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.

Impact of minimally invasive surgery on short-term outcomes after rectal resection for neoplasm within the setting of an enhanced recovery program

BACKGROUND

Minimally invasive surgery (MIS) for rectal cancer has increased in recent years. Enhanced recovery (ER) protocols are associated with improved outcomes, such as decreased length of stay (LOS). We examined the impact of MIS and ER protocols on outcomes after rectal resection for neoplasm.

METHODS

A retrospective analysis was performed for patients undergoing elective open (OS) or MIS rectal resection for neoplasm from 2010 to 2015 at a single institution. MIS was defined as any laparoscopic or robotic procedure. An ER protocol was implemented in 8/2013. Regression models were used to estimate outcomes including LOS, 30-day morbidity, readmission, and hospital costs.

RESULTS

Among 325 patients, 252 (77.5%) underwent OS; 73 (22.5%) underwent MIS rectal resection. Prior to ER implementation, only 6.1% underwent MIS, compared to 23.1 and 54.4% in the 2 years following ER implementation (p < 0.001). Prior to ER implementation, median LOS was 7 days (n = 181) with 23.8% 30-day morbidity. Following ER implementation, median LOS was 4 days (n = 144); patients receiving OS had median LOS of 5.5 days (n = 82) and 30-day morbidity of 19.5%. ER patients receiving MIS had median LOS of 3 days (n = 62) and 30-day morbidity of 14.5%. Univariate regression demonstrated that MIS patients on ER protocol were more likely to have a shortened LOS (< 6 days) compared to OS patients on non-ER protocol (both p < 0.001).

CONCLUSIONS

The combination of MIS and ER protocol is significantly associated with reduced LOS for patients undergoing rectal resection for neoplasm. Further research is needed to determine which patients are best suited to MIS from an oncologic standpoint.

The comprehensive therapeutic effects of rectal surgery are better in laparoscopy: a systematic review and meta-analysis

Background

Laparoscopic-assisted radical resection of rectal cancer was reported as advantageous compared to laparotomy resection. However, this finding remains controversial, especially given the two recent randomized controlled trials published on The Journal of the American Medical Association (JAMA).

Objective

To perform a meta-analysis that compares the short-term and long-term outcomes of laparoscopic and open surgery for rectal cancer.

Data source

To identify clinical trials comparing laparoscopic and open surgery for rectal cancer published by August 2016, we searched the PubMed, Cochrane Library, Springer Link and Clinicaltrials.gov databases by combining various key words. Data were extracted from every identified study to perform a meta-analysis using the Review Manager 5.3 software.

Results

A total of 43 articles from 38 studies with a total of 13408 patients were included. Although laparoscopic radical rectectomy increased operation time (MD = 37.23, 95% CI: 28.88 to 45.57, P < 0.0001), it can significantly decrease the blood loss (MD = –143.13, 95% CI: –183.48 to –102.78, P < 0.0001), time to first bowel movement (MD = –0.97, 95% CI: –1.35 to –0.59, P < 0.0001), length of hospital stay (MD = –2.40, 95% CI: –3.10 to –1.70, P < 0.0001), postoperative complications (OR = 0.78, 95% CI: 0.72 to 0.86, P < 0.0001), mortality (OR = 0.40, 95% CI: 0.28 to 0.57, P < 0.0001) and the CRM positive rate (OR = 0.64, 95% CI: 0.55 to 0.75, P < 0.0001). No significant difference were noted between the groups regarding intraoperative complications, TME completeness and harvesting of lymph nodes. Regarding the long-term survival data, the laparoscopic group was not inferior to laparotomy. Some pooled data, such as 3-year DFS, 5-year OS and 5-year local recurrence were even superior for the laparoscopic group.

Conclusions

Given the definite benefits in short-term outcomes and trending benefits in long-term outcomes that were observed, we recommend laparoscopic surgery be used for rectal cancer resection.

Single-port and multi-port laparoscopic left lateral liver sectionectomy for treating benign liver diseases: a prospective, randomized, controlled study

BACKGROUND

The use of single-port laparoscopy for left-lateral liver sectionectomy (LLLS) has been reported in the literature, but the effectiveness and safety of LLLS has not been validated in randomized, controlled trials. This prospective randomized controlled trial compared the effectiveness and safety of single-port and multi-port laparoscopic LLLS for the surgical treatment of benign liver disease.

METHODS

Altogether, 38 patients aged 17-65 years (16 men, 22 women) with benign liver diseases were hospitalized for elective laparoscopic LLLS between January 2010 and December 2012. Patients were randomly assigned to either single-port (n = 19) or multi-port (n = 19) laparoscopic LLLS. Main outcome measures were operative time, volume of intraoperative blood loss, complication rates, and postoperative hospitalization.

