Recent advances in minimally invasive colorectal cancer surgery

Laparoscopy has improved surgical treatment of various diseases due to its limited surgical trauma and has developed as an interesting therapeutic alternative for the resection of colorectal cancer. Despite numerous clinical advantages (faster recovery, less pain, fewer wound and systemic complications, faster return to work) the laparoscopic approach to colorectal cancer therapy has also resulted in unusual complications, i.e. ureteral and bladder injury which are rarely observed with open laparotomy. Moreover, pneumothorax, cardiac arrhythmia, impaired venous return, venous thrombosis as well as peripheral nerve injury have been associated with the increased intraabdominal pressure as well as patient's positioning during surgery. Furthermore, undetected small bowel injury caused by the grasping or cauterizing instruments may occur with laparoscopic surgery. In contrast to procedures performed for nonmalignant conditions, the benefits of laparoscopic resection of colorectal cancer must be weighed against the potential for poorer long-term outcomes of cancer patients that still has not been completely ruled out. In laparoscopic colorectal cancer surgery, several important cancer control issues still are being evaluated, i.e. the extent of lymph node dissection, tumor implantation at port sites, adequacy of intraperitoneal staging as well as the distance between tumor site and resection margins. For the time being it can be assumed that there is no significant difference in lymph node harvest between laparoscopic and open colorectal cancer surgery if oncological principles of resection are followed. As far as the issue of port site recurrence is concerned, it appears to be less prevalent than first thought (range 0-2.5%), and the incidence apparently corresponds with wound recurrence rates observed after open procedures. Short-term (3-5 years) survival rates have been published by a number of investigators, and survival rates after laparoscopic surgery appears to compare well with data collected after conventional surgery for colorectal cancer. However, long-term results of prospective randomized trials are not available. The data published so far indicate that the oncological results of laparoscopic surgery compare well with the results of the conventional open approach. Nonetheless, the limited information available from prospective studies leads us to propose that minimally invasive surgery for colorectal cancer surgery should only be performed within prospective trials.     

Advances in minimally invasive surgery in the treatment of colorectal cancer

Colorectal cancer (CRC) is the second leading cause of cancer-related death in the USA. Surgery is the primary treatment for most patients with CRC. Over the past 15 years, minimally invasive techniques for colorectal surgery have been developed. There is growing evidence that these techniques have significant advantages in short-term outcomes (e.g., postoperative pain and length of hospital stay) with similar long-term recurrence and overall survival. While transanal local excision has been shown to be inferior to radical resection for early rectal cancer, transanal endoscopic microsurgery (TEM) is a minimally invasive technique that appears to facilitate local excision in appropriate patients. TEM combined with radiotherapy has demonstrated promising early results and is currently being investigated in clinical trials as a potential alternative to radical surgery. We summarize the current literature on these minimally invasive approaches to CRC.     

Frailty indicators and functional status in older patients after colorectal cancer surgery

ObjectivesThe number of older survivors from colorectal cancer is increasing, but little is known regarding long-term consequences of cancer treatment in this patient group. Physical function is an important outcome for older patients, affecting both autonomy and quality of life. We aimed to investigate physical function in older patients with colorectal cancer before and after surgery, and to examine the role of individual frailty indicators as predictors of functional decline.Material and MethodsWe present 16–28 months follow-up data of older patients after elective surgery for colorectal cancer. During a home-visit, physical function was evaluated by activities of daily living (ADL), instrumental activities of daily living (IADL), the timed up-and-go (TUG) test, and grip strength. Measurements were compared with those obtained preoperatively using the Wilcoxon signed rank test. Frailty indicators were dichotomized and implemented in logistic regression models to explore their associations to a decline in the physical function scores.ResultsEighty-four patients were included and the median age was 82 years. There was a significant decrease in ADL (p = 0.04) and IADL scores (p ≤ 0.001) at follow-up. We found no associations between frailty indicators and the risk of decline in physical functioning.ConclusionIn our population of older patients with surgically treated colorectal cancer, there was a significant decline in ADL- and IADL-scores at follow-up. No change was found in TUG or grip strength, and frailty indicators did not predict decline in physical function.     

