Laparoscopic low anterior resection for rectal cancer: improving outcomes
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- Hottenrott, C. Surg Endosc (2009) 23: 2871. doi:10.1007/s00464-009-0643-8
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Laparoscopic colectomy has become a standard treatment for colon cancer in specialized hospitals. High-quality evidence has demonstrated its superiority over open colectomy for resectable stages 1 to 3 disease in terms of improving quality of life (QOL) without worsening long-term survival [1, 2].
However, data on rectal cancer treated by minimally invasive laparoscopically or robotically assisted low anterior resection still are scarce [1, 3]. Although safety and QOL improvement can be reached under specific requirements, some questions remain. What perspectives of closed surgery will allow higher cure rates also to be achieved with this approach? Why particularly for rectal cancer, in contrast to all other gastrointestinal tumors, improvement in these oncologic outcomes can be achieved ?
Park et al.  reported on the long-term results of laparoscopic surgery (LS) versus open surgery (OS) for extraperitoneal rectal cancer in a recent issue of the Surgical Endoscopy. These authors compared short- and long-term results for 170 patients who underwent LS with those for 374 patients who had OS. They found no significant difference in the reoperation rates (5.8% for LS vs. 4.8% for OS) or anastomotic leak rates (5.7% in both groups).
Three important results of this study for both QOL and local recurrence also may have an impact on overall survival. First, sphincter preservation was significantly higher in the LS group (82.9%) than in the OS group (69.8%) (p = 0.001). Second, this result was achieved although the mean distance from the anal verge was significantly shorter in the LS group (4.6 cm) than in the OS group (5.2 cm) (p = 0.002). Third, despite the higher rate for sphincter preservation, no negative impact on the local recurrence rate was observed for either group.
The results of this study are consistent with those of another large-scale retrospective study , supporting the superiority of rectal resection using new technologies. But a sophisticated design of a new randomized trial is required to assess whether laparoscopic or robotic surgery may improve not only QOL but also oncologic outcomes.
Preserving the sphincter while reducing locoregional recurrence of low rectal cancer at the same time is a major surgical goal. Why and how can this goal be achieved with laparoscopic or robotic surgery instead of open surgery?
Precision is the major strength of R0 resection based on new technologies. Indeed, both the Da Vinci robotic system and laparoscopic surgery may provide more accurate, precise, and anatomic resection of the primary tumor and perhaps regional lymph nodes as well than open surgery. Total mesorectal excision (TME) has become a de facto standard of treatment, particularly for disease stages 2 and 3. Due to the anatomic location of the rectum in the pelvis, achievement of a precise TME appears more feasible using the new technical systems rather than open low anterior resection. This anatomic structures-based surgery that preserves the functionality of nerves to vital organs and removes the mesorectum totally not only improves QOL substantially but also may result in reduced locoregional recurrences and mortality.
Locoregional tumor control is important also for overall survival. For most gastrointestinal tumors and breast cancer, local or nodal recurrence may be the first isolated event that results in death [6–17]. Therefore, preventing local events may improve cure rates [18–21].
In rectal cancer, three main surgical-oncologic principles ensure locoregional tumor control: TME, high ligation of inferior mesenteric vessels directly at the aorta abdominalis, and splenic flexure mobilization. Laparoscopic technique and the second-generation Da Vinci S HD surgical system appear to achieve these goals more efficiently than open low anterior rectal resection. New trials with a new complicated design are required to evaluate whether laparoscopic or robotic surgery improves not only QOL but also locoregional failures.
However, even if long-term local events are prevented, and overall survival benefits are achieved, the surgery should be limited. It is surgically naïve and oversimplification to believe that switching from open to closed surgery can reduce local events and mortality. Indeed, most recent extensive genetic studies have shown the great complexity and diversity of solid cancers, including gastrointestinal cancers [22–28]. This fact urgently suggests the need for new predictive and therapeutic strategies to improve the oncologic outcomes of patients with solid cancers [29–36].