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Kang SI, Kim S, Kim JH. Introduction of extraperitoneal tunneling method: a way to secure the drain tube in the pelvic cavity after proctectomy. Ann Coloproctol 2024:ac.2023.00073.0010. [PMID: 38523291 DOI: 10.3393/ac.2023.00073.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/23/2023] [Indexed: 03/26/2024] Open
Abstract
The effectiveness of closed drainage tube insertion after low anterior resection has been controversial. We believe that drain tube displacement, which occurs up to 35% in real clinical practice, reduces the effectiveness of the drain tube. We report in this video a simple way to secure the drain tube in the pelvic cavity after low anterior resection and introduce a case that used the drain fixation method and treated anastomotic leakage without interventional procedure.
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Affiliation(s)
- Sung Il Kang
- Department of Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Sohyun Kim
- Department of Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
| | - Jae Hwang Kim
- Department of Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
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2
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Liu IC, Gearhart S, Ke S, Hu C, Chung H, Efron J, Gabre-Kidan A, Najjar P, Atallah C, Safar B, Christenson ES, Azad NS, Lee V, Zaheer A, Birkness-Gartman JE, Reddy AV, Narang AK, Meyer J. Surgical and local control outcomes after sequential short-course radiation therapy and chemotherapy for rectal cancer. Surg Open Sci 2024; 18:42-49. [PMID: 38318322 PMCID: PMC10838936 DOI: 10.1016/j.sopen.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 02/07/2024] Open
Abstract
Background Total neoadjuvant therapy (TNT) is an accepted approach for the management of locally advanced rectal cancer (LARC) and is associated with a decreased risk of development of metastatic disease compared to standard neoadjuvant therapy. However, questions remain regarding surgical outcomes and local control in patients who proceed to surgery, particularly when radiation is given first in the neoadjuvant sequence. We report on our institution's experience with patients who underwent short-course radiation therapy, consolidation chemotherapy, and surgery. Methods We retrospectively reviewed surgical specimen outcomes, postoperative complications, and local/pelvic control in a large cohort of patients with LARC who underwent neoadjuvant therapy incorporating upfront short-course radiation therapy followed by consolidation chemotherapy. Results In our cohort of 83 patients who proceeded to surgery, a complete/near-complete mesorectal specimen was achieved in 90 % of patients. This outcome was not associated with the time interval from completion of radiation to surgery. Postoperative complications were acceptably low. Local control at two years was 93.4 % for all patients- 97.6 % for those with low-risk disease and 90.4 % for high-risk disease. Conclusion Upfront short-course radiation therapy and consolidation chemotherapy is an effective treatment course. Extended interval from completion of short-course radiation therapy did not impact surgical specimen quality.
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Affiliation(s)
- I-Chia Liu
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan Gearhart
- Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Suqi Ke
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chen Hu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Haniee Chung
- Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan Efron
- Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alodia Gabre-Kidan
- Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter Najjar
- Department of Surgery, Colorectal Research Unit, Ravitch Division of Colorectal Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chady Atallah
- Department of Surgery, Division of Colon and Rectal Surgery, NYU Langone Health, New York, NY, USA
| | - Bashar Safar
- Department of Surgery, Division of Colon and Rectal Surgery, NYU Langone Health, New York, NY, USA
| | - Eric S. Christenson
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Nilofer S. Azad
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Valerie Lee
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA
| | - Atif Zaheer
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Abhinav V. Reddy
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol K. Narang
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeffrey Meyer
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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3
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White B, Naffouje S, Grunvald M, Bhama A, Dahdaleh F. Effect of prolonged operative time on short-term outcomes of open vs minimally invasive proctectomy. J Gastrointest Surg 2024; 28:141-150. [PMID: 38445935 DOI: 10.1016/j.gassur.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/19/2023] [Accepted: 11/30/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Minimally invasive proctectomy (MIP) may offer advantages over open proctectomy (OP). Increased operative times (OTs) are linked to inferior outcomes for various operations; however, the interplay between OT and approach for proctectomy is not well-established. This study aimed to evaluate associations of increasing OT on 30-day morbidity in OP and MIP cohorts. METHODS The American College of Surgeons National Quality Improvement Program Targeted Proctectomy Dataset was used to identify patients undergoing proctectomy. Cases were stratified by open or minimally invasive surgical approach and following propensity score matching between the groups, and OT quartiles were established for each group. Perioperative outcomes were compared among quartiles, and multivariate regression was used to identify factors associated with prolonged OT. RESULTS The median OT was longer for MIP (271 vs 232 min; P < .01). Although increased OT was associated with higher overall morbidity for both open and minimally invasive approaches, this effect was more pronounced in OP than in MIP (63.2% vs 38.4%, respectively; P < .001). Factors associated with prolonged OT included the procedure performed, male sex, higher body mass index scores, diverting ileostomy, and, in malignant disease, mid or lower and T4 tumors (all P < .05). CONCLUSION Herein, prolonged OT was associated with worse short-term outcomes for both OP and MIP cases; however, its detrimental effect was more pronounced for open surgery than for minimally invasive surgery. Our data suggested that MIP may offer short-term advantages for demanding cases requiring longer OTs.
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Affiliation(s)
- Bradley White
- Department of Surgery, University of Illinois Chicago, Chicago, Illinois, United States
| | - Samer Naffouje
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Miles Grunvald
- Department of Surgery, Rush University Medical Center, Chicago, Illinois, United States
| | - Anurhada Bhama
- Department of Surgery, Cleveland Clinic, Cleveland, Ohio, United States
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, Illinois, United States.
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Ferrer-Inaebnit E, Jeri McFarlene S, García-Granero García-Fuster A, González Argenté X. Female near-TME: standardization of proctectomy in women with ulcerative colitis. Cir Esp 2024; 102:32-39. [PMID: 37956717 DOI: 10.1016/j.cireng.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/04/2023] [Indexed: 11/15/2023]
Abstract
Traditionally, 2 surgical techniques for proctectomy in ulcerative colitis have been used: total mesorectal excision (TME), and close rectal dissection (CRD). Recently, our research group has proposed the standardization of the Near-TME technique, which unites the advantages of both methods. It decreases the risk of pelvic autonomic nerve injury and reduces the volume of mesorectal remnant. When performing the Near-TME, the anatomical landmarks differ between men and women, especially in the anterolateral hemicircumference. The objective of this paper is to standardize the Near-TME technique in women (Female Near-TME) using characteristic surgical-anatomic landmarks of the female pelvis based on illustrations and a real case treated laparoscopically. This technique should be carried out by surgeons with experience in inflammatory bowel disease surgery and extensive knowledge of surgical anatomy.
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Affiliation(s)
- E Ferrer-Inaebnit
- Unidad de Coloproctología, Servicio Cirugía General y Aparato Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - S Jeri McFarlene
- Unidad de Coloproctología, Servicio Cirugía General y Aparato Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, Spain; Instituto de Investigación Sanitaria Illes Balears (IdISBa), Spain; Profesor del Departamento de Anatomía y Embriología Humana, Universidad de Islas Baleares (UIB), Palma de Mallorca, Spain
| | - A García-Granero García-Fuster
- Unidad de Coloproctología, Servicio Cirugía General y Aparato Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, Spain; Instituto de Investigación Sanitaria Illes Balears (IdISBa), Spain; Profesor del Departamento de Anatomía y Embriología Humana, Universidad de Islas Baleares (UIB), Palma de Mallorca, Spain.
| | - X González Argenté
- Unidad de Coloproctología, Servicio Cirugía General y Aparato Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, Spain; Profesor del Departamento de Anatomía y Embriología Humana, Universidad de Islas Baleares (UIB), Palma de Mallorca, Spain
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Picciariello A, Kim HJ, Choi GS, Song SH. Robotic abdominoperineal resection for T4b rectal cancer using the da Vinci SP platform. Tech Coloproctol 2023; 27:1119-1122. [PMID: 37368080 DOI: 10.1007/s10151-023-02792-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/14/2023] [Indexed: 06/28/2023]
Abstract
PURPOSE The aim of the present report wasto describe a novel technique of robotic abdominoperineal resection (APR) for the treatment of T4b low rectal cancer using the da Vinci® Single-Port (SP) system (Intuitive Surgical, Sunnyvale, CA, USA). METHODS A 3-cm transverse incision was made in the left lower quadrant of the abdomen, in the area designated for permanent colostomy. A Uniport® (Dalim Medical, Seoul, Korea) was introduced and a 25 mm multichannel SP trocar was inserted into the Uniport. A 5-mm laparoscopic assistant port was introduced on the upper midline. A video showing each step of the technique is attached. RESULTS Two consecutive female patients (70 and 74 years old) underwent SP robotic APR with partial resection of the vagina 8 weeks after preoperative chemoradiotherapy. In both cases, rectal cancer was located 1 cm above the anal verge and invaded the vagina (initial stage and ymrT stage T4b). Operative time was 150 and 180 min, respectively. Estimated blood loss was 10 and 25 ml, respectively. No postoperative complications occurred. The length of postoperative hospital stay was 5 days in both cases. The final pathological stage was ypT4bN0 and ypT3N0 respectively. CONCLUSIONS In this first experience, SP robotic APR appears to be a safe and feasible procedure for locally advanced low rectal cancer. In addition, the invasiveness of the procedure is reduced by means of the SP system, which only requires a single incision in the area designated for colostomy. Prospective studies on a larger number of patients are necessary to confirm the outcomes of this technique compared to other minimally invasive approaches.
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Affiliation(s)
- A Picciariello
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-Gu, Daegu, 41404, Korea
- Department of Precision and Regenerative Medicine and Ionian Area, University "Aldo Moro" of Bari, Bari, Italy
| | - H J Kim
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-Gu, Daegu, 41404, Korea
| | - G-S Choi
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-Gu, Daegu, 41404, Korea.
| | - S H Song
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-Gu, Daegu, 41404, Korea
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Zaepfel S, Marcovei R, Fernandez-de-Sevilla E, Sourrouille I, Honore C, Gelli M, Faron M, Benhaim L. Robotic-assisted surgery for mid and low rectal cancer: a long but safe learning curve. J Robot Surg 2023; 17:2099-2108. [PMID: 37219783 DOI: 10.1007/s11701-023-01624-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 05/15/2023] [Indexed: 05/24/2023]
Abstract
The number of robotic-assisted procedures for rectal cancer is rising. The risk of this procedure when performed by surgeon with limited robotic experience is unknown and the precise duration of the learning curve debated. We, therefore, aimed to analyze the learning curve and its related safety in a single center before the development of mentoring programs. We prospectively recorded all robotic procedures performed for colorectal cancer between 2015 and 2020 by a single surgeon. Operative times for partial and total proctectomy were analyzed. The learning curve was defined by comparison with the standard duration of the laparoscopic procedure performed in expert centers (published in GRECCAR 5 and GRECCAR 6 trials) and calculated using a cumulative summation for learning curve test (LC-CUSUM). Among the 174 patients operated for colorectal cancer, we analyzed the outcomes of the 89 patients operated by partial and total robotic proctectomy. To reach repeatedly the same surgical duration as laparoscopic procedure for partial or complete proctectomy, the LC-CUSUM identified a learning curve of 57 patients. A severe morbidity in this population, defined by Clavien-Dindo classification ≥ 3, was observed in 15 cases (16.8%) with an anastomotic leak rate of 13.5%. The rate of completeness of mesorectal excision was 90% and the mean number of harvested lymph nodes was 15 (± 9). Using operative time as end-point, the learning curve of rectal cancer robotic surgery identified a cut-off of 57 patients. The technic remained safe with acceptable morbidity and oncological outcomes.
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Affiliation(s)
- Sophie Zaepfel
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Raluca Marcovei
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Elena Fernandez-de-Sevilla
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Isabelle Sourrouille
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Charles Honore
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Maximiliano Gelli
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
| | - Matthieu Faron
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France
- Oncostat U1018, Inserm, Université Paris-Saclay, Équipe Labellisée Ligue Contre le Cancer, Villejuif, France
| | - Leonor Benhaim
- Department of Surgical Oncology, Gustave Roussy Cancer Center, 39 rue Camille Desmoulins, 94800, Villejuif, France.
