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Lateral pelvic node dissection has significant technical difficulty and a high incidence of surgical morbidity. A steep learning curve is anticipated in performing lateral pelvic node dissection. However, no study has previously analyzed the learning curve and surgical skill acquisition for this complex procedure.We aimed to evaluate the learning process for performing robotic total mesorectal excision with lateral pelvic node dissection in patients with rectal cancer.This is a retrospective analysis of a prospectively collected database.This study was conducted at a tertiary cancer center.A total of 100 patients who underwent robotic total mesorectal excision with lateral pelvic node dissection between 2011 and 2017 were included.A cumulative sum analysis was calculated based on the number of unilateral retrieved lateral pelvic nodes. Operative time, estimated bloodloss, lateral pelvic node metastatic rate, postoperative morbidities, and local recurrence were also analyzed.Cumulative sum modeling suggested 4 learning phases: learning I (33 patients), learning II (19 patients), consolidation (30 patients), and competence (18 patients). In the consolidation and competence phases, we adopted fluorescence imaging and standardized the surgical procedure on the basis of anatomical planes. The competence phase had the greatest number of unilateral retrieved lateral pelvic nodes (12.8 vs 4.9, 8.2, and 10.4; p0.001). Urinary complications, including urinary retention and postoperative α-blocker usage, were more frequently observed in learning phase I than in the competence phase (39.4% vs 16.7%, p = 0.034). During the median follow-up of 44.2 months, local recurrence in the pelvic sidewall was observed in 4 patients from learning phase I and in 1 patient from learning phase II.This study was limited by its retrospective design.Completeness of the lateral pelvic node dissection procedure increased with the surgeon's experience and as new imaging systems and surgical technique standardization were implemented. Further studies are warranted to determine the oncologic outcomes associated with each phase. See Video Abstract at http://links.lww.com/DCR/B774.ANTECEDENTES:La disección linfática pélvica lateral tiene una dificultad técnica significativa y una alta incidencia de morbilidad quirúrgica. Se prevé una curva de aprendizaje muy pronunciada al realizar la disección linfática pélvica lateral. Sin embargo, ningún estudio ha analizado previamente la curva de aprendizaje y la adquisición de habilidades quirúrgicas para este procedimiento.OBJETIVOS:Nuestro objetivo fue evaluar el proceso de aprendizaje para realizar la escisión total de mesorrecto robótica con disección linfática pélvica lateral en pacientes con cáncer de recto.DISEÑO:Este es un análisis retrospectivo de una base de datos recopilada prospectivamente.AJUSTE:Este estudio se realizó en un centro oncológico terciario.PACIENTES:Un total de 100 pacientes fueron sometidos a escisión total de mesorrecto robótica con disección linfática pélvica lateral entre 2011 y 2017.PRINCIPALES MEDIDAS DE DESENLACE:Se calculó un análisis de suma acumulativa basado en el número unilateral de ganglios pélvicos laterales recuperados. También se analizaron el tiempo operatorio, la pérdida de sangre estimada, la tasa de metástasis ganglionares pélvicas laterales, las morbilidades postoperatorias y la recidiva local.RESULTADOS:El modelado total acumulativo sugirió cuatro fases de aprendizaje: aprendizaje I (33 pacientes), aprendizaje II (19 pacientes), consolidación (30 pacientes) y competencia (18 pacientes). En las fases de consolidación y competencia, adoptamos imágenes de fluorescencia y estandarizamos el procedimiento quirúrgico basado en planos anatómicos, respectivamente. La fase de competencia tuvo el mayor número de ganglios pélvicos laterales recuperados unilateralmente (12,8 frente a 4,9, 8,2 y 10,4; p0,001). Las complicaciones urinarias, incluida la retención urinaria y el uso posoperatorio de bloqueadores beta, se observaron con más frecuencia en la fase de aprendizaje I que en la fase de competencia (39,4% frente a 16,7%, p = 0,034). Durante la mediana de seguimiento de 44,2 meses, se observó una recidiva local en la pared lateral pélvica en cuatro pacientes de la fase de aprendizaje I y en un paciente de la fase de aprendizaje II.LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo.CONCLUSIÓNES:La completitud del procedimiento de disección linfática pélvica lateral aumentó con la experiencia del cirujano y a medida que se implementaron nuevos sistemas de imágenes y estandarización de técnicas quirúrgicas. Se necesitan más estudios para determinar los resultados oncológicos asociados con cada fase. Consulte Video Resumen en http://links.lww.com/DCR/B774.

