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World Journal of Surgical Oncology Dec 2023Robot-assisted surgery has proven to be a safe and feasible approach for the management of rectal cancer, including abdominoperineal resection (APR). However, it often...
BACKGROUND
Robot-assisted surgery has proven to be a safe and feasible approach for the management of rectal cancer, including abdominoperineal resection (APR). However, it often incurs longer operative times and higher costs. This study aimed to overcome these limitations by adopting a synchronous approach utilizing an optimized team composition.
METHODS
Data on patients who underwent robot-assisted APR at our facility between June 2022 and June 2023 were analyzed. The key points of the optimized approach included the following: At the start of the surgery, the surgeon performed an anococcygeal ligament resection from the perineal side while the bedside assistants set up the ports. Then, through console manipulation, the presacral fascia, elevated by previously placed gauze, was easily and safely incised, providing access to the perineal region.
RESULTS
A total of nine patients were included in this study. The median operation time was 231 min, and the intraoperative blood loss was 170 ml. The operation time was reduced to 167.5 min, and the blood loss was 80.5 ml in cases without a trainee. Surgical site infections, classified as Clavien-Dindo grade II complications, were observed in two cases, but no obvious urinary or erectile dysfunction was observed.
CONCLUSION
The study results indicate that the challenges associated with APR can be efficiently addressed without requiring additional personnel by streamlining team composition and the synchronous approach. This optimization strategy minimizes the need for a larger surgical team, while maximizing the utilization of surgical time and resources.
Topics: Male; Humans; Robotic Surgical Procedures; Proctectomy; Rectal Neoplasms; Retrospective Studies; Treatment Outcome; Laparoscopy
PubMed: 38124092
DOI: 10.1186/s12957-023-03260-x -
The Surgical Clinics of North America Dec 2019Medical treatment remains the mainstay of perianal disease management for CD; however, aggressive surgical management should be considered for severe or recurrent... (Review)
Review
Medical treatment remains the mainstay of perianal disease management for CD; however, aggressive surgical management should be considered for severe or recurrent disease. In all cases of perianal CD, medical and surgical treatments should be used in tandem by a multidisciplinary team. Significant development has been made in the treatment of Crohn's-related fistulas, particularly minimally invasive options with recent clinical trials showing success with mesenchymal stem cell applications. Inevitably, some patients with severe refractory disease may require fecal diversion or proctectomy. When considering reversal of a diverting or end ileostomy, cessation of proctitis is the most important factor.
Topics: Combined Modality Therapy; Crohn Disease; Female; Humans; Intestinal Fistula; Male; Proctectomy; Prognosis; Rectal Diseases; Risk Assessment; Severity of Illness Index; Treatment Outcome
PubMed: 31676054
DOI: 10.1016/j.suc.2019.08.012 -
Journal of Gastrointestinal Surgery :... Aug 2018Management of low rectal cancer continues to be a challenge, and decision making regarding the need for an abdominoperineal resection (APR) in patients with low-lying... (Review)
Review
BACKGROUND
Management of low rectal cancer continues to be a challenge, and decision making regarding the need for an abdominoperineal resection (APR) in patients with low-lying tumors is complicated. Furthermore, choices need to be made regarding need for modification of the surgical approach based on tumor anatomy and patient goals.
DISCUSSION
In this article, we address patient selection, preoperative planning, and intraoperative technique required to perform the three types of abdominoperineal resections for rectal cancer: extrasphincteric, extralevator, and intersphincteric. Attention is paid not only to traditional oncologic outcomes such as recurrence and survival but also to patient-reported outcomes and quality of life.
Topics: Abdomen; Evidence-Based Medicine; Humans; Margins of Excision; Neoplasm Recurrence, Local; Patient Selection; Perineum; Proctectomy; Quality of Life; Rectal Neoplasms; Survival Rate
PubMed: 29663303
DOI: 10.1007/s11605-018-3750-9 -
Annals of Surgery Apr 2019
Topics: Humans; Laparoscopy; Proctectomy; Rectal Neoplasms
PubMed: 30849053
DOI: 10.1097/SLA.0000000000003211 -
World Journal of Gastroenterology Jun 2020Since its introduction, extralevator abdominoperineal excision (ELAPE) in the prone position has gained significant attention and recognition as an important surgical... (Review)
Review
Since its introduction, extralevator abdominoperineal excision (ELAPE) in the prone position has gained significant attention and recognition as an important surgical procedure for the treatment of advanced low rectal cancer. Most studies suggest that because of adequate resection and precise anatomy, ELAPE could decrease the rate of positive circumferential resection margins, intraoperative perforation, and may further decrease local recurrence rate and improve survival. Some studies show that extensive resection of pelvic floor tissue may increase the incidence of wound complications and urogenital dysfunction. Laparoscopic/robotic ELAPE and trans-perineal minimally invasive approach allow patients to be operated in the lithotomy position, which has advantages of excellent operative view, precise dissection and reduced postoperative complications. Pelvic floor reconstruction with biological mesh could significantly reduce wound complications and the duration of hospitalization. The proposal of individualized ELAPE could further reduce the occurrence of postoperative urogenital dysfunction and chronic perianal pain. The ELAPE procedure emphasizes precise anatomy and conforms to the principle of radical resection of tumors, which is a milestone operation for the treatment of advanced low rectal cancer.
