Robot-assisted total mesorectal excision for rectal cancer: case-matched comparison of short-term surgical and functional outcomes between the da Vinci Xi and Si

BACKGROUND

Robotic rectal resection with da Vinci Si has some technical limitations, which could be overcome by the new da Vinci Xi. We compare short-term surgical and functional outcomes following robotic rectal resection with total mesorectal excision for cancer, with the da Vinci Xi (Xi-RobTME group) and the da Vinci Si (Si-RobTME group).

METHODS

The first consecutive 30 Xi-RobTME were compared with a Si-RobTME control group of 30 patients, selected using a one-to-one case-matched methodology from our prospectively collected Institutional database, comprising all cases performed between April 2010 and September 2016 by a single surgeon. Perioperative outcomes were compared. The impact of minimally invasive TME on autonomic function and quality of life was analyzed with specific questionnaires.

RESULTS

The docking and overall operative time were shorter in the Xi-RobTME group (p < 0.001 and p < 0.05 respectively). The mean differences of overall operative time and docking time were -33.8 min (95% CI -5.1 to -64.5) and -6 min (95% CI -4.1 to -7.9), respectively. A fully-robotic approach with complete splenic flexure mobilization was used in 30/30 (100%) of the Xi-RobTME cases and in 7/30 (23%) of the Si-RobTME group (p < 0.001). The hybrid approach in males and patients with BMI > 25 kg/m2 was necessary in ten patients (45 vs. 0%, p < 0.001) and in six patients (37 vs. 0%, p < 0.05), in the Si-RobTME and Xi-RobTME groups, respectively. There were no differences in conversion rate, mean hospital stay, pathological data, and in functional outcomes between the two groups before and at 1 year after surgery.

CONCLUSION

The technical advantages offered by the da Vinci Xi seem to be mainly associated with a shorter docking and operative time and with superior ability to perform a fully-robotic approach. Clinical and functional outcomes seem not to be improved, with the introduction of the new Xi platform.

Structured cost analysis of robotic TME resection for rectal cancer: a comparison between the da Vinci Si and Xi in a single surgeon's experience

BACKGROUND

Robotic-assisted surgery by the da Vinci Si appears to benefit rectal cancer surgery in selected patients, but still has some limitations, one of which is its high costs. Preliminary studies have indicated that the use of the new da Vinci Xi provides some added advantages, but their impact on cost is unknown. The aim of the present study is to compare surgical outcomes and costs of rectal cancer resection by the two platforms, in a single surgeon's experience.

METHODS

From April 2010 to April 2017, 90 robotic rectal resections were performed, with either the da Vinci Si (Si-RobTME) or the da Vinci Xi (Xi-RobTME). Based on CUSUM analysis, two comparable groups of 40 consecutive Si-RobTME and 40 consecutive Xi-RobTME were obtained from the prospectively collected database and used for the present retrospective comparative study. Data costs were analysed based on the level of experience on the proficiency-gain curve (p-g curve) by the surgeon with each platform.

RESULTS

In both groups, two homogeneous phases of the p-g curve were identified: Si1 and Xi1: cases 1-19, Si2 and Xi2: cases 20-40. A significantly higher number of full RAS operations were achieved in the Xi-RobTME group (p < 0.001). A statistically significant reduction in operating time (OT) during Si2 and Xi2 phase was observed (p < 0.001), accompanied by reduced overall variable costs (OVC), personnel costs (PC) and consumable costs (CC) (p < 0.001). All costs were lower in the Xi2 phase compared to Si2 phase: OT 265 versus 290 min (p = 0.052); OVC 7983 versus 10231.9 (p = 0.009); PC 1151.6 versus 1260.2 (p = 0.052), CC 3464.4 versus 3869.7 (p < 0.001).

CONCLUSIONS

Our experience confirms a significant reduction of costs with increasing surgeon's experience with both platforms. However, the economic gain was higher with the Xi with shorter OT, reduced PC and CC, in addition to a significantly larger number of cases performed by the fully robotic approach.

Clinical outcomes of stapled transanal rectal resection for obstructed defaecation syndrome at 10-year follow-up

AIM

The long-term efficacy of stapled transanal rectal resection (STARR) for surgical management of obstructed defaecation syndrome (ODS) has not been evaluated. Therefore, we investigated the long-term efficacy (> 10 years) of STARR for treatment of ODS related to rectocele or rectal intussusception and the factors that predict treatment outcome.

METHOD

This study was a retrospective cohort analysis conducted on prospectively collected data. Seventy-four consecutive patients who underwent STARR for ODS between January 2005 and December 2006 in two Italian hospitals were included.

