Conversion of laparoscopic colorectal resection for cancer: What is the impact on short-term outcomes and survival?

Laparoscopic resection for colon and rectal cancer is associated with quicker return of bowel function, reduced postoperative morbidity rates and shorter length of hospital stay compared to open surgery, with no differences in long-term survival. Conversion to open surgery is reported in up to 30% of patients enrolled in randomized control trials comparing open and laparoscopic colorectal resection for cancer. In this review, reasons for conversion are anatomical-related factors, disease-related-factors and surgeon-related factors. Body mass index, local tumour extension and co-morbidities are independent predictors of conversion. The current evidence has shown that patients with converted resection for colon cancer have similar outcomes compared to patients undergoing a laparoscopic completed or open resection. The few studies that have assessed the outcomes after conversion of laparoscopic rectal resection reported significantly higher rates of complications and longer length of hospital stay in converted patients compared to laparoscopically treated patients. No definitive conclusions can be drawn when converted and open rectal resections are compared. Early and pre-emptive conversion appears to have more favourable outcomes than reactive conversion; however, further large studies are needed to better define the optimal timing of conversion. With regard to long-term oncologic outcome, overall and disease-free survival in the case of conversion in laparoscopic colorectal cancer surgery seems to be worse than those achieved in patients in whom resection was successfully completed by laparoscopy. Although a worse long-term oncologic outcome has been suggested, it remains difficult to draw a proper conclusion due to the heterogeneity of the long-term outcomes as well as the inclusion of both colon and rectal cancer patients in most of the studies. Therefore, we discuss the currently available evidence of the impact of conversion in laparoscopic resection for colon and rectal cancer on both short-term outcomes and long-term survival.     

Technical feasibility of laparoscopic extended surgery beyond total mesorectal excision for primary or recurrent rectal cancer

Relatively little is known about the oncologic safety of laparoscopic surgery for advanced rectal cancer.Recently, large randomized clinical trials showed that laparoscopic surgery was not inferior to open surgery, as evidenced by survival and local control rates. However, patients with T4 tumors were excluded from these trials. Technological advances in the instrumentation and techniques used by laparoscopic surgery have increased the use of laparoscopic surgery for advanced rectal cancer. High-definition, illuminated, and magnified images obtained by laparoscopy may enable more precise laparoscopic surgery than open techniques, even during extended surgery for T4 or locally recurrent rectal cancer. To date, the quality of evidence regarding the usefulness of laparoscopy for extended surgery beyond total mesorectal excision has been low because most studies have been uncontrolled series, with small sample sizes, and long-term data are lacking. Nevertheless, laparoscopic extended surgery for rectal cancer, when performed by specialized laparoscopic colorectal surgeons, has been reported safe in selected patients, with significant advantages, including a clear visual field and less blood loss. This review summarizes current knowledge on laparoscopic extended surgery beyond total mesorectal excision for primary or locally recurrent rectal cancer.     

套袖式吻合技术在腹腔镜超低位直肠癌保肛手术中的应用

目的探讨套袖式吻合技术在腹腔镜超低位直肠癌保肛手术的安全性、有效性及近期疗效。 方法回顾性分析中国医学科学院北京协和医学院肿瘤医院2018年4月至2019年2月采用套袖式吻合技术完成的腹腔镜超低位直肠癌保肛手术患者的临床资料,统计并分析患者的临床特征、病理特征、手术和术后恢复情况、围手术期并发症及术后肛门功能等资料。 结果共有40例患者成功完成应用套袖式吻合技术的腹腔镜超低位直肠癌保肛手术,2例患者术中因结肠残端血供较差行预防性回肠造口,其中21例（52.5%）患者术前行新辅助治疗,肿瘤距肛缘中位距离为4 cm,中位手术时间为166.5 min,中位术中出血量为20.0 mL。肿瘤中位长径为2.5 cm,中位近端切缘长度为10.3 cm,中位远端切缘长度为1.0 cm,中位淋巴结检出数目为13.10枚。患者术后中位下地时间、进食时间、排气时间和住院时间分别为19.0 h、12.5 h、20.5 h和6.0 d,中位住院费用为47 646.0元。随访过程中,结肠残端回缩入盆腔的中位时间为12.0 d,其中4例（10%）患者术后出现吻合口漏,行临时性肠造口手术后逐渐好转,1例（2.5%）患者术后出现结肠残端出血,4例（10%）患者术后出现肛周粪水性皮炎,2例（5%）患者术后出现肛周疼痛,均予对症止处理后好转。术后3个月采用低前切除综合征（LARS）评分量表评估肛门功能,其中,8例（20%）无LARS,23例（57.5%）轻度LARS,9例（22.5%）重度LARS。随访期间无患者肿瘤复发或者转移。 结论应用套袖式吻合技术的腹腔镜超低位直肠癌保肛手术安全可行,避免了常规预防性造口,近期疗效较为满意,其远期疗效待进一步随访观察。     

