The Implementation of a Standardized Approach to Laparoscopic Rectal Surgery.

2012·0.11 MB·English

by  Aslak, Katrine Kanstrup

S P
CIENTIFIC APER
The Implementation of a Standardized Approach to
Laparoscopic Rectal Surgery
Katrine Kanstrup Aslak, MD, Orhan Bulut, MD
ABSTRACT INTRODUCTION
BackgroundandObjectives:Thepurposeofthisstudy Over the last 10 years, studies have shown the positive
was to audit our results after implementation of a stan- effect of fast-track (FT) rehabilitation programs on the
dardized operative approach to laparoscopic surgery resultsofsurgicaltreatment.1,2Theintroductionoflapa-
for rectal cancer within a fast-track recovery program. roscopic colorectal surgery (LCRS) and the implemen-
tation of FT programs have been focusing on shorter
Methods: From January 2009 to February 2011, 100 con-
hospital stay and less morbidity and surgical stress.3,4
secutive patients underwent laparoscopic surgery on an
Several large randomized trials5-8 and Cochrane re-
intention-to-treat basis for rectal cancer. The results were
views9,10 have concluded that LCRS has better short-
retrospectively reviewed from a prospectively collected
term outcomes and that oncological outcomes were
database. Operative steps and instrumentation for the
comparable to those of the conventional open ap-
procedure were standardized. A standard perioperative
proach. These trials comparing laparoscopic and open
care plan was used.
surgery have been performed in a traditional perioper-
Results: The following procedures were performed: low ative care setting. However, it remains controversial,
anterior resection (n(cid:1)26), low anterior resection with whether the combination of LCRS and FT programs can
loop-ileostomy (n(cid:1)39), Hartmann’s operation (n(cid:1)14), produceadramaticeffectonperioperativeoutcomesin
and abdominoperineal resection (n(cid:1)21). The median colorectal surgery.
length of hospital stay was 7 days; 9 patients were read-
The laparoscopic rectal procedures can be technically
mitted.Therewere9casesofconversiontoopensurgery.
challenging and are associated with a steep learning
The overall complication rate was 35%, including 6 cases
curve, longer operative time, expensive equipment,
(9%) of anastomotic leakages requiring reoperation. The
and the risk of conversion, which can result in signifi-
30-day mortality was 5%. The median number of har-
cant increases in cost and morbidity. The optimum
vested lymph nodes was 15 (range, 2 to 48). There were
laparoscopic resection of rectal cancer necessitates us-
6 cases of positive circumferential resection margins. The
ing a wide spectrum of efficient and safe operative
median follow-up was 9 (range, 1 to 27) months. One
approaches to ensure oncological clearance and good
patientwithdisseminatedcancerdevelopedport-siteme-
clinical outcomes, regarding medical and surgical com-
tastasis.
plications. During the implementation of LCRS in our
Conclusions: The results confirm the safety of a stan- department, we have standardized our operative ap-
dardized approach, and the oncological outcomes are proachtolaparoscopicrectalsurgeryandperioperative
comparable to those of similar studies. care of the patients. The purpose of this article is to
audit the clinical, surgical, and oncological results dur-
Key Words: Laparoscopic colorectal surgery, Rectal can-
ing this standardization of the operative technique
cer, Low anterior resection, Fast-track surgery.
within a FT recovery setting.
DepartmentofSurgicalGastroenterology,HvidovreUniversityHospital,University
MATERIALS AND METHODS
ofCopenhagen,Copenhagen,Denmark(allauthors).
