Integration of open and laparoscopic approaches for rectal cancer resection: oncologic and short-term outcomes

Background

Laparoscopy is increasingly used for rectal cancer surgery. Laparoscopic surgery is not attempted for some suitable patients because of concerns for conversion or technical difficulty. This study aimed to evaluate oncologic and short-term outcomes for patients undergoing curative resection for rectal cancer via laparoscopic and open approaches.

Methods

A prospective database was reviewed to identify rectal cancer resections from 2005 to 2011. Patients who had primary rectal cancer within 15 cm of the anal verge were included in the study. Those with recurrent or metastatic disease were excluded. Patients were assigned to laparoscopic or open approaches preoperatively based on clinical criteria and imaging. All patients underwent a standard total mesorectal excision and followed a standardized enhanced recovery pathway. The oncologic and clinical outcomes were evaluated by approach.

Results

The analysis included 81 patients. The preoperative assignments consisted of 62 laparoscopic (77 %) and 19 open (23 %) procedures. Nine laparoscopic procedures (14.5 %) were converted to open procedures. After a median follow-up period of 25 months, all oncologic outcomes were comparable. Three patients (two laparoscopic, one open) had a positive circumferential margin (≤1 mm). The laparoscopic and open groups were similar in terms of their 3-year disease-free periods (93.6 vs. 88.2 %; P = 0.450) and overall survival periods (93.5 vs. 90.9 %; P = 0.766). The local recurrence rate was 2.5 %.

Conclusions

Laparoscopic resection for rectal cancer can be attempted for most patients. Conversion to open procedure does not compromise clinical or oncologic outcomes. In practice, combining laparoscopic and open surgery optimizes resource use and results in at least equivalent outcomes.     

Laparoscopic resection for hepatocellular carcinoma: a matched-pair comparative study

Background

Only a few series have demonstrated the safety of laparoscopic resection for hepatocellular carcinoma (HCC) and the benefits of this approach. Moreover, these studies reported mostly minor and nonanatomic hepatic resections. This report describes the results of a pair-matched comparative study between open and laparoscopic liver resections for HCC in a series of essentially anatomic resections.

Methods

Patients were retrospectively matched in pairs for the following criteria: sex, age, American Society of Anesthesiology (ASA) score, severity of liver disease, tumor size, and type of resection. A total of 42 patients undergoing laparoscopy were compared with patients undergoing laparotomy during the same period. Surgeons from the authors’ department not trained in laparoscopy performed open resections. Operative, postoperative, and oncologic outcomes were compared.

Results

The mean duration of surgery was similar in the two groups. Significantly less bleeding was observed in the laparoscopic group (364.3 vs. 723.7 ml; p < 0.0001). Transfusion was required for four patients (9.5%) in the laparoscopic group and seven patients (16.7%) in the open surgery group (p = 0.51). Postoperative ascites was less frequent after laparoscopic resections (7.1 vs. 26.1%; p = 0.03). General morbidity was similar in the two groups (9.5 vs. 11.9%; p = 1.00). The mean hospital stay was significantly shorter for the patients undergoing laparoscopy (6.7 vs. 9.6 days; p < 0.0001). The surgical margin and local recurrence adjacent to the liver stump were not affected by laparoscopy. The overall postoperative survival rates in the laparoscopic group were 93.1% at 1 year, 74.4% at 3 years, and 59.5% at 5 years and, respectively, 81.8, 73, and 47.4% in the open surgery group (p = 0.25). The postoperative disease-free survival rates in the laparoscopic group were at 81.6% at 1 year, 60.9% at 3 years, and 45.6% at 5 years, respectively, 70.2, 54.3, and 37.2% in the open surgery group (p = 0.29).

Conclusions

Laparoscopic resection of HCC for selected patients gave a better postoperative outcome without oncologic consequences. Prospective trials are required to confirm these results.     

Laparoscopic Versus Open Surgery for Stage I Rectal Cancer: Long-term Oncologic Outcomes

Background

Laparoscopic resection is increasingly being performed for rectal cancer. However, few data are available to compare long-term outcomes after open versus laparoscopic surgery for early-stage rectal cancer.

