Comparing short-term outcomes of robot-assisted and conventional laparoscopic total mesorectal excision surgery for rectal cancer in elderly patients

BACKGROUND Da Vinci Robotics-assisted total mesorectal excision(TME)surgery for rectal cancer is becoming more widely used.There is no strong evidence that roboticassisted surgery and laparoscopic surgery have similar outcomes in elderly patients with TME for rectal cancer.AIM To determine the improved oncological outcomes and short-term efficacy of robot-assisted surgery in elderly patients undergoing TME surgery.METHODS A retrospective study of the clinical pathology and follow-up of elderly patients who underwent TME surgery at the Department of Gastrointestinal Oncology at the Affiliated Hospital of Nanjing University of Chinese Medicine was conducted from March 2020 through September 2023.The patients were divided into a robotassisted group(the R-TME group)and a laparoscopic group(the L-TME group),and the short-term efficacy of the two groups was compared.RESULTS There were 45 elderly patients(≥60 years)in the R-TME group and 50 elderly patients(≥60 years)in the L-TME group.There were no differences in demographics,conversion rates,or postoperative complication rates.The L-TME group had a longer surgical time than the R-TME group[145(125,187.5)vs 180(148.75,206.25)min,P=0.005),and the first postoperative meal time in the L-TME group was longer than that in the R-TME(4 vs 3 d,P=0.048).Among the sex and body mass index(BMI)subgroups,the R-TME group had better out-comes than did the L-TME group in terms of operation time(P=0.042)and intraoperative assessment of bleeding(P=0.042).In the high BMI group,catheter removal occurred earlier in the R-TME group than in the L-TME group(3 vs 4 d,P=0.001),and autonomous voiding function was restored.CONCLUSION The curative effect and short-term efficacy of robot-assisted TME surgery for elderly patients with rectal cancer are similar to those of laparoscopic TME surgery;however,robotic-assisted surgery has better short-term outcomes for individuals with risk factors such as obesity and pelvic stenosis.Optimizing the learning curve can shorten the operation time,reduce the recovery time of gastrointestinal function,and improve the prognosis.

Use of artificial intelligence in total mesorectal excision in rectal cancer surgery: State of the art and perspectives

BACKGROUND Colorectal cancer is a major public health problem,with 1.9 million new cases and 953000 deaths worldwide in 2020.Total mesorectal excision(TME)is the standard of care for the treatment of rectal cancer and is crucial to prevent local recurrence,but it is a technically challenging surgery.The use of artificial intelligence(AI)could help improve the performance and safety of TME surgery.AIM To review the literature on the use of AI and machine learning in rectal surgery and potential future developments.METHODS Online scientific databases were searched for articles on the use of AI in rectal cancer surgery between 2020 and 2023.RESULTS The literature search yielded 876 results,and only 13 studies were selected for review.The use of AI in rectal cancer surgery and specifically in TME is a rapidly evolving field.There are a number of different AI algorithms that have been developed for use in TME,including algorithms for instrument detection,anatomical structure identification,and image-guided navigation systems.CONCLUSION AI has the potential to revolutionize TME surgery by providing real-time surgical guidance,preventing complic-ations,and improving training.However,further research is needed to fully understand the benefits and risks of AI in TME surgery.

Laparoscopy-assisted transanal total mesorectal excision for lower rectal cancer:A feasible and innovative technique

BACKGROUND Transanal total mesorectal excision(taTME)is a new technique with many potential technical advantages.Laparoscopy-assisted taTME is a combination of transabdominal taTME and transluminal endoscopic surgery taTME.Laparoscopy-assisted taTME is a combination of techniques such as minimally invasive surgery,intersphincter-assisted resection,natural orifice extraction,ta minimally invasive surgery,and ultralow-level preservation of the anus.AIM To verify the feasibility and safety of an innovative technique of taTME for treatment of cancer located in the lower rectum.METHODS From January 2016 to March 2018,we attempted to perform laparoscopy-assisted taTME surgery in 24 patients with lower rectal cancer.RESULTS The new technique of laparoscopy-assisted taTME was successfully performed in all 24 patients.Mean operating time was 310.0 min and mean intraoperative blood loss was 69.1 mL.The mean time to passing of first flatus was 3.1 d,and mean postoperative hospital stay was 9.2 d.Two patients were given postoperative analgesics due to anal pain.Twenty-three patients were able to walk in first 2 d,and five patients had postoperative complications.CONCLUSION Laparoscopy-assisted taTME is suitable for selected patients with lower rectal cancer,and this technique is worthy of further recommendation.

