Survival following laparoscopic and open colorectal surgery

Background

Laparoscopic colorectal surgery is known to provide increased benefits to patients during the postoperative recovery period. Initial scepticism over the oncological adequacy of resection has been dismissed by a number of major randomized trials. Emerging evidence indicates that laparoscopic surgery may provide a potential survival benefit in colorectal cancer.

Methods

Patients undergoing elective laparoscopic or open resection for colorectal cancer between October 2003 and December 2010 were analyzed. Data were collated and a database compiled. Survival analysis was calculated by using the Kaplan–Meier method.

Results

A total of 665 resections were performed with 457 laparoscopically and 208 open. The median length of stay was 4 days following laparoscopic resection and 7 days following open (p < 0.0005). There was no significant difference between the two groups apart from gender (p = 0.03), ASA (p = 0.03), and the number of patients with extranodal metastatic disease (p = 0.01). The 5-year overall survival (OS) in the completed laparoscopic group was 75.8 versus 72.5 % in the open group (p = 0.12). The 5-year OS in patients who were converted was 52 %. The 5-year OS for nonmetastatic disease in the completed laparoscopic group was significantly greater at 79.4 versus 74 % in the open group (p = 0.03). There was no difference between the groups in OS for rectal cancer (p = 0.66), but there was an OS advantage for laparoscopically resected colon cancer (p = 0.02).

Conclusions

Laparoscopic resection for nonmetastatic colon cancer may provide an overall survival advantage.     

Nationwide trends in laparoscopic colectomy from 2000 to 2004

Background Over the past 5 years, several studies have demonstrated that laparoscopic colon resection is an acceptable and perhaps preferable alternative to open resection for both benign diseases and cancer. The extent to which laparoscopic colon resections are used nationally is not known. Methods The Nationwide Inpatient Sample was used to identify laparoscopic and open elective colon resections performed in the United States each year from 2000 through 2004. The trends in adoption of the laparoscopic technique for each type of colon resection and for the most common diagnoses were identified, and differences in patient and provider characteristics were examined. Results From 2000 to 2004, the proportion of colon resections performed laparoscopically increased from 3% to 6.5%. The proportion performed for cancer increased from 1.4% to 4.3%, and for benign disease from 4.6% to 8.2%. Patients treated laparoscopically tended to be younger (median age, 61 years vs 66 years; p < 0.001) and to have fewer comorbidities (Charlson score of zero for 58.1% vs 37%; p < 0.001). Laparoscopic colon resections were more widely adopted in teaching versus nonteaching hospitals (5.1% vs 3.7%; p < 0.001) and in urban versus rural hospitals (4.7% vs 2.2%; p < 0.001). Conclusion Although the proportion of colon resections performed laparoscopically increased in the first half of this decade, it has remained very low. This trend is similar across procedure types and diagnoses. It remains to be seen whether greater patient demand and more recent trials will result in wider adoption of the laparoscopic approach.     

Impact of laparoscopic surgery on the long‐term outcomes for patients with rectal cancer

Background: This 20‐year retrospective study compared the results of laparoscopic surgery with open surgery for patients with rectal cancer to evaluate the impact of laparoscopic surgery on long‐term oncological outcomes for rectal cancer. Methods: We analysed survival data collected over 20 years for patients with rectal cancer (n= 407) according to surgical methods and tumour stage between those treated with laparoscopic surgery (n= 272) and those with open surgery (n= 135). Clinical factors were analysed to ascertain possible risk factors that might have been associated with survival from and recurrence of rectal cancer. A multivariate analysis was applied by using Cox's regression model to determine the impact of laparoscopic surgery on long‐term oncological outcomes. Results: Overall survival, disease‐specific survival and disease‐free survival rates were statistically higher in the laparoscopic group than in the open‐surgery group. The incidence of local recurrence in the laparoscopic group (7.9%; 95% confidence intervals (CI), 4.2–11.5) was significantly lower than that for the open‐surgery group (30.2%; 95% CI, 21.0–39.3; P < 0.001). By using a multivariate analysis, laparoscopic surgery for rectal cancer appeared not to be an independent factor for disease‐specific survival or disease‐free survival. However, the laparoscopic surgery was an independent factor associated with reduced local recurrence (Hazard ratio (HR), 3.408; 95% CI, 1.890–6.149; P < 0.001). Conclusion: Laparoscopic surgery did not adversely affect the long‐term oncological outcome for patients with rectal cancer.     