RESULTS

Seventy-four patients [66 women; median age 61 (29-77) years] underwent STARR for ODS. No serious postoperative complications were recorded. Ten years postoperatively, 60 (81%) patients completed the expected follow-up. Twenty-three patients (38%) reported persistent perineal pain and 13 (22%) experienced the urge to defaecate. ODS symptoms recurred in 24 (40%) patients after 10 years. At the 10-year follow-up, 35% of patients were very satisfied and 28% would recommend STARR and undergo the same procedure again if necessary. In contrast, 21% of patients would not select STARR again. Previous uro-gynaecological or rectal surgery and high constipation scores were identified as risk factors for recurrence.

CONCLUSIONS

Stapled transanal rectal resection significantly improves the symptoms of ODS in the short term. In the long term STARR is less effective, however.

Impact of a Dual-Ring Wound Protector on Outcome After Elective Surgery for Colorectal Cancer

BACKGROUND

The impact of dual-ring wound protectors (DRWPs) on the long-term outcomes of patients with colorectal cancer (CRC) undergoing elective surgery remains unclear. The aim of this cohort study was to compare short- and long-term outcomes after CRC resection with or without use of a DRWP.

METHODS

This study enrolled 625 patients with stage I-III CRC undergoing curative resection and divided them into DRWP (n = 348) and control (n = 277) groups. Primary endpoints were postoperative short- and long-term complications. Secondary endpoints were oncological outcomes including wound recurrence, disease-free survival, and overall survival.

RESULTS

Rates of postoperative complications (P = 0.004) and laparotomy wound infection (LWI) (P < 0.001) were markedly lower in the DRWP group. Operation quality, as per the number of lymph nodes harvested and rate of R0 resection, did not differ between the groups (all P > 0.05). The DRWP group exhibited significantly lower rates of incisional hernia occurrence (5.3% versus 9.5%, P = 0.045) compared with the control group. Multivariable analyses demonstrated an increased risk of LWI with no wound protector in colorectal surgery (odds ratio, 3.778; P = 0.001), and patients who developed LWI after surgery were more than 4 times more likely to develop an incisional hernia during outpatient follow-up (odds ratio, 4.333; P = 0.001). One patient in the control group (0.36%) had isolated wound recurrence at 12 mo postoperatively.

CONCLUSIONS

Fewer postoperative and late complications, comparable oncological safety, and similar long-term clinical outcomes confirmed the benefits of DRWP use for patients with CRC undergoing elective surgery. Therefore, the use of DRWP may be considered in curative CRC resection.

The value of force and torque measurements in transanal total mesorectal excision (TaTME)

Background

Transanal total mesorectal excision (TaTME) is associated with a relatively long learning curve. Force, motion, and time parameters are increasingly used for objective assessment of skills to enhance laparoscopic training efficacy. The aim of this study was to identify relevant metrics for accurate skill assessment in more complex transanal purse-string suturing.

Methods

A box trainer was designed for TaTME and equipped with two custom made multi-DOF force/torque sensors. These sensors measured the applied forces in the axial direction of the instruments (Fz), instrument load orientation expressed in torque (Mx and My) on the entrance port, and the full tissue interaction force (Fft) at the intestine fixation point. In a construct validity study, novices for TaTME performed a purse-string suture to investigate which parameters can be used best to identify meaningful events during tissue manipulation and instrument handling.

Results

Significant differences exist between pre- and post-training assessment for the mean axial force at the entrance port Fz (p = 0.01), mean torque in the entrance port Mx (p = 0.03) and mean force on the intestine during suturing Fft (p = 0.05). Furthermore, force levels during suturing exceed safety threshold values, potentially leading to dangerous complications such as rupture of the rectum.

Conclusions

Forces and torque measured at the entrance port, and the tissue interaction force signatures provide detailed insight into instrument handling, instrument loading, and tissue handling during purse-string suturing in a TaTME training setup. This newly developed training setup for single-port laparoscopy that enables objective feedback has the potential to enhance surgical training in TaTME.

Sphincter-saving proctectomy for rectal cancer with NO COIL® transanal tube and without ostoma. Clinical outcomes, cost effectiveness and quality of life in the elderly

BACKGROUND

Colorectal cancer is one of the most common invasive cancers, and it is responsible for considerable physical and psychosocial morbidity specially in older patients. However, only few reports focused on quality of life, cost-effectiveness and clinical outcomes of rectal cancer patients undergone to surgery. This retrospective study compares short-term and long-term outcomes in rectal cancer patients with more and less than 75 years of age.

METHODS

Four hundred consecutive patients underwent radical surgery for rectal adenocarcinoma and they were collected in a prospective institutional database and divided into two groups: group 1 (≥75 years, N.=98); group 2 (<75 years, N.=302). Rectal anterior resection (RAR) with sphincter-saving restorative proctectomy and with application of silicone transanal tube NO COIL® 60-80 mm long, was the only procedure considered. Main clinical and pathological data were assessed and compared.

