|
1
|
Alipouriani A, Almadi F, Rosen DR, Liska D, Kanters AE, Ban K, Gorgun E, Steele SR. Margin matters: analyzing the impact of circumferential margin involvement on survival and recurrence after incomplete total mesorectal excision for rectal cancer. Tech Coloproctol 2025; 29:50. [PMID: 39847185 PMCID: PMC11757853 DOI: 10.1007/s10151-024-03098-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Accepted: 12/22/2024] [Indexed: 01/24/2025]
Abstract
BACKGROUND Incomplete mesorectal excision during rectal cancer surgery often leads to positive circumferential margins, with uncertain prognostic impacts. This study examines whether negative margins can mitigate the poorer prognosis typically associated with incomplete total mesorectal excision (TME) in rectal cancer surgery, thus potentially challenging the prevailing emphasis on complete mesorectal excision. PATIENTS AND METHODS A retrospective analysis was conducted on patients who underwent proctectomy for rectal adenocarcinoma with incomplete TME at a single center from 2010 to 2022. Patients were stratified by margin status as determined by pathologic analysis into three groups: involved, not involved with closest margin distance ≤ 2 mm, and not involved with closest margin distance > 2 mm. Outcomes included recurrence and survival. Effects of neoadjuvant therapy protocols on margin status were also assessed. RESULTS From 2010 to 2022, 7941 patients underwent proctectomy for rectal cancer, with 236 (3%) having incomplete TME. The median age of these patients was 64 years, and 63% were male. Overall, margin involvement was observed in 54 (23%) patients. The median tumor size was 3.05 cm (interquartile range (IQR): 2-6) for the whole group. Involved margins (23.2%) had reduced overall survival (60.5 months versus 87.3 months, p < 0.001), increased local recurrence (20.4% versus 9.4%, p = 0.024), and lower disease-free survival (45.2 versus 58.9 months, p = 0.006) versus uninvolved margins. Margin involvement was prognostic for decreased survival even after adjusting for confounders (p < 0.05). Among uninvolved margins, distance (> 2 mm versus ≤ 2 mm) did not affect outcomes. Total neoadjuvant therapy (versus standard chemoradiation) was associated with lower involved margins (p = 0.007). CONCLUSIONS Positive margins retain negative prognostic impact with incomplete TME. Optimization of surgical resection remains vital. Total neoadjuvant therapy was associated with a lower rate of margin involvement.
Collapse
Affiliation(s)
- A Alipouriani
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - F Almadi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - D R Rosen
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - D Liska
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - A E Kanters
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - K Ban
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - E Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA
| | - S R Steele
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
- Department of Colon and Rectal Surgery, Cleveland Clinic Main Campus Submarket, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| |
Collapse
|
|
2
|
Althans AR, Holder-Murray J, Hopkins K, Gamboa A, Regenbogen SE, Silviera M, Hawkins A, Ejaz A, Balch G, Tessler RA. Role of Adjuvant Chemotherapy After Curative Resection in Stage II and III Rectal Cancer. J Surg Res 2024; 303:254-260. [PMID: 39383599 DOI: 10.1016/j.jss.2024.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 08/19/2024] [Accepted: 09/11/2024] [Indexed: 10/11/2024]
Abstract
INTRODUCTION Patients with resected locally advanced rectal cancer (LARC) and an incomplete total mesorectal excision (TME) have worse oncologic outcomes. The associations between TME grade, adjuvant therapy receipt, and oncologic outcomes have not been well-studied. We aimed to determine the association between adjuvant chemotherapy and oncologic outcomes in patients who underwent neoadjuvant chemoradiation (CRT) or short-course radiotherapy (SCRT) followed by proctectomy and to evaluate this association stratified by TME grade. MATERIALS AND METHODS We analyzed a retrospective multi-institutional cohort of primary LARC patients diagnosed between 2010 and 2018 who received neoadjuvant CRT/SCRT followed by proctectomy. Complete TME was defined as complete mesorectal excision, and noncomplete TME was defined as near-complete or incomplete TME. We used adjusted Cox proportional hazards regression to test the association between adjuvant chemotherapy and mortality or locoregional recurrence (LRR) across groups. RESULTS We identified 746 eligible patients. On final pathology, 101 (13.5%) had noncomplete and 645 (86.5%) had complete TME. Rates of adjuvant chemotherapy receipt were similar between noncomplete and complete TME groups (70.3% and 69.5%, respectively). Mean follow-up interval was 35 mo. Adjuvant chemotherapy was associated with lower risk of mortality (HR 0.27, 95% CI 0.19-0.39, P < 0.001); the same association existed when stratifying patients by TME grade. For patients with a complete TME, adjuvant chemotherapy was associated with lower LRR (HR 0.08, 95% CI 0.01-0.56, P = 0.01). The LRR model for the noncomplete TME group did not converge due to few captured recurrences. CONCLUSIONS These data show an association between adjuvant chemotherapy and positive outcomes in LARC patients receiving neoadjuvant CRT/SCRT followed by proctectomy.
Collapse
Affiliation(s)
- Alison R Althans
- Department of Surgery, University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, Pennsylvania.
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Katherine Hopkins
- Department of Surgery, University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Adriana Gamboa
- Department of Surgery, Emory University, NE Atlanta, Georgia
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Alfred Taubman Health Care Center, Ann Arbor, Michigan
| | - Matthew Silviera
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander Hawkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Glen Balch
- Department of Surgery, Emory University, NE Atlanta, Georgia
| | - Robert A Tessler
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Presbyterian Hospital, Pittsburgh, Pennsylvania
| |
Collapse
|
|
3
|
Ruppert R, Junginger T, Kube R, Strassburg J, Lewin A, Baral J, Maurer CA, Sauer J, Lauscher J, Winde G, Thomasmeyer R, Stelzner S, Bambauer C, Scheunemann S, Faedrich A, Wollschlaeger D, Merkel S. Risk-Adapted Neoadjuvant Chemoradiotherapy in Rectal Cancer: Final Report of the OCUM Study. J Clin Oncol 2023; 41:4025-4034. [PMID: 37335957 DOI: 10.1200/jco.22.02166] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 03/13/2023] [Accepted: 05/07/2023] [Indexed: 06/21/2023] Open
Abstract
PURPOSE We investigated whether neoadjuvant chemoradiotherapy (nCRT) in patients with rectal cancer can be restricted to those at high risk of locoregional recurrence (LR) without compromising oncological outcomes. PATIENTS AND METHODS In a prospective multicenter interventional study, patients with rectal cancer (cT2-4, any cN, cM0) were classified according to the minimal distance between the tumor, suspicious lymph nodes or tumor deposits, and mesorectal fascia (mrMRF). Patients with a distance >1 mm underwent up-front total mesorectal excision (TME; low-risk group), whereas those with a distance ≤1 mm and/or cT4 and cT3 tumors in the lower rectal third received nCRT followed by TME surgery (high-risk group). The primary end point was 5-year LR rate. RESULTS Of the 1,099 patients included, 884 (80.4%) were treated according to the protocol. A total of 530 patients (60%) underwent up-front surgery, and 354 (40%) had nCRT followed by surgery. Kaplan-Meier analyses revealed 5-year LR rates of 4.1% (95% CI, 2.7 to 5.5) for patients treated per protocol, 2.9% (95% CI, 1.3 to 4.5) after up-front surgery, and 5.7% (95% CI, 3.2 to 8.2) after nCRT followed by surgery. The 5-year rate of distant metastases was 15.9% (95% CI, 12.6 to 19.2) and 30.5% (95% CI, 25.4 to 35.6), respectively. In a subgroup analysis of 570 patients with lower and middle rectal third cII and cIII tumors, 257 (45.1%) were at low-risk. The 5-year LR rate in this group was 3.8% (95% CI, 1.4 to 6.2) after up-front surgery. In 271 high-risk patients (involved mrMRF and/or cT4), the 5-year rate of LR was 5.9% (95% CI, 3.0 to 8.8) and of metastases 34.5% (95% CI, 28.6 to 40.4); disease-free survival and overall survival were the worst. CONCLUSION The findings support the avoidance of nCRT in low-risk patients and suggest that in high-risk patients, neoadjuvant therapy should be intensified to improve prognosis.
Collapse
Affiliation(s)
- Reinhard Ruppert
- Department of General and Visceral Surgery, Endocrine Surgery, and Coloproctology, Municipal Hospital of Munich-Neuperlach, Munich, Germany
| | - Theodor Junginger
- Department of General and Abdominal Surgery, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Rainer Kube
- Department of Surgery, Carl-Thiem-Klinikum, Cottbus, Germany
| | - Joachim Strassburg
- Department of General and Visceral Surgery, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Andreas Lewin
- Department of General and Visceral Surgery, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Joerg Baral
- Department of General and Visceral Surgery, Municipal Hospital, Karlsruhe, Germany
| | - Christoph A Maurer
- Department of Surgery, Cantonal Hospital Baselland, Liestal, Switzerland
- Hirslanden Private Hospital Group, Clinic Beau-Site, Bern, Switzerland
| | - Joerg Sauer
- Department for General, Visceral and Minimal Invasive Surgery, Arnsberg, Germany
| | - Johannes Lauscher
- Department of Surgery, Campus Benjamin Franklin, Charité, University Medicine, Berlin, Germany
| | - Guenther Winde
- Department for General and Visceral Surgery, Thoracic Surgery and Proctology University Medical Centre Herford, Herford, Germany
| | - Rena Thomasmeyer
- Department for General, Visceral and Minimal-Invasive Surgery, Municipal Hospital Wolfenbüttel, Wolfenbüttel, Germany
| | - Sigmar Stelzner
- Dresden-Friedrichstadt General Hospital, Dresden, Germany
- Current Address: Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | | | - Soenke Scheunemann
- Department for General and Visceral Surgery, Evangelisches Krankenhaus Lippstadt, Lippstadt, Germany
| | - Axel Faedrich
- Department for General and Visceral Surgery, Brüderkrankenhaus St Josef, Paderborn, Germany
| | - Daniel Wollschlaeger
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre, Johannes Gutenberg-University, Mainz, Germany
| | - Susanne Merkel
- Department of Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| |
Collapse
|
|
4
|
Yang WF, Chen W, He Z, Wu Z, Liu H, Li G, Li WL. Simple transanal total mesorectal resection versus laparoscopic transabdominal total mesorectal resection for the treatment of low rectal cancer: a single-center retrospective case-control study. Front Surg 2023; 10:1171382. [PMID: 37576920 PMCID: PMC10413134 DOI: 10.3389/fsurg.2023.1171382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
Aim To evaluate the efficacy and safety of simple TaTNE in the treatment of low rectal cancer compared with laparoscopic transabdominal TME. Methods We collected patients with low rectal cancer admitted to our hospital between January 2019 and November 2021 who received simple TaTME or laparoscopic transabdominal TME. The main outcome was the integrity of the TME specimen. Secondary outcomes were the number of lymph nodes dissected, intraoperative blood loss, operative time, surgical conversion rate, Specimen resection length, circumferential margin (CRM), and distal resection margin (DRM), complication rate. In addition, the Wexner score and LARS score of fecal incontinence were performed in postoperative follow-up. Results Pathological tissues were successfully resected in all patients. all circumferential margins of the specimen were negative. Specimen resection length was not statistically significant (9.94 ± 2.85 vs. 8.90 ± 2.49, P > 0.05). The incidence of postoperative complications in group A (n = 0) was significantly lower than that in group B (n = 3) (P > 0.05). There was no significant difference in operation time between group A and group B (296 ± 60.36 vs. 305 ± 58.28, P > 0.05). Among the patients with follow-up time less than 1 year, there was no significant difference in Wexner score and LARS score between group A and group B (P > 0.05). However, in patients who were followed up for more than 1 year, the Wexner score in group A (9.25 ± 2.73) was significantly lower than that in group B (17.36 ± 10.95) and was statistically significant (P < 0.05). Conclusion For radical resection of low rectal cancer, Simple TaTME resection may be as safe and effective as laparoscopic transabdominal TME, and the long-term prognosis may be better.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Wang-Lin Li
- School of Medicine, South China University of Technology, Guangzhou, China
| |
Collapse
|
|
5
|
Chen W, Liu Y, An Y, Shi W, Qiu X, Lin G, Zhou J. The Effectiveness and Safety of Rectal Modular Resection in Low Rectal Cancer: A Retrospective Study. J Laparoendosc Adv Surg Tech A 2023. [PMID: 36946686 DOI: 10.1089/lap.2022.0592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Background: Described by Heald in 1982, total mesorectal excision (TME) is now routinely performed as the standard procedure for mid-low rectal cancer, with remarkable decrease in local recurrence and improved oncology outcome. However, the integrity of the resected mesentery and damage to autonomic nerves still remain challenging for general surgeons, especially in the cohort of neoadjuvant therapy patients. The concept of rectal modular resection (RMR), based on an integral understanding of the regional anatomy, was proposed as a surgical skill for dissociation of the rectum with shorter surgical duration, function preservation, and improved oncology outcome. Methods: This was a retrospective trial. Patients with resectable rectal lesions, ranging between 3 and 7 cm from the anal verge, were enrolled and grouped by TME surgery based on RMR or classical procedure resection (CPR). We estimated perioperative outcomes, including surgery complications such as anastomotic leak, urine retention, and others. Pathological properties, including distal clearance, harvested lymph nodes, tumor differentiation, and specimen grading, were also taken into account. Patients were followed postoperatively and functional evaluation was recorded at the 3-month and 1-year postoperation visits. Results: From January 2019 to December 2021, a total of 92 patients were enrolled in this study. TME surgery complying with the RMR methodology was performed with a back-to-bilateral-to-front modular proceeding. Duration of operation was significantly shortened in the RMR group, without increase in blood loss or failure rate of anus preservation. The quality of the specimen, graded according to integrity of the mesorectum, stands out in the RMR group. Functional evaluation revealed no statistical difference between RMR and CPR groups regarding sexual ability impairment and defecation disorder since follow-up is still ongoing. Conclusions: RMR-based TME was efficient with compressed operation duration compared with CPR and its safety was well validated with regard to the occurrence of complications and function loss.
