Robotic surgery for rectal cancer has grown popular in recent years and has primarily used the da Vinci Surgical System (Intuitive Surgical, CA, USA; da Vinci). In 2020, Japan introduced the hinotori™ Surgical Robot System (Medicaroid, Kobe, Japan; hinotori). We report our initial surgical experiences with robotic surgery using hinotori for rectal cancer and its feasibility and safety comparing with da Vinci.

A single-institution retrospective study was conducted. Between November 2022 and November 2023, 38 and 96 patients with rectal cancer underwent robotic surgery using hinotori and da Vinci, respectively. The primary endpoint was the incidence of postoperative complications of the Clavien-Dindo classification (CD) grade ≥ II within postoperative 30 days. Secondary endpoints included surgical and console time, blood loss, conversion to other approaches, number of dissected lymph nodes, and postoperative hospital stay. A propensity score matching (PSM) analysis was used to adjust for imbalance in baseline characteristics.

After PSM, a total of 76 patients (hinotori: 38, da Vinci: 38) were included. Compared to the da Vinci group, the hinotori group showed a similar postoperative complication rate of CD ≥ II (15.8% vs. 18.4%), comparable operative time (280.5 vs. 258 min), comparable console time (166 vs. 156 min), and less blood loss (9 vs. 17.5 mL, p = 0.025). There was no conversion in either group. The number of dissected nodes and postoperative stay were similar between the two groups.

Our findings support that robotic surgery for rectal cancer using hinotori is as safe as surgery performed using the da Vinci system.

Conventional laparoscopic surgery (CLS) for rectal cancer may sometimes be difficult. Robot-assisted laparoscopic surgery (RALS) is expected to overcome these technical challenges of CLS and provide better short-term outcomes. However, previous randomized controlled trials indicated that the safety and feasibility of RALS compared to CLS remain controversial; therefore, we assessed the safety and feasibility of RALS for rectal cancer compared with CLS.

This study retrospectively reviewed 702 patients who had undergone anterior resection by CLS or RALS for rectal malignancies from January 2009 to December 2023. Among the patients, 313 and 75 were included in the CLS and RALS groups, respectively. Short- and midterm outcomes of the two groups were compared after performing propensity score matching analysis (PSM) to adjust for patient and tumor characteristics.

A total of 140 and 70 patients in the CLS and RALS groups, respectively, were matched using PSM. The bleeding amount and C-reactive protein (CRP) levels on postoperative days 1 and 3 were significantly lower, the operation time was longer, and the postoperative hospital stay was significantly shorter in the RALS group than in the CLS group. The Kaplan-Meier curves for cause-specific survival, relapse-free survival, and the cumulative incidence of local recurrence demonstrated no difference between the two groups.

RALS for rectal cancer provided superior outcomes to CLS in terms of the bleeding amount, postoperative CRP levels, and postoperative hospital stay. The midterm oncological outcomes in RALS were comparable to those in CLS.

This multi-centric real-world study was carried out to assess the perioperative and histopathological clinical outcomes of rectal resections employing open, laparoscopic, and robotic-assisted techniques. A retrospective chart review was undertaken for patients who underwent rectal resections for Stages I, II, and III rectal cancer (RC) between April 2012 and August 2023. All surgical procedures were performed with the principles of total mesorectal excision (TME) or partial mesorectal excision (for tumors located higher in the rectum). The study analyzed data from 829 patients of which 314 were in the robotic-assisted group (RAS), 206 in the laparoscopic surgery group (LG), and 309 in the open-surgery group (OG). The TNM staging and location of RC were evenly distributed across the three groups. The RAS group had a significantly lower length of hospital stay than LG and OG. Compared to LG and OG, the RAS group had less blood loss and postoperative complications, but significantly longer mean operating room time. The conversion rate of the RAS group was significantly lower than that of the LG group (p = 0.03). In comparison to the OG and LG groups, the RAS group had significantly lower (p < 0.05) rates of positive circumferential resection margin (CRM). Adjuvant treatment was administered in the RAS group significantly earlier (median, 24.5 days, IQR 18-37) compared to the LG (median, 31 days, IQR 23-41) and OG (median, 32.5 days, IQR 27-42). This largest multi‑centric study by the ICRR group has validated the value of a relatively newer technology like RAS in real-world Indian settings for rectal resections.

BackgroundNonoperative management in patients with rectal cancer with complete response to radiation therapy and chemotherapy is of increasing interest. Most of the data on nonoperative management have centered around patients treated with long-course chemoradiotherapy. The ability of short-course radiation-based treatment courses to achieve durable complete responses with sustained organ preservation is less defined. This study updates our institution's long-term experience with nonoperative management following upfront short-course radiation therapy and sequential/consolidation chemotherapy.MethodsWe retrospectively reviewed patients with nonmetastatic rectal cancer treated with sequential short-course radiation therapy and chemotherapy who reached complete response and were subsequently followed with nonoperative management. We report on disease control outcomes, including rates of regrowth and results of salvage surgery. We investigated characteristics associated with local tumor regrowth.ResultsOur study included 52 patients. The 2-year freedom from local regrowth for the entire cohort was 75%. Notably, patients with high-risk disease characteristics at diagnosis exhibited a trend toward a higher rate of local tumor regrowth. No patient with sustained clinical complete response developed metastatic disease. Of the twelve patients undergoing surgical salvage for regrowth of disease, ten were resected with complete/near-complete total mesorectal surgical specimens with negative margins.ConclusionsThe optimal approach to achieving sustained organ preservation through the use of radiation therapy and chemotherapy is not well defined. Our findings show the viability of neoadjuvant therapy incorporating short-course radiation therapy to achieve durable complete responses.

Noninferiority and equivalence trials evaluate whether an experimental therapy's effect on the primary endpoint is contained within an acceptable margin compared with standard of care. The reliability and impact of this conclusion, however, is largely dependent on the justification for this design, the choice of margin, and the analysis population used.

A meta-epidemiological study was performed of phase 3 randomized noninferiority and equivalence oncologic trials registered at ClinicalTrials.gov. Data were extracted from each trial's registration page and primary manuscript.

We identified 65 noninferiority and 10 equivalence trials that collectively enrolled 61 632 patients. Of these, 61 (81%) trials demonstrated noninferiority or equivalence. A total of 65 (87%) trials were justified in the use of a noninferiority or equivalence design either because of an inherent advantage (53 trials), a statistically significant quality-of-life improvement (6 trials), or a statistically significant toxicity improvement (6 trials) of the interventional treatment relative to the control arm. Additionally, 69 (92.0%) trials reported a prespecified noninferiority or equivalence margin of which only 23 (33.3%) provided justification for this margin based on prior literature. For trials with time-to-event primary endpoints, the median noninferiority margin was a hazard ratio of 1.22 (range = 1.08-1.52). Investigators reported a per-protocol analysis for the primary endpoint in only 28 (37%) trials.

Although most published noninferiority and equivalence trials have clear justification for their design, few provide rationale for the chosen margin or report a per-protocol analysis. These findings underscore the need for rigorous standards in trial design and reporting.

