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European Review For Medical and... Sep 2022The aim of our study is to compare the results of robotic surgery-assisted Low Anterior Resection (LAR) and Natural Orifice Specimen Extraction (NOSE) for Rectal Cancer...
OBJECTIVE
The aim of our study is to compare the results of robotic surgery-assisted Low Anterior Resection (LAR) and Natural Orifice Specimen Extraction (NOSE) for Rectal Cancer (RC).
PATIENTS AND METHODS
From November 2015 to June 2021, patients receiving robotic NOSES and robotic surgery assisted resection (RSAR) were retrospectively enrolled in the study. All robotic-assisted LAR of the rectum, NOSE, colorectal anastomosis and loop ileostomies were performed using the Da Vinci Xi system.
RESULTS
A total of 57 patients with robotic NOSES and 93 with robotic RC resection were enrolled. Total mesorectal excision of the rectum, trans-anal or transvaginal specimen extraction (TVSE), anastomoses and protective ileostomy were conducted in all patients. ASA, BMI, tumor histology, stage, nodal stage, mean operative time, estimated blood loss, tumor size, lymph nodes removal, hospital stay morbidity and mortality were evaluated. No patient required conversion to conventional surgery. NOSE has less morbidity and significantly reduces postoperative pain and hospital stay (5.0 vs. 5.5). The two groups were similar in long-term survival.
CONCLUSIONS
According to our literature search, this is the first study to compare RSAR and NOSE for RC using the Da Vinci Xi system. NOSE can be performed safely and successfully on selected patients, providing excellent good results.
Topics: Humans; Laparoscopy; Proctectomy; Rectal Neoplasms; Retrospective Studies; Robotic Surgical Procedures; Treatment Outcome
PubMed: 36196717
DOI: 10.26355/eurrev_202209_29767 -
Annals of Surgery Feb 2022Investigate the association between neoadjuvant treatment strategy and perioperative complications in patients undergoing proctectomy for nonmetastatic rectal cancer.
OBJECTIVE
Investigate the association between neoadjuvant treatment strategy and perioperative complications in patients undergoing proctectomy for nonmetastatic rectal cancer.
SUMMARY OF BACKGROUND DATA
Neoadjuvant SC-TNT is an alternative to neoadjuvant CRT for rectal cancer. Some have argued that short-course radiation and extended radiation-to-surgery intervals increase operative difficulty and complication risk. However, the association between SC-TNT and surgical complications has not been previously investigated.
METHODS
This single-center retrospective cohort study included patients undergoing total mesorectal excision for nonmetastatic rectal cancer after SC-TNT or CRT between 2010 and 2018. Univariate analysis of severe POM and multiple secondary outcomes, including overall POM, intraoperative complications, and resection margins, was performed. Logistic regression of severe POM was also performed.
RESULTS
Of 415 included patients, 156 (38%) received SC-TNT and 259 (62%) received CRT. The cohorts were largely similar, though patients with higher tumors (69.9% vs 47.5%, P < 0.0001) or node-positive disease (76.9% vs 62.6%, P = 0.004) were more likely to receive SC-TNT. We found no difference in incidence of severe POM (9.6% SC-TNT vs 12.0% CRT, P = 0.46) or overall POM (39.7% SC-TNT vs 37.5% CRT, P = 0.64) between cohorts. Neoadjuvant regimen was also not associated with a difference in severe POM (odds ratio 0.42, 95% confidence interval 0.04-4.70, P = 0.48) in multivariate analysis. There was no significant association between neoadjuvant regimen and any secondary outcome.
CONCLUSION
In rectal cancer patients treated with SC-TNT and proctectomy, we found no significant association with POM compared to patients undergoing CRT. SC-TNT does not significantly increase the risk of POM compared to CRT.
Topics: Adolescent; Adult; Aged; Chemoradiotherapy; Cohort Studies; Female; Humans; Male; Middle Aged; Neoadjuvant Therapy; Postoperative Complications; Proctectomy; Rectal Neoplasms; Retrospective Studies; Young Adult
PubMed: 32209914
DOI: 10.1097/SLA.0000000000003885 -
Chirurgia (Bucharest, Romania : 1990) 2020This work's objective was to review the entire literature on colorectal surgery in order to best define the surgical indications and their management specificities. The... (Review)
Review
This work's objective was to review the entire literature on colorectal surgery in order to best define the surgical indications and their management specificities. The literature analysis was carried out according to High Authority for Health (HAS) methodology, by consulting the PubMed database (Medline), from the beginning of January 1995 until the end of June 2015.
