Study of surgical feasibility and outcome of laparoscopic surgery in malignant rectal tumors

ABSTRACT

Objective

To assess the viability, limitations, technical challenges, and outcomes of malignant rectal tumors laparoscopic mesorectal resection with the assessment of postoperative continence.

Patients and Methods

The study involved 20 people who had malignant rectal tumors. All patients underwent laparoscopic mesorectal resection. Data were recorded and investigated during Preoperative, operative, and postoperative periods.

Results

Low anterior, anterior, and intersphincteric resections were performed in 30%, 7%, and 35% of patients, respectively. The mean operative period lasted was on average of 3.10 ± 0.72 h. Only one case (5%) showed postoperative complications. The peristalsis became audible after one to two days, on an average of 1.65 ± 0.49 days. The hospital staying mean duration was 4.25 ± 0.72. Only for 7 patients with intersphincteric resection, the mean Wexner score was 3.0 ± 1.91 after the closure of ileostomy. Patients who underwent low anterior resection had significantly longer postoperative hospital stays (p = 0.020). There was a substantial relationship between the number of both the resected lymph nodes (LN) and the involved ones (p < 0.001).

Conclusion

Laparoscopic mesorectal excision for rectal tumors is superior nowadays on traditional open approach, has no increased operative time and has privileges of decreasing postoperative pain, decreasing complications, decreasing the hospital stay, early recovery and fast first bowel motion and helps for better visualization and resection of all related lymph nodes. Intersphincteric mesorectal excision of rectal tumors is preferred for all patients below 60 years old with distal rectal tumors regardless of the tumor lower edge’s extended length from the anal verge as long as the external sphincters are preserved.

KEYWORDS:

• Laparoscopic surgery
• rectal tumors
• mesorectum
• surgical feasibility

1. Introduction

Globally, among the main causes of cancer-related mortality is rectal cancer. At present, surgical resection is still regarded as the most crucial management option for rectal cancer patients despite significant breakthroughs considering neoadjuvant chemoradiotherapy [1,2].

Surgical rectal cancer resection requires specific technical considerations to achieve enough circumferential margins. This is accomplished through performing appropriate preoperative staging, choosing the optimal neoadjuvant therapy, and employing precise surgical procedures with Total Mesorectal Excision (TME) [3,4]. The main TME goals are the excision of both the rectal involved tumor and the pararectal associated LN, which act as the first lymphatic drainage site for tumor cells, while also preserving the structures outside the rectal fascia, especially the nerve fibers supplying the prostate, vagina, and bladder [5].

Nowadays, laparoscopic surgery offers a great opportunity for improving rectal cancer management. The laparoscopic resection role in the colon cancer treatment is now widely acknowledged [4]. Rectal tumor removal using a minimally invasive technique has been found to be similar to open surgery [6]. Comparable results have been obtained between laparoscopic and open methods for the median tumor distance to the resection margins at the distal and circumferential ends, and degree of resection [7]. A few advantages in laparoscopic surgery involve less intraoperative loss of blood, reduced postpartum involved pain, fewer days spent in the hospital, a quicker time to resume work and less adhesions [8–10].

However, the two elements that will have the most influence on the technical effectiveness of the laparoscopic procedure are learning advanced laparoscopic skills and having a thorough understanding of rectal cancer resection [11]. The purpose of the current investigation was to determine the feasibility, limitations, technical challenges, and outcome results of laparoscopic mesorectal resection of malignant rectal tumors with the assessment of postoperative continence.

2. Patients and methods

The study involved 20 people who had malignant rectal tumors admitted to the main university hospital from the year 2020 to 2022. All participants in the research, including their first-degree relatives, submitted written informed permission.

The included patients were less than 60 years and had malignant rectal tumors with no general co-morbidities, and with no distant metastasis or peritoneal carcinomatosis. On the other hand, we excluded 1) patients with sphincteric involvement by the tumor after neoadjuvant radiotherapy detected by imaging, examination under general anesthesia, or intraoperative, 2) patients with fecal incontinence, and 3) patients with distant metastasis or peritoneal carcinomatosis.

All patients in the study with low and middle rectal tumors were subjected to long course standard neoadjuvant chemoradiation uses 45–50.4 Gy in 25–28 fractions accompanied with concurrent 5-FU chemotherapy followed by 6–8 weeks of rest before surgery.

