Optimal approach to elective resection for rectal cancers (COL1-2b)

From Cancer Guidelines Wiki

Systematic review evidence

In patients diagnosed with rectal cancer, what is the optimal resection strategy to achieve the best outcomes in terms of length and quality of life? (COL1-2b)

A systematic review was undertaken to determine the optimal resection strategy for rectal cancer to maximise survival and quality of life. The review identified studies that examined the effect of rectal cancer resection type on cancer-related outcomes including mortality, cancer-specific survival, disease-free survival, local recurrence and metastases, morbidity, complications, and other adverse events including quality of life, pain and sexual dysfunction.

Three meta-analyses comparing laparoscopic with open resection surgery[1][2][3] were identified. All of these studies had a low risk of bias. One pooled analysis of data comparing laparoscopic with open resection surgery,[4] with a moderate risk of bias, was also identified.

Twenty-eight level II RCTs were reported across 36 papers.[4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] Of these, 20 trials[4][5][6][7][8][9][10][11][12][13][14][16][17][18][19][20][21][22][23][24][25][26][27][28][29][33] compared laparoscopic with open rectal cancer resection, and seven trials compared the following surgical interventions:

  • single-port laparoscopic rectal surgery versus conventional laparoscopic surgery[34]
  • endoscopic mucosal resection with circumferential incision (CIEMR) against endoscopic mucosal resection (EMR)[36]
  • cylindrical abdominoperineal resection versus conventional abdominoperineal resection[35]
  • transanal endoscopic microsurgery versus low anterior resection[30]
  • transanal endoscopic microsurgery versus laparoscopic total mesorectal excision[32][33]
  • endoluminal locoregional resection versus total mesorectal excision[31]
  • laparoscopic anterior resection versus transanal endoscopic microsurgery anterior resection[37]

Of these RCTs, one[15] was assessed as having a low risk of bias. The remainder had an unclear or high overall risk of bias.

The search strategy, inclusion and exclusion criteria, and quality assessment are described in detail in the Technical report.

Survival

Overall survival outcomes, including 15-, 10-, 8-, 5-, 3-, and 1-year survival rates and probability, were reported in 11 RCTs in studies comparing laparoscopic with open rectal cancer resection[5][7][11][12][13][15][16][17][18][28][35] and one meta-analysis of eight studies.[3] Evidence consistently showed no difference between any rectal cancer resection method for these outcomes at any time point.

Three RCTs comparing laparoscopic and open resection reported disease-free survival or recurrence-free survival for stage 1–3 patients.[5][7][15] No statistically significant differences in disease-free survival between open and laparoscopic resection groups were reported.

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Perioperative/30-day/overall mortality

Differences between laparoscopic and open surgery were non-significant for all reported mortality outcomes, including 30-day mortality, perioperative mortality, and overall (> 30 day) mortality.[4][5][6][8][12][13][14][16][17][23][25][26][28][38]

Four RCTs[31][32][33][34] reported mortality outcomes for other surgical interventions. All differences were not statistically significant.

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Recurrence and distant metastasis

Nine RCTs compared 3-year, 5-year, and overall local recurrence rates between groups of patients who underwent laparoscopic and open resection.[5][7][13][15][17][18][23][28][38][39]

Only one of these studies showed significant differences between groups:[7]

  • In patients with middle rectal cancer (intention-to-treat analysis) 3-year local recurrence was higher for laparoscopic resection than open resection (difference 4.1 percentage points; 90% CI 0.7 to 7.5).
  • In patients with lower rectal cancer (as-treated analysis), 3-year local recurrence was lower for laparoscopic resection than open resection (difference 8.9 percentage points; 90% CI –15.6 to –2.2).

However, significance was determined through observation of 90% confidence intervals, and it is questionable whether this difference would be significant at α = 0.05.

One study comparing conventional abdominoperineal resection and cylindrical abdominoperineal resection reported no significant difference in local recurrence rates.[35] However, numerically lower local recurrence rates were observed among patients who underwent cylindrical abdominoperineal resection.[35]

Seven RCTs that compared laparoscopic and open resection reported 1-year, 5-year, and overall distant metastases.[4][11][13][17][18][38][39]Back to top

Complications and morbidity-related outcomes

A wide range of complication and morbidity related outcomes were reported across the studies. Very few significant differences were observed between laparoscopic and open resection patients, and these differences were not consistent overall.