Robotic transanal total mesorectal excision:Is the future now?

Total mesorectal excision(TME)is the standard surgical treatment for the curative radical resection of rectal cancers.Minimally invasive TME has been gaining ground favored by the continuous technological advancements.New procedures,such as transanal TME(TaTME),have been introduced to overcome some technical limitations,especially in low rectal tumors,obese patients,and/or narrow pelvis.The earliest TaTME reports showed promising results when compared with the conventional laparoscopic TME.However,recent publications raised concerns regarding the high rates of anastomotic leaks or local recurrences observed in national series.Robotic TaTME(R-TaTME)has been proposed as a novel technique incorporating the potential benefits of a perineal dissection together with precise control of the distal margins,and also offers all those advantages provided by the robotic technology in terms of improved precision and dexterity.Encouraging short-term results have been reported for R-TaTME,but further studies are needed to assess the real role of the new technique in the long-term oncological or functional outcomes.The present review aims to provide a general overview of R-TaTME by analyzing the body of the available literature,with a special focus on the potential benefits,harms,and future perspectives for this novel approach.

Simple instruments facilitating achievement of transanal total mesorectal excision in male patients

AIM To assess the efficacy of a modified approach with transanal total mesorectal excision(ta TME) using simple customized instruments in male patients with low rectal cancer.METHODS A total of 115 male patients with low rectal cancer from December 2006 to August 2015 were retrospectively studied. All patients had a bulky tumor(tumor diameter ≥ 40 mm). Forty-one patients(group A) underwent a classical approach of transabdominal total mesorectal excision(TME) and transanal intersphincteric resection(ISR), and the other 74 patients(group B) underwent a modified approach with transabdominal TME,transanal ISR, and ta TME. Some simple instruments including modified retractors and an anal dilator with a papilionaceous fixture were used to perform ta TME. The operative time, quality of mesorectal excision, circumferential resection margin, local recurrence, and postoperative survival were evaluated.RESULTS All 115 patients had successful sphincter preservation. The operative time in group B(240 min, range: 160-330 min) was significantly shorter than that in group A(280 min, range: 200-360 min; P = 0.000). Co m pa r e d w it h g r o up A, m o r e c o m p le t e d is t a l mesorectum and total mesorectum were achieved in group B(100% vs 75.6%, P = 0.000; 90.5% vs 70.7%, P = 0.008, respectively). After 46.1 ± 25.6 mo followup, group B had a lower local recurrence rate and higher disease-free survival rate compared with group A, but these differences were not statistically significant(5.4% vs 14.6%, P = 0.093; 79.5% vs 65.1%, P = 0.130). CONCLUSION Retrograde ta TME with simple customized instruments can achieve high-quality TME, and it might be an effective and economical alternative for male patients with bulky tumors.

Meta-analysis of transanal vs laparoscopic total mesorectal excision of low rectal cancer:Importance of appropriate patient selection

