Laparoscopic Rectal Resection Research Articles

Evaluation of the advantage of surgeons certified by the endoscopic surgical skill qualification system participating in laparoscopic low anterior rectal resection.

A technical qualification system was developed in 2004 by the Japan Society for Endoscopic Surgery. An analysis of the EnSSURE study on 3188 stage II-III rectal cancer patients, which was performed by including the participation of qualified surgeons as assistants and advisers without restricting their participation as operators, revealed that the participation of technically qualified surgeons in surgery improved the technical and oncological safety of laparoscopic rectal resection. This secondary retrospective analysis of the EnSSURE study examined the advantage of qualified surgeons participating in laparoscopic low anterior resection (LAR). The outcomes of low anterior resection were compared between groups with and without the participation of surgeons qualified by the Endoscopic Surgical Skill Qualification System (Q and non-Q groups, respectively). We used propensity score matching to generate paired cohorts at a one-to-one ratio. The postoperative complication rate, short-term results (hemorrhage volume, operative time, number of dissected lymph nodes, open conversion rate, intraoperative complication rate, and R0 resection rate), and long-term results (disease-free survival rate, local recurrence rate, and overall survival rate) were evaluated. The frequencies of postoperative complications, anastomotic bleeding, and intraperitoneal abscess were significantly lower, the operative time was significantly shorter, the postoperative hospital stay was significantly shorter, and the number of dissected lymph nodes was higher in the Q group. No significant differences were observed in disease-free survival, local recurrence, or overall survival rate rates between the groups. The participation of qualified surgeons in LAR is technically advantageous.

Transition from laparoscopic to robotic approach in rectal cancer: a single-center short-term analysis based on the learning curve.

As a novel procedure becomes more and more used, knowledge about its learning curve and its impact on outcomes is useful for future implementations. Our aim is (i) to identify the phases of the robotic rectal surgery learning process and assess the safety and oncological outcomes during that period, (ii) to compare the robotic rectal surgery learning phases outcomes with laparoscopic rectal resections performed before the implementation of the robotic surgery program. We performed a retrospective study, based on a prospectively maintained database, with methodological quality assessment by STROBE checklist. All the procedures were performed by the same two surgeons. A total of 157 robotic rectal resections from June 2018 to January 2022 and 97 laparoscopic rectal resections from January 2018 to July 2019 were included. The learning phase was completed at case 26 for surgeon A, 36 for surgeon B, and 60 for the center (both A & B). There were no differences in histopathological results or postoperative complications between phases, achieving the same ratio of mesorectal quality, circumferential and distal resection margins as the laparoscopic approach. A transitory increase of major complications and anastomotic leakage could occur once overcoming the learning phase, secondary to the progressive complexity of cases. Robotic rectal cancer surgery learning curve phases in experienced laparoscopic surgeons was completed after 25-35 cases. Implementation of a robotic rectal surgery program is safe in oncologic terms, morbidity, mortality and length of stay.

Laparoscopic rectal cancer resection yields comparable clinical and oncological results with shorter hospital stay compared to open access: a 5-year national cohort

PurposeAlthough widely applied, the results following laparoscopic rectal resection (LRR) compared to open rectal resection (ORR) are still debated. The aim of this study was to assess clinical short- and long-term results as well as oncological resection quality following LRR or ORR for cancer in a 5-year national cohort.MethodsData from the Norwegian Registry for Gastrointestinal Surgery and the Norwegian Colorectal Cancer Registry were retrieved from January 2014 to December 2018 for patients who underwent elective resection for rectal cancer. Primary end point was 5-year overall survival. Secondary end points were local recurrence rates within 5 years, oncological resection quality, and short-term outcome measures.ResultsA total of 1796 patients were included, of whom 1284 had undergone LRR and 512 ORR. There was no difference in 5-year survival rates between the groups after adjusting for relevant covariates with Cox regression analyses. Crude 5-year survival was 77.1% following LRR compared to 74.8% following ORR (p = 0.015). The 5-year local recurrence rates were 3.1% following LRR and 4.1% following ORR (p = 0.249). Length of hospital stay was median 8.0 days (quartiles 7.0–13.0) after ORR compared to 6.0 (quartiles 4.0–8.0) days after LRR. After adjusting for relevant covariates, estimated additional length of stay after ORR was 3.1 days (p < 0.001, 95% CI 2.3–3.9). Rates of positive resection margins and number of harvested lymph nodes were similar. There were no other significant differences in short-term outcomes between the groups.ConclusionLRR was performed with clinical and oncological outcomes similar to ORR, but with shorter hospital stay.

