Jung Myun Kwak

Robotic vs laparoscopic resection of rectal cancer: short-term outcomes of a case-control study.

PURPOSE: Few data are available to compare robotic and laparoscopic techniques for rectal cancer resection. This study aimed to compare short-term outcomes with these procedures performed by a single surgeon. METHODS: Using data from a prospective database of all operations performed in our department, we retrospectively analyzed data from 117 robotic and 102 laparoscopic rectal cancer resections performed by one surgeon between July 2007 and October 2009. Robotic resection was offered as a treatment option to all patients, and laparoscopic resection was performed for those who refused. This analysis was a case-control study in which patients in the 2 groups were matched according to tumor location, staging, age, and gender. RESULTS: A total of 118 patients (59 matched pairs) were included in the study. No differences were found between robotic and laparoscopic resection regarding number of lymph nodes harvested (median, 20; interquartile range, 12–27 vs 21; 14–28; P = .702) or distal resection margin (median, 2.2 cm; interquartile range, 1.5–3.0 cm vs 2.0; 1.2–3.5 cm; P = .865). The circumferential margin was positive (≤2 mm) in 1 patient in the robotic group but in none of the laparoscopic group (P > .999). Operating time was longer in the robotic group than in the laparoscopic group (P < .0001). No conversions were necessary in the robotic group, but 2 cases (3.4%) were converted to open surgery in the laparoscopic group (P = .496). No differences were observed between groups regarding postoperative complications. Operative mortality was zero in both groups. During a median follow-up of 15.0 months, 2 cases of distant metastases and 1 case of local recurrence were observed in each group. CONCLUSIONS: Robotic rectal cancer resection can be safely performed by experienced laparoscopic surgeons, with acceptable short-term outcomes comparable to those for laparoscopic resection.

Robotic Resection is a Good Prognostic Factor in Rectal Cancer Compared with Laparoscopic Resection: Long-term Survival Analysis Using Propensity Score Matching

BACKGROUND: Robotic total mesorectal excision for rectal cancer has rapidly increased and has shown short-term outcomes comparable to conventional laparoscopic total mesorectal excision. However, data for long-term oncologic outcomes are limited. OBJECTIVE: The aim of this study is to evaluate long-term oncologic outcomes of robotic total mesorectal excision compared with laparoscopic total mesorectal excision. DESIGN: This was a retrospective study. SETTINGS: This study was conducted in a tertiary referral hospital. PATIENTS: A total of 732 patients who underwent totally robotic (n = 272) and laparoscopic (n = 460) total mesorectal excision for rectal cancer were included in this study. MAIN OUTCOME MEASURES: We compared clinicopathologic outcomes of patients. In addition, short- and long-term outcomes and prognostic factors for survival were evaluated in the matched robotic and laparoscopic total mesorectal excision groups (224 matched pairs by propensity score). RESULTS: Before case matching, patients in the robotic group were younger, more likely to have undergone preoperative chemoradiation, and had a lower tumor location than those in the laparoscopic group. After case matching most clinicopathologic outcomes were similar between the groups, but operative time was longer and postoperative ileus was more frequent in the robotic group. In the matched patients excluding stage IV, the overall survival, cancer-specific survival, and disease-free survival were better in the robotic group, but did not reach statistical significance. The 5-year survival rates for robotic and laparoscopic total mesorectal excision were 90.5% and 78.0% for overall survival, 90.5% and 79.5% for cancer-specific survival, and 72.6% and 68.0% for disease-free survival. In multivariate analysis, robotic surgery was a significant prognostic factor for overall survival and cancer-specific survival (p = 0.0040, HR = 0.333; p = 0.0161, HR = 0.367). LIMITATIONS: This study has the potential for selection bias and limited generalizability. CONCLUSIONS: Robotic total mesorectal excision for rectal cancer showed long-term survival comparable to laparoscopic total mesorectal excision in this study. Robotic surgery was a good prognostic factor for overall survival and cancer-specific survival, suggesting potential oncologic benefits.

Preoperative Chest Computerized Tomography in Patients With Locally Advanced Mid or Lower Rectal Cancer: Its Role in Staging and Impact on Treatment Strategy

Pulmonary metastasis is frequent in rectal cancer. Some guidelines recommend chest computerized tomography (CT) for preoperative workup in rectal cancer patients, which have no solid evidence to support this recommendation. This study was designed to evaluate the role of chest CT on preoperative staging in rectal cancer patients and to assess the impact on treatment strategy.

