Short-term clinical outcomes of laparoscopic vs open rectal excision for rectal cancer: A systematic review and meta-analysis

The COMPARE Study: Comparing Perioperative Outcomes of Oncologic Minimally Invasive Laparoscopic, da Vinci Robotic, and Open Procedures: A Systematic Review and Meta-analysis of the Evidence

OBJECTIVE

To assess 30-day outcomes of da Vinci robotic-assisted (dV-RAS) versus laparoscopic or video-assisted thoracoscopic​​​​​ (lap/VATS) or open oncologic surgery.

BACKGROUND

Complex procedures in deep/narrow spaces especially benefit from dV-RAS. Prior procedure-specific comparisons are not generalizable.

METHODS

PubMed, Scopus, and EMBASE were systematically searched (latest: November 17, 2023) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses and PROSPERO (Reg#CRD42023466759). Randomized, prospective, and database studies were pooled as odds ratios (ORs) or mean differences (MDs) in R using fixed effects or random effects (heterogeneity significant). ROBINS-I/RoB 2 were used to assess bias.

RESULTS

Of 56,314 unique references over 12 years from 22 countries, 230 studies (34 randomized, 74 prospective, and 122 database) comparing dV-RAS to lap/VATS or open surgery across 7 procedures, 4 specialties, representing 1,194,559 dV-RAS; 1,095,936 lap/VATS and 1,625,320 open cases were included. Operative time for dV-RAS was longer than lap/VATS [MD: 17.73 minutes (9.80, 25.67), P < 0.01] and open surgery [MD: 40.92 minutes (28.83, 53.00), P < 0.01], whereas hospital stay was shorter [lap/VATS MD: -0.51 days (-0.64, -0.38), P < 0.01; open MD: -1.85 days (-2.09, -1.62), P < 0.01] and blood loss was less versus open [MD: -293.44 mL (-359.53, -227.35)]. There were fewer dV-RAS conversions [OR: 0.44 (0.40, 0.49), P < 0.01], transfusions [OR: 0.79 (0.72, 0.88), P < 0.01], postoperative complications [OR: 0.90 (0.84, 0.96), P < 0.01], readmissions [OR: 0.91 (0.83, 0.99), P = 0.04], and deaths [OR: 0.86 (0.81, 0.92), P < 0.01] versus lap/VATS, and fewer transfusions [OR: 0.25 (0.21, 0.30), P < 0.01], postoperative complications [OR: 0.56 (0.52, 0.61), P < 0.01], readmissions [OR: 0.71 (0.63, 0.81), P < 0.01], operations [OR: 0.89 (0.81, 0.97), P < 0.01], and deaths [OR: 0.54 (0.47, 0.63), P < 0.01] versus open surgery. Blood loss [MD:- 12.26 mL (-29.44, 4.91), P = 0.16] and operations [OR: 1.03 (0.95, 1.11), P = 0.48] were similar for dV-RAS and lap/VATS. There was significant heterogeneity.

CONCLUSIONS

Da Vinci-RAS confers benefits across oncological procedures and study designs. These results provide clinical evidence to multispecialty-care decision-makers considering dV-RAS.

Outcomes of Minimally Invasive Rectal Cancer Resection: Insights From a Resource-Limited Setting

BACKGROUND

Minimally invasive approaches for rectal cancer treatment are emerging as the standard of care. Robotic surgery is unfeasible across the country due to constrained resource allocation. This study aimed to assess the oncologic efficacy of laparoscopic resection for rectal cancer in a resource-limited setting.

METHODS

A propensity score-matched analysis was carried out to compare the oncological outcomes of laparoscopic and open rectal cancer resection at a high-volume tertiary cancer centre in South India.

RESULTS

Two hundred and twenty patients were included (110 patients in each group). The median follow-up was 93 months. There was no difference in positive circumferential resection margin between laparoscopic and open group (4.5% vs. 6.4%, p = 0.55), with a significantly better nodal yield in laparoscopic group. There was no significant difference between the laparoscopic and open groups in terms of local recurrence (5.1% vs. 8.3%, p = 0.12), 5-year disease-free survival (86% vs. 81%, p = 0.22, HR 0.699, 95% CI 0.353-1.27) or overall survival (85% vs. 76%, p = 0.21, HR 0.658, 95% CI 0.340-1.27). The mean cost between the two groups had no difference.

CONCLUSION

In a resource-limited setting with good expertise, laparoscopic surgery is an effective minimally invasive option that has good survival outcomes without imposing a financial burden on patients.

Comparative analysis of the safety and effectiveness of robotic natural orifice specimen extraction versus laparoscopic surgery for colorectal tumors through systematic review and meta-analysis

The purpose of this study and meta-analysis was to evaluate the perioperative and oncologic results of robotic NOSE versus laparoscopic surgery for colorectal tumors. We plan to perform an extensive electronic search on PubMed, CNKI, Embase, and the Cochrane Library to find research articles published from the beginning of the databases until July 2024 that examine the comparison between robotic natural orifice specimen extraction and laparoscopic surgery in patients with colorectal cancer. Both English and Chinese literature will be included. Literature screening will strictly follow predetermined criteria for inclusion and exclusion, specifically targeting randomized controlled trials and cohort studies. The evaluation of quality will be conducted with the Newcastle-Ottawa Scale (NOS). Review Manager 5.4.1 will be utilized to perform a meta-analysis of data gathered from the studies that are included. The ultimate evaluation included seven past cohort studies with a total of 1117 participants (545 who had robotic NOSE and 572 who had laparoscopic surgery). Patients who had robotic NOSE experienced notable enhancements in LOHS, time to first flatus, time to start the liquid diet, EBL, and postoperative ileus when compared to patients undergoing laparoscopic colorectal surgery. There were no notable discrepancies noted in terms of surgical duration, total complications, lymph node collection, and anastomotic leakage between the two methods. In conclusion, the use of robotic technology for extracting specimens through natural body openings in colorectal surgery is considered to be safe and achievable. It offers notable advantages over laparoscopic surgery, including reduced hospital stay, earlier time to first flatus and liquid intake, decreased EBL, and lower incidence of postoperative ileus.

Comparative analysis of safety and effectiveness between natural orifice specimen extraction and conventional transabdominal specimen extraction in robot-assisted colorectal cancer resection through systematic review and meta-analysis

The goal of this systematic review and meta-analysis is to evaluate the perioperative and oncologic results of natural orifice specimen extraction (NOSE) compared to conventional transabdominal specimen extraction (TASE) in robotic-assisted surgery for colorectal cancer. A comprehensive electronic search will be performed on PubMed, Embase, and the Cochrane Library to find research articles published from the beginning of the databases to July 2024 that focus on patients who have undergone robotic-assisted surgery for colorectal cancer. Specifically, this review will compare NOSE with conventional TASE. Only studies published in English will be considered. Literature screening will adhere closely to predetermined criteria for inclusion and exclusion, specifically targeting randomized controlled trials and cohort studies. The evaluation of quality will involve the use of the Newcastle-Ottawa Scale (NOS). Meta-analysis of the included studies' data will be performed using Review Manager 5.4.1. In the final analysis, 9 retrospective cohort studies comprising 1571 patients were included. Out of these, 732 patients opted for NOSE, while 839 patients chose conventional TASE in robotic colorectal surgery. Patients who received TASE experienced enhancements in hospital stay duration, time until first gas passage, wound infection rates, and time until the first intake of a liquid diet. Nevertheless, there were no notable distinctions noted between the two methods regarding surgery duration, projected blood loss, intestinal blockage, or frequency of anastomotic leakage. In patients undergoing robotic-assisted colorectal surgery, the safety and feasibility of NOSE are demonstrated. Compared to traditional TASE, it provides clear benefits including shorter hospital stays, earlier first flatus, quicker initiation of a liquid diet, and lower risk of wound infection.