Endoscopic Surgical Skill Qualification System: propensity-score matched cohort analysis of accredited supervisors in laparoscopic rectal cancer surgery.

The Endoscopic Surgical Skill Qualification System (ESSQS) in Japan evaluates the surgical skills required for laparoscopic surgery as an operator as well as a supervisor. This study aimed to demonstrate the benefits of an ESSQS-certified surgeon's participation in laparoscopic rectal resections as a supervisor (assistant or advisor). We retrospectively reviewed laparoscopic resection results for cStage II and III rectal cancer performed at 56 Japanese hospitals between 2014 and 2016. We used propensity score matching to generate paired cohorts with or without an ESSQS-certified supervisor at a one-to-one ratio. The impact of ESSQS-certified supervisors' participation on short-term outcomes was assessed. In the matched cohort, multivariable logistic regression analysis and multivariable regression analysis of postoperative complication rate and intraoperative blood loss were performed to further mitigate the impact of pathological factors. Two groups (n = 399 each) with or without an ESSQS-certified supervisor were well matched by clinical factors. The group with an ESSQS-certified supervisor had lower blood loss (68 mL vs. 98 mL, P = 0.036) and a lower incidence of severe morbidities of Clavien-Dindo grade ≥IIIa (8.0% vs. 13.3%, P = 0.016). Multivariable logistic regression analysis and multivariable regression analysis confirmed that the attendance of ESSQS-certified supervisors reduced postoperative complication occurrence (adjusted odds ratio: 2.28, 95% confidence interval: 1.38 - 3.80, P = 0.001) and intraoperative blood loss (estimated difference: -15.7 mL, P = 0.016). This study demonstrated the educational benefits of ESSQS-certified supervisors, including assistants and advisors, evidenced by their superior short-term outcomes.

Artificial intelligence (AI) in the management of colorectal cancer: on the horizon?