Collapse
Affiliation(s)
- Weijie Chen
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuxin Liu
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang An
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Weikun Shi
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoyuan Qiu
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Guole Lin
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jiaolin Zhou
- Department of Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
|
6
|
Shao SL, Li YK, Qin JC, Liu L. Comprehensive abdominal composition evaluation of rectal cancer patients with anastomotic leakage compared with body mass index-matched controls. World J Gastrointest Surg 2022; 14:1250-1259. [PMID: 36504512 PMCID: PMC9727572 DOI: 10.4240/wjgs.v14.i11.1250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/27/2022] [Accepted: 11/04/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is a fatal complication in patients with rectal cancer after undergoing anterior resection. However, the role of abdominal composition in the development of AL has not been studied. AIM To investigate the relationship between abdominal composition and AL in rectal cancer patients after undergoing anterior resection. METHODS A retrospective case-matched cohort study was conducted. Complete data for 78 patients with AL were acquired and this cohort was defined as the AL group. The controls were matched for the same sex and body mass index (± 1 kg/m2). Parameters related to abdominal composition including visceral fat area (VFA), subcutaneous fat area (SFA), subcutaneous fat thickness (SFT), skeletal muscle area (SMA), skeletal muscle index (SMI), abdominal circumference (AC), anterior to posterior diameter of abdominal cavity (APD), and transverse diameter of abdominal cavity (TD) were evaluated based on computed tomography (CT) images using the following Hounsfield Unit (HU) thresholds: SFA: -190 to -30, SMA: -29 to 150, and VFA: -150 to -20. The significance of abdominal composition-related parameters was quantified using feature importance analysis; an artificial intelligence method was used to evaluate the contribution of each included variable. RESULTS Two thousand two hundred and thirty-eight rectal cancer patients who underwent anterior resection from 2010 to 2020 in a large academic hospital were investigated. Finally, 156 cases were enrolled in the study. Patients in the AL group showed longer operative time (225.03 ± 55.29 vs 207.17 ± 40.80, P = 0.023), lower levels of preoperative hemoglobin (123.32 ± 21.17 vs 132.60 ±1 6.31, P = 0.003) and albumin (38.34 ± 4.01 vs 40.52 ± 3.97, P = 0.001), larger tumor size (4.07 ± 1.36 vs 2.76 ± 1.28, P < 0.001), and later cancer stage (P < 0.001) compared to the controls. Patients who developed AL exhibited a larger VFA (125.68 ± 73.59 vs 97.03 ± 57.66, P = 0.008) and a smaller APD (77.30 ± 23.23 vs 92.09 ± 26.40, P < 0.001) and TD (22.90 ± 2.23 vs 24.21 ± 2.90, P = 0.002) compared to their matched controls. Feature importance analysis revealed that TD, APD, and VFA were the three most important abdominal composition-related features. CONCLUSION AL patients have a higher visceral fat content and a narrower abdominal structure compared to matched controls.
Collapse
Affiliation(s)
- Sheng-Li Shao
- Department of Surgery, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Yang-Kun Li
- Department of Surgery, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Ji-Chao Qin
- Department of Surgery, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Lu Liu
- Department of Surgery, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| |
Collapse
|
|
7
|
Teng W, Liu J, Chen M, Zang W, Wu A. BMI and pelvimetry help to predict the duration of laparoscopic resection for low and middle rectal cancer. BMC Surg 2022; 22:402. [PMID: 36404329 PMCID: PMC9677663 DOI: 10.1186/s12893-022-01840-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 11/06/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In rectal cancer surgery, recent studies have found associations between clinical factors, especially pelvic parameters, and surgical difficulty; however, their findings are inconsistent because the studies use different criteria. This study aimed to evaluate common clinical factors that influence the operative time for the laparoscopic anterior resection of low and middle rectal cancer. METHODS Patients who underwent laparoscopic radical resection of low and middle rectal cancer from January 2018 to December 2020 were retrospectively analyzed and classified according to the operative time. Preoperative clinical and magnetic resonance imaging (MRI)-related parameters were collected. Logistic regression analysis was used to identify factors for predicting the operative time. RESULTS In total, 214 patients with a mean age of 60.3 ± 8.9 years were divided into two groups: the long operative time group (n = 105) and the short operative time group (n = 109). Univariate analysis revealed that the male sex, a higher body mass index (BMI, ≥ 24.0 kg/m2), preoperative treatment, a smaller pelvic inlet (< 11.0 cm), a deeper pelvic depth (≥ 10.7 cm) and a shorter intertuberous distance (< 10.1 cm) were significantly correlated with a longer operative time (P < 0.05). However, only BMI (OR 1.893, 95% CI 1.064-3.367, P = 0.030) and pelvic inlet (OR 0.439, 95% CI 0.240-0.804, P = 0.008) were independent predictors of operative time. Moreover, the rate of anastomotic leakage was higher in the long operative time group (P < 0.05). CONCLUSION Laparoscopic rectal resection is expected to take longer to perform in patients with a higher BMI or smaller pelvic inlet.
Collapse
Affiliation(s)
- Wenhao Teng
- grid.415110.00000 0004 0605 1140Department of Gastrointestinal Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014 China
| | - Jingfu Liu
- grid.415110.00000 0004 0605 1140Department of Blood Transfusion, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, China
| | - Meimei Chen
- grid.415110.00000 0004 0605 1140Department of Gastrointestinal Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014 China
| | - Weidong Zang
- grid.415110.00000 0004 0605 1140Department of Gastrointestinal Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuzhou, 350014 China
| | - Aiwen Wu
- grid.412474.00000 0001 0027 0586Unit III, Gastrointestinal Cancer Center, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Peking University Cancer Hospital & Institute, Beijing, 100142 China
| |
Collapse
|
|
8
|
Quero G, Mascagni P, Kolbinger FR, Fiorillo C, De Sio D, Longo F, Schena CA, Laterza V, Rosa F, Menghi R, Papa V, Tondolo V, Cina C, Distler M, Weitz J, Speidel S, Padoy N, Alfieri S. Artificial Intelligence in Colorectal Cancer Surgery: Present and Future Perspectives. Cancers (Basel) 2022; 14:3803. [PMID: 35954466 PMCID: PMC9367568 DOI: 10.3390/cancers14153803] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/29/2022] [Accepted: 08/03/2022] [Indexed: 02/05/2023] Open
Abstract
Artificial intelligence (AI) and computer vision (CV) are beginning to impact medicine. While evidence on the clinical value of AI-based solutions for the screening and staging of colorectal cancer (CRC) is mounting, CV and AI applications to enhance the surgical treatment of CRC are still in their early stage. This manuscript introduces key AI concepts to a surgical audience, illustrates fundamental steps to develop CV for surgical applications, and provides a comprehensive overview on the state-of-the-art of AI applications for the treatment of CRC. Notably, studies show that AI can be trained to automatically recognize surgical phases and actions with high accuracy even in complex colorectal procedures such as transanal total mesorectal excision (TaTME). In addition, AI models were trained to interpret fluorescent signals and recognize correct dissection planes during total mesorectal excision (TME), suggesting CV as a potentially valuable tool for intraoperative decision-making and guidance. Finally, AI could have a role in surgical training, providing automatic surgical skills assessment in the operating room. While promising, these proofs of concept require further development, validation in multi-institutional data, and clinical studies to confirm AI as a valuable tool to enhance CRC treatment.
Collapse
Affiliation(s)
- Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Pietro Mascagni
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
- Institute of Image-Guided Surgery, IHU-Strasbourg, 67000 Strasbourg, France
| | - Fiona R. Kolbinger
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Davide De Sio
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Fabio Longo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Carlo Alberto Schena
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Vito Laterza
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Roberta Menghi
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Valerio Papa
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Vincenzo Tondolo
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Caterina Cina
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Marius Distler
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Juergen Weitz
- Department for Visceral, Thoracic and Vascular Surgery, University Hospital and Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | - Stefanie Speidel
- National Center for Tumor Diseases (NCT), Partner Site Dresden, 01307 Dresden, Germany
| | - Nicolas Padoy
- Institute of Image-Guided Surgery, IHU-Strasbourg, 67000 Strasbourg, France
- ICube, Centre National de la Recherche Scientifique (CNRS), University of Strasbourg, 67000 Strasbourg, France
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy
- Faculty of Medicine, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| |
Collapse
|
|
9
|
Yuan Y, Tong D, Liu M, Lu H, Shen F, Shi X. An MRI-based pelvimetry nomogram for predicting surgical difficulty of transabdominal resection in patients with middle and low rectal cancer. Front Oncol 2022; 12:882300. [PMID: 35957878 PMCID: PMC9357897 DOI: 10.3389/fonc.2022.882300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The current work aimed to develop a nomogram comprised of MRI-based pelvimetry and clinical factors for predicting the difficulty of rectal surgery for middle and low rectal cancer (RC). Methods Consecutive mid to low RC cases who underwent transabdominal resection between June 2020 and August 2021 were retrospectively enrolled. Univariable and multivariable logistic regression analyses were carried out for identifying factors (clinical factors and MRI-based pelvimetry parameters) independently associated with the difficulty level of rectal surgery. A nomogram model was established with the selected parameters for predicting the probability of high surgical difficulty. The predictive ability of the nomogram model was assessed by the receiver operating characteristic (ROC) curve and decision curve analysis (DCA). Results A total of 122 cases were included. BMI (OR = 1.269, p = 0.006), pelvic inlet (OR = 1.057, p = 0.024) and intertuberous distance (OR = 0.938, p = 0.001) independently predicted surgical difficulty level in multivariate logistic regression analysis. The nomogram model combining these predictors had an area under the ROC curve (AUC) of 0.801 (95% CI: 0.719–0.868) for the prediction of a high level of surgical difficulty. The DCA suggested that using the nomogram to predict surgical difficulty provided a clinical benefit. Conclusions The nomogram model is feasible for predicting the difficulty level of rectal surgery, utilizing MRI-based pelvimetry parameters and clinical factors in mid to low RC cases.
Collapse
Affiliation(s)
- Yuan Yuan
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Dafeng Tong
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Minglu Liu
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Haidi Lu
- Department of Radiology, Changhai Hospital, Shanghai, China
| | - Fu Shen
- Department of Radiology, Changhai Hospital, Shanghai, China
- *Correspondence: Xiaohui Shi, ; Fu Shen,
| | - Xiaohui Shi
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
- *Correspondence: Xiaohui Shi, ; Fu Shen,
| |
Collapse
|
|
10
|
Adams AM, Vreeland TJ, Teshome M, Francescatti AB, Zheng L, Hunt KK, Katz MHG, Messick CA. American College of Surgeons Commission on Cancer Standard 5.7 for Total Mesorectal Excision for Mid-to-Low Rectal Cancer. J Am Coll Surg 2022; 234:1249-1253. [PMID: 35703824 DOI: 10.1097/xcs.0000000000000175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Alexandra M Adams
- From the Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX (Adams, Vreeland)
| | - Timothy J Vreeland
- From the Department of Surgery, San Antonio Military Medical Center, Fort Sam Houston, TX (Adams, Vreeland)
| | - Mediget Teshome
- the Department of Breast Surgical Oncology (Teshome, Hunt), University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amanda B Francescatti
- the Cancer Surgery Standards Program, American College of Surgeons, Chicago, IL (Francescatti, Zheng)
| | - Linda Zheng
- the Cancer Surgery Standards Program, American College of Surgeons, Chicago, IL (Francescatti, Zheng)
| | - Kelly K Hunt
- the Department of Breast Surgical Oncology (Teshome, Hunt), University of Texas MD Anderson Cancer Center, Houston, TX.,Department of Surgical Oncology (Hunt, Katz), University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthew H G Katz
- Department of Surgical Oncology (Hunt, Katz), University of Texas MD Anderson Cancer Center, Houston, TX
| | - Craig A Messick
- Department of Colon and Rectal Surgery (Messick), University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
|
11
|
Kim JC, Park SH, Kim J, Kim CW, Park IJ, Yoon YS, Lee JL, Kim JH, Hong YS, Kim TW. Involvement of tissue changes induced by neoadjuvant treatment in total mesorectal excision (TME): novel suggestions for determining TME quality. Int J Colorectal Dis 2022; 37:1289-1300. [PMID: 35513539 DOI: 10.1007/s00384-022-04165-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Few studies to date have investigated morphological changes after neoadjuvant treatment (NAT) and their implications in total mesorectal excision (TME). This study was primarily designed to evaluate whether tissue changes associated with NAT affected the quality of TME and additionally to suggest a more objective method evaluating TME quality. METHODS This study enrolled 1322 consecutive patients who underwent curative robot-assisted surgery for rectal cancer. Patients who did and did not receive NAT were subjected to propensity-score matching, yielding 402 patients in each group. RESULTS NAT independently reduced complete achievement of TME [odds ratio (OR) = 2.056, p = 0.017]. Intraoperative evaluation identified seven tissue changes significantly associated with NAT, including tumor perforation, mucin pool, necrosis, fibrosis, fat degeneration, and rectal or perirectal edema NAT (p < 0.001-0.05). Tumor perforation (OR = 5.299, p = 0.001) and mucin pool (OR = 14.053, p = 0.002) were independently associated with inappropriate (near-complete + incomplete) TME. Complete TME resulted in significantly reduced local recurrence (4.3% vs 15.3%, p = 0.003) and increased 5-year DFS rate (80.6% vs 67.6%, p = 0.047) compared with inappropriate one. By contrast, two tiers of complete and near-complete TMEs vs incomplete TME did not. Notably, among patients with complete TME, those who received NAT had a lower 5-year DFS than those who did not (77.8% vs 83.3%, p = 0.048). CONCLUSIONS NAT-associated tissue changes, somewhat interrupting complete TME, may provide unsolved clue to the relative inability of NAT to improve overall survival. The conventional three-tier grading of TME seems to be simplified into two tiers as complete and inappropriate.
