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Standardised approach to laparoscopic total mesorectal excision for rectal cancer: a prospective multi-centre analysis. Langenbecks Arch Surg 2019; 404:547-555. [PMID: 31377857 DOI: 10.1007/s00423-019-01806-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/16/2019] [Indexed: 12/19/2022]
Abstract
PURPOSE Two non-inferiority randomised control trials have questioned the utility of laparoscopic surgery for rectal cancer by failing to prove that pathological markers of high-quality surgery are equivalent to those achieved by open technique. We present short- and long-term post-operative outcomes from the largest single surgeon series of consecutive patients undergoing laparoscopic TME for rectal cancer. We describe the standardised laparoscopic technique developed by the principal surgeon, and the short-term outcomes from three surgeons who were trained in and subsequently adopted the same approach. METHODS Prospectively acquired data from consecutive patients undergoing surgery for rectal cancer by the principal surgeon at the minimally invasive colorectal unit in Portsmouth between 2006 and 2014 were analysed along with data acquired between 2010 and 2017 from surgeons at three further international centres. Endpoints were overall and disease-free survival at 5 years, and early post-operative clinical and pathological outcomes. RESULTS Two hundred sixty-three consecutive patients underwent laparoscopic TME surgery by the principal surgeon. At 5 years, overall survival was 82.9% (Dukes' A = 94.4%; B = 81.6%; C = 73.7%); disease-free survival was 84.0% (Dukes' A = 93.3%; B = 86.8%; C = 72.6%). Post-operative length of stay, lymph node harvest, mean operating time, rate of conversion, major morbidity and 30-day mortality were not significantly different between the principal surgeon and those he had trained when subsequently in independent practices. CONCLUSION Laparoscopic TME produces excellent long-term survival outcomes for patients with rectal cancer. A standardised approach has the potential to improve outcomes by setting benchmarks for surgical quality, and providing a step-by-step method for surgical training.
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Arezzo A, Migliore M, Chiaro P, Arolfo S, Filippini C, Di Cuonzo D, Cirocchi R, Morino M. The REAL (REctal Anastomotic Leak) score for prediction of anastomotic leak after rectal cancer surgery. Tech Coloproctol 2019; 23:649-663. [PMID: 31240416 DOI: 10.1007/s10151-019-02028-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 06/20/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Anastomotic leak after rectal cancer surgery is a severe complication associated with poorer oncologic outcome and quality of life. Preoperative assessment of the risk for anastomotic leak is a key component of surgical planning, including the opportunity to create a defunctioning stoma. OBJECTIVE The purpose of this study was to identify and quantify the risk factors for anastomotic leak to minimize risk by either not restoring bowel continuity or protecting the anastomosis with a temporary diverting stoma. METHODS Potentially relevant studies were identified from the following databases: PubMed, Embase and Cochrane Library. This meta-analysis included studies on transabdominal resection for rectal cancer that reported data about anastomotic leak. The risk for anastomotic leak after rectal cancer surgery was investigated. Preoperative, intraoperative, and postoperative factors were extracted and used to compare anastomotic leak rates. All variables demonstrating a p value < 0.1 in the univariate analysis were entered into a multivariate logistic regression model to determine the risk factors for anastomotic leak. RESULTS Twenty-six centers provided individual data on 9735 patients. Selected preoperative covariates (time before surgery, age, gender, smoking, previous abdominal surgery, BMI, diabetes, ASA, hemoglobin level, TNM classification stage, anastomotic distance) were used as independent factors in a logistic regression model with anastomotic leak as dependent variable. With a threshold value of the receiver operating characteristics (ROC) curve corresponding to 0.0791 in the training set, the area under the ROC curve (AUC) was 0.585 (p < 0.0001). Sensitivity and specificity of the model's probability > 0.0791 to identify anastomotic leak were 79.1% and 32.9%, respectively. Accuracy of the threshold value was confirmed in the validation set with 77.8% sensitivity and 35.2% specificity. CONCLUSIONS We trust that, with further refinement using prospective data, this nomogram based on preoperative risk factors may assist surgeons in decision making. The score is now available online ( http://www.real-score.org ).