Methods

Included in this retrospective study were 160 patients who underwent surgery for stage I rectal cancer between 2001 and 2008. Perioperative outcomes, overall survival (OS), and disease-free survival (DFS) were compared for open versus laparoscopic surgery.

Results

Altogether, 85 patients were treated using open surgery and 80 with laparoscopic surgery. Postoperative mortality (0 vs. 1.3 %; p = 1.00), morbidity (31.3 vs. 25.0 %; p = 0.38), and harvested lymph nodes (22.5 vs. 20.0; p = 0.84) were similar for the two groups. However, operating time was longer (183.8 vs. 221.0 min; p = 0.008), volume of intraoperative bleeding was less (200.0 vs. 150.0 ml; p = 0.03), time to first bowel movement was shorter (3.54 vs. 2.44 days; p < 0.001), rate of superficial surgical-site infection was lower (7.5 vs. 0 %; p = 0.03), and postoperative hospital stay was shorter (11.0 vs. 8.0 days; p < 0.001) in the laparoscopy group than in the open surgery group. At 5 years, there was no difference in OS (98.6 vs. 97.1 %; p = 0.41) or DFS (98.2 vs. 96.4 %; p = 0.30) between the open and laparoscopy groups.

Conclusions

Long-term outcomes of laparoscopic surgery for stage I rectal cancer were comparable to those of open surgery. Laparoscopic surgery, however, produced more favourable short-term outcomes than open surgery.     

Laparoscopic versus open resection of colorectal liver metastasis

Background

Findings have shown laparoscopic liver resection (LLR) to be feasible and safe, but the data in the literature regarding oncologic outcomes are scant. This study aimed to compare the perioperative and short-term oncologic outcomes between LLR and open resection of colorectal liver metastasis (CLM).

Methods

Between January 2006 and April 2012, 40 patients underwent LLR of CLM. These patients were compared with a consecutive matched group of 40 patients who underwent open resection within the same period. Data were obtained from a prospective institutional review board (IRB)-approved database. Statistical analysis was performed using t test, Chi-square, and Kaplan–Meier survival.

Results

The groups were similar in terms of age, gender, tumor size, number of tumors, and type of resections performed. The operative time was similar in the two groups, but the estimated blood loss was less in the LLR group than in the open resection group. The length of stay was shorter in the LLR group (3.7 vs 6.5 days; p < 0.001). The 2-year overall survival rate was 89 % for LLR and 81 % for open resection. The median disease-free survival time was 23 months in each group.

Conclusions

The findings suggest that LLR is associated with less blood loss and a shorter hospital stay than open resection for CLM. According to our short-term results, LLR is equivalent to open resection in terms of oncologic outcomes.     

Comparison of Peristomal Adhesion Formation Between Laparoscopic and Open Low Anterior Resection of Rectal Cancer

Background

Postoperative adhesions appear to be less common following laparoscopic surgery than after conventional open surgery. The purpose of this study was to compare the impact of laparoscopic and conventional open rectal surgery on peristomal adhesion formation.

Methods

We enrolled 97 subjects who were participants in a trial comparing open versus laparoscopic surgery for mid and low rectal cancer after neoadjuvant chemoradiotherapy. These patients had undergone rectal cancer surgery with ileostomy formation. Peristomal adhesions were assessed during ileostomy takedown using an adhesion grading system: (1) no adhesions or fine, filmy adhesions separable by blunt dissection; (2) dense adhesions, separable by sharp dissection; (3) very dense adhesions, resulting in enterotomy and/or requiring extension of the abdominal wall incision.

Results

A total of 57 patients underwent laparoscopic resection (group A) and 40 underwent open resection (group B). Operating time for ileostomy dissection was shorter in group A than in group B (14.6 vs. 19.8 min, respectively; p = 0.047). Dense adhesions (grades 2 and 3) were more common in group B (22/40, 55 %) than in group A (12/57, 21 %; p < 0.001). In particular, grade 3 adhesions were present only in group B (6/40).

Conclusions

The present findings suggest that laparoscopic rectal surgery results in less peristomal adhesion formation than does conventional open surgery.     

