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ABSTRACT: IntroductionMore and more colorectal surgeons believe that total mesorectal excision can achieve favorable oncologic results for the treatment
of rectal cancers. The present study is a feasibility study aiming to evaluate if total mesorectal excision can be safely
performed by laparoscopic approach with beneficial functional recovery.
MethodsA total of 44 patients (from January 2004 to February 2005) with middle rectal cancer (the average distance from anal verge
was 7.8 cm, ranging from 5.0 to 10.0 cm) without preoperative chemoradiation therapy were selected to undergo laparoscopic
total mesorectal excision. Before the study entry, all patients underwent pelvic magnetic resonance imaging or multislice
spiral computed tomography to evaluate the circumferential resection margin of rectal cancer. Only patients whose circumferential
resection margin was not involved by rectal cancer were considered as potentially curable by total mesorectal excision procedures
and were enrolled for this study. The operation procedures were conducted according to the guidelines advocated by Heald et al.1 and were shown in the video. Posteriorly, the dissection was along the ‘holy plane’ downward to the level of levator ani
muscle. Anteriorly, the dissection plane was at the anterior part of Denonvilliers fascia. Laterally, the lateral ligaments
were sharply cauterized at the medial part. The resected bowel was reconstructed with stapled end-to-end anastomosis. The
surgical outcomes of this procedure were prospectively evaluated.
ResultsThe laparoscopic total mesorectal excision was performed with acceptable operation time (234.4±44.4 minutes, mean±standard
deviation) and little blood loss (80.0±24.0 ml) through a small wound (5.0±0.5 cm). Histopathology showed that all patients
were able to get adequate distal section margins (mean: 2.8 cm; range: 1.6–5.4 cm) and negative circumferential resection
margins (mean: 8.4mm; range: 2–14 mm). The number of dissected lymph nodes was 16.0±4.0. The pathologic tumor–node–metastasis
stages were as follows: Stage I: n= 4; Stage II: n = 22; Stage III: n = 18. Two patients (4.5 percent) were diverted by protective
ileostomy. There was no mortality within 30 days after operation. However, anastomotic leakage occurred in 3 patients. The
patients have quick functional recovery, as evaluated by the length of postoperative ileus (48.0±12.0 hours), hospitalization
(9.0±1.0 days) and degree of postoperative pain (3.5±0.5, visual analog scale). Besides the expenses covered by the National
Bureau of Health Insurance in Taiwan, the patient had to pay an extra expense of NT65000.08000.0 (1.0US dollars = 32.0 NT 65000.08000.0 (1.0US dollars = 32.0 NT).
During the follow-up periods (median: 14 months, range. 2 to 27 months), three patients of Stage III and 1 patient of Stage
II developed a recurrent disease (lung metastasis: n = 2; liver metastasis: n = 1, and pelvic recurrence, n = 1).
ConclusionBy laparoscopic approach, the total mesorectal excision for rectal cancers can be safely performed with good functional recovery.
However, with only a median follow-up of 14 months in this case series, the long-term oncologic outcomes for these patients
remain a question. Further randomized prospective study is thus mandatory to provide solid evidence of this approach.
Diseases of the Colon & Rectum 03/2006; 49(4):517-518. · 3.34 Impact Factor
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ABSTRACT: Abdominoanal pull-through procedure is an alternative procedure for lower rectal cancer in which double-stapling technique is difficult to apply and/or the adequate distal safety margin (>2 cm) cannot be achieved in a very narrow male pelvis. The present study is to examine if the pull-through procedure can be effectively performed by laparoscopic approach for male lower rectal cancer downstaged by concurrent chemoradiation therapy.
A total of 14 male patients with advanced lower rectal cancer (Stage II: n=6; Stage III: n=8, by tumor, node, and metastasis staging system of International Union Against Cancer) and successfully downstaged by preoperative concurrent chemoradiation therapy were accrued for this study. All patients underwent three-staged operation including: transverse-colostomy creation before concurrent chemoradiation therapy, laparoscopic pull-through procedure and closure of colostomy. The details of laparoscopic pull-through procedure were shown in the video including: total mobilization for rectum in the fashion of total mesorectal excision, retrieval and transection of bowel through an incision over dentate line, and coloanal anastomosis. The surgical outcome of the patients were prospectively evaluated.