BACKGROUND Achieving a clear resection margins for low rectal cancer is technically challenging.Transanal approach to total mesorectal excision(TME)was introduced in order to address the challenges associated with the laparoscopic approach in treating low rectal cancers.However,previous meta-analyses have included mixed population with mid and low rectal tumours when comparing both approaches which has made the interpretation of the real differences between two approaches in treating low rectal cancer difficult.AIM To investigate the outcomes of transanal TME(TaTME)and laparoscopic TME(LaTME)in patients with low rectal cancer.METHODS A comprehensive systematic review of comparative studies was performed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards.Intraoperative and postoperative complications,anastomotic leak,R0 resection,completeness of mesorectal excision,circumferential resection margin(CRM),distal resection margin(DRM),harvested lymph nodes,and operation time were the investigated outcome measures.RESULTS We included twelve comparative studies enrolling 969 patients comparing TaTME(n=969)and LaTME(n=476)in patients with low rectal tumours.TaTME was associated with significantly lower risk of postoperative complications(OR:0.74,P=0.04),anastomotic leak(OR:0.59,P=0.02),and conversion to an open procedure(OR:0.29,P=0.002)in comparison with LaTME.Moreover,the rate of R0 resection was significantly higher in the TaTME group(OR:1.96,P=0.03).Nevertheless,TaTME and LaTME were comparable in terms of rate of intraoperative complications(OR:1.87;P=0.23),completeness of mesoractal excision(OR:1.57,P=0.15),harvested lymph nodes(MD:-0.05,P=0.96),DRM(MD:-0.94;P=0.17),CRM(MD:1.08,P=0.17),positive CRM(OR:0.64,P=0.11)and procedure time(MD:-6.99 min,P=0.45).CONCLUSION Our findings indicated that for low rectal tumours,TaTME is associated with better clinical and short term oncological outcomes compared to LaTME.More randomised controlled trials are required to confirm these findings and to evaluate long term oncological and functional outcomes.

Real-time in vivo distal margin selection using confocal laser endomicroscopy in transanal total mesorectal excision for rectal cancer

BACKGROUND Transanal total mesorectal excision(TaTME)allows patients with ultralow rectal cancer to be treated with sphincter-saving surgery.However,accurate delineation of the distal resection margin(DRM),which is essential to achieve R0 resection for low rectal cancer in TaTME,is technically demanding.AIM To assess the feasibility of optical biopsy using probe-based confocal laser endomicroscopy(pCLE)to select the DRM during TaTME for low rectal cancer.METHODS A total of 43 consecutive patients who were diagnosed with low rectal cancer and scheduled for TaTME were prospectively enrolled from January 2019 to January 2021.pCLE was used to determine the distal edge of the tumor as well as the DRM during surgery.The final pathological report was used as the gold standard.The diagnostic accuracy of pCLE examination was calculated.RESULTS A total of 86 pCLE videos of 43 patients were included in the analyses.The sensitivity,specificity and accuracy of real-time pCLE examination were 90.00%[95%confidence interval(CI):76.34%-97.21%],86.96%(95%CI:73.74%-95.06%)and 88.37%(95%CI:79.65%-94.28%),respectively.The accuracy of blinded pCLE reinterpretation was 86.05%(95%CI:76.89%-92.58%).Furthermore,our results show satisfactory interobserver agreement(κ=0.767,standard error=0.069)for the detection of cancer tissue by pCLE.There were no positive DRMs(≤1 mm)in this study.The median DRM was 7 mm[interquartile range(IQR)=5-10 mm].The median Wexner score was 5(IQR=3-6)at 6 mo after stoma closure.CONCLUSION Real-time in vivo pCLE examination is feasible and safe for selecting the DRM during TaTME for low rectal cancer(clinical trial registration number:NCT04016948).

Total mesorectal excision with or without preoperative chemoradiotherapy for resectable mid/low rectal cancer: a long-term analysis of a prospective, single-center, randomized trial

Background:The preliminary results of our phase II randomized trial reported comparable functional sphincter pres-ervation rates and short-term survival outcomes between patients undergoing total mesorectal excision(TME)with or without preoperative concurrent chemoradiotherapy(CCRT).We now report the long-term results after a median follow-up of 71 months.Methods:Between March 23,2008 and August 2,2012,192 patients with T3-T4 or node-positive,resectable,mid/low rectal adenocarcinoma were randomly assigned to receive TME with or without preoperative CCRT.The following endpoints were assessed:cumulative rates of local recurrence and distant metastasis,disease-free survival(DFS),and overall survival(OS).Results:The data of 184 eligible patients were analyzed:94 patients in the TME group and 90 patients in the CCRT+TME group.In the whole cohort,the 5-year DFS and OS rates were 84.8%and 85.1%,respectively.The 5-year DFS rates were 85.2%in the CCRT+TME group and 84.3%in the TME group(P=0.969),and the 5-year OS rates were 83.5%in the CCRT+TME group and 86.5%in the TME group(P=0.719).The 5-year cumulative rates of local recur-rence were 6.3%and 5.0%(P=0.681),and the 5-year cumulative rates of distant metastasis were 15.0%and 15.7%(P=0.881)in the CCRT+TME and TME groups,respectively.No significant improvements in 5-year DFS and OS were observed with CCRT by subgroup analyses.Conclusions:Both treatment strategies yielded similar long-term outcomes.A selective policy towards preoperative CCRT is thus recommended for rectal cancer patients if high-quality TME surgery and enhanced chemotherapy can be performed.

