Laparoscopic Proctectomy for Rectal Cancer—A Review of the Current Literature
Table 1: Prospective Randomized Controlled Trials of Laparoscopic Versus Open Proctectomy Trial/Author
Year
Leung15 Zhou18
†CLASICC4,5
(rectal subgroup) Ng17
COLOR II21 ACOSOG Z605122,23
2004 2004 2007
2008 n
403 171 246 95 99
1275 650
AR=anterior resection, APR=abdominoperineal resection, OS=overall survival, tumor location=cm from dentate line. † Three-year OS reported.
randomized trials. Additionally, distal transection of the rectum within the narrow pelvis can pose a technical challenge. Articulating linear staplers have helped combat this problem, and hopefully further advances in instrumentation will help to alleviate the technical constraints of laparoscopic proctectomy.
Review of the Current Literature
Much of the early literature on laparoscopic proctectomy consists of single-institution case series and retrospective reviews.9–14,20
These
reviews raised concerns over the technical feasibility of laparoscopic proctectomy, specifically the adequacy of resection margins and ability to perform laparoscopic TME. These concerns contributed to the exclusion of rectal cancer patients from both the COST and COLOR trials, which demonstrated no survival difference between laparoscopic and open colon resection.1,2,6
Since 2004, there have been four
completed prospective randomized controlled trials (RCTs) for rectal cancer (see Table 1).4,5,15,17,18
No trial has found a significant difference in
survival between the laparoscopic and open group, and most trials have demonstrated short-term laparoscopic benefits (faster return of bowel function and shorter length of stay).
Patients were randomized over a nine-year period (1993–2002) at a single institution in Hong Kong. Survival and disease-free survival were the primary end-points. Patients requiring an anastamosis within 5cm of the dentate line were excluded, but there was no documentation of the proximal extent of tumors in this study. The authors state that rectosigmoid cancers were included, but fail to present a breakdown of the specific location of tumors. Additionally, there is no description of how many patients required sigmoid resection versus anterior resection. Patients requiring emergent surgery were excluded, as were those with bulky tumors (>6cm) or with radiologic evidence of adjacent organ invasion. Neoadjuvant therapy was not offered since its effectiveness was unknown at the onset of the trial.
In 2004, Leung et al. published the results of their RCT that randomized 403 patients to laparoscopic or open resection for rectosigmoid cancer.15
This trial had excellent long-term follow-up, with a median for living patients of over 50 months and only four lost to follow-up.15
There was
no difference in five-year overall survival between the laparoscopic and open group (76 versus 73% respectively, p=0.61), nor was there a difference in recurrence rates or five-year disease-free survival. Additional oncologic outcomes, such as lymph node retrieval and length of distal margin, were also equivalent. The trial did find benefits for the
US GASTROENTEROLOGY & HEPATOLOGY REVIEW Also published in 2004 was a study by Zhou et al.18 This RCT was a
single-institution study from China that randomized 171 patients with rectal cancer over a 15-month period (2001–2002). Unlike the prior study, which included upper rectal and sigmoid cancers, this trial only included patients with rectal cancer below the peritoneal reflection who required TME. Patients with evidence of adjacent organ invasion or those requiring emergent surgery were excluded. It is unclear whether any patients underwent neoadjuvant therapy.
Follow-up was short and ranged from one to 16 months.18 Long-term
overall survival rates were therefore not able to be calculated. Perioperative morbidity was significantly less in the laparoscopic group (6 versus 12%, p<0.02). Additionally, the laparoscopic group had less operative blood loss and faster return of bowel function. Length of stay was dramatically reduced by five days in the laparoscopic group (eight days versus 13 days, p<0.01). This was the first RCT that included only patients with rectal cancer below the peritoneal reflection requiring TME. Additionally, sphincter preservation rate was 100%; all patients underwent low anterior resections. The authors did not report whether any patient required conversion from laparoscopic to open surgery.
The original CLASICC trial was first published in 2005 by Guillou et al.4 This was a European, multicenter RCT that randomized 794 patients (1996–2002) with colorectal cancer to laparoscopic or open resection. The randomization was 2:1 in favor of laparoscopic surgery. This trial included patients with both colon and rectal cancer, and reported outcomes separately for patients with rectal cancer requiring anterior resection (n=246) or abdominoperineal resection (n=95). It was required that each surgeon in the trial had performed at least 20 laparoscopic colon resections. The primary short-term end-points were rates of positive circumferential and longitudinal resection margins. This was the first trial to utilize a detailed pathologic examination of the resected tumor as a surrogate end-point for long-term oncologic outcome.
91
laparoscopic group with respect to reduced post-operative pain, earlier return of bowel function and shorter length of stay. On the other hand, laparoscopic resections took an average of 45 minutes longer than open resections and were associated with increased direct costs. Twenty- three percent of patients randomized to laparoscopic surgery required conversion to an open procedure. If patients who were found intra- operatively to have local invasion were excluded, the conversion rate would have been reduced to 15%.
Lap n
203 82
167 63 51
Open n
200 89 79 32 48
Procedure Tumor
AR AR AR
APR APR
Location >5 <8 >5 <5 <5
<15 <12
23%
34% 34% 10%
Conversion Lap Rate
Open
5-year OS 5-year OS 76%
73%
75% 66% 75%
67% 58% 77%
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