The Role of Laparoscopic Approach for Anastomotic Leakage After Minimally Invasive Surgery for Colorectal Cancer

OBJECTIVES The objectives of this study were to evaluate the feasibility and safety of a re-laparoscopic approach to manage anastomotic leakage after minimally invasive colorectal resection and to compare its clinical outcomes with those obtained using an open approach. METHODS We retrospectively reviewed clinical data from 1714 patients who underwent colorectal cancer resection from September 2006 to August 2009 at the Korea University Medical Center. Clinical data from a total of 57 surgery patients who developed anastomotic leakage were analyzed. RESULTS Twenty-six leakage cases were managed laparoscopically, whereas the remaining 31 leakage cases were managed using an open approach. There were no significant differences in age, sex, or other clinical features between patients in the two groups. The total operation time was shorter in the laparoscopic group (107.3 ± 68.1 minutes) than in the open group (126.5 ± 50.1 minutes), but this difference was not statistically significant (P = .230). Six cases in each group required additional procedures such as reoperation or percutaneous intervention (P = .126). There was one case of postoperative mortality in the open group. Median (quartiles 25%-75%) number of days required to resume a soft diet tended to be shorter in the laparoscopic group than the open group (5 [3-7] versus 6 [5-10] days; P = .057). Patients in both groups showed similar postoperative complications including intraabdominal abscess; however, the incidence of wound infection was significantly lower in the laparoscopic group than the open group (3.8% versus 25.8%; P = .031). CONCLUSIONS Compared with conventional open treatment of anastomotic leakage, the laparoscopic approach resulted in fewer wound complications and tendency of early recovery of bowel movement without an increase in adverse outcomes. Using a laparoscopic approach, all the advantages of minimally invasive surgery can be realized in patients who develop anastomotic leakage after minimally invasive surgery.

Incidence and risk factors of chylous ascites after colorectal cancer surgery

BACKGROUND The aim of this study was to identify possible risk factors associated with chylous ascites after colorectal cancer surgery. METHODS Patients who underwent colorectal cancer resection were enrolled in this study. Data were compared between patients who developed chylous ascites and those who did not. RESULTS Chylous ascites was detected in 48 (6.6%) patients. There were significant differences between the groups with and without chylous ascites in terms of age (65.6 vs 61.6 years, P = .017), operator (5.0% vs 15.5%, P < .001), operative procedure based on tumor location (P = .041), operative time (206.0 vs 229.8 minutes, P = .045), and blood loss (78.1 vs 219.7 mL, P = .036). After subgroup analysis for right-sided colectomy and low anterior resection to compensate for the effects of the operative procedure, the differences in the operative time and blood loss were not significant. In most patients, chylous ascites was resolved with conservative management. CONCLUSIONS Chylous ascites developed significantly more frequently in patients who underwent right-sided colectomy and in elderly patients. In addition, the incidence was also dependent on the operator. Conservative treatment was effective in most patients.

Robotic Surgery for Rectal Cancer: An Update in 2015.

During the last decade, robotic surgery for rectal cancer has rapidly gained acceptance among colorectal surgeons worldwide, with well-established safety and feasibility. The lower conversion rate and better surgical specimen quality of robotic compared with laparoscopic surgery potentially improves survival. Earlier recovery of voiding and sexual function after robotic total mesorectal excision is another favorable outcome. Long-term survival data are sparse with no evidence that robotic surgery offers major benefits in oncological outcomes. Although initial reports are promising, more rigorous scientific evaluation in multicenter, randomized clinical trials should be performed to definitely determine the advantages of robotic rectal cancer surgery.

Transanal gauze packing to manage massive presacral bleeding secondary to prescral abscess caused by rectal anastomotic leakage: A novel approach

Anastomotic leakage following rectal resection is a serious and fearful complication, and may cause presacral abscess and/or peritonitis. To our knowledge, massive hematochezia secondary to presacral abscess caused by anastomotic leakage has not yet been reported in the literature. We observed this rare and life-threatening complication in three patients who were successfully treated with a simple but effective transanal gauze packing technique.

Indeterminate pulmonary nodules in rectal cancer: a recommendation for follow-up guidelines.

Incidental visualization of indeterminate pulmonary nodules is considered a clinical dilemma.

The technique of single-stage totally robotic low anterior resection

The introduction of robotic surgical systems has produced a significant technological advance in minimally invasive surgery. The application of robotics to rectal cancer surgery is being spotlighted as the means to eliminate many of the technical difficulties inherent in conventional laparoscopic surgery. However, standardization of surgical technique has not yet been established. We have developed a single-stage totally robotic low anterior resection for rectal cancer, and describe here our surgical technique.

Risk factors causing structural sequelae after anastomotic leakage in mid to low rectal cancer

AIM To investigate the risk factors causing structural sequelae after anastomotic leakage in patients with mid to low rectal cancer. METHODS Prospectively collected data of consecutive subjects who had anastomotic leakage after surgical resection for rectal cancer from March 2006 to May 2013 at Korea University Anam Hospital were retrospectively analyzed. Two subgroup analyses were performed. The patients were initially divided into the sequelae (stricture, fistula, or sinus) and no sequelae groups and then divided into the permanent stoma (PS) and no PS groups. Univariate and multivariate analyses were performed to identify the risk factors of structural sequelae after anastomotic leakage. RESULTS Structural sequelae after anastomotic leakage were identified in 29 patients (39.7%). Multivariate analysis revealed that diversion ileostomy at the first operation increases the risk of structural sequelae [odds ratio (OR) = 6.741; P = 0.017]. Fourteen patients (17.7%) had permanent stoma during the follow-up period (median, 37 mo). Multivariate analysis showed that the tumor level from the dentate line was associated with the risk of permanent stoma (OR = 0.751; P = 0.045). CONCLUSION Diversion ileostomy at the first operation increased the risk of structural sequelae of the anastomosis, while lower tumor location was associated with the risk of permanent stoma in the management of anastomotic leakage.