RESULTS

Baseline characteristics of the two groups were comparable. Single-port and multi-port laparoscopies were successfully completed in all but one patient (1/19, 5.3 %) who required conversion from a single-port to a multi-port procedure. The two groups had similar mean operative times and volumes of intraoperative blood loss. There were no clinically significant postoperative complications or deaths. The single-port group had a significantly shorter postoperative hospitalization than the multi-port group (2.5 ± 1.7 vs. 4.0 ± 2.1 days; p < 0.05).

CONCLUSIONS

Single-port laparoscopic LLLS is a technically feasible, effective, safe alternative to multi-port laparoscopy for the treatment of benign liver diseases in cautiously selected patients.

Have early postoperative complications from laparoscopic rectal cancer surgery improved over the past 20 years?

AIM

Laparoscopic rectal cancer surgery has been increasingly used since 1991 following the publication of the first case series. Since then, several studies have confirmed that laparoscopic surgery for rectal cancer is challenging with associated morbidity and mortality. The aim of this study was to determine if the rates of early postoperative complications in laparoscopic rectal cancer surgery have improved over the past 20 years.

METHOD

A literature search of the EMBASE and MEDLINE databases between August 1991 and August 2011 was conducted using the keywords laparoscopy, rectal cancer and postoperative complications. Data were analysed using linear regression ANOVA performed in GNUMERICS software.

RESULTS

Ninety-seven studies were included for analysis. Over the last 20 years there has been no significant change in the rate of any early postoperative complications (anastomotic leak, conversion, sexual, urinary or faecal dysfunction, wound infection, overall morbidity or mortality). However, in the last 3 years, the rate of positive resection margins has decreased significantly (P = 0.01).

CONCLUSION

There was no evidence of a statistically significant change in early postoperative complications until 3 years ago. This may reflect the inherent morbidity associated with rectal surgery regardless of the approach used, the limitations of the current laparoscopic instrumentation or the relatively long learning curve. With increasing experience, a repeat analysis in the near future following the publication of ongoing randomized clinical trials might show improved outcomes.

The learning curve of laparoscopic treatment of rectal cancer does not increase morbidity

INTRODUCTION

The treatment of rectal cancer via laparoscopy is controversial due to its technical complexity. Several randomized prospective studies have demonstrated clear advantages for the patient with similar oncological results to those of open surgery, although during the learning of this surgical technique there may be an increase in complications and a worse prognosis.

OBJECTIVE

Our aim is to analyze how the learning curve for rectal cancer via laparoscopy influences intra- and postoperative results and oncological markers. A retrospective review was conducted of the first 120 patients undergoing laparoscopic surgery for rectal neoplasia. The operations were performed by the same surgical team with a wide experience in the treatment of open colorectal cancer and qualified to perform advanced laparoscopic surgery. We analyzed sex, ASA, tumour location, neoadjuvant treatment, surgical technique, operating time, conversion, postoperative complications, length of hospital stay, number of lymph nodes, stage and involvement of margins.

RESULTS

Significant differences were observed with regard to surgical time (224 min in the first group, 204 min in the second group), with a higher rate of conversion in the first group (22.5%) than in the second (11.3%). No significant differences were noted for rate of conservative sphincter surgery, length of hospital stay, post-surgical complications, number of affected/isolated lymph nodes or affected circumferential and distal margins.

CONCLUSIONS

It is possible to learn this complex surgical technique without compromising the patient's safety and oncological outcome.

Laparoscopic resection of rectal cancer results in higher lymph node yield and better short-term outcomes than open surgery: a large single-center comparative study

BACKGROUND

Prognosis in rectal cancer is closely related to mesorectal integrity, margin status, and adequate lymph node dissection. The impact of laparoscopy on the pathologic and short-term outcomes remains controversial.

OBJECTIVE

We aim to compare the pathologic and short-term outcomes of laparoscopic and open resections for rectal cancer.

DESIGN

This is a large single-center retrospective comparative study using a prospective database.

PATIENTS

All patients who underwent primary resections for rectal cancer from January 2007 to September 2011 were identified.

MAIN OUTCOME MEASURES

Pathologic (nodal harvest, mesorectal integrity, circumferential, and distal margins) and operative outcomes were measured.