Short-term results in a population based study indicate advantage for minimally invasive rectal cancer surgery versus open

BACKGROUND

The aim of this study was to determine if minimally invasive surgery (MIS) for rectal cancer is non-inferior to open surgery (OPEN) regarding adequacy of cancer resection in a population based setting.

METHODS

All 9,464 patients diagnosed with rectal cancer 2012-2018 who underwent curative surgery were included from the Swedish Colorectal Cancer Registry.

PRIMARY OUTCOMES

Positive circumferential resection margin (CRM < 1 mm) and positive resection margin (R1). Non-inferiority margins used were 2.4% and 4%.

SECONDARY OUTCOMES

30- and 90-day mortality, clinical anastomotic leak, re-operation < 30 days, 30- and 90-day re-admission, length of stay (LOS), distal resection margin < 1 mm and < 12 resected lymph nodes. Analyses were performed by intention-to-treat using unweighted and weighted multiple regression analyses.

RESULTS

The CRM was positive in 3.8% of the MIS group and 5.4% of the OPEN group, risk difference -1.6% (95% CI -1.623, -1.622). R1 was recorded in 2.8% of patients in the MIS group and in 4.4% of patients in the OPEN group, risk difference -1.6% (95% CI -1.649, -1.633). There were no differences between the groups in adjusted unweighted and weighted analyses. All analyses demonstrated decreased mortality and re-admissions at 30 and 90 days as well as shorter LOS following MIS.

CONCLUSIONS

In this population based setting MIS for rectal cancer was non-inferior to OPEN regarding adequacy of cancer resection with favorable short-term outcomes.

Postoperative decline in renal function after rectal resection and all-cause mortality: a retrospective cohort study

AIM

Fluid loss, dehydration and resultant kidney injury are common when a diverting ileostomy is formed during rectal cancer surgery, the consequences of which are unknown. The aim of this retrospective single-site cohort study is to evaluate the impact of sustained postoperative renal dysfunction after rectal resection on long-term renal impairment and survival.

METHOD

All patients with rectal adenocarcinoma undergoing resection between January 2003 and March 2017 were included, with follow-up to June 2020. The primary outcome was impact on long-term mortality attributed to a 25% or greater drop in estimated glomerular filtration rate (eGFR) following rectal resection. Secondary outcomes were the long-term effect on renal function resulting from the same drop in eGFR and the effect on long-term mortality and renal function of a 50% drop in eGFR. We also calculated the effect on mortality of a 1% drop in eGFR.

RESULTS

A total of 1159 patients were identified. Postoperative reductions in eGFR of 25% and 50% were associated with long-term overall mortality with adjusted hazard ratios of 1.84 (1.22-2.77) (p = 0.004) and 2.88 (1.45-5.71) (p = 0.002). The median survival of these groups was 86.0 (64.0-108.0) months and 53.3 (7.8-98.8) months compared with 144.5 (128.1-160.9) months for controls. Long-term effects on renal function were demonstrated, with those who sustained a >25% drop in renal function having a 38.8% mean decline in eGFR at 10 years compared with 10.2% in controls.

CONCLUSION

Persistent postoperative declines in renal function may be linked to long-term mortality. Further research is needed to assess causal relationships and prevention.

Low- versus standard- pneumoperitoneum in patients undergoing robot-assisted radical prostatectomy: a randomised, triple-blinded study

OBJECTIVE

To investigate the effectiveness and impact of low-pressure pneumoperitoneum (Pnp) on postoperative quality of recovery (QoR) and surgical workspace (SWS) in patients with prostate cancer undergoing robot-assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

A randomised, triple-blinded trial was conducted in a single centre in Denmark from March 2021 to January 2022. A total of 98 patients with prostate cancer undergoing RARP were randomly assigned to either low-pressure Pnp (7 mmHg) or standard-pressure Pnp (12 mmHg). Co-primary outcomes were postoperative QoR measured via the QoR-15 questionnaire on postoperative Day 1 (POD1), POD3, POD14, and POD30, and SWS assessed intraoperatively by a blinded assessor (surgeon) via a validated SWS scale. Data analysis was performed according to the intention-to-treat principle.

RESULTS

Patients who underwent RARP at low Pnp pressure demonstrated better postoperative QoR on POD1 (mean difference = 10, 95% confidence interval [CI] 4.4-15.5), but no significant differences were observed in the SWS (mean difference = 0.25, 95% CI -0.02 to 0.54). Patients allocated to low-pressure Pnp experienced statistically higher blood loss than those in the standard-pressure Pnp group (mean difference = 67 mL, P = 0.01). Domain analysis revealed significant improvements in pain (P = 0.001), physical comfort (P = 0.007), and emotional state (P = 0.006) for patients with low-pressure Pnp. This trial was registered at ClinicalTrials.gov, NCT04755452, on 16/02/2021.

CONCLUSION

Performing RARP at low Pnp pressure is feasible without compromising the SWS and improves postoperative QoR, including pain, physical comfort, and emotional state, compared to the standard pressure.

Quality of life in Tunisian colorectal cancer patients: a cross-sectional study

PURPOSE

Quality of life (QOL) of colorectal cancer (CRC) patients has been little studied in Tunisia. The aim of this work was to evaluate the QOL of CRC patients and to identify factors that may influence it.

METHODS

A cross-sectional, study spread was made over a period of 6 months on patients with CRC treated in the department of Medical Oncology of Farhat Hached University Hospital of Sousse. The EORTC questionnaires translated and validated in Arabic (QLQ-C30 and QLQ-CR29) were used.

RESULTS

142 patients diagnosed with colon or rectal cancer were enrolled. The overall QOL score was 58.5 ± 29.1. The emotional and sexual functional dimensions were the most affected, especially in women and patients under 50 years of age. QOL scores were higher in patients who were in complete remission (71.4 ± 24.7) and in good general condition (63.7 ± 26.6) physical activity may have a significant influence on all functional dimensions of QOL (p < 0.001). Fatigue was significantly (p < 0.001) more present when there was a sedentary lifestyleradiotherapy, palliative chemotherapy (1st and 2nd line) and targeted therapy.

CONCLUSION

Evaluating quality of life of patients with colorectal cancer in Tunisia is necessary especially those under 50 years old and in women. Laparoscopic surgery with restoration of intestinal continuity, less toxic palliative chemotherapy protocols, more accessibility to new radiotherapy technics will improve QOL of CRC patients. Physical activity and nutrition support are also essential in promoting QOL of these patients.

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2-3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non-operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum-assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.

Risk Factors and Preventive Measures for Anastomotic Leak in Colorectal Cancer

Anastomotic leak (AL) represents one of the most detrimental complications after colorectal surgery. The patient-related factors and surgery-related factors leading to AL have been identified in previous studies. Through early identification and timely adjustment of risk factors, preventive measures can be taken to reduce potential AL. However, there are still many problems associated with AL. The debate about preventive measures such as preoperative mechanical bowel preparation (MBP), intraoperative drainage, and surgical scope also continues. Recently, the gut microbiota has received more attention due to its important role in various diseases. Although the underlying mechanisms of gut microbiota on AL have not been validated completely, new strategies that manipulate intrinsic mechanisms are expected to prevent and treat AL. Moreover, laboratory examinations for AL prediction and methods for blood perfusion assessment are likely to be promoted in clinical practice. This review outlines possible risk factors for AL and suggests some preventive measures in terms of patient, surgery, and gut microbiota.

Mid- and low-rectal cancer: laparoscopic vs open treatment-short- and long-term results. Meta-analysis of randomized controlled trials

BACKGROUND

The laparoscopic approach in the treatment of mid- or low-rectal cancer is still controversial. Compared with open surgery, laparoscopic resection of extraperitoneal cancer is associated with improved short-time non-oncological outcomes, although high-level evidence showing similar short- and long-term oncological outcomes is scarce.

OBJECTIVE

The aim of our paper is to study the oncological and non-oncological outcomes of laparoscopic versus open surgery for extraperitoneal rectal cancer.

