A Meta-Analysis of Quality of Life for Abdominoperineal Excision of Rectum versus Anterior Resection for Rectal Cancer

Background Avoiding a permanent stoma following rectal cancer excision is believed to improve quality of life (QoL), but evidence from comparative studies is contradictory. The aim of this study was to compare QoL following abdominoperineal excision of rectum (APER) with that after anterior resection (AR) in patients with rectal cancer. Methods A literature search was performed to identify studies published between 1966 and 2006 comparing values of QoL following APER and AR. Random-effect meta-analysis was used to combine the data. Sensitivity analyses were performed for larger studies, those of higher quality and those using self-administered QoL questionnaires. Results The outcomes for 1,443 patients from 11 studies, of whom 486 (33%) underwent APER, were included. QoL assessments were made at periods of up to 2 years following surgery. There was no significant difference in global health scores between APER and AR. Vitality (WMD −9.82; 95% CI −27.01, −2.04, P = 0.01) and sexual function (WMD −2.73; 95% CI −4.93, −0.64, P = 0.01) were improved in the AR patients. Patients with low AR had improved physical function scores in comparison with APER patients (WMD −4.67; 95% CI −9.10, −0.23; P = 0.004). Cognitive (WMD 3.57; 95% CI 1.41, 5.73; P < 0.001) and emotional function scores (WMD 3.51; 95% CI 1.40, 5.62; P < 0.001) were higher for APER patients. Conclusion Overall, when comparing APER with AR, we identified no differences in general QoL following the procedures. Individualisation of care for rectal cancer patients is essential, but a policy of avoidance of APER cannot currently be justified on the grounds of QoL alone.     

Comparison of Outcome of Open and Laparoscopic Resection for Stage II and Stage III Rectal Cancer

Background  Laparoscopic resection for advanced rectal cancer has not been widely accepted, and there are only few studies with survival data. This study aimed to compare the survival of patients who underwent laparoscopic and open resection for stage II and III rectal cancer. Materials and Methods  Consecutive patients (open resection: n = 310; laparoscopic resection: n = 111) who underwent curative resection for stage II and III rectal cancer from June 2000 to December 2006 were included. The operative details, postoperative complications, postoperative outcomes, and survival data were collected prospectively. Comparison was made between patients who had laparoscopic and open surgery. Results  The age, gender, medical morbidity, types of operation, and American Society of Anesthesiologists (ASA) status were similar between the two groups. There was also no difference in the mortality, morbidity, and pathological staging. Laparoscopic resection was associated with significantly less blood loss and shorter hospital stay. With the median follow-up of 34 months, there was no difference in local recurrence rates. The 5-year actuarial survivals were 71.1% and 59.3% in the laparoscopic and open groups, respectively (P = .029). In the multivariate analysis, laparoscopic resection was one of the independent significant factors associated with better survival (P = .03, hazards ratio: 0.558, 95% confidence interval: 0.339–0.969). Other independent poor prognostic factors included lymph node metastasis, poor differentiation, perineural invasion, presence of postoperative complications, and no chemotherapy. Conclusions  Laparoscopic resection for locally advanced rectal cancer is associated with more favorable overall survival when compared with open resection.     

Metaanalysis of trials comparing laparoscopic and open surgery for Crohn’s disease

Background: Several studies in the literature have suggested that laparoscopic surgery for Crohn’s disease is associated with faster postoperative recovery and a morbidity and recurrence rate similar to that for open surgery. Most of these studies have been limited by a small sample size and a short follow-up period. Methods: To clarify whether open or laparoscopic resection results in a better outcome, a metaanalysis of studies was performed comparing the two procedures for Crohn’s disease. Pooled effects were estimated using a random-effects model. Results: Laparoscopic surgery required more operative time than open surgery (26.8 min; 95% confidence interval [CI], 6.4–47.2 min), but resulted in a shorter duration of ileus and a decreased hospital stay (−2.62 days; 95% CI, −3.62 to −1.62). Laparoscopic surgery also was associated with a decreased rate for postoperative bowel obstruction and surgical recurrences. Conclusions: Laparoscopic surgery for Crohn’s disease is feasible, safe, and associated with shorter duration of ileus and a shorter hospital stay.     