The minimally invasive approach is associated with reduced perioperative thromboembolic and bleeding complications for patients receiving preoperative chronic oral anticoagulant therapy who undergo colorectal surgery

Background

The data on the perioperative risk of both thromboembolism and hemorrhage for patients receiving chronic oral anticoagulation who undergo colorectal surgery are sparse. In addition, it is uncertain whether the use of the laparoscopic instead of open technique entails additional risk for these patients. This study aimed to evaluate surgical outcomes, with a particular focus on perioperative thromboembolic and bleeding complications for patients receiving chronic oral anticoagulation therapy who undergo open or laparoscopic colorectal resection.

Methods

Patients undergoing colorectal resection between 1994 and 2011 on preoperative chronic oral anticoagulant therapy were included in the study. Patient demographics, characteristics, and perioperative outcomes, with particular emphasis on thromboembolism and bleeding risks, were evaluated comparing laparoscopic and open colectomy.

Results

The study enrolled 261 patients receiving chronic anticoagulation therapy (102 laparoscopic colectomy vs 159 open colectomy patients). The patients had a mean age of 57.9 years and a mean body mass index (BMI) of 29.3 kg/m². The conversion rate was 8.8 % (n = 9) for laparoscopic operations. Laparoscopic and open cases had comparable BMIs and levels of preoperative hemoglobin. Anastomotic leak, postoperative hospital stay, and surgical-site infection rates were similar for the two groups. Although the laparoscopic group had a significantly greater mean age (p < 0.001) and American Society of Anesthesiology (ASA) score (p = 0.005), the rates for postoperative venous thromboembolism (24.5 vs 2.9 %; p < 0.001), urinary complications (6.9 vs 0 %; p = 0.008), and overall morbidity (44.7 vs 17.7 %; p < 0.001) were lower after laparoscopic surgery. Although the rates for intra- and postoperative blood transfusion were similar, the postoperative hemoglobin levels were significantly higher after laparoscopic surgery. One patient in the laparoscopic group died of sepsis on postoperative day 3.

Conclusion

For the patients receiving preoperative chronic anticoagulant therapy who underwent colorectal resection, the laparoscopic approach was associated with lower thromboembolic and hemorrhagic complications than open surgery.     

A case-matched comparison of the short-term outcomes between laparoscopic and open abdominoperineal resection for rectal cancer

Purpose

The aim of this study was to evaluate the short-term surgical outcomes of laparoscopic abdominoperineal resection (APR) for rectal cancer, by comparing it with a case–control series of open APR.

Methods

Fourteen patients with rectal cancer who underwent laparoscopic APR between August 2004 and November 2011 were compared with the open APR group of 14 patients matched for age, gender, and surgical procedure.

Results

There were no cases of conversion to laparotomy in the laparoscopic APR group and no mortality in either of the groups. The median operation was longer (P = 0.002), but the median amount of blood loss was smaller (P = 0.019), in the laparoscopic APR group. The median length of hospital stay of the laparoscopic APR group was 8 days, shorter than that of the open APR group (16 days, P < 0.001). The changes of the WBC count and serum CRP level after operations were significantly smaller in the laparoscopic APR group (P < 0.05). There were no significant differences between the groups in terms of the perioperative morbidity and readmission rates within 30 days.

Conclusion

Patients undergoing laparoscopic APR had superior perioperative outcomes to those undergoing open APR, except for the longer operation.     

Transvaginal specimen extraction versus conventional minilaparotomy after laparoscopic anterior resection for colorectal cancer: mid-term results of a case-matched study

Background

Although the vagina is considered a viable route during laparoscopic surgery, a number of concerns have led to a need to demonstrate the safety of a transvaginal approach in colorectal surgery. However, the data for transvaginal access in left-sided colorectal cancer are extremely limited, and no study has compared the clinical outcomes with a conventional laparoscopic procedure.

Objective

We compared the clinical outcomes of totally laparoscopic anterior resection with transvaginal specimen extraction (TVSE) with those of the conventional laparoscopic approach with minilaparotomy (LAP) for anastomosis construction and specimen retrieval in left-sided colorectal cancer.

Methods

Fifty-eight patients underwent TVSE between October 2006 and July 2011 and were matched by age, surgery date, tumor location, and tumor stage with patients who underwent conventional LAP for left-sided colorectal cancer.

