Skip to main content
Download PDF

Effect of neoadjuvant therapy on textbook outcomes in minimally invasive rectal cancer surgery

World Journal of Surgical Oncology volume 23, Article number: 171 (2025) Cite this article

Abstract

Aim

Textbook outcome (TO), a combined quality indicator, encompasses key postoperative indicators such as the absence of complications, R0 resection, and no prolonged length of day. It has been suggested to be of additional value over single outcome parameters in short-term outcomes of surgical treatment. The main objective of this research was to assess the relationship between TO and neoadjuvant therapy (NT), thereby providing insights into NT’s role in surgical quality.

Method

Patients who underwent minimally invasive rectal surgery were enrolled between January 2019 and June 2024. TO was defined as achieving R0 resection, at least 12 lymph nodes harvested, no adverse outcomes (Clavien–Dindo score ≥ 3, readmission, or mortality within 30 days), and length of stay within the ≤ 75th percentile for the treatment year. The relationship between TO and NT was analyzed using regression analyses. Subgroup analysis and hierarchical regression were conducted to investigate potential influencing factors and interactions.

Results

405 patients were enrolled, with 204 achieving TO. NT was associated with a reduction in TO (OR: 0.37, 95% CI: 0.21 ~ 0.65, p < 0.001), while robotic surgery (OR: 2.88, 95% CI: 1.62 ~ 5.11), total laparoscopic surgery (OR: 2.79, 95% CI: 1.71 ~ 4.56), enhanced recovery after surgery (OR: 1.62, 95% CI: 1.02 ~ 2.59), and stoma (OR: 1.87, 95% CI: 1.18 ~ 2.96) were associated with an increased rate of TO. The impact of NT on TO varied depending on surgery duration; prolonged surgical time exacerbated the negative effect of NT on TO. This observation was consistent with a significant interaction effect.

Conclusion

NT is associated with a lower TO rate, especially in patients with prolonged surgical time. Robotic surgery, total laparoscopic surgery, enhanced recovery after surgery, and stoma can improve achieve TO.

Introduction

The global incidence of rectal cancer remains rising [1], with an increasing economic and medical burden on healthcare systems and patients. The insidious onset of rectal cancer often leads to delayed diagnosis, as its symptoms typically remain subtle until it reaches an advanced stage [2]. Nowadays, neoadjuvant therapy (NT) has emerged as a new method in the management of rectal cancer. It offers several benefits, including improved rates of curative resection, anal preservation, pathological complete response, and extended disease-free survival [3]. Recent analysis shows NT does not significantly increase overall complication rates or 30-day mortality [4]. However, its effect on overall surgical quality remains poorly explored.

Surgical resection remains the definitive treatment for rectal cancer [5]. Minimally invasive surgical techniques have benefits like reduced trauma, quicker recovery times, and shorter hospital stays compared to traditional open surgery. In rectal surgery, laparoscopic procedures have shown comparable oncological safety and short-term outcomes to open surgery while significantly minimizing postoperative complications and hospital stay. However, the criteria for evaluating surgical success remain limited and fragmented.

Traditional metrics, such as postoperative complication rates, length of stay (LOS), and 30-day mortality, offer valuable insights into surgical quality and patient recovery [6], but they provide an incomplete picture. The research on NT indicates that while NT does not significantly increase 30-day mortality, it is linked to longer LOS and a reduced yield of lymph nodes [7]. It highlights the limitations of relying solely on traditional metrics. Moreover, the absence of standardized evaluation criteria hampers the ability to make cross-institutional comparisons regarding surgical quality [8]. Therefore, a multidimensional assessment framework is crucial to prevent misleading conclusions from single indicators and offer patients a more comprehensive understanding of treatment effectiveness [9].

The textbook outcome (TO) has been established as a comprehensive measure of surgical success. TO incorporates several key indicators, such as LOS, complications, mortality, readmission rates, and lymph node yield, allowing for a thorough evaluation of surgical quality and short-term recovery[[8]]. In surgical oncology, surgical margins and harvested lymph nodes are also considered [10]. This measure has been validated across various cancer types, including liver, pancreatic, gastric, colorectal, lung, and esophageal malignancies[11]. A series of studies demonstrated a strong correlation between TO and long-term survival[12].

Previous research indicated that patients undergoing NT experience lower rates of TO than those who do not receive NT [8]. This phenomenon is likely due to the enhanced technical difficulties and increased risk of complications associated with NT. NT may negatively impact the achievement of TO due to radiation-induced tissue fibrosis[13], which can complicate surgical procedures and hinder postoperative recovery. It is important to note that most existing studies on the relationship between NT and TO focus on open surgery. The inherent limitations of laparoscopic instruments, such as the restricted field of vision and limited operating space, may heighten these challenges. Therefore, it is essential to investigate the effect of NT on TO in minimally invasive rectal surgery.

This retrospective study assesses the relationship between NT and TO in minimally invasive rectal cancer surgery and explores how NT influences TO across various patient subgroups.

