Positive Circumferential Resection Margin Research Articles

Outcomes of robotic low anterior resection versus transanal total mesorectal excision for rectal cancer.

BackgroundThe quality of total mesorectal excision (TME) is regarded as a fundamental key to the oncological outcome of rectal cancer. Robotic low anterior resection (RLAR) and transanal TME (TaTME) were developed to overcome the technical challenges of conventional open TME. This study aimed to compare the short- and long-term outcomes of RLAR versus TaTME for rectal cancer.MethodsRetrospective data from patients undergoing RLAR or TaTME at a colorectal unit in Singapore were analysed. The primary outcomes were the short-term clinical and pathological results including specimen margins and quality of TME. Secondary outcomes were recurrence, disease-free survival (DFS), and overall survival rates.ResultsA total of 80 patients who underwent either RLAR or TaTME were analysed. The TaTME group had a shorter operating time than the RLAR group (354 versus 481 min respectively; P < 0.001) and fewer stays in the high-dependency and intensive care units (38.1 versus 73.7 per cent; P = 0.010). There was a higher rate of readmissions at 30 days in the TaTME group (19.0 versus 0 per cent; P = 0.006). Specimens from TaTME had greater proximal (14.0 versus 10.0 cm; P = 0.045) and distal (2.50 versus 1.65 cm; P = 0.021) margins. Patients undergoing TaTME had borderline longer DFS (25.9 versus 15.7 months; P = 0.049). Subgroup analysis of patients with (y)pT3–4 tumours showed fewer positive circumferential resection margins with TaTME (0 versus 18.2 per cent; P = 0.019) and improved DFS (25.9 versus 15.7 months; P = 0.017).ConclusionSuperior margins were obtained with TaTME, especially in locally advanced tumours, although TaTME was associated with a higher readmission rate compared with RLAR.

Laparoscopic versus open resection in locally advanced rectal cancers: a propensity matched analysis of oncological and short-term outcomes.

The aim was to compare oncological and short-term outcomes between open and laparoscopic surgery in locally advanced rectal cancers. It is a retrospective analysis conducted in a high volume tertiary centre. Matching was carried out for nine variables, including preoperative factors, neoadjuvant treatment and sphincter preservation. Both the open and laparoscopic surgery arms had 239 patients each. The distributions of pretreatment MRI T3, T4, circumferential resection margin (CRM) positive tumours, neoadjuvant long-course chemoradiation and sphincter preservation were 80.3%, 13.6%, 50%, 89% and 56.4% respectively. The mean number of nodes harvested (12.9 vs. 12.7, P=0.716), pathological CRM positivity (6.3% in open vs. 5.4% in laparoscopic, P=0.697) and distal resection margins were similar. The mean blood loss was higher in open surgeries (910ml vs. 349ml, P<0.001). Anastomotic leaks and Clavien-Dindo Grade 3-4 complications were higher in the open arm than in the laparoscopy arm (5.9% vs. 1.7%, P=0.024, and 12.5% vs. 6.7%, P=0.015 respectively). The median postoperative hospital stay was significantly shorter in the laparoscopy arm (7 vs. 6, P=0.015). In CRM positive and threatened cases, the measured outcomes were similar between the two groups except for blood loss which was significantly higher in the open surgery (872 vs. 379, P=0.000). In high volume centres, in the hands of experienced colorectal surgeons, laparoscopic rectal surgery is oncologically safe in locally advanced rectal cancers and has lesser morbidity and shorter hospital stay than open surgery. In CRM positive and threatened cases the laparoscopic surgery showed less blood loss compared to open surgery, while other outcome measures were similar to open surgery.

Total Neoadjuvant Therapy Versus Standard Neoadjuvant Chemoradiation in Patients with Locally Advanced Rectal Cancer: A Comparison of Short- and Long-term Oncologic Outcomes.

To evaluate the impact of neoadjuvant multi-agent systemic chemotherapy and radiation (TNT) vs neoadjuvant single-agent chemoradiation (nCRT) and multi-agent adjuvant chemotherapy on overall survival (OS), tumor downstaging, and circumferential resection margin (CRM) status in patients with locally advanced rectal cancer. Outside of clinical trials and small institutional reports, there is a paucity of data regarding the short and long-term oncologic impact of TNT as compared to nCRT. Adult patients with stage II-III rectal adenocarcinoma were identified in the National Cancer Database [2006-2015]. Out of 8,548 patients, 36% received TNT and 64% nCRT. In the cohort, 13% had a pCR and 20% a neoadjuvant rectal (NAR) score <8. In multivariable analysis, as compared to nCRT, TNT demonstrated numerically higher pCR rates ( P = 0.05) but had similar incidence of positive CRM ( P = 0.11). Similar results were observed with NAR scores <8 as the primary endpoint. After adjusting for confounders, OS was comparable between the 2 groups. Additional factors independently associated with lower OS included male gender, uninsured status, low income status, high comorbidity score, poorly differentiated tumors, abdominoperineal resection, and positive surgical margins (all P <0.01). In separate models, both pCR and a NAR score <8 were associated with improved OS. In this national cohort, TNT was not associated with better survival and/or CRM negative status in comparison with nCRT, despite numerically higher downstaging rates. Further refinement of patient selection and treatment regimens are needed to establish effective neoadjuvant platforms to improve outcomes of patients with rectal cancer.