Results

Operative time was significantly longer in the TVSE group (149.3 ± 39.8 vs. 131.9 ± 41.4 min; p = 0.023). Patients in the TVSE group experienced less pain (pain score 4.9 ± 1.6 vs. 5.8 ± 1.9; p = 0.008), shorter time to passage of flatus (2.2 ± 1.1 vs. 2.7 ± 1.2 days; p = 0.026), and higher satisfaction with the cosmetic results (cosmetic score 8.0 ± 1.4 vs. 6.3 ± 1.5; p = 0.001). More endolinear staplers for rectal transection were used in the LAP group (1.2 ± 0.5 vs. 1.1 ± 0.2; p = 0.021). Overall morbidities were similar in both groups; however, three wound infections only occurred in the LAP group. After a median follow-up of 34.4 (range 11–60) months, no transvaginal access-site recurrence occurred. The 3-year disease-free survival was similar between groups (91.5 vs. 90.8 %; p = 0.746).

Conclusions

Transvaginal access after totally laparoscopic anterior resection is safe and feasible for left-sided colorectal cancer in selected patients with better short-term outcomes.     

Outcome of Tumor-Specific Mesorectal Excision for Rectal Cancer: The Impact of Laparoscopic Resection

Objective

The study aimed to compare the outcomes of laparoscopic and open resection for rectal cancer in 1,063 consecutive cases in a single center.

Methods

We performed an analysis of 11 years of experience in rectal cancer surgery and compared the outcome of laparoscopic and open surgery. Multivariate and subgroup analysis was performed to look at the effect of the level of tumor and stage of disease on short-term outcomes like conversion rate, anastomotic leak rate, length of stay, complication rate, 30-day mortality, and long-term outcomes like local recurrence and survival.

Results

A total of 1,063 patients underwent rectal resection with 470 (44.2 %) patients undergoing the laparoscopic approach. Groups were comparable in terms of age, sex, or co-morbidities, and the operating time was longer in the laparoscopic group (210 vs. 150 min; p value < 0.001). A conversion rate of 6.8 % was noted, with an anastomotic leak rate of 3.87 % in the open group and 2.97 % in the laparoscopic group. The laparoscopic group had a lower blood loss (100 vs. 350 ml; p < 0.001), lower complication rates, and shorter length of stay (6 vs. 9 days). The local recurrence rate was comparable, and the laparoscopic approach had better overall and cancer-specific survival, even after adjusting for stages. The laparoscopic approach was an independent factor associated with better overall and cancer-specific survival on multivariate analysis.

Conclusion

We confirmed the oncological safety of laparoscopic rectal cancer surgery. Laparoscopic surgery also showed superiority in the short-term and long-term outcomes of rectal cancer.     

Laparoscopic versus open resection of gastrointestinal stromal tumors of the stomach

Background

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Surgical treatment is the only chance of cure for patients with a primary localized GIST. A laparoscopic approach has been considered reasonable for these tumors of gastric origin. The current study compares the outcome of laparoscopic versus open resection of gastric GISTs and compares our series with the few published studies comparing the open versus the laparoscopic approach.

Methods

From a prospectively collected database, we found 53 primary gastric GIST resections that were performed in our department. Laparoscopic (LAP) resections were performed in 37 patients and traditional (OPEN) resections in 16 patients. Clinical and pathologic characteristics and surgical outcomes were analyzed according to surgical procedure.

Results

Patients who underwent LAP or OPEN resection of gastric GISTs did not differ with respect to age at operation, gender, clinical presentation, and tumor size. Operative time was significantly lower for LAP than for OPEN resection, with a mean duration of 45 and 132.5 min, respectively (p < 0.001). LAP resection yielded a significantly shorter length of stay (median 7 vs. 14 days; p = 0.007) and lower 30-day morbidity rate (2.7 % vs. 18.9 %; p = 0.077). The operative mortality was 12.5 % after OPEN resection and there was no operative mortality after LAP (p = 0.087). The recurrence rate was significantly lower after LAP surgery (0 % vs. 37.5 %; p < 0.001). All patients in the LAP group are alive without recurrence, and 25 % (4/16) of the OPEN group are alive with recurrence but in complete remission under imatinib mesylate treatment. Two patients of the open group died due to progression of GIST (p = 0.087).

