Seon Hahn Kim

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.

Multicenter Analysis of Risk Factors for Anastomotic Leakage After Laparoscopic Rectal Cancer Excision The Korean Laparoscopic Colorectal Surgery Study Group

Objective:To assess the risk factors for clinical anastomotic leakage (AL) in patients undergoing laparoscopic surgery for rectal cancer. Background:Little data are available about risk factors for AL after laparoscopic rectal cancer resection. Methods:This was a retrospective analysis of 1609 patients with rectal cancer who had undergone laparoscopic surgery for rectal cancer with sphincter preservation. Clinical data related to AL were collected from 11 institutions. Univariate and multivariate analyses were performed to determine the risk factors for AL. Results:AL was noted in 101 (6.3%) of the patients. The leakage rate ranged from 2.0% to 10.3% for each hospital (P = 0.04). In patients without protective stomas (n = 1187), male sex [hazard ratio (HR), 3.468], advanced tumor stage (HR, 2.520), lower tumor level (HR, 2.418), preoperative chemoradiation (HR, 6.284), perioperative transfusion (HR, 10.705), and multiple firings of the linear stapler (HR, 6.181) were significantly associated with AL. Our theoretical model suggested that the HR for patients with 2 risk factors was significantly higher than that the HR for patients with no or only 1 risk factor. Conclusions:Male sex, low anastomosis, preoperative chemoradiation, advanced tumor stage, perioperative bleeding, and multiple firings of the linear stapler increased the risk of AL after laparoscopic surgery for rectal cancer. A diverting stoma might be mandatory in patients with 2 or more of the risk factors identified in this analysis.

Single-stage totally robotic dissection for rectal cancer surgery: technique and short-term outcome in 50 consecutive patients.

PURPOSE: To overcome the pitfalls of laparoscopy, a robotic system has been introduced in rectal cancer surgery. However, there is no standard procedure to maximize the advantages of the da Vinci® S Surgical System. Therefore, we describe our technique of applying the robotic system during all of the steps of dissection in rectal cancer surgery and the short-term outcome. METHODS: Prospectively collected data were reviewed from 50 consecutive patients who underwent single-stage, totally robotic dissection for rectal cancer resection between July 2007 and June 2008. Robotic dissection was performed following these steps: 1) ligation of the inferior mesenteric vessels and medial to lateral dissection, 2) mobilization of the sigmoid/descending/splenic flexure colon, and 3) rectal dissection. The remaining steps including rectal transection and anastomosis were performed by a conventional laparoscopic method. RESULTS: There were 32 (64%) men and 18 (36%) women. The mean distance from the anal verge to the tumor margin was 7.3 (range, 2–13) cm. The conversion rate was 0%. The mean operative time was 304.8 (range, 190–485) minutes, and 20.6 (range, 6–48) lymph nodes were harvested. The circumferential margin was positive in one patient. The length of hospital stay after surgery was 9.2 (range, 5–24) days. Anastomotic leak rate was 8.3%, and all of the patients with leakage were managed conservatively. CONCLUSIONS: Single-stage robotic dissection for rectal cancer surgery is feasible, and its short-term outcome is acceptable. Our technique can be a suitable procedure to maximize the advantages of the da Vinci® system.

Does laparoscopic vs. conventional surgery increase exfoliated cancer cells in the peritoneal cavity during resection of colorectal cancer

