Systematic Reviews Open Access
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Surg Proced. Mar 28, 2015; 5(1): 147-154
Published online Mar 28, 2015. doi: 10.5412/wjsp.v5.i1.147
Feasibility and oncological outcomes of laparoscopic rectal resection following neo-adjuvant chemo-radiotherapy: A systematic review
Pawan Kumar Dhruva Rao, Manojkumar S Nair, Puthucode N Haray
Pawan Kumar Dhruva Rao, Manojkumar S Nair, Puthucode N Haray, Department of Colorectal Surgery, Prince Charles Hospital, Merthyr Tydfil CF47 9DT, Wales, United Kingdom
Puthucode N Haray, University of South Wales, Pontypridd CF37 1DL, Wales, United Kingdom
Author contributions: Dhruva Rao PK and Nair MS developed the protocol, conduced the literature search and systematic review as per protocol; Haray PN served as a referee and guided the project; all authors contributed to the manuscript.
Conflict-of-interest: All the authors are employed by the National Health Service and confirm that they have no conflicts of interest financial or otherwise to declare.
Data sharing: This is a systematic review and all data pertaining to the study have been summarized in the tables of the manuscript. No additional data are available.
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: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Pawan Kumar Dhruva Rao, MBBS, MS, MRCSEd, Specialty Trainee in Surgery, Department of Colorectal Surgery, Prince Charles Hospital, Gurnos Rd, Merthyr Tydfil CF47 9DT, Wales, United Kingdom. pavankumar_1124@yahoo.co.in
Telephone: +44-1685-721721
Received: December 4, 2014
Peer-review started: December 4, 2014
First decision: December 12, 2014
Revised: December 23, 2014
Accepted: January 9, 2015
Article in press: January 12, 2015
Published online: March 28, 2015

Abstract

AIM: To study the feasibility and oncological outcomes following laparoscopic total mesorectal excision (LTME) in patients who have received Neo-adjuvant long course chemo-radiotherapy (LCRT).

METHODS: A protocol driven systematic review of published literature was undertaken to assess the feasibility and oncological outcomes following LTME in patients receiving LCRT. The feasibility was assessed using peri-operative outcomes and short term results. The oncological outcomes were assessed using local recurrence, disease free survival and overall survival.

RESULTS: Only 8 studies-1 randomized controlled trial, 4 Case Matched/Controlled Studies and 3 Case Series were identified matching the search criteria. The conversion rate was low (1.2% to 28.1%), anastomotic leak rates were similar to open total mesorectal excision (0%-4.1% vs 0%-8.3%). Only 3 studies reported on local recurrence rates (5.2%-7.6%) at median 34 mo follow-up. A single study described disease free survival and overall survival at 3 years as 78.8% and 92.1% respectively.

CONCLUSION: LTME following LCRT is feasible in experienced hands, with acceptable short term surgical outcomes and with the usual benefits associated with minimally invasive procedures. The long term oncological outcomes of LTME after LCRT appear to be comparable to open procedures but need further investigation.

Key Words: Laparoscopic total mesorectal excision, Rectal adenocarcinoma, Feasibility, Outcomes, Neo-adjuvant chemo-radiotherapy

Core tip: Laparoscopic total mesorectal excision (LTME) following long course chemo-radiotherapy (LCRT) is feasible in experienced hands, with acceptable short term surgical outcomes and with the usual benefits associated with minimally invasive procedures. The long term oncological outcomes of LTME after LCRT appear to be comparable to open procedures but need further investigation.



INTRODUCTION

Total Mesorectal Excision using an open approach (OTME) is now accepted as the gold standard for treatment rectal cancer[1]. In recent years, since the medical research council United Kingdom trial, neo-adjuvant long course chemo-radiotherapy is being routinely used as a part of treatment of locally advanced mid and low rectal cancers[2]. Laparoscopic rectal resection has been shown to have superior short term outcomes compared to open resections. However, long term oncological results are still debated[3]. In addition, it is generally accepted that laparoscopic low rectal resection and Abdomino-perineal resections (APR) are technically challenging[4].

