Outcomes Of Surgery For Rectal Cancer Research Articles

Assessing the role of prognostic nutritional index in predicting outcomes for rectal cancer surgery

Background & AimsThe association of Prognostic Nutritional Index (PNI) with prognosis has been established for various cancer types, including rectal cancer. However, the precise relationship between PNI and body composition characteristics in patients with non-metastatic rectal cancer remain unclear. This study aimed to investigate the impact of PNI on overall survival and disease-free survival in non-metastatic rectal cancer patients undergoing total surgical resection. Additionally, it sought to assess the inflammatory status and body composition in patients across different PNI levels. MethodsPatients with non-metastatic rectal cancer who underwent total surgical resection, were consecutively enrolled. PNI was calculated using the formula: PNI = (10 x serum albumin [g/dl]) + (0.005 x lymphocytes/μL). Body composition was assessed using CT-derived measurements and laboratory tests performed at diagnosis were used to calculate inflammatory indices. Univariate and multivariate logistic regression analyses as well as Kaplan-Meier curves were used to determine prognostic values. ResultsA total of 298 patients were included. Patients with low PNI demonstrated significantly reduced overall survival and disease-free survival compared to those with high PNI (Hazard ratio [HR] 1.85; Confidence interval [CI] 1.30-2 .62; p= 0.001). Moreover, patients with low PNI exhibited heightened systemic inflammatory status and reduced skeletal muscle index, increased muscle radiodensity, as well as a decrease in subcutaneous adipose tissue area, subcutaneous fat index, and low attenuation of both subcutaneous and visceral adipose tissue. ConclusionThe PNI, assessed prior to treatment initiation, serves as a prognostic biomarker for non-metastatic rectal cancer patients undergoing total surgical resection and is linked with both inflammation and alterations in body composition.

Effect of surgical risk factors on the short-term outcomes for rectal cancer surgery. Laparoscopic or robotic approach?

Effect of surgical risk factors on the short-term outcomes for rectal cancer surgery. Laparoscopic or robotic approach?

What is the impact of hospital and surgeon volumes on outcomes in rectal cancer surgery?

Evidence for a positive volume-outcome relationship for rectal cancer surgery is unclear. This study aims to evaluate the volume-outcome relationship for rectal cancer surgery at hospital and surgeon level in the English National Health Service (NHS). All patients undergoing a rectal cancer resection in the English NHS between 2015 and 2019 were included. Multilevel multivariable logistic regression was used to model relationships between outcomes and mean annual hospital and surgeon volumes (using a linear plus a quadratic term for volume) with adjustment for patient characteristics. A total of 13 858 patients treated in 166 hospitals were included. Six hospitals (3.6%) performed fewer than 10 rectal cancer resections per year, and 381 surgeons (45.0%) performed fewer than five such resections per year. Patients treated by high-volume surgeons had a reduced length of stay (p = 0.016). No statistically significant volume-outcome relationships were demonstrated for 90-day mortality, 30-day unplanned readmission, unplanned return to theatre, stoma at 18 months following anterior resection, positive circumferential resection margin and 2-year all-cause mortality at either hospital or surgeon level (p values > 0.05). Almost half of colorectal surgeons in England do not meet national guidelines for rectal cancer surgeons to perform a minimum of five major resections annually. However, our results suggest that centralizing rectal cancer surgery with the main focus of increasing operative volume may have limited impact on NHS surgical outcomes. Therefore, quality improvement initiatives should address a wider range of evidence-based process measures, across the multidisciplinary care pathway, to enhance outcomes for patients with rectal cancer.

Rectal cancer surgery: does low volume imply worse outcome-a single surgeon experience.