RESULTS

Two hundred thirty-four (mean age, 61 years; 65% male) patients underwent resections for primary rectal cancer, including 118 laparoscopic (99 restorative proctectomies, 19 abdominoperineal resections) and 116 open (69 restorative proctectomies, 47 abdominoperineal resections) resections. Both groups were similar in demographics, comorbidities, and tumor characteristics. The laparoscopic group had significantly more lymph nodes (26 vs 21, p = 0.02) than the open group, with no differences in circumferential margins, proportion of distal resection margins <l cm, and completeness of total mesorectal excision. The impact of laparoscopic resection on lymph nodes was also observed for restorative proctectomy (27 vs 21, p = 0.03). Furthermore, obese and laparoscopic-converted patients had equivalent pathologic outcomes for laparoscopic and open resection. Laparoscopy was associated with longer operative time (245 vs 213 minutes, p = 0.002); less blood loss (284 vs 388 mL, p = 0.01); shorter incisions (8 vs 20 cm, p = 0.0001) and hospital stay (7 vs 8 days, p = 0.05); and lower rates of 30-day morbidity (25% vs 43%, p = 0.04) and wound infections (9 vs 20%, p = 0.04). On multivariate regression, laparoscopic resection and year of surgery were the only independent predictors of greater lymph node harvest.

CONCLUSIONS

Laparoscopy for primary rectal cancer is associated with a greater number of lymph nodes as well as short-term benefits.

Laparoscopic versus open surgery for rectal cancer: a clinical comparative study

OBJECTIVE

To compare short-term surgical outcomes and long-term survival following laparoscopic or open resection for rectal cancer.

METHODS

A total of 381 patients undergoing laparoscopic surgery and 276 undergoing open surgery for curative resection of rectal cancer were included. Long-term survival and peri- and postoperative data were retrospectively reviewed from a prospectively-collected database.

RESULTS

Surgical groups were comparable regarding age, gender, tumour stage and preoperative comorbidities. Laparascopic surgery was associated with significantly longer duration of surgery, less intraoperative blood loss and fewer postoperative infections than open surgery. Patients who underwent laparoscopic resection had significantly earlier recovery of gastrointestinal function than those who underwent open surgery. There were no significant between-group differences in number of lymph nodes excised, specimen length or distal margin. The 3- and 5-year survival rates and overall survival were similar in the two groups, and survival was not influenced by tumour location.

CONCLUSION

Laparoscopic surgery can achieve the same oncological results as open resection in patients with rectal cancer, supporting its continued use in the management of this disease.

Laparoscopic versus open total mesorectal excision for middle and low rectal cancer: a meta-analysis of results of randomized controlled trials

BACKGROUND

Laparoscopic total mesorectal excision (LTME) for rectal cancer remains controversial. The aim of this meta-analysis of randomized controlled trials (RCTs) is to compare LTME and open total mesorectal excision (OTME) as the primary treatment for patients with middle and low rectal cancer with regard to short-term outcomes.

MATERIALS AND METHODS

Literature searches of electronic databases (PubMed, Embase, and the Cochrane Library) and manual searches up to October 30, 2011 were performed. Prospective randomized clinical trials were eligible if they included patients with middle and low rectal cancer treated by LTME versus OTME. Fixed and random effects models were used. Review Manager version 5.1 software was used for pooled estimates.

RESULTS

Four RCTs enrolling 624 participants (LTME group, 308 cases; OTME group, 316 cases) were included in the meta-analysis. LTME for rectal cancer was associated with a significantly longer operative time but significantly less intraoperative blood loss and earlier time to pass first flatus. We found no significant differences in the number of lymph nodes, overall morbidity, and perioperative mortality rates between the two groups. Time to resume liquid diet, time to resume normal diet, and length of hospital stay, although not significantly different between the two groups, did suggest a positive trend toward LTME.

CONCLUSIONS

It may be concluded that LTME is a safe and effective alternative to OTME and is justifiable under the setting of clinical trials. Additional RCTs that compare LTME and OTME and investigate the long-term oncological outcomes of LTME are required to determine the advantages of LTME over OTME.

Factors influencing the quality of total mesorectal excision

BACKGROUND

Total mesorectal excision (TME) has become the standard of care for rectal cancer. Incomplete TME may lead to local recurrence.

METHODS

Data from the multicentre observational German Quality Assurance in Rectal Cancer Trial were used. Patients undergoing low anterior resection for rectal cancer between 1 January 2005 and 31 December 2009 were included. Multivariable analysis using a stepwise logistic regression model was performed to identify predictors of suboptimal TME.

RESULTS

From a total of 6179 patients, complete data sets for 4606 patients were available for analysis. Pathological tumour category higher than T2 (pT3 versus pT1/2: odds ratio (OR) 1.22, 95 per cent confidence interval 1.01 to 1.47), tumour distance from the anal verge less than 8 cm (OR 1.27, 1.05 to 1.53), advanced age (65-80 years: OR 1.25, 1.03 to 1.52; over 80 years: OR 1.60, 1.15 to 2.22), presence of intraoperative complications (OR 1.63, 1.15 to 2.30), monopolar dissection technique (OR 1.43, 1.14 to 1.79) and low case volume (fewer than 20 procedures per year) of the operating surgeon (OR 1.20, 1.06 to 1.36) were independently associated with moderate or poor TME quality.

CONCLUSION

TME quality was influenced by patient- and treatment-related factors.