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A Single Centre Retrospective Evaluation of Laparoscopic Rectal Resection with TME for Rectal Cancer: 5-Year Cancer-Specific Survival

A Single Centre Retrospective Evaluation of Laparoscopic Rectal Resection with TME for Rectal... Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 473614, 5 pages doi:10.1155/2011/473614 Clinical Study A Single Centre Retrospective Evaluation of Laparoscopic Rectal Resection with TME for Rectal Cancer: 5-Year Cancer-Specific Survival 1 1 1 1 1 Raoul Quarati, Massimo Summa, Fabio Priora, Valeria Maglione, Ferruccio Ravazzoni, 1 1 2 1 Luca Matteo Lenti, Graziella Marino, Federica Grosso, and Giuseppe Spinoglio Department of Surgery, SS. Antonio e Biagio National Hospital, Alessandria, Italy Oncohematologic Department, A.S.O. SS. Antonio e Biagio e C. Arrigo, Via Venezia 16, 15100 Alessandria, Italy Correspondence should be addressed to Giuseppe Spinoglio, gspinoglio@ospedale.al.it Received 1 January 2011; Revised 10 May 2011; Accepted 7 July 2011 Academic Editor: Wolf Heitland Copyright © 2011 Raoul Quarati et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Laparoscopic colon resection has established its role as a minimally invasive approach to colorectal diseases. Better long-term survival rate is suggested to be achievable with this approach in colon cancer patients, whereas some doubts were raised about its safety in rectal cancer. Here we report on our single centre experience of rectal laparoscopic resections for cancer focusing on short- and long-term oncological outcomes. In the last 13 years, 248 patients underwent minimally invasive approach for rectal cancer at our centre. We focused on 99 stage I, II, and III patients with a minimum follow-up period of 5 years. Of them 43 had a middle and 56 lower rectal tumor. Laparoscopic anterior rectal resection was performed in 71 patients whereas laparoscopic abdomino-perineal resection in 28. The overall mortality rate was 1%; the overall morbidity rate was 29%. The 5-year disease-free survival rate was 69.7%, The 5-year overall survival rate was 78.8%. 1. Introduction From an oncological point of view, the noninferiority of colic laparoscopic surgery was established [13]. A better Laparoscopic colon resection has established its role as a long-term survival rate in colon cancer patients has been minimally invasive approach to colorectal diseases. suggested in some experiences [14]. Some doubts were raised about its feasibility and safety in Here we report on our rectal cancer patient series treated rectal cancer because of concern related to thorough surgical with laparoscopic approach that was retrospectively analysed exploration in narrow pelvis and correct total mesorectal focusing on functional results and oncological outcomes. excision with the laparoscopic technique. The risk of port site metastases had also been previously emphasised [1, 2]. No conclusive data are available in this setting, and 2. Patients and Methods further trials are deemed to be needed [3–6]. Three hundred and thirty-one patients with rectal cancer However, several studies demonstrated the technical underwent surgical treatment at our hospital from June 1997 feasibility and safety of laparoscopic rectal resections for to December 2010; 248 of them had minimally invasive cancer. Many authors showed advantages for laparoscopic approach (192 laparoscopic—49 fully robotic). colorectal surgery in terms of reduced postoperative pain, We selected for this analysis 102 patients with a mini- shorter postoperative ileus, and length of hospital stay mum followup of 5 years, therefore excluding 146 patients [3, 7–10]. As a medium-term advantage, a reduced rate operated on after December 2005. Three more patients with on incisional hernia should be considered [11]. A better postoperative recovery, especially for older patients, was also UICC Stage IV disease were also excluded. Eventually we reported [12]. analysed 99 patients, 43 (45.7%) with a middle tumor (>8cm 2 International Journal of Surgical Oncology Table 1: Patients characteristics. Table 2: Complications. Characteristic Middle tumor (n = 43) Lower tumor (n = 56) Complications No. of patient (%) Mean age (range) 71 (42–96) 70 (42–91) Urinary retention 8 (8%) Gender Anastomotic bleeding 5 (7%) Males 25 34 Wound infection 3 (3%) Females 18 22 Anastomotic leakage 3 (4,2%) Small bowel obstruction 2 (2%) Stage TNM I 8 (17%) 5 (42%) II 13 (50%) 24 (30%) Follow-up protocol included a medical examination and III 22 (33%) 27 (28%) serum CEA determination every 3 months for two years, every 6 months for the third year, and annually thereafter. An abdominal sonography, with systematic research of liver metastasis, was performed every 6 months. Additional from anal verge) and 56 with a low tumor (<8cm from anal radiological imaging (chest X-ray, CT scan, MRI scan, etc.) verge). was carried out if appropriate. A flexible colonoscopy was A rectal anterior resection (RAR) was performed in performed every year. 71 patients (71.7%) and a laparoscopic abdominoperineal The cancer-specific disease-free survival rate was anal- resection (APR) in 28 (28.3%). All the patients were operated ysed with a minimum followup of five years: data were on by the same surgeon (GS). considered as uncensored only if the patient died as a direct A written and detailed informed consent was obtained result of colorectal cancer; deaths from all other causes were from each patient. Age at surgery, gender, pathological censored. tumor stage (according to the pTNM classification), and The Kaplan-Meier method was used to plot the survival other relevant variables were prospectively recorded for each curves, and the log-rank test was used for their comparison. patient in an appropriate data base implemented since the A P value of less than 0.05 was set as the statistical beginning of our laparoscopic activity. significance level. Preoperative workup included colonoscopy, contrast- Pearson’s chi-squared test, “t” test, or Fisher’s exact test enhanced CT enema, thoracic CT, magnetic resonance of the was used when appropriate. pelvis, and endorectal ultrasonography. Statistical analysis was performed with commercially After preoperative assessment 68 patients (68%) with available software (SPSS version 13.0, SPSS Inc., Chicago, Ill, extrarectal tumor diffusion (T3 stage) or nodal metastasis USA). (N+) received neoadjuvant radiochemotherapy. Obesity or previous abdominal surgery was not consid- ered contraindications for laparoscopic surgery. 3. Results All rectal resections were carried out with inferior mesenteric vessel ligation and left flexure detachment with The age, distribution, and gender of the study population is a medial-to-lateral approach. showed in Table 1. Total mesorectal excision (TME) was performed in all Mean operating time was lower for middle rectal cancer patients according to the Heald’s principles [15]. group (mean 210 min.) than for low rectal cancer group Bowel reconstruction was performed by Knight-Griffen (mean 270 min.) (P< 0.01). colorectal anastomosis. The conversion rate was 10%, mainly due to adhesions, J-pouch was used both in coloanal hand sewn anasto- difficult isolation of locally advanced bulky tumors, or septic complications. mosis and in mechanical anastomosis within 2 cm from the dentate line, whenever possible. The postoperative mortality rate was 1%; there was 1 fatal To preserve sphincter function in very low tumors, complication, with postoperative death, due to multiorgan bowel reconstruction was performed after intersphincteric failure in systemic candidiasis. resection, by coloanal hand sewn anastomosis. The overall morbidity rate was 29%. A diverting loop ileostomy was performed in 53 patients Postoperative complications included 3/71 (4.2%) cases undergone RAR (14 middle tumors, 39 lower tumors). In all of anastomotic leakage, 3/99 (3%) wound infections, cases a wound protector was used to extract the specimen. 5/71(7%) anastomotic bleeding, 8/99 (8%) transitory uri- The clinical parameters analysed were patient variables, nary retention, and 2/99 (2%) small bowel obstruction operative variables, and clinical outcomes. Patient variables (Table 2). were age at surgery, gender, and pathological tumor stage Patients with anastomotic leakage needed reintervention (according to the pTNM classification) (Table 1). Operative with creation of a diverting ileostomy, peritoneal lavage, and variables included operating time and conversion rate. drainage. Clinical outcomes were surgical complications, recurrence There were no positive proximal, distal, or circumferen- rate, site of first recurrence, disease-free survival, and overall tial margins. The mean number of harvested lymph nodes survival. was19(range2–75). International Journal of Surgical Oncology 3 Table 3: Local and distant recurrence. Disease-free survival Site of recurrence N = 27 Lung 13 (48%) Liver 7 (25%) 0.8 Local 3 (11%) Lymph nodes 2 (7%) 0.6 Peritoneum 1 (3%) Brain 1 (3%) 0.4 Overall survival 0.2 0.8 0 20 40 60 80 100 (months) 0.6 Survival function Censored 0.4 Figure 2: Disease-free survival. 