Impact of laparoscopic surgery on the long‐term outcomes for patients with rectal cancer

Background: This 20‐year retrospective study compared the results of laparoscopic surgery with open surgery for patients with rectal cancer to evaluate the impact of laparoscopic surgery on long‐term oncological outcomes for rectal cancer. Methods: We analysed survival data collected over 20 years for patients with rectal cancer (n= 407) according to surgical methods and tumour stage between those treated with laparoscopic surgery (n= 272) and those with open surgery (n= 135). Clinical factors were analysed to ascertain possible risk factors that might have been associated with survival from and recurrence of rectal cancer. A multivariate analysis was applied by using Cox's regression model to determine the impact of laparoscopic surgery on long‐term oncological outcomes. Results: Overall survival, disease‐specific survival and disease‐free survival rates were statistically higher in the laparoscopic group than in the open‐surgery group. The incidence of local recurrence in the laparoscopic group (7.9%; 95% confidence intervals (CI), 4.2–11.5) was significantly lower than that for the open‐surgery group (30.2%; 95% CI, 21.0–39.3; P < 0.001). By using a multivariate analysis, laparoscopic surgery for rectal cancer appeared not to be an independent factor for disease‐specific survival or disease‐free survival. However, the laparoscopic surgery was an independent factor associated with reduced local recurrence (Hazard ratio (HR), 3.408; 95% CI, 1.890–6.149; P < 0.001). Conclusion: Laparoscopic surgery did not adversely affect the long‐term oncological outcome for patients with rectal cancer.     

Risk Factors for Complications After Laparoscopic Surgery in Colorectal Cancer Patients: Experience of 401 Cases at a Single Institution

Background  Laparoscopic surgery is widely used for the treatment of colorectal cancer, but little is known about perioperative risk factors for complications. Methods  Clinical data were reviewed for 401 consecutive unselected colorectal cancer patients who underwent laparoscopic surgery at Kyoto Medical Center between 1998 and 2005. The outcome variable was incidence of postoperative complications. Using logistic regression analysis, 58 background, clinical, preoperative, and intraoperative factors were assessed as potential predictors of complications. Results  The set of independent protective factors that had the greatest influence on the incidence of local complications after colon surgery was as follows: cefmetazole use for prophylaxis (versus oral only; adjusted odds ratio (OR) 0.18, 95% confidence interval (CI) 0.06–0.54), high operative infusion rate (per ml/min; OR 0.82, 95% CI 0.70–0.95), regular laxative use (OR 0.33, 95% CI 0.12–0.79), and double-stapled anastomosis (versus hand-sewn; OR 0.15, 95% CI 0.03–0.83). Independent risk factors for local complications after rectal surgery were abdominoperineal resection (versus low anterior resection, OR 4.84, 95% CI 1.64–14.9), long operative time (per hour, OR 1.55, 95% CI 1.11–2.23), and history of heart disease (OR 5.18, 95% CI 1.34–21.5). The occurrence of complications was not found to be associated with overall survival in this study. Conclusions  We identified intraoperative management such as low operative infusion rate is one of the independent significant risk factors for complications after laparoscopic surgery for colorectal cancer in addition to patient characteristics and surgical procedure. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

直肠癌行腹腔镜与开腹侧方淋巴结清扫术疗效及安全性的meta分析

目的:比较直肠癌行腹腔镜与开腹侧方淋巴结清扫术(LLND)的临床疗效及安全性。方法:检索中英文数据库中有关比较腹腔镜与开腹手术行LLND的文献,纳入时间为2000年1月至2019年8月的相关对照研究,采用RevMan5.3软件进行meta分析。结果:共纳入7篇文献、593例患者。与开腹组相比,腹腔镜组手术时间延长(WMD=98.55,95%CI=29.43~167.68,P=0.005),术中出血量减少(WMD=-467.16,95%CI=-665.42^-278.89,P<0.00001),术后住院时间缩短(WMD=-7.12,95%CI=-11.14^-3.09,P=0.0005)。两组在R0切除率、清扫侧方淋巴结数量、术后侧方淋巴结转移率、局部复发率、术后3年总生存率、术后3年无病生存率方面差异无统计学意义(P>0.05)。结论:腹腔镜LLND在减少术中出血量、缩短术后住院时间方面具有优势,在肿瘤根治方面,两种术式相似。腹腔镜LLND是安全、可行的,可作为治疗进展期直肠癌的治疗方法。     