Topics: Abdomen; Digestive System Surgical Procedures; Humans; Neoplasm Recurrence, Local; Perineum; Proctectomy; Rectal Neoplasms; Rectum
PubMed: 32587445
DOI: 10.3748/wjg.v26.i22.3012 -
Acta Chirurgica Belgica Oct 2021Conventional abdominoperineal resection (APR) has a high rate of local recurrence. Extralevator abdominoperineal excision (ELAPE) can potentially diminish the rate of...
INTRODUCTION
Conventional abdominoperineal resection (APR) has a high rate of local recurrence. Extralevator abdominoperineal excision (ELAPE) can potentially diminish the rate of intraoperative tumour perforation (IOTP) and can provide wider circumferential resection margins (CRM) but at the price of higher perineal complication rate. The aim of our study was to compare the short term results of conventional APR to ELAPE.
MATERIALS AND METHODS
Thirty-five consecutively operated APRs compared to 38 also consecutively operated ELAPEs. Prospectively collected short-term outcome data were analysed retrospectively.
RESULTS
There was no difference in demographics, disease stage or tumour location between groups. IOTP rate and CRM positivity rates were similar between the two groups ( = .608). No difference was found in major (Clavien-Dindo III-V) complications, but we found statistically significant difference in minor (Clavien-Dindo I-II) complications ( = .01) in favour of the ELAPE group. Frequency of perineal SSI was lower in ELAPE group, but the difference was not significant ( = .320). Intraoperative iatrogenic complications occurred at significantly lower rate in ELAPE group ( = .035). Also, postoperative morbidity connected with the dissection in the perineal phase (e.g. urine incontinence, urinary retention) was significantly lower ( = .018) after ELAPE.
DISCUSSION AND CONCLUSIONS
In our experience ELAPE operations may diminish the rate of Clavien-Dindo I-II complications compared to conventional APR. This effect is ensuing from the decrease of intraoperative iatrogenic complications and from the decrease of minor postoperative complications.
Topics: Digestive System Surgical Procedures; Humans; Neoplasm Recurrence, Local; Perineum; Proctectomy; Rectal Neoplasms; Retrospective Studies; Treatment Outcome
PubMed: 32496868
DOI: 10.1080/00015458.2020.1778265 -
Current Gastroenterology Reports Mar 2019Despite the growth in laparoscopic surgery, comparable oncological outcomes, and reduced complication rates, the majority of colorectal surgery is still performed via an... (Review)
Review
PURPOSE OF REVIEW
Despite the growth in laparoscopic surgery, comparable oncological outcomes, and reduced complication rates, the majority of colorectal surgery is still performed via an open approach. Reasons for this may include technical difficulties associated with operating in narrow spaces such as in the pelvis and inadequate experience. Robotic surgery provides potential solutions to some of these challenges. This review will summarize the state of the literature regarding robotic colorectal surgery.
RECENT FINDINGS
The most consistent benefit of robotic surgery is decreasing operative conversions, specifically in rectal cancer. In partial colectomies, there is evidence to support quicker return to bowel function. Oncologic outcomes compared to the laparoscopic approach are equivalent. Robotic surgery provides solutions to the challenges posed by laparoscopy, including wristed instruments, ease of intracorporeal suturing, and ergonomic advantages. Randomized trials to evaluate peri-operative outcomes will be important. If robotics is able to facilitate conversion of open colectomies to their minimally invasive equivalent, robotics may end up proving to be advantageous in the peri-operative and post-operative period. Continued studies are warranted.