Collapse
Affiliation(s)
- Jin Cheon Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea.
| | - Seong Ho Park
- Department of Radiology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Chan Wook Kim
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - In Ja Park
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Yong Sik Yoon
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jong Lyul Lee
- Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Jong Hoon Kim
- Department of Radiation Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Yong Sang Hong
- Department of Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| | - Tae Won Kim
- Department of Oncology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, 05505, Republic of Korea
| |
Collapse
|
|
12
|
Kim JC, Han JS, Lee JL, Kim CW, Yoon YS, Park SH, Kim J. Re-evaluation of possible vulnerable sites in the lateral pelvic cavity to local recurrence during robot-assisted total mesorectal excision. Surg Endosc 2021; 35:5450-5460. [PMID: 32970206 DOI: 10.1007/s00464-020-08032-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite mechanical and technical improvements in laparoscopic and robot-assisted (LAR) rectal cancer procedures, the absence of prognostic disparities among various approaches cannot improve the quality of TME. The present study re-evaluated robot-assisted total mesorectal excision (TME) procedures to determine whether these procedures may reveal technical faults that may increase the rate of local recurrence (LR). METHODS This study enrolled 886 consecutive patients with rectal cancer, who underwent curative robot-assisted LAR at Asan Medical Center (Seoul, Korea) between July 2010 and August 2017 (the first vs second period; n = 399 vs 487). The quality of TME and lateral pelvic mesorectal excision (LPME) were analyzed, as were LR rates and survival outcomes. RESULTS Complete TME and LPME were achieved in 89.2% and 80.1% of these patients, respectively, with ≤ 1% having incomplete TME excluding intramesorectal excision. LR rates were 13.5 and 14.5 times higher in patients with incomplete TME and LPME, respectively, than in patients with complete TME and LPME (14.8% vs 1.1% and 8.7% vs 0.6%; p < 0.001 each by univariate analyses). Multivariate analyses showed that defective LPME was independently associated with incomplete TME and vice versa (p < 0.001). Cox regression analysis showed that defective LPME was independently correlated with reduced 5-year disease-free survival rate (hazard ratio, 1.563; 95% confidence interval, 1.052-2.323; p = 0.027). CONCLUSIONS LR in rectal cancer patients was largely due to incomplete LPME, which was significantly associated with incomplete TME. Complete LPME may enhance the likelihood of complete TME, reducing LR rates.
Collapse
Affiliation(s)
- Jin Cheon Kim
- Department of Surgery and Institute of Innovative Cancer Research, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Jin Su Han
- Department of Surgery and Institute of Innovative Cancer Research, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jong Lyul Lee
- Department of Surgery and Institute of Innovative Cancer Research, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Chan Wook Kim
- Department of Surgery and Institute of Innovative Cancer Research, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Yong Sik Yoon
- Department of Surgery and Institute of Innovative Cancer Research, University of Ulsan College of Medicine and Asan Medical Center, 88, Olympic-ro-43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Sung Ho Park
- Department of Radiology, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Jihun Kim
- Department of Pathology, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
|
13
|
Park SY, Lee SM, Park JS, Kim HJ, Choi GS. Robot Surgery Shows Similar Long-term Oncologic Outcomes as Laparoscopic Surgery for Mid/Lower Rectal Cancer but Is Beneficial to ypT3/4 After Preoperative Chemoradiation. Dis Colon Rectum 2021; 64:812-821. [PMID: 33833141 DOI: 10.1097/dcr.0000000000001978] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The long-term oncologic efficacy of robotic surgery for patients with rectal cancer is unknown. OBJECTIVE The aim of the study was to investigate survival outcomes of robotic total mesorectal excision for mid/low rectal cancer compared with those of laparoscopic surgery. DESIGN We performed a single-center retrospective analysis. SETTING The data of a tertiary academic institution was reviewed. PATIENTS A total of 705 patients underwent laparoscopic (n = 415) or robotic (n = 118) low anterior resection for stage I to III mid/low rectal cancer. A total of 118 patients in each group were selected from the original data set by using propensity score matching. MAIN OUTCOME MEASURES The main outcomes were 5-year disease-free survival, distant recurrence, and local recurrence. RESULTS The 2 groups were balanced in terms of basic characteristics, perioperative treatment, and pathological stage. The 5-year disease-free survival rate was 80.5% in the laparoscopic group and 87.6% in the robotic group (p = 0.118). The 5-year distant recurrence rate and local recurrence rate were 19.0% and 4.2% in the laparoscopic group and 10.0% and 3.7% in the robotic group (p = 0.048 and p = 0.846). In a subgroup of patients who received preoperative chemoradiation and had ypT3/4 tumors, the 5-year distant recurrence and local recurrence rates were 44.8% and 5.0% in the laparoscopic group and 9.8% and 9.8% in the robotic group (p = 0.014 and p = 0.597). LIMITATIONS The retrospective nature of the study, potential selection bias with distinct demographics between the groups, and relatively small number of cases are limitations. CONCLUSIONS Robotic surgery for mid/low rectal cancer shows similar long-term oncologic outcomes with laparoscopic surgery but is beneficial to a certain group of patients with advanced rectal cancer with poor response to neoadjuvant chemoradiation. Additional studies are required to confirm our results. See Video Abstract at http://links.lww.com/DCR/B546. LA CIRUGA ROBTICA MUESTRA RESULTADOS ONCOLGICOS A LARGO PLAZO SIMILARES A LA CIRUGA LAPAROSCPICA EN CASOS DE CNCER DE RECTO MEDIO / BAJO, PERO ES VENTAJOSA EN CASOS YPT POSTQUIMIORADIOTERAPIA PREOPERATORIA ANTECEDENTES:Se desconoce la eficacia oncológica a largo plazo de la cirugía robótica en pacientes con cáncer de recto.OBJETIVO:La finalidad de nuestro estudio fue el investigar los resultados de supervivencia de la escisión mesorrectal total robótica en casos de cáncer de recto medio / bajo en comparación con los de la cirugía laparoscópica.DISEÑO:Realizamos un análisis retrospectivo mono-céntrico.AJUSTE:Se revisaron los datos de una institución académica terciaria.PACIENTES:705 pacientes fueron sometidos a resección anterior baja laparoscópica (n = 415) o robótica (n = 118) para cáncer de recto medio / bajo en estadio I-III. Se seleccionó un total de 118 pacientes en cada grupo del conjunto de datos original utilizando el emparejamiento por puntuación de propensión.RESULTADOS PRINCIPALES:Éstos fueron, la supervivencia libre de enfermedad a 5 años, la recurrencia a distancia y la recurrencia local.RESULTADOS:Los dos grupos estaban equilibrados en cuanto a características básicas, tratamiento péri-operatorio y estadío patológico. La tasa de sobrevida libre de enfermedad a 5 años fue del 80,5% en el grupo laparoscópico y del 87,6% en el grupo robótico (p = 0,118). La tasa de recurrencia a distancia a 5 años y la tasa de recurrencia local fueron 19,0% y 4,2% en el grupo laparoscópico y 10,0% y 3,7% en el grupo robótico, respectivamente (p = 0,048 y p= 0,846). En el subgrupo de pacientes que recibieron quimio-radioterapia pré-operatoria y tenían tumores ypT3-4, las tasas de recidiva a distancia a 5 años y recidiva local fueron 44,8% y 5,0% en el grupo laparoscópico y 9,8% y 9,8% en el grupo robótico, respectivamente (p = 0.014 y p = 0.597).LIMITACIONES:La naturaleza retrospectiva del estudio, el posible sesgo en la selección con datos demográficos distintos entre los grupos y un número relativamente pequeño de casos son limitaciones importantes.CONCLUSIONES:La cirugía robótica para el cáncer de recto medio / bajo muestra resultados oncológicos a largo plazo similares con la cirugía laparoscópica, pero es mas beneficiosa en ciertos grupos de cáncer de recto avanzado con mala respuesta a la quimio-radioterapia neoadyuvante. Se requieren más estudios para confirmar nuestros resultados. Consulte Video Resumen en http://links.lww.com/DCR/B546.).
Collapse
Affiliation(s)
- Soo Yeun Park
- Colorectal Cancer Center, Kyungpook National University Chilgok Hospital, Department of Surgery, School of Medicine, Kyungpook National University, Daegu, South Korea
| | | | | | | | | |
Collapse
|
|
14
|
Jin H, Zheng L, Lu L, Cui M. Near-infrared intraoperative imaging of pelvic autonomic nerves: a pilot study. Surg Endosc 2021; 36:2349-2356. [PMID: 33909127 DOI: 10.1007/s00464-021-08512-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The pelvic autonomic nerves control and regulate anorectal and urogenital function. The dysfunction of pelvic autonomic nerves lead to disorders of anorectum, bladder and male sex organs. Thus the intraoperative identification of pelvic autonomic nerves could be crucial in complications prevention and diseases treatment. Our clinical trial aims at estimating the effectiveness and validity of intraoperative indocyanine green fluorescence imaging in pelvic autonomic nerves identification. METHODS Intraoperative fluorescence imaging using indocyanine green was performed in ten patients and the feasibility was determined. From February 2019 to June 2019, the seven patients undergoing laparoscopic colorectal resection was administrated 4.5 mg/Kg indocyanine green 24 h before surgery. The near-infrared fluorescence imaging was conducted during surgery. A novel white light and near-infrared dual-channel laparoscopic equipment was applied. For each patient, signal-background ratio values for pelvic autonomic nerves were recorded and analyzed. RESULTS We confirmed the dose and timing of indocyanine green administration was 4.5 mg/Kg and 24 h before surgery. Using the dual laparoscopic equipment, we could observe the splanchnic plexus, inferior mesenteric artery plexus, and sacral plexus successfully with a high signal background ratio value of 3.18 (standard deviation: 0.48). CONCLUSION This pilot trial shows feasibility of intraoperative indocyanine green fluorescence imaging in pelvic autonomic nerves observation. It demonstrates that nerves can be visualized using alternative imaging techniques but it is not ready yet for prime time. This technique might aid observation with white light alone. Registration number: ChiCTR1900025336.
Collapse
Affiliation(s)
- Hao Jin
- The Second Department of General Surgery, Zhuhai People's Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, Guangdong Province, 519000, China
| | - Li Zheng
- The Department of Clinical Laboratory, The Fifth People's Hospital of Zhuhai, Zhuhai, Guangdong Province, 519000, China
| | - Ligong Lu
- Zhuhai People's Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, Guangdong Province, 519000, China.
| | - Min Cui
- Zhuhai People's Hospital (Zhuhai Hospital Affiliated with Jinan University), Zhuhai, Guangdong Province, 519000, China.
| |
Collapse
|
|
15
|
Hallam S, Ahmed F, Gouvas N, Pandey S, Nicol D. Oncological outcomes and stoma-free survival following TaTME, a prospective cohort study. Tech Coloproctol 2021; 25:439-447. [PMID: 33606129 DOI: 10.1007/s10151-020-02390-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Transanal TME (TaTME) was introduced to improve access to the pelvis in difficult cases (male sex, obesity and mid to low rectal cancers) and reduce the risk of anastomotic leak by avoiding cross stapling. In April 2018 the Norwegian hospital to whom all local; recurrences for rectal cancer are referred reported an unexpected rise in early multifocal local recurrences of 9.5% following TaTME compared with 3.4% following conventional TME leading to a nationwide moratorium on the procedure and ending, in an editorial published on the British Journal of Surgery in August 2020, by saying that other countries should consider the issue in the context of local practices and results. There are limited data concerning oncological outcomes of TaTME compared to conventional TME. The aim of this study was to report perioperative and oncological outcomes for patients with rectal cancer treated with TaTME in a high-volume, experienced UK centre. METHODS From January 2015 to January 2020 consecutive patients with histologically confirmed rectal cancer having TaTME at Worcestershire Royal Hospital NHS were prospectively entered into an online international registry. Patients were followed according to local protocol with clinical examination, tumour markers, endoscopy and radiology. RESULTS Seventy patients underwent TaTME for rectal cancer. The median distance of the tumour from the anorectal junction was 4 cm (IQR 2-5). The mesorectal margin was involved in 20 (1%) patients, all of whom received neoadjuvant chemoradiotherapy. Overall survival was 94% at a median follow-up of 15 months (IQR 9-31 months). Distant recurrence occurred in 12 (17%) of patients at a median of 14 months (IQR 10-17 months). The 18-month stoma-free survival rate was 66%. CONCLUSIONS A local recurrence rate of 5.7% supports the oncological safety of TaTME for rectal cancer.
Collapse
Affiliation(s)
- S Hallam
- Worcestershire Acute Hospitals NHS Trust, Colorectal Surgery, Worcester, UK.
| | - F Ahmed
- Worcestershire Acute Hospitals NHS Trust, Colorectal Surgery, Worcester, UK
| | - N Gouvas
- Worcestershire Acute Hospitals NHS Trust, Colorectal Surgery, Worcester, UK
| | - S Pandey
- Worcestershire Acute Hospitals NHS Trust, Colorectal Surgery, Worcester, UK
| | - D Nicol
- Worcestershire Acute Hospitals NHS Trust, Colorectal Surgery, Worcester, UK
| |
Collapse
|
|
16
|
Zuhdy M, Metwally IH, Eldamshety O, Roshdy S. Operative Feasibility and Short-Term Oncologic Outcome of Rigid Versus Flexible Platforms in Transanal Total Mesorectal Excision. Indian J Surg Oncol 2021; 12:222-228. [PMID: 33814857 DOI: 10.1007/s13193-021-01282-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 01/27/2021] [Indexed: 10/22/2022] Open
Abstract
Several transanal platforms were used to perform transanal total mesorectal excision (TaTME). They can be classified into rigid reusable platforms or flexible single-use platforms. The choice of transanal platform usually depends on the availability and the surgeon's discretion. To the best of our knowledge, this is the first study to compare the operative and oncologic outcome of flexible and rigid platforms during TaTME. This is a retrospective cohort study in which rectal cancer patients operated by TaTME in two tertiary centers from June 2013 to April 2019 were included. They were classified into two groups according to the platform used either the rigid platform group (n = 17) or the flexible platform (n = 14). Operative feasibility and short-term oncologic data were analyzed and reported. A total number of 31 patients were divided into either the rigid platform group (n = 17) versus the flexible platform one (n = 14). Shorter operating time, less blood loss, better TME specimens, and lymph node yield were reported in the flexible platform group. Flexible platforms were associated with better operative outcomes. Although there were no differences in circumferential and distal margins between the two groups, better TME specimens' quality and lymph node yield were reported in the flexible platform group. Future prospective trials are encouraged to provide better evidence.