Hospital variation in sphincter-preservation rates in rectal cancer treatment: results of a population-based study in the Netherlands.

BackgroundThis study aimed to examine the sphincter-preservation rate variations in rectal cancer surgery. The influence of hospital volume on sphincter-preservation rates and short-term outcomes (anastomotic leakage (AL), positive circumferential resection margin (CRM), 30- and 90-day mortality rates) were also analysed.MethodsNon-metastasized rectal cancer patients treated between 2009 and 2016 were selected from the Netherlands Cancer Registry. Surgical procedures were divided into sphincter-preserving surgery and an end colostomy group. Multivariable logistic regression models were generated to estimate the probability of undergoing sphincter-preserving surgery according to the hospital of surgery and tumour height (low, 5 cm or less, mid, more than 5 cm to 10 cm, and high, more than 10 cm). The influence of annual hospital volume (less than 20, 20–39, more than 40 resections) on sphincter-preservation rate and short-term outcomes was also examined.ResultsA total of 20 959 patients were included (11 611 sphincter preservation and 8079 end colostomy) and the observed median sphincter-preservation rate in low, mid and high rectal cancer was 29.3, 75.6 and 87.9 per cent respectively. After case-mix adjustment, hospital of surgery was a significant factor for patients’ likelihood for sphincter preservation in all three subgroups (P < 0.001). In mid rectal cancer, borderline higher rates of sphincter preservation were associated with low-volume hospitals (odds ratio 1.20, 95 per cent c.i. 1.01 to 1.43). No significant association between annual hospital volume and sphincter-preservation rate in low and high rectal cancer nor short-term outcomes (AL, positive CRM rate and 30- and 90-day mortality rates) was identified.ConclusionThis population-based study showed a significant hospital variation in sphincter-preservation rates in rectal surgery. The annual hospital volume, however, was not associated with sphincter-preservation rates in low, and high rectal cancer nor with other short-term outcomes.

TaTME: Present and Future Perspectives?

AbstractTransanal total mesorectal excision (TaTME) is a new procedure developed to overcome the specific difficulties posed by rectal surgery, especially in narrow pelvis, male, and obese patients, and can be used in benign and malignant pathologies. The advantages are especially important in rectal cancer, as they could potentially result in a more precise distal dissection, lower rate of positive circumferential resection margins, and increase the rate of sphincter-sparing procedures. The indications for TaTME are currently expanding, despite not yet being standardized. Training programs are increasing day by day, to improve the learning curve related to this difficult technique. The procedure is feasible and safe with similar intraoperative complications and readmission rates compared with open/laparoscopic approach. Oncological results have shown that TaTME is associated with better quality mesorectal excision and safer distal resection margin. In this work, we review the evolution of TaTME, surgical technique, development, applicability, current situation, and implementation, as well as future perspectives for colorectal cancer and other pathologies. While satisfactory short-term results have been reported, it is a new technique, and long-term results and definitive results from controlled trials are pending. As evidence of safety and feasibility accumulates, training programs structured to standardize teaching, training, and safe expansion will aid the safe spread of TaTME.

The effectiveness of double team for transanal total mesorectal excision in treatment of mid-low rectal cancer

