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.     

Long-term evaluation of oncologic and functional outcomes after laparoscopic open-assisted radical cystectomy: a matched-pair analysis

Purpose

To evaluate peri- and postoperative morbidity, and long-term oncologic and functional results of our laparoscopic radical cystectomy (LRC) technique, comparing it with our standard open approach.

Methods

Between 2000 and 2010, 54 patients underwent LRC for urothelial cell carcinoma of the bladder in two academic hospitals. The procedures were performed by two surgeons. Patients were matched 1:1 with patients who underwent open RC in the same years by the same surgical team. Differences in peri- and postoperative complications across the two groups were assessed using Wilcoxon’s rank-sum or χ ² test. Kaplan–Meier curves, log-rank tests and Cox regression models were constructed to assess differences in recurrence-free survival on long-term follow-up between the two groups.

Results

Laparoscopic radical cystectomy was significantly associated with lower blood loss (p < 0.0001) and less frequent postoperative ileus (p = 0.03). Regarding more serious postoperative complications, no difference was found across the two cohorts. Median oncologic follow-up was 42 months (IQR 12–72 months) in the LRC cohort and 18 months (IQR 8–27 months) in patients undergoing open radical cystectomy (ORC). No statistically significant difference in recurrence-free survival was observed between the two groups (log rank p = 0.677). On univariate Cox regression, the surgical approach used was not significantly associated with risk of recurrence.

Conclusions

We found that LRC is safe and associated with lower blood loss and decreased postoperative ileus compared with ORC. Moreover, on long-term oncologic follow-up, LRC appeared non-inferior to ORC with no significant difference in recurrence-free survival. Nonetheless, these results must be confirmed by larger series and stronger long-term follow-up data are needed.     

Long-term oncological outcomes of laparoscopic partial nephrectomy

PURPOSE OF REVIEW: Widespread applicability of laparoscopic partial nephrectomy will only occur when oncologic outcomes are critically analyzed in the context of published open partial nephrectomy series. The most recent oncologic outcomes of laparoscopic partial nephrectomy are reviewed. RECENT FINDINGS: Oncologic outcomes at 5 years of follow-up have recently been published for laparoscopic partial nephrectomy. The low margin positivity demonstrated by earlier series has translated into cancer-specific survival rates comparable to open partial nephrectomy. Local and distant recurrence rates are acceptably low, and in line with both contemporary and historical open partial nephrectomy pT1 controls. SUMMARY: Laparoscopic partial nephrectomy is becoming a standard of care for selected small renal tumors at high volume centers. While the goal of minimizing morbidity is laudable, ultimately its effectiveness as a cancer operation is the most important criterion. At high volume centers, in expert hands this technically advanced procedure has been shown to duplicate the oncologic outcomes of open surgery. The indolent natural history of small renal masses mandates that we await 10-year data, as well as corroboration of these favorable results at multiple institutions.     

腹腔镜与开腹直肠癌根治术肿瘤切除完整性及长期疗效的比较

目的：比较腹腔镜与开腹直肠癌根治术的肿瘤切除完整性及长期预后。方法回顾性分析2005年7月至2011年12月在上海第二军医大学长海医院肛肠外科行直肠癌根治手术的1184例患者的临床及随访资料,根据其手术方式分为腹腔镜手术组（腹腔镜组,104例）和开腹手术组（开腹组,1080例）,对两组患者的一般情况、术中清扫淋巴结数目、远切缘距离、吻合口相关并发症发生率、术后无病生存率及总生存率进行比较。结果腹腔镜组与开腹组患者的临床资料具有可比性,两组平均清扫淋巴结数目（15．5枚/例比14．4枚/例）、远切缘平均距离（2．5 cm比2．1 cm）及吻合口相关并发症发生率[1．9％（2/104）比1．9％（20/1080）]差异均无统计学意义（P＞0．05）;腹腔镜组术后3年和5年无病生存率分别为79．0％和69．3％,开腹组分别为78．0％和72．5％,差异无统计学意义（P＞0．05）;腹腔镜组术后3年和5年总体生存率分别为93．5％和81．2％,开腹组分别为87．6％和80．7％,差异亦无统计学意义（P＞0．05）。结论直肠癌腹腔镜手术肿瘤切除完整性和远期疗效与开腹手术相当。     