Neoadjuvant therapy followed by local excision and two-stage total mesorectal excision:a new strategy for sphincter preservation in locally advanced ultra-low rectal cancer

Background:With the increased usage of neoadjuvant chemoradiotherapy,improved surgical technique and stapling devices,sphincter-preserving resection has become more frequent for patients with rectal cancer.However,as for locally advanced ultra-low rectal cancer,sphincter-preservation is still facing an enormous challenge.Objective:To introduce an NLT strategy of sphincter-preservation-neoadjuvant therapy(NT)followed by local excision(LE)and two-stage total mesorectal excision(TME)-into the treatment of locally advanced ultra-low rectal cancer(lesions with anal sphincter invasion).Methods:From October 2010 to October 2011,nine patients with locally advanced rectal cancer located less than 3 cm from the anal verge were treated by the NLT strategy.All patients had shown good clinical response to NT.The LE procedure was carried transanally 6-8 weeks after completion of the NT.TME was performed to dissect mesorectal lymph nodes 4-6 weeks after LE.Results:Of the nine patients,the lesion was assessed as T2 in two,T3 in five,and T4 in two before NT,and lymph node metastasis was detected in five patients.The median distance from the tumor to the anal verge was 2.5 cm(range:1-3 cm).The median follow-up was 27 months(range:24-34 months).No distant metastasis was detected.Only one patient(11.1%)developed local recurrence at 12 months post-operatively and then underwent abdomino-perineal resection.The remaining eight patients had preserved long-term continence and the median Wexner score at two years post-operation was 4(range:2-6).Conclusion:The new NLT strategy can achieve sphincter-preservation in some patients with ultra-low rectal cancer,with favorable oncological outcome and preservation of normal anal sphincter function.

Management of lateral pelvic lymph nodes in rectal cancer:Is it time to reach an Agreement?

In this editorial,we proceed to comment on the article by Chua et al,addressing the management of metastatic lateral pelvic lymph nodes(mLLN)in stage II/III rectal cancer patients below the peritoneal reflection.The treatment of this nodal area sparks significant controversy due to the strategic differences followed by Eastern and Western physicians,albeit with a higher degree of convergence in recent years.The dissection of lateral pelvic lymph nodes without neoadjuvant therapy is a standard practice in Eastern countries.In contrast,in the West,preference leans towards opting for neoadjuvant therapy with chemoradiotherapy or radiotherapy,that would cover the treatment of this area without the need to add the dissection of these nodes to the total mesorectal excision.In the presence of high-risk nodal characteristics for mLLN related to radiological imaging and lack of response to neoadjuvant therapy,the risk of lateral local recurrence increases,suggesting the appropriate selection of strategies to reduce the risk of recurrence in each patient profile.Despite the heterogeneous and retrospective nature of studies addressing this area,an international consensus is necessary to approach this clinical scenario uniformly.

Feasibility and limitations of combined treatment for lateral pelvic lymph node metastases in rectal cancer

Colorectal cancer ranks among the most commonly diagnosed cancers globally,and is associated with a high rate of pelvic recurrence after surgery.In efforts to mitigate recurrence,pelvic lymph node dissection(PLND)is commonly advocated as an adjunct to radical surgery.Neoadjuvant chemoradiotherapy(NACRT)is a therapeutic approach employed in managing locally advanced rectal cancer,and has been found to increase the survival rates.Chua et al have proposed a combination of NACRT with selective PLND for addressing lateral pelvic lymph node metastases in rectal cancer patients,with the aim of reducing recurrence and improving survival outcomes.Nevertheless,certain studies have indicated that the addition of PLND to NACRT and total mesorectal excision did not yield a significant reduction in local recurrence rates or improvement in survival.Consequently,meticulous patient selection and perioperative chemotherapy may prove indispensable in ensuring the efficacy of PLND.