Conclusions

Compared to open resection, laparoscopic resection of gastric stromal tumors is associated with a shorter operation time, a shorter hospital stay, and a lower recurrence rate.     

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.

     

Single-incision laparoscopic right colectomy compared with conventional laparoscopy for malignancy: assessment of perioperative and short-term oncologic outcomes

Background

Laparoscopic colectomy for malignancy currently is the standard operative technique together with open colectomy. Single-incision laparoscopic surgery (SIL) is a recent advance in minimally invasive surgical techniques. This study aimed to compare SIL right colectomy with conventional laparoscopy (CL) used to treat patients with colon cancer.

Methods

This study was a retrospective analysis of data from the authors’ prospectively collected colorectal surgery database. Between August 2009 and November 2010, 159 patients who underwent primary laparoscopic right colectomy at the Samsung Medical Center were recruited to participate in this study. Of these, 66 patients underwent SIL colectomy.

Results

The SIL and CL right colectomy groups did not differ significantly in terms of general characteristics including age, sex, body mass index (BMI), American society of anesthesiology (ASA) score, previous abdominal operation, and diagnosis. The two groups also did not differ significantly in terms of perioperative complications (9.1 vs. 15.1 %, p = 0.335). Oncologic resection was similar in the two groups. The mean number of harvested lymph nodes was 24 for SIL and 27 for CL right colectomy (p = 0.068). Tumor size, disease stage, adjuvant chemotherapy, and proximal and distal resection margins did not differ significantly between the two groups. The mean follow-up period was 24.5 for the SIL group and 26.4 months for the CL group (p = 0.098), with six recurrences in the SIL group (9.1 %) and three recurrences in the CL group (3.2 %) (p = 0.120). One death occurred in the CL group. Disease-free survival at 24 months did not differ significantly between the two groups (89.7 vs. 96.3 %, p = 0.120).

Conclusion

The findings show that SIL right colectomy for colon cancer is safe and can provide resection and oncologic outcomes equal to those of conventional laparoscopic right colectomy.     

Laparoscopic left hemihepatectomy: a safety and feasibility study of 19 cases

Background

Laparoscopic liver resection was performed at some institutes. The procedure mainly included local resection, segmentectomy, and left lateral segmentectomy. With experience accumulation and technique innovation, laparoscopic left hemihepatectomy was performed in selected patients. This study was designed to introduce and evaluate the safety and feasibility of this procedure.

Methods

Nineteen successive patients underwent laparoscopic left hemihepatectomy from 2005 to 2007. They were compared by the matched-pair method with 19 other patients who underwent conventional open left hemihepatectomy. Surgical feature, postoperative course, and the learning curve of laparoscopic left hemihepatectomy were studied.

Results

Laparoscopic hemihepatectomy was successfully performed in 17 cases. Two conversions were required. Compared with the open group, the blood loss was significantly less in the laparoscopic group (462 ± 372 vs. 895 ± 704, p = 0.03). Postoperative hospital stay of the laparoscopic group was shorter but not significant compared with the open group (9 ± 5 vs. 13 ± 7, p = 0.086). Postoperative albumin level in the laparoscopic group was significantly higher than the open group (33 ± 4.8 vs. 27.6 ± 3.2, p = 0.001). There was no perioperative mortality in either group. Two complications occurred in the laparoscopic group (11%) and four in the open group (21%). A tendency of gradually decreased transecting time was noticed in the early cases (R² = 0.676; p = 0.012).

Conclusions

Laparoscopic left hemihepatectomy is a safe and feasible procedure for select patients.     

A comparison of the feasibility of laparoscopic resection of the primary tumor in patients with stage IV colon cancer with early and advanced disease: the short- and long-term outcomes at a single institution

Purpose

The role of resection of the primary tumor in patients with stage IV colorectal cancer (CRC) remains controversial. Laparoscopic resection has become an accepted therapeutic option for treating early stage I–III CRC; however, it has not been evaluated for use in patients with advanced stage disease.

