Surg Endosc (2014) 28:1940–1948 DOI 10.1007/s00464-014-3419-8
and Other Interventional Techniques
Laparoscopic and converted approaches to rectal cancer resection have superior long-term outcomes: a comparative study by operative approach Deborah S. Keller • Zhamak Khorgami • Brian Swendseid Bradley J. Champagne • Harry L. Reynolds Jr. • Sharon L. Stein • Conor P. Delaney
•
Received: 20 June 2013 / Accepted: 4 January 2014 / Published online: 11 February 2014 Ó Springer Science+Business Media New York 2014
Abstract Background and objectives The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes. Methods Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach. Results Overall, 294 patients were analyzed—116 LAP (39.5 %), 153 OPEN (52.0 %), and 25 (8.5 %) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1–20) LAP, 6 days (range 3–13) CONVERTED, and 8 days (range 1–35) OPEN (p \ 0.01). More OPEN had postoperative complications (p \ 0.01)—complication rates were 43.8 % OPEN, 32.0 % CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6 % OPEN, 16.0 % CONVERTED, 12.1 % LAP). Overall 3-year disease-free survival (DFS) was 98.3 %, and local recurrence rate was 2.0 %. By
D. S. Keller (&) Z. Khorgami B. J. Champagne H. L. Reynolds Jr. S. L. Stein C. P. Delaney Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106-5047, USA e-mail: [email protected] B. Swendseid School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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approach, DFS was 100 % CONVERTED, 93.1 % LAP, and 87.6 % OPEN (p = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1 % LAP, and 97.4 %. OPEN. Local recurrence was 0 % CONVERTED, 2 % OPEN, and 2.6 % LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (p = 0.05), with comparable local recurrence (p = 0.07) and OS rates (0.43). Conclusions LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.
Keywords Rectal cancer Laparoscopy Patient outcomes Oncologic outcomes The use of laparoscopy in colorectal surgery has increased in use over the last decade [1, 2]. Laparoscopic (LAP) colorectal surgery has proven short-term advantages, including reduced postoperative pain, shortened postoperative ileus, better cosmesis and shorter length of stay (LOS) [3–14]. The oncologic equivalency has been demonstrated for benign colorectal and malignant colon disease [3, 6–8, 12, 14]. However, these early trials did not specifically evaluate or support the safety and oncologic equivalence of LAP resection for rectal cancer (LRR). Until recently, the small subset of rectal cancer patients in the CLASICC trial was the highest level of evidence available for LRR [14]. The lack of non-inferiority data from large-scale, randomized trials paired with the technical complexity of operating in the narrow pelvis have resulted in slow integration of LRR into clinical practice for rectal cancer [15]. With time and experience, there has been a general acceptance of the oncologic equivalence of LRR in expert
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hands, and use is increasing. The safety and equivalent oncological outcomes for LRR versus open resection in rectal cancer has been demonstrated in experienced surgeons [7, 8, 16–19] and outcomes reported in numerous single-institution reports and meta-analyses [16, 20–31]. In addition, the long-term follow-up of the CLASICC trial demonstrated no differences in overall survival (OS), disease-free survival (DFS), local, or distant recurrence between LAP and open resection [32]. The recent COLOR II short-term outcomes found similar safety and resection margins, with improved recovery, compared with open surgery for rectal cancer [33]. Furthermore, the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) have given support to LRR in experienced surgeons [34]. As LRR gains acceptance and grows in use, the question of detrimental effects of conversion to open surgery on oncologic outcomes remain unclear [35]. Few studies have described the outcomes of patients who underwent a LAP converted to open approach or the practical integration of a combined approach in routine practice. The objective of this study was to evaluate the long-term oncologic and clinical outcomes for patients undergoing curative resection for rectal cancer using combined, LAP, and open approaches. Our hypothesis is that the majority of patients can be approached with a LAP or combined approach with superior outcomes.
Materials and methods After obtaining Institutional Review Board approval, we identified all patients who underwent primary, curative resection for rectal cancer between February 2005 and February 2013 from a prospectively maintained departmental database. Patients were identified by International Classification of Diseases, Ninth Edition (ICD-9) diagnosis code (154.1) and considered for evaluation if the rectal cancer resection was the primary procedure for that episode of care. Patients under 18 years of age, patients with incomplete medical records, patients who underwent simultaneous multiple organ resections, loop stoma closures, and cases performed through endoscopic, anorectal, or TEM approaches were excluded from the analysis. Patients were stratified by operative approach: LAP, open (OPEN), or LAP converted to open (CONVERTED). Patients were assigned to LAP or OPEN based on clinical criteria and imaging. The indications for OPEN included pelvic exenterations, en-bloc or multivisceral resections for locally advanced disease (radiologically or clinically suspicious T4), intraoperative radiation therapy, and surgeon preference (multiple previous abdominal operations and
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body habitus). All other patients were deemed appropriate for LAP resection, and underwent LAP. Patients were deemed suitable for LAP if they had a localized rectal cancer without invasion of adjacent organ (T1-3) and acceptable body habitus. LAP cases converted intraoperatively to an open approach comprised the CONVERTED cohort. OPEN, LAP, and CONVERTED cases followed the same surgical tenets, including high ligation of the inferior mesenteric vessels and total mesorectal excision (TME) based on the level of the tumor. Patients were determined as candidates for preoperative chemoradiotherapy (CRT) was given to patients with cT3-4N0 or any cTN1-2 lesions based on preoperative imaging (pelvic CT, transanal ultrasonography, or magnetic resonance imaging [MRI]) based on National Comprehensive Cancer Network (NCCN) guidelines and the consensus opinion of a multidisciplinary tumor board. Demographic, perioperative procedural, postoperative outcome, and oncologic recurrence and survival data was examined for each operative approach. Data fields collected included age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) class, Charlson Comorbidity Index, operative type (emergent/ elective), neoadjuvant and adjuvant therapy, pathologic stage, tumor distance from anal verge, operative procedure, operative time, blood loss, transfusion required, intraoperative complications, resection margins, intensive care unit (ICU) required, hospital LOS, discharge disposition, postoperative complications, readmission, unplanned reoperation, recurrence-free survival (RFS), and OS. Descriptive statistics were used to analyze variables in each operative approach. Categorical variables were evaluated using Chi squared or Kruskal–Wallis one-way analysis of variance (ANOVA), as appropriate, with a p value of \0.05 considered statistically significant. Kaplan–Meier analysis was used to evaluate RFS and OS by operative approach. The survival difference was assessed by the log rank test.
