Long-term clinical outcomes after high and low ligations with lymph node dissection around the root of the inferior mesenteric artery in patients with rectal cancer.

PURPOSE: This study aimed to evaluate the long-term clinical outcomes based on the ligation level of the inferior mesenteric artery (IMA) in patients with rectal cancer. METHODS: This was a retrospective analysis of a prospectively collected database that included all patients who underwent elective low anterior resection for rectal cancer between January 2013 and December 2019. The clinical outcomes included oncological outcomes, postoperative complications, and functional outcomes. The oncological outcomes included overall survival (OS) and relapse-free survival (RFS). The functional outcomes, including defecatory and urogenital functions, were analyzed using the Fecal Incontinence Severity Index, International Prostate Symptom Score, and International Index of Erectile Function questionnaires. RESULTS: In total, 545 patients were included in the analysis. Of these, 244 patients underwent high ligation (HL), whereas 301 underwent low ligation (LL). The tumor size was larger in the HL group than in the LL group. The number of harvested lymph nodes (LNs) was higher in the HL group than in the LL group. There were no significant differences in complication rates and recurrence patterns between the groups. There were no significant differences in 5-year RFS and OS between the groups. Cox regression analysis revealed that the ligation level (HL vs. LL) was not a significant risk factor for oncological outcomes. Regarding functional outcomes, the LL group showed a significant recovery in defecatory function 1 year postoperatively compared with the HL group. CONCLUSION: LL with LNs dissection around the root of the IMA might not affect the oncologic outcomes comparing to HL; however, it has minimal benefit for defecatory function.

Exfoliate cancer cell analysis in rectal cancer surgery: comparison of laparoscopic and transanal total mesorectal excision, a pilot study.

PURPOSE: Minimally invasive surgery (MIS) is currently the standard treatment for rectal cancer. However, its limitations include complications and incomplete total mesorectal resection (TME) due to anatomical features and technical difficulties. Transanal TME (TaTME) has been practiced since 2010 to improve this, but there is a risk of local recurrence and intra-abdominal contamination. We aimed to analyze samples obtained through lavage to compare laparoscopic TME (LapTME) and TaTME. METHODS: From June 2020 to January 2021, 20 patients with rectal cancer undergoing MIS were consecutively and prospectively recruited. Samples were collected at the start of surgery, immediately after TME, and after irrigation. The samples were analyzed for carcinoembryonic antigen (CEA) and cytokeratin 20 (CK20) through a quantitative real-time polymerase chain reaction. The primary outcome was to compare the detected amounts of CEA and CK20 immediately after TME between the surgical methods. RESULTS: Among the 20 patients, 13 underwent LapTME and 7 underwent TaTME. Tumor location was lower in TaTME (7.3 cm vs. 4.6 cm, P=0.012), and negative mesorectal fascia (MRF) was more in LapTME (76.9% vs. 28.6%, P=0.044). CEA and CK20 levels were high in 3 patients (42.9%) only in TaTME. There was 1 case of T4 with incomplete purse-string suture and 1 case of positive MRF with dissection failure. All patients were followed up for an average of 32.5 months without local recurrence. CONCLUSION: CEA and CK20 levels were high only in TaTME and were related to tumor factors or intraoperative events. However, whether the detection amount is clinically related to local recurrence remains unclear.

Anastomotic leakage after resection of the rectosigmoid colon in primary ovarian cancer.