Most trials comparing laparoscopic and open resections for rectal cancer suggest that laparoscopic rectal resections are technically feasible however, short and long term outcomes in this group are difficult to determine[5,6]. Also, laparoscopic total mesorectal excision (LTME) following neo-adjuvant chemo-radiotherapy (LCRT) is oncologically and technically challenging due to tissue fibrosis and scarring[7].

This systematic review addresses the feasibility and outcome of laparoscopic rectal resection following neo-adjuvant chemo-radiotherapy. There is no level 1 evidence addressing this and to the best of our knowledge there is no structured review of the published literature on this topic.

MATERIALS AND METHODS

A systematic review of literature was performed as per the protocol described below to address the issue of feasibility of laparoscopic TME following neo-adjuvant chemo-radiotherapy. PubMed, Cochrane, Embase, OVID, and CINAHL were searched for articles published between Jan 2004 to June 2014 using the search criteria as described in Table 1.

Table 1 Search strategy.
Search strategy
1 Rectal adenocarcinoma - tracked to MeSH to include all subheadings and combining with OR and clicking the Explode box; limit to English language and Humans - no time limits selected
2 Surgery - tracked to MeSH to include all subheadings and combining with OR and clicking the Explode box; limit to English language and Humans - no time limits selected
3 Laparoscopy - tracked to MeSH to include all subheadings and combining with OR and clicking Explode box; limit to English language and Humans - no time limits selected
4 Minimally invasive surgery - tracked to MeSH to include all subheadings and combining with OR and clicking Explode box; limit to English language and Humans - no time limits selected
5 Anterior Resection - Keyword search only (not linked to MeSH headings)
6 Neo-adjuvant chemo-radiotherapy
7 Proctectomy - Keyword search only (not linked to MeSH headings)
8 Total Mesorectal Excision - Keyword search only (not linked to MESH headings)
9 Combine 1 and 2 and 5 and 6 and 7 and 8
10 Combine 1 and 3 and 4 and 5 and 6 and 7 and 8

The keywords for search were laparoscopy, minimally invasive surgery, open, rectum, cancer, abdomino-perineal resection, anterior resection, colorectal neoplasms, rectal neoplasms, rectal adenocarcinoma, rectal cancer, neo-adjuvant chemo-radiotherapy, proctectomy, and total mesorectal excision. Search was done as free text words and in their variable combinations.

Study selection

The retrieved results were screened by two authors (Dhruva Rao PK and Nair MS) using the title and abstracts against the inclusion and exclusion criteria as described below. Any studies that did not have published abstracts were excluded. Full text articles of potentially relevant studies were obtained and assessed independently by two authors (Dhruva Rao PK and Nair MS) considering the inclusion and exclusion criteria for review. All references of all guideline articles and review articles were searched to identify any potential articles not already identified. Disagreements were resolved through discussion and by involving the third author (Haray PN).

Inclusion criteria

Randomized studies comparing open and laparoscopic rectal resection following neo-adjuvant chemo-radiotherapy for rectal adenocarcinoma; Case matched series comparing LTME with OTME following neo-adjuvant chemo-radiotherapy for rectal adenocarcinoma; Case control studies comparing LTME with OTME following neo-adjuvant chemo-radiotherapy for rectal adenocarcinoma; Case series with > 20 patients from tertiary centres; Published in English language; Feasibility studies of laparoscopic rectal resections for cancer including historical control cohorts.

Exclusion criteria

Study groups were not clearly defined; Studies in whom the “cancer” group cannot be separated; Studies comparing resections performed for benign indications only; Studies including local resections (trans-anal endoscopic microsurgery, trans-anal excision) but the major resection group cannot be separated; the outcomes of interest defined below were not reported or it was impossible to determine them from the published results; the surgical procedures were performed by surgical trainees or by surgeons during the learning curve for laparoscopic or conventional rectal surgery.

