Top

Published in:

01-02-2019

Mesorectal fat area as a useful predictor of the difficulty of robotic-assisted laparoscopic total mesorectal excision for rectal cancer

Authors: Yusuke Yamaoka, Tomohiro Yamaguchi, Yusuke Kinugasa, Akio Shiomi, Hiroyasu Kagawa, Yushi Yamakawa, Akinobu Furutani, Shoichi Manabe, Kakeru Torii, Kohei Koido, Keita Mori

Published in: Surgical Endoscopy | Issue 2/2019

Abstract

Background

Various predictors of the difficulty of total mesorectal excision for rectal cancer have been described. Although a bulky mesorectum was considered to pose technical difficulties in total mesorectal excision, no studies have evaluated the influence of mesorectum morphology on the difficulty of total mesorectal excision. Mesorectal fat area at the level of the tip of the ischial spines on magnetic resonance imaging was described as a parameter characterizing mesorectum morphology. This study aimed to evaluate the influence of clinical and anatomical factors, including mesorectal fat area, on the difficulty of total mesorectal excision for rectal cancer.

Methods

This study enrolled 98 patients who underwent robotic-assisted laparoscopic low anterior resection with total mesorectal excision for primary rectal cancer, performed by a single expert surgeon, between 2010 and 2015. Magnetic resonance imaging-based pelvimetry data were collected. Linear regression was performed to determine clinical and anatomical factors significantly associated with operative time of the pelvic phase, which was defined as the time interval from the start of rectal mobilization to the division of the rectum.

Results

The median operative time of the pelvic phase was 68 min (range 33–178 min). On univariate analysis, the following variables were significantly associated with longer operative time of the pelvic phase: male sex, larger tumor size, larger visceral fat area, larger mesorectal fat area, shorter pelvic outlet length, longer sacral length, shorter interspinous distance, larger pelvic inlet angle, and smaller angle between the lines connecting the coccyx to S3 and to the inferior middle aspect of the pubic symphysis. On multiple linear regression analysis, only larger mesorectal fat area remained significantly associated with longer operative time of the pelvic phase (p = 0.009).

Conclusions

Mesorectal fat area may serve as a useful predictor of the difficulty of total mesorectal excision for rectal cancer.

Heald RJ, Husband EM, Ryall RD (1982) The mesorectum in rectal cancer surgery-the clue to pelvic recurrence? Br J Surg 69:613–616CrossRefPubMed

Watanabe T, Muro K, Ajioka Y, Hashiguchi Y, Ito Y, Saito Y, Hamaguchi T, Ishida H, Ishiguro M, Ishihara S, Kanemitsu Y, Kawano H, Kinugasa Y, Kokudo N, Murofushi K, Nakajima T, Oka S, Sakai Y, Tsuji A, Uehara K, Ueno H, Yamazaki K, Yoshida M, Yoshino T, Boku N, Fujimori T, Itabashi M, Koinuma N, Morita T, Nishimura G, Sakata Y, Shimada Y, Takahashi K, Tanaka S, Tsuruta O, Yamaguchi T, Yamaguchi N, Tanaka T, Kotake K, Sugihara K; Japanese Society for Cancer of the Colon and Rectum (2017) Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2016 for the treatment of colorectal cancer. Int J Clin Oncol. https://doi.org/10.1007/s10147-017-1101-6 CrossRefPubMedPubMedCentral

Sun WM, Read NW, Katsinelos P, Donnelly TC, Shorthouse AJ (1994) Anorectal function after restorative proctocolectomy and low anterior resection with coloanal anastomosis. Br J Surg 81(2):280–284CrossRefPubMed

Havenga K, Enker WE, McDermott K, Cohen AM, Minsky BD, Guillem J (1996) Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J Am Coll Surg 182(6):495–502PubMed

Maslekar S, Sharma A, Macdonald A, Gunn J, Monson JR, Hartley JE (2007) Mesorectal grades predict recurrences after curative resection for rectal cancer. Dis Colon Rectum 50(2):168–175CrossRefPubMed

Salerno G, Daniels IR, Brown G, Norman AR, Moran BJ, Heald RJ (2007) Variations in pelvic dimensions do not predict the risk of circumferential resection margin (CRM) involvement in rectal cancer. World J Surg 31(6):1313–1320CrossRefPubMed

Baik SH, Kim NK, Lee KY, Sohn SK, Cho CH, Kim MJ, Kim H, Shinn RK (2008) Factors influencing pathologic results after total mesorectal excision for rectal cancer: analysis of consecutive 100 cases. Ann Surg Oncol 15(3):721–728CrossRefPubMed

Targarona EM, Balague C, Pernas JC, Martinez C, Berindoague R, Gich I, Trias M (2008) Can we predict immediate outcome after laparoscopic rectal surgery? Multivariate analysis of clinical, anatomic, and pathologic features after 3-dimensional reconstruction of the pelvic anatomy. Ann Surg 247(4):642–649CrossRefPubMed

Akiyoshi T, Kuroyanagi H, Oya M, Konishi T, Fukuda M, Fujimoto Y, Ueno M, Miyata S, Yamaguchi T (2009) Factors affecting the difficulty of laparoscopic total mesorectal excision with double stapling technique anastomosis for low rectal cancer. Surgery 146(3):483–489CrossRefPubMed

10.