BACKGROUND: The aim of the study is to evaluate the risk factors of anastomotic leakage (AL) and develop a nomogram to predict the risk of AL in surgical management of primary ovarian cancer. METHODS: We retrospectively reviewed 770 patients with primary ovarian cancer who underwent surgical resection of the rectosigmoid colon as part of cytoreductive surgery between January 2000 to December 2020. AL was defined based on radiologic studies or sigmoidoscopy with relevant clinical findings. Logistic regression analyses were performed to identify the risk factor of AL, and a nomogram was developed based on the multivariable analysis. The bootstrapped-concordance index was used for internal validation of the nomogram, and calibration plots were constructed. RESULTS: The incidence of AL after resection of the rectosigmoid colon was 4.2% (32/770). Diabetes (OR 3.79; 95% CI, 1.31-12.69; p = 0.031), co-operation with distal pancreatectomy (OR, 4.8150; 95% CI, 1.35-17.10; p = 0.015), macroscopic residual tumor (OR, 7.43; 95% CI, 3.24-17.07; p = 0<001) and anastomotic level from the anal verge shorter than 10 cm (OR, 6.28; 95% CI, 2.29-21.43; p = 0.001) were significant prognostic factors for AL on multivariable analysis. Using four variables, the nomogram has been developed to predict anastomotic leakage: https://ALnomogram.github.io/ . CONCLUSION: Four risk factors for AL after resection of the rectosigmoid colon are identified from the largest ovarian cancer study cohort. The nomogram from this information provides a numerical risk probability of AL, which could be used in preoperative counseling with patients and intraoperative decision for accompanying surgical procedures and prophylactic use of ileostomy or colostomy to minimize the risk of postoperative leakage. TRIAL REGISTRATION: Retrospectively registered.

Stratification of rate of lymph node metastasis according to risk factors and oncologic outcomes in patients who underwent radical resection for rectal neuroendocrine tumors.

PURPOSE: Most predictive factors for lymph node metastasis in rectal neuroendocrine tumors (NETs) have been based on local and endoscopic resection. We aimed to evaluate the risk factors for lymph node metastasis in patients who underwent radical resection for rectal NETs and stratify the risk of lymph node metastasis. METHODS: Sixty-four patients who underwent radical resection for rectal NETs between January 2001 and January 2018 were included. We investigated the risk factors of lymph node metastasis using clinicopathologic data. We also performed a risk stratification for lymph node metastases using the number of previously known risk factors. For oncologic outcomes, the 5-year overall survival and recurrence-free survival were evaluated in both groups. RESULTS: Among the patients who underwent radical surgery, 32 (50.0%) had lymph node metastasis and 32 (50.0%) had non-lymph node metastasis. In the multivariable analysis, only the male sex was identified as a risk factor for lymph node metastasis (odds ratio, 3.695; 95% confidence interval, 1.128-12.105; P=0.031). When there were 2 or more known risk factors, the lymph node metastasis rate was significantly higher than when there were one or no risk factors (odds ratio, 3.667; 95% confidence interval, 1.023-13.143; P=0.046). There was also no statistical difference between the 2 groups in 5-year overall survival (P=0.431) and 5-year recurrence-free survival (P=0.144). CONCLUSION: We found that the rate of lymph node metastasis increased significantly when the number of known risk factors is 2 or more.

Facile Surface Treatment of 3D-Printed PLA Filter for Enhanced Graphene Oxide Doping and Effective Removal of Cationic Dyes.

The structured adsorption filter material is one of the ways to enhance the practical applicability of powdered adsorbents, which have limitations in the real water treatment process due to difficulty in the separation process. In this study, three-dimensional (3D) printing technology was applied to prepare filter materials for water treatment processes. A 3D-printed graphene-oxide (GO)-based adsorbent is prepared on a polylactic acid (PLA) scaffold. The surface of the PLA scaffold was modified by subjecting it to strong alkaline or organic solvent treatment to enhance GO doping for realizing effective adsorption of cationic dye solutions. When subjected to 95% acetone treatment, the structural properties of PLA changed, and particularly, two main hydrophilic functional groups (carboxylic acids and hydroxyls) were newly formed on the PLA through cleavage of the ester bond of the aliphatic polyester. Owing to these changes, the roughness of the PLA surface increased, and its tensile strength decreased. Meanwhile, its surface was doped mainly with GO, resulting in approximately 75% methylene blue (MB) adsorption on the 3D-printed GO-based PLA filter. Based on the established optimal pretreatment conditions, a kinetic MB sorption study and an isotherm study were conducted to evaluate the 3D-printed GO-based PLA filter. The pseudo-second-order model yielded the best fit, and the MB adsorption was better fitted to the Langmuir isotherm. These results suggested that chemical adsorption was the main driver of the reaction, and monolayer sorption occurred on the adsorbent surface. The results of this study highlight the importance of PLA surface modification in enhancing GO doping and achieving effective MB adsorption in aqueous solutions. Ultimately, this study highlights the potential of using 3D printing technology to fabricate the components required for implementing water treatment processes.