Laparoscopy as a prognostic factor in curative resection for node positive colorectal cancer: Results for a single-institution nonrandomized prospective trial

Background Several studies reporting preliminary long-term survival data after laparoscopic resections for colonic adenocarcinoma did not show any detrimental effect in comparison with historic studies of laparotomies. A previous randomized study has reported an unforeseen better long-term survival for node-positive patients treated by laparoscopic colectomy.Methods A single-institution prospective nonrandomized trial compared short- and long-term results of laparoscopic and open curative resection for adenocarcinoma of the left colon or rectum in 255 consecutive patients from January 1996 to December 2000.Results In this study, 34 left hemicolectomy, 202 anterior resections, and 19 abdominoperineal resections were performed. A total of 74 patients underwent a laparoscopic resection (LR), and 181, an open resection (OR). The tumor site was the descending colon in 32 cases, the sigmoid colon in 98 cases, and the rectum in 125 cases, including 87 mid–low rectal cancers. Ten LR procedures (13.5%) were converted to open surgery. The hospital mortality was 0.08%, and in hospital morbidity was 16.2% for LR and 13.3% for OR (p = 0.56). The median postoperative stay was 1 day shorter for LR (9 days) than for OR (10 days) (p = 0.09). The mean number of lymph nodes retrieved were 13.8 ± 5.7 for OR and 12.7 ± 5; for LR (p = 0.23). Age exceeding 70 years, T stage, N stage, grading, mid–low rectal site, and laparoscopy were found by multivariate analysis to be significant prognostic factors for disease-free and cancer-related survival. When patients were stratified by stage, a trend toward a better disease-free and cancer-related survival was identifyed in stage III patients undergoing LR.Conclusions Laparoscopic colonic resection is a safe procedure in terms of postoperative outcome and long-term survival. Multivariate analysis showed that laparoscopy is a positive prognostic factor for disease-free and cancer-related survival. The current data agrees with the data for the only randomized study reported so far. Both suggest a better outcome for node-positive patients treated by laparoscopy.     

Laparoscopic restorative proctectomy – hybrid approach or totally laparoscopic?

Background: Laparoscopic rectal resection is now a technique that is emerging from experience with laparoscopic colonic resection. We review and present our experience with restorative proctectomy for cancer and compare those performed with a hybrid technique with those performed totally laparoscopically. Methods: A total of 177 patients have undergone laparoscopic restorative proctectomy. All of the patients were planned to have the abdominal portion of their surgery performed laparoscopically and to convert to open for the rectal dissection as required. They were then stratified into those that had their surgery performed completely laparoscopically (laparoscopic group – LG), and to those who had their rectal dissection and or transection performed with an open incision (hybrid group – HG). Results: Short‐term outcomes were compared between the LG (n = 103) and the HG (n = 74). The overall complication rate was higher in the HG (12% versus 35% P < 0.001), mainly with a significantly higher pelvic abscess rate and higher rate of post‐operative ileus. There were no intraoperative or post‐operative deaths. Length of stay was equivalent in both groups (five days). To date, distal recurrence has occurred in 7.7% of the patients, eight in the LG and four in the HG (NS). Two patients, one in each group, have had local recurrence only. Conclusions: Laparoscopic open or laparoscopic hybrid approaches are techniques that can be used in suitable patients. Both have acceptable morbidity and mortality.     

Long-term outcomes of laparoscopic surgery for colorectal cancer

Multiple reports have outlined the potential benefits of the laparoscopic approach to colon surgery. Recently, randomized control trials have demonstrated the safety of applying these techniques to colorectal cancer. This study examined the long-term follow-up assessment of patients after laparoscopic colorectal cancer resections and compared them with a large prospective database of open resections. A total of 231 resections were performed for adenocarcinoma of the colon or rectum between 1992 and 2004. Of these 231 resections, 93 were rectal (40.3%) and 138 were colonic (59.7%). A total of 8 (3.2%) of the resections were performed as emergencies, and 27 (11.7%) were converted to open surgery. The mean follow-up period was 35.84 months (range, 0-132 months). The disease recurred in 51 of the patients (22.1%) before death, involving 14 (6.1%) local and 37 (16%) distant recurrences. Only two patients had wound recurrences (0.8%), and both patients had widespread peritoneal recurrence at the time of diagnosis. The overall survival rate was 65.3% at 60 months and 60.3% at 120 months. The disease-free survival rate was 58% at 60 months and 56% at 120 months. Laparoscopic techniques can be applied to a wide range of colorectal malignancies without sacrificing oncologic results during a long-term follow-up period.     