Dealing with robot-assisted surgery for rectal cancer:current status and perspectives

The laparoscopic approach for treatment of rectal cancer has been proven feasible and oncologically safe, and is able to offer better short-term outcomes than traditional open procedures, mainly in terms of reduced length of hospital stay and time to return to working activity. In spite of this, the laparoscopic technique is usually practised only in high-volume experienced centres, mainly because it requires a prolonged and demanding learning curve. It has been estimated that over 50 operations are required for an experienced colorectal surgeon to achieve proficiency with this technique. Robotic surgery enables the surgeon to perform minimally invasive operations with better vision and more intuitive and precise control of the operating instruments, thus promising to overcome some of the technical difficulties associated with standard laparoscopy. It has high-definition threedimensional vision, it translates the surgeon's hand movements into precise movements of the instruments inside the patient, the camera is held and moved by the first surgeon, and a fourth robotic arm is available as a fixed retractor. The aim of this review is to summarise the current data on clinical and oncologic outcomes of robot-assisted surgery in rectal cancer, focusing on short- and long-term results, and providing original data from the authors' centre.     

Laparoscopic surgery for rectal cancer]

For more than a decade, laparoscopic surgery has been adopted as a treatment of colorectal cancer. With promising evidences from multi-center prospective randomized studies, laparoscopic approach is accepted as an alternative for the management of colon cancer. However, laparoscopic surgery is still technically demanding and has little evidence to convince most surgeons of its usefulness for rectal cancer. Laparoscopic surgery for malignant diseases must stress on oncologic safety as well as its functional excellence. Oncologic principles in surgery for rectal cancer are complete resection of the tumor with safe margins, en-bloc resection of regional lymph nodes and appropriate treatment for metastatic lesion. Despite the lack of results in prospective randomized comparative trials, many studies have been investigating whether laparoscopic resection for rectal cancer can follow these principles. In this review, we analyze early outcomes, long-term result of oncologic adequacy in laparoscopic surgery for rectal cancer, and discuss its potential advantages.     

Laparoscopic rectal cancer surgery: Where do we stand?

Large comparative studies and multiple prospective randomized control trials (RCTs) have reported equivalence in short and long-term outcomes between the open and laparoscopic approaches for the surgical treatment of colon cancer which has heralded widespread acceptance for laparoscopic resection of colon cancer. In contrast, laparoscopic total mesorectal excision (TME) for the treatment of rectal cancer has been welcomed with significantly less enthusiasm. While it is likely that patients with rectal cancer will experience the same benefits of early recovery and decreased postoperative pain from the laparoscopic approach, whether the same oncologic clearance, specifically an adequate TME can be obtained is of concern. The aim of the current study is to review the current level of evidence in the literature on laparoscopic rectal cancer surgery with regard to short-term and long-term oncologic outcomes. The data from 8 RCTs, 3 meta-analyses, and 2 Cochrane Database of Systematic Reviews was reviewed. Current data suggests that laparoscopic rectal cancer resection may benefit patients with reduced blood loss, earlier return of bowel function, and shorter hospital length of stay. Concerns that laparoscopic rectal cancer surgery compromises short-term oncologic outcomes including number of lymph nodes retrieved and circumferential resection margin and jeopardizes long-term oncologic outcomes has not conclusively been refuted by the available literature. Laparoscopic rectal cancer resection is feasible but whether or not it compromises short-term or long-term results still needs to be further studied.     

