Potential Advantages of Lap TME - Less blood loss - Faster recovery - Earlier return of gut function - Lower morbidity and mortality - Magnified view allows precise dissection (pelvic autonomics) - Earlier hospital discharge

1. LAPAROSCOPIC LOW ANTERIOR
RESECTION FOR CANCER:
“Pursued or just Permitted?”
DIMITRIS P. KORKOLIS, MD, PhD.
Senior Consultant Surgeon
“St Savvas” Anticancer – Oncological Hospital
Athens, GREECE

2. Laparoscopic TME
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3. Potential Advantages of Lap TME
• Less blood loss
• Faster recovery
• Earlier return of gut function
• Lower morbidity and mortality
• Magnified view allows precise dissection
(pelvic autonomics)
• Earlier hospital discharge
3

4. Potential Advantages of Lap TME
• Reduced pain
• Decreased need for analgesics
• Improved cosmetic result
• Decreased adhesions
• Decreased wound complications
• Reduced immunosuppressive effect
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5. Potential Disadvantages
• Steep learning curve
• Longer operating times
• Cost
– Instruments / equipment
• Port-site recurrence? (Initial reports 21%!!!)
• Oncological safety compared with open TME?
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6. Potential Disadvantages
• Practical and technical limitations
– Crowding of instruments in the pelvis
– Plume can obscure vision
– Retraction of the rectum can be very difficult
– Division of the rectum can be difficult
– Pneumoperitoneum
• Gas embolism / decreased venous return
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7. Technical Difficulties in Rectal Surgery
- Narrow confines of the bony pelvis
- Angling limitations of the stapling devices
- Identification of tumor site can be difficult
- High BMI
- Level of rectal tumor from anal verge
- Stage of disease
- Higher anastomotic complications
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8. Patients Excluded
• Morbid Obesity
• Adjacent organ invasion
• Metastatic disease
• Cardiovascular, pulmonary or hepatic disease
• Inflammatory bowel disease
• Need for emergency surgery
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9. Critical Points in Rectal Surgery
• TME as “the gold standard”
• CRM
• Distal resection margins
• Adequate lymphadenectomy
• MRI-guided use of neoadjuvant chemoradiotherapy
• Need for autonomic nerve preservation
• Sphincter preservation
• “Experienced Surgeon”
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11. Randomized Trials
Specimen Quality
6% vs 12% LAR
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12. Short – Term Outcomes
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14. Mizrahi I, et al. Role of Laparoscopy in Rectal Cancer:
A Review. World J Gastroenterol 2014
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15. Long – Term Results in Rectal Cancer
Lai JH, et al. Br Med Bull 201215

16. Mizrahi I, et al. Role of Laparoscopy in Rectal Cancer: A Review. World J Gastroenterol 2014
Meta – Analyses of Oncological Outcomes
(2006-2011)
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17. N= 16 Clinical Trials
3528 rectal CA patients
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18. Disease – Free and Overall Survival
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19. Local and Distant Recurrence
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20. LNs Retrieved and CRM Positivity
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21. Postoperative Pain and Hospital Stay
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22. Post - Operative Complications

23. Post – Operative Complications

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25. 25

26. 26

27. 27BJS 2014; 101: 1272–1279

28. MRC CLASSIC:
Financial Results
• Cost – intention to treat (mean)
Open Lap
• Theatre £ 1448 £ 1816
• Hospital £ 3713 £ 3359
• Others £ 2659 £ 3085
• Total £ 7820 £ 8260
Br J Cancer 2006 95:6-1228

29. Lap vs Open Surgery for Rectal CA - USA
• Local recurrence 2% Lap vs 4.2% Open (p=0.42)
Baik, Fleshman, DCR 2011
• Lap & HALS: Conversion 2.9%; LR 5%
Milsom, Sonoda, DCR 2009
• Laparoscopic 26 nodes; open 21. Otherwise identical
outcomes
Boutros and Berho, DCR 2013
• Reduces cost $4283, cost-effective per QALY
Jensen and Abcarian, DCR 2012
29

30. Laparoscopic Resection for Rectal Cancer: What is
the Evidence?
Dedrick Kok HC, et al. Biomed Res Int 2014
4 vs 5
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31. Laparoscopic Resection for Rectal Cancer: What is
the Evidence?
Dedrick Kok HC, et al. Biomed Res Int 2014
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32. Open versus Laparoscopic surgery for mid-rectal or low-
rectal cancer after neoadjuvant chemoradiotherapy
(COREAN trial): Survival Outcomes.
340 patients with locally advanced resectable rectal cancer
Intention to treat analysis
All had neoadjuvant chemoradiotherapy
LAP: 170 OPEN: 170
3-year Disease-Free Survival:
72·5% (95% CI 65·0–78·6) for the open surgery group
79·2% (72·3–84·6) for the laparoscopic surgery group
Jeong SY, et al. Gastrointestinal Cancer 201432

33. 33

34. A Randomized Trial of Laparoscopic versus
Open Surgery for Rectal Cancer
H. Jaap Bonjer, M.D., Ph.D, et al, for the COLOR II Study Group
N Engl J Med 2015; 372:1324-1332
• 30 hospitals 1044 patients
• Rectal adenocarcinoma <15 cm from anal verge - no invasion
• Intention to treat analysis 2:1
• LAP 699 – OPEN 345
• 3-yr RR L: 5% - O: 5%
• 3-yr DFS L: 74.8% - O: 70.8%
• 3-yr OS L: 86.7% - O: 83.6% NS
• Laparoscopic surgery in patients with rectal cancer was associated
with rates of locoregional recurrence and disease-free and overall
survival similar to those for open surgery.
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38. Large Scale Ongoing RCTs
a. COLOR II trial in Europe
b. ACOSOG-Z6051 trial in the USA
c. JCOG 0404 trial in Japan
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39. Conclusion
• Current data suggests that laparoscopic rectal cancer resection
in experienced hands may benefit patients because of:
a. reduced blood loss
b. earlier return of bowel function
c. less postoperative pain
d. shorter hospital length of stay
• Short- and Long-term Oncological outcomes are, at least,
equivalent with open surgery.
• There is a slight paucity of data concerning long-term outcome
and conversion or other complications, such as bladder and
sexual dysfunction after LAP TME.
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40. 40
“…is laparoscopy permitted for the curative
treatment of rectal cancer…?”
…but rather…
“…who should pursue laparoscopic
rectal cancer resections?…”