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Affiliation(s)
- A Arezzo
- Department of Surgical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
| | - M Migliore
- Department of Surgical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - P Chiaro
- Department of Surgical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - S Arolfo
- Department of Surgical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - C Filippini
- Department of Surgical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
| | - D Di Cuonzo
- Cancer Epidemiology Unit, San Giovanni Battista Hospital, CPO Piemonte, University of Turin, Turin, Italy
| | - R Cirocchi
- Department of General Surgery, Terni Hospital, University of Perugia, Terni, Italy
| | - M Morino
- Department of Surgical Sciences, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
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Baiocchi GL, Diana M, Boni L. Indocyanine green-based fluorescence imaging in visceral and hepatobiliary and pancreatic surgery: State of the art and future directions. World J Gastroenterol 2018; 24:2921-2930. [PMID: 30038461 PMCID: PMC6054946 DOI: 10.3748/wjg.v24.i27.2921] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 06/08/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023] Open
Abstract
In recent years, the use of fluorescence-guided surgery (FGS) to treat benign and malignant visceral, hepatobiliary and pancreatic neoplasms has significantly increased. FGS relies on the fluorescence signal emitted by injected substances (fluorophores) after being illuminated by ad hoc laser sources to help guide the surgical procedure and provide the surgeon with real-time visualization of the fluorescent structures of interest that would be otherwise invisible. This review surveys and discusses the most common and emerging clinical applications of indocyanine green (ICG)-based fluorescence in visceral, hepatobiliary and pancreatic surgery. The analysis, findings, and discussion presented here rely on the authors' significant experience with this technique in their medical institutions, an up-to-date review of the most relevant articles published on this topic between 2014 and 2018, and lengthy discussions with key opinion leaders in the field during recent conferences and congresses. For each application, the benefits and limitations of this technique, as well as applicable future directions, are described. The imaging of fluorescence emitted by ICG is a simple, fast, relatively inexpensive, and harmless tool with numerous different applications in surgery for both neoplasms and benign pathologies of the visceral and hepatobiliary systems. The ever-increasing availability of visual systems that can utilize this tool will transform some of these applications into the standard of care in the near future. Further studies are needed to evaluate the strengths and weaknesses of each application of ICG-based fluorescence imaging in abdominal surgery.
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Affiliation(s)
- Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia 25125, Italy
| | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg 67000, France
- IRCAD, Research Institute against Cancer of the Digestive System, Strasbourg 67000, France
| | - Luigi Boni
- General and Emergency Surgery, IRCCS - Ca’ Granda - Policlinico Hospital, Milan 20122, Italy
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Dhruva Rao PK, Nair MS, Haray PN. Feasibility and oncological outcomes of laparoscopic rectal resection following neo-adjuvant chemo-radiotherapy: A systematic review. World J Surg Proced 2015; 5:147-154. [DOI: 10.5412/wjsp.v5.i1.147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 12/23/2014] [Accepted: 01/12/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the feasibility and oncological outcomes following laparoscopic total mesorectal excision (LTME) in patients who have received Neo-adjuvant long course chemo-radiotherapy (LCRT).
METHODS: A protocol driven systematic review of published literature was undertaken to assess the feasibility and oncological outcomes following LTME in patients receiving LCRT. The feasibility was assessed using peri-operative outcomes and short term results. The oncological outcomes were assessed using local recurrence, disease free survival and overall survival.
RESULTS: Only 8 studies-1 randomized controlled trial, 4 Case Matched/Controlled Studies and 3 Case Series were identified matching the search criteria. The conversion rate was low (1.2% to 28.1%), anastomotic leak rates were similar to open total mesorectal excision (0%-4.1% vs 0%-8.3%). Only 3 studies reported on local recurrence rates (5.2%-7.6%) at median 34 mo follow-up. A single study described disease free survival and overall survival at 3 years as 78.8% and 92.1% respectively.
CONCLUSION: LTME following LCRT is feasible in experienced hands, with acceptable short term surgical outcomes and with the usual benefits associated with minimally invasive procedures. The long term oncological outcomes of LTME after LCRT appear to be comparable to open procedures but need further investigation.