Topics: Colectomy; Colonic Neoplasms; Colorectal Surgery; Conversion to Open Surgery; Humans; Laparoscopy; Mesentery; Proctectomy; Rectal Neoplasms; Robotic Surgical Procedures; Treatment Outcome
PubMed: 30840156
DOI: 10.1007/s11894-019-0676-7 -
Intersphincteric Resection Versus Abdominoperineal Resection for Low Rectal Cancer: A Meta-Analysis.Surgical Innovation Aug 2020Abdominoperineal resection (APR) has been the standard surgery for ultra-low rectal cancer for a century. In recent years, intersphincteric resection (ISR) has been... (Meta-Analysis)
Meta-Analysis
Abdominoperineal resection (APR) has been the standard surgery for ultra-low rectal cancer for a century. In recent years, intersphincteric resection (ISR) has been increasingly used to avoid the permanent colostomy. Up to now, there is no relevant meta-analysis comparing the clinical efficacy of ISR and APR. This meta-analysis aimed to compare the outcomes of these 2 procedures. . A comprehensive search of online databases was performed on PubMed, EMBASE, and the Cochrane Library to obtain comparative studies of ISR and APR. Then the data from studies that met the inclusion criteria were extracted and analyzed. . A total of 12 studies covering 2438 patients were included. No significant differences were found between ISR and APR in gender, body mass index, distance from tumor to anal edge, operative time, and blood loss. In addition, hospital stay (weighted mean differences = -2.98 days; 95% confidence interval [CI] = -3.54 to -2.43; < .00001) and postoperative morbidity (odds ratio [OR] = 0.76; 95% CI = 0.59 to 0.99; = .04) were significantly lower in ISR group compared with APR group. However, patients who underwent ISR showed lower pathological T-stage (T3T4%, OR = 0.49; 95% CI = 0.28 to 0.86; = .01) and lymph node metastasis rate (OR = 0.77; 95% CI = 0.59 to 1.01; = .06) compared with those who underwent APR. Moreover, oncological outcomes were similar between the 2 groups. . ISR may provide a safe alternative to APR, with shorter hospital stays, lower postoperative morbidity, and similar oncological outcomes. Well-designed randomized controlled trials are needed to confirm and update the findings of this analysis.
Topics: Anal Canal; Humans; Operative Time; Proctectomy; Rectal Neoplasms; Treatment Outcome
PubMed: 32390544
DOI: 10.1177/1553350620918414 -
Journal of the American College of... Dec 2018
Topics: Myocutaneous Flap; Perforator Flap; Perineum; Proctectomy; Rectus Abdominis
PubMed: 30470281
DOI: 10.1016/j.jamcollsurg.2018.10.006 -
European Journal of Surgical Oncology :... Dec 2023Patients who develop a perineal hernia after abdominoperineal resection may experience discomfort during daily activities and urogenital dysfunction, but the impact on...
INTRODUCTION
Patients who develop a perineal hernia after abdominoperineal resection may experience discomfort during daily activities and urogenital dysfunction, but the impact on quality of life has never been formally assessed.
MATERIALS AND METHODS
Patients who underwent abdominoperineal resection for rectal cancer between 2014 and 2022 in two prospective multicenter trials were included. Primary outcome was defined as median overall scores or scores on functional and symptom scales of the following quality of life questionnaires: 5-level version of the 5-dimensional EuroQol, Short Form-36, and European Organization for Research and Treatment of Cancer QoL Questionnaire Colorectal cancer 29 and 30, Urogenital Distress Inventory-6, Incontinence Impact Questionnaire-7.
RESULTS
Questionnaires were available in 27 patients with a perineal hernia and 62 patients without a perineal hernia. The 5-dimensional EuroQol score was significantly lower in patients with a perineal hernia (83 vs 87, p = 0.048), which implies a reduced level of functioning. The median scores of pain-specific domains were significantly worse in patients with a perineal hernia as measured by the SF-36 (78 vs. 90, p = 0.006), the EORTC-CR29 (17 vs. 11, p=<0.001) and EORTC-C30 (17 vs. 0, p = 0.019). Also, significantly worse physical (73 vs. 100, p = 0.049) and emotional (83 vs. 100, p = 0.048) functioning based on EORTC-C30 was observed among those patients. Minimally important differences were found for role, physical and social functioning of the SF-36 and EORTC-C30. The urological function did not differ between the groups.
CONCLUSION
A symptomatic perineal hernia can significantly worsen quality of life on several domains, indicating the severity of this complication.
Topics: Humans; Quality of Life; Prospective Studies; Rectal Neoplasms; Proctectomy; Hernia; Surveys and Questionnaires
PubMed: 37839295
DOI: 10.1016/j.ejso.2023.107114