Although the dissection plane is a little blurred by preoperative concurrent chemoradiation therapy, the laparoscopic pull-through procedure was preformed with acceptable operation time (274.6+/-52.4 minutes, mean+/-standard deviation) and little blood loss (104.5+/-32.0 ml) through 5 small wounds of abdominal ports. The number of dissected lymph node was 17.0+/-3.0. The distal safety margin of all patients was more than 2 cm. The patients have quick functional recovery, as evaluated by the length of postoperative ileus (48.0+/-8.0 hours), hospitalization (9.0+/-1.0 days), and degree of postoperative pain (3.5+/-0.5, visual analog scale). There were no major postoperative complications yet postoperative fever developed in one patient and wound infection in the other one. Besides the expenses covered by the National Bureau of Health Insurance in Taiwan, the patient had to pay extra expenses of NT$25000.0+/-3500.0 (1.0 US dollars=32.0 NT$). During the follow-up periods (median: 10 months, range, 4 to 16 months), one patient developed a recurrent lung metastasis.
In view of the good functional recovery and fine short-term oncologic results, laparoscopic pull-through procedure was thus a good choice for downstaged male lower rectal cancer in terms of sphincter-preservation and enough distal section margin of tumor.
Diseases of the Colon & Rectum 03/2006; 49(2):259-60. · 3.34 Impact Factor
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ABSTRACT: INTRODUCTIONLaparcoscopic curative left hemicolectomy requires the takedown of colonic splenic flexure and has been challenging. The present
study aims to examine if the technical advantages of medial-to-lateral dissection method, as shown in our previous laparoscopic
rectosigmoid resection, can be extrapolated to the laparoscopic left hemicolectomy.
METHODSA total of 24 consecutive patients (from October 2004 to March 2005) with left-sided colon cancer requiring the takedown of
colonic splenic flexure to facilitate a curative left hemicolectomy were subjected to this laparoscopic procedure that included
initial incision on the mesentery medial to inferior mesenteric vein, ligation of vessels in no-touch isolation fashion, subsequent
medial-to-lateral extension of retroperitoneal dissection along Gerota fascia, opening of lesser sac by transection of gastrocolic
ligament, dissection of mesenteric root of distal transverse colon, and the final separation of splenocolic ligament and lateral
attachments of descending colon. The technical efficiency, the number of cleared lymph node, and functional recovery of patients
were prospectively evaluated.
RESULTSThe laparoscopic medial-to-lateral approach is considered as highly efficient because it was preformed with acceptable operation
time (214.4 ± 54.4 minutes, mean±standard deviation) and little blood loss (40.0 ± 14.0 ml) through a small wound (5.5 ± 0.6
cm). The number of dissected lymph nodes was 14.0 ± 3.0. There were no major complications. Moderate morbidity represented
8 percent of all cases, including minor leakage in 1 case (4 percent) and wound infection in 1 case (4 percent). The patients
have quick functional recovery, as evaluated by the length of postoperative ileus (48.0 ± 12.0 hours), hospitalization (9.0
± 1.0 days), and degree of postoperative pain (3.5 ± 0.5, visual analog scale). The overall costs were NT194,000.0 ± 3200.0 (1.0 US dollar = 32.0 NT194,000.0 ± 3200.0
(1.0 US dollar = 32.0 NT).
CONCLUSIONBy medial-to-lateral dissection method, the laparoscopic takedown of colonic splenic flexure can be performed with highly
technical efficiency, acceptable number of cleared lymph node, and short convalescence. We therefore recommend this dissection
method to the expert surgeons, endeavoring to define a standard technique to curative surgery in the left-sided colon cancers,
and especially to the beginners, seeking to shorten their learning curve of laparoscopic left hemicolectomy.
Diseases of the Colon & Rectum 01/2005; 48(11):2142-2143. · 3.34 Impact Factor