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Martellucci J, Bergamini C, Bruscino A, Prosperi P, Tonelli P, Todaro A, Valeri A. Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: long-term results. Int J Colorectal Dis 2014; 29:1493-1499. [PMID: 25248320 DOI: 10.1007/s00384-014-2017-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2014] [Indexed: 02/08/2023]
Abstract
UNLABELLED The long-term role of laparoscopy in the treatment of rectal cancer is still controversial. The aim of the present study was to evaluate the safety, the feasibility, the perioperative outcome, and the long-term results of laparoscopic total mesorectal excision (TME) for extraperitoneal rectal cancer considering a single center series. METHODS Data about 186 unselected consecutive patients that underwent laparoscopic TME for middle and low rectal cancer between January 2001 and December 2011 were prospectively recorded and were included in the present study. RESULTS Distribution of TNM stage was 5 % T1, 37 % T2, 52.5 % T3, and 6 % T4. Fifty-one percent of patients have lymph node metastases. The average duration of surgery was 234 min. Fourteen patients required conversion (7.5 %). A complete microscopic excision was achieved in 169 patients (91 %). The mean hospital stay was 9 days. The overall postoperative morbidity rate was 24 %. Surgical-related complications were reported in 19 %. Overall mortality was 0.5 %. Sex, tumor level, and the presence of a stoma were the only statistically significant independent risk factors for anastomotic leakage. Median follow-up was 71 months. The 5-year overall survival rate was 77 %, with 89 % for stage 1, 81 % for stage 2, 43 % for stage 3, and 10 % for stage 4. The 5-year disease-free survival rate was 66 %. The 10-year survival rate was 54 %. Nine patients (4.8 %) experienced a pelvic recurrence. Late metastases developed in 31 patients (17.2 %). CONCLUSIONS The study confirms the oncological safety of laparoscopic TME in a long follow-up period.
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Affiliation(s)
- Jacopo Martellucci
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy,
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Shearer R, Gale M, Aly OE, Aly EH. Have early postoperative complications from laparoscopic rectal cancer surgery improved over the past 20 years? Colorectal Dis 2014; 15:1211-26. [PMID: 23711242 DOI: 10.1111/codi.12302] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 01/21/2013] [Indexed: 02/01/2023]
Abstract
AIM Laparoscopic rectal cancer surgery has been increasingly used since 1991 following the publication of the first case series. Since then, several studies have confirmed that laparoscopic surgery for rectal cancer is challenging with associated morbidity and mortality. The aim of this study was to determine if the rates of early postoperative complications in laparoscopic rectal cancer surgery have improved over the past 20 years. METHOD A literature search of the EMBASE and MEDLINE databases between August 1991 and August 2011 was conducted using the keywords laparoscopy, rectal cancer and postoperative complications. Data were analysed using linear regression ANOVA performed in GNUMERICS software. RESULTS Ninety-seven studies were included for analysis. Over the last 20 years there has been no significant change in the rate of any early postoperative complications (anastomotic leak, conversion, sexual, urinary or faecal dysfunction, wound infection, overall morbidity or mortality). However, in the last 3 years, the rate of positive resection margins has decreased significantly (P = 0.01). CONCLUSION There was no evidence of a statistically significant change in early postoperative complications until 3 years ago. This may reflect the inherent morbidity associated with rectal surgery regardless of the approach used, the limitations of the current laparoscopic instrumentation or the relatively long learning curve. With increasing experience, a repeat analysis in the near future following the publication of ongoing randomized clinical trials might show improved outcomes.
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Affiliation(s)
- R Shearer
- Laparoscopic Colorectal Surgery and Training Unit, Aberdeen Royal Infirmary, Aberdeen, UK
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Robotic versus laparoscopic right colectomy: a meta-analysis. World J Surg Oncol 2014; 12:274. [PMID: 25169141 PMCID: PMC4158068 DOI: 10.1186/1477-7819-12-274] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 08/16/2014] [Indexed: 12/18/2022] Open
Abstract
Background The objective of this meta-analysis was to compare the clinical safety and efficacy of robotic right colectomy (RRC) with conventional laparoscopic right colectomy (LRC). Methods A literature search was performed for comparative studies reporting perioperative outcomes of RRC and LRC. The methodological quality of the selected studies was assessed. Depending on statistical heterogeneity, the fixed effects model or the random effects model were used for the meta-analysis. Operative time, estimated blood loss, length of hospital stay, conversion rates to open surgery, postoperative complications, and related outcomes were evaluated. Results Seven studies, including 234 RRC cases and 415 conventional LRC cases, were analyzed. The meta-analysis showed that RRC had longer operative times (P < 0.00001), lower estimated blood losses (P = 0.0002), lower postoperative overall complications (P = 0.02), and significantly faster bowel function recovery (P < 0.00001). There were no differences in the length of hospital stay (P = 0.12), conversion rates to open surgery (P = 0.48), postoperative ileus (P = 0.08), anastomosis leakage (P = 0.28), and bleeding (P = 0.95). Conclusions Compared to LRC, RRC was associated with reduced estimated blood losses, reduced postoperative complications, longer operative times, and a significantly faster recovery of bowel function. Other perioperative outcomes were equivalent.
