Laparoscopic rectal cancer surgery: Where do we stand?

Effect of Robotic Inferior Mesenteric Artery Ligation Level on Low Anterior Resection Syndrome in Rectum Cancer

Background: Life expectancy of patients with rectal cancer is increasing day by day with innovative treatments. Low anterior resection syndrome (LARS), which disrupts the comfort of life in these patients, has become a serious problem. We aimed to evaluate the effect of high ligation (HL) and low ligation (LL) techniques on LARS in rectal cancer surgery performed with the robotic method. Materials and Methods: The data of patients diagnosed with mid-distal rectal cancer between 2016 and 2021 who underwent robotic low anterior resection by the same team in the same center with neoadjuvant chemoradiotherapy were retrospectively evaluated. Patients were divided into two groups as those who underwent HL and LL procedures. Preoperative, 8 weeks after neoadjuvant treatment, 3 and 12 months after ileostomy closure were evaluated. Results: A total of 84 patients (41 HL, 43 LL) were included in the study. There was no statistically significant difference between the demographic characteristics and pathology data of the patients. Although there was a decrease in LARS scores after neoadjuvant treatment, there was a statistically significant difference between the two groups at 3 and 12 months after ileostomy closure (P: .001, P: .015). Conclusions: In patients who underwent robotic low anterior resection, there is a statistically significant difference in the LARS score in the first 1 year with the LL technique compared with that of the HL technique, and the LL technique has superiority in reducing the development of LARS between the two oncologically indistinguishable methods.

Primary Colorectal Cancer

Over the last few decades, the colorectal surgery world has seen a paradigm shift in the care of patients. The introduction of minimally invasive techniques led to the development of procedures resulting in reduced patient morbidity and hospital stay. The vetting process of minimally invasive colorectal surgery involved rigorous studies to ensure that oncologic outcomes were not being compromised. In this chapter, we discuss the most relevant randomized controlled trials that support the practice of minimally invasive colorectal surgery. The multimodal treatment of rectal cancer has developed rapidly, resulting in improved survival and decreased morbidity and mortality. In this review, we also present the latest evidence behind the multidisciplinary approach to rectal cancer.

Laparoscopic Versus Conventional Open Rectum Amputation: a Clinical, Intraoperative, and Short-term Outcome Comparative Study

Objective: To evaluate and compare laparoscopic and conventional open rectum amputation procedures using clinical, intraoperative, postoperative, and oncological criteria.

Methods: Fifty-nine patients with lower rectal and anorectal cancer were included in a retrospective study, conducted between 2014 and 2017. Patients underwent open or laparoscopic rectum amputation surgery and were divided into two groups: group 1 – laparoscopic amputation group (LAG) and group 2 – open amputation group (OAG). The clinical, intraoperative, and postoperative outcomes and oncological results were compared between the two groups.

Results: We found a significantly smaller intraoperative blood loss (325 mL vs. 538.29 mL, p = 0.0002), earlier return of bowel motility (2.41 days vs. 3.10 days, p = 0.036), shorter hospital stays (10.08 days vs. 12.66 days, p = 0.03), and a higher number of lymph nodes removed during surgery (12.33 nodes for LAG vs. 9.98 nodes for OAG, p = 0.049). In the open surgery group we found shorter durations of surgery (199.58 minutes for LAG vs. 157.87 minutes for OAG, p = 0.0046).

Conclusion: Laparoscopic rectum amputation is a technically demanding procedure. The present study demonstrates the benefits and disadvantages of this surgery, with comparable clinical, intraoperative, postoperative, and oncological results compared to the conventional open rectum amputation procedure.

Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery

Several patients' and pathological characteristics in rectal surgery can significantly complicate surgical loco regional tumor clearance. The main factors are obesity, short tumor distance from anal verge, bulky tumors, and narrow pelvis, which have been shown to be associated to poor surgical results in open and laparoscopic approaches. Minimally invasive surgery has the potential to reduce perioperative morbidity with equivalent short- and long-term oncological outcomes compared to conventional open approach. Achilles' heel of laparoscopic approaches is conversion to open surgery. High risk for conversion is evident for patients with bulky and low tumors as well as male gender and narrow pelvis. Hence, patient's characteristics represent challenges in rectal cancer surgery especially in minimally invasive approaches. The available surgical techniques increased remarkably with recently developed and implemented improvements of minimally invasive rectal cancer surgery. The controversial discussions about sense and purpose of these novel approaches are still ongoing in the literature. Herein, we evaluate, if latest technical advances like transanal approach or robotic assisted surgery have the potential to overcome known challenges and pitfalls in rectal cancer surgery in demanding surgical cases and highlight the role of current minimally invasive approaches in rectal cancer surgery.

Lower Gastrointestinal Surgery: Robotic Surgery versus Laparoscopic Procedures

Introduction

For a long time, the comprehensive application of minimally invasive techniques in lower gastrointestinal (GI) surgery was substantially impaired by inherent anatomical and technical complexities. Recently, several new techniques such as robotic operating platforms and transanal total mesorectal excision (taTME) have revolutionized the minimally invasive approach. This review aims to depict the current state of the art and evaluates the advantages and drawbacks in regard to perioperative outcome and quality of oncological resection.

Methods

A systematic literature search was performed using the search terms 'colorectal cancer', 'rectal cancer', 'minimally invasive surgery', 'laparoscopic surgery', and 'robotic' to identify relevant studies reporting on robotic surgery (RS) either alone or in comparison to laparoscopic surgery (LS). Publications on taTME were analyzed separately.

Results

69 studies reporting on RS with a total of 20,872 patients, and 17 articles on taTME including 881 patients, were identified.

Conclusion

Both RS and taTME can facilitate a minimally invasive approach for lower GI surgery in an increasing number of patients. Furthermore, combining both techniques might become an auspicious approach in selected patients; further prospective and randomized trials are needed to verify its benefits over conventional laTME.

Pathological outcomes in rectal cancer following laparoscopic surgery

AIM

This study examined pathological quality-of-surgery indicators in laparoscopic and open rectal cancer resection specimens.

METHODS

Retrospective analysis of consecutive, prospectively recorded laparoscopic (LR) or open (OR) resections for rectal cancer. Indicators included integrity of the perirectal fascial envelope, circumferential margin clearance, lymph node yield and distal margin clearance.

RESULTS

Between January 2007 and December 2013, 168 LR and 189 OR were performed. Univariate analysis showed that the presence of tumor within 1 mm of the circumferential margin was lower in LR (13/168 vs 28/189 cases, P = 0.039) as was a distal margin of clearance of < 1 cm (3/165 vs 12/186, P = 0.032). There was no difference in the surgical disruption of the fascial envelope (P = 0.091) or the percentage of specimens with a lymph node yield < 12 (P = 0.576) between the LR and OR groups. Multivariate analysis did not reveal any significant differences in pathological outcomes.

CONCLUSION

With careful case selection, laparoscopic surgery has similar pathological outcomes to open surgery for rectal cancer.

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.

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.

Shifting Paradigms in Minimally Invasive Surgery: Applications of Transanal Natural Orifice Transluminal Endoscopic Surgery in Colorectal Surgery

Since the advent of laparoscopy, minimally invasive techniques such as single port laparoscopy, robotics, endoscopically assisted laparoscopy, and transanal endoscopic surgery continue to revolutionize the field of colorectal surgery. Transanal natural orifice transluminal endoscopic surgery (NOTES) represents a further paradigm shift by combining the advantages of these earlier techniques to reduce the size and number of abdominal incisions and potentially optimize rectal dissection, especially with respect to performance of an oncologically adequate total mesorectal excision (TME) for rectal cancer. Since the first experimental report of transanal rectosigmoid resection in 2007, the potential impact of transanal NOTES in colorectal surgery has been extensively investigated in experimental models and recently transitioned to clinical application. There have been 14 clinical trials of transanal TME (taTME) for rectal cancer that have demonstrated the feasibility and preliminary oncologic safety of this approach in carefully selected patients, with results comparable to outcomes after laparoscopic and open TME, including cumulative intraoperative and postoperative complication rates of 5.5 and 35.5%, respectively, 97.3% rate of complete or near-complete specimens, and 93.6% rate of negative margins. Transanal NOTES has also been safely applied to proctectomy and colectomy for benign indications. The consensus among published series suggests that taTME is most safely performed with transabdominal assistance by surgeons experienced with laparoscopic TME, transanal endoscopic surgery, and sphincter-preserving techniques including intersphincteric resection. Future applications of transanal NOTES may include evolution to a pure endoscopic transanal approach for TME, colectomy, and sentinel lymph node biopsy for rectal cancer, with a potential role for robotic assistance.