Methods

Study design and patient selection

A retrospective analysis was conducted using clinical data from patients who underwent minimally invasive rectal cancer resections at the Fourth Affiliated Hospital of Guangxi Medical University between January 2019 and June 2024. Using an electronic medical record system, this study comprehensively reviewed the demographic and clinical characteristics, medical treatment history, and oncological outcomes. The inclusion criteria were as follows: (I) pathologically confirmed diagnosis of rectal carcinoma, (II) simultaneous surgical resection of rectal tumors along with metastatic lymph nodes for therapeutic purposes, and (III) availability of complete medical records for analysis. The exclusion criteria included: (I) the recurrence of rectal tumor after abdominal proctectomy in previous; (I) preoperative findings indicating metastatic rectal cancer (excluding patients with a pathological stage IV diagnosis during or after surgery); (III) the multiple primary tumors undergoing surgery during the same period in different locations; and (IV) non-curative resections (during surgery). The research received approval from the institution's Ethics Committee. The analyses used de-identified patient data to ensure utmost respect for patient privacy.

Neoadjuvant treatment protocol

A multidisciplinary team thoroughly discussed and evaluated appropriate treatment options. Following these discussions, NT was administered, including chemoradiotherapy and chemotherapy. The criteria for NT include patients diagnosed with T3 stage or higher and/or those with lymph node involvement (N +) identified through imaging or endoscopic ultrasound. External beam radiation was administered using a 6/15-MV dual-photon linear accelerator (Varian, USA) with intensity-modulated or volumetric-modulated arc therapy, delivering 45.0 to 50.4 Gy in 25–28 fractions[14]. Concurrent chemotherapy consisted of 5-fluorouracil (5-FU) with either calcium folinate (400 mg/m2 5-FU and 20 mg/m2 calcium folinate on Days 1–4 of Weeks 1 and 5) or capecitabine (400 mg/m2 5-FU with 825 mg/m2 capecitabine BID for 5 days). Patients unfit for radiotherapy received neoadjuvant chemotherapy.

Surgical procedures

All patients who underwent NT were recommended for surgery 6 to 8 weeks after neoadjuvant treatment [15]. Before the performance of curative resections, A comprehensive evaluation of tumor staging and resectability was conducted. The surgical procedures were executed using the da Vinci Surgical System XI or the laparoscopic system. Before surgery, the surgeons communicated openly with patients, discussing the additional costs, risks, and alternative options associated with robotic surgery. The patients were then given the autonomy to choose the final surgical platform. All surgeries were conducted by a team performing at least 50 cases yearly. Each procedure adhered to the previous studies'total mesorectal excision (TME) guidelines [16,17,18]. The lead surgeon, with over 300 laparoscopic rectal surgeries, had successfully mastered robotic rectal surgery before starting operations. No patients underwent lateral pelvic lymph node dissection during surgery. The decision to perform total laparoscopic reconstruction was based on the surgeon's assessment of the surgical procedure and the patient's condition rather than being dictated solely by the surgical platform used.

Data collection and variables

The baseline characteristics analyzed comprised age, sex, BMI, hypertension, diabetes, surgical team, enhanced recovery after surgery (ERAS), type of surgery [i.e., abdominoperineal resection (APR) or low anterior resection (LAR)], converted operations, NT, additional organ resection, total laparoscopic surgery, natural orifice specimen extraction surgery (NOSES), stoma, intraoperative fluid therapy, surgical time, blood loss, and histological type. Short-term clinical and oncological data included R0 resection, length of stay (LOS), postoperative complications with Clavien–Dindo (CD) score ≥ 3, 30-day readmission or mortality, number of lymph node resections, and resection margin clearance. ERAS was defined according to the criteria established by the ERAS Society [19]. Additional organ resection refers to removing tissue from neighboring organs, which may include multiple organ systems, and can either encompass or spare these organs. Total laparoscopic surgery was defined as carrying out all anastomoses for gastrointestinal reconstruction through an endoscopic method. Stoma included preventive ileostomy and colostomy, whether permanent or temporary. The histological type was determined by examining the pathology before surgery. The definition of TO was grounded in previous research and clinical experience [12,20]. The evaluation criteria encompassed the following: achievement of R0 resection, at least 12 lymph nodes harvested, no adverse outcomes (CD score ≥ 3, readmission, or mortality within 30 days), and a length of stay (LOS) at or below the 75 th percentile for the treatment year.

Statistical analysis

The baseline characteristics were analyzed to compare those with and without TO and to identify potential confounding factors. Data that followed a normal distribution were presented as mean ± standard deviation (x ± s), while skewed data were expressed as median [interquartile range (IQR)]. Categorical data were described using counts and percentages. For group comparisons, independent-sample t-tests or Mann–Whitney U tests were used for continuous variables, while the X2 test or Fisher's exact test was applied for categorical variables. Incomplete data were excluded to ensure that only complete data were used for further analysis.

The primary outcome examined was the effect of NT on TO. Demographic and surgical factors were evaluated as potential influencing factors. Continuous data points were categorized based on clinical expertise and existing literature [21,22]. Univariate logistic regression models assessed the relationship between TO and various patient characteristics. Variables with a significance level of p < 0.20 from univariate analyses were included in the multivariate regression models using backward stepwise selection. A subgroup analysis explored additional factors that might impact the relationship between NT and TO. Hierarchical multiple regression was used to illustrate interaction effects.