Preservation of sexual and bladder function after laparoscopic rectal surgery

Background  There have recently been reports of higher levels of bladder and sexual dysfunction in men after laparoscopic rectal surgery when compared with those undergoing open surgery. This has led some surgeons to question the role of the laparoscopic approach to rectal surgery.
Method  This study represents a retrospective analysis of a prospectively collected database for a single unit, comprising 2406 patients undergoing laparoscopic colorectal surgery. Bladder function, potency and ejaculation were assessed at postoperative clinic visits for men undergoing laparoscopic low or ultra-low anterior resection and abdominoperineal excision of the rectum.
Results  A total of 101 males were identified (median age 62 years: range 20–90 years). Urinary dysfunction was reported by six (6%) patients. Six (6%) patients had sexual dysfunction, manifesting as retrograde ejaculation in four patients and erectile dysfunction in a further two patients.
Conclusions  The low rates of sexual dysfunction in this unit may be attributable to pelvic dissection only being undertaken by experienced, dedicated laparoscopic colorectal surgeons. Laparoscopic restorative surgery for rectal cancer has been performed here only since 2001 after considerable experience accrued in operating on benign rectal disease and colon cancer. Studies from elsewhere reporting poorer functional outcomes have probably included a significant number of patients on the surgeons'learning curve'.     

Laparoscopic and open surgery in rectal cancer patients in Germany: short and long-term results of a large 10-year population-based cohort

Rectal cancer is frequent in Germany and worldwide. Several studies have assessed laparoscopic surgery as a treatment option and most have shown favorable results. However, long-term oncologic safety remains a controversial issue. The current dataset derives from 30 clinical cancer registries in Germany and includes 16,378 patients diagnosed with rectal cancer between 2007 and 2016. Outcomes were 90-day mortality, overall survival (OS), local recurrence-free survival (RFS) and relative survival of patients treated with either open or laparoscopic surgery. Multivariable logistic regression was used to evaluate factors that affected the probability of a patient undergoing laparoscopic surgery as well as to evaluate short-term mortality. OS and RFS were analyzed by Kaplan–Meier plots and multivariable Cox regression conducted separately for UICC stages I–III, tumor location, and sex as well as by propensity score matching followed by univariable and multivariable survival analysis. Of 16,378 patients, 4540 (27.7%) underwent laparoscopic surgery, a trend which increased during the observation period. Patients undergoing laparoscopy attained better results for 90-day mortality (odds ratio, OR 0.658, 95% confidence interval, CI 0.526–0.822). The 5-year OS rate in the laparoscopic group was 82.6%, vs. 76.6% in the open surgery group, with a hazard ratio (HR) of 0.819 in multivariable Cox regression (95% CI 0.747–0.899, p < 0.001). The laparoscopic group showed a better 5-year RFS, with 81.8 vs. 74.3% and HR 0.770 (95% CI 0.705–0.842, p < 0.001). The 5-year relative survival rates were also in favor of laparoscopy, with 93.1 vs. 88.4% (p = 0.012). Laparoscopic surgery for rectal cancer can be performed safely and, according to this study, is associated with an oncological outcome superior to that of the open procedure. Therefore, in the absence of individual contraindications, it should be considered as a standard approach.     

Results of a multicenter study of 1,057 cases of rectal cancer treated by laparoscopic surgery