RESULTS

Statistically significant differences between the two groups were detected regard to comorbidities and the emergency presentation. Overall survival is lower in patients over 75 age, but cancer-related survival is not different between the two groups.

CONCLUSIONS

Although advanced age is associated with higher morbidity and mortality, in our experience, itself is not a contraindication for surgical sphincter-saving proctetomy in rectal cancer patients. The absence of a stoma also improved the cost effectiveness and patients' quality of life in both groups: psychological morbidity, sexuality, levels of anxiety and depression, body image.

[Prevention of colorectal anastomotic leakage in patients with rectal cancer]

OBJECTIVE

To develop a technique of anastomosis sutures protection using the Foley catheter in rectal cancer surgery.

MATERIAL AND METHODS

There were 42 patients with rectal cancer T1-3N0-2M0 (the 7^th TNM edition) who underwent radical sphincter-sparing surgery with neoadjuvant chemoradiotherapy for the period from November 2016 to June 2018. All procedures were performed at the Regional Clinical Oncology Center. All operations were completed with formation of colorectal anastomosis in 'end-to-side' fashion. Patients were divided into 2 groups (main and control) depending on used technique. In the main group (n=20), Foley catheter #30 in accordance with original method was used to protect the anastomosis. Preventive colostomy was applied in 15 patients. The control group consisted of 22 patients. None of these patients underwent prevention of anastomosis leakage. Preventive colostomy was performed in 14 patients.

RESULTS

There were no early postoperative complications in the main group. The catheter was removed after 7-9 days. In the control group, 5 patients had symptoms of anastomotic leakage (22.5%; p<0.05). Medication was effective in 4 cases. Re-laparotomy were required in 1 patient.

CONCLUSION

Thus, anastomosis sutures protection using the Foley catheter is quite reliable and technically simple procedure with favorable outcomes.

Is early anvil placement an alternative technique to reduce anastomotic leak after rectosigmoid cancer resection?

INTRODUCTION

Anastomotic leakage (AL) is one of the most disastrous complications after rectosigmoid cancer operations. The aim of this study is to investigate the effect of the insertion time of circular stapler anvil on assessing the blood supply of the proximal colon segment, and thus to evaluate the prevention of early anastomotic leaks.

MATERIAL METHODS

A total of 57 patients were included in the study, 25 patients in group A and 32 patients in group B, respectively. From the beginning of the operation to the time of anvil placement in group A, it was 32.08 (± 7.34) minutes, and in group B it was 92.19 (± 16.63) minutes. None of the patients in group A had AL, and 4 patients in group B had AL.

DISCUSSION

Our study shows that the anvil must be placed at the beginning of the dissection to evaluate the anomalies that cause anastomotic leaks. We think that this method increases the reliability of the anastomosis line. Thus, the hospitalization period of the patients was shortened and they returned to their active lives faster. In addition, patients used less antibiotics and they needed less medical treatment.

KEY WORDS

Anastomotic leaks, Anvil, Rectosigmoid cancer placement, Stapler colorectal.

[Application research of presacral space drainage tube combined with subcutaneous vacuum pressure suction in the laparoscopic-assisted abdominoperineal resection]

OBJECTIVE

To study the management for the perineal incision after laparoscopic-assisted abdominoperineal resection for rectal cancer.

METHODS

Clinical data of 87 patients undergoing laparoscopic Miles operation for lower rectal cancer from June 2009 to February 2014 were collected and studied. Presacral space drainage group: presacral space drainage tube was applied in 42 patients. Combined drainage group: presacral space drainage tube combined with subcutaneous vacuum pressure suction was applied in 45 cases. In combined drainage group, except the presacral drainage tube, another drainage tube was placed subcutaneously and connected to a negative pressure ball, which was fixed on the lateral anterior of perineal wound by the further incision and drainage. After subcutaneous tube was placed for 2 weeks, as drainage fluid was limpid and <15 ml/d for 3 days, meanwhile no obvious pelvic fluid was detected by ultrasound, and the wound healed quite well without redness and edema, then the subcutaneous tube with the negative pressure ball could be removed.

RESULTS

There were 51 males and 36 females with the mean age of 26-78(56.9±10.8) years old. The laparoscopic Miles operation was successfully completed in all the cases without death and complications. The drainage tube was placed for 4-13(8.0±2.5) days in presacral space drainage group, and for 4-14(6.7±2.4) days in combined drainage group. The subcutaneous tube was placed for 14-24(15.8±3.0) days. The primary healing rate of perineal wound in presacral space drainage group and combined drainage group was 66.7%(28/42) and 91.1%(41/45) respectively, while the perineal wound infection rate was 21.4%(9/42) and 4.4%(2/45) respectively, whose differences between two groups were both significant (χ²=7.911, P=0.005 and χ²=5.674, P=0.017).