0.2 Overall survival 0 20406080 100 0.8 (months) Survival function 0.6 Censored Figure 1: Overall survival. 0.4 After a median followup of 72 months (min 60 and 0.2 maximum 146), 21 (21,2%) patients died from colorectal cancer and 27 (27,2%) had a cancer recurrence. The most common site of recurrence was the lung, followed by the liver. There were 3 cases of local recurrence 020 40 60 80 100 (Table 3). No cases of peritoneal seeding or portsite recur- (months) rence were reported. The 5-year disease-free survival (DFS) rate was 69.7% Stage (Figure 1). The DFS stratified per stage was 75.6%, 65.7%, and 65.2% for patients in stage I, stage II, and stage III, respectively (Figure 2). The 5-year overall survival (OS) rate was 78.8% Figure 3: Overall survival stratified per stage. (Figure 3). The OS stratified per stage was 87.8%, 71.4%, and 73.9% for patients in stage I, stage II, stage III, respectively (Figure 4). Though laparoscopic colon surgery has gained popular- ity because of its positive influence on short-term outcome, it 4. Discussion and Conclusions should be kept in mind that the first aim of colorectal cancer surgery is to ensure oncological outcomes at least similar to In this single centre series of 99 rectal cancer patients treated those of open surgery. with minimally invasive approach the 5-year DFS rate was Rectal laparoscopic surgery is still a debated issue. The 69.7% and the 5-year OS rate was 78.8%, with 10% of conversion rate and 29% of overall morbidity rate. MRC-CLASICC trial in 2005 [3] had reported impaired Cum survival Cum survival Cum survival 4 International Journal of Surgical Oncology Disease-free survival laparoscopic surgery seemed lower than that previously reported for open colorectal surgery [17, 18]. From a functional point of view laparoscopic magni- fication allows identifying and preserving hypogastric and 0.8 pelvic nerves during the IMA isolation, medium to lateral dissection, and TME. Preservation of sexual function after laparoscopic surgery is still a matter of debate. Ad hoc 0.6 questionnaire on sexual activity is not often administered in clinical studies [19]. Even in our series we did not collect any information in this regard. 0.4 In the same way we did not specifically study the urinary function but we registered in our data base any clinically 0.2 relevant event including urinary tract symptoms: all but 8 patients in this series had the catheter removed within 2 days after surgery and no permanent urinary dysfunction was recorded. The choice to perform a straight colorectal anastomosis 0 20406080 100 after rectal resection was due to the favourable functional (months) results (patient satisfaction) observed in our laparoscopic Stage and open surgery experience and the ease of implementation of this procedure. The straight anastomosis is useful in case of narrow pelvis, obese patients, diverticular colon (contraindication to perform J-pouch), and limited colon Figure 4: Disease-free survival stratified per stage. mobilization is needed. Cochrane meta-analysis in 2008 compared three recon- structive techniques after anterior rectal resection (straight, J-pouch, coloplasty) by analyzing 9 RCTs on straight versus J-pouch anastomosis: J-pouch seems superior for short-term short-term outcomes after laparoscopic anterior resection concluding that its use for rectal cancer could not be yet functional results (within 8 months from the operation) with justified. In 2008 Kim et al. [6] reported an increasing the same complication rate, whereas long-term functional tendency for positive circumferential margins, leak, and results tend to overlap. Of note, the 9 RCTs were all been local recurrence in laparoscopic resection for extraperitoneal published before 2002, and none of them considered the rectal cancer. The Cochrane Review [16] in 2008 concluded laparoscopic approach [20]. that laparoscopic rectal resection with TME appears to have With respect of the use of a diverting loop ileostomy, clinically measurable short-term advantages in patients with although some reports indicate that diversion does not influ- ence the leakage rate, our results suggest that this could not primary