Laparoscopic versus open surgery for rectal cancer after neoadjuvant chemoradiation: Long-term outcomes of a propensity score matched study

Laparoscopy is non-inferior to open surgery for rectal cancer: A systematic review and meta-analysis

BACKGROUND

Laparoscopic surgery has been endorsed by clinical guidelines for colon cancer, but not for rectal cancer on account of unapproved oncologic equivalence with open surgery.

AIMS

We started this largest-to-date meta-analysis to comprehensively evaluate the safety and efficacy of laparoscopy in the treatment of rectal cancer compared with open surgery.

MATERIALS & METHODS

Both randomized and nonrandomized controlled trials comparing laparoscopic proctectomy and open surgery between January 1990 and March 2020 were searched in PubMed, Cochrane Library and Embase Databases (PROSPERO registration number CRD42020211718). The data of intraoperative, pathological, postoperative and survival outcomes were compared between two groups.

RESULTS

Twenty RCTs and 93 NRCTs including 216,615 patients fulfilled the inclusion criteria, with 48,888 patients received laparoscopic surgery and 167,727 patients underwent open surgery. Compared with open surgery, laparoscopic surgery group showed faster recovery, less complications and decreased mortality within 30 days. The positive rate of circumferential margin (RR = 0.79, 95% CI: 0.72 to 0.85, p < 0.0001) and distal margin (RR = 0.75, 95% CI: 0.66 to 0.85 p < 0.0001) was significantly reduced in the laparoscopic surgery group, but the completeness of total mesorectal excision showed no significant difference. The 3-year and 5-year local recurrence, disease-free survival and overall survival were all improved in the laparoscopic surgery group, while the distal recurrence did not differ significantly between the two approaches.

CONCLUSION

Laparoscopy is non-inferior to open surgery for rectal cancer with respect to oncological outcomes and long-term survival. Moreover, laparoscopic surgery provides short-term advantages, including faster recovery and less complications.

Short-term clinical outcomes and five-year survival analysis of laparoscopic-assisted transanal natural orifice specimen extraction versus conventional laparoscopic surgery for sigmoid and rectal cancer: a single-center retrospective study

Background

The cosmetic benefits of natural orifice specimen extraction (NOSE) are easily noticeable, but its principles of aseptic and tumor-free procedure have caused controversy.

Methods

We conducted a retrospective analysis of the clinical data of patients who underwent laparoscopic-assisted transanal NOSE or conventional laparoscopic surgery (CLS) for sigmoid and rectal cancer at our hospital between January 2018 and December 2018. The study aimed to compare the general characteristics, perioperative indicators, postoperative complications, and five-year follow-up results between the two groups.

Results

A total of 121 eligible patients were enrolled, with 52 underwent laparoscopic-assisted transanal NOSE and 69 underwent CLS. There were no significant differences observed between the two groups in terms of gender, age, body mass index (BMI), TNM stage, etc. (P > 0.05). However, the NOSE group exhibited significantly shorter total incision length and longer operation time compared to the CLS group (P < 0.05). There were no statistically significant differences observed between the two groups in terms of positive rate of bacterial culture, incidence rates of intraabdominal infections or anastomotic leakage (P > 0.05). Furthermore, during follow-up period there was no statistically significant difference observed between these two groups concerning overall survival rate and disease-free survival outcomes (P > 0.05).

Conclusions

The management of surgical complications in CLS is exemplary, with NOSE presenting a sole advantage in terms of incision length albeit at the cost of prolonged operative time. Therefore, NOSE may be deemed appropriate for patients who place high emphasis on postoperative cosmetic outcomes.

Outcomes of Laparoscopic Versus Open Surgery in Elderly Patients with Rectal Cancer

Background:

Laparoscopic colorectal resection has been gaining popularity over the past two decades-and the number of elderly patients with colorectal cancer treated with a surgical modality has gradually increased. However, studies about laparoscopic rectal surgery in elderly patients with long-term oncologic outcomes are limited. In this study, we evaluated the safety and effectiveness of laparoscopic resection in patients with rectal cancer aged ≥80 y.

