Laparoscopic Versus Open Surgery for Rectal Cancer
Annals of Surgery • Volume 250, Number 1, July 2009                                                Laparoscopic Surgery fo...
Laurent et al                                                                 Annals of Surgery • Volume 250, Number 1, Ju...
Annals of Surgery • Volume 250, Number 1, July 2009                                              Laparoscopic Surgery for ...
Laurent et al                                                                 Annals of Surgery • Volume 250, Number 1, Ju...
Annals of Surgery • Volume 250, Number 1, July 2009                                                        Laparoscopic Su...
Laurent et al                                                                    Annals of Surgery • Volume 250, Number 1,...
Annals of Surgery • Volume 250, Number 1, July 2009                                                                       ...
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Laparoscopic In Ca Rectal

  1. 1. ORIGINAL ARTICLES Laparoscopic Versus Open Surgery for Rectal Cancer Long-Term Oncologic Results Christophe Laurent, MD, PhD, Fabien Leblanc, MD, Philippe Wutrich, MD, Mathieu Scheffler, MD, ¨ and Eric Rullier, MD vation7–11 and more importantly a lack of long-term data from large Objective: The goal was to assess long-term oncologic outcome after scale series. laparoscopic versus open surgery for rectal cancer and to evaluate the impact A recent meta-analysis including 3 randomized studies has of conversion. compared laparoscopic versus open surgery specifically for rectal Summary Background Data: Laparoscopic resection of rectal cancer is cancer12; however, only short- and mid-term outcomes are available. technically feasible, but there are no data to evaluate the long-term outcome Clearly, laparoscopic rectal resection is feasible with similar com- between laparoscopic and open approach. Moreover, the long-term impact of plication rates, less pain, an earlier return of bowel function, a conversion is not known. shorter hospital stay and facilities to resume social activities com- Methods: Between 1994 and 2006, patients treated by open (1994 –1999) pared with open surgery. Nevertheless, technical difficulties induce and laparoscopic (2000 –2006) curative resection for rectal cancer were a high rate of conversion that may increase morbidity, especially in included in a retrospective comparative study. Patients with fixed tumors or converted patients.13 Although the oncologic safety seems to be metastatic disease were excluded. Those with T3–T4 or N disease received identical between laparoscopic and open rectal excision with similar long course preoperative radiotherapy. Surgical technique and follow-up rates of safe margins,12 there is no comparative data evaluating the were standardized. Survival were analyzed by Kaplan Meier method and 5-year survival. In addition, the long-term outcome of converted compared with the Log Rank test. patients has never been investigated. Results: Some 471 patients had rectal excision for invasive rectal carcinoma: Because definitive long-term results are not yet available, 238 were treated by laparoscopy and 233 by open procedure. Postoperative oncologic adequacy of laparoscopic total mesorectal excision mortality (0.8% vs. 2.6%; P 0.17), morbidity (22.7% vs. 20.2%; P (TME) for treatment of rectal cancer remains unproven. The aim of 0.51), and quality of surgery (92.0% vs. 94.8% R0 resection; P 0.22) were our comparative retrospective study was to assess long-term out- similar in the 2 groups. At 5 years, there was no difference of local come after laparoscopic versus open surgery for rectal cancer, and to recurrence (3.9% vs. 5.5%; P 0.371) and cancer-free survival (82% vs. evaluate the long-term impact of conversion. 