The centralisation of rectal cancer management to high-volume oncology centres has translated to improved oncological and survival outcomes. We hypothesise that individual surgeon caseload, specialisation, and experience may be as significant in determining oncologic and postoperative outcomes in rectal cancer surgery. A prospectively maintained colorectal surgery database was reviewed for patients undergoing rectal cancer surgery between January 2004 and June 2020. Data studied included demographics, Dukes' and TNM staging, neoadjuvant treatment, preoperative risk assessment scores, postoperative complications, 30-day readmission rates, length of stay (LOS), and long-term survival. Primary outcome measures were 30-day mortality and long-term survival compared to national and international standards and best practice guidelines. In total, 87 patients were included (mean age: 66years [range: 36-88]). The mean length of stay (LOS) was 16.5days (SD 6.0). The median ICU LOS was 3days (range 2-17). Overall, 30-day readmission rate was 16.4%. Twenty-four patients (26.4%) experienced ≥ 1 postoperative complication. The 30-day operative mortality rate was 3.45%. Overall 5-year survival rate was 66.6%. A significant correlation was observed between P-POSSUM scores and postoperative complications (p = 0.041), and all four variants of POSSUM, CR-POSSUM, and P-POSSUM scores and 30-day mortality. Despite improved outcomes seen with centralisation of rectal cancer services at an institutional level, surgeon caseload, experience, and specialisation is of similar importance in obtaining optimal outcomes within institutions.

Surgical treatment of rectal cancer: prospective cohort study about good oncologic results and low rates of abdominoperineal excision.

the purpose of this study was to evaluate the outcome of rectal cancer surgery, in a unit adopting the principles of total mesorectal excision (TME) with a high restorative procedure rate and with a low rate of abdominoperineal excision (APE). we enrolles patients with extraperitoneal rectal cancer undergoing TME or TME+APE. Patients with mid rectal tumors underwent TME, and patients with tumors of the lower rectum and no criteria for APE underwent TME and intersphincteric resection. Those in which the intersphincteric space was invaded and in those with a free distal margin less than 1cm or a tumor free radial margin were unattainable underwent APE or extralevator abdominoperineal excision (ELAPE). We assessed local recurrence rates, overall survival and involvement of the radial margin. sixty (89.6%) patients underwent TME and seven (10.4%) TME + APE, of which five underwent ELAPE. The local recurrence, in pacientes undergoing TME+LAR, was 3.3% and in patients undergoing APE, 14.3%. The local recurrence rate (p=0.286) or the distant recurrence rate (p=1.000) was similar between groups. There was no involvement of radial margins. Survival after 120 months was similar (p=0.239). rectal malignancies, including those located in the low rectum, may be surgically treated with a low rate of APE without compromising oncological principles and with a low local recurrence rates.

SP5.2.9 Perioperative immunonutrition in reducing the infectious complications in patients undergoing colorectal cancer resections: a meta-analysis of randomized controlled trials

Abstract Objective Perioperative nutritional interventions have been reported to improve colorectal rectal cancer surgery outcomes. The objective of this article is to assess the influences of immunonutrition intervention during perioperative period in patients undergoing colorectal cancer resections. Method Meta-analysis was conducted according to the PRISMA guidelines. Systematic search of medical databases like MEBASE, MEDLINE and pubmed was performed to find studies exclusively reporting the perioperative use of immunonutrition in patients undergoing colorectal cancer resections and relevant published randomized, controlled trials (RCT) were shortlisted according to the inclusion criteria. The analysis of the pooled data was done using the RevMan statistical software. Result Ten RCTs on 1218 patients with colorectal cancer fulfilled the inclusion criteria. In the random effects model analysis, the use of perioperative immunonutrition in patients undergoing colorectal cancer resections statistically reduced the risk [odds ratio 0.59, 95% CI (0.35–1.0), z= 1.96, p=0.05] of infectious complications. However, there was significant heterogeneity [Tau2 = 0.35; Chi2= 19.11, df = 9 (P < 0.02; I2 = 53%)] among included studies. The variables of postoperative mortality [odds ratio 2.1, 95% CI (0.33–12.36), z= 0.75, p=0.45] and length of hospitalization [standardized mean difference 0.16, 95% CI (-0.08–0.39), z= 1.31, p=0.19] were statistically similar in patients using immunonutrition or standard conventional perioperative nutrition. Conclusion Perioperative immunonutrition in patients undergoing colorectal resections seems to reduce infectious complications but this study failed to demonstrate its role in reducing the postoperative mortality and length of hospitalization.

