The results of the comparison between the laparoscopic versus the open approach for rectal cancer are still under debate. A recent systematic review and meta-analysis of randomized controlled trials (RCT) compared the pathologic outcomes of laparoscopic vs open mesorectal excision for rectal cancer. The primary outcomes were the rate of positive circumferential resection margin (CRM), considered positive at less than 1 mm, and the rate of complete mesorectal excision. The secondary outcomes were the distance to CRM, rate of positive distal rectal margin (DRM), distance to DRM (cm) and number of lymph nodes retrieved.
Fourteen studies between may 2003 and October 2015 were selected, including 4034 patients, with 2265 patients in the laparoscopic group, with a 13.1% conversion rate and 1769 patients in the open group.
Regarding the circumferential resection margin (CRM), 7.9% were positive on the laparoscopic group and 6.1% in the open group, favoring the open group although the results did not achieve statistical significance. The other primary endpoint, the rate of complete mesorectal excision, displayed 86.8% rate in the laparoscopic group versus 89.6% in the open group, favoring the open approach. None of the secondary outcomes achieved statistical significance.
In conclusion, the open approach still displays better pathological outcomes as regards the complete mesorectal excision rate, with the same trend in the rest of parameters, although none of them achieved statistical significance. The findings may question the results of the laparoscopic approach. However, the long-term results of the ongoing RCT are awaited to provide a final response to the question.
Debate with Dr.Lacy and Dr.Martinez
When asked about the applicability of the results of the article into the daily medical environment, Dr. Martinez was very careful analyzing the outcomes, as the result of the meta-analysis is directly related to the quality of the studies, which were not fairly homogeneous.
Dr. Lacy posed a question about the future: if minimally invasive surgery is still under debate after 25 years, will this approach be the future? Dr. Martinez firmly believes laparoscopic colonic resection has become the gold standard technique. However, he agrees that minimally invasive surgery is technically challenging for rectal cancer, and the efforts should be focused on the new approaches to overcome the technical difficulties of this approach in order to become the gold standard.
Do you think we need more technology than technicians? asked Dr. Lacy. Dr. Martinez agreed that technological improvements could be made in the minimally invasive approach field to reduce the drawbacks found by the surgeons nowadays, of which the robotic transanal platform is a perfect example. Regarding the ‘technicians’, Dr. Martinez believes that AIS Channel is a fantastic worldwide learning platform to improve the skills of those ‘technicians’. Both young and experienced surgeons can benefit from this experience, available for free online.
At the end of the interview, a proposal was launched for the 3 more important randomized trials about rectal cancers – ASCOG, ALaCaRT, and COLOR II-, for a conjoined trial to achieve better statistical evidence about the best technique for rectal cancer and give the surgical community a definitive answer.