79%; P 0.52) between laparoscopic and open surgery. Multivariate analysis confirmed that type of surgery did not influence cancer outcome. Conversion (36/238, 15%) had no negative impact on postoperative mortal- ity, local recurrence, and survival. MATERIALS AND METHODS Conclusions: The efficacy of laparoscopic surgery in a team specialized in Patients’ Selection rectal excision for cancer (open and laparoscopic surgery) is suggested with From 1994 to 2006, patients with rectal cancer within 15 cm similar long-term local control and cancer-free survival than open surgery. from anal verge treated by open or laparoscopic curative rectal Moreover, conversion had no negative impact on survival. excision were included in a retrospective study. Evaluation included (Ann Surg 2009;250: 54 – 61) physical examination, colonoscopy with biopsy, endorectal ultra- sonography, and abdominal and pelvic computed tomography scan). Pelvic magnetic resonance imaging was performed routinely since 2003. Rigid rectoscopy was performed to assess the exact level of the tumor from the anal verge. Patients were staged using the clinical T he advent of minimally invasive surgical techniques has given surgeons the option of a laparoscopic approach in the treat- ment of colorectal cancer. The safety and oncologic efficacy of tumor node metastasis classification. Those with T3, T4, or N disease received long-course preoperative radiochemotherapy (45 Gy in 5 weeks with concomitant 5-fluorouracile) and the schedule laparoscopy has been demonstrated for colonic cancer1–5 with was similar during all the period study. After both open and recently confirmation of similar long-term results at 5-year from laparoscopic surgery, patients with stage III disease (ie, positive the COST study group trial.6 However, regarding rectal cancer lymph nodes 1–2) received postoperative adjuvant chemotherapy surgery laparoscopic resection remains controversial mainly because with 5-fluorouracil and folinic acid for 6 months. of a steep learning curve and technical challenges, including diffi- Criteria for laparoscopic approach was tumor growing inside culties for pelvic exposure, rectal dissection, and sphincter preser- the rectum and mesorectum, ie, without invasion of adjacent organ (stages T1, T2, and T3), whatever the level of the lesion (0 –15 cm from the anal verge). Criteria for open surgery were preoperative From the Department of Colorectal Surgery, Saint-Andre Hospital, University of suspicion of fixed tumor into adjacent organ (T4 tumor) needing Bordeaux, Bordeaux, France. extended TME, synchronous liver metastasis suitable for simulta- Presented at the third French Digestive and Hepatobiliary meeting, Paris, France, December 6 – 8, 2007; at the 10th World Congress on Gastrointestinal Cancer, neous resection, and associated disease needing extensive colectomy Barcelona, Spain, June 25–28, 2008; and at the ESCP European Society of (polyposis, ulcerative colitis, and second cancer). To obtain homo- Coloproctology, Nantes, France, September 2008. geneous groups in our comparative study, we included only patients Reprints: Christophe Laurent, MD, PhD, Service de Chirurgie Digestive, Hopitalˆ who had inclusion criteria for a laparoscopic treatment. Patients Saint-Andre, 33075 Bordeaux, France. E-mail: christophe.laurent@chu-bordeaux.fr. ´ Copyright © 2009 by Lippincott Williams & Wilkins treated by a laparoscopic approach between 2000 and 2006 were ISSN: 0003-4932/09/25001-0054 compared with those treated by open surgery between 1994 and DOI: 10.1097/SLA.0b013e3181ad6511 1999. 54 | www.annalsofsurgery.com Annals of Surgery • Volume 250, Number 1, July 2009
  2. 2. Annals of Surgery • Volume 250, Number 1, July 2009 Laparoscopic Surgery for Rectal Cancer Surgical Technique allowing symptomatic therapeutic as antiemetics, antipyretics, anal- Surgery was performed 6 weeks after radiotherapy. All pa- gesics, diuretics, electrolytes, and physiotherapy. This grade also tients had a mechanic bowel preparation the day before the operation included wound infections opened at the bedside. Grade II included and antibioprophylaxia was given during the surgical procedure. pharmacological treatment with drugs other than such allowed for Patients were operated by 2 colorectal surgeons trained in open and grade