Outcomes favor laparoscopic surgery for rectal cancer

Laparoscopic anterior resection for upper rectal cancer is associated with fewer long-term complications than is open surgery, whereas 10-year oncologic outcomes are similar between the two approaches, according to the results of a prospective randomized trial.

At 10 years, the probability of cancer specific survival in the 153-patient study was 82.6% in the Laparoscopic group, compared with 76.2% for the open surgery patients.

The overall recurrence rates of both groups were similar (16.9% among laparoscopic patients and 17.9% for those who underwent open resection), as were the 10-year disease-free probabilities (at 82.6% and 80.2%, respectively), reported at the annual meeting of the American Society of Colon and Rectal Surgeons.

Although past studies have shown that the treatment of colon cancer with laparoscopic surgery results in better short-term clinical outcomes than — and similar oncologic clearance as — open surgery, data on rectal cancer are scarce.

Previously, at the Prince of Wales Hospital, Hong Kong, reported the 5-year results of a randomized trial comparing laparoscopic and open resection for cancer of the upper rectum, rectosigmoid junction, and sigmoid colon. Those results indicated that there was a short-term benefit from laparoscopic surgery and no negative impact on disease control.

The current study was conducted as a follow-up to that investigation, and looked specifically at the long-term morbidity and 10-year oncologic outcomes of a subgroup of patients who underwent treatment for upper rectal cancer (defined as adenocarcinoma located 12-15 cm from the anal verge).

Between September 1993 and October 2002, the investigators randomly assigned 153 patients with upper rectal cancer to receive either laparoscopic resection (76 patients) or open resection (77 patients). Five patients who died prior to surgery were excluded from the outcome evaluation. There were no differences in age, gender, comorbidities, or level of tumor between the two groups.

After surgery, all of the patients in the study were followed regularly at 3-month intervals for the first 2 years, at 6-month intervals until year 5, and annually thereafter until June 2007. The median follow-up period in both treatment groups was at least 9 years.

The primary outcome measure was long-term morbidity, which included any surgical complication requiring readmission or treatment that occurred after discharge, and late complications occurring more than 30 days following primary surgery.

Recurrence and survival were recorded as secondary outcomes.

The results showed that postoperative recovery was better after laparoscopic surgery, with earlier return to bowel function and mobilization.

With respect to long-term morbidity, survival, and disease-free survival, the outcome analysis showed that significantly more patients in the open surgical group developed adhesive intestinal obstruction requiring hospitalization and intervention, compared with patients in the laparoscopic group.

“Only 2 patients in the laparoscopic group developed adhesive bowel obstructions, while 14 in the open group experienced this complication.”

Additionally, “the overall long-term morbidity was significantly higher in the open group,” at 24.3% compared with 10.8%.

“The finding suggest that laparoscopic-assisted anterior for upper rectal cancer improves postoperative recovery compared with open surgery and, importantly, does not jeopardize long-term survival.”

Future long-term studies are needed to compare functional outcomes and quality of life issues related to laparoscopic rectal cancer surgery.