Background  The aim of this study was to clarify the feasibility of laparoscopic surgery for rectal cancer retrospectively in 28 centers throughout Japan. Methods  Between May 1994 and February 2006, 1,057 selected patients with rectal cancer underwent laparoscopic surgery. All the data regarding the patient details, and operative and postoperative outcome were collected retrospectively. Results  Mean follow-up was 30 months. Procedures included anterior resection in 938, abdominoperineal resection in 107, Hartmann’s procedure in 10, and others in two patients. Conversion to open procedures occurred in 77 patients (7.3%). Postoperative surgical complications developed in 235 patients (22.2%), including anastomotic leakage in 84 (9.1%). Median length of postoperative hospital stay was 15 days (7–271 days). Patients with upper rectal cancer had shorter hospital stay than those with lower rectal cancer (14 versus 18 days, p < 0.01). Tumor–node–metastases (TNM) stage included 83(7.9%) stage 0, 495 (46.8%) stage I, 197 (18.6%) stage II, 230 (21.8%) stage III, and 52 (4.9%) stage IV. Recurrence was developed in 67 patients (6.6%) of the 1,011 curatively treated patients. Local recurrence occurred in 11 patients (1.0%). There was no port-site metastasis. Of the 1,011 curatively treated patients, the 3-year disease-free survival rate was 100% in stage 0, 94.6% in stage I, 82.1% in stage II, and 79.7% in stage III. Conclusions  Laparoscopic surgery is feasible and safe in selected patients with rectal cancer, with favorable short-term and mid-term outcome.     

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??Laparoscopic intersphincteric resection versus open intersphincteric resection in sphincter-preserving surgery of ultralow rectal carcinom??A Meta-analysis LI Chang-rong??LI Wei-feng??LI Hong-lang. Department of Gastrointestinal Surgery??the Second Affiliated Hospital of Nanchang University??Nanchang330006??China
Corresponding author??LI Hong-lang??E-mail??lihonglang6802@163.com
Abstract Objective To compare the clinical safety and efficacy of laparoscopic intersphincteric resection versus open intersphincteric resection in sphincter-preserving surgery of ultralow rectal carcinom. Methods Studies comparing laparoscopic intersphincteric resection with open intersphincteric resection in sphincter-preserving surgery of ultralow rectal carcinoma were retreived from PubMed??Medline??Ovid??China National Knowledge Infrastructure (CNKI) and Wanfang databases by 2014. The methodological quality of the selected studies was assessed to determine studies suitable for inclusion. Meta-analysis was performed by fixed or random effects model. Results Ten observational studies with a total of 939 patients (501 patients in laparoscopic surgery groups and 438 patients in open surgery groups) were identified. Compared with open surgery group??laparoscopic surgical operation time extended??WMD=36.28??95%CI 4.30—68.26??P<0.05????intraoperative bleeding reduced (WMD=-95.84??95%CI -123.64—-68.03??P??0.01)??time of bowel function recovering??WMD=-1.05??95%CI -1.70—-0.41??P<0.01????normal dieting (WMD=-0.95??95%CI -1.34—-0.55??P<0.01) and hospital staying (WMD=-2.43??95%CI -3.95—-0.92??P<0.01) shortened respectively. Incidence of overall postoperative complication??OR=0.60??95%CI 0.44—0.84??P<0.01????positiving circumferential resection margin (OR=2.49??95%CI 1.12—5.54??P<0.05) and wound infection??OR=0.20??95%CI 0.07—0.60??P<0.01?? reduced respectively. No statistically significant difference was found on the local recurrence rate??distant metastasis??anastomotic leakage??postoperative intestinal obstruction between the two groups (P>0.05). Conclusion Laparoscopic-assisted intersphincteric resection is a technically feasible and safe alternative to open surgery with better short-term and long-term postoperative outcomes for ultralow rectal carcinoma.     

Laparoscopic versus open total mesorectal excision: a comparative study on short-term outcomes. A single-institution experience regarding anterior resections and abdominoperineal resections

BACKGROUND: Laparoscopic total mesorectal excision (TME) is being used in rectal cancer more frequently. The aim of this study was to analyze the differences in short-term outcomes between open and laparoscopic TME. METHODS: In this nonrandomized consecutive study, the short-term outcomes of 100 patients undergoing TME for proven rectal cancer were analyzed. RESULTS: Two groups of 50 patients underwent an open or laparoscopic TME for rectal cancer. Both groups were comparable. Laparoscopic surgery took longer to perform (250 vs. 197.5 min, p < 0.01), but was accompanied by less blood loss (350 vs. 800 ml, p < 0.01). Enteric function recovered sooner after laparoscopy. The numbers of major and minor complications were comparable between both groups, although fewer patients had major complications in the laparoscopic group (6 vs. 15 patients, p = 0.03). Hospital stay was shorter for patients who underwent a laparoscopic abdominoperineal resection (10 vs. 12 days, p = 0.04). Median follow-up was 17 months for the laparoscopic group and 22 months for the open group. Survival analyses between the groups showed no statistical difference in disease-free and overall survival. CONCLUSION: This study shows that laparoscopic TME for rectal cancer is a safe and feasible technique with some short-term benefits over open TME.     