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Akladios C, Messori P, Faller E, Puga M, Afors K, Leroy J, Wattiez A. Is ileostomy always necessary following rectal resection for deep infiltrating endometriosis? J Minim Invasive Gynecol 2014; 22:103-9. [PMID: 25109779 DOI: 10.1016/j.jmig.2014.08.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 07/31/2014] [Accepted: 08/01/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To verify the hypothesis that in most patients bowel segmental resection to treat endometriosis can be safely performed without creation of a stoma and to discuss the limitations of this statement. DESIGN Retrospective study (Canadian Task Force classification III). SETTING Tertiary referral center. PATIENTS Forty-one women with sigmoid and rectal endometriotic lesions who underwent segmental resection. INTERVENTION Segmental resection procedures performed between 2004 and 2011. Patient demographic, operative, and postoperative data were compared. MEASUREMENTS AND MAIN RESULTS Sigmoid resection was performed in 6 patients (15%), and rectal anterior resection in 35 patients (high in 21 patients [51%], and low, i.e., <10 cm from the anal verge, in 14 [34%]). In 4 patients a temporary ileostomy was created. There was 1 anastomotic leak (2.4%), in a patient with an unprotected anastomosis, which was treated via laparoscopic surgery and creation of a temporary ileostomy. Other postoperative complications included hemoperitoneum, pelvic abscess, pelvic collection, and a ureteral vaginal fistula, in 1 patient each (all 2.4%). CONCLUSION A protective stoma may be averted in low anastomosis if it is >5 cm from the anal verge and there are no adverse intraoperative events.
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Affiliation(s)
- Cherif Akladios
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France; IRCAD, Strasbourg, France.
| | - Pietro Messori
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France; IRCAD, Strasbourg, France
| | - Emilie Faller
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France; IRCAD, Strasbourg, France
| | - Marco Puga
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France; IRCAD, Strasbourg, France
| | - Karolina Afors
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France; IRCAD, Strasbourg, France
| | - Joel Leroy
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France; IRCAD, Strasbourg, France
| | - Arnaud Wattiez
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France; IRCAD, Strasbourg, France
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Laparoscopic versus open distal splenopancreatectomy for the treatment of pancreatic body and tail cancer: a retrospective, mid-term follow-up study at a single academic tertiary care institution. Surg Endosc 2014; 28:2584-91. [PMID: 24705732 DOI: 10.1007/s00464-014-3507-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 03/05/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND/OBJECTIVE Laparoscopic distal splenopancreatectomy (DSP) is an effective and safe surgical modality for treating benign and borderline distal pancreatic tumors, but rarely for pancreatic cancer. This study aimed to examine the feasibility, effectiveness, and safety of laparoscopic versus laparotomic DSP in pancreatic body-tail cancer (PBTC) patients. METHODS Thirty-four PBTC patients were consecutively and retrospectively hospitalized for elective laparoscopic DSP (n = 11) or laparotomy (n = 23) between January 2007 and December 2011. The primary outcome measure was mean overall survival (OS). RESULTS All patients underwent DSP via laparoscopy or laparotomy as scheduled and were followed-up for 12-72 months. The two groups showed statistically similar mean operative time (laparoscopy vs. laparotomy, 150 ± 54 vs. 160 ± 48 min), median volume of intraoperative bleeding (100 [50-400] vs. 150 [50-350] ml), and rate of postoperative pancreatic fistula (18.2 vs. 21.7 %). The laparoscopy group had a significantly shorter median duration of hospitalization (5 [3-12] vs. 8 [7-22] d, P < 0.05). All patients had a clear resection margin and showed statistically similar tumor size (2.8 ± 1.5 vs. 3.1 ± 1.7 cm), number of lymph nodes dissected (14.8 ± 4.5 vs. 16.1 ± 5.7), and mean OS (42.0 ± 8.6 vs. 54.0 ± 5.8 mo, P > 0.05). CONCLUSIONS Laparoscopic DSP is a feasible, effective, and safe alternative to laparotomy in carefully selected PBTC patients and is associated with a more rapid postoperative recovery.