The role of laparoscopy in rectal cancer surgery has evolved considerably since the early 2000s. Initial randomized trials, such as COLOR II and COREAN, indicated that laparoscopic approaches offered similar pathological outcomes with better postoperative recovery than open surgery. In contrast, trials like ACOSOG Z6051 and ALaCaRT suggested noninferiority could not be established. Variability in trial outcomes, focusing on either disease-free survival or pathological measures, initially hindered consensus. Long-term analyses have shown no significant difference in disease-free survival between laparoscopic and open approaches. Meta-analyses have reinforced the benefits of laparoscopic surgery, with reduced mortality and similar oncologic effectiveness to open surgery. However, new techniques like transanal TME (TaTME) and robotic approaches have introduced alternatives, though each presents unique challenges, from recurrence rates in TaTME to costs in robotics. While laparoscopy remains the preferred method due to accessibility and outcomes, robotic surgery is expected to gain traction in high-volume centers.

Surgical start time is considered to influence the quality of surgery due to surgeon fatigue. High-quality studies on middle and low rectal cancer are lacking. The analysis aims to find out the influence of surgical start time on the quality of surgery for middle and low rectal cancer, and whether robotic surgery could avoid the influence.

This study was a post hoc analysis of the REAL (robotic vs. laparoscopic surgery for middle and low rectal cancer) study, a multicenter, randomized, controlled, unblinded, parallel group, superiority trial. This analysis included the modified intention-to-treat population of the REAL study, who were divided into Group I (the surgeon's first surgery of the day), Group II (the surgeon's second surgery of the day), and Group III (the surgeon's third and subsequent surgeries of the day) based on surgical information registered in the REAL study. The primary outcome was the percentage of patients with a positive circumferential resection margin. The second outcomes were the macroscopic completeness of resection the incidence of intraoperative complications and 30-day postoperative complications.

A total of 1171 patients from the REAL study were included and divided into three groups: 547 (46.7%) in Group I (the surgeon's first surgery), 420 (35.9%) in Group II (the surgeon's second surgery), and 204 (17.4%) in Group III (the surgeon's third and subsequent surgeries). There was a lower percentage of circumferential resection margin (CRM)-positive patients in Group I (3.9%) than in Group II (6.6%, unadjusted P = 0.069) and Group III (8.1%, unadjusted P = 0.027, adjusted P = 0.081). Group I also had fewer intraoperative complications (5.3%) than Group II (8.3%, unadjusted P = 0.060) and Group III (9.3%, unadjusted P = 0.046, adjusted P = 0.138). Macroscopic completeness of resection was not significantly different among the three groups (complete rate: Group I vs. Group II, 94.9% vs. 92.4%, unadjusted P = 0.254; Group I vs. Group III, 94.9% vs. 92.6%, unadjusted P = 0.334; Group II vs. Group III, 92.4% vs. 92.6%, unadjusted P = 0.488). The incidence of 30-day postoperative complications showed no significant difference among the three groups (Group I vs. Group II, 18.5% vs. 20.0%, unadjusted P = 0.547; Group I vs. Group III, 18.5% vs. 22.1%, unadjusted P = 0.268; Group II vs. Group III, 20.0% vs. 22.1%, unadjusted P = 0.551). The quality of robotic surgery was not significantly influenced by surgical start time. For laparoscopic surgery, Group I had a lower CRM positivity rate (4.3%) than Group II (9.4%, unadjusted P = 0.029, adjusted P = 0.087) and Group III (10.4%, unadjusted P = 0.031, adjusted P = 0.047).

According to this post hoc analysis of the REAL study, for middle and low rectal cancer surgery, surgical start time could influence surgical quality by affecting surgeon fatigue. Surgeries start later in a day bring worse quality compared to those early in a day. Robotic surgery could reduce this influence to some extent, while laparoscopic surgery is more susceptible.

In this article, we provide an important commentary on the original study Lu et al, which offers insight into the surgical efficacy of transanal total mesorectal excision (TaTME) vs laparoscopic total mesorectal excision (LapTME) in the management of low-lying locally advanced rectal cancer (LARC). We focus specifically on the rate of postoperative complications between the two using existing data from the literature. We additionally introduce robotic total mesorectal excision (RTME) and look at its postoperative complications relative to the TaTME and LapTME. LARC has been conventionally approached by open surgery. However, minimally invasive techniques have emerged over the past two decades as alternatives to open total mesorectal excision, namely robotic, laparoscopic, and transanal. Each approach has its supporters, but conflicting data on resection outcomes and complications has fueled ongoing debate over the optimal minimally invasive technique for low/mid-LARC. This article aims to extend on the data regarding the use of TaTME and RTME in the treatment of low/mid-LARC and further elaborate on their comparative efficacy relative to LapTME.

Robot-assisted total mesorectal excision has been proposed as an alternative to laparoscopic TME for rectal cancer. However, its short-term outcomes and long-term oncological efficacy remain debated, especially in Western populations. This study evaluates the short-term clinical and long-term oncological outcomes of robot-assisted total mesorectal excision performed by experienced surgeons in high-volume European centres.

This multicentre, international, retrospective cohort study included 1390 patients from the EUREKA collaborative dataset who underwent robot-assisted total mesorectal excision for rectal cancer between January 2013 and January 2022. All surgeries were performed by expert surgeons beyond the learning curve. Data were analysed for patient demographics, perioperative outcomes, pathological findings, and three-year survival metrics. Kaplan-Meier analysis was used to evaluate overall and disease-free survival.

Of 1390 patients, 60.6% underwent restorative low anterior resection. Conversion to open surgery occurred in 3.7%, and postoperative complications were reported in 28.7%. Anastomotic leakage occurred in 14.7% of patients who underwent restorative low anterior resection. The median operative time was 223 min. R0 resection was achieved in 94.7%, and circumferential resection margin positivity was 5.5%. Three-year overall survival was 90.1%, disease-free survival was 88.6%, and local recurrence was 2.9%.

Robot-assisted total mesorectal excision performed by experienced surgeons in high-volume European centres is safe, with low conversion rates, acceptable complication rates, and favourable oncological outcomes. These findings underscore the potential of robot-assisted total mesorectal excision as a standard approach for rectal cancer in specialised settings.

