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Zhang Y, Guo Q, Li S, Zhang Z, Xiang F, Su W, Wu Y, Yu J, Xie Y, Luo C, Zheng F. Machine Learning Model for Predicting Pheochromocytomas/Paragangliomas Surgery Difficulty: A Retrospective Cohort Study. Ann Surg Oncol 2025:10.1245/s10434-025-17346-1. [PMID: 40343590 DOI: 10.1245/s10434-025-17346-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2025] [Accepted: 04/04/2025] [Indexed: 05/11/2025]
Abstract
OBJECTIVE We aimed to develop a machine learning (ML) model to preoperatively predict surgical difficulty for pheochromocytomas and paragangliomas (PPGLs) using clinical and radiomic features. METHODS In this study, 212 patients with pathologically confirmed PPGLs were retrospectively enrolled and divided into training (n = 148) and validation cohorts (n = 64). Seven ML models (Classification and Regression Tree, K-Nearest Neighbors, Least Absolute Shrinkage and Selection Operator, Naïve Bayes, Random Forest, Support Vector Machine (SVM), and Extreme Gradient Boosting) were trained using clinical parameters alone or combined with radiomics. Model performance was evaluated and compared through accuracy, sensitivity, specificity, F1 score, area under the curve (AUC), calibration curves, and decision curve analysis. Through comprehensive assessment, the optimal integrated model (clinical + radiomics) was identified and its predictive efficacy was subsequently compared with that of the clinical parameter model. Finally, SHapley Additive exPlanations (SHAP) was applied to enhance the interpretability of the optimal model by visualizing feature contributions. RESULTS Among all integrated models, the SVM model exhibited the most prominent performance, achieving AUC values of 0.96 in the training cohort and 0.85 in the validation cohort, while demonstrating statistically significant superiority over the clinical parameter model (p < 0.05). The SHAP analysis revealed that radiomic signature (Rad score) exerted the most substantial influence on the predictive outcomes, with age, body mass index, maximum tumor diameter, and preoperative heart rate also demonstrating statistically significant contributions to the model predictions. CONCLUSION The SVM model integrating clinical and radiomic features effectively predicts PPGL surgical difficulty, aiding preoperative risk stratification and personalized surgical planning to reduce operative risks.
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Affiliation(s)
- Yubing Zhang
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Qikun Guo
- Department of Interventional Radiology, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Shurong Li
- Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Zhiqiang Zhang
- Department of Andrology, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, People's Republic of China
| | - Fangzheng Xiang
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Wenhui Su
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yukun Wu
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Jiajie Yu
- Department of Andrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Yun Xie
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
| | - Cheng Luo
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
| | - Fufu Zheng
- Department of Urology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China.
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Zhan L, Guo B, Tao Z, Deng X, Ding Z, Wu B, Yang Z, Guo M, Tao X, Gu X, Fan Y. Nomogram for predicting difficult transoral and submental thyroidectomy: a retrospective model development and validation study with large-scale population. Surg Endosc 2025; 39:3202-3214. [PMID: 40216625 PMCID: PMC12041166 DOI: 10.1007/s00464-025-11725-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Accepted: 04/06/2025] [Indexed: 05/01/2025]
Abstract
OBJECTIVE No prior studies have described or stratified the difficulty of transoral and submental thyroidectomy (TOaST). We aimed to investigate preoperative factors as indicators of difficult TOaSTs and to develop a predictive model accordingly. METHODS This retrospective study included 255 eligible DTC patients who underwent total thyroidectomy and central neck dissection (CND) via transoral and submental endoscopic approach between February 2021 and April 2024. These patients were randomized into training and validation groups in a 7:3 ratio. Procedures were categorized into difficult and normal TOaST based on operation time, conversion to open and intraoperative injury. Univariate and multivariate logistic regression analyses were used to assess the association between surgical difficulty and factors regarding demographics, laboratory tests and ultrasound information. A nomogram was then developed and validated internally. Surgical and oncological profiles and follow-up data were also analyzed. RESULTS Five independent risk factors for difficult TOaST were identified in multivariate analysis: age (OR 0.84, p < 0.001), male sex (OR 4.75, p = 0.016), thyromental distance (TMD) < 7 cm (OR 7.59, p < 0.001), presence of diffuse changes on ultrasound (OR 14.5, p < 0.001), and elevated anti-thyroid peroxidase antibody (TPO-Ab) level (OR 5.22, p = 0.005). The nomogram performed well on both the training and the validation datasets, achieving an area under curve (AUC) of 0.908 and 0.888, respectively. Calibration curves for both datasets also fit well. There was no significant difference in complication rates between the difficult and normal TOaST groups. CONCLUSION The developed nomogram provides a reliable, straightforward prediction of difficult TOaST, thus supporting preoperative preparation and consultation, as well as optimizing training and promotion.
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Affiliation(s)
- Ling Zhan
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, China
| | - Bomin Guo
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, China
| | - Zixia Tao
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, China
| | - Xianzhao Deng
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, China
| | - Zheng Ding
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, China
| | - Bo Wu
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, China
| | - Zhili Yang
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, China
| | - Minggao Guo
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, China
| | - Xuanbin Tao
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, China
| | - Xiaohui Gu
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, China
| | - Youben Fan
- Department of General Surgery, Thyroid and Parathyroid Center, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Shanghai, China.
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Ay OF, Firat D, Özçetin B, Ocakoglu G, Ozcan SGG, Bakır Ş, Ocak B, Taşkin AK. Role of pelvimetry in predicting surgical outcomes and morbidity in rectal cancer surgery: A retrospective analysis. World J Gastrointest Surg 2025; 17:104726. [PMID: 40291864 PMCID: PMC12019048 DOI: 10.4240/wjgs.v17.i4.104726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2024] [Revised: 01/28/2025] [Accepted: 02/27/2025] [Indexed: 03/29/2025] Open
Abstract
BACKGROUND Rectal cancer has increased in incidence, and surgery remains the cornerstone of multimodal treatment. Pelvic anatomy, particularly a narrow pelvis, poses challenges in rectal cancer surgery, potentially affecting oncological outcomes and postoperative complications. AIM To investigate the relationship between radiologically assessed pelvic anatomy and surgical outcomes as well as the impact on local recurrence following rectal cancer surgery. METHODS We retrospectively analyzed 107 patients with rectal adenocarcinoma treated with elective rectal surgery between January 1, 2017, and September 1, 2022. Pelvimetric measurements were performed using computed tomography (CT)-based two-dimensional methods (n = 77) by assessing the pelvic inlet area in mm², and magnetic resonance imaging (MRI)-based three-dimensional techniques (n = 52) using the pelvic cavity index (PCI). Patient demographic, clinical, radiological, surgical, and pathological characteristics were collected and analyzed in relation to their pelvimetric data. RESULTS When patients were categorized based on CT measurements into narrow and normal/wide pelvis groups, a significant association was observed with male sex, and a lower BMI was more common in the narrow pelvis group (P = 0.002 for both). A significant association was found between a narrow pelvic structure, indicated by low PCI, and increased surgical morbidity (P = 0.049). Advanced age (P = 0.003) and male sex (P = 0.020) were significantly correlated with higher surgical morbidity. Logistic regression analysis identified four parameters that were significantly correlated with local recurrence: older age, early perioperative readmission, longer operation time, and a lower number of dissected lymph nodes (P < 0.05). However, there were no significant differences between the narrow and normal/wide pelvis groups in terms of the operation time, estimated blood loss, or overall local recurrence rate (P > 0.05). CONCLUSION MRI-based pelvimetry may be valuable in predicting surgical difficulty and morbidity in rectal cancer surgery, as indicated by the PCI. The observed correlation between low PCI and increased surgical morbidity suggests the potential importance of a preoperative MRI-based pelvimetric evaluation. In contrast, CT-based pelvimetry did not show significant differences in predicting surgical outcomes or cancer recurrence, indicating that the utility of pelvimetry alone may be limited in these respects.
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Affiliation(s)
- Oguzhan Fatih Ay
- Department of General Surgery, Kahramanmaras Necip Fazıl City Hospital, Kahramanmaras 46140, Türkiye
| | - Deniz Firat
- Department of General Surgery, University of Health Science, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa 16110, Türkiye
| | - Bülent Özçetin
- Department of General Surgery, University of Health Science, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa 16110, Türkiye
| | - Gokhan Ocakoglu
- Department of Biostatistics, Uludag University Faculty of Medicine, Bursa 16059, Türkiye
| | - Seray Gizem Gur Ozcan
- Department of Radiology, University of Health Science, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa 16110, Türkiye
| | - Şule Bakır
- Department of Pathology, University of Health Science, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa 16110, Türkiye
| | - Birol Ocak
- Department of Medical Oncology, University of Health Science, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa 16110, Türkiye
| | - Ali Kemal Taşkin
- Department of General Surgery, University of Health Science, Bursa Yuksek Ihtisas Training and Research Hospital, Bursa 16110, Türkiye
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Baltus SC, Geitenbeek RTJ, Frieben M, Thibeau-Sutre E, Wolterink JM, Tan CO, Vermeulen MC, Consten ECJ, Broeders IAMJ. Deep learning-based pelvimetry in pelvic MRI volumes for pre-operative difficulty assessment of total mesorectal excision. Surg Endosc 2025; 39:1536-1543. [PMID: 39753930 PMCID: PMC11870868 DOI: 10.1007/s00464-024-11485-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 12/14/2024] [Indexed: 03/03/2025]
Abstract
BACKGROUND Specific pelvic bone dimensions have been identified as predictors of total mesorectal excision (TME) difficulty and outcomes. However, manual measurement of these dimensions (pelvimetry) is labor intensive and thus, anatomic criteria are not included in the pre-operative difficulty assessment. In this work, we propose an automated workflow for pelvimetry based on pre-operative magnetic resonance imaging (MRI) volumes. METHODS We implement a deep learning-based framework to measure the predictive pelvic dimensions automatically. A 3D U-Net takes a sagittal T2-weighted MRI volume as input and determines five anatomic landmark locations: promontorium, S3-vertebrae, coccyx, dorsal, and cranial part of the os pubis. The landmarks are used to quantify the lengths of the pelvic inlet, outlet, depth, and the angle of the sacrum. For the development of the network, we used MRI volumes from 1707 patients acquired in eight TME centers. The automated landmark localization and pelvic dimensions measurements are assessed by comparison with manual annotation. RESULTS A center-stratified fivefold cross-validation showed a mean landmark localization error of 5.6 mm. The inter-observer variation for manual annotation was 3.7 ± 8.4 mm. The automated dimension measurements had a Spearman correlation coefficient ranging between 0.7 and 0.87. CONCLUSION To our knowledge, this is the first study to automate pelvimetry in MRI volumes using deep learning. Our framework can measure the pelvic dimensions with high accuracy, enabling the extraction of metrics that facilitate a pre-operative difficulty assessment of the TME.
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Affiliation(s)
- Simon C Baltus
- Surgery Department, Meander Medical Centre, Maatweg, Amersfoort, 3818 TZ, Utrecht, The Netherlands.
- Robotics and Mechatronics, University of Twente, Drienerlolaan, Enschede, 5722 NB, Overijssel, The Netherlands.
| | - Ritch T J Geitenbeek
- Surgery Department, Meander Medical Centre, Maatweg, Amersfoort, 3818 TZ, Utrecht, The Netherlands
- Surgery Department, University Medical Center Groningen, Hanzeplein, Groningen, 9713 GZ, Groningen, The Netherlands
| | - Maike Frieben
- Surgery Department, University Medical Center Groningen, Hanzeplein, Groningen, 9713 GZ, Groningen, The Netherlands
| | - Elina Thibeau-Sutre
- Department of Applied Mathematics, Technical Medicine Center, University of Twente, Drienerlolaan, Enschede, 5722 NB, Overijssel, The Netherlands
| | - Jelmer M Wolterink
- Department of Applied Mathematics, Technical Medicine Center, University of Twente, Drienerlolaan, Enschede, 5722 NB, Overijssel, The Netherlands
| | - Can O Tan
- Robotics and Mechatronics, University of Twente, Drienerlolaan, Enschede, 5722 NB, Overijssel, The Netherlands
| | - Matthijs C Vermeulen
- Surgery Department, Meander Medical Centre, Maatweg, Amersfoort, 3818 TZ, Utrecht, The Netherlands
| | - Esther C J Consten
- Surgery Department, Meander Medical Centre, Maatweg, Amersfoort, 3818 TZ, Utrecht, The Netherlands
- Surgery Department, University Medical Center Groningen, Hanzeplein, Groningen, 9713 GZ, Groningen, The Netherlands
| | - Ivo A M J Broeders
- Surgery Department, Meander Medical Centre, Maatweg, Amersfoort, 3818 TZ, Utrecht, The Netherlands
- Robotics and Mechatronics, University of Twente, Drienerlolaan, Enschede, 5722 NB, Overijssel, The Netherlands
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Hardacre C, Hibbs T, Fok M, Wiles R, Bashar N, Ahmed S, Mascarenhas Saraiva M, Zheng Y, Javed MA. Predicting Surgical Difficulty in Rectal Cancer Surgery: A Systematic Review of Artificial Intelligence Models Applied to Pre-Operative MRI. Cancers (Basel) 2025; 17:812. [PMID: 40075659 PMCID: PMC11899449 DOI: 10.3390/cancers17050812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2025] [Revised: 02/18/2025] [Accepted: 02/21/2025] [Indexed: 03/14/2025] Open
Abstract
Introduction: Following the rapid advances in minimally invasive surgery, there are a multitude of surgical modalities available for resecting rectal cancers. Robotic resections represent the current pinnacle of surgical approaches. Currently, decisions on the surgical modality depend on local resources and the expertise of the surgical team. Given limited access to robotic surgery, developing tools based on pre-operative data that can predict the difficulty of surgery would streamline the efficient utilisation of resources. This systematic review aims to appraise the existing literature on artificial intelligence (AI)-driven preoperative MRI analysis for surgical difficulty prediction to identify knowledge gaps and promising models warranting further clinical evaluation. Methods: A systematic review and narrative synthesis were undertaken in accordance with PRISMA and SWiM guidelines. Systematic searches were performed on Medline, Embase, and the CENTRAL Trials register. Studies published between 2012 and 2024 were included where AI was applied to preoperative MRI imaging of adult rectal cancer patients undergoing surgeries, of any approach, for the purpose of stratifying surgical difficulty. Data were extracted according to a pre-specified protocol to capture study characteristics and AI design; the objectives and performance outcome metrics were summarised. Results: Systematic database searches returned 568 articles, 40 ultimately included in this review. AI to support preoperative difficulty assessments were identified across eight domains (direct surgical difficulty grading, extramural vascular invasion (EMVI), lymph node metastasis (LNM), lymphovascular invasion (LVI), perineural invasion (PNI), T staging, and the requirement for multiple linear stapler firings. For each, at least one model was identified with very good performance (AUC scores of >0.80), with several showing excellent performance considerably above this threshold. Conclusions: AI tools applied to preoperative rectal MRI to support preoperative difficulty assessment for rectal cancer surgeries are emerging, with the progressing development and strong performance of many promising models. These warrant further clinical evaluation, which can aid personalised surgical approaches and ensure the adequate utilisation of limited resources.
