High-quality clinical practice: laparoscopic rectal cancer resection
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- Baltogiannis, G. & Katsios, C. Surg Endosc (2010) 24: 2913. doi:10.1007/s00464-010-1019-9
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Modern current and emerging technology and scientific expertise drive the outcomes of patients with potentially curable, nonmetastatic solid cancer. Despite advances in multimodal therapeutics, current failure rates in both locoregional and distant systemic treatment remain alarmingly high resulting in the death of most patients with advanced colorectal cancer.
Current day-to-day good clinical practice in the treatment of rectal cancer has to overcome several challenges. These difficulties include (1) accurate pretreatment TNM staging that aids decisions on preoperative or postoperative adjuvant treatment; (2) optimal surgical complete resection (R0) of the primary tumor and regional lymph nodes without surgical overtreatment that limits quality of life (QOL) and increases complications; and (3) selection of the best available adjuvant treatment, including radiotherapy and a safe and effective combination of chemotherapeutic and targeted agents for individual patients.
In the December 2009 issue of this journal, Cheung et al.  provided the results of an international survey on approaches in laparoscopic rectal surgery. From January to March 2008, members of the European Association for Endoscopic Surgery (EAES), the Indian Association of Gastrointestinal Endo-Surgeons (IAGES), the Society of Laparoscopic Surgeons (SLS), and renowned surgeons in the field of laparoscopic total mesorectal excision (LTME) were invited to fill out an online questionnaire about the aspects of LTME. Of the 368 questionnaires returned, 77% of the study participants performed 1–20 LTMEs per year (low volume) and 123 surgeons (33%) performed more than 20 LTMEs per year (high volume). Their study found that ligation at the origin of the inferior mesenteric artery (high tie) with splenic flexure mobilization, partial sigmoid resection, extraction of the specimen by a new minilaparotomy, and end-to-end stapled anastomosis using a 28-29-mm anvil with 3.5-mm staples, and diverting ileostoma were performed by a majority of the surgeons.
Less consistency was found among the surgeons with respect to dissection of Denonvilliers’ fascia, location of the minilaparotomy, and construction of a colonic pouch. There were significant differences between high- and low-volume surgeons and between American and European surgeons. Significantly more low-volume surgeons indicated a preference for an open total mesorectal excision (TME) depending on the age and gender of the patient, the presence of comorbidity, previous laparotomy, and locally advanced tumor. More low-volume surgeons used preoperative bowel preparation (PBP; 83.4 vs. 71.8%; p = 0.017). On average, high-volume surgeons identified more autonomic pelvic nerves during dissection (2.6 vs. 1.8 nerves).
Although the low response rate to the questionnaire limits its power, the study provides very useful information on laparoscopic rectal resection. In the absence of large-scale randomized controlled trials (RCTs) for assessing differences between open and laparoscopic surgery and between low-volume and high-volume surgeons, it is not surprising that no international consensus has taken shape. However, most of the findings of the Cheung et al. study are consistent with that of another recent related review article .
Successful translation of innovation into clinical practice requires the fulfillment of a series of certain criteria. Currently, comparative-effectiveness research (CER) data of high quality guide good clinical practice (GCP). A day-to-day GCP should be based in best evidence that is usually provided by results from phase III RCTs. Yet, level I evidence for GCP in favor of laparoscopic versus open surgery exists only for colon cancer . Although six RCTs have been reported for laparoscopic rectal resection, they have several limitations, as analyzed by Poon and Law .
Theoretically, minimally invasive surgery such as laparoscopic or robotic surgery, particularly for mid or low location of the tumor in the rectum, provides more advantages than open surgery. A better view of the pelvis allows a more accurate and precise TME [1–4]. It should be emphasized here that all oncological principles of open surgery should also be respected in sphincter-saving resection. In a TME this means at least 2-cm distal margins and adequate lymphadenectomy, including high ligation of the inferior mesenteric artery and left colon flexure mobilization. It appears that at least TME can better be achieved with minimally invasive surgery [1–4]. The trend in favor of laparoscopic surgery has expanded to include its use for other gastrointestinal common tumors including gastric cancer [5–7].
Standardized laparoscopic TME rather than open surgery can be performed safely and perhaps more efficiently by high-volume surgeons. However, several questions remain unanswered: Does laparoscopic rectal resection improve local control by improved TME? Is the protective loop ileostomy necessary? Should the distal margin of sphincter-preserving resection be individualized such as for the tumor grade, or should a general 2-cm safety zone be the standard? All these questions are significant in defining an optimal surgical R0 resection for a high-quality clinical practice.
Another important issue is neoadjuvant chemoradiotherapy and how to overcome limitations for appropriate patient selection. Although preoperative chemoradiation has been the current standard of care for advanced resectable rectal cancer, approximately half of the patients selected on the basis of an advanced tumor stage (T3 and T4) do not respond to it. Thus, they not only experience no therapeutic net gain but this strategy may harm these patients because surgical resection is delayed by the neoadjuvant treatment. This challenge of selecting responder patients for preoperative adjuvant treatment is also a problem for all gastrointestinal cancers [8–11]. Irrespective of the timing of adjuvant treatment, high-quality surgery, laparoscopic or open, resulting in a true R0 resection will remain the cornerstone in the treatment of common solid cancers [12–16].
Robust biomarkers are needed for tailoring both neoadjuvant treatment to responder patients and new targeted agents to increase the response rate of solid tumors [17–26]. The anti-EGFR monoclonal antibodies cetuximab and panitumab have been proven effective in a metastatic setting for patients with colorectal cancer without KRAS mutations . In the era of the cancer genome and modern high-throughput technology, there are increased expectations that advances in cancer genetics, genomics, and systems biology [28–34] will lead to the development of novel robust molecular markers and new combinations of chemotherapeutic and targeted agents. These innovations lead to realistic new research directions for improving oncological outcomes. In the real world of day-to-day clinical practice, laparoscopic or robotic surgery for rectal cancer is the procedure of choice, particularly in highly specialized institutions. The two large phase III RCTs that are underway will define whether a wider clinical application of minimally invasive surgery is safe and effective.
G. Baltogiannis and C. Katsios have no conflicts of interest or financial ties to disclose.