IntroductionTransanal total mesorectal (TaTME) is an emerging surgical technique for mid-low rectal cancer. This study investigated the double-team TaTME on the short-term morbidity, quality of surgical specimens, and functional and oncologic outcomes by comparing them with the single-team TaTME. MethodsWe analyzed the surgical results of 72 patients (n = 40 double-team TaTME, n = 32 single-team TaTME) with mid-low rectal cancer who treated for mid-low rectal cancer with single-team TaTME or double-team TaTME. ResultsThe operative time was significantly shorter with a double-team TaTME (180 ± 45 min) than with a single-team TaTME (230 ± 55 min). Also, there were no intraoperative events recorded in both groups. The rate of pre-sacral abscesses complications (grade III) in the double-team (0%) was significantly lower than in the single-team group (3, 9.4%). The proportions of TME grade I, TME grade II, and TME grade III were not significantly different between the single-team and double-team groups. A positive circumferential resection margin (CRM) was not significantly different between the double-team groups (2, 5.0%) and the single-team (3, 9.3%). The mean low anterior resection syndrome (LARS) scores were lower in the double-team group (27 ± 4.5) than in the single-team group (29 ± 3.8) (p = 0.048). Simultaneously, the disease-free survival (DFS) rate was not significantly different between the two groups. ConclusionThe double-team TaTME in treatment of mid-low rectal cancer is effective with the shortness of operative time, the lower rate of the postoperative pre-sacral abscess, and LARS scores, while this method guaranteed the quality of mesorectal specimens and the DFS rate.

Understanding the Anatomy of the Denonvilliers Fascia: Review Article

AbstractThe postoperative outcome of rectal cancer has been improved after the introduction of the principles of total mesorectal excision (TME). Total mesorectal excision includes resection of the diseased rectum and mesorectum with non-violated mesorectal fascia (en bloc resection). Dissection along the mesorectal fascia through the principle of the “holy plane” minimizes injury of the autonomic nerves and increases the chance of preserving them. It is important to stick to the TME principle to avoid perforating the tumor; violating the mesorectal fascia, thus resulting in positive circumferential resection margin (CRM); or causing injury to the autonomic nerves, especially if the tumor is located anteriorly. Therefore, identifying the anterior plane of dissection during TME is important because it is related with the autonomic nerves (Denonvilliers fascia). Although there are many articles about the Denonvilliers fascia (DVF) or the anterior dissection plane, unfortunately, there is no consensus on its embryological origin, histology, and gross anatomy. In the present review article, I aim to delineate and describe the anatomy of the DVF in more details based on a review of the literature, in order to provide insight for colorectal surgeons to better understand this anatomical feature and to provide the best care to their patients.

Circulating tumor DNA and circumferential resection margin as key prognostic indicators for survival in rectal cancer.

3579 Background: Recurrence of colorectal cancer has been linked to the presence of epigenetic circulating tumour DNA (ctDNA) in patient plasma after surgery. The prognostic significance of ctDNA prior to treatment remains unknown. This study investigated the correlation between pre-treatment ctDNA and current radiological (MRI) prognostic markers in patients with rectal cancer. Methods: Forty-two patients with rectal cancer were enrolled, with all having staging MRI prior to treatment. Plasma was taken for ctDNA at diagnosis. The presence of either methylated branched-chain amino acid transaminase 1 (BCAT1) or Ikaros family zinc finger (IKZF1) in cell-free DNA from plasma was deemed a positive ctDNA result. Correlation of MRI prognostic indicators and ctDNA results was assessed with chi-square tests. Univariable and multivariable cox regression analyses were performed to determine variables associated with overall survival (OS). Results: Mean age was 64.4 years (SD 12.5) and majority were male (30/42, 71.4%). 11, 13, 9 &amp; 9 patients had stages I, II, III, IV respectively. Patients had a minimum follow-up of 36 months. Thirty-three (78.6%) patients received neoadjuvant chemoradiotherapy. 29 (69.0%) patients underwent surgical resection. 3-year survival rate was 64% in the overall group. 67% (n=28/42) of patients were positive for the methylated ctDNA at diagnosis. 11 out of 12 patients with a positive circumferential resection margin (CRM +) were ctDNA positive (p=0.03). Univariable analysis showed that prognostic indicators for OS were presence of extramural venous invasion (EMVI) (HR 3.0, 95% CI 1.1-8.4), CRM+ (HR 12.2, 95%CI 3.9-37.6), metastatic disease (HR 7.32, 95% CI 2.63-20.37) and ctDNA% methylation (HR 1.1, 95% CI 1.04-1.13) (Table 1). The presence of CRM+ and a positive ctDNA had a HR of 20.5 (95% CI 5.1-82.3). With multivariable analysis, including adjustment for age and EMVI, only CRM+/ctDNA+ variable was an independent predictor for poor survival (HR 20.2, 95% CI 4.5-90.9). Conclusions: In rectal cancer, almost all patients with CRM involvement have ctDNA, and these patients had the worst prognosis. Future studies with longitudinal ctDNA assessment pre and post treatment could potentially inform prognosis and help tailor patients’ treatment.[Table: see text]

Prognosis Comparisons of Laparoscopy versus Open Surgery for Rectal Cancer Patients after Preoperative Chemoradiotherapy: A Meta-Analysis