Results During the study period, 322 total patients underwent curative resection for rectal cancer. Twenty-eight patients approached via an anorectal (19) and transanal (9) approach were excluded, leaving 294 patients included in the analysis. By operative approach, there were 116 LAP (39.5 %), 153 OPEN (52.0 %), and 25 (8.5 %) CONVERTED. The patients were similar in age (p = 0.88) and BMI (p = 0.49) across groups. There were more males in the CONVERTED and OPEN groups than the LAP group (68 and 62.1 % vs. 54.3 %, respectively; p = 0.29). The
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Table 1 Demographic data
Open (n = 153)
LAP (n = 116)
Converted (n = 25)
Total (n = 294)
Age [years; mean (SD)]
62.4 (12.1)
63.1 (13.6)
63.5 (13.4)
62.8 (12.8)
0.88
BMI [mean (SD)]
29.2 (7.2)
28.7 (6.2)
27.5 (4.6)
28.8 (6.6)
0.49
Gender [n (%)]
0.29
Female
58 (37.9)
53 (45.7)
8 (32)
119 (40.5)
Male
95 (62.1)
63 (54.3)
17 (68)
175 (59.5)
I
1 (0.7)
1 (0.9)
1 (4)
3 (1)
II
43 (28.1)
11 (44)
105 (35.7)
III
109 (71.2)
64 (55.1)
13 (52)
186 (63.3)
3.5 (1.9)
2.6 (1.1)
3.2 (1.5)
3.1 (1.7)
\0.01
Open (n = 153)
LAP (n = 116)
Converted (n = 25)
Total (n = 294)
p value
4 (2.6)
0 (0)
1 (4)
5 (1.7)
ASA Class [n (%)]
SD standard deviation, BMI body mass index, ASA American Society of Anesthesiologists
Charlson Comorbidity Index [mean (SD)]
Table 2 Perioperative data
Emergent operation [n (%)]
0.03 51 (44)
APR
25 (16.3)
22 (19)
6 (24)
53 (18)
LAR
79 (51.6)
91 (78.4)
16 (64)
186 (63.3)
Pelvic exenteration/ multivisceral resection
42 (27.5)
0 (0)
2 (8)
44 (15)
Proctocolectomy, total
7 (4.6)
3 (2.6)
1 (4)
11 (3.7)
Stoma formation [n (%)] Operative time [min; mean (SD)]
60 (39.2) 311.9 (137)
52 (44.8) 242.6 (70.5)
11 (44) 260 (79.8)
123 (41.8) 0.64 278.9 (114.4) \0.01
Operative time [min; median (range)]
270 (60–810)
235 (125–475)
275 (130–420)
258 (60–810)
Blood loss [ml; mean (SD)]
627 (996)
74 (74)
253 (211)
376 (767)
Blood loss [ml; median (range)]
300 (20–8535)
50 (5–400)
200 (25–1000)
150 (5–8535)
Intraoperative complications [n (%)]
21 (13.7)
7 (6)
2 (8)
30 (12.2)
Intraoperative transfusion required [n (%)]
12 (7.8)
0 (0)
0 (0)
12 (4.1)
OPEN group had significantly more comorbidities, as evident by the higher mean Charlson Comorbidity Index (1.1, 1.5, and 1.9 for the LAP, CONVERTED, and OPEN groups, respectively; p \ 0.01) and larger distribution of ASA Class III patients in the OPEN group (70.8 %) compared with the LAP (55.1 %) and CONVERTED groups (52 %) (p = 0.03). Full demographic details are shown in Table 1. The perioperative data by approach is detailed in Table 2. All LAP cases were elective, and the majority of OPEN (97.4 %) and converted (96 %) cases were also elective. The most common operative procedure performed in all groups was a low anterior resection (51.6 % OPEN, 78.4 % LAP, 64.0 % CONVERTED). OPEN patients had
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0.17 \0.01
Operative procedure [n (%)]
SD standard deviation
p value
\0.01
0.11 \0.01
significantly more radical procedures (p \ 0.01). A similar percentage of each group had an ostomy constructed (44.8 % LAP, 44.0 % CONVERTED, 39.2 % OPEN; p = 0.64). The CONVERTED and OPEN procedures had similar operative times (median 275 min and 270 min, respectively); the median LAP operative time was significantly shorter (235 min; p \ 0.01). The intraoperative blood loss was significantly lower LAP, for a median 300 mL for OPEN, 200 mL for CONVERTED, and 50 mL for LAP cases (p \ 0.01). Twelve OPEN cases (7.8 %) required an intraoperative transfusion; no LAP or CONVERTED required transfusion (p \ 0.01). The clinical TNM (cTNM) stages were significantly higher for OPEN than LAP and CONVERTED. The stage
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Table 3 Histopathologic data
Open (n = 153) Preoperative neoadjuvant CRT [n (%)] Postoperative chemotherapy [n (%)] Postoperative radiotherapy [n (%)] Intraoperative radiation therapy [n (%)]
LAP (n = 116)
Converted (n = 25)
Total (n = 294)
p value \0.01
112 (73.2)
63 (54.3)
19 (76)
194 (66)
86 (56.2)
46 (39.7)
10 (40)
142 (48.3)
0.02
2 (1.3)
1 (0.9)
1 (4)
4 (1.4)
0.47
0 (0)
0 (0)
19 (6.5)
\0.01
0 (0)
48 (16.3)
19 (12.4)
\0.01
cTNM stage [n (%)] I
16 (10.5)
32 (27.6)
II
58 (37.9)
45 (38.8)
12 (48.0)
115 (39.1)
III
56 (36.6)
37 (31.9)
12 (48.0)
105 (35.7)
IV
23 (15.0)
2 (1.7)
1 (4.0)
26 (8.8)
25 (16.3)
16 (13.8)
4 (16.0)
45 (15.3)
I
25 (16.3)
45 (38.8)
7 (28.0)
77 (26.2)
II
39 (25.5)
22 (19.0)
6 (24.0)
67 (22.8)
III
38 (24.8)
31 (26.7)
7 (28.0)
76 (25.9)
IV
26 (17.0)
2 (1.7)
1 (4.0)
29 (9.9)
20.2 (9.2)
18.6 (7.8)
19.4 (9.1)
ypTNM stage [n (%)] 0
Lymph nodes [mean (SD)]
18.9 (9.2)
Lymph nodes [median (range)]
17.5 (0–73)
Positive nodes [mean (SD)] Positive nodes [median (range)] Pathologic distal margin [cm; mean (SD)] CRT chemoradiotherapy, cTNM clinical TNM, SD standard deviation, CRM circumferential resection margin
\0.01
Pathologic distal margin [cm; median (range)] CRM [mm; mean (SD)] CRM [mm; median (range)]
distribution was 56.6 % OPEN, 31.9 % LAP, and 48.0 % CONVERTED in Stage III versus 37.9 % OPEN, 38.8 % LAP, and 48.0 % CONVERTED in Stage II (p \ 0.01). Aligned with the TNM stage, most OPEN and CONVERTED (73.2 % and 76 %, respectively) had neoadjuvant CRT; 54.3 % of LAP had neoadjuvant treatment (p \ 0.01). The ypTNM stage was also significantly higher for OPEN than LAP and CONVERTED (p \ 0.01). The largest percentage of OPEN was ypTNM III (25.5 %), while the majority of LAP were ypTNM I (38.8 %), and 28 % of CONVERTED were ypTNM Stage I and III each (Table 3). There were no significant differences in pathologic distal margins (p = 0.23), circumferential resection margin (CRM) (p = 0.23), or lymph node yield (p = 0.48). The mean distal margin was 4.8 cm OPEN, 4.1 cm CONVERTED, and 3.9 cm LAP. The mean CRM was 8.4 mm OPEN, 8.9 mm LAP, and 13.5 mm CONVERTED. The mean number of lymph nodes harvested was 18.6 CONVERTED, 18.9 OPEN, and 20.2 LAP. Table 3 details the tumor histopathologic results.