Data extraction

A structured proforma was used for data extraction for the patients undergoing laparoscopic resection after neo-adjuvant long course chemo-radiotherapy only. No attempt was made to contact the authors of studies if inadequate amount of information was available and such studies were excluded.

Outcome measures/end-points

We have assessed 2 sets of outcomes.

For feasibility assessment, we have considered estimated blood loss, ureteral injuries, other collateral injuries, overall peri-operative morbidity, length of hospital stay, anastomotic leakage, intra-abdominal abscess, urinary retention, postoperative ileus, 30 d mortality. We have also assessed circumferential/radial resection margin (CRM) and lymph node harvest.

For oncological outcome assessment, we have considered loco-regional recurrence, metachronous distant metastasis, disease free survival (DFS) and overall survival.

Statistical analysis

Prior to pooled analysis, the studies must pass 2 assessments of heterogeneity - qualitative and quantitative[8]. Qualitative assessment is based on 4 key concepts of study design (Patients, Interventions, Outcomes and Study Types). If studies are deemed heterogeneous on this assessment, it is inappropriate to proceed to quantitative assessment using statistical tests such as χ2 test or Cochrane Q, etc.[8]. In this review the studies were deemed heterogeneous based on the above mentioned qualitative criteria and so we did not proceed to statistical analysis.

RESULTS

The initial search identified 2583 studies (Figure 1). Two thousand four hundred and seventy were excluded after initial screening of titles and abstracts. The remaining 113 studies were critically reviewed using the full article. Of these, 26 articles met the inclusion criteria and reviewed in detail. However, data relevant to this review could be extracted from only 8 studies (Table 2). Table 3 summarizes the 18 studies from which adequate extraction of appropriate data was not possible.

Figure 1
Figure 1 PRISMA flow diagram.
Table 2 Overview of studies with extractable data.
Ref.YearCountryType of studyTotal No. of patientsPatients LapPatients open
Kang et al[9]2010South KoreaRCT340170170
Kusano et al[11]2014JapanCase control Study331914
Hu et al[14]2013ChinaCase control Study1375186
Seshadri et al[12]2011IndiaCase control Study1447272
Denoya et al[15]2009United StatesCase matched series643232
1Saklani et al[13]2013South KoreaCase series6464NA
1Denost et al[10]2011FranceCase series292292NA
Motson et al[7]2011United KingdomCase series2626NA
Table 3 Studies from which data could not be extracted (sub group analysis not described/reported).
Ref.YearCountryType of studyPercent having LCRT in Lap group
van der Pas et al[5]2013The NetherlandsRCT159
Lujan et al[6]2009SpainRCT72.3
Lujan et al[16]2013SpainCase Control58.1
McKay et al[17]2012AustraliaCase Control48.8
Laurent et al[18]2011FranceCase Control93.6
Patel et al[19]2011United StatesCase Matched50
Li et al[20]2011ChinaCase Control34.5
Kellokumpu et al[21]2011FinlandCase Control34
Greenblatt et al[22]2011United StatesCase Control31.6
da Luz Moreira et al[23]2011United StatesCase Matched33
Baik et al[24]2010United StatesCase Matched79.6
Westerholm et al[25]2012CanadaCase Series7.4
Jefferies et al[26]2011United KingdomCase Series43.8
Glancy et al[27]2011United KingdomCase Series8
Lam et al[28]2010BelgiumCase Series56.7
Sartori et al[29]2010ItalyCase Series39.1
Cheung et al[30]2010Hong KongCase Series21.5
Park et al[31]2010South KoreaCase Series8.1

The selected publications included a combination of randomized controlled trial (RCT) and non RCT. Qualitative assessment of the studies revealed: (1) Type of studies identified were clearly heterogeneous (Table 2); (2) Patient selection criteria for LCRT were different in the different studies (Table 4); and (3) The LCRT regimen patients received was also different (Table 4).