I complications (antibiotics, parenteral nutrition, and blood laparoscopic surgery (E.R. and C.L.). The surgical technique of open transfusions). Grade III was postoperative complications requiring and laparoscopic TME has been previously described.14,15 The surgical, endoscopic, or radiologic intervention with or without technique was standardized as follows: (1) for upper third rectal general anesthesia. Grade IV included life-threatening complication tumors, a 5-cm mesorectal excision (partial TME) with end-to-end requiring intensive care unit management. Grade V was defined by colorectal anastomosis was performed, (2) for mid and low rectal postoperative death of the patient. Minor surgical morbidity was tumors, TME with pouch supra-anal or anal anastomosis was indi- considered as grades I or II and major morbidity as grades III, IV, or cated, and (3) abdominoperineal excision was performed when the V. After surgery, patients were followed prospectively every 6 levator muscle was invaded. The same steps were applied in both months for 5 years. Each consultation included clinical examination, laparoscopic and open procedures. High ligation of the inferior abdominal and pelvic computed tomography scan, and chest x-ray. mesenteric artery and mobilization of the splenic flexure were Colonoscopy was performed 1 year after surgery, then every 5 years. systematically performed first. Mesorectal excision (total or partial) Local recurrence was defined as any recurrence diagnosed or sus- included complete removal of the mesorectum circumferentially pected in the pelvis (tumor bed, pelvic nodes, anastomosis, drain with preservation of the hypogastric and pelvic plexuses. Extra site, or perineum) occurring alone or with other distant metastases. facial anatomic dissection of the mesorectum was performed with Distant metastases were defined as any recurrence occurring outside scissors and bipolar coagulation. The rectum was transected with a the pelvis. linear stapler (Roticulator Endo-GIA 45, Covidien Healthcare Group, Norwalk, Conn for laparoscopic group or TA 45 for open group) or transanally according to the level of the tumor. For very Statistical Analysis low tumors, intersphincteric resection was performed to achieve Data were collected prospectively using a computerized data sphincter preservation with clear distal margin.16 The anastomosis base. Quantitative data were given as median (range). Difference was fashioned using a mechanical circular stapler (Proximate ILS, between laparoscopic and open groups was assessed by Mann- Ethicon endosurgery, Cincinnati, OH) or a coloanal hand-sewn. A Whitney and 2 tests or Fisher exact test when appropriate. Com- colonic pouch was performed when feasible. A loop ileostomy was parisons between the 2 groups were made on the intention-to-treat performed when the anastomosis was below 5 cm from the anal basis: patients in the laparoscopic group converted to the open verge.17 All patients had a pelvic suction drain. In the laparoscopic procedure were not excluded from the analysis. Time to last fol- group, because of potential technical difficulties to achieve low low-up evaluation, treatment failure, or death was measured from rectal dissection and low rectal stapling, the distal part of rectal the date of rectal excision. dissection was performed by the perineal approach and a manual Recurrence and survivals (cancer-free and overall) were eval- coloanal anastomosis was done. In this case, we perform first the uated by using the Kaplan-Meier and compared with the log-rank pelvic dissection by laparoscopic approach, then we transacted the test. Analysis of predictive factors of survival was performed. low rectum through the anus and we removed the specimen transa- Variables analyzed were sex, age, body mass index, tumor height, nally before performing the hand-sewn anastomosis. This strategy tumor stage, surgical approach (laparoscopic vs. open surgery), optimized to obtain both distal and circumferential safe margins, and quality of resection (R0 vs. R1), surgical