BACKGROUND Rectal cancer ranks as the second leading cause of cancer-related mortality worldwide,necessitating surgical resection as the sole treatment option.Over the years,there has been a growing adoption of minima...BACKGROUND Rectal cancer ranks as the second leading cause of cancer-related mortality worldwide,necessitating surgical resection as the sole treatment option.Over the years,there has been a growing adoption of minimally invasive surgical techni-ques such as robotic and laparoscopic approaches.Robotic surgery represents an innovative modality that effectively addresses the limitations associated with traditional laparoscopic techniques.While previous studies have reported favo-rable perioperative outcomes for robot-assisted radical resection in rectal cancer patients,further evidence regarding its oncological safety is still warranted.AIM To conduct a comparative analysis of perioperative and oncological outcomes between robot-assisted and laparoscopic-assisted low anterior resection(LALAR)procedures.METHODS The clinical data of 125 patients who underwent robot-assisted low anterior resection(RALAR)and 279 patients who underwent LALAR resection at Shandong Provincial Hospital Affiliated to Shandong First Medical University from December 2019 to November 2022 were retrospectively analyzed.After performing a 1:1 propensity score matching,the patients were divided into two groups:The RALAR group and the LALAR group(111 cases in each group).Subsequently,a comparison was made between the short-term outcomes within 30 d after surgery and the 3-year survival outcomes of these two groups.RESULTS Compared to the LALAR group,the RALAR group exhibited a significantly earlier time to first flatus[2(2-2)d vs 3(3-3)d,P=0.000],as well as a shorter time to first fluid diet[4(3-4)d vs 5(4-6)d,P=0.001].Additionally,the RALAR group demonstrated reduced postoperative indwelling catheter time[2(1-3)d vs 4(3-5)d,P=0.000]and decreased length of hospital stay after surgery[5(5-7)d vs 7(6-8)d,P=0.009].Moreover,there was an observed increase in total cost of hospitalization for the RALAR group compared to the LALAR group[10777(10780-11850)dollars vs 10550(8766-11715)dollars,P=0.012].No significant differences were found in terms of conversion rate to laparotomy or incidence of postoperative complications between both groups.Furthermore,no significant disparities were noted regarding the 3-year overall survival rate and 3-year disease-free survival rate between both groups.CONCLUSION Robotic surgery offers potential advantages in terms of accelerated recovery of gastrointestinal and urologic function compared to LALAR resection,while maintaining similar perioperative and 3-year oncological outcomes.展开更多
BACKGROUND Low anterior resection syndrome(LARS)severely impairs patient postoperative quality of life,especially major LARS.However,there are few tools that can accurately predict major LARS in clinical practice.AIM ...BACKGROUND Low anterior resection syndrome(LARS)severely impairs patient postoperative quality of life,especially major LARS.However,there are few tools that can accurately predict major LARS in clinical practice.AIM To develop a machine learning model using preoperative and intraoperative factors for predicting major LARS following laparoscopic surgery of rectal cancer in Chinese populations.METHODS Clinical data and follow-up information of patients who received laparoscopic anterior resection for rectal cancer from two medical centers(one discovery cohort and one external validation cohort)were included in this retrospective study.For the discovery cohort,the machine learning prediction algorithms were developed and internally validated.In the external validation cohort,we evaluated the trained model using various performance metrics.Further,the clinical utility of the model was tested by decision curve analysis.RESULTS Overall,1651 patients were included in the present study.Anastomotic height,neoadjuvant therapy,diverting stoma,body mass index,clinical stage,specimen length,tumor size,and age were the risk factors associated with major LARS.They were used to construct the machine learning model to predict major LARS.The trained random forest(RF)model performed with an area under the curve of 0.852 and a sensitivity of 0.795(95%CI:0.681-0.877),a specificity of 0.758(95%CI:0.671-0.828),and Brier score of 0.166 in the external validation set.Compared to the previous preoperative LARS score model,the current model exhibited superior predictive performance in predicting major LARS in our cohort(accuracy of 0.772 for the RF model vs 0.355 for the preoperative LARS score model).CONCLUSION We developed and validated a robust tool for predicting major LARS.This model could potentially be used in the clinic to identify patients with a high risk of developing major LARS and then improve the quality of life.展开更多
BACKGROUND Low anterior resection syndrome(LARS)is one of the common postoperative complications in patients with rectal cancer,which seriously affects their postoperative recovery and quality of life(QoL).Electroacup...BACKGROUND Low anterior resection syndrome(LARS)is one of the common postoperative complications in patients with rectal cancer,which seriously affects their postoperative recovery and quality of life(QoL).Electroacupuncture therapy is one of the characteristic therapies of traditional Chinese medicine.There are few reports on the prevention and treatment of LARS by electroacupuncture therapy.AIM To explore the clinical effectiveness of electroacupuncture in managing rectal cancer patients with postoperative LARS.METHODS A total of 50 patients with LARS after rectal cancer surgery were retrospectively selected as the research subjects.According to the treatment methods,they were divided into an observation group(n=25)and a control group(n=25).During the four-week treatment period,the control group received standard defecation function training,while the observation group received electroacupuncture care and traditional defecation function training.The anal pressure index(which includes anal resting pressure,anal systolic pressure,and maximum tolerable volume),European Organization of Research and Treatment of Cancer(EORTC)QoL C30(QLQ-C30)score,LARS Scale(LARSS)score,Wexner anal incontinence scale score,Xu Zhongfa five-item 10-point scale score,and the occurrence of adverse reactions were compared between the two groups before and after treatment.RESULTS The experimental group showed considerably enhanced LARSS scores compared to those in the control group after four weeks of treatment.In the first week,second week,and fourth week,the LARSS score and Wexner anal incontinence scale score decreased,and the Xu Zhong method five-item 10-point scale score increased,with significant differences(P<0.05).The experimental group showed substantial improvements in anal resting pressure,anal systolic pressure,and maximum tolerance volume after undergoing 4 wk of therapy in the untreated group(P<0.05).The experimental group's QLQ-C30 score on the EORTC QoL questionnaire was higher than that of the control group during the 1st,2nd,and 4th wk(P<0.05).No significant variation between the groups in the frequency of adverse reactions(P>0.05)was observed.CONCLUSION Electroacupuncture positively impacted LARS following rectal cancer surgery,effectively improving clinical symptoms and anal pressure indicators and patients’standard of life.展开更多