DATA SOURCES

A systematic review of MedLine, EMBASE, and CENTRAL from January 1990 to October 2020 was performed by combining various key words.

STUDY SELECTION

Only randomized controlled trials (RCTs) comparing laparoscopic versus open surgery for extraperitoneal rectal cancer were included. The quality of RCTs was assessed using the Cochrane reviewer's handbook. This meta-analysis was based on the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

INTERVENTION(S)

This study analyzes laparoscopic versus open surgery for extraperitoneal rectal cancer.

MAIN OUTCOME MEASURES

Primary outcomes were oncological parameters.

RESULTS

Fifteen RCTs comprising 4,411 patients matched the selection criteria. Meta-analysis showed a significant difference between laparoscopic and open surgery in short-time non-oncological outcomes. Although laparoscopic approach increased operation time, it decreases significantly the blood loss and length of hospital stay. No significant difference was noted regarding short- and long-term oncological outcomes, but 4 and 5 years disease-free survival were statistically higher in the open group.

LIMITATIONS

There are still questions about the long-term oncological outcomes of laparoscopic surgery for extraperitoneal rectal cancer being comparable to the open technique.

CONCLUSIONS

Considering that all surgical resections have been performed in high volume centers by expert surgeons, the minimally invasive surgery in patients with extraperitoneal cancer could still be not considered equivalent to open surgery in terms of oncological radicality.

Chylous ascites has a higher incidence after robotic surgery and is associated with poor recurrence-free survival after rectal cancer surgery

BACKGROUND

Postoperative chylous ascites is an infrequent condition after colorectal surgery and is easily treatable. However, its effect on the long-term oncological prognosis is not well established. This study aimed to investigate the short-term and long-term impact of chylous ascites treated with neoadjuvant therapy followed by rectal cancer surgery and to evaluate the incidence of chylous ascites after different surgical approaches.

METHODS

A total of 898 locally advanced rectal cancer patients treated with neoadjuvant chemoradiotherapy followed by surgery between January 2010 and December 2018 were included. The clinicopathological data and outcomes of the patients with chylous ascites were compared with those of the patients without chylous ascites. The primary endpoint was recurrence-free survival (RFS). To balance baseline confounders between groups, propensity score matching (PSM) was performed for each patient with a logistic regression model.

RESULTS

Chylous ascites was detected in 3.8% (34/898) of the patients. The incidence of chylous ascites was highest after robotic surgery (6.9%, 6/86), followed by laparoscopic surgery (4.2%, 26/618) and open surgery (1.0%, 2/192, P = 0.021). The patients with chylous ascites had a significantly higher number of lymph nodes harvested (15.6 vs. 12.8, P = 0.009) and a 3-day longer postoperative hospital stay (P = 0.017). The 5-year RFS rate was 64.5% in the chylous ascites group, which was significantly lower than the rate in the no chylous ascites group (79.9%; P = 0.007). The results remained unchanged after PSM was performed. The chylous ascites group showed a nonsignificant trend towards a higher peritoneal metastasis risk (5.9% vs. 1.6%, P = 0.120). Univariate analysis and multivariate analysis confirmed chylous ascites (hazard ratio= 3.038, P < 0.001) as an independent negative prognostic factor for RFS.

CONCLUSIONS

Considering the higher incidence of chylous ascites after laparoscopic and robotic surgery and its adverse prognosis, we recommend sufficient coagulation of the lymphatic tissue near the vessel origins, especially during minimally invasive surgery.

Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery

Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.

Robotic transanal total mesorectal excision: Is the future now?

Total mesorectal excision (TME) is the standard surgical treatment for the curative radical resection of rectal cancers. Minimally invasive TME has been gaining ground favored by the continuous technological advancements. New procedures, such as transanal TME (TaTME), have been introduced to overcome some technical limitations, especially in low rectal tumors, obese patients, and/or narrow pelvis. The earliest TaTME reports showed promising results when compared with the conventional laparoscopic TME. However, recent publications raised concerns regarding the high rates of anastomotic leaks or local recurrences observed in national series. Robotic TaTME (R-TaTME) has been proposed as a novel technique incorporating the potential benefits of a perineal dissection together with precise control of the distal margins, and also offers all those advantages provided by the robotic technology in terms of improved precision and dexterity. Encouraging short-term results have been reported for R-TaTME, but further studies are needed to assess the real role of the new technique in the long-term oncological or functional outcomes. The present review aims to provide a general overview of R-TaTME by analyzing the body of the available literature, with a special focus on the potential benefits, harms, and future perspectives for this novel approach.

Comparison of Short-Term and Long-Term outcomes of Laparoscopy Versus Laparotomy in Rectal Cancer: Systematic Review and Meta-analysis of Randomized Controlled Trials

Background and objective: The last randomized controlled trials ,the ACOSOG Z6051 1,2 and the ALaCaRT trial3, 4 could not show the non-inferiority of the laparoscopy in comparison to laparotomy for rectal cancer. In fact, the ten first years of practicing laparoscopy were years when surgeons developed their learning curve. Therefore, by excluding this learning bias, it is possible to end up with a more fair and correct comparison between the two techniques. It is henceforth relevant to pursue a new meta-analysis that compares the two techniques and excludes studies done during the earlier periods of laparoscopic rectal surgery. Results: Six randomized controlled trials met the eligibility criteria, involving a total of 1556 patients in the laparoscopy group and 1188 patients in the laparotomy group. Our meta-analysis was in favor of laparoscopy in a significant way for blood loss, first bowel movement and the number of harvested lymph nodes. It was non-significantly in favour of laparoscopy for 30-days mortality after surgery and length of hospital stay. It was significantly in favor of laparotomy for operative duration. No significant difference was found in anastomotic leakage) , reoperation within 30 days, number of positive CRMs and completeness of mesorectal excision between the two groups. No difference was found in recurrence, disease-free survival and overall survival between laparoscopy group and laparotomy group. Conclusion: The comparison of the randomized controlled trials published before and after 2010, showed no significant difference in outcomes between the learning period and after. Keywords: Laparoscopy, laparotomy, long-term outcomes, meta-analysis, short-term outcomes, rectal cancer

Clinical and oncological outcomes of the low ligation of the inferior mesenteric artery with robotic surgery in patients with rectal cancer following neoadjuvant chemoradiotherapy

Background/aim

The aim of this study is to compare clinical and oncologic outcomes of the high and low ligation techniques of the inferior mesenteric artery (IMA) in rectal cancer patients treated with robotic surgery after neoadjuvant chemoradiotherapy (nCRT).

Materials and methods

In this retrospective study, 77 patients with T3/T4-node negative rectal cancer with tumor penetration through the muscle wall (Stage 2) or node positive disease without distant metastases (Stage 3) who were treated electively with robotic surgical resection following nCRT at a single institution between January 2014 and January 2018 were analyzed. Patients were divided into 2 groups (38 patients were included in the low ligation group and 39 patients in the high ligation group).

Results

There was no statistical difference between the high ligation group and low ligation group in univariate analysis for 2-year overall survival and disease-free survival (OR = 1.146; 95% CI = 0.274 to 4.797; P = 0.950, and OR = 1.141; 95% CI = 0.564 to 2.308; P = 0.713, respectively). There was no significant difference between the 2 groups in the mean number of harvested lymph nodes and mean number of metastatic lymph nodes (P = 0.980 and P = 0.124, respectively). Anastomosis stricture was observed significantly less frequently in the low ligation group versus the high ligation group (2.6% and 28.2%, respectively) (P = 0.002). Also, the difference for the median length of hospital stay for the high and low ligation groups was statistically significant in favor of the low ligation group (P = 0.011).

Conclusion

In robotic rectal surgery, the low ligation technique of the IMA can reduce the rate of anastomosis stricture and provide similar oncological results as the high ligation technique.

Association of Surgical Skill Assessment With Clinical Outcomes in Cancer Surgery

Importance

Complex surgical interventions are inherently prone to variation yet they are not objectively measured. The reasons for outcome differences following cancer surgery are unclear.

