Open Low Anterior Resection Research Articles

Management and Outcome of Rectal Injury During Gynecologic Laparoscopic Surgery

ObjectiveTo assess the incidence and management of accidental rectal injury during gynecologic laparoscopic surgery. DesignA retrospective study with review of outcomes (Canadian Task Force classification II-3). SettingA tertiary care/research/university hospital. PatientsPatients with colon injury during laparoscopy for gynecologic diseases at Samsung Medical Center, Seoul, Korea, from January 2000 to April 2012. InterventionUse of absorbable suture or staples in primary repair of injured colon. Measurements and Main ResultsFrom January 2000 to April 2012, 12 354 patients underwent laparoscopic surgery. Rectal injury occurred in 15 women (0.12%). Their median age was 42.5 years (30–49), and the median length of injury was 3 cm (0.7–7). Among 13 patients with rectal injuries recognized during surgery, 10 patient injuries were repaired primarily with interrupted absorbable sutures without converting laparotomy, 1 patient underwent laparoscopic low anterior resection with Endo-GIA, 1 underwent open primary repair, and 1 underwent open low anterior resection. Two rectal injuries were detected after surgery. One of these patients underwent primary repair under laparotomy at day 4 after surgery. The other patient had development of a rectovaginal fistula requiring open segmental resection 30 days after primary laparoscopy despite conservative management, including percutaneous drainage and prophylactic antibiotics. ConclusionRectal injury during laparoscopy in the gynecologic field can be repaired successfully without the need for a colostomy regardless of mechanism of injury and the size of injury if adequate rectal tissue is available and recognized during surgery.

Treatment of diatal rectal cancer with preoperative intensity-modulated radiation therapy (IMRT) combined with chemotherapy: Updated 5-year results of 42 patients.

e14157 Background: Preoperative chemoradiotherapy is currently the standard of care for patients with distal rectal cancer. With Intensity Modulated Radiation Therapy (IMRT), more conformal doses of radiation can be delivered to tumor while sparing normal tissue. It is our intent to present updated data showing 5 year follow up on patients treated concurrently with chemotherapy and IMRT reporting on local control, overall survival, and toxicity. Methods: From April 2007 to February of 2012 a sequential retrospective study of 42 patients at Lankenau Medical Center were treated for distal rectal cancer using IMRT. Patients staged from T2N0M0 to T3N1M0 and all received 5580 cGy to the pelvis using a 9 field plan to tumor, involved and uninvolved lymph nodes. All but one patient received 5FU based chemotherapy and four patients also received oxaliplatin. All patients then went on to surgery 8 – 12 weeks following neoadjuvant therapy. Twenty six patients underwent transabdominal transanal mesorectal (TATA) resection, 9 patients underwent a transanal endoscopic microsurgery (TEM), and 1 patient had an open low anterior resection. 3 patients have yet to go to surgery. FOLFOX was given to 25 of 42 patients adjuvently. Patients were analyzed for local control (LC), median survival (MS), overall survival (OS), and toxicity. Results: The median follow-up was 35 months. Complete pathological response was achieved in 12 (30.7%) patients, partial response was achieved in 25 (64%) patients, and 2 had stable disease at the time of surgery. There were no patients with local failure and only six (14%) patients progressed with distant metastatic disease. OS at 5 years was 92.8% with a MS of 37 months. Toxicity was acceptable with eight patients with grade 1, 5 patients with grade 2, and 3 grade 3 diarrhea. There were 3 (7%) patients with grade 1 neutropenia. Three patients experienced disease related death. Conclusions: With 5 years of follow-up data, our experience has shown that neoadjuvant chemoradiotherapy using IMRT to treat advanced stage rectal cancer is well tolerated and effective. Still further follow-up and additional studies will be required to confirm our findings.

Outcomes of Low Anterior Resection Anastomotic Leak after Preoperative Chemoradiation Therapy for Rectal Cancer

Anastomotic leak remains a major cause of morbidity and mortality after colorectal surgery, especially with low anastomoses. The aim of this study was to assess outcomes of patients who developed an anastomotic leak after low anterior resection of the rectum for rectal cancer. An Institutional Review Board-approved retrospective review of 89 consecutive patients undergoing open low anterior resection with primary anastomosis for cancer of the mid/lower rectum at a single institution between January 2001 and December 2008 was performed. All patients received neoadjuvant chemotherapy and radiation therapy. Proximal diversion was performed in all patients. Perioperative data were collected and analyzed with attention to management and outcomes after development of anastomotic leak. Nine patients (10.1%) developed anastomotic leak. Mean age was 62 years. Mean tumor level was 4.8 cm above the anal verge. Symptomatic anastomotic leak developed in seven (78%) patients. Percutaneous drainage was performed in five (55.6%) patients with an average of 4.4 procedures required for management of anastomotic leak. Five (55.6%) patients required reoperation. Only two procedures (25%) involved laparotomy. No operative procedures were performed emergently. There were no mortalities. Excluding one patient who received completion proctectomy for local recurrence, restoration of intestinal continuity was achieved in five (63%) of eight patients. Mean time to stoma closure was 289 days. The potentially lethal complication of anastomotic leak after low anterior resection for rectal cancer can be managed expectantly and electively in patients who are proximally diverted with the expectation of stoma reversal in the long term.