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Brachet Contul R, Grivon M, Fabozzi M, Millo P, Nardi MJ, Aimonetto S, Parini U, Allieta R. Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: long-term results of a 18-year single-centre experience. J Gastrointest Surg 2014; 18:796-807. [PMID: 24443203 DOI: 10.1007/s11605-013-2441-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 12/15/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES The oncologic efficacy of laparoscopic total mesorectal excision (TME) for middle-low rectal cancer is still under discussion because of the few long-term data. This study reports the results arising from a single-institution experience during a 18-year period. METHODS Data about 132 consecutive laparoscopic TME performed between January 1994 and January 2012 were analysed with Kaplan-Meier method and a uni- and multi-variate analysis was conducted to define independent survival predictors. RESULTS A total of 116 sphincter-preserving operations and 16 abdominoperineal resections were performed. Postoperative mortality and morbidity were 0.8 and 18.2%, with a rate of anastomotic leakage of 13.8%. Average follow-up was 85.9 months (range 13-210). Actuarial local recurrence rate was 4.13% at 5 years (any pelvic recurrence developed after 3 years from surgery). Overall and disease-free survival was respectively 83 and 79.8% at 5 years, 71 and 73% at 10 years and then remained constant until 18 years. Survival was correlated only to tumour stage and the type of surgery. CONCLUSIONS Laparoscopic TME for extraperitoneal rectal cancer shows long-term oncologic outcomes similar to open rectal resections.
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Affiliation(s)
- Riccardo Brachet Contul
- Department of General, Laparoscopic Colorectal and Bariatric Surgery, "Umberto Parini" Regional Hospital, viale Ginevra 3, 11100, Aosta, Italy,
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Levic K, Bulut O. The short-term outcomes of conventional and single-port laparoscopic surgery for rectal cancer: A comparative non-randomized study. MINIM INVASIV THER 2014; 23:214-22. [DOI: 10.3109/13645706.2014.885909] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
Data from this report supports the view that standardization of the operative steps in laparoscopic rectal surgery seems to limit the risk of anastomotic complications and provides clear indications for early and safe conversion to open surgery. Background and Objectives: The purpose of this study was to audit our results after implementation of a standardized operative approach to laparoscopic surgery for rectal cancer within a fast-track recovery program. Methods: From January 2009 to February 2011, 100 consecutive patients underwent laparoscopic surgery on an intention-to-treat basis for rectal cancer. The results were retrospectively reviewed from a prospectively collected database. Operative steps and instrumentation for the procedure were standardized. A standard perioperative care plan was used. Results: The following procedures were performed: low anterior resection (n=26), low anterior resection with loop-ileostomy (n=39), Hartmann's operation (n=14), and abdominoperineal resection (n=21). The median length of hospital stay was 7 days; 9 patients were readmitted. There were 9 cases of conversion to open surgery. The overall complication rate was 35%, including 6 cases (9%) of anastomotic leakages requiring reoperation. The 30-day mortality was 5%. The median number of harvested lymph nodes was 15 (range, 2 to 48). There were 6 cases of positive circumferential resection margins. The median follow-up was 9 (range, 1 to 27) months. One patient with disseminated cancer developed port-site metastasis. Conclusions: The results confirm the safety of a standardized approach, and the oncological outcomes are comparable to those of similar studies.