- Centre de Recherche Des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Equipe Labellisée Ligue Nationale Contre le Cancer, CNRS SNC 5096, 15 rue de l'école de Médecine, 75006, Paris, France.
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Biegel C, Brock S, Porter J, Kim D. A modified perineal approach for the management of strangulated rectal prolapse: A case report. Int J Surg Case Rep 2023; 109:108504. [PMID: 37467645 PMCID: PMC10372727 DOI: 10.1016/j.ijscr.2023.108504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/21/2023] Open
Abstract
INTRODUCTION Conditions associated with increased intraabdominal pressure may lead to rectal prolapse. Like any pathological herniation, rectal prolapse can strangulate if incarcerated. When a patient presents with signs and symptoms of strangulation, emergent surgical intervention is warranted. This report strives to strengthen existing evidence for the use of an Altemeier-type perineal approach as a viable choice for the management of strangulated rectal prolapse in healthy individuals. PRESENTATION OF CASE A healthy 70-year-old female presents with worsening rectal pain and an irreducible strangulated rectal prolapse. She is brought to the operating suite for an emergent exploration under anesthesia followed by an Altemeier-type procedure without diverting colostomy. The postoperative course is uneventful, and the patient is discharged on postoperative day three. Upon follow up, the patient reports having normal bowel function, and there is no evidence of recurrence. DISCUSSION Rectal prolapse is traditionally managed through either a perineal or transabdominal approach depending on the patient's clinical disposition. Incarcerated prolapse is a precursor to strangulation, and recent case reports have demonstrated the efficacy of the Altemeier procedure (perineal rectosigmoidectomy) to treat strangulated prolapse. Our initial exploration under anesthesia revealed a small section of ischemic rectal mucosa that was proximal to the rectosigmoid junction. As a result, we decided to remain within perineal parameters and perform the resection in an Altemeier-type fashion based on the boundary of ischemia. CONCLUSION An Altemeier approach was a reasonable option for emergent surgical management of strangulated rectal prolapse in an otherwise relatively healthy individual. This case has been reported in line with the SCARE criteria (Agha et al. [1]).
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Affiliation(s)
- C Biegel
- Department of Surgery, St. John's Episcopal Hospital, 327 Beach 19th St, Far Rockaway, NY 11691, United States of America.
| | - S Brock
- William Carey University College of Osteopathic Medicine, 710 William Carey Pkwy, Hattiesburg, MS 39401, United States of America
| | - J Porter
- Department of Surgery, St. John's Episcopal Hospital, 327 Beach 19th St, Far Rockaway, NY 11691, United States of America
| | - D Kim
- Department of Surgery, St. John's Episcopal Hospital, 327 Beach 19th St, Far Rockaway, NY 11691, United States of America
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Yang PF, Ang ZH, Badiani S, Berney CR, Morgan MJ. Impact of obesity on patients undergoing surgery for rectal cancer in Australia and New Zealand. Int J Colorectal Dis 2023; 38:163. [PMID: 37289290 PMCID: PMC10250449 DOI: 10.1007/s00384-023-04447-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/09/2023]
Abstract
PURPOSE Patients with obesity undergoing rectal cancer surgery may have an increased risk of developing complications, though evidence is inconclusive. The aim of this study was to determine the direct impact of obesity on postoperative outcomes using data from a large clinical registry. METHOD The Binational Colorectal Cancer Audit registry was used to identify patients who underwent rectal cancer surgery in Australia and New Zealand from 2007-2021. Primary outcomes were inpatient surgical and medical complications. Logistic regression models were developed to describe the association between body-mass index (BMI) and outcomes. RESULTS Among 3,708 patients (median age 66 years [IQR 56.75-75], 65.0% male), 2.0% had a BMI < 18.5 kg/m2, 35.4% had a BMI of 18.5-24.9 kg/m2, 37.6% had a BMI of 25.0-29.9 kg/m2, 16.7% had a BMI of 30.0-34.9 kg/m2, and 8.2% had a BMI ≥ 35.0 kg/m2. Surgical complications occurred in 27.7% of patients with a BMI of 18.5-24.9 kg/m2, 26.6% of patients with a BMI of 25.0-29.9 kg/m2 (OR 0.91, 95% CI 0.76-1.10), 28.5% with a BMI of 30.0-34.9 kg/m2 (OR 0.96, 95% CI 0.76-1.21), and 33.2% with a BMI ≥ 35.0 kg/m2 (OR 1.27, 95% CI 0.94-1.71). Modelling BMI as a continuous variable confirmed a J-shaped relationship. The association between BMI and medical complications was more linear. CONCLUSION Risk of postoperative complications is increased in patients with obesity undergoing rectal cancer surgery.
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Affiliation(s)
- Phillip F Yang
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | - Zhen Hao Ang
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Department of Surgery, Bankstown-Lidcombe Hospital, Sydney, Australia
| | - Sarit Badiani
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Christophe R Berney
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Department of Surgery, Bankstown-Lidcombe Hospital, Sydney, Australia
| | - Matthew J Morgan
- South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
- Department of Surgery, Bankstown-Lidcombe Hospital, Sydney, Australia
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Larach JT, Flynn J, Tew M, Fernando D, Apte S, Mohan H, Kong J, McCormick JJ, Warrier SK, Heriot AG. Robotic versus laparoscopic proctectomy: a comparative study of short-term economic and clinical outcomes. Int J Colorectal Dis 2023; 38:161. [PMID: 37284889 PMCID: PMC10247549 DOI: 10.1007/s00384-023-04446-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Although several studies compare the clinical outcomes and costs of laparoscopic and robotic proctectomy, most of them reflect the outcomes of the utilisation of older generation robotic platforms. The aim of this study is to compare the financial and clinical outcomes of robotic and laparoscopic proctectomy within a public healthcare system, utilising a multi-quadrant platform. METHODS Consecutive patients undergoing laparoscopic and robotic proctectomy between January 2017 and June 2020 in a public quaternary centre were included. Demographic characteristics, baseline clinical, tumour and operative variables, perioperative, histopathological outcomes and costs were compared between the laparoscopic and robotic groups. Simple linear regression and generalised linear model analyses with gamma distribution and log-link function were used to determine the impact of the surgical approach on overall costs. RESULTS During the study period, 113 patients underwent minimally invasive proctectomy. Of these, 81 (71.7%) underwent a robotic proctectomy. A robotic approach was associated with a lower conversion rate (2.5% versus 21.8%;P = 0.002) at the expense of longer operating times (284 ± 83.4 versus 243 ± 89.8 min;P = 0.025). Regarding financial outcomes, robotic surgery was associated with increased theatre costs (A$23,019 ± 8235 versus A$15,525 ± 6382; P < 0.001) and overall costs (A$34,350 ± 14,770 versus A$26,083 ± 12,647; P = 0.003). Hospitalisation costs were similar between both approaches. An ASA ≥ 3, non-metastatic disease, low rectal cancer, neoadjuvant therapy, non-restorative resection, extended resection, and a robotic approach were identified as drivers of overall costs in the univariate analysis. However, after performing a multivariate analysis, a robotic approach was not identified as an independent driver of overall costs during the inpatient episode (P = 0.1). CONCLUSION Robotic proctectomy was associated with increased theatre costs but not with increased overall inpatient costs within a public healthcare setting. Conversion was less common for robotic proctectomy at the expense of increased operating time. Larger studies will be needed to confirm these findings and examine the cost-effectiveness of robotic proctectomy to further justify its penetration in the public healthcare system.
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Affiliation(s)
- José Tomás Larach
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
- Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Julie Flynn
- Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Australia
| | - Michelle Tew
- Health Economics, Department of Health Services Research, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Diharah Fernando
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Sameer Apte
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Helen Mohan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Joseph Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
- Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Jacob J McCormick
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Australia
| | - Satish K Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
- Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia.
- Department of Oncology, Sir Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia.
- General Surgery and Gastrointestinal Clinical Institute, Epworth Healthcare, Melbourne, Australia.
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Kim EJ, Kim CW, Lee JL, Yoon YS, Park IJ, Lim SB, Yu CS, Kim JC. Partial mesorectal excision can be a primary option for middle rectal cancer: a propensity-score matched retrospective analysis. Ann Coloproctol 2023:ac.2022.00689.0098. [PMID: 36999173 DOI: 10.3393/ac.2022.00689.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/23/2022] [Indexed: 04/01/2023] Open
Abstract
Purpose Although partial and total mesorectal excision (PME and TME) is primarily indicated for the upper and lower rectal cancer, respectively, few studies have evaluated whether PME or TME is more optimal for middle rectal cancer. Methods This study included 671 patients with middle and upper rectal cancer who underwent robot-assisted PME or TME. The 2 groups were optimized by propensity-score matching of sex, age, clinical stage, tumor location, and neoadjuvant treatment. Results Complete mesorectal excision was achieved in 617 of 671 patients (92.0%), without showing a difference between the PME and TME groups. Local (5.3% vs. 4.3%, P>0.999) and systemic (8.5% vs. 16.0%, P=0.181) recurrence rates also did not differ between the 2 groups, respectively, in patients with middle and upper rectal cancer. The 5-year disease-free survival (81.4% vs. 74.0%, P=0.537) and overall survival (88.0% vs. 81.1%, P=0.847) rates also did not differ between the PME and TME groups, confined to middle rectal cancer. Moreover, 5-year recurrence and survival rates were not affected by distal resection margins of 2 cm (P=0.112) to 4 cm (P>0.999), regardless of pathological stages. Postoperative complication rate was higher in the TME than in the PME group (21.4% vs. 14.5%, P=0.027). Incontinence was independently associated with TME (odds ratio [OR], 2.009; 95% confidence interval, 1.015-3.975; P=0.045), along with older age (OR, 4.366, P<0.001) and prolonged operation time (OR, 2.196; P=0.500). Conclusion PME can be primarily recommended for patients with middle rectal cancer with lower margin of >5 cm from the anal verge.
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Affiliation(s)
- Ee Jin Kim
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan Wook Kim
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong Lyul Lee
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong Sik Yoon
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Park
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok-Byung Lim
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Sik Yu
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Cheon Kim
- Division of Colorectal Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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11
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Yoo RN, Kye BH, Kim H, Kim G, Cho HM. The pattern of bowel dysfunction in patients with rectal cancer following the multimodal treatment: anorectal manometric measurements at before and after chemoradiation therapy, and postoperative 1 year. Ann Coloproctol 2023; 39:32-40. [PMID: 35279968 PMCID: PMC10009062 DOI: 10.3393/ac.2021.00696.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/12/2021] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Bowel dysfunction commonly occurs in patients with locally advanced rectal cancer treated with a multimodal approach of chemoradiation therapy (CRT) combined with sphincter-preserving rectal resection. This study investigated the decline in anorectal function using sequential anorectal manometric measurements obtained before and after the multimodal treatment as well as at a 1-year follow-up. METHODS This was a retrospective cohort study conducted in a single center. The study population consisted of patients with locally advanced mid- to low rectal cancer who received the preoperative CRT followed by sphincter-preserving surgery from 2012 to 2016. The anorectal manometric value measured after each treatment modality was compared to demonstrate the degree of decline in anorectal function. A generalized linear model of repeated measures was performed using the manometric values measured pre- and post-CRT, and at 12 months postoperatively. RESULTS Overall, 100 patients with 3 consecutive manometric data were included in the final analysis. In the overall cohort study, the mean resting and maximal squeezing pressures showed insignificant decrement post-neoadjuvant CRT. At a 1-year postoperative follow-up, the maximal squeezing pressure significantly decreased. The maximal rectal sensory threshold demonstrated significant reduction consecutively after each following treatment (P<0.001). CONCLUSION The short-term effect of neoadjuvant CRT on the anal sphincters was relatively trivial. The following sphincter-saving surgery resulted in a profound disruption of the anorectal function. Patients with rectal cancer should be consulted on the consequence of multimodal treatment.
