision (5.9 cm ± 0.7cm vs 15.1 cm ± 2.6 cm), blood loss (96.2 mL ± 20.0 mL vs 181.2 mL ± 117.7 mL), postoperative administration of anodyne (0.5 ± 0.6 vs 0.9 ± 0.8), time to anal exhaust (2.1 d ± 0.8 d vs 3.0 d ± 0.7 d), time of liquid food intake (3.3 d ± 0.5 d vs 4.3 d ± 0.4 d), urinary catheterization time (4.5 d ± 0.5 d vs 6.2 d ± 0.4 d), pelvic cavity drainage tube placement time (7.5 d ± 0.6 d vs 8.2 d ± 0.4 d), and postoperative hospitalization time (11.7 d ± 2.1 d vs 13.8 d ± 2.8 d) were significantly less in the laparoscopy group than in the open surgery group (all P < 0.05). The postoperative complication, mass maximal diameter, the distance between the distal and proximal margin and the mass in rectum specimens, resected lymph node number and positive lymph node number were not significantly different between the two groups (all P > 0.05).

CONCLUSION: The laparoscopic Dixon surgery for rectal cancer is safe and feasible in terms of favorable short-term outcomes and minimal invasiveness.

Laparoscopic surgery for rectal cancer: current status and future perspective

Although laparoscopic surgery for colon cancer is accepted in the treatment guidelines, the laparoscopic approach for rectal cancer is recommended only in clinical trials. Thus far, several trials have shown favorable short-term results such as early recovery and short hospital stay, but long-term results remain a critical concern for laparoscopic rectal cancer surgery. To date, no randomized control trials have shown an increased local recurrence after laparoscopic surgery for rectal cancer. Additionally, according to previous studies, open conversion, which is more frequent in laparoscopic rectal surgery than in laparoscopic colon surgery, may affect short-term and long-term survival. The evidence on male sexual function has been contradictory. Long-term results from ongoing multicenter trials will be available within several years. Based on accumulated evidence from well-organized clinical trials, laparoscopic surgery will likely be accepted as a treatment choice for rectal cancer. In the future, extended laparoscopic rectal surgery might be feasible for additional procedures such as laparoscopic lateral pelvic lymph node dissection and laparoscopic total pelvic exenteration for rectal cancer invading the adjacent pelvic organ.

The role of the robotic technique in minimally invasive surgery in rectal cancer

Laparoscopic rectal surgery is feasible, oncologically safe, and offers better short-term outcomes than traditional open procedures in terms of pain control, recovery of bowel function, length of hospital stay, and time until return to working activity. Nevertheless, laparoscopic techniques are not widely used in rectal surgery, mainly because they require a prolonged and demanding learning curve that is available only in high-volume and rectal cancer surgery centres experienced in minimally invasive surgery. Robotic surgery is a new technology that enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, promising to overcome some of the technical difficulties associated with standard laparoscopy. The aim of this review is to summarise the current data on clinical and oncological outcomes of minimally invasive surgery in rectal cancer, focusing on robotic surgery, and providing original data from the authors’ centre.