OPEN SURGERY MAY BE BETTER FOR RECTAL CANCER

Pooled data suggests that incomplete rectal tumor resection is significantly more likely following a laparoscopic than an open surgical approach, according to French researchers.

As Dr. Nicola de'Angelis explained, "The main treatment for rectal cancer is surgery, which follows the principles of removing the entire tumor together with the surrounding tissues (the so-called mesorectal excision). The prognosis of the patient affected by rectal cancer is strictly dependent on the outcomes of surgery, thus the (importance) of achieving a complete removal of the cancer mass with resection margins free of tumor."

However, Dr. de'Angelis pointed out in an email, "We are in the era of minimally invasive surgery. Laparoscopy is considered the gold standard surgical approach for colon cancers, whereas controversy remains for the treatment of rectal cancer because laparoscopic rectal resection can be technically demanding and highly challenging."

As reported February 8 online in JAMA Surgery, Dr. de'Angelis of Henri Mondor Hospital, Creteil, and colleagues analyzed pathological outcomes in more than 4,000 patients from 14 randomized controlled trials.

In nine studies, 7.9% of 1,697 patients undergoing laparoscopic rectal resection showed a positive circumferential resection margin. This was significantly greater than the 6.1% proportion seen in the 1,292 patients who had the open procedure.

In five studies, Dr. de'Angelis said, the rate of incomplete surgical resection was "significantly higher for laparoscopy than open surgery (13.2% versus 10.4%)."

A number of other outcome measures, including the mean number of lymph nodes retrieved and the mean distance to radial margins, did not differ significantly between approaches. And the researchers rated the overall quality of the evidence from the studies as being high.

Given these findings, continued Dr. de'Angelis, "the question concerning the appropriateness of laparoscopy for the management of rectal cancer remains open until further evidence will prove the impact of the completeness of the surgical resection on long-term survival."

"In the meantime," he concluded, "minimally invasive surgery should not be systemically discouraged, rather efforts should be made to ease and implement minimally invasive surgical techniques, such as robotic and transanal approaches, in order to overcome technical difficulties and improve surgical outcomes."

Commenting by email, Dr. George J. Chang, co-author of an accompanying editorial, told Reuters Health, "This study highlights the difficulty of performing laparoscopic rectal cancer surgery, the importance of careful evaluation of treatment results, and the need to determine the best endpoints for clinical trials."

In fact, Dr. Chang and Dr. Lakhbir Sandhu, both of the University of Texas, Houston, conclude their editorial by observing that "the question remains which surgical approach is best for the management of rectal cancer and what intermediate pathologic end point is most meaningful. We eagerly await the long-term results of the recent randomized clinical trials to determine if the observed pathologic results translate into differences in local recurrence rates or long-term survival."