Resection of rectal cancer: laparoscopy or open surgery?

Laparoscopic TME offers better short-term outcomes without oncological compromise when compared to open TME Advances in instrumentation and imaging technology coupled with increased surgical skill, training and experience have led to several successful reports of laparoscopic resection for rectal cancer with TME and increasing evidence that this is appropriate.5–12 Clinical and short-term results of the larger randomised and non-randomised studies comparing laparoscopic with open rectal resections are shown in Table 1. [...]laparoscopy induces lesser physiological and immunological insults which may contribute to better long-term oncological outcomes.4 Table 2 Oncological/long-term outcomes for laparoscopic versus open rectal resection Table 2 Oncological/long-term outcomes for laparoscopic versus open rectal resection Study MRC CLASICC Trial (RCT) 20051,2 Lujan (RCT)6 2009 Laurent7 (NRCT) 2009 Braga (RCT)8 2007 Bretagnol (NRCT) 200510 Law (NRCT) 200611 Morino (NRCT) 200512 Portsmouth (unpublished) Lap Open Lap Open Lap Open Lap Open Lap Open Lap Open Lap Open Lap Open Sample size 253 128 101 103 238 233 83 85 144 144 98 167 98 93 106 62 CRM involvement < 1 mm (%) 16 14 4 2.9 7 6 1 2 6 6 3.1 4.8 – – 2 7 RO resection rate (%) – – – – 92 94.8 – – 93 90 – – – – 98 93 LN yield (median) (12) (incl. colons) (13.5) 13.6 11.6 (P= 0.026) – – 12.7 13.6 10 12 (P= 0.03) 10 11 12 10 11 12 Local recurrence rate (%) 7.8 (3-yr) 7 4.8 (5-yr) 5.3 3.9 (5-yr) 5.5 4 (3-yr) 5.2 1.4 – 3.3 (3-yr) 4.9 3.2 12.6 (P= 0.038) – – Cancer-free survival rate (%) 70.9 (3-yr) 70.4 84.8 (5-yr) 81 82 (5-yr) 79 Same (5-yr) Same (5-yr) 77 (3-yr) Same (3-yr) Same (3-yr) Same (3-yr) 65.4 (5-yr) 58.9 – – Overall survival rate (%) 74.6 (3-yr) 66.7 72.1 (5-yr) 75.3 83 (5-yr) 72 (P = 0.003) Same (5-yr) Same (5-yr) 89 (3-yr) Same (3-yr) Same (3-yr) Same (3-yr) 80 (5-yr) 68.9 – – Length of follow-up (months) 36.8 36.8 32.8 34.1 52 52 54.2 54.2 18 18 21.2 21.2 46.3 49.7 – – RCT, randomised controlled trial; NRCT, non-randomised controlled trial. A recent systematic review and meta-analysis comparing short- and medium-term outcomes of over 1400 laparoscopic versus 1755 open TMEs concluded that there were no oncological differences between laparoscopic and open resections for treatment of primary rectal cancer.5 Technical issues related to laparoscopic TME surgery Obesity, the male pelvis, pre-operative long course chemoradiotherapy, and locally advanced tumours all increase the difficulty of laparoscopic