Research Article

Surgical and Early Oncological Outcomes of Laparoscopic Versus Open Rectal Surgery: A Comparative Study

10.4274/tjcd.galenos.2019.76768

  • Nidal İflazoğlu
  • Ali Duran
  • Emir Çapkınoğlu
  • Cem Kaan Parsak

Received Date: 18.02.2019 Accepted Date: 26.04.2019 Turk J Colorectal Dis 2019;29(4):171-176

Aim:

In this study, we aimed to evaluate the short-term clinicopathological outcomes of laparoscopic versus open surgery in patients undergoing rectal cancer surgery.

Method:

Between May 2015 and July 2017, 46 patients who underwent curative surgery for rectal cancer were retrospectively analyzed. The patients receiving neoadjuvant therapy were administered long-term fractional chemoradiotherapy. All patients were divided into two groups as open surgery (Group 1, n=21) and laparoscopic surgery (Group 2, n=25). Data including demographic characteristics, type of surgery, postoperative complications, duration of surgery, length of hospital stay, the amount of intraoperative bleeding, and short-term oncological outcomes were recorded.

Results:

Of the patients, 34 were males, and 14 were females. The median age was 55 (range= 28 to 82) years. The median follow-up was 20 months in Group 1 and 19 months in Group 2. The tumor was located in the upper rectum in 19 patients, in the mid-rectum in 14 patients, and the lower rectum in 13 patients. The median length of hospital stay was six days, and the median duration of surgery was 202.5 min. The recurrence rate was 13%, and the mortality rate was 6.5%. The rate of conversion from laparoscopic to open surgery was 21.8%. The complication rate was 54.3%. Anastomotic leak was detected in two patients. The amount of intraoperative bleeding was statistically significantly higher, and the length of the proximal surgical margin was statistically significantly longer in the open surgery group.

Conclusion:

Our study results suggest lower hemorrhage with laparoscopic surgery and similar oncological outcomes with both laparoscopic and open rectal surgery.

Keywords: Rectal cancer, open surgery, laparoscopy, oncological outcomes

Introduction

Surgical oncology has undergone a significant evolution over the last two decades. The fast-growing technological advancements have influenced the practice of new surgical techniques. As in many surgical fields, minimally invasive surgery, which has been widely used in cancer surgery, has become increasingly adopted by many surgeons in the practice of colorectal surgery owing to less tissue trauma and favorable outcomes. There is a growing number of clinical studies, systematic reviews, and meta-analysis comparing laparoscopic versus open rectal cancer surgery in the literature and oncological outcomes of both techniques are still debated.1,2,3,4 In rectal cancer surgery, total mesorectal excision with specific rules has been adopted irrespective of the surgical technique applied.5 In the present study, we aimed to evaluate the short-term clinicopathological outcomes of laparoscopic versus open surgery in patients undergoing rectal cancer surgery.


Materials and Methods

Between May 2015 and July 2017, all patients who underwent curative surgery for rectal cancer at our clinic were retrospectively analyzed. A single surgical team operated all patients. The patients receiving neoadjuvant therapy were administered long-term fractional chemoradiotherapy (1.8x28=50.4 Gy + 5-FU for 28 days). Chemoradiotherapy was applied to the patients with T3, T4, and/or N+ rectal cancer according to the tumor, node, metastasis staging system.6 All patients were operated six to eight weeks after neoadjuvant therapy. Patients with missing data were excluded from the study. No written consent is required in such retrospective studies. The study protocol was approved by the Çukurova University Non-invasive Clinical Research Ethics Committee (01.02.2019/85). The study was conducted following the principles of the Declaration of Helsinki. Tumors were classified according to their distance to the anal verge: <8 cm lower rectum, 8-12 cm mid-rectum, and 12-15 cm upper rectum.7 The patients were divided into two groups as open surgery (Group 1, n=21) and laparoscopic surgery (Group 2, n=25). Data including demographic characteristics such as age and sex, type of surgery, postoperative complications according to the Clavien-Dindo classification,8 duration of surgery, length of hospital stay, the amount of intraoperative bleeding, and short-term oncological outcomes (location of the tumor, neoadjuvant therapy, radial surgical margin, proximal surgical margin, distal surgical margin, tumor stage, specimen size, the number of lymph nodes removed, recurrence, and survival) were recorded. The patients who were switched from laparoscopic to open surgery were included in the open surgery group (Group 1). In the surgical technique, high ligation of the inferior mesenteric artery, close ligation of the inferior mesenteric vein to treitz, and complete splenic flexure mobilization were performed similarly in all patients (both in laparoscopic and open technique). Total mesenteric artery ligation was performed in partial mesorectal excision of upper rectal tumors, in total mesorectal excision of mid-rectal and distal rectal tumors and in all operations (laparoscopic and open surgery) following oncological surgical principles.