rectal cancer. Its long-term impact on oncological endpoints awaits the be the case. In fact the lower incidence of anastomotic leakage results from the on-going randomized trials. seems to correlate with the use of diverting loop ileostomy. In line with previous studies our data suggests that Since 1997 in our surgical department laparoscopy has been largely used and gradually replaced open surgery. We laparoscopic rectal resection provides similar oncological started laparoscopic rectal cancer surgery at a very early long-term outcomes compared to open rectal resection (DFS phase, and in this paper we report on long-term outcome of a 52.1%–81%, OS 52,9%–75,3) [17, 21–25]. The oncological large series of rectal cancer patients. Though acknowledging safety issues of laparoscopic approach, in terms of number of the overt limitation of this retrospective study, the data have harvested lymph nodes, recurrence rate, and cancer-related been collected prospectively in an appropriate data base that survival, are all in line with those reported in Abraham’s was used since the beginning of our laparoscopic activity. The meta-analysis in 2004 [21]. We chose to limit our analysis to those patients with a percentage of patients lost at followup in our series is less than 5%. Our department is a referral center for advanced minimum followup of 5 years. Considering that most of the laparoscopic surgery. This analysis was mainly undertaken cancer-related deaths occur within the first two years after to assess our results in rectal cancer laparoscopic surgery, surgery, such a long time frame seems to be enough to draw being the evaluation of functional results and oncological some initial conclusions. outcomes of the primary end point. At that time there was In conclusion, in an advanced laparoscopic surgical still serious concern about possible inadequacy of tumour setting, laparoscopic rectal resection is feasible and seems to and lymph nodes resection and risk of cancer dissemination accomplish almost the same five-year survival and recurrence rate as open rectal resections. at the port sites. The strength of our study consists in the series size and in Based on the already demonstrated short- and medium- the length of followup. term advantages of laparoscopic surgery and in light of our experience, we support this approach and think that it could The conversion rate was superimposable to that reported in previous studies whereas the wound infection rate after deserve more extensive application. Cum survival International Journal of Surgical Oncology 5 References [17] D. G. Jayne, H. C. Thorpe, J. Copeland, P. Quirke, J. M. Brown, and P. J. Guillou, “Five-year follow-up of the Medical [1] F. J. Berends, G. Kazemier, H. J. Bonjer, and J. F. Lange, Research Council CLASICC trial of laparoscopically assisted “Subcutaneous metastases after laparoscopic colectomy,” The versus open surgery for colorectal cancer,” British Journal of Lancet, vol. 344, no. 8914, p. 58, 1994. Surgery, vol. 97, no. 11, pp. 1638–1645, 2010. 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A Single Centre Retrospective Evaluation of Laparoscopic Rectal Resection with TME for Rectal Cancer: 5-Year Cancer-Specific Survival

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Copyright © 2011 Raoul Quarati et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 473614, 5 pages doi:10.1155/2011/473614 Clinical Study A Single Centre Retrospective Evaluation of Laparoscopic Rectal Resection with TME for Rectal Cancer: 5-Year Cancer-Specific Survival 1 1 1 1 1 Raoul Quarati, Massimo Summa, Fabio Priora, Valeria Maglione, Ferruccio Ravazzoni, 1 1 2 1 Luca Matteo Lenti, Graziella Marino, Federica Grosso, and Giuseppe Spinoglio Department of Surgery, SS. Antonio e Biagio National Hospital, Alessandria, Italy Oncohematologic Department, A.S.O. SS. Antonio e Biagio e C. Arrigo, Via Venezia 16, 15100 Alessandria, Italy Correspondence should be addressed to Giuseppe Spinoglio, gspinoglio@ospedale.al.it Received 1 January 2011; Revised 10 May 2011; Accepted 7 July 2011 Academic Editor: Wolf Heitland Copyright © 2011 Raoul Quarati et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Laparoscopic colon resection has established its role as a minimally invasive approach to colorectal diseases. Better long-term survival rate is suggested to be achievable with this approach in colon cancer patients, whereas some doubts were raised about