Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Sep 21, 2015; 21(35): 10174-10183
Published online Sep 21, 2015. doi: 10.3748/wjg.v21.i35.10174
Laparoscopic vs open abdominoperineal resection in the multimodality management of low rectal cancers
Yu-Wei Wang, Li-Yong Huang, Cheng-Li Song, Chang-Hua Zhuo, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li
Yu-Wei Wang, Li-Yong Huang, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li, Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai 200032, China
Yu-Wei Wang, Li-Yong Huang, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
Cheng-Li Song, Shanghai Institute for Minimally Invasive Therapy, School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
Chang-Hua Zhuo, Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
Author contributions: Wang YW and Huang LY contributed equally to this study; Li XX, Cai GX, Xu Y, Cai SJ designed the research; Wang YW, Huang LY performed the research; Song CL, Zhuo CH contributed to data recording and analyzing tools; Wang YW, Li XX, Shi DB analyzed the data; Wang YW, Li XX wrote the paper.
Institutional review board statement: The study was reviewed and approved by the Ethical Committee and Institutional Review Board of Fudan University Shanghai Cancer Center.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All of the authors declared no conflict-of-interest.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at Consent was not obtained, but the presented data are anonymized and the risk of identification is low.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Xin-Xiang Li, MD, PhD, Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Fudan University, No. 270 Dong An Road, Shanghai 200032, China.
Telephone: +86-21-65642222
Received: March 19, 2015
Peer-review started: March 20, 2015
First decision: April 23, 2015
Revised: May 12, 2015
Accepted: July 15, 2015
Article in press: July 15, 2015
Published online: September 21, 2015

AIM: To evaluate the safety and feasibility of laparoscopic abdominoperineal resection compared with the open procedure in multimodality management of rectal cancer.

METHODS: A total of 106 rectal cancer patients who underwent open abdominoperineal resection (OAPR) were matched with 106 patients who underwent laparoscopic abdominoperineal resection (LAPR) in a 1 to 1 fashion, between 2009 and 2013 at Fudan University Shanghai Cancer Center. Propensity score matching was carried out based on age, gender, pathological staging of the disease and administration of neoadjuvant chemoradiation. Data regarding preoperative staging, surgical technique, pathological results, postoperative recovery and complications were reviewed and compared between the LAPR and OAPR groups. Perineal closure around the stoma and pelvic floor reconstruction were performed only in OAPR, not in LAPR. Therefore, abdominoperineal resection procedure-specific surgical complications including parastomal hernia and perineal wound complications were compared between the open and laparoscopic procedure. Regular surveillance of the two cohorts was carried out to gather prognostic data. Disease-free survival was analyzed using Kaplan-Meier estimate and log-rank test. Subgroup analysis was performed in patients with locally advanced disease treated with preoperative chemoradiation followed by surgical resection.

RESULTS: No significant difference was found between the LAPR group and the OAPR group in terms of clinicopathological features. The operation time (180.8 ± 47.8 min vs 172.1 ± 49.2 min, P = 0.190), operative blood loss (93.9 ± 60.0 mL vs 88.4 ± 55.2 mL, P = 0.494), total number of retrieved lymph nodes (12.9 ± 6.9 vs 12.9 ± 5.4, P = 0.974), surgical complications (12.3% vs 15.1%, P = 0.549) and pathological characteristics were comparable between the LAPR and OAPR group, respectively. Compared with OAPR patients, LAPR patients showed significantly shorter postoperative analgesia (2.4 ± 0.7 d vs 2.7 ± 0.6 d, P < 0.001), earlier first flatus (57.3 ± 7.9 h vs 63.5 ± 9.2 h, P < 0.001), shorter urinary drainage time (6.5 ± 3.4 d vs 7.8 ± 1.3 d, P < 0.001), and shorter postoperative admission (11.2 ± 4.7 d vs 12.6 ± 4.0 d, P = 0.014). With regard to APR-specific complications (perineal wound complications and parastomal hernia), there were no significant differences between the two groups. Similar results were found in the 26 pairs of patients administered neoadjuvant chemoradiation in subgroup analysis. During the follow-up period, no port site recurrences were observed.

CONCLUSION: Laparoscopic abdominoperineal resection for multidisciplinary management of rectal cancer is safe, and is associated with earlier recovery and shorter admission time in combination with neoadjuvant chemoradiation.

Keywords: Abdominoperineal resection, Laparoscopy, Rectal cancer, Total mesorectal excision, Neoadjuvant chemoradiation

Core tip: This retrospective, case-matched study demonstrated that, for abdominoperineal resection of low rectal cancer, laparoscopy improved postoperative recovery, reduced admission time without jeopardizing clear circumferential resection margin, lymph node yield and surgical complications. In particular, the risks of abdominoperineal resection-specific surgical complications, including perineal wound reintervention and parastomal hernia, were comparable between the laparoscopy and open procedure groups. No significant differences regarding local recurrence and metachronous metastasis were detected. Laparoscopy in combination with neoadjuvant chemoradiation for multidisciplinary management of low rectal cancer is safe, and associated with earlier recovery.