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Affiliation(s)
- Katrine Kanstrup Aslak
- Department of Surgical Gastroenterology, Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark
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Baiocchi GL, Sartori CA. Laparoscopic low anterior resection with total mesorectal excision for rectal cancer. Reply. Surg Endosc 2013; 27:1449-1450. [PMID: 23093239 DOI: 10.1007/s00464-012-2601-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 09/06/2012] [Indexed: 10/27/2022]
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Grosso F, Mandalà M, Maglione V, Berretta L, Mariani N, Rossi M, Piovano PL, Drago D, Summa M, Franzone P, Musante F, Spinoglio G. Neoadjuvant Therapy and Mini-Invasive Total Mesorectal Excision for Rectal Cancer: Feasibility and Outcome Analysis from a Single Institution Prospectively Collected Data Base. TUMORI JOURNAL 2012; 98:689-95. [DOI: 10.1177/030089161209800603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim and background Neoadjuvant treatment for rectal adenocarcinoma improves local control and represents the standard for locally advanced disease. Laparoscopic and robotic total mesorectal excision has been increasingly adopted. It provides magnified visualization of the pelvic cavity, thereby facilitating the mesorectal dissection. Methods Consecutive patients with locally advanced/ultralow rectal adenocarcinoma received neoadjuvant treatment and mini-invasive total mesorectal excision at our center. We retrospectively reviewed the clinical records by using a prospectively collected data base and focusing on feasibility, tumor response and treatment outcomes. Results In a 13-year period, 117 rectal adenocarcinoma patients (80 males and 37 females) received neoadjuvant treatment and mini-invasive total mesorectal excision. Median age at diagnosis was 67 years; pre-treatment stage was I in 10 (9%); IIA in 58 (50%); IIC in 5 (4%); IIIA in 10 (9%); IIIB in 31 (26%) and IV in 3 (2%) patients. All patients received external beam radiation therapy, 79 (67%) combined with fluorouracil-based chemotherapy. One-hundred and three patients underwent laparoscopic surgery and 14 robotic surgery. Overall, 90 patients (77%) had anterior resection and 27 (23%) had abdominoperineal resection. Down-staging was obtained in 70 patients (66%). No major intraoperative nor delayed surgical complications were observed. At a median follow up of 52 months, 8 patients (7%) had a local relapse, 7 of them along with distant relapse, and 16 (14%) had distant relapse. The 5-year relapse-free survival was 76.5%. Conclusions Our data suggest that in a community hospital mini-invasive surgery after neoadjuvant treatment is feasible in real clinical practice and achieves consistent results in term of disease control rate.
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Affiliation(s)
- Federica Grosso
- Medical Oncology, Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Alessandria
| | | | - Valeria Maglione
- Surgical Oncology, Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Alessandria, Italy
| | - Laura Berretta
- Radiotherapy, Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Alessandria, Italy
| | - Narciso Mariani
- Pathology, Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Alessandria, Italy
| | - Maura Rossi
- Medical Oncology, Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Alessandria
| | - Pier Luigi Piovano
- Medical Oncology, Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Alessandria
| | - Domenico Drago
- Endoscopy, Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Alessandria, Italy
| | - Massimo Summa
- Surgical Oncology, Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Alessandria, Italy
| | - Paola Franzone
- Radiotherapy, Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Alessandria, Italy
| | - Francesco Musante
- Radiology, Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Alessandria, Italy
| | - Giuseppe Spinoglio
- Surgical Oncology, Azienda Ospedaliera Nazionale SS Antonio e Biagio e C Arrigo, Alessandria, Italy
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Memon S, Heriot AG, Murphy DG, Bressel M, Lynch AC. Robotic versus laparoscopic proctectomy for rectal cancer: a meta-analysis. Ann Surg Oncol 2012; 19:2095-101. [PMID: 22350601 DOI: 10.1245/s10434-012-2270-1] [Citation(s) in RCA: 158] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Robot-assisted laparoscopic surgery is being performed more frequently for the minimally invasive management of rectal cancer. The objective of this meta-analysis was to compare the clinical and oncologic safety and efficacy of robot-assisted versus conventional laparoscopic surgery. METHODS A search of the Medline and Embase databases was performed for studies that compared clinical or oncologic outcomes of conventional laparoscopic proctectomy with robot-assisted laparoscopic proctectomy for rectal cancer. The methodological quality of the selected studies was critically assessed to identify studies suitable for inclusion. Meta-analysis was performed by a random effects model and analyzed by Review Manager. Clinical outcomes evaluated were conversion rates, operation times, length of hospital stay, and complications. Oncologic outcomes evaluated were circumferential margin status, number of lymph nodes collected, and distal resection margin lengths. RESULTS Eight comparative studies were assessed for quality, and seven studies were included in the meta-analysis. Two studies were matched case-control studies, and five were unmatched. A total of 353 robot-assisted laparoscopic surgery proctectomy cases and 401 conventional laparoscopic surgery proctectomy cases were analyzed. Robotic surgery was associated with a significantly lower conversion rate (P=0.03; 95% confidence interval 1-12). There was no difference in complications, circumferential margin involvement, distal resection margin, lymph node yield, or hospital stay (P=NS). CONCLUSIONS Robot-assisted surgery decreased the conversion rate compared to conventional laparoscopic surgery. Other clinical outcomes and oncologic outcomes were equivalent. The benefits of robotic rectal cancer surgery may differ between population groups.