Killeen T, Banerjee S, Vijay V, Al-Dabbagh Z, Francis D, Warren S (2010) Magnetic resonance (MR) pelvimetry as a predictor of difficulty in laparoscopic operations for rectal cancer. Surg Endosc 24(12):2974–2979CrossRefPubMed

11.

Kim JY, Kim YW, Kim NK, Hur H, Lee K, Min BS, Cho HJ (2011) Pelvic anatomy as a factor in laparoscopic rectal surgery: a prospective study. Surg Laparosc Endosc Percutan Tech 21(5):334–339CrossRefPubMed

12.

Chen W, Li Q, Fan Y, Li D, Jiang L, Qiu P, Tang L (2016) Factors predicting difficulty of laparoscopic low anterior resection for rectal cancer with total mesorectal excision and double stapling technique. PLoS ONE 11(3):e0151773CrossRefPubMedPubMedCentral

13.

Chen B, Zhang Y, Zhao S, Yang T, Wu Q, Jin C, He Y, Wang Z (2016) The impact of general/visceral obesity on completion of mesorectum and perioperative outcomes of laparoscopic TME for rectal cancer: A STARD-compliant article. Medicine (Baltimore) 95(36):e4462CrossRef

14.

Zhou XC, Su M, Hu KQ, Su YF, Ye YH, Huang CQ, Yu ZL, Li XY, Zhou H, Ni YZ, Jiang YI, Lou Z (2016) CT pelvimetry and clinicopathological parameters in evaluation of the technical difficulties in performing open rectal surgery for mid-low rectal cancer. Oncol Lett 11(1):31–38CrossRefPubMed

15.

Park IJ, Yu CS, Lim SB, Lee JL, Kim CW, Yoon YS, Park SH, Kim JC (2016) Is preoperative chemoradiotherapy beneficial for sphincter preservation in low-lying rectal cancer patients? Medicine (Baltimore) 95(18):e3463CrossRef

16.

Dayal S, Battersby N, Cecil T (2017) Evolution of surgical treatment for rectal cancer: a review. J Gastrointest Surg 21(7):1166–1173CrossRefPubMed

17.

Boyle KM, Chalmers AG, Finan PJ, Sagar PM, Burke D (2009) Morphology of the mesorectum in patients with primary rectal cancer. Dis Colon Rectum 52(6):1122–1129CrossRefPubMed

18.

Lowry AC, Simmang CL, Boulos P, Farmer KC, Finan PJ, Hyman N, Killingback M, Lubowski DZ, Moore R, Penfold C, Savoca P, Stitz R, Tjandra JJ (2001) Consensus statement of definitions for anorectal physiology and rectal cancer: report of the Tripartite Consensus Conference on Definitions for Anorectal Physiology and Cancer R, Washington, D.C., May 1, 1999. Dis Colon Rectum 44(7):915–919CrossRefPubMed

19.

Yamaoka Y, Kinugasa Y, Shiomi A, Yamaguchi T, Kagawa H, Yamakawa Y, Numata M, Furutani A (2017) Preoperative chemoradiotherapy changes the size criterion for predicting lateral lymph node metastasis in lower rectal cancer. Int J Colorectal Dis 32(11):1631–1637CrossRefPubMed

20.

Brierley JD, Gospodarowicz. MK, Wittekind C (2017) TNM classification of malignant tumours, 8th Edn. Wiley-Blackwell, Oxford

21.

Shiomi A, Kinugasa Y, Yamaguchi T, Kagawa H, Yamakawa Y (2016) Robot-assisted versus laparoscopic surgery for lower rectal cancer: the impact of visceral obesity on surgical outcomes. Int J Colorectal Dis 31(10):1701–1710CrossRefPubMed

22.

Yamaguchi T, Kinugasa Y, Shiomi A, Tomioka H, Kagawa H, Yamakawa Y (2016) Robotic-assisted vs. conventional laparoscopic surgery for rectal cancer: short-term outcomes at a single center. Surg Today 46(8):957–962CrossRefPubMed

23.

Kinugasa Y, Murakami G, Suzuki D, Sugihara K (2007) Histological identification of fascial structures posterolateral to the rectum. Br J Surg 94(5):620–626CrossRefPubMed

24.