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Affiliation(s)
- Conor Hardacre
- University Hospitals of Liverpool Group, Liverpool L7 8YE, UK (N.B.); (M.A.J.)
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZX, UK;
| | - Thomas Hibbs
- University Hospitals of Liverpool Group, Liverpool L7 8YE, UK (N.B.); (M.A.J.)
| | - Matthew Fok
- University Hospitals of Liverpool Group, Liverpool L7 8YE, UK (N.B.); (M.A.J.)
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZX, UK;
| | - Rebecca Wiles
- University Hospitals of Liverpool Group, Liverpool L7 8YE, UK (N.B.); (M.A.J.)
| | - Nada Bashar
- University Hospitals of Liverpool Group, Liverpool L7 8YE, UK (N.B.); (M.A.J.)
| | - Shakil Ahmed
- University Hospitals of Liverpool Group, Liverpool L7 8YE, UK (N.B.); (M.A.J.)
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZX, UK;
| | - Miguel Mascarenhas Saraiva
- Precision Medicine Unit, Department of Gastroenterology, São João University Hospital, 4200-427 Porto, Portugal;
| | - Yalin Zheng
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZX, UK;
| | - Muhammad Ahsan Javed
- University Hospitals of Liverpool Group, Liverpool L7 8YE, UK (N.B.); (M.A.J.)
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 7ZX, UK;
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L69 7TX, UK
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Nakamura T, Kobayashi E, Takenaka S, Endo M, Hayashi K, Nakata E, Ohshika S, Kawashima H, Hamada T, Horiuchi K, Nishida Y, Hasegawa M, Morii T. Predictive variables for intraoperative blood loss and surgical time in resection of malignant soft tissue tumors without reconstruction. Jpn J Clin Oncol 2025:hyaf030. [PMID: 39957416 DOI: 10.1093/jjco/hyaf030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2024] [Accepted: 01/30/2025] [Indexed: 02/18/2025] Open
Abstract
BACKGROUND Procedural techniques such as dissection and separation of blood vessels or nerves from the tumor for preserving limbs and functions involves high surgical difficulty. We hypothesized the relation of vessel and/or nerve preservation to surgical time and blood loss, accurately reflecting surgical difficulty. In this study, we elucidated the variables affecting surgical time and intraoperative bleeding in patients with malignant soft tissue tumors who did not undergo any reconstruction after tumor resection. METHODS We included 153 patients with malignant oft tissue tumors in the trunk (n = 72), thigh (n = 68), and upper arm (n = 13) at nine institutions. We analyzed the possible predictive variables affecting surgical time and intraoperative bleeding. RESULTS Overall, the study included 153 patients (85 men and 68 women) with a mean age of 65 years. The tumors were primary soft tissue sarcoma (STS) (n = 114), local recurrent STS (n = 25), and soft tissue metastasis (n = 14). The median number of participating surgeons was three. The mean and median surgical time were 144.6 and 123 min, respectively. The mean and median intraoperative bleeding were 157.1 and 55 mL, respectively. Tumor size, depth, dissection and separation of blood vessels from the tumor, dissection and separation of nerve from the tumor, and the number of participating surgeons were significantly related to the surgical time and intraoperative bleeding. CONCLUSIONS The procedure of dissection and separation of blood vessels and nerves from the tumor were related to surgical time and intraoperative bleeding in patients with malignant soft tissue tumors, especially large and deep tumors.
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Affiliation(s)
- Tomoki Nakamura
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie 514-8507, Japan
| | - Eisuke Kobayashi
- Department of Musculoskeletal Oncology and Rehabilitation Medicine, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Satoshi Takenaka
- Department of Musculoskeletal Oncology Service, Osaka International Cancer Institute, 3-1-69 Otemae, Osaka 541-8567, Japan
| | - Makoto Endo
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Katsuhiro Hayashi
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa 920-8641, Japan
| | - Eiji Nakata
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama 700-8558, Japan
| | - Shusa Ohshika
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan
| | - Hiroyuki Kawashima
- Division of Orthopaedic Surgery, Department of Regenerative and Transplant Medicine, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachi-Dori Chuoku, Niigata, Niigata 951-8510, Japan
| | - Tetsuya Hamada
- Department of Orthopedic Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan
| | - Keisuke Horiuchi
- Department of Orthopedic Surgery, National Defense Medical College, Namiki 3-2, Tokorozawa, Saitama 359-8513, Japan
| | - Yoshihiro Nishida
- Department of Rehabilitation, Nagoya University Hospital, 65 Tsurumai, Nagoya, Aichi 466-8550, Japan
| | - Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu city, Mie 514-8507, Japan
| | - Takeshi Morii
- Department of Orthopaedic Surgery, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo 181-8611, Japan
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Han M, Guo S, Ma S, Zhou Q, Zhang W, Wang J, Zhuang J, Yao H, Yuan W, Lian Y. Predictive model of the surgical difficulty of robot-assisted total mesorectal excision for rectal cancer: a multicenter, retrospective study. J Robot Surg 2024; 19:19. [PMID: 39648255 PMCID: PMC11625687 DOI: 10.1007/s11701-024-02180-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2024] [Accepted: 11/23/2024] [Indexed: 12/10/2024]
Abstract
Rectal cancer robotic surgery is becoming more and more common, but evidence for predicting surgical difficulty is scarce. Our goal was to look at the elements that influence the complexity of robot-assisted total mesorectal excision (R-TME) in the medical care of middle and low rectal cancer as well as to establish and validate a predictive model on the basis of these factors. Within this multicenter retrospective investigation, 166 consecutive patients receiving R-TME between January 2021 and December 2022 with middle and low rectal cancer were included and categorized according to the median operation time. A nomogram was created to forecast the procedure's complexity after variables that could affect its difficulty were found using logistic regression analysis. Using R software, a total of 166 patients were randomly split into two groups: a test group (48 patients) and a training group (118 patients) at a ratio of 7 to 3. The median operation time of all patients was 207.5 min; patients whose operation time was ≥ 207.5 min were allocated to the difficult surgery group (83 patients), and patients whose operation time was < 207.5 min were allocated to the nondifficult surgery group. Multivariate analysis revealed that body mass index (BMI), the gap between the tumor and the anal verge and the posterior rectal mesenteric thickness were independent predictors of surgical duration. A clinical predictive model was created and assessed employing the above independent predictors. The results of the receiver operating characteristic (ROC) analysis revealed the adequate discriminative ability of the predictive model. Our study revealed that it is feasible to predict surgical difficulty by obtaining clinical and magnetic resonance parameters for imaging (the gap between the anal verge and the tumour, and posterior mesorectal thickness), and these predictions could be useful in making clinical decisions.
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Affiliation(s)
- Mingyu Han
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, Henan Province, People's Republic of China
| | - Shihao Guo
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, Henan Province, People's Republic of China
| | - Shuai Ma
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, Henan Province, People's Republic of China
| | - Quanbo Zhou
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, Henan Province, People's Republic of China
| | - Weitao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, No.95 Yongan Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Jinbang Wang
- Department of General Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, 450000, Henan Province, People's Republic of China
| | - Jing Zhuang
- Department of General Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, 450000, Henan Province, People's Republic of China.
| | - Hongwei Yao
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, No.95 Yongan Road, Xicheng District, Beijing, 100050, People's Republic of China.
| | - Weitang Yuan
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, Henan Province, People's Republic of China.
| | - Yugui Lian
- Department of Colorectal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, Henan Province, People's Republic of China.
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Guo Y, He L, Tong W, Chi Z, Ren S, Cui B, Wang Q. A study of intersphincteric resection rate following robotic-assisted total mesorectal excision versus laparoscopic-assisted total mesorectal excision for patients with middle and low rectal cancer: study protocol for a multicenter randomized clinical trial. Trials 2024; 25:703. [PMID: 39434171 PMCID: PMC11495107 DOI: 10.1186/s13063-024-08561-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 10/15/2024] [Indexed: 10/23/2024] Open
Abstract
INTRODUCTION Robotic-assisted complete mesorectal excision (RATME) is increasingly being used by colorectal surgeons. Most surgeons consider RATME a safe method, and believe it can facilitate total mesorectal excision (TME) in rectal cancer, and may potentially have advantages over intersphincteric resection (ISR) and anus preservation. Therefore, this trial was designed to investigate whether RATME has technical advantages and can increase the ISR rate compared with laparoscopic-assisted TME (LATME) in patients with middle and low rectal cancer. METHODS AND ANALYSIS This is a multicenter, superiority, randomized controlled trial designed to compare RATME and LATME in middle and low rectal cancer. The primary endpoint is the ISR rate. The secondary endpoints are coloanal anastomosis (CAA) rate, conversion to open surgery, conversion to transanal TME (TaTME), abdominoperineal resection (APR) rate, postoperative morbidity and mortality within 30 days, pathological outcomes, long-term survival outcomes, functional outcomes, and quality of life. In addition, certain measurements will be conducted to ensure quality and safety, including centralized photography review and semiannual assessment. DISCUSSION This trial will clarify if RATME improves ISR and promotes anus preservation in patients with mid- and low-rectal cancer. Furthermore, this trial will provide evidence on the optimal treatment strategies for RATME and LATME in patients with mid- and low-rectal cancer regarding improved operational safety. TRIAL REGISTRATION ClinicalTrials.gov NCT06105203. Registered on October 27, 2023.
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Affiliation(s)
- Yuchen Guo
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, China
| | - Liang He
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, China
| | - Weidong Tong
- Daping Hospital and the Research Institute of Surgeryof the, Third Military Medical University , Chongqing, China
| | | | - Shuangyi Ren
- Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Binbin Cui
- Tumor Hospital of Harbin Medical University, Harbin, China
| | - Quan Wang
- Department of Gastrocolorectal Surgery, General Surgery Center, The First Hospital of Jilin University, Changchun, China.
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Matsui T, Kiuchi J, Kuriu Y, Arita T, Shimizu H, Nanishi K, Morimura R, Shiozaki A, Ikoma H, Kubota T, Fujiwara H, Otsuji E. Deep pelvis and low visceral fat mass as risk factors for neurogenic bladder after rectal cancer surgery. BMC Gastroenterol 2024; 24:323. [PMID: 39333910 PMCID: PMC11437677 DOI: 10.1186/s12876-024-03433-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 09/24/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Postoperative neurogenic bladder (PONB) frequently occurs as a complication after rectal cancer surgery. This study aimed to analyze risk factors for developing PONB after rectal cancer surgery, particularly the association between pelvic anatomy and visceral fat mass. METHODS We included 138 patients who underwent rectal resection for lower rectal cancer in our department between 2017 and 2021. PONB was defined as the need for urethral catheter reinsertion or oral medication administration for urinary retention after catheter removal with severe NB that required treatment for ≥ 60 days. We obtained visceral fat area (VFA) at the umbilical level based on a CT scan and measured five pelvic dimensions. RESULTS Of the 138 patients, 19 developed PONB, with 16 being severe cases. PONB more frequently occurs in patients with a height of < 158 cm, age ≥ 70 years, surgery lasting ≥ 8 h, intraoperative bleeding volume ≥ 150 mL, lateral lymph node dissection, and narrower pelvis. It was more prevalent in cases with low VFA. Conversely, gender, body mass index (BMI), and medical history showed no significant correlations. Multivariate analysis revealed older age, prolonged surgery, and low VFA as independent risk factors for PONB. Independent risk factors for severe PONB included low VFA, older age, prolonged surgery, and deep pelvis. CONCLUSION Lower VFA, older age, and prolonged surgery are independent risk factors for developing PONB. Additionally, a deep pelvis is an independent risk factor for severe PONB. Delicate surgical techniques should consider the risk of nerve injury in cases with low VFA and deep pelvis.
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Affiliation(s)
- Tomohiro Matsui
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan
- Division of Digestive System Surgery, Department of Surgery, Iseikai International General Hospital, 4-14, Minami-Ogimachi, Kita-ku, Osaka, 530-0052, Japan
| | - Jun Kiuchi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan.
| | - Yoshiaki Kuriu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Tomohiro Arita
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Hiroki Shimizu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Kenji Nanishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Ryo Morimura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Atsushi Shiozaki
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Hisashi Ikoma
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Takeshi Kubota
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Hitoshi Fujiwara
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan
| | - Eigo Otsuji
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465, Kaji-Cho, Kamigyo-Ku, Kyoto, 602-8566, Japan
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Chen Y, jiang J, He M, Zhong K, Tang S, Deng L, Wang Y. Nomogram for predicting difficult total laparoscopic hysterectomy: a multi-institutional, retrospective model development and validation study. Int J Surg 2024; 110:3249-3257. [PMID: 38537077 PMCID: PMC11175783 DOI: 10.1097/js9.0000000000001406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/12/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Total laparoscopic hysterectomy (TLH) is the most commonly performed gynaecological surgery. However, the difficulty of the operation varies depending on the patient and surgeon. Subsequently, patient's outcomes and surgical efficiency are affected. The authors aimed to develop and validate a preoperative nomogram to predict the operative difficulty in patients undergoing TLH. METHODS This retrospective study included 663 patients with TLH from Southwest Hospital and 102 patients from 958th Hospital in Chongqing, China. A multivariate logistic regression analysis was used to identify the independent predictors of operative difficulty, and a nomogram was constructed. The performance of the nomogram was validated internally and externally. RESULTS The uterine weight, history of pelvic surgery, presence of adenomyosis, surgeon's years of practice, and annual hysterectomy volume were identified as significant independent predictors of operative difficulty. The nomogram demonstrated good discrimination in the training dataset [area under the receiver operating characteristic curve (AUC), 0.827 (95% CI, 0.783-0.872], internal validation dataset [AUC, 0.793 (95% CI, 0.714-0.872)], and external validation dataset [AUC, 0.756 [95% CI, 0.658-0.854)]. The calibration curves showed good agreement between the predictions and observations for both internal and external validations. CONCLUSION The developed nomogram accurately predicted the operative difficulty of TLH, facilitated preoperative planning and patient counselling, and optimized surgical training. Further prospective multicenter clinical studies are required to optimize and validate this model.