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Affiliation(s)
- Sameer Memon
- Department of Colorectal Surgery, Division of Cancer Surgery, Peter MacCallum Cancer Centre, East Melbourne, Australia
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Ruffo G, Sartori A, Crippa S, Partelli S, Barugola G, Manzoni A, Steinasserer M, Minelli L, Falconi M. Laparoscopic rectal resection for severe endometriosis of the mid and low rectum: technique and operative results. Surg Endosc 2011; 26:1035-40. [PMID: 22038165 DOI: 10.1007/s00464-011-1991-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Accepted: 09/22/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although several studies have shown that laparoscopic resection is safe and feasible in bowel endometriosis, limited data are available on the specific treatment for endometriosis of the rectum. The aim of this study is to describe operative and postoperative outcomes after laparoscopic resection of the mid/low rectum for endometriosis. METHODS Between 2002 and 2010, 750 patients (median age 33 years) underwent laparoscopic resection of the mid/low rectum for deep infiltrating endometriosis at a single institution. All operations were performed with a standardized technique by a single surgeon. RESULTS Median operative time was 255 min, and median blood loss 150 ml. Of patients, 7% required blood transfusions. Laparotomic conversion rate was 1.6%. Mechanical low and very low colorectal anastomoses were carried out in 92.5 and 7.5% of patients, respectively. Temporary ileostomy rate was 14.5%. Median length of stay was 8 days. Overall surgical morbidity was 9% with no mortality. Rates of anastomotic leak, rectovaginal fistula, and intraabdominal bleeding were 3, 2, and 1.2%. Forty patients (5.5%) required reoperation. CONCLUSIONS Laparoscopic resection of the mid/low rectum for endometriosis can be performed safely with acceptable rates of morbidity/reoperation and with low rates of specific complications, including anastomotic leak and rectovaginal fistula. The very high surgical volume of the operating surgeon is probably one of the most important factors in order to maximize postoperative outcomes.
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Affiliation(s)
- Giacomo Ruffo
- Department of General Surgery, Ospedale Sacro Cuore-Don Calabria, Via Sempreboni 5, 37024, Negrar, VR, Italy.
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A new laparoscopic surgical procedure to achieve sufficient mesorectal excision in upper rectal cancer. Int J Surg Oncol 2011; 2011:708439. [PMID: 22312519 PMCID: PMC3263670 DOI: 10.1155/2011/708439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 08/22/2011] [Indexed: 01/10/2023] Open
Abstract
Objective. Mesorectal excision corresponding to the location of a tumor, termed tumor-specific mesorectal excision (TSME), is commonly performed for resection of upper rectal cancer. We devised a new laparoscopic procedure for sufficient TSME with rectal transection followed by mesorectal excision. Operative Technique. After mobilization of the sigmoid colon and ligation of inferior mesenteric vessels, we dissected the mesorectum along the layer of the planned total mesorectal excision. The rectal wall was carefully separated from the mesorectum at the appropriate anal side from the tumor. After the rectum was isolated and transected using an endoscopic linear stapler, the rectal stump drew immediately toward the anal side, enabling the mesorectum to be identified clearly. In this way, sufficient TSME can be performed easily and accurately. This technique has been successfully conducted on 19 patients. Conclusion. This laparoscopic technique is a feasible and reliable procedure for achieving sufficient TSME.
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Laparoscopic low anterior resection with total mesorectal excision for rectal cancer. Surg Endosc 2011; 26:578-9. [PMID: 21909855 DOI: 10.1007/s00464-011-1893-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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