Collapse
Affiliation(s)
- Mohammad Zuhdy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt.,Department of Gastrointestinal Surgery, IRCCS San Raffaele, University Vita e Salute, San Raffaele Hospital and San Raffaele Vita-Salute University, Via Olgettina, 60 20132 Milan, Italy
| | - Islam H Metwally
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt
| | - Osama Eldamshety
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt
| | - Sameh Roshdy
- Surgical Oncology Unit, Oncology Center Mansoura University (OCMU), Geehan Street, Mansoura, 35516 Egypt
| |
Collapse
|
|
17
|
Ruppert R, Kube R, Strassburg J, Lewin A, Baral J, Maurer CA, Sauer J, Junginger T, Hermanek P, Merkel S. Avoidance of Overtreatment of Rectal Cancer by Selective Chemoradiotherapy: Results of the Optimized Surgery and MRI-Based Multimodal Therapy Trial. J Am Coll Surg 2020; 231:413-425.e2. [PMID: 32697965 DOI: 10.1016/j.jamcollsurg.2020.06.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (nCRT) in patients with rectal cancer carries a high risk of adverse effects. The aim of this study was to examine the selective application of nCRT based on patient risk profile, as determined by MRI, to find the optimal range between undertreatment and overtreatment. STUDY DESIGN In this prospective multicenter observational study, nCRT before total mesorectal excision (TME) was indicated in high-risk patients with involved or threatened mesorectal fascia (≤1 mm), or cT4 or cT3 carcinomas of the lower rectal third. All other patients received primary surgery. RESULTS Of the 1,093 patients, 878 (80.3%) were treated according to the protocol, 526 patients (59.9%) underwent primary surgery, and 352 patients (40.1%) underwent nCRT followed by surgery. The 3-year locoregional recurrence (LR) rate was 3.1%. Of 604 patients with clinical stages II and III, 267 (44.2%) had primary surgery; 337 (55.8%) received nCRT followed by TME. The 3-year LR rate was 3.9%, without significant differences between groups. In patients with clinical stages II and III who underwent primary surgery, 27.3% were diagnosed with pathological stage I. CONCLUSIONS The results justify the restriction of nCRT to high-risk patients with rectal cancer classified by pretreatment MRI. Provided that a high-quality MRI diagnosis, TME surgery, and standardized examination of the resected specimen are performed, nCRT, with its adverse effects, costs, and treatment time can be avoided in more than 40% of patients with stage II or III rectal cancer with minimal risk of undertreatment. (clinicaltrials.gov NCT325649).
Collapse
Affiliation(s)
- Reinhard Ruppert
- Department of General and Visceral Surgery, Endocrine Surgery, and Coloproctology, Municipal Hospital of Munich-Neuperlach, Germany
| | - Rainer Kube
- Department of Surgery, Carl-Thiem-Klinikum, Cottbus, Germany
| | - Joachim Strassburg
- Departments of General and Visceral Surgery, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | | | | | - Christoph A Maurer
- Departments of Surgery, Cantonal Hospital Baselland, Liestal, Switzerland; Hirslanden Private Hospital Group, Clinic Beau-Site, Bern, Switzerland
| | - Joerg Sauer
- Department for General-Visceral and Minimal Invasive Surgery, Arnsberg, Germany
| | - Theodor Junginger
- Department of General and Abdominal Surgery at the University Medical Centre of the Johannes Gutenber-University, Mainz, Germany.
| | - Paul Hermanek
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Susanne Merkel
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | | |
Collapse
|
|
18
|
Sirák I, Pohanková D, Ferko A, Hovorková E, Rozkoš T, Vošmik M, Hodek M, Paluska P, Buka D, Grepl J, Petera J. The Time Between Chemoradiation and Surgery for Rectal Carcinoma Negatively Influences Mesorectal Excision Quality. Pathol Oncol Res 2020; 26:1565-1572. [PMID: 31482400 DOI: 10.1007/s12253-019-00742-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/27/2019] [Indexed: 01/12/2023]
Abstract
Total mesorectal excision quality (TMEq) is a prognostic factor associated with local recurrence in rectal adenocarcinoma. Neoadjuvant chemoradiotherapy (NCRT) reduces the risk of tumor recurrence, but may compromise TMEq. The time between NCRT and surgery (TTS) and how it influences TMEq and tumor control were evaluated. In prospective registry, 236 patients after NCRT and TME were analyzed. NCRT involved radiotherapy with 45 Gy to the pelvis, plus tumor boost dose 5.4 Gy with concurrent 5-fluorouracil infusion. NCRT was followed by TME after 9 weeks on average (median 9.4 ± SD 2.5). TMEq was parametrically analyzed by standard three-grade system. With median follow-up of 47.5 months, 3-year overall survival (OS) was 83.8%, disease-free survival (DFS) was 77.7%, and 6.4% was the rate of local recurrence (LR). TTS was not associated with OS, DFS, or LR. TMEq was found to be associated with LR in univariate analysis, but not in multivariate, where pathological tumor stage and resection margins remained dominant predictors. TMEq was negatively influenced by inferior location of the tumor, longer TTS, higher tumor and nodal stage, presence of tumor perforation, perineural invasion, and close/positive resection margins. Nonetheless, TTS remained a strong predictor of TMEq in multivariate analyses. TTS was proven to be an independent predictor of TMEq. With longer TTS, fewer complete TME with intact mesorectal plane were observed. However, TTS was not associated with survival deterioration or tumor recurrence. These were negatively influenced by other factors interfering with TMEq, especially by pathological tumor stage and resection margins.
Collapse
Affiliation(s)
- Igor Sirák
- Department of Oncology and Radiotherapy, University Hospital in Hradec Kralove, Sokolská 581, 500 05, Hradec Králové, Czech Republic
| | - Denisa Pohanková
- Department of Oncology and Radiotherapy, University Hospital in Hradec Kralove, Sokolská 581, 500 05, Hradec Králové, Czech Republic
| | - Alexander Ferko
- Department of Surgery and Transplant centre, Jessenius Faculty in Martin, University Hospital Martin, Comenius University Bratislava, Bratislava, Slovak Republic
| | - Eva Hovorková
- Fingerland Department of Pathology, University Hospital in Hradec Králové, Hradec Králové, Czechia
| | - Tomáš Rozkoš
- Fingerland Department of Pathology, University Hospital in Hradec Králové, Hradec Králové, Czechia
| | - Milan Vošmik
- Department of Oncology and Radiotherapy, University Hospital in Hradec Kralove, Sokolská 581, 500 05, Hradec Králové, Czech Republic.
| | - Miroslav Hodek
- Department of Oncology and Radiotherapy, University Hospital in Hradec Kralove, Sokolská 581, 500 05, Hradec Králové, Czech Republic
| | - Petr Paluska
- Department of Oncology and Radiotherapy, University Hospital in Hradec Kralove, Sokolská 581, 500 05, Hradec Králové, Czech Republic
| | - David Buka
- Department of Oncology and Radiotherapy, University Hospital in Hradec Kralove, Sokolská 581, 500 05, Hradec Králové, Czech Republic
| | - Jakub Grepl
- Department of Oncology and Radiotherapy, University Hospital in Hradec Kralove, Sokolská 581, 500 05, Hradec Králové, Czech Republic
| | - Jiří Petera
- Department of Oncology and Radiotherapy, University Hospital in Hradec Kralove, Sokolská 581, 500 05, Hradec Králové, Czech Republic
| |
Collapse
|
|
19
|
A Multicenter Matched Comparison of Transanal and Robotic Total Mesorectal Excision for Mid and Low-rectal Adenocarcinoma. Ann Surg 2020; 270:1110-1116. [PMID: 29916871 DOI: 10.1097/sla.0000000000002862] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To compare the quality of surgical resection of transanal total mesorectal excision (TA-TME) and robotic total mesorectal excision (R-TME). BACKGROUND Both TA-TME and R-TME have been advocated to improve the quality of surgery for rectal cancer below 10 cm from the anal verge, but there are little data comparing TA-TME and R-TME. METHODS Data of patients undergoing TA-TME or R-TME for rectal cancer below 10 cm from the anal verge and a sphincter-saving procedure from 5 high-volume rectal cancer referral centers between 2011 and 2017 were obtained. Coarsened exact matching was used to create balanced cohorts of TA-TME and R-TME. The main outcome was the incidence of poor-quality surgical resection, defined as a composite measure including incomplete quality of TME, or positive circumferential resection margin (CRM) or distal resection margin (DRM). RESULTS Out of a total of 730 patients (277 TA-TME, 453 R-TME), matched groups of 226 TA-TME and 370 R-TME patients were created. These groups were well-balanced. The mean tumor height from the anal verge was 5.6 cm (SD 2.5), and 70% received preoperative radiotherapy. The incidence of poor-quality resection was similar in both groups (TA-TME 6.9% vs R-TME 6.8%; P = 0.954). There were no differences in TME specimen quality (complete or near-complete TA-TME 99.1% vs R-TME 99.2%; P = 0.923) and CRM (5.6% vs 6.0%; P = 0.839). DRM involvement may be higher after TA-TME (1.8% vs 0.3%; P = 0.051). CONCLUSIONS High-quality TME for patients with rectal adenocarcinoma of the mid and low rectum can be equally achieved by transanal or robotic approaches in skilled hands, but attention should be paid to the distal margin.
Collapse
|
|
20
|
Laparoscopic Versus Open Resection for Rectal Cancer: A Noninferiority Meta-analysis of Quality of Surgical Resection Outcomes. Ann Surg 2020; 269:849-855. [PMID: 30339624 DOI: 10.1097/sla.0000000000003072] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine whether laparoscopic surgery is noninferior to open surgery for rectal cancer in terms of quality of surgical resection outcomes. BACKGROUND Randomized clinical trials (RCTs) have evaluated the oncologic safety of laparoscopic versus open surgery for rectal cancer with conflicting results. Prior meta-analyses comparing these operative approaches in terms of quality of surgical resection aimed to demonstrate if one approach was superior. However, this method is not appropriate and potentially misleading when noninferiority RCTs are included. METHODS MEDLINE, EMBASE, and Cochrane were searched to identify RCTs comparing these operative approaches. Risk differences (RDs) were pooled using random-effects meta-analyses. One-sided Z tests were used to determine noninferiority. Noninferiority margins (ΔNI) for circumferential resection margin (CRM), plane of mesorectal excision (PME), distal resection margin (DRM), and a composite outcome ("successful resection") were based on the consensus of 58 worldwide experts. RESULTS Fourteen RCTs were included. Laparoscopic resection was noninferior compared with open resection for the rate of positive CRM [RD 0.79%, 90% confidence interval (CI) -0.46 to 2.04, ΔNI = 2.33%, PNI = 0.026], incomplete PME (RD 1.16%, 90% CI -0.27 to 2.59, ΔNI = 2.85%, PNI = 0.025), and positive DRM (RD 0.15%, 90% CI -0.58 to 0.87, ΔNI = 1.28%, PNI = 0.005). For the rate of "successful resection" (RD 6.16%, 90% CI 2.30-10.02), the comparison was inconclusive when using the ΔNI generated by experts (ΔNI = 2.71%, PNI = 0.07), although no consensus was achieved for this ΔNI. CONCLUSIONS Laparoscopy was noninferior to open surgery for rectal cancer in terms of individual quality of surgical resection outcomes. These findings are concordant with RCTs demonstrating noninferiority for long-term oncologic outcomes between the 2 approaches.
Collapse
|
|
21
|
Wang XM, Xu YY, Yu G, Rong Z, Geng RC, Wang R, Chen LY, Liu G. Pure transanal total mesorectal excision for rectal cancer: experience with 55 cases. Gastroenterol Rep (Oxf) 2019; 8:42-49. [PMID: 32104585 PMCID: PMC7034235 DOI: 10.1093/gastro/goz055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 08/22/2019] [Accepted: 09/30/2019] [Indexed: 12/21/2022] Open
Abstract
Background Although the anatomic difficulties of laparoscopic surgery for rectal cancer have been resolved by hybrid transanal total mesorectal excision (h-taTME), a completely incisionless surgical procedure has not yet been developed. This study was performed to explore the efficacy of pure taTME (p-taTME) without laparoscopic assistance as a completely non-invasive surgical procedure for rectal cancer. Methods We retrospectively evaluated all patients with rectal cancer who underwent p-taTME between December 2015 and April 2018. Relevant patient characteristics and clinical information including the surgical procedure, specimens, pathological characteristics, and patients’ post-operative state were analysed and the feasibility of p-taTME in patients with rectal cancer was assessed. Results Fifty-five patients who had undergone p-taTME were included in this study. They comprised 32 (58.2%) men and 23 (41.8%) women with a mean age of 65.6 ± 10.6 years and mean body mass index of 23.4 ± 3.3 kg/m2. The median surgical time was 180.0 (range, 130–360) min and estimated blood loss was 25.0 (range, 15–80) mL. The commonest post-operative complication was varying degrees of faecal incontinence (56.4%). However, such incontinence greatly improved after pelvic-floor-function-rehabilitation exercises and did not seriously affect the patients’ quality of life. Conclusions p-taTME is a relatively safe and incisionless procedure for patients with middle and low rectal cancer, especially in those with obesity or a narrow pelvis. However, further studies of the indications and long-term efficacy are needed to verify the suitability of this procedure.