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Affiliation(s)
- Ri Na Yoo
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Bong-Hyeon Kye
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - HyungJin Kim
- Department of Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Gun Kim
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hyeon-Min Cho
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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12
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Yang YW, Huang SC, Cheng HH, Chang SC, Jiang JK, Wang HS, Lin CC, Lin HH, Lan YT. Protective loop ileostomy or colostomy? a risk evaluation of all common complications. Ann Coloproctol 2023:ac.2022.00710.0101. [PMID: 36702474 DOI: 10.3393/ac.2022.00710.0101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/15/2022] [Indexed: 01/28/2023] Open
Abstract
Purpose Protective ileostomy and colostomy are performed in patients undergoing low anterior resection with a high leakage risk. We aimed to compare surgical, medical, and daily care complications between these 2 ostomies in order to make individual choice. Methods Patients who underwent low anterior resection for rectal tumors with protective stomas between January 2011 and September 2018 were enrolled. Stoma-related complications were prospectively recorded by wound, ostomy, and continence nurses. The cancer stage and treatment data were obtained from the Taiwan Cancer Database of our Big Data Center. Other demographic data were collected retrospectively from medical notes. The complications after stoma creation and after the stoma reversal were compared. Results There were 176 patients with protective colostomy and 234 with protective ileostomy. Protective ileostomy had higher proportions of high output from the stoma for 2 consecutive days than protective colostomy (11.1% vs. 0%, P<0.001). Protective colostomy resulted in more stoma retraction than protective ileostomy (21.6% vs. 9.4%, P=0.001). Female sex, open operation, ileostomy, and carrying stoma more than 4 months were also significantly associated with a higher risk of stoma-related complications during diversion. The incidence of complication after stoma reversal did not differ between colostomy group and ileostomy group (24.3% vs. 20.9%, P=0.542). Conclusion We suggest avoiding colostomy in patients who are female and potential prolong diversion when stoma retraction is a concern. Otherwise, ileostomy should be avoided for patients with impaired renal function. Wise selection and flexibility are more important than using one type of stoma routinely.
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Affiliation(s)
- Yi-Wen Yang
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Sheng-Chieh Huang
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hou-Hsuan Cheng
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Ching Chang
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jeng-Kai Jiang
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Huann-Sheng Wang
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Chi Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hung-Hsin Lin
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yuan-Tzu Lan
- Division of Colon and Rectal Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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13
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Garcia-Granero A, Pellino G, Spinelli A, Gonzalez-Argente X. Advocating for the use of "near-TME" to describe a surgical technique: a plea to use consistent terminology. Tech Coloproctol 2023; 27:427-428. [PMID: 36662370 DOI: 10.1007/s10151-023-02754-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/04/2023] [Indexed: 01/21/2023]
Affiliation(s)
- A Garcia-Granero
- Colorectal Unit, Hospital Universitario Son Espases, Palma de Mallorca, Spain. .,Applied Surgical Anatomy Unit, Human Embryology and Anatomy Department, University of Valencia, Valencia, Spain. .,Human Embryology and Anatomy Department, University of Islas Baleares, Mallorca, Spain.
| | - G Pellino
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy.,Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - A Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - X Gonzalez-Argente
- Colorectal Unit, Hospital Universitario Son Espases, Palma de Mallorca, Spain
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14
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Kuroki H, Sugita A, Koganei K, Tatsumi K, Nakao E, Obara N. Postoperative results and complications of fecal diversion for anorectal Crohn's disease. Surg Today 2023; 53:386-392. [PMID: 35867163 PMCID: PMC9950159 DOI: 10.1007/s00595-022-02556-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 06/29/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Fecal diversion is a less-invasive technique that can alleviate symptoms in patients with refractory anorectal Crohn's disease. However, complications, including recurrence of residual anorectal Crohn's disease, may develop. We aimed to evaluate the postoperative results and complications associated with fecal diversion in patients with refractory anorectal Crohn's disease. METHODS We enrolled 1218 Crohn's disease patients who underwent laparotomy at our institute. We retrospectively analyzed the clinical features of 174 patients who underwent fecal diversion for refractory anorectal Crohn's disease, complications of the diverted colorectum, and the incidence and risk factors for proctectomy after fecal diversion. RESULTS After fecal diversion, 74% of patients showed improved symptoms. However, bowel continuity restoration was successful in four patients (2.2%), and anorectal Crohn's disease recurred in all patients. Seventeen patients developed cancer with a poor prognosis. The rate of conversion to proctectomy after fecal diversion was 41.3%, and the risk factors included rectal involvement (p = 0.02), loop-type stoma (p < 0.01), and the absence of treatment with biologics after fecal diversion (p = 0.03). CONCLUSION Fecal diversion for refractory anorectal Crohn's disease can improve clinical symptoms. Patients with rectal involvement or loop-type stoma have a greater risk of requiring proctectomy following fecal diversion. The administration of biologic may decrease the rate of proctectomy.
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Affiliation(s)
- Hirosuke Kuroki
- Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen's Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855, Japan.
| | - Akira Sugita
- grid.417366.10000 0004 0377 5418Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855 Japan
| | - Kazutaka Koganei
- grid.417366.10000 0004 0377 5418Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855 Japan
| | - Kenji Tatsumi
- grid.417366.10000 0004 0377 5418Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855 Japan
| | - Eiichi Nakao
- grid.417366.10000 0004 0377 5418Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855 Japan
| | - Nao Obara
- grid.417366.10000 0004 0377 5418Department of Surgery for Inflammatory Bowel Disease, Yokohama Municipal Citizen’s Hospital, 1-1, Mitsuzawanishicho Kanagawa-ku, Yokohama City, 221-0855 Japan
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15
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Abstract
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.
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Affiliation(s)
- Alexander Dowli
- Division of Colorectal Surgery, Department of Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Alessandro Fichera
- Division of Colorectal Surgery, Department of Surgery, Baylor University Medical Center, Dallas, TX, USA.
| | - James Fleshman
- Division of Colorectal Surgery, Department of Surgery, Baylor University Medical Center, Dallas, TX, USA
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16
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Parnasa SY, Chill H, Helou B, Cohen A, Alter R, Shveiky D, Mizrahi I, Abu-Gazala M, Pikarsky AJ, Shussman N. Low anterior resection syndrome following rectal cancer surgery: are incidence and severity lower with long-term follow-up? Tech Coloproctol 2022. [PMID: 36097205 DOI: 10.1007/s10151-022-02699-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is a functional disorder that may follow restorative proctectomy. The aim of this study was to evaluate the long-term incidence and risk factors for LARS following surgery for rectal cancer. METHODS A retrospective study was performed on patients from a prospectively maintained database, who underwent a restorative proctectomy between January 2014 and December 2019 at Hadassah Hebrew University Medical Center. The study cohort was divided into two groups: patients following partial proctectomy with a partial mesorectal excision and a colorectal anastomosis (PME group) and patients following total proctectomy with total mesorectal excision and a coloanal anastomosis (TME group). The incidence and severity of LARS were evaluated using the LARS questionnaire. Risk factors for LARS were also evaluated. RESULTS A total of 240 patients (male: female ratio 134:106, median age 64 years [interquartile range 55-71 years]) were included in the analysis. There were 160 patients in the PME group and 80 patients in the TME group. The overall incidence of LARS was 37.4% (26.5% major LARS and 10.9% minor LARS). Major LARS was observed in 53.8% of patients who underwent TME and in 12.7% of patients who underwent PME (p < 0.001). On multivariate analysis, distance of the anastomosis from the anal verge, TME, and neoadjuvant radiotherapy were independent prognostic factors for LARS. The incidence and severity of LARS were significantly lower in patients with longer follow-up (p = 0.05). CONCLUSIONS Significant improvement in LARS can be expected with longer follow-up. Distance of the anastomosis from the anal verge, TME and neoadjuvant radiotherapy are independent risk factors for LARS.
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Abstract
PURPOSE Our previously published clinical studies described the short-term outcomes of a newly developed intraluminal fecal diverting device (FDD). FDD was a safe and effective substitute for a defunctioning stoma. However, the long-term efficacy and safety of this device remain unknown. We investigated the long-term outcomes of the use of the FDD as a substitute for a defunctioning stoma. METHODS We examined the medical records of patients who participated in our two previous FDD clinical studies. The main outcome was the number of patients with bowel continuity for 2 years after undergoing the FDD procedure or defunctioning stoma creation. RESULTS Between May 2015 and July 2018, 85 patients were screened for inclusion in this study. Of those, 27 patients underwent a defunctioning ileostomy after proctectomy. The remaining 58 underwent the FDD procedure after proctectomy. Seventy-two patients (ileostomy group, n = 22; FDD group, n = 50) with a follow-up duration > 24 months were included in this analysis. The mean duration of fecal diversion was significantly shorter (p < 0.001) in the FDD group (3.1 [1.6-6.1] weeks) than in the ileostomy group (16.7 [10.0-31.6] weeks). However, the rate of permanent stoma creation was not statistically different between the two groups (ileostomy and FDD groups, 13.6% [3/22] and 10.0% [5/50], respectively; p = 0.693). CONCLUSIONS The FDD procedure is a feasible substitute for a defunctioning stoma after proctectomy. Multicenter large-scaled clinical studies are required to validate our results.
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Affiliation(s)
- Sung Il Kang
- Department of Surgery, College of Medicine, Yeungnam University, 170, Hyeonchung-ro, Nam-Gu, Daegu, 42415, Korea.
| | - Sohyun Kim
- Department of Surgery, College of Medicine, Yeungnam University, 170, Hyeonchung-ro, Nam-Gu, Daegu, 42415, Korea
| | - Jae Hwang Kim
- Department of Surgery, College of Medicine, Yeungnam University, 170, Hyeonchung-ro, Nam-Gu, Daegu, 42415, Korea
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18
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Nozawa H, Hata K, Sasaki K, Murono K, Kawai K, Emoto S, Ishihara S. Laparoscopic vs open restorative proctectomy after total abdominal colectomy for ulcerative colitis or familial adenomatous polyposis. Langenbecks Arch Surg 2022; 407:1605-1612. [PMID: 35294600 DOI: 10.1007/s00423-022-02492-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 03/09/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Randomized controlled trials (RCTs) demonstrated that a laparoscopic approach provides short-term benefits, such as reduced blood loss and a shorter hospital stay, in patients who undergo rectal surgery. On the other hand, a few RCTs investigating proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) or familial adenomatous polyposis (FAP) suggested limited advantages of laparoscopic surgery over open surgery. A substantial proportion of patients with UC or FAP may undergo staged operations with IPAA, but no study has compared the two approaches for proctectomy with IPAA after total abdominal colectomy. METHODS We examined 61 consecutive patients with UC or FAP who underwent proctectomy with IPAA after colectomy in our hospital. Patients were divided into the Lap group (n = 37) or the Op group (n = 24) according to surgical approach. Patient background and outcomes, such as operative time, blood loss, first bowel movement, postoperative complications, and pouchitis, were compared between these groups. RESULTS One patient required conversion to open surgery in the Lap group. The median volume of blood loss was 90 mL in the Lap group and 580 mL in the Op group (p < 0.0001). The Lap group showed a shorter time to first bowel movement than the Op group (median: 1 vs 2 days, p = 0.0003). The operative time, frequencies of postoperative complications, and accumulation rate of pouchitis were similar between the two groups. CONCLUSIONS Laparoscopic surgery was beneficial for patients undergoing restorative proctectomy in terms of blood loss and bowel recovery without increasing the operative time or rate of complications.
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Affiliation(s)
- Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Keisuke Hata
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Koji Murono
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Hamabe A, Okita K, Nishidate T, Okuya K, Akizuki E, Sato Y, Ishii M, Miura R, Korai T, Takemasa I. Short-Term Outcomes with Standardized Transperineal Minimally Invasive Abdominoperineal Excision for Rectal Cancer. J Gastrointest Surg 2022; 26:713-9. [PMID: 34608600 DOI: 10.1007/s11605-021-05140-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/25/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Transperineal abdominoperineal excision (TpAPE) is an emerging approach for low rectal cancers but is technically challenging. Based on an anatomical study we conducted previously, we have standardized the TpAPE procedure. Here, we aimed to validate the feasibility of the standardized TpAPE by investigating the short-term outcomes. METHODS From January 2018 to November 2020, a total of 405 patients underwent laparoscopic or robotic rectal resection for rectal cancer in our institution. For the current study, we analyzed data for the 31 patients who underwent TpAPE. The abdominal phase was performed synchronously with the perineal phase using either a laparoscopic or robotic approach. Short-term outcomes included operative and pathological results. RESULTS Of the 31 cases, we identified anterior quadrant tumor invasion in 21. Most of the cases were advanced, with 6 staged as cT3 and 20 as T4. Of the 27 cases not involving distant metastasis, neoadjuvant therapy was performed in 19. No inadvertent rectal perforation or urethral injury was found intraoperatively. The median procedural duration to specimen removal was 250 min (interquartile range, 204-287), and the median intraoperative blood loss was 10 ml (interquartile range, 5-40). Regarding postoperative complications, perineal wound infection developed in 11 cases. A positive circumferential resection margin was found in 3, corresponding to the positive rate of 9.7%. These three cases were among the first 12 cases involving standardized TpAPE. CONCLUSIONS The current results indicate that TpAPE can be performed safely and might represent a useful option for low rectal cancer resection.