ThispaperwaspresentedattheESCP6thScientificandAnnualMeeting,Copen-
hagen,Denmark,September2011. Patient Selection
Addresscorrespondenceto:OrhanBulut,DepartmentofSurgicalGastroenterol-
ogy,HvidovreUniversityHospital,CopenhagenUniversity,Copenhagen,Kette- From January 2009 to February 2011, 100 consecutive
gaardsAlle´30,DK-2650Hvidovre,Copenhagen,Denmark.Telephone:(cid:2)453862
6951;Fax:(cid:2)4538623760;E-mail:[email protected] patients underwent laparoscopic surgery in our depart-
ment on an intention-to-treat basis for rectal cancer. The
DOI:10.4293/108680812X13517013316672
clinical,operative,andpathologicaldataofthesepatients
©2012byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. were retrospectively reviewed from a prospectively col-
264 JSLS(2012)16:264–270
lecteddatabase.Everypatientwhowasoperatedonlapa- umbilicalportforestablishmentofpneumoperitoneumand
roscopically for rectal cancer in an elective setting in the peritonealinspection.Thepatientwasthenplacedinasteep
period was included. There were no exclusion criteria. Trendelenburgpositionandtheoperatingtablewasrotated
towards the right side. (2) Placement of 3 or 4 ports at
Preoperative Workup variable sites: a 10-mm to 12-mm port is inserted into the
rightlowerquadrantapproximately2cmto3cmmedialand
The preoperative workup included biopsy, endoscopy,
superiortotheanteriorsuperioriliacspine.A5-mm port is
computedtomography(CT),liverultrasound,chestX-ray,
theninsertedintherightupperquadrantatleastahand’s
and magnetic resonance imaging (MR). All patients were
breath superior to the lower quadrant port. A 5-mm left
stagedaccordingtonationalguidelines.Eachpatientwas
upper quadrant port is also inserted to aid the traction of
reviewedatourmultidisciplinarycolorectalcancer(MDT)
meetings before and after surgery. Patients with (cid:1)T3 tu- rectosigmoid colon or splenic flexure mobilization. All of
theseportsareinsertedlateraltotheepigastricvessels.An
mors and those with a threatened circumferential resec-
optional5-mmportcanalsobeinsertedatthesuprapubic
tion margin (CRM) underwent neoadjuvant chemoradio-
site, in which a Pfannenstiel incision is anticipated.
therapy.Surgerywascarriedout6weeksto8weeksafter
(3) Mesocolic dissection and inferior mesenteric pedicle
completion of treatment. Patient characteristics, tumor
isolation was achieved with a medial approach, and the
sizeandlocation,aswellasperioperativedata,patholog-
inferior mesenteric artery was ligated close to its origin
icalresults,morbidity,lengthofhospitalstay(LOS),read-
with clips or Endo-GIA. The superior rectal artery was
mission rate, 30-day mortality, and follow-up were re-
divided just below the inferior mesenteric artery after
corded prospectively. All procedures were performed by
application of 5-mm clips in the cases of abdominoperi-
the same surgical team.
neal resection (APR) and Hartmann’s operation (HO).
Tumorswereconsideredrectalcancersiflocatedbelow
(4)Theleftureterwasrecognizedandsubsequently,with
15cm from the anal verge measured with a rigid recto-
thepatientplacedsupineandrotatedleftsideup,medial-
scope.Rectalcancersuitableforsurgerywasdefinedas
to-lateral dissection was continued cranially up until the
a biopsy-proven adenocarcinoma. Patients were con-
left colon was mobilized. (5) The patient was returned to
sidered suitable for laparoscopic surgery if they had no
the Trendelenburg position, and the small bowel was
serious health conditions precluding a laparoscopic
reflected cranially after the completion of mobilization of
procedure. Patients with CT or MR evidence of tumor
theleftcolon.Agrasperwasusedtoelevatetherectosig-
infiltration of adjacent organs and T4 cancers were
moidcolonoutofthepelvisandawayfromtheretroperi-
considered unsuitable for laparoscopic surgery. All pa-
toneum and sacral promontory, to enable entry into the
tients were informed about possible risks and benefits
presacral space. (6) The posterior aspect of the mesorec-
of laparoscopic surgery, and informed written consent
tum was easily identified, and the mesorectal plane dis-
was obtained. A phosphate enema was given as bowel
sected with Harmonic scalpel, preserving the hypogastric
preparation prior to surgery. Stoma sites were marked
nerves. Dissection was continued down to the presacral
preoperatively. All patients received epidural anesthe-
space in this avascular plane toward the pelvic floor.
