Transcript Presentation

LAPAROSCOPIC SURGERY FOR RECTAL
CANCER
WHAT IS THE EVIDENCE?
Jasim Al-Abbad, MD, FACS, FRCSC
Assistant Professor
Colon and Rectal Surgery
Mubarak Al-Kabeer Hospital
Faculty of Medicine – Kuwait University
• No disclosures
• The treatment for rectal cancer has markedly evolved over the past several
decades
• The technical aspects of surgery for rectal cancer have been debated over the
course of history.
• Importance of total mesorectal excision (TME)
• Failure to achieve a completely intact mesorectum and a negative CRM puts
patients at high risk for local recurrence (15-45%)
N Engl J Med, 2001. 345(9): p. 638-46.
• The short-term benefits of minimally invasive surgery are clear and
irrefutable
• Rectal cancer represents one of the most complex technical challenges in
the field of MIS
• Given the complexity of this challenge, controversy persists regarding the
long-term outcomes and safety profile of this technique
Cochrane Database Syst Rev 2006(4):CD005200
Surg Endosc 2015;29(2):334-348
J Am Coll Surg 2010;211(2):232-238.
• The safety and feasibility of laparoscopic colectomy for colon cancer has been
established by large RCT's
• Barcelona trial
• COST trial
• COLOR trial
• CLASICC trial
• This degree of level one data is currently unavailable in the field of rectal
cancer
• The technical demands of pelvic surgery and the potential risks to the patient
lead the surgeon scientist to demand more convincing evidence
• Open rectal cancer surgery >80% in USA
MORBIDITY AND MORTALITY
• Systemic reviews and meta-analysis have shown laparoscopic surgery to
benefit from:
• Lower wound infection rates
• Decreased overall morbidity
• Decreased length of stay
Ann Surg Oncol 2006;13(3):413-424
Int J Colorectal Dis 2006;21(7):652-656
• In 2014 a Cochrane review including 45 studies, with a total number of 3528
patients reviewed laparoscopic rectal cancer surgery
• Positive findings include:
• Faster time to diet
• Less blood loss
• Less pain and narcotic use.
Cochrane Database Syst Rev. 2014 Apr 15;4:CD005200
Postop complications
LOS
ONCOLOGIC MARKERS
• Lymph node harvest
• Circumferential radial margins (CRM)
• Concerns from CLASICC trial
• positive CRM in 12% of laparoscopic versus 6% of open resection
FUNCTIONAL OUTCOMES
• The autonomic plexus to avoid includes:
• the superior hypogastric plexus (sympathetic)
• the inferior hypogastric plexus (mixed)
• the pelvic splanchnic nerves (parasympathetic) (78).
• Sexual dysfunction (0 to 12%)
• Urinary dysfunction (10 to 35%)
Tech Coloproctol 2014;18(11):993-1002
Dis Colon Rectum 2002;45(9):1178-1185
LONG-TERM
ONCOLOGICAL OUTCOMES
• Level one long-term oncologic outcomes in rectal cancer have not fully
matured to date.
• COREAN TRIAL
• 2014
• 3 years
• COLOR II TRIAL
• 2015
• 3 years
• CLASICC TRIAL
• 2012
• 5 years
Lancet Oncol, 2010. 11(7): p. 637-45.
N Engl J Med, 2015. 372(14): p. 1324-32
Br J Surg, 2013. 100(1): p. 75-82
COREAN TRIAL
•
Multicenter RCT (3 Korean Centers)
•
2006 – 2009
•
1408 patients
•
cT3N0–2M0 mid/Low rectal cancer
•
•
Neoadjuvant chemoradiotherapy
COLOR II TRIAL
• Multicenter RCT (30 centers in eight countries).
• 2004 - 2010
• 1103 patients
DFS
OS
The locoregional recurrence rate was 5.0% in the two groups
CLASICC TRIAL
• Multicenter RCT (27 UK centers)
• 1996 – 2002
• 794 patients
Overall survival
Local recurrence
EMERGING DILEMMA!
• ACOSOG Z6051 trial
• ALaCaRT Trial
• A novel combined score of distal margin, CRM, and LN status
• Both unable to claim non inferiority of laparoscopy over open surgery for
rectal cancer
• Ultimately, surrogate markers of quality only become relevant if they indeed
predict long-term oncological outcomes.
JAMA, 2015. 314(13): p. 1346-55
JAMA, 2015. 314(13): p. 1356-63
CONCLUSIONS
• The use of MIS in the treatment of rectal cancer is dependent on the surgeon
and their associated surgical technique and training.
• Hospitals with specialty focus, and surgeon volume continue to be important
predictor of lower mortality, better survival, and lower rates of permanent
stomas
• Until further long-term data can be obtained it is appropriate to suggest that
the laparoscopic treatment of rectal cancer be left in the hands of well-trained
experts
THANK YOU