PURPOSE: Traumatic manipulation of cancer specimens during laparoscopic colectomy may increase exfoliation of malignant cells into the peritoneal cavity, causing an early occurrence of peritoneal carcinomatosis or port-sites recurrence. Because of this concern, the routine use of intraperitoneal chemotherapy after laparoscopic colectomy for cancer was suggested recently. We assessed if laparoscopicvs. conventional surgery increases exfoliated malignant cells in the peritoneal cavity during resection of colorectal cancer. METHODS: In a prospective, randomized fashion, 38 colorectal cancer patients undergoing an elective, curative operation were assigned to either a conventional or laparoscopic procedure between June 1996 and May 1997. In either group (n=19), after the abdominal cavity was entered, saline was instilled into the peritoneal cavity, and the fluid was collected (Specimen 1). During surgery, all irrigating fluids were collected (Specimen 2). Both specimens were assessed for malignancy using four techniques: filtration process (ThinPrep®), smear, cell block, and immunochemistry using Ber-EP4. The change in the amount of tumor cells in both specimens was compared between surgical groups. A pilot study was performed to validate the proposed cytologic method. RESULTS: In the pilot study of 20 consecutive patients with colorectal cancer, postresectional peritoneal cytology was positive in six patients, including two Stage II (T3,N0,M0) patients. The pilot study also validated that our semiquantitative scoring system can be reliably used to assess the amount of free peritoneal cancer cells. In the main study, 16 right colectomies, 3 extended right colectomies, 17 proctosigmoidectomies, and 1 left colectomy were performed. The T and N stages were T1 (n=13), T2 (n=5), T3 (n=8), T4 (n=11); N0 (n=22), N1 (n=8), N2 (n=7). Malignant cells were not detected in any Specimens 1 or, more importantly, in Specimens 2 in either surgical group. CONCLUSION: When performed according to strict oncologic surgical principles, laparoscopic techniques in curative colorectal cancer surgery did not have an increased risk of intraperitoneal cancer cell spillage, compared with conventional techniques. We hope that these results can decrease some of the concerns about tumors cell spillage and seeding during laparoscopy.

The rationale behind complete mesocolic excision (CME) and a central vascular ligation for colon cancer in open and laparoscopic surgery: Proceedings of a consensus conference

BackgroundIt has been evident for a while that the result after resection for colon cancer may not have been optimal. Several years ago, this was showed by some leading surgeons in the USA but a concept of improving results was not consistently pursued. Later, surgeons in Europe and Japan have increasingly adopted the more radical principle of complete mesocolic excision (CME) as the optimal approach for colon cancer. The concept of CME is a similar philosophy to that of total mesorectal excision for rectal cancer and precise terminology and optimal surgery are key factors.MethodThere are three essential components to CME. The main component involves a dissection between the mesenteric plane and the parietal fascia and removal of the mesentery within a complete envelope of mesenteric fascia and visceral peritoneum that contains all lymph nodes draining the tumour area (Hohenberger et al., Colorectal Disease 11:354–365, 2009; West et al., J Clin Oncol 28:272–278, 2009). The second component is a central vascular tie to completely remove all lymph nodes in the central (vertical) direction. The third component is resection of an adequate length of bowel to remove involved pericolic lymph nodes in the longitudinal direction.ResultThe oncological rationale for CME and various technical aspects of the surgical management will be explored.ConclusionThe consensus conference agreed that there are sound oncological hypotheses for a more radical approach than has been common up to now. However, this may not necessarily apply in early stages of the tumour stage. Laparoscopic resection appears to be equally well suited for resection as open surgery.

Laparoscopic colorectal cancer surgery for palliation.

PURPOSE: The aim of this study was to review our experience with laparoscopic colorectal cancer surgery for palliative purposes and to assess its safety and efficacy. METHODS: This was a prospective analysis of 30 patients with incurable colorectal cancer considered for laparoscopic surgery for palliative purposes. RESULTS: Resection of a single segment of the bowel was performed in 15 patients (6 right and 1 left colectomies and 8 proctosigmoidectomies). One patient underwent both right colectomy and sigmoidectomy because of double lesions. Stoma creation only was performed in 11 patients (5 colostomies and 6 ileostomies). Three patients were converted to an open procedure. For resection, median operative time was 170 minutes, and median estimated blood loss was 150 ml. For stoma creation, median operative time was 60 minutes, and median blood loss was 50 ml. There were no intraoperative complications. Postoperative death occurred in two severely debilitated patients after stoma creation. One patient developed a pulmonary embolism eight days postoperatively, later dying of pulmonary failure. Another patient died six hours after loop colostomy. Autopsy was refused. There were no other postoperative complications. Median time to passage of flatus was two days and of stool five days after resection and two days for both flatus and stool after stoma creation. Median time to discharge was eight days after resection and seven days after stoma creation. All patients were able to eat and recover normal bowel function. Among the resection group, six patients died (median time to death, 12 months) during a median follow-up period of 13 months. Among the stoma creation group, five patients died (median time to death, 8 months) during median follow-up period of ten months. There were no port-site recurrences. CONCLUSION: The laparoscopic approach for patients with incurable colorectal cancer can provide effective palliation with avoidance of a major laparotomy in the majority of cases.

