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©The Author(s) 2016.
World J Gastrointest Surg. Jun 27, 2016; 8(6): 452-460
Published online Jun 27, 2016. doi: 10.4240/wjgs.v8.i6.452
Published online Jun 27, 2016. doi: 10.4240/wjgs.v8.i6.452
Table 1 Demographic characteristics of study cohort
| Variables | Lap (%) n = 200 | Converted (%) n = 25 | Open (%) n = 408 | P value | |
| Gender | Male | 128 (64) | 15 (60) | 243 (60) | 0.570 |
| Female | 72 (36) | 10 (40) | 165 (40) | ||
| Median age (yr) | 59 | 63 | 66 | < 0.001 | |
| Ethnic group | Chinese | 172 (86) | 22 (88) | 352 (86.3) | 0.368 |
| Malay | 9 (4.5) | 0 | 19 (4.7) | ||
| Indian | 4 (2) | 2 (8) | 18 (4.4) | ||
| Others | 15 (7.5) | 1 (4) | 19 (4.7) | ||
| ASA | 1 | 75 (37.5) | 4 (16) | 84 (20.6) | 0.002 |
| 2 | 105 (52.5) | 20 (80) | 267 (65.4) | ||
| 3 | 20 (10) | 1 (4) | 55 (13.5) | ||
| 4 | 0 | 0 | 2 (0.4) | ||
| Location of tumor | Lower rectum | 68 (34) | 8 (32) | 131 (32.1) | 0.381 |
| Middle rectum | 90 (45) | 10 (40) | 212 (52) | ||
| Upper rectum | 42 (21) | 7 (28) | 65 (15.9) | ||
| Type of surgery | HAR | 30 (15) | 4 (16) | 24 (5.9) | 0.067 |
| LAR (w/stoma) | 27 (13.5) | 4 (16) | 82 (20.1) | ||
| LAR (w/o stoma) | 32 (16) | 5 (20) | 76 (18.6) | ||
| ULAR | 98 (49) | 12 (48) | 193 (47.3) | ||
| APR | 13 (6.5) | 0 | 33 (8.1) | ||
| Neo-adjuvant therapy status | Chemo-therapy | 5 (2.5) | 0 | 14 (3.4) | < 0.001 |
| Radio-therapy | 3 (1.5) | 0 | 12 (2.9) | < 0.001 | |
| Adjuvant therapy status | Chemo-therapy | 65 (32.5) | 15 (60) | 134 (32.8) | 0.071 |
| Radio-therapy | 28 (14) | 7 (28) | 82 (20.1) | 0.271 |
Table 2 Reasons for laparoscopic conversion to open surgery
| Reason for conversion | No. of patients (% within converted patients) |
| Excessive adhesions | 12 (48) |
| Advanced tumor or excessive tumor fixation | 3 (12) |
| Difficult anatomy | 3 (12) |
| Intraoperative complications (e.g., bleeding, ureteric/urinary tract injury, bowel perforation/injury) | 4 (16) |
| Intolerant of tilt and pneumoperitoneum | 3 (12) |
Table 3 Oncologic characteristics and perioperative outcomes of study cohort
| Variables | Lap (%) n = 200 | Converted (%) n = 25 | Open (%) n = 408 | P value | |
| Tumor grade | Well-differentiated | 20 (10) | 3 (12) | 38 (9.3) | 0.339 |
| Mod-differentiated | 173 (86.5) | 21 (84) | 349 (85.6) | ||
| Poorly-differentiated | 7 (3.5) | 1 (4) | 21 (5.1) | ||
| Median lesion size (cm) | 3.9 | 4.1 | 4.3 | 0.275 | |
| T stage | T1 | 18 (9) | 3 (12) | 23 (5.6) | 0.151 |
| T2 | 43 (21.5) | 4 (16) | 73 (17.9) | ||
| T3 | 126 (63) | 9 (36) | 265 (65) | ||
| T4 | 13 (6.5) | 9 (36) | 47 (11.5) | ||