morbidity, preoperative decreased pitfalls due to a difficult laparoscopic low stapling. Con- version to an open operation was defined as a conventional midline laparotomy, ie, an abdominal incision greater in size than that needed for specimen retrieval.18 Postoperative analgesia was ensured by intravenous morphine chloridrate (patient-controlled administration) at a maximum of 4 mg per hour with a single dose of 1 mg and free interval of 10 minutes for 1 to 2 days. Patients in both groups were treated according to the same postoperative protocol: nasogastric tube removal at the end of the surgical procedure, fluids intake on postoperative day 1, oral solid food at postoperative day 2 or 3, and bladder catheter removal on postoperative day 3. Pathologic Assessment The rectal specimen was examined in the operative room by the surgeon to assess distal resection margin, then addressed freshly to the pathologic department pinned on a cork board with moderate tension. The surface of the mesorectum was inked before slicing to assess the circumferential resection margin. Microscopic assessment included tumor infiltration through the bowel wall (pT), presence of positive lymph nodes, and distal and circumferential resection mar- gins. The resection margin was considered as negative if 1 mm (R0) and positive if 1 mm (R1). Follow-Up Morbidity was stratified as recommended by Dindo et al.19 Grades I was any deviation from the normal postoperative course FIGURE 1. Patient selection. © 2009 Lippincott Williams & Wilkins www.annalsofsurgery.com | 55
  3. 3. Laurent et al Annals of Surgery • Volume 250, Number 1, July 2009 radiotherapy, and adjuvant chemotherapy. Only variables associated with survival with P 0.20 in the univariate analysis were used for TABLE 2. Postoperative Morbidity multivariable analysis using a stepwise Cox proportional hazards Laparoscopy Open regression model. Statistical significance was defined as P 0.05. (n 238) (n 233) n % n % P RESULTS Postoperative mortality 2 0.8 6 2.6 0.172 Postoperative morbidity 77 32.0 88 37.7 0.139 Population Study Pelvic sepsis 28 11.8 30 12.9 0.860 Between January 1994 and December 2006, 732 patients with Anastomotic leakage 12 15 rectal cancer were admitted in our colorectal unit. Of these, 261 Isolated pelvic abscess 10 10 were excluded from the study. The details for exclusion are given in Distal colonic ischemia 4 3 Figure 1. A total of 471 consecutive patients underwent curative Pouch leakage 2 2 rectal excision for rectal cancer and formed the basis of the study: 238 were treated by laparoscopic and 233 by open surgery. The 2 Peritonitis 6 5 groups were similar according to age, sex, body mass index, tumor Pelvic hemorrhage 6 7 stage, postoperative chemotherapy, and protective ileostomy (Table Bowel obstruction 20 21 1). In the laparoscopic group, patient’s ASA score was lower than in Abdominal wall abscess 4 9 the open group and the tumors were slightly lower (50.8% vs. 39.5% Cardio respiratory 2 7 insufficiency Neurological insufficiency 3 4 Urinary dysfunction 7 2 TABLE 1. Demographic Data Phlebitis/Pulmonary 1 3 embolism Laparoscopy Open (n 238) (n 233) Grade of surgical 0.506 morbidity n % n % P Dindo I–II 184 73.3 186 79.8 Age, yr (range) 66 (22–87) 67 3 (2–91) 0.077 Dindo III–V 54 22.7 47 20.2 Sex 0.068 Hospital stay, d (range) 9 (4–92) 16 (3–66) 0.001 Male 140 58.8 156 67.0 Female 98 41.2 77 33.0 Body mass index, kg/m2 24 (16–38) 25 (15–41) 0.138 (range)* of low rectal cancer), receiving more frequently preoperative radio- ASA score* 0.001 therapy (74.8% vs. 63.9%), and sphincter preservation (96.6% vs. 1–2 220 92.4 172 74.5 83.7%). Two-third of patients treated by preoperative radiother- 3–4 18 7.6 59 25.5 apy received concomitant preoperative chemotherapy (75% vs. 68%, P 0.062). Tumor height, cm 0.021 0–5 121 50.8 92 39.5 Short-Term Outcome 5–10 88 37.1 96 41.2 Postoperative mortality and surgical morbidity were similar 10–15 29 12.2 45 19.3 in both groups (Table 2). Mortality included pelvic sepsis in 1 case Pathological tumor stage 0.106 and