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20
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Zbar A. Cutting piles in Crohn's disease. Tech Coloproctol 2022; 26:329-330. [PMID: 35146586 PMCID: PMC8917017 DOI: 10.1007/s10151-022-02571-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/09/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Andrew Zbar
- Department of Anatomy and Neuroscience, The University of Melbourne, Melbourne, Australia. .,Department of Anatomy and Physiology, The University of Melbourne, Melbourne, Australia.
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21
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Garcia-Granero A, Pellino G, Fletcher-Sanfeliu D, Millan M, Primo-Romaguera V, Garcia-Gausí M, Fernandez M, Gonzalez-Argente X, Spinelli A, Valverde-Navarro A, Garcia-Granero E. "Near-TME": proposed standardisation of the technique for proctectomy in male patients with ulcerative colitis. Tech Coloproctol 2022; 26:217-226. [PMID: 35103902 PMCID: PMC8857132 DOI: 10.1007/s10151-022-02579-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/17/2022] [Indexed: 12/19/2022]
Abstract
Background The aim of the present study was to describe in detail an approach to proctectomy in ulcerative colitis (UC), which can be standardized; near-total mesorectal excision (near-TME), to prevent injuries to autonomic pelvic nerves and subsequent sexual dysfunction. Methods We demonstrate the technique ex vivo on a cadaver from a male patient in lithotomy position and on a sagittal section of a male pelvis. We also demonstrate the technique in vivo in two male patients diagnosed with UC, with no history of sexual dysfunction or bowel neoplasia. The study was performed at the Human Embryology and Anatomy Department. University of Valencia, Spain. Results The posterolateral dissection during a near-TME is similar to that of an oncologic TME, whereas the anterolateral is similar to that of a close rectal dissection. The near-TME technique preserves the superior hypogastric plexus, the hypogastric nerves, the nervi erigentes, the inferior hypogastric plexus, the pelvic plexus and the cavernous nerves. Conclusion The near-TME technique is the standardisation of the technique for proctectomy in male patients with ulcerative colitis. Near-TME requires experience in pelvic surgery and an exhaustive knowledge of the embryological development and of the surgical anatomy of the pelvis. Supplementary Information The online version contains supplementary material available at 10.1007/s10151-022-02579-z.
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Affiliation(s)
- A Garcia-Granero
- Colorectal Unit, Hospital Universitario Son Espases, Palma de Mallorca, Spain.,Applied Surgical Anatomy Unit, Human Embryology and Anatomy Department, University of Valencia, Valencia, Spain.,Human Embryology and Anatomy Department, University of Islas Baleares, Palma, Spain
| | - G Pellino
- Department of Advanced Medical and Surgical Sciences, Università Degli Studi Della Campania "Luigi Vanvitelli", Naples, Italy. .,Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - D Fletcher-Sanfeliu
- Cardiac Surgery Department, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - M Millan
- Colorectal Surgery, Hospital Universitario Y Politecnico "La Fe", Valencia, Spain
| | - V Primo-Romaguera
- Colorectal Surgery, Hospital Universitario Y Politecnico "La Fe", Valencia, Spain
| | - M Garcia-Gausí
- Applied Surgical Anatomy Unit, Human Embryology and Anatomy Department, University of Valencia, Valencia, Spain
| | - M Fernandez
- Colorectal Unit, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - X Gonzalez-Argente
- Colorectal Unit, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - A Spinelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - A Valverde-Navarro
- Applied Surgical Anatomy Unit, Human Embryology and Anatomy Department, University of Valencia, Valencia, Spain
| | - E Garcia-Granero
- Colorectal Surgery, Hospital Universitario Y Politecnico "La Fe", Valencia, Spain
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22
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Burns L, Kelly ME, Whelan M, O'Riordan J, Neary P, Kavanagh DO. A contemporary series of surgical outcomes following subtotal colectomy and/or completion proctectomy for management of inflammatory bowel disease. Ir J Med Sci 2022; 191:2705-2710. [PMID: 35037158 DOI: 10.1007/s11845-021-02907-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The main indications for emergency subtotal colectomy (SC) include management of toxic colitis, refractory haemorrhage and/or perforation. Alternatively, elective surgery is performed for those refractory to medical therapy or with evidence of multifocal dysplasia. Overall, the annual incidence of SC has fallen since the introduction of biologic therapies and we aimed to review our current practices. METHODS A retrospective review of inflammatory bowel disease (IBD) patients undergoing subtotal colectomy between 2013 and 2020 was performed. Medical records, operative notes, discharge summaries, histopathology reports and other supporting documents were reviewed. Indication for surgery, management of the rectum (i.e. maintenance of rectal stump, progression to completion proctectomy or IPAA formation) associated morbidity (Clavien-Dindo classification) and length of hospital stay were examined. RESULTS Fifty-six IBD patients underwent a subtotal colectomy. Twenty-five patients (UC 14, Crohn's 11) had an elective procedure, and 31 patients (UC 19 Crohn's 12) had an emergency/semi-urgent procedure. Interestingly, 80% (n = 25) of the emergency cohort and 68% (n = 17) of the elective cohort had a laparoscopic resection. Major morbidity (Clavien-Dindo > 2) was higher among the emergency group (39% vs. 24%). Deep surgical site infection was the commonest morbidity (13%) in the emergency group, while superficial surgical site infection was commonest in the elective cohort (20%). Overall, there was no difference in surgical re-intervention rate (13% vs 12%), and there were no perioperative mortalities. Median post-operative length of stay was shorter in the elective cohort (9 versus 13 days). CONCLUSION A significant proportion of IBD patients still require semi-urgent/emergency colectomy, which is associated with considerable length of stay and morbidity. The results of our study provide real-world outcomes to help counsel patients on expected outcomes.
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Affiliation(s)
- Lucy Burns
- Department of Surgery, Beaumont Hospital, Dublin 9, Ireland.
| | - Michael E Kelly
- Department of Surgery, St James' Hospital, Dublin 8, Ireland
| | - Maria Whelan
- Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | - James O'Riordan
- Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | - Paul Neary
- Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
| | - Dara O Kavanagh
- Department of Surgery, Tallaght University Hospital, Dublin 24, Ireland
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23
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Justiniano CF, Becerra AZ, Loria A, Xu Z, Aquina CT, Temple LK, Fleming FJ. Is robotic utilization associated with increased minimally invasive colorectal surgery rates? Surgeon-level evidence. Surg Endosc 2022; 36:5618-5626. [PMID: 35024928 PMCID: PMC8757409 DOI: 10.1007/s00464-022-09023-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 01/03/2022] [Indexed: 11/26/2022]
Abstract
Background It is unclear whether robotic utilization has increased overall minimally invasive colorectal surgery rates or if robotics is being adopted instead of laparoscopy. The goal was to evaluate whether increasing robotic surgery utilization is associated with increased rates of overall colorectal minimally invasive surgery. Methods The Statewide Planning and Research Cooperative System (New York) was used to identify patients undergoing elective colectomy or proctectomy from 2009 to 2015. Individual surgeons were categorized as having increasing or non-increasing robotic utilization (IRU or non-IRU, respectively) based on the annual increase in the proportion of robotic surgery performed. The odds of surgical approach across the study period were evaluated with multinomial regression. Results Among 72,813 resections from 2009 to 2015, minimally invasive-surgery increased (47–61%, p < 0.0001). For colectomy, overall minimally invasive-surgery rates increased (54–66%, p < 0.0001), laparoscopic remained stable (53–54%), and robotics increased (1–12%). For proctectomy, overall minimally invasive-surgery rates increased (22–43%, p < 0.0001), laparoscopic remained stable (20–21%), and robotics increased (2–22%). Over the study period, 2487 surgeons performed colectomies. Among 156 surgeons with IRU for colectomies, robotics increased (2–29%), while laparoscopy decreased (67–44%), and open surgery decreased (31–27%). Overall, surgeons with IRU performed minimally invasive colectomies 73% of the time in 2015 versus 69% in 2009. Over the study period, 1131 surgeons performed proctectomies. Among 94 surgeons with IRU for proctectomies, robotics increased (3–42%), while laparoscopy decreased (25–15%), and open surgery decreased (73–44%). Overall, surgeons with IRU performed minimally invasive proctectomy 56% of the time in 2015 versus 27% in 2009. Patients in the latter study period had 57% greater odds of undergoing robotic surgery. Conclusions Overall, minimally invasive colorectal resections increased from 2009 to 2015 largely due to increasing robotic utilization, particularly for proctectomies.
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Affiliation(s)
- Carla F Justiniano
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA.
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Anthony Loria
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
| | - Zhaomin Xu
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
| | - Christopher T Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State Medical Center, Columbus, OH, USA
| | - Larissa K Temple
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
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24
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Brouquet A. [Rectal cancer : Is the era for de-escalation arrived?]. Rev Prat 2022; 72:50-54. [PMID: 35258254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Rectal cancer: is the era for de-escalation arrived? The reference treatment of rectal cancer relies on carcinologic resection including total mesorectal excision. In patients with locally advanced rectal cancer (cT3T4 and/or cN+), preoperative treatment is used to improve outcome and includes radiochemotherapy to optimize local control and systemic chemotherapy to decrease metastatic recurrence. The combination of these treatments with rectal cancer surgery induces short term and long-term toxicities potentially leading to treatment related sequelae on digestive and genitourinary function. Lastly, time is coming for de-escalation for the treatment to rectal cancer. For patients with small tumors (cT2T3 inférieur 4 cm) who respond to radiochemotherapy, organ preservation avoiding rectal resection can be discussed. In patients with locally advanced resectable rectal cancer, preoperative chemotherapy without pelvic irradiation could be used before total mesorectal excision to decrease the risk of long-term side effects. In patients with more advanced, primarily non resectable rectal cancer, a tailored strategy based on tumor response to chemotherapy could be used to rationalize the use of preoperative irradiation. New treatment strategies are constantly proposed and the optimal treatment option should be decided on a per patient basis during multidisciplinary discussion.
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Affiliation(s)
- Antoine Brouquet
- Service de chirurgie digestive et oncologique, hôpital Bicêtre, groupe hospitalier universitaire Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France ; faculté de Médecine Paris-Sud, université Paris-Saclay, Le Kremlin-Bicêtre, France
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25
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Bachet JB. [Contribution of neoadjuvant chemotherapy in rectal cancer]. Rev Prat 2022; 72:43-49. [PMID: 35258253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Contribution of neoadjuvant chemotherapy. IN RECTAL CANCER In patients with locally advanced rectal cancer, preoperative radiotherapy and complete mesorectal excision have reduced the risk of locoregional recurrence. However, these treatments have not reduced the risk of metastatic recurrence and the benefit of adjuvant chemotherapy has never been formally demonstrated. The chemotherapy efficacy on the rectal tumor as well as the difficulties to administer adjuvant chemotherapy after proctectomy has led to the development of treatment regimens with neoadjuvant chemotherapy. Two phase III studies evaluating induction chemotherapy with FOLFIRINOX followed by chemoradiotherapy for one and short radiotherapy followed by consolidation chemotherapy for the other are positive for their main objective and constitute new therapeutic standards.
