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AIM: Intersphincteric resection (ISR) is an oncologically complex operation for very low-lying rectal cancers. Yet, definition, anatomical description, operative indications and operative approaches to ISR are not standardized. The aim of this study was to standardize the definition of ISR by reaching international consensus from the experts in the field. This standardization will allow meaningful comparison in the literature in the future. METHOD: A modified Delphi approach with three rounds of questionnaire was adopted. A total of 29 international experts from 11 countries were recruited for this study. Six domains with a total of 37 statements were examined, including anatomical definition; definition of intersphincteric dissection, intersphincteric resection (ISR) and ultra-low anterior resection (uLAR); indication for ISR; surgical technique of ISR; specimen description of ISR; and functional outcome assessment protocol. RESULTS: Three rounds of questionnaire were performed (response rate 100%, 89.6%, 89.6%). Agreement (≥80%) reached standardization on 36 statements. CONCLUSION: This study provides an international expert consensus-based definition and standardization of ISR. This is the first study standardizing terminology and definition of deep pelvis/anal canal anatomy from a surgical point of view. Intersphincteric dissection, ISR and uLAR were specifically defined for precise surgical description. Indication for ISR was determined by the rectal tumour's maximal radial infiltration (T stage) below the levator ani. A new surgical definition of T3isp was reached by consensus to define T3 low rectal tumours infiltrating the intersphincteric plane. A practical flowchart for surgical indication for uLAR/ISR/abdominoperineal resection was developed. A standardized ISR surgical technique and functional outcome assessment protocol was defined.
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Neoplasias del Recto , Recto , Humanos , Consenso , Técnica Delphi , Recto/patología , Canal Anal , Neoplasias del Recto/patología , Diafragma Pélvico , Resultado del TratamientoRESUMEN
AIM: To report long-term oncological outcomes and organ preservation rate with a chemoradiotherapy-consolidation chemotherapy (CRT-CNCT) treatment for locally advanced rectal cancer (LARC). METHOD: Retrospective analysis of prospectively maintained database was performed. Oncological outcomes of mid-low LARC patients (n=60) were analyzed after a follow-up of 63 (50-83) months. Patients with clinical complete response (cCR) were treated with the watch-and-wait (WW) protocol. Patients who could not achieve cCR were treated with total mesorectal excision (TME) or local excision (LE). RESULTS: Thirty-nine (65%) patients who achieved cCR were treated with the WW protocol. TME was performed in 15 (25%) patients and LE was performed in 6 (10%) patients. During the follow-up period, 10 (25.6%) patients in the WW group had regrowth (RG) and 3 (7.7%) had distant metastasis (DM). Five-year overall survival (OS) and disease-free survival (DFS) were 90.1% and 71.6%, respectively, in the WW group. Five-year OS and DFS were 94.9% (95% CI: 88-100%) and 80% (95% CI: 55.2-100%), respectively, in the RG group. For all patients (n=60), 5-year TME-free DFS was 57.3% (95% CI: 44.3-70.2%) and organ preservation-adapted DFS was 77.5% (95% CI: 66.4-88.4%). For the WW group (n=39), 5-year TME-free DFS was 77.5% (95% CI: 63.2-91.8%) and organ preservation-adapted DFS was 85.0% (95% CI: 72.3-97.8%). CONCLUSION: CRT-CNCT provides cCR as high as 2/3 of LARC patients. Regrowths, developed during follow-up, can be successfully salvaged without causing oncological disadvantage if strict surveillance is performed.
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Quimioterapia de Consolidación , Neoplasias del Recto , Humanos , Terapia Neoadyuvante , Estudios Retrospectivos , Preservación de Órganos , Espera Vigilante , Recurrencia Local de Neoplasia/terapia , Resultado del Tratamiento , Neoplasias del Recto/patología , QuimioradioterapiaRESUMEN
BACKGROUND: The objective of this study was to determine how long to wait in locally advanced rectal tumor (LARC) patients who receive total neoadjuvant therapy (TNT) and achieve a clinical complete response (cCR), and to identify the clinical parameters that affect the waiting period for the watch-and-wait strategy (W &W). MATERIALS AND METHODS: The data of patients who achieved cCR between February 2015 and June 2020 were examined retrospectively. The week in which patients with cCR at the end of TNT achieved clearance was determined by reanalyzing recorded endoscopy video images. In the assessment at the time of the initial diagnosis, tumor characteristics, such as digital rectal examination findings, MRI stage, location with respect to the puborectalis muscle, annularity, and tumor size, were recorded prospectively. RESULTS: A total of 54 patients were included in this study. According to the MRI-T stage, 14 cases were cT3a, 22 were cT3b, and 18 were cT3c-T4. Forty-four percent of the cases achieved cCR at 8-10 weeks, 19% at 12-16 weeks, 20% at 16-22 weeks, and 17% at 20-26 weeks. Patients with tumors that were early MRI-T stage (cT3a), negative clinical circumferential resection margin, mobile, small (≤4 cm), located above the puborectalis muscle and showed <180 degrees annularity achieved cCR significantly earlier than those with other tumors (p<0.05). CONCLUSION: In this study, cCR was achieved in less than half (44%) of the cases during the 8-10 week waiting period. In the W&W strategy, the initial assessment for cCR seems insufficient, and we may need to wait up to 26-30 weeks, especially in patients with advanced-stage tumors.