Surgery by a minimally invasive approach is associated with improved textbook outcomes in oesophageal and gastric cancer

IntroductionTextbook outcome (TBO) is a composite measure of a number of peri-operative and clinical outcomes in oesophagogastric malignancy. It has previously been shown that TBOs are associated with improved overall survival in both oesophageal and gastric cancer. The influence of a minimally invasive approach (MIA) on TBO is not well defined. The purpose of this study is to validate TBO in our population, examine the influence of a MIA on achieving a TBO, and the impact of TBO on long-term survival.Methods269 patients undergoing oesophagectomy and 258 patients undergoing subtotal or total gastrectomy were included in this study. Demographic, clinical and pathological differences between patients with and without a TBO were compared using univariable and multivariable analysis. Overall survival for those with and without a TBO was examined. The influence of MIA on overall survival and TBO was determined using Cox proportional hazard models.ResultsPatients undergoing oesophagectomy and gastrectomy were significantly more likely to achieve a TBO when MIA was used (p = 0.01 and 0.001 respectively). When MIA is included as an outcome measure patients achieving a TBO show improved overall survival in both oesophageal and gastric cancer. MIA, clear resection margins and no unplanned admission to critical care are the strongest predictors of overall survival from the putative bundle of TBO parameters.ConclusionMinimally invasive surgery is associated with improved TBO. Completion of a minimally invasive approach should be considered for inclusion as a textbook parameter.     

Plasma monocyte chemotactic protein-1 remains elevated after minimally invasive colorectal cancer resection

AIM: To investigate plasma Monocyte Chemotactic Protein-1 levels preoperatively in colorectal cancer (CRC) and benign patients and postoperatively after CRC resection.METHODS: A plasma bank was screened for minimally invasive colorectal cancer resection (MICR) for CRC and benign disease (BEN) patients for whom preoperative, early postoperative, and 1 or more late postoperative samples (postoperative day 7-27) were available. Monocyte chemotactic protein-1 (MCP-1) levels (pg/mL) were determined via enzyme linked immuno-absorbent assay.RESULTS: One hundred and two CRC and 86 BEN patients were studied. The CRC patient’s median preoperative MCP-1 level (283.1, CI: 256.0, 294.3) was higher than the BEN group level (227.5, CI: 200.2, 245.2; P = 0.0004). Vs CRC preoperative levels, elevated MCP-1 plasma levels were found on postoperative day 1 (446.3, CI: 418.0, 520.1), postoperative day 3 (342.7, CI: 320.4, 377.4), postoperative day 7-13 (326.5, CI: 299.4, 354.1), postoperative day 14-20 (361.6, CI: 287.8, 407.9), and postoperative day 21-27 (318.1, CI: 287.2, 371.6; P < 0.001 for all).CONCLUSION: Preoperative MCP-1 levels were higher in CRC patients (vs BEN). After MICR for CRC, MCP-1 levels were elevated for 1 mo and may promote angiogenesis, cancer recurrence and metastasis.     

Surgical and oncologic outcomes of minimally invasive surgery for stage I high-grade endometrial cancer