BackgroundRectal cancer surgery is technically demanding, especially in males. Robotic assistance may help overcome these challenges. This study aimed to identify factors associated with robotic-assisted proctectomy in rectal cancer.MethodsRetrospective case-control analysis of patients with clinical stage I-III rectal adenocarcinoma who underwent proctectomy from the National Cancer Database (2010-2019) was conducted. Univariable and multivariable binary logistic regression analyses were conducted to determine predictive factors of robotic-assisted proctectomy in rectal cancer.Results67 145 patients (60.9% male; mean age: 61.15 ± 12.49 years) were included. 44.7% had stage III disease and 66.2% received neoadjuvant radiation. The surgical approach was laparotomy (n = 29 725), laparoscopy (n = 21 657), and robotic-assisted proctectomy (n = 15 763). Independent predictors for the use of robotic-assisted proctectomy were age <50 years (OR: 1.06; P = .032), male sex (OR: 1.07, P < .001), Asian race (OR: 1.25; P < .001), private insurance (OR: 1.25; P < .001), rectal cancer treatment between 2015 and 2019 (OR: 3.52; P < .001), stage III disease (OR: 1.06; P = .048), neoadjuvant radiation (OR: 1.26; P < .001), and pull-through coloanal anastomosis (OR: 1.15; P < .001). Robotic-assisted surgery was less often used in Black (OR: .857, P < .001) and American Indian patients (OR: .62, P = .002) and those with a Charlson score = 3 (OR: .818, P = .002), living in rural areas (OR: .865, P = .033), who were uninsured (OR: .611, P < .001), and undergoing pelvic exenteration (OR: .461, P < .001).ConclusionsDemographic and insurance disparities of robotic-assisted proctectomy are Black and American Indian patients and those with higher Charlson comorbidity index scores and uninsured patients were less likely to undergo robotic-assisted proctectomy. While patients with advanced disease and/or received neoadjuvant radiation were more likely to undergo robotic-assisted proctectomy, robotic-assisted surgery was less often performed in pelvic exenteration.

The purpose of this study was to evaluate the surgical and oncological outcomes of robotic-assisted beyond-TME surgery for locally advanced rectal cancer.

Consecutive adult (≥ 18 years old) patients who underwent a robotic-assisted proctectomy beyond-TME planes for primary or recurrent rectal cancer at three Mayo Clinic (USA) hospitals from 2017-2023 were included. Patient demographics and tumor and disease characteristics were obtained by review of the electronic health record. Outcomes of interest included postoperative complications, hospital length of stay, and pathologic and oncologic outcomes.

In total, 72 patients were included in the final cohort. Thirty-five (48.6%) patients underwent an extended resection without exenteration, while 22 (30.6%) underwent a multi-visceral en bloc exenteration; 20 (36.1%) patients underwent a lateral pelvic lymph node dissection, with or without a concomitant extended resection. Most cases had an advanced T-stage and an involved mesorectal fascia on pre-treatment MRI. The median operative time was 425.0 min (340.5-504.0) and the median estimated blood loss was 150.0 mL (75.0-277.5). Conversion to open surgery was needed in two (2.8%) cases. Nearly half the cohort (48.3%) experienced a postoperative complication and the median postoperative length of stay was 3.5 (3.0-7.0) days. Five cases had a positive margin, resulting in an R0 rate of 93.1%. None of the exenteration cases had a positive margin. After a median follow-up of 22.0 (13.0-45.7) months, 10 patients experienced a local recurrence (13.8%).

Robotic-assisted beyond-TME surgery can be performed safely with favorable postoperative clinical and oncologic outcomes.

There has been no prospective multicentre validation of the treatment outcomes of minimally invasive lateral pelvic lymph node dissection for lower rectal cancer; hence, this prospective study aimed to evaluate the treatment outcomes of prophylactic laparoscopic lateral pelvic lymph node dissection.

Between May 2018 and August 2021, 90 patients with Stage II-III rectal cancer were registered. The clearance range for lateral pelvic lymph node dissection included the lymph nodes around the internal iliac artery and the obturator lymph nodes, while the autonomic nerves were generally preserved. The primary outcome was the incidence of Grade III-IV postoperative complications at discharge. The secondary outcomes were surgical and pathological outcomes, urinary function, sexual function, disease-free survival and overall survival. The experience of each facility and surgeon requirements were set to maintain quality control of lateral pelvic lymph node dissection.

Of the 90 patients, 87 were analysed after exclusion of ineligible patients. There were 30 and 57 cases, respectively, of Stage II and III rectal cancer, among which 17 patients underwent neoadjuvant chemotherapy. The median operating time and blood loss were 472 min and 55 mL, respectively. Postoperative complications were observed in 22 patients (25.3%), and the primary outcome of Grade III postoperative complication was observed in five patients (5.7%). Eight lateral lymph nodes were harvested bilaterally, and lateral lymph node metastasis was observed in 14 patients.

Prophylactic lateral pelvic lymph node dissection can be safely performed with adequately quality-controlled laparoscopic procedures.

Minimally invasive surgery is associated with improved short-term outcomes and similar long-term oncologic outcomes for patients with colorectal cancer compared with open surgery. Although the robotic approach has ergonomic and technical benefits, how it has impacted the utilization of traditional laparoscopic surgery and minimally invasive surgery overall is unclear.

Describe trends in open, robotic, and laparoscopic approaches for colorectal cancer resections and examine factors associated with minimally invasive surgery.

Retrospective cohort study using data from the National Cancer Database from 2010 to 2020.

Commission on Cancer-accredited US facilities.

Patients diagnosed with nonmetastatic colon or rectal adenocarcinoma.

Surgical approach rates (open, robotic, and laparoscopic).

We identified 475,001 patients diagnosed with nonmetastatic colorectal adenocarcinoma, of whom 192,237 (40.5%) underwent open surgery, 64,945 (13.7%) underwent robotic surgery, and 217,819 (45.9%) underwent laparoscopic surgery. For colon cancer, laparoscopic minimally invasive surgery use steadily increased, with a peak prevalence of 54.0% in 2016, and total minimally invasive surgery (robotic + laparoscopic) was performed more often than open surgery from 2013 through 2020. For rectal cancer, laparoscopic minimally invasive surgery had a peak prevalence of 37.2% in 2014 and declined from 2014 through 2020; robotic surgery prevalence increased throughout the study period (5.5% in 2010, 24.7% in 2015, and 48.8% in 2020). Minimally invasive surgery use increased in facilities performing robotic surgery every year during the study period. For both colon and rectal cancer, the use of open surgery decreased across all facilities throughout the study period.

This study used the National Cancer Database, which may not be generalizable to non-Commission on Cancer institutions.

Minimally invasive surgery steadily increased across all facilities from 2010 through 2020. Open resections declined, laparoscopic resections plateaued, and robotic resections increased for colon and rectal cancer. Minimally invasive surgery increases may be driven by increases in robot-assisted surgery. See Video Abstract.

