Search

Purpose: Outline learning phases of robot-assisted laparoscopic surgery for rectal cancer and compare surgical and clinical outcomes between each phase of robot-assisted laparoscopic surgery and the mastery phase of conventional laparoscopic surgery., Methods: From 2015 to 2020, 210 patients underwent rectal cancer surgery at Sendai Medical Center. We performed conventional laparoscopic surgery in 110 patients and, laparoscopic surgery in 100 patients. The learning curve was evaluated using the cumulative summation method, risk-adjusted cumulative summation method, and logistic regression analysis., Results: The risk-adjusted cumulative summation learning curve was divided into three phases: phase 1 (cases 1-48), phase 2 (cases 49-80), and phase 3 (cases 81-100). Duration of hospital stay (13.1 days vs. 18.0 days, respectively; p = 0.016) and surgery (209.1 min vs. 249.5 min, respectively; p = 0.045) were significantly shorter in phase 3 of the robot-assisted laparoscopic surgery group than in the conventional laparoscopic surgery group. Blood loss volume was significantly lower in phase 1 of the robot-assisted laparoscopic surgery group than in the conventional laparoscopic surgery group (17.7 ml vs. 79.7 ml, respectively; p = 0.036). The International Prostate Symptom Score was significantly lower in the robot-assisted laparoscopic surgery group (p = 0.0131)., Conclusions: Robot-assisted laparoscopic surgery for rectal cancer was safe and demonstrated better surgical and clinical outcomes, including a shorter hospital stay, less blood loss, and a shorter surgical duration, than conventional laparoscopic surgery. After experience with at least 80 cases, tactile familiarity can be acquired from visual information only (visual haptic feedback)., Clinical Trial Registration: UMIN reference no. UMIN000019857., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

We aimed to evaluate the advantages and disadvantages of initial robotic surgery for rectal cancer in the introduction phase. This study retrospectively evaluated patients who underwent initial robotic surgery (n = 36) vs. patients who underwent conventional laparoscopic surgery (n = 95) for rectal cancer. We compared the clinical and pathological characteristics of patients using a propensity score analysis and clarified short-term outcomes, urinary function, and sexual function at the time of robotic surgery introduction. The mean surgical duration was longer in the robot-assisted laparoscopy group compared with the conventional laparoscopy group (288.4 vs. 245.2 min, respectively; p = 0.051). With lateral pelvic lymph node dissection, no significant difference was observed in surgical duration (508.0 min for robot-assisted laparoscopy vs. 480.4 min for conventional laparoscopy; p = 0.595). The length of postoperative hospital stay was significantly shorter in the robot-assisted laparoscopy group compared with the conventional laparoscopy group (15 days vs. 13.0 days, respectively; p = 0.026). Conversion to open surgery was not necessary in either group. The International Prostate Symptom Score was significantly lower in the robot-assisted laparoscopy group compared with the conventional laparoscopy group. Moderate-to-severe symptoms were more frequently observed in the conventional laparoscopy group compared with the robot-assisted laparoscopy group (p = 0.051). Robotic surgery is safe and could improve functional disorder after rectal cancer surgery in the introduction phase. This may depend on the surgeon's experience in performing robotic surgery and strictly confined criteria in Japan., (© 2021. The Author(s).)

A55 -year-old man was diagnosed with rectal cancer invading the urinary bladder and swollen para-aortic lymph nodes. Since distant metastasis was indicated and total pelvic exenteration was required, 6 courses of chemotherapy with mFOLFOX6 plus panitumumab were performed. After the chemotherapy, the rectal cancer and para-aortic lymph nodes significantly decreased in size, and novel distant metastasis was not observed in CT scans. Therefore, the tumor was considered resectable, and operation was performed. Intraoperative frozen section analysis showed that the para-aortic lymph nodes and surgical margin of the urinary bladder were negative. Thus, low anterior resection of the rectum and partial resection of the urinary bladder were performed. R0 resection was pathologically achieved, and adjuvant chemotherapy with S-1 was administered for 6 months. The patient is alive without recurrence for 10 months. Upfront chemotherapy can be a strategy for advanced rectal cancer with urinary bladder invasion to avoid total pelvic exenteration.