sia (bupivacaine/fentanyl) or intravenous morphine as
(7) Dissection proceeded laterally on both sides of the
postoperative pain relief. Perioperative care was previ-
rectum until circumferential mobilization of the lower
ously described and primarily developed for open co-
rectum was accomplished. (8) Digital examination was
lonic surgery in FT settings.1,2,11 The FT settings in-
performed to verify the distance between the inferior
cluded initiation of mobilization and full oral feeding
margin of the tumor and the line of resection, and the
(minimal oral intake of 1500mL of fluid but a full diet
adequacyofthedistalmarginwasmarkedwithaclip.(9)
was allowed) on the evening of surgery, removal of
An EndoGIA 45-mm Roticulator stapler (Covidien Ltd.,
epiduralcatheterandurinaryorsuprapubiccatheteron
Norwalk, CT, USA) was fired twice to divide the lower
the third day of surgery and planning of discharge as
rectum safely. The abdomen was then deflated, and a
soon as possible hereafter. During the hospital stay, all
suprapubic incision of 4cm to 6cm performed to extract
patients received thromboembolic prophylaxis. Naso-
theleftcolonandresectthespecimen.Awoundprotector
gastric tubes and drains were not used routinely.
(Alexis OTM, Applied Medical Rancho Santo Margarita,
CA) was placed at the incision. (10) Extracorporal prepa-
Surgical Method
ration of the proximate colon was completed with place-
We used 5 port sites. The standardized operative steps ment of the anvil of a 29-mm circular stapler (Proximate
forlaparoscopicrectalresectionare(1)openinsertionofthe ILS circular stapler, Ethicon, Endo-surgery, Cincinnati,
JSLS(2012)16:264–270 265
TheImplementationofaStandardizedApproachtoLaparoscopicRectalSurgery,AslakKKetal.
OH, USA) in position to perform a side-to-end or end-to- RESULTS
end colorectal anastomosis in the cases of low anterior
Patient characteristics are summarized in Table 1, and
resection(LAR).Bowelanastomosiswasperformedintra-
perioperative data are shown in Table 2. Nine patients
corporeally by the double staple technique. The splenic
(9%) were readmitted for a median of 3 days (range, 1 to
flexure was not routinely mobilized. For tension-free
13). There were 9 operations where conversion to open
anastomosis, full splenic flexure mobilization was per-
surgery were necessary. Indications for conversion in-
formedincaseoflackofredundancyofthesigmoidcolon
cluded fixation of the tumor to the surrounding organs
during surgery. The low pelvic dissection in APR was
(n(cid:1)6), dense adherences (n(cid:1)1), tumor growth into the
performed first posteriorly, then anteriorly, and finally
bladder (n(cid:1)1), and progressive respiratory insufficiency
with lateral dissection. The remainder of the deep pelvic
related to establishment of pneumoperitoneum.
dissection was performed through a perineal approach,
includingremovalofthetipofoscoccyxtogetherwiththe Intraoperative complications occurred in 3 cases. One
specimen ad modum Holm.12 In cases of HO and APR, a bladderinjuryandonesuperficiallacerationoftherectum
stoma was placed in the lower left quadrant according to occurred during laparoscopic resections. These injuries
the preoperatively marked stoma-site. A standardized were repaired laparoscopically without conversion. Fi-
perioperative care protocol was used. Conversion to an nally, one perforation of the anal canal occurred during
open procedure was defined as any abdominal incision perineal dissection in an APR-procedure.
largerthantheabove-mentionedtoextractthespecimen.
In the postoperative period, we registered 11 cases of
A protective loop ileostomy was performed for the anastomoticleaksinaccordancewithourpreviouslymen-
patients needing anastomosis within 5cm of the anal tionedcriteriaamongthe65patientswhounderwentlow
verge.Intestinalcontinuitywasre-established3months anteriorresection.Amongthose,6patients(9%)required
lateroraftercompletionofpostoperativeadjuvantther- reoperation. The remaining 5 patients (8%) were treated
apy. conservatively or with endoscopic vacuum-assisted clo-
sure. Table 3 outlines all postoperative complications
Follow-up encountered. We found a 30-day mortality rate of 5% (5
patients). Mean follow-up was 9 months (range, 1 to 27).
