Advertisement

International Journal of Colorectal Disease

, Volume 31, Issue 6, pp 1169–1177 | Cite as

Robotic surgery with high dissection and low ligation technique for consecutive patients with rectal cancer following preoperative concurrent chemoradiotherapy

  • Ching-Wen Huang
  • Yung-Sung Yeh
  • Wei-Chih Su
  • Hsiang-Lin Tsai
  • Tak-Kee Choy
  • Ming-Yii Huang
  • Chun-Ming Huang
  • I-Chen Wu
  • Huang-Ming Hu
  • Wen-Hung Hsu
  • Yu-Chung Su
  • Jaw-Yuan Wang
Original Article

Abstract

Purpose

We present the preliminary experiences with and short-term outcomes of 50 consecutive patients with rectal cancer who underwent preoperative concurrent chemoradiotherapy (CCRT) followed by robotic surgery by using the high dissection and low ligation technique.

Methods

Between October 2013 and August 2015, 50 patients with rectal cancer underwent robotic surgery after preoperative CCRT at a single institution. We performed D3 lymph node dissection and low tie ligation of the inferior mesenteric artery (IMA); this technique is referred to as the high dissection and low ligation technique. Clinicopathological features, perioperative parameters, and postoperative outcomes were retrospectively analyzed.

Results

FOLFOX regimen was used for preoperative CCRT in 26 (52 %) patients. Long-course radiotherapy was concurrently administered. A pathological complete response (pCR) was obtained in 14 (28 %) patients. Of the 50 patients, 23 (46 %) patients received intersphincteric resection (ISR) with coloanal anastomosis, 25 (50 %) patients received lower anterior resection (LAR), and 2 (4 %) patients received abdominoperineal resection (APR). Apical nodes were pathologically harvested in 47 (94 %) patients, and the median number of harvested apical lymph nodes was 2 (range, 0–10). The overall complication rate was 24 % (10 patients with 12 episodes), and most complications were mild.

Conclusion

Roboic rectal surgery combined with appropriate preoperative CCRT helps in achieving a favorable pCR, circumferential resection margin, and sphincter preservation. Moreover, high dissection and low ligation of the IMA can be safely performed using the da Vinci® Surgical System safely which yield favorable short-term clinical outcomes.

Keywords

Robotic surgery Rectal cancer Preoperative concurrent chemoradiotherapy High dissection and low ligation Apical node 

Notes

Acknowledgments

This work was supported by grants from the Excellence for Cancer Research Center Grant through funding by the Ministry of Science and Technology (MOST104-2325-B-037-001) and the Ministry of Health and Welfare (MOHW105-TDU-B-212-134007), Health and welfare surcharge of tobacco products, Taiwan, Republic of China as well as grants from Kaohsiung Medical University Hospital (KMUH104-4M29, KMUHS10422, KMUHS10405, KMUHS10418), the Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University (KMU-TP104C00, KMU-TP104C03, KMU-TP104C04, KMU-TP104C07, KMU-TP104A11, KMU-PT10422, KMU-DK105001), and the Grant of Biosignature in Colorectal Cancers, Academia Sinica, Taiwan.

Compliance with ethical standards

Disclosure

Drs. Ching-Wen Huang, Yung-Sung Yeh, Wei-Chih Su, Hsiang-Lin Tsai, Tak-Kee Choy, Ming-Yii Huang, Chun-Ming Huang, I-Chen Wu, Huang-Ming Hu, Wen-Hung Hsu, Yu-Chung Su, and Jaw-Yuan Wang have no conflicts of interest or financial ties to disclose.