腹腔镜与开腹结直肠癌切除术肿瘤学与形态学根治性评价

目的评价腹腔镜和同期开腹直肠癌根治术在肿瘤学结果的差异;观察腹腔镜形态学下结直肠解剖标志及关键血管区域淋巴清扫程度。方法连续地将符合纳入研究标准的50例结直肠癌患者分别进入腹腔镜组（LO组,27例）和开腹组（CO组,23例）,前瞻性比较两组患者肿瘤学结果;观察腹腔镜形态学下解剖标志及血管区骨骼化,评价区域淋巴清扫效果。结果LO组平均手术时间略短于CO组但差异无统计学意义,LO组术中失血量显著少于CO组;两组外科肿瘤学结果比较均差异无统计学意义（P〉0．05）,标本切缘均阴性;腹腔镜形态下特殊恒定的解剖标志利于选择合适的解剖学平面及融合筋膜间隙进行游离从而实施可靠、安全的完整肿块切除、血管骨骼化及关键区域淋巴结清扫;腹腔镜组患者术后与开腹组相比,术后前3天内腹腔引流量差异无统计学意义（P〉0．05）,术后功能恢复指标及总住院时间均显著减少（P〈0．05）。结论与传统开腹手术相比,腹腔镜结直肠手术安全、可行,达到同等肿瘤学根治效果;腹腔镜形态学下观察发现肿块切除完整,血管解剖结构清晰,区域淋巴清扫满意;平均手术时间短,失血量少,机体功能恢复快,总住院时间短。     

Chronic kidney disease and radical cystectomy for bladder cancer: perioperative and oncologic outcomes in 1,214 patients

Introduction and ObjectiveTo assess the impact of chronic kidney disease (CKD) on outcomes after radical cystectomy (RC) in patients with bladder cancer treated within a high-volume tertiary referral center.MethodsWe identified 1,214 patients who underwent RC with intent to cure from 2009 to 2019. The Modification of Diet in Renal Disease (MDRD) GFR (ml/min/1.73 m²) was calculated and patients were categorized by baseline GFR: Group A = GFR > 60, Group B = GFR > 30–59 and Group C = GFR < 30. Pre-, intra- and postoperative characteristics, oncological outcomes, and 90-day perioperative outcomes were compared. Multivariable logistic regression was used to control for confounding variables.ResultsWe identified 722 (59.5%) patients in Group A, 448 (36.9%) in Group B, and 44 (3.6%) in Group C. Patients with worse CKD were older and had significantly worse overall comorbidity (all P < 0.001). Neoadjuvant chemotherapy was used in 352 patients (29%), including 182 (25.2%) in Group A, 153 in Group B (35.3%), and 12 in Group C (27.3%). On univariate analysis, worse CKD was associated with higher pathologic stage, lymph node metastases and positive soft tissue margins (all P < 0.0001). The rates of blood transfusion, 90-day complications and readmissions were higher in patients with worse CKD (P < 0.0001, P = 0.02, P = 0.04, respectively). Patients with worse CKD had worse overall survival (77% vs. 73% vs. 55%, P < 0.0001). On multivariable analysis, worse CKD was independently associated with adverse pathology (≥pT3 or node positive) (OR = 6.96, 95%CI 3.20–15.12), 90-day readmissions (OR 2.09, 95%CI 1.11–3.94) and perioperative transfusion (OR 2.08, 95%CI 1.05–4.11). Receipt of neoadjuvant chemotherapy was significantly associated with a decreased risk of adverse pathology (OR 0.51, 95%CI 0.36–0.74) and increased risk of transfusion (OR 2.24, 95%CI 1.70–2.96), but not with mortality, complications, readmissions or length or stay.ConclusionCKD is prevalent in patients undergoing radical cystectomy. We found CKD to be independently associated with a higher likelihood of adverse pathology, 90-day readmissions, and transfusion.     