2.1. Preoperative assessment

All patients during the studied period were subjected to preoperative assessment including a detailed history and personal data, digital rectal examination to evaluate the distance from the tumor’s bottom border to the anal verge and to assess anal tone, and general as well as abdominal examination.

Preoperative investigations were performed for all patients. Pelvic magnetic resonance imaging (MRI) was done in order to accurately stage cancer and find out if the sphincter was involved. Contrast-enhanced chest, abdomen, and pelvic CT scans were also taken to rule out distant metastases. Assessment of the fecal continence preoperatively is evaluated by history taking, patients own words (wexner score), digital rectal examination and MRI rectal staging protocol that shows the degree of sphincter muscles invasion if there is any.

2.2. Laparoscopic surgery

In a modified supine lithotomy posture, the patient is laid, after undergoing general anesthesia with the aid of endotracheal intubation. Pneumoperitoneum is obtained after insufflation. After the peritoneal cavity has been examined with a 30-degree laparoscope, one to three more 10 mm ports are placed in direct view. These ports are 2 cm exceeding the umbilicus in the right iliac midclavicular, the right midclavicular line, and possibly the left midclavicular line.

Laying on his right side, the patient’s head is alternately raised and lowered for mobilizing the whole left colon along the Toldt line, roughly from their splenic flexure. It is necessary to separate the gastrocolic ligament away from the transverse colon to properly mobilize the left mesocolon and splenic flexure.

Throughout this method, the left ureter is detected and securely reflected away. The inferior mesenteric artery (IMA) is then clipped and split using a bipolar sealing device at its trying to spare left colic artery (Figure 1), and also the inferior mesenteric vein (IMV) is then clipped and split instantly laterally to the duodenum (Figure 2). The sacral promontory is isolated from the mid-colic vessels at the left mesocolon base, although the marginal arcade is still intact. After that, TME is carried out by entering the pre-sacral space. Up till the levator muscles are reached, the dissection proceeds.

Figure 1. Clipping descending branch of inferior mesenteric artery with left colic artery sparing.

Figure 2. Dissection and clipping of inferior mesenteric vein.

The laparoscopic method offers a great view at this stage of the surgery. The following phase in the operation will depend on whether the sphincter complex has been sufficiently cleared of any malignancy to permit a reconstruction procedure.

An articulating endoscopic linear cutting stapler (60 mm) is used under direct manual and visual guidance from the abdomen to the perineum to transect the distal rectum, ideally 2 cm cephalad to the dentate line. The rectum is taken out of the pelvis following the discharge of the stapler. After extensive irrigation and confirmation of adequate pelvic hemostasis, the incision employed infra-umbilical becomes more extended to 3–4 cm. Through this opening, the left colon is completely removed and a wound protector is introduced. A device of bipolar sealing is utilized in order to separate the mesentery from the sigmoid-descending junction to the IMA high ligation. Also, GIA staplers are employed to split the colon. Then, outside the operational field, the objects are taken out.

The apical enterotomy is then stitched up with a purse-string suture and the circular stapler anvil has been fixed, the colon is then drawn back into the abdominal cavity. When the belly is softly penetrated trans-anally with a circular stapler until the cartridge reaches the point of being flush with the line of the cross-staple, the abdominal and perineal fields give immediate tactile and visual aid. Covering ileostomy is done for all patients.

In Intersphincteric resection, coloanal anastomosis is done by hand sewing technique after mobilization of the part of the colon proximal to the resected part and introducing it outside through the anal verge without colopalasty or colonic pouch.

All patients in where intersphincteric resection was done, galvanic stimulation and biofeedback of the sphincteric muscles were done before closure of ileostomy.

For all cases of low rectal tumors, assessment of fecal continence was done 6 months following closure of ileostomy by digital rectal examination, and wexner score.

Operative details were noted, including the gap between the anal border and the lower tumor edge, to assess sphincteric involvement, operative time, operative blood loss, intraoperative assessment of safety margin, and operative complications.

2.3. Postoperative outcomes

First bowel motion, postoperative hospital stays, and complications were reported to assess postoperative surgical outcomes. All specimens were sent for pathological investigation. For the low rectal tumors, the postoperative continence state was evaluated clinically using the Wexner score [12], Manometric studies, and Electromyography (EMG) studies. Within 6 months, short-term oncologic outcomes were documented, including tumor local and/or distant recurrence, tumor-specific death, and disease-free and short-term survival.