Postoperativecomplicationsweredefinedasanymorbid-
ity, including wound infection, in the postoperative pe- The oncologic outcomes are shown in Table 4. Twenty-
riod in the hospital or in the outpatient clinic within 30 fourpatientsunderwentneoadjuvanttreatmentbeforethe
days after the operation. Perioperative death was defined surgical procedure. Five of these (20.8%) had a complete
as death occurring within 30 days after surgery. Anasto- pathological response with no residual tumor detectable
motic leaks were defined as any dehiscence of the anas- intheresectedspecimen.Themedianlengthofthespec-
tomosisobservedbyendoscopy,digitalexamination,CT- imen was 17cm (range, 10 to 35), the median DRM was
scan,orGastrografinenema.Allpatientswerereferredfor 30mm (range, 2.5 to 35), the median CRM was 10mm
colonoscopy and CT-scan after the first and third year of
surgery.
Table1.
PatientDemographics
Pathologic Method
Sex,m/f(n) 61/39
All specimens were examined by local pathologists with
Age,median(years) 66(range30–88)
specialattentiontothenumberofharvestedlymphnodes,
circumferential resection margin (CRM), distal resection BodyMassIndex,median(kg/m2) 24(range17–40)
margin (DRM) and completeness of the mesorectal fascia ASA-score,median* 2(range1–3)
(MRF). Tumorlocation,median(cmfrom 10(range2–15)
analverge)
Statistical Analysis Previousintraabdominalsurgery(n) 31
Data were collected in an SPSS worksheet (SPSS version Preoperativechemo-radio-therapy
19; SPSS INC. Chicago, IL). All values are presented as None 76
median (range). When appropriate, Fisher’s exact test Chemo-andradiotherapy 24
(chi-square test) was used for nonparametric data. P(cid:3).05
*ASA(cid:1)AmericanSocietyofAnesthesiologists.
was considered statistically significant.
266 JSLS(2012)16:264–270
(range, 0 to 55), and CRM was positive in 6 patients. The in84casesandnotcompletein14cases.TheMRFwasnot
overallmediannumberofharvestedlymphnodeswas15 describedinthehistopathologicalreportsin2cases.One
(range, 2 to 48). The median lymph node harvest in patientwithdisseminatedcancerdevelopedport-siteme-
patients who underwent preoperative neoadjuvant treat- tastasis.
ments(n(cid:1)24)was12(range,4to35),andinpatientswho
underwent primary resection without neoadjuvant treat-
DISCUSSION
ment (n(cid:1)76), the median lymph node harvest was 16
(range,2to28).TheMRFwascompleteornearcomplete The increasing amount of available data on laparoscopic
resection of the rectum suggests that the method is feasi-
ble and safe for select patients with favorable short- and
Table2. mid-term outcomes.13,14 Nonetheless, laparoscopic rectal
PerioperativeData
surgery has been viewed with significant skepticism by
Surgicalprocedure (n) the surgical community, and the majority of rectal resec-
tions continue to be carried out using the conventional
Lowanteriorresection 26
open approach. Currently, several multicenter random-
Lowanteriorresectionwith 39
ized controlled trials comparing laparoscopic and open
loop-ileostomy
surgery for rectal cancer are registered, and until these
Hartmann’soperation 14
data become available, some surgeons believe that open
Abdominoperinealresection 21 totalmesorectalexcisionisregardedasthegoldstandard
Operativetime,median(min) 250(range,51–397) treatment of rectal cancer. The limited access to experi-
Lowanteriorresection 181(range,51–353) enced laparoscopic colorectal surgeons may also play a
role in this turnover process. The resection of low rectal
Lowanteriorresectionwith 261(range,100–376)
loop-ileostomy tumors is technically challenging, and the learning curve
toachieveanadequateclearancemarginissteep.Training
Hartmann’soperation 186(range,114–345)
inadvancedcolorectalworkshopsthatutilizebothanimal
Abdominoperinealresection 280(range,131–397)
and human cadaver models is extremely helpful to
Lossofblood,median(mL) 100(range,0–1145)
shorten this learning curve. Appropriate patient selection
Hospitalstay,median(days) 7(range,3–80) is also an essential component of surgical practice at the
Re-admission(n) 9 beginning of training and ideal cases to start on to help
Table3.