From basic to clinical:Anatomy of Denonvilliers’fascia and its application in laparoscopic radical resection of rectal cancer

The total mesorectal excision(TME)approach has been established as the gold standard for the surgical treatment of middle and lower rectal cancer.This approach is widely accepted to minimize the risk of local recurrence and increase the long-term survival rate of patients undergoing surgery.However,standardized TME causes urogenital dysfunction in more than half of patients,thus lowering the quality of life of patients.Of note,pelvic autonomic nerve damage during TME is the most pivotal cause of postoperative urogenital dysfunction.The anatomy of the Denonvilliers’fascia(DVF)and its application in surgery have been investigated both nationally and internationally.Nevertheless,controversy exists regarding the basic to clinical anatomy of DVF and its application in surgery.Currently,it is a hotspot of concern and research to improve the postoperative quality of life of patients with rectal cancer through the protection of their urinary and reproductive functions after radical resection.Herein,this study systematically describes the anatomy of DVF and its appli-cation in surgery,thus providing a reference for the selection of surgical treatment modalities and the enhancement of postoperative quality of life in patients with middle and low rectal cancer.

New classification system for radical rectal cancer surgery based on membrane anatomy

BACKGROUND Total mesorectal excision along the“holy plane”is the only radical surgery for rectal cancer,regardless of tumor size,localization or even tumor stage.However,according to the concept of membrane anatomy,multiple fascial spaces around the rectum could be used as the surgical plane to achieve radical resection.AIM To propose a new membrane anatomical and staging-oriented classification system for tailoring the radicality during rectal cancer surgery.METHODS A three-dimensional template of the member anatomy of the pelvis was established,and the existing anatomical nomenclatures were clarified by cadaveric dissection study and laparoscopic surgical observation.Then,we suggested a new and simple classification system for rectal cancer surgery.For simplification,the classification was based only on the lateral extent of resection.RESULTS The fascia propria of the rectum,urogenital fascia,vesicohypogastric fascia and parietal fascia lie side by side around the rectum and form three spaces(medial,middle and lateral),and blood vessels and nerves are precisely positioned in the fascia or space.Three types of radical surgery for rectal cancer are described,as are a few subtypes that consider nerve preservation.The surgical planes of the proposed radical surgeries(types A,B and C)correspond exactly to the medial,middle,and lateral spaces,respectively.CONCLUSION Three types of radical surgery can be precisely defined based on membrane anatomy,including nerve-sparing procedures.Our classification system may offer an optimal tool for tailoring rectal cancer surgery.

Effect of postoperative adjuvant chemotherapyon the prognosis of patients with ypT0-3N0 rectalcancer undergoing neoadjuvant chemoradiotherapy

Objective The aim of this study was to investigate the effect of adjuvant chemotherapy (AC) on theprognosis of patients with ypT0-3N0 rectal cancer undergoing neoadjuvant chemoradiotherapy.Methods The study participants were 110 patients with locally advanced rectal cancer. Thirty-fourpatients did not receive postoperative AC treatment, and the other 76 patients received postoperative ACtreatment. The differences in the 5-year overall survival (OS) and disease-free survival (DFS) between thetwo groups were compared.Results Age was an important determinant of the patients’ decision to undergo postoperative treatment.Patients who did not receive AC treatment were significantly older than those who received AC treatment(P < 0.05). The tumor location (distance above anal margin) in the AC group was significantly larger thanthat in the non-AC group (P < 0.05). Moreover, there was no significant difference in the 5-year DFS andOS between the two groups. Postoperative AC did not significantly improve the prognosis of patients withrectal cancer. Age, tumor differentiation, and the number of resected lymph nodes were independent factorsaffecting the OS of patients (P < 0.05). Older patients, patients with lower degree of tumor differentiation,and patients with <12 resected lymph nodes showed worse prognosis (P < 0.05).Conclusion Patients with rectal cancer whose ypT0-3N0 stage is reduced after neoadjuvantchemoradiotherapy, especially those without adverse prognostic factors, do not need AC after surgery.