pulmonary embolism in 1 case in the laparoscopic group and I 110 46.2 87 37.3 pelvic sepsis in 2 cases and cardio-respiratory insufficiency in 4 II 55 23.1 70 30.0 cases in the open group. Major surgical morbidity (22.7% vs. III 76 30.7 76 32.6 20.2%) and especially pelvic sepsis, ie, anastomotic leakage or Surgical procedure 0.001 pelvic abscess (11.8% vs. 12.9%) were similar between laparoscopic Anterior resection 230 96.6 195 83.7 and open surgery. The rate of conversion was 15.1% (36/238). The most Hartmann procedure 2 0.9 7 3.0 common reasons for conversion were difficulty for pelvic dissec- Abdominoperineal 6 2.5 31 13.3 tion (n 10) and rectal fixity not detected by preoperative imaging resection (n 5). There was no difference of postoperative mortality (0% vs. Protective ileostomy 0.347 1%; P 1.000) and morbidity (16.7% vs. 23.8%; P 0.349) Yes 157 66.0 144 61.8 between converted and not converted patients. No 81 34.0 89 38.2 In the overall series (n 471), the rate of complete micro- Preoperative 0.011 scopic excision (R0 resection) was 93.4%. The rates of negative radiotherapy distal or circumferential margins and R0 resection were similar Yes 178 74.8 149 63.9 between laparoscopic and open rectal surgery (Table 3). There was No 60 25.2 84 36.1 no difference between converted and not converted patients. Postoperative 0.152 chemotherapy* Long–Term Outcome Yes 100 42.2 108 48.9 The median follow-up was 52 (range, 1–151) months; 8 No 137 57.8 113 51.1 patients were lost for follow-up at 2, 4, 7, 8, 12, 17, 19, and 27 months. The rate of local recurrence at 5 years was 3.9% in the *Missing data. laparoscopic group and 5.5% in the open group (P 0.371). No 56 | www.annalsofsurgery.com © 2009 Lippincott Williams & Wilkins
  4. 4. Annals of Surgery • Volume 250, Number 1, July 2009 Laparoscopic Surgery for Rectal Cancer patient had port-side metastasis. At 5 years, there was no difference TABLE 3. Quality of Surgery After Rectal Excision for Rectal of metastasis (20.6% vs. 24.9%; P 0.415) and median time for Cancer recurrence (16.9 vs. 15.9 months; P 0.827) between laparoscopic Laparoscopy Open and open surgery. n % n % P The 5-year cancer-free survival was similar between the laparoscopic and the open group, 82% versus 79% (Fig. 2A). No Distal margin 0.176 difference according to the tumor stage was observed (Fig. 2B). By Negative 231 97.1 231 99.1 contrast, the 5-year overall survival was higher in the laparoscopic Positive 7 2.9 2 0.9 group compared with the open group 83% versus 72% (Fig. 3A) and Circumferential margin 0.680 this difference was observed specifically in the subgroup stage III 1 mm 213 93.0 173 94.0 (Fig. 3B). These results were not influenced by postoperative che- 1 mm 16 7.0 11 6.0 motherapy, which was given similarly after laparoscopic and open Quality of resection 0.215 surgery, especially for stage III (78% vs. 70%, P 0.279). Results R0 219 92.0 221 94.8 of univariate and multivariate analyses for predictive factors of R1 19 8.0 12 5.2 survival are in Tables 4 and 5. Predictive factors of both cancer-free and overall survival were tumor stage, quality of resection (R1 vs. FIGURE 2. A, Cancer-free survival after rectal excision for rectal can- cer. B, Cancer-free survival accord- ing to tumor stage. © 2009 Lippincott Williams & Wilkins www.annalsofsurgery.com | 57
  5. 5. Laurent et al Annals of Surgery • Volume 250, Number 1, July 2009 FIGURE 3. A, Overall survival after rectal excision for rectal cancer. B, Overall survival according to tumor stage. R0), and surgical morbidity. Open surgery was a factor of overall Few studies have compared laparoscopic versus open rectal but not cancer-free survival. excision for rectal cancer.20 –25 In our study, we observed no In the laparoscopic group, there was no difference between difference in mortality and morbidity between laparoscopic and converted and not converted patients in terms of local recurrence, open surgery, especially the rate of pelvic sepsis was similar in both metastasis, cancer-free, and overall survival (Table 6) (Fig. 