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Affiliation(s)
- Jean-Baptiste Bachet
- Sorbonne Université, UPMC Université, IUC, Paris France ; AP-HP, Service d'hépato-gastroentérologie et oncologie digestive, Groupe hospitalier La Pitié Salpêtrière, Paris, France
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26
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Welten VM, Wanis KN, Madenci AL, Fields AC, Lu PW, Malizia RA, Yoo J, Goldberg JE, Irani JL, Bleday R, Melnitchouk N. The Effect of Facility Volume on Survival Following Proctectomy for Rectal Cancer. J Gastrointest Surg 2022; 26:150-160. [PMID: 34291364 DOI: 10.1007/s11605-021-05092-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/01/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Prior studies assessing colorectal cancer survival have reported better outcomes when operations are performed at high-volume centers. These studies have largely been cross-sectional, making it difficult to interpret their estimates. We aimed to assess the effect of facility volume on survival following proctectomy for rectal cancer. METHODS Using data from the National Cancer Database, we included all patients with complete baseline information who underwent proctectomy for non-metastatic rectal cancer between 2004 and 2016. Facility volume was defined as the number of rectal cancer cases managed at the treating center in the calendar year prior to the patient's surgery. Overall survival estimates were obtained for facility volumes ranging from 10 to 100 cases/year. Follow-up began on the day of surgery and continued until loss to follow-up or death. RESULTS A total of 52,822 patients were eligible. Patients operated on at hospitals with volumes of 10, 30, and 50 cases/year had similar distributions of grade, clinical stage, and neoadjuvant therapies. 1-, 3-, and 5-year survival all improved with increasing facility volume. One-year survival was 94.0% (95% CI: 93.7, 94.3) for hospitals that performed 10 cases/year, 94.5% (95% CI: 94.2, 94.7) for 30 cases/year, and 94.8% (95% CI: 94.5, 95.0) for 50 cases/year. Five-year survival was 68.9% (95% CI: 68.0, 69.7) for hospitals that performed 10 cases/year, 70.8% (95% CI: 70.1, 71.5) for 30 cases/year, and 72.0% (95% CI: 71.2, 72.8) for 50 cases/year. CONCLUSIONS Treatment at a higher volume facility results in improved survival following proctectomy for rectal cancer, though the small benefits are less profound than previously reported.
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Affiliation(s)
- Vanessa M Welten
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA. .,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont St, MA, 02120, Boston, USA.
| | - Kerollos N Wanis
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, MA, 02115, Boston, USA
| | - Arin L Madenci
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Adam C Fields
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Pamela W Lu
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Robert A Malizia
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - James Yoo
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Joel E Goldberg
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Jennifer L Irani
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Ronald Bleday
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA
| | - Nelya Melnitchouk
- Division of General and Gastrointestinal Surgery, Department of Surgery Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, MA, 02115, Boston, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont St, MA, 02120, Boston, USA
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27
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Lepage C. [Rectal cancers resected for cure: monitoring, secondary prevention and late complications]. Rev Prat 2022; 72:55-60. [PMID: 35258255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Rectal cancers resected for cure: monitoring, secondary prevention and late complications. Colorectal cancer incidence has increased by more than 50 % over the past 30 years. Over the same period, the number of deaths has remained stable, reflecting major therapeutic advances. The 5-year net survival rate of patients resected for cure for rectal cancer varies from 96 % for stage I to 71 % for stage III. Of these, nearly half will develop metachronous cancer or recurrence within 5 years of surgery. This high risk of recurrence raises the question of postoperative surveillance to detect early recurrence and metachronous cancers at a curable stage. The annual incidence of adenomas is low and the cumulative risk of endoluminal recurrence or metachronous cancer is very low. Therefore, intensive endoscopic surveillance is not useful. Posto¬perative surveillance of distant recurrence is poorly codified. However, despite their limitations, recent trials and meta-analyses suggest that survival is increased with clinical monitoring combined with liver and lung imaging. CEA is no longer useful in monitoring after curative resection. The challenge in the future will be to establish predictive scores, in order to adjust surveillance according to the molecular charac¬teristics of the resected tumor. Finally, the detection and management of sequelae is an important element of the follow-up after curative resection of rectal cancer, espe¬cially in patients who have received neoadjuvant radiotherapy.
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Affiliation(s)
- Côme Lepage
- Epicad Inserm U1231, Registre bourguignon des cancers digestifs, Université de Bourgogne Franche-Comté, CHU de Dijon, Dijon, France
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28
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Abstract
Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.
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Affiliation(s)
- Cristopher Varela
- Coloproctology Unit, Department of General Surgery, Hospital Dr. Domingo Luciani, Caracas, Venezuela
| | - Nam Kyu Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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29
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O'Connell E, McDevitt J, Hill ADK, McNamara DA, Burke JP. Centralisation of rectal cancer care has improved patient survival in the republic of Ireland. Eur J Surg Oncol 2021; 48:890-895. [PMID: 34774395 DOI: 10.1016/j.ejso.2021.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 09/17/2021] [Accepted: 10/30/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Centralisation of rectal cancer surgery to designated centres was a key objective of the Irish national cancer control program. A national audit of rectal cancer surgery indicated centralisation was associated with improved early surgical outcomes. This study aimed to determine the impact of implementation of the national cancer strategy on survival from rectal cancer. MATERIALS AND METHODS Data were collected from the National Cancer Registry of Ireland to include all patients with Stage I-III rectal cancer undergoing rectal cancer surgery with curative intent between 2003 and 2012. Five-year overall survival and cancer-specific survival was compared between patients in the pre-centralisation (2003-2007) and post-centralisation period (2008-2012) and between patients receiving surgery in designated cancer centres and non-cancer centres. RESULTS The proportion of rectal cancer surgery performed in a designated cancer centre increased from 42% during 2003-2007 to 58% during 2008-2012. Five-year overall survival increased from 66.1% in 2003-2007 to 73.5% in 2008-2012 (p < 0.001). Five-year cancer-specific survival increased from 75.3% in 2003-2007 to 81.9% in 2008-2012 (p < 0.001). Surgery in a cancer centre and surgery post-centralisation were significantly associated with overall and cancer specific survival using Cox proportional hazards regression. CONCLUSION Survival following resection of rectal cancer was significantly improved following implementation of a national cancer strategy incorporating centralisation of rectal cancer surgery.
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Affiliation(s)
- E O'Connell
- Department of Surgery, Beaumont Hospital, Dublin 9, Ireland
| | - J McDevitt
- National Cancer Registry of Ireland, Kinsale Road, Cork, Ireland
| | - A D K Hill
- Department of Surgery, Beaumont Hospital, Dublin 9, Ireland; National Cancer Control Program Ireland, King's Inn House, Dublin 1, Ireland; Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - D A McNamara
- Department of Surgery, Beaumont Hospital, Dublin 9, Ireland; Department of Surgery, Royal College of Surgeons in Ireland, Dublin 2, Ireland.
| | - J P Burke
- Department of Surgery, Beaumont Hospital, Dublin 9, Ireland; National Cancer Control Program Ireland, King's Inn House, Dublin 1, Ireland
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30
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McKenna NP, Glasgow AE, Behm KT, Habermann EB, Cima RR. Is there Clinical Value to Routine Postoperative Day 1 Labs after Proctectomy? J Gastrointest Surg 2021; 25:2961-2. [PMID: 33948861 DOI: 10.1007/s11605-021-05027-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 04/21/2021] [Indexed: 01/31/2023]
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31
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Choi MS, Yun SH, Shin JK, Park YA, Huh JW, Cho YB, Kim HC, Lee WY. Single-Port Robot-Assisted Abdominoperineal Resection: A Case Review of the Fi rst Four Experiences. Ann Coloproctol 2021:ac.2021.00395.0056. [PMID: 34657409 PMCID: PMC8898626 DOI: 10.3393/ac.2021.00395.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/30/2021] [Indexed: 02/07/2023] Open
Abstract
Recently, abdominoperineal resection (APR) using a robot has been demonstrated in other studies. However, there has been no report on APR for rectal cancer using the single-port robot (SPR) platform. In response to this research gap, we described the clinical experience of APR using a SPR. From April 2019 to March 2020, APR using a SPR platform was performed in a total of 4 patients. Three patients had a transumbilical approach, and 1 patient had a transstoma site approach. The average operation time was 307 minutes, and the patient docking time to the SPR platform was 133.5 minutes. There were no complications during the operation, and no laparoscopy or open conversion. No reoperation occurred within 30 days. Mild postoperative complications occurred in 2 patients. We found that APR has safety and feasibility in surgery using an SPR platform. There was no intraoperative event and severe postoperative complications.
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Affiliation(s)
- Moon Suk Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Hyeon Yun
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Kyong Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Ah Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Wook Huh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Beom Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hee Cheol Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Yong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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32
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Kim S, Kang SI, Kim SH, Kim JH. The Effect of Anastomotic Leakage on the Incidence and Severity of Low Anterior Resection Syndrome in Patients Undergoing Proctectomy: A Propensity Score Matching Analysis. Ann Coloproctol 2021; 37:281-290. [PMID: 34098631 PMCID: PMC8566143 DOI: 10.3393/ac.2021.03.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/15/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Proctectomy for the treatment of rectal cancer results in inevitable changes to bowel habits. Symptoms such as fecal incontinence, constipation, and tenesmus are collectively referred to as low anterior resection syndrome (LARS). Among the several risk factors that cause LARS, anastomotic leakage (AL) is a strong risk factor for permanent stoma formation. Therefore, the purpose of this study was to investigate the relationship between the severity of LARS and AL in patients with rectal cancer based on the LARS score and the Memorial Sloan Kettering Cancer Center (MSKCC) defecation symptom questionnaires. Methods We retrospectively analyzed patients who underwent low anterior resection for rectal cancer since January 2010. Patients who completed the questionnaire were classified into the AL group and control group based on medical and imaging records. Major LARS and MSKCC scores were analyzed as primary endpoints. Results Among the 179 patients included in this study, 37 were classified into the AL group. After propensity score matching, there were significant differences in the ratio of major LARS and MSKCC scores of the control group and AL group (ratio of major LARS: 11.1% and 37.8%, P < 0.001; MSKCC score: 67.29±10.4 and 56.49±7.2, respectively, P < 0.001). Univariate and multivariate analyses revealed that AL was an independent factor for major LARS occurrence and MSKCC score. Conclusion This study showed that AL was a significant factor in the occurrence of major LARS and defecation symptoms after proctectomy.
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Affiliation(s)
- Sungjin Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Sung Il Kang
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - So Hyun Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Jae-Hwang Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
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33
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Simianu VV, Curran T, Gaertner WB, Sklow B, Kuntz KM, Kwaan MR, Madoff RD, Jensen CC. A Cost-Effectiveness Evaluation of Surgical Approaches to Proctectomy. J Gastrointest Surg 2021; 25:1512-1523. [PMID: 32394122 DOI: 10.1007/s11605-020-04615-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 04/16/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Robotic surgery is increasingly used for proctectomy, but the cost-effectiveness of this approach is uncertain. Robotic surgery is considered more expensive than open or laparoscopic approaches, but in certain situations has been demonstrated to be cost-effective. We examined the cost-effectiveness of open, laparoscopic, and robotic approaches to proctectomy from societal and healthcare system perspectives. METHODS We developed a decision-analytic model to evaluate one-year costs and outcomes of robotic, laparoscopic, and open proctectomy based on data from the available literature. The robustness of our results was tested with one-way and multi-way sensitivity analyses. RESULTS Open proctectomy had increased cost and lower quality of life (QOL) compared with laparoscopy and robotic approaches. In the societal perspective, robotic proctectomy costs $497/case more than laparoscopy, with minimal QOL improvements, resulting in an incremental cost-effectiveness ratio (ICER) of $751,056 per quality-adjusted life year (QALY). In the healthcare sector perspective, robotic proctectomy resulted in $983/case more and an ICER of $1,485,139/QALY. One-way sensitivity analyses demonstrated factors influencing cost-effectiveness primarily pertained to the operative cost and the postoperative length of stay (LOS). In a probabilistic sensitivity analysis, the cost-effective approach to proctectomy was laparoscopic in 42% of cases, robotic in 39%, and open in 19% at a willingness-to-pay (WTP) of $100,000/QALY. CONCLUSIONS Laparoscopic and robotic proctectomy cost less and have higher QALY than the open approach. Based on current data, laparoscopy is the most cost-effective approach. Robotic proctectomy can be cost-effective if modest differences in costs or postoperative LOS can be achieved.
