Systematic review of oncological outcomes following laparoscopic vs open total mesorectal excision

Table 1 Characteristics of included trials

Ref.	Year	Country	Age (yr)	Gender (M:F)	Follow up (mo)	Rectal cancer details	Procedure
Araujo et al[32]	2003	Brazil				Lower rectal cancer with neoadjuvant chemoradiotherapy	Abdominoperineal resection
LTME			59.1	9:4	47.2
OTME			56.4	10:5	47.2
Baraga et al[33]	2007	Italy				Adenocarcinoma of the rectum suitable for resection with neoadjuvant chemoradiotherapy	Anterior resection and Abdominoperineal resection
LTME			62.8 ± 12.6	55:28	53.6
OTME			65.3 ± 10.3	64:21
Gong et al[34]	2012	China				Lower and mid rectal adenocarcinoma without neoadjuvant chemoradiotherapy	Anterior resection and Abdominoperineal resection
LTME			58.4 ± 13.6	1.3:1	21 (9-56)
OTME			59.6 ± 9.4	1.29:1
Guillou et al[35]	2005	United Kingdom				Adenocarcinoma of left colon and rectum	Anterior resection and Abdominoperineal resection
LTME			69 ± 11	44% female	3
OTME			69 ± 12	46% female	3
Jayne et al[36]	2007	United Kingdom				Adenocarcinoma of left colon and rectum	Anterior resection and Abdominoperineal resection
LTME			69 ± 11	44% female	36.5
OTME			69 ± 12	46% female	36.5
Kang et al[37]	2010	South Korea				Lower and mid rectal adenocarcinoma with neoadjuvant chemoradiotherapy	Anterior resection and Abdominoperineal resection
LTME			57.8 ± 11.1	110:60	3
OTME			59.1 ± 9.9	110:60	3
Lujan et al[38]	2009	Spain				Upper rectal adenocarcinomaMid or low rectal adenocarcinomacT3N0-2 stagePreoperative chemoradiotherapy	Anterior resection and Abdominoperineal resection
LTME			67.8 ± 12.9	62:39	32.8
OTME			66 ± 9.9	64:39	34.1
Ng et al[39]	2008	Hong Kong				Lower rectal cancer within 5 cm of the anal verge	Abdominoperineal resection
LTME			63.7 ± 11.8	31:20	90.1
OTME			63.5 ± 12.6	30:18	87.2
Ng et al[40]	2009	Hong Kong				Upper rectal adenocarcinomaPreoperative chemoradiotherapy	Anterior resection
LTME			66.5 ± 11.9	37:39	112.5
OTME			65.7 ± 12	48:29	108.8
Ng et al[41]	2013	Hong Kong				Rectal adenocarcinoma located between 5 and 12 cm from the anal verge. None of the included patient had neoadjuvant treatment	Sphincter sparing total mesorectal excision
LTME			60.2 ± 11.3	24:16	84.6
OTME			62.1 ± 12.6	22:18	92.7
Zhou et al[42]	2004	China				Low rectal adenocarcinoma Intraperitoneal and 1.5 to 8 cm from the dentate line Dukes D with local infiltration Anal sphincter sparing	Anterior resection
LTME			26-85(44)	43:46
OTME			30-81(45)	46:36	1-16

LTME: Laparoscopic total mesorectal excision; OTME: Open total mesorectal excision; M: Male; F: Female.