2.4. Statistical analysis of the data

The IBM SPSS program, version 20.0, was used to assess the data that were provided by the computer (IBM Corp., Armonk, NY). Quantitative data were represented as percentages and figures. The distribution normality was assessed by employing the Shapiro–Wilk test. Quantitative data were displayed as a range, mean, and median. There were several tests used, including the Chi-square, Fisher’s Exact or Monte Carlo correction for chi-square, F-test (ANOVA), Mann-Whitney, Kruskal Wallis, and Spearman coefficient. The 5% level was used to determine the obtained results’ significance.

3. Results

This study was carried out randomly involving 20 cases with a mean of 51.45 ± 7.51 years, in which 12 cases (60%) were males. Abdominal pain, bleeding per rectum, and loss of weight were the most presenting symptoms. Using MRI, stage II rectal cancer was identified in 5 individuals while 15 patients were found as stage III rectal cancer. The tumor size found in the MRI ranged from 2 to 8.5 cm (Table 1).

Table 1. The study involved cases related personal, preoperative, and operative data.

	No.	%
Gender
Male	12	60.0
Female	8	40.0
Age (years)
Min. – Max.	32.0 – 59.0
Mean ± SD.	51.45 ± 7.51
Median (IQR)	53.50 (47.0 – 57.50)
Clinical presentation
Abdominal pain	18	90.0
Bleeding per rectum	19	95.0
Loss of weight	15	75.0
Digital rectal examination
Distance from anal verge in cm
Not felt	7	35.0
Felt	13	65.0
Min. – Max.	2.0 – 7.0
Mean ± SD.	4.62 ± 1.94
Median (IQR)	4.0 (3.0 – 6.0)
Preoperative Staging
Staging
Stage II	5	25.0
Stage III	15	75.0
Max. Tumor size (cm)
Min. – Max.	2.0 – 8.50
Mean ± SD.	5.03 ± 2.06
Median (IQR)	4.0 (3.3 – 7.0)
Type of the operation
Low Anterior resection	6	30.0
Anterior resection	7	35.0
Intersphincteric resection	7	35.0
Operative time (hr.)
Min. – Max.	2.0 – 4.50
Mean ± SD.	3.10 ± 0.72
Median (IQR)	3.0 (2.5 – 3.5)

Low anterior resection was carried to six patients, anterior resection was carried to seven patients and intersphincteric resection was carried out to seven patients. The average operative period ranged from 2 h to 4.5 h (Table 1).

Table 2 displays the biopsy results regarding the grade, stage, and total and involved amount of lymph nodes. The Wexner score for assessment of continence after the closure of ileostomy, only for seven patients with intersphincteric resection, was estimated. The score ranged from zero to six in which zero is the best score. All seven patients experienced acceptable score results after 6 months of ileostomy closure. Also, manometric studies and EMG to assess the tone of the external sphincters and the puborectalis muscle were carried out for seven patients and four patients, respectively, for those patients.

Table 2. Postoperative data of the studied cases.

	No.	%
Complications
NoS	19	95.0
Yes	1	5.0
First bowel (days)
Min. – Max.	1.0 – 2.0
Mean ± SD.	1.65 ± 0.49
Median (IQR)	2.0 (1.0 – 2.0)
Hospital stay (days)
Min. – Max.	4.0 – 7.0
Mean ± SD.	4.25 ± 0.72
Median (IQR)	4.0 (4.0 – 4.0)
Biopsy
Grade
I	5	25.0
II	13	65.0
III	2	10.0
Stage
Stage II	2	10.0
Stage III	18	90.0
Total Lymph nodes (Figure 2)
Min. – Max.	13.0 – 30.0
Mean ± SD.	20.65 ± 4.45
Median (IQR)	21.0 (18.0 – 23.5)
Involved lymph nodes (Figure 2)
Min. – Max.	0.0 – 28.0
Mean ± SD.	16.25 ± 8.82
Median (IQR)	19.0 (11.50 – 22.50)
Post-operative continence assessment
Wexner score
Not done	13	65.0
Done for Intersphincteric resection	7	35.0
Min. – Max.	0.0 – 6.0
Mean ± SD.	3.0 ± 1.91
Median (IQR)	3.0 (2.0 – 4.0)
Manometric studies	4	20.0
EMG	7	35.0

Only one case (5%) was diagnosed with a complication postoperative in the form of leakage from the distal bowel loop to the ileostomy covering, mostly iatrogenic and treated conservatively. There was no reported either technical or radiologic leakage from the anastomotic line. The peristalsis was heard within one or 2 days. The average stay duration in hospital was 4.25 ± 0.72 days, but it could have been as long as 7.

