Laparoscopic anterior resection and total mesorectal excision for rectal cancer: a prospective nonrandomized study

Background The purpose of this study was to present our experience of laparoscopic total mesorectal resection, including ultralow resection and coloanal anastomosis. Materials and methods Between 1993 and 2005, patients fit for general anesthesia, with resectable cancers, and with lower edge of tumor beyond 5 cm of the anal verge were subjected to laparoscopic anterior resection with sphincter preservation. Double stapling technique is used to establish bowel continuity. Results A total of 170 patients, 88 males and 82 females, were subjected to successful laparoscopic anterior resection, which included high anterior resection (n=90), low anterior resection (n=52), ultralow anterior resection (n=20), and coloanal anastomosis (n=8). The average age of patients was 58.4 years (12–90 years). Mean operating time was 130 min and mean hospital stay was 7 days. The morbidity was 13.5% with nil mortality. With an average follow-up of 49 months (range 9 years to 3 months), 9 patients developed local recurrence and 45 patients developed distant metastasis. Conclusion In selected cases, laparoscopic anterior resection is possible for all levels of rectal tumors, allowing sphincter preservation and maintaining oncological safety.     

Laparoscopic total mesorectal excision for rectal cancer surgery

The introduction of total mesorectal excision in the early 1980s has improved local control and survival in patients with rectal cancer. Laparoscopic resections for colonic malignancies are gaining acceptance in the light of the recent evidence of oncologic adequacy from randomized clinical trials. Technical difficulties and the difference in the natural history of the disease have excluded rectal cancer from major clinical trials comparing laparoscopic to conventional rectal surgery. This review examined the feasibility, safety and oncologic outcomes of reported laparoscopic total mesorectal excision for surgical treatment of operable rectal cancer.     

经腹腔镜全直肠系膜切除术治疗低位直肠癌

目的探讨经腹腔镜全直肠系膜切除术(TME)治疗低位直肠癌的可行性。方法经腹腔镜对14例低位直肠癌患者实施TME。结果14例患者手术顺利。手术时间120～240分钟，平均180分钟；术中出血30～180ml，平均50ml；术后1～2天恢复胃肠功能并下床活动；住院5～14天，平均6天。术后6例应用镇痛剂，无死亡者，无并发症发生。结论经腹腔镜TME治疗低位直肠癌安全可行，且创伤小、术后疼痛轻、恢复快。     

Laparoscopic total mesorectal excision for extraperitoneal rectal cancer: Long-term results

?

The long-term role of laparoscopy in the treatment of rectal cancer is still controversial. The aim of the present study was to evaluate the safety, the feasibility, the perioperative outcome, and the long-term results of laparoscopic total mesorectal excision (TME) for extraperitoneal rectal cancer considering a single center series.

Methods

Data about 186 unselected consecutive patients that underwent laparoscopic TME for middle and low rectal cancer between January 2001 and December 2011 were prospectively recorded and were included in the present study.

Results

Distribution of TNM stage was 5 % T1, 37 % T2, 52.5 % T3, and 6 % T4. Fifty-one percent of patients have lymph node metastases. The average duration of surgery was 234 min. Fourteen patients required conversion (7.5 %). A complete microscopic excision was achieved in 169 patients (91 %). The mean hospital stay was 9 days. The overall postoperative morbidity rate was 24 %. Surgical-related complications were reported in 19 %. Overall mortality was 0.5 %. Sex, tumor level, and the presence of a stoma were the only statistically significant independent risk factors for anastomotic leakage. Median follow-up was 71 months. The 5-year overall survival rate was 77 %, with 89 % for stage 1, 81 % for stage 2, 43 % for stage 3, and 10 % for stage 4. The 5-year disease-free survival rate was 66 %. The 10-year survival rate was 54 %. Nine patients (4.8 %) experienced a pelvic recurrence. Late metastases developed in 31 patients (17.2 %).

Conclusions

The study confirms the oncological safety of laparoscopic TME in a long follow-up period.     

Laparoscopic low anterior resection for early rectal cancer

Severe superimposed infection during open abdomen treatment with development of intra-abdominal sepsis is a challenging complication associated with high mortality rates. We report our experience with VAC-Instill^® therapy (KCI, San Antonio, USA) used for treatment of an infected open abdomen following pancreatic surgery. A literature search revealed no analogous case reports using VAC-Instill^® therapy for treatment of an infected laparostomy. The encouraging result of the case presented seems to indicate that VAC-Instill^® therapy could be used as adjunctive treatment in the management of the infected open abdomen when traditional therapy fails to control the infection.     