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Affiliation(s)
- Vlad V Simianu
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA.
| | - Thomas Curran
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Wolfgang B Gaertner
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Bradford Sklow
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Karen M Kuntz
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - Mary R Kwaan
- Department of Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert D Madoff
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Christine C Jensen
- Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
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Horsey ML, Sparks AD, Simkins A, Kim G, Ng M, Obias VJ. Comparing outcomes for non-metastatic rectal cancer in academic vs. community centers: A propensity-matched analysis of the National Cancer Database. Am J Surg 2021; 222:989-997. [PMID: 34024628 DOI: 10.1016/j.amjsurg.2021.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/26/2021] [Accepted: 05/07/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Little is known regarding the impact of hospital academic status on outcomes following rectal cancer surgery. We compare these outcomes for nonmetastatic rectal adenocarcinoma at academic versus community institutions. METHODS The National Cancer Database (2010-2016) was queried for patients with nonmetastatic rectal adenocarcinoma who underwent resection. Propensity score matching was performed across facility cohorts to balance confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze survival, other short and long-term outcomes were analyzed by way of logistic regression. RESULTS After matching, 15,096 patients were included per cohort. Academic centers were associated with significantly decreased odds of conversion and positive margins with significantly increased odds of ≥12 regional nodes examined. Academic programs also had decreased odds of 30 and 90-day mortality and decreased 5-year mortality hazard. After matching for facility volume, no significant differences in outcomes between centers was seen. CONCLUSIONS No difference between academic and community centers in outcomes following surgery for non-metastatic rectal cancer was seen after matching for facility procedural volume.
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Affiliation(s)
- Michael L Horsey
- Walter Reed National Military Medical Center, Bethesda, MD, USA.
| | - Andrew D Sparks
- Department of Surgery, George Washington University Medical Faculty Associates, Washington, DC, USA
| | - Aron Simkins
- Department of Hematology & Oncology, George Washington University Hospital, Washington, DC, USA
| | - George Kim
- Department of Hematology & Oncology, George Washington University Hospital, Washington, DC, USA
| | - Matthew Ng
- Department of Colon and Rectal Surgery at the George Washington University Hospital, Washington, DC, USA
| | - Vincent J Obias
- Department of Colon and Rectal Surgery at the George Washington University Hospital, Washington, DC, USA
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El Amrani M, Clement G, Lenne X, Turpin A, Valibouze C, Rogosnitzky M, Theis D, Pruvot FR, Zerbib P. Failure to rescue following proctectomy for rectal cancer: the additional benefit of laparoscopic approach in a nationwide observational study of 44,536 patients. Surg Endosc 2021. [PMID: 33871717 DOI: 10.1007/s00464-021-08303-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 01/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND There is growing evidence that failure to rescue (FTR) is an important factor of postoperative mortality (POM) after rectal cancer surgery and surgical approach modified post-operative outcomes. However, the impact of laparoscopy on FTR after proctectomy for rectal cancer remains unknown. The aim of this study was to compare the rates of postoperative complications and FTR after laparoscopy vs open proctectomy for cancer. METHODS All patients who underwent proctectomy for rectal cancer between 2012 and 2016 were included. FTR was defined as the 90-day POM rate among patients with major complications. Outcomes of patients undergoing open or laparoscopic rectal cancer surgery were compared after 1:1 propensity score matching by year of surgery, hospital volume, sex, age, Charlson score, neoadjuvant chemotherapy, tumor localization and type of anastomosis. RESULTS Overall, 44,536 patients who underwent proctectomy were included, 7043 of whom (15.8%) developed major complications. The rates of major complications, POM and FTR were significantly higher in open compared to laparoscopic procedure (major complications: 19.2% vs 13.7%, p < 0.001; POM: 5.4% vs 2.3%, p < 0.001; FTR: 13.6% vs 8.3%, p < 0.001; respectively). After matching, open and laparoscopic groups were comparable. Multivariate analysis showed that age, Charlson score, sphincter-preserving procedure and surgical approach were predictive factors for FTR. Open proctectomy was found to be a risk factor for FTR (OR 1.342, IC95% [1.066; 1.689], p = 0.012) compared to laparoscopic procedure. CONCLUSION When complications occurred, patients operated on by open proctectomy were more likely to die.
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Quezada-Diaz FF, Elfeki H, Emmertsen KJ, Pappou EP, Jimenez-Rodriguez R, Patil S, Laurberg S, Garcia-Aguilar J. Comparative analysis of the Memorial Sloan Kettering Bowel Function Instrument and the Low Anterior Resection Syndrome Questionnaire for assessment of bowel dysfunction in rectal cancer patients after low anterior resection. Colorectal Dis 2021; 23:451-460. [PMID: 33405307 PMCID: PMC8023229 DOI: 10.1111/codi.15515] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/08/2020] [Accepted: 12/28/2020] [Indexed: 12/31/2022]
Abstract
AIM Neoadjuvant therapy and total mesorectal excision (TME) for rectal cancer are associated with bowel dysfunction symptoms known as low anterior resection syndrome (LARS). Our study compared the only two validated instruments-the LARS Questionnaire (LARS-Q) and the Memorial Sloan Kettering Bowel Function Instrument (MSK-BFI)-in rectal cancer patients undergoing sphincter-preserving TME. METHODS One hundred and ninety patients undergoing sphincter-preserving TME for Stage I-III rectal cancer completed the MSK-BFI and LARS-Q simultaneously at a median time of 12 (range 1-43) months after restoration of bowel continuity. Associations between the MSK-BFI total/subscale scores and the LARS-Q score were investigated using Spearman rank correlation (r s ). Discriminant validity for the two questionnaires was assessed, and the questionnaires were compared with the European Quality of Life Instrument. RESULTS Major LARS was identified in 62% of patients. The median MSK-BFI scores for no LARS, minor LARS and major LARS were 76.5, 70 and 57, respectively. We found a strong association between MSK-BFI and LARS-Q (r s -0.79). The urgency/soilage subscale (r s -0.7) and the frequency subscale (rs -0.68) of MSK-BFI strongly correlated with LARS-Q. Low correlation was observed between the MSK-BFI diet subscale and LARS-Q (r s -0.39). On multivariate analysis, both questionnaires showed worse bowel function in patients with distal tumours. A low to moderate correlation with the European Quality of Life Instrument was observed for both questionnaires. CONCLUSIONS The MSK-BFI and LARS-Q showed good correlation and similar discriminant validity. As the LARS-Q is easier to complete, it may be considered the preferred tool to screen for bowel dysfunction.
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Affiliation(s)
| | - Hossam Elfeki
- Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | - Katrine J. Emmertsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| | - Emmanouil P. Pappou
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Søren Laurberg
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
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Feitosa MR, Freitas LFD, Filho AB, Nakiri GS, Abud DG, Landell LM, Brunaldi MO, Rocha JJRD, Feres O, Parra RS. Preoperative rectal tumor embolization as an adjunctive tool for bloodless abdominoperineal excision: A case report. World J Clin Oncol 2020; 11:1070-1075. [PMID: 33437668 PMCID: PMC7769720 DOI: 10.5306/wjco.v11.i12.1070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/20/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Abdominoperineal excision (APE)-related hemorrhage can be challenging due to difficult access to pelvic organs and the risk of massive blood loss. The objective of the present study was to demonstrate the use of preoperative embolization (PE) as a strategy for blood preservation in a patient with a large low rectal tumor with a high risk of bleeding, scheduled for APE.
CASE SUMMARY A 56-year-old man presented to our institution with a one-year history of anal bleeding and rectal tenesmus. The patient was diagnosed with bulky adenocarcinoma limited to the rectum. As the patient refused any clinical treatment, surgery without previous neoadjuvant chemoradiation was indicated. The patient underwent a tumor embolization procedure, two days before surgery performed via the right common femoral artery. The tumor was successfully devascularized and no major bleeding was noted during APE. Postoperative recovery was uneventful and a one-year follow-up showed no signs of recurrence.
CONCLUSION Therapeutic tumor embolization may play a role in bloodless surgeries and increase surgical and oncologic prognoses. We describe a patient with a bulky low rectal tumor who successfully underwent preoperative embolization and bloodless abdominoperineal resection.
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Affiliation(s)
- Marley Ribeiro Feitosa
- Department of Surgery and Anatomy, Medicine School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14048900, São Paulo, Brazil
| | - Lucas Fernandes de Freitas
- Department of Surgery and Anatomy, Medicine School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14048900, São Paulo, Brazil
| | - Antonio Balestrim Filho
- Department of Surgery and Anatomy, Medicine School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14048900, São Paulo, Brazil
| | - Guilherme Seizem Nakiri
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14048900, São Paulo, Brazil
| | - Daniel Giansante Abud
- Department of Internal Medicine, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14048900, São Paulo, Brazil
| | - Ligia Magnani Landell
- Department of Pathology and Forensic Medicine, Medicine School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14048900, São Paulo, Brazil
| | - Mariângela Ottoboni Brunaldi
- Department of Pathology and Forensic Medicine, Medicine School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14048900, São Paulo, Brazil
| | - Jose Joaquim Ribeiro da Rocha
- Department of Surgery and Anatomy, Medicine School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14048900, São Paulo, Brazil
| | - Omar Feres
- Department of Surgery and Anatomy, Medicine School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14048900, São Paulo, Brazil
| | - Rogério Serafim Parra
- Department of Surgery and Anatomy, Medicine School of Ribeirão Preto, University of São Paulo, Ribeirão Preto 14048900, São Paulo, Brazil
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Wolf JH, Hung YC, Cox S, Aghedo B, Mavanur A, Svoboda S, D'Adamo CR. Pathologic complete response is associated with decreased morbidity following rectal cancer resection. Am J Surg 2021; 222:390-4. [PMID: 33261851 DOI: 10.1016/j.amjsurg.2020.11.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/21/2020] [Accepted: 11/25/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND There are conflicting data regarding the relationship between pathologic complete response (pCR) and post-operative complications following rectal cancer resection. The objective of this study was to compare the rates of morbidity among pCR patients and non-pCR patients and to identify factors that predict pCR morbidity in a large national database. METHODS This is a retrospective study using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted proctectomy data (2016-18). Patients with neoadjuvant chemoradiation therapy followed by proctectomy were included, and divided into pCR and non-pCR groups according to final stage. The groups were compared with Student's t-test, Chi-squared or Fisher's exact test. Multivariate logistic regression models were constructed to estimate the association between pCR status and post-operative morbidity while adjusting for key covariates. RESULTS 244 pCR and 1656 non-pCR patients were included. pCR patients had higher body mass index (28.1 ± 6.2 vs. 29.1 ± 5.9 kg/m2; p = 0.01) and lower pre-operative stage (T stage, p = 0.03; N stage, p < 0.001). The groups were equivalent with respect to surgical approach, type of surgery, and operative time (p > 0.05). Post-operative complications in pCR patients were less frequent than in non-pCR patients (23.0% vs. 29.3%; p = 0.04). This association was robust to adjustment for confounders in logistic regression, as patients with pCR had decreased odds of post-operative morbidity (OR 0.66, CI [0.43, 0.96], p = 0.04). CONCLUSION pCR is associated with fewer post-operative complications compared to non-pCR, suggesting that pCR is not a marker of severe pelvic fibrosis. This difference may be due to underlying tumor biology, and associated increased technical challenges resecting larger, non-responsive tumors.
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Xia ZX, Cong JC, Zhang H. Rectoseminal vesicle fistula after radical surgery for rectal cancer: Four case reports and a literature review. World J Clin Cases 2020; 8:5645-5656. [PMID: 33344556 PMCID: PMC7716322 DOI: 10.12998/wjcc.v8.i22.5645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 09/16/2020] [Accepted: 09/25/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A rectoseminal vesicle fistula (RSVF) is a rare complication after anterior or low anterior proctectomy for rectal cancer mainly due to anastomotic leakage (AL). Limited literature documenting this rare complication is available. We report four such cases and review the literature to investigate the etiology, clinical manifestations, and the diagnostic and treatment methods of RSVF in order to provide greater insight into this disorder.