Methods:

From 2007-2015, a total of 84 consecutive patients with rectal cancer from a single institution were included, 45 patients undergoing laparoscopic rectal resection were compared with 39 patients undergoing open rectal resection.

Results:

The two groups were well balanced in terms of age, gender, body mass index, American society of anesthesiologists scores, previous abdominal surgery, neoadjuvant therapy, tumor stage, distance of tumor from the anal verge, and comorbidities. One (2.2%) patient in the laparoscopic group required conversion to open surgery. Laparoscopic surgery was associated with significantly longer operating time (160.1±28.2 versus 148.2±41.3 min; P=0.031), less intraoperative blood loss (80.5±20.9 versus 160.3±42.4 mL; P=0.002), less need of blood transfusion (6.7% versus 20.5%; P=0.003), a shorter time to diet recovery (2.5±1.5 versus 4.9±1.1; P=0.015) and postoperative hospital stay (7.5±4.5 versus 10.8±4.2; P=0.035), lower overall postoperative complication rate (8.9% versus 20.5%; P=0.017), and wound-related complication rate (4.4% versus 10.2%; P=0.013) when compared with open surgery. Specimen length, no. of retrieced lymph nodes, positive distal and circumferential margin rate, mortality rate, and reoperation rate were not significantly different between two groups. The disease-free and overall 5-year survival rates were similar between two groups.

Conclusions:

Laparoscopic rectal surgery is safe and feasible in patients aged≥80 y and is associated with similar long-term oncologic outcomes when compared with open surgery.

One-stitch method vs. traditional method of protective loop ileostomy for rectal cancer: the impact of BMI obesity

PURPOSE

Protective loop ileostomy is an effective diversion measure often used to reduce the risk of anastomotic leakage. The purpose of the present study was to evaluate the surgical outcomes of the one-stitch method (OM) of protective loop ileostomy in laparoscopic low anterior resection for BMI obesity patients with rectal cancer compared with the traditional method (TM).

METHODS

The patients diagnosed as rectal adenocarcinoma cases by preoperative pathology were included in this retrospective study. The subjects underwent protective loop ileostomy in laparoscopic low anterior resection from January 2016 to June 2019 in the Shandong Provincial Hospital affiliated to Shandong University. The data of loop ileostomy and stoma closure operation were retrieved from the medical cases system of the hospital.

RESULTS

242 patients were included in the present study. In the BMI obese cohort, the OM group showed a shorter operative time both in the loop ileostomy (232.5 vs. 250.0 min, p = 0.04) and stoma closure operation (102.5 vs. 115.0 min, p = 0.001) and a lower peristomal adhesion extent (p = 0.02) and a shorter median postoperative stay (6 vs. 7 days, p = 0.03) during stoma closure operation than that of the TM group. In the TM group, obese cases showed a higher operative time of stoma closure operation (115.0 vs. 95.0, p < 0.001), a higher parastomal hernia rate (p = 0.04), a higher peristomal adhesion extent (p = 0.005) and a longer postoperative stay of stoma closure operation (p = 0.02) compared with the non-obese cases, while in the OM group, no significant differences were observed between the obese and non-obese cases in terms of the above-mentioned factors.

CONCLUSIONS

The OM exhibited more advantages than TM, notably in BMI obesity patients.

Laparoscopic surgery for rectal cancer reveals comparable oncological outcome even in context of worse short-term results-long-term analysis of nearly 500 patients from two high-volume centers

PURPOSE

Large randomized controlled trials have investigated the oncological value of the laparoscopic approach to colorectal cancer. Mainly, non-inferiority for the laparoscopic approach regarding long-term survival could be shown. Nevertheless, some recent trials revealed inferiority especially due to histopathological quality of specimen or location of the tumor in the rectum. The main objective of this study was to compare two historical patient collectives of specialized centers for either the laparoscopic or the open resection approach, regarding long-term survival and disease progression of rectal cancer according to tumor localization in a retrospective propensity score-matched analysis.