Objective

To quantify surgical skill within advanced laparoscopic procedures and its association with histopathological and clinical outcomes.

Design, Setting, and Participants

This analysis of data and video from the Australasian Laparoscopic Cancer of Rectum (ALaCaRT) and 2-dimensional/3-dimensional (2D3D) multicenter randomized laparoscopic total mesorectal excision trials, which were conducted at 28 centers in Australia, the United Kingdom, and New Zealand, was performed from 2018 to 2019 and included 176 patients with clinical T1 to T3 rectal adenocarcinoma 15 cm or less from the anal verge. Case videos underwent blinded objective analysis using a bespoke performance assessment tool developed with a 62-international expert Delphi exercise and workshop, interview, and pilot phases.

Interventions

Laparoscopic total mesorectal excision undertaken with curative intent by 34 credentialed surgeons.

Main Outcomes and Measures

Histopathological (plane of mesorectal dissection, ALaCaRT composite end point success [mesorectal fascial plane, circumferential margin, ≥1 mm; distal margin, ≥1 mm]) and 30-day morbidity. End points were analyzed using surgeon quartiles defined by tool scores.

Results

The laparoscopic total mesorectal excision performance tool was produced and shown to be reliable and valid for the specialist level (intraclass correlation coefficient, 0.889; 95% CI, 0.832-0.926; P < .001). A substantial variation in tool scores was recorded (range, 25-48). Scores were associated with the number of intraoperative errors, plane of mesorectal dissection, and short-term patient morbidity, including the number and severity of complications. Upper quartile-scoring surgeons obtained excellent results compared with the lower quartile (mesorectal fascial plane: 93% vs 59%; number needed to treat [NNT], 2.9, P = .002; ALaCaRT end point success, 83% vs 58%; NNT, 4; P = .03; 30-day morbidity, 23% vs 50%; NNT, 3.7; P = .03).

Conclusions and Relevance

Intraoperative surgical skill can be objectively and reliably measured in complex cancer interventions. Substantial variation in technical performance among credentialed surgeons is seen and significantly associated with clinical and pathological outcomes.

Comparison of robotic and laparoscopic rectal cancer surgery: a meta-analysis of randomized controlled trials

OBJECTIVE

Robotic and laparoscopic surgery for rectal cancer has been applied in the clinic for decades; nevertheless, which surgical approach has a lower rate of postoperative complications is still inconclusive. Therefore, the aim of this meta-analysis was to compare the postoperative complications within 30 days between robotic and laparoscopic rectal cancer surgery based on randomized controlled trials.

METHODS

Randomized controlled trials (until May 2020) that compared robotic and laparoscopic rectal cancer surgery were searched through PubMed, EMBASE, the Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Data Knowledge Service Platform, and China Biology Medicine disc (CBMdisc). Data regarding sample size, clinical and demographic characteristics, and postoperative complications within 30 days, including overall postoperative complications, severe postoperative complications (Clavien-Dindo score ≥ III), anastomotic leakage, surgical site infection, bleeding, ileus, urinary complications, respiratory complications, conversion to open surgery, unscheduled reoperation, perioperative mortality, and pathological outcomes, were extracted. The results were analyzed using RevMan v5.3.

RESULTS

Seven randomized controlled trials that included 507 robotic and 516 laparoscopic rectal cancer surgery cases were included. Meta-analysis showed that the overall postoperative complications within 30 days [Z = 1.1, OR = 1.18, 95% CI (0.88-1.57), P = 0.27], severe postoperative complications [Z = 0.22, OR = 1.12, 95% CI (0.41-3.07), P = 0.83], anastomotic leakage [Z = 0.96, OR = 1.27, 95% CI (0.78-2.08), P = 0.34], surgical site infection [Z = 0.18, OR = 1.05, 95% CI (0.61-1.79), P = 0.86], bleeding [Z = 0.19, OR = 0.89, 95% CI (0.27-2.97), P = 0.85], ileus [Z = 1.47, OR = 0.66, 95% CI (0.38-1.15), P = 0.14], urinary complications [Z = 0.66, OR = 1.22, 95% CI (0.67-2.22), P = 0.51], respiratory complications [Z = 0.84, OR = 0.64, 95% CI (0.22-1.82), P = 0.40], conversion to open surgery [Z = 1.73, OR = 0.61, 95% CI (0.35-1.07), P = 0.08], unscheduled reoperation [Z = 0.14, OR = 0.91, 95% CI (0.26-3.20), P = 0.89], perioperative mortality [Z = 0.28, OR = 0.79, 95% CI (0.15-4.12), P = 0.78], and pathological outcomes were similar between robotic and laparoscopic rectal surgery.

CONCLUSION

Robotic surgery for rectal cancer was comparable to laparoscopic surgery with respect to postoperative complications within 30 days.

Prophylactic negative-pressure wound therapy after ileostomy reversal for the prevention of wound healing complications in colorectal cancer patients: a randomized controlled trial

Background

The aim of this study was to assess the usefulness of protective negative-pressure wound therapy (NPWT) in the reduction of wound healing complications (WHC) and surgical site infections (SSI) after diverting ileostomy closure in patients who underwent surgery for colorectal cancer.

Methods

In this prospective randomized clinical trial in a tertiary academic surgical center, patients who had colorectal cancer surgery with protective loop ileostomy and were scheduled to undergo ileostomy closure with primary wound closure from January 2016 to December 2018 were randomized to be treated with or without NPWT. The primary endpoint was the incidence of WHC. Secondary endpoints were incidence of SSI, length of postoperative hospital stay (LOS), and length of complete wound healing (CWH) time.

Results

We enrolled 35 patients NPWT (24 males [68.6%]; mean age 61.6 ± 11.3 years), with NPWT and 36 patients (20 males [55.6%]; mean age 62.4 ± 11.3 years) with only primary wound closure (control group). WHC was observed in 11 patients (30.6%) in the control group and 3 (8.57%) in the NPWT group (p = 0.020). Patients in the NPWT group had a significantly lower incidence of SSI (2 [5.71%] vs. 8 [22.2%] in the control group; p = 0.046) as well as significantly shorter median CWH (7 [7–7] days vs. 7 [7–15.5] days, p = 0.030). There was no difference in median LOS between groups (3 [2.5–5] days in the control group vs. 4 [2–4] days in the NPWT group; p = 0.072).

Conclusions

Prophylactic postoperative NPWT after diverting ileostomy closure in colorectal cancer patients reduces the incidence of WRC and SSI.

Clinical trial registration

clinicaltrials.gov (NCT04088162).

Impact of robotic learning curve on histopathology in rectal cancer: A pooled analysis

BACKGROUND

A beneficial impact of robotic proctectomy on circumferential resection margin (CRM) is expected due to the robot's articulating instruments in the pelvis. There are however concerns about a negative impact on the quality of total mesorectal excision (TME) due to the lack of tactile feedback. The aim of this study was to assess whether surgeons' learning curve impacted CRM and TME quality.

METHODS

In a multicenter study, individual patient data of robotic proctectomy for resectable rectal cancer were pooled. Patients were stratified into two phases of surgeons' learning curve. Cumulative sum (CUSUM) analysis was used to determine the transition from learning phase (LP) to plateau phase (PP), which were compared. CRM was microscopically measured in mm by pathologists. TME quality was classified by pathologists as complete, nearly complete or incomplete. T-test and Chi-squared tests were used to compare continuous and categorical variables, respectively.

RESULTS

235 patients underwent robotic proctectomy by five surgeons. 83 LP patients were comparable to 152 PP patients for age (p = 0.20), gender (67.5% vs. 65.1% males; p = 0.72), BMI (p = 0.82), cancer stage (p = 0.36), neoadjuvant chemoradiation (p = 0.13), distance of tumor from anal verge (5.8 ± 4.4 vs. 5.5 ± 3.3; p = 0.56). CRM did not differ (7.7 ± 11.4 mm vs. 8.4 ± 10.3 mm; p = 0.62). The rate of complete TME quality was significantly improved in PP patients as compared to LP patients (73.5% vs. 92.1%; p < 0.001).