AIM:To analyze the clinical manifestations and risk fac-tors of complications in laparoscopic low anterior resection(LAR)for rectal cancer patients.METHODS:A series of 132 consecutive patients who received laparoscopi...AIM:To analyze the clinical manifestations and risk fac-tors of complications in laparoscopic low anterior resection(LAR)for rectal cancer patients.METHODS:A series of 132 consecutive patients who received laparoscopic LAR for rectal cancer in our center were included.The etiology,diagnosis,treatment and prevention of rectal cancer were studied among the patients with surgery-related complications using both univariate and multivariate regression analysis.RESULTS:No conversion to open surgery was observed and 5 cases converted to hand-assisted laparoscopic operation.The overall morbidity rate was 20.5%.Complications occurred during the operation in 7 patients(5.3%),within 30 postoperative days in 24 patients(18.2%),and within 3 mo in 2 patients(1.5%).The most significant complications were anastomotic leak-age(9.1%)and anastomotic hemorrhage(5.3%).Sizeand location of tumor,pathological staging and preoperative nutrition were significant factors associated with LAR complications,while gender,age and pathological type showed no relevance.Binary logistics regression showed that the size and location of tumor,and pathological staging were independent factors of laparoscopic LAR.All the complications were treated during their onset of clinical manifestations by interventional or conservative therapy.CONCLUSION:Anastomotic leakage is a major com-plication in laparoscopic LAR.The complications may be associated with tumor size and site,and pathological stage.Interventional therapies are of value in the management of laparoscopic LAR complications.展开更多
AIM:To determine the incidence and factors responsible for anastomotic leaks and stricture following anterior resection(AR)and its subsequent management.METHODS:Retrospective analysis of data from 108 patients with re...AIM:To determine the incidence and factors responsible for anastomotic leaks and stricture following anterior resection(AR)and its subsequent management.METHODS:Retrospective analysis of data from 108 patients with rectal carcinoma who underwent AR or low anterior resection(LAR)to identify the various preoperative,operative,and post operative factors that might have influence on anastomotic leaks and strictures.RESULTS:There were 68 males and 40 females with an average of 47 years(range 21-75 years).The median distance of the tumor from the anal verge was 8 cm(range 3-15 cm).Sixty(55.6%)patients underwent handsewn anastomosis and 48(44.4%)were stapled.The median operating time was 3.5 h(range2.0-7.5 h).Sixteen(14.6%)patients had an anastomotic leak.Among these,11 patients required reexploration and five were managed expectantly.The anastomotic leak rate was similar in patients with and without diverting stoma(8/60,13.4%with stoma and 8/48;16.7%without stoma).In 15(13.9%)patients,resection margins were positive for malignancy.Ninteen(17.6%)patients developed anastomotic strictures at a median duration of 8 mo(range 3-20 mo).Among these,15 patients were successfully managed with per-anal dilatation.On multivariate analysis,advance age(>60 years)was the only risk factor for anastomotic leak(P=0.004).On the other hand,anastomotic leak(P=0.00),mucin positive tumor(P =0.021),and lower rectal growth(P=0.011)were found as risk factors for the development of an anastomotic stricture.CONCLUSION:Advance age is a risk factor for an anastomotic leak.An anastomotic leak,a mucin-secreting tumor,and lower rectal growth predispose patients to develop anastomotic strictures.展开更多
This study examined the expression of connexin and protease-activated receptor 3 (par-3) in the distal resection margin of rectal cancer and the correlation of the expression of the two proteins with tumor relapse. ...This study examined the expression of connexin and protease-activated receptor 3 (par-3) in the distal resection margin of rectal cancer and the correlation of the expression of the two proteins with tumor relapse. A total of 40 patients with rectal cancer underwent ultra-low anterior resection with curved cutter stapler. The pathological specimens were divided into 3 groups in terms of sampling sites: tumor group, 2.0-cm group (in which the tissues were harvested 2.0 cm distal to the tumor tissues), 3.0-cm group (in which the tissues were taken 3.0 cm away from the tumor tissues). All the samples were pathologically observed and then measured for the expression of connexin and par-3 by employing immunohistochemistry and Western blotting. The operations in this series went uneventfully. No anastomotic stoma bleeding, stenosis and death occurred postoperatively. Histopathologically, in the tumor group, epithelial cells lost normal pattern of arrangement and polarity, and were loosely connected and even detached. In the 3.0-cm group, the epithelia had normal appearance, obvious cell polarity and essentially intact cell junction. Immunohistochemistry and Western blotting indicated that the 3.0-cm group had the strongest expression of connexin and par-3, and the expression in the 2.0-cm group and the tumor group was relatively weak. There existed significant difference in the expression of the two proteins among the three groups (P〈0.05 for all). It was concluded that the down-regulated connexin and par-3 in the distal margin of rectal cancer tissues may indicate the progression of the disease and high likelihood of recurrence and metastasis. Although no tumor cells were found in the sections of the 2.0cm group, the decreased expression of connexin and par-3 may suggest the development of anaplasia and the increased odds of tumor relapse. Therefore, we are led to speculate that tumor resection only including 2.0 cm of unaffected rectum could not completely avoid the distant metastasis and local relapse.展开更多
Objective:To analyze the efficacy of laparoscopic resection of anterior rectal cancer in treating rectal cancer.Methods:Fifty patients with rectal cancer who were treated in Gucheng County Hospital of Hebei Province f...Objective:To analyze the efficacy of laparoscopic resection of anterior rectal cancer in treating rectal cancer.Methods:Fifty patients with rectal cancer who were treated in Gucheng County Hospital of Hebei Province from September 2017 to September 2019 were selected and recruited in the present study.These patients were divided into two groups,namely the control group and observation groups,by random number table method.Each group consisted of 25 patients.The control group underwent laparoscopic assisted transanorectal mesorectal excision,whereas the observation group underwent laparoscopic resection of anterior rectal cancer.The two groups were compared for related indicators,indicators pertaining to postoperative recovery,and complications.Results:There was no significant difference in the number of lymph node dissections between the two groups(P>0.05).The amount of intraoperative blood loss,surgical operation time,and incision length in the observation group were lower than those in the control group,and the differences were statistically significant(P<0.05).The time of getting out of bed,anal exhaust,and duration of hospital stay were shorter in the observation group than those of the control group,and the differences were statistically significant(P<0.05).In addition,the incidence of postoperative complications in the observation group was lower than that in the control group,and the differences were statistically significant(P<0.05).Conclusions:Laparoscopic resection of anterior rectal cancer is effective for rectal cancer patients.This treatment method can effectively reduce the amount of intraoperative bleeding,shorten the operation time,the time of anal exhaust,get out of bed,and the length of hospital stay,as well as improve condition of the patients.展开更多