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Affiliation(s)
- Yin Chen
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Jiahong jiang
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Min He
- Department of Obstetrics and Gynecology, The 958th Army Hospital of the Chinese People’s Liberation Army (958th Hospital)
| | - Kuiyan Zhong
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Shuai Tang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Li Deng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
| | - Yanzhou Wang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital (Southwest Hospital), Army Medical University, Chongqing, China
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Zhou XC, Guan SW, Ke FY, Dhamija G, Wang Q, Chen BF. Construction of a nomogram model to predict technical difficulty in performing laparoscopic sphincter-preserving radical resection for rectal cancer. World J Gastroenterol 2024; 30:2418-2439. [PMID: 38764764 PMCID: PMC11099392 DOI: 10.3748/wjg.v30.i18.2418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/06/2024] [Accepted: 04/17/2024] [Indexed: 05/11/2024] Open
Abstract
BACKGROUND Colorectal surgeons are well aware that performing surgery for rectal cancer becomes more challenging in obese patients with narrow and deep pelvic cavities. Therefore, it is essential for colorectal surgeons to have a comprehensive understanding of pelvic structure prior to surgery and anticipate potential surgical difficulties. AIM To evaluate predictive parameters for technical challenges encountered during laparoscopic radical sphincter-preserving surgery for rectal cancer. METHODS We retrospectively gathered data from 162 consecutive patients who underwent laparoscopic radical sphincter-preserving surgery for rectal cancer. Three-dimensional reconstruction of pelvic bone and soft tissue parameters was conducted using computed tomography (CT) scans. Operative difficulty was categorized as either high or low, and multivariate logistic regression analysis was employed to identify predictors of operative difficulty, ultimately creating a nomogram. RESULTS Out of 162 patients, 21 (13.0%) were classified in the high surgical difficulty group, while 141 (87.0%) were in the low surgical difficulty group. Multivariate logistic regression analysis showed that the surgical approach using laparoscopic intersphincteric dissection, intraoperative preventive ostomy, and the sacrococcygeal distance were independent risk factors for highly difficult laparoscopic radical sphincter-sparing surgery for rectal cancer (P < 0.05). Conversely, the anterior-posterior diameter of pelvic inlet/sacrococcygeal distance was identified as a protective factor (P < 0.05). A nomogram was subsequently constructed, demonstrating good predictive accuracy (C-index = 0.834). CONCLUSION The surgical approach, intraoperative preventive ostomy, the sacrococcygeal distance, and the anterior-posterior diameter of pelvic inlet/sacrococcygeal distance could help to predict the difficulty of laparoscopic radical sphincter-preserving surgery.
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Affiliation(s)
- Xiao-Cong Zhou
- Department of Colorectal Surgery, The Dingli Clinical Institute of Wenzhou Medical University (Wenzhou Central Hospital), Wenzhou 325000, Zhejiang Province, China
| | - Shi-Wei Guan
- Department of Hepatobiliary Surgery, The Dingli Clinical Institute of Wenzhou Medical University (Wenzhou Central Hospital), Wenzhou 325000, Zhejiang Province, China
| | - Fei-Yue Ke
- Postgraduate Training Base Alliance of Wenzhou Medical University, Wenzhou Central Hospital, Wenzhou 325000, Zhejiang Province, China
| | - Gaurav Dhamija
- School of International Studies, Wenzhou Medical University, Wenzhou Central Hospital, Wenzhou 325000, Zhejiang Province, China
| | - Qiang Wang
- Department of Radiology, The Dingli Clinical Institute of Wenzhou Medical University (Wenzhou Central Hospital), Wenzhou 325000, Zhejiang Province, China
| | - Bang-Fei Chen
- Department of Colorectal Surgery, The Affiliated Zhejiang Hospital, Zhejiang University School of Medicine (Zhejiang Hospital), Hangzhou 310000, Zhejiang Province, China
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Li X, Zhou Z, Zhu B, Wu Y, Xing C. Development and validation of machine learning models and nomograms for predicting the surgical difficulty of laparoscopic resection in rectal cancer. World J Surg Oncol 2024; 22:111. [PMID: 38664824 PMCID: PMC11044303 DOI: 10.1186/s12957-024-03389-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 04/14/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND The objective of this study is to develop and validate a machine learning (ML) prediction model for the assessment of laparoscopic total mesorectal excision (LaTME) surgery difficulty, as well as to identify independent risk factors that influence surgical difficulty. Establishing a nomogram aims to assist clinical practitioners in formulating more effective surgical plans before the procedure. METHODS This study included 186 patients with rectal cancer who underwent LaTME from January 2018 to December 2020. They were divided into a training cohort (n = 131) versus a validation cohort (n = 55). The difficulty of LaTME was defined based on Escal's et al. scoring criteria with modifications. We utilized Lasso regression to screen the preoperative clinical characteristic variables and intraoperative information most relevant to surgical difficulty for the development and validation of four ML models: logistic regression (LR), support vector machine (SVM), random forest (RF), and decision tree (DT). The performance of the model was assessed based on the area under the receiver operating characteristic curve(AUC), sensitivity, specificity, and accuracy. Logistic regression-based column-line plots were created to visualize the predictive model. Consistency statistics (C-statistic) and calibration curves were used to discriminate and calibrate the nomogram, respectively. RESULTS In the validation cohort, all four ML models demonstrate good performance: SVM AUC = 0.987, RF AUC = 0.953, LR AUC = 0.950, and DT AUC = 0.904. To enhance visual evaluation, a logistic regression-based nomogram has been established. Predictive factors included in the nomogram are body mass index (BMI), distance between the tumor to the dentate line ≤ 10 cm, radiodensity of visceral adipose tissue (VAT), area of subcutaneous adipose tissue (SAT), tumor diameter >3 cm, and comorbid hypertension. CONCLUSION In this study, four ML models based on intraoperative and preoperative risk factors and a nomogram based on logistic regression may be of help to surgeons in evaluating the surgical difficulty before operation and adopting appropriate responses and surgical protocols.
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Affiliation(s)
- Xiangyong Li
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
| | - Zeyang Zhou
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China
| | - Bing Zhu
- Department of Anesthesiology, Dongtai People's Hospital, Yancheng, Jiangsu Province, China
| | - Yong Wu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China.
| | - Chungen Xing
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu province, China.
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Yu M, Yuan Z, Li R, Shi B, Wan D, Dong X. Interpretable machine learning model to predict surgical difficulty in laparoscopic resection for rectal cancer. Front Oncol 2024; 14:1337219. [PMID: 38380369 PMCID: PMC10878416 DOI: 10.3389/fonc.2024.1337219] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/15/2024] [Indexed: 02/22/2024] Open
Abstract
Background Laparoscopic total mesorectal excision (LaTME) is standard surgical methods for rectal cancer, and LaTME operation is a challenging procedure. This study is intended to use machine learning to develop and validate prediction models for surgical difficulty of LaTME in patients with rectal cancer and compare these models' performance. Methods We retrospectively collected the preoperative clinical and MRI pelvimetry parameter of rectal cancer patients who underwent laparoscopic total mesorectal resection from 2017 to 2022. The difficulty of LaTME was defined according to the scoring criteria reported by Escal. Patients were randomly divided into training group (80%) and test group (20%). We selected independent influencing features using the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression method. Adopt synthetic minority oversampling technique (SMOTE) to alleviate the class imbalance problem. Six machine learning model were developed: light gradient boosting machine (LGBM); categorical boosting (CatBoost); extreme gradient boost (XGBoost), logistic regression (LR); random forests (RF); multilayer perceptron (MLP). The area under receiver operating characteristic curve (AUROC), accuracy, sensitivity, specificity and F1 score were used to evaluate the performance of the model. The Shapley Additive Explanations (SHAP) analysis provided interpretation for the best machine learning model. Further decision curve analysis (DCA) was used to evaluate the clinical manifestations of the model. Results A total of 626 patients were included. LASSO regression analysis shows that tumor height, prognostic nutrition index (PNI), pelvic inlet, pelvic outlet, sacrococcygeal distance, mesorectal fat area and angle 5 (the angle between the apex of the sacral angle and the lower edge of the pubic bone) are the predictor variables of the machine learning model. In addition, the correlation heatmap shows that there is no significant correlation between these seven variables. When predicting the difficulty of LaTME surgery, the XGBoost model performed best among the six machine learning models (AUROC=0.855). Based on the decision curve analysis (DCA) results, the XGBoost model is also superior, and feature importance analysis shows that tumor height is the most important variable among the seven factors. Conclusions This study developed an XGBoost model to predict the difficulty of LaTME surgery. This model can help clinicians quickly and accurately predict the difficulty of surgery and adopt individualized surgical methods.
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Affiliation(s)
| | | | | | | | - Daiwei Wan
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoqiang Dong
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
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Huang CK, Shih CH, Kao YS. Elderly Rectal Cancer: An Updated Review. Curr Oncol Rep 2024; 26:181-190. [PMID: 38270849 DOI: 10.1007/s11912-024-01495-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2024] [Indexed: 01/26/2024]
Abstract
PURPOSE OF REVIEW Treatment of rectal cancer patients of advanced age should be modulated by life expectancy and tolerance. Due to the rapid advance of this field, we aim to conduct an updated review of this topic. RECENT FINDINGS The field of elderly rectal cancer has advanced a lot. This review covers all the treatment aspects of elderly rectal cancer, including the prognostic factor, surgery, radiotherapy, chemotherapy, and palliative treatment. We also provide the future aspect of the management of elderly rectal cancer. The advancement of prognostic factor research, surgery, radiotherapy, chemotherapy, and palliative treatment has made the care of elderly rectal cancer patients better. The future of these fields should focus on the definition of the elderly and the application of particle therapy.
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Affiliation(s)
- Chih-Kai Huang
- Division of General Surgery, Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Chi-Hsiu Shih
- Division of Hematology and Oncology, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Yung-Shuo Kao
- Department of Radiation Oncology, Taoyuan General Hospital, Ministry of Health and Welfare, No.1492, Zhongshan Rd., Taoyuan Dist., Taoyuan City, 330, Taiwan.
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Guo F, Xia C, Wang Z, Wang R, Gao J, Meng Y, Pan J, Zhang Q, Ren S. Nomogram for predicting the surgical difficulty of laparoscopic total mesorectal excision and exploring the technical advantages of robotic surgery. Front Oncol 2024; 14:1303686. [PMID: 38347843 PMCID: PMC10860337 DOI: 10.3389/fonc.2024.1303686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/09/2024] [Indexed: 02/15/2024] Open
Abstract
Background Total mesorectal excision (TME), represents a key technique in radical surgery for rectal cancer. This study aimed to construct a preoperative nomogram for predicting the surgical difficulty of laparoscopic total mesorectal excision (L-TME) and to investigate whether there were potential benefits of robotic TME (R-TME) for patients with technically challenging rectal cancer. Methods Consecutive mid-low rectal cancer patients receiving total mesorectal excision were included. A preoperative nomogram to predict the surgical difficulty of L-TME was established and validated. Patients with technically challenging rectal cancer were screened by calculating the prediction score of the nomogram. Then patients with technically challenging rectal cancer who underwent different types of surgery, R-TME or L-TME, were analyzed for comparison. Results A total of 533 consecutive patients with mid-low rectal cancer who underwent TME at a single tertiary medical center between January 2018 and January 2021 were retrospectively enrolled. Multivariable analysis demonstrated that mesorectal fat area, intertuberous distance, tumor size, and tumor height were independent risk factors for surgical difficulty. Subsequently, these variables were used to construct the nomogram model to predict the surgical difficulty of L-TME. The area under the receiver operating characteristic curve of the nomogram was 0.827 (95% CI 0.745 - 0.909) and 0.809 (95% CI 0.674- 0.944) in the training and validation cohort, respectively. For patients with technically challenging rectal cancer, R-TME was associated with a lower diverting ileostomy rate (p = 0.003), less estimated blood loss (p < 0.043), shorter procedure time (p = 0.009) and shorter postoperative hospital stay (p = 0.037). Conclusion In this study, we established a preoperative nomogram to predict the surgical difficulty of L-TME. Furthermore, this study also indicated that R-TME has potential technical advantages for patients with technically challenging rectal cancer.
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Affiliation(s)
- Fangliang Guo
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Cong Xia
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Zongheng Wang
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Ruiqi Wang
- Department of Public Health, China Medical University, Shenyang, Liaoning, China
| | - Jianfeng Gao
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yue Meng
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jiahao Pan
- Department of General Surgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Qianshi Zhang
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Shuangyi Ren
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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Yasar NF, Gundogdu E, Yilmaz AS, Badak B, Bayav FD, Ozen A, Oner S. Can 3D radiological calculations predict operational difficulties for rectal cancer?: A single center retrospective analysis. Medicine (Baltimore) 2024; 103:e36961. [PMID: 38241536 PMCID: PMC10798752 DOI: 10.1097/md.0000000000036961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/21/2023] [Indexed: 01/21/2024] Open
Abstract
Low anterior resection, performing total mesorectal excision with appropriate pelvic dissection to prevent local recurrence, is probably the most challenging type of surgery in colorectal surgery, especially in a narrow pelvis. In this study, we aimed to predict the operation difficulty of rectal cancer by comparing the operation time with 2D and 3D pelvimetry. Sixty-six patients who underwent total mesorectal excision after neoadjuvant chemoradiotherapy due to primary rectal cancer located in the middle and lower rectum (10 cm from the anus) were included in the study. Surgery notes were reviewed and data on demographic factors, tumor stage, duration of surgery, and types of surgery were collected, as well as pelvimetric parameters. All protocols had 2D T2-weighted sequences in 3 planes (axial, sagittal, and coronal). Pelvimetric measurements were made by measuring 8 pelvic lengths and 2 angles. Pelvis and tumor volume were measured by manual margin monitoring. In each slice, both pelvis and tumor boundaries were manually drawn individually in the sagittal plane. Pelvis and tumor volumes were calculated from the set of adjacent images by summing slice thickness and products of area measurements within the pelvis and tumor boundaries. In our results, no correlation was observed with operation time, including pelvic volume. Exception for this were interacetabular distance and tumor volume. In the regression test, the only parameter that correlated with the operation time was tumor volume. In conclusion, we believe that tumor volumetric calculations may be useful in predicting difficult distal rectal carcinoma surgeries.