CONCLUSION

Presacral space drainage tube combined with subcutaneous vacuum pressure suction in laparoscopic-assisted abdominoperineal resection for rectal cancer has better efficacy and lower infection rate for perineal incision, which is worth wide application.

[Usefulness of self-made gasbag double-cannula stool drainage device for prevention of anastomotic leakage following anterior resection]

OBJECTIVE

To evaluate the efficacy of self-made gasbag double-cannula stool drainage device for prevention of anastomotic leakage following anterior resection.

METHODS

Clinical data of 169 rectal cancer patients in the 8th Affiliated Hospital of Sun Yat-sen University between October 2010 and October 2016 were retrospectively analyzed. Among them, a self-made gasbag double-cannula stool drainage device was placed in 71 patients(stool drainage group), and the remaining 98 patients were taken as control. After an anastomosis, the drainage device was transanally placed by the assistant and the distal tube of drainage device was stretched more than 15 cm from anastomosis. The gasbag was inflated to fully expand the intestine. The main tube was fixed on perianal skin with 7-0 suture, kept more than 3-5 cm outside the anus, and connected to the drainage bag. The incidence of anastomotic leakage was compared between the two groups.

RESULTS

The baseline data were similar between the two groups (all P>0.05). The differences in operative time, intraoperative blood loss, and time to bowel function recovery were not statistically significant (all P>0.05), however, time to oral intake and postoperative stay were shorter in stool drainage group as compared to the control group (both P<0.05). There was no perioperative death in both groups. In stool drainage group, there were 6 cases whose drainage device was pulled out within 48 hours due to intolerance. The ruptured gasbag was replaced 5 times and the tube was clogged by fecal material 21 times. After flushing, the tube did not recanalized and was pulled out in 3 cases. The incidence of anastomotic leakage in stool drainage group was significantly lower than that in the control group (2.8% vs. 11.2%, P=0.043). As for the low anastomosis (the distance to anal verge less than 5 cm), the incidence of anastomotic leakage in stool drainage group was also significantly lower than that in the control group (2.3% vs. 15.4%, P=0.028), while as for the high anastomosis, the difference was not statistically significant (3.6% vs. 3.0%, P=0.906). Logistic regression analysis revealed that the presence of a stool drainage device was an independent protective factor for anastomotic leakage (OR=0.316, 95%CI:0.114 ~ 0.769, P=0.003).

CONCLUSIONS

The self-made gasbag double-cannula stool drainage device effectively prevents anastomotic leakage after anterior resection of rectal cancer. However it is not suitable for those patients with high anastomosis.

[Not Available]

Incidence of cancer recti (CR)in Ukraine constitutes 38 in 100 thousands of population. There are two main trends in surgical treatment of precancerous states and early stage CR: radical rectal resection and local transanal excision of the affection zone. After a single—port procedure introduction into laparoscopic surgery the alternative method of rectal tumors resection have had evolved — a transanal minimally invasive surgery with single—port (TAMIS). In the clinic the TAMIS procedure was applied in 3 patients for adenomatous rectal polyps. Оperative intervention was done using transanal videoen' doscopic excision of villous rectal tumor. First experience of application of TAMIS wit' nessed the method efficacy, its relatively low cost and low risk of complications occur' rence. Application of this adopted procedure contributes for improvement of the treat' ment results in rectal tumors.

SafeHeal Colovac Colorectal Anastomosis Protection Device evaluation (SAFE-2) pivotal study: an international randomized controlled study to evaluate the safety and effectiveness of the Colovac Colorectal Anastomosis Protection Device

AIM

Although proximal faecal diversion is standard of care to protect patients with high-risk colorectal anastomoses against septic complications of anastomotic leakage, it is associated with significant morbidity. The Colovac device (CD) is an intraluminal bypass device intended to avoid stoma creation in patients undergoing low anterior resection. A preliminary study (SAFE-1) completed in three European centres demonstrated 100% protection of colorectal anastomoses in 15 patients, as evidenced by the absence of faeces below the CD. This phase III trial (SAFE-2) aims to evaluate the safety and effectiveness of the CD in a larger cohort of patients undergoing curative rectal cancer resection.

METHODS

SAFE-2 is a pivotal, multicentre, prospective, open-label, randomized, controlled trial. Patients will be randomized in a 1:1 ratio to either the CD arm or the diverting loop ileostomy arm, with a recruitment target of 342 patients. The co-primary endpoints are the occurrence of major postoperative complications within 12 months of index surgery and the effectiveness of the CD in reducing stoma creation rates. Data regarding quality of life and patient's acceptance and tolerance of the device will be collected.

DISCUSSION

SAFE-2 is a multicentre randomized, control trial assessing the efficacy and the safety of the CD in protecting low colorectal anastomoses created during oncological resection relative to standard diverting loop ileostomy.

TRIAL REGISTRATION

NCT05010850.