The Effectiveness and Safety of Open Versus laparoscopic Surgery for Rectal Cancer after Preoperative Chemo-radiotherapy: A Meta-Analysis

Author(s): Jun-Jie Zhang, Bao-Ling Guo, Qiu-Xiang Zheng, Zhi-Yong Chen*.

Journal Name: Combinatorial Chemistry & High Throughput Screening
Accelerated Technologies for Biotechnology, Bioassays, Medicinal Chemistry and Natural Products Research

Volume 22 , Issue 3 , 2019

Become EABM
Become Reviewer

Abstract:

Background: Only a limited number of studies considered the combined chemo-radiation therapy after surgery for treating locally advanced rectal cancer. Comparative studies on laparoscopic and open procedures indicated that laparoscopy surgery may be associated with fewer postoperative complications. Despite encouraging results from rectal cancer patients who received neoadjuvant chemo-radiotherapy prior to laparoscopic surgery, the acceptance of this procedure remains controversial, and conflicting evidence exists only in the form of retrospective trials.

Objectives: Since laparoscopic surgery was introduced into clinical practice to treat rectal cancer after neoadjuvant chemo-radiotherapy, it has been discussed controversially whether laparoscopic surgery can be performed as effectively as an open procedure. To overcome the biases inherent in any nonrandomized comparison, we analyzed the propensity-matched analysis and randomized clinical trial. In this study, we set out to determine whether laparoscopic resection was non-inferior to open resection in treatment outcomes of rectal cancer after neoadjuvant chemo-radiotherapy.

Methods: Publications on laparoscopic surgery in comparison with open thoracotomy in treatment outcomes of rectal cancer after neo-adjuvant chemo-radiotherapy to November 2017 were collected. Summary hazard ratios (HRs) of endpoints of interest such as 3-OS (overall survival), 3-DFS (disease-free survival), and individual postoperative complications were analyzed in all trials. By using fixed- or random-effects models according to the heterogeneity, meta-analysis Revman 5.3 software was applied to analyze combined pooled HRs.

Results: A total of 6 trials met our inclusion criteria. The pooled analysis of 3-DFS showed that laparoscopic surgery did not improve disease -free survival, compared with open thoracotomy (OR =1.48, 95% CI 0.95 – 2.29; P = 0.08), as well with the 3-OS (OR=0.96, 95%CI=0.66-1.41, P=0.084). The pooled result of duration of surgery indicated that laparoscopic surgery had a tendency towards a longer surgery time (SMD= 43.96, 95% CI 34.04– 53.88; P < 0.00001) and a shorter hospital stay (SMD= -0.97, 95% CI -1.75– -0.18; P=0.02). However, no significant differences between laparoscopic surgery and open thoracotomy were observed in terms of the meta-analysis on the number of removed lymph nodes (SMD =-0.37, 95% CI -0.1.77 – 1.03; P = 0.60), blood loss (SMD =-21.30, 95% CI -0.48.36 – 5.77; P = 0.12), positive circumferential resection margin (OR =0.73, 95% CI 0.22– 2.48; P = 0.61) or postoperative complications (OR =0.89, 95% CI 0.67 – 1.17; P = 0.40) l.

Conclusion: The current data supported the concept that laparoscopic surgery had correlated with a longer operative time but a shorter hospital stay, without superior advantages in short-term survival rates or oncologic efficiency for locally treating advanced rectal cancer after neoadjuvant chemoradiotherapy. However, prospective investigation on long-term oncological results from laparoscopic surgery is required in the future to verify the benefits of laparoscopic surgery over open surgery after chemo-radiation therapy for treating locally advanced rectal cancer.

Keywords: Rectal cancer, open surgery, laparoscopic surgery, neoadjuvant therapy, meta-analysis, chemo-radio therapy.