Collapse
Affiliation(s)
- Xiao-Ming Wang
- Department of Colorectal and Anal Surgery, Linzi District People's Hospital, Linzi, Shandong, P. R. China
| | - Yan-Yan Xu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, P. R. China
| | - Gang Yu
- Department of General Surgery, Qilu Hospital of Shandong University, Qingdao, Shandong, P. R. China
| | - Zhen Rong
- Department of Colorectal and Anal Surgery, Linzi District People's Hospital, Linzi, Shandong, P. R. China
| | - Rui-Chao Geng
- Department of Colorectal and Anal Surgery, Linzi District People's Hospital, Linzi, Shandong, P. R. China
| | - Rui Wang
- Department of Colorectal and Anal Surgery, Linzi District People's Hospital, Linzi, Shandong, P. R. China
| | - Long-Yi Chen
- Department of Colorectal and Anal Surgery, Linzi District People's Hospital, Linzi, Shandong, P. R. China
| | - Gang Liu
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, P. R. China
| |
Collapse
|
|
22
|
Transanale totale mesorektale Exzision – eine sinnvolle Operationstechnik zur individualisierten Behandlung von Patienten mit Rektumkarzinom. COLOPROCTOLOGY 2019. [DOI: 10.1007/s00053-019-0362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
|
23
|
Factors associated with noncomplete mesorectal excision following surgery for rectal adenocarcinoma. Am J Surg 2019; 217:465-468. [DOI: 10.1016/j.amjsurg.2018.10.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/09/2018] [Accepted: 10/13/2018] [Indexed: 01/16/2023]
|
|
24
|
Silva-Velazco J, Stocchi L, Valente MA, Church JM, Liska D, Gorgun E, Kalady MF, Kessler H, Steele SR, Delaney CP. The relationship between mesorectal grading and oncological outcome in rectal adenocarcinoma. Colorectal Dis 2019; 21:315-325. [PMID: 30565830 DOI: 10.1111/codi.14535] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 10/29/2018] [Indexed: 02/08/2023]
Abstract
AIM The prognostic association between mesorectal grading and oncological outcome in patients undergoing resection for rectal adenocarcinoma is controversial. The aim of this retrospective chart review was to determine the individual impact of mesorectal grading on rectal cancer outcomes. METHOD We compared oncological outcomes in patients with complete, near-complete and incomplete mesorectum who underwent rectal excision with curative intent from 2009 to 2014 for Stage cI-III rectal adenocarcinoma. We also assessed the independent association of mesorectal grading and oncological outcome using multivariate models including other relevant variables. RESULTS Out of 505 patients (339 men, median age of 60 years), 347 (69%) underwent a restorative procedure. There were 452 (89.5%), 33 (6.5%) and 20 (4%) patients with a complete, near-complete and incomplete mesorectum, respectively. Local recurrence was seen in 2.4% (n = 12) patients after a mean follow-up of 3.1 ± 1.7 years. Unadjusted 3-year Kaplan-Meier analysis by mesorectal grade showed decreased rates of overall, disease-free and cancer-specific survival and increased rates of overall and distant recurrence with a near-complete mesorectum, while local recurrence was increased in cases of an incomplete mesorectum (all P < 0.05). On multivariate analyses, a near-complete mesorectum was independently associated with decreased cancer-specific survival (hazard ratio 0.26, 95% CI 0.1-0.7; P = 0.007). There were no associations between mesorectal grading and overall survival, disease-free survival, overall recurrence or distant recurrence (all P > 0.05). CONCLUSION Mesorectal grading is independently associated with oncological outcome. It provides unique information for optimizing surgical quality in rectal cancer.
Collapse
Affiliation(s)
- J Silva-Velazco
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - L Stocchi
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - M A Valente
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - J M Church
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - D Liska
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - E Gorgun
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - M F Kalady
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - S R Steele
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - C P Delaney
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
|
25
|
de'Angelis N, Pigneur F, Martínez-Pérez A, Vitali GC, Landi F, Gómez-Abril SA, Assalino M, Espin E, Ris F, Luciani A, Brunetti F. Assessing surgical difficulty in locally advanced mid-low rectal cancer: the accuracy of two MRI-based predictive scores. Colorectal Dis 2019; 21:277-286. [PMID: 30428156 DOI: 10.1111/codi.14473] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 10/29/2018] [Indexed: 02/08/2023]
Abstract
AIM Predicting surgical difficulty is a critical factor in the management of locally advanced rectal cancer (LARC). This study evaluates the accuracy and external validity of a recently published morphometric score to predict surgical difficulty and additionally proposes a new score to identify preoperatively LARC patients with a high risk of having a difficult surgery. METHODS This is a retrospective study based on the European MRI and Rectal Cancer Surgery (EuMaRCS) database, including patients with mid/low LARC who were treated with neoadjuvant chemoradiation therapy and laparoscopic total mesorectal excision (L-TME) with primary anastomosis. For all patients, pretreatment and restaging MRI were available. Surgical difficulty was graded as high and low based upon a composite outcome, including operative (e.g. duration of surgery) and postoperative variables (e.g. hospital stay). Score accuracy was assessed by estimating sensitivity, specificity and area under the receiver operating characteristic curve (AROC). RESULTS In a total of 136 LARC patients, 17 (12.5%) were graded as high surgical difficulty. The previously published score (calculated on body mass index, intertuberous distance, mesorectal fat area, type of anastomosis) showed low predictive value (sensitivity 11.8%; specificity 92.4%; AROC 0.612). The new EuMaRCS score was developed using the following significant predictors of surgical difficulty: body mass index > 30, interspinous distance < 96.4 mm, ymrT stage ≥ T3b and male sex. It demonstrated high accuracy (AROC 0.802). CONCLUSION The EuMaRCS score was found to be more sensitive and specific than the previous score in predicting surgical difficulty in LARC patients who are candidates for L-TME. However, this score has yet to be externally validated.
Collapse
Affiliation(s)
- N de'Angelis
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - F Pigneur
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - A Martínez-Pérez
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - G C Vitali
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - F Landi
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - S A Gómez-Abril
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
| | - M Assalino
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - E Espin
- Unit of Colorectal Surgery, Department of General and Digestive Surgery, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - F Ris
- Service of Abdominal Surgery, Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - A Luciani
- Department of Radiology, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| | - F Brunetti
- Unit of Digestive, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Henri Mondor Hospital, AP-HP, University of Paris Est, UPEC, Créteil, France
| |
Collapse
|
|
26
|
Sun XY, Xu L, Lu JY, Zhang GN. Robotic versus conventional laparoscopic surgery for rectal cancer: systematic review and meta-analysis. MINIM INVASIV THER 2019; 28:135-142. [PMID: 30688139 DOI: 10.1080/13645706.2018.1498358] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The purpose of this meta-analysis is to evaluate the evidence available on the safety as well as effectiveness of robotic resection as compared to conventional laparoscopic surgery for rectal cancer. MATERIAL AND METHODS A comparison of laparoscopic and robotic surgical treatments for rectal cancer was collected. Eligible trials that analyzed probabilistic hazard ratios (HR) for endpoints of interest (including perioperative morbidity) and postoperative complications were included in our review. RESULTS A total of six studies were included based on the present inclusion criteria. The pooled data showed that R-TME appeared to have association with remarkable reduction in the postoperative morbidity rate as compared to L-TME. Moreover, R-TME was also linked to lower conversion, decreased lymph node number, and longer operation time compared with L-TME. However, there was no difference in hospital stay, positive range of circumferential resection and blood loss between the two study groups. CONCLUSIONS Robotic rectal cancer surgery provides favorable outcomes and is considered as a safe surgical technique in terms of postoperative oncological safety. Like laparoscopic TME surgery, robotic surgery may be a valid alternative and complementary approach with beneficial effects on minimally-invasive surgery.
Collapse
Affiliation(s)
- Xi-Yu Sun
- a Department of General Surgery , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Lai Xu
- a Department of General Surgery , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Jun-Yang Lu
- a Department of General Surgery , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Guan-Nan Zhang
- a Department of General Surgery , Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| |
Collapse
|
|
27
|
Transanal Total Mesorectal Excision for Treatment of Carcinoma in the Middle or Lower Third Rectum: the Technical Feasibility of the Procedure, Pathological Results, and Clinical Outcome. Indian J Surg Oncol 2018; 9:442-451. [PMID: 30538370 DOI: 10.1007/s13193-018-0808-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 07/27/2018] [Indexed: 01/14/2023] Open
Abstract
We are trying to illustrate operative, short-term, and pathological outcomes of transanal total mesorectal excision (TaTME) as a surgical procedure for patients who are suffering cancer in the lower or middle rectum. This study included 25 consecutive patients who underwent TaTME for the mid and low cancer rectum. The primary outcome measures included frequency of postoperative (PO) bleeding, leakage, ileus, days to regain bowel function, days for Foley's removal, and erectile function. The secondary outcome measures included operation time, status of resection margins, number, the quality of TME, and duration PO hospital stay. No recorded intraoperative complications. The mean hospital stay was 6.9 ± 2.6 days. The mean duration need for urinary catheter removal and flatus passage were 2.4 ± 2.1 and 1.5 + 0.9 days, respectively. The mean IPSS was returned to normal 12 months after surgery. The mean distal margin distance was 1.9 ± 1.1. Circumferential margin distance was > 1 mm in 23 (92%) patients. The mesorectum was complete in 22 (88%) patients. The survival rate was 88% over 3 years. TaTME could be considered as a safe, feasible, and effective surgical modality for patients who had mid and lower rectal tumors with an excellent pathological outcome.
Collapse
|
|
28
|
Magnetic resonance-based pelvimetry and tumor volumetry can predict surgical difficulty and oncologic outcome in locally advanced mid-low rectal cancer. Surg Today 2018; 48:1040-1051. [PMID: 29961173 DOI: 10.1007/s00595-018-1690-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/24/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE To investigate the impact of the pelvic dimensions and tumor volume on surgery in locally advanced rectal cancer. METHODS Patients who underwent open surgery after neoadjuvant long-course chemoradiation for primary rectal cancer were included. The predictive value of magnetic resonance-based pelvic measurements and tumor volume on the surgical difficulty and oncologic outcome were analyzed. RESULTS 125 patients were included. The independent risk factors related to the circumferential resection margin status were the pT stage [odds ratio (OR) 3.64, confidence interval (CI) 1.409-7.327] and tumor volume after neoadjuvant chemoradiotherapy (OR 1.59, CI 1.018-2.767). The operative time (p = 0.014, OR 1.453) and pelvic depth (p = 0.023, OR 1.116) were independent predictive factors for anastomotic leak. The median follow-up was 72 (2-113) months. Local recurrence was seen in 17 (14.1%) patients. Anastomotic leak (OR 1.799, CI 0.978-3.277), the circumferential resection margin status (OR 3.217, CI 1.262-7.870) and the relative tumor volume rate (OR 1.260, CI 1.004-1.912) were independent prognosticators of local recurrence. The 5-year overall survival was 66.7%. The circumferential resection margin status (hazard ratio: 4.739, CI 2.276-9.317), pN stage (OR 3.267, CI 1.195-8.930) and relative tumor volume rate (OR 2.628, CI 1.042-6.631) were independent prognostic factors for the overall survival. CONCLUSIONS Relative dimensions of the tumor in the pelvis influence the local recurrence and overall survival rates. Magnetic resonance-based measurements can predict the difficulty of surgery and allow surgeons to consider the appropriate surgical approach.
Collapse
|
|
29
|
Abstract
BACKGROUND Total mesorectal excision is the standard of care for patients with rectal cancer. Pathological evaluation of the quality of the total mesorectal excision specimen is an important prognostic factor that correlates with local recurrence, but is potentially subjective. OBJECTIVE This study aimed to determine the degree of variation in grading, both between assessors and between fresh and formalin-fixed specimens. DESIGN Raters included surgeons, pathologists, pathology residents, pathologists' assistants, and pathologists' assistant trainees. Specimens were assessed by up to 6 raters in the fresh state and by 2 raters postfixation. Four parameters were evaluated: mesorectal bulk, surface regularity, defects, and coning. Interrater agreement was measured using ordinal α-values. SETTING The study was conducted at a single academic center. MAIN OUTCOME MEASURES The primary outcome was agreement between individuals when grading total mesorectal excision specimens. RESULTS A total of 37 total mesorectal excision specimens were assessed. Reliability between all raters for fresh specimens for mesorectal bulk, surface regularity, defects, coning, and overall grade were 0.85, 0.85, 0.92, 0.84, and 0.91. When compared with all raters, pathologists and residents had higher agreement and pathologists and surgeons had lower agreement. Ordinal α-values comparing pathologist and pathologist's assistant agreement for overall grade were similar pre- and postfixation (0.78 vs 0.80), but agreement for assessing defects decreased postfixation. Among pathologists' assistants, agreement was higher when grading specimens postfixation than when grading fresh specimens. LIMITATIONS Assessment bias may have occurred because of the greater number of pathologists' assistants participating than the number of residents and pathologists. CONCLUSIONS The results indicate good interrater agreement for the assessment of overall grade, with defects showing the best interrater agreement in fresh specimens. Although total mesorectal excision specimens may be consistently graded postfixation, the assessment of defects postfixation may be less reliable. This study highlights the need for additional knowledge-transfer activities to ensure consistency and accurate grading of total mesorectal excision specimens. See Video Abstract at http://links.lww.com/DCR/A497.
Collapse
|
|
30
|
Song SB, Wu GJ, Pan HD, Yang H, Hu ML, Li Q, Yan QX, Xiao G. The quality of total mesorectal excision specimen: A review of its macroscopic assessment and prognostic significance. Chronic Dis Transl Med 2018; 4:51-58. [PMID: 29756123 PMCID: PMC5938287 DOI: 10.1016/j.cdtm.2018.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Indexed: 12/28/2022] Open
Abstract
As a surgical procedure which could significantly lower the recurrence rate of cancers, total mesorectal excision (TME) has been the gold standard for middle and lower rectal cancer treatment. However, previous studies have shown that the procedure did not achieve the ideal theoretical local recurrence rates of rectal cancers. Some researchers pointed out it was very likely that not all so-called TME treatments completely removed the mesorectum, implying that some of these TME surgical treatments failed to meet oncological quality standards. Therefore, a suitable assessment tool for the surgical quality of TME is necessary. The notion of “macroscopic assessment of mesorectal excision (MAME)” was put forward by some researchers as a better assessment tool for the surgical quality of TME and has been confirmed by a series of studies. Besides providing rapid and accurate surgical quality feedbacks for surgeons, MAME also effectively assesses the prognosis of patients with rectal cancer. However, as a new assessment tool used for TME surgical quality, MAME has an only limited influence on the current guidelines and is yet to be widely applied in most countries. The aims of this review are to provide a detailed introduction to MAME for clinical practice and to summarize the current prognostic significance of MAME.