ObjectiveTo evaluate the prevalence and outcomes of minimally invasive surgery for stage I high grade endometrial cancer. We hypothesized that route of surgery is not associated with survival.MaterialsPatients diagnosed between 2010 and 2014, with stage I grade 3 endometrioid, serous, clear cell and carcinosarcoma endometrial carcinoma, who underwent hysterectomy with lymphadenectomy were drawn from the National Cancer Database. Patients converted to open surgery were excluded. Overall survival was assessed with Kaplan-Meier curves and compared with the log-rank test. A Cox model was constructed to control for confounders.ResultsA total of 12852 patients were identified. The rate of minimally invasive surgery was 62.2%. An increase in the use between 2010 and 2014 was noted (p < 0.001). Open surgery was associated with longer hospital stay (median 3 vs 1 day, p < 0.001), higher 30-day unplanned re-admission rate (4.5% vs 2.4%, p < 0.001) and 30-day mortality (0.6% vs 0.3%, p = 0.008). There was no difference in overall survival between patients who had open or minimally invasive surgery, p = 0.22; 3-yr overall survival rates were 83.7% and 84.4% respectively. After controlling for patient age, tumor histology, substage, type of insurance, type of reporting facility, receipt of radiation therapy and chemotherapy, extent of lymphadenectomy, the presence of comorbidities and personal history of another tumor, minimally invasive surgery was not associated with a worse survival (hazard ratio: 1.06, 95% confidence interval: 0.97, 1.15).ConclusionsMinimally invasive surgery for patients with stage I high grade endometrial cancer, was associated with superior short-term outcomes with no difference in overall survival noted.     

Indications for minimally invasive surgery for ovarian cancer

Epithelial ovarian cancer is often diagnosed in advanced stages and typically managed with surgical debulking followed by chemotherapy. For patients with presumed early-stage ovarian cancer, comprehensive surgical staging is essential for management, because 31% are upstaged. Over the past 15 years, minimally invasive techniques have improved and are increasingly being used to treat patients with ovarian cancer. Currently, only retrospective data support laparoscopic staging of patients with a suspicious adnexal mass or those surgically diagnosed with presumed early-stage ovarian cancer. Laparoscopy is also used in patients undergoing second-look procedures and to help evaluate whether patients should undergo optimal tumor debulking procedures or be initially managed with neoadjuvant chemotherapy. Randomized clinical studies are needed to further support the role of minimally invasive surgery in the treatment of ovarian cancer.     

History of minimally invasive surgery for gastric cancer in Korea

Laparoscopic gastrectomy was begun in 1995 in Korea. But, there was 4 years gap to reactivate in 1999. High incidence of gastric cancer and increasing proportion of early cancer through national screening program along with huge effort and enthusiasm of laparoscopic gastric surgeon, and active academic exchange with Japanese doctors contributed development of laparoscopic gastrectomy in Korea. Study group activity of Korean Laparoscopic Gastrointestinal Surgery Study (KLASS) group and Collaborative Action for Gastric Cancer (COACT) group were paramount to evoke large scale multicenter clinical study and various well performed clinical studies. This review encompasses mainly international publications about this area so far in Korea.     

Research progress of minimally invasive surgery for gastric cancer

Since the first laparoscopic radical surgery for early gastric cancer 30 years ago, there has been a gradual shift from“open” to “minimally invasive” surgery for gastric cancer. This transition is due to advancements in refined anatomy, enlarged field of view, faster recovery, and comparable oncological outcomes. Several high-quality clinical studies have demonstrated the safety and effectiveness of laparoscopy in the treatment of both early and locally advanced gastric cancer. The role of perio...     

加速康复外科护理措施在直肠癌微创手术围术期中的应用效果分析

目的 探讨加速康复外科(enhanced recorvery after surgery,ERAS)护理措施在直肠癌微创手术中的应用效果.方法 回顾性分析2015年3月至2016年3月在中山大学附属第一医院行直肠癌微创手术的157例患者临床资料,根据患者围术期护理措施的不同,分为ERAS组(87例)和传统组(70例).传统组患者接受传统围术期护理,ERAS组患者接受围术期的加速康复外科护理措施.比较两组患者术后康复情况和术后并发症的发生情况.结果 ERAS组在术后胃肠功能恢复时间、进食流质时间、进食半流时间及术后住院时间均明显短于传统组(均P<0.05).两组总体并发症发生率无明显差异[10.3%(9/87)vs 18.6%(13/70),P=0.168].ERAS组在围术期的护理满意度高于传统组[(93±5.6)分vs.(86±6.5)分,t=7.245,P<0.001].结论 围术期实施加速康复外科护理措施能促进直肠癌微创手术患者的术后康复.     