Laparoscopic-Assisted Versus Open Abdominoperineal Resection for Low Rectal Cancer: A Prospective Randomized Trial

Background  Laparoscopic resection of colonic cancer has been shown to improve postoperative recovery without jeopardizing tumor clearance and survival, but information on low rectal cancer is scarce. The aim of this randomized trial was to compare postoperative recovery between laparoscopic-assisted versus open abdominoperineal resection (APR) in patients with low rectal cancer. Recurrence and survival data were also recorded and compared between the two groups. Methods  Between September 1994 and February 2005, 99 patients with low rectal cancer were randomized to receive either laparoscopic-assisted (51 patients) or conventional open (48 patients) APR. The median follow-up time of living patients was about 90 months for both groups. The primary and secondary endpoints of the study were postoperative recovery and survival, respectively. Data were analyzed by intention-to-treat principle. Results  The demographic data of the two groups were comparable. Postoperative recovery was better after laparoscopic surgery, with earlier return of bowel function (P < .001) and mobilization (P = .005), and less analgesic requirement (P = .007). This was at the expense of longer operative time and higher direct cost. There were no differences in morbidity and operative mortality rates between the two groups. After curative resection, the probabilities of survival at 5 years of the laparoscopic-assisted and open groups were 75.2% and 76.5% respectively (P = .20). The respective probabilities of being disease-free were 78.1% and 73.6% (P = .55). Conclusions  Laparoscopic-assisted APR improves postoperative recovery and seemingly does not jeopardize survival when compared with open surgery for low rectal cancer. A larger sample size is needed to fully assess oncological outcomes. Part of this paper has been presented as free paper in the Congress of Endoscopic and Laparoscopic Surgeons of Asia 2006, October 18–21, 2006, Seoul, Korea. An erratum to this article can be found at     

Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma

Objectives  The aim was to conduct a meta-analysis of the randomized evidence to determine the relative merits of laparoscopic assisted (LADG) and open (ODG) distal gastrectomy for proven gastric cancer. Data sources and review methods  A search of the Medline, Embase, Science Citation Index, Current Contents, and PubMed databases identified all randomized clinical trials (RCTs) that compared LADG and OGD and were published in the English language between January 1990 and the end of June 2007. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement. The eight outcome variables analysed were operating time, blood loss, retrieval of lymph nodes, oral intake, hospital stay, postoperative complications, tumor recurrence, and mortality. Random effects meta-analyses were performed using odds ratios (OR) and weighted mean differences (WMD). Results  Four trials were considered suitable for meta-analysis. A total of 82 patients underwent LADG and 80 had ODG. For only one of the eight outcomes, the summary point estimates favoured LADG over ODG; there was a significant reduction of 104.26 ml in intraoperative blood loss for LADG (WMD, −104.26, 95% confidence interval (CI) −189.01 to −19.51; p = 0.0159). There was however a 83.08 min longer duration of operating time for the LADG group compared with the ODG group (WMD 83.08, 95% CI 40.53 to 125.64; p = 0.0001) and significant reduction in lymph nodes harvesting of 4.34 lymph nodes in the LADG group (WMD −4.3, 95% CI −6.66 to −2.02; p = 0.0002). Other outcome variables such as time to commencement of oral intake (WMD −0.97, 95% CI −2.47 to 0.54; p = 0.2068), duration of hospital stay (WMD −3.32, 95% CI −7.69 to 1.05; p = 0.1365), rate of complications (OR 0.66, 95% CI 0.27 to 1.60; p = 0.3530), mortality rates (OR 0.94, 95% CI 0.21 to 4.19; p = 0.9363), and tumor recurrence (OR 1.08, 95% CI 0.42 to 2.79; p = 0.8806) were not found to be statistically significant for either group. However, for commencement of oral intake, duration of hospital stay, and complication rate, the trend was in favor of LADG. Conclusion  LADG was associated with a significantly reduced rate of intraoperative blood loss, at the expense of significantly longer operating time and significantly reduced lymph node retrieval compared to its open counterpart. Mortality and tumor recurrence rates were similar between the two groups. Furthermore, time to commencement of oral intake, postprocedural discharge from hospital, and perioperative complication rate, although not significantly different between the two groups, did suggest a positive trend toward LADG. Based on this meta-analysis, the authors cannot recommend the routine use of LADG over ODG for the treatment of distal gastric cancer. However, significant limitations exist in the interpretation of this data due to the limited number of published randomised control trials, the small sample sizes to date, and the limited duration of follow up. Further large multicentre randomized controlled trials are required to delineate significantly quantifiable differences between the two groups.     