Locally recurrent rectal cancer

PURPOSE: After curative surgery for rectal cancer, patients with pelvic recurrence may undergo curative surgical resection. We determined whether salvage surgery in appropriately selected patients could significantly lengthen disease-free survival time and if so what factors predicted this outcome. METHOD: We reviewed the records of all patients treated for rectal cancer at our institution between 1980 and 1993. Of 937 patients who underwent surgery with curative intent after proctectomy or transanal local excision, 81 (8.6 percent) experienced local recurrence. During the same period 36 patients with locally recurrent rectal cancer were referred from other institutions. Logistic regression analysis was used to identify predictors of salvage surgery. The Kaplan-Meier method was used to estimate cancer-specific and disease-free survival times in 43 patients who underwent salvage surgery. The Cox proportional hazard model was used to identify factors associated with these outcomes. RESULTS: Of 117 patients with locally recurrent rectal cancer, 43 (36.7 percent) underwent salvage surgery. Factors associated with higher chance of receiving salvage surgery were female gender, the first operation performed at outside institutions, and transanal local excision as the initial operation. For 43 patients who underwent salvage surgery, five-year cancer-specific and disease-free survival rates were 49.7 and 32.2 percent, respectively. No factors were significantly associated with death caused by cancer. However, a trend for poor prognosis was observed in patients with recurrence diameter >3 cm and tumor fixation Degree 2. CONCLUSION: Salvage surgery for properly selected patients with locally recurrent rectal cancer allows long-term palliation and significantly lengthens disease-free survival.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio Texas, May 2 to 7, 1998.     

机器人腹部无切口直肠癌前切除术

目的经自然腔道取标本手术（NOSES）可避免腹部切口,具有美观、术后恢复快的优势。本中心采用NOSES术式,创新性地开展了机器人无切口直肠癌前切除术。 方法本研究纳入2013年10月至2015年12月期间共19例早期完成该手术的患者,分析其临床病理特征,围手术期相关结果及术后随访资料。 结果所有手术均成功实施,术后恢复良好,均顺利出院。随访期间,未发生严重腹、盆腔感染;无明显排尿困难、性功能障碍和排便失禁;肿瘤学结果较好。 结论结果证实,机器人腹部无切口直肠癌前切除术安全、可行,但其远期结果评估需增加样本量,并行进一步随访。     

利用套袖式吻合技术的低位直肠癌新辅助放化疗后NOSES手术20例临床分析

目的探讨利用套袖式吻合技术的低位直肠癌新辅助放化疗后经自然腔道取标本手术（NOSES）的安全性、可行性及近期疗效。 方法回顾性分析中国医学科学院北京协和医学院肿瘤医院2018年10月至2021年10月20例利用套袖式吻合技术完成NOSES手术的低位直肠癌新辅助放化疗后患者的临床资料,统计并分析患者的临床特征、手术情况、术后恢复、病理特征、围手术期并发症以及术后复发转移等资料,并分别于术后1个月、3个月及6个月采用低位前切除综合征（LARS）评分量表评估肛门功能。 结果20例低位直肠癌新辅助放化疗后患者均成功完成利用套袖式吻合技术的NOSES手术,术前肿瘤距肛缘中位距离为4.0 cm,术中未行预防性造口,中位手术时间为171.5 min,中位吻合时间为17.0 min,中位术中出血量为35.0 mL。患者术后中位下地时间、进食时间、排气时间和住院时间分别为18.5 h、12.0 h、30.0 h和7.0 d,中位住院费用为47 678.0元。术后病理显示中位肿瘤长径为3.3 cm,中位近端切缘长度为10.3 cm,中位远端切缘长度为1.0 cm,中位淋巴结检出数目为14.5枚。随访过程中,结肠残端回缩入盆腔的中位时间为11.5 d,其中1例（5.0%）患者于术后第五天出现吻合口漏,另外有3例（15.0%）患者出现肛周粪水性皮炎伴肛周疼痛,均予对症止处理后好转。1例（5.0%）患者术后1年出现肝转移,其余患者无肿瘤局部复发或转移。12例（60%）患者术后1个月LARS评分较高,但术后3个月15例（75%）患者肛门功能较为满意。 结论利用套袖式吻合技术的低位直肠癌新辅助放化疗后NOSES手术安全可行,避免了预防性造口,经对症指导治疗肛门功能恢复满意,具有较好的近期疗效,其远期疗效待进一步随访观察。     