Table 4 Comparison of criteria for long course chemo-radiotherapy and regimes.
Ref.Staging imagingCriteria for LCRTChemo agentRad dose/duration
Kang et al[9]CT, MRI, ERUScT3N0-2 M0 Mid/low rectal cancerI/V 5FU + leucovorin or oral capecitabine50.4 Gy over 5.5 wk (tumour boost used)
Kusano et al[11]CT, MRIT3N0-3M02Different protocolsTotal dose = 45 Gy/duration not reported
Hu et al[14]CT, MRI, ERUSStage 2/3 tumoursCapecitabine and oxaliplatin50 Gy over 5 wk
1Seshadri et al[12]CTT2/T3 N+, T4 excludedMitomycin and 5FUTotal dose = 50 Gy/duration not reported
Denoya et al[15]CT, MRI, ERUST3/4 or N+ disease5FU or XelodaTotal dose = 50.4 Gy/duration not reported
Saklani et al[13]NRT3/4 or N+ disease5FUTotal dose = 50.4 Gy/duration not reported
Denost et al[10]CT, MRI, ERUST3/4 = 265 (90.8%), T1/2 = 27 (9.2%)I/V 5FU and leucovorin45 Gy over 5 wk
Motson et al[7]CT, MRIT3/4 N+ + involved/ threatened CRM5FU or Uftoral45/50 Gy over 5 wk (3/4 fields)

Thus the studies were heterogeneous in terms of Study Design, Patient Groups and Interventions. Due to this heterogeneity, a pooled analysis or meta-analysis was considered inappropriate and hence was not carried out.

Of the 8 studies included, one was a RCT and 4 were case controlled studies or case matched series. The number of patients in the Laparoscopic group in the selected studies range from 19 to 292. The only RCT (COREAN trial[9]) that we have been able to identify had 170 patients in the study arm. The study with largest number of patients with LTME following LCRT is from France with 292 patients[10].

The patient characteristics of all the studies are shown in Table 5. As can be seen from the table, they were mid or low rectal tumours. The APR rates varied from 11.2% to 89%. All studies had reported the imaging modalities and selection criteria for LCRT with the type and dose of chemo and radiotherapy (Table 4). There was wide heterogeneity in the type, dose and duration of LCRT among the studies.

Table 5 Patient characteristics.
Ref.Age (yr)
Laparoscopic Group
Open Group
BMI
Distance from Anal Verge (cm)
Laparoscopic Group
Open Group
LapOpenMenWomenMenWomenLapOpenLapOpenARAPRARAPR
1Kang et al[9]57.8 (11.1)59.1 (9.9)64.7%35.3%64.7%35.3%24.1 (3.2)24.1 (3.2)5.6 (2.3)5.3 (2.5)151 (88.8%)19 (11.2%)146 (85.9%)24 (14.1%)
Kusano et al[11]58 (32-82)55 (39-73)15 (78.9%)4 (21.1%)8 (57.1%)6 (42.9%) ≤ 25 = 14 (73.7%) > 25 = 5 (26.3%) ≤ 25 = 9 (64.3%) >25 = 5 (35.7%)2 (0-50)3.7 (0-10)11 (57.9%)8 (42.1%)4 (28.6%)10 (71.4%)
Hu et al[14]55 (35-78)55 (29-82)34 (66.7%)17 (33.3%)56 (65.1%)30 (34.9%)23.4 (16-31.2)24.2 (16.3-36.2) ≤ 5 = 33 (64.7%) > 5 = 18 (35.3%) ≤ 5 = 54 (62.8%) > 5 = 32 (37.2%)32 (62.7%)18 (35.3%)36 (41.9%)44 (51.2%)
Seshadri et al[12]48 (22-73)48 (19-71)47 (65%)25 (35%)45 (62%)27 (38%)21 (15-33)22 (14-38)3 (0-8)3 (0-10)8 (11%)64 (89%)8 (11%)64 (89%)
1Denoya et al[15]56.357.119 (59.4%)13 (40.6%)18 (56.3%)14 (43.7%)2526.44.14.624 (75%)8 (25%)24 (75%)8 (25%)
Denost et al[10]65 (20-85)NA179 (61.3%)113 (38.7%)NANA25 (16-39)NA< 5 = 175 (59.9%) > 5 = 117 (40.1%)NANRNRNANA
Motson et al[7]63 (39-81)NA21 (80.8%)5 (19.2%)NANANRNA< 5 = 11 (42.3%) > 5 = 15 (57.7%)NA16 (61.5%)10 (38.5%)NANA