Statistical Analysis

Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) for Windows version 22 statistical software (IBM Corp., Armonk, NY, USA). Continuous variables were expressed in median (minimum-maximum) values, and categorical variables were expressed in number and frequency. The chi-square test was used to analyze qualitative data. The Mann-Whitney U test was used to analyze quantitative data. A p value of <0.05 was considered statistically significant.


Results

A total of 46 patients were included in the study. Of these patients, 32 were males, and 14 were females. The median age was 55 (range=28 to 82) years. A total of 21 patients (45.7%) underwent open surgery (Group 1), while 25 patients (54.3%) underwent laparoscopic surgery (Group 2). The median follow-up was 19 (range=14 to 34) months in Group 1 and 20 (range=13 to 37) months in Group 2. The tumor was located in the upper rectum in 19 patients, in the mid-rectum in 14 patients, and in the lower rectum in 13 patients. The median length of hospital stay was six (range=3 to 17) days, and the median duration of surgery was 202.5 (range=90 to 375) min. The recurrence rate was 13% (6/46), and the mortality rate was 6.5% (3/46). Baseline demographic and clinicopathological characteristics of patients are shown in Table 1. Anterior resection was performed in 12 patients (n=3 laparoscopic and n=9 open surgery), abdominoperineal resection in seven patients (n=3 laparoscopic and n=4 open surgery), intersphincteric resection with pull-through coloanal anastomosis in three patients (n=2 laparoscopic and n=1 open surgery), and low anterior resection in 24 patients (n=17 laparoscopic and n=7 open surgery). The rate of conversion from laparoscopic to open surgery was 21.8% (10/46). The rate of complication was 54.3% (25/46). Anastomotic leak was detected in two patients and was treated with interventional radiological techniques and conservative methods without the need for surgery. Postoperative complications are summarized in Table 2. First flatus were seen between days postoperatively (po) 2-5 days (median=3), oral intakes were started po 1-4 days (median=2) days, urinary catheters were removed between po 2-10 days (median=3), drainage catheters were removed between po 2-7 days (median=3), mobilization was started between po 0-2. days (median=1), and pain relief intake was left to the patient’s request after performed routine at po 0-1. days. There was no significant difference between laparoscopic and open surgery groups in terms of first flatus, oral intake, urine catheter removal, drainage catheter removal, need of painkiller (p>0.05). The number of patients receiving neoadjuvant chemoradiotherapy was statistically significantly higher in Group 2 than Group 1 (p=0.009). The amount of intraoperative bleeding was statistically significantly higher in Group 1 than Group 2 (p=0.000). The length of the proximal surgical margin was statistically significantly longer in Group 1 than Group 2 (p=0.048). However, there was no statistically significant difference in the length of distal and radial surgical margins between Group 1 and Group 2 (p=0.666 and p=0.277, respectively). Also, there was no statistically significant difference in the duration of surgery, length of hospital stay, the need for diverting ileostomy, number of lymph nodes dissected, specimen size, and recurrence rate between Group 1 and Group 2 (p>0.05 for both). The clinicopathological outcomes of both patient groups are presented in Table 3.


