Robot-Assisted Total Mesorectal Excision Versus Laparoscopic Total Mesorectal Excision: A Retrospective Propensity Score–Matched Cohort Analysis in Experienced Centers

Sikkenk

Crolla

et al. 2022

Preprint

Purpose Evidence regarding the learning curve of robot-assisted total mesorectal excision is scarce and of low quality. Case-mix is mostly not taken into account, and learning curves are based on operative time, while preferably clinical outcomes and literature-based limits should be used. Therefore this study aims to assess the learning curve of robot-assisted total mesorectal excision. Methods A retrospective study was performed in four Dutch centres. The primary aim was to assess the safety of the individual and institutional learning curves using a RA-CUSUM analysis based on intraoperative complications, major postoperative complications and compound pathological outcome (positive circumferential margin or incomplete TME specimen). The learning curve for efficiency was assessed using a LC-CUSUM analysis for operative time. Outcomes of patients before and after the learning curve were compared. Results In this study, seven participating surgeons performed robot-assisted total mesorectal excisions in 531 patients. Learning curves for intraoperative complications, postoperative complications, and compound pathological outcome did not exceed predefined literature-based limits. The LC-CUSUM for operative time showed lengths of the learning curve ranging from 12–35 cases. Intraoperative, postoperative and pathological outcome did not differ between patients operated during and after the learning curve. Conclusion The learning curve of robot-assisted total mesorectal excision based on intraoperative complications, postoperative complications and compound pathological outcome did not exceed predefined limits, and is therefore suggested to be safe. Using operative time as a surrogate for efficiency, the learning curve is estimated to be between 12 and 35 procedures.

Section: Discussionmentioning

confidence: 99%

Assessing the learning curve of robot-assisted total mesorectal excision. A multi-centre study considering procedural safety, pathological safety and efficiency

Sikkenk

Crolla

et al. 2022

Preprint

“… 10–14 Furthermore, R-TME and TaTME are suggested to result in more primary anastomosis for low rectal cancers. 15 16 However, the effect on quality of life and functional results remains unknown. This is of special importance as LARS symptoms are highly associated with a low anastomosis.…”

Section: Introduction and Rationalementioning

confidence: 99%

“…In addition, as survival rates are increasing, the effects of preoperative neoadjuvant therapy, postoperative complications and the construction of a (temporary) stoma on quality of life and functional outcomes are becoming more pronounced 10–14. Furthermore, R-TME and TaTME are suggested to result in more primary anastomosis for low rectal cancers 15 16. However, the effect on quality of life and functional results remains unknown.…”

Section: Introduction and Rationalementioning

confidence: 99%

Prospective multicentre observational cohort to assess quality of life, functional outcomes and cost-effectiveness following minimally invasive surgical techniques for rectal cancer in ‘dedicated centres’ in the Netherlands (VANTAGE trial): a protocol

Geitenbeek

Hompes³

et al. 2022

BMJ Open

IntroductionTotal mesorectal excision is the standard of care for rectal cancer, which can be performed using open, laparoscopic, robot-assisted and transanal technique. Large prospective (randomised controlled) trials comparing these techniques are lacking, do not take into account the learning curve and have short-term or long-term oncological results as their primary endpoint, without addressing quality of life, functional outcomes and cost-effectiveness. Comparative data with regard to these outcomes are necessary to identify the optimal minimally invasive technique and provide guidelines for clinical application.Methods and analysisThis trial will be a prospective observational multicentre cohort trial, aiming to compare laparoscopic, robot-assisted and transanal total mesorectal excision in adult patients with rectal cancer performed by experienced surgeons in dedicated centres. Data collection will be performed in collaboration with the prospective Dutch ColoRectal Audit and the Prospective Dutch ColoRectal Cancer Cohort. Quality of life at 1 year postoperatively will be the primary outcome. Functional outcomes, cost-effectiveness, short-term outcomes and long-term oncological outcomes will be the secondary outcomes. In total, 1200 patients will be enrolled over a period of 2 years in 26 dedicated centres in the Netherlands. The study is registered at https://www.trialregister.nl/9734 (NL9734).Ethics and disseminationData will be collected through collaborating parties, who already obtained approval by their medical ethical committee. Participants will be included in the trial after having signed informed consent. Results of this study will be disseminated to participating centres, patient organisations, (inter)national society meetings and peer-reviewed journals.

“…Up to now no clear benefits regarding post-operative morbidity have been shown [9][10][11]. However, in patients operated by experienced surgeons, the rate of primary anastomosis is suggested to be higher [12,13]. Additionally, oncological outcomes are suggested to be equal between L-TME and R-TME [14].…”

Section: Introductionmentioning

confidence: 99%

Local recurrence of robot-assisted total mesorectal excision: a multicentre cohort study evaluating the initial cases

Crolla

Fahim

et al. 2022

Int J Colorectal Dis

Purpose Evidence regarding local recurrence rates in the initial cases after implementation of robot-assisted total mesorectal excision is limited. This study aims to describe local recurrence rates in four large Dutch centres during their initial cases. Methods Four large Dutch centres started with the implementation of robot-assisted total mesorectal excision in respectively 2011, 2012, 2015, and 2016. Patients who underwent robot-assisted total mesorectal excision with curative intent in an elective setting for rectal carcinoma defined according to the sigmoid take-off were included. Overall survival, disease-free survival, systemic recurrence, and local recurrence were assessed at 3 years postoperatively. Subsequently, outcomes between the initial 10 cases, cases 11–40, and the subsequent cases per surgeon were compared using Cox regression analysis. Results In total, 531 patients were included. Median follow-up time was 32 months (IQR: 19–50]. During the initial 10 cases, overall survival was 89.5%, disease-free survival was 73.1%, and local recurrence was 4.9%. During cases 11–40, this was 87.7%, 74.1%, and 6.6% respectively. Multivariable Cox regression did not reveal differences in local recurrence between the different case groups. Conclusion Local recurrence rate during the initial phases of implantation of robot-assisted total mesorectal procedures is low. Implementation of the robot-assisted technique can safely be performed, without additional cases of local recurrence during the initial cases, if performed by surgeons experienced in laparoscopic rectal cancer surgery.