Midterm outcomes of laparoscopic surgery for rectal cancer

In this study, the authors examine midterm survival and recurrence after laparoscopic and open surgery for rectal cancer. This is a retrospective review of a prospective database for rectal cancer surgeries performed at the authors' institution, with follow-up data obtained through chart review. In all, 74 patients in this study had open surgery, and 93 had laparoscopic surgery. The 5-year overall survival was 73.6% ± 12.0% in the open group and 80.0% ± 12.8% in the laparoscopic group (P = .159). Disease-free survival at 5 years was better in the laparoscopic group (71.0% ± 13.4%) than in the open group (50.3% ± 12.7%), with a P value of .01. Laparoscopic surgery remained an independent predictor of disease-free survival in the multivariate analysis. Results of prospective randomized trials are awaited, and the authors expect that the laparoscopic approach will be shown to be a safe and effective option for the management of rectal cancer.     

Laparoscopic extraperitoneal rectal cancer surgery: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

Background

The laparoscopic approach is increasingly applied in colorectal surgery. Although laparoscopic surgery in colon cancer has been proved to be safe and feasible with equivalent long-term oncological outcome compared to open surgery, safety and long-term oncological outcome of laparoscopic surgery for rectal cancer remain controversial. Laparoscopic rectal cancer surgery might be efficacious, but indications and limitations are not clearly defined. Therefore, the European Association for Endoscopic Surgery (EAES) has developed this clinical practice guideline.

Methods

An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. The expert panel constituted for a consensus development conference in May 2010. Thereafter, the recommendations were presented at the annual congress of the EAES in Geneva in June 2010 in a plenary session. A second consensus process (Delphi process) of the recommendations with the explanatory text was necessary due to the changes after the consensus conference.

Results

Laparoscopic surgery for extraperitoneal (mid- and low-) rectal cancer is feasible and widely accepted. The laparoscopic approach must offer the same quality of surgical specimen as in open surgery. Short-term outcomes such as bowel function, surgical-site infections, pain and hospital stay are slightly improved with the laparoscopic approach. Laparoscopic resection of rectal cancer is not inferior to the open in terms of disease-free survival, overall survival or local recurrence. Laparoscopic pelvic dissection may impair genitourinary and sexual function after rectal resection, like in open surgery.

Conclusions

Laparoscopic surgery for mid- and low-rectal cancer can be recommended under optimal conditions. Still, most level 1 evidence is for colon cancer surgery rather than rectal cancer. Upcoming results from large randomised trials are awaited to strengthen the evidence for improved short-term results and equal long-term results in comparison with the open approach.     

Laparoscopic colectomy for colon adenocarcinoma: an 11-year retrospective review with 5-year survival rates

Background Laparoscopic colectomy for the management of colon cancer remains a controversial therapeutic option, especially when the outcomes are compared with the historically accepted survival data and recurrence rates after open surgery. The purpose of this study was to evaluate the 5-year overall and disease-free survival rates after laparoscopic colon resection for invasive colon adenocarcinoma.Methods A total of 129 patients underwent consecutive laparoscopic colectomies for colon adenocarcinoma (between April 1992 and 2004 January) by a single surgeon at a single institution. Records were analyzed retrospectively and follow-up data was obtained. The Student t-test, Cox regression analysis, and Kaplan-Meier survival data were used for statistical analysis.Results After patients with noninvasive disease on final pathology were excluded, the study population comprised 88 patients who underwent laparoscopic colectomies for invasive colon cancer with > 2 years of follow-up. Of these cases, 81 (93%) were amenable for complete follow-up at 11years (41 women and 40 men; mean age, 76 years). Mean follow-up was 61 months. There was one perioperative death (1.2%), and the overall postoperative morbidity rate was 13.6%. The average number of lymph nodes harvested was 10.1 (±6). There were no port site recurrences. The Kaplan-Meier survival data were as follows for 5-year overall survival and 5-year disease-free survival, respectively stage I (n = 34) 89% and 89%; stage II (n = 22), 65% and 59%; stage III (n = 19), 72% and 67%; stages I–III combined, (n = 75), 77% and 73%.Conclusions For this specific cohort of patients undergoing curative laparoscopic colectomies for invasive colon adenocarcinoma, the mean follow-up was > 5 years. Overall survival and disease-free survival for stage I, II, and III colon cancer as well as for stages I–III combined are favorable and comparable to historically acceptable open colectomy survival rates. Overall survival and disease-free survival after laparoscopic colectomy for invasive colon cancer is no worse, and perhaps better than, the previously reported rates for the same procedure done by an open technique.     

