A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer

Bonjer, H. Jaap; Deijen, Charlotte L.; Abis, Gabor A.; Cuesta, Miguel A.; Klerk, Lange-de; Lacy, Antonio M.; Bemelman, Willem A.; Andersson, John; Rosenberg, Jacob; Fuerst, Alois; Haglind, Eva

doi:10.1056/nejmoa1414882

Cited by 1,220 publications

(904 citation statements)

References 22 publications

(21 reference statements)

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“…The rates among only clinical T3 patients (11% and 13%, in Figure 3) were consistent with results of lower lesions in the randomized COLOR‐II trial (4%‐13%) 6. Our data have some features such as simultaneous LLN dissection or lower rate of radiotherapy, but we surmise that our results would be generalizable to other countries because similar tendencies could be observed even after stratification by these factors (Figure 3).…”

Section: Discussionsupporting

confidence: 87%

“…Third, the follow‐up duration was relatively short. Although we thought that LR would generally be identified within 3 years after surgery35, 36, 37 and some RCT were also designed to compare the OS, DFS, or LR at this time point,6, 38, 39 longer follow up is required to confirm these results. We plan to follow up this cohort until 5 years after surgery.…”

Section: Discussionmentioning

confidence: 99%

“…However, the authors also pointed out that, in these studies, tumors for APR were lower and more locally advanced. Distance from the AV is strongly associated with margin involvement and LR,5, 6, 7 and tumor stage should therefore be addressed. Candidates for APR also included patients with tumors that were ineligible for anastomotic procedures as a result of location or worse response to preoperative treatment.…”

Section: Introductionmentioning

confidence: 99%

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Local control of sphincter‐preserving procedures and abdominoperineal resection for locally advanced low rectal cancer: Propensity score matched analysis

Okamura

Hida

Yamaguchi

et al. 2017

Annals of Gastroent Surgery

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Sphincter‐preserving procedures (SPPs) for surgical treatment of low‐lying rectal tumors have advanced considerably. However, their oncological safety for locally advanced low rectal cancer compared with abdominoperineal resection (APR) is contentious. We retrospectively analyzed cohort data of 1500 consecutive patients who underwent elective resection for stage II‐III rectal cancer between 2010 and 2011. Patients with tumors 2‐5 cm from the anal verge and clinical stage T3‐4 were eligible. Primary outcome was 3‐year local recurrence rate, and confounding effects were minimized by propensity score matching. The study involved 794 patients (456 SPPs and 338 APR). Before matching, candidates for APR were more likely to have lower and advanced lesions, whereas SPPs were carried out more often following preoperative treatment, by laparoscopic approach, and at institutions with higher case volume. After matching, 398 patients (199 each for SPPs and APR) were included in the analysis sample. Postoperative morbidity was similar between the SPPs and APR groups (38% vs 39%; RR 0.98, 95% CI 0.77‐1.27). Margin involvement was present in eight patients in the SPPs group (one and seven at the distal and radial margins, respectively) and in 12 patients in the APR group. No difference in 3‐year local recurrence rate was noted between the two groups (11% vs 14%; HR 0.77, 95% CI 0.42‐1.41). In this observational study, comparability was ensured by adjusting for possible confounding factors. Our results suggest that SPPs and APR for locally advanced low rectal cancer have demonstrably equivalent oncological local control.

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Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Local control of sphincter‐preserving procedures and abdominoperineal resection for locally advanced low rectal cancer: Propensity score matched analysis

Okamura

Hida

Yamaguchi

et al. 2017

Annals of Gastroent Surgery

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“…9, 10 A recent study in which laparoscopic versus open surgery for rectal cancer was compared, showed similar overall rates of locoregional recurrence, disease-free and overall survival. 11 However, a small benefit in disease-free survival after laparoscopy of patients with stage III disease was suggested. Further studies are required to establish if reducing surgical trauma during cancer surgery is correlated with improved survival.…”

Section: Introductionmentioning

confidence: 99%

Spillage of bacterial products during colon surgery increases the risk of liver metastases development in a rat colon carcinoma model.

et al. 2018

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Surgical resection of the primary tumor provides the best chance of cure for patients with colorectal carcinoma (CRC). However, bacterial translocation during intestinal surgery has been correlated with poor long-term oncological outcome. Therefore, we investigated the influence of bacterial contamination during colon surgery on CRC liver metastases development. Blood and liver samples of patients undergoing resection of primary CRC or liver metastases were collected. Cell numbers, activation markers and inflammatory mediators were determined. Tumor cell adhesion and outgrowth after sham- or colectomy operations were determined in a rat model, in which tumor cells had been injected into the portal vein.White blood cells and granulocytes were increased in per- and post-operative patient blood samples. IL-6 was also increased post-operatively compared to the preoperative level. Expression of NOX-2, NOX-4 and polymorphonuclear cells (PMNs) numbers were elevated in post-operative human liver samples. In vitro stimulation of macrophages with plasma of rats after colectomy resulted in production of reactive oxygen species (ROS). Colectomy in rats increased D-lactate levels in plasma, supporting bacterial translocation. Decreased expression of tight junction molecules and increased tumor cell adhesion and outgrowth was observed. Treatment with a selective decontamination of the digestive tract (SDD) cocktail decreased tumor cell adherence after colectomy.In conclusion, postoperative bacterial translocation may activate liver macrophages and PMNs, resulting in ROS production. As we previously showed that ROS release led to liver vasculature damage, circulating tumor cells may adhere to exposed extracellular matrix and grow out into liver metastases. This knowledge is pivotal for development of therapeutic strategies to prevent surgery-induced liver metastases development.

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“…Several studies have shown laparoscopic rectal surgery has failed to reach noninferiority when compared to open resection in terms of short term pathological outcomes [10,17] . However, early reports from some of the major trials are suggesting that laparoscopic rectal surgery and open resection are equivalent regarding long-term disease-free survival, overall survival and local recurrence [18][19][20] .…”

Section: Introductionmentioning

confidence: 99%

Is laparoscopic rectal surgery really not non-inferior?

O'Donohue¹,

Warren²,

Chow³

2018

MIS

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Laparoscopic rectal surgery has gained popularity over the last 20 years. Currently there are still questions surrounding the safety and efficacy of this technique as compared to the traditional open modalities. To date, despite the initial enthusiasm for laparoscopic rectal surgery this technique is yet to reach non-inferiority in trials when compared to open resection. This review article discusses the current evidence exploring the value of laparoscopic rectal surgery. It will discuss its evolution over the last 20 years, exploring all the major randomised control trials and their results. It is our belief that laparoscopic rectal surgery for malignancy is not non-inferior to conventional open surgery.

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A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer

Cited by 1,220 publications

References 22 publications

Local control of sphincter‐preserving procedures and abdominoperineal resection for locally advanced low rectal cancer: Propensity score matched analysis

Local control of sphincter‐preserving procedures and abdominoperineal resection for locally advanced low rectal cancer: Propensity score matched analysis

Spillage of bacterial products during colon surgery increases the risk of liver metastases development in a rat colon carcinoma model.

Is laparoscopic rectal surgery really not non-inferior?

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