Specialization improves outcomes in rectal cancer surgery

Scope of specialtyColorectal surgery encompasses any procedure performed on the colon and/or rectum. This section focuses on rectal surgery, specifically regarding surgery for rectal cancer and its technical complexity and disease complexity that often requires a multidisciplinary team-based approach. The emergence of rectal cancer surgical specialists exhibits improvements in rectal cancer outcomes.Colorectal surgery fellowships are available for general surgeons who desire specialization. Roughly 70 colorectal surgery fellowship programs exist, of which 39 are accredited by the National Accreditation Program for Rectal Cancer (NAPRC). Patient care and quality outcomesThe OSTRiCh (Optimizing the Surgical Treatment of Rectal Cancer) Consortium (OC) and NAPRC developed guidelines for a standardized pathway for rectal cancer care and outline standards for patient care and performance indicators. These efforts focus on the recognition of disparities in rectal cancer outcomes, a system for improvement, delivery of quality care, and optimizing patient results by minimizing morbidity and mortality. Regulatory requirementsIn the United States, Board certification for surgeons performing colorectal surgery is granted by the American Board of Colon and Rectal Surgery (ABCRS). While the United States lags behind its European counterparts in development of rectal cancer quality measures, significant changes have been made to close the gap. Improvement initiatives launched by the OC implemented a myriad of quality metrics for longitudinal outcome tracking; surgical site infection, positive circumferential margin rate, rate of colostomy creation, recurrence rate, to name a few.

Systematic review and meta-analysis of randomized controlled trials evaluating the effect of the level of ligation of inferior mesenteric artery on functional outcomes in rectal cancer surgery.

This systematic review and meta-analysis studied the role of high (HL) versus low (LL) inferior mesenteric artery (IMA) ligation on genitourinary and defecatory dysfunction in patients who had undergone resection for rectal cancer (RC). A systematic literature search of four major databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Randomized controlled trials (RCTs) comparing HL and LL of IMA in RC surgery were identified. Those studies that looked at genitourinary or defecatory dysfunction were included. Random-effects modeling to summarize statistics was performed. The risk of bias was assessed using Cochrane's Risk-of-Bias tool 2. Three RCTs were included. There was clinical heterogeneity with regard to cancer stage and location as well as operative techniques and adjuvant treatments. Functional outcomes (FO) that were reported by at least two studies were International Consultation on Incontinence Questionnaire (ICIQ), International Index for Erectile Function (IIEF), Jorge-Wexner incontinence score (J-W). Difference was observed in ICIQ at 9months after surgery favoring LL (standard mean difference: - 0.66; 95% confidence intervals (CI): - 0.92, - 0.40; P = 0.37; I 2 = 0%). Difference was also observed in IIEF at 9months favoring LL (mean difference: 7.43; CI: 1.86, 13.00; P = 0.16; I 2 = 50%). Although our study has demonstrated the superiority of LL in genitourinary function preservation, these results should be taken with consciousness due to significant heterogeneity between included studies, small sample size, and potential bias. More high-quality studies are needed. CRD4202121099 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021210998.

Urogenital dysfunction in patients after miniinvasive restorative low anterior resection with total mesorectal excision.

IntroductionOver the last decades outcomes for rectal cancer surgery have improved, with increasing survival rates. Nevertheless, functional disorders are still frequent.AimTo evaluate sexual and urinary outcomes of miniinvasive total mesorectal excision (TME).Material and methodsBetween March 2016 and June 2018 patients with rectal cancer who underwent miniinvasive TME with a sphincter-saving procedure were enrolled. The questionnaires were completed before therapy, and 6, 12, and 24 months after stoma closure. We used the Female Sexual Function Index (FSFI), the International Prostate Symptom Score (IPSS) and the International Index of Erectile Function questionnaire (IIEF).ResultsNinety-eight patients completed the questionnaires. Only patients who underwent laparoscopic (39) or robotic TME (27) were enrolled. The characteristics and surgical outcomes did not differ significantly between these groups. The IPSS between the groups was comparable before and after the operation with no significant difference, increased at 6 months and then decreased consecutively. In comparison with baseline, IPSS was significantly lower in the laparoscopic and robotic groups at 6 months and was comparable to baseline at 24 months in both groups. Oppositely, the IIEF was significantly lower at 6 months after ileostomy closure in the robotic group (p < 0.05), but not in the laparoscopic group (p = 0.59) and both returned to baseline at 24 months. FSFI was significantly lower in the laparoscopic group (p = 0.017) 6 months after surgery and returned to baseline at 24 months in both groups.ConclusionsLaparoscopic and robotic TME showed similar functional results 2 years after stoma resection.