CONCLUSION

While learning had no impact on circumferential resection margins, the quality of TME significantly improved during surgeons' plateau phase as compared to their learning phase.

Short- and long-term outcomes for transvaginal specimen extraction versus minilaparotomy after robotic anterior resection for colorectal cancer: a mono-institution retrospective study

BACKGROUND

Colorectal cancer resection surgery with transvaginal specimen extraction is becoming increasingly accepted and used by surgeons. However, few publications on robotic anterior sigmoid colon and rectal cancer resection with transvaginal specimen extraction (TVSE) have been reported, and a clinical outcome comparison between conventional robotic minilaparotomy (LAP) and transvaginal specimen extraction in anterior sigmoid colon and rectal cancer resection has not been performed. The current study compared the short- and long-term outcomes of TVSE and LAP for sigmoid colon cancer and rectal cancer in a mono-institution.

METHODS

From December 2014 to October 2018, 45 patients who underwent TVSE and 45 patients who underwent LAP matched by tumor location, tumor stage, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, gender, and age at the same period were included in the current study. The short- and long-term outcomes of TVSE and LAP were discussed.

RESULTS

No significant differences were found in patient characteristics. For the short-term outcomes, the operative time in the TVSE group was longer than that in the LAP group, and the postoperative pain and additional analgesia were lower in the TVSE group. Patients in the TVSE group required slightly less time to pass first flatus. There were no significant differences in overall complications, time to regular diet, length of hospital stay after surgery, estimated blood loss, or pathological outcomes. For long-term outcomes, the 3-year overall survival (94.9% vs. 91.7%, p = 0.702) and 3-year disease-free survival (88.4% vs. 86.2%, p = 0.758) were comparable between the two groups.

CONCLUSION

The robotic TVSE is safe and feasible in selected sigmoid/upper rectal cancer patients with tumor diameter < 5 cm. This approach has slightly better short-term outcomes in terms of less postoperative pain and less analgesic requirements without any significant difference in long-term outcomes.

Laparoscopic vs. open mesorectal excision for rectal cancer: Are these approaches still comparable? A systematic review and meta-analysis

BACKGROUND

To analyze pathologic and perioperative outcomes of laparoscopic vs. open resections for rectal cancer performed over the last 10 years.

METHODS

A systematic literature search of the following databases was conducted: Cochrane Central Register of Controlled Trials, MEDLINE (through PubMed), EMBASE, and Scopus. Only articles published in English from January 1, 2008 to December 31, 2018 (i.e. the last 10 years), which met inclusion criteria were considered. The review only included articles which compared Laparoscopic rectal resection (LRR) and Open Rectal Resection (ORR) for rectal cancer and reported at least one of the outcomes of interest. The analyses followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement checklist. Only prospective randomized studies were considered. The body of evidence emerging from this study was evaluated using the Grading of Recommendations Assessment Development and Evaluation (GRADE) system. Outcome measures (mean and median values, standard deviations, and interquartile ranges) were extracted for each surgical treatment. Pooled estimates of the mean differences were calculated using random effects models to consider potential inter-study heterogeneity and to adopt a more conservative approach. The pooled effect was considered significant if p <0.05.

RESULTS

Five clinical trials were found eligible for the analyses. A positive involvement of CRM was found in 49 LRRs (8.5%) out of 574 patients and in 30 ORRs out of 557 patients (5.4%) RR was 1.55 (95% CI, 0.99-2.41; p = 0.05) with no heterogeneity (I2 = 0%). Incorrect mesorectal excision was observed in 56 out of 507 (11%) patients who underwent LRR and in 41 (8.4%) out of 484 patients who underwent ORR; RR was 1.30 (95% CI, 0.89-1.91; p = 0.18) with no heterogeneity (I2 = 0%). Regarding other pathologic outcomes, no significant difference between LRR and ORR was observed in the number of lymph nodes harvested or concerning the distance to the distal margin. As expected, a significant difference was found in the operating time for ORR with a mean difference of 41.99 (95% CI, 24.18, 59.81; p <0.00001; heterogeneity: I2 = 25%). However, no difference was found for blood loss. Additionally, no significant differences were found in postoperative outcomes such as postoperative hospital stay and postoperative complications. The overall quality of the evidence was rated as high.

CONCLUSION

Despite the spread of laparoscopy with dedicated surgeons and the development of even more precise surgical tools and technologies, the pathological results of laparoscopic surgery are still comparable to those of open ones. Additionally, concerning the pathological data (and particularly CRM), open surgery guarantees better results as compared to laparoscopic surgery. These results must be a starting point for future evaluations which consider the association between ''successful resection" and long-term oncologic outcomes. The introduction of other minimally invasive techniques for rectal cancer surgery, such as robotic resection or transanal TME (taTME), has revealed new scenarios and made open and even laparoscopic surgery obsolete.

Voluntary perioperative colorectal cancer registry from Kerala-An initial overview

BACKGROUND

Although colorectal cancer (CRC) may not be uncommon in India, accurate data regarding its demographics and surgical outcomes is sparse.

METHODS

With an aim to assess demographics and perioperative outcomes of CRC in Kerala, all members of Association of Surgical Gastroenterologists of Kerala (ASGK) were invited to participate in a registry. Data of operated cases of CRC were entered on a web-based questionnaire by participating members from January 2016. Analysis of accrued data until March 2018 was performed.

RESULTS

From 25 gastrointestinal surgical centers in Kerala, 15 ASGK member hospitals contributed 1018 CRC cases to the database (M:F 621:397; median age-63.5 years [15-95 years]). Rectum (39.88%) and rectosigmoid (20.33%) cancers comprised the majority of the patients. Among them, preoperative bowel preparation was given to 37.68%, minimally invasive surgery (MIS) was performed in 73%, covering stoma in 47% and had an overall leak rate of 3.58%. In colonic malignancies, MIS was performed in 56.74%, covering stoma created in 13% and had a leak rate of 2.71%. Of 406 patients with rectal cancers, neo-adjuvant radiotherapy/chemoradiotherapy was given to 51.23%. The mean hospital stay for MIS in both rectal and colonic cancer patients was significantly shorter than open approach (10.46 ± 5.08 vs. 12.26 ± 6.03 days; p = 0.001and 10.29 ± 4.58 vs. 12.46 ± 6.014 days; p = <0.001). Mortality occurred in 2.2% patients.

CONCLUSION

A voluntary non-funded registry for CRC surgery was successfully created. Initial data suggest that MIS was performed in majority, which was associated with shorter hospital stay than open approach. Overall mortality and leak rate appeared to be low.

Outcomes of Minimally Invasive Versus Open Proctectomy for Rectal Cancer: A Propensity-Matched Analysis of Bi-National Colorectal Cancer Audit Data

BACKGROUND

Minimally invasive surgery is commonly used in the treatment of rectal cancer, despite the lack of evidence to support oncological equivalence or improved recovery compared with open surgery.

OBJECTIVE

This study aims to analyze prospectively collected data from a large Australasian colorectal cancer database.

DESIGN

This is a retrospective cohort study using propensity score matching.

SETTING

This study was conducted using data supplied by the Bi-National Colorectal Cancer Audit.

PATIENTS

A total of 3451 patients who underwent open (n = 1980), laparoscopic (n = 1269), robotic (n = 117), and transanal total mesorectal excision (n = 85) for rectal cancer were included in this study.

MAIN OUTCOME MEASURE

The primary outcome was positive margin rates (circumferential resection margin and/or distal resection margin) in patients treated with curative intent.