1.3 (3) 0 (0–19) 4.8 (3.4) 4 (0.3–19) 8.4 (9) 5 (0–35)
0.48
18 (5–68)
17 (6–36)
18 (0–73)
1.1 (3)
1.4 (3)
1.2 (3)
0 (0–18) 3.9 (2.3) 3.6 (0–13) 8.9 (11) 6 (1–50)
0 (0–12) 4.1 (3.3) 4 (0.3–15)
0.54
0 (0–19) 4.4 (3)
0.23
4 (0–19)
13.5 (19.5)
9.1 (11.1)
7.25 (1–70)
5 (0–70)
0.89
Table 4 demonstrates short-term patient outcomes. Postoperatively, 31 OPEN patients (20.3 %), two CONVERTED (8.0 %), and three LAP (2.6 %) patients required ICU care (p \ 0.01). There were a total of 100 patients with postoperative complications—67 OPEN (43.8 %), 25 LAP (21.5 %), and 8 CONVERTED (32.0 %). OPEN had a significantly higher rate of overall complications (p \ 0.01), and also had a higher rate of complications in every category, except anastomotic leak. The most common complications in the OPEN and LAP groups were postoperative ileus/small bowel obstruction (SBO) (14.4 and 6 %, respectively); the most common complication in CONVERTED was a superficial wound infection (20 %). The median LOS was significantly shorter in LAP (median 4 days, range 1–20) compared with CONVERTED (6 days, range 3–13) and OPEN (median 8 days, range 1–35) (p = 0.01). At discharge, the majority of patients in all three groups were discharged to home (77.6 % LAP, 60.0 % CONVERTED, 71.2 % OPEN; p = 0.34). 32 % of CONVERTED patients required home-care services.
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Table 4 Short-term outcomes
Open (n = 153) ICU stay required [n (%)]
31 (20.3)
LOS [mean (SD)]
9.2 (5.8)
LOS [median (range)]
LAP (n = 116) 3 (2.6) 4.4 (3.2)
Converted (n = 25) 2 (8) 6.8 (2.8) 6 (3–13)
Total (n = 294) 36 (12.2)
\0.01
7.1 (5.2)
\0.01
8 (3–35)
4 (1–20)
6 (1–35)
109 (71.2)
90 (77.6)
15 (60)
214 (72.8)
Home care
29 (19)
18 (15.5)
8 (32)
55 (18.7)
SNF/rehabilitation center
15 (9.8)
8 (6.9)
2 (8)
67 (43.8)
25 (21.5)
8 (32)
Ileus/SBOa
22 (14.4)
7 (6.0)
1 (4)
30 (10.2)
Superficial wound infection
11 (7.2)
2 (1.7)
4 (20)
17 (5.8)
Intra-abdominal collection
11 (7.2)
4 (3.4)
2 (8)
17 (5.8)
Discharge disposition [n (%)]
0.34
Home
Postoperative complications by category [n (%)]
Cardiovascular
SD standard deviation, SNF skilled nursing facility, SBO small bowel obstruction a
Ileus/SBO defined as lack of return of bowel function by postoperative day 5
b
Cardiovascular events include arrhythmia and myocardial infarction
b
25 (8.5) 100 (34)
8 (5.2)
1 (0.9)
2 (8)
11 (3.7)
Bleeding
7 (4.6)
2 (1.7)
1 (4)
10 (3.4)
Urinary tract infection
6 (3.9)
1 (0.9)
1 (4)
8 (2.7)
Pneumonia
2 (1.3)
4 (3.4)
0 (0)
6 (2)
Dehydration
5 (3.3)
1 (0.9)
0 (0)
6 (2)
Thromboembolic events
3 (2)
1 (0.9)
1 (4)
5 (1.7)
Anastomotic leak
1 (0.6)
3 (2.6)
0 (0)
4 (1.4)
Wound dehiscence/breakdown
2 (1.3)
1 (0.9)
1 (4)
4 (1.4)
Seroma
0 (0)
1 (0.9)
0 (0)
1 (0.3)
\0.01
Unplanned readmission (within 30 days) [n (%)]
33 (21.6)
14 (12.1)
4 (16)
51 (17.3)
0.12
Unplanned reoperation (within 30 days) [n (%)]
13 (8.5)
8 (6.9)
0 (0)
21 (7.1)
0.31
0 (0)
1 (0.9)
0 (0)
1 (0.3)
0.46
Mortality (within 30 days) [n (%)]
Unplanned readmissions were comparable (p = 0.12). The readmission rate was 21.6 % in OPEN, 16.0 % in CONVERTED, and 12.1 % in LAP. The most common indications for readmission were postoperative ileus/SBO and dehydration. The reoperation rate within 30 days of the rectal cancer resection was similar across groups (p = 0.31). Eight LAP (6.9 %) and 13 OPEN patients (8.5 %) required an unplanned re-operation; no patients in the CONVERTED group had an unplanned 30-day reoperation. There was one 30-day mortality in the LAP group (0.9 %). The cause of death was related to pre-existing respiratory failure, and the family made the patient ‘do not resuscitate’ postoperatively. Long-term outcomes were evaluated for each treatment group (Table 5). Over a median 3-year period (range 0–92 months), the DFS and OS rate for all patients was 90.8 % and 98.3 %, respectively. The local recurrence rate for all patients was 2.0 %. By approach, local recurrence was 2.0 % OPEN, 2.6 % LAP, and 0 % CONVERTED (p = 0.07). Metastatic recurrence was significantly higher in OPEN (10.4 %) than LAP (6.9 %) or CONVERTED (7.2 %) (p = 0.05). The 3-year DFS was significantly lower for OPEN (87.6 %) than LAP (93.1 %) and
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p value
CONVERTED (100 %) (p = 0.05). The OS was comparable by approach (0.43). OS for CONVERTED was 100 %, 99.1 % LAP, and 97.4 % for OPEN (Table 5). Kaplan–Meier analysis of DFS and OS are demonstrated in Figs. 1 and 2, respectively.
Discussion In this study, we aimed to evaluate the long-term outcomes of rectal cancer resection across surgical approaches on clinical and oncologic outcomes. Large-scale, randomized trials have demonstrated the non-inferiority of laparoscopy in curative rectal cancer resections after several years of follow-up [32, 33]. Short-term outcome benefits of shorter LOS, less blood loss, and lower postoperative complication rates, paired with oncologic equivalence, have been reported from single-center studies with LRR for rectal cancer [16, 20–31, 36–40]. However, oncologic benefits of LRR are now being reported. In evaluating the impact of LRR, Boutros et al. [41] found an advantage for LRR in lymph nodes yield (p = 0.02), with no significant differences in TME quality, CRM, or distal resection margin.