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Quimioradioterapia , Neoplasias del Recto , Quimioradioterapia/métodos , Humanos , Recurrencia Local de Neoplasia , Neoplasias del Recto/tratamiento farmacológico , Neoplasias del Recto/terapia , Estudios Retrospectivos , Resultado del Tratamiento , Espera Vigilante/métodosRESUMEN
INTRODUCTION: Laparoscopic rectal resection with total mesorectal excision is a technically challenging procedure, and there are limitations in conventional laparoscopy. A surgical robotic system may help to overcome some of the limitations. The aim of our study was to compare long-term oncological outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision in male patients with mid-low rectal cancer. MATERIALS AND METHODS: The study was conducted as a retrospective review of a prospectively maintained database. One-hundred-three robotic and 84 laparoscopic sphincter-saving total mesorectal excisions were performed by a single surgeon between January 2011 and January 2020. Patient characteristics, perioperative recovery, postoperative complications, pathology results, and oncological outcomes were compared between the two groups. RESULTS: The patients' characteristics did not differ significantly between the two groups. Median operating time was longer in the robotic than in the laparoscopic group (180 minutes versus 140 minutes, p=0.033). Macroscopic grading of the specimen in the robotic group was complete in 96 (93.20%), near complete in four (3.88%) and incomplete in three (2.91%) patients. In the laparoscopic group, grading was complete in 37 (44.04%), near complete in 40 (47.61%) and incomplete in seven (8.33%) patients (p=0.03). The median length of follow up was 48 (9-102) months in the robotic, and 75.6 (11-113) months in the laparoscopic group. Overall, five-year survival was 87% in the robotic and 85.3% in the laparoscopic groups. Local recurrence rates were 3.8% and 7.14%, respectively, in the robotic and laparoscopic groups (p<0.05). CONCLUSION: Sphincter-saving robotic total mesorectal excision is a safe and feasible tool, which provides good mesorectal integrity and better local control in male patients with mid-low rectal cancer.
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Laparoscopía , Neoplasias del Recto , Procedimientos Quirúrgicos Robotizados , Humanos , Masculino , Recurrencia Local de Neoplasia , Neoplasias del Recto/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: The development of new surgical techniques and devices, as well as the improvements in neoadjuvant chemoradiotherapy enabled intersphincteric resection (ISR), has reduced permanent colostomy usage. The aim of this study was to assess the long-term oncological and functional outcomes of patients who underwent partial ISR for rectal cancer located less than 5cm from the anal verge. MATERIALS AND METHODS: A series of 106 consecutive patients with very low rectal cancer underwent curative partial ISR from January 2006 to September 2019 were retrospectively evaluated. One-hundred-three (97%) of 106 patients received neoadjuvant chemo-radiotherapy. Overall survival (OS), disease-free survival (DFS), and local recurrence (LR) rates were calculated using Kaplan-Meier methods. The Wexner incontinence score and Kirwan classification were used to evaluate patients' functional results. RESULTS: The median follow up was 60 months (range, 18-174). The estimated five-year overall and disease-free survival rates were 89% and 81.6%, respectively. Five-year local recurrence and distant metastasis rates were 6.6% and 10.4%, respectively. There was no in-hospital and 30-day mortality. The median Wexner score was 9 (range, 0-20) for 72 patients. Age (<65 years, p=0.027) and gender (male, p=0.019) had a positive effect on functional outcomes after surgery. One and five years colostomy-free survival rates were 96% and 89%, respectively. CONCLUSION: Intersphincteric resection techniques are feasible for patients with very low rectal cancer, providing good oncological and functional outcomes.