BACKGROUND Multiple linear stapler firings during double stapling technique(DST)after laparoscopic low anterior resection(LAR)are associated with an increased risk of anastomotic leakage(AL).However,it is difficult to...BACKGROUND Multiple linear stapler firings during double stapling technique(DST)after laparoscopic low anterior resection(LAR)are associated with an increased risk of anastomotic leakage(AL).However,it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis.AIM To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging(MRI).METHODS We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis,which were randomly divided into a training set(n=260)and testing set(n=68).Binary logistic regression was adopted to create a clinical model using six factors.The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed.Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks.Sensitivity,specificity,accuracy,positive predictive value(PPV),and area under the receiver operating characteristic curve(AUC)was calculated for each model.RESULTS The prevalence of≥3 linear stapler cartridges was 17.7%(58/328).The prevalence of AL was statistically significantly higher in patients with≥3 cartridges compared to those with≤2 cartridges(25.0%vs 11.8%,P=0.018).Preoperative carcinoembryonic antigen level>5 ng/mL(OR=2.11,95%CI 1.08-4.12,P=0.028)and tumor size≥5 cm(OR=3.57,95%CI 1.61-7.89,P=0.002)were recognized as independent risk factors for use of≥3 linear stapler cartridges.Diagnostic performance was better with the integrated model(accuracy=94.1%,PPV=87.5%,and AUC=0.88)compared with the clinical model(accuracy=86.7%,PPV=38.9%,and AUC=0.72)and the image model(accuracy=91.2%,PPV=83.3%,and AUC=0.81).CONCLUSION MRI-based deep learning model can predict the use of≥3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery.This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for≥3 linear stapler cartridges.展开更多
AIM:To evaluate trans-anal reinforcing sutures in low anterior resection using the double-stapled anastomosis technique for primary rectal cancers performed at a single institution.METHODS:The data of patients who rec...AIM:To evaluate trans-anal reinforcing sutures in low anterior resection using the double-stapled anastomosis technique for primary rectal cancers performed at a single institution.METHODS:The data of patients who received transanal reinforcing sutures were compared with those of patients who did not receive them after low anterior resection.Patients who underwent laparoscopic low anterior resection and the double-stapled anastomosis technique for primary rectal cancer between January2008 and December 2011 were included in this study.Patients with no anastomosis,a hand-sewn anastomosis,high anterior resection,or preoperative chemoradiation were excluded.The primary outcomes measured were the incidence of postoperative anastomotic complications and placement of a diverting ileostomy.RESULTS:Among 110 patients,the rate of placement of a diverting ileostomy was significantly lower in the suture group(SG)compared with the non-suture control group(CG)[SG,n=6(12.8%);CG,n=19(30.2%),P=0.031].No significant difference was observed in the rate of anastomotic leakage[SG,n=3(6.4%);CG,n=5(7.9%)].CONCLUSION:Trans-anal reinforcing sutures may reduce the need for diverting ileostomy.A randomized prospective study with a larger population should be performed in the future to demonstrate the efficacy of trans-anal reinforcing sutures.展开更多
AIM:To provide a comprehensive evaluation of the role of a protective stoma in low anterior resection(LAR)for rectal cancer.METHODS:The Pub Med,EMBASE,and MEDLINE databases were searched for studies and relevant liter...AIM:To provide a comprehensive evaluation of the role of a protective stoma in low anterior resection(LAR)for rectal cancer.METHODS:The Pub Med,EMBASE,and MEDLINE databases were searched for studies and relevant literature published between 2007 and 2014 regarding the construction of a protective stoma during LAR.A pooled risk ratio(RR)with 95%confidence intervals(CIs)was used to assess the outcomes of the studies,including the rate of postoperative anastomotic leakage and reoperations related to leakage.Funnel plots and Egger’s tests were used to evaluate the publication biases of the studies.P values<0.05 were considered statistically significant.RESULTS:A total of 11 studies were included in the meta-analysis.In total,5612 patients were examined,2868 of whom had a protective stoma and 2744 of whom did not.The sample size of the studies varied from 34 to 1912 patients.All studies reported the number of patients who developed an anastomotic leakage and required a reoperation related to leakage.A random effects model was used to calculate the pooled RR with the corresponding 95%CI because obvious heterogeneity was observed among the 11 studies(I2=77%).The results indicated that the creation of a protective stoma during LAR significantly reduces the rate of anastomotic leakage and the number of reoperations related to leakage,with pooled RRs of 0.38(95%CI:0.30-0.48,P<0.00001)and 0.37(95%CI:0.29-0.48,P<0.00001),respectively.The shape of the funnel plot did not reveal any evidence of obvious asymmetry.CONCLUSION:The presence of a protective stoma effectively decreased the incidences of anastomotic leakage and reoperation and is recommended in patients undergoing low rectal anterior resections for rectal cancer.展开更多
AIM: There is some evidence of functional superiority of colonic J-pouch over straight coloanal anastomosis (CAA)in ultralow anterior resection (ULAR) or intersphincteric resection. On the assumption that colonic J-po...AIM: There is some evidence of functional superiority of colonic J-pouch over straight coloanal anastomosis (CAA)in ultralow anterior resection (ULAR) or intersphincteric resection. On the assumption that colonic J-pouch anal anastomosis is superior to straight CAA in ULAR with upper sphincter excision (USE: excision of the upper part of the internal sphincter) for low-lying rectal cancer, we compare functional outcome of colonic J-pouch vs the straight CAA.METHODS: Fifty patients of one hundred and thirty-three rectal cancer patients in whom lower margin of the tumors were located between 3 and 5 cm from the anal verge received ULAR including USE from September 1998 to January 2002. Patients were randomized for reconstruction using either a straight (n = 26) or a colonic J-pouch anastomosis (n = 24) with a temporary diverting-loop ileostomy. All patients were followed-up prospectively by a standardized questionnaire [Fecal Inco-ntinence Severity Index (FISI) scores and Fecal Incontinence Quality of Life (FIQL) scales].RESULTS: We found that, compared to straight anastomosis patients, the frequency of defecation was significantly lower in J-pouch anastomosis patients for 10 mo afterileostomy takedown. The FISI scores and FIQL scales were significantly better in J-pouch patients than in straight patients at both 3 and 12 mo after ileostomy takedown.Furthermore, we found that FISI scores highly correlated with FIQL scales.CONCLUSION: This study indicates that colonic J-pouch anal anastomosis decreases the severity of fecal incontinence and improves the quality of life for 10 mo after ileostomy takedown in patients undergoing ULAR with USE forlow-lying rectal cancer.展开更多