Risk factors of low anterior resection syndrome after miniinvasive restorative rectal resection.

Over the last decades outcomes for rectal cancer surgery have improved with increasing survival and lower recurrence rates. Nevertheless, functional disorders are still frequent. Low anterior resection with total mesorectal excision (TME) in patients with rectal cancer has improved oncological outcomes. However, most of them will have significant changes in quality of life, including varying degree of bowel dysfunction. Aim of this study was to analyse prevalence of LARS (low anterior resection syndrome) in patients with rectal cancer after miniinvasive restorative resection and to define its risk factors. Between March 2016 and June 2018, patients who underwent elective miniinvasive (laparoscopic or robotic) rectal resection were enrolled. Bowel dysfunction was evaluated by LARS questionnaire and filled out 6, 12, and 24 months after primary operation or after ileostomy closure. 98 patients completed the questionnaires - 58 laparoscopic operations, 34 robotic and 6 open procedures. 69 patients underwent TME, tumor-specific mesorectal excision 21 patients. 8 patients underwent transanal TME. The clinical characteristics, surgical perioperative and postoperative outcomes did not differ between these groups. Only, significantly more patients underwent neoadjuvant radiotherapy in the robotic group (p=0.004). 59.8% patients reported major LARS 6 months after surgery and 29.7% after 24 months. Protentional risk factors are age (p.

Systematic Review and Meta-analysis of Randomized Controlled Trials Evaluating the Effect of the Level of Ligation of Inferior Mesenteric Artery on Functional Outcomes in Rectal Cancer Surgery

Systematic Review and Meta-analysis of Randomized Controlled Trials Evaluating the Effect of the Level of Ligation of Inferior Mesenteric Artery on Functional Outcomes in Rectal Cancer Surgery

Improving postoperative outcome in rectal cancer surgery: Enhanced Recovery After Surgery in an era of increasing laparoscopic resection.

The Enhanced Recovery After Surgery (ERAS) protocol reduces complications and length of stay (LOS) in colon cancer, but implementation in rectal cancer is different because of neo-adjuvant therapy and surgical differences. Laparoscopic resection may further improve outcome. The aim of this study was to evaluate the effects of introducing ERAS on postoperative outcome after rectal cancer resection in an era of increasing laparoscopic resections. Patients who underwent elective rectal cancer surgery from 2009 till 2015 were included in this observational cohort study. In 2010, ERAS was introduced and adherence to the protocol was registered. Open and laparoscopic resections were compared. With regression analysis, predictive factors for postoperative outcome and LOS were identified. A total of 499 patients were included. The LOS decreased from 12.3days in 2009 to 5.7days in 2015 (p = 0.000). Surgical site infections were reduced from 24% in 2009 to 5% in 2015 (p = 0.013) and postoperative ileus from 39% in 2009 to 6% in 2015 (p = 0.000). Only postoperative ERAS items and laparoscopic surgery were associated with an improved postoperative outcome and shorter LOS. ERAS proved to be feasible, safe, and contributed to improving short-term outcome in rectal cancer resections. The benefits of laparoscopic surgery may in part be explained by reaching better ERAS adherence rates. However, the laparoscopic approach was also associated with anastomotic leakage. Despite the potential of bias, this study provides an insight in effects of ERAS and laparoscopic surgery in a non-randomized real-time setting.