Laparoscopic radical nephrectomy for advanced kidney cancer

The management of advanced renal cell carcinoma (RCC) continues to evolve. With the advent of laparoscopic radical nephrectomy (LRN), minimally invasive approaches to kidney cancer have developed. Laparoscopic resection of locally advanced RCC yields a similar cancer-control rate with the advantage of decreased morbidity. Although cytoreductive LRN is a technically challenging procedure, it may be completed safely in selected patients. Further prospective study of the role of LRN for advanced RCC is warranted.     

Comparison of short-term and oncologic outcomes of robotic and laparoscopic resection for mid- and distal rectal cancer

Surgical Endoscopy - Laparoscopic rectal resection with total mesorectal excision is a technically challenging procedure, and there are limitations in conventional laparoscopy. A surgical robotic...     

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.     

腹腔镜肾癌根治性切除术后的护理体会

目的探讨腹腔镜肾癌根治性切除术的护理要点。方法总结4例腹腔镜肾癌根治性切除术及9例后腹腔镜肾癌根治性切除术的护理经验,制定手术前后护理程序。结果 13例肾癌患者均手术成功,康复出院。结论做好肾癌患者的术前心理辅导,积极术前准备,术后密切监测患者的护理指标变化,随时做出相应处理,可帮助患者早日治愈康复。     

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.     

Influence of conversion on the perioperative and oncologic outcomes of laparoscopic resection for rectal cancer compared with primarily open resection

Background

This study aimed to evaluate the influence of conversion on perioperative and short- and long-term oncologic outcomes in laparoscopic resection for rectal cancer and to compare these with those for an open control group.

Methods

The data of 276 consecutive patients who underwent surgery for rectal cancer between 2006 and 2010 at a single institution were prospectively collected. Of the 276 patients, 114 underwent primarily open surgery, and 162 underwent laparoscopic surgery (on an intention-to-treat basis). Of the 162 laparoscopic patients, 38 (23.5 %) underwent conversion to open surgery. The three groups of patients were compared: the conversion surgery group, the open surgery group, and the completed laparoscopy surgery group.

Results

The converted patients had more wound infections (18.4 vs 4.8 %, p = 0.009), but the wound infection rate in the primarily open group also was significantly higher than in the laparoscopic resection group (p = 0.007). No further differences in perioperative morbidity, including anastomotic leakage, were found. The perioperative 30-day mortality rate was comparable between all the groups (0.6 vs 2.6 vs 2.6 %, nonsignificant difference). The oncologic parameters such as number of harvested lymph nodes and rate of R0 resection were equal in all the groups. The completed laparoscopy group had a shorter hospital stay [12 vs 16 days in the primarily open group (p = 0.02) vs 15 days in the converted group (p = 0.03)]. The rates for survival, local recurrence (4.5 vs 3 vs 3 %), and metachronous metastasis (10.1 vs 9.3 vs 9 %) did not differ significantly between the three groups after a period of 3 years.

Conclusion

Conversion to open surgery in laparoscopic rectal resection has no negative effect on perioperative or long-term oncologic outcome.     

Surgical and oncologic outcomes between laparoscopic and radical abdominal hysterectomy for IB1-IIA2 cervical cancer