RESULTS

Propensity score matching yielded 1132 patients in each of the open and minimally invasive surgery groups. Margin positivity rates and lymph node yields did not differ between groups. The open group had a significantly lower total complication rate (27.6% vs 35.8%, p < 0.0001), including a lower rate of postoperative small-bowel obstruction (1.2% vs 2.5%, p = 0.03). The minimally invasive surgery group had significantly lower wound infection rate (2.9% vs 5.0%, p = 0.02) and a shorter length of hospital stay (8 vs 9 days, p < 0.0001). There was no difference in 30-day mortality.

LIMITATIONS

Results are limited by the quality of registry data entries.

CONCLUSION

In this patient population, minimally invasive proctectomy demonstrated similar margin rates in comparison with open proctectomy, with a reduced length of stay but a higher overall complication rate. See Video Abstract at http://links.lww.com/DCR/B190. RESULTADOS DE LA PROCTECTOMÍA MÍNIMA INVASIVA VERSUS ABIERTA PARA EL CÁNCER DE RECTO: UN ANÁLISIS DE PROPENSIÓN DE LOS DATOS BINACIONALES DE AUDITORÍA DEL CÁNCER COLORRECTAL: La cirugía mínima invasiva, frecuentemente se utiliza en el tratamiento del cáncer rectal, a pesar de la falta de evidencia que respalde la equivalencia oncológica o la mejor recuperación, en comparación con la cirugía abierta.El estudio tiene como objetivo analizar datos prospectivamente obtenidos, de una gran base de datos de cáncer colorrectal de Australia.Estudio de cohorte retrospectivo utilizando el emparejamiento de puntaje de propensión.Este estudio se realizó utilizando datos proporcionados por la Auditoría Binacional del Cáncer Colorrectal.Se incluyeron en este estudio un total de 3451 pacientes que se trataron de manera abierta (n = 1980), laparoscópica (n = 1269), robótica (n = 117) y taTME (n = 85) para cáncer rectal.Los resultados primarios fueron de tasas de margen positivas (margen de resección circunferencial y/o margen de resección distal) en pacientes con intención curativa.La coincidencia de puntaje de propensión arrojó 1132 pacientes en cada uno de los grupos de cirugía abierta y mínima invasiva. Las tasas de positividad del margen y los rendimientos de los ganglios linfáticos no difirieron entre los dos grupos. El grupo abierto tuvo una tasa de complicaciones totales significativamente menor (27.6% vs 35.8%, p <0.0001), incluida una tasa menor de obstrucción postoperatoria del intestino delgado (1.2% vs 2.5%, p = 0.03). El grupo de cirugía mínimamente invasiva tuvo una tasa de infección de la herida significativamente menor (2.9% frente a 5.0%, p = 0,02) y una estancia hospitalaria más corta (8 frente a 9 días, p <0.0001). No hubo diferencias en la mortalidad a los 30 días.Los resultados están limitados por la calidad de la entrada de datos de registro.En esta población de pacientes, la proctectomía mínima invasiva demostró tasas de margen similares en comparación con la proctectomía abierta, con una estadía reducida pero una tasa más alta de complicaciones en general. Consulte Video Resumen en http://links.lww.com/DCR/B190. (Traducción-Dr. Fidel Ruiz Healy).

Comparison of Changes in Disease-Free and Overall Survival of Resectable Rectal Adenocarcinoma between 2010 and 2015

Background

Management of rectal cancer (RC) has undergone many changes in recent decades. A multidisciplinary approach to this complex disease is essential, ensuring high-quality diagnostic, treatment, and outcomes. We aimed to compare treatment results of RC in a single-centre setting between 2010 and 2015.

Methods

A retrospective comparative study included patients with newly diagnosed and operated resectable RC. Patients' diagnostic and treatment data were analysed. Postoperative morbidity was measured according to the Clavien-Dindo classification. Survival data were received from the Lithuanian Cancer Registry. Continuous variables were expressed as mean and SD. Student t test and one-way ANOVA were used for parametric data and the Mann-Whitney test for non-parametric. A multivariate logistic regression analysis was used to identify independent factors for increased survival. Association between categorical variables was verified using Pearson χ².

Results

The study included 179 patients: 80 from 2010 and 99 from 2015. Mean sample age was 67.1 ± 10.7 years. There was no significant difference regarding age, gender, median ASA (3 in both groups), but mean hospital stay was 2 days shorter (8 vs. 10 days) in 2015 (p = 0.002). There were only 8 patients (4%) admitted to the hospital on an emergency basis. Pelvis MRI and abdominal CT were performed more often in 2015: from 37.5 to 77.8% (p < 0.001) and from 52.5 to 97% in 2015, respectively. Circumferential margin evaluation increased from 13.8 to 36.4% (p = 0.001). Neoadjuvant therapy increased from 20% in 2010 to 44.9% in 2015 (p = 0.01). The overall postoperative Clavien-Dindo complication rate was higher in 2015 (13.8 vs. 20.2%, p = 0.596), but in-hospital mortality was lower (1 vs. 0 patients). Comparison of radiological TNM and pathological TNM with one-way ANOVA showed a significant difference staging between 2010 (p = 0.002) and 2015 (p = 0.001). The 2-year overall survival (OS) increased from 76.3 to 86.9% (p = 0.046) and the median disease-free survival from 27 (range 0-35) months to 28 (range 0-35) months (72.5-83.5%, p = 0.077). Multivariate logistic regression analysis determined that availability and performance of MRI were associated with an increased OS (OR = 1.529, 95% CI 0.916-2.554, p = 0.020).

Conclusions

The expanded quantity of preoperative imaging, an improved radiological staging, and compulsory multidisciplinary team board discussions have led to selective neoadjuvant treatment decision followed by surgery which can positively affect the 2-year OS rate.

First Feasibility Study and Short-term Outcomes of Laparoscopic-Assisted Anterior Resection in Colorectal Cancer in Malaysia

PURPOSE

The purpose of this study was to demonstrate the feasibility and safety of laparoscopic-assisted anterior resection (LAAR) for colorectal cancer in a local Asian population.

METHODS

This is a retrospective review of all patients with colorectal cancer operated from November 2017 to October 2018. Main variables of interest were demography, type and surgery, length of stay (LOS), and the involvement of proximal and distal doughnut. Postoperative complications were analysed using chi-square or Fisher exact and Mann-Whitney tests.

RESULTS

There were 23 patients with a mean age of 62.5 ± 12.2 years. The mean time from diagnosis to surgery was 97.1 ± 154.84 days. There were 12 patients in the LAAR group and 11 in the open anterior resection (OAR) group. Duration of surgery was shorter in OAR (129.58 ± 51.38 minutes) compared to LAAR (147.91 ± 39.37 minutes). Mean LOS was shorter in the LAAR group with 5±1.5 days compared to the OAR group of 7.42 ± 4.25 days. However, there was no significant P-value for both duration of surgery (P = 0.322) or LOS (P = 0.87). A total of 3 complications were recorded after OAR and 2 after LAAR. Both groups had clear proximal and distal margins with 16 (12-18.5) harvested lymph nodes in LAAR and 18 (16-22) in OAR, which were equal (P = 0.155).

CONCLUSION

This study reports a shorter LOS in the minimally invasive group of 2 days with similar oncologic resection outcomes. This shows that LAAR is feasible in Malaysia and has potential outcome benefits.

Identification of the surgical indication line for the Denonvilliers' fascia and its anatomy in patients with rectal cancer

Background

The high rate of urogenital dysfunction after traditional total mesorectal excision (TME) has caused doubts among scholars on the standard fashion of dissection. We have proposed the necessity to preserve the Denonvilliers’ fascia in patients with rectal cancer. However, how to accurately locate the Denonvilliers’ fascia is unclear. This study aimed to explore anatomical features of the Denonvilliers’ fascia by comparing autopsy findings and observations of surgical videos so as to propose a dissection method for the preservation of pelvic autonomic nerves during rectal cancer surgery.

Methods

Five adult male cadaver specimens were dissected, and surgical videos of 135 patients who underwent TME for mid‐low rectal cancer between January 2009 and February 2019 were reviewed to identify and compare the structure of the Denonvilliers’ fascia.

