Role of minimally invasive surgery for rectal cancer

Table 1 Goals of care in rectal cancer patients

Goals	Parameters
Oncological	Overall survival, disease-free survival, local recurrence rate, cure
Ostomy	Avoidance of permanent ostomy, stoma-free survival
Anatomical	Organ preservation
	Sphincter preservation
Functional	Preservation of QoL
	Anorectal and defacatory function
	Sexual and urinary function
Peri-/postoperative morbidity	Low intraoperative complication rate
	Avoidance of collateral injuries
	Low postoperative complication rates (leak, SSI, and any Clavien-Dindo complication > 2)

QoL: Quality of life.

Table 2 Surgical platforms for rectal neoplasias

	Oncological resection	Endoluminal local excision
Sphincter preserving/restorative surgery	Open TME	Colonoscopic EMR/ESD
	Laparoscopic TME	Transanal excision
	Robotic TME	Transanal endoscopic microsurgery
	Transanal TME	Transanal minimally invasive surgery (L-TAMIS)
		Robotic TAMIS
Nonrestorative surgery	Open APR
	Laparoscopic APR
	Robotic APR
	Transanal APR

TME: Total mesorectal excision; APR: Abdominal perineal resection; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; TAMIS: Transanal minimally invasive surgery.

Table 3 Major randomized controlled trials in minimally invasive surgery for rectal cancer

Trial	Year	Comparison	Enrollment	Primary end point	Findings
MRC CLASICC[6]	2005	Lap vs Open	253 vs 128	Clear margins/mortality	Colon and rectal surgery compared, 12% vs 6% positive CRM
MRC CLASICC FU[81]	2013				No differences seen OS, DFS, LR at 62 mo
COREAN[7]	2010	Lap vs Open	170 vs 170		No differences seen in multiple short-term outcomes
COREAN FU[82]	2014			3-yr disease free survival	Noninferiority of laparoscopic approach was met, 79% vs 72% DFS
COLOR II[32]	2013	Lap vs Open	699 vs 345		Similar safety and margins, laparoscopic surgery had quicker recovery
COLOR II FU[8]	2015			3-yr locoregional recurrence	Similar recurrence rates at 5% for each group
ACOSOG Z6051[9]	2015	Lap vs Open	240 vs 222	Clear margins	Noninferiority study not able to reach boundary of 6%
ACOSOG Z6051 FU[11]	2019				No differences seen in long term oncologic outcomes
ALaCaRT[10]	2015	Lap vs Open	238 vs 237	Clear margins	Noninferiority study not able to reach boundary of 8%
ALaCaRT FU[12]	2019				No differences seen in long term oncologic outcomes
ROLARR[15]	2017	Lap vs Robot	234 vs 237	Conversion to open surgery	No differences seen in conversion rate, 12% vs 8%
Kim et al[16]	2018	Lap vs Robot	73 vs 66	Completeness of TME	Similar TME specimens, 78% vs 80%
Bordeaux[17]	2014	Lap vs TaTME	50 vs 50	Quality of oncologic surgery	Significant decrease in CRM positivity for TaTME, 4% vs 18%
Bordeaux FU[54]	2018				No differences seen in long term oncologic outcomes at 60 months

FU: Follow up study; TME: Total mesorectal excision; TaTME: Transanal TME; CRM: Circumferential resection margin; OS: Overall survival; DFS: Disease-free survival.

Table 4 Selected laparoscopic vs open rectal cancer surgery studies

Ref.	Yr	Trial	Surgery	n	OR Time (min)	EBL (mL)	CVR (%)	LOS (d)	Comp (%)	Mort (%)	DRM+ (%)	CRM+ (%)	LN	C-TME (%)	DFS (%)	OS (%)	LRR (%)
Guillou et al[6]	2005	MC RCT	Lap	253				11	59	4		12
			Open	128				13	50	5		6
Lujan et al[83]	2009	SC RCT	Lap	101	193	127	17	8	33		0	4	13		85	72	4.8
			Open	103	172	234		10	33		0	3	11		81	75	5.4
Kang et al[7]	2010	MC RCT	Lap	170	244	200	1	8	21			4	17	75
			Open	170	197	217		9	23			3	18	72
Liang et al[43]	2011	SC RCT	Lap	169	138				20				7			76
			Open	174	118				19				7			83
Lujan et al[84]	2013	MC PR	Lap	1387	217			8	38	1	1	10	14	82
			Open	3018	186			11	45	4	1	16	14	75
Van Der Pas et al[32]	2013	MC RCT	Lap	739	240	200	17	8	40	1		10	13	88
			Open	364	188	400		9	37	2		10	14	92
Jeong et al[82]	2014	MC RCT	Lap	170											72	88	2.6
			Open	170											79	85	4.9
Bonjer et al[8]	2015	MC RCT	Lap	699											75	87	5
			Open	345											71	84	5
Stevenson et al[10]	2015	MC RCT	Lap	238	210	100	9	8	19		1	7		87
			Open	235	190	150		8	25		1	3		92
Stevenson et al[12]	2019	MC RCT	Lap	225											80	94	5.4
			Open	225											82	93	3.1
Fleshman et al[9]	2015	MC RCT	Lap	240	266	256	11	7	57	1	2	12	18	92
			Open	222	220	318		7	58	1	2	8	17	95
Fleshman et al[11]	2019	MC RCT	Lap	240											80	85	4.6
			Open	222											83	86	4.5

CVR: Conversion rate; Comp: Complications; Mort: Mortality; CRM/DRM: Circumferential/distal resection margin; C-TME: Complete total mesorectal excision; sMC: Multicenter; RCT: Randomized controlled trial: SC: Single center; PR: Prospective review; OS: Overall survival; DFS: Disease-free survival; LRR: Local recurrence rates.