Table 6 reports the peri-operative course. The interval between LCRT and surgery was reported by all except by one study[11] with the median minimum and maximum intervals being 6 and 8 wk respectively. The reported conversion rates from laparoscopic to open operations ranged from 1.2% to 28.1%. In the Laparoscopic arm, three of the eight identified studies reported a median estimated blood loss of 200 mL.

Table 6 Peri-operative outcomes.
Ref.Interval to surgeryConversionEstimated blood loss
Intra-op injury
Diversion stoma
LapOpenLapOpenLapOpen
1Kang et al[9]26-8 wk1.2%Median - 200 mLMedian - 217.5 mLYes1Yes191.4%88.4%
Kusano et al[11]NRNR< 200 mL = 47.4% > 200 = 52.6%< 200 = 92.9% > 200 = 7.1%NRNRNRNR
Hu et al[14]Mean 53 d (28-105 d)5.9%Mean 204.7 (80-1000 mL)Mean 352.5 (100-1200) mLNoUreteric injury = 1.2%NRNR
Seshadri et al[12]Median 8 (4-36) wk4.1%Median 200 (100-600) mLMed 400 (150-1500) mLNRNRNRNR
Denoya et al[15]Mean 6.5 wk28.1%Mean 313 ± 443Mean 279 ± 229NRNR75%75%
Denost et al[10]26 wk18.8%NRNANRNA81.2%NA
Motson et al[7]Median 11 wk11.5%NRNANRNA75%NA

While only two studies reported intra operative complications (Table 6), all studies have reported post-operative complications (Table 7). In the studies where comparative data was available, the laparoscopic group had a low anastomotic leak rate compared to the open group (0%-4% vs 0%-8.3% respectively). The COREAN trial reported a higher leak rate for LTME vs OTME (1.2% vs 0% respectively). However, 2 case series reported anastomotic leak rates of 12.7%[10] and 18.7%[7]. Interestingly these had higher conversion rates as well (18.8%[10] and 11.5%[7] respectively). Pelvic abscess was also less in laparoscopic group compared to the open group (0%-10.5% vs 0.6%-14.2%). Post-operative ileus was less in Laparoscopic group (0%-10% vs 1.2%-12.9%). Post-operative voiding difficulty varied from 2%-10% in laparoscopic group compared to 2.3%-7.1% in open group.

Table 7 Post-operative complications.
Ref.Anastomotic leak (%)
Pelvic abscess (%)
Post-op Ileus (%)
Acute voiding difficulty (%)
Stoma complications (%)
LapOpenLapOpenLapOpenLapOpenLapOpen
Kang et al[9]1.2000.61012.9104.10.60
Kusano et al[11]07.110.514.25.27.107.1NRNR
2Hu et al[14]3.18.301.201.21.22.302
Seshadri et al[12]4.18.3NRNRNRNR117NRNR
Denoya et al[15]NRNRNRNR55NRNRNRNR
Denost et al[10]12.7NANRNANRNANRNANRNA
1Motson et al[7]18.7NANRNANRNA15.4NANRNA

The short term outcomes are summarized in Table 8. All except 2 studies have reported post-operative length of stay with the median stay ranging between 8-24 d for the laparoscopic group and 9-35 for the open group. Only 2 case series[7,10] reported procedure related mortality (0.3%-3.8%).

