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

Laparoscopic TME

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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”

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Randomized TrialsSpecimen Quality

6% vs 12% LAR

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Short – Term Outcomes

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14Mizrahi I, et al. Role of Laparoscopy in Rectal Cancer: A Review. World J Gastroenterol 2014

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Long – Term Results in Rectal Cancer

Lai JH, et al. Br Med Bull 2012

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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N= 16 Clinical Trials3528 rectal CA patients

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Disease – Free and Overall Survival

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Local and Distant Recurrence

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LNs Retrieved and CRM Positivity

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Postoperative Pain and Hospital Stay

Post - Operative Complications

Post – Operative Complications

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27BJS 2014; 101: 1272–1279

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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

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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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“…is laparoscopy permitted for the curative

treatment of rectal cancer…?”

…but rather…

“…who should pursue laparoscopic

rectal cancer resections?…”