Effects of laparoscopic surgery on the patterns of death in elderly colorectal cancer patients: competing risk analysis compared with open surgery

Purpose

The effects of laparoscopic colorectal surgery (LAC) on the long-term outcomes of elderly patients remain unclear. This study aimed to assess the short- and long-term outcomes of LAC in elderly colorectal cancer patients and to quantify the effects of LAC on the patient death patterns.

Methods

The clinicopathological data of elderly colorectal cancer patients aged ≥80 years old who were treated between 2006 and 2014 were extracted. The relationships between the clinicopathological factors and overall survival (OS) were assessed using the Cox proportional hazards model and Kaplan–Meier analyses. The risk factors for the types of death were estimated using a competing risk analysis.

Results

A total of 107 patients were included. Fifty-two patients underwent LAC, whereas 55 underwent open surgery (OC). There were no significant differences in the American Society of Anesthesiologists grade or comorbidity rate between the groups. The postoperative complication rate was significantly lower with LAC than OC (p < 0.001). After adjustment for covariates, laparoscopic surgery was not a significant risk factor for any of the types of death.

Conclusions

LAC is an effective and safe technique for elderly patients with colorectal cancer. Furthermore, there was no significant association between the surgical procedure and the pattern of death.

     

Risk of anastomotic leak after laparoscopic versus open colectomy

Background

Anastomotic leak following colorectal surgery is associated with significant morbidity and mortality. With the widespread adoption of laparoscopy, data from initial clinical trials evaluating the efficacy of laparoscopic when compared to open surgery may not currently be generalizable. We assess the risk of anastomotic leak after laparoscopic versus open colorectal resection using a nationwide database with standardized definitions.

Methods

The 2012–2013 ACS-NSQIP targeted colectomy data were queried for all elective colorectal resections. Characteristics were compared for those patients undergoing laparoscopic versus open operations. Univariable and multivariable analyses, followed by a propensity score-matched analysis, were performed to assess the impact of laparoscopy on the development of an anastomotic leak.

Results

Of 23,568 patients, 3.4 % developed an anastomotic leak. Laparoscopic surgery was associated with a leak rate of 2.8 % (n = 425) and open surgery, 4.5 % (n = 378, p < 0.0001). Patients who developed a leak were more likely to die within 30 days of surgery (5.7 vs. 0.6 %, p < 0.0001). Patients who underwent laparoscopic surgery compared to open were younger (61 vs. 63 years, p = 0, p = 0.045) and with fewer comorbidities. On univariable analysis laparoscopic surgery was associated with reduced odds of developing an anastomotic leak (OR 0.60, p < 0.0001), and this remained after adjusting for all significant preoperative and disease-related confounders (OR 0.69, 95 % CI 0.58–0.82). A propensity score-matched analysis confirmed benefit of laparoscopic surgery over open surgery for anastomotic leak.

Conclusion

Laparoscopic colectomy is safe and associated with reduced odds of developing an anastomotic leak following colectomy when controlling for patient-, disease- and procedure-related factors.

     

Laparoscopic-assisted abdominoperineal resection for low rectal cancer provides a shorter length of hospital stay while not affecting the recurrence or survival: a propensity score-matched analysis

Purpose

To compare the short- and intermediate-term outcomes of open versus laparoscopic abdominoperineal resection (APR) for low rectal cancer.

Methods

Elective open and laparoscopic APRs were identified in a prospective database and were 1:1 propensity score-matched for age, ASA grade, tumour stage and type of neoadjuvant therapy. The short- and intermediate-term outcomes were compared.

Results

From January 2003 until June 2013, a total of 135 APRs (87 open, 48 laparoscopic) were identified and matched (n = 96, standardised mean difference of covariates <0.25). The thirty-day mortality, R0 rate, lymph nodes harvested and reoperations were similar. The length of the hospital stay was shorter in the laparoscopic group [10 versus 14 days, p = 0.004 (Mann–Whitney U test), Bonferroni-corrected significance level = 0.0083]. The median follow-up was 4.6 (IQR: 2.0–6.0) years. The overall and recurrence-free 3-year survival rate estimates (Kaplan–Meier method; 95 % CI in brackets) were 71 % (59–86) and 57 % (44–73) in the open group versus 78 % (66–92) and 72 % (60–87) in the laparoscopic group, respectively [p = 0.167 and p = 0.186 (log-rank test), respectively]. The 3-year cumulative incidence of recurrence was 27 % (15–40) in the open group and 16 % (8–29) in the laparoscopic group [p = 0.359 (Gray’s test)].