Laparoscopic resection of lower rectal cancer with telescopic anastomosis without abdominal incisions

AIM: To assess laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions.

METHODS: From March 2010 to June 2014, 30 patients (14 men and 16 women, aged 36-78 years, mean age 59.8 years) underwent laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through anus-preserving transanal resection. The tumors were 5-7 cm away from the anal margin in 24 cases, and 4 cm in six cases. In preoperative assessment, there were 21 cases of T₁N₀M₀ and nine of T₂N₀M₀. Through the middle approach, the sigmoid mesentery was freed at the root with an ultrasonic scalpel and the roots of the inferior mesenteric artery and vein were dissected, clamped and cut. Following the total mesorectal excision principle, the rectum was separated until the anorectal ring reached 3-5 cm from the distal end of the tumor. For perineal surgery, a ring incision was made 2 cm above the dentate line, and sharp dissection was performed submucosally towards the superior direction, until the plane of the levator ani muscle, to transect the rectum. The rectum and distal sigmoid colon were removed together from the anus, followed by a telescopic anastomosis between the full thickness of the proximal colon and the mucosa and submucosal tissue of the rectum.

RESULTS: For the present cohort of 30 cases, the mean operative time was 178 min, with an average of 13 positive lymph nodes detected. One case of postoperative anastomotic leak was observed, requiring temporary colostomy, which was closed and recovered 3 mo later. The postoperative pathology showed T₁-T₂N₀M₀ in 19 cases and T₂N₁M₀ in 11 cases. Twelve months after surgery, 94.4% patients achieved anal function Kirwan grade 1, indicating that their anal function returned to normal. The patients were followed up for 1-36 mo, with an average of 23 mo. There was no local recurrence, and 17 patients survived for > 3 years (with a survival rate of 100%).

CONCLUSION: Laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions is safe and feasible.

Laparoscopic versus open low anterior resection for rectal cancer: results from the national cancer data base

BACKGROUND

While the use of laparoscopy has increased among patients undergoing colorectal surgery, there is ongoing debate regarding the oncologic equivalence of laparoscopy compared to open low anterior resection (LAR) for rectal cancer.

METHODS

The 2010-2011 NCDB was queried for patients undergoing LAR for rectal cancer. Subjects were grouped by laparoscopic (LLAR) versus open (OLAR) technique. Baseline characteristics were compared. Subjects were propensity matched, and outcomes were compared between groups.

RESULTS

A total of 18,765 patients were identified (34.3% LLAR, 65.7% OLAR). After propensity matching, all baseline variables were highly similar except for carcinoembryonic antigen (CEA) level. Complete resection was more common in patients undergoing LLAR (91.6 vs. 88.9%, p < 0.001), and statistically significant benefits were observed for gross, microscopic, and circumferential (>1 mm) margins (all p < 0.001). There was no difference in median number of lymph nodes obtained (15 vs. 15). Patients undergoing LLAR had shorter lengths of stay (5 vs. 6 days, p < 0.001) without a corresponding increase in 30-day readmission rates (6 vs. 7%, p = 0.02).

CONCLUSIONS

Laparoscopic LAR appears to result in equivalent short-term oncologic outcomes compared to the traditional open approach as measured via surrogate endpoints in the NCDB. While these results support the increasing use of laparoscopy in rectal surgery, further data are necessary to assess long-term outcomes.

