Summary Background Compared with open resection, laparoscopic resection of rectal cancers is associated with improved short-term outcomes, but high-level evidence showing similar long-term outcomes is scarce. We aimed to compare survival outcomes of laparoscopic surgery with open surgery for patients with mid-rectal or low-rectal cancer. Methods The Comparison of Open versus laparoscopic surgery for mid or low REctal cancer After Neoadjuvant chemoradiotherapy (COREAN) trial was an open-label, non-inferiority, randomised controlled trial done between April 4, 2006, and Aug 26, 2009, at three centres in Korea. Patients (aged 18–80 years) with cT3N0–2M0 mid-rectal or low-rectal cancer who had received preoperative chemoradiotherapy were randomly assigned (1:1) to receive either open or laparoscopic surgery. Randomisation was stratified by sex and preoperative chemotherapy regimen. Investigators were masked to the randomisation sequence; patients and clinicians were not masked to the treatment assignments. The primary endpoint was 3 year disease-free survival, with a non-inferiority margin of 15%. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00470951. Findings We randomly assigned 340 patients to receive either open surgery (n=170) or laparoscopic surgery (n=170). 3 year disease-free survival was 72·5% (95% CI 65·0–78·6) for the open surgery group and 79·2% (72·3–84·6) for the laparoscopic surgery group, with a difference that was lower than the prespecified non-inferiority margin (–6·7%, 95% CI −15·8 to 2·4; p Interpretation Our results show that laparoscopic resection for locally advanced rectal cancer after preoperative chemoradiotherapy provides similar outcomes for disease-free survival as open resection, thus justifying its use. Funding National Cancer Center, South Korea.

https://www.thelancet.com/pdfs/journals/lanonc/PIIS1470-2045(14)70205-0.pdf

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.

Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice

Cancer of the colon

One of the main uses of robotic assisted abdominal surgery is the mesorectal excision in patients with rectal cancer. The aim of the present study is to analyse the learning curve for robotic assisted laparoscopic resection of rectal cancer. We included in our study 43 consecutive rectal cancer resections (16 females and 27 males) performed from January 2008 through December 2010. Mean age of patients was 66 ± 9.0 years. Surgical procedures included both abdomino-perineal and anterior resections. We analysed the following parameters: demographic data of the patients included in the study, intra- and postoperative data, time taking to set up the robot for operations (set-up or docking time), operative time, intra- and postoperative complications, conversion rates and pathological specimen features. The learning curve was analysed using cumulative sum (CUSUM) methodology. The procedures understudied included seven abdomino-perineal resections and 36 anterior resections. In our series of patients, mean robotic set-up time was 62.9 ± 24.6 min, and the mean operative time was 197.4 ± 44.3 min. Once we applied CUSUM methodology, we obtained two graphs for CUSUM values (operating time and success), both of them showing three well-differentiated phases: phase 1 (the initial 9–11 cases), phase 2 (the middle 12 cases) and phase 3 (the remaining 20–22 cases). Phase 1 represents initial learning; phase 2 plateau represents increased competence in the use of the robotic system, and finally, phase 3 represents the period of highest skill or mastery with a reduction in docking time (p = 0.000), but a slight increase in operative time (p = 0.007). The CUSUM curve shows three phases in the learning and use of robotic assisted rectal cancer surgery which correspond to the phases of initial learning of the technique, consolidation and higher expertise or mastery. The data obtained suggest that the estimated learning curve for robotic assisted rectal cancer surgery is achieved after 21–23 cases.

Learning curve for robotic-assisted laparoscopic rectal cancer surgery

Objectives

To describe how learning curves are measured and what procedural variables are used to establish a ‘learning curve’ (LC).
To assess whether LCs are a valuable measure of competency.




Patients and Methods

A review of the surgical literature pertaining to LCs was conducted using the Medline and OVID databases.




Results

Variables should be fully defined and when possible, patient-specific variables should be used. Trainee's prior experience and level of supervision should be quantified; the case mix and complexity should ideally be constant.
Logistic regression may be used to control for confounding variables.
Ideally, a learning plateau should reach a predefined/expert-derived competency level, which should be fully defined.
When the group splitting method is used, smaller cohorts should be used in order to narrow the range of the LC.
Simulation technology and competence-based objective assessments may be used in training and assessment in LC studies.




Conclusions

Measuring the surgical LC has potential benefits for patient safety and surgical education. However, standardisation in the methods and variables used to measure LCs is required.
Confounding variables, such as participant's prior experience, case mix, difficulty of procedures and level of supervision, should be controlled.
Competency and expert performance should be fully defined.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/bju.12197

Measuring the surgical ‘learning curve’: methods, variables and competency

Background: The need for an initial learning experience in laparoscopic colorectal cancer surgery has been well established. However, the inherent differences in the complexity and results of laparoscopic rectal cancer surgery, as compared to colon surgery, warrant a study to analyze the learning curve exclusively for rectal cancer resections. Materials and Methods: four hundred thirty-one patients operated on between April 1994 and March 2006 were analyzed retrospectively for changes in surgical outcomes according to case sequence. A multidimensional analysis was done, based on the following parameters: conversion to laparotomy, intraoperative complications, postoperative complications, reoperations, operative time, and transfusion volumes. Multiple statistical methods were used for evaluation of the learning curve, which included the cumulative sum (CUSUM) method, risk-adjusted CUSUM, moving average method, and analysis of variance (ANOVA). Results: The risk factors for conversion were prior ab...