Laparoscopic rectal resection with anal sphincter preservation for rectal cancer

Background Total mesorectal excision (TME) is the surgical gold standard treatment for middle and low third rectal carcinoma. Laparoscopy has gradually become accepted for the treatment of colorectal malignancy after a long period of questions regarding its safety. The purposes of this study were to examine prospectively our experience with laparoscopic TME and high rectal resections, to evaluate the surgical outcomes and oncologic adequacy, and to discuss the role of this procedure in the treatment of rectal cancer. Methods Between December 1992 and December 2004, all patients who underwent elective laparoscopic sphincter preserving rectal resection for rectal cancer were enrolled prospectively in this study. Data collection included preoperative, operative, postoperative and oncologic results with long-term follow-up. Results A total of 218 patients were operated on during the study period: 142 patients underwent laparoscopic TME and 76 patients underwent anterior resection. Of the TME patients, 122 patients were operated using the double-stapling technique, and 20 patients underwent colo-anal anastomosis with hand-sewn sutures. Mean operative time was 138 min (range, 107–205), and mean blood loss was 120 ml (range, 30–350). Conversion to open surgery occurred in 26 cases (12%). Mortality rate during the first 30 days was 1%. Anastomotic leaks were observed in 10.5% of the patients. Of these, 61.9% needed reoperation and diverting stoma, and the rest were treated conservatively. Three patients had postoperative bleeding requiring relaparoscopy. Other minor complications (infection and urinary retention) occurred in 9.1% of patients. Mean ambulation time and mean hospital stay were 1.6 days (range, 1–5) and 6.4 days (range, 3–28) , respectively. Patients were followed for a mean period of 57 months. No port site metastases were observed during follow-up. The recurrence rate was 6.8 %. Overall survival rate was 67% after 5 years and 53.5% after 10 years. Conclusion Laparoscopic anterior resection and TME with anal sphincter preservation for rectal cancer is feasible and safe. The short- and long-term outcomes reported in this series are comparable with those of conventional surgery.     

Laparoscopic Colonic Resection for Rectosigmoid Colonic Tumours: A Retrospective Analysis and Comparison with Open Resection

Laparoscopic approach for treatment of colorectal malignancy is gaining acceptance gradually; however the benefits of laparoscopic surgery in colonic and rectal tumours is still open to debate. This study aims at a retrospective analysis of operative and short term outcome of patients with rectosigmoid tumours. A retrospective analysis of operative, postoperative and short-term outcome of 62 patients who underwent laparoscopic colorectal resection for cancer of rectosigmoid region were compared with a same number of parameters-matched patients who underwent open colorectal resection. Blood transfusion requirement was significantly more in the open group compared to the laparoscopy group (38.7% versus 6.4%, p = 0.001). ICU stay was less in the laparoscopy group (p = <0.05) and they were started on oral liquid diet earlier (p = 0.013). The number of the lymph nodes retrieved, positive distal margin and radial involvement were similar in both groups. The hospital stay was significantly shorter in laparoscopy group (8.4 versus 13.8 days, p < 0.05). Radical operation for rectosigmoid tumors is technically feasible with laparoscopic surgery. Laparoscopic approach is associated with less blood loss, transfusion and significantly less ICU stay. Laparoscopic group recovers early and needs less hospital stay     

Short- and midterm outcomes of laparoscopic surgery compared for 131 patients with rectal and rectosigmoid cancer