Higher risk of incomplete mesorectal excision and positive circumferential margin in low rectal cancer regardless of surgical technique

INTRODUCTION

Currently, the predominant question is whether a laparoscopic approach is comparatively radical in comparison with an open access approach, especially in the circumferential resection margin and quality of the completeness of total mesorectal excision. These factors are important in determining the quality of surgical care as well as long-term results of the treatment.

AIM

This article focuses on the evaluation of circumferential resection margins and on the quality of mesorectal excision of middle and lower rectum tumors. In addition, laparoscopic and open techniques are compared.

MATERIAL AND METHODS

Data were collected prospectively and stored in a rectal cancer registry over a 3-year period. The parameters studied were age, sex, body mass index, localization and topography of the tumor, clinical stage, neoadjuvant chemotherapy and its response, the type of surgery, character of the circumferential and distal margins, quality of the mesorectal excision, pT and pN.

RESULTS

One hundred and twenty-five patients were chosen for our study. Laparoscopy was performed in 53 operations and a conventional approach was performed in 72 operations. Complete mesorectal excision was achieved in 54.7% of laparoscopic operations versus 44.4% in the conventional technique; partially complete excision was performed in 20.8 and 12.5%, respectively. Incomplete excisions were described in 24.5 and 43.1% (p = 0.085). Positive circumferential margin occurred during laparoscopic surgery in 11 (20.8%) patients, and in the case of conventional resection in 27 (37.5%) patients (p = 0.044).

CONCLUSIONS

Our study showed comparable results between laparoscopic and open access procedures during rectal resection. The results achieved, in particular in the quality of the mesorectal excision and negative circumferential resection margin, show that the laparoscopic approach is comparable to conventional surgical techniques, with an adequate surgical outcome, in the treatment of rectal cancer.

Improving outcomes and cost-effectiveness of colorectal surgery

In order to truly make an impact on improving the cost effectiveness, and most importantly, the outcomes of patients undergoing colorectal surgery, all aspects of care need to be scrutinized, re-evaluated, and refined. To accomplish this, everything from the way we train surgeons to the adoption of a minimally invasive approach for colorectal disease, along with the use of adjunct intraoperative measures to decrease morbidity and mortality, may all need to be incorporated within an ERAS program. Only then will this approach lead the provider to a patient-centric care plan which can successfully reduce metrics such as morbidity, mortality, and length of stay (even with the obligatory readmission rate) and provide it all at a lower cost of care.

A prospective video-controlled study of genito-urinary disorders in 35 consecutive laparoscopic TMEs for rectal cancer

INTRODUCTION

Genito-urinary disorders (GUD) for radical rectal cancer surgery range from 10 to 30%. In this study, primary endpoint is to prospectively assess their incidence in patients undergoing Laparoscopic Total Mesorectal Excision (LTME) without neoadjuvant chemo-radiation (NCR). Secondary endpoint is to detect the potential lesion site evaluating video-recordings of surgery.

PATIENTS AND METHODS

A study of 35 consecutive patients treated by LTME for extra-peritoneal rectal cancer not subjected to NCR, M:F = 23:12, median age 70, was evaluated preoperatively by Uroflowmetry and US postvoid residual urine measurement (PVR), International Prostatic Symptoms Score (IPSS), and International Consultation on Incontinence Modular Questionnaire (ICIQ) at 1 and 9 months post-operatively. Evaluation of sexual function was carried out by International Index of Erectile Function (IIEF) in males. Data were analyzed performing Fisher and paired samples t tests. Surgical videos of patients affected by GUD were reviewed to identify lesion sites.