Collapse
Affiliation(s)
- Shi-Bo Song
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.,Peking University Fifth School of Clinical Medicine, Beijing 100730, China
| | - Guo-Ju Wu
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| | - Hong-Da Pan
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| | - Hua Yang
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| | - Mao-Lin Hu
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.,Peking University Fifth School of Clinical Medicine, Beijing 100730, China
| | - Qiang Li
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.,Peking University Fifth School of Clinical Medicine, Beijing 100730, China
| | - Qiu-Xia Yan
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China.,Peking University Fifth School of Clinical Medicine, Beijing 100730, China
| | - Gang Xiao
- Department of Gastrointestinal Surgery, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| |
Collapse
|
|
31
|
Escal L, Nougaret S, Guiu B, Bertrand MM, de Forges H, Tetreau R, Thézenas S, Rouanet P. MRI-based score to predict surgical difficulty in patients with rectal cancer. Br J Surg 2017; 105:140-146. [PMID: 29088504 DOI: 10.1002/bjs.10642] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 05/06/2017] [Accepted: 06/14/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND Rectal cancer surgery is technically challenging and depends on many factors. This study evaluated the ability of clinical and anatomical factors to predict surgical difficulty in total mesorectal excision. METHODS Consecutive patients who underwent total mesorectal excision for locally advanced rectal cancer in a laparoscopic, robotic or open procedure after neoadjuvant treatment, between 2005 and 2014, were included in this retrospective study. Preoperative clinical and MRI data were studied to develop a surgical difficulty grade. RESULTS In total, 164 patients with a median age of 61 (range 26-86) years were considered to be at low risk (143, 87·2 per cent) or high risk (21, 12·8 per cent) of surgical difficulty. In multivariable analysis, BMI at least 30 kg/m2 (P = 0·021), coloanal anastomosis (versus colorectal) (P = 0·034), intertuberous distance less than 10·1 cm (P = 0·041) and mesorectal fat area exceeding 20·7 cm2 (P = 0·051) were associated with greater surgical difficulty. A four-item score (ranging from 0 to 4), with each item (BMI, type of surgery, intertuberous distance and mesorectal fat area) scored 0 (absence) or 1 (presence), is proposed. Patients can be considered at high risk of a difficult or challenging operation if they have a score of 3 or more. CONCLUSION This simple morphometric score may assist surgical decision-making and comparative study by defining operative difficulty before surgery.
Collapse
Affiliation(s)
- L Escal
- Institut Régional du Cancer de Montpellier, Centre Hospitalier Universitaire Montpellier, St Eloi, Montpellier, France.,Department of Radiology, Centre Hospitalier Universitaire Montpellier, St Eloi, Montpellier, France
| | - S Nougaret
- Institut Régional du Cancer de Montpellier, Centre Hospitalier Universitaire Montpellier, St Eloi, Montpellier, France
| | - B Guiu
- Department of Radiology, Centre Hospitalier Universitaire Montpellier, St Eloi, Montpellier, France
| | - M M Bertrand
- Institut Régional du Cancer de Montpellier, Centre Hospitalier Universitaire Montpellier, St Eloi, Montpellier, France
| | - H de Forges
- Institut Régional du Cancer de Montpellier, Centre Hospitalier Universitaire Montpellier, St Eloi, Montpellier, France
| | - R Tetreau
- Institut Régional du Cancer de Montpellier, Centre Hospitalier Universitaire Montpellier, St Eloi, Montpellier, France
| | - S Thézenas
- Institut Régional du Cancer de Montpellier, Centre Hospitalier Universitaire Montpellier, St Eloi, Montpellier, France
| | - P Rouanet
- Institut Régional du Cancer de Montpellier, Centre Hospitalier Universitaire Montpellier, St Eloi, Montpellier, France
| |
Collapse
|
|
32
|
Creavin B, Kelly ME, Ryan E, Winter DC. Meta-analysis of the impact of surgical approach on the grade of mesorectal excision in rectal cancer. Br J Surg 2017; 104:1609-1619. [PMID: 29044484 DOI: 10.1002/bjs.10664] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/17/2017] [Accepted: 07/07/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The subspecialization of colorectal surgeons, and improvements in the quality of mesorectal excision have revolutionized rectal cancer surgery. With the increasing use of minimally invasive techniques, the completeness of the mesorectal excision has been questioned. This study aimed to assess the pathological outcomes of open versus laparoscopic rectal resection. METHODS A meta-analysis of RCTs was undertaken. The primary endpoint was the adequacy of the mesorectal excision. Secondary endpoints included circumferential resection margin and distance to resection margins. RESULTS Four studies were included, reporting on 2319 patients; 972 (41·9 per cent) had open and 1347 (58·1 per cent) had laparoscopic resections. Meta-analysis of adequacy of the mesorectal excision showed a small difference in achieving an intact mesorectum in favour of open surgery (risk ratio (RR) 1·06, 95 per cent c.i. 1·02 to 1·10; P = 0·001). Superficial defects were more common in laparoscopic surgery (RR 0·70, 0·54 to 0·89; P = 0·004). Deep mesorectal defects (RR 0·78, 0·51 to 1·20; P = 0·256), circumferential margin (CRM) positivity (RR 0·85, 0·62 to 1·16; P = 0·310), and distance to radial (mean difference (MD) -0·06, 95 per cent c.i. -0·10 to 0·23; P = 0·443) and distal (MD 0·03, -0·06 to 0·12; P = 0·497) margins were all similar. A complete resection (intact mesorectum, negative CRM and distal margin) was achieved in 350 of 478 patients (73·2 per cent) in the laparoscopic group and 372 of 457 (81·4 per cent) in the open group (risk difference (RD) 8 (95 per cent c.i. 3 to 13) per cent; P = 0·003). However, an acceptable mesorectum (intact or superficial defects only) was present in 1254 of 1308 (95·9 per cent) and 916 of 949 (96·5 per cent) in the laparoscopic and open groups respectively (RD 1 (-1 to 3) per cent; P = 0·263). CONCLUSION Small differences in mesorectal quality were evident between open and laparoscopic rectal resections. This may be attributable to use of laparoscopic instruments; however, to date minor defects have not affected oncological outcomes.
Collapse
Affiliation(s)
- B Creavin
- Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - M E Kelly
- Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - E Ryan
- Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - D C Winter
- Centre for Colorectal Disease, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| |
Collapse
|
|
33
|
Cui Y, Li C, Xu Z, Wang Y, Sun Y, Xu H, Li Z, Sun Y. Robot-assisted versus conventional laparoscopic operation in anus-preserving rectal cancer: a meta-analysis. Ther Clin Risk Manag 2017; 13:1247-1257. [PMID: 29026312 PMCID: PMC5626418 DOI: 10.2147/tcrm.s142758] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Objective The aim of this meta-analysis is to provide recommendations for clinical practice and prevention of postoperative complications, such as circumferential resection margin (CRM) involvement, and compare the amount of intraoperative bleeding, safety, operative time, recovery, outcomes, and clinical significance of robot-assisted and conventional laparoscopic procedures in anus-preserving rectal cancer. Methods A literature search (PubMed) was performed to identify biomedical research papers and abstracts of studies comparing robot-assisted and conventional laparoscopic procedures. We attempted to obtain the full-text link for papers published between 2000 and 2016, and hand-searched references for relevant literature. RevMan 5.3 software was used for the meta-analysis. Results Nine papers (949 patients) were eligible for inclusion; there were 473 patients (49.8%) in the robotic group and 476 patients (50.2%) in the laparoscopic group. According to the data provided in the literature, seven indicators were used to complete the evaluation. The results of the meta-analysis suggested that robot-assisted procedure was associated with lower intraoperative blood loss (mean difference [MD] −41.15; 95% confidence interval [CI] −77.51, −4.79; P=0.03), lower open conversion rate (risk difference [RD] −0.05; 95% CI −0.09, −0.01; P=0.02), lower hospital stay (MD −1.07; 95% CI −1.80, −0.33; P=0.005), lower overall complication rate (odds ratio 0.58; 95% CI 0.41, 0.83; P=0.003), and longer operative time (MD 33.73; 95% CI 8.48, 58.99; P=0.009) compared with conventional laparoscopy. There were no differences in the rate of CRM involvement (RD −0.02; 95% CI −0.05, 0.01; P=0.23) and days to return of bowel function (MD −0.03; 95% CI −0.40, 0.34; P=0.89). Conclusion The Da Vinci robot was superior to laparoscopy with respect to blood loss, open conversion, hospital stay, and postoperative complications during anus-preserving rectal cancer procedures; however, conventional laparoscopy had an advantage regarding operative time. The remaining indicators (CRMs and recovery from intestinal peristalsis) did not differ.
Collapse
Affiliation(s)
- Yongzhen Cui
- Department of Gastrointestinal Cancer Surgery, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences.,School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences
| | - Cheng Li
- Department of President's Office, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences
| | - Zhongfa Xu
- Department of Gastrointestinal Surgery, The Affiliated Hospital of Shandong Academy of Medical Sciences, Jinan
| | - Yingming Wang
- Department of Gastrointestinal Cancer Surgery, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences.,School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences
| | - Yamei Sun
- Department of Clinical Laboratory, Zhucheng People's Hospital of Shandong Province, Zhucheng, People's Republic of China
| | - Huirong Xu
- Department of Gastrointestinal Cancer Surgery, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences
| | - Zengjun Li
- Department of Gastrointestinal Cancer Surgery, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences
| | - Yanlai Sun
- Department of Gastrointestinal Cancer Surgery, Shandong Cancer Hospital Affiliated to Shandong University, Shandong Academy of Medical Sciences
| |
Collapse
|
|
34
|
Xu C, Song HY, Han SL, Ni SC, Zhang HX, Xing CG. Simple instruments facilitating achievement of transanal total mesorectal excision in male patients. World J Gastroenterol 2017; 23:5798-5808. [PMID: 28883706 PMCID: PMC5569295 DOI: 10.3748/wjg.v23.i31.5798] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 06/18/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the efficacy of a modified approach with transanal total mesorectal excision (taTME) using simple customized instruments in male patients with low rectal cancer.
METHODS A total of 115 male patients with low rectal cancer from December 2006 to August 2015 were retrospectively studied. All patients had a bulky tumor (tumor diameter ≥ 40 mm). Forty-one patients (group A) underwent a classical approach of transabdominal total mesorectal excision (TME) and transanal intersphincteric resection (ISR), and the other 74 patients (group B) underwent a modified approach with transabdominal TME, transanal ISR, and taTME. Some simple instruments including modified retractors and an anal dilator with a papilionaceous fixture were used to perform taTME. The operative time, quality of mesorectal excision, circumferential resection margin, local recurrence, and postoperative survival were evaluated.
RESULTS All 115 patients had successful sphincter preservation. The operative time in group B (240 min, range: 160-330 min) was significantly shorter than that in group A (280 min, range: 200-360 min; P = 0.000). Compared with group A, more complete distal mesorectum and total mesorectum were achieved in group B (100% vs 75.6%, P = 0.000; 90.5% vs 70.7%, P = 0.008, respectively). After 46.1 ± 25.6 mo follow-up, group B had a lower local recurrence rate and higher disease-free survival rate compared with group A, but these differences were not statistically significant (5.4% vs 14.6%, P = 0.093; 79.5% vs 65.1%, P = 0.130).
CONCLUSION Retrograde taTME with simple customized instruments can achieve high-quality TME, and it might be an effective and economical alternative for male patients with bulky tumors.
Collapse
Affiliation(s)
- Chang Xu
- Department of General Surgery, the Second Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
- Department of Colorectal Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Hua-Yu Song
- Department of Colorectal Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Shao-Liang Han
- Department of Colorectal Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Shi-Chang Ni
- Department of Colorectal Surgery, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Hu-Xiang Zhang
- Department of Pathology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejiang Province, China
| | - Chun-Gen Xing
- Department of General Surgery, the Second Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| |
Collapse
|
|
35
|
Lino-Silva LS, Loaeza-Belmont R, Gómez Álvarez MA, Vela-Sarmiento I, Aguilar-Romero JM, Domínguez-Rodríguez JA, Salcedo-Hernández RA, Ruiz-García EB, Maldonado-Martínez HA, Herrera-Gómez Á. Mesorectal Invasion Depth in Rectal Carcinoma Is Associated With Low Survival. Clin Colorectal Cancer 2017; 16:73-77. [PMID: 27364575 DOI: 10.1016/j.clcc.2016.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 05/31/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Most cases of rectal cancer (RC) in our institution are in pathologic stage T3. They are a heterogeneous group but have been classified in a single-stage category. We performed the present study to validate the prognostic significance of the mesorectal extension depth (MED) in T3 RC measured in millimeters beyond the muscularis propria plane. MATERIALS AND METHODS We performed a retrospective analysis of 104 patients with T3 RC who had undergone curative surgery after a course of preoperative chemoradiotherapy at a tertiary referral cancer hospital. The patients were grouped by MED (T3a, < 1 mm; T3b, 1-5 mm; T3c > 5-10 mm; and T3d > 10 mm). The clinicopathologic data and disease-free survival were analyzed. RESULTS The 5-year disease-free survival rate according to the T3 subclassification was 87.5% for those with T3a, 57.9% for T3b, 38.7% for T3c, and 40.3% for those with T3d tumors (P = .050). On univariate and multivariate analysis, the prognostic factors affecting survival were overall recurrence (hazard ratio [HR], 3.670; 95% confidence interval [CI], 1.710-7.837; P = .001), histologic grade (HR, 2.204; 95% CI, 1.156-4.199; P = .016), mesorectal invasion depth (HR, 1.885; 95% CI, 1.164-3.052; P = .010), and lymph node metastasis (HR, 1.211; 95% CI, 1.015-1.444; P = .033). CONCLUSION MED is a significant prognostic factor in patients with T3 RC who have undergone neoadjuvant chemoradiotherapy, especially when the MED is > 5 mm. The MED could be as important as other clinicopathologic factors in predicting disease-specific survival.
Collapse
Affiliation(s)
- Leonardo S Lino-Silva
- Department of Gastrointestinal Pathology, Instituto Nacional de Cancerología, Mexico City, Mexico.
| | - Reynaldo Loaeza-Belmont
- Department of Gastrointestinal Pathology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Miguel A Gómez Álvarez
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Itzel Vela-Sarmiento
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | | | | | | | - Erika B Ruiz-García
- Department of Translational Oncology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | | | - Ángel Herrera-Gómez
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Mexico City, Mexico
| |
Collapse
|
|
36
|
Demetter P, Jouret-Mourin A, Silversmit G, Vandendael T, Sempoux C, Hoorens A, Nagy N, Cuvelier C, Van Damme N, Penninckx F. Review of the quality of total mesorectal excision does not improve the prediction of outcome. Colorectal Dis 2016; 18:883-8. [PMID: 27586703 DOI: 10.1111/codi.13254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 10/21/2015] [Indexed: 12/31/2022]
Abstract
AIM A fair to moderate concordance in grading of the total mesorectal excision (TME) surgical specimen by local pathologists and a central review panel has been observed in the PROCARE (Project on Cancer of the Rectum) project. The aim of the present study was to evaluate the difference, if any, in the accuracy of predicting the oncological outcome through TME grading by local pathologists or by the review panel. METHOD The quality of the TME specimen was reviewed for 482 surgical specimens registered on a prospective database between 2006 and 2011. Patients with a Stage IV tumour, with unknown incidence date or without follow-up information were excluded, resulting in a study population of 383 patients. Quality assessment of the specimen was based on three grades including mesorectal resection (MRR), intramesorectal resection (IMR) and muscularis propria resection (MPR). Using univariable Cox regression models, local and review panel histopathological gradings of the quality of TME were assessed as predictors of local recurrence, distant metastasis and disease-free and overall survival. Differences in the predictions between local and review grading were determined. RESULTS Resection planes were concordant in 215 (56.1%) specimens. Downgrading from MRR to MPR was noted in 23 (6.0%). There were no significant differences in the prediction error between the two models; local and central review TME grading predicted the outcome equally well. CONCLUSION Any difference in grading of the TME specimen between local histopathologists and the review panel had no significant impact on the prediction of oncological outcome for this patient cohort. Grading of the quality of TME as reported by local histopathologists can therefore be used for outcome analysis. Quality control of TME grading is not warranted provided the histopathologist is adequately trained.