Port site/wound metastases

Seven RCTs[11][13][16][17][18][23][38] that compared laparoscopic and open resection reported wound/port site metastases as an outcome. No significant differences were observed, with five studies reporting 0% recurrence in both groups.[11][13][16][17][38]

Blood loss and transfusion

Twelve RCTs comparing laparoscopic and open surgery reported significantly lower blood loss in the laparoscopic group, with significant differences ranging from 17.5 mL to 220.3 mL (p < 0.001 to p = 0.036).[6][8][12][13][14][17][24][25][26][27][28][38]

Similarly, the rate of blood transfusions and amount of blood required were lower among patients who underwent laparoscopic resection in studies reporting these outcomes, including one meta-analysis.[1][4][11][14][16][24]

Length of hospital stay

Of the RCTs that compared laparoscopic and open resection, five reported significantly shorter postoperative hospital stay in the laparoscopic group, with differences ranging from 1.6 to 3.4 days (p < 0.001 to p = 0.036).[11][12][23][28][38] Findings reported by studies that did not report statistical significance were inconsistent, with a trend towards shorter hospital stays in the laparoscopic group in five studies.[8][11][13][14][17][25][26]

Circumferential resection margin positivity

Nine RCTs that compared laparoscopic and open resection reported rates of positive circumferential resection margins.[7][11][12][14][17][25][27][28] Six of these studies observed numerically higher rates of positive circumferential resection margins in groups who underwent open resection,[7][11][14][27][28] while the remaining three studies[12][17][25] observed numerically higher rates in groups who underwent laparoscopic resection. However, none of these differences were statistically significant.

Number of lymph nodes retrieved

Of the 13 RCTs that compared open and laparoscopic resection,[4][7][8][11][12][13][14][16][17][24][25][28][38] only one study[17] found a significant difference in the number of lymph nodes retrieved. The remaining studies showed mixed not statistically significant differences between groups.

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Sexual function

Sexual function outcomes were reported in three RCTs that compared laparoscopic resection with open resection[9][14][20] and one RCTA study in which people are allocated at random (by chance alone) to receive one of several clinical interventions. One of these interventions is the standard of comparison or control. that compared cylindrical abdominoperineal resection with conventional abdominoperineal resection.[35] Although sexual function was negatively affected by any type of resection procedure, none of these studies observed significant differences between types of resection.

Conversion

Fifteen RCTs that compared laparoscopic resection with open resection reported rates of conversion from laparoscopic to open surgery.[4][5][6][11][12][13][14][16][17][24][25][26][27][28][38] Conversion rates ranged from 0 to 30.3%, with a median rate of 7.9%.

For other interventions, including transanal endoscopic microsurgery, endoluminal locoregional resection and single-port approaches, reported rates of conversion to laparoscopic anterior resection, open total mesorectal excision, and conventional laparoscopic surgery were between 5 and 11.4%.[30][31][32][33][34]

Morbidity/complications

Although a wide array of short-term and long-term complications and morbidities were reported, only two significant differences were observed:

  • Open resection was associated with a higher rate of nerve injury than laparoscopic resection[6]
  • Higher rates of major postoperative complications were observed among patients undergoing total mesorectal excision, compared with those receiving endoluminal locoregional resection.[31]

    Postoperative pain

Postoperative pain was reported by only two RCTs: one that compared laparoscopic resection with open resection[14] and one that compared single-port resection with conventional laparoscopic resection.[34]

The second study reported significantly lower pain scores within 3-4 days after surgery among patients who underwent single-port laparoscopic resection than among those who underwent conventional laparoscopic resection.[34]

The search strategy, inclusion and exclusion criteria, and quality assessment are described in detail in the Technical report.

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Evidence summary and recommendations

Evidence summary Level References
Laparoscopic versus open resection
For overall survival and mortality, there was no difference between patients undergoing laparoscopic resection and patients undergoing open resection for rectal cancer. I, II [1], [3], [4], [5], [6], [7], [8], [11], [12], [13], [14], [15], [16], [17], [18], [23], [25], [26], [28], [38]
There was no statistically significant difference in rates of local recurrence, distant metastases and disease-free survival between patients having an open approach and a laparoscopic approach to rectal cancer surgery. I, II [3], [4], [5], [7], [11], [12], [13], [15], [16], [17], [18], [23], [28], [29], [38], [39]
Rates of blood transfusion and the amount of perioperative blood loss were consistently and significantly lower for patients undergoing laparoscopic resection, compared with patients undergoing open rectal cancer resection. I, II [1], [4], [6], [8], [11], [12], [13], [14], [16], [17], [23], [24], [25], [26], [27], [28], [38]
Length of hospital stay was significantly shorter for laparoscopic patients, compared with open resection patients. I, II [1], [4], [11], [12], [13], [14], [17], [23], [24], [28], [38]
Rates of positive circumferential resection margins did not differ significantly between patients who underwent laparoscopic resection and those who underwent open resection, and reported differences did not consistently favour either approach.


Two recent large multicentre RCTs did not demonstrate pathological oncological equivalence of laparoscopic to open rectal resection. However, data on local recurrence and survival are not yet available.

II [7], [14], [17], [25], [27], [28]
Differences in the number of lymph nodes retrieved between patients who underwent laparoscopic resection and those who underwent open resection were mostly not statistically significant. One study observed that significantly more lymph nodes were retrieved among the laparoscopic group. II [7], [8], [14], [16], [17], [24], [25], [28]
Although sexual function was negatively affected by all surgery, no difference between patients receiving laparoscopic and open rectal cancer resection for colorectal cancer was observed. II [9], [10], [14], [20], [35]
Comparisons between other surgical approaches
Transanal endoscopic microsurgery was associated with reductions in blood loss and length of hospital stay, compared with laparoscopic total mesorectal excision and low anterior resection.