The risk of surgical site infection of oral sulfate tablet versus sodium picosulfate for bowel preparation in colorectal cancer surgery: a randomized clinical trial.

Purpose: Oral sulfate tablets are abundantly used for bowel preparation before colonoscopy. However, their efficiency and safety for bowel preparation before colorectal surgery remain ill-defined. Herein, we aimed to compare the surgical site infection rates and efficiency between oral sulfate tablets and sodium picosulfate. Methods: We designed a prospective, randomized, phase 2 clinical trial. Patients with colorectal cancer aged 19-75 years who underwent elective bowel resection and anastomosis by minimally invasive surgery were administered oral sulfate tablets or sodium picosulfate. Eighty-three cases were analyzed from October 2020 to December 2021. Surgical site infection within 30 days after surgery was considered the primary endpoint. Postoperative morbidities, the degree of bowel cleansing, and tolerability were the secondary endpoints. Results: Surgical site infection was detected in 1 patient (2.5%) in the oral sulfate tablet group and 2 patients (4.7%) in the sodium picosulfate group, indicating no significant difference between the 2 groups. Postoperative morbidity and the degree of bowel cleansing bore no statistically significant differences. Furthermore, none of the investigated tolerability criteria, namely bloating, pain, nausea, vomiting, and discomfort, differed significantly between the 2 groups. The patients' willingness to reuse the drug was also not significantly different between the 2 groups. Conclusion: Although we could not establish the noninferiority of oral sulfate tablets to sodium picosulfate, we found no evidence suggesting that oral sulfate tablets are less safe or tolerable than sodium picosulfate in preoperative bowel preparation.

Assessment of the learning curve for the novel transanal minimally invasive surgery simulator model.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) is technically demanding and requires extensive training. We developed the TAMIS simulator model by remodeling an existing laparoscopic training system to educate trainees and analyzed their learning curves. METHODS: Between March 2020 and June 2020, 12 trainees performed TAMIS simulator training sessions. The total operative time, including specimen removal and wound closure, was recorded. The wound closure and specimen quality, trainee self-confidence, and supervisor evaluation of technical performance were documented. A moving average was used to analyze the number of training sessions required to stabilize the procedure time, while a cumulative sum analysis was performed to identify that required to reach proficiency with each item. RESULTS: Each trainee completed 20 TAMIS simulator training sessions. The median total procedure time was 13 min (range, 4-60 min), which stabilized after 15 training sessions. The median times for specimen removal and wound closure were 3 min (range, 1-18 min) and 10 min (range, 2-50 min), respectively, which stabilized after 7 and 15 training sessions, respectively. The mean specimen and wound closure quality scores were 2.9 ± 0.9 (on a scale from 1 to 4) and 2.3 ± 1.1 (on a scale from 1 to 4), respectively, competencies in which were achieved after 16 and 20 training sessions, respectively. The mean trainee self-confidence and supervisor evaluation of technical performance scores were 2.4 ± 1.2 (on a scale from 1 to 5) and 2.7 ± 1.2 (on a scale from 1 to 5), respectively, competencies in which were achieved after 20 and 17 training sessions, respectively. CONCLUSION: Trainees required 15 training sessions to stabilize the procedure time and 16-20 training sessions to demonstrate competencies with the TAMIS simulator model. We expect this simulator model may help surgeons more rapidly acquire the skills required for TAMIS.

Efficacy and Safety of Endoscopic Clipping for Acute Anastomotic Bleeding After Colorectal Surgery.