Table 2 Treatment protocol adopted in included trials

Ref.	LTME group	OTME group
Araujo et al[32]	4 × 10/11 mm ports were used with some variations	Procedure protocol was not reported
	Trendelenburg position
	Harmonic scalpel for dissection
	Lateral to medial dissection
	Endoscopic stapler for inferior mesenteric pedicle division
	Colonic division by endostapler
	Standard technique of colostomy construction
	Standard perineal phase, dissection and closure
Baraga et al[33]	Intracorporeal vascular pedicle division, rectal mobilization and division, and anastomosis	Procedure protocol was not reported
	Anastomosis by Knight-Griffen technique	Selective defunctioning stoma placement
	Selective defunctioning stoma placement
Gong et al[34]	4 ports were used with some variations	Standard open TME
	Medial to lateral dissection	Sphincter preserving surgery in both groups in selective patients
	Clips to secure inferior mesenteric pedicle	No defunctioning stoma in both groups
	Rectal division by endostapler
	Standard technique of colostomy construction
	Standard perineal phase, dissection and closure
Guillou et al[35]	Detailed procedure protocol was not reported	Detailed procedure protocol was not reported
Jayne et al[36]	3 yr results of Guillou et al[35]	3 yr results of Guillou et al[35]
	Detailed procedure protocol was not reported	Detailed procedure protocol was not reported
Kang et al[37]	Six weeks after completion of chemoradiotherapy	Detailed procedure protocol was not reported
	5 ports were used	Sphincter preservation in selective patients in both groups
	Clips to secure inferior mesenteric pedicle
	Splenic flexure was mobilized in all patients
	Harmonic scalpel or diathermy for dissection
	Rectal division by endostapler
	Colorectal anastomosis by double staple technique or by trans-anal suture
	All patients had defunctioning stoma
Lujan et al[38]	4 ports were used	Lloyd-Davis position and midline laparotomy
	Stapled side to end colorectal or colo-anal hand sewn anastomosis	Stapled side to end colorectal or colo-anal hand sewn anastomosis
	Selective defunctioning stoma placement	Sphincter preservation in selective patients in both groups
		Selective defunctioning stoma placement
Ng et al[39]	4 or 5 ports were used	Standard open abdominoperineal resection
	Staplers for vascular pedicle and bowel transection
	Standard perineal resection
Ng et al[40]	Protocol of the laparoscopic resection technique was not reported	Protocol of the open resection technique was not reported
Ng et al[41]	Lateral to medial mobilization	Protocol of the open resection technique was not reported
	Endostapler for rectal and vascular pedicle transection
	Electrocautry was used to dissect through “Holy plane” for total mesorectal resection
	Splenic flexure mobilization in selective patients
	Anastomosis by double stapling technique
	Defunctioning stoma in selective patients
Zhou et al[42]	Lithotomy position with head down tilt	Standard open total mesorectal excision previously published by Heald et al[10,11]
	Laparoscopy technique was not reported	Electrocautry was used for hemostasis
	Intracorporeal anastomosis	No defunctioning stoma
	Endostapler for vascular and rectal transactions
	Harmonic scalpel was used for dissection
	No defunctioning stoma

TME: Total mesorectal excision; LTME: Laparoscopic total mesorectal excision; OTME: Open total mesorectal excision.

Table 3 Quality variables reported in the included trials

Ref.	Randomization	Power calculations	ITT	Blinding	Concealment
Araujo et al[32]	Not reported	Not reported	Not reported	Not reported	Not reported
Baraga et al[33]	Computer generated	Yes	Yes	Yes	Sealed blinded envelops
Gong et al[34]	Not reported	Not reported	Not reported	Not reported	Not reported
Guillou et al[35]	Random allocation with 2 to 1 ratio	Yes	Yes	Not reported	Allocation communicated by telephone
Jayne et al[36]	Random allocation with 2 to 1 ratio	Yes	Yes	Not reported	Allocation communicated by telephone
Kang et al[37]	Computer generated with block permutation	Yes	Yes	Yes	Allocation communicated by telephone
Lujan et al[38]	Computer generated	Yes	Yes	Yes	Sealed blinded envelops
Ng et al[39]	Computer generated random sequence	Yes	Yes	Yes	Concealed by theatre coordinator
Ng et al[40]	Computer generated	Yes	Yes	Not reported	Not reported
Ng et al[41]	Computer generated random sequence	Yes	Yes	Yes	Concealed by theatre coordinator
Zhou et al[42]	Not reported	Not reported	Not reported	Not reported	Not reported

ITT: Intention-to-treat.