Background This study aimed to clarify and compare the short- and midterm surgical outcomes of laparoscopic surgery for rectal and rectosigmoid cancer. Methods Between June 1992 and December 2004, 131 selected patients with cancer of the rectum (n = 60) and rectosigmoid (n = 71) underwent laparoscopic surgery. The indications for laparoscopy included a preoperative diagnosis of T1/T2 tumor in the rectum and T1–T3 tumors in the rectosigmoid. Results The mean follow-up period was 42 months. The procedures included anterior resection for 117 patients, abdominoperineal resection for 11 patients, Hartmann’s procedure for 1 patient, and restorative proctocolectomy for 1 patient. Conversion to an open procedure occurred for four patients (3.1%). Postoperative complications developed in 29 patients (22.1%), including anastomotic leakage in 14 patients (11.8%). The length of hospital stay for the rectal cases was significantly longer than for the rectosigmoid cases (10 vs 7 days; p = 0.0049). The tumor node metastasis (TNM) stages included 0 (n = 14), I (n = 72), II (n = 15), III (n = 29), and IV (n = 1). Recurrences were experienced by 13 patients, including local recurrence (n = 7) and recurrences involving the liver ((n = 2), lung (n = 3), and distant lymph nodes (n = 1). The 5-year disease-free and overall survival rates were, respectively 91.7% and 97.9% for stage I, 86.7% and 90.9% for stage II, and 77.1% and 90.0% for stage III. Conclusions Laparoscopic surgery is feasible and safe for selected patients with rectal or rectosigmoid cancer. The selected patients in this study experienced favorable short- and midterm outcomes.     

腹腔镜手术治疗直肠癌疗效的Meta分析

目的 评价腹腔镜手术治疗直肠癌的疗效.方法 系统检索Medline、Embase、Cochrane中的相关文献,所有检索截止至2010年3月.由2名评价员独立筛选并提取数据资料,对符合纳入标准的研究使用RevMan5软件进行统计分析.对腹腔镜（LR）与开腹（OR）直肠癌手术的术中及术后情况进行比较分析.结果 共检索到1042篇文献摘要,通过筛选最终纳入16个临床对照研究,病例总数2850例,其中LR组1145例,OR组1705例.结果 显示,与OR组相比,LR组手术时间延长（WMD=42.50,95%CI：29.27～55.74,P＜0.05）、淋巴结检出数目减少（WMD=-0.94,95%CI：-1.47～-0.41,P＜0.05）、术中出血量减少（WMD=-158.46,95%CI：-221.08～-95.84,P＜0.05）、手术死亡率降低（OR=0.40,95%CI：0.18～0.92,P=0.03）、术后并发症发生率降低（OR=0.73,95%CI：0.61～0.87,P＜0.05）、5年总体生存率增高（OR=1.56,95%CI：1.21～2.02,P＜0.05）,两组环周切缘阳性率差异无统计学意义（OR=1.00,95%CI：0.45～2.20,P=1.00）.结论 腹腔镜直肠癌手术的短期和长期疗效均优于开腹手术.     

Interpretation of the Randomized EVAR Trials

Purpose : Laparoscopic surgery for colon cancer has been proven safe, but controversy continues over implementation of laparoscopic technique for rectal cancer. The aim of this study was to compare the long-term outcomes of laparoscopically assisted and open surgery for nonmetastatic colorectal cancer.

Material and methods : From January 2001 to December 2006 all patients with nonmetastatic adenocarcinoma of the colon and rectum were considered for inclusion in this prospective non-randomised trial. The primary endpoint was overall survival, disease free survival and recurrence rate. Analysis was by intention to treat.

Results : A total of 365 resections were performed for nonmetastatic adenocarcinoma of the colon and rectum during the study period. Of those resections, 220 were colonic and 145 were rectal. In the patients with colon cancer 119 (54.1%) were operated laparoscopically and 101 (45.9%) by open surgery, in the patients with rectal cancer 75 (51.7%) were treated by laparoscopy and 70 (48.3%) by open technique. No statistically significant difference was found between the laparoscopic and open group regarding 5-year overall survival (p = 0.17 for colon cancer, p = 0.60 for rectal cancer), 5-year disease free survival (p = 0.25 for colon cancer, p = 0.81 for rectal cancer) and overall recurrence (p = 0.78 for colon cancer, p = 0.79 for rectal cancer). With respect to the tumor stage, in rectal cancer the probability of 5-year disease free survival was significantly higher in the laparoscopic group in stage III (p = 0.03).