In the sensitivity analysis, we adjusted for confounders not balanced by randomization using a multivariable logistic regression model, with a significance level of p < 0.20 for baseline comparisons. Confounders included diabetes and surgical intervention. We also performed logistic and subgroup analyses to evaluate treatment outcomes for patients without APR.

All statistical analyses were conducted using R software (version 4.2.2), MSTATA software, and Zstats v0.90.

Result

Four hundred twenty patients who underwent minimally invasive rectal cancer resections between 2019 and 2024 were identified. After excluding those with tumor recurrence (N = 1), multiple primary tumors (N = 3), and non-curative resections (N = 11), the final analysis included 405 patients with no missing data (Fig. 1).

Fig. 1
figure 1

Flowchart of patient selection

Full size image

The median age was 68 years (IQR = 17), and 256 (63.21%) were male. Among the patients, 79 (19.51%) received NT, with 10.12% (8/79) receiving neoadjuvant chemotherapy (CapeOX) alone and 89.87% (71/79) receiving neoadjuvant chemoradiotherapy. Two hundred and eighty-six (70.62%) received ERAS management, and 80 (19.75%) received robotic surgery. The histological types were listed in Table 1. All patients who underwent NT had surgery 6 to 8 weeks after treatment. None of the 405 included patients underwent salvage resection following a watch-and-wait (W&W) strategy or local excision. The proportion of patients who achieve achieving cCR before surgery is in Table S5. Additionally, 288 (71.11%) underwent total laparoscopic surgery, and 255 (62.96%) established a stoma. Ultimately, 34 (8.40%) patients underwent APR, with eight receiving NT. The demographic and clinical characteristics are presented in Tables 1 and 2.

Table 1 Demographic characteristics
Full size table

Textbook outcome

Of the 405 patients, 204 (50.4%) achieved a TO. Within 30 days post-surgery, five patients (1.2%) experienced readmission or mortality. Ninety-six patients (23.7%) had prolonged length of stay, and 31 patients (7.7%) had complications classified as Clavien-Dindo ≥ 3. The rate of patients with 12 or more lymph nodes examined was 66.1% (268 patients), and no residual tumor was detected at surgical margins. The circumferential resection margin was confirmed as negative (CRM > 1 mm) in all cases.

The differences between the TO and no-TO groups are summarized in Tables 1 and 2. Patients who achieved TO had lower rates of APR (5.39% vs. 11.44%, p = 0.028), NT (13.73% vs. 25.37%, p = 0.003), and blood loss of ≥ 100 mL (28.43% vs. 40.30%, p = 0.041). Additionally, TO patients more frequently received ERAS protocols (76.47% vs. 64.68%, p = 0.009) and underwent robotic surgery (25.00% vs. 14.43%, p = 0.008) and total laparoscopic surgery (79.90% vs. 62.19%, p < 0.001).

Table 2 Perioperative clinical data
Full size table

Univariable and multivariable analyses

The univariable analysis identified predictors of TO, including sex, hypertension, NT, BMI, robotic surgery, ERAS, total laparoscopic surgery, stoma, and blood loss. The multivariable analysis showed that NT was significantly negatively associated with a reduction in TO [odds ratio (OR): 0.37, 95% confidence intervals (CIs): 0.21–0.65, p < 0.001]. In contrast, robotic surgery (OR: 2.88, 95% CIs: 1.62–5.11, p < 0.001), total laparoscopic surgery (OR: 2.79, 95% CIs: 1.71–4.56, p < 0.001), ERAS (OR: 1.62, 95% CIs: 1.02–2.59, p = 0.042), and stoma (OR: 1.87, 95% CIs: 1.18–2.96, p = 0.008) were linked to increased TO rates (Table 3).

Table 3 Univariable and multivariable logistic regression odds ratios for TO
Full size table

Subgroup analysis

As presented in Fig. 2, a significant difference in prolonged surgical time was observed in the relationship between NT and TO. In cases with prolonged surgical time, NT negatively correlated with TO; this was not the case for durations under 245 min. No significant interactions were observed within any of the 16 pre-established subgroups. The hierarchical multiple regression analysis followed a structured approach, as presented in Table 4. The control variables are introduced in Model 1, the main effect variables in Model 2, and interaction terms in Model 3. The hierarchical regression analysis indicated that prolonged surgical time negatively moderated the NT-TO relationship (β = 0.253, p for interaction = 0.043) (Table 4).

Fig. 2
figure 2

Interactions of the primary outcome for prespecified subgroups according to the treatment group

Full size image
Table 4 Hierarchical multiple regression results of NT on TO
Full size table

Sensitivity analysis

Sensitivity analyses adjusting for diabetes and surgery showed no significant changes in risk estimates (Table S1). Among patients without baseline APR, NT did not significantly increase the risk of not achieving TO compared to non-NT patients (Table S2), and prolonged surgical time enhanced NT's effect on TO (Fig. S1).

Discussion

This study explored the relationship between NT and TO underwent minimally invasive rectal cancer resections. Our findings indicated that NT was associated with a decrease in the number of TOs achieved. A subgroup analysis considering various factors—including gender, hypertension, diabetes, ERAS, intraoperative fluid therapy ≥ 1,850 mL, robotic and laparoscopic surgeries, stoma, age, BMI ≥ 25 kg/m2, and blood loss—observed consistent findings. Notably, the impact of NT on TO worsened with longer surgical durations. However, ERAS protocols, robotic surgery, total laparoscopic surgery, and stoma presence were linked to a better rate of TO.