Integration of open and laparoscopic approaches for rectal cancer resection: oncologic and short-term outcomes

Background

Laparoscopy is increasingly used for rectal cancer surgery. Laparoscopic surgery is not attempted for some suitable patients because of concerns for conversion or technical difficulty. This study aimed to evaluate oncologic and short-term outcomes for patients undergoing curative resection for rectal cancer via laparoscopic and open approaches.

Methods

A prospective database was reviewed to identify rectal cancer resections from 2005 to 2011. Patients who had primary rectal cancer within 15 cm of the anal verge were included in the study. Those with recurrent or metastatic disease were excluded. Patients were assigned to laparoscopic or open approaches preoperatively based on clinical criteria and imaging. All patients underwent a standard total mesorectal excision and followed a standardized enhanced recovery pathway. The oncologic and clinical outcomes were evaluated by approach.

Results

The analysis included 81 patients. The preoperative assignments consisted of 62 laparoscopic (77 %) and 19 open (23 %) procedures. Nine laparoscopic procedures (14.5 %) were converted to open procedures. After a median follow-up period of 25 months, all oncologic outcomes were comparable. Three patients (two laparoscopic, one open) had a positive circumferential margin (≤1 mm). The laparoscopic and open groups were similar in terms of their 3-year disease-free periods (93.6 vs. 88.2 %; P = 0.450) and overall survival periods (93.5 vs. 90.9 %; P = 0.766). The local recurrence rate was 2.5 %.

Conclusions

Laparoscopic resection for rectal cancer can be attempted for most patients. Conversion to open procedure does not compromise clinical or oncologic outcomes. In practice, combining laparoscopic and open surgery optimizes resource use and results in at least equivalent outcomes.     

Laparoscopic resection of colon Cancer: Consensus of the European Association of Endoscopic Surgery (EAES)

Background The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002.Methods A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer.Results Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is <1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery.Conclusion Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.     

Comparison of Outcome of Open and Laparoscopic Resection for Stage II and Stage III Rectal Cancer

Background  Laparoscopic resection for advanced rectal cancer has not been widely accepted, and there are only few studies with survival data. This study aimed to compare the survival of patients who underwent laparoscopic and open resection for stage II and III rectal cancer. Materials and Methods  Consecutive patients (open resection: n = 310; laparoscopic resection: n = 111) who underwent curative resection for stage II and III rectal cancer from June 2000 to December 2006 were included. The operative details, postoperative complications, postoperative outcomes, and survival data were collected prospectively. Comparison was made between patients who had laparoscopic and open surgery. Results  The age, gender, medical morbidity, types of operation, and American Society of Anesthesiologists (ASA) status were similar between the two groups. There was also no difference in the mortality, morbidity, and pathological staging. Laparoscopic resection was associated with significantly less blood loss and shorter hospital stay. With the median follow-up of 34 months, there was no difference in local recurrence rates. The 5-year actuarial survivals were 71.1% and 59.3% in the laparoscopic and open groups, respectively (P = .029). In the multivariate analysis, laparoscopic resection was one of the independent significant factors associated with better survival (P = .03, hazards ratio: 0.558, 95% confidence interval: 0.339–0.969). Other independent poor prognostic factors included lymph node metastasis, poor differentiation, perineural invasion, presence of postoperative complications, and no chemotherapy. Conclusions  Laparoscopic resection for locally advanced rectal cancer is associated with more favorable overall survival when compared with open resection.     

