Laparoscopic Versus Open Surgery for Rectal Cancer: Long-Term Oncologic Results

Long-Term Oncologic Results

Laurent, Christophe MD, PhD; Leblanc, Fabien MD; Wütrich, Philippe MD; Scheffler, Mathieu MD; Rullier, Eric MD

Disclosures

Annals of Surgery. 2009;250(1):54-61. 

In This Article

Results

Population Study

Between January 1994 and December 2006, 732 patients with rectal cancer were admitted in our colorectal unit. Of these, 261 were excluded from the study. The details for exclusion are given in Figure 1. A total of 471 consecutive patients underwent curative rectal excision for rectal cancer and formed the basis of the study: 238 were treated by laparoscopic and 233 by open surgery. The 2 groups were similar according to age, sex, body mass index, tumor stage, postoperative chemotherapy, and protective ileostomy ( Table 1 ). In the laparoscopic group, patient's ASA score was lower than in the open group and the tumors were slightly lower (50.8% vs. 39.5% of low rectal cancer), receiving more frequently preoperative radiotherapy (74.8% vs. 63.9%), and sphincter preservation (96.6% vs. 83.7%). Two-third of patients treated by preoperative radiotherapy received concomitant preoperative chemotherapy (75% vs. 68%, P = 0.062).

Figure 1.

Patient selection.

Short-Term Outcome

Postoperative mortality and surgical morbidity were similar in both groups ( Table 2 ). Mortality included pelvic sepsis in 1 case and pulmonary embolism in 1 case in the laparoscopic group and pelvic sepsis in 2 cases and cardio-respiratory insufficiency in 4 cases in the open group. Major surgical morbidity (22.7% vs. 20.2%) and especially pelvic sepsis, ie, anastomotic leakage or pelvic abscess (11.8% vs. 12.9%) were similar between laparoscopic and open surgery.

The rate of conversion was 15.1% (36/238). The most common reasons for conversion were difficulty for pelvic dissection (n = 10) and rectal fixity not detected by preoperative imaging (n =5). There was no difference of postoperative mortality (0% vs. 1%; P = 1.000) and morbidity (16.7% vs. 23.8%; P = 0.349) between converted and not converted patients.

In the overall series (n = 471), the rate of complete microscopic excision (R0 resection) was 93.4%. The rates of negative distal or circumferential margins and R0 resection were similar between laparoscopic and open rectal surgery ( Table 3 ). There was no difference between converted and not converted patients.

Long-Term Outcome

The median follow-up was 52 (range, 1-151) months; 8 patients were lost for follow-up at 2, 4, 7, 8, 12, 17, 19, and 27 months. The rate of local recurrence at 5 years was 3.9% in the laparoscopic group and 5.5% in the open group (P = 0.371). No patient had port-side metastasis. At 5 years, there was no difference of metastasis (20.6% vs. 24.9%; P = 0.415) and median time for recurrence (16.9 vs. 15.9 months; P = 0.827) between laparoscopic and open surgery.

The 5-year cancer-free survival was similar between the laparoscopic and the open group, 82% versus 79% (Fig. 2A). No difference according to the tumor stage was observed (Fig. 2B). By contrast, the 5-year overall survival was higher in the laparoscopic group compared with the open group 83% versus 72% (Fig. 3A) and this difference was observed specifically in the subgroup stage III (Fig. 3B). These results were not influenced by postoperative chemotherapy, which was given similarly after laparoscopic and open surgery, especially for stage III (78% vs. 70%, P = 0.279). Results of univariate and multivariate analyses for predictive factors of survival are in Table 4 and Table 5 . Predictive factors of both cancer-free and overall survival were tumor stage, quality of resection (R1 vs. R0), and surgical morbidity. Open surgery was a factor of overall but not cancer-free survival.

Figure 2.

A, Cancer-free survival after rectal excision for rectal cancer. B, Cancer-free survival according to tumor stage.

Figure 3.

A, Overall survival after rectal excision for rectal cancer. B, Overall survival according to tumor stage.

In the laparoscopic group, there was no difference between converted and not converted patients in terms of local recurrence, metastasis, cancer-free, and overall survival ( Table 6 ) (Fig. 4).

Figure 4.

Cancer-free survival in the laparoscopic group according to conversion.

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