Relations between type of the operation and different parameters were studied. There is a significant relation between feeling the mass by rectal examination and the type of surgery as low anterior and intersphincteric resections were done for patients where the masses are felt. Regarding the operating time for the three operations, there is statistically significant difference which means that the operative time is almost near for all laparoscopic mesorectal excision. There is also no significant difference between all types of operations and the total lymph nodes involved indicating adequate removal of all lymph nodes related to the tumor. Manometric studies of the sphincter muscles, after galvanic stimulation and biofeedback in the cases we intersphincteric resection, revealed normal values ranging from 40 to 50 mmHg in the resting pressure and 100–120 mmHg in the squeeze pressure. Also, assessment of sphincteric tone by EMG and electrophysiological studies in cases, where intersphincteric resection was done, was found to be helpful. The decision of the surgery is not changed regarding the patient's age or gender. There is no significant increase in the first peristalsis heard or the first bowel motion. The ileostomy was closed after 3 months for all patients after finishing the postoperative course of chemotherapy.

There was existing reported association between staging by biopsy and staging by MRI. There is no significant difference between the staging of the rectal tumor by MRI preoperative and staging of the tumor by biopsy postoperative indicating adequate mesorectal excision in most of the cases. However, It was found that the biopsy showed lymph node involvement which was not present in the MRI indicating that the stage is considered III in only three cases. T

It was found that most of the resected lymph nodes in mesorectal excision are involved by the tumor cells in most of the cases in relation to the total amount of lymph nodes (Figure 3). Our study showed that the tumor size does not affect the operative time. (Also Wexner score was done and found accepted even with large tumor size.

Figure 3. Correlation between total lymph nodes with involved lymph nodes.

As regard the short term oncologic outcomes, there were no reported cases in our study with local or distant recurrence. No tumor-specific deaths were reported and the short-term survival rate of our patients in the time zone of the study was 100%.

4. Discussion

In our study, we concluded that laparoscopic surgery is the best method for managing rectal tumors for many reasons, including, decreasing postoperative pain and complications, decreasing hospital stay, saving operative time, decreasing blood loss, providing adequate safety margins, helping patients for early recovery as well as fasting first bowel motion. Nonetheless, the difference detected in the long-term post-operative consequences was not significant statistically as shown in recently published data comparing between laparoscopic and traditional open approaches [13,14].

According to research by Chen et al. [15] patients who underwent laparoscopic procedures to remove rectal tumors had lower morbidity rates. They claimed that laparoscopic surgeries have a reduced surgical site infection rate because the wound is much smaller in size, but they added that no detected difference statistically in fatalities among both surgeries the laparoscopic and the open ones.

Araujo et al. [16] found that the operative time for laparoscopic approach for rectal surgeries is short with good hands and experienced surgeons. However, their investigation only involved a limited patients number, and the majority of them did not indicate whether the duration of the surgery was determined by measuring the time spent entering and leaving the operating room, or beginning with the skin incision and ending with its closure. In research conducted by Zhou et al. [17], the average laparoscopic approaches operative time for rectal surgeries was 120 min, and it was approximately 266 min in Fleshman et al. [18] study. These studies support our assertion that the laparoscopic approach for rectal tumor excision requires significantly less operative time, as the mean operative time for our patients was 3.10 ± 0.72 h. Furthermore, Milone et al. [19] discovered a number of important and satisfying outcomes for laparoscopic rectal surgeries with regard to oral intake, blood loss and surgical site infection in their research. Furthermore, Arezzo et al. [20] discovered decreased mortality and morbidity with laparoscopic rectal surgeries in a meta-analysis prospective trial research.

We mentioned in our research that the first bowel motion is somewhat fast and short after laparoscopic surgery for rectal masses, which is consistent with the Zhang et al. findings [21] who got similar results in their systemic reviews. They also demonstrated that laparoscopic approaches reduce blood loss, which reduces the frequency of perioperative blood transfusions, which has the risk of postoperative adverse effects and complications.