Our result shows that 51.6% of patients achieved TO, which is consistent with previous research findings (44.7%–76.6%) [23,24,25]. These outcomes, including mortality, readmission rates, complications, and length of stay, are critical quality metrics [26,27]. Considering the precise classification of TNM grade [28], the TO criterion in studies on proctectomy often excludes cases with fewer than 12 harvested lymph nodes. Although our criteria align with earlier studies, Farah's more lenient criteria for excluding complications resulted in a higher TO rate (67.5% vs. 51.6%) [29]. The incidence of TO reported by Naffouje[23] (44.7%) was lower than ours, which was related to including patients who had only undergone surgery after NT. Our findings also support the notion above that NT negatively impacts TO.

Our findings reveal an inverse correlation between NT and TO, consistent with previous results [8]. While short-term adverse surgical outcomes after NT showed no significant differences between groups in isolated metrics, the number of lymph nodes harvested was lower in patients without NT [30]. This reduction may be due to fibrosis from radiotherapy, which complicates the identification and removal of lymph nodes [13]. Additionally, treatment-induced edema and inflammation can hinder the healing of anastomoses, increasing the risk of postoperative leakage [31,32]. These mechanisms may explain the observation that NT was associated with prolonged LOS following elective rectal surgery [7]. In our study, the patients who underwent NT had low-lying rectal tumors. Low-lying pelvic surgery presents anatomical challenges that can complicate the surgical procedure and increase the risk of complications [33]. The lower the tumor is located, the greater the risk of postoperative recurrence [34], which necessitates a more aggressive treatment plan. Radical resections of low-lying tumors often require permanent or protective stomas, which can significantly affect the quality of life and lead to complications such as parastomal hernias and prolapse [35,36]. Moreover, these patients may be at a greater risk for pelvic infections and hemorrhage, resulting in longer recovery times and increased readmission rates. For patients who are at high risk of postoperative complications, doctors tend to adopt a conservative approach in their hospitalization treatment plans, leading to extended observation periods. While NT offers benefits for organ preservation and long-term outcomes in rectal cancer, its side effects necessitate the development of strategies to improve results, particularly for high-risk patients.

Notably, our results indicate that surgical procedures exceeding 245 min worsen the negative effects of neurotoxic agents on outcomes. Extended Surgical time is linked to a higher risk of unfavorable results in minimally invasive proctectomy [37,38]. According to Duchalais et al. [39], adverse outcomes may not be linked to increased surgical difficulty resulting from longer surgical times. Prolonged surgery extends anesthesia and fluid administration [40], raising the risk of impaired intestinal function [41]. Additionally, prolonged stress from longer procedures can trigger inflammatory responses, leading to postoperative hyperglycemia and increased infection risk, which may prolong hospital stays [42,43]. Interestingly, one study found that the morbidity associated with longer surgeries could be reduced through minimally invasive techniques [44], underscoring the importance of patient choices in attaining better outcomes. Choosing the appropriate treatment may benefit patients undergoing surgery with long operation time. Furthermore, positive recovery strategies, such as prehabilitation and electroacupuncture stimulation [45,46], should be explored for their value. The latter, rooted in traditional Chinese medicine, has demonstrated preliminary efficacy in ameliorating gut motility disorders following colorectal surgery [47,48].

Robotic surgery, ERAS, stoma, and total laparoscopic surgery were identified as benefits for achieving positive outcomes [29,49,50]. However, direct evidence of their contribution to enhancing TO rates in patients with prolonged duration following NT remains limited. In a study, ERAS mitigated the adverse effects of extended surgical duration, with a higher TO rate in the cohort under ERAS [51]. Conversely, stomas reduce complications such as anastomotic leakage [52,53], potentially elevating TO rates [adjusted OR = 1.86 (0.92—3.77), P = 0.083] [24], though this effect lacks statistical significance. Meanwhile, stoma is tempered by negative impacts on quality of life and psychosocial well-being [54,55], and its absence remains an evaluated criterion of TO in long-term prognostic studies [12], yet its role remains insufficiently explored. This potential interaction between stoma, ERAS, and TO achievement in patients with prolonged surgical duration post-neoadjuvant therapy needs further research to clarify these relationships and optimize strategies.

Our results indicate a positive association between robotic surgery and the achievement of TO, although it comes with prolonged operative time and higher costs that require careful consideration. The robotic system enhances precision in TME in the tight confines of the pelvis [56,57], reducing complications [58,59], which aids in TO achievement. However, the surgeon's choice to adopt a strategy emphasizing"more refined anatomy"may lead to prolonged operation times. Essential tasks such as equipment setup and troubleshooting will add to this duration. It remains unclear whether the benefits of robotic surgery, such as reduced blood loss by precise performance, can offset the impact of prolonged operative times. Nonetheless, its clinical advantages continue to support its use in complex rectal resections. While robotic procedures have higher direct costs than conventional laparoscopy, increased rates of TO may offset these expenses. Achieving TO leads to lower complication costs, including less antibiotic use, fewer imaging evaluations, reduced unplanned reoperations, and shorter hospital stays. This aligns with research indicating that robotic surgery does not significantly elevate overall hospitalization costs [60]. Future studies should target high-complexity cohorts (e.g., BMI ≥ 30 kg/m2, narrow pelvises, prolonged surgeries, post-neoadjuvant therapy patients) to delineate thresholds where robotic surgery’s technical advantages provide a significant advantage in terms of time and costs, improving patient-specific surgical strategies.