No consistent significant differences between groups in were observed for survival or quality-of-life outcomes in RCTs comparing the following:

  • transanal endoscopic microsurgery versus laparoscopic lower anterior resection
  • endoluminal locoregional resection versus laparoscopic total mesorectal excision
  • transanal endoscopic versus total mesorectal laparoscopic resection.
II [30], [31], [32], [33], [37]
Postoperative pain
Of two studies that reported postoperative pain, one found that single-port laparoscopic resection was associated with significantly less pain within 3 days of surgery than conventional laparoscopic resection. II [14], [34]
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Evidence-based recommendationA recommendation formulated after a systematic review of the evidence, indicating supporting references.Question mark transparent.png Grade
Open surgery is the standard approach for resection of rectal cancer. Laparoscopic resection can be considered in selected cases if the surgical expertise (including advanced laparoscopic skills) and hospital infrastructure are available noting that it is a technique that has yet to be proven safe and efficacious in all patients for rectal cancer.
C
Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

Regardless of the approach utilised, rectal cancer resection must be undertaken by surgeons who have been appropriately trained in surgical resection of rectal cancer, utilising the principles of total mesorectal resection as proposed by Heald. This should include sharp dissection undertaken along the mesorectal plane. Surgical resection undertaken by inadequately trained surgeons is likely to result in inferior oncological outcomes.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

Case selection is important, as it is suboptimal to generalise the surgical approach for rectal cancer to all patients. Factors such as patient body mass index, tumour stage, and surgeon experience are important considerations when determining whether a laparoscopic or open approach is optimal for the patient.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

The laparoscopic approach may have a higher potential for an inferior quality TME specimen, as demonstrated by two recent multicentre RCTs, though long-term outcome data are not yet available on these studies (Fleshman et al 2015, Stevenson et al 2015). Two other large multicentre RCTs have reported long-term outcomes with no difference in local recurrence or survival (Jeong et al 2014, Bonjer et al 2015). The surgeon should discuss with the patient the potential impact on oncological outcome of the laparoscopic approach along with the potential improvements on short term recovery.

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Considerations in making these recommendations

Laparoscopic resection of rectal cancer would be considered preferable in terms of reduced length of stay and blood loss, however case selection is important when considering whether a laparoscopic or open approach is optimal. Overall pathological equivalence has yet to be proven and in the decision over which approach is optimal for a particular case, oncological principles must not be compromised.

Long-term local recurrence and survival data for two of the recent large randomised control trials which have not demonstrated pathological equivalence between open and laparoscopic rectal resection are awaited.[25][27] Long-term local recurrence and survival data are available for two other multicentre randomised controlled trials comparing open and laparoscopic rectal cancer resection which do demonstrate equivalence.[7][15] Whilst laparoscopic resection appears equivalent to open resection, when undertaken by surgeons who have had appropriate training and experience, it is likely that there are some case where a laparoscopic approach is not optimal with due consideration of patient, tumour and surgeon factors.

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Health system implications

Clinical practice

This review included RCTs from a wide range of countries, including Australia and New Zealand. Although about half of the studies were conducted in Asian populations, the evidence may be generalisable to an Australian population. However, there may be some important differences in the practice of rectal cancer resection.

Whilst laparoscopic resection of rectal cancer appears to have equivalent oncological outcomes to open surgery and some potential benefits to the patient over open surgery, it is essential that surgeons have been formally trained in laparoscopic rectal resection prior to undertaking this procedure.

Resourcing

There are no resource implications associated with implementing the recommendations.

Barriers to implementation

No barriers to the implementation of these recommendations are envisaged.

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Discussion

Unresolved issues

More longer-term evidence is needed from RCTs comparing survival data for laparoscopic versus open resection, especially from recent multicentre RCTA study in which people are allocated at random (by chance alone) to receive one of several clinical interventions. One of these interventions is the standard of comparison or control. trials.

RCTA study in which people are allocated at random (by chance alone) to receive one of several clinical interventions. One of these interventions is the standard of comparison or control. evidence regarding the role of alternative approaches, such robotic resection or transanal total mesorectal excision, is required before conclusions can be made on their role.

Studies currently underway

Results are awaited on the ROLARR trial comparing laparoscopic versus robotic resection of rectal cancer. However no data have yet been published.

COLOR III, a RCTA study in which people are allocated at random (by chance alone) to receive one of several clinical interventions. One of these interventions is the standard of comparison or control. comparing laparoscopic resection versus transanal total mesorectal excision, is currently recruiting.

Future research priorities

Evidence comparing longer-term survival data and alternative approaches would be valuable.

Next section: local versus radical resection for T1-T2 rectal tumours

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References

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