its safety in rectal cancer. Here we report on our single centre experience of rectal laparoscopic resections for cancer focusing on short- and long-term oncological outcomes. In the last 13 years, 248 patients underwent minimally invasive approach for rectal cancer at our centre. We focused on 99 stage I, II, and III patients with a minimum follow-up period of 5 years. Of them 43 had a middle and 56 lower rectal tumor. Laparoscopic anterior rectal resection was performed in 71 patients whereas laparoscopic abdomino-perineal resection in 28. The overall mortality rate was 1%; the overall morbidity rate was 29%. The 5-year disease-free survival rate was 69.7%, The 5-year overall survival rate was 78.8%. 1. Introduction From an oncological point of view, the noninferiority of colic laparoscopic surgery was established [13]. A better Laparoscopic colon resection has established its role as a long-term survival rate in colon cancer patients has been minimally invasive approach to colorectal diseases. suggested in some experiences [14]. Some doubts were raised about its feasibility and safety in Here we report on our rectal cancer patient series treated rectal cancer because of concern related to thorough surgical with laparoscopic approach that was retrospectively analysed exploration in narrow pelvis and correct total mesorectal focusing on functional results and oncological outcomes. excision with the laparoscopic technique. The risk of port site metastases had also been previously emphasised [1, 2]. No conclusive data are available in this setting, and 2. Patients and Methods further trials are deemed to be needed [3–6]. Three hundred and thirty-one patients with rectal cancer However, several studies demonstrated the technical underwent surgical treatment at our hospital from June 1997 feasibility and safety of laparoscopic rectal resections for to December 2010; 248 of them had minimally invasive cancer. Many authors showed advantages for laparoscopic approach (192 laparoscopic—49 fully robotic). colorectal surgery in terms of reduced postoperative pain, We selected for this analysis 102 patients with a mini- shorter postoperative ileus, and length of hospital stay mum followup of 5 years, therefore excluding 146 patients [3, 7–10]. As a medium-term advantage, a reduced rate operated on after December 2005. Three more patients with on incisional hernia should be considered [11]. A better postoperative recovery, especially for older patients, was also UICC Stage IV disease were also excluded. Eventually we reported [12]. analysed 99 patients, 43 (45.7%) with a middle tumor (>8cm 2 International Journal of Surgical Oncology Table 1: Patients characteristics. Table 2: Complications. Characteristic Middle tumor (n = 43) Lower tumor (n = 56) Complications No. of patient (%) Mean age (range) 71 (42–96) 70 (42–91) Urinary retention 8 (8%) Gender Anastomotic bleeding 5 (7%) Males 25 34 Wound infection 3 (3%) Females 18 22 Anastomotic leakage 3 (4,2%) Small bowel obstruction 2 (2%) Stage TNM I 8 (17%) 5 (42%) II 13 (50%) 24 (30%) Follow-up protocol included a medical examination and III 22 (33%) 27 (28%) serum CEA determination every 3 months for two years, every 6 months for the third year, and annually thereafter. An abdominal sonography, with systematic research of liver metastasis, was performed every 6 months. Additional from anal verge) and 56 with a low tumor (<8cm from anal radiological imaging (chest X-ray, CT scan, MRI scan, etc.) verge). was carried out if appropriate. A flexible colonoscopy was A rectal anterior resection (RAR) was performed in performed every year. 71 patients (71.7%) and a laparoscopic abdominoperineal The cancer-specific disease-free survival rate was anal- resection (APR) in 28 (28.3%). All the patients were operated ysed with a minimum followup of five years: data were on by the same surgeon (GS). considered as uncensored only if the patient died as a direct A written and detailed informed consent was obtained result of colorectal cancer; deaths from all other causes were from each patient. Age at surgery, gender, pathological censored. tumor stage (according to the pTNM classification), and The Kaplan-Meier method was used to plot the survival other relevant variables were prospectively recorded for each curves, and the log-rank test was used for their comparison. patient in an appropriate data base implemented since the A P value of less than 0.05 was