CASE SUMMARY Four cases of RSVF were presented and summarized, and a further 12 cases selected from the literature were discussed. The main clinical symptoms in these patients were pneumaturia, fever, scrotal swelling and pain, anal pain, orchitis, diarrhea, dysuria, epididymitis and fecaluria. Imaging methods such as pelvic X-ray, computed tomography (CT), sinus radiography, barium enema and other techniques confirmed the diagnosis. CT was the imaging modality of choice. In cases presenting with reduced levels of AL, minimal surrounding inflammation, and controlled infection, the RSVF was conservatively treated by urethral catheterization, antibiotics administration and parenteral nutrition. In cases of severe RSVF, incision and drainage of the abscess or fistula and urinary or fecal diversion surgery successfully resolved the fistula.
CONCLUSION This study provides an extensive analysis of RSVF, and outlines, summarizes and examines the causes, clinical manifestations, diagnostic procedures and treatment options, in order to prevent misdiagnosis and treatment errors.
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Affiliation(s)
- Zhi-Xiu Xia
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Jin-Chun Cong
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Hong Zhang
- Department of General Surgery, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
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Lam D, Jones O. Changes to gastrointestinal function after surgery for colorectal cancer. Best Pract Res Clin Gastroenterol 2020; 48-49:101705. [PMID: 33317788 DOI: 10.1016/j.bpg.2020.101705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/19/2020] [Accepted: 11/05/2020] [Indexed: 01/31/2023]
Abstract
Bowel function is increasingly considered as an important outcome for patients undergoing surgery for colorectal cancer. Increasing technical skills and technological advances have meant fewer patients require a long-term stoma but this comes at the cost, often, of poor function. With a larger range of treatment options available for a given cancer, both function and oncology should be considered in parallel when counselling patients before surgery. In the perioperative phase, bowel function can be improved with minimally invasive surgery and enhanced recovery after surgery protocols, with limited evidence for targeted medical therapies. Early detection and sound management of surgical complications such as anastomotic leak and stricture can mitigate their adverse effects on bowel function. Long-term gastrointestinal dysfunction manifests as diarrhoea and low anterior resection syndrome for colon and rectal cancer respectively. Multi-modal strategies for low anterior resection syndrome are emerging to improve significantly quality of life after restorative rectal cancer surgery.
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Affiliation(s)
- David Lam
- Senior Clinical Fellow in Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Department of Colorectal Surgery, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
| | - Oliver Jones
- Consultant Colorectal Surgeon and Clinical Director of Surgery, Oxford University Hospitals NHS Foundation Trust, Department of Colorectal Surgery, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
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Clement E, Dang J, Laffin M, Wang H. Incidence of Venous Thromboembolism Following Proctectomy Is Greater in Ulcerative Colitis than in Malignancy or Crohn's Disease. J Gastrointest Surg 2020; 24:2664-2666. [PMID: 32705609 DOI: 10.1007/s11605-020-04738-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/02/2020] [Indexed: 01/31/2023]
Affiliation(s)
- Elizabeth Clement
- Department of Surgery, University of Alberta, 2G2 DTC 2G2, 8440-112st NW, Edmonton, AB, T6G 2R7, Canada.
| | - Jerry Dang
- Department of Surgery, University of Alberta, 2G2 DTC 2G2, 8440-112st NW, Edmonton, AB, T6G 2R7, Canada
| | - Micheal Laffin
- Department of Surgery, University of Alberta, 2G2 DTC 2G2, 8440-112st NW, Edmonton, AB, T6G 2R7, Canada
| | - Haili Wang
- Department of Surgery, University of Alberta, 2G2 DTC 2G2, 8440-112st NW, Edmonton, AB, T6G 2R7, Canada
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Concors SJ, Murken DR, Hernandez PT, Mahmoud NN, Paulson EC. The volume-outcome relationship in robotic protectectomy: does center volume matter? Results of a national cohort study. Surg Endosc 2020; 34:4472-4480. [PMID: 31637603 DOI: 10.1007/s00464-019-07227-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/04/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Utilization of robotic proctectomy (RP) for rectal cancer has steadily increased since the inception of robotic surgery in 2002. Randomized control trials evaluating the safety of RP are in process to better understand the role of robotic assistance in proctectomy. This study aimed to characterize the trends in the use of RP for rectal cancer, and to compare oncologic outcomes with center-level RP volume. MATERIALS AND METHODS 8107 patients with rectal adenocarcinoma who underwent RP were identified in the National Cancer Database (2010-2015). Logistic regression was used to evaluate associations between center-level volume and conversion to open proctectomy, margin status, lymph node yield, 30- and 90-day post-operative mortality, and overall survival. RESULTS The utilization of RP increased from 2010 to 2015. On multivariate regression, lower center-level volume of RP was associated with significantly higher rates of conversion to open, positive margins, inadequate lymph node harvest (≥ 12), and lower overall survival. The present study was limited by its retrospective design and lack of information regarding disease-specific survival. CONCLUSIONS This series suggests a volume-outcome relationship association; patients who have robot-assisted proctectomies performed at low-volume centers are more likely to have poorer overall survival, positive margins, inadequate lymph node harvest, and require conversion to open surgery. While these data demonstrate the increased adoption of robot-assisted proctectomy, an understanding of the appropriateness of this intervention is still lacking. As with any new intervention, further information from ongoing randomized controlled trials is needed to better clarify the role of RP in order to optimize patient outcomes.
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Affiliation(s)
- Seth J Concors
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA, 19104, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.
| | - Douglas R Murken
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Paul T Hernandez
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Najjia N Mahmoud
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - E Carter Paulson
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Chau J, Solomon J, Liberman AS, Charlebois P, Stein B, Lee L. Pelvic dimensions on preoperative imaging can identify poor-quality resections after laparoscopic low anterior resection for mid- and low rectal cancer. Surg Endosc 2020; 34:4609-4615. [PMID: 31620910 DOI: 10.1007/s00464-019-07209-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND High-quality surgery is essential for optimal oncologic outcomes in rectal cancer, but total mesorectal excision (TME) can be difficult for mid- and low rectal cancers. Preoperative identification of patients at risk for difficult TME may change the operative approach. The objective of this study was to determine if MRI pelvimetry can predict poor-quality surgery in patients undergoing laparoscopic low anterior resection (LAR) for mid- and low rectal cancer. METHODS All patients undergoing laparoscopic LAR for rectal cancer ≤ 9 cm from the anal verge at a single tertiary care referral center from 2011 to 2017 were retrospectively reviewed. Pelvic dimensions were measured from preoperative staging MRI on sagittal and axial views. Pelvimetry variables were all dichotomized based on median values. Exploratory factor analysis then identified the most relevant variables for regression analysis. The primary outcome was poor-quality resection, defined as an incomplete mesorectal grade, or involved circumferential (CRM) or distal (DRM) resection margins. RESULTS There were 92 patients included in this study, of which 70% were male, the mean BMI was 26.0 kg/m2, and the mean tumor height was 6.6 cm. Preoperative (chemo)radiotherapy was administered in 70%, and the pathologic T-stage was T3/T4 in 41%. The overall incidence of poor-quality resection was 17%, including 13% incomplete TME, 7% involved CRM, and 1% involved DRM. Factor analysis identified S1-pubic symphysis and the angle between S1 and S5-bottom of symphysis (angle ABD) as relevant variables. After adjusting for pathologic T-stage, BMI, and tumor height, a S1-S5-bottom of symphysis angle > 74.3° (OR 6.19, 95% CI 1.18-32.37) independently predicted poor-quality resection. CONCLUSIONS MRI pelvimetry can identify patients at risk for a poor-quality resection after laparoscopic proctectomy for mid- and low rectal cancer. These patients may benefit from the selective use of more advanced access methods to improve surgical resection quality.
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Affiliation(s)
- Johnny Chau
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, Centre for Colon and Rectal Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Joshua Solomon
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada
| | - A Sender Liberman
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, Centre for Colon and Rectal Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Patrick Charlebois
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, Centre for Colon and Rectal Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Barry Stein
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada.,Department of Surgery, Centre for Colon and Rectal Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada
| | - Lawrence Lee
- Department of Surgery, Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, Montreal, QC, Canada. .,Department of Surgery, Centre for Colon and Rectal Surgery, McGill University Health Centre, 1001 Decarie Boulevard, DS1-3310, Montreal, QC, H4A 3J1, Canada.
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Hu KY, Wu R, Szabo A, Ridolfi TJ, Ludwig KA, Peterson CY. Laparoscopic Versus Robotic Proctectomy Outcomes: An ACS-NSQIP Analysis. J Surg Res 2020; 255:495-501. [PMID: 32622164 DOI: 10.1016/j.jss.2020.05.094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/11/2020] [Accepted: 05/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The robotic platform is increasingly used in colorectal surgery. Recent upgrades in the robotic platform and introduction of proctectomy-specific reports from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) warrant updated evaluation of minimally invasive proctectomy outcomes. The aim of this study was to compare outcomes in robotic versus laparoscopic proctectomy using ACS-NSQIP data. MATERIALS AND METHODS The ACS-NSQIP data set was used to identify adult patients undergoing elective robotic and laparoscopic proctectomy in 2016 and 2017. Demographics, preoperative and intraoperative data, and postoperative outcomes were collected. Propensity-weighted analysis was used to estimate the effect of robotic versus laparoscopic surgery on outcomes. RESULTS Of 3845 patients meeting inclusion criteria, 2681 (70%) underwent a laparoscopic approach and 1164 (30%) underwent a robotic approach. Patients undergoing a robotic procedure were more likely to be older, have higher American Society of Anesthesiologists scores, low rectal tumors, and have undergone chemotherapy or radiation before surgery. After propensity adjustment, a robotic approach was associated with a decrease in conversion to open operation (estimated mean difference, -6.7%; P < 0.01), length of stay (-0.6 d; P = 0.01), occurrence of postoperative ileus (-3.7%; P = 0.01), and an increase in operative time (20.3 min; P < 0.01). CONCLUSIONS Using data from a national cohort, we found that compared with laparoscopy, robotic proctectomy is associated with decreased conversion to open operation, longer operation time, decreased length of stay, and decreased postoperative ileus. Our study identified several advantages to a robotic approach; however, further work is needed to assess cost-effectiveness in conjunction with clinical outcomes.
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Affiliation(s)
- Katherine Y Hu
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ruizhe Wu
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Timothy J Ridolfi
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kirk A Ludwig
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Carrie Y Peterson
- Division of Colorectal Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Wolf JH, Ahuja V, D'Adamo CR, Coleman J, Katlic M, Blumberg D. Preoperative Nutritional Status Predicts Major Morbidity After Primary Rectal Cancer Resection. J Surg Res 2020; 255:325-331. [PMID: 32593891 DOI: 10.1016/j.jss.2020.05.081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 05/11/2020] [Accepted: 05/24/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Malnutrition has been associated with adverse surgical outcomes, but data regarding its impact specifically in rectal cancer are sparse. The goal of this study was to use national data to determine the effects of malnutrition on surgical outcomes in rectal cancer resection. METHODS Data were obtained from the American College of Surgeons National Surgical Quality Initiative Program from the years 2012-2015. Patients were included on the basis of International Classification of Disease 9/10 and Current Procedural Terminology codes for rectal cancer and proctectomy. Malnutrition was defined as body mass index <18.5 kg/m2, weight loss >10% in 6 mo, or preoperative albumin <3.5 mg/dL. Associations between malnutrition and postoperative outcomes were assessed by the Student t-test and chi-square test. Multivariate regression models were constructed to adjust for potential confounders of the association between malnutrition and surgical outcomes. RESULTS Of the 9289 patients with primary rectal cancer who underwent resection, 1425 (15%) were in a state of malnutrition at the time of surgery. Patients with malnutrition had longer mean length of stay (LOS), and higher rates of 30-d mortality, wound infection, organ-space infection, sepsis, reoperation, prolonged LOS (>30 d), failure to wean off ventilator, renal failure, and cardiac arrest. With the exception of LOS, renal failure, and organ-space infection, malnutrition was still significantly associated with higher rates of these adverse outcomes after adjustment for confounders in multivariate regression models. CONCLUSIONS Malnutrition is a practical marker associated with a variety of adverse outcomes after rectal cancer surgery, and it represents a potential target for nutritional therapies to improve surgical outcomes.