Selective total mesorectal excision for rectal cancer

PURPOSE: Total mesorectal excision has been advocated for rectal cancer, but its use in upper rectal and rectosigmoid tumors remains a point of debate. METHODS: One hundred seventeen patients with rectal cancers were subjected to a prospective policy of total mesorectal excision for mid and low rectal cancers and a wide (5 cm) distal margin mesorectal excision for upper rectal and rectosigmoid cancers. RESULTS: Forty-one patients underwent ultralow anterior resection, 10 underwent abdominoperineal excision, 64 had anterior resection and 2 had Hartmann's procedure. The median follow-up was 39 months. Forty-three patients had a defunctioning ileostomy. Three patients (7.3 percent) had anastomotic leaks after ultralow anterior resection with total mesorectal excision. Ninety-three patients had palliative resections. There were four locoregional recurrences in this group, giving an actuarial locoregional recurrence rate of 9.3 percent at five years. The actuarial locoregional recurrence rate after anterior resection was 6.5 percent at five years. The actuarial five-year cancer-specific survival rate was 81.4 percent at five years. CONCLUSION: These results demonstrate that a policy of wide excision of the mesorectum for upper rectal and rectosigmoid cancer and total mesorectal excision for mid and low rectal cancer is associated with a low locoregional recurrence rate and may be as efficacious as routine total mesorectal excision for all rectal cancers.     

Functional outcome following low anterior resection with total mesorectal excision in the elderly

BACKGROUND AND AIMS: Disturbance of bowel function is not uncommon following low anterior resection, but the effect of low anterior resection on the elderly has seldom been documented. This study investigated the functional outcome in elderly patients following low anterior resection for carcinoma of the rectum. PATIENTS AND METHODS: The study included 87 patients with carcinoma of middle and lower rectum who underwent curative low anterior resection with total mesorectal excision and remained alive without recurrence for at least 6 months following the resection or closure of stoma. Anorectal manometry and questionnaire survey of the patients' bowel function were performed during follow-up (median 24.1 months) to investigate the functional outcome after surgery. RESULTS: The median number of bowel motions was 2.5 per day in both elderly and young patients. Complete continence was achieved in 71.3% of patients, with both elderly and young patients performing similarly. The most common symptoms were clustering of bowel motions and urgency, which occurred in 30.3% and 34.9% of patients respectively, regardless of age. Manometric findings were also similar between the elderly and their younger counterparts. CONCLUSION: Bowel function and manometric findings following low anterior resection with total mesorectal excision in the elderly are not worse than in younger patients.     

Laparoscopic total mesorectal excision

This article describes the operative technique that my colleagues and I apply to total mesorectal excision in patients with rectal cancer. A body of data support improvement of short-term outcomes over open resection. Although long-term data remain scarce, several ongoing trials may clarify this deficiency. The appropriateness of laparoscopy in the treatment for rectal cancer should be carefully weighed with consideration of patient preferences, surgeon experience, and available infrastructure.     

Study protocol for a multicenter prospective controlled and randomized trial of transanal total mesorectal excision versus laparoscopic low anterior resection in rectal cancer

Purpose

Compared with the open approach, laparoscopic total mesorectal excision (TME) achieves faster patient recovery, reduces morbidity rates, and shortens hospital stay. However, in laparoscopic low anterior resection (L-LAR), conversion to open surgery is required in almost 20% of cases. Transanal TME (Ta-TME) combined with laparoscopy, also called hybrid natural orifice transluminal endoscopic surgery (NOTES), is a less invasive procedure that can overcome some of the limitations of laparoscopic rectal surgery. In this study, we aim to determine whether Ta-TME has a lower rate of conversion to open surgery than L-LAR, and thus achieves faster patient recovery without altering the pathological, functional, or oncological results. The main objective is to compare the results for conversion to open surgery between Ta-TME and L-LAR.