4). groups. Our results are in accordance with the short-term outcome of previous series12,20 –26 and confirm the safety of laparoscopic sur- DISCUSSION gery for rectal cancer. Microscopic assessment of the specimen is a This study was designed to compare the long-term outcome well-recognized indicator of quality of resection in rectal cancer after laparoscopic and open surgery for rectal cancer. At our knowl- surgery. Both distal and circumferential resection margins are risk edge, this is the first unicentric comparative series including more factors of recurrence after rectal excision.27,28 Only 4 comparative than 400 curative rectal excisions with 5 years results. We observed studies reported data of circumferential margin.13,21–23 The MRC similar quality of surgery, ie, R0 resection and demonstrated no CLASICC trial13 demonstrated a higher rate of positive circumfer- difference in local recurrence and cancer-free survival at 5 years ential margin after laparoscopic compared with open anterior resec- between laparoscopic and open surgery. In addition, we showed that tion (12% vs. 6%; P 0.19). These results may be due to the conversion had no negative impact on 5-year survival. learning curve associated with the surgical technique. Indeed, in our 58 | www.annalsofsurgery.com © 2009 Lippincott Williams & Wilkins
  6. 6. Annals of Surgery • Volume 250, Number 1, July 2009 Laparoscopic Surgery for Rectal Cancer TABLE 4. Prognostic Factors of 5 Year Survival: Univariate Analysis No. Patients Cancer-Free Survival (%) P Overall Survival (%) P 471 81 77 Age, yr 0.880 0.001 66 244 80 84 66 227 81 70 Sex 0.071 0.018 Male 296 78 73 Female 175 85 85 Body mass index* 0.796 0.189 25 kg/m2 229 80 75 25 kg/m2 217 81 81 Tumor height, cm 0.388 0.812 0–5 213 79 80 5–10 184 80 74 10–15 74 85 77 Pathological tumor stage 0.001 0.001 I 197 94 93 II 125 83 74 III 149 61 60 Preoperative radiotherapy 0.209 0.160 Yes 327 80 79 No 144 82 74 Surgical approach 0.515 0.003 Laparoscopy 238 82 83 Open 233 79 72 Quality of resection 0.001 0.003 R0 440 83 79 R1 31 48 54 Surgical morbidity 0.002 0.001 Yes 101 68 54 No 370 83 83 Adjuvant chemotherapy* 0.029 0.098 Yes 208 77 81 No 250 84 74 *Missing data. TABLE 6. Outcome After Laparoscopic Rectal Excision TABLE 5. Cancer-Free and Overall Survival: Multivariate According to Conversion Analysis Not Converted Converted Hazard Ratio (95% CI) P* Cancer-free survival n % n % P Tumor stage III vs. I 6.85 (3.50–13.40) 0.001 Short-term outcome Tumor stage II vs. I 2.99 (1.40–4.04) 0.004 Postoperative mortality 0 0.0 1 1.0 1.000 Tumor stage III vs. II 2.29 (1.30–4.04) 0.004 Surgical morbidity 6 16.7 48 23.8 0.349 R1 resection 2.64 (1.46–4.77) 0.001 Long-term outcome Surgical morbidity 2.27 (1.64–4.37) 0.001 5-yr local recurrence 3.5 3.8 0.739 Overall survival 5 yr distant recurrence 19.4 19.9 0.466 Age 66 yr 2.08 (1.33–3.24) 0.001 5-yr cancer-free survival 79 83 0.383 Tumor stage III vs. I 5.13 (2.89–9.10) 0.001 5-yr overall survival 91 83 0.350 Tumor stage II vs. I 3.41 (1.91–6.10) 0.001 Open procedure 2.17 (1.40–3.36) 0.001 R1 resection 2.34 (1.23–4.46) 0.010 study resection margins did not differ between laparoscopic and Surgical morbidity 3.86 (2.54–5.87) 0.001 open surgery (7% vs. 6% of positive circumferential margin), although most patients had low anterior resection (97% in the *Cox proportional hazard regression model. laparoscopic group). Our results are similar to those of skilled © 2009 Lippincott Williams & Wilkins www.annalsofsurgery.com | 59