Background:?To clarify the pudendal motor (PMN) and sensory (PSN) nerves?play in preventing fecal incontinence (FI) after low anterior resection (LAR) for lower rectal cancer, the PMN and PSN functions were studied. M...Background:?To clarify the pudendal motor (PMN) and sensory (PSN) nerves?play in preventing fecal incontinence (FI) after low anterior resection (LAR) for lower rectal cancer, the PMN and PSN functions were studied. Methods:?Sixty patients were divided into groups A (n = 20, FI) and B (n = 40, continence). These were compared with group C (n = 30, control subjects). PMN latency (PMNL) (right, left, and posterior sides of the anal canal) was studied by sacral magnetic stimulation. Anal mucosal electric sensitivity (AMES) was measured at the lower, dentate line (DL), and upper zones. Results:?The distance of anastomosis from anal verge (DAAV) in group A was significantly shorter than in group B (p?value p?value p?value p?value Conclusion:?FI after LAR with a short DAAV?may?lead to?external anal sphincter dysfunction due to damage of both PMN and PSN.展开更多
Objective:To evaluate the results of low anteriorresection treatment for middle and lower rectal cancer. Methods:Clinical and follow-up data of 196 patients with middle and lower rectal cancer who received low anteri...Objective:To evaluate the results of low anteriorresection treatment for middle and lower rectal cancer. Methods:Clinical and follow-up data of 196 patients with middle and lower rectal cancer who received low anteriorresection treatment from June 1991 to June 2001 wereretrospectively analyzed. Results: anterior resectiontechnique including double stapling technique、pull-through and Park抯 operations could get a standard radicalresection and had no significant differences in 1, 3, 5 and 10 years survival rates comparing with the abdominoperineal resection(Miles?. Conclusion:The experience suggests that the low anterior resection technique was safe and simplehad less bleeding and fewer complications and couldincrease the life-quality of the patients with rectal cancer.展开更多
Laparoscopic colorectal surgery(LCS) is an evolving subject.Recent studies show that LCS can not only offer safe surgery but evidence is growing that this new technique can be superior to classical open procedures.Few...Laparoscopic colorectal surgery(LCS) is an evolving subject.Recent studies show that LCS can not only offer safe surgery but evidence is growing that this new technique can be superior to classical open procedures.Fewer perioperative complications and faster postoperative recovery are regularly mentioned when studies of LCS are presented.Even though the learning curve of LCS is frequently debated when limitations of laparoscopic surgeries are reviewed,studies show that in experienced hands LCS can be a safe procedure for colorectal cancer treatment.The learning curve however,is associated with high conversion rates and economical aspects such as higher costs and prolonged hospital stay.Nevertheless,laparoscopic colorectal cancer surgery(LCCR) offers several advantages such as less co-morbidity and less postoperative pain in comparison with open procedures.Furthermore,the good exposure of the pelvic cavity by laparoscopy and the magnification of anatomical structures seem to facilitate pelvic dissection laparoscopically.Moreover,recent studies describe no difference in safety and oncological radicalness in LCCR compared to the open total mesorectal excision(TME).The oncological adequacy of LCCR still remains unproven today,because long-term results do not yet exist.To date,only a few studies have described the results of laparoscopic TME combined with preoperative adjuvant treatment for colorectal cancer.The aim of this review is to examine the various areas of development and controversy of LCCR in comparison to the conventional open approach.展开更多
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 ...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.展开更多
BACKGROUND Pelvic exenteration for locally advanced rectal cancer involving prostate has been performed via open surgery.Robotic pelvic exenteration offers benefits of better pelvic visualisation and dissection for bl...BACKGROUND Pelvic exenteration for locally advanced rectal cancer involving prostate has been performed via open surgery.Robotic pelvic exenteration offers benefits of better pelvic visualisation and dissection for bladder preserving prostatectomy with vesicourethral anastomosis,while achieving clear margins.AIM To determine the feasibility of robotic assisted bladder sparing pelvic exenteration.METHODS We describe robotic assisted pelvic exenteration in three cases of locally advanced rectal cancer involving prostate and seminal vesicles(SV).The da Vinci S robotic system was used.Robotic console was docked at left oblique position for abdominal phase and redocked to between the patient’s legs for pelvic phase.All three cases were performed fully robotically at Tan Tock Seng Hospital by colorectal and urological teams.RESULTS Case 1:67-year-old with low rectal tumour 3 cm from anal verge involving the prostate.He underwent neo-adjuvant chemoradiotherapy and robotic abdominoperineal resection with en-bloc prostatectomy.Case 2:66-year-old with low rectal tumour 3 cm from anal verge involving prostate and bilateral SV.He underwent neo-adjuvant chemoradiotherapy and robot assisted ultra-low anterior resection with coloanal anastomosis and en-bloc prostatectomy.Case 3:57-year-old with metachronous rectal tumour in the rectovesical pouch inseparable from the anterior mid rectum,prostate and bilateral SV.He underwent robot assisted ultra-low anterior resection with en-bloc prostatectomy.Bladder neck margin revealed cauterized tumour cells,and he underwent total cystectomy and ileal conduit creation.Histology revealed no residual tumour.All patients are currently disease free CONCLUSION Robot assisted bladder sparing pelvic exenteration can be safely performed in locally advanced rectal cancer with acceptable surgical outcome while preserving benefits of minimally invasive surgery.展开更多
AIM: To systematically analyze the randomized trials comparing the oncological and clinical effectiveness of laparoscopic total mesorectal excision(LTME) vs open total mesorectal excision(OTME) in the management of re...AIM: To systematically analyze the randomized trials comparing the oncological and clinical effectiveness of laparoscopic total mesorectal excision(LTME) vs open total mesorectal excision(OTME) in the management of rectal cancer.METHODS: Published randomized, controlled trials comparing the oncological and clinical effectiveness of LTME vs OTME in the management of rectal cancer were retrieved from the standard electronic medical databases. The data of included randomized, controlled trials was extracted and then analyzed according to the principles of meta-analysis using RevMan? statistical software. The combined outcome of the binary variables was expressed as odds ratio(OR) and the combined outcome of the continuous variables waspresented in the form of standardized mean difference(SMD). RESULTS: Data from eleven randomized, controlled trials on 2143 patients were retrieved from the electronic databases. There was a trend towards the higher risk of surgical site infection(OR = 0.66; 95%CI: 0.44-1.00; z = 1.94; P < 0.05), higher risk of incomplete total mesorectal resection(OR = 0.62; 95%CI: 0.43-0.91; z = 2.49; P < 0.01) and prolonged length of hospital stay(SMD,-1.59; 95%CI:-0.86--0.25; z = 4.22; P < 0.00001) following OTME. However, the oncological outcomes like number of harvested lymph nodes, tumour recurrence and risk of positive resection margins were statistically similar in both groups. In addition, the clinical outcomes such as operative complications, anastomotic leak and all-cause mortality were comparable between both approaches of mesorectal excision.CONCLUSION: LTME appears to have clinically and oncologically measurable advantages over OTME in patients with primary rectal cancer in both short term and long term follow ups.展开更多
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...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.展开更多
基金Supported by the National Natural Science Foundation of China,No.81672379.