ObjectiveTo compare sugrical and survival outcomes between laparoscopic radical hysterectomy (LRH) and radical abdominal hysterectomy (RAH).MethodsAll the patients with IB1-IIA2 cervical cancer who performed LRH or RAH in Fudan University Shanghai Cancer Center between 1/2016 and 12/2017 were retrospectively analyzed.ResultsThere were no significant differences between LRH and RAH groups except deep stromal invasion (35.2% vs 54.4%, p = 0.000), operating time (232.3 ± 61.9 min vs. 106.7 ± 36.2 min, p = 0.000), blood loss (169.5 ± 96.2 ml vs. 219.6 ± 149.3 ml, p = 0.000), and lymph node counts (21.1 ± 7.1 vs. 23.2 ± 8.7 min, p = 0.012). The LRH group displayed poorer disease-free survival (DFS) (5-year rate, 79.4% vs. 90.0%; p = 0.046) and overall survival (OS) (5-year rate, 74.7% vs. 90.0%; p = 0.026) compared to the RAH group. On multivariate analysis, LRH was an independent risk factor for DFS (hazard ratio, 0.377; 95% confidence interval [CI], 0.227–0.625; p = 0.000) and OS (hazard ratio, 0.434; 95% CI, 0.254–0.740; p = 0.003).ConclusionsLRH affected the survival of cervical cancer patients with tumor size >2 cm (p < 0.05). Adjuvant therapy could not improve the prognosis of laparoscopic patients (p < 0.05).     

新辅助治疗后腹腔镜直肠癌根治术的中短期疗效

目的：探讨中低位直肠癌患者在新辅助治疗后行腹腔镜手术的安全性、可行性。 方法：回顾性分析41例新辅助治疗后行腹腔镜手术的中低位直肠癌患者（观察组）与同期48例单纯腹腔镜手术（对照组）中低位直肠癌患者的临床资料。比较两组患者的手术相关指标、术后恢复情况及术后并发症发生率。 结果：两组患者术前条件具有可比性,两组均无手术相关死亡患者。观察组淋巴结清除数明显低于对照组（8.3 vs. 15.2,P<0.01）,其余手术相关指标、术后恢复情况以及术后并发症发生率两组间差异均无统计学意义（均P>0.05）。 结论：腹腔镜直肠癌根治术在行新辅助治疗后的中低位直肠癌患者中应用是安全、可行的。     

腹腔镜和开腹直肠癌根治术的安全性及远期疗效比较

目的 探讨腹腔镜和开腹直肠癌根治术的安全性及远期疗效的差异.方法 回顾性分析2000年1月至2008年12月福建医科大学附属协和医院收治的602例行直肠癌根治术患者的临床资料.根据手术方式将患者分为腹腔镜组(324例)和开腹组(278例).比较两组患者淋巴结清扫数目、切除肿瘤标本的近端和远端切缘长度、局部复发率、远处转移率、生存率、无瘤生存率等.计数资料采用独立样本t检验,生存率采用寿命表法计算,采用Wilcoxon( Gehan)检验进行比较,复发率和转移率的比较采用x2检验或Fisher确切概率法.结果 腹腔镜组和开腹组平均淋巴结清扫数目分别为(21±8)枚和(21±9)枚,两组比较,差异无统计学意义(t=1.120,P＞0.05)；腹腔镜组和开腹组近端切缘长度分别为(15.1±1.3)cm和(15.0 ±0.8)cm,两组比较,差异无统计学意义(t=1.452,P＞0.05)；远端切缘长度分别为(4.0±1.6)cm和(3.3±1.4)cm,两组比较,差异有统计学意义(t=5.587,P＜0.05).局部总体复发率为5.6％( 34/602),无切口或戳孔种植.腹腔镜组与开腹组局部复发率分别为6.2％( 20/324)和5.0％ (14/278),两组比较,差异无统计学意义(x2=0.363,P＞0.05).总体远处转移率为11.5％ (69/602),腹腔镜组和开腹组远处转移率分别为11.1％ (36/324)和11.9％(33/278),两组比较,差异无统计学意义(x2 =0.085,P＞0.05).腹腔镜组和开腹组3年生存率分别为87.8％和84.9％,5年生存率分别为83.0％和79.3％,两组比较,差异无统计学意义(P＞0.05).两组3年无瘤生存率分别为79.4％和79.7％,5年无瘤生存率分别为69.2％和73.1％,两组比较,差异无统计学意义(P＞0.05).本组随访率为81.2％(489/602),49例患者死亡,其中腹腔镜组20例,开腹组29例.结论 腹腔镜直肠癌根治术不仅在肿瘤学安全性上是可靠的,而且可以达到和传统开腹手术同样的远期疗效.