Retrospective Study
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Mar 27, 2024; 16(3): 777-789
Published online Mar 27, 2024. doi: 10.4240/wjgs.v16.i3.777
Feasibility and safety of minimally invasive multivisceral resection for T4b rectal cancer: A 9-year review
Kai Siang Chan, Biquan Liu, Ming Ngan Aloysius Tan, Kwang Yeong How, Kar Yong Wong
Kai Siang Chan, Biquan Liu, Ming Ngan Aloysius Tan, Kwang Yeong How, Kar Yong Wong, Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
Co-corresponding authors: Kai Siang Chan and Kar Yong Wong.
Author contributions: Wong KY conceptualized and designed the research; Chan KS, Liu B, and Wong KY acquired and analysed the data; Chan KS, Liu B, Tan MNA, How KY and Wong KY interpreted the data; Chan KS drafted the paper; Chan KS, Tan MNA, How KY and Wong KY revised the article; Chan KS, Liu B, Tan MNA, How KY and Wong KY approved the final article. Both Chan KS and Wong KY have made crucial and indispensable contributions towards the administration and completion of the project and are thus qualified as the co-corresponding authors of the paper; Wong KY was instrumental in the conceptualization and design of the study. In addition, Wong KY was also responsible for the analysis, interpretation of data and review of the article prior to its final publication. Chan KS was responsible for data collection, played a major role in the data analysis and draft of the initial manuscript. Hence both authors are qualified as co-corresponding authors of the paper.
Institutional review board statement: This study was approved by our local institutional review board. Prior to April 2019, institutional board review approval was not required by our institution; data was prospectively collected and extracted from a database managed by our colorectal department coordinator using FileMaker© (Claris International Inc., United States of America) from January 2015. Data was de-identified when extracted for analysis with no traceable data or reference codes for re-identification of included patients. For data after April 2019, institutional review board approval was obtained for our prospectively maintained database. Data was stored on REDCap and de-identified by our colorectal department coordinator prior to analysis by the study team. The study team made no attempts to access patients' medical records.
Informed consent statement: Informed consent was obtained from patients included (No. SDB-2023-0069-TTSH-01).
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The data used in this study is not publicly available due to institutional policies. However, requests may be made to the corresponding author for access to de-identified data at kchan023@e.ntu.edu.sg.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Kai Siang Chan, MBBS, Doctor, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore. kchan023@e.ntu.edu.sg
Received: December 17, 2023
Peer-review started: December 17, 2023
First decision: January 4, 2024
Revised: January 9, 2024
Accepted: February 18, 2024
Article in press: February 18, 2024
Published online: March 27, 2024
Processing time: 90 Days and 11.6 Hours
Abstract
BACKGROUND

Colorectal cancer is the third most common cancer and the second highest cause of cancer-related mortality worldwide. About 5%-10% of patients are diagnosed with locally advanced rectal cancer (LARC) on presentation. For LARC invading into other structures (i.e. T4b), multivisceral resection (MVR) and/or pelvic exenteration (PE) remains the only potential curative surgical treatment. MVR and/or PE is a major and complex surgery with high post-operative morbidity. Minimally invasive surgery (MIS) has been shown to improve short-term post-operative outcomes in other gastrointestinal malignancies, but there is little evidence on its use in MVR, especially so for robotic MVR.

AIM

To assess the feasibility and safety of minimally invasive MVR (miMVR), and compare post-operative outcomes between robotic and laparoscopic MVR.

METHODS

This is a single-center retrospective cohort study from 1st January 2015 to 31st March 2023. Inclusion criteria were patients diagnosed with cT4b rectal cancer and underwent MVR, or stage 4 disease with resectable systemic metastases. Patients who underwent curative MVR for locally recurrent rectal cancer, or metachronous rectal cancer were also included. Exclusion criteria were patients with systemic metastases with non-resectable disease. All patients planned for elective surgery were enrolled into the standard enhanced recovery after surgery pathway with standard peri-operative management for colorectal surgery. Complex surgery was defined based on technical difficulty of surgery (i.e. total PE, bladder-sparing prostatectomy, pelvic lymph node dissection or need for flap creation). Our primary outcomes were the margin status, and complication rates. Categorical values were described as percentages and analysed by the chi-square test. Continuous variables were expressed as median (range) and analysed by Mann-Whitney U test. Cumulative overall survival (OS) and recurrence-free survival (RFS) were analysed using Kaplan-Meier estimates with life table analysis. Log-rank test was performed to determine statistical significance between cumulative estimates. Statistical significance was defined as P < 0.05.

RESULTS

A total of 46 patients were included in this study [open MVR (oMVR): 12 (26.1%), miMVR: 36 (73.9%)]. Patients’ American Society of Anesthesiologists score, body mass index and co-morbidities were comparable between oMVR and miMVR. There is an increasing trend towards robotic MVR from 2015 to 2023. MiMVR was associated with lower estimated blood loss (EBL) (median 450 vs 1200 mL, P = 0.008), major morbidity (14.7% vs 50.0%, P = 0.014), post-operative intra-abdominal collections (11.8% vs 50.0%, P = 0.006), post-operative ileus (32.4% vs 66.7%, P = 0.04) and surgical site infection (11.8% vs 50.0%, P = 0.006) compared with oMVR. Length of stay was also shorter for miMVR compared with oMVR (median 10 vs 30 d, P = 0.001). Oncological outcomes–R0 resection, recurrence, OS and RFS were comparable between miMVR and oMVR. There was no 30-d mortality. More patients underwent robotic compared with laparoscopic MVR for complex cases (robotic 57.1% vs laparoscopic 7.7%, P = 0.004). The operating time was longer for robotic compared with laparoscopic MVR [robotic: 602 (400-900) min, laparoscopic: Median 455 (275-675) min, P < 0.001]. Incidence of R0 resection was similar (laparoscopic: 84.6% vs robotic: 76.2%, P = 0.555). Overall complication rates, major morbidity rates and 30-d readmission rates were similar between laparoscopic and robotic MVR. Interestingly, 3-year OS (robotic 83.1% vs 58.6%, P = 0.008) and RFS (robotic 72.9% vs 34.3%, P = 0.002) was superior for robotic compared with laparoscopic MVR.

CONCLUSION

MiMVR had lower post-operative complications compared to oMVR. Robotic MVR was also safe, with acceptable post-operative complication rates. Prospective studies should be conducted to compare short-term and long-term outcomes between robotic vs laparoscopic MVR.

Keywords: Laparoscopy; Minimally invasive surgical procedures; Multivisceral resection; Pelvic Exenteration; Rectal neoplasms; Robotic surgical procedures

Core Tip: Multivisceral resection (MVR) remains the only potential curative surgical treatment for locally advanced rectal cancer but bears high morbidity. Literature on minimally invasive MVR (miMVR) is scarce. Our results showed that miMVR had lower major morbidity and shorter length of stay compared to open MVR with comparable R0 resection and long-term survival. Robotic MVR was used for more complex cases but had similar post-operative complications compared to laparoscopic MVR. Use of robotic MVR is feasible and safe even in lower volume institutions for locally advanced rectal cancer.