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Long-term outcome, socioeconomic aspects and postoperative inflammatory response in minimally invasive rectal cancer surgery
Örebro University, School of Medical Sciences.ORCID iD: 0000-0002-6671-7130
2024 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In Sweden, more than 2,200 individuals are diagnosed with rectal cancer each year and surgical resection is the cornerstone of treatment. Minimally invasive surgery (MIS) was introduced for abdominal rectal cancer resection in the 1990s. Proven advantages of MIS in the short term include less intraoperative bleeding, less postoperative pain, faster postoperative mobilization, and shorter hospital stay. Large randomized studies have also shown that MIS is not inferior to OPEN with regard to the oncological short-term or long-term outcome.

The aim of this thesis was to increase the knowledge of MIS from a Swedish perspective regarding long-term oncological outcome, socioeconomic aspects, and the postoperative inflammatory response in curative abdominal rectal cancer surgery.

Study I included all patients who were diagnosed with clinical stage I-III rectal cancer during 2010-2016. More than 8,300 patients were identified via the Swedish Colorectal Cancer Registry (SCRCR). The study had a so-called non-inferiority design and investigated overall 5-year survival. The results showed that survival was not worse in patients who underwent minimally invasive surgery in comparison to patients who underwent open surgery.

Study II included all patients who were diagnosed with pathological stage I-III cancer of the colon 2010-2016. More than 11,000 patients were identified via the SCRCR. The study was designed in the same way as Study I. The results demonstrated that minimally invasive surgery was not inferior to open surgery.

Study III analysed the potential impact of socioeconomic status, measured as level of education and household income, regarding the likelihood of receiving minimally invasive surgery. All patients who underwent curative abdominal rectal resection surgery during 2010-2016 were included. More than 8,000 patients were identified. The results showed that patients with the highest level of education and those in the highest income quartile were more likely to be operated on with minimally invasive technique.

Study IV analysed the inflammatory response, measured as serum C-reactive protein during postoperative days 1-5, in all 520 patients undergoing abdominal rectal resection in Örebro between 2011 and 2021. Following exclusions based on postoperative adverse events, 382 patients remained for final analysis. The study demonstrated a trend for a less pronounced inflammatory response in patients operated with robot-assisted laparoscopy compared with conventional laparoscopy.

Place, publisher, year, edition, pages
Örebro: Örebro University , 2024. , p. 70
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 286
National Category
Surgery
Identifiers
URN: urn:nbn:se:oru:diva-110084ISBN: 9789175295343 (print)OAI: oai:DiVA.org:oru-110084DiVA, id: diva2:1817671
Public defence
2024-02-02, Örebro universitet, Campus USÖ, X2502 (Tidefeltsalen), Södra Grev Rosengatan 32, Örebro, 09:00 (English)
Opponent
Supervisors
Available from: 2023-12-07 Created: 2023-12-07 Last updated: 2024-02-16Bibliographically approved
List of papers
1. Long term oncological outcomes for laparoscopic versus open surgery for rectal cancer: a population based nationwide non-inferiority study
Open this publication in new window or tab >>Long term oncological outcomes for laparoscopic versus open surgery for rectal cancer: a population based nationwide non-inferiority study
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2022 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 24, no 11, p. 1308-1317Article in journal (Refereed) Published
Abstract [en]

AIM: The aim was to compare five-year overall survival in a national cohort of patients undergoing curative abdominal resection for rectal cancer by laparoscopic (LAP) or open (OPEN) technique.

METHODS: All patients diagnosed with clinical stage I-III rectal cancer and who underwent LAP or OPEN abdominal curative surgery between 2010 and 2016 in Sweden were retrieved from the Swedish Colorectal Cancer Registry. A non-inferiority study design was employed with a statistical power of 90%, a one-side type I error of 2.5%, and a non-inferiority margin of 2%. The analyses were performed as intention-to-treat and the relationship between surgical technique and overall mortality within five years was analyzed. Multilevel regression models with the patients matched by propensity scores adjusted for patient and tumour related variables.

RESULTS: A total of 8410 cancer stage I-III patients were included whereof 2094 LAP (24.9%) and 6316 underwent OPEN (74.9%) and were followed until December 31, 2020. Multivariable Cox regression demonstrated that five-year overall survival was higher in LAP; Hazard Ratio (HR): 0.877;(95% CI: 0.877-0.993). Outcome was similar when employing multiple imputation and propensity score matching. When excluding cT4 there was no difference; HR: 0.885;(95% CI: 0.790-1.033). At five years follow up, local recurrence was not different, 2.9% in LAP and 3.6% in OPEN (P=0.075), while metastatic disease was more frequent in OPEN, 19.6% compared with 15.6% in LAP (P<0.001).