Aim: We aimed to compare the oncological outcomes of laparoscopy and open resection for patients with rectal cancer following neoadjuvant chemoradiotherapy (NCRT). Methods: We searched the publications that compared the efficacy of laparoscopic surgery and open thoracotomy in treatment outcomes of rectal cancer after NCRT. All trials analyzed the summary hazard ratios of the endpoints of interest, including survival and individual postoperative complications. Results: Totally, 10 trials met our inclusion criteria. The pooled analysis of 3-year disease-free survival (OR 1.39, 95% CI 0.93–2.06; p = 0.11) and 3-year overall survival (OR 1.01, 95% CI 0.70–1.45; p = 0.97) showed that laparoscopic surgery did not achieve beneficial effects compared with open thoracotomy. The pooled result of duration of surgery indicated that laparoscopic surgery was associated with a trend for longer surgery time (SMD 27.53, 95% CI 1.34–53.72; p = 0.04), shorter hospital stay (SMD –1.64, 95% CI –2.70 to –0.58; p = 0.002), more postoperative complications (OR 0.77, 95% CI 0.60–0.99; p = 0.04), and decreased blood loss (SMD –49.87, 95% CI –80.61 to –19.14; p = 0.001). However, the number of removed lymph nodes, positive circumferential resection margin, as well as complications after surgery showed significant differences between the 2 groups. Conclusions: We focused on current evidence and reviewed the studies indicating that similar oncological outcomes were associated with laparoscopic surgery following NCRT for patients with locally advanced lower rectal cancer in comparison with open surgery.

Predictors of Positive Circumferential Resection Margin in Rectal Cancer: A Current Audit of the National Cancer Database.

Positive circumferential resection margin is a predictor of local recurrence and worse survival in rectal cancer. National programs aimed to improve rectal cancer outcomes were first created in 2011 and continue to evolve. The impact on circumferential resection margin during this time frame has not been fully evaluated in the United States. The purpose of this study was to determine the incidence and predictors of positive circumferential resection margin after rectal cancer resection, across patient, provider, and tumor characteristics. This was a retrospective cohort study. The study was conducted using the National Cancer Database, 2011-2016. Adults who underwent proctectomy for pathologic stage I to III rectal adenocarcinoma were included. Rate and predictors of positive circumferential resection margin, defined as resection margin ≤1 mm, were measured. Of 52,620 cases, circumferential resection margin status was reported in 90% (n = 47,331) and positive in 18.4% (n = 8719). Unadjusted analysis showed that patients with positive circumferential resection margin were more often men, had public insurance and shorter travel, underwent total proctectomy via open and robotic approaches, and were treated in Southern and Western regions at integrated cancer networks (all p < 0.001). Multivariate analysis noted that positive proximal and/or distal margin on resected specimen had the strongest association with positive circumferential resection margin (OR = 15.6 (95% CI, 13.6-18.1); p < 0.001). Perineural invasion, total proctectomy, robotic approach, neoadjuvant chemoradiation, integrated cancer network, advanced tumor size and grade, and Black race had increased risk of positive circumferential resection margin (all p < 0.050). Laparoscopic approach, surgery in North, South, and Midwest regions, greater hospital volume and travel distance, lower T-stage, and higher income were associated with decreased risk (all p < 0.028). This was a retrospective cohort study with limited variables available for analysis. Despite creation of national initiatives, positive circumferential resection margin rate remains an alarming 18.4%. The persistently high rate with predictors of positive circumferential resection margin identified calls for additional education, targeted quality improvement assessments, and publicized auditing to improve rectal cancer care in the United States. See Video Abstract at http://links.lww.com/DCR/B584. ANTECEDENTES:El margen positivo de resección circunferencial es un predictor de recurrencia local y peor sobrevida en el cáncer de recto. Los programas nacionales destinados a mejorar los resultados del cáncer de recto se crearon por primera vez en 2011 y continúan evolucionando. La repercusión del margen de resección circunferencial durante este período de tiempo no se ha evaluado completamente en los Estados Unidos.OBJETIVO:Determinar la incidencia y los predictores para un margen positivo de resección circunferencial posterior a la resección del cáncer de recto, según las características del paciente, el proveedor y el tumor.DISEÑO:Estudio de cohorte retrospectivo.AMBITO:Base de datos nacional de cáncer, 2011-2016.PACIENTES:Adultos que se sometieron a proctectomía por adenocarcinoma de recto con un estadío por patología I-III.PRINCIPALES VARIABLES EVALUADAS:Tasa y predictores para un margen positivo de resección circunferencial, definido como margen de resección ≤ 1 mm.RESULTADOS:De 52,620 casos, la condición del margen de resección circunferencial se informó en el 90% (n = 47,331) y positivo en el 18.4% (n = 8,719). El análisis no ajustado mostró que los pacientes con margen positivo de resección circunferencial se presentó con mayor frecuencia en hombres, tenían un seguro social y viajes más cortos, se operaron de proctectomía total abierta y robótica, y fueron tratados en las regiones del sur y el oeste en redes integradas de cáncer (todos p <0,001). El análisis multivariado destacó que el margen proximal y / o distal positivo de la pieza resecada tenía la asociación más fuerte con el margen postivo de resección circunferencial (OR 15,6; IC del 95%: 13,6-18,1, p <0,001). La invasión perineural, la proctectomía total, el abordaje robótico, la quimioradioterapia neoadyuvante, la red de cáncer integrada, el tamaño y grado del tumor avanzado y la raza afroamericana tenían un mayor riesgo de un margen de una resección positiva circunferencial (todos p <0,050). El abordaje laparoscópico, la cirugía en las regiones Norte, Sur y Medio Oeste, un mayor volumen hospitalario y distancia de viaje, estadio T más bajo y mayores ingresos se asociaron con una disminución del riesgo (todos p <0,028).LIMITACIONES:Estudio de cohorte retrospectivo con variables limitadas disponibles para análisis.CONCLUSIONES:A pesar del establecimiento de iniciativas nacionales, la tasa de margen positivo de resección circunferencial continúa siendo alarmante, 18,4%. El índice continuamente elevado junto a los predictores de un margen positivo de resección circunferencial hace un llamado para una mayor educación, evaluaciones específicas de mejora de la calidad y difusión de las auditorías para mejorar la atención del cáncer de recto en los Estados Unidos. Vea el resumen de video en http://links.lww.com/DCR/B584. Consulte Video Resumen en http://links.lww.com/DCR/B584.