Collapse
Affiliation(s)
- P Demetter
- Department of Pathology, Erasme University Hospital, ULB, Brussels, Belgium
| | - A Jouret-Mourin
- Department of Pathology, Cliniques Universitaires Saint-Luc, UCL, Brussels, Belgium
| | - G Silversmit
- Foundation Belgian Cancer Registry, Brussels, Belgium
| | - T Vandendael
- Foundation Belgian Cancer Registry, Brussels, Belgium
| | - C Sempoux
- Department of Pathology, Cliniques Universitaires Saint-Luc, UCL, Brussels, Belgium
| | - A Hoorens
- Department of Pathology, Universitair Ziekenhuis Brussel, VUB, Brussels, Belgium
| | - N Nagy
- Department of Pathology, CHU de Charleroi, Charleroi, Belgium
| | - C Cuvelier
- Department of Pathology, UG, Ghent, Belgium
| | - N Van Damme
- Foundation Belgian Cancer Registry, Brussels, Belgium
| | - F Penninckx
- Department of Abdominal Surgery, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
| | | |
Collapse
|
|
37
|
Affiliation(s)
- Rahila Essani
- Division of Colon & Rectal Surgery, State University of New York, Nichols Road, Stony Brook, NY 11794-819, USA
| | - Roberto Bergamaschi
- Division of Colon & Rectal Surgery, State University of New York, Nichols Road, Stony Brook, NY 11794-819, USA.
| |
Collapse
|
|
38
|
Al-Sukhni E, Attwood K, Gabriel E, Nurkin SJ. Predictors of circumferential resection margin involvement in surgically resected rectal cancer: A retrospective review of 23,464 patients in the US National Cancer Database. Int J Surg 2016; 28:112-7. [PMID: 26906328 DOI: 10.1016/j.ijsu.2016.01.098] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 01/17/2016] [Accepted: 01/27/2016] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The circumferential resection margin (CRM) is a key prognostic factor after rectal cancer resection. We sought to identify factors associated with CRM involvement (CRM+). METHODS A retrospective review was performed of the National Cancer Database, 2004-2011. Patients with rectal cancer who underwent radical resection and had a recorded CRM were included. Multivariable analysis of the association between clinicopathologic characteristics and CRM was performed. Tumor <1 mm from the cut margin defined CRM+. RESULTS AND DISCUSSION Of 23,464 eligible patients, 13.3% were CRM+. Factors associated with CRM+ were diagnosis later in the study period, lack of insurance, advanced stage, higher grade, undergoing APR, and receiving radiation. Nearly half of CRM+ patients did not receive neoadjuvant therapy. CRM+ patients who did not receive neoadjuvant therapy were more likely to be female, older, with more comorbidities, smaller tumors, earlier clinical stage, advanced pathologic stage, and CEA-negative disease compared to those who received it. CONCLUSIONS Factors associated with CRM+ include features of advanced disease, undergoing APR, and lack of health insurance. Half of CRM+ patients did not receive neoadjuvant treatment. These represent cases where CRM status may be modifiable with appropriate pre-operative selection and multidisciplinary management.
Collapse
Affiliation(s)
- Eisar Al-Sukhni
- Roswell Park Cancer Institute, Department of Surgical Oncology, Elm & Carlton Streets, Buffalo, NY, 14263, USA.
| | - Kristopher Attwood
- Roswell Park Cancer Institute, Department of Biostatistics, Elm & Carlton Streets, Buffalo, NY, 14263, USA
| | - Emmanuel Gabriel
- Roswell Park Cancer Institute, Department of Surgical Oncology, Elm & Carlton Streets, Buffalo, NY, 14263, USA
| | - Steven J Nurkin
- Roswell Park Cancer Institute, Department of Surgical Oncology, Elm & Carlton Streets, Buffalo, NY, 14263, USA
| |
Collapse
|
|
39
|
Roscio F, Boni L, Clerici F, Frattini P, Cassinotti E, Scandroglio I. Is laparoscopic surgery really effective for the treatment of colon and rectal cancer in very elderly over 80 years old? A prospective multicentric case-control assessment. Surg Endosc 2016; 30:4372-82. [PMID: 26895891 DOI: 10.1007/s00464-016-4755-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 01/11/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND To evaluate the effectiveness of laparoscopic surgery (LCS) for colon and rectal cancer in the very elderly over 80 years old. METHODS We performed a prospective multicentric analysis comparing patients over 80 years (Group A) and patients between 60 and 69 years (Group B) undergoing LCS for cancer from January 2008 to December 2013. Colon and rectal cancers were analyzed separately. Comorbidity and complications were classified using the Charlson comorbidity index (CCI) and the Clavien-Dindo system, respectively. Oncological parameters included tumor-free margins, number of lymph nodes harvested and circumferential resection margin. RESULTS Group A included 96 and 33 patients, and Group B 220 and 82 for colon and rectal cancers, respectively. Groups were similar except for ASA score and CCI, as expected. There was no significant difference in operative time [colon; rectum] (180[IQR 150-200] vs 180[150-210] min; NS-180[160-210] vs 180[165-240] min; NS), estimated blood loss (50[25-75] vs 50[25-120] mL; NS-50[0-150] vs 50[25-108.7] mL; NS) and conversion rate (2.1 vs 2.7 %; NS-3.0 vs 2.4 %; NS). Timing of first stool (3[2-3.25] vs 3[2-5] dd; NS-3[2-4] vs 3[2-5] dd; NS), length of stay (7[6-8] vs 7[6-8] dd; NS-8[8-9] vs 8[7-9] dd; NS) and readmission rate (1.0 vs 0.45 %; NS-6.1 vs 1.2 %; NS) were similar. Tumor-free margins were appropriate, and positivity of CRM is poor (6.1 vs 4.9; NS). We did not record significant differences in complications rate (47.9 vs 43.6 %; NS-63.6 vs 52.4 %; NS). CONCLUSIONS Laparoscopic surgery is effective for the treatment of colorectal cancer even in the very elderly. Age is not a risk factor or a limitation for LCS.
Collapse
Affiliation(s)
- Francesco Roscio
- Division of General Surgery, Department of Surgery, Galmarini Hospital, Piazzale A. Zanaboni, 1, 21049, Tradate, Italy.
- PhD Program in Surgery and Surgical Biotechnologies, University of Insubria, Varese, Italy.
| | - Luigi Boni
- PhD Program in Surgery and Surgical Biotechnologies, University of Insubria, Varese, Italy
- Minimally Invasive Surgery Research Center, University of Insubria, Varese, Italy
| | - Federico Clerici
- Division of General Surgery, Department of Surgery, Galmarini Hospital, Piazzale A. Zanaboni, 1, 21049, Tradate, Italy
| | - Paolo Frattini
- Division of General Surgery, Department of Surgery, Galmarini Hospital, Piazzale A. Zanaboni, 1, 21049, Tradate, Italy
| | - Elisa Cassinotti
- Minimally Invasive Surgery Research Center, University of Insubria, Varese, Italy
| | - Ildo Scandroglio
- Division of General Surgery, Department of Surgery, Galmarini Hospital, Piazzale A. Zanaboni, 1, 21049, Tradate, Italy
| |
Collapse
|
|
40
|
Muratore A, Mellano A, Failla A, Marsanic P, De Luca R. Transanal total mesorectal excision in rectal cancer: why, how and when. COLORECTAL CANCER 2016. [DOI: 10.2217/crc.15.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Down-to-up total mesorectal excision (TME) or transanal TME (taTME) has gained worldwide popularity. taTME is one of the most promising innovations of the last years in the field of gastrointestinal surgery. Due to the better view of the dissection planes even in difficult patients (i.e., narrow pelvis or low rectal cancer), taTME seems to achieve both better TME quality reducing the rate of incomplete TME and lower rates of positive circumferential resection margins. taTME has overall morbidity and anastomotic leak rates comparable with the up-to-down TME. Mid-term results of taTME seems to be comparable with those of the up-to-down approach but definitive conclusions cannot be drawn since the short follow-up and small cohort of patients of the present studies.
Collapse
Affiliation(s)
- Andrea Muratore
- Department Surgical Oncology, Candiolo Cancer Institute – FPO, IRCCS, 10060 Candiolo, Torino, Italy
| | - Alfredo Mellano
- Department Surgical Oncology, Candiolo Cancer Institute – FPO, IRCCS, 10060 Candiolo, Torino, Italy
| | - Andrea Failla
- Department Surgical Oncology, Candiolo Cancer Institute – FPO, IRCCS, 10060 Candiolo, Torino, Italy
| | - Patrizia Marsanic
- Department Surgical Oncology, Candiolo Cancer Institute – FPO, IRCCS, 10060 Candiolo, Torino, Italy
| | - Raffaele De Luca
- Department Surgical Oncology, Istituto Tumori ‘G Paolo II’, Bari, Italy
| |
Collapse
|
|
41
|
Lino-Silva LS, García-Gómez MA, Aguilar-Romero JM, Domínguez-Rodríguez JA, Salcedo-Hernández RA, Loaeza-Belmont R, Ruiz-García EB, Herrera-Gómez Á. Mesorectal pathologic assessment in two grades predicts accurately recurrence, positive circumferential margin, and correlates with survival. J Surg Oncol 2015; 112:900-906. [PMID: 26487289 DOI: 10.1002/jso.24076] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 10/10/2015] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES We aimed to determine the prognostic value of the mesorectum quality assessed in a two-grade system compared with a classic system. METHODS Consecutive patients undergoing surgery for rectal cancer were included (n = 103). Mesorectum was assessed into three grades (classic system: complete, nearly complete, incomplete) and compared with a two-grade system (adequate, inadequate). RESULTS Mesorectum was complete in 62 (60.25%) patients, nearly complete in 21, and incomplete in 20. Reassessment showed adequate mesorectum in 83 (80.5%) patients and inadequate in 20. A R0 resection was achieved in 90.4% of adequate mesorectum and in 65% of inadequate mesorectum (P = 0.006). Recurrence was present in 18% of adequate mesorectum patients as compared with 50% of inadequate mesorectum (P = 0.003). The classic system failed to accurately predict the 5-year survival rate between complete (78.9%) and nearly complete (86.2%) categories (P = 0.235); whereas a two grading system showed a 5-year survival rate of 80.8% for adequate versus 39.3% for inadequate (P = 0.034). CONCLUSION High recurrence occurred in inadecuate mesorectum patients and was correlated with R1/R2 resections, positive margins, and decreased survival. We propose a simplified classification of mesorectum that correlates with survival and overall recurrence.
Collapse
Affiliation(s)
- Leonardo S Lino-Silva
- Department of Gastrointestinal Pathology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Miguel A García-Gómez
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | | | | | | | - Reynaldo Loaeza-Belmont
- Department of Gastrointestinal Pathology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Erika B Ruiz-García
- Department of Translational Oncology, Instituto Nacional de Cancerología, Mexico City, Mexico
| | - Ángel Herrera-Gómez
- Department of Surgical Oncology, Instituto Nacional de Cancerología, Mexico City, Mexico
| |
Collapse
|
|
42
|
Kraima AC, West NP, Treanor D, Magee DR, Bleys RLAW, Rutten HJT, van de Velde CJH, Quirke P, DeRuiter MC. Understanding the surgical pitfalls in total mesorectal excision: Investigating the histology of the perirectal fascia and the pelvic autonomic nerves. Eur J Surg Oncol 2015; 41:1621-9. [PMID: 26422586 DOI: 10.1016/j.ejso.2015.08.166] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 08/07/2015] [Accepted: 08/17/2015] [Indexed: 12/13/2022] Open
Abstract
AIM Excellent understanding of fasciae and nerves surrounding the rectum is necessary for total mesorectal excision (TME). However, fasciae anterolateral to the rectum and surrounding the low rectum are still poorly understood. We studied the perirectal fascia enfolding the extraperitoneally located part of the rectum in en-bloc cadaveric specimens and the University Medical Center Utrecht (UMCU) pelvic dataset, and describe implications for TME. METHODS Four donated human adult cadaveric specimens (two males, two females) were obtained through the Leeds GIFT Research Tissue Programme. Paraffin-embedded blocks were produced and serially sectioned at 50 and 250 μm intervals. Whole mount sections were stained with haematoxylin & eosin, Masson's trichrome and Millers' elastin. Additionally, the UMCU pelvic dataset including digitalised cryosections of a female pelvis in three axes was studied. RESULTS The mid and lower rectum were surrounded by a multi-layered perirectal fascia, of which the mesorectal fascia (MRF) and parietal fascia bordered the 'holy plane'. There was no extra constant fascia forming a potential surgical plane. Nerves ran laterally to the MRF. More caudally, the mesorectal fat strongly reduced and the MRF approached the rectal muscularis propria. The MRF had a variable appearance in terms of thickness and completeness, most prominently at the anterolateral lower rectum. CONCLUSION Dissection onto the MRF allows nerve preservation in TME. Rectal surgeons are challenged in doing so as the MRF varies in thickness and shows gaps, most prominently at the anterolateral lower rectum. At this site, the risk of entering the mesorectum is great and may result in an incomplete specimen.