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Table 5 Long-term oncologic and survival data
Open (n = 153) Follow-up time [month; mean (SD)]
Converted (n = 25)
Total (n = 294)
p value 0.53
46.8 (42.8)
38.2 (36.7)
34.2 (33.6)
38.1 (36.5)
Follow-up time [month; median (range)]
45 (0–92)
33.5 (0–70)
32 (0–61)
34 (0–92)
Overall recurrence [n (%)]
19 (12.4)
8 (6.9)
0 (0)
27 (9.2)
\0.01
3 (2.0)
3 (2.6)
0 (0)
6 (2.0)
0.07
Metastatic recurrence [n (%)]
16 (10.4)
5 (4.3)
0 (0)
21 (7.2)
0.05
Recurrence-free survival [months; mean (SD)]
25 (16.3)
27 (16.1)
23.1 (13.4)
25.6 (16)
0.31
Recurrence-free survival [months; median (range)]
30 (0–92)
32 (0–70)
31 (3–61)
Local recurrence [n (%)]
Mortality [n (%)]
SD standard deviation
LAP (n = 116)
31.5 (0–92)
4 (2.6)
1 (0.9)
0 (0)
5 (1.7)
0.43
3-year DFS [n (%)]
134 (87.6)
108 (93.1)
25 (100)
267 (90.8)
0.05
3-year OS [n (%)]
149 (97.4)
115 (99.1)
25 (100)
289 (98.3)
0.43
Fig. 1 Kaplan–Meier survival curve for RFS. RFS recurrence-free survival
Fig. 2 Kaplan–Meier survival curve for OS. OS overall survival
This is aligned with our results in the present study. We found LAP and CONVERTED procedures had shorter operative times, less blood loss, and lower complications, with comparable lymph nodes harvested and resection margins compared with OPEN procedures. As expected, LAP had the shortest LOS. Even with the short LOS, LAP had the lowest readmission rates. Furthermore, the 3-year DFS for LAP and CONVERTED were superior to open resections, with comparable local recurrence and OS rates. Our secondary goal was to assess the impact of conversion on the operative outcome and survival of patients who underwent LRR. Few previous studies have evaluated outcomes of conversion. Furthermore, results have varied,
complicating the impact on the treatment of patients with colorectal cancer. Moloo et al. reviewed 377 LAP resections for colon cancer between 1991 and 2002. There were 46 converted cases (12.8 %) in the cohort. The authors found significantly lower 2-year survival (75.7 % vs. 87.2 %; p = 0.02) and a trend towards lower 5-year survival (61.9 % vs. 69.7 %; p = 0.077) in the CONVERTED group compared with the LAP group [42]. Chan et al. [43] evaluated outcomes of 470 patients who underwent LAP colectomy for colorectal malignancy over a 6-year period. In the 41 CONVERTED cases (8.7 %), there was increased blood loss (461.9 vs. 191.2 ml; p \ 0.001), postoperative complication rate (56.1 vs. 16.7 %; p = 0.001) and
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hospital LOS (10 vs. 6 days; p \ 0.001). The CONVERTED group also had significantly lower DFS (9.8 vs. 2.8 %; p \ 0.001) and cancer-free survival rates [43]. A case-matched study by Casillas et al. [44] of 51 LAP to 51 open colectomies for both benign and malignant colorectal disease found conversion did not result in inappropriately prolonged operative time, LOS, direct costs, or unexpected readmissions compared with similarly complex laparotomies. Rottoli et al. [45] evaluated conversion in colon and rectal cancer by comparing 31 CONVERTED cases with 62 LAP and 155 OPEN cases; they found a significantly lower 5-year DFS rate for CONVERTED (40.2 %) compared with the LAP (70.7 %; p = 0.01) and OPEN groups (63.3 %; p = 0.04); the 5-year cancer-specific survival rates were similar, leading the authors to conclude that conversion to open surgery does not affect oncologic outcomes. In the sole study evaluating the impact of conversion in patients undergoing LRR for rectal cancer, Rottoli et al. [46] found that conversion to open surgery did not affect postoperative outcome. The 26/173 (15 %) CONVERTED patients had no significant differences in 5-year DFS (71.1 % CONVERTED vs. 85.3 % LAP; p = 0.17). In our series, we found conversion had no negative effects. Intraoperatively, CONVERTED patients had similar numbers of lymph nodes harvested, and adequate CRMs and distal margins compared with LAP and OPEN. Short-term outcomes for CONVERTED were better than the OPEN patients. CONVERTED patients had shorter LOS, lower postoperative complication, readmission, and reoperative rates than the OPEN group. Furthermore, the long-term DFS and OS for CONVERTED was superior to both the LAP and OPEN groups. By attempting the LAP approach, the CONVERTED subset of patients was able to realize many of the beneficial results normally reserved for LAP patients without sacrificing oncological outcomes. We recognize the limitations in the current study. First, the study was a retrospective, non-randomized review, and subject to selection biases inherent in the retrospective design. As the study is not prospective, randomized, or case matched, the study groups were inherently different. We acknowledge that our conclusions may be affected by the variability and selection bias. However, our objective was to report the outcomes across groups; our goal was not to compare outcomes across the dissimilar groups. Furthermore, as a retrospective review, we are limited to the documentation in medical records for treatment decisions. While the converted sample size was small, our study demonstrates the safety and efficacy of the LAP converted to open approach for rectal cancer resection. Our surgeons performed more than 1,000 LAP colorectal resections before starting this study [47–50], therefore their experience and results may not be generalizable. Regardless, the results should encourage the LAP approach whenever
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possible, without fear of inferior outcomes when necessary to convert to an open procedure.
Conclusions Our results support the attempt to perform more rectal cancer resections through a LAP approach. If the procedure cannot be completed laparoscopically, oncologic outcomes are not compromised for the converted patients. Furthermore, converted patients are able to realize short-term outcomes similar to LAP patients, optimizing recovery, survival, and potentially healthcare utilization. Acknowledgments Dr. Keller: conception and design; acquisition of data; analysis and interpretation of data; drafting the article; critical revisions for important intellectual content; final approval of the version to be published. Drs. Zhorgami, Champagne and Stein, and Mr Swendseid: conception and design; acquisition of data; analysis and interpretation of data; drafting the article; final approval of the version to be published. Drs. Reynolds and Delaney: conception and design; analysis and interpretation of data; critical revisions for important intellectual content; final approval of the version to be published. Disclosures Drs. Keller, Khorgami, Champagne, Stein, Reynolds, Delaney and Mr. Swendseid have no conflicts of interest, no disclosures, and no financial interests to declare. Funding The authors received no funding or financial support for this project.