Economic conditions can significantly impact the implementation of robotic surgery and NT [61,62]. These financial constraints limit patients'ability to pay, making robotic surgery unaffordable for some [63], particularly after NT. Robotic surgery can improve the rate of TO, and patients with more significant financial resources are more likely to choose this option [63]. In contrast, those with limited resources may have to forgo robotic surgery, leading to a bias related to economic status. Furthermore, variations in insurance coverage across different regions contribute to medical inequality, affecting the TO rates among various socio-economic groups [64]. Therefore, there could be a demand for more equitable insurance coverage and reimbursement policies in the future.

This study has important limitations. First, it is a single-centre retrospective analysis, which calls for validating its findings across multiple centres. The assessment of TO was conducted over a short term and was subjective, rendering it inadequate for a comprehensive understanding of long-term surgical results. The limited application of NT may also skew short-term results and affect consistency among different centres. The study focused on only a few preoperative factors, which limits its applicability in clinical decision-making. Variations in surgical experience, hospital capacity, and the nutritional status of patients could further impact the accuracy of the findings. Although a positive correlation was identified between the presence of a stoma and the achievement of TO, the study did not investigate the potential adverse effects of a stoma on quality of life. Therefore, the subordinary research should increase the sample size, consider more relevant factors, and use a multicenter prospective design.

This study found that NT negatively affects the achievement of TO in minimally invasive rectal cancer surgery. In our results, NT was negatively associated with the TO rate, whereas robotic surgery, total laparoscopic surgery, ERAS, and stoma contribute to achieving TO. Moreover, prolonged surgical time may exacerbate the adverse effects of NT on TO. Thus, it is crucial to increase the TO rate in the future research, especially for patients with a high possibility of prolonged surgical time after NT.

Data availability

No datasets were generated or analysed during the current study.

References

  1. Danpanichkul P, Suparan K, Tothanarungroj P, et al. Epidemiology of gastrointestinal cancers: a systematic analysis from the Global Burden of Disease Study 2021. Gut. 2025;74:26–34.

  2. Li SY, Yang MQ, Liu YM, et al. Endoscopic and pathological characteristics of de novo colorectal cancer: Retrospective cohort study. World J Gastroenterol. 2023;29(18):2836–49.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Altomare NJ, Mulcahy MF. Evolution of therapy for locally advanced rectal cancer. J Surg Oncol. 2023;129(1):78–84.

    Article  PubMed  Google Scholar 

  4. Chapman BC, Hosokawa P, Henderson W, et al. Impact of neoadjuvant chemoradiation on perioperative outcomes in patients with rectal cancer. J Surg Oncol. 2017;115(8):1033–44.

    Article  CAS  PubMed  Google Scholar 

  5. Hajirawala LN, Leonardi C, Orangio GR, et al. Trends in open, laparoscopic, and robotic approaches to colorectal operations. Am Surg. 2023;89(5):2129–31.

    Article  PubMed  Google Scholar 

  6. Heus C, Cakir H, Lak A, et al. Visceral obesity, muscle mass and outcome in rectal cancer surgery after neo-adjuvant chemo-radiation. Int J Surg. 2016;29:159–64.

    Article  PubMed  Google Scholar 

  7. Chan DKH, Ang JJ. A simple prediction score for prolonged length of stay following elective colorectal cancer surgery. Langenbecks Arch Surg. 2021;406(2):319–27.

    Article  PubMed  Google Scholar 

  8. Warps AK, Detering R, Tollenaar RAEM, et al. Textbook outcome after rectal cancer surgery as a composite measure for quality of care: A population-based study. Eur J Surg Oncol. 2021;47(11):2821–9.

    Article  CAS  PubMed  Google Scholar 

  9. Azevedo JM, Panteleimonitis S, Mišković D, et al. Textbook oncological outcomes for robotic colorectal cancer resections: An observational study of five robotic colorectal units. Cancers. 2023;15(15):3760.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Aiken T, Abbott DE. Textbook oncologic outcome: A promising summary metric of high-quality care, but are we on the same page? J Surg Oncol. 2020;121(6):923–4.

    Article  PubMed  Google Scholar 

  11. Mac Curtain BM, Qian W, O’Mahony A, et al. “Textbook outcome(s)” in colorectal surgery: A systematic review and meta-analysis. Ir J Med Sci. 2024;193(5):2187–94.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Maeda Y, Iwatsuki M, Mitsuura C, et al. Textbook outcome contributes to long-term prognosis in elderly colorectal cancer patients. Langenbecks Arch Surg. 2023;408(1):245.