ANTECEDENTES:La cirugía mínimamente invasiva se asocia con mejores resultados a corto plazo y resultados oncológicos similares a largo plazo para pacientes con cáncer colorrectal en comparación con la cirugía abierta. Aunque el abordaje robótico tiene beneficios ergonómicos y técnicos, no está claro cómo ha afectado la utilización de la cirugía laparoscópica tradicional y la cirugía mínimamente invasiva en general.OBJETIVO:Describir las tendencias en los abordajes abiertos, robóticos y laparoscópicos para las resecciones de cáncer colorrectal y examinar los factores asociados con la cirugía mínimamente invasiva.DISEÑO:Estudio de cohorte retrospectivo utilizando datos de la Base de Datos Nacional del Cáncer desde 2010 hasta 2020.ESCENARIO:Centros estadounidenses acreditados por la Comisión sobre el Cáncer.PACIENTES:Pacientes diagnosticados con adenocarcinoma de colon o recto no metastásico.PRINCIPALES MEDIDAS DE VALORACIÓN:Tasas de abordaje quirúrgico (abierto, robótico, laparoscópico).RESULTADOS:Identificamos 475.001 pacientes con diagnóstico de adenocarcinoma colorrectal no metastásico, de los cuales 192.237 (40,5%) se sometieron a cirugía abierta, 64.945 (13,7%) se sometieron a cirugía robótica y 217.819 (45,9%) se sometieron a cirugía laparoscópica. Para el cáncer de colon, el uso de cirugía mínimamente invasiva laparoscópica aumentó de manera constante, con una prevalencia máxima del 54,0% en 2016, y la cirugía mínimamente invasiva total (robótica + laparoscópica) se realizó con mayor frecuencia que la cirugía abierta desde 2013 hasta 2020. Para el cáncer de recto, la cirugía mínimamente invasiva laparoscópica tuvo una prevalencia máxima del 37,2% en 2014 y disminuyó desde 2014 hasta 2020; La prevalencia de la cirugía robótica aumentó durante el período de estudio (5,5 % en 2010, 24,7 % en 2015, 48,8 % en 2020). El uso de cirugía mínimamente invasiva aumentó en los centros que realizan cirugía robótica cada año durante el período de estudio. Tanto para el cáncer de colon como para el cáncer de recto, el uso de cirugía abierta disminuyó en todos los centros durante el período de estudio.LIMITACIONES:Se utilizó la base de datos nacional sobre el cáncer, que puede no ser generalizable a instituciones que no pertenecen a la Comisión sobre el Cáncer.CONCLUSIONES:La cirugía mínimamente invasiva aumentó de manera constante en todos los centros entre 2010 y 2020. Las resecciones abiertas disminuyeron, las resecciones laparoscópicas se estabilizaron y las resecciones robóticas aumentaron para el cáncer de colon y recto. Los aumentos de la cirugía mínimamente invasiva pueden estar impulsados por aumentos en la cirugía asistida por robot. (Traducción--Ingrid Melo ).

Randomized studies have demonstrated that laparoscopic abdominoperineal resection is not inferior to open abdominoperineal resection for rectal cancer.

Evaluate the immediate and extended results of laparoscopic abdominoperineal resection versus open abdominoperineal resection for rectal cancer.

From January 2006 to December 2017, a total of 1852 patients with rectal cancer who had undergone abdominoperineal resection were enrolled in this investigation. The groups were matched in a 1:1 ratio using propensity score matching. The primary endpoints were overall survival and disease-free survival. The secondary endpoints were pathology and short-term postoperative outcomes.

Compared to the open abdominoperineal resection group, the laparoscopic abdominoperineal resection group exhibited a higher rate of positive circumferential resection margins (P < 0.001) and fewer postoperative complications (P < 0.001). 5-year disease-free survival (P = 0.449) and overall survival rates (P = 0.664) were comparable. Age (P < 0.001), comorbidity (P = 0.040), (y)pT (P = 0.024), (y)pN (P < 0.001), lymphovascular invasion (P = 0.003) and positive circumferential resection margins (P = 0.014) were independent prognostic risks for overall survival.

The pathological outcomes of laparoscopic abdominoperineal resection are inferior compared to open abdominoperineal resection. However, they demonstrate comparable long-term oncological outcomes, and laparoscopic abdominoperineal resection offers certain short-term advantages over the open approach.

Background/Objectives: The aim of the study was to compare the perioperative and oncologic outcomes of patients who underwent surgery for colorectal cancer (CRC) performed using laparoscopy or using the Medtronic Hugo™ Robotic-Assisted Surgery (RAS) system. Methods: This is a retrospective comparative single-center study of consecutive minimally invasive surgeries for CRC performed by two colorectal surgeons with extensive laparoscopic experience at the beginning of their robotic expertise. Patients were not selected for the surgical approach, but waiting lists and operating room availability determined whether the patients were in the robotic group or the laparoscopic group. The primary outcome was to compare 30-day postoperative complications according to the Clavien-Dindo classification and the Complication Comprehensive Index (CCI). The secondary outcomes included operating times, conversion rates, intraoperative complications, length of hospital stays (LOS), readmission rates, and short-term oncologic outcomes, such as the R0 resection, the number of lymph nodes harvested, the total mesorectal excision (TME) quality, and the circumferential resection margin (CRM). Results: Of the 109 patients, 52 underwent robotic and 57 laparoscopic CRC surgery. Patient demographic and clinical characteristics were similar in the two groups. There was no significant difference between the robotic and the laparoscopic groups regarding postoperative complications, the Clavien-Dindo classification, and the CCI. They also had similar operating times, conversion rates, intraoperative complications, LOSs, readmission rates, and short-term oncologic outcomes (the lymph nodes harvested, the R0 resection, TME quality, and CRM status). Conclusions: This study reports the largest cohort of CRC surgery performed using the Medtronic Hugo™ RAS system and is the first comparative study with laparoscopy. The perioperative and oncologic outcomes were similar, demonstrating that the Medtronic Hugo™ RAS system is safe and feasible for CRC as compared to laparoscopic surgery, even at the beginning of the robotic experience.

Background and Objectives: Recent studies have supported the non-inferiority of the minimally invasive treatment approach over the open approach. However, they have also underlined its inferiority regarding its oncological results, while preserving the short-term benefits. The direct effects of these results were represented by indication changes in international guidelines on the application of minimally invasive surgery for treating early-stage cervical cancer. Material and metods: Herein, a literature review, including studies between 1992 and 2017, was performed. Results: The results show that the studies published during this period supported the non-inferiority of the minimally invasive treatment approach for early-stage cervical cancer compared with the open approach. However, the studies included were unicentric, non-randomized and relied on a reduced number of patients. The results of the Laparoscopic Approach to Cervical Cancer [LACC] trial could not have been considered, since only studies published between 1992 and 2017 were included. This trial firmly supported the advantages of the minimally invasive approach in treating early-stage cervical cancer. The literature published after 2018 highlighted the necessity for new clinical studies, randomized and prospective ones, to cover the defects of this study and to verify (or not) its results. Conclusions: the studies published after 2018 mainly focused on the deficiencies of the LACC trial and also on developing new methods that could improve this surgical technique, thus enhancing the safety of the minimally invasive approach in treating early-stage cervical cancer. However, none of the included studies succeeded to provide enough evidence to oppose the results obtained in the LACC trial. Therefore, in order to clarify the state of this surgical approach, the results of three ongoing randomized clinical trials are expected.

This study aims to examine why we encounter a pathological circumferential resection margin (pCRM)-positive specimen whose preoperative MRI indicates negative mesorectal fascia involvement in middle to low rectal cancer.

Forty-four consecutive patients included in this study had c(yc)T1-3 primary rectal adenocarcinoma without mesorectal fascia involvement and underwent laparoscopic total mesorectal excision (TME) with curative intent in the Department of Gastrointestinal Surgery of Kansai Medical University Hospital from January 2014 to April 2018. We adopted three checkpoints to investigate the misleading point causing positive pCRM (≤ 1 mm). (1) c(yc)CRM diagnosis by two radiologists with more than 20 and 15 years of experience in rectal cancer MRI diagnosis. (2) The specimen was assessed using the TME score presented by Nagtegaal. (3) We compared the standard sectioning according to UK guidelines (group A; n = 26) with the specimen MRI image navigation-based section (group B; n = 18) in terms of estimation of pCRM by c(yc)CRM.

