Post on 07-Aug-2015
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
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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
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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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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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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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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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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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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”
16Mizrahi 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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MRC CLASSIC:Financial Results
• Cost – intention to treat (mean)
Open Lap
• Theatre £ 1448 £ 1816• Hospital £ 3713 £ 3359• Others £ 2659
£ 3085
• Total £ 7820 £ 8260Br J Cancer 2006 95:6-12
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
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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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Laparoscopic Resection for Rectal Cancer: What is the Evidence?
Dedrick Kok HC, et al. Biomed Res Int 2014
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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 cancerIntention to treat analysisAll had neoadjuvant chemoradiotherapyLAP: 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
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 GroupN 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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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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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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