Follow-up after colorectal cancer surgery

Although most institutions offer some kind of follow-up to patients operated on for colorectal cancer, its value with respect to prolonged survival has been challenged. However, improved results of liver surgery and chemotherapy make it reasonable to assume that a follow-up programme leading to detection of more asymptomatic recurrences would result in improved survival. Liver metastases and extramural local recurrences are the most common secondary lesions and 5-year survival rates of about 30% are reported after radical resection. From these observations a survival benefit could be expected when follow-up is directed to these forms of recurrence. From six randomized studies, six comparative cohort studies and four meta-analyses it can be concluded that an intensive follow-up programme results in more recurrences being resected for cure and about a 10% higher 5-year survival rate compared with less intensive or no follow-up. However, the differences in the follow-up protocols make it difficult to conclude how a follow-up programme should be designed. Liver imaging and carcinoembryonic antigen assay should probably be included, while the yield of frequent colonoscopies is small. A follow-up regimen based on these principles is suggested. Future studies should focus on which tests are the most cost-effective for follow-up after colorectal cancer resection.     

Long-term oncological safety of minimally invasive surgery in high-risk endometrial cancer

BackgroundSeveral studies showed that women with low-risk endometrial cancers staged by minimally invasive surgery (MIS) experience fewer postoperative complications compared to those staged by laparotomy with similar disease-free survival (DFS) and overall survival (OS). However, high-risk patients were poorly represented. In this study, we compared DFS and OS in high-risk endometrial cancer patients who underwent surgical staging via MIS versus laparotomy.MethodsUsing a multicentric database, we compared DFS and OS between 114 patients with high-risk histology who underwent surgical staging via MIS and 114 patients who underwent laparotomy. Patients were matched for age, tumour type, FIGO stage and management criteria.ResultsAmong the 114 patients who underwent MIS, 93 underwent laparoscopy and 21 robotic surgery. Groups were comparable for stage, body mass index, histology and adjuvant therapies. However, patients in the MIS group underwent paraaortic lymphadenectomy less frequently (13% versus 29%; p = 0.01), had less lymph nodes removed (19.0 versus 28.6; p < 0.01) and had lower mean tumour size (30 versus 40 mm; p < 0.01). With a median follow-up time of 49 months, DFS and OS were not significantly different between the surgical cohorts. In multivariable analysis, both higher stage (hazard ratio [HR] = 2.2) and histology (HR = 4.9) were associated with DFS in contrast to surgical procedure (HR = 0.9).ConclusionsBeyond the benefit of MIS on immediate surgical outcome, our results show that fear for a poor long-term outcome should not be the reason to refrain from MIS in patients with high-risk endometrial cancer.     

直肠癌患者微创保肛手术效果研究

目的：探讨直肠癌患者微创保肛手术效果。方法分别采取微创保肛手术和传统手术患者,将100例直肠癌患者随机分为微创保肛组和对照组各50例,对比两组患者的手术效果和手术并发症等情况。结果与对照组相比,微创保肛组患者术中出血量较少[（63.5±9.6）ml vs（89.2±12.7）ml]、手术切口较短[（4.1±0.4）cm vs（6.2±0.8）cm]、手术持续时间较短[（174.5±30.1）min vs（208.4±14.8）min]、住院时间较短[（7.8±0.9）天 vs（9.5±1.2天）]、切口拆线时间较早[（6.6±0.5）天 vs（8.2±1.1）天]、开始排气时间较早[（4.1±0.4）天vs （5.2±0.6）天]、导尿管拔除时间明显较短[（4.0±0.5）天vs（5.4±0.8）天],两组差异均具有统计学意义（均P＜0.001）。微创保肛组患者与对照组患者相比,其总的并发症发生率较低（12%vs 30%,P＝0.027）,大便次数增多的并发症发生率较低（6%vs 20%,P＝0.037）。结论微创保肛术能够提高患者的手术效果,降低术后并发症发生率,值得在临床上广泛应用。     

Functional intronic ERCC1 polymorphism from regulomeDB can predict survival in lung cancer after surgery

