Impact of frailty on short-term postoperative outcomes in patients undergoing colorectal cancer surgery:A systematic review and meta-analysis

BACKGROUND Colorectal cancer is a major global health challenge that predominantly affects older people.Surgical management,despite advancements,requires careful consideration of preoperative patient status for optimal outcomes.AIM To summarize existing evidence on the association of frailty with short-term postoperative outcomes in patients undergoing colorectal cancer surgery.METHODS A literature search was conducted using PubMed,EMBASE and Scopus databases for observational studies in adult patients aged≥18 years undergoing planned or elective colorectal surgery for primary carcinoma and/or secondary metastasis.Only studies that conducted frailty assessment using recognized frailty assess-ment tools and had a comparator group,comprising nonfrail patients,were included.Pooled effect sizes were reported as weighted mean difference or relative risk(RR)with 95%confidence intervals(CIs).RESULTS A total of 24 studies were included.Compared with nonfrail patients,frailty was associated with an increased risk of mortality at 30 d(RR:1.99,95%CI:1.47-2.69),at 90 d(RR:4.76,95%CI:1.56-14.6)and at 1 year(RR:5.73,95%CI:2.74-12.0)of follow up.Frail patients had an increased risk of any complications(RR:1.81,95%CI:1.57-2.10)as well as major complications(Clavien-Dindo classification grade≥III)(RR:2.87,95%CI:1.65-4.99)compared with the control group.The risk of reoperation(RR:1.18,95%CI:1.07-1.31),readmission(RR:1.70,95%CI:1.36-2.12),need for blood transfusion(RR:1.67,95%CI:1.52-1.85),wound complications(RR:1.49,95%CI:1.11-1.99),delirium(RR:4.60,95%CI:2.31-9.16),risk of prolonged hospitalization(RR:2.09,95%CI:1.22-3.60)and discharge to a skilled nursing facility or rehabilitation center(RR:3.19,95%CI:2.0-5.08)was all higher in frail patients.CONCLUSION Frailty in colorectal cancer surgery patients was associated with more complications,longer hospital stays,higher reoperation risk,and increased mortality.Integrating frailty assessment appears crucial for tailored surgical management.

Clinical effect of laparoscopic radical resection of colorectal cancer based on propensity score matching

BACKGROUND The incidence of colorectal cancer(CRC)is increasing annually.Laparoscopic radical resection of CRC is a minimally invasive procedure preferred in clinical practice.AIM To investigate the clinical effect of laparoscopic radical resection of CRC on the basis of propensity score matching(PSM).METHODS The clinical data of 100 patients who received inpatient treatment for CRC at Changde Hospital,Xiangya School of Medicine,Central South University(The First People’s Hospital of Changde City)were analyzed retrospectively.The control group included patients who underwent open surgery(n=43),and those who underwent laparoscopic surgery formed the observation group(n=57).The baseline information of both groups was equipoised using 1×1 PSM.Differences in the perioperative parameters,inflammatory response,immune function,degree of pain,and physical status between the groups were analyzed.RESULTS Thirty patients from both groups were successfully matched.After PSM,baseline data showed no statistically significant differences between the groups:(1)Periop-erative parameters:The observation group had a longer surgery time,less intra-operative blood loss,earlier first ambulation and first anal exhaust times,and shorter gastric tube indwelling time than the control group;(2)Inflammatory response:24 h after surgery,the levels of interleukin-6(IL-6),C-reactive protein(CRP),and tumor necrosis factor-α(TNF-α)between groups were higher than preoperatively.IL-6,CRP,and TNF-αlevels in the observation group were lower than in the control group;(3)Immune function:At 24 h after surgery,counts of CD4-positive T-lymphocytes(CD4+)and CD4+/CD8-positive T-lymphocytes(CD8+)in both groups were lower than those before surgery,whereas CD8+was higher than that before surgery.At 24 h after surgery,both CD4+counts and CD4+/CD8+in the observation group were higher than those in the control group,whereas CD8+counts were lower;(4)Degree of pain:The visual analog scale scores in the observation group were lower than those in the control group at 24 and 72 h after surgery;and(5)Physical status:One month after surgery,the Karnofsky performance score in the observation group was higher than that in the control group.CONCLUSION Laparoscopic radical resection of CRC has significant benefits,such as reducing postoperative pain and postoperative inflammatory response,avoiding excessive immune inhibition,and contributing to postoperative recovery.