[1]
Kusano, T.; Inomata, M.; Hiratsuka, T.; Akagi, T.; Ueda, Y.; Tojigamori, M.; Shiroshita, H.; Etoh, T.; Shiraishi, N.; Kitano, S. A comparison of laparoscopic and open surgery following pre-operative chemoradiation therapy for locally advanced lower rectal cancer. Jpn. J. Clin. Oncol., 2014, 44(4), 305-310.
[2]
Monson, J.R.; Weiser, M.R.; Buie, W.D.; Chang, G.J.; Rafferty, J.F.; Buie, W.D.; Rafferty, J. Standards Practice Task Force of the AmericanSociety of Colon and Rectal Surgeons.Practice parameters for the management of rectal cancer (revised). Dis. Colon Rectum, 2013, 56(5), 535-550.
[3]
Ghoneum, M.; Felo, N.; Nwaogu, O.M.; Fayanju, I.Y.; Jeffe, J.A.; Margenthaler, D.B. Clinical trials in surgical oncology. Asian Pac. J. Surg. Oncol., 2015, 1(2), 73-82.
[4]
Liu, K.; Chen, X.Z.; Nakamura, I.; Ohki, S.; Eslick, G.D. Laparoscopic surgery for gastric cancer: Survival outcome and prognostic factor. Asian Pac. J. Surg. Oncol., 2016, 2(2), 135-142.
[5]
Mellotte, G.; Maher, V.; Devitt, P.G.; Shin, V.Y.; Leung, C.P. Minimally invasive surgical oncology: State of the art. Asian Pac. J. Surg. Oncol., 2015, 1(2), 101-112.
[6]
Morise, Z.; Kayaalp, C.; Nakatsuji, M. Laparoscopic surgery for operable colon cancer: State of the art. Asian Pac. J. Surg. Oncol, 2016, 2(1), 25-36.
[7]
Clinical Outcomes of Surgical Therapy Study Group,Nelson, H.; Sargent, D.J.; Wieand, H.S.; Fleshman, J.; Anvari, M.; Stryker, S.J.; Beart, Jr.R.W.; Hellinger, M.; Flanagan, Jr.R.; Peters, W.; Ota, D. A comparison of laparoscopically assisted and open colectomy for colon cancer. N. Engl. J. Med., 2004, 350(20), 2050-2059.
[8]
Jayne, D.G.; Guillou, P.J.; Thorpe, H.; Quirke, P.; Copeland, J.; Smith, A.M.; Heath, R.M.; Brown, J.M. UK MRC CLASICC Trial Group.Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. J. Clin. Oncol., 2007, 25(21), 3061-3068.
[9]
Colon Cancer Laparoscopic or Open Resection Study G.Buunen, M.; Veldkamp, R.; Hop, W.C.; Kuhry, E.; Jeekel, J.; Haglind, E.; Påhlman, L.; Cuesta, M.A.; Msika, S.; Morino, M.; Lacy, A.; Bonjer, H.J. Survival after laparoscopic surgery versus open surgery for colon cancer: long-term outcome of a randomised clinical trial. Lancet Oncol., 2009, 10(1), 44-52.
[10]
Dorrance, H.R.; Docherty, G.M.; O’Dwyer, P.J. Effect of surgeon specialty interest on patient outcome after potentially curative colorectal cancer surgery. Dis. Colon Rectum, 2000, 43(4), 492-498.
[11]
Sauer, R.; Becker, H.; Hohenberger, W.; Rödel, C.; Wittekind, C.; Fietkau, R.; Martus, P.; Tschmelitsch, J.; Hager, E.; Hess, C.F.; Karstens, J.H.; Liersch, T.; Schmidberger, H.; Raab, R. German Rectal Cancer Study Group.Preoperative versus postoperative chemoradiotherapy for rectal cancer. N. Engl. J. Med., 2004, 351(17), 1731-1740.
[12]
Lange, M.M.; Rutten, H.J.; van de Velde, C.J. One hundred years of curative surgery for rectal cancer: 1908-2008. Eur. J. Surg. Oncol., 2009, 35(5), 456-463.
[13]
Kim, J.C.; Yu, C.S.; Lim, S.B.; Park, I.J.; Kim, C.W.; Yoon, Y.S. Comparative analysis focusing on surgical and early oncological outcomes of open, laparoscopy-assisted, and robot-assisted approaches in rectal cancer patients. Int. J. Colorectal Dis., 2016, 31(6), 1179-1187.
[14]
Lacy, A.M.; Garcia-Valdecasas, J.C.; Delgado, S.; Castells, A.; Taurá, P.; Piqué, J.M.; Visa, J. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet, 2002, 359(9325), 2224-2229.
[15]
Ceelen, W.P. Use of laparoscopy for rectal cancer: a word of caution. J. Clin. Oncol., 2007, 25(31), 5040.
[16]
Tierney, J.F.; Stewart, L.A.; Ghersi, D.; Burdett, S.; Sydes, M.R. Practical methods for incorporating summary time-to-event data into meta-analysis. Trials, 2007, 8, 16.
[http://dx.doi.org/10.1186/1745-6215-8-16]