AB014. SOH21AS002. Rectal cancer surgery: does low volume imply worse outcome?—a single surgeon experience

Background: Studies have shown that rectal cancer patients managed in high-volume centres may have improved outcomes. However, others suggest that individual surgeon caseload, specialisation and experience may be more significant in improving postoperative outcomes in rectal cancer surgery. As a low-volume, single surgeon study, we hypothesise that surgeon experience, rather than high hospital volume alone, may result in optimal surgical outcomes in rectal cancer surgery, in keeping with best international practice.

Risk factors for anastomotic leakage after laparoscopic low anterior resection: A single-center retrospective study.

Anastomotic leakage (AL) is a serious complication affecting short-term and long-term outcomes in rectal cancer surgery. While laparoscopic low anterior resection is a widespread procedure, the risk factors for AL are not well established. This study aimed to evaluate risk factors for AL after laparoscopic low anterior resection with double stapling technique (DST) anastomosis. We performed a retrospective cohort study of laparoscopic low anterior resection with DST anastomosis for rectal cancer between January 2010 and February 2019. Finally, a total of 1197 patients were eligible for the study. Twenty-five variables were collected for univariate and multivariate analyses. AL occurred in 49 patients (4.1%). In multivariate analysis, blood loss (≥70 mL) and no defunctioning stoma were independent risk factors (odds ratio [OR] 2.23; 95% confidence interval [CI] 1.08-4.34; P=.030 and OR 3.15; 95% CI 1.66-6.37; P=.0003, respectively). In addition, risk factors for AL were analyzed in 601 patients without defunctioning stoma. As a result, AL occurred in 36 patients (6.0%) and multivariate analysis demonstrated that blood loss (≥70 mL) and anastomotic level from anal verge (<5 cm) were independent risk factors (OR 3.11; 95% CI 1.24-7.44; P=.016 and OR 2.33; 95% CI 1.14-4.69; P=.020, respectively). Laparoscopic low anterior resection is feasible and safe with a low AL rate. Important factors associated with AL were blood loss and defunctioning stoma. Without defunctioning stoma, blood loss and distal anastomosis are also important factors.

Sacrococcygeal dimensions and curvature are associated with resection quality in rectal cancer excision.

Technical factors affect oncologic outcomes in rectal cancer surgery. The anatomy of the bony pelvis can affect technical aspects of surgery, but is seldom considered preoperatively. We performed a morphometric analysis of the bony pelvis in patients having rectal cancer resection to assess its effect on surgical specimen quality. We performed a retrospective analysis of a prospectively maintained database of patients who had resection for rectal cancer from January 2014 to December 2017. Preoperative magnetic resonance imaging (MRI) and computed tomography (CT) images were accessed and measurements of sacrococcygeal distance, sacrococcygeal recess depth/area, sacrococcygeal angulation, anteroposterior pelvic inlet/outlet, pubic height and interspinous distance were made. Outcome measures included anatomical variation, operating time and mesorectal specimen grade. In patients having extra-levator abdominoperineal excision (eLAPE) with coccygectomy, the completeness of coccygeal resection was assessed by postoperative CT scan. Data were analysed using binomial and multinomial logistic regression and linear regression. One hundred and twenty-two consecutive rectal cancer resections were performed (39 open, 42 laparoscopic, 12 laparoscopic-converted and 29 robotic). The median age was 72years (range: 29-88years). The male:female ratio was 83:39. Eighty-one patients had anterior resection, 8 had low Hartmann's resection and 32 had APE. Of those who had APE, 21 had eLAPE (all with coccygectomy). Females had a larger pelvic inlet (female: 124.9mm, male: 114.9mm), interspinous diameter(female:112.8mm, male:97.6mm), sacrococcygeal depth (female:42.6mm, 39.35mm) and sacrococcygeal area recess than males (female: 3697mm2, male: 3481.5mm2). Males had a greater pubic height (female: 51.8mm, male: 54.05mm) and greater sacrococcygeal distance (female: 116.7mm, male: 123.65mm) than females. In patients having anterior resection, tumour distance from the anal verge (p = 0.004), sacrococcygeal distance (p = 0.006) and sacrococcygeal curvature (p = 0.002) were associated with specimen quality. In patients who had eLAPE, median preoperative coccygeal length was 41mm (IQR: 35.1-45.5). The median length of coccygeal resection was 9mm (IQR: 1-17.45mm). The median length of coccyx remaining postoperatively was 33mm (IQR: 21.35-39mm). Sacrococcygeal curvature and distance as well as tumour distance from the anal margin were associated with specimen quality in anterior resection. Coccygectomy was not performed as completely as surgeons thought. Surgeons should include sacrococcygeal bony anatomy in rectal cancer surgical planning to potentially improve outcomes in both anterior resection and eLAPE approaches.