Quality assessment of surgery for colorectal cancer:Where do we stand?

Quality assurance in surgery has been one of the most important topics of debate among colorectal surgeons in the past decade.It has produced new surgical standards that led in part to the impressive oncological outcomes we see in many units today.Total mesorectal excision,complete mesocolic excision(CME),and the Japanese D3 lymphadenectomy are now benchmark techniques embraced by many surgeons and widely recommended by surgical societies.However,there are still ongoing discrepancies in outcomes largely based on surgeon performance.This is one of the main reasons why many countries have shifted colorectal cancer surgery only to high volume centers.Defining markers of surgical quality is thus a perquisite to ensure that standards and oncological outcomes are met at an institutional level.With the evolution of CME surgery,various quality markers have been described,mostly based on measurements on the surgical specimen and lymph node yield,while others have proposed radiological markers(i.e.arterial stumps)measured on postoperative scans as part of the routine cancer follow-up.There is no ideal marker;however,taken together and assembled into a new score or set of criteria may become a future point of reference for reporting outcomes of colorectal cancer surgery in research studies and defining subspecialization requirements both at an individual and hospital level.

Prediction model of stress ulcer after laparoscopic surgery for colorectal cancer established by machine learning algorithm

BACKGROUND Patients with colorectal cancer(CRC)are prone to stress ulcer after laparoscopic surgery.The analysis of risk factors for stress ulcer(SU)in patients with CRC is important to reduce mortality and improve patient prognosis.AIM To identify risk factors for SU after laparoscopic surgery for CRC,and develop a nomogram model to predict the risk of SU in these patients.METHODS The clinical data of 135 patients with CRC who underwent laparoscopic surgery between November 2021 and June 2022 were reviewed retrospectively.They were divided into two categories depending on the presence of SUs:The SU group(n=23)and the non-SU group(n=112).Univariate analysis and multivariate logistic regression analysis were used to screen for factors associated with postoperative SU in patients undergoing laparoscopic surgery,and a risk factor-based nomogram model was built based on these risk factors.By plotting the model's receiver operating characteristic(ROC)curve and calibration curve,a Hosmer-Lemeshow goodness of fit test was performed.RESULTS Among the 135 patients with CRC,23 patients had postoperative SU,with an incidence of 17.04%.The SU group had higher levels of heat shock protein(HSP)70,HSP90,and gastrin(GAS)than the non-SU group.Age,lymph node metastasis,HSP70,HSP90,and GAS levels were statistically different between the two groups,but other indicators were not statistically different.Logistic regression analysis showed that age≥65 years,lymph node metastasis,and increased levels of HSP70,HSP90 and GAS were all risk factors for postoperative SU in patients with CRC(P<0.05).According to these five risk factors,the area under the ROC curve for the nomogram model was 0.988(95%CI:0.971-1.0);the calibration curve demonstrated excellent agreement between predicted and actual probabilities,and the Hosmer-Lemeshow goodness of fit test revealed that the difference was not statistically significant(χ2=0.753,P=0.999),suggesting that the nomogram model had good discrimination,calibration,and stability.CONCLUSION Patients with CRC aged≥65 years,with lymph node metastasis and elevated HSP70,HSP90,GAS levels,are prone to post-laparoscopic surgery SU.Our nomogram model shows good predictive value.