Table 8 Short term and long term outcomes.
Ref.Post-op length of stay
30 d mortality (%)Length of follow-upLocal recurrence
LapOpenLapOpen
Kang et al[9]8 (7-12)9 (8-12)NR3 moNANA
Kusano et al[11]24 (14-92)35 (14-70)NRMedian 39 mo1 (5.2%)3 (21.4%)
Hu et al[14]10 (6-34)16 (6-44)NRShort term outcomes onlyNANA
Seshadri et al[12]12 (6-45)15 (10-50)NoneShort term outcomes onlyNANA
1Denoya et al[15]6.1 ± 2.47.6 ± 2.3NRShort term outcomes onlyNANA
Denost et al[10]NRNA0.3NRNRNA
Motson et al[7]8 (5-17)NA3.8Median 34 mo2 (7.6%)NA
Saklani et al[13]NRNANRMedian 36 mo4 (6.3%)NA

The markers of surgical quality are reported in Table 9. Only the COREAN trial[9] reported the TME quality with 72.4% of the resection as complete. One study[12] defined the CRM positivity as 2 mm while the others used the standard 1 mm measurement. The CRM positivity in the laparoscopic group was 1.3% to 2.9% and that for the open group was 3.5%-9.7%. The numbers of lymph nodes harvested did not differ between laparoscopic and open groups.

Table 9 Quality markers.
Ref.CRM positivity
Lymph node harvest1
LapOpenLapOpen
Kang et al[9]2.9%4.1%17 (12-22)18 (13-24)
3Kusano et al[11]NRNR< 12 = 73.7% > 12 = 26.3%< 12 = 64.3% > 12 = 35.7%
Hu et al[14]1.9%3.5%12 (2-20)11 (1-25)
4Seshadri et al[12]1.3%9.7%7 (1-24)7 (1-25)
Denoya et al[15]Yes5Yes519 ± 9219 ± 92
Denost et al[10]NRNANRNA
6Motson et al[7]Yes6NA5 (0-14)NA

Only 3 studies reported a follow up period of 34 mo or above (Table 8). The rest had data on short term follow up with one study not reporting any follow up data. Local recurrence was reported as 5.2%-7.6% in the laparoscopic groups after 34 mo of follow up. Only one study reported comparative local recurrence between the laparoscopic and open groups (5.2% for laparoscopic vs 21.4% for open)[11]. Only one study[13] reported disease free survival and overall survival at 3 years (78.8% and 92.1 % respectively).

DISCUSSION

The studies were heterogeneous. In spite of this, the reported short term outcomes for LTME were not inferior to OTME. Available data shows LTME offers the same short term advantages in outcomes like estimated blood loss, other collateral injuries, overall intra-operative morbidity, post-operative length of stay, intra-abdominal abscess and post-operative ileus even after LCRT. Short term surrogate measures of oncologic parameters are at least equal to the open procedure.

LCRT makes the normal anatomical planes within the pelvis challenging due to tissue fibrosis and scarring. The tissue planes can be more difficult to follow compared with non-irradiated cases[7].

The magnified view of operative field and the improving technology with efficient energy devices in addition to meticulous attention to haemostasis to maintain good views during LMTE are factors that help reduce the blood loss as reflected in the reported estimated blood loss of these studies. Pelvic abscess was also less in laparoscopic group compared to open. This may be due to the fact that the blood loss is less with consequent less postoperative haematoma, etc.

Irradiation causes fibrosis and ischaemia[10] and increases the thickness of the rectal wall making a safe rectal division by stapling devices technically more difficult[10]. It is also thought to increase the risk of anastomotic leak. However, the reported anastomotic leak rate in LTME was generally low. One study[7] reported a higher leak rate (18.7%) but this is probably due to low number of patients in this study.

The surrogate markers of oncological outcome like lymph node harvest, positivity of CRM margins with LTME were comparable and not inferior to both contemporaneous open procedures as well as historically reported data.