Table 5 Selected laparoscopic vs robotic rectal cancer surgery studies

Ref.	Yr	Trial	Surgery	n	OR time (min)	EBL (mL)	CVR (%)	LOS (d)	Comp (%)	Mort (%)	DRM+ (%)	CRM+ (%)	LN	C-TME (%)	DFS (%)	OS (%)	LRR (%)
Patriti et al[36]	2009	SC RR	Lap	37	208	127	20	10	32			0	11
			Robot	29	202	137	0	12	26			0	10
Cho et al[85]	2015	SC PSM	Lap	278	272	147	1	10	23		1	4.7	16		79	93	3.9
			Robot	278	361	179	1	10	25		0	5	15		81	92	5.9
Jayne et al[15]	2017	MC RCT	Lap	234	261		12	8	31	1		6.3	24	75
			Robot	237	298		8	8	33	1		5.1	23	75
Wang et al[59]	2017	SC RCT	Lap	66	207								16
			Robot	71	246								16
Kim et al[53]	2017	SC PSM	Lap	224	249		1	14	24	1		4.9	21		68	78
			Robot	224	285		0	13	32	1		4	20		72	90
Law et al[49]	2017	SC PR	Lap	171	225	100	4	6	22	1		8.2	12		80	74	5
			Robot	200	260	100	1	6	19	1		4.1	14		82	71	5
Rouanet et al[37]	2018	SC RR	Lap	200	232	100	10	11	24			11	19	90		88
			Robot	200	243	200	2	10	25			8	15	85		84
Sammour et al[44]	2018	SC O	Robot	276	100		2	4	34			2.5	22	76	82	87	2.4
Chang et al[86]	2019	SC O	Robot	1145	166	73	6	6	16	1		1.3	17	90			2.3

CVR: Conversion rate, Comp: Complications, Mort: Mortality; CRM/DRM: Circumferential/distal resection margin; MC: Multicenter; RCT: Randomized controlled trial; SC: Single center; PR: Prospective review; RR: Retrospective review; PSM: Propensity score matched; O: Observational study; OS: Overall survival; DFS: Disease-free survival; LRR: Local recurrence rates.

Table 6 Selected transanal total mesorectal excision rectal cancer surgery studies

Ref.	Yr	Trial	Surgery	n	OR time (min)	EBL (mL)	CVR (%)	LOS (d)	Comp (%)	Mort (%)	DRM+ (%)	CRM+ (%)	LN	C-TME (%)	DFS (%)	OS (%)	LRR (%)
Denost et al[17]	2014	SC RCT	Lap	50	264		10	8	44	2	2	18	17	62
			TaTME	50	240		4	7	32	0	8	4	17	70
Lacy et al[31]	2015	SC O	TaTME	140			0		34			6	15	97	91	97	2.3
Chen et al[51]	2016	MC PMR	Lap	100	178	88	5	7	17			10	17
			TaTME	50	182	68	2	7	20			4	17
Marks et al[55]	2017	SC O	TaTME	373												90	7.4
Penna et al[87]	2017	MC O	TaTME	720	277		9	8	32	2	0	2	17	85
Denost et al[54]	2017	SC RCT	Lap	50											71	74	4.8
			TaTME	50											73	87	2.6
Persiani et al[42]	2018	SC PSM	Lap	46	272		20	7	21			0		84
			TaTME	46	276		0	7	23			0		87
Perdawood et al[33]	2018	SC PSM	Lap	100	334	239	11	14			1	13	22	68
			TaTME	100	285	82	0	8			0	7	22	58
			Open	100	325	704		15			1	10	18	68
Perez et al[88]	2017	SC RR	Robot	60	276		10	8	37				15	88
			TaTME	55	291		3	7	22				15	90
Detering et al[18]	2019	MC PSM	Lap	396			9	6	36	1		4
			TaTME	396			2	7	42	0		4
Law et al[34]	2019	SC PSM	Robot	40	270	150	5	6	17			1	13
			TaTME	40	254	90	5	6	12			0	13
Lee et al[19]	2019	MC PMR	Robot	453	189		4		35	0	1	6	16	95
			TaTME	277	189		3		33	0	2	6	16	92
Hol et al[56]	2019	SC O	TaTME	159					52		0	1		87	81	77	3.8
Wasmuth et al[20]	2019	MC O	TaTME	157													11.6

MC: Multicenter; RCT: Randomized controlled trial; SC: Single center; PMR: Prospective matched review; RR: Retrospective review; PSM: Propensity score matched; O: Observational study; TaTME: Transanal total mesorectal excision. OS: Overall survival; DFS: Disease-free survival; CVR: Conversion rate; Mort: Mortality; Comp: Complications; CRM: Circumferential resection margin; DRM: Distal resection margin; C-TME: Complete total mesorectal excision; LRR: Local recurrence rates.