Conclusions

Compared to open APR, laparoscopic APR provided a shorter length of hospital stay while showing no intermediate-term differences in the survival or cumulative incidence of recurrence.

     

Should Surgical Treatment Be Provided to Patients with Colorectal Cancer Who Are Aged 90 Years or Older?

Purpose

The number of patients aged ≥?90 years is increasing worldwide; however, the treatment guidelines for colorectal cancer in elderly patients remain unclear. This study aimed to investigate the clinical outcomes of patients with primary colorectal cancer aged ≥?90 years.

Methods

We retrospectively reviewed the medical records of 100 patients (aged ≥?90 years) with primary colorectal adenocarcinoma. Their demographic and clinical characteristics and surgical outcomes were assessed.

Results

The patients who underwent tumor resections (n?=?71) showed longer overall and cancer-specific survival than those who underwent non-operative treatments (n?=?29) (median overall survival time: 23.92 months vs. 2.99 months, P?<?0.0001). Age, body mass index, performance status, advanced cancer stage (stages 3 and 4), and treatment strategy were identified as risk factors, prognostic factors, and predictors of overall survival. No significant differences in the postoperative morbidity rate, in-hospital mortality rate, and survival time were found between the elective laparoscopic (n?=?27) and elective open (n?=?37) surgery subgroups. However, the in-hospital mortality rate was 6.25% (4/64) in the patients who underwent elective open surgeries and 42.9% (3/7) in those who underwent emergent open surgeries (p?=?0.0179).

Conclusions

In clinical practice, surgical treatment should not be denied to patients with primary colorectal cancer aged ≥?90 years. However, the high complication and mortality rates for emergency surgeries act as a deterrent. Further studies to eliminate the bias between operative and non-operative groups may be needed to validate our results.

     

A national evaluation of clinical and economic outcomes in open versus laparoscopic colorectal surgery

Background

Surgical value is based on optimizing clinical and financial outcomes. The clinical benefits of laparoscopic surgery are well established; however, many patients are still not offered a laparoscopic procedure. Our objective was to compare the modern clinical and financial outcomes of laparoscopic and open colorectal surgery.

Methods

The Premier Perspective database identified patients undergoing elective colorectal resections from January 1, 2013 to December 31, 2013. Cases were stratified by operative approach into laparoscopic and open cohorts. Groups were controlled on all demographics, diagnosis, procedural, hospital characteristics, surgeon volume, and surgeon specialty and then compared for clinical and financial outcomes. The main outcome measures were length of stay (LOS), complications, readmission rates, and cost by surgical approach.

Results

A total of 6343 patients were matched and analyzed in each cohort. The most common diagnosis was diverticulitis (p = 0.0835) and the most common procedure a sigmoidectomy (p = 0.0962). The LOS was significantly shorter in laparoscopic compared to open (mean 5.78 vs. 7.80 days, p < 0.0001). The laparoscopic group had significantly lower readmission (5.82 vs. 7.68 %, p < 0.0001), complication (32.60 vs. 42.28 %, p < 0.0001), and mortality rates (0.52 vs. 1.28 %, p < 0.0001). The total cost was significantly lower in laparoscopic than in open (mean $17,269 vs. $20,552, p < 0.0001). By category, laparoscopy was significantly more cost-effective for pharmacy (p < 0.0001), room and board (p < 0.0001), recovery room (p = 0.0058), ICU (p < 0.0001), and laboratory and imaging services (both p < 0.0001). Surgical supplies (p < 0.0001), surgery (p < 0.0001), and anesthesia (p = 0.0053) were higher for the laparoscopic group.

Conclusions

Laparoscopy is more cost-effective and produces better patient outcomes than open colorectal surgery. Minimally invasive colorectal surgery is now the standard that should be offered to patients, providing value to both patient and provider.