文摘BACKGROUND Rectal cancer ranks as the second leading cause of cancer-related mortality worldwide,necessitating surgical resection as the sole treatment option.Over the years,there has been a growing adoption of minimally invasive surgical techni-ques such as robotic and laparoscopic approaches.Robotic surgery represents an innovative modality that effectively addresses the limitations associated with traditional laparoscopic techniques.While previous studies have reported favo-rable perioperative outcomes for robot-assisted radical resection in rectal cancer patients,further evidence regarding its oncological safety is still warranted.AIM To conduct a comparative analysis of perioperative and oncological outcomes between robot-assisted and laparoscopic-assisted low anterior resection(LALAR)procedures.METHODS The clinical data of 125 patients who underwent robot-assisted low anterior resection(RALAR)and 279 patients who underwent LALAR resection at Shandong Provincial Hospital Affiliated to Shandong First Medical University from December 2019 to November 2022 were retrospectively analyzed.After performing a 1:1 propensity score matching,the patients were divided into two groups:The RALAR group and the LALAR group(111 cases in each group).Subsequently,a comparison was made between the short-term outcomes within 30 d after surgery and the 3-year survival outcomes of these two groups.RESULTS Compared to the LALAR group,the RALAR group exhibited a significantly earlier time to first flatus[2(2-2)d vs 3(3-3)d,P=0.000],as well as a shorter time to first fluid diet[4(3-4)d vs 5(4-6)d,P=0.001].Additionally,the RALAR group demonstrated reduced postoperative indwelling catheter time[2(1-3)d vs 4(3-5)d,P=0.000]and decreased length of hospital stay after surgery[5(5-7)d vs 7(6-8)d,P=0.009].Moreover,there was an observed increase in total cost of hospitalization for the RALAR group compared to the LALAR group[10777(10780-11850)dollars vs 10550(8766-11715)dollars,P=0.012].No significant differences were found in terms of conversion rate to laparotomy or incidence of postoperative complications between both groups.Furthermore,no significant disparities were noted regarding the 3-year overall survival rate and 3-year disease-free survival rate between both groups.CONCLUSION Robotic surgery offers potential advantages in terms of accelerated recovery of gastrointestinal and urologic function compared to LALAR resection,while maintaining similar perioperative and 3-year oncological outcomes.
基金Supported by the National Natural Science Foundation of China,No.82173368 and 81903047.
文摘BACKGROUND Low anterior resection syndrome(LARS)severely impairs patient postoperative quality of life,especially major LARS.However,there are few tools that can accurately predict major LARS in clinical practice.AIM To develop a machine learning model using preoperative and intraoperative factors for predicting major LARS following laparoscopic surgery of rectal cancer in Chinese populations.METHODS Clinical data and follow-up information of patients who received laparoscopic anterior resection for rectal cancer from two medical centers(one discovery cohort and one external validation cohort)were included in this retrospective study.For the discovery cohort,the machine learning prediction algorithms were developed and internally validated.In the external validation cohort,we evaluated the trained model using various performance metrics.Further,the clinical utility of the model was tested by decision curve analysis.RESULTS Overall,1651 patients were included in the present study.Anastomotic height,neoadjuvant therapy,diverting stoma,body mass index,clinical stage,specimen length,tumor size,and age were the risk factors associated with major LARS.They were used to construct the machine learning model to predict major LARS.The trained random forest(RF)model performed with an area under the curve of 0.852 and a sensitivity of 0.795(95%CI:0.681-0.877),a specificity of 0.758(95%CI:0.671-0.828),and Brier score of 0.166 in the external validation set.Compared to the previous preoperative LARS score model,the current model exhibited superior predictive performance in predicting major LARS in our cohort(accuracy of 0.772 for the RF model vs 0.355 for the preoperative LARS score model).CONCLUSION We developed and validated a robust tool for predicting major LARS.This model could potentially be used in the clinic to identify patients with a high risk of developing major LARS and then improve the quality of life.
基金Supported by Jiangsu Province Traditional Chinese Medicine Technology Development Plan Project,No.ZD201903China Medical Education Association,No.2022KTZ005.
文摘BACKGROUND Low anterior resection syndrome(LARS)is one of the common postoperative complications in patients with rectal cancer,which seriously affects their postoperative recovery and quality of life(QoL).Electroacupuncture therapy is one of the characteristic therapies of traditional Chinese medicine.There are few reports on the prevention and treatment of LARS by electroacupuncture therapy.AIM To explore the clinical effectiveness of electroacupuncture in managing rectal cancer patients with postoperative LARS.METHODS A total of 50 patients with LARS after rectal cancer surgery were retrospectively selected as the research subjects.According to the treatment methods,they were divided into an observation group(n=25)and a control group(n=25).During the four-week treatment period,the control group received standard defecation function training,while the observation group received electroacupuncture care and traditional defecation function training.The anal pressure index(which includes anal resting pressure,anal systolic pressure,and maximum tolerable volume),European Organization of Research and Treatment of Cancer(EORTC)QoL C30(QLQ-C30)score,LARS Scale(LARSS)score,Wexner anal incontinence scale score,Xu Zhongfa five-item 10-point scale score,and the occurrence of adverse reactions were compared between the two groups before and after treatment.RESULTS The experimental group showed considerably enhanced LARSS scores compared to those in the control group after four weeks of treatment.In the first week,second week,and fourth week,the LARSS score and Wexner anal incontinence scale score decreased,and the Xu Zhong method five-item 10-point scale score increased,with significant differences(P<0.05).The experimental group showed substantial improvements in anal resting pressure,anal systolic pressure,and maximum tolerance volume after undergoing 4 wk of therapy in the untreated group(P<0.05).The experimental group's QLQ-C30 score on the EORTC QoL questionnaire was higher than that of the control group during the 1st,2nd,and 4th wk(P<0.05).No significant variation between the groups in the frequency of adverse reactions(P>0.05)was observed.CONCLUSION Electroacupuncture positively impacted LARS following rectal cancer surgery,effectively improving clinical symptoms and anal pressure indicators and patients’standard of life.