PURPOSE: Anastomotic bleeding after colorectal surgery is a rare, mostly self-limiting, postoperative complication that could lead to a life-threatening condition. Therefore, prompt management is required. This study aimed to evaluate the efficacy and safety of endoscopic clipping for acute anastomotic bleeding after colorectal surgery. METHODS: We retrospectively reviewed the data of patients pathologically diagnosed with colorectal cancer at National Cancer Center, Korea from January 2018 to November 2020, which presented with anastomotic bleeding within the first postoperative week and were endoscopically managed with clips. RESULTS: Nine patients had anastomotic bleeding, underwent endoscopic management, and, therefore, were included in this study. All patients underwent laparoscopic (low/ultralow) anterior resection with mechanical double-stapled anastomosis. Anastomotic bleeding was successfully managed through a colonoscopy with clips on the first trial in all patients. Hypovolemic shock occurred in one patient, following anastomotic breakdown. CONCLUSION: Endoscopic clipping seems to be an effective and safe treatment for anastomotic bleeding with minimal physiologic stress, easy accessibility, and scarce postoperative complications. However, a surgical backup should always be considered for massive bleeding.

Factors associated with diet failure after colon cancer surgery.

BACKGROUND: Since the introduction of Enhanced Recovery After Surgery (ERAS), early diet after surgery has been emphasized and clinical outcomes have improved, though vomiting has been reported frequently. We defined diet failure based on clinical manifestation and images after colon cancer surgery and attempted to analyze underlying risk factors by comparing the early diet group with the conventional diet group. METHODS: All consecutive patients underwent colectomy with curative intent at a single institution between August 2015 and July 2017. The early diet group was started on soft diet on the second day after surgery, while the conventional group started the same after flatulence. The primary outcome was the difference in the incidence of diet failure between the two groups. Secondary outcomes were analyzed to determine risk factors for diet failure and readmission due to ileus. RESULTS: Overall, 293 patients were included in the conventional diet group and 231 in the early diet group. There were no significant differences between the two groups, except for shorter hospital stays in the early diet group (median 8 days, p < 0.001). A total of 46 patients (early diet, n = 20; conventional diet, n = 26, p = 1.000) had diet failure. Multivariate analysis showed that operation time (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.33-2.32) and side-to-side anastomosis compared with the end-to-end method (OR 4.41, 95% CI 2.10-9.24) were independent risk factors for diet failure. Sixteen patients were readmitted due to ileus that occurred within 2 months after surgical operation. Diet resumption time was not a risk factor for both diet failure and ileus. CONCLUSIONS: Early diet resumption does not increase diet failure and can reduce hospital stay. Anastomosis and operation time may be related to diet failure. Our study suggests that evaluation of surgical factors is important for postoperative recovery, and well-designed follow-up studies are needed.

Comparison between early surgical treatment and conservative treatment of appendicitis in cancer patients.

BACKGROUNDS: In cancer patients, the optimal appendicitis treatment has not been established. Therefore, we aimed to determine the ideal treatment option for appendicitis in cancer patients. METHODS: This retrospective study included 185 cancer patients with acute appendicitis who were divided into the early surgical group (n = 152) involving surgery performed within 48 h following the appendicitis diagnosis or the conservative group (n = 33) involving intravenous antibiotics. We compared the appendicitis treatment efficacy between the groups. RESULTS: In the early surgical group, the antibiotic duration [5.5 days (4.0-8.0) vs. 17.0 days (12.5-25.0), p < 0.001] and hospital stay length [7.0 days (5.0-11.75) vs. 10.0 days (8.0-32.0), p < 0.001] were significantly shorter. Regarding pathology, 16/171 (9.4%) patients who underwent surgery exhibited appendiceal tumours. During the 1-year follow-up period, one recurrence occurred in each group [1/152 (0.7%) vs. 1/33 (3.0%), p = 0.326]. The 1-year treatment success rate was higher in the early surgical group [99.3% (151/152) vs. 42.4% (14/33), p < 0.001]. CONCLUSION: Early surgical treatment yielded a significantly higher success rate than conservative treatment for appendicitis in cancer patients. Surgery for appendicitis in cancer patients should be considered not only for treatment but also for pathologic confirmation.

