A single institutional experience in laparoscopic colorectal surgery: clinical and oncological outcomes over 10 years

was discussed by multidisciplinary team of oncologists, radiotherapists and surgeons. In some patients with locally advanced tumor a neoadjuvant therapy was applied according to the protocol which involved the oncological and of laparoscopic colorectal Methods: Data were collected prospectively from 66 patients undergoing laparoscopic colorectal surgery between December 2009 and December 2019. Registered data included sex, age, surgical indication and type for the procedure, indication and reason for conversion to open surgery, operative time, performing temporary or permanent stoma, intraoperative bowel perforation, pathologic TNM grade, number of harvested lymph nodes, inclusion of positive resection margin, number of postoperative days at the hospital, postoperative complications, postoperative mortality, presence of distant metastases and survival rates. Results: Laparoscopic procedures were right hemicolectomy in 11/66 (16.7%), left hemicolectomy in 1/66 (1.5%), sigmoid colectomy in 19/66 (28.8%), high anterior rectal resection in 13/66 (19.7%), low anterior rectal resection in 12/66 (18.2%), abdominoperineal amputation of the rectum in 7/66 (10.6%), colectomy in 2/66 (3%) and proctocolectomy in 1/66 (1.5%) patient. 37.5 (range to 128). The total number of surviving patients was 60 (90.9%). Conclusion: This study showed that laparoscopic colorectal surgery has good clinical and oncological outcomes.


INTRODUCTION
. Following the publication of first studies, there was a period of nonacceptance of the laparoscopy in oncologic colorectal surgery due to the assumption of higher rates of disease relapse compared to conventional surgery. The assumptions of metastasis at the site of the placed ports, the long learning curve and the longer duration of surgery were also the main arguments against laparoscopy in colorectal cancer surgery (6)(7)(8)(9). In the past two decades, laparoscopic colorectal surgery has been proven to have numerous advantages over standard surgery. Less intraoperative blood loss, faster postoperative recovery, fewer complications, shorter hospital stay, better aesthetic result, faster return to work commitments with similar short and long-term clinical outcomes. The initial assumptions and arguments against laparoscopy in oncological colorectal surgery have been proven to be inaccurate in many studies (10)(11)(12)(13). Today, laparoscopic surgery presents the gold standard in the treatment of malignant colon and rectal diseases. With the further development of technology and the introduction of robotic colorectal surgery, a new era of modern surgical treatment begins (14,15).
Laparoscopic colorectal surgery was introduced in at the Oncology Institute of Vojvodina in December 2009, when first laparoscopic procedure-a resection of the sigmoid colon due to cancer was performed. The purpose of this study was to analyze the clinical outcomes and survival rates of colorectal cancer patients operated by laparoscopic approach at the Oncology Institute of Vojvodina, Serbia.