The trial conducted by Bonjer et al. [22] showed increased positive safety margins and circumferential margins in laparoscopic management of rectal surgeries, supporting our claim that this type of management provides better safety margins in the resected specimen. Furthermore, in 2015, Stevenson et al. [23] published the ALaCaRT randomized trial, which elicited a score assessing circumferential resected margins, distal safety margins, and total mesorectal excision in laparoscopic rectal surgeries, concluding that these parameters are equivalent to or better than the well-known open surgeries.

During our study period, we did not report any local recurrence. When Han et al. [24] compared the oncological results of intersphincteric resection to abdominoperineal resection, they discovered that the local recurrence rate after intersphincteric resection ranges from 0% to 22.7%, which is less than the rate following an abdominal-perineal resection (10–57%) for rectal cancer of the middle or low grade. While in research comparing laparoscopic intersphincteric resection to open surgery, Kuo et al. [25] found comparable surgical and oncological consequences to those of open resection. Furthermore, Saito et al. [26] compared the intersphincteric resection results to those of abdominoperineal resection. Local recurrence rates and death after 5 years of disease-free status were comparable. Compared to those who received abdominal-perineal resection, those who underwent intersphincteric resection had a considerably greater 5-year overall survival rate. Finally, intersphicteric resection has no effect on local or remote oncologic outcomes. It is believed that circumferential margin involvement, as opposed to distal margin involvement, is related to the likelihood of local recurrence.

In the current work, the Wexner score for assessment of continence before the closure of ileostomy, only for 7 patients with intersphincteric resection, was estimated. The mean of this score in our patients was 3.0 ± 1.91. Also, manometric studies and EMG to assess the tone of the external sphincters and the puborectalis muscle were carried out for seven patients and four patients, respectively. The Wexner score indicated that anal continence was relatively excellent. Anorectal manometric examination may be helpful for determining anal function objectively. Our results favor the closure of ileostomy with no risk of anal incontinence.

In significant research evaluating functional results following intersphincteric excision, Denost et al. [27] found that 39% of patients had light fecal incontinence, 11% had serious incontinence, and 50% of patients had a “good functional result.”

Supporting our technique not doing coloplasty or colonic pouch in laparoscopic rectal resection of low rectal tumors, the functional outcomes following j-pouch and side-to-end anastomosis procedures have not been shown to be significantly affected by Siddiqui et al. and C. Si et al. meta-analyzes [28,29]. According to Matsuoka et al., patients with colonic j-pouch may have delayed evacuation issues that call for the administration of enemas and laxatives [30].

In their analysis of the literature, Martin et al.‘s [31] review of the literature revealed that patients had an average of 2.7 bowel-involved movements per day, 51.2% experienced full continence, 29.1% had fecal soiling, 23.8% experienced incontinence to flatus, 18.6% had felt urgency, and 18.4% used drugs of antidiarrhea. Long-term monitoring reveals that this functional result becomes better over time. In a retrospective analysis of 513 patients with nonsurgical fecal incontinence, Bryne et al. [32] discovered that the fecal incontinence incidence reduced, the anal-sphincter-muscle maximum pressure rose, and continence was improved in more than 70% of the patients.

The main recognized limitations in this work are the small sample size, lack of a control group, and overlooking the long-term consequences.

5. Conclusion

Rectal tumors Laparoscopic mesorectal excision is considered superior nowadays having accepted operative time, and has the privileges of decreasing postoperative pain, decreasing complications, decreasing the hospital stay, early recovery, and fast first bowel motion. The choice of anterior resection, low anterior resection or intersphincteric resection is determined according to how is the border of the tumor from the anal verge. Intersphincteric mesorectal excision of rectal tumors should be carried out for all patients below 60 years old with distal rectal tumors regardless of the length between the anal verge and the lower tumor edge as long as the external sphincters are preserved, showing satisfactory results. Galvanic stimulation and biofeedback should be carried out to test the anal tone before the closure of ileostomy in patients where intersphincteric resection is performed. The laparoscopic approach for rectal tumors helps for better visualization and resection of all related lymph nodes.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Islam Abdelkhalek

Islam Abdelkhalek Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.

Galal AbuElnagah

Galal AbuElnagah Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.

Tarek Elfayoumi

Tarek Elfayoumi Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.

Ahmed shoukry Hafez

Ahmed Shoukry Hafez Laparoscopic and Oncology Surgery Department, Elsalam Oncology Center, Cairo, Egypt

Mohamed Asal

Mohamed Asal Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt.