Major outcomes of laparoscopic surgery for rectal cancer by the use of a circular stapling technique

JOURNAL OF MILITARY PHARMACO MEDICINE N03 2022 204 MAJOR OUTCOMES OF LAPAROSCOPIC SURGERY FOR RECTAL CANCER BY THE USE OF A CIRCULAR STAPLING TECHNIQUE Cao Minh Tiep1,3, Bui Tuan Anh1, Pham Van Binh2[.]

MAJOR OUTCOMES OF LAPAROSCOPIC SURGERY FOR RECTAL CANCER BY THE USE OF A CIRCULAR STAPLING TECHNIQUE

Summary

Objectives: To evaluate the major outcomes of laparoscopic surgery for rectal

cancer by the use of a circular side stapling technique at Military Hospital 103,

Military Medical University from 1/2016 to 4/2019 Subjects and methods: A cross-sectional study was conducted on 88 patients with rectal cancer Results

and conclusion: Time for post-surgical pain-relief was 3.49 ± 0.66 days; time to

passage of first flatus following surgery was 3.52 ± 0.64 days; time to passage of first stool was 4.51 ± 1.08 Early complications included anastomosis leak (2.3%); surgical site infection (4.5%); early intestinal obstruction (1.3%); bladder dysfunction (11.4%) Late complications consisted of anastomotic stenosis (1.1%), inflammation at the anastomosis (4.5%), defecation disorders (5.7%), semi-intestinal obstruction (2.3%), protrusion of the abdominal wall (1.1%) 75%

of patients recovered well after 3 months of surgery No recurrence was found in 79.5%, recurrence and distal metastasis accounted for 20.5%

* Keywords: Complication; Laparoscopic surgery for rectal cancer; Circular

side stapling technique

INTRODUCTION

Colorectal cancer (CRC) is a common

malignant disease of digestive tract and

the third most deadly cancer in the

world [1] Among these digestive

cancers, rectal cancer (RC) is the third

most common cancer and is responsible

for almost 40,000 new cases per year

in USA [2] According to GLOBOCAN

2018 data, RC is the eighth most incident cancer in the world The incidence of colorectal malignancy is higher in males than in females and the male/female ratio is 1.5/1, and RC predominantly affects persons over the age of 65 years [1] In Vietnam,

3 Vietnamese-Czechoslovak Friendship Hospital, Hai Phong

Corresponding author: Cao Minh Tiep (caominhtiepbsn9@gmail.com)

Date received: 17/4/2022

Date accepted: 27/4/2022

in terms of incidence, RC ranks fourth

in among males and second among

females, and is a leading cause of

cancer-related deaths According to

recent statistcs, each year, Vietnam has

recorded about 15,000 new cases,

corresponding to 13.4/100.000 population

and 7,000 deaths It is predicted by

2025 to be the second most common

cause of cancer deaths when numbers

for men and women are combined [3]

The first endoscopic surgery on

colorectal cancer was performed in

1990 This technique showed the

prominent advantages compared to

open surgery in terms of short- and

long-term outcomes, and it is gradually

replacing open surgery [4] There

have been a number of reports on

better short-term outcomes following

laparoscopic surgery including

reduction of morbidity, reduction of

blood loss, pain relief, and faster

recovery Some reports showed that

the endoscopic surgery must be

considered “the golden standard” in the

treatment of rectal cancer, but its

surgical application is not high because

its potential treatment, particularly in

lymph node removal is still doubtful

Thus, many studies were conducted to

evaluate the outcomes of laparoscopic

surgery for rectal cancer [5]

Laparoscopic surgery for rectal cancer by the use of a circular side stapling technique has been extensively used in clinics To date, there have been some domestic researches on the feasibility as well as the benefit of this technique, but few studies have been done to evaluate its outcomes From the clinical practice together with great demand for improvement of the treatment quality, we did this research

with the following objectives: To

evaluate the outcomes of laparoscopic surgery for rectal cancer by the use of

a circular side stapling technique in the Gastroenterology Department, Military Hospital 103, and Abdominal Surgery Department, K Tan Trieu Hospital from 1/2016 to 4/2019

SUBJECTS AND METHODS

1 Subjects, location, and study time

88 patients with rectal cancer were treated at Gastroenterology Department, Military Hospital 103, and Abdominal Surgery Department, K Tan Trieu Hospital from 1/2016 to 4/2019

* Inclusion criteria:

+ Patients with RC were treated by laparoscopic surgery using a circular stapling technique;

+ Having pathologic results

showing RC;

+ Agree to participate in the study;

+ Patients’ medical records included

adequately necessary information and

were followed post-operation

* Exclusion criteria:

+ RC combined with other cancer in

the different parts of the colon

+ Patients previously underwent

surgical treatment of rectal cancer

+ Patients with recurrent RC

2 Methods

* Study design:

This was a cross-sectional study

using prospective data

* Sample size/sampling process:

All patients with RC fulfilled adequate

inclusion criteria; using a convenient

sampling process

* Indices and variables according to

study content:

- Patients’ general characteristics:

+ Common features: age, gender,

BMI

+ Laboratory features: Patient

classification according to the

macroscopic image of colorectal

cancer results of rectal biopsy

- Surgical outcomes:

+ Surgical outcomes: operating time,

kind of circular side stapling technique,

postoperative follow-up, and care, early complications, early outcomes, late complications, sequelea, recovery outcomes at three postoperative months + Oncologic outcomes: cancer cell, postoperative TNM classification, survival rate

* Data collection:

+ Evaluating the early outcomes by pre/post operative examination

+ Collecting fully clinical/laboratory information during the treatment, postoperative follow-up according to the well-designed medical record

+ Listing patients according to their number of medical record

+ Inviting patients to be directly reexamined or sending them questionnaires so that the patients can evaluate themselves or interviewing them by phone

* Technique process:

- Indication for laparoscopic surgery for RC by using a circular side stapling technique:

+ In case rectal tumors are in the upper 2/3 and 6 cm or above from the anal margin, conservative surgery of the sphincter can be used that included:

High Anterior Resection: HAR:

anastomosis above peritoneal reflection

Low Anterior resection: LAR:

anastomosis is located under the

rectovesical pouch or 2 cm above the

dentate line

+ In case rectal tumors are in the

lower third and located up to 4 cm or

above and less than 6cm from the anal

margin, those which do not yet invade

the anal sphincter and tumors in the

early stage, Super Low Anterior resection can be performed: SLRA: the anastomosis

is located 0-2 cm from the dentate line

* Data analysis:

Data were entered and analysed

by using software STATA 14 and the analysis process was at the

Mathematics and Informatics Departure, Military Medical University

RESULTS

1 Patients characteristics

* Age and gender:

Patients’ mean age was 58.88 ± 12.2 years (min: 23-max: 81); 51.1% were

male and 48.9% were female male/female ratio was proximately 1:1

* Clinical features:

There were 10.2% underweight, 63.3% normal weight, 9.1% overweight and

obese patients, class 1 obesity was found in 17%

* Laboratory features of studied subjects:

Figure 1: Macroscopy of rectal cancer

Damage morphology was mainly wart (64.9%) and wart-ulcer (23.7%)

2 Features of cancer cells and postoperative TNM stage

Table 1: Type of cancer cell

In terms of pathological anatomy, glandular epithelial carcinoma represented 86.4%, and there was one case of the cancerous polyp

Table 2: Postoperative TNM stage

The majority of patients belonged to the stage II-III constituting 78.4% 19.3%

of patients were in stage I, and 2.3% of them were in stage IV

3 Surgical outcomes

Mean operating time: 151.99 ± 41.967 minutes with a minimum of 100 minutes and a maximum of 270 minutes

Table 3: Type of circular staplers

Type of circular staplers Number (n) Percentage (%)

The circular stapler most frequently used was CDH 29 and CDH 31

Table 4: Treatment follow-up and postoperative care

Mean time for taking pain relief medication after the operation was 3.49 ± 0.66 days Mean time for passage of flatus after the operation was 3.52 ± 0.64, and mean time for passage of first stool after the operation was 4.51 ± 1.08 days Table 5: Early complications

In the study, there were 15 cases with postoperative complications representing 17% which is primarily associated with bladder dysfunction (10 cases, representing 11.4%)

Figure 2: Early outcome evaluation

Among 88 cases, 83% achieved good results, and no postoperative complications occurred There were 15.9% of patients with early complications who had fairly

good results These patients received internal treatment without surgical intervention Poor result was observed in 1.1% that needed to be re-operated

Table 6: Late complication and sequelae

Upon re-examining patients, 13 patients had late complications in which one case suffered from anastomotic stenosis, 4 cases had inflammation at the anastomosis detected by rectal endoscopy, 5 cases had defecation disorder, and 2 cases had semi-intestinal obstruction requiring internal therapy There was one case with the protrusion of the abdominal wall that was successfully operated Table 7: Recovery outcomes at 3 months after surgery

Postoperative recovery was achieved by 75% of the patients, they could integrate into social life in the third month There were only 14.8% of patients who could do it by themselves, and 10.2% needed the support from others after the operation