We achieved a "complete" resection specimen in all cases. A simple correlation coefficient in group B revealed a significant correlation between c(yc)CRM and pCRM (r = 0.663, p = 0.00513); this correlation was not significant in group A (r = 0.261, p = 0.19824). However, tests for differences between linear regression coefficients in groups A and B showed no significant differences (p = 0.12596). There were five cases of pCRM ≤ 1 mm: three in group A and two in group B. An anterior lesion caused pCRM ≤ 1 mm in three cases; the tumor deposits or extramural vascular invasion caused the other cases.

The cause of misleading pCRM was the inaccurate preoperative MRI diagnosis of c(yc)CRM.

This study aims to assess the short- and long-term outcomes of rectal cancer patients undergoing robotic versus laparoscopic surgery after receiving neo-adjuvant therapy. There is a lack of clarity on this topic, necessitating a comprehensive comparison.

Between January 2017 and December 2021, consecutive patients who underwent laparoscopic and robotic rectal resection at a major public medical center were enrolled. All participants received neo-adjuvant chemoradiotherapy (nCRT) before surgery. The primary objective of this study was to assess the sphincter preservation rate and the rate of conversion to open surgery, using propensity score matching (PSM) analysis. Secondary endpoints included 5-year disease-free survival (DFS), 5-year overall survival (OS), short-term postoperative complications, long-term oncological prognosis, and the occurrence of low anterior resection syndrome (LARS).

A total of 575 patients diagnosed with rectal cancer participated in the cohort study, with 183 individuals undergoing robotic surgery and 392 undergoing laparoscopic surgery. Patients in the robotic group tended to be younger and had higher ypT, cT, and cN stages, lower tumor locations, and higher rates of extramural vascular invasion (EMVI) and circumferential resection margin (CRM) positivity. PSM resulted in 183 patients in the robotic group and 187 in the laparoscopic group. We found a higher sphincter preservation rate in robotic group compared with laparoscopic group (92.9% vs. 86.1%, P = 0.033), with no significant difference in conversion to open surgery(P > 0.05). The robotic group had a higher incidence of postoperative chylous ascites (4.9% vs. 1.1%, P = 0.029) and potentially lower sepsis occurrence (0% vs. 1.6%, P = 0.085). No significant differences were observed in long-term oncological prognosis or 5-year survival rates (P > 0.05). The median survival time for each group was 34 months. Subgroup analysis of 76 rectal cancer patients who underwent intersphincteric resection (ISR) surgery indicated that those who selected robotic surgery had higher cN and cT stages. Furthermore, no statistically significant differences were observed in short-term and long-term clinical outcomes, LARS, OS time, and DFS time between the two surgical modalities. The primary outcomes of interest, specifically the rate of sphincter preservation and the rate of conversion to open laparotomy, showed no significant differences.

Robotic surgery for rectal cancer, following preoperative nCRT, demonstrates comparable technical safety and oncological outcomes to laparoscopic surgery. Further comprehensive studies are needed to to confirm the potential advantages of robotic surgical interventions.

Background/Objectives: Robotic-assisted surgery is an attractive and promising option with unique advantages in rectal cancer surgery, but the optimal surgical approach is still debatable. Therefore, we aimed to compare the short- and long-term outcomes of the robotic-assisted approach with the laparoscopic-assisted and open approaches. Methods: A single referral center in Israel retrospectively reviewed all patients that underwent an elective rectal resection for primary non-metastatic rectal cancer between 2010 and 2020. The cohort was separated into three groups according to the surgical approach: robotic, laparoscopic, or open. Results: The cohort included 526 patients with a median age of 64 years (range 31-89), of whom 103 patients were in the robotic group, 144 in the open group, and 279 patients in the laparoscopic group. The robotic group had significantly more lower rectal tumors (24.3% versus 12.7% and 6%, respectively, p < 0.001), more locally advanced tumors (65.6% versus 51.2% and 50.2%, respectively, p = 0.004), and higher rates of neoadjuvant radiotherapy (70.9% versus 54.2% and 39.5%, respectively, p < 0.001). Conversion to an open laparotomy was more common in the laparoscopy group (23.1% versus 6.8%, respectively, p = 0.001). The open approach had higher rates of intraoperative complications (23.2% compared with 10.7% and 13.5% in the robotic and laparoscopic groups, respectively, p = 0.011), longer hospital stays (10 days compared with 7 and 8 days, respectively, p < 0.001), and higher rates of postoperative complications (76% compared with 68.9% and 59.1%, respectively, p = 0.002). The groups were similar in the number of harvested lymph nodes (14) and the incidence of positive resection margins (2.1%). The 5-year overall survival in the robotic group was 92.3% compared with 90.5% and 88.3% in the laparoscopic and open groups, respectively (p = 0.12). The 5-year disease-free survival in the robotic group was 68% compared with 71% and 63%, respectively (p = 0.2). Conclusions: The robotic, laparoscopic, and open approaches had similar histopathological outcomes and long-term oncological outcomes. The open approach was associated with higher rates of perioperative morbidity. These findings suggest that the robotic approach is safe and effective in rectal cancer surgery.

The study aimed to determine whether increased use of minimally invasive surgical approaches, compared with open, improves long-term survival after colon and rectal cancer resections.

Existing prospective and observational data comparing surgical approach for colon and rectal cancer are limited by selection bias, necessitating better approaches for causal inference to understand the relationship between surgical approach and long-term survival.

We included colon and rectal cancer patients who underwent colon or rectal resection from the American College of Surgeons National Cancer Database between 2011 and 2018. Using an instrumental variable (IV) approach, we accounted for measured and unmeasured differences between patients undergoing colon or rectal cancer resection based on operative approach - robotic, laparoscopic, or open. The IV used in this study was rate of robotic-assisted colon and rectal cancer surgery within 81 different hospital regions based on US Census region and rurality during the 12 months before each patient's operation. Proportional hazard modeling was used to estimate risk-adjusted mortality rates.

There were 326,406 colon and 96,979 rectal cancer patients included in this study. The risk-adjusted 5-year cumulative incidence of mortality for colon and rectal cancer was highest for patients who underwent open approaches (35.73 [95% confidence interval {CI}: 35.37-36.1] and 39.27 [95% CI: 28.44-30.13], respectively), compared with lower mortality for those undergoing laparoscopic (28.91 [95% CI: 28.55-29.27] and 22.93 [95% CI: 22.11-23.78], respectively) and robotic approaches (26.39 [95% CI: 24.51-28.42] and 19.77 [95% CI: 17.32-22.43], respectively). Growth in utilization of minimally invasive approaches outpaced improvements in long-term survival.

Patients undergoing minimally invasive surgical approaches for colon and rectal cancer had improved long-term survival. However, long-term survival changes did not correlate with the large expansion of minimally invasive approaches, which suggests that growing these approaches is not a viable strategy to improve long-term patient outcomes.