PostoperativeComplications
Complication Numberofpatients(n) Treatment
Urinetractinfection 5 Antibiotics
Gastrointestinalbleeding 1 Self-resolved
Superficialwoundinfection 2 Drainage
Leakageoftherectal“stump” 3 Ultrasound-guideddrainage
Compartmentsyndrome 2 Fasciotomy
Necrosisofthestoma 2 Stomarefashioned
Ileus(adhesions) 1 Lysisoftheadherences
Earlyport-sitehernia 1 Repaired
Peritonitis 2 Laparotomy
Parastomalhernia 2 Repaired
Presacralabscess 3 Ultrasound-guideddrainage
Anastomoticleak 5 Conservativetreatment/Endo-VACa
Anastomoticleak 6 Reoperation
Total 35
aEndo-VAC(cid:1)Endoscopicvacuum-assistedclosure.
JSLS(2012)16:264–270 267
TheImplementationofaStandardizedApproachtoLaparoscopicRectalSurgery,AslakKKetal.
scopicmethodforalmostallpatients,onlyexclusionsbeingT4
Table4.
tumorsorlocalgrowthintoneighboringorgans.
OncologicResults
Circumferentialresectionmargin, 10(range0–55) Amedianpostoperativehospitalstayofonly7daysinthis
median(mm) series is short compared to that in other studies with a
Distalresectionmargin,median(mm) 30(range2,5–70) median hospital stay of 8 days to 15 days.8,16,19-22 This
great variety of results is probably due to cultural and
Lengthofspecimen,median(cm) 17(range10–35)
economic differences in health care systems between
Harvestedlymph-nodes,median(n) 15(2–48)
countries. In our department, there are very well-estab-
Mesorectalfascia(n)
lishedroutinesinourfast-tracksurgeryprogramthatwas
Complete 68 originally developed for postoperative care after colon
Nearcomplete 16 surgery.1,2 It has over the years been adjusted for rectal
Incomplete 14 surgery. Hence, all patients were already prepared for
stoma self-care prior to surgery by one of the specialist
R0resection 94
nurses from our ward. Furthermore, all patients, if possi-
ble,receivedepiduralanalgesiaupto3daysaftersurgery,
climb the learning curve. However, permanent supervi- andallpatientswereencouragedtoearlyoralfeedingand
sion and training with experienced surgeons who rou- mobilizationassoonaspossibleaftersurgery,atthelatest
tinelyperformasignificantnumberoflaparoscopicrectal thefirstdayaftersurgery,anddrainsandcatheterswerewith-
procedures,inouropinion,isthebestwaytoacquirethe drawnthethirdpostoperativeday.Ourreadmissionrateof9%
requiredskillsinthisprocedure,becausethereislesscase withamediansecondaryhospitalstayof3daysiscomparable
selectionwithvaryingdifficultyoftheoperationsandthe tothatinsimilarstudieswhereupto23%ofthepatientswere
multitude of factors that effect the outcomes in laparo- readmittedafterfast-trackrectalcancersurgery.23
scopic rectal surgery in the later period of training. Lind-
Table 3 shows that the majority of complications were
setmoandDelaney15describedastandard,stepwiselapa-
surgical. There is no difference in complication rates be-
roscopicprocedureforrectalresections.Wehaveadapted
tween the first and the last 50 patients in this series. Our
this technique, which makes the operation predictable
overall complication rate of 35% matches results of other
andreproducibleforthewholesurgicalteam.Theprocess
studies.8,16,21Thereisasmalltendencytowardsincreased
ofadaptingthisstandardizedtechniqueisprobablyoneof
risk of complications, if the patient had received preop-
the causes for the median operative time of 250 minutes,
erative radiotherapy, as 40.9% of the radiated patients
whichislongerthantimeincomparablestudies.8,16Other
experienced complications versus 35.9% of the nonradi-
causes could be that a new surgical setting was imple-
ated patients. The tendency is however not statistically
mented and that 2 new surgeons in our team were edu-
significant (P(cid:1).803). Although a total of 15 reoperations
cated to perform laparoscopic rectal surgery during the
seem to be a high figure, it is comparable to that in other
study period. Furthermore there were a high number of
reported series of laparoscopic rectal surgery.24,25
patientswithahistoryofpreviousabdominalsurgeriesin
our series (31%). Much depends on the author’s definition of anastomotic
leakage when it comes to calculating leakage rates. We
There have been reports about increasing complication
have used wide-spanning criteria for our definition of
rates in patients converted from laparoscopic to open
anastomotic leaks. Our rate of leakages that required re-
surgery.17 Our rate of conversion was 9%, which is lower
operation (9%) is acceptable in comparison with that in
thanthatinotherstudies.8,18Thismayreflectsomedegree
other series.8,16,22 Neither conversion nor neoadjuvant
ofbias,becauseourpatientswereselectedcandidatesfor
therapy resulted in higher risk of development of anasto-
laparoscopic surgery and not randomized to either open
motic leakage in this series. However, Figure 1 shows
or laparoscopic surgery. Morbidity and length of hospital
that there is a decreasing tendency in the leakage rate in
stayforconvertedpatientswerehoweversimilartothose
thelatterpartofthestudyperiod(studyperiodB),where
completed laparoscopically. Our data therefore confirm
the standardized surgical approach had been fully imple-
that careful selection of patients for laparoscopic surgery
mented.Thedifferencebetweentheseratesofleakagesis
makestheprocedurepracticableandtheneedtoconvertsmall.
however not significant (P(cid:1).094).
Thisstudyalsoconfirmsthatourstrategytoconvertwhenever
thereisfailuretoprogressintheverydifficultoperativefieldis Our 30-day mortality was 5%, which is relatively high
safe. At present, our approach is to initially plan the laparo- compared to that in other studies.18,20 The postoperative
268 JSLS(2012)16:264–270
from the mesorectum during surgery is also an important
predictorofprognosis.30Inourstudy,therewasamedian
harvest of 15 lymph nodes, and 80% of the specimens
contained 12 lymph nodes or more, which is equal to
results of several studies.14,16,18,20 The mesorectal fascia
was not complete in 16% of our patients. Macroscopic
evaluation of the mesorectal fasciae is considered an im-
portantqualitymeasureinrectalcancersurgery.Tearsand
shallow breaks in the mesorectum, however, are difficult
to avoid, particularly when dealing with large bulky tu-
morsinLCRS.Otherfactorslikeanarrowpelvisandafatty
mesorectumincreasetheriskofdamagingthemesorectal
Figure1.Anastomoticleakagerates.InstudyperiodA,patients fascia with the laparoscopic instruments as well. For that
no.1–50underwentsurgeryand9hadanastomoticleak(25%). reason, the grading of the mesorectal fasciae was charac-
InstudyperiodB,patientsno.51–100underwentsurgery,and2 terized as only nearly complete in some cases, even
hadanastomoticleaks(6.9%)(P(cid:1).094). though dissection was carried out in the correct plane.
Nagtegaal et al30 have shown that a complete or nearly
morbidityandmortalityinFTsettingsremainchallenging complete mesorectal fascia is prognostic for good long-
and controversial due to mainly a nonselected, high-risk termoncologicaloutcomes,whereasanincompletefascia
elderly population with coexisting illnesses.26-28 In the is prognostic for unfortunate oncological long-term out-
presentseries,the5patientswhodiedwere78to88years comes. Because of the short follow-up period, it is not
of age at the time of the operation. They all suffered possible to conclude whether our oncologic result influ-
preoperativelyfromseveredegreesofischemicheartfail- encesthelong-termoncologicoutcome.Onlyonepatient
ure. Moreover, one of the patients suffered from severe withdisseminatedcancerdevelopedaport-sitemetastasis.
chronic obstructive lung disease and non-insulin depen-
dent diabetes mellitus, one patient suffered from renal Themainlimitationsofthisstudyarefurthermorethatthis
failure and obesity (BMI(cid:1)33), and one patient had re- retrospective series with prospectively registered data
cently been hospitalized due to lung embolia. After pri- doesnotincludealargenumberofpatients.Moredataare
mary surgery, all 5 patients experienced surgical compli- neededfromlargerandomizedcontrolledtrialsregarding
cations and underwent reoperations. In 2 patients, long-term oncological outcome.
reoperationwasneededbecauseoffecalperitonitis(anas-
tomotic leak and small bowel perforation), in 2 cases CONCLUSION
because of severe ischemia of the stoma, and in 1 case
because of nonfecal peritonitis of unknown origin. All 5 Our data support the view that standardization of the
patientsdiedduetosepsisandfailureofmultipleorgans. operative steps in laparoscopic rectal surgery seems to
limit the risk of anastomotic complications and provides
Large randomized trials comparing laparoscopic versus
clear indications for early and safe conversion to open
open resection for colorectal cancer have shown an
surgery. This stepwise technique can be used to train
equivalent oncological outcome.6,7 Adequate surgical colorectal surgeons in the future. Oncological outcomes
margin clearance remains crucial for local recurrence
arecomparabletothoseofsimilarstudies,butweneedto
rates.TheresultsoftheCLASICCtrialwithatrendtowards
optimize the short-term outcome further.
increasedrateofinvolvedCRM(6%openvs.12%laparo-
scopic) for anterior resection were initially alarming.8
References:
However,arecentmetaanalysissuggeststhatthereareno
differences between laparoscopic and open surgery for 1. Nygren J, Hausel J, Kehlet H, et al. A comparison in five
rectal cancer in terms of number of harvested lymph European centres of case mix, clinical managements and out-
nodes, involvement of CRM and local recurrence.29 The comes following either conventional or fast-track perioperative
rate of positive CRM was 6% in our study. All positive careincolorectalsurgery.ClinNutr.2005;24:455–461.
margins occurred in patients with T4 tumors or node 2. Basse L, Hjort Jakobsen D, Billesbølle P, Werner M, Kehlet
positive (N2) disease. This rate is comparable to that in H.Aclinicalpathwaytoacceleraterecoveryaftercolonicresec-
other reports.8,16 The number of lymph nodes harvested tion.AnnSurg.2000;232(1):51–57.
JSLS(2012)16:264–270 269
TheImplementationofaStandardizedApproachtoLaparoscopicRectalSurgery,AslakKKetal.
3. Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive co- 18. Stro¨hleinMA,Gru¨tznerKU,JauchKW,HeissMM.Comparisonof
lon resection (laparoscopic coloctomy). Surg Laparosc Endosc. laparoscopicvs.openaccesssurgeryinpatientswithrectalcancer:a
1991;1(3):144–150. prospectiveanalysis.DisColonRectum.2008;51:385–391.
4. WilmoreDW,KehletH.Managementofpatientsinfasttrack 19. Good DW, O’Riordan JM, Moran D, et al. Laparoscoic sur-
surgery.BMJ.2001;322:473–476. gery for rectal cancer: a single-centre experience of 120 cases.
IntJColorectalDis.2011;26(10):1309–1315.
5. Lacy AM, García-Veldecasas JC, Delgado S, et al. Laparoscopy-
assistedcolectomyversusopencolectomyfortreatmentofnon-meta- 20. KangS-B,ParkJW,JeongS-Y,etal.Openversuslaparoscopic
staticcoloncancer:arandomizedtrial.Lancet.2002;359:2224–2229. surgery for mid or low rectal cancer after neoadjuvant chemoradio-
therapy (COREAN trial): short term outcomes of an open-label ran-
6. The COlon cancer Laparoscopic or Open Resection Study
domizedcontrolledtrial.LancetOncol.2010;11:637–645.
Group. Laparoscopic surgery versus open surgery for colon
cancer:short-termoutcomesofarandomisedtrial:LancetOncol. 21. GonzalezIA,LuisHD,Malago´nAM,Ferna´ndezEML,Duran
2005;6:477–484. JA,PallaresAC.Acomparativeclinicalstudyofshort-termresults
of laparoscopic surgery for rectal cancer during the learning
7. TheClinicalOutcomesofSurgicalTherapyStudyGroup.A
curve.IntJColorectalDis.2006;21:590–595.
comparisonoflaparoscopicallyassistedandopencolectomyfor
coloncancer.NEnglJMed.2004;350:2050–2059. 22. SartoriCA,DalPozzoA,FranzatoB,BalduinoM,SartoriA,
Baiocchi GL. Laparoscopic total mesorectal excision for rectal
8. GuillouPJ,QuirkeP,ThorpeH,etal.Short-termendpoints
cancer: experience of a single center with a series of 174 pa-
ofconventionalversuslaparoscopic-assistedsurgeryinpatients
tients.SurgEndsosc.2011;25:508–514.
with colorectal cancer (MRC CLASICC trial): multicenter, ran-
domizedcontrolledtrial.Lancet.2005;365:1718–1726. 23. Schwenk W, Neudecker J, Raue W, Haase O, Mu¨ller JM.