     

Comparison of Open and Laparoscopic Gastrectomy in Elderly Patients

Purpose

The purpose of this study was to estimate surgical outcomes of elderly patients older than 80 years who received laparoscopic or open gastrectomy for gastric cancer and to identify risk factors for postoperative complications.

Methods

Two hundred forty-two elderly patients older than 80 years underwent gastric cancer surgery between January 2010 and December 2016 in three tertiary hospitals. They were divided into two groups: laparoscopic gastrectomy (N?=?59) and open gastrectomy (N?=?183). The surgical outcomes and risk factors for postoperative complication were evaluated.

Results

Among the elderly patients, 24.4% showed an ASA score of 3 or 4, and 20.7% showed a Charlson comorbidity index (CCI) score of 2 or more. 46.3% of patients had hypertension and 15.3% had diabetes. The laparoscopic gastrectomy group showed similar operation time, less intraoperative blood loss, and faster postoperative gastrointestinal recovery compared to the open gastrectomy group. The incidence of postoperative complications was 30.1% in the open group and 22.0% in the laparoscopic group (P?=?0.249). One patient died for pulmonary complication in the open gastrectomy group. In multivariate analysis, older age, male, higher CCI score, and open approach were found to be correlated with increased risk for postoperative complications.

Conclusions

Although elderly patients over 80 years had a high incidence of comorbidity, gastric cancer surgery can be safely performed. The laparoscopic approach might be feasible for open surgery in improving quality of life in these patients, given a faster postoperative intestinal recovery period, with similar risk for postoperative complications.

     

Identische onkologische Ergebnisse bei niedrigerer perioperativer Morbidität nach laparoskopischer Leberresektion

Background

Laparoscopic liver resection belongs to the standard repertoire in hepatobiliary surgery. The advantages and disadvantages are still the subject of controversial discussion.

Objective

The aim of the study was to compare the perioperative and long-term outcomes of laparoscopic and open liver resections.

Material and methods

All patients who underwent liver resection in the Department of Surgery at the certified liver center of the  municipal hospital Karlsruhe were analyzed. From a total of 268 hepatic resections 65 laparoscopic liver resections were identified and matched 1:1 with 65 open resections, based primarily on the extent of the resection and secondarily on diagnosis, age and gender of the patients. The demographic data, comorbidities, perioperative and long-term outcomes were compared.

Results

Both groups had comparable demographic parameters and comorbidities. Operation time, duration of intensive care stay and percentage of negative resection margins were comparable in both groups. The 30-day mortality was 0% and 90-day mortality 1.5% in both groups. The laparoscopic group showed lower intraoperative and postoperative transfusion rates (p?<?0.001), shorter hospital stay (p?<?0.001) and lower overall morbidity (p?<?0.001). The 1-, 3- and 5-year overall and tumor-free survival of patients with colorectal liver metastases was comparable (p?=?0.984; p?=?0.947). The same applied for patients with hepatocellular carcinomas (p?=?0.803; p?=?0.935).

Conclusion

Laparoscopic liver resections have identical long-term outcomes with lower overall morbidity. Laparoscopic liver resections offer advantages regarding transfusion rates, length of hospital stay and postoperative complications.

     

Safety of laparoscopic surgery for colorectal cancer in patients over 80 years old: a propensity score matching study

Purposes

To establish the safety of laparoscopic-assisted colorectal resection for colorectal cancer in elderly patients aged?≥80 years.

Methods

Data were obtained from a chart review of patients who underwent colorectal cancer resection between 2009 and 2014 in Kochi Medical School. The effect of patient age on the extent of lymph node dissection and operative safety was assessed by comparing the short-term results of elderly patients with those of younger patients after propensity score matching.

Results

Of a total of 506 patients with colorectal cancer, 398 underwent laparoscopic surgery and 23% of these patients were aged?≥80 years old. The elderly patients tended to have poorer general condition and larger tumors, although no significant differences were found in tumor invasion, lymph node metastasis, or synchronous distant metastasis between the groups. After adjustment for preoperative factors, we noted that the elderly patients tended to undergo less aggressive surgical resection (P?=?0.01). Further analysis after including surgical factors for propensity score matching revealed a similar rate of complications in the two groups (24 vs. 25%, respectively; P?=?0.85), and similar postoperative death rates and length of postoperative hospital stay.