[17]
Higgins, J.P.; Thompson, S.G. Quantifying heterogeneity in a meta-analysis. Stat. Med., 2002, 21(11), 1539-1558.
[18]
Higgins, J.P.; Thompson, S.G.; Deeks, J.J.; Altman, D.G. Measuring inconsistency in meta-analyses. BMJ, 2003, 327(7414), 557-560.
[19]
Fleshman, J.; Branda, M.; Sargent, D.J.; Boller, A.M.; George, V.; Abbas, M.; Peters, W.R. Jr.; Maun, D.; Chang, G.; Herline, A.; Fichera, A.; Mutch, M.; Wexner, S.; Whiteford, M.; Marks, J.; Birnbaum, E.; Margolin, D.; Larson, D.; Marcello, P.; Posner, M.; Read, T.; Monson, J.; Wren, S.M.; Pisters, P.W.; Nelson, H. Effect of laparoscopic-assisted resection vs open resection of stage II or III rectal cancer on pathologic outcomes: The ACOSOG Z6051 randomized clinical trial. JAMA, 2015, 314(13), 1346-1355.
[20]
Seshadri, R.A.; Swaminathan, R.; Srinivasan, A. Laparoscopic versus open surgery for rectal cancer after neoadjuvant chemoradiation: Long-term outcomes of a propensity score matched study. J. Surg. Oncol., 2018, 117(3), 506-513.
[21]
Jeong, S.Y.; Park, J.W.; Nam, B.H.; Kim, S.; Kang, S.B.; Lim, S.B.; Choi, H.S.; Kim, D.W.; Chang, H.J.; Kim, D.Y.; Jung, K.H.; Kim, T.Y.; Kang, G.H.; Chie, E.K.; Kim, S.Y.; Sohn, D.K.; Kim, D.H.; Kim, J.S.; Lee, H.S.; Kim, J.H.; Oh, J.H. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): Survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol., 2014, 15(7), 767-774.
[22]
Ju, W.; Luo, X.; Han, B. Laparoscopic surgery is feasible for the treatment of rectal cancer after neoadjuvant chemoradiotherapy. Pak. J. Pharm. Sci., 2016, 29(5)(Suppl.), 1817-1821.
[23]
Wang, Y.W.; Huang, L.Y.; Song, C.L.; Zhuo, C.H.; Shi, D.B.; Cai, G.X.; Xu, Y.; Cai, S.J.; Li, X.X. Laparoscopic vs open abdominoperineal resection in the multimodality management of low rectal cancers. World J. Gastroenterol., 2015, 21(35), 10174-10183.
[24]
Denoya, P.; Wang, H.; Sands, D.; Nogueras, J.; Weiss, E.; Wexner, S.D. Short-term outcomes of laparoscopic total mesorectal excision following neoadjuvant chemoradiotherapy. Surg. Endosc., 2010, 24(4), 933-938.
[25]
Arezzo, A.; Passera, R.; Scozzari, G.; Verra, M.; Morino, M. Laparoscopy for extraperitoneal rectal cancer reduces short-term morbidity: Results of a systematic review and meta-analysis. United European Gastroenterol. J., 2013, 1(1), 32-47.
[26]
Arezzo, A.; Passera, R.; Salvai, A.; Arolfo, S.; Allaix, M.E.; Schwarzer, G.; Morino, M. Laparoscopy for rectal cancer is oncologically adequate: A systematic review and meta-analysis of the literature. Surg. Endosc., 2015, 29(2), 334-348.
[27]
Green, B.L.; Marshall, H.C.; Collinson, F.; Quirke, P.; Guillou, P.; Jayne, D.G.; Brown, J.M. Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br. J. Surg., 2013, 100(1), 75-82.
[28]
van der Pas, M.H.; Haglind, E.; Cuesta, M.A.; Fürst, A.; Lacy, A.M.; Hop, W.C.; Bonjer, H.J. COlorectal cancer Laparoscopic or Open Resection II (COLOR II) Study Group. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol., 2013, 14(3), 210-218.
[29]
Bonjer, H.J.; Deijen, C.L.; Abis, G.A.; Cuesta, M.A.; van der Pas, M.H.; de Lange-de Klerk, E.S.; Lacy, A.M.; Bemelman, W.A.; Andersson, J.; Angenete, E.; Rosenberg, J.; Fuerst, A.; Haglind, E. COLOR II Study Group.A randomized trial of laparoscopic versus open surgery for rectal cancer. N. Engl. J. Med., 2015, 372(14), 1324-1332.
[30]
Huang, M.J.; Liang, J.L.; Wang, H.; Kang, L.; Deng, Y.H.; Wang, J.P. Laparoscopic-assisted versus open surgery for rectal cancer: a meta-analysis of randomized controlled trials on oncologic adequacy of resection and long-term oncologic outcomes. Int. J. Colorectal Dis., 2011, 26(4), 415-421.
[31]