References

  1. 1.
    MacFarlane JK, Ryall RD, Heald RJ (1993) Mesorectal excision for rectal cancer. Lancet 341:457–460CrossRefPubMedGoogle Scholar
  2. 2.
    Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg 69:613–616CrossRefPubMedGoogle Scholar
  3. 3.
    Sauer R, Liersch T, Merkel S, Fietkau R, Hohenberger W, Hess C, Becker H, Raab HR, Villanueva MT, Witzigmann H, Wittekind C, Beissbarth T, Rödel C (2012) Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J Clin Oncol 30:1926–1933CrossRefPubMedGoogle Scholar
  4. 4.
    Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R, German Rectal Cancer Study Group (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740CrossRefPubMedGoogle Scholar
  5. 5.
    Weber PA, Merola S, Wasielewski A, Ballantyne GH (2002) Telerobotic-assisted laparoscopic right and sigmoid colectomies for benign disease. Dis Colon Rectum 45:1689–94CrossRefPubMedGoogle Scholar
  6. 6.
    Baek JH, Pastor C, Pigazzi A (2010) Robotic and laparoscopic total mesorectal excision for rectal cancer: a case-matched study. Surg Endosc 25:521–525CrossRefPubMedGoogle Scholar
  7. 7.
    Park JS, Choi GS, Lim KH, Jang YS, Jun SH (2011) S052: a comparison of robot-assisted, laparoscopic, and open surgery in the treatment of rectal cancer. Surg Endosc 25:240–248CrossRefPubMedGoogle Scholar
  8. 8.
    Kim JY, Kim NK, Lee KY, Hur H, Min BS, Kim JH (2012) A comparative study of voiding and sexual function after total mesorectal excision with autonomic nerve preservation for rectal cancer: laparoscopic versus robotic surgery. Ann Surg Oncol 19:2485–2493CrossRefPubMedGoogle Scholar
  9. 9.
    Hellan M, Ouellette J, Lagares-Garcia JA, Rauh SM, Kennedy HL, Nicholson JD, Nesbitt D, Johnson CS, Pigazzi A (2015) Robotic rectal cancer resection: a retrospective multicenter analysis. Ann Surg Oncol 22:2151–2158CrossRefPubMedGoogle Scholar
  10. 10.
    Huang CW, Yeh YS, Ma CJ, Choy TK, Huang MY, Huang CM, Tsai HL, Hsu WH, Wang JY (2015) Robotic colorectal surgery for laparoscopic surgeons with limited experience: preliminary experiences for 40 consecutive cases at a single medical center. BMC Surg 15:73CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Kim YS, Kim MJ, Park SC, Sohn DK, Kim DY, Chang HJ, Nam BH, Oh JH (2015) Robotic versus laparoscopic surgery for rectal cancer after preoperative chemoradiotherapy: case-matched study of short-term outcomes. Cancer Res Treat. doi: 10.4143/crt.2014.365 Google Scholar
  12. 12.
    Saklani AP, Lim DR, Hur H, Min BS, Baik SH, Lee KY, Kim NK (2013) Robotic versus laparoscopic surgery for mid-low rectal cancer after neoadjuvant chemoradiation therapy: comparison of oncologic outcomes. Int J Colorectal Dis 28:1689–98CrossRefPubMedGoogle Scholar
  13. 13.
    Lange MM, Buunen M, van de Velde CJ, Lange JF (2008) Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie. A review. Dis Colon Rectum 51:1139–1145CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Chen CW, Chen MJ, Yeh YS, Tsai HL, Chang YT, Lu CY, Shih YL, Sun LC, Wang JY (2013) Intraoperative anastomotic dye test significantly decrease anastomotic leaks in patients with rectal cancers receiving resection. Techniques in Coloproctology 17:579–583CrossRefPubMedGoogle Scholar
  15. 15.
    Sobin LH, Gospodarowicz MK, Wittekind C (2009) TNM classification of malignant tumors, 7th edn. Wiley-Liss Inc., New York, pp 100–105Google Scholar
  16. 16.
    Pigazzi A, Ellenhorn JD, Ballantyne GH, Paz IB (2006) Robotic-assisted laparoscopic low anterior resection with total mesorectal excision for rectal cancer. Surg Endosc 20:1521–1525CrossRefPubMedGoogle Scholar
  17. 17.
    Baik SH, Lee WJ, Rha KH, Kim NK, Sohn SK, Chi HS, Cho CH, Lee SK, Cheon JH, Ahn JB, Kim WH (2008) Robotic total mesorectal excision for rectal cancer using four robotic arms. Surg Endosc 22:792–797CrossRefPubMedGoogle Scholar
  18. 18.
    Luca F, Valvo M, Ghezzi TL, Zuccaro M, Cenciarelli S, Trovato C, Sonzogni A, Biffi R (2013) Impact of robotic surgery on sexual and urinary functions after fully robotic nerve-sparing total mesorectal excision for rectal cancer. Ann Surg 257:672–678CrossRefPubMedGoogle Scholar
  19. 19.
    Kwak JM, Kim SH, Kim J, Son DN, Baek SJ, Cho JS (2011) Robotic vs laparoscopic resection of rectal cancer: short-term outcomes of a case-control study. Dis Colon Rectum 54:151–156CrossRefPubMedGoogle Scholar
  20. 20.
    Baik SH, Kwon HY, Kim JS, Hur H, Sohn SK, Cho CH, Kim H (2009) Robotic versus laparoscopic low anterior resection of rectal cancer: short-term outcome of a prospective comparative study. Ann Surg Oncol 16:1480–1487CrossRefPubMedGoogle Scholar
  21. 21.
    Baek JH, McKenzie S, Garcia-Aguilar J, Pigazzi A (2010) Oncologic outcomes of robotic-assisted total mesorectal excision for the treatment of rectal cancer. Ann Surg 251:882–886CrossRefPubMedGoogle Scholar
  22. 22.