Collapse
Affiliation(s)
- A C Kraima
- Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, The Netherlands; Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - N P West
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - D Treanor
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - D R Magee
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - R L A W Bleys
- Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - H J T Rutten
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; GROW School of Oncology and Developmental Biology, University of Maastricht, Maastricht, The Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - P Quirke
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, Leeds, UK
| | - M C DeRuiter
- Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, The Netherlands.
| |
Collapse
|
|
43
|
CT/MRI pelvimetry as a useful tool when selecting patients with rectal cancer for transanal total mesorectal excision. Surg Endosc 2015; 30:1164-71. [PMID: 26123334 DOI: 10.1007/s00464-015-4324-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 04/11/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The quality of a total mesorectal excision (TME) is one of the most important prognostic factors for local recurrence of rectal carcinoma. The aim of this study was to clarify the manner in which lesser pelvis dimensions affect the quality of TME via the transabdominal approach, while simultaneously defining the criteria for selecting patients most likely to have Grade 3 TME outcomes for a transanal approach using the TaTME technique. METHODS An analysis from the registry was conducted using 93 of total 198 patients with rectal cancer of the mid- and lower third of the rectum who underwent: (1) a low anterior resection, (2) an ultra-low resection with coloanal anastomosis, or (3) an intersphincteric rectal resection, all with total mesorectal excision. The procedures were carried out at the Department of Surgery at the University Hospital Hradec Králové between 2011 and 2014. Rectal specimens were histopathologically examined according to a standardized protocol. Pelvimetry data were obtained using anteroposterior, transverse, and sagittal CT or MRI scans. RESULTS A correlation was found between the quality of the TME and pelvimetry parameter A5, i.e., the angle between the longitudinal axis of the symphysis, and the lines between the symphysis and the promontory (R(2) = -0.327, p < 0.001). The ordinal regression method was used to identify parameters of the model describing levels of probability for TME quality. These relationships were described by equations that provide probability of the achievement of each grade of TME. CONCLUSION The correlation described by obtained equations between pelvimetry parameters and the quality of TME represents a new tool for use in preoperative decision-making with regard to resection via the transanal approach (TaTME).
Collapse
|
|
44
|
Simple criteria to predict margin involvement after chemoradiotherapy and sphincter-sparing for low rectal cancer. Eur J Surg Oncol 2015; 41:1210-6. [PMID: 26108736 DOI: 10.1016/j.ejso.2015.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/01/2015] [Accepted: 05/27/2015] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Low rectal cancers carry a high risk of circumferential margin involvement (CRM+). The anatomy of the lower part of the rectum and a long course of chemoradiotherapy (CRT) limit the accuracy of imaging to predict the CRM+. Additional criteria are required. METHODS Eighty six patients undergoing rectal resection with a sphincter-sparing procedure after CRT for low rectal cancer between 2000 and 2013 were retrospectively reviewed. Risk factors of CRM+ and the cut-off number of risk factors required to accurately predict the CRM+ were analyzed. RESULTS The CRM+ rate was 9.3% and in the multivariate analysis, the significant risk factors were a tumor size exceeding 3 cm, poor response to CRT and a fixed tumor. The best cut-off to predict CRM+ was the presence of 2 risk factors. Patients with 0-1 and 2-3 risk factors had a CRM+ respectively in 1.3% and 50% of cases and a 3-year recurrence rate of 7% and 35% after a median follow-up of 50 months. CONCLUSIONS Poor response, a residual tumor greater than 3 cm and a fixed tumor are predictive of CRM+. Sphincter sparing is an oncological safety procedure for patients with 0-1 criteria but not for patients with 2-3 criteria.
Collapse
|
|
45
|
Borreca D, Bona A, Bellomo MP, Borasi A, De Paolis P. The new approach to the rectal cancer: 'down-to-up' double endolaparoscopic pelvic access. Preliminary evaluation of outcomes. Updates Surg 2015; 67:293-9. [PMID: 26109139 DOI: 10.1007/s13304-015-0306-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 05/28/2015] [Indexed: 12/16/2022]
Abstract
Laparoscopic access in low anterior rectal resection is widely adopted, performing an 'up-to-down' dissection. The aim of this study is to present and analyze the outcomes of a novel surgical 'down-to-up' total mesorectal excision technique that could obviate to the well-known issues of the standard treatment. 18 suitable patients underwent double endolaparoscopic pelvic access (DEPA) 'down-to-up' technique. DEPA TME was completed in all patients, with intact mesorectum. Mean operative time was 365 min (range 280-510 min). The morbidity rate was 22%, including three radiologically detected leakage (grade A) and one pelvic abscess, requiring only a conservative management. Mortality rate at 30 and 90 days was 0%. Resection margins were negative in all patients. A median of 11 nodes (range 5-19) was retrieved per specimen. Mean length of hospital stay was 9 days (range 7-19 days). Patients were followed for an average of 14 months (range 0-42 months), with no recurrence. Despite exiguous patient's sample in this pilot study, transanal endoscopic TME with laparoscopic assistance seems to be feasible and safe, and is a promising alternative to open and laparoscopic TME. However, a conspicuous functional and oncologic long-term evaluation is required, before the widespread adoption could be recommended.
Collapse
Affiliation(s)
- Dario Borreca
- Department of General Surgery, Gradenigo Hospital, Turin, Italy,
| | | | | | | | | |
Collapse
|
|
46
|
Kraima AC, West NP, Treanor D, Magee DR, Rutten HJ, Quirke P, DeRuiter MC, van de Velde CJH. Whole mount microscopic sections reveal that Denonvilliers' fascia is one entity and adherent to the mesorectal fascia; implications for the anterior plane in total mesorectal excision? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2015; 41:738-45. [PMID: 25892592 DOI: 10.1016/j.ejso.2015.03.224] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 03/25/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Excellent anatomical knowledge of the rectum and surrounding structures is essential for total mesorectal excision (TME). Denonviliers' fascia (DVF) has been frequently studied, though the optimal anterior plane in TME is still disputed. The relationship of the lateral edges of DVF to the autonomic nerves and mesorectal fascia is unclear. We studied whole mout microscopic sections of en-bloc cadaveric pelvic exenteration and describe implications for TME. METHODS Four donated human adult cadaveric specimens (two males, two females) were obtained from the Leeds GIFT Research Tissue Programme. Paraffin-embedded mega blocks were produced and serially sectioned at 50 and 250 μm intervals. Sections were stained with haematoxylin & eosin, Masson's trichrome and Millers' elastin. Additionally, a series of eleven human fetal specimens (embryonic age of 9-20 weeks) were studied. RESULTS DVF consisted of multiple fascial condensations of collagen and smooth muscle fibres and was indistinguishable from the anterior mesorectal fascia and the prostatic fascia or posterior vaginal wall. The lateral edges of DVF appeared fan-shaped and the most posterior part was continuous with the mesorectal fascia. Fasciae were not identified in fetal specimens. CONCLUSION DVF is adherent to and continuous with the mesorectal fascia. Optimal surgical dissection during TME should be carried out anterior to DVF to ensure radical removal, particularly for anterior tumours. Autonomic nerves are at risk, but can be preserved by closely following the mesorectal fascia along the anterolateral mesorectum. The lack of evident fasciae in fetal specimens suggested that these might be formed in later developmental stages.
Collapse
Affiliation(s)
- A C Kraima
- Department of Anatomy and Embryology, Leiden University Medical Center, P.O. Box 9600, 2300 ZC Leiden, The Netherlands; Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - N P West
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - D Treanor
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - D R Magee
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - H J Rutten
- Department of Surgery, Catherina Hospital Eindhoven, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands
| | - P Quirke
- Pathology and Tumour Biology, Leeds Institute of Cancer and Pathology, University of Leeds, St. James's University Hospital, Beckett Street, Leeds LS9 7TF, United Kingdom
| | - M C DeRuiter
- Department of Anatomy and Embryology, Leiden University Medical Center, P.O. Box 9600, 2300 ZC Leiden, The Netherlands
| | - C J H van de Velde
- Department of Surgery, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
| |
Collapse
|
|
47
|
Campa-Thompson M, Weir R, Calcetera N, Quirke P, Carmack S. Pathologic processing of the total mesorectal excision. Clin Colon Rectal Surg 2015; 28:43-52. [PMID: 25733973 DOI: 10.1055/s-0035-1545069] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Total mesorectal excision (TME) is the current optimal surgical treatment for patients with rectal carcinoma. A complete TME is related to lower local recurrence rates and increased patient survival. Many confounding factors in the patient's anatomy and prior therapy can make it difficult to obtain a perfect plane, and thus a complete TME. The resection specimen can be thoroughly evaluated, grossly and microscopically, to identify substandard surgical outcomes and increased risk of local recurrence. Complete and accurate data reporting is critical for patient care and helps surgeons improve their technique.
Collapse
Affiliation(s)
- Molly Campa-Thompson
- Department of Pathology, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Robert Weir
- Department of Pathology, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Natalie Calcetera
- Department of Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Philip Quirke
- Department of Pathology and Tumor Biology, Leeds Institute of Cancer and Pathology, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Susanne Carmack
- Department of Pathology, Baylor University Medical Center at Dallas, Dallas, Texas
| |
Collapse
|
|
48
|
Szold A, Bergamaschi R, Broeders I, Dankelman J, Forgione A, Langø T, Melzer A, Mintz Y, Morales-Conde S, Rhodes M, Satava R, Tang CN, Vilallonga R. European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery. Surg Endosc 2015; 29:253-88. [PMID: 25380708 DOI: 10.1007/s00464-014-3916-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/19/2014] [Indexed: 12/14/2022]
Abstract
Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.
Collapse
Affiliation(s)
- Amir Szold
- Technology Committee, EAES, Assia Medical Group, P.O. Box 58048, Tel Aviv, 61580, Israel,
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
49
|
Bhatti ABH, Waheed A, Hafeez A, Akbar A, Syed AA, Khattak S, Kazmi AS. Can induction chemotherapy before concurrent chemoradiation impact circumferential resection margin positivity and survival in low rectal cancers? Asian Pac J Cancer Prev 2015; 16:2993-2998. [PMID: 25854395 DOI: 10.7314/apjcp.2015.16.7.2993] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Distance from anal verge and abdominoperineal resection are risk factors for circumferential resection margin (CRM) positivity in rectal cancer. Induction chemotherapy (IC) before concurrent chemoradiation (CRT) has emerged as a new treatment modification. Impact of IC before concurrent CRT on CRM positivity in low rectal cancer remains to be independently studied. The objective of this study was to determine CRM positivity in low rectal cancer, with and without prior IC, and to identify predictors of disease free and overall survival. MATERIALS AND METHODS Patients who underwent surgery for rectal cancer between 2005 and 2011 were retrospectively reviewed and divided into two groups. Group 1 received IC before CRT and Group 2 did not. Demographics, clinicopathological variables and CRM status were compared. Actuarial 5 year disease free survival (DFS), overall survival (OS) and independent predictors of survival were determined. RESULTS Patients in the IC group presented with advanced stage (Stage 3=89.2% versus 75.4%) (P=0.02) but a high rate of total mesorectal excision (TME) (100% versus 93.4%) (P=0.01) and sphincter preservation surgery (54.9 % versus 22.9%) (P=0.001). Patients with low rectal cancer who received IC had a significantly low positive CRM rate (9.2% versus 34%) (P=0.002). Actuarial 5 year DFS in IC and no IC groups were 39% and 43% (P=0.9) and 5 year OS were 70% and 47% (P=0.003). Pathological tumor size [HR: 2.2, CI: 1.1-4.5, P=0.01] and nodal involvement [HR: 2, CI: 1.08-4, P=0.02] were independent predictors of relapse while pathological nodal involvement [HR: 2.6, CI: 1.3-4.9, P=0.003] and IC [HR: 0.7, CI: 0.5-0.9, P=0.02] were independent predictors of death. CONCLUSIONS In low rectal cancer, induction chemotherapy before CRT may significantly decrease CRM positivity and improve 5 year overall survival.
Collapse
Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan E-mail :
| | | | | | | | | | | | | |
Collapse
|
|
50
|
Ferko A, Orhalmi J, Dusek T, Chobola M, Hovorkova E, Nikolov DH. Higher risk of incomplete mesorectal excision and positive circumferential margin in low rectal cancer regardless of surgical technique. Wideochir Inne Tech Maloinwazyjne 2014; 9:569-77. [PMID: 25561995 PMCID: PMC4280422 DOI: 10.5114/wiitm.2014.45733] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Revised: 03/24/2014] [Accepted: 09/14/2014] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Currently, the predominant question is whether a laparoscopic approach is comparatively radical in comparison with an open access approach, especially in the circumferential resection margin and quality of the completeness of total mesorectal excision. These factors are important in determining the quality of surgical care as well as long-term results of the treatment. AIM This article focuses on the evaluation of circumferential resection margins and on the quality of mesorectal excision of middle and lower rectum tumors. In addition, laparoscopic and open techniques are compared. MATERIAL AND METHODS Data were collected prospectively and stored in a rectal cancer registry over a 3-year period. The parameters studied were age, sex, body mass index, localization and topography of the tumor, clinical stage, neoadjuvant chemotherapy and its response, the type of surgery, character of the circumferential and distal margins, quality of the mesorectal excision, pT and pN. RESULTS One hundred and twenty-five patients were chosen for our study. Laparoscopy was performed in 53 operations and a conventional approach was performed in 72 operations. Complete mesorectal excision was achieved in 54.7% of laparoscopic operations versus 44.4% in the conventional technique; partially complete excision was performed in 20.8 and 12.5%, respectively. Incomplete excisions were described in 24.5 and 43.1% (p = 0.085). Positive circumferential margin occurred during laparoscopic surgery in 11 (20.8%) patients, and in the case of conventional resection in 27 (37.5%) patients (p = 0.044). CONCLUSIONS Our study showed comparable results between laparoscopic and open access procedures during rectal resection. The results achieved, in particular in the quality of the mesorectal excision and negative circumferential resection margin, show that the laparoscopic approach is comparable to conventional surgical techniques, with an adequate surgical outcome, in the treatment of rectal cancer.
Collapse
Affiliation(s)
- Alexander Ferko
- Department of Surgery, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Julius Orhalmi
- Department of Surgery, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Tomas Dusek
- Department of Surgery, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
- Department of Military Surgery, Faculty of Military Health Sciences, University of Defense, Hradec Kralove, Czech Republic
| | - Milan Chobola
- Department of Surgery, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Eva Hovorkova
- The Fingerland Department of Pathology, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Dimitar Hadzi Nikolov
- The Fingerland Department of Pathology, University Hospital Hradec Kralove, Charles University in Prague, Faculty of Medicine, Hradec Kralove, Czech Republic
| |
Collapse
|