Page 31 - Journal of World Association of Laparoscopic Surgeons

Comparative Analysis of Surgical and Pathological Outcomes
open vs laparoscopic resection. Although laparoscopic procedures was difficult to make. Likewise, Lujan et al. included 4,970 patients
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took longer time (244.9 vs 197 minutes), the patients in that group with rectal cancer. They found that laparoscopic surgery resulted
had earlier return of bowel movements (38.6 vs 60 hours) and in decreased blood loss, lower 28-day morbidity, increased
shorter hospital LOS (8 vs 9 days). The results of our study correlate completeness of TME, and a 3-day decrease in the hospital LOS.
with this randomized control trial (RCT). In contrast to the CLASICC trial, the rate of CRM positivity was
With regard to operative morbidity, COLOR II trial documented significantly lower, prompting the authors’ conclusions that
equal complication rates in both laparoscopic and open laparoscopic resection is the preferred approach for patients with
surgeries (40% in lap vs 37% in open). CLASSIC trial documented rectal cancer.
intraoperative complications such as bowel injury (1% in lap vs 1% On the other hand, the American ACOSOG Z6051 trial comparing
in open), bladder injury (2% in lap vs 0% in open), ureteric injury laparoscopic to open resection of stage IIA, IIIA, or IIIB rectal cancer
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(0% in lap vs 3% in open) and postoperative complications (40% originating within 12 cm from the anal verge showed the quality
in lap vs 37% in open) such as anastomotic leakage rate (10% in of TME specimen in 462 operated patients. They reported surgeries
lap vs 7% in open) and wound infection (5% in lap vs 5% in open). as complete (77%) and nearly complete (16.5%) TME in 93.5% of the
COREAN trial documented wound infection rate (1.2% in lap vs cases. Negative circumferential radial margin was observed in 90%
6.5% in open), anastomotic leakage rate (2% in lap vs 0% in open), of the overall group (87.9% laparoscopic resection and 92.3% open

and pelvic abscess (0% in lap vs 0.6% in open). Our study reports resection; p = 0.11). Distal margin result was negative in more than
revealed intraoperative complications such as bladder injury (0% 98%of patients irrespective of the type of surgery (p = 0.91). The

in lap vs 4.5% in open) and ureteric injury (0% in lap vs 4.5% in authors of ACOSOG Z6051 trial demonstrated that laparoscopic
open) and postoperative complications (29.5% in lap vs 45.8% resection did not meet the criteria for noninferiority of pathologic
in open) such as anastomotic leakage rate (11.8% in lap vs 12.5% outcomes compared with open surgery. Only one patient of LARS
in open) and wound infection (17.6% in lap vs 37.5% in open) with group had positive circumferential resected margin and one patient
no statistical significant differences made between laparoscopic in ORS group had positive distal resected margin.
and open surgeries. Our results are therefore comparable with the Stevenson et al. randomized 475 patients with T1–T3 low rectal
existing international RCTs. cancer (<15 cm from the anal verge) to undergo laparoscopic or
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With regard to 30-day mortality, CLASSIC trial and COLOR II trial open resections. The circumferential resection margin was clear
reported a mortality rate of 4% in laparoscopy, 5% in open, 1% in in 222 patients (93%) in the laparoscopic surgery group and in 228
laparoscopy, and 2% in open surgeries, respectively. Our results patients (97%) in the open surgery group (risk difference of −3.7%;
showed a 30-day mortality of 0%. A meta-analysis of prospective p = 0.06), the distal margin was clear in 236 patients (99%) in the

trials was conducted by Arezzo et al. and included 23 studies, 8 of laparoscopic surgery group and in 234 patients (99%) in the open
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which were randomized, representing a total of 4,539 patients. A surgery group (risk difference of −0.4% p = 0.67), and TME was
mortality incidence of 1.0% was observed in the laparoscopic group complete in 206 patients (87%) in the laparoscopic surgery group
compared with 2.4% in the open group (p = 0.048). A significant and 216 patients (92%) in the open surgery group (risk difference

difference was also seen in the morbidity rate between the two of −5.4%, p = 0.06). This study also failed to establish noninferiority
groups (31.8% in the laparoscopic group vs 35.4% in the open of laparoscopic surgery compared with open surgery, especially in

group; p < 0.001). patients with larger T3 tumors. The authors concluded that there
Boutros et al. retrospectively compared 234 patients is not enough evidence supporting the routine use of laparoscopy
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undergoing open or laparoscopic TME for rectal cancer. in the management of rectal cancer.
Laparoscopy was associated with longer operative time (245 vs The number of lymph nodes harvested is another parameter
213 minutes) but with less blood loss (284 vs 388 mL), shorter LOS frequently adopted to evaluate the oncological quality of the
(7 vs 8 days), and lower rates of 30-day morbidity (25 vs 43%) and surgical procedures. In our study, the mean number in the LARS
surgical site infections (9 vs 20%). Similarly, Lee et al. included group was slightly lower than ORS group. The requirement for
160 patients in their retrospective study; however, all these patients accurate pathological staging was comparable to the reported
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had stage I rectal cancer. Overall, morbidity and mortality were numbers of 11–23 for the laparoscopic groups in other studies.
similar in both the laparoscopic and open groups. The laparoscopic Considering that the number of lymph nodes may decrease after
group had longer operative time (221 vs 184 minutes) but neoadjuvant chemoradiation, the present findings were even
significantly less blood loss (150 vs 200 mL), time to first bowel more favorably comparable with previous findings in patients
movement (2.44 vs 3.54 days), rate of superficial surgical-site undergoing neoadjuvant chemoradiation as in COREAN trial
infection (0 vs 7.5%), and LOS (8 vs 11 days). (17 in lap vs 18 in open), CLASSIC trial (12 in lap vs 13.5 in open), and
ACOSOG Z6051 trial (17.9 in lap vs 16.5 in open).
Pathological Outcomes The analysis of long-term outcomes is necessary for establishing
Local recurrence is related to several oncological parameters that the value of laparoscopic surgery in the treatment of rectal cancer.
can be objectively measured. These include completeness of the None of the short-term advantages would be important if the
TME, involvement of the CRM, and number of harvested lymph incidence of local recurrence and survival was compromised.
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nodes.
In fact, in three large randomized controlled trials (COLOR II, conclusIon
CLASICC, and COREAN) and in a large-scale multicenter prospective Our study demonstrated that laparoscopic TME is safe and feasible,
review by Lujan et al., there were no statistical differences in with an oncological adequacy comparable to the open approach.
those parameters when laparoscopic and open approaches were During surgery, it seems that the operating time is longer in the
compared. 7,10,13–15 laparoscopic group with less blood loss. Important short-term
However, different standards for pathological
evaluation were applied to each study, and an overall comparison advantages will be the quicker recovery of the bowel function and

World Journal of Laparoscopic Surgery, Volume 12 Issue 1 (January–April 2019) 23