Laparoscopic rectal cancer surgery: Where do we stand?

Large comparative studies and multiple prospective randomized control trials (RCTs) have reported equivalence in short and long-term outcomes between the open and laparoscopic approaches for the surgical treatment of colon cancer which has heralded widespread acceptance for laparoscopic resection of colon cancer. In contrast, laparoscopic total mesorectal excision (TME) for the treatment of rectal cancer has been welcomed with significantly less enthusiasm. While it is likely that patients with rectal cancer will experience the same benefits of early recovery and decreased postoperative pain from the laparoscopic approach, whether the same oncologic clearance, specifically an adequate TME can be obtained is of concern. The aim of the current study is to review the current level of evidence in the literature on laparoscopic rectal cancer surgery with regard to short-term and long-term oncologic outcomes. The data from 8 RCTs, 3 metaanalyses, and 2 Cochrane Database of Systematic Reviews was reviewed. Current data suggests that laparoscopic rectal cancer resection may benefit patients with reduced blood loss, earlier return of bowel function, and shorter hospital length of stay. Concerns that laparoscopic rectal cancer surgery compromises short-term oncologic outcomes including number of lymph nodes retrieved and circumferential resection margin and jeopardizes long-term oncologic outcomes has not conclusively been refuted by the available literature. Laparoscopic rectal cancer resection is feasible but whether or not it compromises short-term or long-term results still needs to be further studied.

Colonic pouch confers better bowel function and similar postoperative outcomes compared to straight anastomosis for low rectal cancer

BACKGROUND With advancements in laparoscopic technology and the wide application of linear staplers,sphincter-saving procedures are increasingly performed for low rectal cancer.However,sphincter-saving procedures have led to the emergence of a unique clinical disorder termed anterior rectal resection syndrome.Colonic pouch anastomosis improves the quality of life of patients with rectal cancer>7 cm from the anal margin.But whether colonic pouch anastomosis can reduce the incidence of rectal resection syndrome in patients with low rectal cancer is unknown.AIM To compare postoperative and oncological outcomes and bowel function of straight and colonic pouch anal anastomoses after resection of low rectal cancer.METHODS We conducted a retrospective study of 72 patients with low rectal cancer who underwent sphincter-saving procedures with either straight or colonic pouch anastomoses.Functional evaluations were completed preoperatively and at 1,6,and 12 mo postoperatively.We also compared perioperative and oncological outcomes between two groups that had undergone low or ultralow anterior rectal resection.RESULTS There were no significant differences in mean operating time,blood loss,time to first passage of flatus and excrement,and duration of hospital stay between the colonic pouch and straight anastomosis groups.The incidence of anastomotic leakage following colonic pouch construction was lower(11.4%vs 16.2%)but not significantly different than that of straight anastomosis.Patients with colonic pouch construction had lower postoperative low anterior resection syndrome scores than the straight anastomosis group,suggesting better bowel function(preoperative:4.71 vs 3.89,P=0.43;1 mo after surgery:34.2 vs 34.7,P=0.59;6 mo after surgery:22.70 vs 29.0,P<0.05;12 mo after surgery:15.5 vs 19.5,P=0.01).The overall recurrence and metastasis rates were similar(4.3%and 11.4%,respectively).CONCLUSION Colonic pouch anastomosis is a safe and effective procedure for colorectal reconstruction after low and ultralow rectal resections.Moreover,colonic pouch construction may provide better functional outcomes compared to straight anastomosis.

Limited segmental rectal resection in the treatment of deeply infiltrating rectal endometriosis:10 years’experience from a tertiary referral unit

Background.The management of symptomatic rectal endometriosis is a challenging condition that may necessitate limited stripping or limited segmental anterior rectal resection(LSARR)depending upon the extent and severity of the disease.Objective.To report the efficacy of LSARR in terms of pain,quality of life and short-and long-term complications—in particular,those pertaining to bowel function.Methods.The case notes of all patients undergoing LSARR were reviewed.The analysed variables included surgical complications,overall symptomatic improvement rate,dysmenorrhoea,dyspareunia,and dyschezia.Chronic pain was measured using a visual analogue scale.Quality of life was measured using the EQ-5D questionnaire.Bowel symptoms were assessed using the Memorial Sloan Kettering Cancer Centre(MSKCC)questionnaire.Results.Seventy-four women who underwent LSARR by both open and laparoscopic approaches were included in this study.Sixty-nine(93.2%)women reported improvement in pain and the same percentage would recommend the similar procedure to a friend with the same problem.Approximately 42%of women who wished to conceive had at least one baby.The higher frequency of defecation was a problem in the early post-operative period but this settled in later stages without influencing the quality of life score.Post-operative complications were recorded in 14.9%of cases.Conclusions.LSARR for rectal endometriosis is associated with a high degree of symptomatic relief.Pain relief achieved following LSARR does not appear to degrade with time.As anticipated,some rectal symptoms persist in few patients after long-term follow-up but LSARR is nonetheless still associated with a very high degree of patient satisfaction.