    Article  PubMed  Google Scholar 

  13. Arndt K, Ore AS, Quinn J, et al. Outcomes following recent and distant neoadjuvant radiation in rectal cancer: An institutional retrospective review and analysis of NSQIP. Clin Colorectal Cancer. 2023;22(4):474–84.

    Article  PubMed  Google Scholar 

  14. Myerson RJ, Garofalo MC, El Naqa I, et al. Elective clinical target volumes for conformal therapy in anorectal cancer: A radiation therapy oncology group consensus panel contouring atlas. Int J Radiat Oncol Biol Phys. 2009;74(3):824–30.

    Article  PubMed  Google Scholar 

  15. Benson AB, Venook AP, Al-Hawary MM, et al. Rectal cancer, version 2.2018, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2018;16(7):874–901.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Baxter NN, Garcia-Aguilar J. Organ preservation for rectal cancer. J Clin Oncol. 2007;25(8):1014–20.

    Article  PubMed  Google Scholar 

  17. Lindsetmo RO, Joh YG, Delaney CP. Surgical treatment for rectal cancer: An international perspective on what the medical gastroenterologist needs to know. World J Gastroenterol. 2008;14(21):3281–9.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Panteleimonitis S, Harper M, Hall S, et al. Precision in robotic rectal surgery using the da Vinci Xi system and integrated table motion, a technical note. J Robot Surg. 2018;12(3):433–6.

    Article  PubMed  Google Scholar 

  19. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced recovery after surgery (ERAS®) society recommendations: 2018. World J Surg. 2019;43(3):659–95.

    Article  CAS  PubMed  Google Scholar 

  20. Rubio García JJ, Mauri Barberá F, Villodre Tudela C, et al. Textbook outcome in colon carcinoma: Implications for overall survival and disease-free survival. Langenbecks Arch Surg. 2023;408(1):218.

    Article  PubMed  Google Scholar 

  21. World Health Organization. Physical Status: The Use and Interpretation of Anthropometry. WHO Technical Report Series No. 854. Geneva: WHO; 1995.

    Google Scholar 

  22. Huang L, Yin Y, Liao Y, et al. Risk factors for postoperative urinary retention in patients undergoing colorectal surgery: A systematic review and meta-analysis. Int J Colorectal Dis. 2022;37(12):2409–20.

    Article  PubMed  Google Scholar 

  23. Naffouje SA, Ali MA, Kamarajah SK, et al. Assessment of textbook oncologic outcomes following proctectomy for rectal cancer. J Gastrointest Surg. 2022;26(6):1286–97.

    Article  PubMed  Google Scholar 

  24. Taffurelli G, Montroni I, Ghignone F, et al. Frailty assessment can predict textbook outcomes in senior adults after minimally invasive colorectal cancer surgery. Eur J Surg Oncol. 2023;49(3):626–32.

    Article  PubMed  Google Scholar 

  25. Sun Y, Jiang W, Tang Z, et al. Textbook outcome in low rectal cancer after neoadjuvant chemoradiotherapy: Post hoc analysis of the LASRE randomized clinical trial. Eur J Surg Oncol. 2024;50(9):108519.

    Article  PubMed  Google Scholar 

  26. Busweiler LA, Schouwenburg MG, van Berge Henegouwen MI, et al. Textbook outcome as a composite measure in oesophagogastric cancer surgery. Br J Surg. 2017;104(6):742–50.

    Article  CAS  PubMed  Google Scholar 

  27. Merath K, Chen Q, Bagante F, et al. Textbook outcomes among Medicare patients undergoing hepatopancreatic surgery. Ann Surg. 2020;271(6):1116–23.

    Article  PubMed  Google Scholar 

  28. Compton CC, Byrd DR, Garcia-Aguilar J, et al. AJCC Cancer Staging Atlas. New York: Springer; 2012. p. 185–201.

    Book  Google Scholar 

  29. Farah E, Abreu AA, Rail B, et al. Perioperative outcomes of robotic and laparoscopic surgery for colorectal cancer: A propensity score-matched analysis. World J Surg Oncol. 2023;21(1):272.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Abdel-Misih SR, Wei L, Benson AB, et al. Neoadjuvant therapy for rectal cancer affects lymph node yield and status without clear implications on outcome: The case for eliminating a metric and using preoperative staging to guide therapy. J Natl Compr Canc Netw. 2016;14(12):1528–34.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Lee J, Han HJ, Min BS, et al. The role of endoscopic evaluation for radiation proctitis in patients receiving intermediate-dose postoperative radiotherapy for rectal cancer. Jpn J Clin Oncol. 2018;48(11):988–94.

    Article  PubMed  Google Scholar 

  32. Chen G, Han Y, Zhang H, et al. Radiotherapy-induced digestive injury: Diagnosis, treatment and mechanisms. Front Oncol. 2021;11: 757973.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Yuan Y, Ju H, Liu Y, et al. Comparison of short-term surgical outcomes between high and low tie ligation of the inferior mesenteric artery in robotic rectal cancer surgery: A propensity score matching analysis. J Robot Surg. 2025;19(1):41.

    Article  PubMed  Google Scholar 

  34. Rosén R, Thorlacius H, Rönnow CF. Is tumour location a dominant risk factor of recurrence in early rectal cancer? Surg Endosc. 2025;39(3):1056–66.