Short- and long-term results of open vs laparoscopic multisegmental resection and anastomosis for synchronous colorectal cancer located in separate segments

BACKGROUND It remains unclear whether laparoscopic multisegmental resection and ana-stomosis(LMRA)is safe and advantageous over traditional open multisegmental resection and anastomosis(OMRA)for treating synchronous colorectal cancer(SCRC)located in separate segments.AIM To compare the short-term efficacy and long-term prognosis of OMRA as well as LMRA for SCRC located in separate segments.METHODS Patients with SCRC who underwent surgery between January 2010 and December 2021 at the Cancer Hospital,Chinese Academy of Medical Sciences and the Peking University First Hospital were retrospectively recruited.In accordance with the RESULTS LMRA patients showed markedly less intraoperative blood loss than OMRA patients(100 vs 200 mL,P=0.006).Compared to OMRA patients,LMRA patients exhibited markedly shorter postoperative first exhaust time(2 vs 3 d,P=0.001),postoperative first fluid intake time(3 vs 4 d,P=0.012),and postoperative hospital stay(9 vs 12 d,P=0.002).The incidence of total postoperative complications(Clavien-Dindo grade:≥II)was 2.9%and 17.1%(P=0.025)in the LMRA and OMRA groups,respectively,while the incidence of anastomotic leakage was 2.9%and 7.3%(P=0.558)in the LMRA and OMRA groups,respectively.Furthermore,the LMRA group had a higher mean number of lymph nodes dissected than the OMRA group(45.2 vs 37.3,P=0.020).The 5-year overall survival(OS)and disease-free survival(DFS)rates in OMRA patients were 82.9%and 78.3%,respectively,while these rates in LMRA patients were 78.2%and 72.8%,respectively.Multivariate prognostic analysis revealed that N stage[OS:HR hazard ratio(HR)=10.161,P=0.026;DFS:HR=13.017,P=0.013],but not the surgical method(LMRA/OMRA)(OS:HR=0.834,P=0.749;DFS:HR=0.812,P=0.712),was the independent influencing factor in the OS and DFS of patients with SCRC.CONCLUSION LMRA is safe and feasible for patients with SCRC located in separate segments.Compared to OMRA,the LMRA approach has more advantages related to short-term efficacy.

Medium-term surgical outcomes and health-related quality of life after laparoscopic vs open colorectal cancer resection: SF-36 health survey questionnaire

BACKGROUND Previous studies that compared the postoperative health-related quality of life(HRQoL)outcomes after receiving laparoscopic resection(LR)or open resection(OR)in patients with colorectal cancer(CRC)have different conclusions.AIM To explore the medium-term effect of postoperative HRQoL in such patients.METHODS This study randomized 567 patients undergoing non-metastatic CRC surgery managed by one surgeon to the LR or OR groups.HRQoL was assessed during the preoperative period and 3,6,and 12 mo postoperative using a modified version of the 36-Item Short Form(SF-36)Health Survey questionnaire,emphasizing eight specific items.RESULTS This cohort randomly assigned 541 patients to receive LR(n=296)or OR(n=245)surgical procedures.More episodes of postoperative urinary tract infection(P<0.001),wound infection(P<0.001),and pneumonia(P=0.048)were encountered in the OR group.The results demonstrated that the LR group subjectively gained mildly better general health(P=0.045),moderately better physical activity(P=0.006),and significantly better social function recovery(P=0.0001)3 mo postoperatively.Only the aspect of social function recovery was claimed at 6 mo,with a significant advantage in the LR group(P=0.001).No clinical difference was found in HRQoL during the 12 mo.CONCLUSION Our results demonstrated that LR resulted in better outcomes,including intra-operative blood loss,surgery-related complications,course of recovery,and especially some health domains of HRQoL at least within 6 mo postoperatively.Patients should undergo LR if there is no contraindication.

