1. 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

2. No disclosures

3. Importance of total mesorectal excision (TME)
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, (9): p

4. 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):
J Am Coll Surg 2010;211(2):

5. Open rectal cancer surgery >80% in USA
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

6. Morbidity and Mortality
I’m going today to review the most recent data regarding MIS for rectal cancer

7. 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):
Int J Colorectal Dis 2006;21(7):

8. Positive findings include:
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

9. Postop complications

10. LOS

11. Oncologic markers

12. Circumferential radial margins (CRM)
Lymph node harvest
Circumferential radial margins (CRM)
Concerns from CLASICC trial
positive CRM in 12% of laparoscopic versus 6% of open resection

13. Functional outcomes

14. 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):
Dis Colon Rectum 2002;45(9):
Given this mix of data it is likely that MIS provides neither an advantage nor disadvantage to sexual function.

15. Long-term Oncological Outcomes

16. Level one long-term oncologic outcomes in rectal cancer have not fully matured to date.

17. COREAN TRIAL COLOR II TRIAL CLASICC TRIAL 2014 3 years 2015 2012
Lancet Oncol, (7): p
N Engl J Med, (14): p
Br J Surg, (1): p

18. COREAN TRIAL Multicenter RCT (3 Korean Centers) 2006 – 2009
1408 patients
cT3N0–2M0 mid/Low rectal cancer
Neoadjuvant chemoradiotherapy

20. COLOR II TRIAL Multicenter RCT (30 centers in eight countries).
1103 patients

21. The locoregional recurrence rate was 5.0% in the two groups
DFS OS
The locoregional recurrence rate was 5.0% in the two groups

22. CLASICC TRIAL Multicenter RCT (27 UK centers) 1996 – 2002 794 patients
Rectum 128 (48%) 253 (48%) 132 (48%) 160 (46%) 82 (57%)

23. Overall survival
Local recurrence

24. emerging dilemma!

25. A novel combined score of distal margin, CRM, and LN status
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, (13): p
JAMA, (13): p
Controversy however has risen due to the publication of the ACOSOG Z6051 and ALaCaRT Trials suggesting that a novel combined score of distal margin, CRM, and LN status may indeed be worse than open surgery

26. Conclusions

27. 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

28. Thank you