Engstrom, P.F.; Arnoletti, J.P.; Benson, A.B. 3rd, Chen, Y.J.; Choti, M.A., Cooper, H.S.; Covey, A.; Dilawari, R.A.; Early, D.S.; Enzinger, P.C.; Fakih, M.G.; Fleshman, J.;Jr, Fuchs, C.; Grem, J.L.; Kiel, K.; Knol, J.A.; Leong, L.A.; Lin, E.; Mulcahy, M.F.; Rao, S.; Ryan, D.P.; Saltz, L.; Shibata, D.; Skibber, J.M; Sofocleous, C.; Thomas, J.; Venook, A.P.; Willett, C.; National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: Rectal cancer. J. Natl. Compr. Canc. Netw., 2009, 7(8), 838-881.
[32]
Ishihara, S.; Hayama, T.; Yamada, H.; Nozawa, K.; Matsuda, K.; Watanabe, T. Benefit of tegafur-uracil and leucovorin in chemoradio-therapy for rectal cancer. Hepatogastroenterology, 2011, 8, 756-762.
[33]
Kang, S.B.; Park, J.W.; Jeong, S.Y.; Nam, B.H.; Choi, H.S.; Kim, D.W.; Lim, S.B.; Lee, T.G.; Kim, D.Y.; Kim, J.S.; Chang, H.J.; Lee, H.S.; Kim, S.Y.; Jung, K.H.; Hong, Y.S.; Kim, J.H.; Sohn, D.K.; Kim, D.H.; Oh, J.H. Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): short-term outcomes of an open-label randomised controlled trial. Lancet Oncol., 2010, 11(7), 637-645.
[34]
Bege, T.; Lelong, B.; Esterni, B.; Turrini, O.; Guiramand, J.; Francon, D.; Mokart, D.; Houvenaeghel, G.; Giovannini, M.; Delpero, J.R. The learning curve for the laparoscopic approach to conservative mesorectal excision for rectal cancer: lessons drawn from a single institution’s experience. Ann. Surg., 2010, 251(2), 249-253.
[35]
Kayano, H.; Okuda, J.; Tanaka, K.; Kondo, K.; Tanigawa, N. Evaluation of the learning curve in laparoscopic low anterior resection for rectal cancer. Surg. Endosc., 2011, 25(9), 2972-2979.
[36]
Son, G.M.; Kim, J.G.; Lee, J.C.; Suh, Y.J.; Cho, H.M.; Lee, Y.S.; Lee, I.K.; Chun, C.S. Multidimensional analysis of the learning curve for laparoscopic rectal cancer surgery. J. Laparoendosc. Adv. Surg. Tech. A, 2010, 20(7), 609-617.
[37]
Gunderson, L.L.; Sargent, D.J.; Tepper, J.E.; Wolmark, N.; O’Connell, M.J.; Begovic, M.; Allmer, C.; Colangelo, L.; Smalley, S.R.; Haller, D.G.; Martenson, J.A.; Mayer, R.J.; Rich, T.A.; Ajani, J.A.; MacDonald, J.S.; Willett, C.G.; Goldberg, R.M. Impact of T and N stage and treatment on survival and relapse in adjuvant rectal cancer: A pooled analysis. J. Clin. Oncol., 2004, 22(10), 1785-1796.
[38]
Bege, T.; Lelong, B.; Esterni, B.; Turrini, O.; Guiramand, J.; Francon, D.; Mokart, D.; Houvenaeghel, G.; Giovannini, M.; Delpero, J.R. The learning curve for the laparoscopic approach to conservative mesorectal excision for rectal cancer: Lessons drawn from a single institution’s experience. Ann. Surg., 2010, 251(2), 249-253.
[39]
Law, W.L.; Chu, K.W. Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann. Surg., 2004, 240(2), 260-268.
[40]
Merkel, S.; Mansmann, U.; Hohenberger, W.; Hermanek, P. Time to locoregional recurrence after curative resection of rectal carcinoma is prolonged after neoadjuvant treatment: A systematic review and meta-analysis. Colorectal Dis., 2011, 13(2), 123-131.
[41]
Sauer, R.; Liersch, T.; Merkel, S.; Fietkau, R.; Hohenberger, W.; Hess, C.; Becker, H.; Raab, H.R.; Villanueva, M.T.; Witzigmann, H.; Wittekind, C.; Beissbarth, T.; Rödel, C. Preoperative versus postoperative chemoradiotherapy for locally advanced rectal cancer: results of the German CAO/ARO/AIO-94 randomized phase III trial after a median follow-up of 11 years. J. Clin. Oncol., 2012, 30(16), 1926-1933.
[42]
Xiong, B.; Ma, L.; Zhang, C.; Cheng, Y. Robotic versus laparoscopic total mesorectal excision for rectal cancer: A meta-analysis. J. Surg. Res., 2014, 188(2), 404-414.


Rights & PermissionsPrintExport Cite as

Article Details

VOLUME: 22
ISSUE: 3
Year: 2019
Page: [153 - 159]
Pages: 7
DOI: 10.2174/1386207322666190415102505
Price: $58

Article Metrics

PDF: 14
HTML: 2

Special-new-year-discount