文摘AIM:To analyze the clinical manifestations and risk fac-tors of complications in laparoscopic low anterior resection(LAR)for rectal cancer patients.METHODS:A series of 132 consecutive patients who received laparoscopic LAR for rectal cancer in our center were included.The etiology,diagnosis,treatment and prevention of rectal cancer were studied among the patients with surgery-related complications using both univariate and multivariate regression analysis.RESULTS:No conversion to open surgery was observed and 5 cases converted to hand-assisted laparoscopic operation.The overall morbidity rate was 20.5%.Complications occurred during the operation in 7 patients(5.3%),within 30 postoperative days in 24 patients(18.2%),and within 3 mo in 2 patients(1.5%).The most significant complications were anastomotic leak-age(9.1%)and anastomotic hemorrhage(5.3%).Sizeand location of tumor,pathological staging and preoperative nutrition were significant factors associated with LAR complications,while gender,age and pathological type showed no relevance.Binary logistics regression showed that the size and location of tumor,and pathological staging were independent factors of laparoscopic LAR.All the complications were treated during their onset of clinical manifestations by interventional or conservative therapy.CONCLUSION:Anastomotic leakage is a major com-plication in laparoscopic LAR.The complications may be associated with tumor size and site,and pathological stage.Interventional therapies are of value in the management of laparoscopic LAR complications.
文摘AIM:To determine the incidence and factors responsible for anastomotic leaks and stricture following anterior resection(AR)and its subsequent management.METHODS:Retrospective analysis of data from 108 patients with rectal carcinoma who underwent AR or low anterior resection(LAR)to identify the various preoperative,operative,and post operative factors that might have influence on anastomotic leaks and strictures.RESULTS:There were 68 males and 40 females with an average of 47 years(range 21-75 years).The median distance of the tumor from the anal verge was 8 cm(range 3-15 cm).Sixty(55.6%)patients underwent handsewn anastomosis and 48(44.4%)were stapled.The median operating time was 3.5 h(range2.0-7.5 h).Sixteen(14.6%)patients had an anastomotic leak.Among these,11 patients required reexploration and five were managed expectantly.The anastomotic leak rate was similar in patients with and without diverting stoma(8/60,13.4%with stoma and 8/48;16.7%without stoma).In 15(13.9%)patients,resection margins were positive for malignancy.Ninteen(17.6%)patients developed anastomotic strictures at a median duration of 8 mo(range 3-20 mo).Among these,15 patients were successfully managed with per-anal dilatation.On multivariate analysis,advance age(>60 years)was the only risk factor for anastomotic leak(P=0.004).On the other hand,anastomotic leak(P=0.00),mucin positive tumor(P =0.021),and lower rectal growth(P=0.011)were found as risk factors for the development of an anastomotic stricture.CONCLUSION:Advance age is a risk factor for an anastomotic leak.An anastomotic leak,a mucin-secreting tumor,and lower rectal growth predispose patients to develop anastomotic strictures.
文摘This study examined the expression of connexin and protease-activated receptor 3 (par-3) in the distal resection margin of rectal cancer and the correlation of the expression of the two proteins with tumor relapse. A total of 40 patients with rectal cancer underwent ultra-low anterior resection with curved cutter stapler. The pathological specimens were divided into 3 groups in terms of sampling sites: tumor group, 2.0-cm group (in which the tissues were harvested 2.0 cm distal to the tumor tissues), 3.0-cm group (in which the tissues were taken 3.0 cm away from the tumor tissues). All the samples were pathologically observed and then measured for the expression of connexin and par-3 by employing immunohistochemistry and Western blotting. The operations in this series went uneventfully. No anastomotic stoma bleeding, stenosis and death occurred postoperatively. Histopathologically, in the tumor group, epithelial cells lost normal pattern of arrangement and polarity, and were loosely connected and even detached. In the 3.0-cm group, the epithelia had normal appearance, obvious cell polarity and essentially intact cell junction. Immunohistochemistry and Western blotting indicated that the 3.0-cm group had the strongest expression of connexin and par-3, and the expression in the 2.0-cm group and the tumor group was relatively weak. There existed significant difference in the expression of the two proteins among the three groups (P〈0.05 for all). It was concluded that the down-regulated connexin and par-3 in the distal margin of rectal cancer tissues may indicate the progression of the disease and high likelihood of recurrence and metastasis. Although no tumor cells were found in the sections of the 2.0cm group, the decreased expression of connexin and par-3 may suggest the development of anaplasia and the increased odds of tumor relapse. Therefore, we are led to speculate that tumor resection only including 2.0 cm of unaffected rectum could not completely avoid the distant metastasis and local relapse.
文摘Objective:To analyze the efficacy of laparoscopic resection of anterior rectal cancer in treating rectal cancer.Methods:Fifty patients with rectal cancer who were treated in Gucheng County Hospital of Hebei Province from September 2017 to September 2019 were selected and recruited in the present study.These patients were divided into two groups,namely the control group and observation groups,by random number table method.Each group consisted of 25 patients.The control group underwent laparoscopic assisted transanorectal mesorectal excision,whereas the observation group underwent laparoscopic resection of anterior rectal cancer.The two groups were compared for related indicators,indicators pertaining to postoperative recovery,and complications.Results:There was no significant difference in the number of lymph node dissections between the two groups(P>0.05).The amount of intraoperative blood loss,surgical operation time,and incision length in the observation group were lower than those in the control group,and the differences were statistically significant(P<0.05).The time of getting out of bed,anal exhaust,and duration of hospital stay were shorter in the observation group than those of the control group,and the differences were statistically significant(P<0.05).In addition,the incidence of postoperative complications in the observation group was lower than that in the control group,and the differences were statistically significant(P<0.05).Conclusions:Laparoscopic resection of anterior rectal cancer is effective for rectal cancer patients.This treatment method can effectively reduce the amount of intraoperative bleeding,shorten the operation time,the time of anal exhaust,get out of bed,and the length of hospital stay,as well as improve condition of the patients.