Kinugasa Y, Murakami G, Uchimoto K, Takenaka A, Yajima T, Sugihara K (2006) Operating behind Denonvilliers’ fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision: a histologic study using cadaveric specimens, including a surgical experiment using fresh cadaveric models. Dis. Colon Rectum 49(7):1024–1032CrossRefPubMed

25.

Escal L, Nougaret S, Guiu B, Bertrand MM, de Forges H, Tetreau R, Thézenas S, Rouanet P (2018) MRI-based score to predict surgical difficulty in patients with rectal cancer. Br J Surg 105(1):140–146CrossRefPubMed

26.

Yamaguchi T, Kinugasa Y, Shiomi A, Tomioka H, Kagawa H (2016) Robotic-assisted laparoscopic versus open lateral lymph node dissection for advanced lower rectal cancer. Surg Endosc 230(2):721–728CrossRef

27.

Zhang X, Wei Z, Bie M, Peng X, Chen C (2016) Robot-assisted versus laparoscopic-assisted surgery for colorectal cancer: a meta-analysis. Surg Endosc 30(12):5601–5614CrossRefPubMed

28.

Kim JY, Kim NK, Lee KY, Hur H, Min BS, Kim JH (2012) A comparative study of voiding and sexual function after total mesorectal excision with autonomic nerve preservation for rectal cancer: laparoscopic versus robotic surgery. Ann Surg Oncol 19(8):2485–2493CrossRefPubMed

29.

Kim J, Baek SJ, Kang DW, Roh YE, Lee JW, Kwak HD, Kwak JM, Kim SH (2017) Robotic resection is a good prognostic factor in rectal cancer compared with laparoscopic resection: long-term survival analysis using propensity score matching. Dis Colon Rectum 60(3):266–273PubMed

30.

Baek SJ, Kim CH, Cho MS, Bae SU, Hur H, Min BS, Baik SH, Lee KY, Kim NK (2015) Robotic surgery for rectal cancer can overcome difficulties associated with pelvic anatomy. Surg Endosc 29(6):1419–1424CrossRefPubMed

31.

Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna GB, Mortensen NJ, Tekkis PP, TaTME Registry Collaborative (2017) Transanal total mesorectal excision: international registry results of the first 720 cases. Ann Surg 266(1):111–117CrossRefPubMed

32.

Penna M, Hompes R, Arnold S, Wynn G, Austin R, Warusavitarne J, Moran B, Hanna GB, Mortensen NJ, Tekkis PP, International TaTME Registry Collaborative (2018) Incidence and risk factors for anastomotic failure in 1594 patients treated by transanal total mesorectal excision: results from the International TaTME Registry. Ann Surg. https://doi.org/10.1097/SLA.0000000000002653 CrossRefPubMed

33.

Deijen CL, Velthuis S, Tsai A, Mavroveli S, de Lange-de Klerk ES, Sietses C, Tuynman JB, Lacy AM, Hanna GB, Bonjer HJ (2016) COLOR III: a multicentre randomised clinical trial comparing transanal TME versus laparoscopic TME for mid and low rectal cancer. Surg Endosc 30(8):3210–3215CrossRefPubMed

34.

Yamaguchi T, Kinugasa Y, Shiomi A, Sato S, Yamakawa Y, Kagawa H, Tomioka H, Mori K (2015) Learning curve for robotic-assisted surgery for rectal cancer: use of the cumulative sum method. Surg Endosc 29(7):1679–1685CrossRefPubMed

Title: Mesorectal fat area as a useful predictor of the difficulty of robotic-assisted laparoscopic total mesorectal excision for rectal cancer
Authors: Yusuke Yamaoka
Tomohiro Yamaguchi
Yusuke Kinugasa
Akio Shiomi
Hiroyasu Kagawa
Yushi Yamakawa
Akinobu Furutani
Shoichi Manabe
Kakeru Torii
Kohei Koido
Keita Mori
Publication date: 01-02-2019
Publisher: Springer US
Published in: Surgical Endoscopy / Issue 2/2019
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-018-6331-9

At a glance: The STEP trials

Springer Medicine

Mesorectal fat area as a useful predictor of the difficulty of robotic-assisted laparoscopic total mesorectal excision for rectal cancer

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 2/2019

Closed Facebook™ groups and CME credit: a new format for continuing medical education

Implementation of 3D printed superior mesenteric vascular models for surgical planning and/or navigation in right colectomy with extended D3 mesenterectomy: comparison of virtual and physical models to the anatomy found at surgery

Outcome of endoscopic small-bore naso-jejunal tube stenting in early postoperative jejunal limb obstruction after gastrectomy

Laparoscopic duodenum-preserving total pancreatic head resection: a novel surgical approach for benign or low-grade malignant tumors

Laparoscopic splenectomy for immune thrombocytopenia (ITP): long-term outcomes of a modern cohort

Self-expandable metallic stenting as a bridge to surgery for malignant colorectal obstruction: pooled analysis of 426 patients from two prospective multicenter series