Results

The monolayer structure of the Denonvilliers’ fascia was observed in 5 male cadaver specimens, and it was located between the rectum, the bottom of the bladder, the seminal vesicles, the vas deferens, and the prostate. The Denonvilliers’ fascia was originated from the rectovesical pouch (or rectum‐uterus pouch), down to fuse caudally with the rectourethral muscle at the apex of the prostate, and fused to the lateral ligaments on both sides. The fascia was thinner on the midline with a thickness of 1.06 ± 0.10 mm. The crown shape of the Denonvilliers’ fascia was slightly triangular, with a height of approximately 5.42 ± 0.16 cm at midline. Nerves were more densely distributed in front of the Denonvilliers’ fascia than behind, especially on both sides of it. Under laparoscopic view, the Denonvilliers’ fascia was originated at the lowest point of the rectovesical pouch (or rectum‐uterus pouch), with a thickened white line which was a good mark for identifying the Denonvilliers’ fascia.

Conclusion

Identification of the surgical indication line for the Denonvilliers’ fascia could help us identify the Denonvilliers’ fascia, and it would improve our ability to protect the pelvic autonomic function of patients undergoing TME for rectal cancer.

Open Versus Laparoscopic Versus Robotic Versus Transanal Mesorectal Excision for Rectal Cancer: A Systematic Review and Network Meta-analysis

OBJECTIVE

To compare techniques for rectal cancer resection.

SUMMARY BACKGROUND DATA

Different surgical approaches exist for mesorectal excision.

METHODS

Systematic literature review and Bayesian network meta-analysis performed.

RESULTS

Twenty-nine randomized controlled trials included, reporting on 6237 participants, comparing: open versus laparoscopic versus robotic versus transanal mesorectal excision. No significant differences identified between treatments in intraoperative morbidity, conversion rate, grade III/IV morbidity, reoperation, anastomotic leak, nodes retrieved, involved distal margin, 5-year overall survival, and locoregional recurrence. Operative blood loss was less with laparoscopic surgery compared with open, and with robotic surgery compared with open and laparoscopic. Robotic operative time was longer compared with open, laparoscopic, and transanal. Laparoscopic operative time was longer compared with open. Laparoscopic surgery resulted in lower overall postoperative morbidity and fewer wound infections compared with open. Robotic surgery had fewer wound infections compared with open. Time to defecation was longer with open surgery compared with laparoscopic and robotic. Hospital stay was longer after open surgery compared with laparoscopic and robotic, and after laparoscopic surgery compared with robotic. Laparoscopic surgery resulted in more incomplete or nearly complete mesorectal excisions compared with open, and in more involved circumferential resection margins compared with transanal. Robotic surgery resulted in longer distal resection margins compared with open, laparoscopic, and transanal.

CONCLUSIONS

The different techniques result in comparable perioperative morbidity and long-term survival. The laparoscopic and robotic approaches may improve postoperative recovery, and the open and transanal approaches may improve oncological resection. Technique selection should be based on expected benefits by individual patient.

Short-term and long-term outcomes of robotic rectal surgery-from the real word data of 1145 consecutive cases in China

Background

Due to a limited patient sample size, substantial data on robotic rectal resection (RRR) is lacking. Here, we reported a large consecutive cases from the real word data to assess the safety and efficacy of RRR.

Methods

From September 2010 to June 2017, a total of 1145 consecutive RRR procedures were performed in patients with stage I–IV disease. We conducted an analysis based on information from a prospectively designed database to evaluate surgical outcomes, urogenital function, and long-term oncological outcomes.

Results

Of three types of RRR performed, 227 (24.2%) were abdominoperineal resections, 865 (75.5%) were anterior resections, and 3 (0.3%) were Hartmann. Conversion to an open procedure occurred in 5.9% of patients. The overall positive circumferential margin rate was 1.3%. Surgical complication rate and mortality were 16.2% and 0.8% within 30 days of surgery, respectively. Mean hospital stay after surgery and hospital cost were 6.3 ± 2.9 days and 10442.5 ± 3321.5 US dollars, respectively. Risk factors for surgical complications included male gender, tumor location (mid-low rectum), combined organ resection, and clinical T category (cT3–4). Urinary function and general sexual satisfaction decreased significantly 1 month after surgery for both sexes. Subsequently, both parameters increased progressively, and the values 1 year after surgery were comparable to those measured before surgery. At a median follow-up of 34.6 months, local recurrence and distant metastases occurred in 2.3% and 21.1% of patients, respectively.

Conclusions

Robotic rectal resection was safe with preserved urogenital function and arrived equivalent oncological outcomes in a nonselected group of patients with rectal cancer.

Barbed Suture and Gastrointestinal Surgery. A Retrospective Analysis

Although minimally invasive surgery is recognized as the gold standard of many surgical procedures, laparoscopic suturing is still considered as the most difficult skill in laparoscopic surgery. The introduction of barbed sutures facilitates laparoscopic suturing because it is not necessary to tie a knot. The efficacy of this method has been evaluated in different types of surgery; however, less is known about general surgery. We retrospectively analysed data from 378 patients who had undergone bariatric or surgical treatment for colic or gastric malignancy requiring a closure of gastroentero, entero-entero or enterocolotomy from January 2014 to January 2019, admitted to the General Surgery Unit and Operative Unit of Surgical Endoscopy of the University Federico II (Naples, Italy). We registered 12 anastomotic leaks (3.1%), 16 anastomotic intraluminal bleedings (4.2%) and 7 extraluminal bleedings. Other complications included 23 cases of postoperative nausea and vomit (6%), 14 cases of postoperative ileus (3.7%) and 3 cases of intra-abdominal abscess (0.8%). Overall complications rate was 19.8% (75/378). No postoperative death was registered. Thus, by pooling together 378 patients, we can assess that barbed suture could be considered safe and effective for closure of holes used for the introduction of a branch of mechanical stapler to perform intracorporeal anastomosis.

Early Outcomes of Laparoscopic Versus Open Surgery for Urachal Remnant Resection in Children: A Retrospective Analysis Using a Nationwide Inpatient Database in Japan

Background: There was no large study that assessed the surgical safety of laparoscopic surgery (LS) for urachal remnant resection. This study compared early postoperative outcomes between LS and open surgery (OS) for pediatric urachal remnant resection, using a national inpatient database. Patients and Methods: Using the Diagnosis Procedure Combination database in Japan, we compared postoperative complications, duration of anesthesia, postoperative length of stay, and total hospitalization cost between LS and OS for children undergoing urachal remnant surgery from April 2015 to March 2017. Propensity score-adjusted analyses were performed for outcomes. Results: Among 882 eligible patients (306 LS; 576 OS), there were no significant differences between LS and OS for postoperative complications (odds ratio: 1.02; 95% confidence interval [CI]: 0.48-2.18; P = .96) and postoperative length of stay (difference: 0.14 day; 95% CI: -0.27 to 0.54; P = .39). Compared with OS, LS had significantly longer duration of anesthesia (difference: 51 minutes; 95% CI: 42-60; P < .001) and significantly higher total hospitalization cost (difference: US$824; 95% CI: 399-1249; P < .001). Conclusions: In this large nationwide cohort study, LS for urachal remnant resection was associated with longer duration of anesthesia and higher total hospitalization cost. However, no differences were detected between LS and OS regarding postoperative complications and length of stay. LS for urachal remnant resection is equivalent to OS in terms of surgical safety.

Completeness of total mesorectum excision of laparoscopic versus robotic surgery: a review with a meta-analysis

BACKGROUND

TME has revolutionized the surgical management of rectal cancer, and since the introduction of robotic TME (RTME), many reports have shown the feasibility and the safety of this approach. However, concerns persist regarding the advantages of robotic in surgery for the completeness of TME. The aim of this review is to compare robotic versus laparoscopic total mesorectal excision (TME) in rectal cancer, focusing on the completeness of TME.