Methods

We conducted a retrospective observational study to evaluate the feasibility of laparoscopic resection of the primary tumor exclusively in patients with stage IV colon cancer compared to open resection in patients with stage IV colon cancer and laparoscopic resection in patients with stage I–III colon cancer in terms of operative results and short- and long-term outcomes.

Results

Laparoscopic resection was performed in 35 stage IV patients and open resection was performed in 40 stage IV patients. One hundred and eighteen stage I–III patients who underwent laparoscopic resection were evaluated. In the comparison between the laparoscopic group and the open group among patients with stage IV colon cancer, postoperative recovery appeared to be better in the laparoscopic group than in the open group, as reflected by shorter times to resumption of a regular diet (p = 0.049), shorter lengths of hospitalization (p = 0.083), increased feasibility of postoperative chemotherapy (p < 0.001), shorter time intervals from surgery to chemotherapy (p = 0.031) and longer median survival (p = 0.078) at the expense of longer operative times (p = 0.025). In the comparison between the laparoscopic resection in stage IV and stage I–III disease groups, no significant differences were observed in operative results and short- and long-term outcomes, except for the rate of ostomy creation (48.5 vs. 8.5 %, p = 0.02).

Conclusion

Laparoscopic resection of the primary tumor in patients with stage IV colon cancer achieves equivalent results to that performed in patients with stage I–III disease and that performed in patients with stage IV disease using open resection. The use of a minimally invasive approach in the laparoscopic procedure is beneficial because it results in shorter times to resumption of a normal diet, shorter lengths of hospitalization, increased feasibility of postoperative chemotherapy and shorter time intervals from surgery to chemotherapy at the expense of longer operative times. We believe that patients undergoing laparoscopic resection can receive targeted chemotherapy earlier and more aggressively, which might provide a survival benefit.     

Comparison of tumor recurrence between laparoscopic total mesorectal excision with sphincter preservation and laparoscopic abdominoperineal resection for low rectal cancer

Background

By traditional open surgery, the tumor recurrence rate of total mesorectal excision with sphincter-preserving procedure was lower than that of abdominoperineal resection (APR) for the treatment of low rectal cancer. The present study aimed to rescrutinize whether the same conclusion can be drawn when both surgical procedures are performed laparoscopically.

Methods

We retrospectively reviewed the prospectively recorded clinicopathologic data of 344 consecutive patients with low rectal cancer, in which 170 patients underwent preoperative chemoradiotherapy followed by laparoscopic total mesorectal excision (TME), whereas 174 patients underwent laparoscopic TME directly without chemoradiotherapy. Such patients were further stratified according to the pathologic tumor, node, metastasis stage (stage II or III disease) and surgical strategy (APR or sphincter-preserving operation [SPO]). The surgical procedures are presented in supplemental videos. The disease-free survival, recurrence patterns, and functional recovery of patient groups stratified as appropriate were compared.

Results

In patients who received preoperative chemoradiotherapy, the estimated recurrence rate were similar between laparoscopic TME with SPO and laparoscopic APR with 10.6 %, 7 of 66, versus 18.5 %, 5 of 27, in stage II disease (p = 0.811, log-rank test); and 19.3 %, 11 of 57, versus 20 %, 4 of 20, in stage III disease (p = 0.980). In patients without preoperative chemoradiotherapy, the recurrence rate was significantly higher in laparoscopic APR than in the laparoscopic TME with SPO group of patients with stage III disease (45 %, 9 of 20, vs. 19.3 %, 16 of 83, p = 0.025), whereas the recurrence rate of the two procedures was similar (21.4 %, 3 of 14, vs. 17.5 %, 10 of 57, p = 0.702) in stage II disease.

Conclusions

When low rectal cancer was operated on by laparoscopic approach, the poorer prognosis of APR compared to SPO was only observed in stage III patients without preoperative chemoradiotherapy.     

Short-term clinical outcome of robot-assisted intersphincteric resection for low rectal cancer: a retrospective comparison with conventional laparoscopy

Background

A robotic system (da Vinci^® Surgical System, Intuitive Surgical Inc., Sunnyvale, CA, USA) has technical advantages over conventional laparoscopic surgery because it increases the precision and accuracy of anatomical dissection. The present study aimed to compare the short-term outcomes between robot-assisted intersphincteric resection (ISR) and laparoscopic ISR for distal rectal cancer.