  7. 7. Laurent et al Annals of Surgery • Volume 250, Number 1, July 2009 FIGURE 4. Cancer-free survival in the laparoscopic group according to conversion. teams21–23 and support the concept that laparoscopic approach for converted patients13; however, mid- or long-term outcome of con- rectal cancer is an oncologic safe procedure. verted patients was not analyzed.24 This question seems relevant Oncologic outcome after laparoscopic versus open rectal because a German study reported a higher rate of local recurrence excision has been reported in 2 randomized23,24 and 3 no random- after converted compared with not converted patients: 16% versus ized studies.20,22,25 Although these series suggested no difference of 6.9%.25 Reasons for conversion were tumor fixity and rectal perfo- survival between groups, in 3 studies the follow-up was less than 3 ration, 2 factors associated with a higher risk of local recurrence.35 years22,24,25 and 2 studies included patients with synchronous met- Our series is the first evaluating the 5-year survival in the sub group astatic disease.20,23 Moreover, some series analyzed mainly early of converted patients after laparoscopic TME for rectal cancer. The rectal cancer22 and upper rectal tumors.22,23,25 In the present study, rate of conversion was 15%. At 5 years, the rate of local recurrence more than 80% of the lesions were mid and low rectal tumors and was 3.5% in converted patients and 3.8% in not converted patients most of them were locally advanced. All patients were treated with (P 0.739), and the cancer-free survival was 79% versus 83%, curative intention, no patient had metastatic disease, and the median respectively. The lack of negative long-term impact of conver- follow-up was 52 months. We observed a low local recurrence rate sion in our experience is in accordance with the lack of rectal with no difference between laparoscopic and open surgery, 3.9% perforation in our series due to exhaustive preoperative imaging versus 5.5%. These good results at 5 years are in accordance with assessment, optimal patient selection, and policy for early con- the high rate of R0 resection in the study (92% vs. 95%) and are due version.18 to specialization in TME surgery in our department.15,16 We also The present study was obviously limited in that patients were demonstrated a similar 5-year cancer-free survival between the 2 not randomized into the 2 treatments arms. Although the patient groups. Indeed, by using multivariate analysis, the surgical approach ASA score was higher in the open group and tumors were lower in was not found to influence cancer outcome. Therefore, these find- the laparoscopic group, there was no difference in tumor staging in ings confirm the results of previous series20,22,23 showing that each group. We therefore believe our results are consistent. This specialized laparoscopic surgeons can obtain similar long-term on- study has confirmed the feasibility of the laparoscopic TME for cologic results than open surgeons for rectal cancer. rectal cancer and demonstrated similar local recurrence and cancer- In our study, the overall survival at 5 years was better in the free survival at 5 years between laparoscopic and open TME. It also laparoscopic than in the open group, especially in tumor stage III. demonstrated that long-term outcome was not altered by conversion. Two series similarly reported a higher survival due to the laparo- These results were obtained by a team specialized in both open and scopic approach after colorectal surgery,20,29 again for stage III. The laparoscopic TME, operating a high volume of cases. They must potential impact of laparoscopic surgery on survival is not clear. The therefore be confirmed at a national level to verify the potential role of immunosuppression has been suggested because mediators of impact of specialization and volume on outcome. In the future, the immunologic response (TNF alpha, interleukin 1– 6, and C-reactive laparoscopic surgery should become a standard in selected rectal protein) are decreased after laparoscopic compared with open colo- cancer, due to the development of technology,36 specialization of rectal surgery.30,31 On the other hand, immunosuppression facili- surgeons, and demonstration of the advantages of the procedure.37 tates both septic complications32 and neoplastic cell prolifera- tion.33,34 Laparoscopic surgery could therefore increase either REFERENCES overall20 or cancer-free29 survival. This positive impact of the 1. The Clinical Outcomes of Surgical Therapy Study Group. 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