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Neoplasias del Recto , Anciano , Canal Anal/cirugía , Anastomosis Quirúrgica , Humanos , Masculino , Neoplasias del Recto/cirugía , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: A robotic surgical approach provides advantages compared to laparoscopy in male patients with mid- and low-lying rectal cancer located in the narrow pelvic space. The aim of this report is to present a single-surgeon experience with robotic sphincter-saving total mesorectal excision of rectal cancer in male patients. METHODS: A series of 103 consecutive male patients who underwent robotic rectal surgery between January 2012 and June 2019 were analyzed retrospectively in terms of demographics, histopathological data, and surgical and oncological outcomes. RESULTS: All of the patients underwent robotic sphincter-saving resection: 76 (73.8%) underwent low-anterior resection and 27 (26.2%) underwent intersphincteric resection with colo-anal anastomosis. There was no conversion. The median distal resection margin of the operative specimen was 3 (0.2-7) cm. The circumferential resection margin was positive in 3 (2.91%) cases. The median number of retrieved lymph nodes was 22 (18-42). The median hospital stay was 4 (3-16) days. Whereas the overall morbidity was 13%, there was no in-hospital or 30-day mortality. The median length of follow-up was 48 (9-80) months. The 5-year overall survival rate was 87%. The 5-year disease-free survival rate was 84%. Local and distant recurrence rates were 3.8% and 5.82%, respectively. CONCLUSIONS: In male patients with rectal cancer, a robotic approach is a promising alternative and is expected to overcome the low penetration rate of laparoscopy in this field.
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Laparoscopía , Neoplasias del Recto , Procedimientos Quirúrgicos Robotizados , Cirujanos , Canal Anal/cirugía , Humanos , Masculino , Recurrencia Local de Neoplasia , Neoplasias del Recto/epidemiología , Neoplasias del Recto/cirugía , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
The current therapeutic approach to patients with locally advanced rectal cancer is neoadjuvant radiotherapy or chemoradiotherapy followed by total mesorectal excision. We aimed to investigate the number, size, and distribution of metastatic and nonmetastatic lymph nodes within the mesorectum; whether neoadjuvant therapy has any impact on the number and size of the lymph nodes; and the impact of metastatic lymph node localization on overall and disease-free survival. Specimens from 50 consecutive patients with stage II/III rectal cancer receiving either neoadjuvant radiotherapy or chemoradiotherapy were investigated. Lymph node dissection was carried out by careful visual inspection and palpation. The localization of the each lymph node within the mesorectum and the relation with the tumor site were noted. The size and the number of lymph nodes retrieved decreased significantly with neoadjuvant therapy. Majority of the metastatic and nonmetastatic lymph nodes were located at or proximally to the tumor level and posterior side of the mesorectum. No relation was observed between the overall and disease-free survival, and the localization of the metastatic lymph nodes. Presence of lymph node metastases proximal to the tumor level has no impact on survival compared with the presence of lymph node metastasis only in the peritumoral region of the mesorectum. Although neoadjuvant therapy decreases the size and the number of lymph nodes, reaching an ideal number of lymph nodes for accurate staging is still possible with careful naked eye examination and dissection of perirectal fat. As the majority of metastatic and nonmetastatic lymph nodes are located in peritumoral and proximal compartment, and posterior side of the mesorectum, these regions should be the major interest of dissection.
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Adenocarcinoma/patología , Ganglios Linfáticos/efectos de los fármacos , Ganglios Linfáticos/efectos de la radiación , Metástasis Linfática/patología , Terapia Neoadyuvante/métodos , Neoplasias del Recto/patología , Adenocarcinoma/mortalidad , Adenocarcinoma/terapia , Adulto , Anciano , Anciano de 80 o más Años , Quimioradioterapia , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Escisión del Ganglio Linfático/métodos , Ganglios Linfáticos/patología , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias/métodos , Radioterapia , Neoplasias del Recto/mortalidad , Neoplasias del Recto/terapiaRESUMEN
OBJECTIVE: We aimed to evaluate the effect of intraperitoneal cetuximab administration on the healing of anastomosis and development of early adhesion formation in a rat model. MATERIALS AND METHODS: Twenty-four female rats were used. A colon segment was resected and end-to-end anastomosis was performed. The rats were randomized into three groups after the performance of colonic anastomosis and received 10 mL of intraperitoneal solution including study drugs after closure of abdominal cavity: normal saline was administered to the normal saline group (n=8), cetuximab (400 mg/m(2)) was administered to the postoperative 1 group (n=8) 1 day after surgery, and cetuximab (400 mg/m(2)) was administered to the peroperative group (n=8) during surgery. RESULTS: The mean adhesion grade was 2.63±0.92, and 0.50±0.76 and 0.63±0.74 for control and test groups, respectively. Cetuximab reduced adhesion formation in test groups (p<0.05). When all groups were compared, it was found that vascular endothelial growth factor levels decreased significantly only in the abdomen (p<0.05). Hydroxyproline levels and anastomosis bursting pressure were examined, and a statistical difference was found between groups (hydroxyproline p<0.05, bursting pressure p<0.05). However, when postoperative 1 day group was compared with the control group, it was found that there was no difference between groups according to these parameters (p>0.05), but when peroperative group was compared with the control group a significant decrease was observed in both parameters. Histopathological healing score was also evaluated. No statistical difference between groups was found. CONCLUSION: Twenty-four hours later from the operation, intraperitoneal cetuximab therapy may be a safe and feasible treatment for metastatic colorectal patients.