In the era of personalized medicine, an ever increasing emphasis is being placed on prognostication and prediction of surgical outcomes and treatment responses in colorectal cancer (CRC).1 Recent advances in information technology have allowed AI integration into clinical practice. Machine learning (ML) is a subfield of AI in which algorithms iteratively ‘learn’ from data to make predictions based on discerned patterns, without being explicitly programmed to do so. Deep learning (DL) is a further subfield of ML, whereby artificial neural networks (ANN) loosely modelled on the human brain structure, are exposed to large or ‘deep’ datasets, deriving predictive capacity from learned patterns in the data.2 Computer vision (CV) refers to the training of computers to read and interpret images, a field closely involved in the last half-decade with DL approaches. Within Radiomics, AI is making an impact in CRC staging.1 DL platforms have demonstrated the ability to distinguish between T2 and T3 rectal cancer on MRI with 90% accuracy,3 and to detect lymph node disease with a higher accuracy than radiologists.4 The combination of histopathological outcomes with MRI and CT imaging shows promise. It allows models to predict a complete pathological response in rectal cancer patients treated with neoadjuvant therapy and the identification of systemic therapy responders with metastatic CRC.1 Colonoscopy is an area in which AI is already being used. AI algorithms designed to aid polyp detection have been shown to increase adenoma detection rates, even amongst experienced endoscopists,5 thus providing a cost effective method of reducing CRC during population screening.6 DL models can both detect and classify polyps with high sensitivity and specificity.7 The development of AI-assisted clinical tools that can provide decision support such as future endoscopic surveillance intervals are ongoing.5 Such tools can also enhance endoscopy training through improved polyp pattern recognition identification.5 Support systems which provide evidence-based clinical decision making tools for CRC are already available. The Watson for Oncology (WFO) program developed by IBM and the Memorial Sloan Kettering Cancer Centre has been trained to follow the U.S. National Comprehensive Cancer Network guidelines.8 Treatment recommendations suggested by the WFO have shown concordance rates of 80%–90% for CRC management compared to a multidisciplinary team (MDT).8, 9 Although not designed to supplant the MDT, AI tools can become an adjunct for clinicians to increase workload time efficiency, and decrease the risk of errors.8 Though still in its infancy, the utilization of AI tools is becoming increasingly relevant within colorectal surgery, through the intraoperative use of CV10 for operative precision and training. Using laparoscopic image data from multiple rectal resections, DL models have been able to recognize the correct phase of the operation, and also act as an intra-operative guide in the identification of complex anatomical structures, such as the total mesorectal excision plane of dissection.10, 11 A recent pilot study has demonstrated the utilization of DL-based software to automate the surgical skill assessment of various steps within a laparoscopic rectal resection, paving its way for future applications in surgical training.12 Despite these exciting developments, many limitations remain. Significant financial investment and creation of regulatory and legal frameworks will be required to integrate AI into existing healthcare systems.13 Furthermore, AI is constrained by the quality and quantity of available data used to train them. As the majority of relevant studies come from only a few geographical locations, AI models are susceptible to inherent biases related to differing patient cohorts.14 AI has the potential to revolutionize the management of CRC. However, there are many challenges to be addressed before AI programs can become embedded into routine care for CRC. Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians. Matthew Y. K. Wei: Conceptualization; writing – original draft; writing – review and editing. Junyao Zhang: Writing – review and editing. Reuben Schmidt: Validation; writing – review and editing. Andrew S. Miller: Writing – review and editing. Justin M. C. Yeung: Supervision; validation; writing – review and editing.

Skeletal Muscle Mass and Surgical Morbidity After Laparoscopic Rectal Cancer Resection.

Background: Sarcopenia is a useful tool in predicting short-term results in patients undergoing surgery for gastrointestinal cancer. However, there are few studies addressing this issue in colorectal cancer, and even less specifically focused on rectal cancer. We evaluated the prognostic relevance of preoperative skeletal mass index on postoperative morbidity in patients undergoing laparoscopic curative resection for rectal cancer. Methods: Skeletal mass index data and clinicopathological characteristics of rectal cancer patients in a 15-year period (June 2005-December 2020) were evaluated; patients with metastatic disease at surgery were excluded; postoperative complications within 30 days were evaluated using the Clavien-Dindo classification. Results: A total of 166 patients were included in the study. The overall prevalence of sarcopenia was 60%. BMI, Hb, or albumin were not associated with sarcopenia. Hospital stay was not correlated with sarcopenia. Postoperative complications occurred in 51 patients (31%); by the Clavien-Dindo classification 31 (61%) grade I, 10 (14.5%) grade II, and 10 (14.5%) grade III. Overall complications were not significantly different in sarcopenic and nonsarcopenic patients (P = .10). Considering only patients with complications, sarcopenia was found to be a predictor of more severe postoperative morbidity (odds ratio 12.7, P = .021). On multivariable analysis, sarcopenia was not associated with postoperative morbidity. Conclusions: Skeletal muscle status in rectal cancer patients undergoing curative resection was not associated with overall postoperative morbidity, although there was a correlation between sarcopenia and more severe complications. Further studies in a larger cohort of patients are needed before conclusions can be drawn on the relationship between muscular depletion and surgical outcomes in rectal cancer patients.