Topics: Colectomy; Colon; Colonic Diseases; Humans; Intestine, Large; Liver Cirrhosis; Proctectomy; Rectal Diseases; Rectum
PubMed: 32369718
DOI: 10.21614/chirurgia.115.2.148 -
JAMA Surgery Jul 2020Complex surgical interventions are inherently prone to variation yet they are not objectively measured. The reasons for outcome differences following cancer surgery are...
IMPORTANCE
Complex surgical interventions are inherently prone to variation yet they are not objectively measured. The reasons for outcome differences following cancer surgery are unclear.
OBJECTIVE
To quantify surgical skill within advanced laparoscopic procedures and its association with histopathological and clinical outcomes.
DESIGN, SETTING, AND PARTICIPANTS
This analysis of data and video from the Australasian Laparoscopic Cancer of Rectum (ALaCaRT) and 2-dimensional/3-dimensional (2D3D) multicenter randomized laparoscopic total mesorectal excision trials, which were conducted at 28 centers in Australia, the United Kingdom, and New Zealand, was performed from 2018 to 2019 and included 176 patients with clinical T1 to T3 rectal adenocarcinoma 15 cm or less from the anal verge. Case videos underwent blinded objective analysis using a bespoke performance assessment tool developed with a 62-international expert Delphi exercise and workshop, interview, and pilot phases.
INTERVENTIONS
Laparoscopic total mesorectal excision undertaken with curative intent by 34 credentialed surgeons.
MAIN OUTCOMES AND MEASURES
Histopathological (plane of mesorectal dissection, ALaCaRT composite end point success [mesorectal fascial plane, circumferential margin, ≥1 mm; distal margin, ≥1 mm]) and 30-day morbidity. End points were analyzed using surgeon quartiles defined by tool scores.
RESULTS
The laparoscopic total mesorectal excision performance tool was produced and shown to be reliable and valid for the specialist level (intraclass correlation coefficient, 0.889; 95% CI, 0.832-0.926; P < .001). A substantial variation in tool scores was recorded (range, 25-48). Scores were associated with the number of intraoperative errors, plane of mesorectal dissection, and short-term patient morbidity, including the number and severity of complications. Upper quartile-scoring surgeons obtained excellent results compared with the lower quartile (mesorectal fascial plane: 93% vs 59%; number needed to treat [NNT], 2.9, P = .002; ALaCaRT end point success, 83% vs 58%; NNT, 4; P = .03; 30-day morbidity, 23% vs 50%; NNT, 3.7; P = .03).
CONCLUSIONS AND RELEVANCE
Intraoperative surgical skill can be objectively and reliably measured in complex cancer interventions. Substantial variation in technical performance among credentialed surgeons is seen and significantly associated with clinical and pathological outcomes.
Topics: Adenocarcinoma; Aged; Clinical Competence; Female; Humans; Laparoscopy; Male; Middle Aged; Proctectomy; Randomized Controlled Trials as Topic; Rectal Neoplasms; Treatment Outcome
PubMed: 32374371
DOI: 10.1001/jamasurg.2020.1004 -
World Journal of Surgical Oncology Sep 2022Currently, high or low ligation of the inferior mesenteric artery (IMA) is a controversial issue in laparoscopic radical surgery for colorectal cancer. High or low... (Review)
Review
Currently, high or low ligation of the inferior mesenteric artery (IMA) is a controversial issue in laparoscopic radical surgery for colorectal cancer. High or low ligation of the IMA has both advantages and disadvantages, and the level of ligation during the left colon and/or rectum resection has been a dilemma for surgeons. One important factor influencing the surgeon's decision to ligate the IMA in a high or low position is the anatomical type of the IMA and its branches. Some studies confirm that the anatomy of the IMA and its branches is critical to the anastomotic blood supply and, therefore, influences the choice of surgical approach (level of ligation of the IMA). However, many vascular variations in the anatomy of the IMA and its branches exist. Herein, we have summarized the anatomical types of the IMA and its branches, finding that the classification proposed by Yada et al. in 1997 is presently accepted by most scholars. Based on Yada's classification, we further summarized the characteristics of the IMA's various anatomical types as a guide for high or low ligation in radical colorectal cancer surgery.
Topics: Anatomic Variation; Colorectal Neoplasms; Humans; Laparoscopy; Mesenteric Artery, Inferior; Proctectomy
PubMed: 36085239
DOI: 10.1186/s12957-022-02744-6 -
The Lancet. Gastroenterology &... Feb 2021Radical surgery via total mesorectal excision might not be the optimal first-line treatment for early-stage rectal cancer. An organ-preserving strategy with selective... (Comparative Study)
Comparative Study Randomized Controlled Trial
Radical surgery versus organ preservation via short-course radiotherapy followed by transanal endoscopic microsurgery for early-stage rectal cancer (TREC): a randomised, open-label feasibility study.