    Article  PubMed  Google Scholar 

  35. Karadağ A, Menteş BB, Uner A, et al. Impact of stomatherapy on quality of life in patients with permanent colostomies or ileostomies. Int J Colorectal Dis. 2003;18(3):234–8.

    Article  PubMed  Google Scholar 

  36. Takashima Y, Hino H, Shiomi A, et al. Risk factors for stoma prolapse after laparoscopic loop colostomy. Surg Endosc. 2024;38(5):2834–41.

    Article  PubMed  Google Scholar 

  37. Wang X, Yao Y, Qian H, et al. Longer operating time during gastrectomy has adverse effects on short-term surgical outcomes. J Surg Res. 2019;243:151–9.

    Article  CAS  PubMed  Google Scholar 

  38. Poles G, Stafford C, Francone T, et al. What is the relationship between operative time and adverse events after colon and rectal surgery? Am Surg. 2018;84(5):712–6.

    Article  PubMed  Google Scholar 

  39. Duchalais E, Machairas N, Kelley SR, et al. Does prolonged operative time impact postoperative morbidity in patients undergoing robotic-assisted rectal resection for cancer? Surg Endosc. 2018;32(8):3659–66.

    Article  CAS  PubMed  Google Scholar 

  40. Ding S, Li K, Han X, et al. Long-term use of etomidate disrupts the intestinal homeostasis and nervous system in mice. Toxicology. 2024;504: 153802.

    Article  CAS  PubMed  Google Scholar 

  41. Lobo DN, Bostock KA, Neal KR, et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: A randomised controlled trial. Lancet. 2002;359(9320):1812–8.

    Article  PubMed  Google Scholar 

  42. Finnerty CC, Mabvuure NT, Ali A, et al. The surgically induced stress response. JPEN J Parenter Enteral Nutr. 2013;37(Suppl 5):21S–29S.

    PubMed  PubMed Central  Google Scholar 

  43. Floh AA, Manlhiot C, Redington AN, et al. Insulin resistance and inflammation are a cause of hyperglycemia after pediatric cardiopulmonary bypass surgery. J Thorac Cardiovasc Surg. 2015;150(3):498–504.e1.

    Article  CAS  PubMed  Google Scholar 

  44. White B, Naffouje S, Grunvald M, et al. Effect of prolonged operative time on short-term outcomes of open vs minimally invasive proctectomy. J Gastrointest Surg. 2024;28(2):141–50.

    Article  PubMed  Google Scholar 

  45. Zhu Y, Li X, Ma J, et al. Transcutaneous electrical acustimulation improves gastrointestinal disturbances induced by transcatheter arterial chemoembolization in patients with liver cancers. Neuromodulation. 2020;23(8):1180–8.

    Article  PubMed  Google Scholar 

  46. Wang XF, Lin Q, Wang GH, et al. Electroacupuncture stimulation suppresses postoperative inflammatory response and hippocampal neuronal injury. Mediators Inflamm. 2022;2022:3288262.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Zhao X, Si S, Liu X, et al. Does invasive acupuncture improve postoperative ileus after colorectal cancer surgery? A systematic review and meta-analysis. Front Med (Lausanne). 2023;25(10):1201769.

    Article  Google Scholar 

  48. Ng SS, Leung WW, Hon SS, et al. Electroacupuncture for ileus after laparoscopic colorectal surgery: a randomised sham-controlled study. Hong Kong Med J. 2013;19(Suppl 9):33–5.

    PubMed  Google Scholar 

  49. Bayat Z, Govindarajan A, Victor JC, et al. Impact of structured multicentre enhanced recovery after surgery (ERAS) protocol implementation on length of stay after colorectal surgery. BJS Open. 2024;8(5):zrae094.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Zhang G, Pan S, Yang S, et al. Impact of robotic surgery on postoperative gastrointestinal dysfunction following minimally invasive colorectal surgery: incidence, risk factors, and short-term outcomes. INT J COLORECTAL DIS. 2024;39(1):166.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Moazzam Z, Hawkins AT, Regenbogen SE, et al. Association of Enhanced Recovery After Surgery (ERAS) with textbook outcomes among patients undergoing surgery for rectal cancer. Surgery. 2025;180:109062.

    Article  PubMed  Google Scholar 

  52. Yang S, Tang G, Zhang Y, et al. Meta-analysis: loop ileostomy versus colostomy to prevent complications of anterior resection for rectal cancer. Int J Colorectal Dis. 2024;39(1):68.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Yang S, Lin Y, Zhong W, et al. Impact of ileostomy on postoperative wound complications in patients after laparoscopic rectal cancer surgery: A meta-analysis. Int Wound J. 2024;21(3):e14493.

    Article  PubMed  Google Scholar 

  54. Downing A, Glaser AW, Finan PJ, et al. Functional Outcomes and Health-Related Quality of Life After Curative Treatment for Rectal Cancer: A Population-Level Study in England. Int J Radiat Oncol Biol Phys. 2019;103(5):1132–42.

    Article  PubMed  Google Scholar 

  55. Afiyanti Y, Milanti A, Wahidi KR, et al. Embracing My Stoma: Psychosocial Adjustment of Indonesian Colorectal Cancer Survivors Living With a Stoma. Cancer Nurs. 2025;48(2):E121–8.