Critical appraisal of laparoscopic vs open rectal cancer surgery

AIM: To evaluate the long-term clinical and oncological outcomes of laparoscopic rectal resection (LRR) and the impact of conversion in patients with rectal cancer.METHODS: An analysis was performed on a prospective database of 633 consecutive patients with rectal cancer who underwent surgical resection. Patients were compared in three groups: Open surgery (OP), laparoscopic surgery, and converted laparoscopic surgery. Short-term outcomes, long-term outcomes, and survival analysis were compared.RESULTS: Among 633 patients studied, 200 patients had successful laparoscopic resections with a conversion rate of 11.1% (25 out of 225). Factors predictive of survival on univariate analysis include the laparoscopic approach (P = 0.016), together with factors such as age, ASA status, stage of disease, tumor grade, presence of perineural invasion and vascular emboli, circumferential resection margin < 2 mm, and postoperative adjuvant chemotherapy. The survival benefit of laparoscopic surgery was no longer significant on multivariate analysis (P = 0.148). Neither 5-year overall survival (70.5% vs 61.8%, P = 0.217) nor 5-year cancer free survival (64.3% vs 66.6%, P = 0.854) were significantly different between the laparoscopic group and the converted group.CONCLUSION: LRR has equivalent long-term oncologic outcomes when compared to OP. Laparoscopic conversion does not confer a worse prognosis.     

Laparoscopic Total Mesorectal Excision for Extraperitoneal Rectal Cancer: Long-Term Results of a 18-Year Single-Centre Experience

Background and Objectives

The oncologic efficacy of laparoscopic total mesorectal excision (TME) for middle–low rectal cancer is still under discussion because of the few long-term data. This study reports the results arising from a single-institution experience during a 18-year period.

Methods

Data about 132 consecutive laparoscopic TME performed between January 1994 and January 2012 were analysed with Kaplan–Meier method and a uni- and multi-variate analysis was conducted to define independent survival predictors.

Results

A total of 116 sphincter-preserving operations and 16 abdominoperineal resections were performed. Postoperative mortality and morbidity were 0.8 and 18.2 %, with a rate of anastomotic leakage of 13.8 %. Average follow-up was 85.9 months (range 13–210). Actuarial local recurrence rate was 4.13 % at 5 years (any pelvic recurrence developed after 3 years from surgery). Overall and disease-free survival was respectively 83 and 79.8 % at 5 years, 71 and 73 % at 10 years and then remained constant until 18 years. Survival was correlated only to tumour stage and the type of surgery.

Conclusions

Laparoscopic TME for extraperitoneal rectal cancer shows long-term oncologic outcomes similar to open rectal resections.     

腹腔镜在胃肠恶性肿瘤中的应用现状及存在问题

Laparoscopic surgery has gained wide acceptance for its use in benign gastrointestinal cancer in the past 20 years, while its use in malignant gastrointestinal cancer has been highly controversial until the recent 3-5 years. Several prospective randomized clinical trials have suggested that the long-term outcome of laparoscopic surgery for colon cancer is the same as or better than that of open surgery. As for rectal cancer, whether the principles of total mesorectal excision can be well followed in laparoscopic surgery remains. Most recently, the trial of large number of patients doesn't show any differences upon local recurrence and 3-year survival rate between rectal cancer patients in laparoscopic group and open group. Laparoscopic surgery has been widely accepted as a standard treatment regimen for early gastric cancer in many specialized centers. Meanwhile, the feasibility and effectiveness of laparoscopic D2 lymphadenectomy for gastric cancer has been proved by several scholars. The use of laparoscopic surgery for advanced gastric cancer especially for T3 gastric cancer still remains controversial. The early concern that laparoscopic surgery for malignant cancer might increase tumor dissemination is not confirmed. The system of technical training and occupational qualification, proper selection of patients and adherence to all the principles of cancer clearance will ensure a good result of laparoscopic surgery for malignant gastrointestinal cancer.     