BACKGROUND
Radical surgery via total mesorectal excision might not be the optimal first-line treatment for early-stage rectal cancer. An organ-preserving strategy with selective total mesorectal excision could reduce the adverse effects of treatment without substantially compromising oncological outcomes. We investigated the feasibility of recruiting patients to a randomised trial comparing an organ-preserving strategy with total mesorectal excision.
METHODS
TREC was a randomised, open-label feasibility study done at 21 tertiary referral centres in the UK. Eligible participants were aged 18 years or older with rectal adenocarcinoma, staged T2 or lower, with a maximum diameter of 30 mm or less; patients with lymph node involvement or metastases were excluded. Patients were randomly allocated (1:1) by use of a computer-based randomisation service to undergo organ preservation with short-course radiotherapy followed by transanal endoscopic microsurgery after 8-10 weeks, or total mesorectal excision. Where the transanal endoscopic microsurgery specimen showed histopathological features associated with an increased risk of local recurrence, patients were considered for planned early conversion to total mesorectal excision. A non-randomised prospective registry captured patients for whom randomisation was considered inappropriate, because of a strong clinical indication for one treatment group. The primary endpoint was cumulative randomisation at 12, 18, and 24 months. Secondary outcomes evaluated safety, efficacy, and health-related quality of life assessed with the European Organisation for Research and Treatment of Cancer (EORTC) QLQ C30 and CR29 in the intention-to-treat population. This trial is registered with the ISRCTN Registry, ISRCTN14422743.
FINDINGS
Between Feb 22, 2012, and Dec 19, 2014, 55 patients were randomly assigned at 15 sites; 27 to organ preservation and 28 to radical surgery. Cumulatively, 18 patients had been randomly assigned at 12 months, 31 at 18 months, and 39 at 24 months. No patients died within 30 days of initial treatment, but one patient randomly assigned to organ preservation died within 6 months following conversion to total mesorectal excision with anastomotic leakage. Eight (30%) of 27 patients randomly assigned to organ preservation were converted to total mesorectal excision. Serious adverse events were reported in four (15%) of 27 patients randomly assigned to organ preservation versus 11 (39%) of 28 randomly assigned to total mesorectal excision (p=0·04, χ test). Serious adverse events associated with organ preservation were most commonly due to rectal bleeding or pain following transanal endoscopic microsurgery (reported in three cases). Radical total mesorectal excision was associated with medical and surgical complications including anastomotic leakage (two patients), kidney injury (two patients), cardiac arrest (one patient), and pneumonia (two patients). Histopathological features that would be considered to be associated with increased risk of tumour recurrence if observed after transanal endoscopic microsurgery alone were present in 16 (59%) of 27 patients randomly assigned to organ preservation, versus 24 (86%) of 28 randomly assigned to total mesorectal excision (p=0·03, χ test). Eight (30%) of 27 patients assigned to organ preservation achieved a complete response to radiotherapy. Patients who were randomly assigned to organ preservation showed improvements in patient-reported bowel toxicities and quality of life and function scores in multiple items compared to those who were randomly assigned to total mesorectal excision, which were sustained over 36 months' follow-up. The non-randomised registry comprised 61 patients who underwent organ preservation and seven who underwent radical surgery. Non-randomised patients who underwent organ preservation were older than randomised patients and more likely to have life-limiting comorbidities. Serious adverse events occurred in ten (16%) of 61 non-randomised patients who underwent organ preservation versus one (14%) of seven who underwent total mesorectal excision. 24 (39%) of 61 non-randomised patients who underwent organ preservation had high-risk histopathological features, while 25 (41%) of 61 achieved a complete response. Overall, organ preservation was achieved in 19 (70%) of 27 randomised patients and 56 (92%) of 61 non-randomised patients.
INTERPRETATION
Short-course radiotherapy followed by transanal endoscopic microsurgery achieves high levels of organ preservation, with relatively low morbidity and indications of improved quality of life. These data support the use of organ preservation for patients considered unsuitable for primary total mesorectal excision due to the short-term risks associated with this surgery, and support further evaluation of short-course radiotherapy to achieve organ preservation in patients considered fit for total mesorectal excision. Larger randomised studies, such as the ongoing STAR-TREC study, are needed to more precisely determine oncological outcomes following different organ preservation treatment schedules.
FUNDING
Cancer Research UK.