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and Other Interventional Techniques
Laparoscopic and converted approaches to rectal cancer resection have superior long-term outcomes: a comparative study by operative approach Deborah S. Keller • Zhamak Khorgami • Brian Swendseid Bradley J. Champagne • Harry L. Reynolds Jr. • Sharon L. Stein • Conor P. Delaney
•
Received: 20 June 2013 / Accepted: 4 January 2014 / Published online: 11 February 2014 Ó Springer Science+Business Media New York 2014
Abstract Background and objectives The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes. Methods Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach. Results Overall, 294 patients were analyzed—116 LAP (39.5 %), 153 OPEN (52.0 %), and 25 (8.5 %) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1–20) LAP, 6 days (range 3–13) CONVERTED, and 8 days (range 1–35) OPEN (p \ 0.01). More OPEN had postoperative complications (p \ 0.01)—complication rates were 43.8 % OPEN, 32.0 % CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6 % OPEN, 16.0 % CONVERTED, 12.1 % LAP). Overall 3-year disease-free survival (DFS) was 98.3 %, and local recurrence rate was 2.0 %. By
D. S. Keller (&) Z. Khorgami B. J. Champagne H. L. Reynolds Jr. S. L. Stein C. P. Delaney Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Ave, Cleveland, OH 44106-5047, USA e-mail: [email protected] B. Swendseid School of Medicine, Case Western Reserve University, Cleveland, OH, USA
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approach, DFS was 100 % CONVERTED, 93.1 % LAP, and 87.6 % OPEN (p = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1 % LAP, and 97.4 %. OPEN. Local recurrence was 0 % CONVERTED, 2 % OPEN, and 2.6 % LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (p = 0.05), with comparable local recurrence (p = 0.07) and OS rates (0.43). Conclusions LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.
Keywords Rectal cancer Laparoscopy Patient outcomes Oncologic outcomes The use of laparoscopy in colorectal surgery has increased in use over the last decade [1, 2]. Laparoscopic (LAP) colorectal surgery has proven short-term advantages, including reduced postoperative pain, shortened postoperative ileus, better cosmesis and shorter length of stay (LOS) [3–14]. The oncologic equivalency has been demonstrated for benign colorectal and malignant colon disease [3, 6–8, 12, 14]. However, these early trials did not specifically evaluate or support the safety and oncologic equivalence of LAP resection for rectal cancer (LRR). Until recently, the small subset of rectal cancer patients in the CLASICC trial was the highest level of evidence available for LRR [14]. The lack of non-inferiority data from large-scale, randomized trials paired with the technical complexity of operating in the narrow pelvis have resulted in slow integration of LRR into clinical practice for rectal cancer [15]. With time and experience, there has been a general acceptance of the oncologic equivalence of LRR in expert
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hands, and use is increasing. The safety and equivalent oncological outcomes for LRR versus open resection in rectal cancer has been demonstrated in experienced surgeons [7, 8, 16–19] and outcomes reported in numerous single-institution reports and meta-analyses [16, 20–31]. In addition, the long-term follow-up of the CLASICC trial demonstrated no differences in overall survival (OS), disease-free survival (DFS), local, or distant recurrence between LAP and open resection [32]. The recent COLOR II short-term outcomes found similar safety and resection margins, with improved recovery, compared with open surgery for rectal cancer [33]. Furthermore, the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) have given support to LRR in experienced surgeons [34]. As LRR gains acceptance and grows in use, the question of detrimental effects of conversion to open surgery on oncologic outcomes remain unclear [35]. Few studies have described the outcomes of patients who underwent a LAP converted to open approach or the practical integration of a combined approach in routine practice. The objective of this study was to evaluate the long-term oncologic and clinical outcomes for patients undergoing curative resection for rectal cancer using combined, LAP, and open approaches. Our hypothesis is that the majority of patients can be approached with a LAP or combined approach with superior outcomes.
Materials and methods After obtaining Institutional Review Board approval, we identified all patients who underwent primary, curative resection for rectal cancer between February 2005 and February 2013 from a prospectively maintained departmental database. Patients were identified by International Classification of Diseases, Ninth Edition (ICD-9) diagnosis code (154.1) and considered for evaluation if the rectal cancer resection was the primary procedure for that episode of care. Patients under 18 years of age, patients with incomplete medical records, patients who underwent simultaneous multiple organ resections, loop stoma closures, and cases performed through endoscopic, anorectal, or TEM approaches were excluded from the analysis. Patients were stratified by operative approach: LAP, open (OPEN), or LAP converted to open (CONVERTED). Patients were assigned to LAP or OPEN based on clinical criteria and imaging. The indications for OPEN included pelvic exenterations, en-bloc or multivisceral resections for locally advanced disease (radiologically or clinically suspicious T4), intraoperative radiation therapy, and surgeon preference (multiple previous abdominal operations and
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body habitus). All other patients were deemed appropriate for LAP resection, and underwent LAP. Patients were deemed suitable for LAP if they had a localized rectal cancer without invasion of adjacent organ (T1-3) and acceptable body habitus. LAP cases converted intraoperatively to an open approach comprised the CONVERTED cohort. OPEN, LAP, and CONVERTED cases followed the same surgical tenets, including high ligation of the inferior mesenteric vessels and total mesorectal excision (TME) based on the level of the tumor. Patients were determined as candidates for preoperative chemoradiotherapy (CRT) was given to patients with cT3-4N0 or any cTN1-2 lesions based on preoperative imaging (pelvic CT, transanal ultrasonography, or magnetic resonance imaging [MRI]) based on National Comprehensive Cancer Network (NCCN) guidelines and the consensus opinion of a multidisciplinary tumor board. Demographic, perioperative procedural, postoperative outcome, and oncologic recurrence and survival data was examined for each operative approach. Data fields collected included age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) class, Charlson Comorbidity Index, operative type (emergent/ elective), neoadjuvant and adjuvant therapy, pathologic stage, tumor distance from anal verge, operative procedure, operative time, blood loss, transfusion required, intraoperative complications, resection margins, intensive care unit (ICU) required, hospital LOS, discharge disposition, postoperative complications, readmission, unplanned reoperation, recurrence-free survival (RFS), and OS. Descriptive statistics were used to analyze variables in each operative approach. Categorical variables were evaluated using Chi squared or Kruskal–Wallis one-way analysis of variance (ANOVA), as appropriate, with a p value of \0.05 considered statistically significant. Kaplan–Meier analysis was used to evaluate RFS and OS by operative approach. The survival difference was assessed by the log rank test.