Relationship between diversion colitis and quality of life in rectal cancer

AIM To investigated the incidence of diversion colitis (DC) and impact of DC symptoms on quality of life (QoL) after ileostomy reversal in rectal cancer. METHODS We performed a prospective study with 30 patients who underwent low anterior resection and the creation of a temporary ileostomy for the rectal cancer between January 2008 and July 2009 at the Department of Surgery, Korea University Anam Hospital. The participants totally underwent two rounds of the examinations. At first examination, endoscopies, tissue biopsies, and questionnaire survey about the symptom were performed 3-4 mo after the ileostomy creations. At second examination, endoscopies, tissue biopsies, and questionnaire survey about the symptom and QoL were performed 5-6 mo after the ileostomy reversals. Clinicopathological data were based on the histopathological reports and clinical records of the patients. RESULTS At the first examination, all of the patients presented with inflammation, which was mild in 15 (50%) patients, moderate in 11 (36.7%) and severe in 4 (13.3%) by endoscopy and mild in 14 (46.7%) and moderate in 16 (53.3%) by histology. At the second examination, only 11 (36.7%) and 17 (56.7%) patients had mild inflammation by endoscopy and histology, respectively. There was no significant difference in DC grade between the endoscopic and the histological findings at first or second examination. The symptoms detected on the first and second questionnaires were mucous discharge in 12 (40%) and 5 (17%) patients, bloody discharge in 5 (17%) and 3 (10%) patients, abdominal pain in 4 (13%) and 2 (7%) patients and tenesmus in 9 (30%) and 5 (17%) patients, respectively. We found no correlation between the endoscopic or histological findings and the symptoms such as mucous discharge, bleeding, abdominal pain and tenesmus in both time points. Diarrhea was detected in 9 patients at the second examination; this number correlated with the severity of DC (0%, 0%, 66.7%, 33.3% vs 0%, 71.4%, 23.8%, 4.8%, P = 0.001) and the symptom-related QoL (r = -0.791, P < 0.001). CONCLUSION The severity of DC is related to diarrhea after an ileostomy reversal and may adversely affect QoL.

Robotic-assisted surgery for rectal adenocarcinoma: short-term and midterm outcomes from 200 consecutive cases at a single institution.

BACKGROUND: Although robotic surgery is increasingly used in the management of rectal cancer, its oncologic safety remains uncertain. OBJECTIVE: We aimed to evaluate the feasibility and safety of robotic-assisted rectal cancer resection in terms of short-term and midterm outcomes. DESIGN: A prospectively collected set of samples was retrospectively evaluated. SETTINGS: Data included in this study were collected at a single institution from 2007 to 2011. PATIENTS: The study included 200 consecutive rectal cancer patients. INTERVENTION: The patients underwent robotic-assisted resection surgery performed by a single surgeon. MAIN OUTCOME MEASURES: The short-term (surgical outcome and pathologic data) and midterm outcomes (local pelvic control and overall and disease-free survival) were evaluated and compared with those in the published literature. RESULTS: The median patient age was 60 years, and the male:female ratio was 2:1. The median distance of rectal tumors from the anal verge was 6 cm. Preoperative radiotherapy was performed in 55 patients. The median operation time was 270 minutes, and the median blood loss was 190 mL. Grade 3 to 5 complications, according to the Clavien-Dindo classification, were observed in 15 patients (7.5%). The circumferential resection margin was positive in 5 patients (2.5%). During the median follow-up period of 29.8 months, recurrence occurred in 27 patients (distant metastasis, 18 patients; local recurrence, 7 patients; and both local recurrence and distant metastases, 2 patients). The local pelvic control and overall and disease-free survival rates of stage III patients at 5 years were 93.0%, 88.6%, and 76.6%. LIMITATIONS: This was a retrospective, uncontrolled study of selected patients by a single surgeon. CONCLUSIONS: Our results demonstrated an acceptable morbidity and a low rate of positive circumferential resection margin with effective local control. We also achieved excellent survival data. The midterm oncologic safety justifies the practice of robotic rectal cancer resection to further investigate its role on long-term outcomes.

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.

First report: Robotic pelvic exenteration for locally advanced rectal cancer.

The aim of this study was to present the feasibility and surgical outcome of robotic en bloc resection of the rectum and with prostate and seminal vesicle invaded by rectal cancer.