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The objective of this study was to evaluate the clinical significance of serum ADP-ribosylation and NAD glycohydrolase activity in patients with colorectal cancer (CRC). A total of 108 patients with CRC who underwent curative surgery and 20 healthy volunteers were enrolled in this study. ADP-ribosylation and NAD glycohydrolase activity levels were determined. The association of ADP-ribosylation and NAD glycohydrolase with clinical and laboratory factors and their impact on overall survival (OS) and disease free survival (DFS) were shown. The preoperative ADP-ribosylation and NAD glycohydrolase activity levels were significantly higher in patients with CRC than in the control group (p<0.001). ADP-ribosylation and NAD glycohydrolase activity levels were correlated with tumor stage (p=0.05, p=0.001), stage of disease (p<0.001, p<0.001), serum CEA level (p<0.001, p<0.001), and site of lesion (p<0.001, p<0.001), respectively. Patients with high ADP-ribosylation had significantly unfavorable OS and DFS compared with those with lower levels (p<0.001, p<0.001), respectively. Moreover, the patients with high NAD glycohydrolase activity showed significantly worse OS and DFS rates, similar to ADP-ribosylation. Serum levels of ADP-ribosylation and NAD glycohydrolase activity correlate well with tumor stage, stage of disease, serum CEA level, and site of lesion. In conclusion, elevated levels of preoperative ADP-ribosylation and NAD glycohydrolase levels in serum are associated with poor prognosis in patients with CRC.
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Adenosina Difosfato/metabolismo , Neoplasias Colorrectales/mortalidad , NAD+ Nucleosidasa/sangre , Adulto , Anciano , Anciano de 80 o más Años , Antígeno Carcinoembrionario/sangre , Neoplasias Colorrectales/metabolismo , Neoplasias Colorrectales/patología , Supervivencia sin Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estadificación de NeoplasiasRESUMEN
Although there's growing information about the long-term oncological effects of robotic surgery for rectal cancer, the procedure is still relatively new. This study aimed to assess the long-term oncological results of total mesorectal excision (TME) performed laparoscopically versus robotically in the setting of rectal cancer. Restrospective analysis of a prospectively maintained database. A total of 489 laparoscopic (L-TME) and 183 robotic total mesorectal excisions (R-TME) were carried out by a single surgeon between 2013 and 2023. The groups were compared in terms of perioperative and long-term oncological outcomes. In the R-TME and L-TME groups, male sex predominated (75.4% and 57.3%, respectively), although the robotic group was significantly greater (p = 0.008). There was no conversion in R-TME group, whereas three (0.6%) converted to open surgery in L-TME group. The R-TME group had a statistically significant higher number of distal rectal tumors (85%) compared to the L-TME group (54.6%). Only three (1.7%) patients in the R-TME group received abdomineperineal resection (APR); in contrast, 25 (5%) patients in the L-TME group received APR (p < 0.001). For R-TME, the mean follow-up was 70.7 months (range 18-138) and for L-TME, it was 60 months (range 14-140). Frequency of completed mesorectum was significantly greater in R-TME group (98.9% vs 94.2%, p < 0.001). The 5 year overall survival rates for R-TME and L-TME groups were 89.6% and 88.7%, respectively. The 5 year disease-free survival for R-TME and L-TME groups were 84.1% and 81.1%, respectively. The local recurrences rates were 7.6% and 6.3%, respectively in R-TME and L-TME groups (p = 0.274). R-TME is characterized by no conversion and improved mesorectal integrity. R-TME had longer operation time. The long-term oncological outcomes were comparable between groups.
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Laparoscopía , Neoplasias del Recto , Procedimientos Quirúrgicos Robotizados , Humanos , Masculino , Procedimientos Quirúrgicos Robotizados/métodos , Estudios Retrospectivos , Resultado del Tratamiento , Laparoscopía/métodosRESUMEN
The treatment role of Total Mesorectal Excision (TME) in proximal rectal cancers (PRC) is still debated. Partial Mesorectal Excision (PME) can reduce morbidity in PRC patients. The purpose of this study was to compare short-term clinical and long-term oncological outcomes between the two groups. A total of 157 PRC patients were enrolled in this study (114 performed with PME and 43 with TME). The two groups were compared in terms of perioperative and long-term oncological outcomes. The overall postoperative complications rate was higher in TME group (18.4% vs. 32.5%, p < 0.05). The incidence of diverting ileostomy was also significantly higher in TME group (86.0% vs. 2.6%, p < 0.001). Overall survival rates for 3, 5, and 7 years in PME and TME group accordingly were: 94.6%, 89.3%, 81.5% and 93.2%, 87.6%, 78.4% (p = 0.324). Disease-free survival rates for 3, 5, and 7 years in PME and TME group were: 90.2%, 84.5%, 78.6% and 88.7%, 81.2%, 75.3% (p = 0.297), respectively. Local recurrence rates for 3, 5, and 7 years in PME and TME group were: 2.6%, 6.1%, 8.8% and 4.6%, 9.3%, 11.2% (p = 0.061), respectively. PME is feasible and can be safely performed in PRC patients with favorable oncological outcomes. TME is associated with increasing risk of surgical complications and requires a two-step surgery for stoma takedown.
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AIMS: To assess the efficacy of extended lymph node dissection in gastric cancer and to identify factors affecting lymph node detection. METHODS: A prospective study of 126 gastric cancer patients was conducted. Patients eligible for curative resection received total gastrectomy and extended lymphadenectomy (D2) and paraaortic lymph node sampling as the standard of care (study group). Supramesocolic total lymphadenectomy of the upper gastrointestinal tract was performed on 23 autopsy cases as a control group. RESULTS: Fifty-five gastric carcinoma patients were included in the study group. Median age was 58 years (range 31-80 years); 14 patients were female (25%), and 41 were male (75%). The median number of lymph nodes harvested from the specimen was 47 (24-95), and the median number of metastatic lymph nodes was 15 (1-71). In contrast, in the autopsy comparative group, the median number of harvested lymph nodes was 72 (50-91). The median number of stational lymph nodes excised (lymph nodes excised from stations 4, 5, 10, 11, 12, and 16) was significantly higher in the control group than in the study group (P<0.05). Lymph node detection was adversely affected by body mass index (BMI) (P<0.03). In the study group, stations 5, 12, 11, and 10 had the highest lymph node absence (LNA) (noncompliance) ratio with percentages of 53, 36, 33, and 22%, respectively. In the autopsy group, LNA (noncompliance) was not detected. CONCLUSIONS: Lymph nodes should be dissected by surgeons with sufficient technical and anatomical experience, and then examined and counted by experienced pathologists to reduce the occurrence of LNA. The results of this anatomical study can serve as a guideline to assess the success of lymph node dissection during gastric cancer surgery. Similar studies should be conducted in every country to establish national guidelines.
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Carcinoma/cirugía , Escisión del Ganglio Linfático/normas , Neoplasias Gástricas/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Aorta , Autopsia , Índice de Masa Corporal , Carcinoma/secundario , Distribución de Chi-Cuadrado , Femenino , Gastrectomía , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Estudios Prospectivos , Estadísticas no Paramétricas , Neoplasias Gástricas/patologíaRESUMEN
BACKGROUND: Few reports have demonstrated the feasibility and efficacy of laparoscopic resection in patients with rectal cancer (RC). The objective of the present study was to assess the effectiveness of laparoscopic resection for RC, with an emphasis on perioperative variables and long-term oncological outcomes. METHODS: This prospective study was carried out between January 2005 and September 2010 and included 513 patients diagnosed with RC who underwent laparoscopic surgery. Patients with locally advanced RC (cT3/cT4 or N+) received neoadjuvant treatment. Adjuvant treatment was applied to patients with stage II/III disease or according to the neoadjuvant protocol. All patients were followed-up prospectively for the evaluation of complications and oncological outcome. Survival rate analysis was performed using the Kaplan-Meier method. RESULTS: Sphincter-preserving surgery was performed on 389 patients, and the remaining 124 patients underwent abdominoperineal resection. Perioperative mortality occurred in only one patient (0.2 %), and 27 (5.3 %) intraoperative complications were recorded. The most common postoperative complication was anastomotic leakage (5.5 %). The conversion rate was 6.4 %. The mean number of harvested lymph nodes was 23.6 ± 13. The mean distance to the distal margin was 2.6 ± 1.9 (0-7) cm. Distal margin positivity was detected in 9 (1.7 %) patients. The circumferential margin was positive in 39 (7.6 %) cases. After a median follow-up period of 30 (1-78) months, recurrence occurred in a total of 59 patients (11.5 %). Local recurrence was detected in 16 patients (3.1 %), and both local and distant recurrence was found in 7 patients (1.4 %). Distant recurrence only was detected in 43 patients (8.4 %). The overall 5-year survival rate was 84 %, and the 5-year disease-free survival rate was 77.4 %. The local recurrence-free survival rate was 98.4 % at 2 years, 95.7 % at 3 years, and 94.3 % at 5 years. CONCLUSIONS: Our results, together with the review of the literature, clearly demonstrate that laparoscopic resection for RC is a feasible method at specialized high-volume centers. The long-term outcomes are at least as good as those from open surgery as long as the principles of oncologic surgery are respected and faithfully performed.
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Laparoscopía , Neoplasias del Recto/cirugía , Recto/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Quimioradioterapia Adyuvante , Conversión a Cirugía Abierta/estadística & datos numéricos , Estudios de Factibilidad , Femenino , Estudios de Seguimiento , Humanos , Complicaciones Intraoperatorias/epidemiología , Laparoscopía/métodos , Laparoscopía/mortalidad , Escisión del Ganglio Linfático , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante , Metástasis de la Neoplasia , Recurrencia Local de Neoplasia/epidemiología , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Neoplasias del Recto/mortalidad , Neoplasias del Recto/patología , Neoplasias del Recto/terapia , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
AIM: The purpose of this study is to investigate the effect of intraperitoneal (IP) bevacizumab on colonic anastomosis and evaluate the effects on early postoperative adhesion formation. MATERIALS AND METHODS: A total of 24 mature female Sprague-Dawley rats were used for this study. Rats were randomly assigned to a control group that received saline (n = 8) or to experimental groups (n = 8 each) that received bevacizumab at a dose of 2.5 mg/kg (group 1) or 5 mg/kg (group 2). Animals were killed humanely on the seventh day after operation, and measurements of anastomotic strength and biochemical variables were performed. RESULTS: The mean adhesion grade was 2.63 ± 0.92, and 1 ± 0.93 and 0.75 ± 0.71 for the control and test groups, respectively. Bevacizumab significantly reduced adhesion formation in both low-dose and high-dose IP applications (P < .05). When all groups were compared, it was found that VEGF levels decreased significantly only in the tissue (P = .001), whereas there was no significant difference in the blood and the IP fluid (P = .73 and .08, respectively). We evaluated hydroxyproline levels, anastomosis bursting pressure, and histopathological healing scores. When each of these parameters were examined, there was statistical difference between groups (P = .01, .004, and .01, respectively). It was found that these parameters significantly decreased depending on increasing drug dose. CONCLUSION: IP administration of bevacizumab effectively reduced the formation of adhesions and caused significant impairment of anastomotic wound healing when standard doses were administered (5 mg/kg), but the 2.5-mg/kg dosage did not affect the anastomotic wound healing and also effectively reduced the formation of adhesions.
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Anastomosis Quirúrgica/métodos , Anticuerpos Monoclonales Humanizados/administración & dosificación , Adherencias Tisulares/prevención & control , Anastomosis Quirúrgica/efectos adversos , Animales , Bevacizumab , Fenómenos Biomecánicos/efectos de los fármacos , Femenino , Inyecciones Intraperitoneales , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/prevención & control , Distribución Aleatoria , Ratas , Ratas Sprague-Dawley , Adherencias Tisulares/tratamiento farmacológico , Adherencias Tisulares/etiología , Factor A de Crecimiento Endotelial Vascular/metabolismoRESUMEN
The aim of this study was to compare perioperative and long-term oncological outcomes between laparoscopic sphincter-preserving total mesorectal excision in female patients (F-Lap-TME) and robotic sphincter-preserving total mesorectal excision in male patients (M-Rob-TME) with mid-low rectal cancer (RC). A retrospective analysis of a prospectively maintained database was performed. 170 cases (F-Lap-TME: 60 patients; M-Rob-TME: 110 patients) were performed by a single surgeon (January 2011-January 2020). Clinical characteristics did not differ significantly between the two groups. Operating time was longer in M-Rob-TME than in F-Lap-TME group (185.3 ± 28.4 vs 124.5 ± 35.8 min, p < 0.001). There was no conversion to open surgery in both groups. Quality of mesorectum was complete/near-complete in 58 (96.7%) and 107 (97.3%) patients of F-Lap-TME and M-Rob-TME (p = 0.508), respectively. Circumferential radial margin involvement was observed in 2 (3.3%) and 3 (2.9%) in F-Lap-TME and M-Rob-TME patients (p = 0.210), respectively. Median length of follow-up was 62 (24-108) months in the F-Lap-TME and 64 (24-108) months in the M-Rob-TME group. Five-year overall survival rates were 90.5% in the F-Lap-TME and 89.6% in the M-Rob-TME groups (p = 0.120). Disease-free survival rates in F-Lap-TME and M-Rob-TME groups were 87.5% and 86.5% (p = 0.145), respectively. Local recurrence rates were 5% (n = 3) and 5.5% (n = 6) (p = 0.210), in the F-Lap-TME and M-Rob-TME groups, respectively. The robotic technique can potentially overcome some technical challenges related to the pelvic anatomical difference between sex compared to laparoscopy. Laparoscopic and robotic approach, respectively in female and male patients provide similar surgical specimen quality, perioperative outcomes, and long-term oncological results.
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Laparoscopía , Neoplasias del Recto , Procedimientos Quirúrgicos Robotizados , Humanos , Masculino , Femenino , Neoplasias del Recto/cirugía , Resultado del Tratamiento , Estudios Retrospectivos , Canal Anal/cirugíaRESUMEN
BACKGROUND: This study aimed to compare perioperative, long-term oncological, and anorectal functional outcomes of robotic total mesorectal excision (R-TME) and laparoscopic total mesorectal excision (L-TME) sphincter-saving total mesorectal excision in female patients with rectal cancer. METHODS: Retrospective analysis of prospectively maintained database was performed. Sixty-eight cases (L-TME, n = 34; R-TME, n = 34) were performed by a single surgeon (January 2014-January 2019). Patient characteristics, perioperative recovery, postoperative complications, pathology results, and oncological outcomes were compared between the two groups. RESULTS: Clinical characteristics did not differ between the groups. Mean operating time was longer in R-TME (165.50 ± 95.50 vs. 124.50 ± 82.60 min, p < 0.001). There was no conversion to open surgery in both groups. Mesorectal integrity was complete in both groups (100%). Length of distal and circumferential resection margins (CRM) did not differ between groups. CRM involvement was observed in 1 (2.8%) and 1 (2.8%) in L-TME and R-TME patients, respectively. Incidence of anastomotic leakage was 5.8% (n = 2) in L-TME and 8.8% (n = 3) in R-TME, respectively. Mean length of follow-up was 62.5 (36-102) months for R-TME and 63 (36-103) months for L-TME. Five-year overall survival rates were 92.8% in L-TME and 89.6% in R-TME. Disease-free survival rates were 87.5% in L-TME and 89.6% in R-TME. Local recurrence rates were 3.0% for both groups. Mean Wexner score for L-TME and R-TME patients was: 9.42 ± 8.23 and 9.22 ± 3.64 (p = 0.685), respectively. Daily stool frequency was similar between groups. CONCLUSION: Robotic total mesorectal excision (R-TME) and laparoscopic TME (L-TME) have similar perioperative, oncological, and anorectal functional results in female patients with rectal cancer. The robotic approach for rectal cancers in female patients could be not as critical as for male patients.
Asunto(s)
Laparoscopía , Neoplasias del Recto , Procedimientos Quirúrgicos Robotizados , Robótica , Humanos , Masculino , Femenino , Procedimientos Quirúrgicos Robotizados/métodos , Estudios Retrospectivos , Laparoscopía/métodos , Robótica/métodos , Neoplasias del Recto/patología , Resultado del TratamientoRESUMEN
BACKGROUND: The aim of this study was to evaluate apoptotic (Bcl-2, Bax expression, caspase-3 activity, and cytochrome-c) and angiogenic (MMP-9 levels and VEGF expression) markers in operable rectal cancer patients who were treated with preoperative chemoradiotherapy (CRT) followed by total mesorectal excision (TME). Understanding these factors will facilitate the identification of potential pathological responders before treatment, leading to better local control and survival rates. METHODS: Between March 2006 and March 2008, 29 patients withTNM Stage III (cT3 N+) mid or low rectal cancer were included in this study. Our sample consisted of 17 males (58.6%) and 12 females (41.4%). The median age was 60 years (range 24-88 years). Biopsy samples were taken from different portions of the tumors using flexible endoscopy before neoadjuvant CRT. Preoperatively, all patients received radiation (45-50.4 gray (Gy) in 25 cycles with concurrent 5-florouracil (5-FU) chemotherapy. RESULTS: A complete response was observed in 7 of 29 patients (24%). Bax staining was negative in 1 of the 7 patients (14%) in the pathological complete response (PCR) group and in 18 of the 22 patients (82%) in the no pathological complete response (noPCR) group (p = 0.001). MMP-9 and VEGF levels were higher in the noPCR group than the PCR group (p = 0.04, p = 0.05 respectively). No statistically significant differences were found between VEGF and MMP-9 levels in nodal downstaging. No statistically significant relationships were found between the other apoptotic factors (Bcl 2, cytochrome-c, and caspase-3 activity) and pathological response rate (p > 0.05). CONCLUSION: In neoadjuvant CRT patients, high levels of Bax expression and low levels of VEGF and MMP-9 expression on preoperative biopsies indicate that the patient will potentially be a good pathological responder.
RESUMEN
The aim of this study was to determine the superiority between the robotic da Vinci Si® (Si group) and da Vinci Xi® (Xi group) generation in patients with mid-low rectal cancer. Between December 2011 and December 2017, 88 patients with mid-low rectal cancer were operated on using the Si robotic system, from January 2018 to May 2021, 62 more patients with mid-low rectal cancer were operated on using the Xi robotic system. Perioperative and postoperative short-term outcomes were compared between the two groups. Univariate and multivariate Cox-regression analysis were performed to determine factors affecting operating time. A cumulative sum (CUSUM) analysis was also performed to determine the learning curve of the primary surgeon. All patients underwent sphincter saving total mesorectal excision (TME). The overall operating time was significantly shorter in the Xi group (181.3 ± 31.8 min in Si group vs 123.6 ± 25.7 min in the Xi group, p < 0.001). There were no significant differences in terms of conversion rates, mean hospital stays, complications and histopathologic data. CUSUM analysis show completion of learning curve in 44th case of Si group. Univariate and multivariate analysis demonstrated that the learning curve of the primary surgeon (p < 0.001) and the type of robotic system (Xi) are only two factors associated with operating time (OR, 95% CI p; 3.656, 0.665-9.339, p < 0.001). Our study found that the robotic da Vinci Xi systems provide significantly shorter operating time comparing with Si systems, when performing sphincter-preserving TME in mid-low rectal cancer patients. Surgical system (da Vinci Xi) and primary surgeon learning curve are two independent risk factors which associated shortened operating time. Postoperative complication rates and histopathologic outcomes are similar in both groups.
Asunto(s)
Neoplasias del Recto , Procedimientos Quirúrgicos Robotizados , Humanos , Procedimientos Quirúrgicos Robotizados/métodos , Resultado del Tratamiento , Neoplasias del Recto/cirugía , Tiempo de Internación , Curva de Aprendizaje , Estudios RetrospectivosRESUMEN
Aim of this study was to compare operative, long-term oncological and functional outcomes of laparoscopic (LISR) and robotic (RISR) intersphincteric resection in low-lying rectal cancer. Retrospective analysis of prospectively maintained database was performed. 115 cases (LISR, n = 55; RISR, n = 60) were performed by a single surgeon (January 2011-January 2020). Clinical characteristics did not differ between the groups. Operating time was longer in RISR (160.0 ± 45.7 vs. 205.0 ± 36.5 min, p = 0.035). There was no conversion in RISR, whereas in LISR, two patients (3.6%) converted to open surgery. Complete mesorectum was 61.8% and 83.3% for LISR and RISR (p = 0.046), respectively. Circumferential radial margin involvement was 10.9% and 8.3% in LISR and RISR (p = 0.365), respectively. Median follow-up was 82.8 (30-138) months for LISR and 83.6 (30-138) months for RISR. Three-, five-, and seven-year overall survival rates (OS) for LISR and RISR were: 88.6%, 80.4%, 73.4% and 90.4%, 86.3%, 76.9%, respectively. Three-, five-, and seven-year disease-free survival (DFS) rates for LISR and RISR were 80.5%, 75.2%, 70.4% and 84.4%, 81.4%, 79.8% (p = 0.328), respectively. Three-, five-, and seven-year local recurrence-free survival rates in LISR and RISR were: 96.1%, 92.6%, 88.4% and 96.7%, 94.2%, 90.4% (p = 0.573), respectively. Mean Wexner score for LISR (n = 32) and RISR (n = 40) was: 10.5 ± 4.7 and 9.8 ± 4.2 (p = 0.782), respectively. Colostomy-free survival in LISR and RISR was: 3 years 94.5%/95.2%, 5 years 89.1%/91.7%, and 7 years 83.6%/85.0%. RISR is associated with better mesorectal integrity, no conversion, and lower postoperative complication rate. RISR has longer operation time. Oncological and anorectal functional outcomes are similar in both groups.
Asunto(s)
Laparoscopía , Neoplasias del Recto , Procedimientos Quirúrgicos Robotizados , Robótica , Humanos , Estudios Retrospectivos , Neoplasias del Recto/cirugía , Resultado del TratamientoRESUMEN
Acute rectal ischemia is a rare entity because the rectum has abundant blood supply from the inferior mesenteric, internal iliac, internal pudendal, and marginal artery with rich collaterals. We present a case of an acute ischemic proctosigmoiditis with a history of rectal cancer who completely recovered after total neoadjuvant treatment and was in the "watch-and-wait" protocol. Urgent laparoscopic low anterior resection and protective ileostomy were performed. Causes of acute rectosigmoid ischemia include old age, diabetes, atherosclerosis, previous aortic surgery due to aneurysm, vasculitis, and radiotherapy. Ischemia may be present as only involving the mucosa, which can be managed conservatively, but full-thickness necrosis requires urgent surgical intervention. Endoscopic examination is the gold standard in initial diagnosis. Ischemic gangrene of the rectosigmoid colon is a rare condition and can be life-threatening unless an urgent surgical intervention is performed.