Conclusion

The findings of the present study demonstrate that laparoscopic surgery for colorectal cancer should not be avoided based on simply the age of the patient.

     

Robotic-Assisted Surgery for Upper Tract Urothelial Carcinoma: A Comparative Survival Analysis

Background

We performed a comparative survival analysis of patients undergoing robotic-assisted versus laparoscopic or open surgery for upper tract urothelial carcinoma (UTUC).

Materials and Methods

Patients diagnosed with non-metastatic UTUC undergoing removal of the kidney and/or ureter were identified using Medicare-linked Surveillance, Epidemiology, and End Results Program data (2004–2013). Patients aged 65–85 years were categorized based on surgical approach (open, laparoscopic, or robotic-assisted). Kaplan–Meier methods were used to determine survival (overall and cancer-specific) and intravesical recurrence rates, the former using a propensity score-weighted model. Independent predictors of survival were determined using multivariable Cox proportional hazards regression analysis.

Results

We identified a total of 3801 patients meeting the final inclusion criteria: open (n?=?1862), laparoscopic (n?=?1624), and robotic (n?=?315). Robotic surgery was associated with the shortest length of hospital stay (p?<?0.001) but highest in-hospital charges (p?<?0.001), with no difference in readmission rates (p?=?0.964). No difference was found in overall or cancer-specific survival in the robotic cohort when compared with open or laparoscopic surgery. In addition, no difference in the rate of intravesical recurrence was noted in robotic-assisted laparoscopy compared with the other groups. The sole predictor of improved survival was extent of lymphadenectomy, which was highest in the robotic cohort.

Conclusions

Using a large, population-based cancer database, there was no survival difference when a robotic-assisted approach was utilized in patients undergoing surgery for UTUC. These findings are important with the increased use of robotic surgery in the management of UTUC.

     

Comparison of perioperative and oncologic outcomes between open and laparoscopic liver resection for intrahepatic cholangiocarcinoma

Background

Laparoscopic liver resection (LLR) has become an essential method for treating malignant liver tumors. Although the perioperative and oncologic outcomes of LLR in patients with hepatocellular carcinoma have been reported, there are few reports of LLR for intrahepatic cholangiocarcinoma (IHCC).

Methods

Patients who underwent liver resection for T1 or T2 IHCC between March 2010 and March 2015 in Gyeongsang National University Hospital were enrolled. They were divided into open (n = 23) and laparoscopic (n = 14) approaches, and the perioperative and oncologic outcomes were compared.

Results

The Pringle maneuver was less frequently used (p = 0.015) and estimated blood loss was lesser (p = 0.006) in the laparoscopic group. There were no significant differences in complication rate (p = 1.000), hospital stay (p = 0.371), tumor size (p = 0.159), lymph node metastasis (p = 0.127), and the number of retrieved lymph nodes (p = 0.553). The patients were followed up for a median of 21 months. The 3-year overall survival (OS) and recurrence-free survival (RFS) rates were 74.7 and 55.2 %, respectively. No differences were observed in the 3-year OS (75.7 vs 84.6 %, p = 0.672) and RFS (56.7 vs 76.9 %, p = 0.456) rates between the open and laparoscopic groups, even after the groups were divided into patients that received liver resection with or without lymph node dissection.

Conclusion

LLR for IHCC is a treatment modality that should be considered as an option alongside open liver resection in selected patients.

     

Comparison of open,laparoscopic, and robotic approaches for total abdominal colectomy

Background

The utilization of minimally invasive surgery is increasing in colorectal surgery. We sought to compare the outcomes of patients who underwent elective open, laparoscopic, and robotic total abdominal colectomy.

Methods

The NIS database was used to examine the clinical data of patients who underwent an elective total colectomy procedure during 2009–2012. Multivariate regression analysis was performed to compare the three surgical approaches.