Diverting ileostomy itself may not increase the rate of postoperative readmission related to dehydration after low anterior resection.

PURPOSE: This study was performed to evaluate the risk of readmission in the first year after low anterior resection (LAR) for patients with rectal cancer and to identify the contributing factors for readmission related to dehydration specifically. METHODS: This was a retrospective analysis of 570 patients who underwent LAR for rectal cancer at National Cancer Center, Republic of Korea. A diverting loop ileostomy was performed in 357 (62.6%) of these patients. Readmission was defined as an unplanned visit to the emergency room or admission to the ward. The reasons for readmission were reviewed and compared between the ileostomy (n = 357) and no-ileostomy (n = 213) groups. The risk factors for readmission and readmission due to dehydration were analyzed using multivariable logistic and Cox proportional hazard model. RESULTS: Dehydration was the most common cause of readmission in both groups (ileostomy group, 6.7%, and no-ileostomy group, 4.7%, P = 0.323). On multivariable analysis, risk factors for readmission were an estimated intraoperative blood loss of ≥400 mL (odds ratio [OR], 1.757; 95% confidence interval [CI], 1.058-2.918; P = 0.029), and postoperative chemotherapy (OR, 2.914; 95% CI, 1.824-4.653; P < 0.001). On multivariable analysis, postoperative chemotherapy, and not a diverting loop ileostomy, was an independent risk factor for dehydration-related readmission (OR, 5.102; 95% CI, 1.772-14.688; P = 0.003). CONCLUSION: The most common cause of readmission after LAR for rectal cancer was dehydration, as reported previously. Postoperative chemotherapy, not the creation of a diverting ileostomy, was identified as the risk factor associated with readmission related to dehydration.

Comparison of patient-reported quality of life and functional outcomes following laparoscopic and transanal total mesorectal excision of rectal cancer.

PURPOSE: The effect of transanal total mesorectal excision (TaTME) on patients' quality of life and functional outcomes is not fully understood. This study aimed to compare the quality of life and bowel, anorectal, and urogenital functions after laparoscopic and TaTME. METHODS: Laparoscopic or TaTME was performed for 202 propensity score-matched patient pairs with rectal cancer between January 2014 and December 2017 at the National Cancer Center, Korea. The outcomes for all patients were assessed using anorectal manometry, the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30) and Colorectal Cancer-Specific Quality of Life Questionnaire (QLQ-CR38), low anterior resection syndrome (LARS) score, Fecal Incontinence Severity Index, and International Prostate Symptom Score (IPSS). This retrospective comparative study included patients who completed anorectal manometry and the questionnaires before treatment and at 1 year after surgery. RESULTS: The EORTC QLQ-C30 and QLQ-CR38 showed comparable outcomes regarding the quality of life in both groups. More patients experienced major LARS in the transanal group at 1 year postoperatively (31.0% vs. 6.8% in the laparoscopic group, P = 0.004). Multivariable analysis revealed no significant difference in the LARS score between the groups at 1 year postoperatively (odds ratio, 2.30; 95% confidence interval, 0.79-6.72; P = 0.127). Significant differences in the IPSS were not noted between the groups. CONCLUSION: The quality of life and functional outcomes were comparable between the laparoscopic and transanal approaches; however, our findings suggest a higher rate of LARS after TaTME.

CORRIGENDUM: Correction of acknowledgements & funding/grant support: The effect of curative resection on fecal microbiota in patients with colorectal cancer: a prospective pilot study.

[This corrects the article on p. 44 in vol. 99, PMID: 32676481.].

Comparison of endoscopic submucosal dissection and transanal endoscopic microsurgery for T1 rectal neuroendocrine tumors: a propensity score-matched study.

