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Laparoscopic, open surgery yield similar outcomes for rectal cancer
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Patients with rectal cancer demonstrated comparable rates of locoregional recurrence, DFS and OS when they underwent laparoscopic or open surgery, according to study results.
“Laparoscopic surgery has progressively replaced open colonic surgery in recent decades owing to favorable short-term outcomes, such as less pain, reduced blood loss and improved recovery time,” H. Jaap Bonjer, MD, PhD, of the department of surgery at the VU Medical Center Amsterdam, and colleagues wrote. “In various trials in which patients with colon cancer were randomly assigned to undergo either open or laparoscopic surgery, evidence was obtained that laparoscopic surgery was associated with similar [DFS] and [OS] rates as open surgery.”
However, conclusive evidence that laparoscopic surgery is noninferior to open surgery in rectal cancer was lacking, according to study background.
The analysis included 1,044 patients with a solitary adenocarcinoma of the rectum from 30 centers in eight countries. The majority of patients (n = 659) were men.
Researchers randomly assigned patients to laparoscopic surgery (n = 699) or open surgery (n = 345). Follow-up examinations took place each year for 5 years after index surgery.
Locoregional recurrence in the pelvic or perineal area 3 years after surgery served as the study’s primary endpoint. DFS and OS served as secondary endpoints.
Locoregional recurrence at 3 years occurred in 5% of patients in the laparoscopic surgery (n = 31) and open surgery arms (n = 15; difference, 0 percentage points; 90% CI, –2.6 to 2.6). The as-treated analysis indicated rates for locoregional recurrence varied in the laparoscopic and open surgery arms with regard to tumor location for upper (3% vs. 3.9%), middle (5.7% vs. 4.1%) and lower rectal cancers (3.8% vs. 12.7%).
Three-year DFS was 74.8% in the laparoscopic surgery arm and 70.8% in the open surgery arm (difference, 4 percentage points; 95% CI, –1.9 to 9.9). DFS rates were comparable in both groups among patients with stage I and stage II rectal cancer; however, patients with stage III rectal cancer demonstrated greater DFS rates in the laparoscopic arm (64.9% vs. 52%; difference, 12.9 percentage points, 95% CI, 2.2-23.6).
OS rates also were similar in the laparoscopic and open surgery cohorts (86.7% vs. 83.6%; difference, 3.1 percentage points, 95% CI, –1.6 to 7.8). Researchers noted OS rates were similar between the arms in analyses stratified by tumor stage.
The rate for distant metastases 3 years after surgery was 19.1% in the laparoscopic surgery arm and 22.1% in the open surgery arm.
The absence of centralized macroscopic and microscopic evaluation of the resected specimens and the use of different imaging methods to determine tumor location may be limitations to these findings, the researchers wrote.
“Laparoscopic surgery is as safe and effective as open surgery in patients with rectal cancer without invasion of adjacent tissues,” Bonjer and colleagues concluded. “Further studies are necessary to determine whether laparoscopic surgery for cancer is associated with improved survival.” – by Cameron Kelsall
Disclosure: Bonjer reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Joshua Shaeffer Hill, MD, MS
The recent publication of the COLOR II study group trial, which compared oncologic outcomes between open and laparoscopic surgery for rectal cancer, provides important information for surgeons. During the past decade, there has been a rapid adoption of minimally invasive techniques for the treatment of colon cancer. However, concern for the feasibility of and outcomes after minimally invasive rectal surgery remained due to the confined space of the pelvis. The COLOR II trial, as recently published in The New England Journal of Medicine, demonstrates that these concerns are false.In a very well designed trial, the COLOR II group randomly assigned patients to either an open or laparoscopic total mesorectal excision (TME) operation. Salient points of the study design include a standardized method of reviewing the completeness of the TME specimen, and the inclusion of tumors within all zones of the rectum.
The major finding that locoregional recurrence rates were lower in the minimally invasive group compared with the open surgery cohort adds to a growing body of literature that supports the oncologic outcomes of laparoscopic surgery. The authors discuss improvements in visualization afforded by laparoscopic surgery as a plausible mechanism for this effect. In my practice, I wholeheartedly agree with this assessment. The avascular plane surrounding the mesorectum can be difficult to trace in a narrow pelvis. The use of a magnified laparoscope can overcome the anatomic limitations, allowing for a complete mesorectal excision.
It is well established that minimally invasive surgery can improve patient recovery, but the improvements in oncologic outcomes will be a driving force in the adoption of minimally invasive techniques and patient referral.
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