    Park JS, Choi GS, Lim KH, Jang YS, Jun SH (2010) Robotic-assisted versus laparoscopic surgery for low rectal cancer: case-matched analysis of short-term outcomes. Ann Surg Oncol 17:3195–3202CrossRefPubMedGoogle Scholar
  23. 23.
    Bujko K, Nowacki MP, Nasierowska-Guttmejer A, Michalski W, Bebenek M, Kryj M (2006) Long-term results of a randomized trial comparing preoperative short-course radiotherapy with preoperative conventionally fractionated chemoradiation for rectal cancer. Br J Surg 93:1215–1223CrossRefPubMedGoogle Scholar
  24. 24.
    Ngan SY, Burmeister B, Fisher RJ, Solomon M, Goldstein D, Joseph D, Ackland SP, Schache D, McClure B, McLachlan SA, McKendrick J, Leong T, Hartopeanu C, Zalcberg J, Mackay J (2012) Randomized trial of short-course radiotherapy versus long-course chemoradiation comparing rates of local recurrence in patients with T3 rectal cancer: Trans-Tasman Radiation Oncology Group trial 01.04. J Clin Oncol 30:3827–3833CrossRefPubMedGoogle Scholar
  25. 25.
    Wallace MH, Glynne-Jones R (2007) Saving the sphincter in rectal cancer: are we prepared to change practice? Colorectal Dis 9:302–308CrossRefPubMedGoogle Scholar
  26. 26.
    Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, Choi HS, Kim DW, Chang HJ, Kim DY, Jung KH, Kim TY, Kang GH, Chie EK, Kim SY, Sohn DK, Kim DH, Kim JS, Lee HS, Kim JH, Oh JH (2014) Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 15:767–774CrossRefPubMedGoogle Scholar
  27. 27.
    Chou JF, Row D, Gonen M, Liu YH, Schrag D, Weiser MR (2010) Clinical and pathologic factors that predict lymph node yield from surgical specimens in colorectal cancer: a population-based study. Cancer 116:2560–2570CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Persiani R, Biondi A, Gambacorta MA, Bertucci Zoccali M, Vecchio FM, Tufo A, Coco C, Valentini V, Doglietto GB, D’Ugo D (2014) Prognostic implications of the lymph node count after neoadjuvant treatment for rectal cancer. Br J Surg 101:133–142CrossRefPubMedGoogle Scholar
  29. 29.
    Cirocchi R, Trastulli S, Farinella E, Desiderio J, Vettoretto N, Parisi A, Boselli C, Noya G (2012) High tie versus low tie of the inferior mesenteric artery in colorectal cancer: a RCT is needed. Surg Oncol 21:e111–123CrossRefPubMedGoogle Scholar
  30. 30.
    Liang JT, Lai HS (2014) Surgical technique of robotic D3 lymph node dissection around the inferior mesenteric artery with preservation of the left colic artery and autonomic nerves for the treatment of distal rectal cancer. Surg Endosc 28:1727–1733CrossRefPubMedGoogle Scholar
  31. 31.
    Ubukata M, Itabashi M, Kameoka S (2014) Japanese D3 lymph node dissection in low rectal cancer with inferior mesenteric lymph node metastases. World J Surg 38:2724–2729CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Ching-Wen Huang
    • 1
    • 2
    • 3
  • Yung-Sung Yeh
    • 3
    • 4
  • Wei-Chih Su
    • 5
  • Hsiang-Lin Tsai
    • 1
    • 3
    • 6
    • 7
  • Tak-Kee Choy
    • 8
  • Ming-Yii Huang
    • 9
    • 10
  • Chun-Ming Huang
    • 9
  • I-Chen Wu
    • 11
    • 12
  • Huang-Ming Hu
    • 11
    • 12
  • Wen-Hung Hsu
    • 11
    • 12
  • Yu-Chung Su
    • 11
    • 12
  • Jaw-Yuan Wang
    • 1
    • 3
    • 7
    • 13
  1. 1.Graduate Institute of Medicine, College of MedicineKaohsiung Medical UniversityKaohsiungTaiwan
  2. 2.Division of Colorectal Surgery, Department of Surgery, Kaohsiung Medical University HospitalKaohsiung Medical UniversityKaohsiungTaiwan
  3. 3.Division of Gastroenterology and General Surgery, Department of Surgery, Kaohsiung Medical University HospitalKaohsiung Medical UniversityKaohsiungTaiwan
  4. 4.Division of Trauma, Department of Surgery, Kaohsiung Medical University HospitalKaohsiung Medical UniversityKaohsiungTaiwan
  5. 5.Graduate Institute of Clinical Medicine, College of MedicineKaohsiung Medical UniversityKaohsiungTaiwan
  6. 6.Division of General Surgery Medicine, Department of Surgery, Kaohsiung Medical University HospitalKaohsiung Medical UniversityKaohsiungTaiwan
  7. 7.Department of Surgery, Faculty of Medicine, College of MedicineKaohsiung Medical UniversityKaohsiungTaiwan
  8. 8.Division of Colorectal Surgery, Department of SurgeryYuan’s General HospitalKaohsiungTaiwan
  9. 9.Department of Radiation Oncology, Kaohsiung Medical University HospitalKaohsiung Medical UniversityKaohsiungTaiwan
  10. 10.Department of Radiation Oncology, Faculty of Medicine, College of MedicineKaohsiung Medical UniversityKaohsiungTaiwan
  11. 11.Division of Gastroenterology, Department of Internal Medicine, Kaohsiung Medical University HospitalKaohsiung Medical UniversityKaohsiungTaiwan
  12. 12.Department of Internal Medicine, Faculty of Medicine, College of MedicineKaohsiung Medical UniversityKaohsiungTaiwan
  13. 13.Center for Biomarkers and Biotech DrugsKaohsiung Medical UniversityKaohsiungTaiwan

Personalised recommendations