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Affiliation(s)
- Necdet Fatih Yasar
- Department of General Surgery, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey
| | - Elif Gundogdu
- Department of Radiology, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey
| | - Arda Sakir Yilmaz
- Department of General Surgery, Yunus Emre State Hospital, Eskişehir, Turkey
| | - Bartu Badak
- Department of General Surgery, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey
| | - Fatma Didem Bayav
- Department of Radiology, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey
| | - Alaattin Ozen
- Department of Radiation Oncology, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey
| | - Setenay Oner
- Department of Biostatistics, Faculty of Medicine, Eskisehir Osmangazi University, Eskişehir, Turkey
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Guo F, Sun Z, Wang Z, Gao J, Pan J, Zhang Q, Ren S. Nomogram for predicting prolonged postoperative ileus after laparoscopic low anterior resection for rectal cancer. World J Surg Oncol 2023; 21:380. [PMID: 38082330 PMCID: PMC10712154 DOI: 10.1186/s12957-023-03265-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 12/04/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Prolonged postoperative ileus (PPOI) is a common complication after colorectal surgery that increases patient discomfort, hospital stay, and financial burden. However, predictive tools to assess the risk of PPOI in patients undergoing laparoscopic low anterior resection have not been developed. Thus, the purpose of this study was to develop a nomogram to predict PPOI after laparoscopic low anterior resection for rectal cancer. METHODS A total of 548 consecutive patients who underwent laparoscopic low anterior resection for mid-low rectal cancer at a single tertiary medical center were retrospectively enrolled between January 2019 and January 2023. Univariate and multivariate logistic regression analysis was performed to analyze potential predictors of PPOI. The nomogram was constructed using the filtered variables and internally verified by bootstrap resampling. Model performance was evaluated by receiver operating characteristic curve and calibration curve, and the clinical usefulness was evaluated by the decision curve. RESULTS Among 548 consecutive patients, 72 patients (13.1%) presented with PPOI. Multivariate logistic analysis showed that advantage age, hypoalbuminemia, high surgical difficulty, and postoperative use of opioid analgesic were independent prognostic factors for PPOI. These variables were used to construct the nomogram model to predict PPOI. Internal validation, conducted through bootstrap resampling, confirmed the great discrimination of the nomogram with an area under the curve of 0.738 (95%CI 0.736-0.741). CONCLUSIONS We created a novel nomogram for predicting PPOI after laparoscopic low anterior resection. This nomogram can assist surgeons in identifying patients at a heightened risk of PPOI.
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Affiliation(s)
- Fangliang Guo
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, 116023, People's Republic of China
| | - Zhiwei Sun
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, 116023, People's Republic of China
| | - Zongheng Wang
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, 116023, People's Republic of China
| | - Jianfeng Gao
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, 116023, People's Republic of China
| | - Jiahao Pan
- Department of General Surgery, Shanghai Changzheng Hospital, Shanghai, 200003, People's Republic of China
| | - Qianshi Zhang
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, 116023, People's Republic of China.
| | - Shuangyi Ren
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, 116023, People's Republic of China.
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Yuan W, Wang X, Wang Y, Wang H, Yan C, Song G, Liu C, Li A, Yang H, Gao C, Chen J. Development and validation of a nomogram for predicting operating time in laparoscopic anterior resection of rectal cancer. J Cancer Res Ther 2023; 19:964-971. [PMID: 37675724 DOI: 10.4103/jcrt.jcrt_2223_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
Aims The goal of this study is to create and verify a nomogram estimate operating time in rectal cancer (RC) patients based on clinicopathological factors and MRI/CT measurements before surgery. Materials and Methods The nomogram was developed in a cohort of patients who underwent laparoscopic anterior resection (L-AR) for RC. The clinicopathological and pelvis parameters were collected. Risk factors for a long operating time were determined by univariate and multivariate logistic regression analyses, and a nomogram was established with independent risk factors. The performance of the nomogram was evaluated. An independent cohort of consecutive patients served as the validation dataset. Results The development group recruited 159 RC patients, while 54 patients were enrolled in the validation group. Independent risk factors identified in multivariate analysis were a distance from the anal verge <5 cm (P = 0.024), the transverse diameter of the pelvic inlet (P < 0.001), mesorectal fat area (P = 0.017), and visceral fat area (P < 0.001). Then, a nomogram was built based on these four independent risk factors. The C-indexes of the nomogram in the development and validation group were 0.886 and 0.855, respectively. And values of AUC were the same with C-indexes in both groups. Besides, the calibration plots showed satisfactory consistency between actual observation and nomogram-predicted probabilities of long operating time. Conclusions A nomogram for predicting the risk of long operating duration in L-AR of RC was developed. And the nomogram displayed a good prediction effect and can be utilized as a tool for evaluating operating time preoperatively.
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Affiliation(s)
- Wenguang Yuan
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Xiao Wang
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yi Wang
- Department of Radiology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Haoran Wang
- Department of General Surgery, Shandong Provincial Qianfoshan Hospital, Weifang Medical University, Weifang, China
| | - Chuanwang Yan
- Department of General Surgery, Shandong Provincial Qianfoshan Hospital, Weifang Medical University, Weifang, China
| | - Gesheng Song
- Department of Radiology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Chang Liu
- Department of Gastrointestinal Surgery, Feicheng People's Hospital, Tai'an, Shandong, China
| | - Aiyin Li
- Department of Radiology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Hui Yang
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Chengsheng Gao
- General Surgery Department of Laiwu People's Hospital of Jinan City, Jinan, China
| | - Jingbo Chen
- Department of General Surgery, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
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19
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Shioi I, Yamaoka Y, Shiomi A, Kagawa H, Hino H, Manabe S, Chen K, Nanishi K, Notsu A. The impact of mesorectal fat area on recurrence following total mesorectal excision for lower rectal cancer. Langenbecks Arch Surg 2023; 408:147. [PMID: 37046049 DOI: 10.1007/s00423-023-02888-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/05/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND The mesorectal fat area (MFA) at the tip of the ischial spines on magnetic resonance imaging has been used to characterize mesorectal morphology. Recent studies reported that a larger MFA correlated with difficulties in rectal cancer surgery. However, the relationship between MFA and rectal cancer prognosis remains unclear. This study evaluated the impact of MFA on recurrence following robotic total mesorectal excision (TME) for rectal cancer. METHODS Patients who underwent robotic TME for lower rectal cancer from December 2011 to December 2016 were enrolled. Cox regression analysis was performed to determine variables associated with relapse-free survival (RFS). Patients were divided into groups based on MFA, and RFS was compared. RESULTS Of 230 patients, 173 (75.3%) were male. The median age was 63 years, and median MFA was 19.7 cm2. In multivariate analysis, smaller MFA (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.88-0.97; p < 0.01), p/yp stage II (HR, 3.81; 95% CI, 1.40-10.35; p < 0.01), and p/yp stage III (HR, 5.35; 95% CI, 1.88-15.27; p < 0.01) were independently associated with worse RFS. Sex, body mass index, and visceral fat area were not correlated with RFS. In the median follow-up period of 60.8 months, patients with MFA < 19.7 cm2 had a significantly lower 5-year RFS rate (72.7%) than those with MFA ≥ 19.7 cm2 (85.0%). CONCLUSIONS Smaller MFA was associated with worse RFS in patients undergoing robotic TME for lower rectal cancer. MFA is considered to be a prognostic factor in rectal cancer.
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Affiliation(s)
- Ikuma Shioi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka Pref., 411-8777, Japan
| | - Yusuke Yamaoka
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka Pref., 411-8777, Japan.
| | - Akio Shiomi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka Pref., 411-8777, Japan
| | - Hiroyasu Kagawa
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka Pref., 411-8777, Japan
| | - Hitoshi Hino
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka Pref., 411-8777, Japan
| | - Shoichi Manabe
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka Pref., 411-8777, Japan
| | - Kai Chen
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka Pref., 411-8777, Japan
| | - Kenji Nanishi
- Division of Colon and Rectal Surgery, Shizuoka Cancer Center, 1007 Shimo-Nagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka Pref., 411-8777, Japan
| | - Akifumi Notsu
- Clinical Research Center, Shizuoka Cancer Center, Shizuoka, Japan
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Sun Z, Hou W, Liu W, Liu J, Li K, Wu B, Lin G, Xue H, Pan J, Xiao Y. Establishment of Surgical Difficulty Grading System and Application of MRI-Based Artificial Intelligence to Stratify Difficulty in Laparoscopic Rectal Surgery. Bioengineering (Basel) 2023; 10:bioengineering10040468. [PMID: 37106657 PMCID: PMC10135707 DOI: 10.3390/bioengineering10040468] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
(1) Background: The difficulty of pelvic operation is greatly affected by anatomical constraints. Defining this difficulty and assessing it based on conventional methods has some limitations. Artificial intelligence (AI) has enabled rapid advances in surgery, but its role in assessing the difficulty of laparoscopic rectal surgery is unclear. This study aimed to establish a difficulty grading system to assess the difficulty of laparoscopic rectal surgery, as well as utilize this system to evaluate the reliability of pelvis-induced difficulties described by MRI-based AI. (2) Methods: Patients who underwent laparoscopic rectal surgery from March 2019 to October 2022 were included, and were divided into a non-difficult group and difficult group. This study was divided into two stages. In the first stage, a difficulty grading system was developed and proposed to assess the surgical difficulty caused by the pelvis. In the second stage, AI was used to build a model, and the ability of the model to stratify the difficulty of surgery was evaluated at this stage, based on the results of the first stage; (3) Results: Among the 108 enrolled patients, 53 patients (49.1%) were in the difficult group. Compared to the non-difficult group, there were longer operation times, more blood loss, higher rates of anastomotic leaks, and poorer specimen quality in the difficult group. In the second stage, after training and testing, the average accuracy of the four-fold cross validation models on the test set was 0.830, and the accuracy of the merged AI model was 0.800, the precision was 0.786, the specificity was 0.750, the recall was 0.846, the F1-score was 0.815, the area under the receiver operating curve was 0.78 and the average precision was 0.69; (4) Conclusions: This study successfully proposed a feasible grading system for surgery difficulty and developed a predictive model with reasonable accuracy using AI, which can assist surgeons in determining surgical difficulty and in choosing the optimal surgical approach for rectal cancer patients with a structurally difficult pelvis.
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Affiliation(s)
- Zhen Sun
- Division of Colorectal Surgery, Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan, Dongcheng District, Beijing 100730, China
| | - Wenyun Hou
- Division of Colorectal Surgery, Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan, Dongcheng District, Beijing 100730, China
- Department of Colorectal Surgery, National Cancer Center, National Clinical Research Center for Cancer, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Weimin Liu
- State Key Laboratory of Virtual Reality Technology and Systems, Beihang University, No. 37 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Jingjuan Liu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Kexuan Li
- Division of Colorectal Surgery, Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan, Dongcheng District, Beijing 100730, China
| | - Bin Wu
- Division of Colorectal Surgery, Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan, Dongcheng District, Beijing 100730, China
| | - Guole Lin
- Division of Colorectal Surgery, Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan, Dongcheng District, Beijing 100730, China
| | - Huadan Xue
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Junjun Pan
- State Key Laboratory of Virtual Reality Technology and Systems, Beihang University, No. 37 Xueyuan Road, Haidian District, Beijing 100191, China
- Peng Cheng Laboratory, No. 2 Xingke 1st Street, Nanshan District, Shenzhen 518055, China
| | - Yi Xiao
- Division of Colorectal Surgery, Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan, Dongcheng District, Beijing 100730, China
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Felsenreich DM, Gachabayov M, Bergamaschi R. Does the mesorectal fat area impact the histopathology metrics of the specimen in males undergoing TME for distal rectal cancer? Updates Surg 2023; 75:581-588. [PMID: 36513913 DOI: 10.1007/s13304-022-01429-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022]
Abstract
The aim of this study was to evaluate whether the mesorectal fat area (MFA) has an impact on the histopathology metrics of the specimen in male patients undergoing robotic total mesorectal excision (rTME) for cancer in the distal third of the rectum. Prospectively collected data of patients undergoing rTME for resectable rectal cancer by five surgeons during 3 years were extracted from the REgistry of Robotic SURgery for RECTal cancer (RESURRECT). MFA was measured at preoperative MRI. Distal rectal cancer was defined as within 6 cm from the anal verge. Specimen metrics included circumferential resection margin (CRM) measured by pathologists as involved if < 1 mm, distal resection margin (DRM) and TME quality. Of 890 patients who underwent rTME for rectal cancer, a subgroup analysis compared 116/581 (33.4%) with MFA > 20 cm2 to 231/581 (66.6%) with MFA ≤ 20 cm2. The mean CRM in patients with MFA > 20 cm2 was neither statistically nor clinically significantly different from patients with MFA ≤ 20 m2 (6.8 ± 5.6 mm vs. 6.0 ± 7.5 mm; p = 0.544). The quality of TME did not significantly differ: complete TME 84.3% vs. 80.3%; nearly complete TME 12.9% vs. 10.1%; incomplete TME 6.8% vs. 5.6%. The DRM was not significantly different: 1.9 ± 1.9 cm vs. 1.9 ± 2.5 cm; p = 0.847. In addition, the intraoperative complication rate was not significantly different: 4.3% (n = 5) vs. 2.2% (n = 5) (p = 0.314). This prospective multicenter study did not find any evidence to support that larger MFA would result in poorer histopathology metrics of the specimen when performing rTME in male patients with distal rectal cancer.
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Affiliation(s)
- Daniel Moritz Felsenreich
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Mahir Gachabayov
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Roberto Bergamaschi
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA.
