Successful patient-oriented surgical outcomes in robotic vs laparoscopic right hemicolectomy for cancer - a systematic review.

AIM: Minimally invasive surgical approaches for cancer of the right colon have been well described with significant patient and equivalent oncological benefits. Robotic surgery has advanced in its ability to provide multi-quadrant abdominal access, leading the surgical community to widen its application outside of the pelvis to other abdominal compartments. Globally it is being realized that a patient's surgical episode of care is becoming the epicentre of cancer treatment. In order to establish the role of robotic surgery in a patient's episode of care, 'successful patient-oriented surgical' parameters in right hemicolectomy for malignancy were measured. The objective was to examine the rates of successful patient-oriented surgical outcomes in robotic right hemicolectomy (RRH) compared to laparoscopic right hemicolectomy (LRH) for cancer. METHODS: A systematic search of MEDLINE (Ovid: 1946-present), PubMed (NCBI), Embase (Ovid: 1966-present) and Cochrane Library was conducted using PRISMA for parameters of successful patient-oriented surgical outcomes in RRH and LRH for malignancy alone. The parameters measured included postoperative ileus, anastomotic complication, surgical wound infection, length of stay (LOS), incisional hernia rate, conversion to open, margin status, lymph node harvest and overall morbidity and mortality. RESULTS: There were 15 studies which included 831 RRH patients and 3241 LRH patients, with a median age of 62-74 years. No study analysed the concept of successful patient-oriented surgical outcomes. There was no significant difference in the incidence of postoperative ileus, with less time to first flatus in RRH (2.0-2.7 days, compared with 2.5-4.0 days, P < 0.05). Anastomotic leak rate in one study reported a significant increase in LRH compared to RRH (P < 0.05, 0% vs 8.3%). Significantly decreased LOS following RRH was outlined in six studies. One study reported a significantly higher rate of incisional hernias following LRH with extracorporeal anastomoses compared to RRH with intracorporeal anastomoses. Overall rates of conversion to open surgery were less with RRH (0%-3.9% vs 0%-18%, P < 0.001, 0.05). One study outlined significantly higher rates of incomplete resection with an open right hemicolectomy compared with minimally invasive laparoscopic and robotic resections, with positive margin rates of 2.3%, 0.9% and 0% respectively (P < 0.001). Two studies reported significantly higher lymph node harvest in RRH (P < 0.05). Overall morbidity and 30-day mortality were comparable in both approaches. CONCLUSION: Thirty-day morbidity and mortality were comparable between the two approaches, with patients undergoing RRH having lower anastomotic complications, increased lymph node harvest, and reduced LOS, conversion to open and incisional hernia rates in a number of studies. There are limited data on surgical approach and impact on quality of life and what patients deem successful surgical outcomes. There is a further need for a randomized controlled trial examining successful patient-oriented outcomes in right hemicolectomy for malignancy.

Transanal endoscopic microsurgery for carcinoma of the rectum.

BACKGROUND: The authors present their experience with rectal cancers managed by transanal endoscopic microsurgery (TEM). METHODS: This prospective study investigated patients undergoing primary TEM excision for definitive treatment of rectal cancer between January 1996 and December 2003 by a single surgeon in a tertiary referral colorectal surgical unit. RESULTS: For this study, 52 patients (30 men and 22 women) underwent TEM excision of a rectal cancer. Their mean age was 74.3 years (range, 48-93 years). The median diameter of the lesions was 3.44 cm (range, 1.6-8.5 cm). The median distance of the lesions from the anal verge was 8.8 cm (range, 3-15 cm), with the tumor more than 10 cm from the anal verge in 36 patients. The median operating time was 90 min (range, 20-150 min), and the median postoperative stay was 2 days. All patients underwent full-thickness excisions. There were 11 minor complications, 2 major complications, and no deaths. The mean follow-up period was 40 months (range, 22-82 months). None of the pT1 rectal cancers received adjuvant therapy. Eight patients with pT2 rectal cancer and two patients with pT3 rectal cancer received postoperative adjuvant therapy. The overall local rate of recurrence was 14%, and involved cases of T2 and T3 lesions, with no recurrence after excision of T1 cancers. Three patients died during the follow-up period, but no cancer-specific deaths occurred. CONCLUSIONS: The findings warrant the conclusion that TEM is a safe, effective treatment for selected cases of rectal cancer, with low morbidity and no mortality. The TEM procedure broadens the range of lesions suitable for local resection to include early cancers (pTis and pT1) and more advanced cancers only in frail people.

Cost analysis of transanal endoscopic microsurgery for rectal tumours.