Robotic surgery for rectal cancer: Current immediate clinical and oncological outcomes

Laparoscopic rectal surgery continues to be a challenging operation associated to a steep learning curve. Robotic surgical systems have dramatically changed minimally invasive surgery. Three-dimensional, magnified and stable view, articulated instruments, and reduction of physiologic tremors leading to superior dexterity and ergonomics. Therefore, robotic platforms could potentially address limitations of laparoscopic rectal surgery. It was aimed at reviewing current literature on short-term clinical and oncological (pathological) outcomes after robotic rectal cancer surgery in comparison with laparoscopic surgery. A systematic review was performed for the period 2002 to 2014. A total of 1776 patients with rectal cancer underwent minimally invasive robotic treatment in 32 studies. After robotic and laparoscopic approach to oncologic rectal surgery, respectively, mean operating time varied from 192-385 min, and from 158-297 min; mean estimated blood loss was between 33 and 283 mL, and between 127 and 300 mL; mean length of stay varied from 4-10 d; and from 6-15 d. Conversion after robotic rectal surgery varied from 0% to 9.4%, and from 0 to 22% after laparoscopy. There was no difference between robotic (0%-41.3%) and laparoscopic (5.5%-29.3%) surgery regarding morbidity and anastomotic complications (respectively, 0%-13.5%, and 0%-11.1%). Regarding immediate oncologic outcomes, respectively among robotic and laparoscopic cases, positive circumferential margins varied from 0% to 7.5%, and from 0% to 8.8%; the mean number of retrieved lymph nodes was between 10 and 20, and between 11 and 21; and the mean distal resection margin was from 0.8 to 4.7 cm, and from 1.9 to 4.5 cm. Robotic rectal cancer surgery is being undertaken by experienced surgeons. However, the quality of the assembled evidence does not support definite conclusions about most studies variables. Robotic rectal cancer surgery is associated to increased costs and operating time. It also seems to be associated to reduced conversion rates. Other short-term outcomes are comparable to conventional laparoscopy techniques, if not better. Ultimately, pathological data evaluation suggests that oncologic safety may be preserved after robotic total mesorectal excision. However, further studies are required to evaluate oncologic safety and functional results.     

Current status of laparoscopy for the treatment of rectal cancer

Surgery for rectal cancer in complex and entails many challenges. While the laparoscopic approach in general and specific to colon cancer has been long proven to have short term benefits and to be oncologically safe, it is still a debatable topic for rectal cancer. The attempt to benefit rectal cancer patients with the known advantages of the laparoscopic approach while not compromising their oncologic outcome has led to the conduction of many studies during the past decade. Herein we describe our technique for laparoscopic proctectomy and assess the current literature dealing with short term outcomes, immediate oncologic measures (such as lymph node yield and specimen quality) and long term oncologic outcomes of laparoscopic rectal cancer surgery. We also briefly evaluate the evolving issues of robotic assisted rectal cancer surgery and the current innovations and trends in the minimally invasive approach to rectal cancer surgery.     

Meta-analysis of robotic and laparoscopic surgery for treatment of rectal cancer

AIM: To conduct a meta-analysis to determine the relative merits of robotic surgery (RS) and laparoscopic surgery (LS) for rectal cancer. METHODS: A literature search was performed to identify comparative studies reporting perioperative outcomes for RS and LS for rectal cancer. Pooled odds ratios and weighted mean differences (WMDs) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or random effects model. RESULTS: Eight studies matched the selection criteria and r...     

Transanal total mesorectal excision:Towards standardization of technique

AIM: To describe the role of Transanal total mesorectal excision(Ta TME) in minimally invasive rectal cancer surgery, to examine the differences in patient selection and in reported surgical techniques and their impactson postoperative outcomes and to discuss the future of Ta TME. METHODS: MEDLINE(Pub Med), EMBASE, and The Cochrane Library were systematically searched through the 1st of March 2015 using a predefined search strategy. RESULTS: A total of 20 studies with 323 patients were included. Most studies were single-arm prospective studies with fewer than 100 patients. Multiple transanal access platforms were used, and the laparoscopic approach was either multi- or single port. The procedure was initiated transanally or transabdominally. If a simultaneous approach with 2 operating surgeons was chosen, the operative time was significantly reduced. CONCLUSION: Ta TME was also associated with better TME specimens and a longer distal resection margin. Ta TME is thus feasible in expert hands, but the learning curve and safety profile are not well defined. Longterm follow-up regarding anal function and oncological outcomes should be performed in the future.     