set as the statistical beginning of our laparoscopic activity. significance level. Preoperative workup included colonoscopy, contrast- Pearson’s chi-squared test, “t” test, or Fisher’s exact test enhanced CT enema, thoracic CT, magnetic resonance of the was used when appropriate. pelvis, and endorectal ultrasonography. Statistical analysis was performed with commercially After preoperative assessment 68 patients (68%) with available software (SPSS version 13.0, SPSS Inc., Chicago, Ill, extrarectal tumor diffusion (T3 stage) or nodal metastasis USA). (N+) received neoadjuvant radiochemotherapy. Obesity or previous abdominal surgery was not consid- ered contraindications for laparoscopic surgery. 3. Results All rectal resections were carried out with inferior mesenteric vessel ligation and left flexure detachment with The age, distribution, and gender of the study population is a medial-to-lateral approach. showed in Table 1. Total mesorectal excision (TME) was performed in all Mean operating time was lower for middle rectal cancer patients according to the Heald’s principles [15]. group (mean 210 min.) than for low rectal cancer group Bowel reconstruction was performed by Knight-Griffen (mean 270 min.) (P< 0.01). colorectal anastomosis. The conversion rate was 10%, mainly due to adhesions, J-pouch was used both in coloanal hand sewn anasto- difficult isolation of locally advanced bulky tumors, or septic complications. mosis and in mechanical anastomosis within 2 cm from the dentate line, whenever possible. The postoperative mortality rate was 1%; there was 1 fatal To preserve sphincter function in very low tumors, complication, with postoperative death, due to multiorgan bowel reconstruction was performed after intersphincteric failure in systemic candidiasis. resection, by coloanal hand sewn anastomosis. The overall morbidity rate was 29%. A diverting loop ileostomy was performed in 53 patients Postoperative complications included 3/71 (4.2%) cases undergone RAR (14 middle tumors, 39 lower tumors). In all of anastomotic leakage, 3/99 (3%) wound infections, cases a wound protector was used to extract the specimen. 5/71(7%) anastomotic bleeding, 8/99 (8%) transitory uri- The clinical parameters analysed were patient variables, nary retention, and 2/99 (2%) small bowel obstruction operative variables, and clinical outcomes. Patient variables (Table 2). were age at surgery, gender, and pathological tumor stage Patients with anastomotic leakage needed reintervention (according to the pTNM classification) (Table 1). Operative with creation of a diverting ileostomy, peritoneal lavage, and variables included operating time and conversion rate. drainage. Clinical outcomes were surgical complications, recurrence There were no positive proximal, distal, or circumferen- rate, site of first recurrence, disease-free survival, and overall tial margins. The mean number of harvested lymph nodes survival. was19(range2–75). International Journal of Surgical Oncology 3 Table 3: Local and distant recurrence. Disease-free survival Site of recurrence N = 27 Lung 13 (48%) Liver 7 (25%) 0.8 Local 3 (11%) Lymph nodes 2 (7%) 0.6 Peritoneum 1 (3%) Brain 1 (3%) 0.4 Overall survival 0.2 0.8 0 20 40 60 80 100 (months) 0.6 Survival function Censored 0.4 Figure 2: Disease-free survival. 0.2 Overall survival 0 20406080 100 0.8 (months) Survival function 0.6 Censored Figure 1: Overall survival. 0.4 After a median followup of 72 months (min 60 and 0.2 maximum 146), 21 (21,2%) patients died from colorectal cancer and 27 (27,2%) had a cancer recurrence. The most common site of recurrence was the lung, followed by the liver. There were 3 cases of local recurrence 020 40 60 80 100 (Table 3). No cases of peritoneal seeding or portsite recur- (months) rence were reported. The 5-year disease-free survival (DFS) rate was 69.7% Stage (Figure 1). The DFS stratified per stage was 75.6%, 65.7%, and 65.2% for patients in stage I, stage II, and stage III, respectively (Figure 2). The 5-year overall survival (OS) rate was 78.8% Figure 3: Overall survival stratified per stage. (Figure 3). The OS stratified per stage was 87.8%, 71.4%, and 73.9% for patients in stage I, stage II, stage III, respectively (Figure 4). Though laparoscopic colon surgery has gained popular- ity because of its positive influence on short-term outcome, it 4. Discussion and Conclusions should be kept in mind that the first aim of colorectal cancer surgery is