Methods

Multicenter, prospective randomized controlled study of patients diagnosed with rectal adenocarcinoma who will be randomly allocated to Ta-TME or L-LAR groups after the application of inclusion and exclusion criteria. The main endpoint is conversion to open surgery and the secondary endpoints are general morbidity and mortality and hospital stay. Demographic, surgical, and pathological variables will also be studied, along with quality of life and survival. A sample size of 53 patients per group is calculated. With an estimated loss of 10%, the final sample required will be 116 patients.

Conclusions

Ta-TME achieves a lower conversion rate to open surgery than L-LAR, thus improving patient recovery and reducing overall morbidity.

Trial registration

ClinicalTrials.gov Identifier: NCT02550769. Registration no. Ethical and Clinical Research Committee, Parc Taulí University Hospital: ID 2014/064.

     

Laparoscopic total mesorectal excision of low rectal cancer with preservation of anal sphincter： A report of 82 cases

AIM: To assess the feasibility and efficacy of laparoscopic total mesorectal excision (LTME) of low rectal cancer with preservation of anal sphincter. METHODS: From June 2001 to June 2003, 82 patients with low rectal cancer underwent laparoscopic total mesorectal excision with preservation of anal sphincter. The lowest edge of tumors was below peritoneal reflection and 1.5-7 cm from the dentate line (1.5-5 cm in 48 cases, 5-7 cm in 34 cases). RESULTS: LTME with anal sphincter preservation was performed on 82 randomized patients with low rectal cancer, and 100 % sphincter preservation rate was achieved. There were 30 patients with laparoscopic low anterior resection (LLAR) at the level of the anastomosis below peritoneal reflection and 2 cm above from the dentate line; 27 patients with laparoscopic ultralow anterior resection (LULAR) at the level of anastomoses 2 cm below from the dentate line; and 25 patients with laparoscopic coloanal anastomoses (LCAA) at the level of the anastomoses at or below the dentate line. No defunctioning ileostomy was created in any case. The mean operating time was 120 minutes (ranged from 110-220 min), and the mean operative blood loss was 20 mL (ranged from 5-120 mL). Bowel function was restored and diet was resumed on day 1 or 2 after operation. The mean hospital stay was 8 days (ranged from 5-14). Postoperative analgesics were used in 45 patients. After surgery, 2 patients had urinary retention, one had anastomotic leakage, and another 2 patients had local recurrence one year later. No interoperative complication was observed. CONCLUSION: LTME with preservation of anal sphincter is a feasible, safe and minimally invasive technique with less postoperative pain and rapid recovery, and importantly, it has preserved the function of the sphincter.     

机器人和腹腔镜治疗中低位直肠癌对照研究

目的对比机器人和腹腔镜治疗中低位直肠癌的近期疗效。 方法自2017年3月18日至2017年10月25日,共有56例中低位直肠癌患者在解放军总医院普通外二科接受直肠癌根治术,患者被随机分组接受机器人或腹腔镜手术,对两组的临床资料进行了比较。 结果最终机器人组27例,腹腔镜组29例。机器人组较腹腔镜组在手术时间、术后镇痛时间、排气时间、恢复饮食时间、导尿管留置时间、住院日和淋巴结清扫数目方面差异均无统计学意义（均P>0.05）。机器人组术中失血量比腹腔镜少［（77.0±50.0）mL vs.（121.0±129.8）mL］,但差异无统计学意义（Z=-1.825,P=0.068）。机器人组术后有1例吻合口漏和1例肠梗阻,腹腔镜组术后有1例吻合口出血和1例肺部感染,术后并发症发生率方面差异无统计学意义（7.4% vs. 6.9%,χ²=0.006,P=1.000）。 结论机器人和腹腔镜直肠癌根治术围术期效果相当,远期功能学和肿瘤学效果有待进一步随访。     