Conclusion : Laparoscopic surgery for colorectal cancer is an oncologically safe procedure that is associated with a survival and recurrence rate equal to open surgery.     

Robotic resection compared with laparoscopic rectal resection for cancer: systematic review and meta-analysis of short-term outcome

Aim The study aimed to compare robotic rectal resection with laparoscopic rectal resection for cancer. Robotic surgery has been used successfully in many branches of surgery but there is little evidence in the literature on its use in rectal cancer. Methods We performed a systematic review of the available literature in order to evaluate the feasibility, safety and effectiveness of robotic versus laparoscopic surgery for rectal cancer. We compared robotic and laparoscopic surgery with respect to twelve end‐points including operative and recovery outcomes, early postoperative mortality and morbidity, and oncological parameters. A subgroup analysis of patients undergoing full‐robotic or robot‐assisted rectal resection and robotic total mesorectal excision was carried out. All aspects of Cochrane Handbook for systematic reviews and Preferred Reporting Items for Systematic Reviews and Metanalysis (PRISMA) statement were followed to conduct this systematic review. Comprehensive electronic search strategies were developed using the following electronic databases: PubMed, EMBASE, OVID, Medline, Cochrane Database of Systematic Reviews, EBM reviews and CINAHL. Randomized and nonrandomized clinical trials comparing robotic and laparoscopic resection for rectal cancer were included. No language or publication status restrictions were imposed. A data‐extraction sheet was developed based on the data extraction template of the Cochrane Group. The statistical analysis was performed using the odd ratio (OR) for categorical variables and the weighted mean difference (WMD) for continuous variables. Results Eight non randomized studies were identified that included 854 patients in total, 344 (40.2%) in the robotic group and 510 (59.7%) in the laparoscopic group. Meta‐analysis suggested that the conversion rate to open surgery in the robotic group was significantly lower than that with laparoscopic surgery (OR = 0.26, 95% CI: 0.12–0.57, P = 0.0007). There were no significant differences in operation time, length of hospital stay, time to resume regular diet, postoperative morbidity and mortality, and the oncological accuracy of resection. Conclusion Robotic surgery for rectal cancer has a lower conversion rate and a similar operative time compared with laparoscopic surgery, with no difference in recovery, oncological and postoperative outcomes.     

Laparoscopy decreases complications for obese patients undergoing elective rectal surgery

Introduction

While there are many reported advantages to laparoscopic surgery compared to open surgery, the impact of a laparoscopic approach on postoperative morbidity in obese patients undergoing rectal surgery has not been studied. Our goal was to determine whether obese patients undergoing laparoscopic rectal surgery experienced the same benefits as non-obese patients.

Methods

We identified patients undergoing rectal resections using the National Surgical Quality Improvement Project Participant Use Data File. We performed multivariable analyses to determine the independent association between laparoscopy and postoperative complications.

Results

A total of 26,437 patients underwent rectal resection. The mean age was 58.5 years, 32.6 % were obese, and 47.2 % had cancer. Laparoscopic procedures were slightly less common in obese patients compared to non-obese patients (36.0 vs. 38.2 %, p = 0.0006). In unadjusted analyses, complications were lower with the laparoscopic approach in both obese (18.9 vs. 32.4 %, p < 0.0001) and non-obese (15.6 vs. 25.3 %, p < 0.0001) patients. In a multivariable analysis controlling for potential confounders, the risk of postoperative complications increased as the degree of obesity worsened. The likelihood of experiencing a postoperative complication increased by 25, 45, and 75 % for obese class I, obese class II, and obese class III patients, respectively. A laparoscopic approach was associated with a 40 % decreased odds of a postoperative complication for all patients (OR 0.60, 95 % CI 0.56–0.64).

Conclusion

Laparoscopic rectal surgery is associated with fewer complications when compared to open rectal surgery in both obese and non-obese patients. Obesity was an independent risk factor for postoperative complications. In appropriately selected patients, rectal surgery outcomes may be improved with a minimally invasive approach.