The importance of radiotherapy in rectal cancer-an update from a surgeon's perspective

Neoadjuvant chemoradiotherapy was implemented in the treatment of rectal cancer for UICC stagesII andIII in 2004. Recent studies have provided new insights with respect to the indications and sequence of radiotherapy in the concept of multimodal treatment. The aim of the study was to review the status of radiotherapy in the context of current developments in the treatment of rectal cancer, such as magnetic resonance imaging (MRI)-based surgery, total neoadjuvant therapy and the watch and wait strategy for complete clinical remission. The indications for neoadjuvant radiotherapy based on the clinical T and Nstages are not exact and can lead to overtreatment in 18-27% of cases. Radiotherapy is associated with a worsening of anorectal and urogenital functions. Local recurrence rates of 3% with surgery alone can be achieved in patients with negative circumferential resection margins (low risk cancer) in MRI. For rectal cancer with high-risk features, such as cT4 tumor, positive circumferential resection margins and extramural vascular invasion, an improved disease-free survival and alower rate of distant metastases could be achieved with total neoadjuvant therapy compared to standard neoadjuvant chemoradiotherapy in recent phaseIII randomized trials. Pathological complete remission is achieved in28% of patients after total neoadjuvant therapy. The high rate of complete remission has fired the debate regarding watch and wait after total neoadjuvant therapy; however, no prospective randomized phase III trials comparing total mesorectal resection vs. watch and wait in complete clinical remission have been published. Hence, resection remains the gold standard in this scenario given the excellent long-term oncological results.

Real-world comparison of curative open, laparoscopic and robotic resections for sigmoid and rectal cancer–single center experience

There has been an increase in the utilization of robotic surgery in addition to traditional open or laparoscopic approaches. Aim of this study is to compare the short-term outcomes for open, laparoscopic, and robotic surgery for rectal and sigmoid cancer. One hundred and forty-seven patients (open n = 48, laparoscopic n = 49, robotic n = 50) undergoing curative resections by two surgeons between 2013 and 2020 were included. Data analyzed included patient demographics, tumor characteristics, length of stay, post-operative outcomes, and pathologic surrogates of oncologic results, including total mesorectal excision (TME) quality, circumferential resection margin (CRM) involvement and lymph node (LN) yield. Median age of population was 68years (IQR 59-73), majority (68%) were males. Median distance from anal verge in the robotic surgery group was 8cm, compared to 15 and 14.5cm in the open and laparoscopic groups, respectively, p = 0.029, (laparoscopic vs robotic, p = 0.005 and open vs robotic, p = 0.027). Proportion of patients who received neoadjuvant radiotherapy in robotic surgery group was higher, p = 0.04. In sub-group of tumors between 3 and 7cm from anal verge more patients in the robotic surgery group had sphincter preservation, p = 0.006. Length of stay, maximum C-reactive protein, and white blood cell rise favored minimally invasive approaches compared to open surgery. There were no differences in post-operative complications, lymph node yield or CRM positivity rate between the three groups. Robotic surgery approach is safe and allows sphincter preservation without compromising TME quality in rectal cancer surgery.