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are the most effective endoscopic resection methods for T1 rectal neuroendocrine tumors (NETs). We aimed to compare the efficacy and safety of ESD and TEM for rectal NETs ≤20 mm. METHODS: Patients with rectal NETs ≤20 mm who underwent ESD or TEM were enrolled in this retrospective observational study. ESD and TEM groups were matched for pathologic tumor size and EMR history. We evaluated between-group differences in R0 resection rate, adverse event rate, procedure time, and hospital stay. RESULTS: We included 285 patients (ESD = 226, TEM = 59) in the final cohort, with 104 patients in the matched groups (ESD = 52, TEM = 52). The R0 resection rate was significantly higher for TEM (ESD 71.2% vs TEM 92.3%, P = .005). However, the median procedure time (ESD 22 [range, 11-65] vs TEM 35 [17-160] minutes, P < .001) and hospital stay (ESD 2.5 range 1-5] vs TEM 4 [3-8] days, P < .001) were significantly shorter for ESD. In the subgroup analysis of patients divided by tumor size <10 mm (ESD = 218, TEM = 49) and 10 to 20 mm (ESD = 8, TEM = 10)], there was no significant between-group difference in the R0 resection rate (83.5% vs 93.9%, P = .063 and 37.5% vs 80%, P = .145, respectively) or the rate of recurrence. CONCLUSIONS: Although TEM showed a better overall R0 resection rate for rectal NETs ≤20 mm, ESD could be a viable treatment modality concerning adverse events, procedure time, and hospital stay for rectal NETs <10 mm with similar R0 resection rates in comparison with TEM.

Laparoscopic approach for T4 colon cancer can be associated with poor prognosis in right-sided T4b tumours.

INTRODUCTION: Although recent studies have demonstrated the safety of laparoscopic surgery in T4 colon cancer, some patients could have poor prognosis. In this study, we aimed to analyse the risk factors affecting oncologic outcome of laparoscopic surgery. MATERIALS AND METHODS: Among the 1033 T4 colon cancer patients collected from a multicentre database (2004-2017), 584 patients (458 T4a and 126 T4b) underwent laparoscopic approach for radical surgery. Risk factors associated with 3-year disease-free survival (DFS) and overall survival (OS) were evaluated through multivariate analysis. In addition, subgroups were classified using a combination of risk factors, and the survival rate was evaluated. RESULTS: During this period, 188 (32.2%) had recurrence, and 151 (25.9%) died. In the multivariate analysis for oncologic outcome, elevated carcinoembryonic antigen level (hazard ratio [HR] 1.37) and absence of adjuvant chemotherapy (HR 1.60) were associated with poor DFS. T4b (HR 1.56, 1.46), right-sided location (HR 1.52, 1.42), and open conversion (HR 2.70, 2.12) were independently associated with both poor DFS and OS. When four subgroups were analysed through the combination of tumour location and T stage, the DFS and OS rates were significantly lower in patients with right-sided T4b cancer than in other groups (log-rank p < 0.001). CONCLUSION: Right-sided T4b colon cancer for laparoscopic surgery may lead to poor oncologic outcome. This approach could be a caution in suspected cases preoperatively.

Analysis of treatment success with new inclusion criteria for antibiotic therapy for uncomplicated appendicitis: A multicentre cohort study.

BACKGROUND: Conservative antibiotic treatment for uncomplicated appendicitis is debated because of the unproven criteria for use and relatively high failure rate. We developed inclusion criteria to optimize antibiotic therapy use and compared the success rate to that seen in previous literature. METHODS: Our antibiotic therapy inclusion criteria were developed based on clinical findings (symptom onset ≤48 hours and body temperature ≤38.3℃), laboratory parameters (white blood cell count ≤12000/mL) and radiologic findings (appendiceal diameter ≤12 mm and no appendicolith). Patients who met inclusion criteria were enrolled from three hospitals between 2016 and 2017. Treatment success was defined as a response to antibiotic therapy and no recurrent symptoms within 1 year. We compared our success rate with previous clinical trial success rates. RESULTS: There were 240 patients enrolled (116 men and 124 women) with a mean age of 38.7 years. After initial antibiotic treatment, 233 patients (97.1%) responded to therapy and were discharged. There were no post-treatment complications with Clavien-Dindo grade ≥III. During the 1-year follow-up period, the treatment success rate was 88.8% (213/240) and the recurrence rate was 8.6% (20/233; 15 underwent surgery and 5 received antibiotics again). In contrast, the combined treatment success rate for six previous clinical trials was 76.5% (573/749) and the recurrence rate was 21.6% (157/727). CONCLUSIONS: The group enrolled with the new inclusion criteria showed an improved treatment success rate compared to previous studies. These criteria will aid in determining optimal conservative treatment use in patients with uncomplicated appendicitis.