METHODS
Data were collected prospectively from patients undergoing laparoscopic surgery for colon and rectal cancer or familial adenomatous colon polyposis (FAP) between December 2009 and December 2019. A total of 66 patients underwent laparoscopic surgery. Patient survival rate was measured in months from the surgery until death. Surviving patients were followed until June 2020. Laparoscopic surgery was performed mainly in primary colon and rectal cancers and only in 2/66 (3%) cases due to FAP. Registered data included sex, age, surgical indication and type for the procedure, indication and reason for conversion to open surgery, operative time, performing temporary or permanent stoma, intraoperative bowel perforation (IOP), pathologic TNM grade, number of harvested lymph nodes, inclusion of positive resection margin (CRM), number of postoperative days at the hospital, postoperative complications, postoperative mortality, presence of distant metastases and survival rates. Preoperative diagnostics included digital rectal examination, colonoscopy with tumor biopsy, pelvic magnetic resonance imaging (MRI), abdominal computed tomography (CT). For each patient the treatment protocol was discussed by multidisciplinary team of oncologists, radiotherapists and surgeons. In some patients with locally advanced tumor a neoadjuvant therapy was applied according to the protocol which involved the www.onk.ns.ac.rs/Archive • Published online November 2020 • https://doi.org/10.2298/AOO200728006D application of fluorouracil and leucovorin (5 FU/LV) and radiotherapy at a dose of 50 Gy (25 x 2 Gy). Patients were admitted to the hospital the day before the planned surgery. Preoperative preparation of patients included bowel cleansing, prevention of thrombosis with low molecular weight heparin and a single dose of dual antibiotic prophylaxis 30 min before surgery. The surgeries performed were laparoscopic left and right hemicolectomy, sigmoid colectomy, high and low anterior rectal resection (HAR and LAR), abdominoperineal amputation of the rectum (APE), colectomy and proctocolectomy. The used approach during laparoscopic surgery was medial-to-lateral. The continuity of the digestive tract was established by extracorporeal intestinal anastomosis through mini laparotomy or double stapler technique. Permanent stoma procedure was performed in patients who underwent abdominoperineal amputation of the rectum (colostomy) and proctocolectomy (ileostomy), and in some patients a temporary colostomy was performed to protect the low colorectal anastomosis. In the second act, the continuity of the digestive tract was established with stoma closure. In the early postoperative course, rapid mobilization and early translation to the oral diet were highly encouraged. Postoperative follow-up included regular routine medical check-ups, digital rectal examination, colonoscopy, tumor markers (CEA, CA 19-9), MRI of the abdomen and pelvis and CT of the chest. These follow-ups were every three months during the first year, twice per year for the second and third postoperative year and once annually after that. This study showed overall characteristics and survival rates of patients who underwent laparoscopic surgery. The analysis and use of data for this retrospective study was approved by the Ethics Committee of the Oncology Institute of Vojvodina. Data were presented as numbers with corresponding percentages, and the difference was determined by Chi-square and Fisher's exact test. Patient age and number of lymphatic nodes were presented as the mean values. Procedure time was presented as median (IKR 25-75 percentile). Overall survival rates were calculated using the Kaplan-Meier method. Follow-up time was measured as the time elapsed since the initial surgery. For statistical analysis SPSS Statistics 20 (IBM, USA) program was used.

DISCUSSION
As laparoscopic colorectal surgery evolved it has been accepted by a large number of surgeons and it was shown to have better short-term and similar long-term and oncological results compared to open surgery (16,17). Due to development of global technology surgery, which for many years has been based exclusively on classical open approaches, is also changing. With the introduction of laparoscopy in our hospital, we have gone a step further in surgery, although in many centers laparoscopic colorectal surgery is being replaced by single-port, hand-assisted and robotic colorectal surgery (18)(19)(20). Although laparoscopic colorectal surgery has become the standard in operative oncological treatment, open surgery still has its indications. Patient's preoperative staging, resectability and operative risk assessment are mandatory when deciding on a surgical approach. Oncological justified surgical resection is R0 resection. For locally advanced colorectal tumors where it is not possible to perform en-block (R0) resection by laparoscopy, an open surgical approach is an absolute indication (21). In the meta-analysis of Hajibandeh et al. eight comparative studies were evaluated with a total of 1477 patients (626 with medial-to-lateral and 851 lateral-to-medial approach in laparoscopic colorectal surgery) (22).
In the group with the medial-to-lateral approach, that we also practice, the total number of complications was 14.8%, but in our study it was 18.2%. Anastomotic leak in this meta-analysis was 2.5%, and 4.5% in our case. In this meta-analysis conversion to open surgery was 3.5%, the mean procedure time was 160.4 min, the mean length of hospital stay was 9.3 days, and the mean number of lymph nodes removed was n=17.2 (22). In our study, the conversion rate was 9.1%, median procedure time was 150 min, mean value of days of hospitalization was 6  We will strive to increase the number of laparoscopic surgery cases in the future and to introduce the newest procedures into our surgical practice.

Declaration of Interests
Authors declare no conflicts of interest.