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Meta-Analysis
. 2014 Apr 15;2014(4):CD005200.
doi: 10.1002/14651858.CD005200.pub3.

Laparoscopic versus open total mesorectal excision for rectal cancer

Sandra Vennix  1 , Loeki Pelzers, Nicole Bouvy, Geerard L Beets, Jean-Pierre Pierie, Theo Wiggers, Stephanie Breukink
Affiliations
Meta-Analysis

Laparoscopic versus open total mesorectal excision for rectal cancer

Sandra Vennix et al. Cochrane Database Syst Rev. .

Abstract

Background: Colorectal cancer including rectal cancer is the third most common cause of cancer deaths in the western world. For colon carcinoma, laparoscopic surgery is proven to result in faster postoperative recovery, fewer complications and better cosmetic results with equal oncologic results. These short-term benefits are expected to be similar for laparoscopic rectal cancer surgery. However, the oncological safety of laparoscopic surgery for rectal cancer remained controversial due to the lack of definitive long-term results. Thus, the expected short-term benefits can only be of interest when oncological results are at least equal.

Objectives: To evaluate the differences in short- and long-term results after elective laparoscopic total mesorectal excision (LTME) for the resection of rectal cancer compared with open total mesorectal excision (OTME).

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2013, Issue 2), MEDLINE (January 1990 to February 2013), EMBASE (January 1990 to February 2013), ClinicalTrials.gov (February 2013) and Current Controlled Trials (February 2013). We handsearched the reference lists of the included articles for missed studies.

Selection criteria: Only randomised controlled trials (RCTs) comparing LTME and OTME, reporting at least one of our outcome measures, was considered for inclusion.

Data collection and analysis: Two authors independently assessed study quality according to the CONSORT statement, and resolved disagreements by discussion. We rated the quality of the evidence using GRADE methods.

Main results: We identified 45 references out of 953 search results, of which 14 studies met the inclusion criteria involving 3528 rectal cancer patients. We did not consider the risk of bias of the included studies to have impacted on the quality of the evidence. Data were analysed according to an intention-to-treat principle with a mean conversion rate of 14.5% (range 0% to 35%) in the laparoscopic group.There was moderate quality evidence that laparoscopic and open TME had similar effects on five-year disease-free survival (OR 1.02; 95% CI 0.76 to1.38, 4 studies, N = 943). The estimated effects of laparoscopic and open TME on local recurrence and overall survival were similar, although confidence intervals were wide, both with moderate quality evidence (local recurrence: OR 0.89; 95% CI 0.57 to1.39 and overall survival rate: OR 1.15; 95% CI 0.87 to1.52). There was moderate to high quality evidence that the number of resected lymph nodes and surgical margins were similar between the two groups.For the short-term results, length of hospital stay was reduced by two days (95% CI -3.22 to -1.10), moderate quality evidence), and the time to first defecation was shorter in the LTME group (-0.86 days; 95% CI -1.17 to -0.54). There was moderate quality evidence that 30 days morbidity were similar in both groups (OR 0.94; 95% CI 0.8 to 1.1). There were fewer wound infections (OR 0.68; 95% CI 0.50 to 0.93) and fewer bleeding complications (OR 0.30; 95% CI 0.10 to 0.93) in the LTME group.There was no clear evidence of any differences in quality of life after LTME or OTME regarding functional recovery, bladder and sexual function. The costs were higher for LTME with differences up to GBP 2000 for direct costs only.

Authors' conclusions: We have found moderate quality evidence that laparoscopic total mesorectal excision (TME) has similar effects to open TME on long term survival outcomes for the treatment of rectal cancer. The quality of the evidence was downgraded due to imprecision and further research could impact on our confidence in this result. There is moderate quality evidence that it leads to better short-term post-surgical outcomes in terms of recovery for non-locally advanced rectal cancer. Currently results are consistent in showing a similar disease-free survival and overall survival, and for recurrences after at least three years and up to 10 years, although due to imprecision we cannot rule out superiority of either approach. We await long-term data from a number of ongoing and recently completed studies to contribute to a more robust analysis of long-term disease free, overall survival and local recurrence.

