Laparoscopic proctectomy stands up to open surgery

Laparoscopic surgery produces comparable results to open surgery for rectal cancer, show the findings of the first, large, randomized trial of the technique.

Laparoscopic proctectomy resulted in similar safety, resection margins, and completeness of resection compared with the traditional approach, and also led to slightly faster recovery.

The researchers studied 1044 patients with non-metastatic TI-III rectal cancer from the COlorectal cancer Laparoscopic or Open Resection (COLOR II) study who were enrolled at 30 centers worldwide between 2004 and 2010. Patients were randomly assigned to undergo total or partial mesorectal excision by either laparoscopic (n=699) or open surgery (n=345).

The median tumor distance to distal resection margin, at 3 cm in both groups, was above the required 2 cm, and there was no significant difference between groups in the proportion of patients with positive circumferential resection margins (CRMs; <2 mm).

However, patients with upper rectal cancer (10-15 cm from the anal verge) had significantly more incomplete resections under laparoscopy than with open surgery (1.00 vs 0.29%).

Conversely, while the rate of incomplete resection was comparable, patients with cancer of the lower rectum (<5 cm from the anal verge) were significantly less likely to have positive CRMs if they underwent the laparoscopic procedure (9 vs 22% for open surgery). The authors say this is likely due to improved visualization of the lower pelvis with the laparoscope.

There was no significant difference between groups in the rate of intraoperative complications, post-operative morbidity and mortality, or the proportion of patients who required reintervention.

However, patients who underwent laparoscopic surgery recovered slightly quicker in hospital, reflected in a median time to first bowel movement of 2 days and a median hospital stay of 8 days, compared with 3 days and 9 days, respectively, among open surgery patients. Patients in the laparoscopic surgery group also had less need for epidural pain relief in the 3 days after surgery.

Despite a lack of robust large studies, a recent report showed that almost three-quarters of colorectal surgeons already perform laparoscopic proctectomy, explain Hendrik Jaap Bonjer (VU University Medical Center, Amsterdam, the Netherlands) and colleagues.

"Long-term results are necessary to determine the definitive role of laparoscopic surgery in this group of patients," they conclude in TheLancet Oncology.

The researchers add that the long-term results of their trial, including 3-year recurrence data, are expected later in the year.

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