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

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World Journal of Gastrointestinal Surgery 2024年第5期16卷 1271-1279页

作者： Hao Yang Gang Yang Wen-Ya Wu Fang Wang Xue-Quan Yao Xiao-Yu Wu The Affiliated Hospital of Nanjing University of Chinese Medicine Nanjing University of Chinese MedicineNanjing 210029Jiangsu ProvinceChina Department of Surgical Oncology The Affiliated Hospital of Nanjing University of Chinese MedicineNanjing 210029Jiangsu ProvinceChina

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

关键词： Robotic surgery Laparoscopy Rectal cancer total mesorectal excision Elderly

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

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World Journal of Gastrointestinal Surgery 2022年第12期14卷 1397-1410页

作者： Pratik Bhattacharya Ishaan Patel Noureen Fazili Shahab Hajibandeh Shahin Hajibandeh Department of Surgery Sandwell and West Birmingham Hospitals NHS TrustBirmingham B714HJUnited Kingdom Department of Surgery Queen Elizabeth Hospital BirminghamBirmingham B152GWUnited Kingdom Department of Surgery University Hospital of WalesCardiff CF144XWUnited Kingdom Department of Surgery Royal Stoke University HospitalStoke-on-Trent ST46QGUnited Kingdom

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

关键词： total mesorectal excision Laparoscopic Transanal Rectal cancer

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

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World Journal of Gastroenterology 2017年第31期23卷 5798-5808页

作者： Chang Xu Hua-Yu Song Shao-Liang Han Shi-Chang Ni Hu-Xiang Zhang Chun-Gen Xing Department of General Surgery the Second Affiliated Hospital of Soochow University Department of Colorectal Surgery the First Affiliated Hospital of Wenzhou Medical University Department of Pathology the First Affiliated Hospital of Wenzhou Medical University

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.

关键词： Rectal neoplasm total mesorectal excision Transanal approach Intersphincteric resection Longterm outcome Local recurrence

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

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World Journal of Gastrointestinal Oncology 2021年第1期13卷 12-23页

作者： Ying-Jie Li Lin Wang Ting-Ting Sun Ai-Wen Wu Gastrointestinal Cancer Center Unit III Beijing Cancer Hospital and Beijing Institute for Cancer ResearchBeijing 100142China Department of Gastrointestinal Surgery Key Laboratory of Carcinogenesis and Translational Research(Ministry of Education)Beijing Cancer Hospital and Beijing Institute for Cancer ResearchBeijing 100142China

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.

关键词： Laparoscopy-assisted total mesorectal excision Technique Lower rectal cancer Trans-abdominal Trans-anus

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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

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Gastroenterology Report 2014年第1期2卷 37-43页

作者： Ting Wang Jianping Wang Yanhong Deng Xiaojian Wu Lei Wang Department of Colorectal Surgery The Sixth Affiliated Hospital(The Gastrointestinal&Anal Hospital)of Sun Yat-sen UniversityGuangzhouChina Department of Oncology The Sixth Affiliated Hospital of Sun Yat-sen UniversityGuangzhouChina

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.

关键词： rectal cancer sphincter-preservation neoadjuvant therapy local excision total mesorectal excision

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

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Artificial Intelligence in Gastroenterology 2023年第3期4卷 64-71页

作者： Vinicio Mosca Giacomo Fuschillo Guido Sciaudone Kapil Sahnan Francesco Selvaggi Gianluca Pellino Department of Advanced Medical and Surgical Sciences Universitàdegli Studi della Campania“Luigi Vanvitelli”Napoli 80138Italy Department of Medicine and Health Sciences“Vincenzo Tiberio” University of MoliseCampobasso 86100Italy Department of Colorectal Surgery St Mark’s HospitalLondon HA13UJUnited Kingdom Department of Surgery and Cancer Imperial College LondonLondon SW75NHUnited Kingdom Colorectal Surgery Vall d’Hebron University HospitalBarcelona 08035Spain

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.

关键词： Artificial intelligence Machine learning Rectal cancer total mesorectal excision Colorectal surgery

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Robotic transanal total mesorectal excision:Is the future now?

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World Journal of Gastrointestinal Surgery 2021年第8期13卷 834-847页

作者： Juan Carlos Sebastián-Tomás Aleix Martínez-Pérez Elías Martínez-López Nicola de'Angelis Marcos Gómez Ruiz Eduardo García-Granero Department of Surgery Universidad de ValenciaValencia 46010Spain Department of General and Digestive Surgery Hospital Universitario Doctor PesetValencia 46017Spain Faculty of Health Sciences Valencian International UniversityValencia 46002Spain Minimally Invasive and Robotic Digestive Surgery Unit Miulli HospitalAcquaviva delle Fonti 70021Italy Department of General and Digestive Surgery Hospital Universitario Marqués de ValdecillaSantander 39008Spain Grupo de Investigación en Innovación Quirúrgica Instituto de Investigación Biomédica Valdecilla(IDIVAL)Santander 39008Spain Department of General and Digestive Surgery Hospital Universitarioy Politécnico la FeValencia 46026Spain

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.

关键词： Rectal cancer Minimally-invasive surgery Robotics total mesorectal excision Transanal approach Natural orifice surgery

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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

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Cancer Communications 2018年第1期38卷 773-782页

作者： Fulong Wang Wenhua Fan Jianhong Peng Zhenhai Lu Zhizhong Pan Liren Li Yuanhong Gao Hui Li Gong Chen Xiaojun Wu Peirong Ding Zhifan Zeng Desen Wan Sun Yat-sen University Cancer Center State Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineGuangzhou 510060GuangdongP.R.China Department of Colorectal Surgery Sun Yat-sen University Cancer Center651 Dongfeng Road EastGuangzhou 510060GuangdongP.R.China Department of Radiation Oncology Sun Yat-sen University Cancer CenterGuangzhou 510060GuangdongP.R.China Department of Gynecological Oncology Sun Yat-sen Memorial HospitalSun Yat-sen UniversityGuangzhou 510060GuangdongP.R.China

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.

关键词： Rectal cancer total mesorectal excision Chemoradiotherapy Long-term outcomes Phase II randomized trial

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

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World Journal of Clinical Oncology 2024年第4期15卷 472-477页

作者： Sigfredo E Romero-Zoghbi Fernando López-Campos Felipe Couñago Department of Radiation Oncology GenesisCareTalavera de la Reina 45600ToledoSpain Department of Radiation Oncology Hospital Universitario Ramón Y CajalMadrid 28034Spain Department of Radiation Oncology GenesisCare-Hospital Universitario Vithas Madrid La MilagrosaMadrid 28010Spain

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.

关键词： Rectal cancer Lateral pelvic lymph node metastases Pelvic lymph node dissection total neoadjuvant therapy Selective management of the lateral pelvic nodes Prophylactic management of the lateral pelvic nodes Chemoradiotherapy total mesorectal excision

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

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World Journal of Clinical Oncology 2024年第5期15卷 591-593页

作者： Ying-Zi Zheng Fang-Fang Yan Lian-Xiang Luo The First Clinical College Guangdong Medical UniversityZhanjiang 524023Guangdong ProvinceChina The Marine Biomedical Research Institute Guangdong Medical UniversityZhanjiang 524000Guangdong ProvinceChina

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.

关键词： Rectal cancer Lateral pelvic lymph nodes metastases Pelvic lymph node dissection Neoadjuvant chemoradiotherapy total mesorectal excision

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