LAPAROSCOPIC SURGERY FOR RECTAL CANCER

Three-year recurrence and survival rates are similar after laparoscopic vs open surgery for patients with noninvasive rectal cancer, according to new results from the Colorectal Cancer Laparoscopic or Open Resection (COLOR) II trial. The study was published in the April 2 issue of the New England Journal of Medicine.

"This study in more than 1000 patients assures patients and medical doctors that laparoscopic surgery is safe for rectal cancer [which has not invaded adjacent organs] and offers short term benefits such as less pain and faster postoperative recovery," commented first author H. Jaap Bonjer, MD, PhD, professor of surgery at the VU University Medical Center Amsterdam, the Netherlands.

"Therefore, laparoscopic surgery should be offered to such patients with rectal cancer," Dr Bonjer concluded.

Laparoscopic surgery is already widely used for colorectal cancer. Compared with open surgery, it has the advantage of good short-term outcomes, less pain, less blood loss, and better recovery time, according to background information in the article.

However, although long-term randomized studies have suggested similar cancer outcomes for laparoscopic compared with open surgery for colon cancer, surgeons lack good-quality evidence for laparoscopic surgery for rectal cancer, Dr Bonjer explained. About one third of colorectal cancers are confined to the rectum, he added.

The study took place at 30 hospitals in eight countries. From January 2004 to May 2010, researchers randomly assigned participants to receive either laparoscopic or open surgery. Participants had solitary adenocarcinoma of the rectum within 15 cm of the anal verge, no invasion into adjacent tissues, and no distant metastases. Researchers excluded participants if they had large tumors for which laparoscopic resection would have been difficult (stage T4 or T3 tumors within 2 mm of the endopelvic fascia on computed tomography or magnetic resonance imaging scan).

Participants received neoadjuvant therapy according to local standards at participating hospitals, with no differences between the two groups. Follow-up included imaging of the pelvis, liver, and chest at 3 years, and annual clinical exams up to 5 years after surgery. Researchers verified quality of laparoscopic surgery by reviewing recordings of the procedures at each centre.

The analysis included 1044 participants (699 laparoscopic and 345 open surgery). Results at 3 years showed similar rates of local and regional recurrence for both groups (5% for both; difference, 9 percentage points [90% confidence interval (CI), −2.6 to 2.6 percentage points]). Both groups also had similar disease-free survival rates (laparoscopic, 74.8% vs open, 70.8%; difference, 4.0 percentage points [95% CI, −1.9 to 9.9 percentage points]) and overall survival rates (laparoscopic, 86.7% vs open, 83.6%; difference, 3.1 percentage points [95% CI, −1.6 to 7.8 percentage points]).

Patients who had cancers in the lower third of the rectum and had laparoscopic surgery had lower local and regional recurrence rates than similar patients who received open surgery. One reason could be that laparoscopic surgery may allow for better visualization of narrow spaces such as the lower pelvis than open surgery, the authors write.

"There are indications that disease-free survival after laparoscopic surgery is better in patients with lymph node positive disease and that fewer locoregional recurrences of rectal cancer occur after laparoscopic resection of low rectal cancer," Dr Bonjer added.

Compared with the open surgery group, the laparoscopic group had longer operating times (by 52 minutes), shorter hospital stays (by 1 day), and earlier return of bowel function (by 1 day).

The researchers did not perform centralized macroscopic or microscopic evaluation of resected specimens, which could have limited the study. In addition, various hospitals in the study used different imaging modalities to evaluate the tumor, which could have further limited the study. Finally, the study excluded use of hand-assisted laparoscopic surgery (in which the surgeon inserts a hand through a port into the abdomen to manually retract tissues).

"Laparoscopic surgery offers short-term and possibly also long-term advantages but requires considerable expertise of the surgeon," Dr Bonjer emphasized.

One coauthor reports receiving personal fees from AbbVie, Merck Sharp & Dome, Takeda, and Johnson & Johnson. Another coauthor reports receiving research support from the Swedish Research Council, the Swedish Cancer Foundation, and the Sahlgreska University Hospital. Another coauthor reports receiving grant support from Covidien, Olympus Medical, and Applied Medical. Dr Bonjer and the other authors have disclosed no relevant financial relationships.

N Engl J Med. 2015;372:1324-1332. Abstract