Prognostic Consequences of Anastomotic Leakage in Patients after Laparoscopic Rectal Cancer Resection

Introduction: Anastomotic leakage is the horrendous complication after the laparoscopic rectal cancer resection. The main objective of the present study is to assess the relationship between AL, tumor recurrence and overall survival in rectal cancer patients treated with laparoscopic surgery. Methods: One hundred seventy patients who were diagnosed as rectal cancer with stages 1-3 followed by laparoscopic surgery between March 2012 and February 2017 from Beijing Friendship Hospital were evaluated retrospectively. Twelve factors after laparoscopic surgery were evaluated by the univariate analysis and multivariate analysis. The disease-free survival and overall survival curves were performed by the Kaplan- Meier method and were compared with the log-rank test. Results: The incidence rate of AL was 18.82%. The multivariate analysis showed AL [Hazard Ratio (HR); 3.114, 95% Confidence Interval (CI); 1.029-9.428, P; 0.044], advanced TNM stage [HR; 12.714, 95%CI; 2.364-68.377, P; 0.003] and intraoperative blood loss [HR; 0.269, 95%CI; 0.085-0.859, P; 0.027] were associated with poor OS. In addition, AL [Hazard Ratio (HR); 3.134, 95% Confidence Interval (CI); 1.274-7.711, P; 0.013] and advanced TNM stage [HR; 88.378, 95%CI; 2.231-31.465, P; 0.002] were associated with poor DFS. The logrank test p-value for OS and DFS curve by Kaplan-Meier method were 0.382 and 0.108 respectively. Conclusion: Anastomotic leakage was associated with poorer overall survival and increased risk of tumor recurrence. Moreover, there was no difference in three-year/five-year overall survival rate and disease-frees survival rate between the leakage and non-leakage groups in the present analysis.

Application of the advance incision in robotic-assisted laparoscopic rectal anterior resection.

The incidence of rectal cancer is increasing each year. Robotic surgery is being used more frequently in the surgical treatment of rectal cancer; however, several problems associated with robotic surgery persist, such as docking the robot repeatedly to perform auxiliary incisions and difficulty exposing the operative field of obese patients. Herein we introduce a new technology that effectively improves the operability and convenience of robotic rectal surgery. To simplify the surgical procedure, enhance operability, and improve healing of the surgical incision, we developed an advance incision (AI) technique for robotic-assisted laparoscopic rectal anterior resection, and compared its safety and feasibility with those of intraoperative incision. Between January 2016 and October 2021, 102 patients with rectal cancer underwent robotic-assisted laparoscopic rectal anterior resection with an AI or intraoperative incision (iOI) incisions. We compared the perioperative, incisional, and oncologic outcomes between groups. No significant differences in the operating time, blood loss, time to first passage of flatus, time to first passage of stool, duration of hospitalization, and rate of overall postoperative complications were observed between groups. The mean time to perform auxiliary incisions was shorter in the AI group than in the iOI group (14.14 vs. 19.77 min; p < 0.05). The average incision length was shorter in the AI group than in the iOI group (6.12 vs. 7.29 cm; p < 0.05). Postoperative incision pain (visual analogue scale) was lower in the AI group than in the iOI group (2.5 vs. 2.9 p = 0.048). No significant differences in incision infection, incision hematoma, incision healing time, and long-term incision complications, including incision hernia and intestinal obstruction, were observed between groups. The recurrence (AI group vs. iOI group = 4.0% vs. 5.77%) and metastasis rates (AI group vs. iOI group = 6.0% vs. 5.77%) of cancer were similar between groups. The advance incision is a safe and effective technique for robotic-assisted laparoscopic rectal anterior resection, which simplifies the surgical procedure, enhances operability, and improves healing of the surgical incision.

Prognostic effect of sarcopenia in patients undergoing laparoscopic rectal cancer resection.

