Laparoscopically assisted transsacral resection of rectal cancer with primary anastomosis. A preliminary review

Laparoscopic resection for rectal cancer: outcomes in 194 patients and review of the literature

BACKGROUND

There are few reports on laparoscopic rectum resection demonstrating its feasibility and efficacy in patients with rectal cancer. Most patient series are small, and results must be considered preliminary and medium-term. Our large prospective conducted study aimed to assess the effectiveness of a totally laparoscopic resection for rectum carcinoma with emphasis on perioperative and long-term oncological outcomes.

METHODS

Between November 1992 and July 2003, 194 unselected patients were resected laparoscopically for rectal carcinoma. Patients with locally advanced rectum carcinoma (uT3/uT4) and no evidence of distant metastases were candidates for neoadjuvant chemoradiation. Adjuvant treatment was administered to patients with UICC stage II/III disease. All patients were followed up prospectively to evaluate complications and late outcomes. Survival probability analysis was performed using the Kaplan-Meier method. Study selection was made by Medline search using the following key words: rectal cancer, rectal neoplasms, laparoscopy, and resection. Single case reports and abstracts were excluded. When surgical series were reported more than once, only the most recent reports were considered and listed.

RESULTS

The most common procedures were low anterior resection with total mesorectum excision in 65.5% of patients and high anterior resection in 25.3%. Average operative time was 174 min. Average number of lymph nodes removed was 25.4 and length of specimen resected was 27.6 cm. Resection was curative in 145 patients and palliative in 49 cases. UICC tumor stages were as follows: stage I: 25.2%, stage II: 27.3%, stage III: 30.4%, and stage IV: 17%. Intraoperative complications were <1% for lesions of the ureter, urinary bladder, and deferent duct. Conversion to conventional surgery was necessary in two cases (1%). The most common postoperative complication was anastomotic leakage in 13.5% of patients. There was no postoperative mortality. Follow-up evaluation ranged from 1 to 128 months with a mean of 46.1 months. The most common late complication was incisional hernia in 3.6% of patients. Port-site metastases occurred in one patient (0.5%). Tumor recurrence developed in 23 of the 145 curative resected patients (11.7% distant metastases and 4.1% local recurrence). Overall local recurrence rate was 6.7% (4.1% after curative resection and 14.3% after palliative resection). Overall survival rate was 90.6% at 1 year, 74.5% at 3 years, and 66.3% at 5 years. Overall 5-year survival rate was 76.9% after curative resection and 31.8% after palliative resection. Cancer-related survival rate was 94% at 1 year, 82.4% at 3 years, and 78.9% at 5 years. At 5 years it was 87.7% after curative resection and 48.5% after palliative resection. At 5 years, the survival rate was 100% for stage I, 94.4% for stage II, 66.6% for stage III, and 44.6% for stage IV.

CONCLUSIONS

Our results and the literature review clearly demonstrate that laparoscopic resection for rectal cancer is not associated with higher morbidity and mortality. Established oncological and surgical principles are respected and long-term outcomes are at least as good as those after open surgery.

Laparoscopy and Malignancy

BACKGROUND

The advantages of pneumoperitoneum-based surgery are well documented. Laparoscopy is the gold standard of treatment in certain benign conditions such as cholelithiasis and gastroesophageal disease. This success has led to the application of laparoscopy in the management algorithm of malignant conditions. There is currently no universally accepted consensus of the role of pneumoperitoneum-based surgery in the treatment of cancer. This is due to the early reports of port site metastasis, initial lack of randomized controlled trials and the concern of performing oncologically adequate operations. The aim of this section is to review the current literature and attempt to obtain a consensus of the role of laparoscopy in the treatment of cancer.

MATERIALS AND METHODS

A literature search was conducted through Pubmed with key words laparoscopy, pneumoperitoneum, carbon dioxide, malignancy, cancer, and port site metastasis. The obtained results were divided into various sections such as non-randomized reports, randomized reports, animal studies, human studies, etc. A comparison was made between laparoscopic and open resections when possible.

RESULTS

There are several published reports of studies in animal models and in humans relating to pneumoperitoneum-based surgery in the setting of malignancy. There are also a few randomized controlled trials that compared open versus laparoscopic surgery for malignancies of various organ systems. In addition, the early reports of alarmingly high rate of port site metastasis have been scaled down to rates comparable to wound recurrences after open resections.

SUMMARY

Laparoscopy has added another dimension to the management of patients with cancer. Advanced training, superior instrumentation, and a better understanding of the pathophysiology of carbon dioxide pneumoperitoneum has led to the successful application of laparoscopy. The improved results are obtained in centers with high volume of patients and with experience in both fields of oncology and minimally invasive surgery. Laparoscopy is now an integral tool in the management algorithm of malignancies of some organ systems and its role will be further expanded in the future.

Complications are Increased with the Need for an Abdominal-Assisted Kraske Procedure

The Kraske procedure offers a sphincter-saving alternative for surgical correction of rectal disease. This study was performed to investigate the complication rate with the traditional (transsacral) Kraske procedure versus an abdominal-assisted Kraske approach (laparoscopic or open). We conducted a retrospective review of all patients undergoing the Kraske procedure at Harper University Hospital over a 10-year period. A total of 54 patients were identified. Indications for surgery included rectal carcinoma (43), large villous adenomas (6), and other (5). Average postoperative follow-up was 40 ± 25 months (mean ± SD). Complications included rectocutaneous fistulae (9), perineal infections (13), and incontinence (8). In patients requiring an abdominal-assisted approach for colorectal mobilization, the fistula rate was significantly higher (33% vs 3%; P = 0.007), as were the rates of perineal infections (33% vs 17%) and of initial incontinence (25% vs 7%). The laparoscopic-assisted approach significantly reduced the operating time (272 ± 72 minutes) compared to the open-assisted approach (498 ± 138 minutes) ( P < 0.001). The traditional Kraske procedure can be utilized in a safe, effective manner for treatment of rectal disease. Knowledge of the increased rate of complications with the abdominal-assisted Kraske approach can guide the patient and physician considering sphincter salvage.