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Laparoscopic surgery for rectal cancer What is the evidence?

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.

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Laparoscopic surgery for rectal cancer What is the evidence?

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  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. 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.

  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 SurgEndosc 2015;29(2):334-348 J Am CollSurg 2010;211(2):232-238.

  5. 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

  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 SurgOncol 2006;13(3):413-424 Int J Colorectal Dis 2006;21(7):652-656

  8. 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. 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):993-1002 Dis Colon Rectum 2002;45(9):1178-1185

  15. Long-termOncological Outcomes

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

  17. 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

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

  19. COLOR II TRIAL • Multicenter RCT (30 centers in eight countries). • 2004 - 2010 • 1103 patients

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

  21. CLASICC TRIAL • Multicenter RCT (27 UK centers) • 1996 – 2002 • 794 patients

  22. Overall survival Local recurrence

  23. emerging dilemma!

  24. 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

  25. Conclusions

  26. 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

  27. Thank you

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