Laparoscopic resection for middle and low rectal cancer.

AIMS: The purpose of this study was to evaluate the technical feasibility, safety and oncological outcomes of laparoscopic resection for middle and low rectal cancers.
MATERIALS AND METHODS: From January 2004 to December 2011, review of prospectively collected database revealed a series of 97 laparoscopic resections for middle and low rectal cancer within 10 cm from the anal verge. Five patients with multiple primary cancers were excluded. Operation time, intra-operative blood loss, surgical complications, duration of hospital stay, retrieved lymph nodes, tumour, node, metastasis (TNM) stage and recurrence were retrospectively analysed.
RESULTS: Tumours were located within 5 cm of the anal verge in 28 patients (30.4%) and from 5 cm to 10 cm in 64 patients (69.6%). Abdominoperineal resection was performed in 12 patients (13%), and conversion to open surgery was necessary in four patients (4.3%). The mean operation time was 199.7 min (range 105-450 min) and the mean intra-operative blood loss was 169.9 mL (range 20-800 mL). The mean hospital stay was 11.8 days (range 5-45 days) and a mean of 12.2 lymph nodes were retrieved. The incidence of surgical complications was 11.9%, including anastomosis site leakage in five patients (5.4%). There were no mortalities resulting from laparoscopic surgery. The median follow-up period was 28.4 months (range 7-85 months). Recurrence occurred in eight patients (8.7%).
CONCLUSIONS: Laparoscopic resection can be applied for middle and low rectal cancers with acceptable surgical and oncological outcomes.

INTRODUCTION

Since its use was first reported in 1991,[1] the laparoscopic approach has gained wide clinical acceptance in the treatment of patients with colorectal cancer.[23] Compared to conventional open surgery, this minimally invasive approach offers decreased surgical trauma, fewer perioperative complications, and faster postoperative recovery with similar survival rates. Although laparoscopic colon resections have been shown to be both feasible and safe, uncertainty remains regarding the application of laparoscopic procedures for the treatment of rectal cancers.[34] Due to the limited availability of data regarding long-term oncological outcomes, it remains unclear whether laparoscopic resection is feasible for the treatment of rectal cancers, particularly due to the difficulty in performing a proper mesorectal excision.[56] However, during the last decade, data from multicenter studies and a meta-analysis have shown that rectal tumours may be laparoscopically removed without increasing the rate of morbidity or worsening oncological results.[78910] The aim of this study is to evaluate the technical feasibility, safety and oncological outcomes of laparoscopic resection for middle and low rectal cancers.

MATERIALS AND METHODS

From January 2004 to December 2011, 152 patients were identified who underwent laparoscopic resection for rectal cancers. Procedures performed included anterior resection, abdominoperineal resection and Hartmann's operation. After excluding 55 patients with upper rectal cancer (greater than 10 cm from the anal verge) and five patients with synchronous multiple primary cancers (e.g., thyroid cancer, gastric cancer, lymphoma, oropharyngeal cancer), the records of 92 patients with middle and low rectal cancer were retrospectively investigated. All tumours were treated with total mesorectal excision (TME). The decision to preserve the sphincters or complete an abdominoperineal resection or Hartmann's operation was based on the ability to achieve clear distal margins and functional outcomes.

The preoperative assessment included digital examination, colonoscopy with biopsy, rectal ultrasound, abdomino-pelvic computed tomography (CT), serum carcinoembryonic antigen (CEA), biochemical analyses, and a chest x-ray. Patients with a CT showing a locally advanced tumour (i.e., a tumour penetrating through the rectal wall (T3)), and/or a tumour with lymph node involvement without any evidence of distant metastasis were given the option of preoperative neoadjuvant chemoradiotherapy (two cycles of 5-Fluorouracil (5-FU) 450 mg/m2 in continuous infusion and leucovorin 20 mg/m2 for 5 days in the first and fifth weeks and radiotherapy 4,500 Gy in 25 fraction). The surgery was performed between 6 weeks and 8 weeks after completion of neoadjuvant treatment. All patients underwent mechanical bowel preparation.

Operative outcome was determined with respect to intra-operative blood loss, operation time, conversion to open surgery, the number of days until bowel function resumed, duration of hospital stay and surgical complications. Oncological outcome was assessed based on the number of retrieved lymph nodes, Tumour, Node, Metastasis (TNM) stage (7th edition of the American Joint Committee on Cancer clinical tumor node metastasis (TNM) classification),[11] and recurrence rate.

RESULTS

Of the total 92 patients, 51 (55.4%) were male, and 41 (44.6%) were female. The mean age was 60.4 years. Regarding tumour site, 63 patients (68.5%) had tumours that were within 5-10 cm of the anal verge (middle rectal cancer) and 29 patients (31.5%) had a tumour located 5 cm from the anal verge (low rectal cancer). Sixteen patients (17.4%) with locally advanced rectal adenocarcinoma were enrolled in neoadjuvant chemo-radiotherapy. Low anterior resection was performed in 76 cases (82.6%), abdominoperineal resection in 10 (10.9%) and Hartmann's operation in two (2.2%). Protective ileostomy was done in 12 patients (13.0%). Conversion to open surgery occurred in four patients (4.3%) [Table 1].