Results During the study period, 322 total patients underwent curative resection for rectal cancer. Twenty-eight patients approached via an anorectal (19) and transanal (9) approach were excluded, leaving 294 patients included in the analysis. By operative approach, there were 116 LAP (39.5 %), 153 OPEN (52.0 %), and 25 (8.5 %) CONVERTED. The patients were similar in age (p = 0.88) and BMI (p = 0.49) across groups. There were more males in the CONVERTED and OPEN groups than the LAP group (68 and 62.1 % vs. 54.3 %, respectively; p = 0.29). The
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Table 1 Demographic data
Open (n = 153)
LAP (n = 116)
Converted (n = 25)
Total (n = 294)
Age [years; mean (SD)]
62.4 (12.1)
63.1 (13.6)
63.5 (13.4)
62.8 (12.8)
0.88
BMI [mean (SD)]
29.2 (7.2)
28.7 (6.2)
27.5 (4.6)
28.8 (6.6)
0.49
Gender [n (%)]
0.29
Female
58 (37.9)
53 (45.7)
8 (32)
119 (40.5)
Male
95 (62.1)
63 (54.3)
17 (68)
175 (59.5)
I
1 (0.7)
1 (0.9)
1 (4)
3 (1)
II
43 (28.1)
11 (44)
105 (35.7)
III
109 (71.2)
64 (55.1)
13 (52)
186 (63.3)
3.5 (1.9)
2.6 (1.1)
3.2 (1.5)
3.1 (1.7)
\0.01
Open (n = 153)
LAP (n = 116)
Converted (n = 25)
Total (n = 294)
p value
4 (2.6)
0 (0)
1 (4)
5 (1.7)
ASA Class [n (%)]
SD standard deviation, BMI body mass index, ASA American Society of Anesthesiologists
Charlson Comorbidity Index [mean (SD)]
Table 2 Perioperative data
Emergent operation [n (%)]
0.03 51 (44)
APR
25 (16.3)
22 (19)
6 (24)
53 (18)
LAR
79 (51.6)
91 (78.4)
16 (64)
186 (63.3)
Pelvic exenteration/ multivisceral resection
42 (27.5)
0 (0)
2 (8)
44 (15)
Proctocolectomy, total
7 (4.6)
3 (2.6)
1 (4)
11 (3.7)
Stoma formation [n (%)] Operative time [min; mean (SD)]
60 (39.2) 311.9 (137)
52 (44.8) 242.6 (70.5)
11 (44) 260 (79.8)
123 (41.8) 0.64 278.9 (114.4) \0.01
Operative time [min; median (range)]
270 (60–810)
235 (125–475)
275 (130–420)
258 (60–810)
Blood loss [ml; mean (SD)]
627 (996)
74 (74)
253 (211)
376 (767)
Blood loss [ml; median (range)]
300 (20–8535)
50 (5–400)
200 (25–1000)
150 (5–8535)
Intraoperative complications [n (%)]
21 (13.7)
7 (6)
2 (8)
30 (12.2)
Intraoperative transfusion required [n (%)]
12 (7.8)
0 (0)
0 (0)
12 (4.1)
OPEN group had significantly more comorbidities, as evident by the higher mean Charlson Comorbidity Index (1.1, 1.5, and 1.9 for the LAP, CONVERTED, and OPEN groups, respectively; p \ 0.01) and larger distribution of ASA Class III patients in the OPEN group (70.8 %) compared with the LAP (55.1 %) and CONVERTED groups (52 %) (p = 0.03). Full demographic details are shown in Table 1. The perioperative data by approach is detailed in Table 2. All LAP cases were elective, and the majority of OPEN (97.4 %) and converted (96 %) cases were also elective. The most common operative procedure performed in all groups was a low anterior resection (51.6 % OPEN, 78.4 % LAP, 64.0 % CONVERTED). OPEN patients had
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0.17 \0.01
Operative procedure [n (%)]
SD standard deviation
p value
\0.01
0.11 \0.01
significantly more radical procedures (p \ 0.01). A similar percentage of each group had an ostomy constructed (44.8 % LAP, 44.0 % CONVERTED, 39.2 % OPEN; p = 0.64). The CONVERTED and OPEN procedures had similar operative times (median 275 min and 270 min, respectively); the median LAP operative time was significantly shorter (235 min; p \ 0.01). The intraoperative blood loss was significantly lower LAP, for a median 300 mL for OPEN, 200 mL for CONVERTED, and 50 mL for LAP cases (p \ 0.01). Twelve OPEN cases (7.8 %) required an intraoperative transfusion; no LAP or CONVERTED required transfusion (p \ 0.01). The clinical TNM (cTNM) stages were significantly higher for OPEN than LAP and CONVERTED. The stage
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Table 3 Histopathologic data
Open (n = 153) Preoperative neoadjuvant CRT [n (%)] Postoperative chemotherapy [n (%)] Postoperative radiotherapy [n (%)] Intraoperative radiation therapy [n (%)]
LAP (n = 116)
Converted (n = 25)
Total (n = 294)
p value \0.01
112 (73.2)
63 (54.3)
19 (76)
194 (66)
86 (56.2)
46 (39.7)
10 (40)
142 (48.3)
0.02
2 (1.3)
1 (0.9)
1 (4)
4 (1.4)
0.47
0 (0)
0 (0)
19 (6.5)
\0.01
0 (0)
48 (16.3)
19 (12.4)
\0.01
cTNM stage [n (%)] I
16 (10.5)
32 (27.6)
II
58 (37.9)
45 (38.8)
12 (48.0)
115 (39.1)
III
56 (36.6)
37 (31.9)
12 (48.0)
105 (35.7)
IV
23 (15.0)
2 (1.7)
1 (4.0)
26 (8.8)
25 (16.3)
16 (13.8)
4 (16.0)
45 (15.3)
I
25 (16.3)
45 (38.8)
7 (28.0)
77 (26.2)
II
39 (25.5)
22 (19.0)
6 (24.0)
67 (22.8)
III
38 (24.8)
31 (26.7)
7 (28.0)
76 (25.9)
IV
26 (17.0)
2 (1.7)
1 (4.0)
29 (9.9)
20.2 (9.2)
18.6 (7.8)
19.4 (9.1)
ypTNM stage [n (%)] 0
Lymph nodes [mean (SD)]
18.9 (9.2)
Lymph nodes [median (range)]
17.5 (0–73)
Positive nodes [mean (SD)] Positive nodes [median (range)] Pathologic distal margin [cm; mean (SD)] CRT chemoradiotherapy, cTNM clinical TNM, SD standard deviation, CRM circumferential resection margin
\0.01
Pathologic distal margin [cm; median (range)] CRM [mm; mean (SD)] CRM [mm; median (range)]
distribution was 56.6 % OPEN, 31.9 % LAP, and 48.0 % CONVERTED in Stage III versus 37.9 % OPEN, 38.8 % LAP, and 48.0 % CONVERTED in Stage II (p \ 0.01). Aligned with the TNM stage, most OPEN and CONVERTED (73.2 % and 76 %, respectively) had neoadjuvant CRT; 54.3 % of LAP had neoadjuvant treatment (p \ 0.01). The ypTNM stage was also significantly higher for OPEN than LAP and CONVERTED (p \ 0.01). The largest percentage of OPEN was ypTNM III (25.5 %), while the majority of LAP were ypTNM I (38.8 %), and 28 % of CONVERTED were ypTNM Stage I and III each (Table 3). There were no significant differences in pathologic distal margins (p = 0.23), circumferential resection margin (CRM) (p = 0.23), or lymph node yield (p = 0.48). The mean distal margin was 4.8 cm OPEN, 4.1 cm CONVERTED, and 3.9 cm LAP. The mean CRM was 8.4 mm OPEN, 8.9 mm LAP, and 13.5 mm CONVERTED. The mean number of lymph nodes harvested was 18.6 CONVERTED, 18.9 OPEN, and 20.2 LAP. Table 3 details the tumor histopathologic results.