Results

We sampled a total of 26,721 patients who underwent elective total colectomy. Of these, 16,780 (62.8 %) had an open operation, while 9934 (37.2 %) had a minimally invasive approach (9614 laparoscopic surgery, and 326 robotic surgery). The most common indication for an operation was ulcerative colitis (31 %). Patients who underwent open surgery had significantly higher mortality and morbidity compared to laparoscopic (AOR 2.48, 1.30, P < 0.01) and robotic approaches (AOR 1.04, 1.30, P < 0.01 and P = 0.04, respectively). There was no significant difference in mortality and morbidity between the laparoscopic and robotic approaches (AOR 0.96, 1.03, P = 0.10, P = 0.78). However, conversion rate of laparoscopic surgery to open was significantly higher than that of robotic approach (13.3 vs. 1.5 %, P < 0.01). Patients who underwent laparoscopic surgery had significantly lower total hospital charges compared to patients who underwent open surgery (mean difference = $21,489, P < 0.01). Also, total hospital charges for a robotic approach were significantly higher than for a laparoscopic approach (mean difference = $15,595, P < 0.01).

Conclusion

Minimally invasive approaches to total colectomy are safe, with the advantage of lower mortality and morbidity compared to an open approach. Although there was no significant difference in the morbidity between minimally invasive approaches, robotic surgery had a significantly lower conversion rate compared to laparoscopic approach. Total hospital charges are significantly higher in robotic surgery compared to laparoscopic approach.

     

Safety and feasibility of laparoscopic gastrectomy for gastric cancer patients with a history of abdominal surgery

Purpose

To assess the safety and feasibility of laparoscopic gastrectomy (LG) for gastric cancer patients with a history of abdominal surgery (HAS).

Methods

This retrospective study analyzed data collected from gastric cancer patients with HAS, who underwent LG between 2004 and 2015. We compared the clinicopathological features that correlated with conversion to open surgery and the development of severe postoperative complications (Clavien–Dindo classification of grade III or higher).

Results

Of the 41 patients identified, 6 (14.6%) required conversion to open surgery. The incidence of conversion to open surgery was associated with a history of lower gastrointestinal tract surgery (p?=?0.009), attempted laparoscopic total gastrectomy (p?=?0.002), and excessive blood loss (p?<?0.001). Severe postoperative complications developed in six patients (14.6%). Although the development of complications was associated with high postoperative serum C-reactive protein, the type of past abdominal surgery was not significantly correlated with severe complications.

Conclusions

LG was feasible for gastric cancer patients with a HAS, but for those with a history of lower abdominal surgery or those who require total gastrectomy, surgeons should carefully consider the indications for LG.

     

Comparative benefits of laparoscopic surgery for colorectal cancer in octogenarians: a case-matched comparison of short- and long-term outcomes with middle-aged patients

Purpose

The aim of this study was to compare the postoperative short- and long-term outcomes after laparoscopic colorectal surgery (LCS) between octogenarians and healthy middle-aged patients.

Methods

Between January 1997 and July 2009, 655 consecutive laparoscopic surgeries for colorectal cancer patients were operated by 1 colorectal surgeon. Ninety-three patients were octogenarians (≥80 years), and 133 patients were case-matched middle-aged (60–69 years) patients. We analyzed the mean operative time, blood loss, type of surgery for rectal cancer, length of hospital stay, mortality, and morbidity. The overall survival curve was constructed using the Kaplan–Meier method.

Results

The American Society of Anesthesiologists classification was significantly higher in the octogenarians than in the middle-aged controls. However, there were no significant differences between the two groups in terms of the incidence of morbidities (11.7 vs. 9.2 %) and length of hospital stay (12.1 vs. 10.9 days). The number of lymph nodes harvested was significantly fewer (p < 0.05) and the operative time significantly shorter (p < 0.05) in the octogenarians than in the middle-aged controls. At a mean follow-up of 38.2 months, the overall 5-year survival rate was 64.8 % in the octogenarians and 92.4 % in the middle-aged group, whereas the cancer-specific 5-year survival rate was 91 % in the octogenarians and 95.7 % in the middle-aged group.