to ensure oncological outcomes at least similar to In this single centre series of 99 rectal cancer patients treated those of open surgery. with minimally invasive approach the 5-year DFS rate was Rectal laparoscopic surgery is still a debated issue. The 69.7% and the 5-year OS rate was 78.8%, with 10% of conversion rate and 29% of overall morbidity rate. MRC-CLASICC trial in 2005 [3] had reported impaired Cum survival Cum survival Cum survival 4 International Journal of Surgical Oncology Disease-free survival laparoscopic surgery seemed lower than that previously reported for open colorectal surgery [17, 18]. From a functional point of view laparoscopic magni- fication allows identifying and preserving hypogastric and 0.8 pelvic nerves during the IMA isolation, medium to lateral dissection, and TME. Preservation of sexual function after laparoscopic surgery is still a matter of debate. Ad hoc 0.6 questionnaire on sexual activity is not often administered in clinical studies [19]. Even in our series we did not collect any information in this regard. 0.4 In the same way we did not specifically study the urinary function but we registered in our data base any clinically 0.2 relevant event including urinary tract symptoms: all but 8 patients in this series had the catheter removed within 2 days after surgery and no permanent urinary dysfunction was recorded. The choice to perform a straight colorectal anastomosis 0 20406080 100 after rectal resection was due to the favourable functional (months) results (patient satisfaction) observed in our laparoscopic Stage and open surgery experience and the ease of implementation of this procedure. The straight anastomosis is useful in case of narrow pelvis, obese patients, diverticular colon (contraindication to perform J-pouch), and limited colon Figure 4: Disease-free survival stratified per stage. mobilization is needed. Cochrane meta-analysis in 2008 compared three recon- structive techniques after anterior rectal resection (straight, J-pouch, coloplasty) by analyzing 9 RCTs on straight versus J-pouch anastomosis: J-pouch seems superior for short-term short-term outcomes after laparoscopic anterior resection concluding that its use for rectal cancer could not be yet functional results (within 8 months from the operation) with justified. In 2008 Kim et al. [6] reported an increasing the same complication rate, whereas long-term functional tendency for positive circumferential margins, leak, and results tend to overlap. Of note, the 9 RCTs were all been local recurrence in laparoscopic resection for extraperitoneal published before 2002, and none of them considered the rectal cancer. The Cochrane Review [16] in 2008 concluded laparoscopic approach [20]. that laparoscopic rectal resection with TME appears to have With respect of the use of a diverting loop ileostomy, clinically measurable short-term advantages in patients with although some reports indicate that diversion does not influ- ence the leakage rate, our results suggest that this could not primary rectal cancer. Its long-term impact on oncological endpoints awaits the be the case. In fact the lower incidence of anastomotic leakage results from the on-going randomized trials. seems to correlate with the use of diverting loop ileostomy. In line with previous studies our data suggests that Since 1997 in our surgical department laparoscopy has been largely used and gradually replaced open surgery. We laparoscopic rectal resection provides similar oncological started laparoscopic rectal cancer surgery at a very early long-term outcomes compared to open rectal resection (DFS phase, and in this paper we report on long-term outcome of a 52.1%–81%, OS 52,9%–75,3) [17, 21–25]. The oncological large series of rectal cancer patients. Though acknowledging safety issues of laparoscopic approach, in terms of number of the overt limitation of this retrospective study, the data have harvested lymph nodes, recurrence rate, and cancer-related been collected prospectively in an appropriate data base that survival, are all in line with those reported in Abraham’s was used since the beginning of our laparoscopic activity. The meta-analysis in 2004 [21]. We chose to limit our analysis to those patients with a percentage of patients lost at followup in our series is less than 5%. Our department is a referral center for advanced minimum followup of 5 years. 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