Safety and efficacy of synchronous robotic surgery for colorectal cancer with liver metastases

Abstract

Timing of resection and treatment of colorectal cancer (CRC) with liver metastases varies based on patient characteristics and center protocols. Concerns of increased morbidity and mortality (M&M) related to anesthetic time and blood loss have limited widespread adaptation of synchronous colorectal and liver resections. Furthermore, technical challenges have made minimally invasive synchronous resections less common. We present our series of synchronous robotic surgery for CRC with liver metastases. Retrospective review of prospectively collected data of patients with stage IV CRC with liver metastases treated at a tertiary center from February 2013 to June 2014. Patients who underwent synchronous robotic surgery for CRC with liver metastasis(es) were included and selected by a multidisciplinary cancer committee. Data included patient demographics, disease stage, OR time, EBL, and complications. All resections were performed robotically by the same well-experienced surgeons. A radiologist was present for intraoperative ultrasound. Liver treatment was performed first in consideration of intraoperative bleeding risk. Sixty-six patients with Stage IV CRC were seen at the tertiary center during the study period. Six patients met inclusion criteria (2 male, 4 female). Mean age was 59.3 years and mean BMI was 23.46. Mean of 2.25 liver segments were resected and mean of 1.75 liver segments were ablated. Four patients underwent metastatectomy; three with concurrent microwave ablation. One patient had ablation without resection and another had no identifiable lesion on ultrasound. The colonic resections included 3 low anterior resections, 2 abdominal perineal resections (APR), and 1 right hemicolectomy. Mean operative time was 401 min (349-506 min) with mean EBL of 316 mL (150-1000 mL). No conversions to an open approach occurred. Median length of stay (LOS) was 4.5 days (3-10 days). Complications included delayed wound healing after an APR and a delayed rectal anastomotic failure after ileostomy reversal. There was no 30-day mortality. At a mean follow-up of 19 months, one death occurred at 26 months and the remaining patients had documented metastatic disease. Synchronous resection for metastatic CRC carries risks. We report our series of synchronous robotic surgery for CRC with liver metastases. The robotic approach contributed to low blood loss, appropriate LOS, and no 30-day mortality. Morbidity experienced was consistent with the procedures and not related to the robotic technique. This series supports the potential benefits of synchronous resection from a technical standpoint. Further data are required to determine treatment and survival benefits. Limitations include small number and retrospective review of data.

Robotic and laparoscopic liver surgery for colorectal liver metastases: an experience from a German Academic Center

“…Even the simultaneous minimally invasive resection of colorectal liver metastases and the primary tumor can be performed safely and effectively [6][7][8]. A recent meta-analysis showed that simultaneous minimally invasive resection of colorectal cancer and synchronous liver metastases caused significantly lower intra-operative blood loss and blood transfusion, faster recovery of intestinal function and diet, shorter length of stay, and lower rates of surgical complications in comparison to open surgery.…”

Robotic synchronous treatment of colorectal cancer and liver metastasis: state of the art

“…Postoperative morbidity and mortality are acceptable, confirming the data reported by minimally invasive surgery. In the series of Dwyer et al [11] , an anastomotic leakage is described, and this event strongly impact postoperative course due to the necessity of reoperation, questioning the risk of performing the colorectal anastomosis during synchronous resection.…”

“…Conversion tax ranged from 0% to 12%. Complications and major morbidity included delayed wound healing after an abdominal perineal resection (APR) and a delayed rectal anastomotic failure after ileostomy reversal in synchronous resection [11] , 1 postoperative bile leak, 2 heart failure [9] . 90 days mortality was 0%.…”

“…Guadagni et al [10] described 20 cases of CRLM resection but only three synchronous RAS, performing 2 right colectomies, 1 APR. Dwyer et al [11] described 3 low anterior resection, 1 right colectomy and 2 APR. Only in 2 cases colorectal anastomosis was performed, describing 1 anastomotic leakage.…”

Robotic liver surgery: literature review and current evidence

“…Fifty-four simultaneous resections of the primary tumor and liver metastases were included. In these cases, RS added additional safety and effectiveness in the management of multiple metastases, improving shortterm outcomes such as EBL, bowel function return time and LOS, with the exception of operative time, reaching excellent R0 resection rates [34,55] . Even in selected cases requiring major liver resections, robotic surgery gained acceptable morbidity [56] .…”