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Conflict of interest statement

No funding/conflicts of interest declared by all authors.

Figures

1
1
Study selection flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Forest plot of comparison: 2 Survival and recurrences, outcome: 2.1 Disease free survival.
4
4
Forest plot of comparison: 4 Short term morbidity and mortality, outcome: 4.1 30d morbidity (total).
5
5
Forest plot of comparison: 5 Post op recovery, outcome: 5.3 Hospital stay.
1.1
1.1. Analysis
Comparison 1 Survival and recurrences, Outcome 1 Disease‐free survival.
1.2
1.2. Analysis
Comparison 1 Survival and recurrences, Outcome 2 Overall survival.
1.3
1.3. Analysis
Comparison 1 Survival and recurrences, Outcome 3 Local recurrences.
1.4
1.4. Analysis
Comparison 1 Survival and recurrences, Outcome 4 Distant recurrences.
1.5
1.5. Analysis
Comparison 1 Survival and recurrences, Outcome 5 Wound/port site metastases.
2.1
2.1. Analysis
Comparison 2 Surgical data, Outcome 1 Lymph nodes retrieved.
2.2
2.2. Analysis
Comparison 2 Surgical data, Outcome 2 CRM positivity.
2.3
2.3. Analysis
Comparison 2 Surgical data, Outcome 3 Duration of surgery.
2.4
2.4. Analysis
Comparison 2 Surgical data, Outcome 4 Incision length.
2.6
2.6. Analysis
Comparison 2 Surgical data, Outcome 6 Blood loss.
2.7
2.7. Analysis
Comparison 2 Surgical data, Outcome 7 Transfusion requirement.
2.8
2.8. Analysis
Comparison 2 Surgical data, Outcome 8 Intraoperative morbidity.
3.1
3.1. Analysis
Comparison 3 Short‐term morbidity and mortality, Outcome 1 30‐day morbidity (total).
3.2
3.2. Analysis
Comparison 3 Short‐term morbidity and mortality, Outcome 2 Wound infection.
3.3
3.3. Analysis
Comparison 3 Short‐term morbidity and mortality, Outcome 3 Bleeding.
3.4
3.4. Analysis
Comparison 3 Short‐term morbidity and mortality, Outcome 4 Urinary complications.
3.5
3.5. Analysis
Comparison 3 Short‐term morbidity and mortality, Outcome 5 Pneumonia.
3.6
3.6. Analysis
Comparison 3 Short‐term morbidity and mortality, Outcome 6 Anastomotic leakage.
3.7
3.7. Analysis
Comparison 3 Short‐term morbidity and mortality, Outcome 7 Need for reoperation.
3.8
3.8. Analysis
Comparison 3 Short‐term morbidity and mortality, Outcome 8 30‐day mortality.
4.1
4.1. Analysis
Comparison 4 Postoperative recovery, Outcome 1 Analgesia use (number of doses).
4.2
4.2. Analysis
Comparison 4 Postoperative recovery, Outcome 2 Day 1 pain score (VAS).
4.3
4.3. Analysis
Comparison 4 Postoperative recovery, Outcome 3 Hospital stay (days).
4.4
4.4. Analysis
Comparison 4 Postoperative recovery, Outcome 4 Time to normal diet (days).
4.5
4.5. Analysis
Comparison 4 Postoperative recovery, Outcome 5 Time to first defecation (days).
5.1
5.1. Analysis
Comparison 5 Long term morbidity, Outcome 1 Incisional hernia.
5.2
5.2. Analysis
Comparison 5 Long term morbidity, Outcome 2 Intestinal obstruction.
See this image and copyright information in PMC

Update of

References

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References to ongoing studies

ACTRN12609000663257 {published data only}
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