Lateral node dissection and total mesorectal excision for rectal cancer

PURPOSE: Although the existence of lateral lymphatic drainage of the rectum has been verified anatomically, the clinical importance of it has not yet been fully investigated. The lack of a definition of lateral lymphatic flow makes it difficult to analyze and compare data. The aim of this study was to define the concept of lateral lymphatic drainage and explore its relationship to total mesorectal excision and to disclose the incidence and efficacy of dissection of lateral node involvement. METHODS: Review of anatomic and clinical research on lateral lymphatic flow was made to create a definition of lateral lymphatic flow. Based on this review, a three-space dissection was designed and applied. A retrospective analysis was made of 764 patients with rectal cancer treated by a curative three-space dissection operation during 20 years starting in 1975 at Cancer Institute Hospital. RESULTS: Lateral lymphatic flow passes from the lower rectum and through the lateral ligament laterally beyond the mesorectum. It then ascends along the internal iliac artery and, in addition, inside the obturator space. Sixty-six cases proved to have lateral node involvement, which comprised 8.6 percent of all rectal cancer and 16.4 percent of low-lying (lower margin below 5 cm above the dentate line) rectal cancer cases. The five-year survival rate of these 66 cases was 42.4 percent. There were 16 cases that had a solo lateral node involvement. CONCLUSION: Lateral lymphatic flow from low-lying rectal cancer passes outside the boundaries of total mesorectal excision but within the range of curative surgery by three-space dissection.     

Laparoscopic mesorectal excision with preservation of the pelvic autonomic nerves for rectal cancer

BACKGROUND/AIMS: Laparoscopic mesorectal excision with preservation of the autonomic pelvic nerves for rectal cancer including selected advanced lower rectal cancer is now challenging. The aims of the study were to assess the surgical results and short-term outcomes of this procedure prospectively. METHODOLOGY: Seventy-four of 281 rectal cancer patients, since the introduction of laparoscopic colorectal surgery in our hospital, have undergone laparoscopic rectal surgery. The location of the tumor distributed in upper rectum; 33, middle; 22, and lower 19. The mesorectal excision with preservation of the autonomic pelvic nerves was performed for all the patients. The laparoscopic mesorectal excision was performed under 8 to 10 cmH2O CO2 pneumoperitoneum and lymph node dissection was performed along the feeding artery depend on individuals. Ipsilateral lateral lymph node dissection was added for 5 cases of advanced lower rectal cancer. RESULTS: Open conversion occurred in 4 cases, 2 of those were due to locally advanced tumors and 2 technical difficulties in transaction of the distal rectum. There were 15 postoperative complications, 7 anastomotic leakage (10.6%), 3 transient urinary retention (4.1%), 4 wound infection (5.3%), and 1 small bowel obstruction (1.4%). No mortality was recorded in this series. Time of operation was 203 +/- 54 min in mesorectal excision cases and 270 +/- 42 min mesorectal excision with lateral lymph node dissection cases. Blood loss was 92 +/- 90g and 276 +/- 66 g respectively. The hospital length-of-stay was 11.7 days in average. CONCLUSIONS: Laparoscopic mesorectal excision with preservation of autonomic pelvic nerves for rectal cancer patients including selected advanced lower rectal cancer is favorable.     

Transanal total mesorectal excision for rectal cancer with indocyanine green fluorescence angiography

Background

The aim of this study was to evaluate the impact of fluorescence angiography (FA) on any change in proximal resection margin and/or anastomotic leak (AL) following transanal total mesorectal excision (TaTME) for rectal cancer (RC).

Methods

This retrospective cohort study was conducted at two centers by three senior surgeons. Both institutions’ prospectively maintained Institutional Review Board-approved databases were retrospectively queried for all consecutive patients between July 2015 and May 2017 who had laparoscopic hybrid trans-abdominal total mesorectal excision (TME) and TaTME for RC with colorectal or coloanal anastomosis?<?10 cm from the anal verge. All patients had intraoperative FA to assess colonic perfusion of the planned proximal resection margin before bowel transection and after construction of the anastomosis. Primary outcomes measured any changes in proximal resection margins and AL rates.

Results

Fifty-four patients (31 males; mean age 63?±?12 years) were included; 30 (55%) of whom received neoadjuvant chemoradiation. The average anastomotic height was 3.6 cm from the anal verge and 8 (14.5%) patients required intersphincteric dissection. Forty-six patients (85%) had loop ileostomy. FA led to a change in the proximal resection margin in 10 patients (18.5%), one of whom had AL on postoperative day 3 requiring diagnostic laparoscopy and loop ileostomy. A second patient, without a change in the proximal resection margin, also had an AL. The overall AL rate was 3.7%.

Conclusions

FA changed the planned proximal resection margin in 18.5% of patients, possibly accounting for the relatively low AL rate. FA is imperfect, and subjective but does have the potential to improve outcomes.