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22
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Yu A, Li Y, Zhang H, Hu G, Zhao Y, Guo J, Wei M, Yu W, Yan Z. Development and validation of a preoperative nomogram for predicting the surgical difficulty of laparoscopic colectomy for right colon cancer: a retrospective analysis. Int J Surg 2023; 109:870-878. [PMID: 36999773 PMCID: PMC10389525 DOI: 10.1097/js9.0000000000000352] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/09/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND In laparoscopic right hemicolectomy for right colon cancer, complete mesocolic excision is a standard procedure that involves extended lymphadenectomy and blood vessel ligation. This study aimed to establish a nomogram to facilitate evaluation of the surgical difficulty of laparoscopic right hemicolectomy based on preoperative parameters. MATERIALS AND METHODS The preoperative clinical and computed tomography-related parameters, operative details, and postoperative outcomes were analyzed. The difficulty of laparoscopic colectomy was defined using the scoring grade reported by Escal et al . with modifications. Multivariable logistic analysis was performed to identify parameters that increased the surgical difficulty. A preoperative nomogram to predict the surgical difficulty was established and validated. RESULTS A total of 418 consecutive patients with right colon cancer who underwent laparoscopic radical resection at a single tertiary medical center between January 2016 and May 2022 were retrospectively enrolled. The patients were randomly assigned to a training data set ( n =300, 71.8%) and an internal validation data set ( n =118, 28.2%). Meanwhile, an external validation data set with 150 consecutive eligible patients from another tertiary medical center was collected. In the training data set, 222 patients (74.0%) comprised the non-difficulty group and 78 (26.0%) comprised the difficulty group. Multivariable analysis demonstrated that adipose thickness at the ileocolic vessel drainage area, adipose area at the ileocolic vessel drainage area, adipose density at the ileocolic vessel drainage area, presence of the right colonic artery, presence of type III Henle's trunk, intra-abdominal adipose area, plasma triglyceride concentration, and tumor diameter at least 5 cm were independent risk factors for surgical difficulty; these factors were included in the nomogram. The nomogram incorporating seven independent predictors showed a high C-index of 0.922 and considerable reliability, accuracy, and net clinical benefit. CONCLUSIONS The study established and validated a reliable nomogram for predicting the surgical difficulty of laparoscopic colectomy for right colon cancer. The nomogram may assist surgeons in preoperatively evaluating risk and selecting appropriate patients.
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Affiliation(s)
- Ao Yu
- Department of General Surgery
| | | | - Haifeng Zhang
- Department of General Surgery, Linyi People’s Hospital, Linyi, People’s Republic of China
| | - Guanbo Hu
- Shandong Healthcare Industry Development Group Co. Ltd., Shandong Healthcare, Zaozhuang
| | - Yuetang Zhao
- Department of General Surgery, Yutai County People’s Hospital, Jining
| | - Jinghao Guo
- Department of Gastrointestinal Surgery, Qilu Hospital of Shandong University, Jinan
| | - Meng Wei
- Department of Gastrointestinal Surgery, Qilu Hospital of Shandong University, Jinan
| | - Wenbin Yu
- Department of Gastrointestinal Surgery, Qilu Hospital of Shandong University, Jinan
| | - Zhibo Yan
- Department of Gastrointestinal Surgery, Qilu Hospital of Shandong University, Jinan
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23
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Felsenreich DM, Gachabayov M, Bergamaschi R. Does the mesorectal fat area impact the histopathology metrics of the specimen in males undergoing TME for distal rectal cancer? Updates Surg 2023. [PMID: 36513913 DOI: 10.1007/s13304-022-01429-9,dec13,2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
The aim of this study was to evaluate whether the mesorectal fat area (MFA) has an impact on the histopathology metrics of the specimen in male patients undergoing robotic total mesorectal excision (rTME) for cancer in the distal third of the rectum. Prospectively collected data of patients undergoing rTME for resectable rectal cancer by five surgeons during 3 years were extracted from the REgistry of Robotic SURgery for RECTal cancer (RESURRECT). MFA was measured at preoperative MRI. Distal rectal cancer was defined as within 6 cm from the anal verge. Specimen metrics included circumferential resection margin (CRM) measured by pathologists as involved if < 1 mm, distal resection margin (DRM) and TME quality. Of 890 patients who underwent rTME for rectal cancer, a subgroup analysis compared 116/581 (33.4%) with MFA > 20 cm2 to 231/581 (66.6%) with MFA ≤ 20 cm2. The mean CRM in patients with MFA > 20 cm2 was neither statistically nor clinically significantly different from patients with MFA ≤ 20 m2 (6.8 ± 5.6 mm vs. 6.0 ± 7.5 mm; p = 0.544). The quality of TME did not significantly differ: complete TME 84.3% vs. 80.3%; nearly complete TME 12.9% vs. 10.1%; incomplete TME 6.8% vs. 5.6%. The DRM was not significantly different: 1.9 ± 1.9 cm vs. 1.9 ± 2.5 cm; p = 0.847. In addition, the intraoperative complication rate was not significantly different: 4.3% (n = 5) vs. 2.2% (n = 5) (p = 0.314). This prospective multicenter study did not find any evidence to support that larger MFA would result in poorer histopathology metrics of the specimen when performing rTME in male patients with distal rectal cancer.
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Affiliation(s)
- Daniel Moritz Felsenreich
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Mahir Gachabayov
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA
| | - Roberto Bergamaschi
- Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Taylor Pavilion, Suite D-365, 100 Woods Road, Valhalla, NY, 10595, USA.
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Lv J, Guan X, Wei R, Yin Y, Liu E, Zhao Z, Chen H, Liu Z, Jiang Z, Wang X. Development of artificial blood loss and duration of excision score to evaluate surgical difficulty of total laparoscopic anterior resection in rectal cancer. Front Oncol 2023; 13:1067414. [PMID: 36959789 PMCID: PMC10028132 DOI: 10.3389/fonc.2023.1067414] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 01/03/2023] [Indexed: 03/09/2023] Open
Abstract
PURPOSE Total laparoscopic anterior resection (tLAR) has been gradually applied in the treatment of rectal cancer (RC). This study aims to develop a scoring system to predict the surgical difficulty of tLAR. METHODS RC patients treated with tLAR were collected. The blood loss and duration of excision (BLADE) scoring system was built to assess the surgical difficulty by using restricted cubic spline regression. Multivariate logistic regression was used to evaluate the effect of the BLADE score on postoperative complications. The random forest (RF) algorithm was used to establish a preoperative predictive model for the BLADE score. RESULTS A total of 1,994 RC patients were randomly selected for the training set and the test set, and 325 RC patients were identified as the external validation set. The BLADE score, which was built based on the thresholds of blood loss (60 ml) and duration of surgical excision (165 min), was the most important risk factor for postoperative complications. The areas under the curve of the predictive RF model were 0.786 in the training set, 0.640 in the test set, and 0.665 in the external validation set. CONCLUSION This preoperative predictive model for the BLADE score presents clinical feasibility and reliability in identifying the candidates to receive tLAR and in making surgical plans for RC patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Xishan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Evaluation of surgical complexity by automated surgical process recognition in robotic distal gastrectomy using artificial intelligence. Surg Endosc 2023:10.1007/s00464-023-09924-9. [PMID: 36823363 PMCID: PMC9949687 DOI: 10.1007/s00464-023-09924-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 01/28/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Although radical gastrectomy with lymph node dissection is the standard treatment for gastric cancer, the complication rate remains high. Thus, estimation of surgical complexity is required for safety. We aim to investigate the association between the surgical process and complexity, such as a risk of complications in robotic distal gastrectomy (RDG), to establish an artificial intelligence (AI)-based automated surgical phase recognition by analyzing robotic surgical videos, and to investigate the predictability of surgical complexity by AI. METHOD This study assessed clinical data and robotic surgical videos for 56 patients who underwent RDG for gastric cancer. We investigated (1) the relationship between surgical complexity and perioperative factors (patient characteristics, surgical process); (2) AI training for automated phase recognition and model performance was assessed by comparing predictions to the surgeon-annotated reference; (3) AI model predictability for surgical complexity was calculated by the area under the curve. RESULT Surgical complexity score comprised extended total surgical duration, bleeding, and complications and was strongly associated with the intraoperative surgical process, especially in the beginning phases (area under the curve 0.913). We established an AI model that can recognize surgical phases from video with 87% accuracy; AI can determine intraoperative surgical complexity by calculating the duration of beginning phases from phases 1-3 (area under the curve 0.859). CONCLUSION Surgical complexity, as a surrogate of short-term outcomes, can be predicted by the surgical process, especially in the extended duration of beginning phases. Surgical complexity can also be evaluated with automation using our artificial intelligence-based model.
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Nagai Y, Kawai K, Nozawa H, Sasaki K, Murono K, Emoto S, Yokoyama Y, Matsuzaki H, Abe S, Sonoda H, Yoshioka Y, Shinagawa T, Ishihara S. Three-dimensional visualization of the total mesorectal excision plane for dissection in rectal cancer surgery and its ability to predict surgical difficulty. Sci Rep 2023; 13:2130. [PMID: 36747080 PMCID: PMC9902389 DOI: 10.1038/s41598-023-29426-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/03/2023] [Indexed: 02/08/2023] Open
Abstract
Total mesorectal excision (TME) for rectal cancer is often technically challenging. We aimed to develop a method for three-dimensional (3D) visualization of the TME dissection plane and to evaluate its ability to predict surgical difficulty. Sixty-six patients with lower rectal cancer who underwent robot-assisted surgery were retrospectively analyzed. A 3D TME dissection plane image for each case was reconstructed using Ziostation2. Subsequently, a novel index that reflects accessibility to the deep pelvis during TME, namely, the TME difficulty index, was defined and measured. Representative bony pelvimetry parameters and clinicopathological factors were also analyzed. The operative time for TME was used as an indicator of surgical difficulty. Univariate regression analysis revealed that sex, body mass index, mesorectal fat area, and TME difficulty index were associated with the operative time for TME, whereas bony pelvimetry parameters were not. Multivariate regression analysis found that TME difficulty index (β = - 0.398, P = 0.0025) and mesorectal fat area (β = 0.223, P = 0.045) had significant predictability for the operative time for TME. Compared with conventional bony pelvimetry parameters, the TME difficulty index and mesorectal fat area might be more useful in predicting the difficulty of rectal cancer surgery.
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Affiliation(s)
- Yuzo Nagai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
| | - Kazushige Kawai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yuichiro Yokoyama
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hiroyuki Matsuzaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Shinya Abe
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Hirofumi Sonoda
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Yuichiro Yoshioka
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Takahide Shinagawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Teng W, Liu J, Chen M, Zang W, Wu A. BMI and pelvimetry help to predict the duration of laparoscopic resection for low and middle rectal cancer. BMC Surg 2022; 22:402. [PMID: 36404329 PMCID: PMC9677663 DOI: 10.1186/s12893-022-01840-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 11/06/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In rectal cancer surgery, recent studies have found associations between clinical factors, especially pelvic parameters, and surgical difficulty; however, their findings are inconsistent because the studies use different criteria. This study aimed to evaluate common clinical factors that influence the operative time for the laparoscopic anterior resection of low and middle rectal cancer. METHODS Patients who underwent laparoscopic radical resection of low and middle rectal cancer from January 2018 to December 2020 were retrospectively analyzed and classified according to the operative time. Preoperative clinical and magnetic resonance imaging (MRI)-related parameters were collected. Logistic regression analysis was used to identify factors for predicting the operative time. RESULTS In total, 214 patients with a mean age of 60.3 ± 8.9 years were divided into two groups: the long operative time group (n = 105) and the short operative time group (n = 109). Univariate analysis revealed that the male sex, a higher body mass index (BMI, ≥ 24.0 kg/m2), preoperative treatment, a smaller pelvic inlet (< 11.0 cm), a deeper pelvic depth (≥ 10.7 cm) and a shorter intertuberous distance (< 10.1 cm) were significantly correlated with a longer operative time (P < 0.05). However, only BMI (OR 1.893, 95% CI 1.064-3.367, P = 0.030) and pelvic inlet (OR 0.439, 95% CI 0.240-0.804, P = 0.008) were independent predictors of operative time. Moreover, the rate of anastomotic leakage was higher in the long operative time group (P < 0.05). CONCLUSION Laparoscopic rectal resection is expected to take longer to perform in patients with a higher BMI or smaller pelvic inlet.
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Affiliation(s)
- Wenhao Teng
- grid.415110.00000 0004 0605 1140Department of Gastrointestinal Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014 China
| | - Jingfu Liu
- grid.415110.00000 0004 0605 1140Department of Blood Transfusion, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Meimei Chen
- grid.415110.00000 0004 0605 1140Department of Gastrointestinal Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014 China
| | - Weidong Zang
- grid.415110.00000 0004 0605 1140Department of Gastrointestinal Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014 China
| | - Aiwen Wu
- grid.412474.00000 0001 0027 0586Unit III, Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142 China
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Yuval JB, Thompson HM, Fiasconaro M, Patil S, Wei IH, Pappou EP, Smith JJ, Guillem JG, Nash GM, Weiser MR, Paty PB, Garcia-Aguilar J, Widmar M. Predictors of operative difficulty in robotic low anterior resection for rectal cancer. Colorectal Dis 2022; 24:1318-1324. [PMID: 35656853 PMCID: PMC9701150 DOI: 10.1111/codi.16212] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/12/2022] [Accepted: 05/24/2022] [Indexed: 02/08/2023]
Abstract
AIM This study evaluates the relationship of tumour and anatomical features with operative difficulty in robotic low anterior resection performed by four experienced surgeons in a high-volume colorectal cancer practice. METHODS Data from 382 patients who underwent robotic low anterior resection by four expert surgeons between January 2016 and June 2019 were included in the analysis. Operating time was used as a measure of operative difficulty. Univariate and multivariate mixed models were used to identify associations between baseline characteristics and operating time, with surgeon as a random effect, thereby controlling for variability in surgeon speed and proficiency. In an exploratory analysis, operative difficulty was defined as conversion to laparotomy, a positive margin or an incomplete mesorectum. RESULTS Median operating time was 4.28 h (range 1.95-11.33 h) but varied by surgeon from 3.45 h (1.95-6.10 h) to 5.93 h (3.33-11.33 h) (P < 0.001). Predictors of longer operating time in multivariate analysis were male sex, higher body mass index, neoadjuvant radiotherapy, low tumour height, greater sacral height and larger mesorectal area at the S5 vertebral level. Conversion occurred in two cases (0.5%), and incomplete mesorectum and positive margins were found in nine (2.4%) and 19 (5.0%) patients, respectively. Neoadjuvant radiotherapy and larger pelvic outlet were the only characteristics associated with the exploratory measure of difficulty. CONCLUSION Predicting operative difficulty based on easy to identify, preoperative radiological and clinical variables is feasible in robotic anterior resection.
