Imaging and Navigation
Laparoscopic Proctectomy for Rectal Cancer— A Review of the Current Literature
Matthew L Silviera, MD1 and John Migaly, MD, FASCRS2
1. Department of Surgery, Temple University Hospital; 2. Assistant Professor of Surgery, Colon and Rectal Surgery, Division of General Surgery, Duke University Medical Center
Abstract
Laparoscopic resection for colon cancer was first performed in 1991. Early case reports raised concerns over adequacy of oncologic resection, which prompted multiple prospective randomized controlled trials to address these issues. Multiple randomized trials including the Clinical outcomes of surgical therapy (COST), Conventional versus laparoscopic-assisted surgery in colorectal cancer (CLASICC) and Laparoscopic versus open rectal cancer removal (COLOR) trials established non-inferiority of oncologic outcomes for laparoscopic colectomy, and also reported improved post-operative recovery. The application of laparoscopic techniques to the treatment of rectal cancer is becoming increasingly popular; however, its equivalence to open total mesorectal excision is not strongly supported in the current literature. The following article is a review of the current literature regarding laparoscopic treatment of rectal cancer and provides an introduction to on-going randomized trials comparing laparoscopic and open resections for rectal cancer.
Keywords Laparoscopy, rectal cancer, outcomes
Disclosure: The authors have no conflicts of interest to declare. Received: May 7, 2010 Accepted: October 5, 2010 Citation: US Gastroenterology & Hepatology Review, 2010;6:90–3 Correspondence: John Migaly, MD, FASCRS, Assistant Professor of Surgery, Colon and Rectal Surgery, Division of General Surgery, Duke University Medical Center, 7674 HAFS Building, DN, Erwin Road, Durham, NC 27710. E:
john.migaly@duke.edu
Laparoscopic resection for colon cancer was first performed in 1991. Early case reports raised concerns over port-site metastases and adequacy of oncologic resection, which prompted multiple prospective randomized controlled trials to address these issues. The Clinical outcomes of surgical therapy (COST) trial, which began in 1994, has now recently published five-year oncologic results (time to recurrence, overall survival and disease-free survival).1,2
This study has shown non-
inferiority of oncologic outcomes for laparoscopic colectomy, and also reported improved post-operative recovery (less use of narcotics and shorter length of stay) in the laparoscopic group. Similarly, the European Laparoscopic versus open rectal cancer removal (COLOR) and Conventional versus laparoscopic-assisted surgery in colorectal cancer (CLASICC) trials have not shown differences in oncologic outcomes between the laparoscopic and open arms.3–6
Additionally,
these trials have also demonstrated faster return of bowel function and shorter length of stay in the laparoscopic arm.
It is currently agreed that laparoscopic colectomy for colon cancer is oncologically non-inferior to open surgery, with the addition of improved short-term recovery.1–7
These early trials specifically excluded
rectal cancer patients due to surgeon inexperience and technical limitations in the pelvis.1,6
that total mesorectal excision (TME) is the gold-standard for rectal cancer as it has been shown to improve oncologic outcomes.8
90 As We have learned from the work of Dr Heald
There have only been a handful of small randomized controlled trials that compare laparoscopic and open proctectomy for rectal cancer, and we await the results of larger ongoing trials to definitively prove equivalence.4,5,15–18
surgeons have gained more experience with laparoscopic colectomy and instruments have improved, so has the interest in laparoscopic proctectomy for rectal cancer. We cannot, however, generalize our findings from colon cancer to endorse laparoscopic proctectomy for rectal cancer. Early case-series of laparoscopic anterior resection and laparoscopic abdominoperineal resection have demonstrated feasibility of the techniques, but oncologic equivalence has not been definitively proven.9–14
In 2005, the American Society of
Colon and Rectal Surgeons (ASCRS) issued a statement regarding the role of laparoscopy for rectal cancer: “The absence of five-year survival data makes it premature to endorse laparoscopic proctectomy for curable cancer.”19
Technical Limitations
The technical aspects of TME and the narrow confines of the pelvis have contributed to considerable variability in local recurrence and overall survival rates among patients undergoing proctectomy for rectal cancer. It is feasible that laparoscopy will further magnify the oncologic variability seen in rectal cancer outcomes. Until we have reached a consensus regarding oncologic quality for laparoscopic proctectomy, outcomes must be prospectively tracked, preferably as part of large
© TOUCH BRIEFINGS 2010
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