Total Mesorectal Excision Technique-Past, Present, and Future.

While the treatment of rectal cancer is multimodal, above all, a proper oncological resection is critical. The surgical management of rectal cancer has substantially evolved over the past 100 years, and continues to progress as we seek the best treatment. Rectal cancer was historically an unsurvivable disease, with poor understanding of the embryological planes, lymphatic drainage, and lack of standardized technique. Major improvements in recurrence, survival, and quality of life have resulted from advances in preoperative staging, pathologic assessment, the development and timing of multimodal therapies, and surgical technique. The most significant contribution in advancing rectal cancer care may be the standardization and widespread implementation of total mesorectal excision (TME). The TME, popularized by Professor Heald in the early 1980s as a sharp, meticulous dissection of the tumor and mesorectum with all associated lymph nodes through the avascular embryologic plane, has shown universal reproducible reductions in local recurrence and improvement in disease-free and overall survival. Widespread education and training of surgeons worldwide in the TME have significantly impact outcomes for rectal cancer surgery, and the procedure has become the gold standard for curative resection of rectal cancer. In this article, we discuss the evolution of the standard abdominal approach to the TME, with emphasis on the history, relevant anatomy, standard procedure steps, oncologic outcomes, and technical evolution.

Oncological Impact of High Vascular Tie After Surgery for Rectal Cancer: A Nationwide Cohort Study.

The purpose of this study was to investigate the impact of tie level on oncological outcomes in rectal cancer surgery. Theoretically, a high tie of the inferior mesenteric artery could facilitate removal of apical node metastases and improve tumor staging accuracy. However, no appropriately sized randomized controlled trial exists and results from observational studies are not consistent. All stage I-III rectal cancer patients who underwent abdominal surgery with curative intention in 2007 to 2014 were identified and followed, using the Swedish Colorectal Cancer Registry. Primary outcome was cancer-specific survival, whereas overall and relative survival, locoregional and distant recurrence, and lymph node harvest were secondary outcomes, with high tie as exposure. We used propensity score matching to emulate a randomized controlled trial, and then performed Cox regression analyses to estimate hazard ratios (HRs) with confidence intervals (CIs). Some 8287 patients remained for analysis, of which 37% had high tie surgery. After propensity score matching, the 5-year cancer-specific survival rate was overall 86% and we found no association between the level of tie and cancer-specific (HR 0.92, 95% CI 0.79-1.07) or overall (HR 0.98, 95% CI 0.89-1.08) survival, nor to locoregional (HR 0.85, 95% CI 0.59-1.23) or distant (HR 1.01, 95% CI 0.88-1.15) recurrence, nor to relative survival (HR 1.05, 95% CI 0.85-1.28). Stratification and sensitivity analyses were similarly insignificant, after adjustment for confounding. Total lymph node harvest was, however, increased after high tie surgery (P < 0.01), but no differences were seen regarding positive nodes (P = 0.72). In this nationwide cohort study, the level of tie did not influence any patient-oriented oncological outcome, neither overall nor in node-positive patients. This would allow the patient's anatomical configuration and the surgeon's preferences to determine the level of tie.