Discussion

Conventional treatment of rectal cancer includes open surgery and total mesorectal resection.5 Currently, laparoscopic surgical techniques have been increasingly used in colorectal surgery, and it is a safe and feasible technique in colon surgery.4,9,10 Although favorable non-oncological outcomes of laparoscopy have been reported in rectal surgery, there is still a controversy among surgeons since some have advocated that laparoscopy yields poor oncological outcomes.1,2 The open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy trial11 and the Colorectal cancer Laparoscopic or Open Resection II trial12 demonstrated oncological equivalence with both techniques. However, the Australasian laparoscopic cancer of the rectum trial1 and the American College of Surgeons Oncology Group-Z6051 trial2 failed to show non-inferiority of surgical outcomes for laparoscopic vs. open resection. In a meta-analysis including 2.319 patients, Creavin et al.13 reported that the mesorectal quality was slightly better with open surgery than laparoscopy; however, minor defects did not affect oncological outcomes. In a study, Yang et al.14 concluded that laparoscopy was more likely effective in achieving complete total mesorectal excision. In another meta-analysis, including 3.258 patients with rectal cancer, Vennix et al.15 reported similar long-term survival rates between laparoscopic and open rectal surgery. In our study, despite the lack of long-term outcomes, we found oncopathological equivalence with both surgical methods in the short-term; however, the length of proximal surgical margin was longer in open surgery. Longer proximal margin maybe because of the comfort of the surgeon in open surgeries regarding the decision of point of proximal margin. Also, none of the patients had positive surgical margins in any of the groups.

Previous studies have well-demonstrated that laparoscopic surgery is associated with favorable short-term non-oncological outcomes including shorter hospital stay, less pain, less postoperative complications, less scarring and less scar-related problems, a lower need for blood transfusion, a lower amount of bleeding and a lower rate of postoperative ileus, despite prolonged duration of operation, and that open surgery is associated with higher morbidity and mortality.3,10,16 In the present study, consistent with the literature, we observed a statistically significantly lower amount of bleeding during laparoscopy compared to open surgery. However, we found no significant difference in the duration of operation, length of hospital stays, and complication rates between the two techniques. This discrepancy can be attributed to the small sample size and to the fact that more eligible cases for laparoscopic surgery were selected in our study. Furthermore, the number of patients receiving neoadjuvant chemoradiotherapy was statistically significantly higher in the laparoscopy group than open surgery in our study, and this can be explained by the non-homogeneous distribution of the patients due to the retrospective nature of the study and the small sample size. Also, the rate of conversion from laparoscopic to open surgery was 21.8%, which is consistent with the literature data [14.5% (range=0 to 35%)].15 In their study, Yang et al.14 reported a significantly shorter length of hospital stay in the laparoscopy group than open surgery (5.2±1.8 days vs. 7.0±2.1 days, respectively). In our study, we also found a shorter median length of hospital stay in the laparoscopy group (5 days vs. seven days, respectively), although it did not reach statistical significance. Also, the rate of wound infections was 13% in our study, consistent with the literature.17 The rate of ureter injury was 3% in our study, which is also consistent with previous studies reporting a rate of 1 to 8%.18 On the other hand, we found sexual dysfunction in 4% of our patients; however, this rate varies from 19 to 69% in the literature.16 This discrepancy in the results can be attributed to the small sample size in our study and its retrospective design since we were unable to evaluate the complaints of the patients in detail. Also, the rate of anastomotic leak was significantly lower in our study (<1%) than reported in the literature.19,20 This can be explained by the fact that there might be anastomotic leaks that were clinically undiagnosed in our series, as we performed diverting ileostomy in the majority of the patients who underwent lower anterior resection. In the present study, the rate of other postoperative complications is consistent with previous studies. The retrospective design with a small sample size is the main limitation of this study. Also, the non-homogeneous distribution of the patients can be regarded as another limitation. Lastly, the other limitation is that the majority of the patients have a diagnosis of upper rectal cancer in the study. Therefore, we recommend further large-scale prospective studies to establish a definite conclusion.


Conclusion

In conclusion, our study results showed similar oncological outcomes with both laparoscopic and open rectal surgery. However, the amount of intraoperative bleeding was higher, and the length of the proximal surgical margin was longer in the open rectal surgery group. Nonetheless, there was no significant difference in other clinical and short-term oncopathological outcomes between laparoscopic and open rectal surgery. Based on these findings, we suggest that both surgical techniques have oncological equivalence. However, further prospective, randomized clinical studies in a large-scale, homogeneous patient group are needed.


Ethics

Ethics Committee Approval: The study protocol was approved by the Çukurova University Non-invasive Clinical Research Ethics Committee (no: 01.02.2019/85).

Informed Consent: Retrospective study.