The importance of body composition, in particular skeletal muscle mass, as risk factor affecting survival of cancer patients has recently gained increasing attention. The relationship between sarcopenia and oncological outcomes has become a topic of research in particular in patients with gastrointestinal cancer. However, there are few studies addressing this issue in colorectal cancer, and even less specifically focused on rectal cancer, in particular in Western countries. The aim of this study was to evaluate the prognostic relevance of preoperative skeletal mass index (SMI) on long-term outcomes in patients undergoing laparoscopic curative resection for rectal cancer. SMI data and clinicopathological characteristics of rectal cancer patients in a 15-year period (June 2005-December 2020) were evaluated; patients with metastatic disease at surgery were excluded; overall and disease-free survival as well as recurrence were evaluated. Hundred and sixty-five patients were included in the study. Sarcopenia was identified in 30 (18%) patients. Multivariate analysis identified sarcopenia (HR=3.28, CI=1.33-8.11, P=0.015), along with age (HR=1.06, CI=1.02-1.10, P =0.002) and stage III (HR=2.63, CI=1.13-6.08, P < 0.03) as independent risk factors for overall survival. Long-term results of rectal cancer patients undergoing curative resection are affected by their preoperative skeletal muscle status. Larger studies including comprehensive data on muscle strength along with SMI are awaited to confirm these results on both Eastern and Western rectal cancer patient populations before strategies to reverse muscle depletion can be extensively applied.

Outcomes of Robot-Assisted Surgery in Rectal Cancer Compared with Open and Laparoscopic Surgery.

With increasing trends for the adoption of robotic surgery, many centers are considering changing their practices from open or laparoscopic to robot-assisted surgery for rectal cancer. We compared the outcomes of robot-assisted rectal resection with those of open and laparoscopic surgery. We searched Medline, Web of Science, and CENTRAL databases until October 2022. All randomized controlled trials (RCTs) and prospective studies comparing robotic surgery with open or laparoscopic rectal resection were included. Fifteen RCTs and 11 prospective studies involving 6922 patients were included. The meta-analysis revealed that robotic surgery has lower blood loss, less surgical site infection, shorter hospital stays, and higher negative resection margins than open resection. Robotic surgery also has lower conversion rates, lower blood loss, lower rates of reoperation, and higher negative circumferential margins than laparoscopic surgery. Robotic surgery had longer operation times and higher costs than open and laparoscopic surgery. There were no differences in other complications, mortality, and survival between robotic surgery and the open or laparoscopic approach. However, heterogeneity between studies was moderate to high in some analyses. The robotic approach can be the method of choice for centers planning to change from open to minimally invasive rectal surgery. The higher costs of robotic surgery should be considered as a substitute for laparoscopic surgery (PROSPERO: CRD42022381468).

Fluorescent ICG angiography in laparoscopic rectal resection - a randomized controlled trial. Preliminary report.

Anastomotic leakage is one of the most dangerous complications after rectal surgery. It can cause systemic complications, reduce the quality of life and worsen the results of oncological treatment. One of the causes of anastomotic leak is insufficient blood supply to the anastomosis. Intraoperative infrared angiography with indocyanine green (ICG) is expected to improve the assessment of intestinal perfusion and thus prevent anastomotic leakage. To present the results of the use of ICG intraoperative angiography during rectal surgery in the prevention of anastomotic leakage. The study included 76 patients undergoing rectal cancer surgery. Patients were randomized to 2 groups: Group I - 41 patients with ICG intraoperative angiography; and Group II - 35 patients without ICG imaging. Anastomotic leak, length of hospitalization, and complication rate were compared. Group I patients received intravenous ICG before the anastomosis. Average time of intestinal wall contrasting was 42 s (22-65 s). Average ICG procedure time was 4 min (3.2% of total time of surgery). Three (7.3%) patients after angiography revealed intestinal ischemia requiring widened resection. No anastomotic leak was found post-operatively, and no side effects were observed after administration of ICG. In group II, 3 (8.6%) anastomotic leakages were diagnosed, 2 of which required reoperation. Intraoperative angiography with ICG in near-infrared light is a safe and effective method of assessing intestinal perfusion. ICG angiography may change the surgical plan and reduce the risk of anastomotic leakage. It is necessary to continue the study until the assumed number of patients is reached.

The learning curve of laparoscopic rectal cancer surgery of millennial surgeons: Lessons for a safe implementation in low- and middle-income countries.

