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PREDICTORS OF SURGICAL DIFFICULTY IN MINIMALLY INVASIVE TOTAL MESORECTAL EXCISION AFTER TOTAL NEOADJUVANT THERAPY
Salih N. Karahan
*, Mustafa Oruc, Scott Steele, Michael Valente, Hermann Kessler, David R. Rosen, David Liska, Emre Gorgun
Colorectal Surgery, Cleveland Clinic, Cleveland, OH
Background: Total neoadjuvant treatment (TNT) has shown to improve organ preservation and distant-metastasis free survival compared to neoadjuvant chemoradiation, making it the treatment of choice in leading centers. While most studies on TNT focus on oncologic outcomes, optimizing surgical outcomes is also important as difficult surgeries can lead to increased complications and prolonged recovery. There is a widespread perception among surgeons that some surgeries become challenging following TNT, yet the underlying reasons remain unclear. There are no studies predicting surgeon perceived difficulty and associated outcomes after TNT. Our aim is to identify predictors of difficult minimally invasive total mesorectal excision after TNT.
Methods: Patients with locally advanced rectal cancer who underwent minimally invasive sphincter preserving TME following TNT between January 2018 and July 2024 were included in this study. Patients with additional en-bloc organ resection and synchronous surgery were excluded. Surgeon perceived subjective difficulty was defined by identifying from operative reports using keywords such as "difficult TME planes", "fibrosis" and "inflammation". Patient and treatment characteristics were evaluated using univariate and multivariate analysis to predict surgical difficulty. High surgical difficulty and low surgical difficulty groups were compared regarding operative time, estimated blood loss, conversion rates, postoperative complications and quality of mesorectum.
Results: Out of the 93 patients who underwent minimally invasive TME, 35 (37.6%) was reported as having high surgical difficulty. High surgical difficulty group had significantly longer operative time (361 vs 270 mins, p<0.01), higher estimated blood loss (200 vs 50 mL, p<0.01), increased conversion rate (42.1% vs 8.6%, p<0.01) and higher Clavien-Dindo ?3 postoperative complication rate (14.3% vs 1.7%, p=0.03). Two groups were comparable in terms of age, tumor location, clinical T stage, clinical lymph node metastasis, chemotherapy regimens, duration between end of TNT and surgery and rate of laparoscopic/robotic surgery. Multivariate analysis revealed that higher BMI (OR: 1.12, 95%CI [1.02-1.22] and longer craniocaudal length of tumor on initial MRI (OR: 1.38, 95%CI [1.05-1.82]) were independent predictors of high surgical difficulty.
Conclusion: The study demonstrates that surgeon perceived subjective difficulty in minimally invasive sphincter preserving total mesorectal excision correlates with perioperative outcomes, with increased operative time, estimated blood loss, higher conversion and postoperative complication. Patients with increased craniocaudal length on initial MRI and higher BMI are more likely to have difficult surgery. Identifying these predictors can help in risk stratification and surgical planning.
Table 1: Comparison of patient demographics, tumor characteristic, total neoadjuvant therapy features and outcomes depending on surgeon-perceived surgical difficulty.
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