Table 1

Patient characteristics

The mean operation time was 199.71 ± 70.72 minutes and median blood loss was 166.89 ± 153.49 ml. The mean postoperative length of stay was 11.8 ± 6.51 days, and the mean number of days to toleration of clear fluids was 2.65 ± 1.58 days [Table 2]. The overall surgical complication rate was 9.8%, which included five anastomotic leakages (5.4%), one anal stricture (1.1%), one case of anastomotic fistula (1.1%) and two cases of urinary retention (2.2%) [Table 3]. There were no postoperative mortalities.

Table 2

Surgical outcome

Table 3

Surgical complications

The mean number of lymph nodes retrieved was 12.25 ± 8.14. The mean length of the distal resection margins was 2.22 ± 1.75 cm. Stage I tumours were present in 42 patients (41.3%), stage II in 20 patients (21.8%) and stage III in 30 patients (32.6%). No patients presented with stage IV disease [Table 4]. Mean follow-up period was 28.4 months (range 7-85 months). Recurrence occurred in a total of eight patients (8.7%). The most common site of recurrence was the lung (37.5%) [Table 5]. There were no port-site recurrences and all of the recurrences occurred in node-positive patients [Table 6].

Table 4

Disease stage distribution

Table 5

Duration and sites of recurrence

Table 6

Stage and recurrence

DISCUSSION

Laparoscopy has emerged as a valuable means of surgical treatment for diseases of the colon and rectum. It offers a lower rate of wound complications, intraoperative blood loss, analgesic use, shorter time to bowel movement, earlier recovery, lower morbidity, shorter postoperative hospital stay, and better quality of life postoperatively.[1213] Laparoscopic resection of rectal cancer entered practice after the introduction of laparoscopic colon surgery in 1991.[1] But unlike colon cancer, treatment of rectal cancer does not comprise a single surgical entity. The type of resection depends mainly on the location of the tumour. Laparoscopic anterior resection of tumours in the recto-sigmoid and upper-rectum is technically easier to perform with oncological outcomes that are not different from those for colon cancer. However, with tumours in the middle and low rectum, the laparoscopic approach is a technical challenge, especially if sphincter preservation is required.

Laparoscopic rectal cancer surgery is technically more challenging compared with laparoscopic colon surgery because it involves TME in a limited pelvic cavity. This procedure regards the rectum and mesorectum as one lymphovascular structure and requires its excision within an intact fascia propria,[14] and TME has conclusively been shown to reduce the rate of local recurrence and increases the rate of survival.[1516] This approach has been reported to be feasible and safe while offering the advantages of laparoscopic surgery.[171819] However, long-term outcomes including local recurrence, disease-free survival and overall survival have not yet been consistently studied.

Laparoscopic surgery for rectal cancer may be associated with relatively high morbidity and conversion rates. In this study, the morbidity rate was 9.8% without mortality. This is similar or lower to rates reported previously (21.9-27.0%).[820] Also, the anastomotic leakage rate of 6.5% was lower than the rate reported in other studies (9.8-27%).[810202122] The 4.3% conversion rate in our study compares favourably with the results of laparoscopic resection of the rectum (1-33%).[38921] Major causes of conversion are a narrow pelvis and technical failure. Targarona et al., suggested that the local anatomy (lower pelvis diameter, sex, body mass index) and pathologic features (tumor size) directly affect surgical outcome in the laparoscopic approach to the rectum and should be taken into account when planning for this kind of procedure.[23] The rate of protective ileostomy was 13.0%.

In the present study, the mean hospital stay was 11.84 ± 6.51 (range 4-12), and the mean operation time was 199.71 ± 70.72 minutes (range 105-450), which is comparable to previously reported operation times ranging from 138 minutes to 250 minutes.[89202224] The mean amount of blood loss of 166.89 ± 153.49 cc (range 10-800 cc) in the present study is comparable to the amount previously reported.[20] The mean of 2.10 ± 1.34 days to gas out and the mean of 2.65 ± 1.58 days to intake of a liquid diet in the present study are both comparable to the values previously reported.[8202224]

Examination of the oncologic adequacy of laparoscopic rectal resection in our study showed negative resection margins, including radial margins and the mean number of retrieved lymph nodes was 12.25 ± 8.15. The recurrence rate with laparoscopic resection in our study was 8.7% at a mean of 24.5 months of follow-up. These data are comparable to previously published laparoscopic results.[82526]

In conclusion, laparoscopic resection for middle and low rectal cancer is feasible and can be performed safely with acceptable rates of overall morbidity and reoperation and low rates of specific complications, including anastomotic leakage. The limitations of this study include the relatively small sample size and the relatively short follow-up time, particularly for maintenance of oncologic issues. Planned randomised controlled trials addressing this issue with a larger sample size and long-term follow-up should be performed.