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

Discussion

This study was designed to compare the long-term outcome after laparoscopic and open surgery for rectal cancer. At our knowledge, this is the first unicentric comparative series including more than 400 curative rectal excisions with 5 years results. We observed similar quality of surgery, ie, R0 resection and demonstrated no difference in local recurrence and cancer-free survival at 5 years between laparoscopic and open surgery. In addition, we showed that conversion had no negative impact on 5-year survival.

Few studies have compared laparoscopic versus open rectal excision for rectal cancer.[20,21,22,23,24,25] In our study, we observed no difference in mortality and morbidity between laparoscopic and open surgery, especially the rate of pelvic sepsis was similar in both groups. Our results are in accordance with the short-term outcome of previous series[12,20,21,22,23,24,25,26] and confirm the safety of laparoscopic surgery for rectal cancer. Microscopic assessment of the specimen is a well-recognized indicator of quality of resection in rectal cancer surgery. Both distal and circumferential resection margins are risk factors of recurrence after rectal excision.[27,28] Only 4 comparative studies reported data of circumferential margin.[13,21,22,23] The MRC CLASICC trial[13] demonstrated a higher rate of positive circumferential margin after laparoscopic compared with open anterior resection (12% vs. 6%; P = 0.19). These results may be due to the learning curve associated with the surgical technique. Indeed, in our study resection margins did not differ between laparoscopic and open surgery (7% vs. 6% of positive circumferential margin), although most patients had low anterior resection (97% in the laparoscopic group). Our results are similar to those of skilled teams[21,22,23] and support the concept that laparoscopic approach for rectal cancer is an oncologic safe procedure.

Oncologic outcome after laparoscopic versus open rectal excision has been reported in 2 randomized[23,24] and 3 no randomized studies.[20,22,25] Although these series suggested no difference of survival between groups, in 3 studies the follow-up was less than 3 years[22,24,25] and 2 studies included patients with synchronous metastatic disease.[20,23] Moreover, some series analyzed mainly early rectal cancer22 and upper rectal tumors.[22,23,25] In the present study, more than 80% of the lesions were mid and low rectal tumors and most of them were locally advanced. All patients were treated with curative intention, no patient had metastatic disease, and the median follow-up was 52 months. We observed a low local recurrence rate with no difference between laparoscopic and open surgery, 3.9% versus 5.5%. These good results at 5 years are in accordance with the high rate of R0 resection in the study (92% vs. 95%) and are due to specialization in TME surgery in our department.[15,16] We also demonstrated a similar 5-year cancer-free survival between the 2 groups. Indeed, by using multivariate analysis, the surgical approach was not found to influence cancer outcome. Therefore, these findings confirm the results of previous series[20,22,23] showing that specialized laparoscopic surgeons can obtain similar long-term oncologic results than open surgeons for rectal cancer.

In our study, the overall survival at 5 years was better in the laparoscopic than in the open group, especially in tumor stage III. Two series similarly reported a higher survival due to the laparoscopic approach after colorectal surgery,[20,29] again for stage III. The potential impact of laparoscopic surgery on survival is not clear. The role of immunosuppression has been suggested because mediators of immunologic response (TNF alpha, interleukin 1-6, and C-reactive protein) are decreased after laparoscopic compared with open colorectal surgery.[30,31] On the other hand, immunosuppression facilitates both septic complications[32] and neoplastic cell proliferation.[33,34] Laparoscopic surgery could therefore increase either overall[20] or cancer-free[29] survival. This positive impact of the laparoscopic procedure is probably marginal, that could explain why it is observed only in stage III patients where the risk of death is more significant.

The CLASICC MRC trial demonstrated a higher rate of postoperative mortality and morbidity in converted patients than not converted patients;[13] however, mid- or long-term outcome of converted patients was not analyzed.[24] This question seems relevant because a German study reported a higher rate of local recurrence after converted compared with not converted patients: 16% versus 6.9%.[25] Reasons for conversion were tumor fixity and rectal perforation, 2 factors associated with a higher risk of local recurrence.[35] Our series is the first evaluating the 5-year survival in the sub group of converted patients after laparoscopic TME for rectal cancer. The rate of conversion was 15%. At 5 years, the rate of local recurrence was 3.5% in converted patients and 3.8% in not converted patients (P = 0.739), and the cancer-free survival was 79% versus 83%, respectively. The lack of negative long-term impact of conversion in our experience is in accordance with the lack of rectal perforation in our series due to exhaustive preoperative imaging assessment, optimal patient selection, and policy for early conversion.[18]

The present study was obviously limited in that patients were not randomized into the 2 treatments arms. Although the patient ASA score was higher in the open group and tumors were lower in the laparoscopic group, there was no difference in tumor staging in each group. We therefore believe our results are consistent. This study has confirmed the feasibility of the laparoscopic TME for rectal cancer and demonstrated similar local recurrence and cancer-free survival at 5 years between laparoscopic and open TME. It also demonstrated that long-term outcome was not altered by conversion. These results were obtained by a team specialized in both open and laparoscopic TME, operating a high volume of cases. They must therefore be confirmed at a national level to verify the potential impact of specialization and volume on outcome. In the future, the laparoscopic surgery should become a standard in selected rectal cancer, due to the development of technology,[36] specialization of surgeons, and demonstration of the advantages of the procedure.[37]

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