Walter Reed National Military Medical Center, Bethesda, MD, USA.
Eastern Virginia Medical School, Norfolk, VA, USA.
J Robot Surg. 2021 Oct;15(5):701-710. doi: 10.1007/s11701-020-01166-4. Epub 2020 Oct 26.
Historically, T4 tumors of the colon have been a contraindication to minimally invasive resection. The purpose of this study was to conduct a National Cancer Database analysis to compare the outcomes after curative treatment for T4 colon cancer between robotic, laparoscopic, and open approaches. The US National Cancer Database was queried for patients with T4 adenocarcinoma of the colon who underwent curative resection. Groups were separated based on approach (open, laparoscopic, robotic). One to one nearest neighbor propensity score matching (PSM) ± 1% caliper was performed across surgical approach cohorts to balance potential confounding covariates. Kaplan-Meier estimation and Cox-proportional hazards regression were used to analyze primary outcome of survival. Secondary outcomes were analyzed by way of logistic regression. Inclusion criteria and PSM identified 876 cases per treatment approach (n = 2628). PSM provided adequate discrimination between treatment cohorts (0.6 < AUC < 0.8) and potential confounding covariates did not significantly differ between cohorts (all respective P > 0.05). Patients who underwent a robotic approach had lower odds of conversion to laparotomy compared to the laparoscopic cohort (P < 0.0001). Laparoscopic and robotic approaches were associated with increased odds of > 12 lymph nodes examined, decreased odds of positive margins, and decreased odds of 30-day readmission, 30-day mortality, and 90-day mortality compared to the open approach. Cox-proportional hazards regression showed that both robotic and laparoscopic approaches were significantly associated with decreased mortality hazards relative to open. Both laparoscopic and robotic-assisted surgeries achieved improved oncologic outcomes and survival compared to open resection of T4 cancers. A robotic-assisted approach was significantly associated with a lower conversion rate compared to the laparoscopic approach. This case-matched study demonstrates safety of using minimally invasive techniques in T4 cancers.
从历史上看，结肠 T4 肿瘤一直是微创手术切除的禁忌症。本研究的目的是通过国家癌症数据库分析，比较机器人、腹腔镜和开放手术治疗 T4 结肠癌的结果。美国国家癌症数据库对接受根治性切除术的 T4 结肠腺癌患者进行了查询。根据方法（开放、腹腔镜、机器人）将患者分为不同组。在手术方法队列之间进行了 1 对 1 最近邻居倾向评分匹配（PSM）±1%卡尺，以平衡潜在的混杂协变量。采用 Kaplan-Meier 估计和 Cox 比例风险回归分析生存的主要结局。采用逻辑回归分析次要结局。纳入标准和 PSM 确定了每种治疗方法的 876 例病例（n=2628）。PSM 在治疗队列之间提供了足够的区分（0.6<AUC<0.8），并且队列之间潜在的混杂协变量没有显著差异（所有相应的 P>0.05）。与腹腔镜组相比，接受机器人方法的患者中转开腹的可能性较低（P<0.0001）。与开放组相比，腹腔镜和机器人方法与增加检查淋巴结数量>12 个、降低切缘阳性率以及降低 30 天再入院率、30 天死亡率和 90 天死亡率的可能性增加相关。Cox 比例风险回归显示，与开放相比，机器人和腹腔镜方法均与死亡率降低显著相关。与开放切除 T4 癌症相比，腹腔镜和机器人辅助手术在肿瘤学结果和生存方面都得到了改善。与腹腔镜方法相比，机器人辅助方法与较低的转化率显著相关。这项病例匹配研究表明，在 T4 癌症中使用微创技术是安全的。