This study aimed to analyse the learning curve (LC) in laparoscopic rectal cancer resections of 2 millennial surgeons during the implementation of the first laparoscopic rectal cancer surgery programme in low- and middle-income country (LMIC) cancer centre. All consecutive patients operated by two millennial surgeons for primary rectal adenocarcinoma between January 2018 and March 2020 were included. The LC was analysed for operative duration and conversion to open surgery using both cumulative sum (CUSUM) and/or variable life-adjusted display (VLAD) charts. Eighty-four patients were included, 45 (53.6%) men with a mean age of 57.3 years. Abdominoperineal resection was performed in 31 (36.9%) cases and resections were extended to other organs in 20 (23.8%) patients. Thirteen patients (15.5%) had conversion to open surgery. Using CUSUM, Learning curve based on conversion was completed at 12 cases for the first surgeon versus 10 cases for the second. While using VLAD and learning curve-CUSUM (LC-CUSUM), the cases needed were 26 vs 24 respectively. The median operative duration was 314 min with a LC completed at cases (17 vs. 26), and (18 vs. 29) using, respectively, standard and LC-CUSUM. This study shows a safe and short LC of millennial surgeons during the implementation of a laparoscopic rectal cancer surgery in an LMIC cancer centre, and the valuable use of modern statistical methods in the prospective assessment of LC safety during surgical training.

Minimally invasive laparoscopic rectal resection: Take the rough with the smooth

Minimally invasive laparoscopic rectal resection: Take the rough with the smooth

Interischial Spine Distance Is a Simple Index of the Narrow Pelvis That Can Predict Difficulty During Laparoscopic Low Anterior Resection.

A narrow pelvis makes laparoscopic rectal resection difficult. This study aimed to evaluate whether a simple measurement on computed tomography can predict procedural difficulty. A total of 62 patients with low rectal cancer underwent conventional laparoscopic low anterior resection. The interischial spine (IS) distance (ie, the distance between the ischial spines) was measured on an axial computed tomography slice. The operative time, blood loss, and time from the insertion of linear staplers to completion of clamping on the distal end of the rectum (clamp time) were compared between patients with narrow or wide pelvises. Overall, 42 men and 20 women with low rectal cancer were assessed. The mean tumor size was 34.5mm. Total or tumor-specific mesorectal excisions were performed in all cases; high ligation and resection of the inferior mesenteric arteries were carried out in 92% of patients. The mean operative time and blood loss were 206 minutes and 15mL, respectively. Four patients (6.5%) experienced postoperative complications, including 2 anastomotic leaks (3.2%). The mean IS distance was 93.3mm. In simple linear regression analysis, a shorter IS distance correlated with a longer operative time ( R2 =0.08, P =0.030) and the clamp time ( R2 =0.07, P =0.046). Using a receiver operating characteristic curve, a narrow pelvis was defined as an IS distance <94.7mm. Multivariate regression analysis revealed that an IS distance <94.7mm (odds ratio: 3.51; P =0.04) was independently associated with a longer clamp time. The IS distance is a simple and useful measurement for predicting the difficulty of laparoscopic low anterior resection.

Robot-assisted rectal resections-Scoping review for level1a evidence and retrospective analysis of in-clinic data

Robot-assisted rectal resections are said to overcome the known difficulties of laparoscopic rectal surgery through technical advantages, leading to better treatment results; however, published studies reported very heterogeneous results. The aim of this paper is therefore to determine whether there is class1a evidence comparing robotic versus laparoscopic rectal resections. Furthermore, we would like to compare the treatment results of our clinic with the calculated effects from the literature. A systematic literature search for class1a evidence was performed and the calculated effects for7 preselected outcomes were compared. We then analyzed all elective rectal resections performed in our hospital between 2017 and 2020 and compared the treatment outcomes with the results of the identified meta-analyses. The results of the7 identified meta-analyses did not show homogeneous effects for the outcomes operating time and conversion rate, while the calculated effects of the other outcomes studied were largely consistent. Our patient data showed that robotic rectal resections were associated with significantly longer operation times, while the other outcomes were hardly influenced by the surgical technique. Although class1a meta-analyses comparing robotic and laparoscopic rectal resections already exist, they do not enable an evidence-based recommendation regarding the preference of one of the two surgical techniques. The analysis of our patient data showed that the results achieved in our clinic are largely consistent with the observed effects of the meta-analyses.

