Advancement in Colorectal Surgery - All You Need to Know

Introduction

Globally, colorectal cancer ranks as the fourth most deadly type of cancer. The Vital Statistics of Japan report that colorectal cancer deaths in Japan have surpassed 50,000. The number of deaths from the disease has been steadily rising. Primary resection combined with dissection of lymph nodes has remained the cornerstone of surgical treatment for colorectal cancer. On the other hand, novel techniques like laparoscopic, robotic, transanal total mesorectal excision (TaTME), and sphincter preservation surgery are becoming increasingly popular.

What Is Colorectal Surgery?

Various procedures to address issues with the lower intestine are collectively called colorectal surgeries. This can apply to organs like the colon, rectum, bowel, and anus. Several surgical techniques have been developed for use in colorectal surgeries. The least amount of complications arise from laparoscopic and robotic procedures, although in certain more complex cases, open surgeries (requiring a large abdominal incision) may still be necessary.

What Are the Recent Advancements in Colorectal Surgery?

Technology is advancing quickly and impacts every aspect of life, including surgery. The primary investigation of colonic cancer is becoming easier and more patient-acceptable with modern endoscopes with features like magnifying variable stiffness and localization capabilities. Digital data sets are used in imaging investigations focusing on primary, metastatic, and recurrent disease. These sets can be stored, reviewed remotely, combined with other modalities, and reconstructed as three-dimensional (3D) images for computer-assisted surgery and advanced diagnostic interpretation. The recent advancements in colorectal surgery can include:

1. Laparoscopic Approach: While prior clinical trials have demonstrated the superiority of laparoscopic surgery over open surgery for colon cancer in terms of short-term outcomes, the ability to achieve complete excision or dissection has raised serious concerns. A meta-analysis was published from the United Kingdom (UK) analyzing the non-inferiority of open surgery compared to laparoscopic CME or D3 surgery. According to their analysis, there was no variation in short-term mortality and morbidity. There was only a tendency for longer operative time and shorter hospital stay in laparoscopic surgery compared to open surgery, even though intraoperative blood loss was significantly lower in the laparoscopic group. Neither overall survival nor disease-free survival differed significantly. These reports suggest that even when performing complete excision or dissection, laparoscopic surgery is regarded as a standard and acceptable treatment for colon cancer.

2. Robotic Surgery: Prete et al. found that although robotic surgery had a lower conversion rate than open surgery, the operating time was noticeably longer than that of laparoscopic surgery in their systematic review of rectal cancer. Perioperative mortality, however, was comparable. The open group had significantly higher estimated blood loss, length of stay, intraoperative transplantation, and postoperative complications. Both the overall direct and direct costs of hospitalization for primary resection were considerably higher in the robotic group. Huang et al. (2021) found that even in patients who had preoperative chemoradiotherapy (CRT) and showed more advanced disease, robotic surgery might have a shorter learning curve than laparoscopic surgery. At the moment, robotic surgery may be used selectively for patients who may benefit from this innovative technology due to the additional time and financial costs.

3. Transanal Total Mesorectal Excision (TaTME): Sylla et al. initially described transanal TME (TaTME) in 2010. Numerous case studies have since reported on the safety and viability of this surgery, with satisfactory short-term results. Studies by Perdawood et al. showed that TaTME had better results than the other two groups regarding shorter hospital stays, less blood loss, and shorter operation periods. However, those who adopted this technique early have acknowledged its technical difficulty. TaTME registry data have identified visceral injuries during perineal dissection. TaTME is among the most alluring and promising developments for colorectal surgeons. Still, physicians need to be aware of the potential risks connected to this innovative method's widespread, unchecked use.

4. Lateral Pelvic Lymph Node Dissection: There has long been discussion about the potential benefits of lateral pelvic lymph node dissection (LLND). It is a process by which the lymph nodes in the lateral area are removed. It has shown a good five-year overall survival and local recurrence-free survival rates. However, it is technically challenging

5. Pre-operative Therapy: For locally advanced rectal cancer, fluorouracil-based chemoradiotherapy (CRT) is currently the gold standard for preoperative treatments. However, the extra benefit of oxaliplatin to CRT is controversial. Patients who received radiotherapy showed higher levels of toxicity and more complications following surgery. A wait-and-see strategy is becoming increasingly popular as a management option for patients with rectal cancer who have had preoperative therapy. The effect of primary tumor resection is debatable in cases of stage IV colorectal cancer with concurrent unresectable metastases. In contrast to chemotherapy alone, systemic chemotherapy combined with primary tumor resection significantly improved overall or cancer-specific survival, according to recent large-scale retrospective studies.

6. Adjuvant Therapy: Disease recurrence among patients who have had potentially curative resections is believed to be caused by clinically occult micrometastases that were present during surgery. To improve the recovery rate, postoperative (adjuvant) therapy aims to eradicate these micrometastases. In patients with stage III disease, the advantages of adjuvant chemotherapy have been most clearly shown. Additionally crucial is choosing patients who will genuinely benefit from adjuvant therapy. According to a retrospective analysis of colon cancer patients, patients with stage II or III colon cancer who had tumors that were microsatellite-stable or that showed low-frequency Microsatellite Instability (MSI) benefited from fluoropyrimidine adjuvant chemotherapy, but not those whose tumors showed high-frequency MSI. Lately, it was discovered that the absence of expression for the transcription factor 2 (CDX2) caudal type homeobox may be a prognostic biomarker for stage II colon cancer patients who will benefit from adjuvant chemotherapy. The creation of these novel biomarkers would facilitate additional advancements in adjuvant treatment.

Conclusion

Treatment options for colorectal cancer have evolved over the last few years due to discoveries in clinical trials and recent advancements in medical technology. Thus, it is necessary to revise the available treatment options and approaches to provide patients with the best possible customized care. While laparoscopic surgery remains the most popular method for treating colorectal cancer, new surgical techniques are becoming available, including robotic surgery, transanal total mesorectal excision, and laparoscopic lateral pelvic lymph node dissection.