Association Between Hospital and Surgeon Volume and Rectal Cancer Surgery Outcomes in Patients With Rectal Cancer Treated Since 2000: Systematic Literature Review and Meta-analysis

Previous reviews and meta-analyses, which predominantly focused on patients treated before 2000, have reported conflicting evidence about the association between hospital/surgeon volume and rectal cancer outcomes. Given advances in rectal cancer resection, such as total mesorectal excision, it is essential to determine whether volume plays a role in rectal cancer outcomes among patients treated since 2000. The purpose of this study was to determine whether there is an association between hospital/surgeon volume and rectal cancer surgery outcomes among patients treated since 2000. We searched PubMed and EMBASE for articles published between January 2000 and December 29, 2017. Articles that analyzed the association between hospital/surgeon volume and rectal cancer outcomes were selected. Rectal cancer resection was the study intervention. The outcome measures of this study were surgical morbidity, postoperative mortality, surgical margin positivity, permanent colostomy rates, recurrence, and overall survival. Although 2845 articles were retrieved and assessed by the search strategy, 21 met the inclusion and exclusion criteria. There was a significant protective association between higher hospital volume and surgical morbidity (OR = 0.80 (95% CI, 0.70-0.93); I = 35%), permanent colostomy (OR = 0.51 (95% CI, 0.29-0.92); I = 34%), and postoperative mortality (OR = 0.62 (95% CI, 0.43-0.88); I = 34%), and overall survival (OR = 0.99 (95% CI, 0.98-1.00); I = 3%). Stratified analysis showed that the magnitude of association between hospital volume and rectal cancer surgery outcomes was stronger in the United States compared with other countries. Surgeon volume was not significantly associated with overall survival. The articles included in this analysis were high quality according to the Newcastle-Ottawa scale. Funnel plots suggested that the potential for publication bias was low. Some articles included rectosigmoid cancers. Among patients diagnosed since 2000, higher hospital volume has had a significant protective effect on rectal cancer surgery outcomes.

Survival following rectal cancer surgery: does the age matter?

Introduction: Information regarding rectal cancer surgery outcomes and survival benefits in the elderly is sparse. Radical rectal surgery can be associated with substantial morbidity and mortality. We investigated age-specific survival for patients undergoing radical rectal surgery to determine outcomes in elderly patientsMethods: Over a 10-year period data on all patients who underwent rectal cancer surgery was performed. Patients were grouped according to age and eight other variables including cancer stage (Duke’s/TNM). Data analysed using computer program R. Kaplan–Meier survival curves estimated for age groups and compared using a modified log-rank permutation test. Survival curves fitted using Cox proportional hazard models and hazard ratios obtainedResults: About 374 patients underwent surgery. Survival percentages at 1 year by age group are 91.3% for age <50, and 75.5% for age >80. At 5 years these are 87.0% for age <50 and 57.1% for >80. Overall the variation among the survival curves for the age groups is significant (p < .001). The hazard ratio for over the 80+ with the age group <50 as the reference is 4.79 (95% CI: 1.44–15.92) and is significant (p = .011)Conclusion: Overall survival is significantly less in the elderly. There is a striking reduction in survival in >80 year olds in the first post-operative year. This study highlights that care must be taken in deciding whether radical surgery should be offered to those patients and careful consideration is given to allow the best overall survival and quality of life.

Robotic-assisted surgery for rectal cancer: Current state and future perspective.

Interest in minimally invasive surgery has increased in recent decades. Robotic‐assisted laparoscopic surgery (RALS) was introduced as the latest advance in minimally invasive surgery. RALS has the potential to provide better clinical outcomes in rectal cancer surgery, allowing for precise dissection in the narrow pelvic space. In addition, RALS represents an important advancement in surgical education with respect to use of the dual‐console robotic surgery system. Because the public health insurance systems in Japan have covered the cost of RALS for rectal cancer since April 2018, RALS has been attracting increasingly more attention. Although no overall robust evidence has yet shown that RALS is superior to laparoscopic or open surgery, the current evidence supports the notion that technically demanding subgroups (patients with obesity, male patients, and patients treated by extended procedures) may benefit from RALS. Technological innovation is a constantly evolving field. Several companies have been developing new robotic systems that incorporate new technology. This competition among companies in the development of such systems is anticipated to lead to further improvements in patient outcomes as well as drive down the cost of RALS, which is one main concern of this new technique.