METHODS

A systematic search was performed in the electronic databases for all available studies comparing RTME versus conventional laparoscopic LTME with declared grade of mesorectum excision. Data regarding sample size, clinical and demographic characteristics, number of complete, nearly complete, and incomplete TME were extracted. Primary outcome was the number of complete TME in robotic and laparoscopic procedures. Secondary outcomes were the numbers of nearly complete and incomplete TME in robotic and laparoscopic rectal resections.

RESULTS

Twelve articles were included in the final analysis. Complete TME was reported by all authors, involving 1510 procedures, showing a significant difference in favor of robotic surgery (OR = 1.83, 95% CI 1.08-3.10, p = 0.03). Nearly complete and incomplete TME showed no significant difference between the procedures. Meta-regression analysis showed that none of patients' and tumors' characteristics significantly impacted on complete TME.

CONCLUSIONS

Our results underline that the robotic approach to rectal resection is the better way to obtain a complete TME. However, it is mandatory that randomized clinical trials should be performed to assess definitively if robotic minimally invasive surgery is better than a laparoscopic resection.

Open versus minimally invasive surgery for rectal cancer: a single-center cohort study on 237 consecutive patients

Minimally invasive surgery (MIS) is gaining popularity in rectal tumor treatment. However, contrasting data are available regarding its safety and efficacy. Our aim is to compare the open and MIS approaches for rectal cancer treatment. Two-hundred-thirty-seven patients were included: 113 open and 124 MIS rectal resections. After the propensity score matching analysis (PS), the cases were matched into 42 open and 42 MIS. Short- and long-term outcomes, and pathological findings were analyzed before and after PS. A further comparison of the same outcomes and costs was conducted between the laparoscopic and the robotic approaches. As a whole, a sphincter-preserving procedure was more frequently performed in the MIS group (110 vs 75 cases; p < 0.0001). The estimated blood loss during MIS was significantly lower than during open surgery [127 (± 92) vs 242 (± 122) mL; p < 0.0001], with clear advantages for the robotic approach over laparoscopy [113 (± 87) vs 147 (± 93) mL; p 0.01]. Complication rate was comparable between the two groups. A higher rate of CRM positivity was evidenced after open surgery (12.4% vs 1.7%; p 0.004). A higher number of lymph nodes was harvested in the MIS group [12.5 (± 6.4) vs 11 (± 5.6); p 0.04]. After PS, no difference in terms of perioperative outcomes was noted, with the only exception of a higher blood loss in the open approach [242 (± 122) vs 127 (± 92) mL; p < 0.0001]. For the matched cases, no difference in 5-year overall and disease-free survival was evidenced (p 0.50 and 0.88, respectively). Mean costs were higher for robotics as compared to laparoscopy [9812 (±1974)€ vs 9045 (± 1893)€; p 0.02]. MIS could be considered as a treatment option for rectal cancer. The PS study evidenced clear advantages in terms of estimated blood loss over the open surgery. Costs still remain the main limit for robotics.

Transanal total mesorectal excision for low rectal cancer: a case-matched study comparing TaTME versus standard laparoscopic TME

Background

Transanal total mesorectal excision (TaTME) is emerging as a novel alternative to laparoscopic total mesorectal excision (LaTME). The aim of this study was to compare clinical and pathological results from these two techniques in patients undergoing rectal resections because of low rectal cancer.

Materials and methods

Thirty-five patients undergoing TaTME were matched with 35 patients operated on using LaTME. Composite primary endpoint (complete TME, negative circumferential resection margin [pCRM], and distal resection margin [pDRM]) was used to assess pathological quality specimens. Secondary outcomes included operative and postoperative parameters (operative time, total blood loss, postoperative morbidity, length of stay, 30-day mortality).

Results

Composite primary endpoint was achieved by 85% of subjects in the TaTME group and 82% of subjects in the LaTME group (P=0.66). Mean pCRM was 1.1±1.29 vs 0.99±0.78 mm (P=0.25). Distal pDRM was 1.57±0.92 and 1.98±1.22 cm (P=0.15). In the TaTME and LaTME groups, respectively, complete mesorectal excision was achieved in 89% and 83% of subjects, while excision was nearly complete for the remaining 11% and 17% (P=0.23).

Conclusion

TaTME appears to be a noninferior alternative to laparoscopic surgery. TaTME allows for quality retrieval of surgical specimens with comparable clinical outcomes with LaTME.

Surgical resection for rectal cancer. Is laparoscopic surgery as successful as open approach? A systematic review with meta-analysis

BACKGROUND

Recently, it has been questioned if minimally invasive surgery for rectal cancer was surgically successful. We decided to perform a meta-analysis to determine if minimally invasive surgery is adequate to obtain a complete resection for curable rectal cancer.

METHODS

A systematic search pertaining to evaluation between laparoscopic and open rectal resection for rectal cancer was performed until 30th November 2016 in the electronic databases (PubMed, Web of Science, Scopus, EMBASE), using the following search terms in all possible combinations: rectal cancer, laparoscopy, minimally invasive and open surgery. Outcomes analyzed were number of clear Distal Resection Margins (DRM or DM), complete Circumferential Resection Margins (CRM) and complete, nearly complete and incomplete Total Mesorectal Excision (TME) and of patients who received laparoscopic or open treatment for rectal cancer.

RESULTS

12 articles were included in the final analysis. The prevalence of successful surgical resection was similar between open and laparoscopic surgery. About distance from distal margin of the specimen, clear CRM and complete TME there were no statistically significant difference between the two groups (MD = -0.090 cm, p = 0.364, 95% CI -0.283, 0.104; OR = 1.032, p = 0.821, 95% CI 0.784, 1.360; OR = 0.933, p = 0.720, 95% CI 0.638, 1.364, respectively). The analysis of nearly complete TME showed a significant difference between the two groups (OR = 1.407, p = 0.006, 95% CI 1.103, 1.795), while the analysis of incomplete TME showed a non-significant difference (OR = 1.010, p = 0.964, 95% CI 0.664, 1.534).

CONCLUSIONS

By pooling together data from 5 RCTs and 7 nRCTs, we are able to provide evidence of safety and efficacy of minimally invasive surgery. Waiting for further randomized clinical trials, our results are encouraging to introduce laparoscopic rectal resection in daily practice.

Predictors of surgical outcomes and survival in rectal cancer patients undergoing laparoscopic total mesorectal excision after neoadjuvant chemoradiation therapy: the interest of pelvimetry and restaging magnetic resonance imaging studies

BACKGROUND

Locally advanced rectal cancer (LARC) requires a multimodal therapy tailored to the patient and tumor characteristics. Pretreatment magnetic resonance imaging (MRI) is necessary to stage the primary tumor, while restaging MRI, which is not systematically performed, may be of interest to identify poor responders to neoadjuvant chemoradiation therapy (NCRT), and redefine therapeutic approach. The EuMaRCS study group aimed to investigate the role and accuracy of pretreatment (including pelvimetry) and restaging MRIs in predicting surgical difficulties and surgical outcomes in LARC therapy.

METHODS

Patients with mid or low LARC who were administered NCRT, who underwent laparoscopic total mesorectal excision, and for whom pretreatment and restaging MRIs were available, were included.

RESULTS

MRIs of 170 patients (median age: 61 years) were reanalyzed by the same radiologist. Pelvimetry differed significantly between males and females, but no gender difference was noted in the clinical and tumor characteristics. Tumor volume and tumor height assessed on the restaging MRI were associated, respectively, with operative time and estimated blood loss. Conversion was predicted by tumor volume, interischial distance and pubic tubercle height. The quality of the surgical resection was found to be a predictor of overall and disease-free survival. The sensitivity and specificity of tumor regression grade 1 to identify a pathologic complete response were 76.9% and 89.3%, respectively.

CONCLUSIONS

In LARC management, pelvimetry and restaging MRI may be useful to predict surgical difficulties and surgical outcomes. However, the main independent predictor of patient survival appears to be the achievement of a successful surgical resection.