Laparoscopic natural orifice specimen extraction, a minimally invasive surgical technique for mid-rectal cancers: Retrospective single-center analysis and single-surgeon experience of selected patients.

To evaluate the feasibility, safety, and short-term outcomes of middle rectal resection followed by transanal specimen extraction. Forty-four patients with small mid-rectal tumors underwent laparoscopic rectal resection followed by transanal specimen extraction. The procedure was successful in all patients without intraoperative conversion or additional access. The mean operation time was 182.7 minutes (range, 130-255 minutes), the mean blood loss was 26.5 mL (range, 5-120 mL), the mean postoperative exhaust time was 31.3 hours (range, 16-60 hours), and the mean length of hospital stay was 9.5 days (range, 8-19 days). One patient developed anastomotic leakage, which was treated by intravenous antibiotics and daily pelvic cavity flushes through the abdominal drainage tube. No infection-related complications or anal incontinence were observed. The mean tumor size was 2.1 cm (range, 1.6-3.2 cm), the mean number of harvested lymph nodes was 16.5 (range, 6-31), and the mean follow-up time was 8.5 months (range, 2-16 months). By the last follow-up, no signs of recurrence had been found in any patient. The combination of standard laparoscopic proctectomy and transanal specimen extraction could become a well-established strategy for selected patients.

Robotic-assisted versus laparoscopic rectal surgery in obese and morbidly obese patients: ACS-NSQIP analysis

Laparoscopic rectal surgery within the confines of a narrow pelvis may be associated with a high rate of open conversion. In the obese and morbidly obese patient, the complexity of laparoscopic surgery increases substantially. Robotic technology is known to reduce the risk of conversion, but it is unclear if it can overcome the technical challenges associated with obesity. The ACS NSQIP database was used to identify obese patients who underwent elective laparoscopic or robotic-assisted rectal resection from 2015 to 2016. Obesity was defined as a body mass index (BMI) greater than or equal to 30 kg/m2. Morbid obesity was defined as a BMI greater than or equal to 35 kg/m2. The primary outcome was unplanned conversions to open. Other outcomes measures assessed included anastomotic leak, operative time, surgical site infections, length of hospital stay, readmissions and mortality. Statistical analyses were performed using SPSS 22.0 (IBM SPSS, USA). 1490 patients had robotic-assisted and 4967 patients had laparoscopic rectal resections between 2015 and 2016. Of those patients, 561 obese patients had robotic-assisted rectal resections and 1824 patients underwent laparoscopic rectal surgery. In the obese cohort, the rate of unplanned conversion to open in the robotic group was 14% compared to 24% in the laparoscopic group (P < 0.0001). Median operative time was significantly longer in the robotic group (248 min vs. 215 min, P < 0.0001). There was no difference in anastomotic leak or systemic sepsis between the laparoscopic and robotic rectal surgery groups. In morbidly obese patients (BMI ≥ 35 kg/m2), the rate of unplanned conversion to open in the robotic group was 19% compared to 26% in the laparoscopic group (P < 0.027). There was no difference in anastomotic leak, systemic sepsis or surgical site infection rates between robotic and laparoscopic rectal resection. Multivariate analysis showed that robotic-assisted surgery was associated with fewer unplanned conversions to open (OR 0.28, P < 0.0001). Robotic-assisted surgery is associated with a decreased risk of conversion to open in obese and morbidly obese patients when compared to conventional laparoscopic surgery. However, robotic surgery was associated with longer operative time and despite improvement in the rate of conversion to open, there was no difference in complications or length of stay. Our findings are limited by the retrospective non-randomised nature of the study, demographic differences between the two groups, and the likely difference in surgeon experience between the two groups. Large randomised controlled studies are needed to further explore the role of robotic rectal surgery in obese and morbidly obese patients.

Operative and oncological outcomes after robotic rectal resection compared with laparoscopy: a systematic review and meta-analysis.