Local recurrence and survival after laparoscopic mesorectal resection for rectal adenocarcinoma

Background: Laparoscopic resection for rectal cancer is controversial. Actuarial survival and local recurrence rates have not been determined. Methods: A prospective database containing 80 consecutive unselected laparoscopic resections of rectal cancers performed between November 1991 and 1999 was reviewed. Local recurrence was defined as any detectable local disease at follow-up assessment occurring either alone or in conjunction with generalized recurrence. The tumor node metastases (TNM) classification for colorectal cancers and the Kaplan-Meier method were used to determine staging and survival curves. The mesorectal excision technique was used during surgery. Results: The median follow-up period was 31 months for patients with stages I, II, and III cancer, and 15.5 months for patients with stage IV cancer. The overall 5-year survival rate was 65.1% for all cancer stages and 72.1% for stages I, II, and III cancer. No trocar-site recurrence was observed. The overall local recurrence rate was 3.75% (3/80) for all cancer stages, and 4.3% (3/70) for stages I, II, and III cancer. Conclusions: The survival and local recurrence rates for patients with rectal cancer treated by laparoscopic mesorectal excision do not differ negatively from those in the literature for open mesorectal excision. Further validation is needed.     

Outcome of laparoscopic colectomy for cancer in elderly patients

Background

Resection for colon cancer in the elderly is a major undertaking. However, data on the outcome and survival of elderly patients who underwent laparoscopic resection for colon cancer are limited. This study of patients older than 75 years compared outcome and survival between those who underwent laparoscopic resection and those who had open resection for colorectal cancer.

Methods

From 2000 to 2009, 434 patients ages 75 years and older who underwent elective resection for colon cancer were included in the study. Patients who had rectal cancer or had undergone emergency operations were excluded. Preoperative diagnosis was determined by colonoscopy, and computed tomography scan was performed for preoperative staging. Data on the patients’ demographics, operative details, pathology results, postoperative results, and survival were collected prospectively. The patients who underwent laparoscopic surgery were compared with those who had open surgery.

Results

The study included 434 patients (210 men) with a median age of 80 years (range 75–95 years). Of these 434 patients, 189 underwent laparoscopic resection. Nine patients (4.8 %) required conversion to open operation. The patients did not differ in terms of age, gender, incidence of medical comorbidities, or stage of disease. The median operating time was longer in the laparoscopic group, but the blood loss was significantly less. Laparoscopic resection was associated with a lower mortality rate and a shorter hospital stay (p < 0.05). The open resection group had significantly more cardiac complications (p < 0.05). The overall 5-year survival rates were similar between the patients who had laparoscopic resections and those who had open surgery.

Conclusions

For patients older than 75 years, laparoscopic resection of colon is associated with less intraoperative blood loss, a shorter hospital stay, fewer cardiac complication, and a lower mortality rate than open resection. Therefore, the authors recommend laparoscopic resection of colon cancer as the treatment of choice for elderly patients.     

Long-term results of laparoscopic versus open resections for rectal cancer for 124 unselected patients

Background: Controversy continues to surround laparoscopic rectal resection for malignancy. A longer follow-up period is required to evaluate the long-term efficacy of the procedure and its impact on survival. Furthermore, no data from ongoing randomized controlled trials are yet available. The aims of this study were to compare long-term outcomes for unselected patients undergoing either laparoscopic or open rectal resection for cancer. Methods: A series of 124 unselected consecutive patients with rectal cancer, who underwent surgery by the same surgical team, have been included in this study. Patients with T1N0 tumors underwent local excision, and emergency cases were excluded from the study. Written consent was submitted by each patient, and inclusion in either group (laparoscopic or open) was left to the patients choice. The laparoscopic approach was chosen by 81 patients, and 43 patients chose open surgery. All the patients underwent preoperative radiotherapy (5,040 cGy), performed in selected cases with chemotherapy (for patients younger than 70 years). The following parameters were compared between the two groups: length of the surgical specimen, clearance of the margins of the specimen, number of lymph nodes identified, local recurrence rate, incidence of distant metastases, and survival probability analysis. The mean follow-up period for both groups was 43.8 months (range, l–9 years). Results: We performed 60 laparoscopic and 27 open anterior resections, as well as 21 laparoscopic and 16 open abdomino perineal resections, respectively. No mortality occurred in either group. The mean length of the resected specimens was 24.3 cm in the laparoscopic group and 23.8 cm in the open group (p = 0.47). The mean tumor-free margin was 3.0 cm in the laparoscopic group and 2.8 cm in the open group (p = 0.57), and the mean number of lymph nodes identified was 10.3 in the laparoscopic group and 9.8 in the open group (p = 0.63). Of the 124 patients, 86 (52 laparoscopic and 34 open) were included in out study. We excluded patients who underwent a palliative resection (6 laparoscopic and 6 open patients) or conversion to open surgery (n = 10) and patients who had undergone surgery in the past year (n = 16). One laparoscopic patient was lost to follow-up evaluation, whereas three laparoscopic patients and one open patient died of causes not related to cancer. No wound recurrence was observed. The local recurrence rate after laparoscopic resection was 20.8%, as compared with 16.6% after open resection (p = 0.687). Distant metastases occurred in 18.2% of the patients in the laparoscopic group, as compared with 21.2% in the open group (p = 0.528). Cumulative survival probability was 0.709 after laparoscopic resection after LR and 0.606 after open resection (p = 0.162), whereas for Dukes stages A, B, and C in the laparoscopic group versus the open group, it was 0.875 vs 0.889 (p = 0.392), 0.722 vs 0.584 (p = 0.199), and 0.500 vs 0.417 (p = 0.320), respectively. At this writing 20 laparoscopic patients (62.5%) and 20 open patients (60.6%) are disease free (p = 0.623). Conclusions: Oncologic surgical principles were respected. Long-term outcome after laparoscopic resection of rectal cancer was comparable with that after conventional resection. We should wait to draw conclusive scientific statements until the completion of ongoing international radomized controlled trials.     