Incidence,characteristics and risk factors for alveolar recruitment maneuver-related hypotension in patients undergoing laparoscopic colorectal cancer resection

BACKGROUND Alveolar recruitment maneuvers(ARMs)may lead to transient hypotension,but the clinical characteristics of this induced hypotension are poorly understood.We investigated the characteristics of ARM-related hypotension in patients who underwent laparoscopic colorectal cancer resection.AIM To investigate the characteristics of ARM-related hypotension in patients who underwent laparoscopic colorectal cancer resection.METHODS This was a secondary analysis of the PROtective Ventilation using Open Lung approach Or Not trial and included 140 subjects.An ARM was repeated every 30 min during intraoperative mechanical ventilation.The primary endpoint was ARM-related hypotension,defined as a mean arterial pressure(MAP)<60 mmHg during an ARM or within 5 min after an ARM.The risk factors for hypotension were identified.The peri-ARM changes in blood pressure were analyzed for the first three ARMs(ARM_(1,2,3))and the last ARM(ARMl_(ast)).RESULTS Thirty-four subjects(24.3%)developed ARM-related hypotension.Of all 1027 ARMs,37(3.61%)induced hypotension.More ARMs under nonpneumoperitoneum(33/349,9.46%)than under pneumoperitoneum conditions(4/678,0.59%)induced hypotension(P<0.01).The incidence of hypotension was higher at ARM_(1)points than at non-ARM_(1)points(18/135,13.3%vs 19/892,2.1%;P<0.01).The median percentage decrease in the MAP at ARM1 was 14%.Age≥74 years,blood loss≥150 mL and peak inspiratory pressure under pneumoperitoneum<24 cm H_(2)O were risk factors for ARM-related hypotension.CONCLUSION When the ARM was repeated intraoperatively,a quarter of subjects developed ARM-related hypotension,but only 3.61%of ARMs induced hypotension.ARM-related hypotension most occurred in a hemodynamically unstable state or a hypovolemic state,and in elderly subjects.Fortunately,ARMs that were performed under pneumoperitoneum conditions had less impact on blood pressure.

Effect of screening colonoscopy frequency on colorectal cancer mortality in patients with a family history of colorectal cancer

BACKGROUND Colorectal cancer is a common malignant tumor in China,and its incidence in the elderly is increasing annually.Inflammatory bowel disease is a group of chronic non-specific intestinal inflammatory diseases,including ulcerative colitis and Crohn’s disease.We included the clinicopathological and follow-up data of patients with colorectal cancer who underwent laparoscopic colectomy or open colectomy at our Gastrointestinal Department between January 2019 and December 2022.Surgical indicators,oncological indicators,and survival rates were compared between the groups.The results of 104 patients who met the above criteria were extracted from the database(laparoscopic colectomy group=63,open colectomy group=41),and there were no statistically significant differences in the baseline data or follow-up time between the two groups.RESULTS Intraoperative blood loss,time to first ambulation,and time to first fluid intake were significantly lower in the laparoscopic colectomy group than in the open colectomy group.The differences in overall mortality,tumor-related mortality,and recurrence rates between the two groups were not statistically significant,and survival analysis showed that the differences in the cumulative overall survival,tumor-related survival,and cumulative recurrence-free rates between the two groups were not statistically significant.CONCLUSION In elderly patients with colorectal cancer,laparoscopic colectomy has better short-term outcomes than open colectomy,and laparoscopic colectomy has superior long-term survival outcomes compared with open colectomy.

Impact of anastomotic leakage on long-term prognosis after colorectal cancer surgery

Colorectal cancer(CRC)is one of the most common malignancies in the world.Despite significant improvements in surgical technique,postoperative complications still occur in a fair percentage of patients undergoing colorectal surgery.The most feared complication is anastomotic leakage.It negatively affects shortterm prognosis,with increased post-operative morbidity and mortality,higher hospitalization time and costs.Moreover,it may require further surgery with the creation of a permanent or temporary stoma.While there is no doubt about the negative impact of anastomotic dehiscence on the short-term prognosis of patients operated on for CRC,still under discussion is its impact on the long-term prognosis.Some authors have described an association between leakage and reduced overall survival,disease-free survival,and increased recurrence,while other Authors have found no real impact of dehiscence on long term prognosis.The purpose of this paper is to review all the literature about the impact of anastomotic dehiscence on long-term prognosis after CRC surgery.The main risk factors of leakage and early detection markers are also summarized.