Multidimensional Analysis of the Learning Curve for Laparoscopic Rectal Cancer Surgery

Intravascular papillary endothelial hyperplasia (Masson's hemangioma) is a disease characterized by exuberant endothelial proliferation within the lumen of medium-sized veins. In 1923, Masson regarded this disease as a neoplasm inducing endothelial proliferation, however, now it is considered to be a reactive vascular proliferation following traumatic vascular stasis. The lesion has a propensity to occur in the head, neck, fingers, and trunk. Occurrence within the abdominal cavity is known to be very rare, and especially in the liver, there has been no reported case up to date. The authors have experienced intravascular papillary endothelial hyperplasia of the liver in a 69-yr-old woman, and report the case with a review of the literature.

/pdf/intravascular-papillary-endothelial-hyperplasia-masson-s-l39t78lmvc.pdf

Intravascular Papillary Endothelial Hyperplasia (Masson's Hemangioma) of the Liver: A New Hepatic Lesion

Background: We aimed to evaluate the learning curve (LC) for laparoscopic right-sided colon cancer surgery (LRCCS) by comparing the results between two surgeons (first-generation colorectal surgeon versus laparoscopically trained surgeon). Methods: The study was a retrospective analysis that evaluated 117 consecutive LRCCSs performed by two surgeons, the first-generation surgeon (Surgeon A) and laparoscopically trained surgeon (Surgeon B), from April 1995 to August 2006. Patients were divided into two groups; patients included in groups I and II received LRCCSs from surgeons A and B, respectively. Results: The moving average method revealed that the operation times of surgeons A and B began to shorten after the 9th case. The cumulative sum (CUSUM) analysis of group I data showed that the 24th case was the peak point of conversion. The 35th case was the peak for intraoperative complications, and the 17th case was the peak for postoperative complications. There was only one case of conversion in gr...

Learning curves in laparoscopic right-sided colon cancer surgery: a comparison of first-generation colorectal surgeon to advance laparoscopically trained surgeon.

Background: This 20-year retrospective study compared the results of laparoscopic surgery with open surgery for patients with rectal cancer to evaluate the impact of laparoscopic surgery on long-term oncological outcomes for rectal cancer.



Methods:  We analysed survival data collected over 20 years for patients with rectal cancer (n= 407) according to surgical methods and tumour stage between those treated with laparoscopic surgery (n= 272) and those with open surgery (n= 135). Clinical factors were analysed to ascertain possible risk factors that might have been associated with survival from and recurrence of rectal cancer. A multivariate analysis was applied by using Cox's regression model to determine the impact of laparoscopic surgery on long-term oncological outcomes.



Results:  Overall survival, disease-specific survival and disease-free survival rates were statistically higher in the laparoscopic group than in the open-surgery group. The incidence of local recurrence in the laparoscopic group (7.9%; 95% confidence intervals (CI), 4.2–11.5) was significantly lower than that for the open-surgery group (30.2%; 95% CI, 21.0–39.3; P < 0.001). By using a multivariate analysis, laparoscopic surgery for rectal cancer appeared not to be an independent factor for disease-specific survival or disease-free survival. However, the laparoscopic surgery was an independent factor associated with reduced local recurrence (Hazard ratio (HR), 3.408; 95% CI, 1.890–6.149; P < 0.001).



Conclusion:  Laparoscopic surgery did not adversely affect the long-term oncological outcome for patients with rectal cancer.

Impact of laparoscopic surgery on the long-term outcomes for patients with rectal cancer.

A malignant fibrous histiocytoma (MFH) is the most common soft tissue sarcoma in adults. About 70% of tumors arise from the soft tissue of the extremities with only 1214% of the tumors occur in the retroperitoneum. The clinical characteristics of this tumor consist of an abdominal mass, tendency for local recurrence, paraneoplastic syndrome and a poor prognosis. A 51-year-old woman was admitted to St. Vincent's Hospital with complaining of fever and an abdominal mass. Ultrasound and computed tomography revealed a huge, heterogenous mass in the lesser sac area. The patient underwent an extensive mass resection with a histologic examination revealing a MFH which was positive for -antitrypsin. We report a case of MFH presenting in the lesser sac with a review of the literatures.

Chung-Soo Chun

Papers

Multidimensional Analysis of the Learning Curve for Laparoscopic Rectal Cancer Surgery

Intravascular Papillary Endothelial Hyperplasia (Masson's Hemangioma) of the Liver: A New Hepatic Lesion

Learning curves in laparoscopic right-sided colon cancer surgery: a comparison of first-generation colorectal surgeon to advance laparoscopically trained surgeon.

Impact of laparoscopic surgery on the long-term outcomes for patients with rectal cancer.

소낭에 발생한 악성 섬유성 조직구종