BACKGROUND Venous invasion is a poor prognostic factor in colon cancer but is often underreported with significant variability. OBJECTIVES We aimed to determine the impact of an elastin stain on venous invasion detection in colon cancer and evaluate the value of venous invasion in predicting disease recurrence in combination with lymph node status and other prognostic factors. DESIGN This is a retrospective analysis of a prospectively collected database. SETTING This study was conducted at a tertiary cancer center. PATIENTS A total of 418 patients who underwent curative resection for stage I to III colon cancer and routinely adopted an elastin stain were evaluated. MAIN OUTCOME MEASURES Venous invasion detection rate after adopting elastin stain, prognostic factors influencing disease recurrences by multivariate Cox regression models, and survival were measured. The zones of lymph node metastasis were defined as LNZ1, LNZ2, and LNZ3, corresponding to metastases in the pericolic, intermediate, and apical nodes. RESULTS Venous invasion detection rate increased from 11.3% to 35.4% compared with the previous period in which only hematoxylin and eosin stain was performed. Cox regression analysis showed venous invasion (HR, 3.856; 95% CI, 1.249-11.910; p = 0.019) and lymph node metastases (HR, 3.156; 95% CI, 1.094-9.108; p = 0.034) in all stages and LNZ 2, 3 (HR, 2.649; 95% CI, 1.244-5.640; p = 0.012) in stage III to be significantly associated with poor disease-free survival. When stratifying all patients by these 3 factors, patients with stage III [LNZ1/venous invasion (-)] had disease-free survival comparable with stage I, but significantly better disease-free survival than those with stage II [venous invasion (+)] (p = 0.018). Patients with stage II [venous invasion (+)] had better disease-free survival by using adjuvant chemotherapy (p < 0.001). LIMITATIONS This study was limited by its retrospective design. CONCLUSION Elastin stain contributed to a considerable increase in venous invasion detection. Venous invasion can be a powerful predictor of poor disease-free survival beyond lymph node metastases when limited to the pericolic area and is useful for deciding the use of adjuvant chemotherapy in stage II colon cancer. See Video Abstract at http://links.lww.com/DCR/B573. EL VALOR PRONSTICO DE LA INVASIN VENOSA DETECTADA POR LA TINCIN DE ELASTINA PUEDE SUPERAR EL ESTADO DE LOS GANGLIOS LINFTICOS EN EL CNCER DE COLON ANTECEDENTES:Invasion venosa (IV) es un factor de mal pronostico en el cancer de colon, que frecuentemente no se informa con una variabilidad significativa.OBJETIVOS:Nuestro objetivo fue determinar el impacto de tincion de elastina en la deteccion de IV en el cancer de colon y evaluar el valor de IV en la prediccion de la recurrencia de la enfermedad en combinacion con el estado de los ganglios linfaticos y otros factores pronosticos.DISENO:Este es un analisis retrospectivo de una base de datos recopilada prospectivamente.ENTORNO CLINICO:Este estudio se realizo en un centro oncologico de referencia de tercer nivel.PACIENTES:Se valoraron un total de 418 pacientes sometidos a reseccion curativa por cancer de colon en estadio I-III utilizando de manera rutinaria una tincion de elastina.PRINCIPALES MEDIDAS DE VALORACION:Se midieron la tasa de deteccion de IV despues de adoptar la tincion de elastina, los factores de pronostico que influyen en las recurrencias de la enfermedad mediante modelos de regresion de Cox multivariados y la supervivencia. La zona de metastasis ganglionares se definio como, LNZ1, LNZ2 y LNZ3, correspondientes a las metastasis en los ganglios pericolicos, intermedios y apicales, respectivamente.RESULTADOS:La tasa de deteccion de IV aumento de 11,3% a 35,4% en comparacion con el periodo anterior en el que solo se realizo tincion con hematoxilina y eosina. El analisis de regresion de Cox mostro VI (razon de riesgo, 3.856; intervalo de confianza [IC] del 95%, 1.249-11.910, p = 0.019) y metastasis en los ganglios linfaticos (razon de riesgo, 3.156; IC del 95%, 1.094-9.108, p = 0.034) en todos los estadios y LNZ 2, 3 (cociente de riesgo, 2.649; IC del 95%, 1.244-5.640, p = 0.012) en el estadio III se asociaron significativamente con una pobre supervivencia libre de enfermedad. Al estratificar a todos los pacientes segun estos tres factores, los pacientes con estadio III [LNZ1 / VI (-)] tuvieron una sobrevivencia sin enfermedad (SSE) comparable con el estadio I, pero una supervivencia libre de enfermedad significativamente mejor que aquellos con estadio II [VI (+)] (p = 0,018). Pacientes en estadio II [VI (+)] tuvieron una mejor supervivencia sin enfermedad mediante el uso de quimioterapia adyuvante (p

BACKGROUND The long-term oncologic efficacy of robotic surgery for patients with rectal cancer is unknown. OBJECTIVE The aim of the study was to investigate survival outcomes of robotic total mesorectal excision for mid/low rectal cancer compared with those of laparoscopic surgery. DESIGN We performed a single-center retrospective analysis. SETTING The data of a tertiary academic institution was reviewed. PATIENTS A total of 705 patients underwent laparoscopic (n = 415) or robotic (n = 118) low anterior resection for stage I to III mid/low rectal cancer. A total of 118 patients in each group were selected from the original data set by using propensity score matching. MAIN OUTCOME MEASURES The main outcomes were 5-year disease-free survival, distant recurrence, and local recurrence. RESULTS The 2 groups were balanced in terms of basic characteristics, perioperative treatment, and pathological stage. The 5-year disease-free survival rate was 80.5% in the laparoscopic group and 87.6% in the robotic group (p = 0.118). The 5-year distant recurrence rate and local recurrence rate were 19.0% and 4.2% in the laparoscopic group and 10.0% and 3.7% in the robotic group (p = 0.048 and p = 0.846). In a subgroup of patients who received preoperative chemoradiation and had ypT3/4 tumors, the 5-year distant recurrence and local recurrence rates were 44.8% and 5.0% in the laparoscopic group and 9.8% and 9.8% in the robotic group (p = 0.014 and p = 0.597). LIMITATIONS The retrospective nature of the study, potential selection bias with distinct demographics between the groups, and relatively small number of cases are limitations. CONCLUSIONS Robotic surgery for mid/low rectal cancer shows similar long-term oncologic outcomes with laparoscopic surgery but is beneficial to a certain group of patients with advanced rectal cancer with poor response to neoadjuvant chemoradiation. Additional studies are required to confirm our results. See Video Abstract at http://links.lww.com/DCR/B546. LA CIRUGA ROBTICA MUESTRA RESULTADOS ONCOLGICOS A LARGO PLAZO SIMILARES A LA CIRUGA LAPAROSCPICA EN CASOS DE CNCER DE RECTO MEDIO / BAJO, PERO ES VENTAJOSA EN CASOS YPT POSTQUIMIORADIOTERAPIA PREOPERATORIA ANTECEDENTES:Se desconoce la eficacia oncologica a largo plazo de la cirugia robotica en pacientes con cancer de recto.OBJETIVO:La finalidad de nuestro estudio fue el investigar los resultados de supervivencia de la escision mesorrectal total robotica en casos de cancer de recto medio / bajo en comparacion con los de la cirugia laparoscopica.DISENO:Realizamos un analisis retrospectivo mono-centrico.AJUSTE:Se revisaron los datos de una institucion academica terciaria.PACIENTES:705 pacientes fueron sometidos a reseccion anterior baja laparoscopica (n = 415) o robotica (n = 118) para cancer de recto medio / bajo en estadio I-III. Se selecciono un total de 118 pacientes en cada grupo del conjunto de datos original utilizando el emparejamiento por puntuacion de propension.RESULTADOS PRINCIPALES:Estos fueron, la supervivencia libre de enfermedad a 5 anos, la recurrencia a distancia y la recurrencia local.RESULTADOS:Los dos grupos estaban equilibrados en cuanto a caracteristicas basicas, tratamiento peri-operatorio y estadio patologico. La tasa de sobrevida libre de enfermedad a 5 anos fue del 80,5% en el grupo laparoscopico y del 87,6% en el grupo robotico (p = 0,118). La tasa de recurrencia a distancia a 5 anos y la tasa de recurrencia local fueron 19,0% y 4,2% en el grupo laparoscopico y 10,0% y 3,7% en el grupo robotico, respectivamente (p = 0,048 y p= 0,846). En el subgrupo de pacientes que recibieron quimio-radioterapia pre-operatoria y tenian tumores ypT3-4, las tasas de recidiva a distancia a 5 anos y recidiva local fueron 44,8% y 5,0% en el grupo laparoscopico y 9,8% y 9,8% en el grupo robotico, respectivamente (p = 0.014 y p = 0.597).LIMITACIONES:La naturaleza retrospectiva del estudio, el posible sesgo en la seleccion con datos demograficos distintos entre los grupos y un numero relativamente pequeno de casos son limitaciones importantes.CONCLUSIONES:La cirugia robotica para el cancer de recto medio / bajo muestra resultados oncologicos a largo plazo similares con la cirugia laparoscopica, pero es mas beneficiosa en ciertos grupos de cancer de recto avanzado con mala respuesta a la quimio-radioterapia neoadyuvante. Se requieren mas estudios para confirmar nuestros resultados. Consulte Video Resumen en http://links.lww.com/DCR/B546.).

Few studies that meticulously match individual lymph nodes seen on MRI with their precise histologic counterparts after total mesorectal excision have been reported.The objective of this study was to determine whether preoperative MRI could detect lymph node metastases accurately in the node-by-node analysis.This was a prospective, observational cohort study.The study was conducted at a tertiary-care hospital.Forty patients with rectal cancer were enrolled.Specimens were assessed using MRI for clinical staging. After surgical resection of the tumor, the specimens were again imaged with ex vivo ultrasound scan to localize the perirectal node. The locations of each lymph node were precisely matched with its corresponding magnetic resonance image to enable a node-for-node comparison of magnetic resonance images and histologic findings.Agreement between MRI and histologic assessment of T stage was 82.5%. Of the 341 nodes harvested, 120 were too small (3 mm) to be depicted on magnetic resonance images, and 18 of these contained metastasis (15%). A correlation between the results of MRI and histopathology was feasible for 205 lymph nodes, and the overall success rate of matching between the 2 techniques was 91.1% (205 of 221). Preoperative MRI revealed a node-by-node sensitivity and positive predictive value of 58.0%, and 61.7%. There was no difference in the diagnostic accuracy between the primary surgery subgroup and preoperative radiation subgroups.The study is limited by its heterogeneity of cohorts including the subgroup with preoperative chemoradiation and the lack of preoperative ultrasound assessment.Preoperative MRI was moderately accurate for the prediction of mesorectal lymph node metastasis. Moreover, preoperative MRI was insufficient for detecting small lymph nodes (3 mm) with metastasis.

The goal of this study is to evaluate the technical feasibility, safety, and clinical outcomes of totally laparoscopic colectomy with transvaginal anastomosis and extraction of specimen in female patients with right-sided colon cancer.A review of prospectively collected database at the Kyungpook National University Hospital from April 2007 to December 2007 revealed a series of 14 consecutive patients affected by right colon cancer were operated by use of the totally laparoscopic colectomy with transvaginal anastomosis and extraction of specimen approach. For this approach, the bowel was fully mobilized and a D3 lymphadenectomy was performed with established laparoscopic technique, followed by transvaginal anastomosis and removal of the resected specimen. Data regarding clinicopathological outcomes, surgical morbidity, and short-term oncologic results were analyzed.No case required an open conversion, but in 2 patients the planned transvaginal retrieval of the specimen was aborted because of inadequate posterior colpotomy. The median operative time was 150.0 minutes (range, 110-330 min) and the median blood loss was 50.0 mL (range, 20.0-115 mL). The median tumor size was 4.0 cm and the number of harvested lymph nodes was 36.0 (range, 13-65). There was no surgical mortality or major morbidity, except one case of postoperative ileus that was conservatively managed. No patient experienced complications directly associated the transvaginal approach; nor did any patient have infection or prolonged spotting from the extraction site postoperatively. Recovery after the procedure was rapid and the median hospital stay was 7.0 days (range, 6-12 d). With a median follow-up 34 months, one patient experienced distant metastasis (7.1%).In selected cases, totally laparoscopic colectomy with transvaginal anastomosis and extraction of specimen is feasible and reproducible and may be an alternative technique for treatment of women with right colon cancer. This approach may provide both an attractive way to increase patient comfort and a bridge to "pure" natural orifice colon surgery.