Intraoperative and postoperative data collected from patients with low rectal cancer who had undergone robotic and laparoscopic intersphincteric resection (ISR) procedures were retrospectively analyzed to evaluate factors linked to anastomotic leakage and postoperative recovery of urinary function, bowel control, and long-term prognosis.

This single-center study enrolled patients with low rectal cancer who had undergone robotic ISR (n = 150) or laparoscopic ISR (n = 150) from January 2016 to July 2019.

The respective mean tumor distances from the anal margin in the robotic and laparoscopic ISR groups were 3.94 ± 0.48 cm and 5.66 ± 0.47 cm, while the mean times to postoperative catheter removal in these respective groups were 4.9 ± 1.4 days and 5.3 ± 1.6 days (P = 0.007). Binary logistic regression analyses indicated that a higher BMI (≥ 25 kg/m2), diabetes, the absence of left colic artery presentation, T3 pathological T stage, the absence of temporary ileostomy, and DRM (distal resection margin) < 1 cm were linked to a greater likelihood of postoperative anastomotic leakage. Relative to patients in the laparoscopic group, those in the robotic ISR group exhibited better anal and urinary function from 6 months postoperatively, as indicated by a lower frequency of bowel movements, reduced LARS (The Low Anterior Resection Syndrome) severity, and lower IPSS (the International Prostate Symptom Score) scores. Five-year overall and disease-free survival did not differ significantly between the groups.

These results highlight the promise of robotic ISR as an approach to managing cases of low and ultra-low rectal tumors, providing a safe and feasible alternative to conventional laparoscopic ISR treatment.

Over the past two decades, minimally invasive approaches in rectal surgery have changed the landscape of surgical interventions, impacting both malignant and benign pathologies. The dynamic nature of rectal cancer treatment owes much to innovations in surgical techniques, reflected in the expanding literature on available treatment modalities. Local excision, facilitated by minimally invasive surgery, offers curative potential for patients with early T1 rectal cancers and favorable pathologic features. For more complex cases, laparoscopic and robotic surgery have demonstrated significant efficacy and provided precise, durable outcomes while reducing perioperative morbidity and enhancing postoperative recovery. Additionally, advancements in imaging, surgical instrumentation, and enhanced recovery protocols have further optimized patient care. The integration of multidisciplinary care has also emerged as a cornerstone of treatment, emphasizing collaboration among surgeons, oncologists, and radiologists to deliver personalized, evidence-based care. This narrative review aims to elucidate current minimally invasive surgical techniques and approaches for rectal pathologies, spanning benign and malignant conditions, while also exploring future directions in the field, including the potential role of artificial intelligence and next-generation robotic platforms.

One of the critical steps involved is the distal transection of the rectum in rectal cancer surgeries. Multiple staple firings have been proven to increase the rate of anastomotic leakage. In this study, we intended to learn the effectiveness of the robotic SureForm SmartFire (SS) stapling system and its application in robotic sigmoid colon and rectal procedures performed at our institution.

Prospective study of patients who underwent surgeries for sigmoid/rectal cancer at our centre was considered. During the surgery, SS staplers were used, and its internal data log with regard to reload selection by the colour, reloads, clamp attempts and staple fires was considered along with intra- and post-operative outcomes.

246 firings were done in 147 cases with mean body mass index of 26.3 ± 4.3 kg/m2; mean blood loss was 53.6 ± 21.8 ml. None of our patients had stapler-related complications, and the mean length of stay was 7.18 ± 1.5 days. Average reloads used in robotic-low anterior resection (LAR) were 1.73 with the fire attempts beyond lap angle occurring only in robotic-assisted LAR (RA-LAR)/abdominoperineal resection in 87 fires (41%) with 120 instances of controlled and sequential pauses occurred in 246 fires once fire pedal was activated.

Apart from oncological nodal and margin clearance in the carcinoma rectum surgery, obtaining adequate distal margin, sphincter preserving approach and distal transection of the rectum forms one of the key steps in the low anterior resection. Robotic SS staplers have 120° angulation in both axes with EndoWrist technology that has better manoeuvrability within the confines of the pelvis.

As part of an organ sparing strategy, a surgical local excision may be performed in patients with early-stage rectal cancer or following neoadjuvant (chemo)radiotherapy. In selected cases, a completion total mesorectal excision may be recommended which can be more complex because of the preceding local excision. A transanal approach to perform completion total mesorectal excision may offer an advantage through the better visualization of the surgical field in the distal rectum and less forceful retraction for exposure. However, the oncologic safety and technical feasibility of this approach have yet to be demonstrated in these patients. Therefore, the aim of this study was to evaluate the oncological and technical safety of completion transanal total mesorectal excision following a local excision in patients with rectal cancer.

Patients from the prospective International Transanal Total Mesorectal Excision Registry who underwent a surgical local excision prior to completion transanal total mesorectal excision were retrospectively analyzed.

In total, 189 patients were included of which 22% received neoadjuvant radiotherapy. In 94% of the patients, a low anterior resection was performed. A primary anastomosis was constructed in 91% (n = 171/189) of the patients, with the majority also receiving a defunctioning stoma (84%, n = 144/171), of which 69% (n = 100/144) were reversed. Within 30 days, 7% developed an anastomotic leakage. The two-year local recurrence rate was 5% (n = 5/104) with an estimated rate of 3% (95% CI 0-7%). Two-year disease-free survival was 85% (n = 88/104) and overall survival was 95% (n = 99/104).

Transanal completion total mesorectal excision following local excision for rectal cancer is oncologically safe, with low complication rates and high restorative rates.

Rectal cancer surgery remains a significant technical challenge. The development and implementation of a new technology offer hope for more accurate and precise surgery. To evaluate whether single-port robotic (SPr) technology helps achieve this goal, an international SPr registry was established. This study reported short-term clinical and oncologic outcomes from an international SPr registry for rectal cancer.

A review of a prospective international registry of SPr technology approved for colorectal surgery with an investigational design exemption was conducted. Patients with rectal adenocarcinoma who had resection for curative intent using the SPr platform between November 2018 and September 2022 were included. Frequency statistics described patient and tumor characteristics and intraoperative, oncologic, and clinical outcome variables. The main outcome measure was the quality of the total mesorectal excision (TME) specimen. The secondary outcome measures were intraoperative conversion and 30-day postoperative morbidity and mortality.

A total of 113 SPr procedures for rectal cancer were performed at 2 centers by 4 colorectal surgeons. Of note, 9 local excisions were excluded, leaving 104 cases analyzed. The cohort consisted of 53 men (50.96%), had a mean age of 60.00 years (SD, 11.29), and had a body mass index of 25.80 kg/m2 (SD, 6.18). The most common T stage was 3 (55 [52.8%]), followed by 2 (19 [18.26%]). More than 60% of patients had preoperative neoadjuvant chemoradiation. The mean tumor distance from the anorectal ring was 2.90 cm (SD, 2.62), and the mean tumor size was 4.52 cm (SD, 1.82). The procedures performed included transanal abdominal transanal/transanal TME (52 [46%]), low anterior resection (49 [43.3%]), and abdominoperineal resection (3 [2.7%]). The mean operating time was 168.0 min (SD, 56.9). There were no intraoperative complications and 2 (1.9%) conversions to laparoscopy. There was a median of 2 incisions, with a mean size of 2.30 cm (SD, 1.31). The TME specimens were complete in 101 cases (97.1%) and near complete in 3 cases (2.9%). The R1 rate was 3.8%, with 3 positive distal margins and 1 positive circumferential margin. Postoperatively, there were 15 total complications, of which 4 were major complications and 11 were minor complications. There were 2 readmissions (ileus and small bowel obstruction). There were no mortalities.