Methods

Patients who underwent robot- or laparoscopy-assisted ISR for rectal cancer between March 2008 and July 2011 were included in this retrospective comparative study. Perioperative and postoperative data, including complications and early functional outcomes, were analyzed between the two groups. Functional outcomes were evaluated using the Wexner scoring system, the International Prostate Symptom Score, and the 5-item version of the International Index of Erectile Function.

Results

A total of 40 patients underwent robot-assisted and 40 underwent laparoscopic ISR. The mean operative time was significantly longer in the robotic group than in the laparoscopic group (235.5 vs. 185.4 min; p < 0.001). Transabdominal ISR, in which intersphincteric dissection is completed in the pelvic cavity, was performed more with robotic assistance than with laparoscopic surgery (8 vs. 2 cases; p = 0.043). No difference was observed between groups regarding postoperative morbidity and pathological outcomes. The robot-assisted group showed a trend toward less postoperative blood loss and early recovery of functional outcomes.

Conclusion

Robot-assisted surgery was safe and effective for ISR of distal rectal cancer and showed surgical outcomes similar to those of the latest laparoscopic ISR. The favorable results of the robot-assisted ISR included reduced adaptation time, alleviated difficulty of perineal phase, and early recovery of functional outcomes in this analysis of short-term clinical outcomes.     

Accelerated learning curve for colorectal resection, open versus laparoscopic approach, can be attained with expert supervision

Background

Laparoscopic colorectal resection (LCR) is gaining popularity. Nonetheless, open surgery remains an important technique. Thus, surgeons should be technically proficient in both open and laparoscopic surgery. One question however remains unanswered: Can training for open and LCR occur simultaneously? The objective of this paper is to review the learning curve for open and laparoscopic colon resection of one surgeon who underwent a rigorous training program.

Methods

A review of consecutive patients who underwent surgery for colon and rectosigmoid junction cancers by one trainee surgeon was performed. This surgeon had completed his basic surgical residency but had limited experience in colorectal cancer surgery. In total, 75 patients were included in this study. All operations were supervised by at least one staff surgeon with experience of more than 300 LCR cases. The trainee surgeon was allowed to train in both laparoscopic and open colorectal resection simultaneously.

Results

Forty-three patients underwent laparoscopic resection, while 32 patients underwent open surgery. Age, gender, mean body mass index (BMI), preoperative risk, and history of past abdominal surgery showed no significant difference between laparoscopic and open groups. There were no differences in tumor stage [International Union against Cancer (UICC)] or tumor size (p = 0.068 and 0.228, respectively). The morbidity rate for open and laparoscopic surgery was 3.1% (1/32) and 4.7% (2/43), respectively (p = 0.484). Operation time decreased with increasing experience, and plateaued after 25 cases in the laparoscopic group and 22 cases in the open group. The learning curve for open cases was 11 cases, and 7 for laparoscopic surgery.

Conclusions

Surgeons who have completed a basic surgical residency but have limited colorectal surgery experience can learn both open and laparoscopic colorectal surgery simultaneously in an effective manner under supervision by well-experienced surgeons.     

Long-term oncologic outcome after laparoscopic surgery for rectal cancer

Background

Recent studies demonstrated favorable short- and mid-term results after laparoscopic surgery for rectal cancer. However, long-term results from large series are lacking. The present study analyses long-term results of laparoscopic rectal cancer surgery from a large-volume center.

Methods

From January 1998 until March 2005, 225 patients underwent laparoscopic rectal resection due to carcinoma at the Medical Centre of the University of Regensburg. From 224 patients, a follow-up over 10 years was performed using the data of the Tumour Centre of the University of Regensburg. The data were analysed using oncological data (tumour recurrence) as well as overall survival. In addition, the effect of conversion to open resection on overall survival was analysed.