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Affiliation(s)
- Jonathan B. Yuval
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hannah M. Thompson
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Megan Fiasconaro
- Departments of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Departments of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Iris H. Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emmanouil P. Pappou
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - J. Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jose G. Guillem
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Garrett M. Nash
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Martin R. Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Philip B. Paty
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria Widmar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Yuan Y, Tong D, Liu M, Lu H, Shen F, Shi X. An MRI-based pelvimetry nomogram for predicting surgical difficulty of transabdominal resection in patients with middle and low rectal cancer. Front Oncol 2022; 12:882300. [PMID: 35957878 PMCID: PMC9357897 DOI: 10.3389/fonc.2022.882300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The current work aimed to develop a nomogram comprised of MRI-based pelvimetry and clinical factors for predicting the difficulty of rectal surgery for middle and low rectal cancer (RC). Methods Consecutive mid to low RC cases who underwent transabdominal resection between June 2020 and August 2021 were retrospectively enrolled. Univariable and multivariable logistic regression analyses were carried out for identifying factors (clinical factors and MRI-based pelvimetry parameters) independently associated with the difficulty level of rectal surgery. A nomogram model was established with the selected parameters for predicting the probability of high surgical difficulty. The predictive ability of the nomogram model was assessed by the receiver operating characteristic (ROC) curve and decision curve analysis (DCA). Results A total of 122 cases were included. BMI (OR = 1.269, p = 0.006), pelvic inlet (OR = 1.057, p = 0.024) and intertuberous distance (OR = 0.938, p = 0.001) independently predicted surgical difficulty level in multivariate logistic regression analysis. The nomogram model combining these predictors had an area under the ROC curve (AUC) of 0.801 (95% CI: 0.719–0.868) for the prediction of a high level of surgical difficulty. The DCA suggested that using the nomogram to predict surgical difficulty provided a clinical benefit. Conclusions The nomogram model is feasible for predicting the difficulty level of rectal surgery, utilizing MRI-based pelvimetry parameters and clinical factors in mid to low RC cases.
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Affiliation(s)
- Yuan Yuan
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Dafeng Tong
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Minglu Liu
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Haidi Lu
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Fu Shen
- Department of Radiology, Changhai Hospital, Shanghai, China
- *Correspondence: Xiaohui Shi, ; Fu Shen,
| | - Xiaohui Shi
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
- *Correspondence: Xiaohui Shi, ; Fu Shen,
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Wang Z, Wang Y, Sun D. A retrospective and prospective study to establish a preoperative difficulty predicting model for video-assisted thoracoscopic lobectomy and mediastinal lymph node dissection. BMC Surg 2022; 22:135. [PMID: 35392865 PMCID: PMC8991718 DOI: 10.1186/s12893-022-01566-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 03/18/2022] [Indexed: 12/03/2022] Open
Abstract
Background In previous studies, the difficulty of surgery has rarely been used as a research object. Our study aimed to develop a predictive model to enable preoperative prediction of the technical difficulty of video-assisted thoracoscopic lobectomy and mediastinal lymph node dissection using retrospective data and to validate our findings prospectively. Methods Collected data according to the designed data table and took the operation time as the outcome variable. A nomogram to predict the difficulty of surgery was established through Lasso logistic regression. The prospective datasets were analyzed and the outcome was the operation time. Results This retrospective study enrolled 351 patients and 85 patients were included in the prospective datasets. The variables in the retrospective research were selected by Lasso logistic regression (only used for modeling and not screening), and four significantly related influencing factors were obtained: FEV1/FVC (forced expiratory volume in the first second/forced vital capacity) (p < 0.001, OR, odds ratio = 0.89, 95% CI, confidence interval = 0.84–0.94), FEV1/pred FEV1 (forced expiratory volume in the first second/forced expiratory volume in the first second in predicted) (p = 0.076, OR = 0.98, 95% CI = 0.95–1.00), history of lung disease (p = 0.027, OR = 4.00, 95% CI = 1.27–15.64), and mediastinal lymph node enlargement or calcification (p < 0.001, OR = 9.78, 95% CI = 5.10–19.69). We used ROC (receiver operating characteristic) curves to evaluate the model. The training set AUC (area under curve) value was 0.877, the test set’s AUC was 0.789, and the model had a good calibration curve. In a prospective study, the data obtained in the research cohort were brought into the model again for verification, and the AUC value was 0.772. Conclusion Our retrospective study identified four preoperative variables that are correlated with a longer surgical time and can be presumed to reflect more difficult surgical procedures. Our prospective study verified that the variables in the prediction model (including prior lung disease, FEV1/pred FEV1, FEV1/FVC, mediastinal lymph node enlargement or calcification) were related to the difficulty.
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Affiliation(s)
- Zixiao Wang
- Tianjin Medical University, Heping, Tianjin, 300070, People's Republic of China
| | - Yuhang Wang
- Tianjin Medical University, Heping, Tianjin, 300070, People's Republic of China
| | - Daqiang Sun
- Department of Thoracic Surgery, Tianjin Chest Hospital, Jinnan, Tianjin, 300222, People's Republic of China. .,Department of Thoracic Surgery, Tianjin Hospital of ITCWM Nankai Hospital, No. 6 Changjiang Road, Nankai, Tianjin, 300100, People's Republic of China.
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Wlodarczyk JR, Lee SW. New Frontiers in Management of Early and Advanced Rectal Cancer. Cancers (Basel) 2022; 14:938. [PMID: 35205685 PMCID: PMC8870151 DOI: 10.3390/cancers14040938] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/29/2022] [Accepted: 02/08/2022] [Indexed: 02/04/2023] Open
Abstract
It is important to understand advances in treatment options for rectal cancer. We attempt to highlight advances in rectal cancer treatment in the form of a systematic review. Early-stage rectal cancer focuses on minimally invasive endoluminal surgery, with importance placed on patient selection as the driving factor for improved outcomes. To achieve a complete pathologic response, various neoadjuvant chemoradiation regimens have been employed. Short-course radiation therapy, total neoadjuvant chemotherapy, and others provide unique advantages with select patient populations best suited for each. With a clinical complete response, a "watch and wait" non-operative surveillance has been introduced with preliminary equivalency to radical resection. Various modalities for total mesorectal excision, such as robotic or transanal, have advantages and can be utilized in select patient populations. Tumors demonstrating solid organ or peritoneal spread, traditionally defined as unresectable lesions conveying a terminal diagnosis, have recently undergone advances in hepatic and pulmonary metastasectomy. Hepatic and pulmonary metastasectomy has demonstrated clear advantages in 5-year survival over standard chemotherapy. With the peritoneal spread of colorectal cancer, HIPEC with cytoreductive therapy has emerged as the preferred treatment. Understanding the various therapeutic interventions will pave the way for improved patient outcomes.
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Affiliation(s)
| | - Sang W. Lee
- Division of Colorectal Surgery, Norris Cancer Center, Keck School of Medicine, University of Southern California, 1441 Eastlake Avenue, Suite NTT-7418, Los Angeles, CA 90033, USA;
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Hong JSY, De Robles MS, Brown C, Brown KGM, Young CJ, Solomon MJ. Can MRI pelvimetry predict the technical difficulty of laparoscopic rectal cancer surgery? Int J Colorectal Dis 2021; 36:2613-2620. [PMID: 34338870 DOI: 10.1007/s00384-021-04000-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Selection of an open or minimally invasive approach to total mesorectal excision (TME) is generally based on surgeon preference and an intuitive assessment of patient characteristics but there consensus on criteria to predict surgical difficulty. Pelvimetry has been used to predict the difficult surgical pelvis, typically using only bony landmarks. This study aimed to assess the relationship between pelvic soft tissue measurements on preoperative MRI and surgical difficulty. METHODS Preoperative MRIs for patients undergoing laparoscopic rectal resection in the Australasian Laparoscopic Cancer of the Rectum Trial (ALaCaRT) were retrospectively reviewed by two blinded surgeons and pelvimetric variables measured. Pelvimetric variables were analyzed for predictors of successful resection of the rectal cancer, defined by clear circumferential and distal resection margins and completeness of TME. RESULTS There was no association between successful surgery and any measurement of distance, area, or ratio. However, the was a strong association between the primary outcome and the estimated total pelvic volume on adjusted logistic regression analysis (OR = 0.99, P = 0.01). For each cubic centimeter increase in the pelvic volume, there was a 1% decrease in the odds of successful laparoscopic rectal cancer surgery. Intuitive prediction of unsuccessful surgery was correct in 43% of cases, and correlation between surgeons was poor (ICC = 0.18). CONCLUSIONS A surgeon's intuitive assessment of the difficult pelvis, based on visible MRI assessment, is not a reliable predictor of successful laparoscopic surgery. Further assessment of pelvic volume may provide an objective method of defining the difficult surgical pelvis.
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Affiliation(s)
- Jonathan S Y Hong
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.
- The Institute of Academic Surgery At RPA, Royal Prince Alfred Hospital, Sydney, Australia.
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
- Faculty of Health and Medicine, University of Sydney, Sydney, Australia.
| | | | - Chris Brown
- NHMRC Clinical Trials Center, University of Sydney, Sydney, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia
- The Institute of Academic Surgery At RPA, Royal Prince Alfred Hospital, Sydney, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Christopher J Young
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia
- The Institute of Academic Surgery At RPA, Royal Prince Alfred Hospital, Sydney, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Health and Medicine, University of Sydney, Sydney, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia
- The Institute of Academic Surgery At RPA, Royal Prince Alfred Hospital, Sydney, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Health and Medicine, University of Sydney, Sydney, Australia
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Shapiro DD, Davis JW, Williams WH, Chapin BF, Ward JF, Pettaway CA, Gregg JR. Increased body mass index is associated with operative difficulty during robot‐assisted radical prostatectomy. BJUI COMPASS 2021; 3:68-74. [PMID: 35475154 PMCID: PMC8988518 DOI: 10.1002/bco2.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/01/2021] [Accepted: 08/09/2021] [Indexed: 11/17/2022] Open
Abstract
Objective This study aimed to identify factors associated with surgeon perception of robot‐assisted radical prostatectomy (RARP) difficulty. Patients and Methods This study surveyed surgeons performing RARP between 2017 and 2018 and asked them to rate operative conditions and difficulty as optimal, good, acceptable, or poor. These answers were stratified as optimal or suboptimal for this study. Associations between surgeon responses and variables hypothesized to affect surgical difficulty, including anatomic factors such as pelvic diameter and prostate volume:pelvic diameter ratio, were assessed. Results Between November 2017 and September 2018, a total of 100 patients were prospectively enrolled in the study of which 58 cases were rated as optimal and 42 were rated as suboptimal. Of the evaluated variables, only increasing clinical T stage (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.03–2.15, p = 0.03) and increasing body mass index (BMI) (OR 1.14, 95% CI 1.03–1.26, p = 0.01) were associated with increased difficulty; 90‐day complication rates were similar between the optimal and suboptimal cohorts (17.3% vs. 23.8%, respectively; p = 0.5). The number of patients with previous surgery, pelvic diameter, and prostate size:pelvic diameter ratio were not significantly different between cohorts (p > 0.05 for all). Operative time (ρ = 0.23, p = 0.02) and estimated blood loss (EBL) (ρ = 0.38, p = 0.0001) were correlated with suboptimal difficulty. Conclusion The factors associated with surgeon‐reported RARP difficulty were patient BMI and clinical T stage among surgeons with significant RARP experience. These data should be incorporated into surgical decision making and patient counseling prior to performing a RARP.
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Affiliation(s)
- Daniel D. Shapiro
- Department of Urology The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - John W. Davis
- Department of Urology The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Wendell H. Williams
- Department of Anesthesiology The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Brian F. Chapin
- Department of Urology The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - John F. Ward
- Department of Urology The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Curtis A. Pettaway
- Department of Urology The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Justin R. Gregg
- Department of Urology The University of Texas MD Anderson Cancer Center Houston Texas USA
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Quezada-Diaz FF, Smith JJ. Options for Low Rectal Cancer: Robotic Total Mesorectal Excision. Clin Colon Rectal Surg 2021; 34:311-316. [PMID: 34512198 DOI: 10.1055/s-0041-1726449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Low rectal cancers (LRCs) may offer a difficult technical challenge even to experienced colorectal surgeons. Although laparoscopic surgery offers a superior exposure of the pelvis when compared with open approach, its role in rectal cancer surgery has been controversial. Robotic platforms are well suited for difficult pelvic surgery due to its three-dimensional visualization, degree of articulation of instruments, precise movements, and better ergonomics. The robot may be suitable especially in the anatomically narrow pelvis such as in male and obese patients. Meticulous dissection in critical steps, such as splenic flexure takedown, nerve-sparing mesorectal excision, and distal margin clearance, are potential technical advantages. In addition, robotic rectal resections are associated with lower conversion rates to open surgery, less blood loss, and shorter learning curve with similar short-term quality of life outcomes, similar rates of postoperative complications, and equivalent short-term surrogate outcomes compared with conventional laparoscopy. Robotic surgery approach, if used correctly, can enhance the skills and the capabilities of the well-trained surgeon during minimally invasive procedures for LRC.