OBJECTIVE: Transanal endoscopic microsurgery (TEM) is considered to be a safe and effective treatment for selected rectal neoplasms. We demonstrate that in addition to the recognized clinical benefits of the less invasive TEM approach, there are substantial economic benefits. METHOD: We reviewed our prospective database of patients undergoing TEM excision of a rectal lesion between July 1997 and December 2003. A cost analysis was undertaken, including procedural and related costs of TEM and compared with the relevant open procedures. RESULTS: 124 patients (80 men, 44 women) with a median age of 71.5 years underwent TEM excision of rectal lesions (52 cancers and 72 adenomas). The morbidity rate was 8% and mortality was zero. A controlled case series of 52 patients undergoing open resection for early rectal cancers with similar characteristics as above was compared in terms of clinical outcome. The morbidity rate in these patients was 29.5%. The cost analysis comparison was undertaken using National Health Service mean reference costs for major large intestinal surgery, Intensive care unit/high dependency unit and hospital accommodation for each procedure. The average cost of open resection was 4135 pound, vs 567 pound for TEM excision. Our total saving over the series was 525,576 pound. Although the initial capital cost of the TEM equipment is high at approximately 40,000 pound given the massive cost savings, these initial equipment costs are recovered within a rapid time frame. CONCLUSION: This study has shown that TEM is a safe and extremely cost-effective approach for excision of selected rectal tumours including rectal adenomas and early well differentiated rectal cancers (pTis & pT1).

Endoscopic mucosal resection (EMR) in the management of large colo-rectal polyps.

BACKGROUND: Colonoscopic polypectomy plays a major role in preventing colo-rectal cancer. However, resection of sessile, broad-based pedunculated and flat lesions carries a high risk of perforation. Endoscopic Mucosal Resection (EMR) may significantly reduce this risk. We aim to assess the safety and efficacy of EMR in our unit. PATIENTS AND METHODS: A review of a prospective database over a 3-year period identified 87 patients who underwent endoscopic polypectomy for polyps in sizes from 10 to 50 mm, performed by two experienced endoscopists. A total of 33 EMRs were performed on 30 lesions in 24 of these patients. RESULTS: Median size of lesions was 20 mm. Most were located in the rectum and sigmoid. 22 lesions were resected en-bloc while 8 were resected piecemeal. Histologically these lesions were predominantly adenomatous polyps. An incidental focus of adenocarcinoma was found in 7 lesions. Histologically complete excision was achieved in 10 lesions. Although histological completeness of excision was not confirmed in 19 lesions, repeat colonoscopy confirmed successful excision. Only one lesion was incompletely excised requiring surgical resection. Bleeding occurred during 2 EMRs, both times successfully controlled by further injection of adrenaline locally. There was no case of bowel perforation. Further surveillance colonoscopy was performed according to established guidelines. Median follow-up period was 21 months. None of the patients diagnosed with adenocarcinoma showed any evidence of recurrence. CONCLUSION: Within our unit endoscopic mucosal resection appeared to be safe and effective procedure for resecting large colorectal polyps not suitable for conventional polypectomy. This data would support prompt referral of lesions fulfilling these criteria to specialist units offering this service to avoid unnecessary surgery.

Randomized clinical trial of suction versus standard clearance of the diathermy plume.

BACKGROUND: Diathermy smoke contains complex hydrocarbons and organic material, and may contain viable tumour cells or viral particles. These particles measure from 0.05 to more than 25 microm, and long-term exposure to such particles may have adverse effects on health. This study investigated whether a suction clearance device reduces the amount of smoke reaching the surgeon's mask. METHODS: This was a randomized clinical trial in which subjects were randomized to standard diathermy equipment (group 1) or a diathermy smoke extraction system (group 2). All patients underwent thyroid or parathyroid surgery with standard anterior cervical collar incision and division of the strap muscles. The difference in the amount of smoke reaching the level of the operator's mask was measured by means of an aerosol monitor. RESULTS: Fifteen patients were randomized to each group. The mean amount of smoke detected at the level of the operator's mask was 0.137 mg/m(3) in group 1 and 0.012 mg/m(3) in group 2 (P < 0.001). The maximum amount detected was 2.411 and 0.255 mg/m(3) respectively (P < 0.001). There were no significant differences between the groups in terms of incision time or background particles measured before and after surgery. There was no correlation between gland weight and incision time or amount of smoke detected. CONCLUSION: Suction clearance of the diathermy plume resulted in a significant reduction in the amount of smoke reaching the level of the operator's mask. Although the risk of diathermy smoke inhalation is currently unknown, use of such a system appears advisable.