Topics: Adenocarcinoma; Adolescent; Adult; Aged; Aged, 80 and over; Feasibility Studies; Female; Follow-Up Studies; Humans; Male; Middle Aged; Neoplasm Staging; Organ Sparing Treatments; Proctectomy; Radiotherapy, Adjuvant; Rectal Neoplasms; Transanal Endoscopic Microsurgery; Treatment Outcome; Young Adult
PubMed: 33308452
DOI: 10.1016/S2468-1253(20)30333-2 -
The Journal of Surgical Research Apr 2021Depression has been linked to increased morbidity and mortality in patients after surgery. The purpose of this study is to investigate the impact of documented...
BACKGROUND
Depression has been linked to increased morbidity and mortality in patients after surgery. The purpose of this study is to investigate the impact of documented depression diagnosis on in-hospital postoperative outcomes of patients undergoing colorectal surgery.
MATERIALS AND METHODS
Patients from the National Inpatient Sample (2002-2017) who underwent proctectomies and colectomies were included. The outcomes measured included total hospital charge, length of stay, delirium, wound infection, urinary tract infection (UTI), pneumonia, deep vein thrombosis, pulmonary embolism, mortality, paralytic ileus, leak, and discharge trends. Multivariable logistic and Poisson regression analyses were performed.
RESULTS
Of the 4,212,125 patients, depression diagnosis was present in 6.72% of patients who underwent colectomy and 6.54% of patients who underwent proctectomy. Regardless of procedure type, patients with depression had higher total hospital charges and greater rates of delirium, wound infection, UTI, leak, and nonroutine discharge, with no difference in length of stay. On adjusted analysis, patients with a depression diagnosis who underwent colectomies had increased risk of delirium (odds ratio (OR) 2.11, 95% confidence interval (CI) 1.93-2.32), wound infection (OR 1.08, 95% CI 1.03-1.12), UTI (OR 1.15, 95% CI 1.10-1.20), paralytic ileus (OR 1.06, 95% CI 1.03-1.09), and leak (OR 1.37, 95% CI 1.30-1.43). Patients who underwent proctectomy showed similar results, with the addition of significantly increased total hospital charges among the depression group. Depression diagnosis was independently associated with lower risk of in-hospital mortality (colectomy OR 0.58, 95% CI 0.53-0.62; proctectomy OR 0.72, 95% CI 0.55-0.94).
CONCLUSIONS
Patients with a diagnosis of depression suffer worse in-hospital outcomes but experience lower risk of in-hospital mortality after undergoing colorectal surgery. Further studies are needed to validate and fully understand the driving factors behind this.
Topics: Adult; Aged; Aged, 80 and over; Colectomy; Databases, Factual; Depression; Female; Hospital Charges; Hospital Mortality; Humans; Length of Stay; Logistic Models; Male; Middle Aged; Postoperative Complications; Preoperative Period; Proctectomy; Retrospective Studies; Risk Factors; United States
PubMed: 33272593
DOI: 10.1016/j.jss.2020.11.006 -
BMC Surgery Jun 2022Extralevator (ELAPE) and abdominoperineal excision (APE) are two major surgical approaches for low rectal cancer patients. Although excellent short-term efficacy is...
PURPOSE
Extralevator (ELAPE) and abdominoperineal excision (APE) are two major surgical approaches for low rectal cancer patients. Although excellent short-term efficacy is achieved in patients undergoing ELAPE, the long-term benefits have not been established. In this study we evaluated the safety, pathological and survival outcomes in rectal cancer patients who underwent ELAPE and APE.
METHODS
One hundred fourteen patients were enrolled, including 68 in the ELAPE group and 46 in the APE group at the Beijing Chaoyang Hospital, Capital Medical University from January 2011 to November 2020. The baseline characteristics, overall survival (OS), progression-free survival (PFS), and local recurrence-free survival (LRFS) were calculated and compared between the two groups.
RESULTS
Demographics and tumor stage were comparable between the two groups. The 5-year PFS (67.2% versus 38.6%, log-rank P = 0.008) were significantly improved in the ELAPE group compared to the APE group, and the survival advantage was especially reflected in patients with pT3 tumors, positive lymph nodes or even those who have not received neoadjuvant chemoradiotherapy. Multivariate analysis showed that APE was an independent risk factor for OS (hazard ratio 3.000, 95% confidence interval 1.171 to 4.970, P = 0.004) and PFS (hazard ratio 2.730, 95% confidence interval 1.506 to 4.984, P = 0.001).