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Affiliation(s)
- Felipe F Quezada-Diaz
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - J Joshua Smith
- Department of Surgery, Colorectal Service, Memorial Sloan Kettering Cancer Center, New York, New York
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Surgical coaching applied to laparoscopic TME for continuous professional development in rectal surgery: proof of concept. Updates Surg 2021; 73:1805-1810. [PMID: 34417982 DOI: 10.1007/s13304-021-01137-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Coaching is maturing as a strategy for surgeons' continuous professional development in different types of surgery. Laparoscopic total mesorectal excision (LAP TME) is one of the recognized difficult procedures in colorectal surgery. Aim of this trial is to introduce the surgical coaching as a tool for a continuous technical education of LAP TME for cancer in a consultant surgeon carrier. METHODS Twelve Italian colorectal surgeons were enrolled as trainees in the AIMS Academy rectal cancer surgical coaching project and attended a face-to-face 90-min surgical coaching on a pre-edited 45-min-long video of a laparoscopic proctectomy according to pre-determined guidelines. At the end of the coaching, all mentors were asked to fill a questionnaire evaluating the trainee's skills. All trainees had to fill a post-coaching questionnaire addressing the appropriateness of the coaching with respect to their actual level. RESULTS Trainees were more confident in performing the extra-pelvic part of the surgical procedures compared to the intra-pelvic dissection. The most challenging steps according to the trainees were the seminal vesicles identification and the pelvic floor dissection. Mentors found the trainees quite confident in the approach to the vascular structures, lymphadenectomy, stapler utilization and bleeding control. The sharpness and the efficacy of the dissection, the dissection of the surgical planes and the anastomosis fashioning were reported at a lower level of confidence. The higher grade of satisfaction reported by the trainee came from the attention that the mentors demonstrated towards them, from the availability of the mentors to take into consideration the surgical issues raised and from the willingness to apply the suggestions received during their next proctectomies. CONCLUSIONS The surgical coaching applied to LAP TME should be considered as an innovative tool for continuous professional development.
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Posterior mesorectal thickness as a predictor of increased operative time in rectal cancer surgery: a retrospective cohort study. Surg Endosc 2021; 36:3520-3532. [PMID: 34382121 DOI: 10.1007/s00464-021-08674-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND In rectal cancer surgery, larger mesorectal fat area has been shown to correlate with increased intraoperative difficulty. Prior studies were mostly in Asian populations with average body mass indices (BMIs) less than 25 kg/m2. This study aimed to define the relationship between radiological variables on pelvic magnetic resonance imaging (MRI) and intraoperative difficulty in a North American population. METHODS This is a single-center retrospective cohort study analyzing all patients who underwent low anterior resection (LAR) or transanal total mesorectal excision (TaTME) for stage I-III rectal adenocarcinoma from January 2015 until December 2019. Eleven pelvic magnetic resonance imaging measures were defined a priori according to previous literature and measured in each of the included patients. Operative time in minutes and intraoperative blood loss in milliliters were utilized as the primary indicators of intraoperative difficulty. RESULTS Eighty-three patients (39.8% female, mean age: 62.4 ± 11.6 years) met inclusion criteria. The mean BMI of included patients was 29.4 ± 6.2 kg/m2. Mean operative times were 227.2 ± 65.1 min and 340.6 ± 78.7 min for LARs and TaTMEs, respectively. On multivariable analysis including patient, tumor, and MRI factors, increasing posterior mesorectal thickness was significantly associated with increased operative time (p = 0.04). Every 1 cm increase in posterior mesorectal thickness correlated with a 26 min and 6 s increase in operative time. None of the MRI measurements correlated strongly with BMI. CONCLUSION As the number of obese rectal cancer patients continues to expand, strategies aimed at optimizing their surgical management are paramount. While increasing BMI is an important preoperative risk factor, the present study identifies posterior mesorectal thickness on MRI as a reliable and easily measurable parameter to help predict operative difficulty. Ultimately, this may in turn serve as an indicator of which patients would benefit most from pre-operative resources aimed at optimizing operative conditions and postoperative recovery.
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Martínez-Pérez A, Espin E, Pucciarelli S, Ris F, de'Angelis N. Commentary on "The role of MRI pelvimetry in predicting technical difficulty and outcomes of open and minimally invasive total mesorectal excision: a systematic review". Tech Coloproctol 2021; 25:981-982. [PMID: 32915336 DOI: 10.1007/s10151-020-02343-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/03/2020] [Indexed: 12/18/2022]
Affiliation(s)
- A Martínez-Pérez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - E Espin
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall D'Hebron, Barcelona, Spain
| | - S Pucciarelli
- 1st Surgical Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - F Ris
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - N de'Angelis
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, 51 Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil, France.
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Ye C, Wang X, Sun Y, Deng Y, Huang Y, Chi P. A nomogram predicting the difficulty of laparoscopic surgery for rectal cancer. Surg Today 2021; 51:1835-1842. [PMID: 34296313 DOI: 10.1007/s00595-021-02338-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/02/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE This study aimed to identify the risk factors associated with performing a difficult laparoscopic radical resection of rectal cancer, and to establish a predictive nomogram to help individual clinical treatment decisions. METHODS A total of 977 patients with rectal cancer who underwent laparoscopic radical resection between January 2014 and December 2016 were enrolled in this study. The difficulty of laparoscopic-assisted rectal resection (LARR) was defined according to the scoring criteria reported by Escal. A logistic regression analysis was performed to identify the variables that may affect the difficulty of LARR, and a nomogram predicting the surgical difficulty was created. RESULTS A multivariate analysis demonstrated that a BMI > 28 kg/m2, the distance between the tumor and the anal margin ≤ 5 cm, the maximum transverse tumor diameter > 3 cm tumor, interspinous distance < 10 cm, history of abdominal surgery, and preoperative radiotherapy were independent risk factors and they were, therefore, included in the predictive nomogram for identifying a difficult LARR. CONCLUSIONS This study defined a difficult LARR and identified independent risk factors for a difficult operation and created a predictive nomogram for difficult LARR. This nomogram may facilitate the stratification of patients at risk for being associated with a difficult LARR for rectal cancer.
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Affiliation(s)
- Chengwei Ye
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian Province, People's Republic of China.,Department of Gastrointestinal Surgery, Fujian Medical University Affiliated First Quanzhou Hospital, Quanzhou, 1028 Anji South Road, 362000, Fujian Province, People's Republic of China
| | - Xiaojie Wang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian Province, People's Republic of China.,Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian Province, People's Republic of China
| | - Yanwu Sun
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian Province, People's Republic of China.,Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian Province, People's Republic of China
| | - Yu Deng
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian Province, People's Republic of China
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian Province, People's Republic of China. .,Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian Province, People's Republic of China.
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian Province, People's Republic of China. .,Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian Province, People's Republic of China.
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Can We Find, Today, Robotic Rectal Surgery Advantages? Dis Colon Rectum 2021; 64:771-773. [PMID: 33833144 DOI: 10.1097/dcr.0000000000002081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Kong JC, Prabhakaran S, Fraser A, Warrier S, Heriot AG. Predictors of Surgical Difficulty in Laparoscopic Total Mesorectal Excision. POLISH JOURNAL OF SURGERY 2021; 93:33-39. [DOI: 10.5604/01.3001.0014.9721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Concerns have been raised regarding the oncological safety of laparoscopic total mesorectal excision (TME) as compared to an open approach.
This study aimed to identify risk factors for surgically difficult laparoscopic TME.
All consecutive laparoscopic rectal cancer cases were included from a prospectively maintained colorectal cancer database. The primary outcome was to identify risk factors for surgically difficult TME. A Surgical Difficulty Risk Score (SDRS) between 0 and 6 was calculated for each case with cases achieving an SDRS of 2 or greater being deemed as surgically difficult.
A total of 2795 consecutive cases of laparoscopic TME were identified, with 464 (16.6%) surgically difficult cases. Univariate analysis found that operating in the male pelvis, performing abdomino-perineal resections, Hartmann’s procedures, and proctocolectomies were all significantly associated with higher operative difficulty (P < 0.001). A higher nodal stage of cancer (P = 0.046), and the resection of another organ (P = 0.003) were significantly associated with higher surgical difficulty. On multivariate analysis, a female pelvis was associated with a favorable laparoscopic resection (Odds ratio [OR] 0.54, 95% CI 0.43–0.67, P < 0.001), whereas patients who had another organ resection (OR 2.6, 95% CI 1.53–4.42, P < 0.001), nodal positivity (OR 1.37, 95% CI 1.11–1.69, P = 0.003), and high ASA scores had more difficult surgeries.
Predictive factors for surgically difficult laparoscopic TME include male gender, high ASA scores, mid and low rectal cancer, positive nodal stage, and resection of another organ at time of surgery.
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Affiliation(s)
- Joseph C. Kong
- Division of Cancer Surgery Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | | | - Alison Fraser
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Satish Warrier
- Division of Cancer Surgery Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alexander G. Heriot
- Division of Cancer Surgery Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
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Teste B, Rullier E. Intraoperative complications during laparoscopic total mesorectal excision. Minerva Surg 2021; 76:332-342. [PMID: 33944516 DOI: 10.23736/s2724-5691.21.08691-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Intraoperative complication during laparoscopic mesorectal excision for rectal cancer is a common complication occurring in 11% to 15% of the cases. They are probably underestimated because not systematically reported. The most frequent intraoperative complications are haemorrhage (3-7%), tumour perforation (1-4%), bowel injury (1-3%), ureter injury (1%), urogenital injury (2%), other organ injury (<1%), and anastomotic complications (1%). The mechanisms, management and prevention of vascular port injury, inferior mesenteric artery bleeding, small bowel and colon perforation, ureteral and urethral injury, pelvic nerve damage, tumour perforation and anastomotic failure are described. This review underlines the necessity to prevent intraoperative complication to avoid operative death and severe side-effects.
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Affiliation(s)
- Blanche Teste
- Department of Colorectal Surgery, Haut-Levèque Hospital, University of Bordeaux, Pessac, France
| | - Eric Rullier
- Department of Colorectal Surgery, Haut-Levèque Hospital, University of Bordeaux, Pessac, France -
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Sun Y, Chen J, Ye C, Lin H, Lu X, Huang Y, Chi P. Pelvimetric and Nutritional Factors Predicting Surgical Difficulty in Laparoscopic Resection for Rectal Cancer Following Preoperative Chemoradiotherapy. World J Surg 2021; 45:2261-2269. [PMID: 33821350 DOI: 10.1007/s00268-021-06080-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 01/01/2023]
Abstract
AIM Laparoscopic total mesorectal excision (LaTME) following preoperative chemoradiotherapy (PCRT) in locally advanced rectal cancer (LARC) is technically demanding. The present study is intended to evaluate predictive factors of surgical difficulty of LaTME following PCRT by using pelvimetric and nutritional factors. METHOD Consecutive LARC patients receiving LaTME after PCRT were included. Surgical difficulty was classified based upon intraoperative (operation time, blood loss, and conversion) and postoperative outcomes (postoperative hospital stay and morbidities). Pelvimetry was performed using preoperative T2-weighted MRI. Nutritional factors such as albumin-to-globulin ratio (AGR) and prognostic nutritional index (PNI) were calculated. Multivariable logistic analysis was used to identify predictors of high surgical difficulty. A predictive nomogram was developed and validated internally. RESULTS Among 294 patients included, 36 (12.4%) patients were graded as high surgical difficulty. Logistic regression analysis demonstrated that previous abdominal surgery (OR = 6.080, P = 0.001), tumor diameter (OR = 1.732, P = 0.003), intersphincteric resection (vs. low anterior resection, OR = 13.241, P < 0.001), interspinous distance (OR = 0.505, P = 0.009), and preoperative AGR (OR = 0.041, P = 0.024) were independently predictive of high surgical difficulty of LaTME after PCRT. Then, a predictive nomogram was built (C-index = 0.867). CONCLUSION Besides previous abdominal surgery, type of surgery (intersphincteric resection), tumor diameter, and interspinous distance, we found that preoperative AGR could be useful for the prediction of surgical difficulty of LaTME after PCRT. A predictive nomogram for surgical difficulty may aid in planning an appropriate approach for rectal cancer surgery after PCRT.
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Affiliation(s)
- Yanwu Sun
- Colorectal Surgery Department, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, PR China
| | - Jianhua Chen
- Radiology Department, Fujian Medical University Union Hospital, Fuzhou, PR China
| | - Chengwei Ye
- Colorectal Surgery Department, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, PR China
| | - Huiming Lin
- Colorectal Surgery Department, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, PR China
| | - Xingrong Lu
- Colorectal Surgery Department, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, PR China
| | - Ying Huang
- Colorectal Surgery Department, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, PR China.
| | - Pan Chi
- Colorectal Surgery Department, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, PR China.
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Tripathi P, Hai Y, Li Z, Shen Y, Hu X, Hu D. Morphometric assessment of the mesorectal fat in Chinese Han population: A clinical MRI study. Sci Prog 2021; 104:368504211016214. [PMID: 33960865 PMCID: PMC10364940 DOI: 10.1177/00368504211016214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The study aimed to analyze morphometric assessment of the mesorectal fat thickness and its correlation with body mass index in Chinese Han population. The anterior, posterior, right lateral, and left lateral mesorectal fat thickness were measured using MRI T2-weighted images. The mean distance from the rectal wall to the mesorectal fascia were 3.8, 8.4, 11.3, and 11.7 mm in anterior, posterior, right lateral, and left lateral portion, respectively. The mesorectal area, rectal area, mesorectal fat thickness area, and rectal height were 2395.3 ± 691.1 mm2, 709.6 ± 403.5 mm2, 1685.7 ± 525.3 mm2, and 9.1 ± 0.8 cm. BMI was found to be directly proportional to and statistically significant to the mesorectal fat area (p = 0.01). Since the mean mesorectal fat thickness was found to be <12 mm, T3d staged rectal cancer is less likely to be found in an average Chinese population that may affect the overall-survival and progression-free survival in rectal cancer patients. Anterior portion of the rectum was least thick compared to all other sides. Therefore, extra-caution should be taken in handling tumors on the anterior part of the rectum.
