Laparoscopic resection for rectal cancer is not supported by studiesBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5308 (Published 07 October 2015) Cite this as: BMJ 2015;351:h5308
Minimally invasive laparoscopic resection for colorectal cancer does not provide better outcomes than open resection, two randomised controlled trials published in JAMA have found.
In the first study, conducted at 35 institutions in the United States and Canada, 462 patients with clinical stage II or III rectal cancer were randomly assigned to laparoscopic or open pelvic resection.1 Successful resection was defined by a number of measures including the completeness of the total mesorectal excision, uninvolved circumferential resection margin, and uninvolved distal resection margin.
Successful resection occurred in 82% of laparoscopic resection cases (95% confidence interval 76.7% to 86.9%) and in 87% of open resection cases (82.5% to 91.4%). A 6% non-inferiority margin was chosen by the researchers as being a clinically important difference between the two groups. “Laparoscopic resection failed to meet the criterion for non-inferiority for pathologic outcomes compared with open resection and was thus potentially inferior,” the authors wrote.
Operative time was also considerably longer with laparoscopic resection. Length of hospital stay, readmission within 30 days, and severe complications were not significantly different between the two groups.
The second study was carried out at 24 sites in Australia and New Zealand.2 In this study 475 patients with T1-T3 rectal cancer were randomised to open laparotomy and rectal resection. Half of the patients received preoperative radiotherapy. The primary outcome of a successful resection was achieved in 194 patients (82%) in the laparoscopic surgery group and in 208 patients (89%) in the open surgery group. The non-inferiority boundary was set at 8% in this study but again was not achieved. No differences were seen between the two groups in hospital length of stay, intensive care unit stay, or analgesic requirement.
In both studies, only surgeons accredited after a video review of relevant operations were allowed to participate. The technical quality of surgery in both trials was high, as they included few laparoscopic conversions, high rates of sphincter preservation, and low rates of complications.
The researchers said that one reason for the findings was that resection of the rectum is challenging and that it can be difficult to work in the deep pelvis with inline rigid instruments from angles that require complicated manoeuvres to reach the extremes of the pelvis. Access to this difficult area of the body might be better with the open procedure, they noted.
In an accompanying editorial Scott Strong and Nathaniel Soper, of the Northwestern University Feinberg School of Medicine in Chicago, USA, wrote, “The studies do not signal a moratorium on these approaches, but surgeons must proceed in a judicious manner to ensure that patients are informed about the benefits and risks associated with minimally invasive and open operations.”3
Cite this as: BMJ 2015;351:h5308