Conclusions

We suggest that advanced age should not be a contraindication for LCS, even for complex procedures, such as laparoscopic rectal resection.

     

Impact of laparoscopy on adherence to an enhanced recovery pathway and readiness for discharge in elective colorectal surgery: Results from the PeriOperative Italian Society registry

Introduction

Previous studies reported that laparoscopic surgery (LPS) improved postoperative outcomes in patients undergoing colorectal surgery within an enhanced recovery program (ERP). However, the effect of minimally invasive surgery on each ERP item has not been clarified, yet. The aim of this study is to assess the impact of LPS on adherence to ERP items and recovery as measured by time to readiness for discharge (TRD).

Methods

Prospectively collected data entered in an electronic Italian registry specifically designed for ERP were reviewed. Patients undergoing elective colorectal surgery were divided into three groups: successful laparoscopy, conversion to open surgery, primary open surgery. Adherence to 19 ERP elements and postoperative outcomes were compared among groups. Multivariate regression analysis was used to identify whether LPS had an independent role to improve ERP adherence and postoperative outcomes.

Results

714 patients (successful LPS 531, converted 42, open 141) underwent elective colorectal surgery within an ERP. Epidural analgesia was used in the 75.1% of open group patients versus 49.9% of LPS group patients (p?=?0.012). After surgery, oral feeding recovery, i.v. fluids suspension, removal of both urinary and epidural catheters occurred earlier in the LPS group both in the overall series and in uneventful patients only. Mean TRD and length of hospital stay were significantly shorter in the LPS group (p?<?0.001 for both). Overall morbidity rate was 18.7% in the LPS group versus 32.6% in the open group (p?=?0.001). At multivariate analysis, LPS was significantly associated to an increased adherence to postoperative ERP items, a shorter TRD, and a reduced overall morbidity, whereas rectal surgery and new stoma formation impaired postoperative recovery.

Conclusions

The present study showed that a successful laparoscopic procedure had an independent role to increase the adherence to postoperative ERP and to improve short-term postoperative outcome.

     

Feasibility of the liver-first approach for patients with initially unresectable and not optimally resectable synchronous colorectal liver metastases

Purpose

To investigate the outcomes of patients with colorectal cancer and initially unresectable or not optimally resectable liver metastases, who were treated using the liver-first approach in the era of modern chemotherapy in Japan.

Methods

We analyzed and compared data retrospectively on patients with asymptomatic resectable colorectal cancer and initially unresectable or not optimally resectable liver metastases, who were treated either using the liver-first approach (n = 12, LF group) or the primary-first approach (n = 13, PF group).

Results

Both groups of patients completed their therapeutic plan and there was no mortality. Postoperative morbidity rates after primary resection and hepatectomy, and post-hepatectomy liver failure rate were comparable between the groups (p = 1.00, p = 0.91, and p = 0.55, respectively). Recurrence rates, median recurrence-free survival since the last operation, and 3-year overall survival rates from diagnosis were also comparable between the LF and PF groups (58.3 vs. 61.5 %, p = 0.87; 10.5 vs. 18.6 months, p = 0.57; and 87.5 vs. 82.5 %, p = 0.46, respectively).

Conclusions

The liver-first approach may be an appropriate treatment sequence without adversely affecting perioperative or survival outcomes for selected patients.

     

A population-based study comparing laparoscopic and robotic outcomes in colorectal surgery

Background

Current data addressing the role of robotic surgery for the management of colorectal disease are primarily from single-institution and case-matched comparative studies as well as administrative database analyses. The purpose of this study was to compare minimally invasive surgery outcomes using a large regional protocol-driven database devoted to surgical quality, improvement in patient outcomes, and cost-effectiveness.

Methods

This is a retrospective cohort study from the prospectively collected Michigan Surgical Quality Collaborative registry designed to compare outcomes of patients who underwent elective laparoscopic, hand-assisted laparoscopic, and robotic colon and rectal operations between July 1, 2012 and October 7, 2014. We adjusted for differences in baseline covariates between cases with different surgical approaches using propensity score quintiles modeled on patient demographics, general health factors, diagnosis, and preoperative co-morbidities. The primary outcomes were conversion rates and hospital length of stay. Secondary outcomes included operative time, and postoperative morbidity and mortality.