The only RCT identified, the COREAN trial[9], randomised 340 patients after LCRT to LTME or OTME. It observed no difference between CRM positivity, macroscopic quality of the total mesorectal excision, number of harvested lymph nodes or perioperative morbidity between the two groups[9]. The short term benefits were better in LTME. This trial demonstrated LTME after LCRT was safe in the hands of experienced surgeons (participating surgeons had a median experience of 75 LTMEs). Although this trial was not sufficiently powered to address survival outcomes (one of the limitations of this trial), the long term outcome from COREAN trial is expected to shed more light on the oncological effectiveness of LTME in this group of rectal cancer patients.

The other end-points of this review were the local recurrence rates, and DFS. These results are based on case controlled study or data from experienced tertiary centres. The rate of local recurrence varied from 5.2% to 7.6% in the LTME group. Only one study[11] reported comparative data for OTME (21.4%). Only one study reported DFS of 78.8% in LTME after 3 years of follow up. Unfortunately this did not report on a similar figure for OTME[13].

We identified 18 other studies which had a subgroup of patients who underwent LCRT followed by laparoscopic rectal resection. However, insufficient data were included for relevant data extraction and analysis. An analysis of the raw data from these published studies may provide interim results quicker. However, such an exercise would require the co-operation of various authors from around the world to contribute their data to help create an international registry for analysis: this is unlikely to be feasible retrospectively. Hence, a prospective, multicentre randomised trial recruiting patients from appropriate centres and adequately powered to address survival outcomes is needed to answer the question of oncological effectiveness.

Although there is paucity of published data on the rates of local and distant disease recurrence (Disease Free Survival) following LTME after LCRT, available data shows LTME following LCRT is not inferior to open TME with the inherent advantages of Laparoscopic surgery.

LTME is feasible in experienced hands, with acceptable short term surgical outcomes and with the usual benefits associated with minimally invasive procedures. The long term oncological outcomes of LTME after LCRT appear to be comparable to open procedures but need further investigation probably with a well-designed adequately powered multicentre trial.

COMMENTS
Background

Laparoscopic total mesorectal excision (LTME) has been shown to be feasible with acceptable short and intermediate term results in management of rectal cancers. However, the increasing use of neo-adjuvant long course chemo-radiotherapy (LCRT), and the resultant increased fibrosis and alterations to the tissue planes has increased the challenges of the LTME. To the authors’ knowledge, there is no level 1 evidence to support its use.

Research frontiers

Over the recent years, numerous publications addressing this area of rectal cancer management have been published. The authors aimed to conduct a systematic review of the published literature to inform future practice.

Innovations and breakthroughs

This systematic review has shown that LTME in patients undergoing LCRT is feasible with acceptable short and intermediate term surgical and oncological outcomes in experienced hands. It has also identified the need for a sufficiently powered RCT to address this issue. In the interim, this study which has assimilated and analysed the raw data from various publications could provide useful information on the subject.

Applications

This review lends support to the practice of LTME in experienced centres within the multimodal approach to rectal cancer. However, long term outcomes (as in all oncological treatments) need to be continuously monitored.

Terminology

Total mesorectal excision (TME): this is the gold standard surgical technique for the management of mid to low rectal cancers and involves the complete removal of the rectum and mesorectal tissue. As it is traditionally performed by an open approach, it can also be called open TME. Laparoscopic TME: Using the laparoscopic approach to perform TME. LCRT: Use of pre-operative course of radiotherapy with potentiating chemotherapy (neo-adjuvant treatment) over a few weeks, usually a 5 wk cycle. Following the chemo-radiation, surgery in the form of TME is performed after a delay of several weeks. The aim is to shrink the tumour or “sterilize” the circumferential resection margin.

Peer-review

This review addresses a very interesting and timely clinical issue.

Footnotes

P- Reviewer: Lorenzon L, Morino M, Wang SK S- Editor: Ji FF L- Editor: A E- Editor: Liu SQ

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