  56. Aliyev V, Goksel S, Bakir B, et al. Sphincter-Saving Robotic Total Mesorectal Excision Provides Better Mesorectal Specimen and Good Oncological Local Control Compared with Laparoscopic Total Mesorectal Excision in Male Patients with Mid-Low Rectal Cancer. Surg Technol Int. 2021;20(38):160–6.

    Google Scholar 

  57. Aliyev V, Piozzi GN, Bulut A, et al. Robotic vs. laparoscopic intersphincteric resection for low rectal cancer: a case matched study reporting a median of 7-year long-term oncological and functional outcomes. Updates Surg. 2022;74(6):1851–60.

    Article  PubMed  Google Scholar 

  58. Giuratrabocchetta S, Formisano G, Salaj A, et al. Update on Robotic Total Mesorectal Excision for Rectal Cancer. J Pers Med. 2021;11(9):900.

  59. Aliyev V, Tokmak H, Goksel S, et al. Robotic Sphincter-Saving Total Mesorectal Excision for Rectal Cancer Treatment: A Single-Surgeon Experience in 103 Consecutive Male Patients. Surg Technol Int. 2020;28(37):93–8.

    Google Scholar 

  60. Patel SV, Wiseman V, Zhang L, et al. The impact of robotic surgery on a tertiary care colorectal surgery program, an assessment of costs and short term outcomes: A Canadian perspective. Surg Endosc. 2022;36(8):6084–94.

    Article  PubMed  Google Scholar 

  61. Khajeh E, Aminizadeh E, Dooghaie Moghadam A, et al. Outcomes of Robot-Assisted Surgery in Rectal Cancer Compared with Open and Laparoscopic Surgery. Cancers (Basel). 2023;15(3):839.

    Article  PubMed  Google Scholar 

  62. Van Den Brink M, Van Den Hout WB, Stiggelbout AM, et al. Cost-utility analysis of preoperative radiotherapy in patients with rectal cancer undergoing total mesorectal excision: a study of the Dutch Colorectal Cancer Group. J Clin Oncol. 2004;22(2):244–53.

    Article  PubMed  Google Scholar 

  63. Groysman M, Yi SK, Robbins JR, et al. The impact of socioeconomic and geographic factors on access to transoral robotic/endoscopic surgery for early stage oropharyngeal malignancy. Am J Otolaryngol. 2022;43(1):103243.

    Article  PubMed  Google Scholar 

  64. Jacobs MA, Kim J, Tetley JC, et al. Cost of Failure to Achieve Textbook Outcomes: Association of Insurance Type with Outcomes and Cumulative Cost for Inpatient Surgery. J Am Coll Surg. 2023;236(2):352–64.

    Article  PubMed  Google Scholar 

Download references

Funding

This research was funded by a grant from the Liuzhou Science and Technology Plan (2022SB019), the Guangxi Zhuang Autonomous Region Traditional Chinese Medicine Administration (GXZYB20220430), and the Guangxi Zhuang Autonomous Region Health Commission (Z-B20231432, Z20210069).

Author information

Author notes

  1. Yuan Liu and Dongbo Wu contributed equally to this work and should be considered co-corresponding authors.

Authors and Affiliations

  1. Department of General Surgery, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China

    Guiqi Zhang, Jiashun Wei, Jie Rong, Yuan Liu & Dongbo Wu

  2. Department of Spinal Surgery, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China

    Shiquan Pan

  3. Department of Gastrointestinal, Metabolic and Bariatric Surgery, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Nanning, China

    Dongbo Wu

Authors
  1. Guiqi Zhang
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Shiquan Pan
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Jiashun Wei
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Jie Rong
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Yuan Liu
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Dongbo Wu
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

Guiqi Zhang: Study conception, Data analysis and interpretation, Writing—original draft, Writing—review and editing, and Final approval; Shiquan Pan: Data acquisition and analysis, Writing—original draft; Jiashun Wei: Data acquisition, and Writing—original draft; Jie Rong: Study conception, Data acquisition and analysis, and Funding acquisition; Yuan Liu: Study conception, Writing—original draft, and Final approval, Project administration; Dongbo Wu: Study conception, Writing—review and editing, Final approval, Project administration, Funding acquisition, and Supervision.

Corresponding author

Correspondence to Dongbo Wu.

Ethics declarations

Ethics approval and consent to particpate

Given that all individuals who underwent minimally invasive colorectal surgery were provided with prior notification that their perioperative clinical information could potentially be examined and shared in a retrospective manner, it is important to note that the collection of such data was an integral component of routine surgical care. Following data collection, comprehensive analyses were performed without identifying patients to guarantee that the findings did not impact therapy delivery. The research protocol for this study was officially approved by the Ethical Committee at the Fourth Affiliated Hospital of Guangxi Medical University (no. KY2022260).

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhang, G., Pan, S., Wei, J. et al. Effect of neoadjuvant therapy on textbook outcomes in minimally invasive rectal cancer surgery. World J Surg Onc 23, 171 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12957-025-03804-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12957-025-03804-3

Keywords

World Journal of Surgical Oncology

ISSN: 1477-7819

Contact us