Favorable short-term oncologic outcomes following laparoscopic surgery for small T4 colon cancer: a multicenter comparative study.

BACKGROUND: Laparoscopic surgery for T4 colon cancer may be safe in selected patients. We hypothesized that small tumor size might preoperatively predict a good laparoscopic surgery outcome. Herein, we compared the clinicopathologic and oncologic outcomes of laparoscopic and open surgery in small T4 colon cancer. METHODS: In a retrospective multicenter study, we reviewed the data of 449 patients, including 117 patients with tumors ≤ 4.0 cm who underwent surgery for T4 colon cancer between January 2014 and December 2017. We compared the clinicopathologic and 3-year oncologic outcomes between the laparoscopic and open groups. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test. Univariate and multivariate analyses were performed using the Cox proportional hazards model. A p < 0.05 was considered statistically significant. RESULTS: Blood loss, length of hospital stay, and postoperative morbidity were lower in the laparoscopic group than in the open group (median [range], 50 [0-700] vs. 100 [0-4000] mL, p < 0.001; 8 vs. 10 days, p < 0.001; and 18.0 vs. 29.5%, p = 0.005, respectively). There were no intergroup differences in 3-year overall survival or disease-free survival (86.6 vs. 83.2%, p = 0.180, and 71.7 vs. 75.1%, p = 0.720, respectively). Among patients with tumor size ≤ 4.0 cm, blood loss was significantly lower in the laparoscopic group than in the open group (median [range], 50 [0-530] vs. 50 [0-1000] mL, p = 0.003). Despite no statistical difference observed in the 3-year overall survival rate (83.3 vs. 78.7%, p = 0.538), the laparoscopic group had a significantly higher 3-year disease-free survival rate (79.2 vs. 53.2%, p = 0.012). CONCLUSIONS: Laparoscopic surgery showed similar outcomes to open surgery in T4 colon cancer patients and may have favorable short-term oncologic outcomes in patients with tumors ≤ 4.0 cm.

Early Experience With Transanal Total Mesorectal Excision Compared With Laparoscopic Total Mesorectal Excision for Rectal Cancer: A Propensity Score-Matched Analysis.