基金Shanghai Jiaotong University,No.YG2019QNB24This study was reviewed and approved by Ruijin Hospital Ethics Committee(Approval No.2019-82).
文摘BACKGROUND Multiple linear stapler firings during double stapling technique(DST)after laparoscopic low anterior resection(LAR)are associated with an increased risk of anastomotic leakage(AL).However,it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis.AIM To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging(MRI).METHODS We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis,which were randomly divided into a training set(n=260)and testing set(n=68).Binary logistic regression was adopted to create a clinical model using six factors.The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed.Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks.Sensitivity,specificity,accuracy,positive predictive value(PPV),and area under the receiver operating characteristic curve(AUC)was calculated for each model.RESULTS The prevalence of≥3 linear stapler cartridges was 17.7%(58/328).The prevalence of AL was statistically significantly higher in patients with≥3 cartridges compared to those with≤2 cartridges(25.0%vs 11.8%,P=0.018).Preoperative carcinoembryonic antigen level>5 ng/mL(OR=2.11,95%CI 1.08-4.12,P=0.028)and tumor size≥5 cm(OR=3.57,95%CI 1.61-7.89,P=0.002)were recognized as independent risk factors for use of≥3 linear stapler cartridges.Diagnostic performance was better with the integrated model(accuracy=94.1%,PPV=87.5%,and AUC=0.88)compared with the clinical model(accuracy=86.7%,PPV=38.9%,and AUC=0.72)and the image model(accuracy=91.2%,PPV=83.3%,and AUC=0.81).CONCLUSION MRI-based deep learning model can predict the use of≥3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery.This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for≥3 linear stapler cartridges.
文摘AIM:To evaluate trans-anal reinforcing sutures in low anterior resection using the double-stapled anastomosis technique for primary rectal cancers performed at a single institution.METHODS:The data of patients who received transanal reinforcing sutures were compared with those of patients who did not receive them after low anterior resection.Patients who underwent laparoscopic low anterior resection and the double-stapled anastomosis technique for primary rectal cancer between January2008 and December 2011 were included in this study.Patients with no anastomosis,a hand-sewn anastomosis,high anterior resection,or preoperative chemoradiation were excluded.The primary outcomes measured were the incidence of postoperative anastomotic complications and placement of a diverting ileostomy.RESULTS:Among 110 patients,the rate of placement of a diverting ileostomy was significantly lower in the suture group(SG)compared with the non-suture control group(CG)[SG,n=6(12.8%);CG,n=19(30.2%),P=0.031].No significant difference was observed in the rate of anastomotic leakage[SG,n=3(6.4%);CG,n=5(7.9%)].CONCLUSION:Trans-anal reinforcing sutures may reduce the need for diverting ileostomy.A randomized prospective study with a larger population should be performed in the future to demonstrate the efficacy of trans-anal reinforcing sutures.
文摘AIM:To provide a comprehensive evaluation of the role of a protective stoma in low anterior resection(LAR)for rectal cancer.METHODS:The Pub Med,EMBASE,and MEDLINE databases were searched for studies and relevant literature published between 2007 and 2014 regarding the construction of a protective stoma during LAR.A pooled risk ratio(RR)with 95%confidence intervals(CIs)was used to assess the outcomes of the studies,including the rate of postoperative anastomotic leakage and reoperations related to leakage.Funnel plots and Egger’s tests were used to evaluate the publication biases of the studies.P values<0.05 were considered statistically significant.RESULTS:A total of 11 studies were included in the meta-analysis.In total,5612 patients were examined,2868 of whom had a protective stoma and 2744 of whom did not.The sample size of the studies varied from 34 to 1912 patients.All studies reported the number of patients who developed an anastomotic leakage and required a reoperation related to leakage.A random effects model was used to calculate the pooled RR with the corresponding 95%CI because obvious heterogeneity was observed among the 11 studies(I2=77%).The results indicated that the creation of a protective stoma during LAR significantly reduces the rate of anastomotic leakage and the number of reoperations related to leakage,with pooled RRs of 0.38(95%CI:0.30-0.48,P<0.00001)and 0.37(95%CI:0.29-0.48,P<0.00001),respectively.The shape of the funnel plot did not reveal any evidence of obvious asymmetry.CONCLUSION:The presence of a protective stoma effectively decreased the incidences of anastomotic leakage and reoperation and is recommended in patients undergoing low rectal anterior resections for rectal cancer.
文摘AIM: There is some evidence of functional superiority of colonic J-pouch over straight coloanal anastomosis (CAA)in ultralow anterior resection (ULAR) or intersphincteric resection. On the assumption that colonic J-pouch anal anastomosis is superior to straight CAA in ULAR with upper sphincter excision (USE: excision of the upper part of the internal sphincter) for low-lying rectal cancer, we compare functional outcome of colonic J-pouch vs the straight CAA.METHODS: Fifty patients of one hundred and thirty-three rectal cancer patients in whom lower margin of the tumors were located between 3 and 5 cm from the anal verge received ULAR including USE from September 1998 to January 2002. Patients were randomized for reconstruction using either a straight (n = 26) or a colonic J-pouch anastomosis (n = 24) with a temporary diverting-loop ileostomy. All patients were followed-up prospectively by a standardized questionnaire [Fecal Inco-ntinence Severity Index (FISI) scores and Fecal Incontinence Quality of Life (FIQL) scales].RESULTS: We found that, compared to straight anastomosis patients, the frequency of defecation was significantly lower in J-pouch anastomosis patients for 10 mo afterileostomy takedown. The FISI scores and FIQL scales were significantly better in J-pouch patients than in straight patients at both 3 and 12 mo after ileostomy takedown.Furthermore, we found that FISI scores highly correlated with FIQL scales.CONCLUSION: This study indicates that colonic J-pouch anal anastomosis decreases the severity of fecal incontinence and improves the quality of life for 10 mo after ileostomy takedown in patients undergoing ULAR with USE forlow-lying rectal cancer.