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Affiliation(s)
- Pratik Tripathi
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yucheng Hai
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Zhen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yaqi Shen
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Xuemei Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Daoyu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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Chen J, Sun Y, Chi P, Sun B. MRI pelvimetry-based evaluation of surgical difficulty in laparoscopic total mesorectal excision after neoadjuvant chemoradiation for male rectal cancer. Surg Today 2021; 51:1144-1151. [PMID: 33420827 PMCID: PMC8215037 DOI: 10.1007/s00595-020-02211-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/10/2020] [Indexed: 12/16/2022]
Abstract
Purpose Laparoscopic total mesorectal excision (LaTME) is technically demanding in rectal cancer after neoadjuvant chemoradiotherapy (NCRT). This study aimed to predict the surgical difficulty of LaTME after NCRT based on pelvimetric parameters. Methods This study enrolled 147 patients who underwent LaTME after NCRT. The surgical difficulty was graded as high or low according to the operative time, estimated blood loss, conversion to open surgery, postoperative hospital stay, and postoperative complications. Pelvimetry parameters were collected based on preoperative MRI. A logistic regression analysis was performed to identify predictors of high surgical difficulty, and a nomogram was developed. Results Totally, 18 (12.2%) patients were graded as high surgical difficulty. High surgical difficulty was correlated with a shorter interspinous distance (P = 0.014), a small angle α and γ (P = 0.008, P = 0.008, respectively), and a larger mesorectal area and mesorectal fat area (P = 0.041, P = 0.046, respectively). Tumor distance from the anal verge (OR = 0.619, P = 0.024), tumor diameter (OR = 3.747, P = 0.004), interspinous distance (OR = 0.127, P = 0.007), and angle α (OR = 0.821, P = 0.039) were independent predictors of high surgical difficulty. A predictive nomogram was developed with a C-index of 0.867. Conclusion A shorter tumor distance from the anal verge, larger tumor diameter, shorter interspinous distance, and smaller angle α could help to predict high surgical difficulty of LaTME in male LARC patients after NCRT. Supplementary Information The online version contains supplementary material available at 10.1007/s00595-020-02211-3.
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Affiliation(s)
- Jianhua Chen
- Department of Radiology, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China
| | - Yanwu Sun
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Bin Sun
- Department of Radiology, Fujian Medical University Union Hospital, 29 Xinquan Road, Fuzhou, 350001, Fujian, People's Republic of China.
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Risk factors for suboptimal laparoscopic surgery in rectal cancer patients. Langenbecks Arch Surg 2020; 406:309-318. [PMID: 33244719 DOI: 10.1007/s00423-020-02029-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 11/05/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Laparoscopic surgery for rectal cancer is technically complex. This study aimed to identify risk factors for suboptimal laparoscopic surgery (involved margins, incomplete mesorectal excision, and/or conversion to open surgery) in patients with rectal cancer. METHODS We included patients undergoing laparoscopic anterior resection for rectal cancer between June 2009 and June 2018. We defined the outcome variable suboptimal laparoscopic surgery as conversion to open surgery or inadequate histopathological specimens (margins < 1 mm or involved and/or poor-quality mesorectal excision). To identify independent predictors of suboptimal laparoscopic surgery, we analyzed 15 prospectively recorded demographic, clinical, and anthropometric variables obtained from our rectal cancer unit's database. Subanalyses examined the same variables with respect to conversion and to inadequate histopathological specimens. RESULTS Of the 323 patients included, 91 (28.2%) had suboptimal laparoscopic surgery. In the multivariate analysis, the independent factors associated with all suboptimal laparoscopic surgery were tumor location ≤ 5 cm from the anal verge (OR = 2.95, 0.95% CI 1.32-6.60; p = 0.008) and the intertuberous distance (OR = 0.79, 0.95% CI 0.65-0.96; p = 0.019). In the subanalyses, the promontorium-retropubic axis was an independent predictor of conversion (OR 0.70, 0.95% CI 0.51-0.96; p = 0.026), and tumor location ≤ 5 cm from the anal verge (OR 3.71, 0.95% 1.51-9.15; p = 0.004) was an independent predictor of inadequate histopathological specimens. CONCLUSIONS Predictive factors for suboptimal laparoscopic anterior resection for rectal cancer were tumor location and the intertuberous distance. These results could help surgeons decide whether to use other surgical approaches in complex cases. TRIAL REGISTRATION The study was registered at Clinicaltrials.org (No. NCT03107650).
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Hong JSY, Brown KGM, Waller J, Young CJ, Solomon MJ. The role of MRI pelvimetry in predicting technical difficulty and outcomes of open and minimally invasive total mesorectal excision: a systematic review. Tech Coloproctol 2020; 24:991-1000. [PMID: 32623536 DOI: 10.1007/s10151-020-02274-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The difficulty of performing total mesorectal excision (TME) for rectal cancer partly relies on the surgeon's subjective assessment of the individual patient's pelvic anatomy and tumour characteristics, which generally influences the choice of platform used (open, laparoscopic, robotic or trans-anal surgery). Recent studies have found associations between several anatomical pelvic measurements and surgical difficulty. The aim of this study was to systematically review existing data reporting the use of magnetic resonance imaging (MRI)-based pelvic measurements to predict technical difficulty and outcomes of TME, and determine whether pelvimetry could optimise patient-specific selection of a particular surgical approach. METHODS MEDLINE, Embase and Cochrane Library databases were systematically searched for studies reporting MRI-based pelvic measurements in patients undergoing surgery for rectal cancer, and the effect of these measurements on surgical difficulty. RESULTS Eleven studies reporting the association between MRI-pelvimetry measurements and rectal cancer surgical outcomes were included. Indicators for surgical difficulty used in the included studies were involved circumferential resection margin, longer operative time, incomplete TME, higher blood loss, anastomotic leak, conversion to open surgery and overall complications. Bony pelvic measurements which were associated with increased surgical difficulty in more than one study were a smaller interspinous distance, a smaller intertubercle distance, a smaller pelvic inlet and larger pubic tubercle height. Two studies identified larger mesorectal fat area as a predictor of surgical difficulty. CONCLUSIONS Bony pelvic measurements may predict surgical difficulty during TME, however, use of different indicators of difficulty limit comparison between studies. Early data suggest MRI soft tissue measurements may predict surgical difficulty and warrants further investigation.
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Affiliation(s)
- J S-Y Hong
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.
- Institute of Academic Surgery at RPA, Royal Prince Alfred Hospital, Missenden Road, PO Box M40, Camperdown, NSW, 2050, Australia.
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
- Central Clinical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia.
| | - K G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia
- Institute of Academic Surgery at RPA, Royal Prince Alfred Hospital, Missenden Road, PO Box M40, Camperdown, NSW, 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - J Waller
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - C J Young
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia
- Institute of Academic Surgery at RPA, Royal Prince Alfred Hospital, Missenden Road, PO Box M40, Camperdown, NSW, 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Central Clinical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia
| | - M J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia
- Institute of Academic Surgery at RPA, Royal Prince Alfred Hospital, Missenden Road, PO Box M40, Camperdown, NSW, 2050, Australia
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia
- Central Clinical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia
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Huang S, Chen M, Deng Y, Wang X, Lu X, Jiang W, Huang Y, Chi P. Mesorectal fat area and mesorectal area affect the surgical difficulty of robotic-assisted mesorectal excision and intersphincteric resection respectively in different ways. Colorectal Dis 2020; 22:1130-1138. [PMID: 32040248 DOI: 10.1111/codi.15012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/03/2020] [Indexed: 01/07/2023]
Abstract
AIM Many studies have demonstrated predictors of the difficulty of laparoscopic anterior resection for rectal cancer. Few studies focus on the influence of pelvic dimensions on robotic-assisted mesorectal excision (ME) and intersphincteric resection (ISR). This study aimed to evaluate the influences of the mesorectal fat area (MFA) and mesorectal area on the difficulty of robotic sphincter-saving surgery. METHODS We included 156 patients with middle and low rectal cancer who underwent robotic sphincter-saving surgery. Clinical and anatomical factors, including the pelvic dimensions, were collected. Linear regression was performed for variables associated with surgical duration. We also performed subgroup analyses for robotic-assisted ME and ISR. Logistic regression was used to find variables associated with transanal dissection. RESULTS For patients with middle or low rectal cancer, the sacral length and tumour distance from the anal verge were independently associated with surgical duration. The pT stage, sacral length and the MFA were independent predictors for the surgical duration of robotic-assisted ME. By contrast, a small mesorectal area was independently related to a longer duration of robotic-assisted ISR. The pelvic outlet length was independently associated with the use of transanal dissection for ISR. CONCLUSION It is suggested that a large MFA could affect the difficulty of ME in robotic-assisted ME, while a small mesorectal area could increase the surgical difficulty of robotic-assisted ISR for low rectal cancer. Besides, the pelvic outlet length was associated with the use of transanal dissection. Further studies are needed to validate the results and draw more scientific conclusions.
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Affiliation(s)
- S Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - M Chen
- Department of Radiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Y Deng
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - X Wang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - X Lu
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - W Jiang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Y Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - P Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Training Center of Minimally Invasive Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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Krizzuk D, Yellinek S, Parlade A, Liang H, Dasilva G, Wexner SD. A simple difficulty scoring system for laparoscopic total mesorectal excision. Tech Coloproctol 2020; 24:1137-1143. [PMID: 32666360 DOI: 10.1007/s10151-020-02285-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/25/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The proposed difficulty scoring system (DSS) may aid in preoperative planning for laparoscopic total mesorectal excision (L-TME) for rectal cancer. METHODS Fifty-three patients [28 males; 59.0 (31.0-88.0) years of age] treated for rectal cancer at our institution from 2/2011-5/2018 were identified. "Difficult operation" (DO) was defined as the presence of ≥3 factors: operative time ≥320 min, estimated blood loss >250 ml, intraoperative complications, conversion to laparotomy, >2 stapler applications, incomplete TME quality, and/or subjective perceived difficulty. Univariate analysis and multivariate logistic regression model with backward elimination method were used to obtain a DSS which consists of two factors: sex (male = 1 and female = 0) and body mass index (BMI) (≥30 kg/m2 = 1, <30 kg/m2 = 0). RESULTS In univariate analysis, sex (p = 0.0217), BMI (p = 0.0026), American Society of Anesthesiologists (ASA) score (p = 0.0372), and magnetic resonance imaging transverse diameter (p = 0.0441) correlated to DO. Multivariate analysis revealed that sex and BMI were the most important risk factors for a DO [area under the receiver operating characteristic curve [AUC] = 0.7761, 95% CI = (0.6443-0.9080)]. Male patients with a BMI ≥ 30 kg/m2 were more likely to experience a DO (77.8%). The simplified DSS did not weaken the discriminating power compared to multivariate logistic regression model (AUC 0.7696 vs. 0.7761, p = 0.7387). L-TME with a DSS of 0, 1, and 2 had a DO rate of 10%, 33.3%, and 77.8%, respectively. CONCLUSIONS A simplified DSS may be used preoperatively in preparation for L-TME.
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Affiliation(s)
- Dimitri Krizzuk
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Shlomo Yellinek
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Albert Parlade
- Department of Imaging, Cleveland Clinic Florida, Weston, FL, USA
| | - Hong Liang
- Department of Clinical Research, Cleveland Clinic Florida, Weston, FL, USA
| | - Giovanna Dasilva
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA.
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Yu ZL, Liu XH, Liu HS, Ke J, Zou YF, Cao WT, Xiao J, Zhou ZY, Lan P, Wu XJ, Wu XR. Impact of pelvic dimensions on anastomotic leak after anterior resection for patients with rectal cancer. Surg Endosc 2020; 35:2134-2143. [PMID: 32410082 DOI: 10.1007/s00464-020-07617-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 05/02/2020] [Indexed: 02/03/2023]
Abstract
AIM The impact of pelvis on the development of anastomotic leak (AL) in rectal cancer (RC) patients who underwent anterior resection (AR) remains unclear. The aim of this study was to evaluate the impact of pelvic dimensions on the risk of AL. METHODS A total of 1058 RC patients undergoing AR from January 2013 to January 2016 were enrolled. Pelvimetric parameters were obtained using abdominopelvic computed tomography scans. RESULTS Univariate analyses showed that pelvic inlet, pelvic outlet, interspinous distance, and intertuberous distance were significantly associated with the risk for AL (P < 0.05). Multivariate analysis confirmed that pelvic inlet and intertuberous distance were independent risk factors for AL (P < 0.05). Significant factors from multivariate analysis were assembled into the nomogram A (without pelvic dimensions) and nomogram B (with pelvic dimensions). The area under curve (AUC) of nomogram B was 0.72 (95% CI 0.67-0.77), which was better than the AUC of nomogram A (0.69, [95% CI 0.65-0.74]), but didn't reach a statistical significance (P = 0.199). Decision curve supported that nomogram B was better than nomogram A. CONCLUSION Pelvic dimensions, specifically pelvic inlet and intertuberous distance, seemed to be independent predictors for postoperative AL in RC patients. Pelvic inlet and intertuberous distance incorporated with preoperative radiotherapy, preoperative albumin, conversion, and tumor diameter in the nomogram might provide a clinical tool for predicting AL.
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Affiliation(s)
- Zhao-Liang Yu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xuan-Hui Liu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Hua-Shan Liu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jia Ke
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yi-Feng Zou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Wu-Teng Cao
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China.,Department of Radiology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jian Xiao
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China.,Department of Medical Oncology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zhi-Yang Zhou
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China.,Department of Radiology, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xiao-Jian Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China. .,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China.
| | - Xian-Rui Wu
- Department of Colorectal Surgery, The Sixth Affiliated Hospital of Sun Yat-Sen University, 26 Yuancun Erheng Rd, Guangzhou, 510655, Guangdong, China. .,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China.
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Knol J, Keller DS. Total Mesorectal Excision Technique-Past, Present, and Future. Clin Colon Rectal Surg 2020; 33:134-143. [PMID: 32351336 DOI: 10.1055/s-0039-3402776] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
While the treatment of rectal cancer is multimodal, above all, a proper oncological resection is critical. The surgical management of rectal cancer has substantially evolved over the past 100 years, and continues to progress as we seek the best treatment. Rectal cancer was historically an unsurvivable disease, with poor understanding of the embryological planes, lymphatic drainage, and lack of standardized technique. Major improvements in recurrence, survival, and quality of life have resulted from advances in preoperative staging, pathologic assessment, the development and timing of multimodal therapies, and surgical technique. The most significant contribution in advancing rectal cancer care may be the standardization and widespread implementation of total mesorectal excision (TME). The TME, popularized by Professor Heald in the early 1980s as a sharp, meticulous dissection of the tumor and mesorectum with all associated lymph nodes through the avascular embryologic plane, has shown universal reproducible reductions in local recurrence and improvement in disease-free and overall survival. Widespread education and training of surgeons worldwide in the TME have significantly impact outcomes for rectal cancer surgery, and the procedure has become the gold standard for curative resection of rectal cancer. In this article, we discuss the evolution of the standard abdominal approach to the TME, with emphasis on the history, relevant anatomy, standard procedure steps, oncologic outcomes, and technical evolution.
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Affiliation(s)
- Joep Knol
- Department of Abdominal Surgery, Jessa Hospital, Hasselt, Belgium
| | - Deborah S Keller
- Division of Colorectal Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York
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