Laparoscopic Resection of Rectal Cancer in the Elderly

Abstract

Recent published trials have failed to demonstrate that laparoscopic resection is not inferior to open resection of rectal cancer in terms of pathologic outcomes. However, there have been numerous studies showing the benefit of laparoscopic resection in terms of short-term complications and quality of life. Fewer complications and shorter hospital stays improve the chance of maintaining functional status, which is very important for the elderly population. Thus, laparoscopic resection of rectal cancer remains a viable option for the elderly. W hile surgical resection remains the cornerstone of treatment for stage II or III colorectal cancer, there is some debate regarding the effi cacy of a laparoscopic technique in patients with rectal cancer. Th e recently published ACOSOG Z6051 trial failed to demonstrate that laparoscopic resection of rectal cancer was not inferior to open resection in terms of pathologic outcomes. Th e concern is that while laparoscopic surgery might be benefi cial in terms of short-term complications, it might sacrifi ce long-term recurrence prevention and survival. Since the incidence and death rates for colorectal cancer increase with age ( 1 ), determining the best approach to resection in elderly patients with rectal cancer is particularly important.Th e Z6051 trial asked, "Is laparoscopic resection noninferior to open resection for the treatment of rectal cancer?" Th e trial consisted of 462 patients with clinical stage II or III rectal cancer within 12 cm of the anal verge who were randomized to laparoscopic or open low anterior or abdominoperineal resection of the rectum after receiving neoadjuvant therapy. Successful resection was defi ned as a negative distal margin, a circumferential radial margin (CRM) >1 mm between the deepest extent of tumor invasion into the mesorectal fat and inked surface on the fi xed specimen, and a complete or nearly complete total mesorectal excision (TME). A 6% noninferiority margin was chosen for the study. Laparoscopic resection of rectal cancer in the elderly L. August Clark, MD, and Walter R. Peters, MD, MBA A successful resection was achieved in 81.7% of the laparoscopic cases compared with 86.9% of the open cases. While the diff erence in success rates was less than the preset noninferiority margin of 6%, the 95% confi dence limits extended to a possible diff erence of up to 10.8%, forcing the authors to acknowledge possible inferiority of the laparoscopic technique. While the authors admitted to using a "novel composite measure of resection quality," tumor pathologic staging has been shown to be the most important prognostic determinant for the development of recurrent rectal cancer ( 2 ). Th e importance of negative margins also extends to survival data; the 5-year survival of patients with stage III rectal cancer decreased to 42% in those with CRM involvement compared with 81% in those with negative CRM ( 3 ). Because the Z6051 trial failed to show that laparoscopic resection was not inferior to open resection, the authors concluded that the d...