机器人与腹腔镜在低位直肠癌经括约肌间切除术的近期疗效对比

目的比较机器人和腹腔镜在低位直肠癌经括约肌间切除术的近期疗效，探讨机器人经括约肌间切除术的安全性及可行性。 方法回顾性分析2015年10月至2017年10月甘肃省人民医院肛肠科确诊为低位直肠癌并行机器人或者腹腔镜经括约肌间切除患者的人口及临床资料。收集并比较两组的手术时间、术中出血量、中转开腹率、首次通气时间、术后住院时间、并发症、肿瘤距远切缘的距离、环周切缘的阳性数、清扫淋巴结数量等。 结果机器人组流质饮食时间、首次通气时间、术后住院时间较腹腔镜组短（均P<0.05）；机器人组术中失血量多于腹腔镜组（P<0.05）；机器人与腹腔镜组在手术时间上差异无统计学意义，两组的术后并发症的差异无统计学意义，机器人组的总费用高于腹腔镜组（P<0.001）。 结论机器人低位直肠癌经括约肌间切除术是安全、可行的。与腹腔镜组手术相比，机器人组术后肠功能恢复快，住院时间短，近期肿瘤学的结果安全可靠，可作为低位直肠癌治疗的有效手段之一。     

Surgical techniques for improving outcomes in pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma is a devastating disease with extremely poor survival despite patients undergoing potentially curative resections and improvements in chemotherapeutic agents. Surgery for operable cancer in the head of the pancreas typically involves an open pancreaticoduodenectomy with a post-operative median survival of 21 months. Newer surgical techniques, however, aim to improve patient outcomes in terms of both their hospital experience and better oncological results. This article focuses on the evidence to date for some of these surgical techniques including laparoscopic and robotic surgery, the no-touch technique, venous and arterial resection, intra-operative radiofrequency ablation and intra-operative irreversible electroporation. With the increased use of these techniques we hope to see better quality of life and survival for these patients.     

Using stents in the management of malignant bowel obstruction: the current situation and future progress

Introduction: The use of self-expanding metal stents (SEMS) has been considered an effective and safe alternative to emergency surgery as bridge to surgery or for palliation in advanced colorectal cancer even though more recent data have raised concerns on both early and long-term outcomes when patients are treated with bridge to surgery indications.

Areas covered: A comprehensive literature review of articles on endoscopic management of malignant bowel obstruction was performed. Indication, technique, outcomes, benefits and risks of these treatments in acute malignant colonic obstruction were reviewed. The clinical effectiveness and safety of SEMS in obstructive colorectal cancer, as bridge to surgery or for palliation compared to surgery, is discussed.

Expert commentary: SEMS placement, when performed in tertiary level center with appropriate expertise in colorectal stenting, may have several advantages over surgery avoiding the potential for surgical morbidity in a typically frail group of patients even though these advantages are to be carefully balanced over the risk of life-threatening, stent-related complications.     

Comparison of Laparoscopic <Emphasis Type="Italic">vs.</Emphasis> Open Access Surgery in Patients with Rectal Cancer: A Prospective Analysis

Purpose Laparoscopic surgery of colon cancer has been accepted to be oncologically adequate compared with open resection. However, the situation in rectal cancer remains unclear, because anatomy and complex surgical procedures might specifically influence the long-term outcome. This study was designed to analyze perioperative and long-term outcome of patients with rectal cancer after laparoscopic vs. open access surgery. Methods A total of 389 patients (1998–2005) were prospectively analyzed; 114 patients had laparoscopic beginning, and 25 patients had conversion and were separately analyzed. Eighty-nine patients remained in the laparoscopic group and 275 had open access surgery. Results Both groups were comparable regarding age, gender, tumor localization, stage, and complications. Differences were found in harvested lymph nodes (laparoscopic 13.5/open access 16.9; P = 0.001) and hospitalization (15.1/18.7 days; P = 0.037). Local recurrence rate and metachronous metastasis were comparable. In patients with deep anterior resection with total mesenteric excision, favorable long-term survival in the laparoscopic group was found (P = 0.035, log-rank). Conclusions Minimally invasive surgery is equivalent in the treatment of rectal cancer and shows advantages of shorter hospitalization and faster recovery. Especially in patients with low rectal cancer, minimally invasive surgery with exact preparation of the total mesenteric excision seems to be favorable compared with open access surgery.     