Results

With a median of 10 years at follow-up, the overall and disease-free survival was 50.5 and 50.1 %, respectively. Local recurrence of all patients was 5.8 % and none of the converted patients was within this group. The median time interval for the development of local recurrence was 30 months. Six of the 13 patients with local recurrence (46.1 %) had received neoadjuvant radiochemotherapy before surgery. Patients with a conversion to open surgery had primarily a significantly worse outcome than patients resected completely laparoscopically (p = 0.003). However, this difference was no longer apparent using a multivariant analysis (hazard ratio 1.221; p = 0.478).

Conclusions

Overall survival and local recurrence rate of patients undergoing laparoscopic resection of rectal cancer are comparable to open surgery. However, in our analysis, patients undergoing laparoscopic anterior resection had a higher survival rate compared with patients with abdominoperineal resection.     

Intraoperative colonoscopy does not worsen the outcomes of laparoscopic colorectal surgery: a case-matched study

Background

Intraoperative colonoscopy is sometimes needed as an adjunct to colorectal surgery. When it is performed with laparoscopic surgery, there is the potential for prolonged bowel distension, obstructed surgical exposure, and increased morbidity. This study aimed to evaluate the overall safety and outcomes of laparoscopic colorectal procedures in which intraoperative colonoscopy was performed.

Methods

The study group consisted of patients who underwent intraoperative colonoscopy during laparoscopic intestinal resection at our institution between 1995 and 2011. They were individually matched for a number of factors including age, gender, diagnosis, American Society of Anesthesiologists (ASA) physical status score, and type of surgical procedure with a cohort of patients who underwent laparoscopic intestinal resection with no intraoperative colonoscopy during the same period. Early postoperative outcomes and time to flatus and first bowel movement were compared.

Results

For the study, 30 patients (18 females) and 30 matched control subjects were identified. The study and control groups did not differ in terms of operating time (132 vs 151 min; p = 0.5), estimated blood loss (216 vs 212 ml; p = 0.9), conversion to open surgery (n = 1 vs 5; p = 0.2), time to first flatus (3 vs 4 days; p = 0.4), time to first bowel movement (4 vs 4 days; p = 0.4), reoperation (n = 0 vs 1; p = 1), length of hospital stay (6 vs 9 days; p = 0.3), overall morbidity (n = 10 vs 14; p = 0.4), or readmission (n = 0 vs 1; p = 1). The complications that developed during or after surgery were similar in the two groups. No colonoscopy-related complications or deaths occurred.

Conclusions

Intraoperative colonoscopy does not complicate the application and outcomes of laparoscopic intestinal resection. Surgeons should perform an intraoperative colonoscopy when it is indicated during laparoscopic surgery.     

Robotic versus laparoscopic anterior resection of sigmoid colon cancer: comparative study of long-term oncologic outcomes

Background

Robotically assisted colon resection is a new type of surgery for colon cancer. However, the evidence is inadequate for the general adaptation of robotic colon surgery. This study aimed to show the oncologic and perioperative clinical results of robotically assisted anterior resection (R-AR) compared with those of laparoscopically assisted anterior resection (L-AR) for sigmoid colon cancer.

Methods

A total of 180 patients (sigmoid colon cancer stages 1–3) were assigned to receive either R-AR (n = 34) or L-AR (n = 146) between April 2006 and September 2008. Patient characteristics, perioperative clinical results, and long-term oncologic outcomes were compared between the two groups.

Results

The patient characteristics did not differ significantly between the two groups. The mean operation time was 217.6 ± 70.7 min for L-AR versus 252.5 ± 94.9 min for R-AR (p = 0.016). The total postoperative complication rate was 10.3 % for R-AR versus 5.9 % for L-AR (p = 0.281). The 3-year overall survival rate for all the patients was 93.4 % for L-AR versus 92.1 % for R-AR (p = 0.723). The 3-year overall survival rate was 100 % for both L-AR and R-AR in stage 1, 95.5 % for L-AR versus 100 % for R-AR (p = 0.386) in stage 2, and 88.4 % for L-AR versus 72.9 % (p = 0.881) for R-AR in stage 3.

Conclusion

In this study, R-AR showed safety and feasibility in terms of perioperative clinical and long-term oncologic outcomes. However, the advanced technologies of R-AR did not translate into better long-term oncologic outcomes compared with L-AR.