Identification of multiple risk factors for colorectal cancer relapse after laparoscopic radical resection

BACKGROUND Colorectal cancer(CRC)is a common life-threatening disease that often requires surgical intervention,such as laparoscopic radical resection.However,despite successful surgeries,some patients experience disease relapse.Identifying the risk factors for CRC relapse can help guide clinical interventions and improve patient outcomes.AIM To determine the risk factors that may lead to CRC relapse after laparoscopic radical resection.METHODS We performed a retrospective analysis using the baseline data of 140 patients with CRC admitted to our hospital between January 2018 and January 2020.All included participants were followed up until death or for 3 years.The baseline data and laboratory indicators were compared between the patients who experienced relapse and those who did not experienced relapse.RESULTS Among the 140 patients with CRC,30 experienced relapse within 3 years after laparoscopic radical resection and 110 did not experience relapse.The relapse group had a higher frequency of rectal tumors with low differentiation and lymphatic vessel invasion than that of the non-relapse group.The expression of serum markers and the prognostic nutritional index were lower,whereas the neutrophil-to-lymphocyte ratio,expression of cytokeratin 19 fragment antigen 21-1,vascular endothelial growth factor,and Chitinase-3-like protein 1 were significantly higher in the relapse group than those in the non-relapse group.The groups did not differ significantly based on other parameters.Logistic regression analysis revealed that all the above significantly altered factors were independent risk factors for CRC relapse.CONCLUSION We identified multiple risk factors for CRC relapse following surgery,which can be considered for the clinical monitoring of patients to reduce disease recurrence and improve patient survival.

Robotic surgery in elderly patients with colorectal cancer: Review of the current literature

With an ageing global population,we will see an increasing number of elderly patients with colorectal cancer(CRC)requiring surgery.However,it should be recognized that the elderly are a heterogenous group,with varying physiological and functional status.While traditionally viewed to be associated with frailty,comorbidities,and a higher risk of post operative morbidity,the advancements in minimally invasive surgery(MIS)and improvements in perioperative care have allowed CRC surgery to be safe and feasible in the elderly-chronological age alone should therefore not strictly be an exclusion criterion for curative surgery.However,as a form of MIS,laparoscopic assisted colorectal surgery(LACS)has the inherent disadvantages of:(1)Dependence on a trained assistant for retraction and laparoscope control;(2)The loss of wristed movement with reduced dexterity and suboptimal ergonomics;(3)A lack of intuitive movement due to the levering effect of trocars;and(4)An amplification of physiological tremors.Representing a technical evolution of LACS,robotic assisted colorectal surgery was introduced to overcome these limitations.In this minireview,we examine the evidence for robotic surgery in the elderly with CRC.

Bariatric surgery reduces colorectal cancer incidence in obese individuals:Systematic review and meta-analysis

BACKGROUND Colorectal cancer ranks third in global cancer prevalence and stands as the second leading cause of cancer-related mortalities.With obesity recognized as a pivotal risk factor for colorectal cancer,the potential protective role of bariatric surgery,especially laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy,has garnered attention.AIM To investigate the Roux-en-Y gastric bypass(RYGB)vs sleeve gastrectomy(SG)effect on colorectal cancer incidence in obese individuals.METHODS A systematic review and meta-analysis of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.Seventeen studies with a total of 12497322 patients were included.The primary outcome was the relative risk(RR)of developing colorectal cancer in obese patients who underwent weight loss surgery compared to those who did not.Secondary outcomes included determining the RR for colon and rectal cancer separately and subgroup analyses by gender and type of weight loss surgery.RESULTS The meta-analysis revealed a 54%reduction in colorectal cancer risk in morbidly obese patients who underwent bariatric surgery compared to those who did not.A significant 46%reduction in colorectal cancer risk was observed among female patients.However,no significant differences were found in the meta-analysis for various types of bariatric surgery,such as SG and RYGB.CONCLUSION This meta-analysis reveals weight loss surgery,regardless of type,reduces colorectal cancer risk,especially in women,as indicated by RR and hazard ratio assessments.Further validation is essential.