Favorable short-term and long-term outcome after elective radical rectal cancer resection in patients 75 years of age or older

PURPOSE: Because the elderly population in Western countries is rapidly increasing, as is their life expectancy, studies aimed at determining the impact of major surgery for primary rectal cancer in this group are warranted. The purpose of this study was to compare perioperative morbidity and mortality and long-term disease-specific and overall survival in primary rectal cancer patients, older and younger than 75 years of age, subject to major pelvic surgery. METHODS: From September 1986 to December 1996, the Prospective Colorectal Service Database identified 1,120 consecutive patients who underwent major pelvic surgery for primary rectal cancer. Of these, 157 (15 percent) were 75 years of age or older and comprise the elderly group. From the remaining 963 patients younger than 75 years of age, a representative random sample of 174 was selected and constitutes the younger group. Data were obtained from computerized databases and confirmed via chart review and telephone interviews. RESULTS: Perioperative complications were observed in 53 (34 percent) elderly and 63 (36 percent;P=not significant) younger patients. Perioperative deaths occurred in two (1.3 percent) elderly and one (0.6 percent;P=not significant) younger patient. The median follow-up time was 48 months. Although the overall survival was lower in the elderly group (P=0.02; the 5-year overall survival rates were 51 and 66 percent), the disease-specific survival rate was similar in the two groups (P=0.75; the 5-year disease-specific survival rates were 69 and 71 percent). CONCLUSION: In select individuals 75 years of age or older, major pelvic surgery for primary rectal cancer can be done with perioperative morbidity and mortality rates comparable to those obtained in younger individuals, while achieving excellent disease-specific and overall long-term survival.     

Minimally invasive surgery for rectal cancer

This article discusses the results of systematic reviews and meta-analyses addressing short- and long-term outcomes of laparoscopic rectal surgery for rectal cancer. Randomized clinical trials investigating the advantages of the minimally invasive technique compared to open surgery will be critically reviewed.     

Total mesorectal excision for mid and low rectal cancer: laparoscopic vs robotic surgery

AIM: To compare the short- and long-term outcomes of laparoscopic and robotic surgery for middle and low rectal cancer.METHODS: This is a retrospective study on a prospectively collected database containing 111 patients who underwent minimally invasive rectal resection with total mesorectal excision(TME) with curative intent between January 2008 and December 2014(robot, n = 53; laparoscopy, n = 58). The patients all had a diagnosis of middle and low rectal adenocarcinoma with stage?Ⅰ-Ⅲ disease. The median follow-up period was 37.4 mo. Perioperative results, morbidity a pathological data were evaluated and compared. The 3-year overall survival and disease-free survival rates were calculated and compared.RESULTS: Patients were comparable in terms of preoperative and demographic parameters. The median surgery time was 192 min for laparoscopic TME(L-TME) and 342 min for robotic TME(R-TME)(P 0.001). There were no differences found in the rates of conversion to open surgery and morbidity. Thepatients who underwent laparoscopic surgery stayed in the hospital two days longer than the robotic group patients(8 d for L-TME and 6 d for R-TME, P 0.001). The pathologic evaluation showed a higher number of harvested lymph nodes in the robotic group(18 for R-TME, 11 for L-TME, P 0.001) and a shorter distal resection margin for laparoscopic patients(1.5 cm for L-TME, 2.5 cm for R-TME, P 0.001). The three-year overall survival and disease-free survival rates were similar between groups.CONCLUSION: Both L-TME and R-TME achieved acceptable clinical and oncologic outcomes. The robotic technique showed some advantages in rectal surgery that should be validated by further studies.