New technology-based innovation changes surgical practice and research direction in solid cancers

Without innovation, no progress can be achieved. To improve oncological outcomes and the quality of life (QOL) of patients with rectal cancer and other solid tumors, we should change both surgical and adjuvant treatment. For improving survival and cure rates, more efficient surgery and novel combinations of chemotherapeutic and targeted agents are needed. Moreover, we need new markers for identifying individual responder patients to specific drug combinations. In the field of day-to-day surgical practice, the next generation of the robotic da Vinci surgical system, and in the field of biomarkers and next-generation targeted agents, the latest high-throughput technologies provide exciting scientific promise for the future. Over the coming decade, next-generation DNA sequencing technology for understanding cancer’s origin, progression, and metastasis [1, 2] and a new generation of the da Vinci surgical robotic system for clinical practice [3] are fundamental for changing the management of solid cancers, including rectal cancer. Dramatic progress has been made in the surgical treatment of low rectal cancer. A safe and effective sphincterpreserving procedure resulting in complete resection of the primary tumor and regional lymph nodes (R0) resection has been established as the standard of care. This optimal low anterior resection includes total mesorectal excision (TME), a safety zone from the tumor of at least 2 cm, and high inferior mesenteric ligation with splenic flexure mobilization. This standard open low anterior resection has recently been adopted into laparoscopic surgery with the substantial benefits of a minimally invasive approach. It should be emphasized that according to evidence-based principles in biomedical science, results from comparativeeffectiveness research from phase III randomized trials

Laparoscopic low versus high anterior resection for rectal cancer

I thank Dr. Hanisch and colleagues for their interest in myarticle. They questioned my statement: ‘‘The authors usedstrict selection criteria, for example, 6 cm distance oftumor from anal verge, and thus pathological examinationof the specimens showed no positive margins. For less than6 cm distance of tumor from anal verge at preoperativecolonoscopy, what was or is the strategy? Open low ante-rior resection or abdominoperineal rectal excision?’’However, in our article, we did not describe 6 cm distanceof a tumor from the anal verge as one of our criteria forlaparoscopic surgery.One of our criteria for laparoscopic rectal surgery is thatthe tumor must have a diameter of less than 6 cm, asmentioned in the article. We do not exclude a tumor forlaparoscopic surgery only because of its location. In fact,45 of 61 patients undergoing laparoscopic surgery forlower rectal cancer located within 75 mm of the anal verge(group B) had a tumor less than 6 cm from the anal verge.Furthermore, during the same period as this study, 37patients underwent laparoscopic rectal resection for atumor located within 6 cm from the anal verge without adouble-stapling reconstruction technique. These proce-dures consisted of 14 abdominoperineal resections and 23intersphincteric resections.Although we adopt strict selection criteria regardingtumor conditions (e.g., ‘‘not bulky’’ or ‘‘not invading to theadjacent organs’’), we do not think that tumor location is abig obstacle for laparoscopic rectal surgery. On the con-trary, our idea is that the laparoscope can be of great help inthe resection of such lower rectal lesions.

Beyond quality-of-life improvement: how robotic surgery for low anterior resection with total mesorectal excision also may improve oncologic outcomes

High-quality evidence for laparoscopic colectomy used to treat resectable stages 1–3 colon cancer has demonstrated substantial quality of life (QOL) without any worsening of oncologic outcomes. But evidence for the safety and efficiency of either laparoscopically or robotically assisted low anterior resection is scarce [1]. Minimally invasive surgery, either laparoscopic or robotic, improves QOL. But beyond this, is there any probability of improving also recurrence-free, overall survival and even projecting a cure? Hellan et al. [2] in a recent issue of Surgical Endoscopy reported on the second generation of robotic surgery. However, multiple challenges need to be overcome. Can robotic surgery replace open surgery in the treatment of gastric cancer? What are the challenges, benefits, and risks for patients, surgeons, society, public and private insurance, and public health? These are crucial questions considering the dramatic increase of cancer by 55% projected for 2020. Interest in robotic surgery using the Da Vinci system has exploded over the past few years. This is delineated by the rapidly growing number of patients with gastrointestinal and other solid tumors who are treated by robotically assisted resection [3, 4]. It is of fundamental importance for the scientific community to use evidence-based tools when moving from a current standard surgical treatment practice to a novel experimental new-technology-based surgery. Most recent extensive genetic studies have shown the high complexity and diversity of solid cancers including gastrointestinal cancers [5–9]. This fact urgently suggests the need for new design and development of targeted agents and biomarkers for more effective treatment of solid cancers [10–18]. Therefore, it is surgically naive to believe that switching from open to closed surgery can alter oncologic outcomes. But particularly for rectal cancer, such a probability cannot be excluded. The Da Vinci system may allow a better locoregional control than open low anterior resection for the following reasons. To begin with, the Da Vinci system may ensure a more accurate and precise anatomic total mesorectal excision (TME). Indeed, due to its anatomic location in the pelvis, a precise TME appears in most cases of open surgery to be unfeasible. The second-generation da Vinci System model, as reported by Hellan et al. [2], offers smaller profile instrument arms with increased length and greater range of motion intracorporeally, thus enabling multiquadrant access to the abdominal cavity. This technological improvement was one reason for developing a ‘‘one-step’’ surgical setup for robotic rectal resections requiring mobilization of the splenic flexure. What benefits are realized in the precision of TME? The advantages include local recurrence rate reduction and perhaps avoidance of unnecessary radiotherapy and its adverse effects when the mesorectum has been completely removed. Furthermore, this anatomic structure-based surgery, preventing nerves of vital organ functionality, substantially improves QOL. Hellan et al. [2] noted that robotic technology is especially suitable for dissection in confined spaces such as the E. Hanisch Klinik fur Allgemein-,Viszeralund Endokrine Chirurgie, Asklepios Klinik Langen, Akademisches Lehrkrankenhaus der Johann Wolfgang Goethe-Universitat, Frankfurt, Germany