1.3 (3) 0 (0–19) 4.8 (3.4) 4 (0.3–19) 8.4 (9) 5 (0–35)
0.48
18 (5–68)
17 (6–36)
18 (0–73)
1.1 (3)
1.4 (3)
1.2 (3)
0 (0–18) 3.9 (2.3) 3.6 (0–13) 8.9 (11) 6 (1–50)
0 (0–12) 4.1 (3.3) 4 (0.3–15)
0.54
0 (0–19) 4.4 (3)
0.23
4 (0–19)
13.5 (19.5)
9.1 (11.1)
7.25 (1–70)
5 (0–70)
0.89
Table 4 demonstrates short-term patient outcomes. Postoperatively, 31 OPEN patients (20.3 %), two CONVERTED (8.0 %), and three LAP (2.6 %) patients required ICU care (p \ 0.01). There were a total of 100 patients with postoperative complications—67 OPEN (43.8 %), 25 LAP (21.5 %), and 8 CONVERTED (32.0 %). OPEN had a significantly higher rate of overall complications (p \ 0.01), and also had a higher rate of complications in every category, except anastomotic leak. The most common complications in the OPEN and LAP groups were postoperative ileus/small bowel obstruction (SBO) (14.4 and 6 %, respectively); the most common complication in CONVERTED was a superficial wound infection (20 %). The median LOS was significantly shorter in LAP (median 4 days, range 1–20) compared with CONVERTED (6 days, range 3–13) and OPEN (median 8 days, range 1–35) (p = 0.01). At discharge, the majority of patients in all three groups were discharged to home (77.6 % LAP, 60.0 % CONVERTED, 71.2 % OPEN; p = 0.34). 32 % of CONVERTED patients required home-care services.
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Table 4 Short-term outcomes
Open (n = 153) ICU stay required [n (%)]
31 (20.3)
LOS [mean (SD)]
9.2 (5.8)
LOS [median (range)]
LAP (n = 116) 3 (2.6) 4.4 (3.2)
Converted (n = 25) 2 (8) 6.8 (2.8) 6 (3–13)
Total (n = 294) 36 (12.2)
\0.01
7.1 (5.2)
\0.01
8 (3–35)
4 (1–20)
6 (1–35)
109 (71.2)
90 (77.6)
15 (60)
214 (72.8)
Home care
29 (19)
18 (15.5)
8 (32)
55 (18.7)
SNF/rehabilitation center
15 (9.8)
8 (6.9)
2 (8)
67 (43.8)
25 (21.5)
8 (32)
Ileus/SBOa
22 (14.4)
7 (6.0)
1 (4)
30 (10.2)
Superficial wound infection
11 (7.2)
2 (1.7)
4 (20)
17 (5.8)
Intra-abdominal collection
11 (7.2)
4 (3.4)
2 (8)
17 (5.8)
Discharge disposition [n (%)]
0.34
Home
Postoperative complications by category [n (%)]
Cardiovascular
SD standard deviation, SNF skilled nursing facility, SBO small bowel obstruction a
Ileus/SBO defined as lack of return of bowel function by postoperative day 5
b
Cardiovascular events include arrhythmia and myocardial infarction
b
25 (8.5) 100 (34)
8 (5.2)
1 (0.9)
2 (8)
11 (3.7)
Bleeding
7 (4.6)
2 (1.7)
1 (4)
10 (3.4)
Urinary tract infection
6 (3.9)
1 (0.9)
1 (4)
8 (2.7)
Pneumonia
2 (1.3)
4 (3.4)
0 (0)
6 (2)
Dehydration
5 (3.3)
1 (0.9)
0 (0)
6 (2)
Thromboembolic events
3 (2)
1 (0.9)
1 (4)
5 (1.7)
Anastomotic leak
1 (0.6)
3 (2.6)
0 (0)
4 (1.4)
Wound dehiscence/breakdown
2 (1.3)
1 (0.9)
1 (4)
4 (1.4)
Seroma
0 (0)
1 (0.9)
0 (0)
1 (0.3)
\0.01
Unplanned readmission (within 30 days) [n (%)]
33 (21.6)
14 (12.1)
4 (16)
51 (17.3)
0.12
Unplanned reoperation (within 30 days) [n (%)]
13 (8.5)
8 (6.9)
0 (0)
21 (7.1)
0.31
0 (0)
1 (0.9)
0 (0)
1 (0.3)
0.46
Mortality (within 30 days) [n (%)]
Unplanned readmissions were comparable (p = 0.12). The readmission rate was 21.6 % in OPEN, 16.0 % in CONVERTED, and 12.1 % in LAP. The most common indications for readmission were postoperative ileus/SBO and dehydration. The reoperation rate within 30 days of the rectal cancer resection was similar across groups (p = 0.31). Eight LAP (6.9 %) and 13 OPEN patients (8.5 %) required an unplanned re-operation; no patients in the CONVERTED group had an unplanned 30-day reoperation. There was one 30-day mortality in the LAP group (0.9 %). The cause of death was related to pre-existing respiratory failure, and the family made the patient ‘do not resuscitate’ postoperatively. Long-term outcomes were evaluated for each treatment group (Table 5). Over a median 3-year period (range 0–92 months), the DFS and OS rate for all patients was 90.8 % and 98.3 %, respectively. The local recurrence rate for all patients was 2.0 %. By approach, local recurrence was 2.0 % OPEN, 2.6 % LAP, and 0 % CONVERTED (p = 0.07). Metastatic recurrence was significantly higher in OPEN (10.4 %) than LAP (6.9 %) or CONVERTED (7.2 %) (p = 0.05). The 3-year DFS was significantly lower for OPEN (87.6 %) than LAP (93.1 %) and
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p value
CONVERTED (100 %) (p = 0.05). The OS was comparable by approach (0.43). OS for CONVERTED was 100 %, 99.1 % LAP, and 97.4 % for OPEN (Table 5). Kaplan–Meier analysis of DFS and OS are demonstrated in Figs. 1 and 2, respectively.
Discussion In this study, we aimed to evaluate the long-term outcomes of rectal cancer resection across surgical approaches on clinical and oncologic outcomes. Large-scale, randomized trials have demonstrated the non-inferiority of laparoscopy in curative rectal cancer resections after several years of follow-up [32, 33]. Short-term outcome benefits of shorter LOS, less blood loss, and lower postoperative complication rates, paired with oncologic equivalence, have been reported from single-center studies with LRR for rectal cancer [16, 20–31, 36–40]. However, oncologic benefits of LRR are now being reported. In evaluating the impact of LRR, Boutros et al. [41] found an advantage for LRR in lymph nodes yield (p = 0.02), with no significant differences in TME quality, CRM, or distal resection margin.