RESULTS

Urinary function:IPSS average score: baseline 6.03 ± 5.51, 8.93 ± 6.42 (p = .005) at 1 month, and 7.26 ± 5.55 (p = .041) at 9 months. ICIQ baseline 2.67 ± 5.42, 4.27 ± 6.19 (p = NS) at 1 month, and 3.63 ± 5.23 (p = NS) at 9 months. Maximum urine flow rate baseline 15.95 ± 4.78 ml/s, 14.23 ± 5.27 after 1 month (p = .041), and 15.22 ± 4.01 after 9 months (p = NS). Mean urine flow rate baseline 9.15 ± 2.96 ml/s, 7.99 ± 4.12 ml/s at 1 month (p = .044), and 8.54 ± 4.19 ml/s at 9 months (p = NS). PVR baseline 59.62 ± 54.49, 64.59 ± 58.71 (p = NS) at 1 month, and 68.82 ± 77.72 (p = NS) at 9 months. Sexual function: IIEF baseline 19.38 ± 6.25, 14.06 ± 8.65 at 1 month (p = .011), and 15.4 ± 8.41 at 9 months, (p = NS). Video review of patients with disorders showed potential damage at the site of ligation of IMA (high hypogastric plexus) in 1 case, lateral and posterior mesorectum dissection (hypogastric nerves) in 2 cases, anterior dissection of the Denonvilliers fascia from seminal vesicles in 2 cases.

CONCLUSIONS

GUD at 1 month from LTME for rectal cancer are significant but improve at 9 months. Surgical video review of patients with GUD provides an important tool for detection of lesion sites.

A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the Nationwide Inpatient Sample

BACKGROUND

The use of minimally invasive surgery (MIS) techniques for pancreatic and liver operations remains ill defined. We sought to compare inpatient outcomes among patients undergoing open versus MIS pancreas and liver operations using a nationally representative cohort.

METHODS

We queried the Nationwide Inpatient Sample database for all major pancreatic and hepatic resections performed between 2000 and 2011. Appropriate International Classification of Diseases, 9th Revision (ICD-9) coding modifiers for laparoscopy and robotic assist were used to categorize procedures as MIS. Demographics, comorbidities, and inpatient outcomes were compared between the open and MIS groups.

RESULTS

A total of 65,033 resections were identified (pancreas, n = 36,195 [55.7%]; liver, n = 28,035 [43.1%]; combined pancreas and liver, n = 803 [1.2%]). The overwhelming majority of operations were performed open (n = 62,192, 95.6%), whereas 4.4% (n = 2,841) were MIS. The overall use of MIS increased from 2.3% in 2000 to 7.5% in 2011. Compared with patients undergoing an open operation, MIS patients were older and had a greater incidence of multiple comorbid conditions. After operation, the incidence of complications for MIS (pancreas, 35.4%; liver, 29.5%) was lower than for open (pancreas, 41.6%; liver, 33%) procedures (all P < .05) resulting in a shorter median length of stay (8 vs 7 days; P = .001) as well as a lower in-hospital mortality (5.1% vs 2.8%; P = .001).

CONCLUSION

During the last decade, the number of MIS pancreatic and hepatic operations has increased, with nearly 1 in 13 HPB cases now being performed via an MIS approach. Despite MIS patients tending to have more preoperative medical comorbidities, postoperative morbidity, mortality, and duration of stay compared favorably with open surgery.

Future directions in surgery for colorectal cancer: the evolving role of transanal endoscopic surgery

SUMMARY 

The morbidity associated with radical surgery for rectal cancer has launched a revolution in increasingly less-invasive methods of resection, including a recent resurgence in transanal endoscopic surgical approaches. The next evolution in transanal surgery for rectal cancer is natural orifice translumenal endoscopic surgery (NOTES). To date, 14 series of transanal NOTES total mesorectal excision (TME) for rectal cancer have been published (n = 76). Overall, the intraoperative and postoperative complication rates of 8 and 28%, respectively, compare favorably to those expected from laparoscopic and open TME. Short-term follow-up after NOTES TME has yielded no cancer recurrence in average-risk patients. High-risk patients have cancer recurrence rates similar to those after laparoscopic TME. Overall, these early data support transanal NOTES TME as a safe and viable alternative to conventional TME. Advances in instrumentation, surgical expertise and neoadjuvant treatment may expand current indications for NOTES even further.