Does a high Mandard score really define a poor response to chemotherapy in oesophageal adenocarcinoma?

A high Mandard score implies a non-response to chemotherapy in oesophageal adenocarcinoma. However, some patients exhibit tumour volume reduction and a nodal response despite a high score. This study examines survival and recurrence patterns in these patients. Clinicopathological factors were analysed using multivariable Cox regression assessing time to death and recurrence. Computed tomography-estimated tumour volume change was examined in a subgroup of consecutive patients. Five hundred and fifty-five patients were included. Median survival was 55 months (Mandard 1-3) and 21 months (Mandard 4 and 5). In the Mandard 4 and 5 group (332 patients), comparison between complete nodal responders and persistent nodal disease showed improved survival (90 vs 18 months), recurrence rates (locoregional 14.75 vs 28.74%, systemic 24.59 vs 48.42%) and circumferential resection margin positivity (22.95 vs 68.11%). Complete nodal response independently predicted improved survival (hazard ratio 0.34 (0.16-0.74). Post-chemotherapy tumour volume reduction was greater in patients with a complete nodal response (-16.3 vs -7.7 cm3, p = 0.033) with no significant difference between Mandard groups. Patients with a complete nodal response to chemotherapy have significantly improved outcomes despite a poor Mandard score. High Mandard score does not correspond with a non-response to chemotherapy in all cases and patients with nodal downstaging may still benefit from adjuvant chemotherapy.

Difference in surgical outcomes of rectal cancer by study design: meta-analyses of randomized clinical trials, case-matched studies, and cohort studies.

BackgroundRCTs are considered the standard in surgical research, whereas case-matched studies and propensity score matching studies are conducted as an alternative option. Both study designs have been used to investigate the potential superiority of robotic surgery over laparoscopic surgery for rectal cancer. However, no conclusion has been reached regarding whether there are differences in findings according to study design. This study aimed to examine similarities and differences in findings relating to robotic surgery for rectal cancer by study design.MethodsA comprehensive literature search was conducted using PubMed, Scopus, and Cochrane CENTRAL to identify RCTs, case-matched studies, and cohort studies that compared robotic versus laparoscopic surgery for rectal cancer. Primary outcomes were incidence of postoperative overall complications, incidence of anastomotic leakage, and postoperative mortality. Meta-analyses were performed for each study design using a random-effects model.ResultsFifty-nine articles were identified and reviewed. No differences were observed in incidence of anastomotic leakage, mortality, rate of positive circumferential resection margins, conversion rate, and duration of operation by study design. With respect to the incidence of postoperative overall complications and duration of hospital stay, the superiority of robotic surgery was most evident in cohort studies (risk ratio (RR) 0.83, 95 per cent c.i. 0.74 to 0.92, P < 0.001; mean difference (MD) –1.11 (95 per cent c.i. –1.86 to –0.36) days, P = 0.004; respectively), and least evident in RCTs (RR 1.12, 0.91 to 1.38, P = 0.27; MD –0.28 (–1.44 to 0.88) days, P = 0.64; respectively).ConclusionResults of case-matched studies were often similar to those of RCTs in terms of outcomes of robotic surgery for rectal cancer. However, case-matched studies occasionally overestimated the effects of interventions compared with RCTs.

Implementation of robot-assisted total mesorectal excision by multiple surgeons in a large teaching hospital: Morbidity, long-term oncological and functional outcome.

Robot-assisted total mesorectal excision (TME) might offer benefits in less morbidity, better functional and long-term outcome over laparoscopic TME. All consecutive patients undergoing robot-assisted TME for rectal cancer during implementation between May 2015 and December 2019 performed by five surgeons in a single centre were included. Outcomes included local recurrence rate at 3years, conversion rate, circumferential resection margin (CRM) positivity rate, 30-day postoperative morbidity and outcomes of low anterior resection syndrome (LARS) questionnaires. In 105 robot-assisted TME, local recurrence rate at 3years was 7.4%, conversion to open surgery rate was 8.6%, CRM positivity rate was 5.7%, 73.3% had good quality specimen, postoperative morbidity rate was 47.6% and anastomotic leakage rate was 9.0%. Incidence of major LARS was 55.3%. results of this study described acceptable morbidity, functional and long-term outcome during implementation of robotic TME for rectal cancer by multiple surgeons in a single centre.