“Fast-track”rehabilitationafterrectalcancerresection.IntJColo-
9. Bruikink S, Pierie JP, Wiggers T. Laparoscopic versus open
rectalDis.2006;21:547–553.
totalmesorectalresectionforrectalcancer.CochraneDatabase
SystRev.2006;4:CD005200. 24. Ba¨rlehnerE,BenhidjebT,AndersS,SchickeB.Laparoscopic
resectionforrectalcancer.Outcomesin194patientsandreview
10. Schwenk W, Haase O, Neudecker JJ, Myller JM. Short term
oftheliterature.SurgEndosc.2005;19:757–766.
benefits for laparoscopic colorectal resection. Cochrane Data-
baseSystRev.2005;2:CD003145. 25. MorinoM,PariniU,GiraudoG,SalvalM,ContulR,Garrone
C. Laparoscopic total mesorectal excision. A consecutive series
11. BardramL,Funch-JensenP,KehletH.Rapidrehabilitationin
of100patients.AnnSurg.2003;237(3):335–342.
elderly patients after laparoscopic colonic resection. Br J Surg.
2000;87:1540–1545. 26. Vlug MS, Wind J, Hollmann MW, et al. Laparoscopy in
combinationwithfasttrackmultimodalmanagementisthebest
12. Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J. Ex-
perioperative strategy in patients undergoing colonic surgery.
tended abdominoperineal resection with gluteus maximus flap
AnnSurg.2011;00:1–8.
reconstruction of the pelvic floor for rectal cancer. Br J Surg.
2007;94(2):232–238. 27. StottmeierS,HarlingH,Wille-JørgensenP,BallebyL,Kehlet
H.Postoperativemorbidityafterfast-tracklaparoscopicresection
13. Liakakos T, Kopanakis K, Scizas D. Favorable outcomes with
of rectal cancer. Colorectal Dis. 2011;Doi:10.1111/j.1463-
laparoscopic surgery for rectal cancer. Surg Endosc. 2010;24:1217–
1318.2011.02767.x.
1218.
28. GouvasN,TsiaoussisJ,PechlivanidesG,etal.Laparoscopic
14. MiyajimaN,FukunagaM,HasegawaH,TanakaJ,OkudaJ,Wa-
oropensurgeryforthecancerofthemiddleandlowerrectum
tanabeM.Resultsofamulticenterstudyof1,057casesofrectalcancer
short-term outcomes of a comparative non-randomised study.
treatedbylaparoscopicsurgery.SurgEndosc.2009;23:113–118.
IntJColorectalDis.2009;24:761–769.
15. LindsetmoRO,DelaneyCP.Astandardizedtechniqueforlaparo-
29. HuangM-J,LiangJ-L,WangH,KangL,DengJ-H,WangJ-P.
scopicrectalresection.JGastrointestSurg.2009;13:2059–2063.
Laparoscopic-assisted versus open surgery for rectal cancer: a
16. LujanJ,ValeroG,HernandezQ,SanchezA,FrutosMD,ParillaP. metaanalysis of randomized controlled trials on oncologic ade-
Randomizedclinicaltrialcomparinglaparoscopicandopensurgeryin quacy of resection and long-term oncologic outcomes. Int J
patientswithrectalcancer.BrJSurg.2009;96:982–989. ColorectalDis.2011;26:415–421.
17. TekkisPP,SenagoreAJ,DelaneyCP,FazioVW.Evaluationofthe 30. NagtegaalID,vandeVeldeCJH,vanderWorpE,Kapiteijn
learningcurveinlaparoscopiccolorectalsurgery.Comparisonofright- E,QuirkeP,vanKriekenJHJM.Macroscopicevaluationofrectal
sidedandleft-sidedresections.AnnSurg.2005;242(1):83–91. cancer resection specimen: clinical significance of the patholo-
gistinqualitycontrol.JClinOncol.2002;20(7):1729–1734.
270 JSLS(2012)16:264–270