Selective lateral lymph node dissection after neoadjuvant chemoradiotherapy in rectal cancer

BACKGROUND Lateral lymph node metastasis is one of the leading causes of local recurrence in patients with advanced mid or low rectal cancer.Neoadjuvant chemoradiotherapy(NCRT)can effectively reduce the postoperative recurrence rate;thus,NCRT with total mesorectal excision(TME)is the most widely accepted standard of care for rectal cancer.The addition of lateral lymph node dissection(LLND)after NCRT remains a controversial topic.AIM To investigate the surgical outcomes of TME plus LLND,and the possible risk factors for lateral lymph node metastasis after NCRT.METHODS This retrospective study reviewed 89 consecutive patients with clinical stage II-III mid or low rectal cancer who underwent TME and LLND from June 2016 to October 2018.In the NCRT group,TME plus LLND was performed in patients with short axis(SA)of the lateral lymph node greater than 5 mm.In the non-NCRT group,TME plus LLND was performed in patients with SA of the lateral lymph node greater than 10 mm.Data regarding patient demographics,clinical workup,surgical procedure,complications,and outcomes were collected.Multivariate logistic regression analysis was performed to evaluate the possible risk factors for lateral lymph node metastasis in NCRT patients.RESULTS LLN metastasis was pathologically confirmed in 35 patients(39.3%):26(41.3%)in the NCRT group and 9(34.6%)in the non-NCRT group.The most common site of metastasis was around the obturator nerve(21/35)followed by the internal iliac artery region(12/35).In the NCRT patients,46%of patients with SA of LLN greater than 7 mm were positive.The postoperative 30-d mortality rate was 0%.Two(2.2%)patients suffered from lateral local recurrence in the 2-year follow up.Multivariate analysis showed that cT4 stage(odds ratio[OR]=5.124,95%confidence interval[CI]:1.419-18.508;P=0.013),poor differentiation type(OR=4.014,95%CI:1.038-15.520;P=0.044),and SA≥7 mm(OR=7.539,95%CI:1.487-38.214;P=0.015)were statistically significant risk factors associated with LLN metastasis.CONCLUSION NCRT is not sufficient as a stand-alone therapy to eradicate LLN metastasis in lower rectal cancer patients and surgeons should consider performing selective LLND in patients with greater LLN SA diameter,poorer histological differentiation,or advanced T stage.Selective LLND for NCRT patients can have a favorable oncological outcome.

Intraoperative use of indocyanine green fluorescence imaging in rectal cancer surgery: The state of the art

Indocyanine green(ICG)fluorescence imaging is widely used in abdominal surgery.The implementation of minimally invasive rectal surgery using new methods like robotics or a transanal approach required improvement of optical systems.In that setting,ICG fluorescence optimizes intraoperative vision of anatomical structures by improving blood and lymphatic flow.The purpose of this review was to summarize all potential applications of this upcoming technology in rectal cancer surgery.Each type of use has been separately addressed and the evidence was investigated.During rectal resection,ICG fluorescence angiography is mainly used to evaluate the perfusion of the colonic stump in order to reduce the risk of anastomotic leaks.In addition,ICG fluorescence imaging allows easy visualization of organs such as the ureter or urethra to protect them from injury.This intraoperative technology is a valuable tool for conducting lymph node dissection along the iliac lymphatic chain or to better identifying the rectal dissection planes when a transanal approach is performed.This is an overview of the applications of ICG fluorescence imaging in current surgical practice and a synthesis of the results obtained from the literature.Although further studies are need to investigate the real clinical benefits,these findings may enhance use of ICG fluorescence in current clinical practice and stimulate future research on new applications.

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide.Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy(total mesorectal excision).This has traditionally been performed transabdominally through an open incision.Over the last thirty years,minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach.There are currently three resective modalities that complement the traditional open operation:(1)Laparoscopic surgery;(2)Robotic surgery;and(3)Transanal total mesorectal excision.In addition,there are several platforms to carry out transluminal local excisions(without lymphadenectomy).Evidence on the various modalities is of mixed to moderate quality.It is unreasonable to expect a randomized comparison of all options in a single trial.This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks,recovery and complications,oncological and functional outcomes.