Changing trends in rectal cancer surgery in Ontario: 2002–2009

Aim The safety and efficacy of laparoscopic surgery for colon cancer have been demonstrated in large, multicentre clinical trials. The study aimed to determine the use of laparoscopic surgery for rectal cancer in Ontario over a 7‐year period. Method We conducted a retrospective study examining rates of elective rectal cancer surgery among 10.5 million adults in Ontario, Canada, from 1 April 2002 to 31 March 2009. We linked the Canadian Institute for Health Information Discharge Abstract Database, the Registered Persons Database and the database of the Ontario Cancer Registry to assess procedures used over the period. Data on demographics were collected. Trends were assessed using time series analysis. Results Over the 7‐year period, 8189 open and 1079 laparoscopic elective operations for rectal cancer were identified. The annual rate of laparoscopic rectal cancer procedures increased from 0.60 per 100 000 population in 2003 to 2.24 per 100 000 population in 2008 (P < 0.01). Laparoscopic patients were similar to open with respect to age (66.5 ± 11.8 vs 66.2 ± 12.1 years; standardized difference 0.02), gender (63.2%vs 59.4%; standardized difference 0.08), Charlson Comorbidity Index score (standardized difference < 0.1) and socioeconomic status (standardized difference < 0.1). Conclusion Laparoscopic rectal cancer surgery rates are increasing in Ontario. Ongoing research regarding the long‐term safety and effectiveness of the laparoscopic approach for rectal cancer surgeries may lead to greater increases in its utilization.     

Intersphincteric resection for low rectal cancer: laparoscopic vs open surgery approach

Aim Laparoscopic sphincter‐saving surgery has been investigated for rectal cancer but not for tumours of the lower third. We evaluated the feasibility and efficacy of laparoscopic intersphincteric resection for low rectal cancer. Method From 1990 to 2007, patients with rectal tumour below 6 cm from the anal verge and treated by open or laparoscopic curative intersphincteric resection were included in a retrospective comparative study. Surgery included total mesorectal excision with internal sphincter excision and protected low coloanal anastomosis. Neoadjuvant treatment was given to patients with T3 or N+ tumours. Recurrence and survival were evaluated by the Kaplan–Meier method and compared using the Logrank test. Function was assessed using the Wexner continence score. Results Intersphincteric resection was performed in 175 patients with low rectal cancer: 110 had laparoscopy and 65 had open surgery. The two groups were similar according to age, sex, body mass index, ASA score, tumour stage and preoperative radiotherapy. Postoperative mortality (zero) and morbidity (23%vs 28%; P = 0.410) were similar in both groups. There was no difference in 5‐year local recurrence (5%vs 2%; P = 0.349) and 5‐year disease‐free survival (70%vs 71%; P = 0.862). Function and continence scores (11 vs 12; P = 0.675) were similar in both groups. Conclusion Intersphincteric resection did not alter long‐term tumour control of low rectal cancer. The safety and efficacy of the laparoscopic approach for intersphincteric resection are suggested by a similar short‐ and long‐term outcome as obtained by open surgery.