Surg Endosc (2014) 28:1940–1948
1945
Table 5 Long-term oncologic and survival data
Open (n = 153) Follow-up time [month; mean (SD)]
Converted (n = 25)
Total (n = 294)
p value 0.53
46.8 (42.8)
38.2 (36.7)
34.2 (33.6)
38.1 (36.5)
Follow-up time [month; median (range)]
45 (0–92)
33.5 (0–70)
32 (0–61)
34 (0–92)
Overall recurrence [n (%)]
19 (12.4)
8 (6.9)
0 (0)
27 (9.2)
\0.01
3 (2.0)
3 (2.6)
0 (0)
6 (2.0)
0.07
Metastatic recurrence [n (%)]
16 (10.4)
5 (4.3)
0 (0)
21 (7.2)
0.05
Recurrence-free survival [months; mean (SD)]
25 (16.3)
27 (16.1)
23.1 (13.4)
25.6 (16)
0.31
Recurrence-free survival [months; median (range)]
30 (0–92)
32 (0–70)
31 (3–61)
Local recurrence [n (%)]
Mortality [n (%)]
SD standard deviation
LAP (n = 116)
31.5 (0–92)
4 (2.6)
1 (0.9)
0 (0)
5 (1.7)
0.43
3-year DFS [n (%)]
134 (87.6)
108 (93.1)
25 (100)
267 (90.8)
0.05
3-year OS [n (%)]
149 (97.4)
115 (99.1)
25 (100)
289 (98.3)
0.43
Fig. 1 Kaplan–Meier survival curve for RFS. RFS recurrence-free survival
Fig. 2 Kaplan–Meier survival curve for OS. OS overall survival
This is aligned with our results in the present study. We found LAP and CONVERTED procedures had shorter operative times, less blood loss, and lower complications, with comparable lymph nodes harvested and resection margins compared with OPEN procedures. As expected, LAP had the shortest LOS. Even with the short LOS, LAP had the lowest readmission rates. Furthermore, the 3-year DFS for LAP and CONVERTED were superior to open resections, with comparable local recurrence and OS rates. Our secondary goal was to assess the impact of conversion on the operative outcome and survival of patients who underwent LRR. Few previous studies have evaluated outcomes of conversion. Furthermore, results have varied,
complicating the impact on the treatment of patients with colorectal cancer. Moloo et al. reviewed 377 LAP resections for colon cancer between 1991 and 2002. There were 46 converted cases (12.8 %) in the cohort. The authors found significantly lower 2-year survival (75.7 % vs. 87.2 %; p = 0.02) and a trend towards lower 5-year survival (61.9 % vs. 69.7 %; p = 0.077) in the CONVERTED group compared with the LAP group [42]. Chan et al. [43] evaluated outcomes of 470 patients who underwent LAP colectomy for colorectal malignancy over a 6-year period. In the 41 CONVERTED cases (8.7 %), there was increased blood loss (461.9 vs. 191.2 ml; p \ 0.001), postoperative complication rate (56.1 vs. 16.7 %; p = 0.001) and
123
1946
hospital LOS (10 vs. 6 days; p \ 0.001). The CONVERTED group also had significantly lower DFS (9.8 vs. 2.8 %; p \ 0.001) and cancer-free survival rates [43]. A case-matched study by Casillas et al. [44] of 51 LAP to 51 open colectomies for both benign and malignant colorectal disease found conversion did not result in inappropriately prolonged operative time, LOS, direct costs, or unexpected readmissions compared with similarly complex laparotomies. Rottoli et al. [45] evaluated conversion in colon and rectal cancer by comparing 31 CONVERTED cases with 62 LAP and 155 OPEN cases; they found a significantly lower 5-year DFS rate for CONVERTED (40.2 %) compared with the LAP (70.7 %; p = 0.01) and OPEN groups (63.3 %; p = 0.04); the 5-year cancer-specific survival rates were similar, leading the authors to conclude that conversion to open surgery does not affect oncologic outcomes. In the sole study evaluating the impact of conversion in patients undergoing LRR for rectal cancer, Rottoli et al. [46] found that conversion to open surgery did not affect postoperative outcome. The 26/173 (15 %) CONVERTED patients had no significant differences in 5-year DFS (71.1 % CONVERTED vs. 85.3 % LAP; p = 0.17). In our series, we found conversion had no negative effects. Intraoperatively, CONVERTED patients had similar numbers of lymph nodes harvested, and adequate CRMs and distal margins compared with LAP and OPEN. Short-term outcomes for CONVERTED were better than the OPEN patients. CONVERTED patients had shorter LOS, lower postoperative complication, readmission, and reoperative rates than the OPEN group. Furthermore, the long-term DFS and OS for CONVERTED was superior to both the LAP and OPEN groups. By attempting the LAP approach, the CONVERTED subset of patients was able to realize many of the beneficial results normally reserved for LAP patients without sacrificing oncological outcomes. We recognize the limitations in the current study. First, the study was a retrospective, non-randomized review, and subject to selection biases inherent in the retrospective design. As the study is not prospective, randomized, or case matched, the study groups were inherently different. We acknowledge that our conclusions may be affected by the variability and selection bias. However, our objective was to report the outcomes across groups; our goal was not to compare outcomes across the dissimilar groups. Furthermore, as a retrospective review, we are limited to the documentation in medical records for treatment decisions. While the converted sample size was small, our study demonstrates the safety and efficacy of the LAP converted to open approach for rectal cancer resection. Our surgeons performed more than 1,000 LAP colorectal resections before starting this study [47–50], therefore their experience and results may not be generalizable. Regardless, the results should encourage the LAP approach whenever
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Surg Endosc (2014) 28:1940–1948
possible, without fear of inferior outcomes when necessary to convert to an open procedure.
Conclusions Our results support the attempt to perform more rectal cancer resections through a LAP approach. If the procedure cannot be completed laparoscopically, oncologic outcomes are not compromised for the converted patients. Furthermore, converted patients are able to realize short-term outcomes similar to LAP patients, optimizing recovery, survival, and potentially healthcare utilization. Acknowledgments Dr. Keller: conception and design; acquisition of data; analysis and interpretation of data; drafting the article; critical revisions for important intellectual content; final approval of the version to be published. Drs. Zhorgami, Champagne and Stein, and Mr Swendseid: conception and design; acquisition of data; analysis and interpretation of data; drafting the article; final approval of the version to be published. Drs. Reynolds and Delaney: conception and design; analysis and interpretation of data; critical revisions for important intellectual content; final approval of the version to be published. Disclosures Drs. Keller, Khorgami, Champagne, Stein, Reynolds, Delaney and Mr. Swendseid have no conflicts of interest, no disclosures, and no financial interests to declare. Funding The authors received no funding or financial support for this project.
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