| Nodal status | N0 | 95 (47.5) | 10 (40) | 188 (46.1) | 0.77 |
| N+ | 105 (52.5) | 15 (60) | 320 (53.9) | ||
| TNM stage | Stage I | 47 (23.5) | 3 (12) | 69 (16.9) | 0.086 |
| Stage II | 51 (25.5) | 4 (16) | 111 (27.2) | ||
| Stage III | 75 (37.5) | 9 (36) | 162 (39.7) | ||
| Stage IV | 27 (13.5) | 9 (36) | 66 (16.2) | ||
| Perineural invasion | + | 38 (19) | 8 (32) | 90 (22.1) | 0.652 |
| - | 162 (81) | 17 (68) | 318 (77.9) | ||
| Vascular invasion | + | 61 (30.5) | 11 (44) | 135 (33.1) | 0.617 |
| - | 139 (69.5) | 14 (56) | 275 (66.9) | ||
| Median lymph nodes harvested (range) | 14 (4-90) | 15 (4-55) | 14 (3-56) | 0.447 | |
| Proximal margin (cm) | 9.9 (0-30) | 10 (2-22) | 12 (0-39) | 0.004 | |
| Distal margin (cm) | 2.1 (1-15) | 1.8 (1-15) | 2 (1-14) | 0.55 | |
| CRM < 2 mm | 29 (14.5) | 5 (20) | 75 (18.4) | 0.494 | |
| Median duration of surgery (min) | 162 | 147 | 119 | < 0.001 | |
| Length of hospitalization | 7 (3-159) | 7 (5-16) | 8 (3-78) | < 0.001 |
Table 4 Distribution of long-term and short-term outcomes across three surgery groups
| Laparoscopic surgery n = 200 | Converted surgery n = 25 | Open surgery n = 408 | P value | |
| No. of patients (%) | No. of patients (%) | No. of patients (%) | ||
| Short-term outcomes | ||||
| Anastomotic leaks | 13 (6.5) | 0 (0) | 17 (4.2) | 0.233 |
| Wound complications | 8 (4) | 2 (8.0) | 31 (7.6) | 0.227 |
| Bleeding complications | 5 (2.5) | 1 (4.0) | 9 (2.2) | 0.840 |
| Ileus | 3 (1.5) | 2 (8.0) | 18 (4.4) | 0.097 |
| Pneumonia | 1 (0.5) | 0 (0) | 8 (2) | 0.298 |
| Cardiac events | 7 (3.5) | 2 (8) | 17 (4.2) | 0.562 |
| 30 d mortality | 2 (1) | 0 (0) | 8 (2.0) | 0.545 |
| Long-term | ||||
| Intestinal obstruction | 23 (11.5) | 5 (20) | 59 (14.5) | 0.396 |
| Incisional hernia | 9 (4.5) | 1 (4) | 33 (8.1) | 0.218 |
| Local recurrence | 9 (4.5) | 1 (4.0) | 36 (8.8) | 0.126 |
| Distant recurrence | 45 (22.5) | 6 (24) | 106 (26) | 0.644 |
Table 5 Prognostic factors of overall survival: Univariate and multivariate analysis
| Variable | 5 yr overall survival (%) | Univariate P value | Overall survival HR (95%CI) | Multivariate P value |
| Age ≥ 65 vs < 65 | 50.9 vs 68.3 | < 0.0011 | 1.4557 (1.083-1.9568) | 0.0032 |
| Gender (male vs female) | 60.6 vs 60 | 0.921 | - | - |
| Lap vs converted vs open | 70.5 vs 61.8 vs 52.7 | 0.0161 | - | 0.148 |
| ASA 1/2 vs 3/4 | 62.6 vs 45.7 | 0.0161 | - | 0.131 |
| NeoadjChemo (yes vs no) | 59.5 vs 60.4 | 0.36 | - | - |
| NeoadjRT (yes vs no) | 66.7 vs 60.2 | 0.654 | - | - |
| AdjChemo (yes vs no) | 40.8 vs 70.5 | < 0.0011 | - | 0.06 |
| AdjRT (yes vs no) | 53.2 vs 62.3 | 0.206 | - | - |
