Are oncological long-term outcomes equal after laproscopic completed and converted laparoscopic converted rectal resection for cancer?

BACKGROUND: The aim of this study was to compare long-term survival after laproscopic completed and laparoscopic converted rectal resection for cancer. METHODS: All consecutive patients who underwent curative laparoscopic rectal surgery for cancer at our institution between January 2001 and December 2016 were included in a single-center retrospective study. Patients were divided into two groups: the converted (CONV) group and the totally laparoscopic (LAP) group. The primary outcomes were long-term oncologic outcomes including overall survival (OS) and disease-free survival (DFS), as well as local and distant recurrence (LR, DR). The secondary outcomes included postoperative mortality and morbidity as defined as death or any complication occurring within 90 days postoperatively. RESULTS: Of 214 consecutive patients included, 57 were converted to open surgery (CONV group), leading to a 26.6% conversion rate. Mean length of follow-up was 68 ± 42 months in the LAP group and 70 ± 41 months in the CONV group. Five-year OS was significantly shorter in the CONV group compared to the LAP group (p = 0.0016). On multivariate analysis, rectal tumor location (middle and low) and conversion to open surgery were predictors of both OS and DFS. CONCLUSIONS: This study suggests that conversion to open surgery after laparoscopic rectal resection appears to significantly reduce OS without having a significant impact on DFS and recurrence rates.

Does conversion during laparoscopic rectal oncological surgery increases postoperative complications and anastomotic leakage rates? A meta-analysis.

OBJECTIVE: To evaluate, regarding previous published studies, postoperative outcomes between patients undergoing rectal cancer resection performed by totally laparoscopic approach (LAP) compared to those who underwent peroperative conversion (CONV). METHODS: Studies comparing LAP versus CONV for rectal cancer published until December 2017 were selected and submitted to a systematic review and meta-analysis. Articles were searched in Medline and Cochrane Trials Register Database. Meta-analysis was performed with Review Manager 5.0. RESULTS: Twelve prospective and retrospective studies with a total of 4503 patients who underwent fully laparoscopic approach for rectal cancer and a total of 612 patients who underwent conversion were included. Meta-analysis did not show any significant difference on overall mortality between both approaches (OR=0.47, 95%CI=0.18-1.22, P=0.12). However, Meta-analysis showed that anastomotic leakage rate, wound abscess rate and postoperative morbidity rate were significantly decreased with totally laparoscopic approach (OR=0.37, 95%CI =0.24-0.58, P<0.0001; OR=0.29, 95%CI=0.19-0.45, P<0.00001; OR=0.56, 95%CI=0.46-0.67, P<0.00001 respectively). CONCLUSION: This meta-analysis suggests that conversion increases anastomotic leakage, overall morbidity and wound abscess rates without increasing mortality rate for patients who underwent rectal resection for cancer.

Has adherence to treatment guidelines for mid/low rectal cancer affected the management of patients? A monocentric study of 604 consecutive patients.

INTRODUCTION: In 2006 under the supervision of the French health authorities (HAS), recommendations for clinical practice (RCP) in the management of rectal cancers were first published. The primary objective of this study was to assess the impact of these guidelines on multidisciplinary management in terms of therapeutic strategies based on disease staging and quality indicators for surgical excision. Secondarily, we assessed the impact of the RCPs on postoperative and oncological outcomes. METHODS: All consecutive patients having undergone curative surgical excision for middle and low (subperitoneal) rectal cancer from 1995 to 2017 in the university hospital of Caen were included in accordance with the relevant French guidelines. They were divided into two groups: before (Gr1) and after (Gr2) 2006. For each group, a chart review was conducted on demographic variables, preoperative rectal tumor features, disease severity variables and quality of surgery variables. Postoperative and oncological outcomes were likewise assessed and compared between the two groups. RESULTS: Six hundred and four patients were included (Gr1, n=266; Gr2, n=338). Compliance with French guidelines significantly improved (i) use of magnetic resonance imaging (P<0.0001) and CT-scan (P<0.0001)]; (ii) organization of multidisciplinary tumor boards (P<0.0001) leading to suitable neo-adjuvant treatment plan classification (P<0.0001). Consequently, compliance improved widespread total mesorectal excision (P<0.0001), sphincter-sparing surgery (P=0,0005), and completeness of curative resection in the specimen (P<0.0001). Although postoperative 90-day mortality was similar, overall postoperative morbidity significantly increased in Gr2 (P<0.0001). Overall (P=0.0005) and disease-free survival (P=0.0016) of patients in Gr2 were significantly prolonged and correlated with a significant reduction in local and distant recurrences. CONCLUSION: Compliance with the relevant French guidelines improved the quality of multidisciplinary management of patients undergoing curative surgery for subperitoneal rectal cancer. However, further progress is still needed to render accession to the recommendations more comprehensive.