This early international experience with the SPr procedure showed that it is a safe and effective technique for distal rectal cancers, with excellent specimen quality. The complication and conversion rates observed with other techniques and platforms used in rectal cancer surgery were not demonstrated. An international registry was used to better understand the opportunities and limitations of SPr technology in rectal cancer surgery as the technology is adopted and applied more widely. Although structured training and controlled trials will be required to develop best practices and define the use of the SPr technology, initial international registry data are encouraging.

Defecation disorders following rectal resection have long been overlooked as an inevitable surgical complication due to the lack of established diagnostic criteria or definitions. However, these disorders have been recently termed low anterior resection syndrome (LARS), which is a defecation disorder that occurs following rectal resection and impairs the patient's quality of life (QOL). The LARS score developed by Emmertsen et al., which is a patient-reported outcome measure to evaluate the severity of bowel dysfunction following rectal surgery by scoring the major symptoms of LARS, facilitates the diagnosis and assessment of LARS and enables international comparison and validation through the use of validated scores generated according to the international standards. Based on comparisons with other evaluation instruments, the use of the LARS score is strongly recommended internationally for LARS screening in patients following rectal resection. Recent findings have indicated that multiple pathophysiological changes, including reservoir function and evacuation of the neorectum, anal sphincter function, negative impact of a diverting stoma, autonomic denervation, and radiotherapy, are involved in the etiology of LARS. Due to the lack of established treatments and prevention of LARS, a suggested treatment chart for patients with LARS was presented in the Management Guidelines for Low Anterior Resection Syndrome (MANUEL) project. Future surgical treatment should focus not only on the radical cure of cancer and safety of treatment but also on the maintenance and improvement of QOL, with particular attention to the preservation of function. Particularly for rectal cancer, surgeons must formulate treatment plans that consider the prevention and treatment of LARS.

Differences in oncological outcomes between conservative and surgical treatments for anastomotic leakage (AL) in patients undergoing colorectal cancer surgery remain unclear.

From July 2011 to June 2020, 385 patients underwent curative resection with double-stapling anastomosis for left-sided colon and rectal cancers. Among them, 33 patients who experienced AL were retrospectively evaluated and categorized into two groups: conservative (n = 20) and surgical (n = 13). In the surgical group, abdominal lavage using a sufficient amount of normal saline was performed during reoperation. The primary endpoint was the 3-year cumulative incidence of local recurrence (LR).

Seven (21.2%) patients in the conservative group experienced LR, while none in the surgical group. Survival analysis indicated no differences in overall and recurrent-free survival. However, the 3-year cumulative incidence of LR was significantly lower in the surgical group than in the conservative group (0% versus 31.3%, p=0.045).

Differences in AL management were associated with oncological outcomes, specifically a decreased LR. Therefore, surgeons should consider our findings when determining the most appropriate AL treatment to improve oncological outcomes.

While total mesorectal excision is the gold standard for rectal cancer, the optimal surgical approach to achieve adequate oncological outcomes remains controversial. This network meta-analysis aims to compare the histopathological outcomes of robotic (R-RR), transanal (Ta-RR), laparoscopic (L-RR), and open (O-RR) resections for rectal cancer.

MEDLINE, Embase, and the Cochrane Library were screened from inception to June 2024. Of the 4186 articles screened, 27 RCTs were selected. Pairwise comparisons and Bayesian network meta-analyses applying random effects models were performed.

The 27 RCTs included a total of 8696 patients. Bayesian pairwise meta-analysis revealed significantly lower odds of non-complete mesorectal excision with Ta-RR (Odds Ratio, OR, 0.60; 95%CI, 0.33, 0.92; P = .02; I2:11.7 %) and R-RR (OR, 0.68; 95%CI, 0.46, 0.94; P = .02; I2:41.7 %) compared with laparoscopy. Moreover, lower odds of positive CRMs were observed in the Ta-RR group than in the L-RR group (OR, 0.36; 95%CI, 0.13, 0.91; P = .02; I2:43.9 %). The R-RR was associated with more lymph nodes harvested compared with L-RR (Mean Difference, MD, 1.24; 95%CI, 0.10, 2.52; P = .03; I2:77.3 %). Conversely, Ta-RR was associated with a significantly lower number of lymph nodes harvested compared with all other approaches. SUCRA plots revealed that Ta-RR had the highest probability of being the best approach to achieve a complete mesorectal excision and negative CRM, followed by R-RR, which ranked the best in lymph nodes retrieved.

When comparing the effectiveness of the available surgical approaches for rectal cancer resection, Ta-RR and R-RR are associated with better histopathological outcomes than L-RR.

The relative benefits of robotic surgery and laparoscopic surgery are controversial in rectal cancer. This study compared the short- and long-term outcomes of robotic surgery with those of laparoscopic surgery in patients with rectal cancer using propensity score analysis.

This study analyzed consecutive patients who underwent minimally invasive surgery for stage I-III rectal cancer between April 2014 and October 2020. After propensity score matching (PSM), short-term outcomes, relapse-free survival, and overall survival were compared between the robotic surgery (RS) group and the laparoscopic surgery (LS) group.

During the study period, 251 patients underwent laparoscopic surgery and 193 underwent robotic surgery. PSM resulted in 160 matched pairs (After PSM, the percentages of patients with stage I, II, and III disease were respectively 56%, 19%, and 24% in the LS group and 49%, 23%, and 28% in the RS group (P = 0.462). Median operation time was 239 min in the LS group and 284 min in the RS group (P = 0.001). The C-reactive protein level on postoperative day 3 was significantly lower in the RS group (4.63 mg/mL vs. 5.86 mg/mL, P = 0.013). Postoperative complications, including ileus and Clavien-Dindo grade II or higher complications, were 6% vs. 1% (P = 0.006) and 21% vs. 12% (P = 0.024) in the LS and RS groups, respectively. The 5-year relapse-free survival rate was 88.5% in the LS group and 90.5% in the RS group (P = 0.525); the respective 5-year overall survival rates were 97.3 and 93.8% (P = 0.283). The 5-year cumulative local and distant recurrence rates were 3.3% vs. 3.3% (P = 0.665) and 9.7% vs. 7.7% (P = 0.464) in the LS and RS groups, respectively CONCLUSION: Robotic surgery can be a feasible treatment modality for rectal cancer, with lower frequencies of postoperative ileus and Clavien-Dindo grade II or higher complications than laparoscopic surgery and no difference in long-term outcomes.

Laparoscopic surgery is increasingly used for rectal cancer, but the long-term oncological outcomes for low rectal cancer have not been fully established. We aimed to evaluate the 3-year survival outcomes of laparoscopic surgery versus open surgery in the treatment of low rectal cancer.