METHODS

A retrospective analysis, based on two prospectively maintained institutional colorectal cancer databases, was performed. The database of the reference center in Erlangen maintained almost exclusively open operations whereas the database in Lübeck maintained to a vast majority laparoscopic operations. To adjust risk profiles, a 1:1 propensity score matching was performed.

RESULTS

Seven hundred fifty-five patients of both centers (Erlangen, n = 507, Lübeck n = 248) were included. Propensity score matching resulted in two equalized groups with 248 patients. Regarding the postoperative complications, advantages for the open approach were seen. Analyzing the survival data, no differences in disease-free as well as overall survival were shown. Also, no differences in the overall loco-regional recurrence and distant metastasis rate were detected.

CONCLUSION

In centers with adequate expertise, open and laparoscopic procedures result in equivalent oncologic long-term outcomes. Advantages for the open resected group concerning short-term results and complications were detected, due to remarkably low rates of anastomotic leakage.

The Effectiveness and Safety of Open Versus laparoscopic Surgery for Rectal Cancer after Preoperative Chemo-radiotherapy: A Meta-Analysis

BACKGROUND

Only a limited number of studies considered the combined chemo-radiation therapy after surgery for treating locally advanced rectal cancer. Comparative studies on laparoscopic and open procedures indicated that laparoscopy surgery may be associated with fewer postoperative complications. Despite encouraging results from rectal cancer patients who received neoadjuvant chemo-radiotherapy prior to laparoscopic surgery, the acceptance of this procedure remains controversial, and conflicting evidence exists only in the form of retrospective trials.

OBJECTIVES

Since laparoscopic surgery was introduced into clinical practice to treat rectal cancer after neoadjuvant chemo-radiotherapy, it has been discussed controversially whether laparoscopic surgery can be performed as effectively as an open procedure. To overcome the biases inherent in any nonrandomized comparison, we analyzed the propensity-matched analysis and randomized clinical trial. In this study, we set out to determine whether laparoscopic resection was non-inferior to open resection in treatment outcomes of rectal cancer after neoadjuvant chemo-radiotherapy.

METHODS

Publications on laparoscopic surgery in comparison with open thoracotomy in treatment outcomes of rectal cancer after neo-adjuvant chemo-radiotherapy to November 2017 were collected. Summary hazard ratios (HRs) of endpoints of interest such as 3-OS (overall survival), 3-DFS (disease-free survival), and individual postoperative complications were analyzed in all trials. By using fixed- or random-effects models according to the heterogeneity, meta-analysis Revman 5.3 software was applied to analyze combined pooled HRs.

RESULTS

A total of 6 trials met our inclusion criteria. The pooled analysis of 3-DFS showed that laparoscopic surgery did not improve disease -free survival, compared with open thoracotomy (OR =1.48, 95% CI 0.95 - 2.29; P = 0.08), as well with the 3-OS (OR=0.96, 95%CI=0.66-1.41, P=0.084). The pooled result of duration of surgery indicated that laparoscopic surgery had a tendency towards a longer surgery time (SMD= 43.96, 95% CI 34.04- 53.88; P < 0.00001) and a shorter hospital stay (SMD= -0.97, 95% CI -1.75- -0.18; P=0.02). However, no significant differences between laparoscopic surgery and open thoracotomy were observed in terms of the meta-analysis on the number of removed lymph nodes (SMD =-0.37, 95% CI -0.1.77 - 1.03; P = 0.60), blood loss (SMD =-21.30, 95% CI -0.48.36 - 5.77; P = 0.12), positive circumferential resection margin (OR =0.73, 95% CI 0.22- 2.48; P = 0.61) or postoperative complications (OR =0.89, 95% CI 0.67 - 1.17; P = 0.40) l.

CONCLUSION

The current data supported the concept that laparoscopic surgery had correlated with a longer operative time but a shorter hospital stay, without superior advantages in short-term survival rates or oncologic efficiency for locally treating advanced rectal cancer after neoadjuvant chemoradiotherapy. However, prospective investigation on long-term oncological results from laparoscopic surgery is required in the future to verify the benefits of laparoscopic surgery over open surgery after chemo-radiation therapy for treating locally advanced rectal cancer.