CONCLUSION
Compared with APE, ELAPE improved long-term outcomes for low rectal cancer patients, especially among patients with pT3 tumors, positive lymph nodes or those without neoadjuvant chemoradiotherapy.
Topics: Abdomen; Digestive System Surgical Procedures; Humans; Perineum; Proctectomy; Rectal Neoplasms; Treatment Outcome
PubMed: 35733206
DOI: 10.1186/s12893-022-01692-y -
Colorectal Disease : the Official... Jan 2021Approximately 20%-30% of patients with ulcerative colitis (UC) will undergo surgery during their disease course, the vast majority being elective due to chronic... (Meta-Analysis)
Meta-Analysis Review
AIM
Approximately 20%-30% of patients with ulcerative colitis (UC) will undergo surgery during their disease course, the vast majority being elective due to chronic refractory disease. The risks of elective surgery are reported variably. The aim of this systematic review and meta-analysis is to summarize the outcomes after elective surgery for UC.
METHODS
A systematic review was conducted that analysed studies reporting outcomes for elective surgery in the modern era (>2002). It was prospectively registered on the PROSPERO database (ref: CRD42018115513). Searches were performed of Embase and MEDLINE on 15 January 2019. Outcomes were split by operation performed. Primary outcome was quality of life; secondary outcomes were early, late and functional outcomes after surgery. Outcomes reported in five or more studies underwent a meta-analysis of incidence using random effects. Heterogeneity is reported with I , and publication bias was assessed using Doi plots and the Luis Furuya-Kanamori index.
RESULTS
A total of 34 studies were included (11 774 patients). Quality of life was reported in 12 studies, with variable and contrasting results. Thirteen outcomes (eight early surgical complications, five functional outcomes) were included in the formal meta-analysis, all of which were outcomes for ileal pouch-anal anastomosis (IPAA). A further 71 outcomes were reported (50 IPAA, 21 end ileostomy). Only 14 of 84 outcomes received formal definitions, with high inter-study variation of definitions.
CONCLUSION
Outcomes after elective surgery for UC are variably defined. This systematic review and meta-analysis highlights the range of reported incidences and provides practical information that facilitates shared decision making in clinical practice.
Topics: Colitis, Ulcerative; Colonic Pouches; Humans; Ileostomy; Postoperative Complications; Proctocolectomy, Restorative; Quality of Life; Treatment Outcome
PubMed: 32777171
DOI: 10.1111/codi.15301 -
Medicine Mar 2021One-stage resections of primary colorectal cancer and liver metastases have been reported to be feasible and safe. Minimally invasive approaches have become more common... (Observational Study)
Observational Study
One-stage resections of primary colorectal cancer and liver metastases have been reported to be feasible and safe. Minimally invasive approaches have become more common for both colorectal and hepatic surgeries. This study aimed to investigate outcomes of these combined surgical procedures among different approaches.We retrospectively analyzed patients diagnosed as having primary colorectal cancer with synchronous liver metastases and who underwent 1-stage primary resection and hepatectomy with curative intent in our hospital. According to the surgical approach for the primary tumor and hepatic lesions, namely open laparotomy (Op) or laparoscopic approach (Lap), patients were classified into Op-Op, Lap-Op (laparoscopic colorectal resection plus open hepatectomy), and Lap-Lap groups, respectively. Clinicopathological factors were reviewed, and short- and long-term outcomes were compared among the groups.The Op-Op, Lap-Op, and Lap-Lap groups comprised 36, 18, and 17 patients, respectively. The superior/posterior hepatic segments were more frequently resected via an open approach. There was no laparoscopic major hepatectomy. The median volume of intraoperative blood loss was smaller in the Lap-Lap and Lap-Op groups (290 and 270 mL) than in the Op-Op group (575 mL, P = .008). The hospital stay after surgery was shorter in the Lap-Lap and Lap-Op groups (median: 17 days and 15 days, vs 19 days for the Op-Op group, P = .033). The postoperative complication rates and survivals were similar among the groups.Application of laparoscopy to 1-stage resections of primary colorectal cancer and liver metastases may offer advantages of enhanced recovery from surgical treatment, given appropriate patient selection.
Topics: Adult; Aged; Aged, 80 and over; Blood Loss, Surgical; Colectomy; Colorectal Neoplasms; Combined Modality Therapy; Feasibility Studies; Female; Hepatectomy; Humans; Laparoscopy; Laparotomy; Liver Neoplasms; Male; Middle Aged; Neoplasms, Multiple Primary; Operative Time; Proctectomy; Retrospective Studies; Treatment Outcome
PubMed: 33726015
DOI: 10.1097/MD.0000000000025205