Results

A total of 2735 minimally invasive colorectal operations met inclusion criteria. Conversion rates were lower with robotic as compared to laparoscopic operations, and this was statistically significant for rectal resections (colon 9.0 vs. 16.9 %, p < 0.06; rectum 7.8 vs. 21.2 %, p < 0.001). The adjusted length of stay for robotic colon operations (4.00 days, 95 % CI 3.63–4.40) was significantly shorter compared to laparoscopic (4.41 days, 95 % CI 4.17–4.66; p = 0.04) and hand-assisted laparoscopic cases (4.44 days, 95 % CI 4.13–4.78; p = 0.008). There were no significant differences in overall postoperative complications among groups.

Conclusions

When compared to conventional laparoscopy, the robotic platform is associated with significantly fewer conversions to open for rectal operations, and significantly shorter length of hospital stay for colon operations, without increasing overall postoperative morbidity. These findings and the recent upgrades in minimally invasive technology warrant continued evaluation of the role of the robotic platform in colorectal surgery.

     

Role of pulmonary metastasectomy in colorectal cancer in the era of modern multidisciplinary therapy

Purpose

To clarify the role of pulmonary metastasectomy in colorectal cancer in the era of modern multidisciplinary therapy.

Methods

The characteristics and outcomes of the patients who underwent pulmonary metastasectomy for colorectal cancer through 2002 (n?=?26) and from 2003 (n?=?68) were compared.

Results

The patients treated from 2003 had a smaller tumor size and more frequently had a history of extra-pulmonary relapses than did those treated through 2002. There was a significant improvement in the 5-year overall survival (42.0% vs. 73.1%, p?=?0.03) but not the 5-year relapse-free survival (41.4% vs. 37.5%, p?=?0.85) after pulmonary metastasectomy from 2003. The rate of patients who received local therapy with curative intent after the first pulmonary metastasectomy was significantly higher in patients treated from 2003 than in those treated through 2002 [4/13, (31%) vs. 25/39 (64%), p?=?0.04]. The survival after relapse after the first pulmonary metastasectomy was significantly longer in patients treated from 2003 than in those treated through 2002 (median survival time: 14 vs. 47 months).

Conclusions

Pulmonary metastasectomy for colorectal cancer remains an important treatment option in the sense that it can achieve a good relapse-free survival.

     

CXCR4 Expression Predicts Patient Outcome and Recurrence Patterns after Hepatic Resection for Colorectal Liver Metastases

Background

The purpose of this study was to determine if the expression of the chemokine receptors, CXCR4 and CCR7, and the chemokine ligand, CXCL12, in completely resected colorectal cancer hepatic metastases are predictive of disease-specific survival, recurrence-free survival and patterns of recurrence.

Methods

Immunohistochemical analysis of CXCR4, CCR7 and CXCL12 expression within resected hepatic metastases was performed and correlated with clinicopathological variables, disease-specific survival, recurrence-free survival and patterns of recurrence.

Results

Seventy-five patients who underwent partial hepatectomy with curative intent were studied. CXCR4 expression (hazard ratio [HR] 3.6, 95% confidence interval [95% CI] 1.4–9.1) and clinical risk score >2 (HR 2.3, 95% CI 1.1–4.7) were independently associated with disease-specific survival by multivariate analysis. The 5-year estimated disease-specific survival rates for positive and negative CXCR4 tumor expression were 44 and 77%, respectively (P = 0.005). CXCR4 expression (HR 2.2, 95% CI 1.2–4.2) and clinical risk score >2 (HR 1.9, 95% CI 1.1–3.4) were independently associated with recurrence-free survival by multivariate analysis. The five year estimated recurrence-free survival rates for positive and negative CXCR4 tumor expression were 20 and 50%, respectively (P = 0.004). Neither CXCL12 nor CCR7 expression in tumors predicted disease-specific survival or recurrence-free survival. Forty-nine patients (65%) developed recurrent disease after initial hepatectomy. Negative CXCR4 tumor expression was associated with favorable recurrence patterns amenable to salvage resection and/or ablation.

