Clinical Study Of Three-port Laparoscopy-assisted Colorectomy For Colorectal Cancer

Part One Three-Port Vs Five-Port Laparoscopy-AssistedColorectomy For Colorectal Cancer: A Case-Matched ComparativeStudyObjectlve:To clarify the feasibility, safey, radicality and short-term outcome oflaparoscopic-assisted colorectomy by comparing cilinical outcomes from a series ofthree-port laparoscopic-assisted colorectomies with matched five-portlaparoscopic-assisted colorectomies for colorectal cancer.Methods:Between April2012and December2013,114patients from a prospectivelymaintained database were enrolled in a case-matched study. The patients werematched for gender, age, body mass index (BMI), type of operative procedure andtumor stage(AJCC,7th edition,2010).Pathological results, morbidity, perioperativerecovery, hospitalization costs and short-term oncological results were comparedbetween the two groups. Results:The mean operative time was (129.8±41.0min)for TLAC patients and(144.2±47.4min) for FLAC patients (p=0.017).The mean blood loss during operationwas (57.0±84.9m1) for TLAC patients and (75.4±93.7m1) for FLACpatients(P=0.222).The mean number of harvested lymph nodes was (10.83±6.19)withTLAC and (11.26±4.94) with FLAC (p=0.622).No difference was noted in lengths ofproximal or distal resection margins,times until a liquid diet, or postoperative hospitalstays (P>0．05).Negative distal resection margins (DRMs) were noted in all surgicalspecimens.The complication rate after surgery did not differ between TLAC (n=9,11.7%) and FLAC (n=9,11.7%).There was no intraoperative death or operativemortality within30days after surgery in either group.The mean fees for material were（￥16272.3±4286.6）with TLAC patients and （￥18409.3±5606.5）with FLACpatients(p=0.004).The total hospitalization costs were lower in the TLACgroup,although the difference did not reach statistical significance.The medianfollow-up was15months after TLAC and16months after FLAC. The recurrencerates of TLAC group and FLAC group are both2.6%.The overall survival for bothgroups are96.1%.Conclusion:For colorectal cancer, TLAC may be as feasible，safe and radical as FLAC in termsof technical and oncologic issues.At present the TLAC progressed technically matureand reduced material charge。This practice leads to satisfactory treatment and willreach the same level of short-term outcome as FLAC.Further prospective randomizedtrials are necessary for conclusions to be drawn concerning definite oncologicoutcomes of TLAC procedures for colorectal cancer. Part Two Defining A Learning Curve For Three-Port LaparoscopicAssisted Colorectal ResectionsObjectlve:The purpose of this review was to define the learning curve for three-portlaparoscopic assisted colorectal resections performed by one surgeon with experiencein laparoscopic colorectal surgery. This study also aimed to compare outcomes ofdifferent operative sequences and differences in the methods for defining learningcurves.Methods:Between April2012and December2013,from a total of539laparoscopiccolorectal procedures, one surgeon performed self-educated114three-portlaparoscopic assisted colorectal resections. Data were obtained by chart review. Thelearning curve for the surgeon was generated using the moving average method toassess changes in operation time and cumulative sum (CUSUM) analysis to assesschanges in failure rates [(failure=failure to harvest an adequate number of lymphnodes (≤12nodes)]. Procedures were divided into six groups according to thesequences of operative periods. All the procedures were analyzed as six consecutiveequal groups: A, B,C,D,E and F. Demographic data, indications for surgery, procedureperformed, operation time, frequency and kind of complications, conversion rate, anddays to discharge were recorded and compared among the six groups.Results:There were no significant differences between the six groups in terms of age, sex,operative procedure, tumor stage. Group D, E and F showed significantly lessretrieved lymph nodes than group A, B, C. For both blood loss and operative time, theamount decreased as procedures increased, although the difference did not reachstatistical significance. The complication rate after surgery did not differ among the six consecutive equal groups. Learning curves generated with the moving averagemethod indicated that the operation time reached a steady state after51cases for thesurgeon. Based on a decline in failure to harvest an adequate number of lymph nodes,the steady state was reached after approximately55interventions for the samesurgeon.Conclusions:Approximately57cases were needed to achieve proficiency in three-portlaparoscopic assisted colorectal resections based on the significant increase inretrieved lymph nodes after the first57TLAC procedures. Learning curves generatedusing CUSUM analysis based on a90%success rate showed that adequate learningoccurred after55cases for the same surgeon. Learning curves generated with themoving average method indicated that adequate oncologic resections may be achievedafter51cases in the learning curve. The assessment of a learning curve should not belimited to measurement of a decrease in operation time but should also include failurerates. The cumulative sum technique and moving average method as proposed in thisstudy seem appropriate to evaluate the learning curve in this clinical domain.