BACKGROUND: Laparoscopic total mesorectal excision is widely used for rectal cancers; however, it is sometimes challenging, especially in obese patients with low tumors, particularly after chemoradiotherapy. Transanal total mesorectal excision was developed to overcome these limitations in terms of visualization, dissection, and stapling. OBJECTIVE: The purpose of this study was to compare the pathologic and early oncologic outcomes of the laparoscopic and transanal approaches. DESIGN: This was a retrospective comparative study using propensity score-matched analysis. SETTING: The study was conducted at a tertiary hospital specializing in oncology. PATIENTS: In total, 722 inpatients who underwent total mesorectal excision for rectal cancer from January 2014 to December 2017 were included. INTERVENTIONS: Laparoscopic (N = 514) and transanal (N = 208) total mesorectal excision were performed. MAIN OUTCOME MEASURES: The primary outcome was pathologic outcome including circumferential and distal resection margin involvement. The secondary outcomes were intraoperative and postoperative complications and overall survival, recurrence-free survival, and local recurrence rates. RESULTS: The 2 groups of the cohort had several differences; thus, we performed propensity score matching. The circumferential resection margin was involved in 13.4% and 12.9% of the laparoscopic and transanal groups (p = 0.88). The distal resection margin was involved in 1% and 3% of the laparoscopic and transanal groups (p = 0.28). Complete or nearly complete total mesorectal excision was 98.0% and 96.5% in the laparoscopic and transanal groups (p = 0.41). Postoperative complications with Clavien-Dindo grade III or higher did not differ significantly between groups (p = 0.54) but were significantly higher in patients with tumors <5 cm from the anal verge who underwent laparoscopy (laparoscopic group = 11.9%; transanal group = 1.7%; p = 0.04). There were no statistical differences in the 3-year overall survival, recurrence-free survival, or local recurrence rates between groups. LIMITATIONS: This was a retrospective study design with a short follow-up period. CONCLUSIONS: Early experience with the transanal approach showed similar pathologic outcomes as those of conventional laparoscopy; hence, it should be considered as a surgical option for lower rectal cancer. See Video Abstract at http://links.lww.com/DCR/B352. EXPERIENCIA TEMPRANA CON LA ESCISIÓN MESORRECTAL TOTAL TRANSANAL EN COMPARACIÓN CON LA ESCISIÓN MESORRECTAL TOTAL LAPAROSCÓPICA PARA EL CÁNCER DE RECTO: UN ANÁLISIS DE PUNTUACIÓN DE PROPENSIÓN: La escisión mesorrectal total laparoscópica se usa ampliamente para los cánceres rectales; Sin embargo, a veces es un desafío, especialmente en pacientes obesos con tumores bajos, particularmente después de la quimiorradioterapia. La escisión mesorrectal total transanal se desarrolló para superar estas limitaciones en términos de visualización, disección y grapado.Comparar los resultados patológicos y oncológicos precoces de los enfoques laparoscópico y transanal.estudio comparativo retrospectivo con puntaje de propensión-análisis emparejadoHospital terciario especializado en oncología.En total, se incluyeron 722 pacientes hospitalizados que se sometieron a una escisión mesorrectal total por cáncer rectal desde Enero de 2014 hasta Diciembre de 2017.Se realizó escisión mesorrectal total laparoscópica (n = 514) y transanal (n = 208).El resultado primario fue el resultado patológico, incluyendo el involucramiento del margen de resección circunferencial y distal. Los resultados secundarios fueron complicaciones intraoperatorias, postoperatorias y supervivencia general, supervivencia libre de recurrencia y tasas de recurrencia local.Los dos grupos de la cohorte tuvieron varias diferencias; así, realizamos un emparejamiento de puntuación de propensión. El margen de resección circunferencial estuvo involucrado en 13.4% y 12.9% de los grupos laparoscópico y transanal, respectivamente (p = 0.88). El margen de resección distal estuvo involucrado en 1% y 3% de los grupos laparoscópico y transanal, respectivamente (p = 0.28). La escisión mesorrectal total completa o casi completa fue de 98.0% y 96.5% en los grupos laparoscópico y transanal, respectivamente (p = 0.41). Las complicaciones postoperatorias con Clavien-Dindo grado ≥ III no difirieron significativamente entre los grupos (p = 0,54), pero fueron significativamente mayores en pacientes con tumores de < 5 cm del borde anal que se sometieron a laparoscopia (grupo laparoscópico, 11,9%; grupo transanal, 1,7%; p = 0,04). No hubo diferencias estadísticas en la supervivencia general a 3 años, la supervivencia libre de recurrencia y las tasas de recurrencia local entre los grupos.Diseño de estudio retrospectivo, corto período de seguimiento.La experiencia temprana con el enfoque transanal mostró resultados patológicos similares a los de la laparoscopia convencional; por lo tanto, debe considerarse como una opción quirúrgica para el cáncer rectal mas bajo. Consulte Video Resumen en http://links.lww.com/DCR/B352. (Traducción-Dr Yesenia Rojas-Khalil).