We searched for potential regulatory single nucleotide polymorphisms (SNPs) in excision repair cross-complementing group 1 (ERCC1) using RegulomeDB, a database integrating information from the Encyclopedia of DNA Elements (ENCODE) project, and investigated their association with survival after surgery in non-small cell lung cancer (NSCLC). Among 364 SNPs found within ERCC1 region using RegulomeDB, four top priority SNPs (rs2298881C>A, rs1049739A>G, rs10415949A>G and rs6509214G>T) were selected for this study. The four SNPs were investigated in 316 patients. A replication study was performed (n = 579). Of the four SNPs analyzed in the discovery set, rs2298881C>A and rs6509214G>T were significantly associated with survival outcomes. The association was consistently observed only for rs2298881C>A in the validation cohort. In combined analysis, rs2298881C>A was significantly associated with worse overall survival and disease-free survival (P = 0.0002 and 0.02, respectively). A decreased reporter gene expression for rs2298881 A allele was observed compared with C allele by luciferase assay (P = 0.02). ERCC1 rs2298881C>A, an intronic SNP, is the first genetic polymorphism with functional evidence of regulating its expression, and the SNP is associated with prognosis of NSCLC. Our result supports the role of RegulomeDB as a comprehensive source of prioritized candidate SNPs for genetic association studies.     

Functional recovery in senior adults undergoing surgery for colorectal cancer: Assessment tools and strategies to preserve functional status

Colorectal cancer is a widely-recognized aging-associated disease. Recent advances in the care of senior colorectal cancer patients has led to similar cancer-related life expectancy for older patients when compared to their younger counterparts.Recent data suggests that onco-geriatric patients place as much value on maintenance of functional independence and quality of life after treatment as they do on the potential improvements in survival that a treatment might offer. As a result, there has been significant interest in the geriatric literature surrounding the concept of “functional recovery,” a multidimensional outcome metric that takes into account several domains, including physical, physiologic, psychological, social, and economic wellbeing.This review introduces the concept of functional recovery and highlights a number of predictors of post-treatment functional trajectory, including several office-based tools that clinicians can use to help guide informed decision making surrounding potential treatment options. This review also highlights a number of validated metrics that can be used to assess a patient's progress in functional recovery after surgery.While the timeline of each individual's functional recovery may vary, most data suggests that if patients are to return to their pre-operative functional status, this could occur up to 6 months post-surgery. For those patients identified to be at risk for post-operative functional decline this review also delineates strategies for prehabilitation and rehabilitation that may improve functional outcomes.     

Plasma chitinase 3-like 1 is persistently elevated during first month after minimally invasive colorectal cancer resection

AIM: To assess blood chitinase 3-like 1 (CHi3L1) levels for 2 mo after minimally invasive colorectal resection (MICR) for colorectal cancer (CRC). METHODS: CRC patients in an Institutional Review Board approved data/plasma bank who underwent elective MICR for whom preoperative (PreOp), early postoperative (PostOp), and 1 or more late PostOp samples [postoperative day (POD) 7-27] available were included. Plasma CHi3L1 levels (ng/mL) were determined in duplicate by enzyme linked immunosorbent assay. RESULTS: PreOp and PostOp plasma sample were available for 80 MICR cancer patients for the study. The median PreOp CHi3L1 level was 56.8 CI: 41.9-78.6 ng/mL (n = 80). Significantly elevated (P < 0.001) median plasma levels (ng/mL) over PreOp levels were detected on POD1 (667.7 CI: 495.7, 771.7; n = 79), POD 3 (132.6 CI: 95.5, 173.7; n = 76), POD7-13 (96.4 CI: 67.7, 136.9; n = 62), POD14-20 (101.4 CI: 80.7, 287.4; n = 22), and POD 21-27 (98.1 CI: 66.8, 137.4; n = 20, P = 0.001). No significant difference in plasma levels were noted on POD27-41. CONCLUSION: Plasma CHi3L1 levels were significantly elevated for one month after MICR. Persistently elevated plasma CHi3L1 may support the growth of residual tumor and metastasis.