Most studies comparing robotic and laparoscopic surgery, show little difference in clinical outcomes to justify the expense. We systematically reviewed and pooled evidence from studies comparing robotic and laparoscopic rectal resection. Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (EMBASE), and Cochrane databases were searched for studies between 1996 and 2021 comparing clinical outcomes between laparoscopic and robotic rectal surgeries involving total mesorectal excision. Outcome measures included operative times, conversions to open, complications, recurrence and survival rates. Fifty eligible studies compared outcomes between robotic and laparoscopic rectal resections; three were randomized trials. Pooled results showed significantly longer operating times for robotic surgery but lower conversion and complications rates, shorter lengths of stay in hospital, better rates of complete mesorectal resection and better three-year overall survival. However, the low number of randomized studies makes most data subject to bias. Available evidence supports the safety and ongoing use of robotic rectal cancer surgery, while further high-quality evidence is sought to justify the expense.

End-to-end versus side-to-end anastomosis after bowel resection for deep infiltrating endometriosis: A retrospective study

ObjectiveDeep infiltrating endometriosis(DIE) of the bowel may require segmental bowel resection. The subsequent reconstruction can be performed through an end-to-end(E-E) or a side-to-end (S-E)anastomosis, the latter being used in low resection due to the reduced risk of anastomotic leakage. This study aims at comparing those two anastomosis techniques in women submitted to bowel resection for DIE, in terms of post-operative morbidity and functional outcomes. MethodsThis was a single-center retrospective study on women undergoing laparoscopic rectal resection for deep infiltrating endometriosis with subsequent E-E or S-E anastomosis performed according to the level of rectal resection. The two groups were compared for postoperative complication rates and functional outcomes by means of validated questionnaires. ResultsThe study population included 30 patients undergoing a S-E anastomosis (group A), and 49 cases undergoing an E-E anastomosis (group B). No differences were found between the two groups in terms of length of hospital stay, anastomotic leakages, protective ileostomies and short-term complications. At follow up no differences were found between the two groups in terms of bowel function and pain symptoms. ConclusionsA S-E anastomosis in case of low rectal resections for DIE presents similar complication rates and functional outcomes compared with an E-E anastomosis.

Implementation of robotic rectal cancer surgery: a cross-sectional nationwide study

AimAn increasing number of centers have implemented a robotic surgical program for rectal cancer. Several randomized controls trials have shown similar oncological and postoperative outcomes compared to standard laparoscopic resections. While introducing a robot rectal resection program seems safe, there are no data regarding implementation on a nationwide scale. Since 2018 robot resections are separately registered in the mandatory Dutch Colorectal Audit. The present study aims to evaluate the trend in the implementation of robotic resections (RR) for rectal cancer relative to laparoscopic rectal resections (LRR) in the Netherlands between 2018 and 2020 and to compare the differences in outcomes between the operative approaches.MethodsPatients with rectal cancer who underwent surgical resection between 2018 and 2020 were selected from the Dutch Colorectal Audit. The data included patient characteristics, disease characteristics, surgical procedure details, postoperative outcomes. The outcomes included any complication within 90 days after surgery; data were categorized according to surgical approach.ResultsBetween 2018 and 2020, 6330 patients were included in the analyses. 1146 patients underwent a RR (18%), 3312 patients a LRR (51%), 526 (8%) an open rectal resection, 641 a TaTME (10%), and 705 had a local resection (11%). The proportion of males and distal tumors was higher in the RR compared to the LRR. Over time, the proportion of robotic procedures increased from 15% (95% confidence intervals (CI) 13–16%) in 2018 to 22% (95% CI 20–24%) in 2020. Conversion rate was lower in the robotic group [4% (95% CI 3–5%) versus 7% (95% CI 6–8%)]. Anastomotic leakage rate was similar with 16%. Defunctioning ileostomies were more common in the RR group [42% (95% CI 38–46%) versus 29% (95% CI 26–31%)].ConclusionRectal resections are increasingly being performed through a robot-assisted approach in the Netherlands. The proportion of males and low rectal cancers was higher in RR compared to LRR. Overall outcomes were comparable, while conversion rate was lower in RR, the proportion of defunctioning ileostomies was higher compared to LRR.