CONCLUSIONS: This study demonstrated that LAP was not inferior to OPEN with regard to overall five-year survival. These results support the use of laparoscopic surgery.

Place, publisher, year, edition, pages
Blackwell Publishing, 2022
Keywords
Rectal cancer, laparoscopy, minimally invasive surgery, multiple imputation, non-inferiority, oncological outcome, population based, propensity score, survival
National Category
Cancer and Oncology Surgery
Identifiers
urn:nbn:se:oru:diva-99524 (URN)10.1111/codi.16204 (DOI)000822846800001 ()35656573 (PubMedID)2-s2.0-85133674068 (Scopus ID)
Note

Funding agency:

Research Committee, Region Örebro County, Örebro OLL-964736

Available from: 2022-06-15 Created: 2022-06-15 Last updated: 2024-01-12Bibliographically approved
2. Long term oncological outcomes for minimally invasive surgery versus open surgery for colon cancer: A population-based nationwide study with a non-inferiority design
Open this publication in new window or tab >>Long term oncological outcomes for minimally invasive surgery versus open surgery for colon cancer: A population-based nationwide study with a non-inferiority design
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2023 (English)In: Colorectal Disease, ISSN 1462-8910, E-ISSN 1463-1318, Vol. 25, no 5, p. 954-963Article in journal (Refereed) Published
Abstract [en]

AIM: The study aimed to compare five-year overall survival in a national cohort of patients undergoing curative abdominal resection for colon cancer by minimally invasive surgery (MIS) or open (OPEN) technique.

METHODS: All patients diagnosed between 2010 and 2016 in Sweden with pathological UICC stage I-III colon cancer localized in the cecum, ascending colon, hepatic flexure or sigmoid colon, and those who underwent curative right sided hemicolectomy, sigmoid resection or high anterior resection by MIS or OPEN were included. Patients were identified in the Swedish Colorectal Cancer Registry from which all data was retrieved. The analyses were performed as intention-to-treat and the relationship between surgical technique (MIS or OPEN) and overall mortality within five years was analysed. For the primary research question a non-inferiority hypothesis was assumed with a statistical power of 90%, a one-side type I error of 2.5%, and a non-inferiority margin of 2%. For the secondary analyses, multilevel survival regression models with the patients matched by propensity scores were employed, adjusted for patient- and tumuor-related variables.

RESULTS: A total of 11605 pathological UICC cancer stage I-III patients were included with 3297 MIS (28.4%) and 8308 OPEN (71.6%) and were followed until December 31, 2020. The primary analysis demonstrated superiority for MIS compared to OPEN. The multilevel survival regression analyses confirmed that five-year overall survival was higher in MIS with a hazard ratio (HR) of 0.874 (95% confidence interval (CI): 0.791-0.965), and if excluding pT4, outcome was similar, with a HR of 0.847 (95% CI: 0.756-0.948).

CONCLUSION: This observational study demonstrated that MIS was favourable to OPEN with regard to five-year overall survival. These results support the use of laparoscopic colon cancer surgery in routine practise.

Place, publisher, year, edition, pages
Blackwell Publishing, 2023
Keywords
colon cancer, LAP, laparoscopy, long term outcome, minimally invasive surgery, MIS, non-inferiority, oncological outcome, overall survival, population based, propensity score
National Category
Cancer and Oncology
Identifiers
urn:nbn:se:oru:diva-104137 (URN)10.1111/codi.16512 (DOI)000947019500001 ()36762443 (PubMedID)2-s2.0-85150627454 (Scopus ID)
Note

Funding agency:

Research Committee, Region Örebro County, Örebro

Available from: 2023-02-13 Created: 2023-02-13 Last updated: 2024-02-08Bibliographically approved
3. Does socio-economic status influence the choice of surgical techniquein abdominal rectal cancer surgery?
Open this publication in new window or tab >>Does socio-economic status influence the choice of surgical techniquein abdominal rectal cancer surgery?
Show others...
(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-110694 (URN)
Available from: 2024-01-12 Created: 2024-01-12 Last updated: 2024-01-12Bibliographically approved
4. Postoperative inflammatory response in patients undergoinglaparoscopic and robotic rectal cancer resection
Open this publication in new window or tab >>Postoperative inflammatory response in patients undergoinglaparoscopic and robotic rectal cancer resection
(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-110695 (URN)
Available from: 2024-01-12 Created: 2024-01-12 Last updated: 2024-01-12Bibliographically approved

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Dehlaghi Jadid, Kaveh

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