Neoadjuvant Therapy for Advanced Rectal Carcinoma in China:Whether Radiochemotherapy Is Superior to Radiotherapy?

Objective： To verify whether the 30 Gy preoperative radiotherapy regimen is effective to advanced rectal cancer, and whether the preoperative chemoradiation offers an advantage in sphincter preservation and tumor control compared with irradiation alone. Methods： A total of 141 patients administered neoadjuvant treatment with resectable lower rectal carcinoma from 2002 to 2006 were collected retrospectively. The patients were divided into two groups： preoperative radiotherapy alone （30Gy by 10 fractions） （PRT group） and preoperative chemoradiotherapy （PCRT group）. All patients underwent radical surgery after neoadjuvant treatment. Results： The overall sphincter-preservation rate was 68.8% （97/141）, with no significant difference between the two groups. The overall downstaging rate was 48.2% （68/141）, including 4 patients completely response （2.8%）. The T and N downstaging rate were 30.5% （43/141） and 53.8% （57/106） respectively, showing no statistically difference between the two groups. The 2-year overall survival rate was 93.6%; no survival benefit were observed in PCRT group. The 2-year cumulative local recurrence rates were similar as well （4.2% vs 6.7%, P=0.63）. Two patients with severe marrow suppression higher than grade 3 and 1 patient with severe perineum ulcer was observed in PCRT group, which did not occur in PRT group. Conclusion： The preoperative adjuvant treatment of 30Gy radiotherapy alone may be an optional treatment for Chinese lower rectal carcinoma. Preoperative chemoradiotherapy does not show actual superiority compared with radiotherapy alone.

Special surgical approaches during peri-COVID-19 pandemic:Robotic and transanal minimally invasive surgery

During the peri-coronavirus disease 2019 pandemic,the need of special care has raised,not only for our patients but also for health care workers.These needs are different regarding the procedure and the approach performed.This is a dynamic review in the use of robotics and transanal approaches for colorectal diseases.We searched PubMed and KSREvidence.com for studies related to coronavirus disease and robotic surgery/transanal mesorectal excision/transanal surgery(primary and systematic reviews).From 147 results in PubMed,11 were selected for full text screening,and 11 were included in this paper.From 3 results in KSREvidence,no relevant systematic reviews were identified.We also checked the references in identified papers for further relevant studies.European Society of Coloproctology guidelines were including as part of the recommendations available.Robotic and transanal MIS can be performed safely during the pandemic,but particular characteristics of these procedure need to be taken into consideration.

对比经肛全直肠系膜切除术与腹腔镜全直肠系膜切除术:一项多中心III期随机临床试验(TaLaR试验)方案

背景:全直肠系膜切除术是直肠癌治疗的标准手术方法。经肛全直肠系膜切除术(taTME)是治疗低位直肠癌的新术式。既往研究表明,与腹腔镜全直肠系膜切除术(lapTME)相比,taTME应用于低位直肠癌患者可提供更高质量的手术标本,但其长期肿瘤学结果仍需进一步观察。因此,我们设计了这个非劣效性临床试验(TaLaR试验),比较taTME与lapTME治疗直肠癌的短期和长期结果。方法/设计:TaLaR试验是一项多中心III期随机对照试验。研究对象为经磁共振成像、直肠指检或结肠镜检查被诊断为位于腹膜反折以下的直肠癌,若肿瘤分期≤cT3N2直接手术,若>cT3N2则先行新辅助治疗。通过计算,本研究需纳入1,114例患者(每组557例)。纳入病例随机分配到taTME或lapTME组。本研究的主要终点是3年无病生存率(DFS)和5年总生存率(OS)。次要终点包括手术标本质量、围手术期结果、骨盆和肛门功能以及生活质量。讨论:我们认为,TaLaR试验将阐明taTME是否可以达到与lapTME相似的肿瘤学结果,以及是否可改善直肠癌患者的手术标本质量及恢复情况。