Single-incision laparoscopic colorectal surgery for cancer: State of art

A number of clinical trials have demonstrated that the laparoscopic approach for colorectal cancer resection provides the same oncologic results as open surgery along with all clinical benefits of minimally invasive surgery.During the last years,a great effort has been made to research for minimizing parietal trauma,yet for cosmetic reasons and in order to further reduce surgery-related pain and morbidity.New techniques,such as natural orifice transluminal endoscopic surgery(NOTES)and single-incision laparoscopy(SIL)have been developed in order to reach the goal of"scarless"surgery.Although NOTES may seem not fully suitable or safe for advanced procedures,such as colectomies,SIL is currently regarded as the next major advance in the progress of minimally invasive surgical approaches to colorectal disease that is more feasible in generalized use.The small incision through the umbilicus allows surgeons to use familiar standard laparoscopic instruments and thus,perform even complex procedures which require extraction of large surgical specimens orintestinal anastomosis.The cosmetic result from SIL is also better because the only incision is made through the umbilicus which can hide the wound effectively after operation.However,SIL raises a number of specific new challenges compared with the laparoscopic conventional approach.A reduced capacity for triangulation,the repeated conflicts between the shafts of the instruments and the difficulties to achieve a correct exposure of the operative field are the most claimed issues.The use therefore of this new approach for complex colorectal procedures might understandingly be viewed as difficult to implement,especially for oncologic cases.

Short-and long-term outcomes following laparoscopic vs open surgery for pathological T4 colorectal cancer: 10 years of experience in a single center

AIM To evaluate the short-term and long-term outcomes following laparoscopic vs open surgery for pathological T4(pT 4) colorectal cancer.METHODS We retrospectively analyzed the short-and long-term outcomes of proven p T4 colorectal cancer patients who underwent complete resection by laparoscopic or open surgery from 2006 to 2015 at Guangdong General Hospital.RESULTS A total of 211 p T4 colorectal cancer patients were included in this analysis, including 101 cases in thelaparoscopy(LAP) group and 110 cases in the open surgery(OPEN) group [including 15(12.9%) cases of conversion to open surgery]. Clinical information(age, gender, body mass index, comorbidities, American Society of Anesthesiologists score, etc.) did not differ between the two groups. In terms of blood loss, postoperative complications and rate of recovery, the LAP group performed significantly more favorably(P < 0.05). With regard to p T4 a/b and combined organ resection, there were significantly more cases in the OPEN group(P < 0.05). The 3-and 5-year overall survival rates were 74.9% and 60.5%, respectively, for the LAP group and 62.4% and 46.5%, respectively, for the OPEN group(P = 0.060). The 3-and 5-year disease-free survival rates were 68.0% and 57.3%, respectively, for the LAP group and 55.8% and 39.8%, respectively, for the OPEN group(P = 0.053). Multivariate analysis showed that ⅢB/ⅢC stage, lymph node status, and CA19-9 were significant predictors of overall survival. PT4 a/b, ⅢC stage, histological subtypes, CA19-9, and adjuvant chemotherapy were independent factors affecting disease-free survival.CONCLUSION Laparoscopy is safely used in the treatment of p T4 colorectal cancer while offering advantages of minimal invasiveness and faster recovery. Laparoscopy is able to achieve good oncologic outcomes similar to those of open surgery. We recommend that laparoscopy be carried out in experienced centers. It is still required to screen the appropriate cases for laparoscopic surgery, optimize the preoperative diagnosis process, and reduce the conversion rate. Multi-center, prospective, and large-sample studies are required to assess these issues.