文摘Background:?To clarify the pudendal motor (PMN) and sensory (PSN) nerves?play in preventing fecal incontinence (FI) after low anterior resection (LAR) for lower rectal cancer, the PMN and PSN functions were studied. Methods:?Sixty patients were divided into groups A (n = 20, FI) and B (n = 40, continence). These were compared with group C (n = 30, control subjects). PMN latency (PMNL) (right, left, and posterior sides of the anal canal) was studied by sacral magnetic stimulation. Anal mucosal electric sensitivity (AMES) was measured at the lower, dentate line (DL), and upper zones. Results:?The distance of anastomosis from anal verge (DAAV) in group A was significantly shorter than in group B (p?value p?value p?value p?value Conclusion:?FI after LAR with a short DAAV?may?lead to?external anal sphincter dysfunction due to damage of both PMN and PSN.
文摘Objective:To evaluate the results of low anteriorresection treatment for middle and lower rectal cancer. Methods:Clinical and follow-up data of 196 patients with middle and lower rectal cancer who received low anteriorresection treatment from June 1991 to June 2001 wereretrospectively analyzed. Results: anterior resectiontechnique including double stapling technique、pull-through and Park抯 operations could get a standard radicalresection and had no significant differences in 1, 3, 5 and 10 years survival rates comparing with the abdominoperineal resection(Miles?. Conclusion:The experience suggests that the low anterior resection technique was safe and simplehad less bleeding and fewer complications and couldincrease the life-quality of the patients with rectal cancer.
文摘Laparoscopic colorectal surgery(LCS) is an evolving subject.Recent studies show that LCS can not only offer safe surgery but evidence is growing that this new technique can be superior to classical open procedures.Fewer perioperative complications and faster postoperative recovery are regularly mentioned when studies of LCS are presented.Even though the learning curve of LCS is frequently debated when limitations of laparoscopic surgeries are reviewed,studies show that in experienced hands LCS can be a safe procedure for colorectal cancer treatment.The learning curve however,is associated with high conversion rates and economical aspects such as higher costs and prolonged hospital stay.Nevertheless,laparoscopic colorectal cancer surgery(LCCR) offers several advantages such as less co-morbidity and less postoperative pain in comparison with open procedures.Furthermore,the good exposure of the pelvic cavity by laparoscopy and the magnification of anatomical structures seem to facilitate pelvic dissection laparoscopically.Moreover,recent studies describe no difference in safety and oncological radicalness in LCCR compared to the open total mesorectal excision(TME).The oncological adequacy of LCCR still remains unproven today,because long-term results do not yet exist.To date,only a few studies have described the results of laparoscopic TME combined with preoperative adjuvant treatment for colorectal cancer.The aim of this review is to examine the various areas of development and controversy of LCCR in comparison to the conventional open approach.
文摘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.
文摘BACKGROUND Pelvic exenteration for locally advanced rectal cancer involving prostate has been performed via open surgery.Robotic pelvic exenteration offers benefits of better pelvic visualisation and dissection for bladder preserving prostatectomy with vesicourethral anastomosis,while achieving clear margins.AIM To determine the feasibility of robotic assisted bladder sparing pelvic exenteration.METHODS We describe robotic assisted pelvic exenteration in three cases of locally advanced rectal cancer involving prostate and seminal vesicles(SV).The da Vinci S robotic system was used.Robotic console was docked at left oblique position for abdominal phase and redocked to between the patient’s legs for pelvic phase.All three cases were performed fully robotically at Tan Tock Seng Hospital by colorectal and urological teams.RESULTS Case 1:67-year-old with low rectal tumour 3 cm from anal verge involving the prostate.He underwent neo-adjuvant chemoradiotherapy and robotic abdominoperineal resection with en-bloc prostatectomy.Case 2:66-year-old with low rectal tumour 3 cm from anal verge involving prostate and bilateral SV.He underwent neo-adjuvant chemoradiotherapy and robot assisted ultra-low anterior resection with coloanal anastomosis and en-bloc prostatectomy.Case 3:57-year-old with metachronous rectal tumour in the rectovesical pouch inseparable from the anterior mid rectum,prostate and bilateral SV.He underwent robot assisted ultra-low anterior resection with en-bloc prostatectomy.Bladder neck margin revealed cauterized tumour cells,and he underwent total cystectomy and ileal conduit creation.Histology revealed no residual tumour.All patients are currently disease free CONCLUSION Robot assisted bladder sparing pelvic exenteration can be safely performed in locally advanced rectal cancer with acceptable surgical outcome while preserving benefits of minimally invasive surgery.
文摘AIM: To systematically analyze the randomized trials comparing the oncological and clinical effectiveness of laparoscopic total mesorectal excision(LTME) vs open total mesorectal excision(OTME) in the management of rectal cancer.METHODS: Published randomized, controlled trials comparing the oncological and clinical effectiveness of LTME vs OTME in the management of rectal cancer were retrieved from the standard electronic medical databases. The data of included randomized, controlled trials was extracted and then analyzed according to the principles of meta-analysis using RevMan? statistical software. The combined outcome of the binary variables was expressed as odds ratio(OR) and the combined outcome of the continuous variables waspresented in the form of standardized mean difference(SMD). RESULTS: Data from eleven randomized, controlled trials on 2143 patients were retrieved from the electronic databases. There was a trend towards the higher risk of surgical site infection(OR = 0.66; 95%CI: 0.44-1.00; z = 1.94; P < 0.05), higher risk of incomplete total mesorectal resection(OR = 0.62; 95%CI: 0.43-0.91; z = 2.49; P < 0.01) and prolonged length of hospital stay(SMD,-1.59; 95%CI:-0.86--0.25; z = 4.22; P < 0.00001) following OTME. However, the oncological outcomes like number of harvested lymph nodes, tumour recurrence and risk of positive resection margins were statistically similar in both groups. In addition, the clinical outcomes such as operative complications, anastomotic leak and all-cause mortality were comparable between both approaches of mesorectal excision.CONCLUSION: LTME appears to have clinically and oncologically measurable advantages over OTME in patients with primary rectal cancer in both short term and long term follow ups.
基金Supported by Chongqing Key Diseases Research and Application Demonstration Program(Colorectal Cancer Prevention and Treatment Technology and Research Application Demonstration),No.2019ZX003.
文摘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.