An Update on Laparoscopic Resection for Rectal Cancer
An Update on Laparoscopic Resection for Rectal Cancer
Background: In the current age of minimally invasive surgery, laparoscopic surgery for colon cancer has been established as oncologically equivalent to conventional open surgery. The advantages of laparoscopic surgery have translated into smaller incisions and shorter recovery. However, the narrow confines of the bony pelvis and angling limits in current stapling technology, along with the standard practice of autonomic nerve-sparing total mesorectal excision, have made laparoscopic surgery in the setting of rectal cancer more challenging. The available literature focusing on laparoscopic resection for rectal cancer has been predominantly retrospective in nature, with a limited number of prospective studies.
Methods: This article discusses the current status of laparoscopic rectal cancer resection. A review of the more recent retrospective and prospective data specifically on laparoscopic resection for mid to low rectal cancer was performed.
Results: The number of prospective randomized trials addressing laparoscopic rectal cancer resection is limited. In the largest trial (MRC CLASICC), an initial increased rate of positive circumferential margins within the laparoscopic anterior resection cohort, although nonsignificant, raised concerns regarding its oncologic adequacy. These concerns did not translate into a difference in local recurrence at 3 years. Improved short-term outcomes, including quicker recovery times, shorter hospital stays, and reduced analgesic requirements (albeit at the price of longer operative times and higher overall cost), have been demonstrated in some studies.
Conclusions: In view of the limited prospective data, laparoscopic resection for mid to low rectal cancer is still investigational in the United States. While feasibility studies are promising, open surgical resection remains the current standard of care. It is hoped that the long-term results of ongoing and newly initiated multi-institutional trials will fully define the role of laparoscopy in the treatment of mid to low rectal cancer.
Since its original implementation as a diagnostic modality in the field of gynecology, minimally invasive techniques in general surgery have become the standard approach for some procedures (eg, cholecystectomy, appendectomy, gastric bypass, Nissen fundoplication). Laparoscopy has also become the favored approach in many other procedures (eg, bilateral/recurrent herniorrhaphy, gastrectomy, splenectomy, and adrenalectomy). Laparoscopic resection results in more cosmetically appealing incisions, decreased analgesic requirements, and earlier return of patients to functionality. Not unexpectedly, use of this minimally invasive surgical technique found its way into colon and rectal surgery. Although it was accepted relatively quickly for surgical treatment of benign disease, the application of laparoscopic technique to colorectal malignancy was initially steeped in controversy because of concerns over port site recurrences and oncologic adequacy. This prompted the initiation of several randomized trials that have compared laparoscopic and open colectomy for colon cancer, showing equivalent recurrence and survival rates.
The number of prospective randomized trials evaluating laparoscopic resection for rectal cancer is limited. Of these, only two specifically address mid to low rectal cancers. This may be due in part to the various technically challenging components of a rectal cancer operation, such as preservation of the autonomic nerves while performing total mesorectal excision (TME), the angling limitations of current stapling devices, and the often narrow confines of the bony pelvis. Because of the absence of long-term (5-year) data on survival and recurrence, the role of laparoscopy in rectal cancer resection has been debated. Additionally, clinicopathologic differences among patients such as body mass index (BMI), gender, tumor bulk, and tumor location have contributed to the challenges involved in studying this surgical modality.
This review provides an update on more recent data regarding laparoscopic resection for rectal cancer and discusses the ongoing challenges associated with this procedure.
Abstract and Introduction
Abstract
Background: In the current age of minimally invasive surgery, laparoscopic surgery for colon cancer has been established as oncologically equivalent to conventional open surgery. The advantages of laparoscopic surgery have translated into smaller incisions and shorter recovery. However, the narrow confines of the bony pelvis and angling limits in current stapling technology, along with the standard practice of autonomic nerve-sparing total mesorectal excision, have made laparoscopic surgery in the setting of rectal cancer more challenging. The available literature focusing on laparoscopic resection for rectal cancer has been predominantly retrospective in nature, with a limited number of prospective studies.
Methods: This article discusses the current status of laparoscopic rectal cancer resection. A review of the more recent retrospective and prospective data specifically on laparoscopic resection for mid to low rectal cancer was performed.
Results: The number of prospective randomized trials addressing laparoscopic rectal cancer resection is limited. In the largest trial (MRC CLASICC), an initial increased rate of positive circumferential margins within the laparoscopic anterior resection cohort, although nonsignificant, raised concerns regarding its oncologic adequacy. These concerns did not translate into a difference in local recurrence at 3 years. Improved short-term outcomes, including quicker recovery times, shorter hospital stays, and reduced analgesic requirements (albeit at the price of longer operative times and higher overall cost), have been demonstrated in some studies.
Conclusions: In view of the limited prospective data, laparoscopic resection for mid to low rectal cancer is still investigational in the United States. While feasibility studies are promising, open surgical resection remains the current standard of care. It is hoped that the long-term results of ongoing and newly initiated multi-institutional trials will fully define the role of laparoscopy in the treatment of mid to low rectal cancer.
Introduction
Since its original implementation as a diagnostic modality in the field of gynecology, minimally invasive techniques in general surgery have become the standard approach for some procedures (eg, cholecystectomy, appendectomy, gastric bypass, Nissen fundoplication). Laparoscopy has also become the favored approach in many other procedures (eg, bilateral/recurrent herniorrhaphy, gastrectomy, splenectomy, and adrenalectomy). Laparoscopic resection results in more cosmetically appealing incisions, decreased analgesic requirements, and earlier return of patients to functionality. Not unexpectedly, use of this minimally invasive surgical technique found its way into colon and rectal surgery. Although it was accepted relatively quickly for surgical treatment of benign disease, the application of laparoscopic technique to colorectal malignancy was initially steeped in controversy because of concerns over port site recurrences and oncologic adequacy. This prompted the initiation of several randomized trials that have compared laparoscopic and open colectomy for colon cancer, showing equivalent recurrence and survival rates.
The number of prospective randomized trials evaluating laparoscopic resection for rectal cancer is limited. Of these, only two specifically address mid to low rectal cancers. This may be due in part to the various technically challenging components of a rectal cancer operation, such as preservation of the autonomic nerves while performing total mesorectal excision (TME), the angling limitations of current stapling devices, and the often narrow confines of the bony pelvis. Because of the absence of long-term (5-year) data on survival and recurrence, the role of laparoscopy in rectal cancer resection has been debated. Additionally, clinicopathologic differences among patients such as body mass index (BMI), gender, tumor bulk, and tumor location have contributed to the challenges involved in studying this surgical modality.
This review provides an update on more recent data regarding laparoscopic resection for rectal cancer and discusses the ongoing challenges associated with this procedure.
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