Prospective Study of Ambulation After Open and Laparoscopic Colorectal Resection

Open and laparoscopic surgical approaches each have specific advantages. This study compares ambulation, hospital length of stay (LOS), and incision length after open and laparoscopic colorectal resection. All consecutive patients undergoing colorectal resection over a 2 year period ending August 2002 were followed prospectively. Ambulation, LOS, and incision length were recorded. Hybrid low anterior resection (LAR) patients had laparoscopic splenic flexure takedown, vessel ligation, and proximal rectal mobilization followed by planned inferior laparotomy to complete the case. Groups were compared using Student's t test. Equivalent open and laparoscopic groups were comparable in terms of gender, age, body mass index, ASA class, indication for operation, and resection performed. Seventy open colectomy patients were compared with 99 laparoscopic-assisted colectomy patients. On average, patients in the open and laparoscopic groups ambulated 67 and 390 feet, respectively, on postoperative day 1 (P < .001), 290 and 752 feet on day 2 (P < .001), and 495 and 965 feet on day 3 (P < .001). The average LOS in the open group was 9.3 days compared with 5.9 days in the laparoscopic group (P < .001). The average incision length in the open group was 19.7 cm compared with 5.3 cm in the laparoscopic group (P < .001). Seventeen open LAR patients were compared with 30 hybrid LAR patients. On average, patients in the open and hybrid groups ambulated 22 and 150 feet, respectively, on postoperative day 1 (P = .003), 105 and 433 feet on day 2 (P = .003), and 369 and 488 feet on day 3 (P = .43). The average LOS in the open group was 10 days compared with 8.5 days in the hybrid group (P = .46). The average incision length in the open group was 19.8 cm compared with 10.8 cm in the hybrid group (P < .001). When all 216 patients were considered, the 91 patients with incisions shorter than 8 cm (average 4.6 cm) ambulated 396, 752, and 956 feet on consecutive days whereas the 125 patients with incisions 8 cm or longer (average 16.9 cm, P < .001) ambulated 101, 334, and 521 feet on consecutive days (all P values <.001). Average LOS in the <8-cm group was 6 days compared with 8.9 days in the > or =8-cm group (P < .001). Patients undergoing minimal-access colorectal surgery ambulated significantly further than equivalent open patients in the early postoperative period and had a shorter LOS.

Laparoscopic radiofrequency ablation of liver tumors combined with colorectal procedures.

Laparoscopic radiofrequency ablation (RFA) is gaining increasing acceptance as a treatment option for primary and secondary liver tumors with minimal morbidity. The purpose of this study is to see if adding a colorectal procedure to RFA increases the risk of hepatic abscess. Of the 310 patients with 1,080 primary and secondary liver tumors undergoing laparoscopic radiofrequency ablation (RFA), 16 patients underwent RFA in combination with various colorectal procedures. Data were collected prospectively. The concomitant procedures included loop ileostomy closures in 6 patients; laparoscopic-assisted right hemicolectomy in 3 patients; laparoscopic-assisted anterior resection in 2 patients; and open transverse colectomy, open anterior resection, open low anterior resection, open loop transverse colostomy formation, and anal stricture dilatation in 1 patient each. Mean +/- SD hospital stay was 2.9 +/- 1.7 days. There was no mortality, and the only complication was the development of a right flank abscess after laparoscopic-assisted right hemicolectomy that was treated with percutaneous drainage. Although patients undergoing laparoscopic RFA in combination with a clean-contaminated procedure could be at high risk for secondary infection of ablated foci, this was not observed. This approach is safe and does not impair recovery from either procedure. These data support the concept that RFA may be safely used with concomitant colon resections to treat liver metastases that may be resectable but are associated with increased morbidity if resected synchronously.