Neoadjuvant chemotherapy with modified FOLFOXIRI for locally advanced rectal cancer: A single center phase II trial.

69 Background: Chemoradiotherapy (CRT) remains the standard treatment choice for locally advanced rectal cancer (LARC). Neoadjuvant chemotherapy alone with doublet mFOLFOX6 (folinic acid, 5-fluorouracil, and oxaliplatin) seemed not to influence recurrence free survival with the advantage of less treatment-related complications. This phase II trial was designed to evaluate the efficacy and safety of neoadjuvant triplet chemotherapy with mFOLFOXIRI (folinic acid, 5-fluorouracil, oxaliplatin, and irinotecan) in patients with LARC (NCT03443661). Methods: Patients with LARC received up to 5 cycles of mFOLFOXIRI (irinotecan 150 mg/m2, oxaliplatin 85 mg/m2, leucovorin 200 mg/m2 were administered on Day 1, fluorouracil 2400 mg/m2 was administered as a continuous intravenous infusion for 48 hours on Day 1, and was repeated every 14 days). Magnetic resonance imaging (MRI) was performed to assess the baseline and post-chemotherapy TN stage. Radical resection was performed within 4–6 weeks of the last dose of chemotherapy if the tumor shrank or remained stable. Adjuvant chemotherapy with mFOLFOX6 or XELOX (oxaliplatin and capecitabine) was recommended. Postoperative radiation was planned for R1 resection, ypT4b, ypN2, and positive circumferential resection margin (CRM). The primary endpoint was the pathological complete response (pCR) rate. Results: Between December 2015 to March 2019, a total of 50 patients were enrolled. 48 (96%) of the patients were clinically node-positive, 28 (56.5%) were CRMnvolved, and 39 (78.4%) were extramural venous invasion (EMVI)-positive. The median cycle of neoadjuvant mFOLFOXIRI chemotherapy was 5 (range, 1–5). A total of 46/50 (92%) patients underwent total mesorectal excision (TME) surgery, all with R0 resection. The pCR rate was 4.3% (2/46). Twenty-three of 46 (50%) patients achieved pathological node-negative status. The proportion of pathologically positive CRM and EMVI were 2.2% and 34.7%, respectively (table). Adjuvant radiotherapy was given to 14/46 (30.4%) patients. The most common Grade 3 or more toxicities included neutrocytopenia (50%), leukopenia (14%), and diarrhea (12%) during neoadjuvant chemotherapy. Clinical meaningful surgical morbidities included pneumonia (n=1), pelvic infection (n=1), and anastomotic fistula (n=1). With a median follow-up time of 33 months (range, 14–73 months), local recurrences and distant metastases were confirmed in 3 (6.5%) and 8 (17.4%) cases, respectively. Conclusions: Neoadjuvant chemotherapy with mFOLFOXIRI yielded a significant down-staging effect with an ordinary pCR rate, and seemed effective in eliminating EMVI and transforming CRM-positive to CRM-negative status in patients with LARC. The preliminary survival results are promising. This regimen could serve as a potential alternative to CRT in selected patients with LARC. Clinical trial information: NCT03443661. [Table: see text]

Comparison of pathologic outcomes of robotic and open resections for rectal cancer: A systematic review and meta-analysis

ObjectiveThe application of robotic surgery for rectal cancer is increasing steadily. The purpose of this meta-analysis is to compare pathologic outcomes among patients with rectal cancer who underwent open rectal surgery (ORS) versus robotic rectal surgery (RRS).MethodsWe systematically searched the literature of EMBASE, PubMed, the Cochrane Library of randomized controlled trials (RCTs) and nonrandomized controlled trials (nRCTs) comparing ORS with RRS.ResultsFourteen nRCTs, including 2711 patients met the predetermined inclusion criteria and were included in the meta-analysis. Circumferential resection margin (CRM) positivity (OR: 0.58, 95% CI, 0.29 to 1.16, P = 0.13), number of harvested lymph nodes (WMD: −0.31, 95% CI, −2.16 to 1.53, P = 0.74), complete total mesorectal excision (TME) rates (OR: 0.93, 95% CI, 0.48 to 1.78, P = 0.83) and the length of distal resection margins (DRM) (WMD: −0.01, 95% CI, −0.26 to 0.25, P = 0.96) did not differ significantly between the RRS and ORS groups.ConclusionBased on the current evidence, robotic resection for rectal cancer provided equivalent pathological outcomes to ORS in terms of CRM positivity, number of harvested lymph nodes and complete TME rates and DRM.

