Laparoscopic versus Open Total Mesorectal Excision: A Comparative Study on Short-Term Outcomes
Background: Laparoscopic total mesorectal excision (TME) is being used in rectal cancer more frequently. The aim of this study was to analyze the differences in short-term outcomes between open and laparoscopic TME. Methods: In this nonrandomized consecutive study, the short-term outcomes of 100 patients undergoing TME for proven rectal cancer were analyzed. Results: Two groups of 50 patients underwent an open or laparoscopic TME for rectal cancer. Both groups were comparable. Laparoscopic surgery took longer to perform (250 vs. 197.5 min, p ! 0.01), but was accompanied by less blood loss (350 vs. 800 ml, p ! 0.01). Enteric function recovered sooner after laparoscopy. The numbers of major and minor complications were comparable between both groups, although fewer patients had major complications in the laparoscopic group (6 vs. 15 patients, p = 0.03). Hospital stay was shorter for patients who underwent a laparoscopic abdominoperineal resection (10 vs. 12 days, p = 0.04). Median follow-up was 17 months for the lapReceived: January 15, 2007 Accepted: March 20, 2007 Published online: August 31, 2007 Miguel A. Cuesta Department of Surgery, Vrije Universiteit Medical Center Post bus 7057 NL–1007 MB Amsterdam (The Netherlands) Tel. +31 20 444 4781, Fax +31 20 444 4511, E-Mail ma.cuesta@vumc.nl © 2007 S. Karger AG, Basel 0253–4886/07/0245–0367$23.50/0 Accessible online at: www.karger.com/dsu Veenhof et al. Dig Surg 2007;24:367–374 368 ly in male patients – and possibly a less radical resection. Moreover, the increased use of coloanal anastomosis has also increased the need for better visualization during pelvic dissection. The laparoscopic approach to rectal cancer may be an attractive alternative for open TME because it offers better visualization, more delicate instrumentation and better tissue handling. This in turn, may lead to an adequate dissection up to the pelvic floor in combination with a better preservation of the hypogastric plexus and erigent nerves, possibly resulting in an improved functional and oncological outcome. Several recently published randomized studies have shown short-term benefits of the laparoscopic approach to colon cancer over the open approach, without compromising oncological outcome [6–9] . Hence, we performed a study to compare laparoscopic TME with open TME in terms of perioperative and oncological outcomes in patients with rectal cancer. Materials and Methods Patients In April 2002, a laparoscopic TME trial was started at the Vrije Universiteit Medical Center (VUmc), with a planned evaluation after approximately 3 years. Subsequently, a series of 50 consecutive patients who underwent conventional open TME with curative intent for rectal cancer, operated just before the laparoscopic TME trial was initiated, was compared with a group of 50 consecutive patients who underwent laparoscopic TME for rectal cancer. The conventional group included patients who were operated on in the pre-laparoscopic period between February 1999 and April 2002, whereas the laparoscopic group included patients who were operated on between April 2002 and November 2005. Patients with previous abdominal surgery via median laparotomy were excluded from this study, as were patients undergoing palliative surgery or surgery for benign tumors. No fast-track postoperative recovery programs were used in either group. Patients from both groups were operated on by the same surgical team from the VUmc with extensive previous laparoscopic experience in colectomies (participants in the COLOR I trial), palliative rectal resections and esophageal resections for cancer. All patients received the same pretreatment workup, including a colonoscopy with biopsies, MRI or rectal endoscopic ultrasound for local staging, and an abdominal CT scan, chest X-ray and carcinoembryonic antigen level for dissemination status. Tumors had to be located within 17 cm of the anal verge, measured by rigid scope, and were defined according to Goligher [10] : 7 cm or less from the anal verge = low rectum; over 7 cm but less than or equal to 12 cm = mid-rectum; over 12 cm but less than or equal to 17 cm = high rectum. Surgical Technique Laparoscopic TME. Using a 6-trocar approach the inferior mesenteric vessels were taken down with left ureter identification, followed by retromesenteric dissection from medial to lateral. Going up, the splenic flexure was mobilized, followed by laparoscopic TME dissection with preservation of the hypogastric plexus and nerves. Following the principles of the TME, three different operations were performed: For tumors in the high rectum (12–17 cm), a high TME or partial mesorectal excision was performed laparoscopically with transection of the mesorectum 5 cm distal of the tumor, followed by a double-stapled anastomosis. For tumors located in the mid(7–12 cm) and distal rectum (anal verge to 7 cm), a complete TME was performed laparoscopically, after splenic flexure mobilization. Hereafter, the rectum was transected with an endoscopic or conventional stapler through a Pfannenstiel incision at the level of the pelvic floor (with at least a 2-cm distal margin from the tumor). A transanal coloanal anastomosis was performed if at least 1 cm from the dentate line could be spared with an adequate oncological distal margin of 2 cm. Higher anastomoses were double stapled. An abdominoperineal resection without mobilization of the splenic flexure was considered appropriate for tumors with sphincter involvement, a margin of less than 3 cm to the dentate line thus making a coloanal anastomosis impossible and in patients with sphincter dysfunction making a functional outcome after a coloanal anastomosis unlikely. Protective loop ileostomy was left to the discretion of the surgeon. In our institution a liberal policy concerning protective loop ileostomies is maintained. In patients with a midor low anastomosis, or in the case of marginal donuts, a diversion of fecal load is created. Open TME. Open TME was performed according to previously described techniques [11] . Collected Data – Patient data: age, body mass index and preoperative morbidity. – Perioperative data: operating time, blood loss and complications. – Postoperative data: length of hospital stay (including preoperative night spent in hospital), time to first liquid intake, time to unrestricted food intake, time to first stool passage and postoperative complications. – Pathology data: Astler-Coller classification, total number of lymph nodes harvested, length of the resected specimen, tumor diameter, tumor distance to distal resection margin and circumferential margin status. – Follow-up: time to local recurrence, time to occurrence of distant metastases, overall survival (OS) and disease-free survival (DFS) were noted. Patients with lowand mid-rectum tumors (T2 and T3) received neoadjuvant therapy as depicted in table 1 . Statistical Analysis Statistical analysis was performed using the SPSS software package (SPSS 11.5 for Windows; SPSS, Chicago, Ill., USA). All data were analyzed according to the ‘intention-to-treat’ principle. Medians and interquartile ranges were calculated and subsequently depicted when appropriate. The Mann-Whitney U test, 2 test or Fisher’s exact test were applied when appropriate for group comparisons. Survival curves were obtained using the KaplanMeier method. Survival of both groups was compared with the log-rank test. Significance was set at p ! 0.05.