Authorship Contributions

Surgical and Medical Practices: N.İ., A.D., E.Ç., C.K.P., Concept: N.İ., A.D., Design: N.İ., A.D., Data Collection or Processing: N.İ., A.D., E.Ç., C.K.P., Analysis or Interpretation: N.İ., E.Ç Literature Search: N.İ., Writing: N.İ., A.D., E.Ç., C.K.P.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

Images

  1. Stevenson AR, Solomon MJ, Lumley JW, Hewett P, Clouston AD, Gebski VJ, et al. ALaCaRT Investigators. Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial. JAMA 2015;314:1356-1363.
  2. Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, et al. Effect of Laparoscopic-Assisted Resection vs Open Resection of Stage II or III Rectal Cancer on Pathologic Outcomes: The ACOSOG Z6051 Randomized Clinical Trial. JAMA 2015;314:1346-1355.
  3. Martinez-Perez A, Carra MC, Brunetti F, de’Angelis N. Short-term clinical outcomes of laparoscopic vs open rectal excision for rectal cancer: A systematic review and meta-analysis. World J Gastroenterol 2017;23:7906-7916.
  4. Kuhry E, Schwenk WF, Gaupset R, Romild U, Bonjer HJ. Long-term results of laparoscopic colorectal cancer resection. Cochrane Database Syst Rev 2008;CD003432.
  5. Grade M, Flebbe H, Ghadimi BM. Evidence-based surgery of rectal cancer. Chirurg 2019;90:387-397.
  6. https://www.nccn.org/professionals/physician_gls/pdf/rectal.pdf last access; 15. 01.2019
  7. Lowry AC, Simmang CL, Boulos P, Farmer KC, Finan PJ, Hyman N, et al; American Society of Colon and Rectal Surgeons; Association of Coloproctology of Great Britain and Ireland; Coloproctology Surgical Society of Australia. Consensus statement of definitions for anorectal physiology and rectal cancer. Colorectal Dis 2001;3:272-275.
  8. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009;250:187-196.
  9. Stormark K, Soreide K, Soreide JA, Kvaloy JT, Pfeffer F, Eriksen MT, et al. Nationwide implementation of laparoscopic surgery for colon cancer: short-term outcomes and long-term survival in a population-based cohort. Surg Endosc 2016;30:4853-4864.
  10. Ghadban T, Reeh M, Bockhorn M, Heumann A, Grotelueschen R, Bachmann K, et al. Minimally invasive surgery for colorectal cancer remains underutilized in Germany despite its nationwide application over the last decade. Sci Rep 2018;8:15146. 
  11. Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 2014;15:767-774.
  12. Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES, et al; COLOR II Study Group.  A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 2015;372:1324-1332.
  13. Creavin B, Kelly ME, Ryan E, Winter DC. Meta-analysis of the impact of surgical approach on the grade of mesorectal excision in rectal cancer. Br J Surg 2017;104:1609-1619.
  14. Yang Q, Xiu P, Qi X, Yi G, Xu L.  Surgical margins and short-term results of laparoscopic total mesorectal excision for low rectal cancer. JSLS 2013;17:212-218.
  15. Vennix S, Pelzers L, Bouvy N, Beets GL, Pierie JP, Wiggers T, et al. Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev 2014;CD005200.
  16. Greenblatt DY, Rajamanickam V, Pugely AJ, Heise CP, Foley EF, Kennedy GD. Short-term outcomes after laparoscopic-assisted proctectomy for rectal cancer: results from the ACS NSQIP. J Am Coll Surg 2011;212:844-854.
  17. Segal CG, Waller DK, Tilley B, Piller L, Bilimoria K. An evaluation of differences in risk factors for individual types of surgical site infections after colon surgery. Surgery 2014;156:1253-1260.
  18. Halabi WJ, Jafari MD, Nguyen VQ, Carmichael JC, Mills S, Pigazzi A, et al. Ureteral injuries in colorectal surgery: an analysis of trends, outcomes, and risk factors over a 10-year period in the United States. Dis Colon Rectum 2014;57:179-186.
  19. Platell C, Barwood N, Dorfmann G, Makin G. The incidence of anastomotic leaks in patients undergoing colorectal surgery. Colorectal Dis 2007;9:71-79.
  20. Ureyen O, Ilhan E, Dadalı E, Gokcelli O, Alay D, Altıntas SB, et al. Evaluation of Factors Associated with Anastomotic Leakage in Colorectal Surgery. Turk J Colorectal Dis 2018;28:129-135.