A woman in her 40s who presented to a local hospital with bloody stool was referred to our hospital. Colonoscopy showed a rectal tumor, and histological examination showed moderately differentiated adenocarcinoma. CT and MRI revealed that the tumor was 65mm in diameter with no distant metastasis. After the construction of ileostomy, neoadjuvant chemoradiothera- py(NACRT: 45 Gy/25 Fr, S-1 80mg/m2)was performed. The tumor shrank remarkably, and then we performed laparoscopy- assisted low anterior resection. Pathological examination revealed complete disappearance of the cancer cells in the primary site and no appearance of cancer cells in all dissected lymph nodes. NACRT has been recently reported to provide pathological complete response, and these patients are supposed to have a good prognosis. In our case, NACRT enhanced the performance of laparoscopic curative resection while preserving anal function. NACRT should contribute to the curative resection while preserving anal function in patients with locally advanced rectal cancer.

Case 1: A female patient in her 60s underwent laparoscopic intersphincteric resection for rectal cancer. After 42 months, the serum level of carcinoembryonic antigen(CEA)was elevated, and PET-CT showed a locally recurrent rectal cancer that increased FDG-uptake. Carbon ion radiotherapy(CIRT)(73.6 GyE/16 Fr)was performed. Serum CEA level and FDG-uptake were normalized. No regrowth of tumor has been found for 12 months. Case 2: A female patient in her 60s underwent abdominoperineal resection for rectal cancer. After 42 months, the serum level of CEA was elevated, and CT revealed a local recurrence of rectal cancer. Subsequently, the tumor was resected; however, resection margin was microscopically positive. Therefore, chemoradiotherapy(S-1, 60 Gy)was performed. At 31 months after local resection, a re-recurrent tumor was noted in her left ischium. Therefore, CIRT(70.4 GyE/16 Fr)was performed. Serum CEA level and FDG-uptake were normalized. No regrowth of tumor has been found for 24 months. CIRT is an effective therapy for locally recurrent rectal cancer.

According to the treatment guideline for rectal neuroendocrine tumor(NET), tumor with a diameter ofC10mm should be resected endoscopically, while tumor with a diameter of>10mm should be resected surgically with lymph node dissection. We experienced a case of a rectal NET with a diameter of 5mm with lymph node metastasis. A 69-year-old man underwent colonoscopy for positive fecal occult blood test. The colonoscopy revealed a submucosal tumor(SMT)with a diameter of 5 mm in the lower rectum. An endoscopic mucosal resection(EMR)was performed after SMT was diagnosed as NET by biopsy. Histopathological findings were NET-G1, 4.5×2.5 mm, v(+), ly(+). Then, laparoscopically assisted rectal resection with D2 lymph node dissection was performed. In histopathological examination, no tumor residue was observed in the specimu; however, a regional lymph node metastasis was detected. Risk factors of lymph node metastasis with rectal NET are a diameter of>10 mm, recessed or ulcerated surface, and lymphovascular invasion. However, we have to keep in mind that lymph node metastasis may occur even in small rectal NET with a diameter of ≤10mm.

Case: A70-year-old man was diagnosed with lower rectal cancer with right inguinal lymph node metastasis. Surgical resection was not suitable for this patient. Chemotherapy(IRIS plus bevacizumab followed by XELOX plus bevacizumab)was administered for 16 months. After the chemotherapy, the rectal tumor and lymph node swelling were significantly reduced and distant metastasis was not observed on CT scans. Therefore, the tumor was considered to be resectable and abdominoperineal resection of the rectum with lymph node dissection was performed. On histopathological examination, cancer cells partially remained in the rectal tumor and lateral lymph nodes, although there were no cancer cells in the inguinal lymph nodes. The patient is alive without recurrence a year later. In cases with a good response to chemotherapy, conversion therapy may become an important therapeutic option.