Systematic review of laparoscopic vs open surgery for colorectal cancer in elderly patients

AIM: To verify the safety and validity of laparoscopic surgery for the treatment of colorectal cancer in elderly patients.METHODS: A meta-analysis was performed of a systematic search of studies on an electronic database. Studies that compared laparoscopic colectomy(LAC) in elderly colorectal cancer patients with open colectomy(OC) were retrieved, and their short and long-term outcomes compared. Elderly people were defined as 65 years old or more. Inclusion criteria were set at: Resection of colorectal cancer, comparison between laparoscopic and OC and no significant difference in backgrounds between groups.RESULTS: Fifteen studies were identified for analysis. LAC was performed on 1436 patients, and OC performed on 1810 patients. In analyses of short-term outcomes, operation time for LAC was longer than for OC(mean difference = 34.4162, 95%CI: 17.8473-50.9851, P < 0.0001). The following clinical parameters were lower in LAC than in OC: Amount of estimated blood loss(mean difference =-93.3738, 95%CI:-132.3437 to-54.4039, P < 0.0001), overall morbidity(OR = 0.5427, 95%CI: 0.4425-0.6655, P < 0.0001), incisional surgical site infection(OR = 0.6262, 95%CI: 0.4310-0.9097, P = 0.0140), bowel obstruction and ileus(OR = 0.6248, 95%CI: 0.4519-0.8638, P = 0.0044) and cardiovascular complications(OR = 0.4767, 95%CI: 0.2805-0.8101, P = 0.0062). In analyses of long-term outcomes(median follow-up period: 36.4 mo in LAC, 34.3 mo in OC), there was no significant difference in overall survival(mean difference = 0.8321, 95%CI: 0.5331-1.2990, P = 0.4187) and disease specific survival(mean difference = 1.0254, 95%CI: 0.6707-1.5675, P = 0.9209). There was also no significant difference in the number of dissected lymph nodes(mean difference =-0.1360, 95%CI:-4.0553-3.7833, P = 0.9458).CONCLUSION: LAC in elderly colorectal cancer patients had benefits in short-term outcomes compared with OC except operation time. The long-term outcomes and oncological clearance of LAC were similar to that of OC. These results support the assertion that LAC is an effective procedure for elderly patients with colorectal cancer.

Single-incision laparoscopic surgery for colorectal cancer

AIM: To determine the effect of single-incision laparoscopic colectomy(SILC) for colorectal cancer on short-term clinical and oncological outcomes by comparison with multiport conventional laparoscopic colectomy(CLC).METHODS: A systematic review was performed using MEDLINE for the time period of 2008 to December 2014 to retrieve all relevant literature. The search terms were "laparoscopy", "single incision", "single port", "single site", "SILS", "LESS" and "colorectal cancer". Publications were included if they were randomized controlled trials, case-matched controlled studies, or comparative studies, in which patients underwent single-incision(SILS or LESS) laparoscopic colorectal surgery. Studies were excluded if they were non-comparative, or not including surgery involving the colon or rectum. A total of 15 studies with 589 patients who underwent SILC for colorectal cancer were selected.RESULTS: No significant differences between the groups were noted in terms of mortality or morbidity. The benefit of the SILC approach included reduction in conversion rate to laparotomy, but there were no significant differences in other short-term clinical outcomes between the groups. Satisfactory oncological surgical quality was also demonstrated for SILC for the treatment of colorectal cancer with a similar average lymph node harvest and proximal and distal resection margin length as multiport CLC.CONCLUSION: SILC can be performed safely with similar short-term clinical and oncological outcomes as multiport CLC.

