Χαμηλή Πρόσθια...

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  1. 1. : . .
  2. 2. Laparoscopic TME 2
  3. 3. Potential Advantages of Lap TME Less blood loss Faster recovery Earlier return of gut function Lower morbidity and mortality Magnified view allows precise dissection (pelvic autonomics) Earlier hospital discharge 3
  4. 4. Potential Advantages of Lap TME Reduced pain Decreased need for analgesics Improved cosmetic result Decreased adhesions Decreased wound complications Reduced immune effect of surgery 4
  5. 5. Potential Disadvantages Steep learning curve Longer operating times Cost Instruments / equipment Port-site recurrence? (Initial reports 21%!!!) Oncological soundness compared with open? 5
  6. 6. Potential Disadvantages Practical and technical limitations Crowding of instruments in the pelvis Plume can obscure vision Retraction of the rectum can be very difficult Division of the rectum can be difficult Pneumoperitoneum Gas embolism / decreased venous return 6
  7. 7. Technical Difficulties in Rectal Surgery - Narrow confines of the bony pelvis - Angling limitations of the stapling devices - Identification of tumor site can be difficult - High BMI - Level of rectal tumor from anal verge - Stage of disease - Higher anastomotic complications 7
  8. 8. Critical Points in Rectal Surgery TME as the gold standard CRM Distal resection margins Adequate lymphadenectomy Neo-adjuvant chemo-radiotherapy Need for autonomic nerve preservation Sphincter preservation Experienced Surgeon 8
  9. 9. 9
  10. 10. Randomized Trials Specimen Quality 6% vs 12% LAR 10
  11. 11. Short Term Outcomes 11
  12. 12. 12
  13. 13. Mizrahi I, et al. Role of Laparoscopy in Rectal Cancer: A Review. World J Gastroenterol 2014 13
  14. 14. Long Term Results in Rectal Cancer Lai JH, et al. Br Med Bull 201214
  15. 15. Mizrahi I, et al. Role of Laparoscopy in Rectal Cancer: A Review. World J Gastroenterol 2014 Meta Analyses of Oncological Outcomes (2006-2011) 15
  16. 16. N= 16 Clinical Trials 3528 rectal CA patients 16
  17. 17. Disease Free and Overall Survival 17
  18. 18. Local and Distant Recurrence 18
  19. 19. LNs Retrieved and CRM Positivity 19
  20. 20. Postoperative Pain and Hospital Stay 20
  21. 21. Post - Operative Complications
  22. 22. Post Operative Complications
  23. 23. 23
  24. 24. Br J Surgery 2014 24
  25. 25. MRC CLASSIC: Financial Results Cost intention to treat (mean) Open Lap Theatre 1448 1816 Hospital 3713 3359 Others 2659 3085 Total 7820 8260 Br J Cancer 2006 95:6-1225
  26. 26. Lap vs Open Surgery for rectal CA - USA Local recurrence 2% Lap vs 4.2% Open (p=0.42) Baik, Fleshman, DCR 2011 Lap & HALS: Conversion 2.9%; LR 5% Milsom, Sonoda, DCR 2009 Laparoscopic 26 nodes; open 21. Otherwise identical outcomes Boutros and Berho, DCR 2013 Reduces cost $4283, cost-effective per QALY Jensen and Abcarian, DCR 2012 26
  27. 27. Laparoscopic Resection for Rectal Cancer: What is the Evidence? Dedrick Kok HC, et al. Biomed Res Int 2014 4 vs 5 27
  28. 28. Laparoscopic Resection for Rectal Cancer: What is the Evidence? Dedrick Kok HC, et al. Biomed Res Int 2014 28
  29. 29. Open versus Laparoscopic Surgery for mid-Rectal or low-Rectal Cancer after Neoadjuvant Chemoradiotherapy (COREAN trial): Survival Outcomes. 340 patients with locally advanced resectable rectal cancer Intention to treat analysis All had neoadjuvant chemoradiotherapy LAP: 170 OPEN: 170 3-year Disease-Free Survival: 725% (95% CI 650786) for the open surgery group 792% (723846) for the laparoscopic surgery group Jeong SY, et al. Gastrointestinal Cancer 201429
  30. 30. A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer H. Jaap Bonjer, M.D., Ph.D, et al, for the COLOR II Study Group N Engl J Med 2015; 372:1324-1332 30 hospitals 1044 patients Rectal adenocarcinoma within 15 cm from anal verge Intention to treat analysis 2:1 LAP 699 OPEN 345 3-yr RR L: 5% - O: 5% 3-yr DFS L: 74.8% - O: 70.8% OS L: 86.7% - O: 83.6% NS Laparoscopic surgery in patients with rectal cancer was associated with rates of locoregional recurrence and disease-free and overall survival similar to those for open surgery. (Funded by Ethicon Endo- Surgery Europe and others; COLOR II ClinicalTrials.gov number, NCT00297791.) 30
  31. 31. Large Scale Ongoing RCTs a. COLOR II trial in Europe b. ACOSOG-Z6051 trial in the USA c. JCOG 0404 trial in Japan 31
  32. 32. Conclusion Current data suggests that laparoscopic rectal cancer resection in experienced hands may benefit patients because of: a. reduced blood loss b. earlier return of bowel function c. less postoperative pain d. shorter hospital length of stay Short- and Long-term Oncological outcomes are, at least, equivalent with open surgery. There is a slight paucity of data concerning long-term outcome and conversion or other complications, such as bladder and sexual dysfunction after LAP TME. 32