This multicentre, randomised, controlled, non-inferiority trial was conducted at 22 tertiary hospitals in China. Individuals aged 18-75 years with histologically confirmed cT1-2N0, cT3-4aN0, or cT1-4aN1-2 rectal adenocarcinoma within 5 cm from the dentate line were eligible for inclusion. Participants were randomly assigned (2:1) to undergo laparoscopic surgery or open surgery. Central randomisation was conducted using a web response system, and was stratified by clinical stage, age, sex, BMI, and American Society of Anesthesiologists classification. Investigators, patients and statisticians were not masked to group allocation. The primary outcome was 3-year disease-free survival, defined as the time from the date of surgery to the date of locoregional recurrence, distant metastasis, or death from any cause, whichever occurred first. Non-inferiority was defined as a lower limit of one-sided 97·5% CI for group difference (laparoscopic surgery group minus open surgery group) of greater than -10%. The primary analyses were performed in the modified intention-to-treat population, which excluded patients with distant metastasis discovered during surgery and those who did not undergo surgery or underwent local resection only. The trial is registered with ClinicalTrials.gov, NCT01899547, and has been completed.

Between Nov 12, 2013, and June 6, 2018, 1070 patients were enrolled and randomly assigned to treatment. 1039 patients (685 in the laparoscopic surgery group and 354 in the open surgery group; median age 57 years, IQR 50 to 64; 620 [60%] male and 419 [40%] women) were included in the modified intention-to-treat analysis. 3-year disease-free survival was 81·4% (95% CI 78·2 to 84·1) in the laparoscopic surgery group and 79·8% (75·2 to 83·6) in the open surgery group (hazard ratio [HR] 0·92, 95% CI 0·69 to 1·23; p=0·56). The difference between groups was 1·60% (one-sided 97·5% CI -3·34 to ∞, p<0·0001 for non-inferiority). 3-year overall survival was 91·7% (95% CI 89·3 to 93·5) in the laparoscopic surgery group and 93·7% (90·6 to 95·8) in the open surgery group (HR 1·34, 95% CI 0·82 to 2·19; p=0·24). 3-year locoregional recurrence was 3·7% (95% CI 2·5 to 5·3) and 2·3% (1·1 to 4·3), respectively (HR 1·64, 95% CI 0·74 to 3·63; p=0·22). 5-year overall survival was 84·6% (95% CI 81·5 to 87·1) and 86·6% (82·5 to 89·8) in the open group (HR 1·16, 95% CI 0·82 to 1·64; p=0·41).

Laparoscopic surgery performed by experienced surgeons is non-inferior to open surgery for 3-year disease-free survival among patients with low rectal cancer. These results support the use of laparoscopic surgery for low rectal cancer.

The Key Clinical Specialty Discipline Construction Program of the National Health and Family Planning Commission of China; Minimally Invasive Medical Center Construction Program, Fujian Province, China; and Joint Funds for the Innovation of Science and Technology, Fujian Province, China.

Colorectal cancer (CRC) surgeries can be performed using either laparoscopic or open laparotomy approaches. However, the long-term outcomes based on tumor location and age remain unclear. This study compared the long-term outcomes of laparoscopic and laparotomy surgeries in patients with CRC, focusing on tumor location and age to identify suitable subgroups and determine an optimal cut-off age.

This retrospective study analyzed 2,014 patients with CRC who underwent radical surgery. Patients were categorized into laparoscopy and laparotomy groups, and propensity score matching (PSM) was performed. Kaplan-Meier analysis, log-rank tests, and Cox regression models were used to identify the independent factors affecting overall survival (OS).

Analysis results before PSM indicated higher OS in the laparoscopy group (P=0.035); however, it was no significant difference in mean OS between the two groups after PSM analysis. Cox regression analysis identified several factors influencing the OS of patients with CRC, with age, T stage, nodal involvement, poorly differentiated adenocarcinoma, ascites, preoperative intestinal obstruction, and local tumor spread as independent risk factors. Family history was a protective factor [hazard ratio (HR)=0.33; 95% CI, 0.16-0.68; P=0.002], and the surgical modality did not independently affect OS. The subgroup analysis highlighted the advantages of laparoscopic surgery in specific subgroups.

Overall, laparoscopic and laparotomy surgeries resulted in similar mid- and long-term prognoses for patients with CRC. Laparoscopic surgery showed better outcomes in specific subgroups, particularly in patients aged >60 years and in those with right-sided colon carcinoma. This study suggests that age >64 years might be the optimal cut-off age for laparoscopic surgery.

Minimally invasive approaches for rectal cancer treatment are emerging as the standard of care. Robotic surgery is unfeasible across the country due to constrained resource allocation. This study aimed to assess the oncologic efficacy of laparoscopic resection for rectal cancer in a resource-limited setting.

A propensity score-matched analysis was carried out to compare the oncological outcomes of laparoscopic and open rectal cancer resection at a high-volume tertiary cancer centre in South India.

Two hundred and twenty patients were included (110 patients in each group). The median follow-up was 93 months. There was no difference in positive circumferential resection margin between laparoscopic and open group (4.5% vs. 6.4%, p = 0.55), with a significantly better nodal yield in laparoscopic group. There was no significant difference between the laparoscopic and open groups in terms of local recurrence (5.1% vs. 8.3%, p = 0.12), 5-year disease-free survival (86% vs. 81%, p = 0.22, HR 0.699, 95% CI 0.353-1.27) or overall survival (85% vs. 76%, p = 0.21, HR 0.658, 95% CI 0.340-1.27). The mean cost between the two groups had no difference.

In a resource-limited setting with good expertise, laparoscopic surgery is an effective minimally invasive option that has good survival outcomes without imposing a financial burden on patients.

Chemoradiotherapy (CRT) for rectal cancer is limited by its harmful side effects and its insufficient benefit on lateral lymph node metastases. The purpose of this study was to evaluate the long-term outcomes of S-1 and oxaliplatin with total mesorectal excision (TME) and lateral lymph node dissection (LLND) without radiation for rectal cancer.

The inclusion criteria were patients with stage II or III rectal cancer located within 10 cm from the anal verge. Fifty-two patients who underwent neoadjuvant chemotherapy (NAC) followed by TME and LLND were evaluated. The primary endpoint was the 3-year local recurrence. The secondary endpoints were the 3-year rates of relapse-free survival and overall survival. Expected post-NAC and surgical outcomes were prospectively analyzed.

The overall recurrence rate was 15.4%, with eight patients developing distant recurrences. The local recurrence rate was 7.7% (n = 4). Among the 4 patients with local recurrence, 3 (5.8%) patients had central pelvis recurrence, and 1 (1.9%) patient had lateral pelvic recurrence. The 3-year survival rate was 98.1%, and the 3-year relapse-free survival rate was 84.6%. The risk factors for local recurrence were mucinous carcinoma (p = 0.016) and a positive resection margin (p = 0.009). Pathological mesorectal lymph node metastasis and local recurrence were independent risk factors for poor survival.

Although preoperative chemotherapy and TME with LLND are sufficient to control local recurrence, some cases will require more aggressive chemotherapy with radiation therapy.