Present laparoscopic surgery for colorectal cancer in Japan

In many clinical studies,laparoscopic surgery(LS) for colon cancer has been shown to be less invasive than open surgery(OS) while maintaining similar safety.Furthermore,there are no significant differences between LS and OS in long-term outcomes.Thus,LS has been accepted as one of the standard treatments for colon cancer.In the treatments of rectal cancer as well,LS has achieved favorable outcomes,with many reports showing long-term outcomes comparable to those of OS.Furthermore,the magnification in laparoscopy improves visualization in the pelvic cavity and facilitates precise manipulation,as well as providing excellent educational effects.For these reasons,rectal cancer has seemed to be well indicated for LS,as has been colon cancer.The indication for LS in the treatment of locally advanced rectal cancer,which is relatively unresectable(e.g.,cancer invading other organs),remains an open issue.In recent years,new techniques such as singleport and robotic surgery have begun to be introduced for LS.Presently,various clinical studies in our country as well as in most Western countries have demonstrated that LS,with these new techniques,are gradually showing long-term outcomes.

Simultaneous laparoscopic multi-organ resection combined with colorectal cancer:Comparison with non-combined surgery

AIM: To access the short-term outcomes of simultaneous laparoscopic surgery combined with resection for synchronous lesions in patients with colorectal cancer. METHODS: Between March 1996 and April 2010 prospectively collected data were reviewed from 93 consecutive patients who had colorectal cancer and underwent simultaneous multiple organ resection (combined group) and 1090 patients who underwent conventional laparoscopic right hemicolectomy or laparoscopic low/ anterior resection for colorectal cancer (non-combined group). In the combined group, there were nine gastric resections, three nephrectomies, nine adrenalectomies, 56 cholecystectomies, and 21 gynecologic resections. In addition, f ive patients underwent simultaneous laparoscopic resection for three organs. The patient demographics, intra-operative outcomes, surgical morbidity, and short-term outcomes were compared between thetwo groups (the combined and non-combined groups). RESULTS: There were no signifi cant differences in the clinicopathological variables between the two groups. The operating time was signifi cantly longer in the combined group than in the non-combined group, regardless of tumor location (laparoscopic right hemicolectomy and laparoscopic low/anterior resection groups; P = 0.048 and P < 0.001, respectively). The other intraoperative outcomes, such as the complications and open conversion rate, were similar in both groups. The rate of post-operative morbidity in the combined group was similar to the non-combined group (combined vs non-combined, 15.1% vs 13.5%, P = 0.667). Oncological safety for the colon and synchronous lesions were obtained in the combined group. CONCLUSION: Simultaneous laparoscopic multiple organ resection combined with colorectal cancer is a safe and feasible option in selected patients.

Is laparoscopic colorectal cancer surgery equal to open surgery? An evidence based perspective

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.

Overview of single-port laparoscopic surgery for colorectal cancers: Past, present, and the future

Single-port laparoscopic surgery(SPLS)is implemented through a tailored minimal single incision through which a number of laparoscopic instruments access.Introduction of operation-customized port system,utilization of a camera without a separate external light,and instruments with different lengths has brought the favorable environment for SPLS.However,performing SPLS still creates several hardships compared to multiport laparoscopic surgery;a single-port system inevitably leads to clashing of surgical instruments due to crowding.To overcome such difficulties,investigators has developed novel concepts and maneuvers,including the concept of inverse triangulation and the maneuvers of pivoting,spreading out dissection,hanging suture,and transluminal traction.The final destination of SPLS is expected to be a completely seamless operation,maximizing the minimal invasiveness.Specimen extraction through the umbilicus can undermine cosmesis by inducing a larger incision.Therefore,hybrid laparoscopic technique,which combined laparoscopic surgical technique with natural orifice specimen extraction(NOSE)-i.e.,transvaginal or transanal route-,has been developed.SPLS and NOSE seemed to be the best combination in pursuit of minimal invasiveness.In the near future,robotic SPLS with natural orifice transluminal endoscopic surgery’s way of specimen extraction seems to be pursued.It is expected to provide a completely or nearly complete seamless operation regardless of location of the lesion in the abdomen.