Extralevator abdominoperineal excision for low rectal cancer: oncological outcome after five-year follow-up

ABSTRACT BACKGROUND: Extralevator abdominoperineal excision (ELAPE) is a surgical technique that is indicated for low rectal cancer where sphincter preservation is not possible. Compared to conventional abdominoperineal excision major advantages of ELAPE are the risk reduction of intraoperative bowel perforation and positive circumferential margin which lead to a better oncological outcome. The aim of this study was to present our results in ELAPE surgery METHODS: From February 2011 to February 2015, 40 patients underwent surgery for low rectal cancer at the Oncology Institute of Vojvodina. The collected data included sex, age, preoperative staging, neoadjuvant treatment, operative time, rate of intraoperative bowel perforation, rate of positive circumferential resection margins, histopathological analysis, postoperative mortality, tumour, node and metastasis (TNM) classification, local recurrence (LR) rate and presence of distant metastases RESULTS: Positive circumferential margin was found in three (7.5%) patients while eight (20%) patients had intraoperative bowel perforation. LR during follow-up was seen in seven (17.5%) patients, three of them had intraoperative bowel perforation and two patients had positive circumferential margin. The estimated five-year cumulative incidence of LR is 7%. Distant metastases occurred in 18 (45%) patients. The estimated five-year survival rate is 62% CONCLUSION: The study shows satisfactory five-year survival rates of 62% in a highly complex patient group treated by ELAPE procedure Keywords: rectal cancer, extralevator abdominoperineal excision, local recurrence, overall survival

Trans-anal total mesorectal excision in low rectal cancers: Preliminary oncological results of a comparative study.

The management of lower rectal cancers is a therapeutic challenge both from the oncological and functional viewpoints. The aim of this study is to assess the oncological results and postoperative morbidity after transanal total mesorectal excision (TaTME) for low rectal cancer. In this monocentric retrospective study, we compared the quality of carcinologic resection and the morbidity-mortality between a group of 20 patients undergoing TaTME and 21 patients treated by abdomino-perineal resection (APR) between 2016 to 2019. More patients had a positive circumferential resection margin (CRM) (≤1mm) in the APR group (47.6% vs. 5%; P<0.0036). The difference in the rates of grades I-II and III-IV complications (Clavien-Dindo classification) between the two groups was not statistically significant (50% vs. 57.1% and 5% vs. 9.5% in TaTME and APR, respectively; P=0.7579, P=1.00). The median follow-up was longer in the TaTME group (20 months vs. 11 months; P=0.58). The local recurrence rate did not differ between the two groups (5% vs. 4.8%; P=1.00) CONCLUSION: TaTME provides a reliable total mesorectal resection with an acceptable CRM. However, like any new technique, it requires experience and the learning curve is long.

High Rate of Positive Circumferential Resection Margin in Colon Cancer: A National Appraisal and Call for Action.

To identify rates of positive circumferential resection margin (CRM) for colon cancer surgery in the US. CRM is one of the most important determinants of local control in colorectal cancers. The extent to which CRM involvement exists after colon cancer surgery is unknown. Colon cancer cases with resection 2010 to 2015 were identified from the National Cancer Data Base. Adjusting for patient and tumor characteristics, comparisons were made between cases with CRM > 1 mm (negative margin) and those with margin involved with tumor or ≤ 1 mm (positive margin, CRM+). Hospital-level analysis was performed, examining observed-to-expected CRM+ rates. In total, 170,022 cases were identified: 150,291 CRM- and 19,731 CRM+ (11.6%). Pathologic T-category was the greatest predictor of CRM+, with higher rates in pT4(25.8%), pT4A(24.7%), and pT4B(31.5%) versus pT1(4.5%), pT2(6.3%) and pT3 (10.9%, P < 0.001). Within pT4 patients, predictors of CRM+ included signet-ring histology (38.1% vs 26.7% nonmucinous, and 26.9% mucinous adenocarcinoma, P < 0.001), removing < 12 lymph nodes (36.5% vs 26.1% >12, P < 0.001), community facilities (32.7%) versus academic/research (23.6%, P < 0.001), year (30.1% 2010 vs 22.6% 2015, P < 0.001), and hospital volume (24.5% highest quartile vs 32.7% lowest, P < 0.001). Across 1288 hospitals, observed-to-expected ratios for CRM+ ranged from 0 to 7.899; 429 facilities had higher than expected rates. Overall rate of CRM+ in US colon cancer cases is high. Variation exists across hospitals, with higher than expected rates in many facilities. Although biology is a major influencing factor, CRM+ rates represent an area for multidisciplinary improvement in quality of colon cancer care.