A 49-year-old man had undergone Hartmann's operation for rectal cancer in August 2002. The disease stage (TNM 7th) was T3, N1, M0, Stage ⅢB. He was treated with UFT and Krestin for a year as adjuvant chemotherapy. No recurrence had been detected after the surgery. In July 2014, he presented with symptoms of acute renal failure. A CT scan showed bilateral hydronephrosis and a pelvic tumor between the urinary bladder and rectum. The pathological diagnosis based on biopsy specimens was adenocarcinoma. Because immunostaining studies of the tumor biopsy specimen revealed that CK20, CEA, CA19-9, and p53 were positive and CK7 and PSA were negative, this pelvic tumor was diagnosed as a local recurrence of rectal cancer. Total pelvic exenteration and ileal conduit urinary diversion were carried out for the recurrent tumor with curative intent. The reported recurrence rate of Stage Ⅲ colorectal cancer 5 years after the initial curative operation is 0.67%. Local recurrence of rectal cancer 12 years after the initial operation is quite rare. Immunostaining is helpful to discriminate between rectal cancer and a tumor of the urinary organs. It is important to consider that recurrence of rectal cancer might still occur a long time after the initial operation.

A 54-year-old man presented with an enlarged left (lt) lateral lymph node (LLN), which was detected by magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET-CT). Endoscopic examination of the colon revealed the presence of a type 1 tumor, 20mm in diameter, in the lower rectum; the tumor was diagnosed as a well-differentiated adenocarcinoma (tub1). The patient received combined neoadjuvant chemoradiotherapy (nCRT)with S- 1 for treatment of the rectal cancer and LLN metastasis (MP, T2N3M0, Stage IIIb). S-1 was administered orally at a dose of 120 mg/day on days 1-14, and 22-35; a total dose of 45 Gy was delivered (1.8 Gy/day, for 25 days). Upon nCRT, there was a remarkable reduction in the tumor size, the primary tumor receded, and the LLN decreased from 16 mm to 8 mm in diameter. The maximum standardized uptake value (SUVmax) also decreased from 3.8 to 1.9 on PET-CT. Six weeks after nCRT, ultralow anterior resection and bilateral lymph node dissections were performed. Histopathological examination showed a partial presence of cancer cells in the scarred primary tumor; however, no viable cancer cells were observed in the lt. LLN.

A-39-year-old man presented to a nearby clinic owing to long-term diarrhea and painful defecation. He was diagnosed with a well-differentiated tubular adenocarcinoma of the rectosigmoid and underwent a laparotomy at another hospital. At surgery, the tumor was seen to deeply invade into the urinary bladder with the presence of intra-abdominal abscess. Loop sigmoid colostomy was performed due to possible invasion into the pelvic wall and peritoneal dissemination. The patient was referred to the our hospital for systemic chemotherapy. After 32 courses of FOLFIRI, 10 courses of CapeOX + Bmab, and 34 courses of LV5FU2 + Bmab, radiographic examination revealed complete response (CR) of the rectal tumor, and low anterior resection of the rectum was carried out. Since pathological examination showed no viable cancer cells in any specimen, the patient was considered to have achieved a CR from a pathological standpoint.

The clinicopathological features of neuroendocrine tumor (NET) of the rectum were retrospectively analyzed in 25 patients( 17 men and 8 women; mean age, 57 years[ 30-78 years]) at Tohoku University Hospital from January 1998 to December 2012. The average diameter of 25 tumors was 15 mm (5-70 mm). Local resections and rectal resections with lymph node dissection were performed in 16 and 9 tumors, respectively. Three of the 9 tumors had lymph node metastases (33%), including 2 tumors with a diameter of 10 mm. In a median follow-up of 48 months, tumor recurrence was observed in 3 of 25 patients( 12%); local recurrence was observed in 1 patient; and liver metastasis was observed in 2 patients. Of the 2 patients with liver metastasis, liver metastasis recurred in a patient whose primary tumor, with a diameter of 10 mm, had been locally resected 40 months ago. According to histopathological analysis, 3 primary tumors with local recurrence or liver metastasis were categorized as G2 or G3 according to the World Health Organization (WHO) classification. Tumors with a diameter of ≥10 mm, in principle, may be removed by rectal resection with lymph node dissection. However, histopathological findings such as a proliferation of tumor cells should also be taken into consideration when deciding the treatment strategy for rectal NET.