Conclusions

Negative CXCR4 expression in resected colorectal cancer hepatic metastases is independently associated with improved disease-specific and recurrence-free survival and favorable patterns of recurrence.

     

Propensity Score-Matched Analysis of Clinical and Financial Outcomes After Robotic and Laparoscopic Colorectal Resection

Purpose

The study aims to evaluate the clinical and financial outcomes of the use of robotic when compared to laparoscopic colorectal surgery and any changes in these over time.

Methods

From the Premier Perspective database, patients who underwent elective laparoscopic and robotic colorectal resections from 2012 to 2014 were included. Laparoscopic colorectal resections were propensity score matched to robotic cases for patient, disease, procedure, surgeon specialty, and hospital type and volume. The two groups were compared for conversion, hospital stay, 30-day post-discharge readmission, mortality, and complications. Direct, cumulative, and total (including 30-day post-discharge) costs were evaluated. Clinical and financial outcomes were also separately assessed for each of the included years.

Results

Of 36,701 patients, 32,783 (89.3%) had laparoscopic colorectal resection and 3918 (10.7%) had robotic colorectal resection; 4438 procedures (2219 in each group) were propensity score matched. For the entire period, conversion to open approach (4.7 vs. 3.7%, p?=?0.1) and hospital stay (mean days [SD] 6 [5.3] vs. 5 [4.6], p?=?0.2) were comparable between robotic and laparoscopic procedures. Surgical and medical complications were also the same for the two groups. However, the robotic approach was associated with lower readmission (6.3 vs. 4.8%, p?=?0.04). Wound or abdominal infection (4.7 vs. 2.3%, p?=?0.01) and respiratory complications (7.4 vs. 4.7%, p?=?0.02) were significantly lower for the robotic group in the final year of inclusion, 2014. Direct, cumulative, and total (including 30-day post-discharge) costs were significantly higher for robotic surgery. The difference in costs between the two approaches reduced over time (direct cost difference: 2012, $2698 vs. 2013, $2235 vs. 2014, $1402).

Conclusion

Robotic colorectal surgery can be performed with comparable clinical outcomes to laparoscopy. With greater use of the technology, some further recovery benefits may be evident. The robotic approach is more expensive but cost differences have been diminishing over time.

     

Short- and Long-Term Oncological Outcome After Rectal Cancer Surgery: a Systematic Review and Meta-Analysis Comparing Open Versus Laparoscopic Rectal Cancer Surgery

Background

While several trials have compared laparoscopic to open surgery for colon cancer showing similar oncological results, oncological quality of laparoscopic versus open rectal resection is not well investigated.

Methods

A systematic literature search for randomized controlled trials was conducted in MEDLINE, the Cochrane Library, and Embase. Qualitative and quantitative meta-analyses of short-term (rate of complete resections, number of harvested lymph nodes, circumferential resection margin positivity) and long-term (recurrence, disease-free and overall survival) oncologic results were conducted.

Results

Fourteen randomized controlled trials were identified including 3528 patients. Patients in the open resection group had significantly more complete resections (OR 0.70; 95% CI 0.51–0.97; p?=?0.03) and a higher number of resected lymph nodes (mean difference ??0.92; 95% CI ??1.08 to 0.75; p?<?0.001). No differences were detected in the frequency of positive circumferential resection margins (OR 0.82; 95% CI 0.62–1.10; p?=?0.18). Furthermore, no significant differences of long-term oncologic outcome parameters after 5 years including locoregional recurrence (OR 0.95; 95% CI 0.44–2.05; p?=?0.89), disease-free survival (OR 1.16; 95% CI 0.84–1.58; p?=?0.36), and overall survival (OR 1.04; 95% CI 0.76–1.41; p?=?0.82) were found. Most trials exhibited a relevant risk of bias and several studies provided no information on the surgical expertise of the participating surgeons.

Conclusion

Differences in oncologic outcome between laparoscopic and open rectal surgery for rectal cancer were detected for the complete resection rate and the number of resected lymph nodes in favor of the open approach. No statistically significant differences were found in oncologic long-term outcome parameters.