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Affiliation(s)
- Joshua H Wolf
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland.
| | - Vanita Ahuja
- Department of Surgery, Yale University, New Haven, Connecticut
| | - Christopher R D'Adamo
- Center for Integrative Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - JoAnn Coleman
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Mark Katlic
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - David Blumberg
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, Maryland
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Friedman S, Nielsen J, Nøhr EA, Jølving LR, Nørgård BM. Comparison of Time to Pregnancy in Women With and Without Inflammatory Bowel Diseases. Clin Gastroenterol Hepatol 2020; 18:1537-1544.e1. [PMID: 31446182 DOI: 10.1016/j.cgh.2019.08.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/29/2019] [Accepted: 08/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients are often diagnosed with inflammatory bowel diseases (IBD) during their peak reproductive years. We investigated how IBD affects fertility in a population study of women in Denmark. METHODS We collected data from the Danish National Birth Cohort, a nationwide study of 92,274 pregnant women recruited from 1996 through 2002. Women who had been actively trying to conceive reported their time to pregnancy through a computer-assisted telephone interview at approximately 16 weeks of gestation. Information regarding IBD was retrieved from the Danish National Patient Register. Using regression models and adjusting for important confounders, we compared time to pregnancy in women with and without IBD. RESULTS We calculated time to pregnancy for 74,471 pregnancies in women without IBD, 340 pregnancies in women with ulcerative colitis (UC), and 206 pregnancies in women with Crohn's disease (CD). Compared to non-IBD pregnancies, the adjusted relative risk ratios for time to pregnancy of more than 12 months in women with IBD, UC, and CD were 1.28 (95% CI, 0.99-1.65), 1.10 (95% CI, 0.80-1.51), and 1.54 (95% CI, 1.03-2.30), respectively. The adjusted relative risk ratio was 2.54 (95% CI, 1.39-4.65) for a time to pregnancy of more than 12 months in women who had CD surgery prior to conception vs non-IBD pregnancies. There were too few patients with UC with surgery prior to conception to perform meaningful analyses of this group. CONCLUSIONS In a study of women with IBD not confounded by voluntary childlessness, we found that women with CD, especially those who have undergone surgery, have a significant increase in time to pregnancy compared to women without IBD. This indicates reduced fertility in subgroups of women with IBD.
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Affiliation(s)
- Sonia Friedman
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts; Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Jan Nielsen
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ellen Aagaard Nøhr
- Research Unit for Gynecology and Obstetrics, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Line Riis Jølving
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bente Mertz Nørgård
- Division of Gastroenterology, Hepatology, and Endoscopy, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts and Harvard Medical School, Boston, Massachusetts; Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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Ye SP, Zhu WQ, Liu DN, Lei X, Jiang QG, Hu HM, Tang B, He PH, Gao GM, Tang HC, Shi J, Li TY. Robotic- vs laparoscopic-assisted proctectomy for locally advanced rectal cancer based on propensity score matching: Short-term outcomes at a colorectal center in China. World J Gastrointest Oncol 2020; 12:424-434. [PMID: 32368320 PMCID: PMC7191331 DOI: 10.4251/wjgo.v12.i4.424] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 12/28/2019] [Accepted: 03/22/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Reports in the field of robotic surgery for rectal cancer are increasing year by year. However, most of these studies enroll patients at a relatively early stage and have small sample sizes. In fact, studies only on patients with locally advanced rectal cancer (LARC) and with relatively large sample sizes are lacking.
AIM To investigate whether the short-term outcomes differed between robotic-assisted proctectomy (RAP) and laparoscopic-assisted proctectomy (LAP) for LARC.
METHODS The clinicopathological data of patients with LARC who underwent robotic- or laparoscopic-assisted radical surgery between January 2015 and October 2019 were collected retrospectively. To reduce patient selection bias, we used the clinical baseline characteristics of the two groups of patients as covariates for propensity-score matching (PSM) analysis. Short-term outcomes were compared between the two groups.
RESULTS The clinical features were well matched in the PSM cohort. Compared with the LAP group, the RAP group had less intraoperative blood loss, lower volume of pelvic cavity drainage, less time to remove the pelvic drainage tube and urinary catheter, longer distal resection margin and lower rates of conversion (P < 0.05). However, the time to recover bowel function, the harvested lymph nodes, the postoperative length of hospital stay, and the rate of unplanned readmission within 30 days postoperatively showed no difference between the two groups (P > 0.05). The rates of total complications and all individual complications were similar between the RAP and LAP groups (P > 0.05).
CONCLUSION This retrospective study indicated that RAP is a safe and feasible method for LARC with better short-term outcomes than LAP, but we have to admit that the clinically significant of part of indicators are relatively small in the practical situation.
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Affiliation(s)
- Shan-Ping Ye
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
- Department of Graduate Student, Jiangxi Medical College of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Wei-Quan Zhu
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
- Department of Graduate Student, Jiangxi Medical College of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Dong-Ning Liu
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Xiong Lei
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Qun-Guang Jiang
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Hui-Min Hu
- Department of Graduate Student, Jiangxi Medical College of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Bo Tang
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
- Department of Graduate Student, Jiangxi Medical College of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Peng-Hui He
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Geng-Mei Gao
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
- Department of Graduate Student, Jiangxi Medical College of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - He-Chun Tang
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
- Department of Graduate Student, Jiangxi Medical College of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Jun Shi
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Tai-Yuan Li
- Department of General Surgery, First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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Song EM, Lee HS, Kim YJ, Oh EH, Ham NS, Kim J, Hwang SW, Park SH, Yang DH, Ye BD, Byeon JS, Myung SJ, Lee JL, Yoon YS, Yu CS, Yang SK. Incidence and Outcomes of Perianal Disease in an Asian Population with Crohn's Disease: A Nationwide Population-Based Study. Dig Dis Sci 2020; 65:1189-96. [PMID: 31485994 DOI: 10.1007/s10620-019-05819-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 08/23/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Little is known about the natural history of perianal fistulas in Asian populations with Crohn's disease (CD). AIMS We investigated the incidence and outcomes of perianal CD (pCD) in Korean CD patients. METHODS A nationwide population-based cohort of 6265 CD patients diagnosed in 2010-2014 was analyzed to investigate the incidence and outcomes of pCD. The results were validated in a hospital-based cohort of 2923 CD patients diagnosed in 1981-2015. Factors associated with pCD development were analyzed. The incidence and outcomes of pCD were compared between the prebiologic and biologic eras. RESULTS pCD occurred in 39.2% of the population-based cohort and 56.1% of the hospital-based cohort during the median follow-up of 4.2 and 8.5 years, respectively. The cumulative incidence of pCD was 40.0% at 5 years after CD diagnosis in the population-based cohort and 62.5% at 20 years in the hospital-based cohort. In multivariate analysis, pCD development was positively associated with male sex, younger age and colonic involvement at diagnosis, early diagnosis, and CD diagnosis in the prebiologic era. The cumulative probability of proctectomy at 10, 20, and 30 years after pCD diagnosis was 2.9%, 12.2%, and 16.2%, respectively. The cumulative incidence of pCD occurring after CD diagnosis and the cumulative probability of proctectomy were significantly lower in the biologic era than in the prebiologic era (p < 0.001 and p = 0.03, respectively). CONCLUSIONS Compared with Western patients with CD, Korean patients show a high incidence of pCD but have a low probability of proctectomy, suggesting the favorable course of pCD.
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Yan X, Su H, Zhang S, Zhou L, Lu J, Yang X, Li J, Xue P, He Z, Wang M, Lu A, Ma J, Zang L, Cai Z, Sun J, Hong H, Zheng M, Feng B. Pelvic peritoneum closure reduces postoperative complications of laparoscopic abdominoperineal resection: 6-year experience in single center. Surg Endosc 2020; 35:406-414. [PMID: 32086621 DOI: 10.1007/s00464-020-07414-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 01/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND To investigate feasibility of laparoscopic abdominoperineal resection with pelvic peritoneum closure (LAPR-PPC) for lower rectal cancer. METHODS LAPR-PPC has been used for lower rectal cancer in our institution since 2014. In this study, we retrospectively analyzed the data from 86 patients who underwent LAPR-PPC and compared with the data from 96 patients who underwent laparoscopic APR without PPC (LAPR) from January 2013 to December 2018. RESULTS The rate of perineal surgical site infection (SSI) (18.75% (18/96) vs. 5.81% (5/86), p < 0.01), delayed (> 4 weeks) perineal healing (12.50% (12/96) vs. 3.49% (3/86), p = 0.027), ileus (7.29% (7/96) vs 1.16% (1/86), p = 0.044), and postoperative perineal hernia (PPH, 5.21% (5/96) vs. 0% (0/86), p = 0.032) were significantly lower in LAPR-PPC group than LAPR group. The patients in LAPR-PPC group had shorter hospitalization time (21.32 ± 11.95 days vs. 13.93 ± 11.51 days, p < 0.01). CONCLUSIONS PPC procedure enabled the reduction in perineal wound complications, ileus, PPH, and consequently shortened hospitalization time. LAPR-PPC is beneficial for the patients with lower rectal cancer.
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Affiliation(s)
- Xialin Yan
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hao Su
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Sen Zhang
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Leqi Zhou
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Jiaoyang Lu
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Xiao Yang
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Jianwen Li
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Pei Xue
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Zirui He
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Mingliang Wang
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Aiguo Lu
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Junjun Ma
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Lu Zang
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Zhenghao Cai
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Jing Sun
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Hiju Hong
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China
| | - Minhua Zheng
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China.
| | - Bo Feng
- Department of General Surgery, Shanghai Minimally Invasive Surgery Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, No. 197, Ruijin Er Road, Shanghai, 200025, China.
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D'Andrea AP, McLemore EC, Bonaccorso A, Cuevas JM, Basam M, Tsay AT, Bhasin D, Attaluri V, Sylla P. Transanal total mesorectal excision (taTME) for rectal cancer: beyond the learning curve. Surg Endosc 2020; 34:4101-9. [PMID: 31602515 DOI: 10.1007/s00464-019-07172-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 09/26/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Transanal total mesorectal excision (taTME) is a surgical approach for low rectal cancer with a learning curve estimated at 40-50 cases. The experience among taTME surgeons beyond their learning curve is limited. METHODS A retrospective analysis of all taTME cases performed for rectal cancer at two tertiary care hospitals from 2014 to 2019 was conducted. Transanal surgeons had previously performed > 50 taTME cases. Demographic, perioperative, and short-term outcomes were analyzed. RESULTS Among 54 taTME patients, 74.1% were male and 27.8% had a BMI ≥ 30. Tumors were stage I (8), II (13), III (29), and IV (4). Complex cases included 4 local recurrences, 4 prior liver resections, and 2 with prior prostate cancer. Thirty tumors were located ≤ 6 cm from the anal verge. On staging MRI, 12 had a positive predicted circumferential radial margin (+CRM), and 4 had internal anal sphincter involvement (+IAS). Forty-seven patients received neoadjuvant therapy. A 2-team approach was used in 51 patients with laparoscopic (83.3%) or robotic (16.7%) abdominal assistance with a 9.2% conversion rate. Low anterior resection with sphincter salvage was achieved in 87% with 8 patients requiring intersphincteric resection. Anastomoses were hand-sewn in 57.4% and all patients were diverted. Median LOS was 5 days with a 42.6% 30-day morbidity rate and 3 postoperative mortalities (ARDS, pulmonary embolism and pseudomembranous colitis). Complete and near complete TME grade was achieved in 94.4% with a 3.7% rate of +CRM. At a median follow-up of 28 months, local and distant recurrence rates were 3.9% and 17.6%, respectively, with no cancer-related mortality. CONCLUSION Indications for taTME at experienced centers have expanded to include complex reoperative cases, local recurrences, metastatic cancer, and tumors with threatened CRM or IAS with evidence of post-treatment tumor regression. In the latter cases, taTME achieves good short-term outcomes and may facilitate R0 resection.
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