| TNM stage (I-IV) | < 0.0011 | < 0.0012 | ||
| Stage I | 77.2 | Reference | ||
| Stage II | 73.8 | 1.04 (0.58-1.84) | 0.907 | |
| Stage III | 60.3 | 1.52 (0.89-2.58) | 0.124 | |
| Stage IV | 13.9 | 5.80 (3.26-10.33) | < 0.001 | |
| Tumor grade | 0.0021 | 0.0152 | ||
| Well differentiated | 75 | Reference | ||
| Moderately differentiated | 60.1 | 2.10 (1.00-4.40) | 0.049 | |
| Poorly differentiated | 39.1 | 1.18 (0.54-2.54) | 0.682 | |
| CRM < 2 mm vs > 2 mm | 40.1 vs 63.5 | < 0.0011 | 1.66 (1.19-2.32) | 0.0032 |
| No. of lymph nodes ≥ 12 vs < 12 | 62.2 vs 56.1 | 0.08 | - | - |
| Perineural invasion | 36.2 vs 67.3 | < 0.0011 | - | 0.276 |
| Vascular emboli | 46.2 vs 68.5 | < 0.0011 | - | 0.14 |
| Clinical symptoms of obstruction at presentation (yes vs no) | 35.3 vs 64.6 | < 0.0011 | 1.95 (1.39-2.74) | < 0.0012 |
Table 6 Summary of studies reporting at least 5 year survival outcomes of laparoscopic vs open rectal resection
| Ref. | Type of study | No. of patients with rectal cancer | 5 yr overall survival | Remarks |
| Lujan et al[4] | Randomized Controlled Trial | 204 (103 open, 101 lap) | 75.3% (open) vs 72.1% (lap) P = 0.980 | Middle and low rectal cancers only |
| Green et al[26], (MRC CLASICC trial) | Randomized Controlled Trial | 381 (128 open, 253 lap) | 52.9% (open) vs 60.3% (lap) P = 0.132 | |
| Ng et al[29] | Pooled Analysis of 3 RCT | 278 (142 open, 136 lap) | 61.1% (open) vs 63.0% (lap) P = 0.505 | 10 yr overall survival |
| Laurent et al[6] | Retrospective Comparative Study | 471 (233 open, 239 lap) | 79% (open) vs 82% (lap) P = 0.52 | Cancer free survival main outcome measure |
| Day et al[25] | Retrospective | 222 (133 open, 89 lap) | 58% (open) vs 75% (lap) P = 0.014 | Laparoscopic group had better survival on multivariate analysis as well |
| Baik et al[24] | Case-matched Controlled Analysis | 162 (108 open, 54 lap) | 88.5% (open) vs 90.8% (lap) P = 0.261 | |
| Li et al[28] | Retrospective | 238 (123 open, 113 lap) | 78.9% (open) vs 77.9% (lap) P = 0.913 | Middle and low rectal cancers only |
| Lim et al[21] | Retrospective | 191 (91 open, 100 lap) | 72.6% (open) vs 74.7% (lap) P = 0.54 | |
| Zhong et al[30] | Retrospective | 514 (238 open, 186 lap) | 61.3% (open) vs 69.4% (lap) P = 0.067 | |
| Agha et al[23] | Retrospective | 225 (all laparoscopic) | 50.5% (lap) | 10 yr overall survival |
- Citation: Tan WJ, Chew MH, Dharmawan AR, Singh M, Acharyya S, Loi CTT, Tang CL. Critical appraisal of laparoscopic vs open rectal cancer surgery. World J Gastrointest Surg 2016; 8(6): 452-460
- URL: https://www.wjgnet.com/1948-9366/full/v8/i6/452.htm
- DOI: https://dx.doi.org/10.4240/wjgs.v8.i6.452