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[.]
JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 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 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 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, Military Hospital 103, Military Medical University National Cancer Hospital, Tan Trieu, Thanh Tri, Ha Noi Vietnamese-Czechoslovak Friendship Hospital, Hai Phong Corresponding author: Cao Minh Tiep (caominhtiepbsn9@gmail.com) Date received: 17/4/2022 Date accepted: 27/4/2022 204 JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 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 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; 205 JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 + Having showing RC; pathologic results + 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 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, 206 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 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 JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 Low Anterior resection: LAR: anastomosis is located under the rectovesical pouch or cm above the dentate line early stage, Super Low Anterior resection can be performed: SLRA: the anastomosis is located 0-2 cm from the dentate line + In case rectal tumors are in the lower third and located up to cm or above and less than 6cm from the anal margin, those which not yet invade the anal sphincter and tumors in the Data were entered and analysed by using software STATA 14 and the analysis process was at the Mathematics and Informatics Departure, Military Medical University * Data analysis: RESULTS 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 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%) 207 JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 Features of cancer cells and postoperative TNM stage Table 1: Type of cancer cell Type of cancer cell Number (n) Percentage (%) Glandular epithelial carcinoma 76 86.4 Mucus epithelial carcinoma 5.7 Squamous cell carcinoma 1.1 Cancerous polyps 1.1 Papillary adenocarcinoma 5.7 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 Stage Number (n) Percentage (%) Stage 0 0.0 Stage I 17 19.3 Stage II 31 35.2 Stage III 38 43.2 Stage IV 2.3 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 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 (%) CDH 29 66 75.0 CDH 31 22 25.0 CDH 33 0.0 Total 88 100 The circular stapler most frequently used was CDH 29 and CDH 31 208 JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 Table 4: Treatment follow-up and postoperative care Time (day) Min Max Mean ± SD Post-surgical pain-relief 3.49 ± 0.66 Passage of first flatus 3.52 ± 0.64 Passage of first stool 4.51 ± 1,08 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 Early complication Number (n) Percentage (%) Anastomosis leak 2.3 Surgical site infection 4.5 Early intestinal obstruction 1.3 Mild bladder dysfunction 3.4 Moderate bladder dysfunction 5.7 Severe bladder dysfunction 2.3 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 209 JOURNAL OF MILITARY PHARMACO - MEDICINE N03 - 2022 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 Late complication Number (n) Percentage (%) Anastomotic stricture 1.1 Inflammation at the anastomosis 4.5 Defecation disorder 5.7 Semi-intestinal obstruction 2.3 Protrusion of Abdominal wall 1.1 Upon re-examining patients, 13 patients had late complications in which one case suffered from anastomotic stenosis, cases had inflammation at the anastomosis detected by rectal endoscopy, cases had defecation disorder, and 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 months after surgery Recovery outcomes Number (n) Percentage (%) Normal 66 75,0 Self-service 13 14.8 Need support 10.2 Total 88 100 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 it by themselves, and 10.2% needed the support from others after the operation 210 ... 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... software STATA 14 and the analysis process was at the Mathematics and Informatics Departure, Military Medical University * Data analysis: RESULTS Patients characteristics * Age and gender: Patients’... 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