The Era of Robotic Surgery for Colorectal Cancer
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- Roukos, D.H. Ann Surg Oncol (2010) 17: 338. doi:10.1245/s10434-009-0715-y
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To the Editors:
The age of robotic surgery is here. Within a short period, 55 patients with colorectal cancer were treated by using the Da Vinci system at a single institution.1 Expecting a dramatic increase in cancer incidence in the next decade, what are the perspectives for robotic surgery? Beyond better quality of life (QOL), can robotic surgery, particularly for rectal cancer, improve also recurrence-free and overall survival?2
Luca et al.1 report on early results of robotic surgical treatment of patients with left colon and rectal cancer in an online-first publication (February 26) of the Annals of Surgical Oncology. This modern surgical technology provides a series of strengthens in terms of patient outcomes. Will the Da Vinci system alter surgery for colorectal cancer? What are the benefits, risks, and costs of this surgical tool? These and several other issues are addressed in our comment.
Beyond prevention of distant recurrences, locoregional tumor control by adequate surgery with or without radiotherapy is also considered a crucial step in the treatment strategy of solid tumors. Complete resection of the primary tumor and involved lymph nodes R0, according to the International Union against Cancer/American Joint Committee on Cancer (UICC/AJCC), is fundamental for locoregional event prevention and cure.
The Da Vinci robotic system may provide more accurate, precise, and anatomical resection of the primary tumor and perhaps of regional lymph nodes than either its relative, closed laparoscopic resection, or open surgery in specific tumor locations. A characteristic example is rectal cancer. Total mesorectal excision has become a de facto standard of treatment, particularly for stage II and III disease. Because of its anatomic location in the pelvis, precise total mesorectal excision appears more feasible to be achieved by robotic surgery rather than open low anterior resection. This anatomic-structures-based surgery preventing nerves of vital organs functionality and totally removing the mesorectum not only substantially improves QOL, but also may result in reduced locoregional recurrence and mortality.
What are the advantages of the study by Luca et al.?1 Adhering to current guidelines, and based on appropriate surgical–oncological thinking on the fundamental clinical utility of R0 resection and carefully selecting patients, they achieved the following: First, circumferential margin was negative in all cases. Second, distal margin for low anterior rectal resection patients was 25.15 ± 12.9 mm (range 6–55 mm). Distal resection margins are important and, although it is controversial, it appears that at least 2 cm margins microscopically free of cancer cells are required. Therefore, the margin of only 0.6 cm raises some questions. Third, the median number of lymph nodes harvested was 18.5. Despite a recent review of retrospective cohort study suggesting no benefit when more than 12 lymph nodes were resected and evaluated for colon cancer, and in the absence of well-designed and conducted randomized controlled trials, we have the feeling that appropriate standardized lymphadenectomy should be performed to avoid nodal recurrence and mortality.3 Fourth, there was no conversion to open surgery.
However, there were also weaknesses. Anastomotic leak rate was 12.7% (7/55). This is a relatively high failure rate, but in all cases conservative treatment was successful. The mean operative time was long (290 ± 69 min). With increasing experience and a sufficient learning curve with robotic surgery, it is expected that the challenges with operating time and anastomotic leak will be overcome.
Can closed surgery, laparoscopic- or robotic-assisted resection, improve survival? Given the high complexity of solid cancers is a surgical naïve to thought that transforming an R0 resection from open to closed approach may improve oncological outcomes. This is an oversimplified conception. Indeed, high-quality evidence from randomized trials and meta-analyses excludes any disease-free or overall survival benefit derived by laparoscopic colectomy for colorectal cancer, as compared with open classical surgery.4 At the same time, these data demonstrate no worsening of oncological outcomes, as had been previously supposed.
For rectal cancer, however, a positive impact of robotic surgery on survival cannot be excluded. This benefit can emerge from the appropriate excision of the mesorectum. Nevertheless, to confirm or reject this hypothesis requires results from prospective studies with long-term follow-up, when they become available.
Modern technologies undoubtedly influence and alter surgical-oncological thinking, research, and clinical practice. In the field of early postoperative outcomes and QOL of patients with colorectal and gastrointestinal cancers, robotic-assisted surgery using the Da Vinci system will change surgical practice in the decades to come, but its impact on long-term survival is limited.
The change in systemic treatment toward dramatic survival improvement will also emerge with new technologies. Latest high-throughput techniques and third-generation DNA technology will collect myriad reliable and robust genetic, epigenetic, gene-expression profiling, whole-genome scans, and personal genomics data.5–14 The analysis, synthesis, and interpretation of the tremendous volume of all these data by bioinformatics and systems biology may lead to a new generation of targeted agents and biomarkers towards personalized medicine.15–20