Progress in surgical treatment of familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is an autosomal dominant genetic disease with a high tendency to develop colorectal cancer. The timing and choice of preventive surgical interventions should be based on the number, size and severity of adenomas, combined with a variety of considerations, in order to effectively prevent cancer and make patients easy to accept. Total proctocolectomy and ileal pouch-anal anastomosis (IPAA) procedure, which could minimize the residual rectal mucosa and reduce the risk of adenoma recurrence, has become the first choice for patients with FAP. Besides, laparoscopic IPAA has obvious advantages such as cosmetic appearance, quick recovery, little adhesion and high pregnancy rate. Patients with FAP should be managed by experienced surgeons working in specialized medical centers in order to get the most reasonable treatment at the best time and achieve long-term effective outcomes.

A Systematic Review and Bayesian Network Meta-Analysis: Short-Term and Long-Term Outcomes of Three Surgery Procedures Following Neoadjuvant Chemoradiotherapy for Rectal Cancer

Aim: Our aim was to perform a Bayesian network meta-analysis of short-term and long-term outcomes of open surgery (OS), laparoscopic surgery (LS), and robotic surgery (RS) after neoadjuvant chemoradiotherapy (nCRT) for rectal cancer. Methods: We searched randomized controlled trials (RCTs) and non-RCTs published up to October 2018 from PubMed, Embase, Cochrane Library, and Web of Science. We selected studies referencing the comparison between at least two of OS, LS, and RS. Short-term and long-term outcomes of different surgery procedures were evaluated. Mean differences or odds ratios and their 95% credible interval were pooled with Bayesian modeling. Results: In the network meta-analysis, 15 studies were identified through database searching and other sources that included three RCTs and nine non-RCTs enrolling 2360 patients. As for long-term outcomes, we did not find any significant difference among these surgery procedures after nCRT for rectal cancer in this network meta-analysis. As for short-term outcomes, no significant outcomes were obtained except for operative time, blood loss, length of incision, and time to pass first flatus. Our meta-analysis illustrated that RS had the longest operative time. However, LS had a significantly shorter operative time than RS, shorter incision than OS, shorter time to pass first flatus than OS, and less blood loss than OS. Conclusions: RS was regarded as the inferior surgery procedure after nCRT for rectal cancer. Meanwhile, LS might possibly be the most safe and feasible surgery procedure after nCRT for rectal cancer.

Comparison Between Laparoscopic and Open Resection Following Neoadjuvant Chemoradiotherapy for Mid-Low Rectal Cancer Patients: A Meta-Analysis

INTRODUCTION

The optimal approach of resection for mid-low rectal cancer after neoadjuvant chemoradiotherapy (nCRT) is still controversial. The aim of this meta-analysis was to clarify the safety and feasibility of laparoscopic surgery compared with open resection.

MATERIALS AND METHODS

We performed a literature search for studies on PubMed, Embase and Cochrane Library up to March 1, 2018. Review Manager software was applied for data analysis. We used weighted mean difference (WMD) for continuous parameters and odds ratio (OR) for dichotomous variables. Confidence interval (CI) was set at 95% and a P value <.05 was considered statistically significant.

RESULTS

A total of seven studies met the inclusion criteria for the meta-analysis: 466 patients in laparoscopic group and 491 in open group. The pooled result revealed that laparoscopic resection had a favorable blood loss (WMD = -116.88 mL; 95% CI: -189.78 to -43.99; P = .002), analogous lymph nodes harvest (WMD = -0.30; 95% CI: -1.29 to 0.70; P = .56), less postoperative complications (OR = 0.63; 95% CI: 0.46-0.88; P = .006), shorter time to pass first flatus (WMD = -0.76 day; 95% CI: -1.00 to -0.51; P < .00001), and stay in hospital (WMD = -2.71 days; 95% CI: -4.54 to -0.88; P = .004), despite similar operating time (WMD = 11.17 minutes; 95% CI: -14.37 to 36.70; P = .39).

CONCLUSIONS

Laparoscopic resection might be a technically safe and feasible approach for mid-low rectal cancer patients after nCRT compared with open resection.