Lymph Node Clearance after Total Mesorectal Excision for Rectal Cancer: Laparoscopic versus Open Approach

Abstract

Background: Laparoscopic resection of the rectum is still under scrutiny for its adequacy of oncological clearance. Aim: To assess lymph node yield after laparoscopic total mesorectal excision (TME) for rectal cancer as compared to the open approach. Methods: 74 patients with middle and low rectal cancer were prospectively randomized in two groups. Group A included 39 patients who had an open TME (35 with low anterior resection of the rectum (LARR) and 4 with abdominoperineal resection of the rectum (APR)). In group B, there were 34 patients who had a laparoscopic TME (27 with LARR and 7 with APR). 10 of the LARR patients in group A and 14 of the LARR patients in group B had a defunctioning ileostomy. All operations were performed by one surgeon or under his supervision. Results: Gender and age distribution were similar for both groups (group A: 23 males; mean age 69 (41–85); group B: 20 males; mean age 72 (31–84)). The mean distance of the tumor from the dentate line was 7.6 cm (1–12 cm) for group A and 6.1 cm (1–12 cm) for group B. Anastomosis was formed at a mean distance of 5.5 cm (1.5–8.5 cm) from the dentate line in group A and 3.5 cm (1–4.5 cm) in group B. At histology, in group A there were 5 T4 tumors, 9 T3, 10 T3+ (<1 mm distance from the circumferential resection margin), 13 T2 and 2 T1. In group B, there were 3 T4 tumors, 14 T3, 8 T3+, 7 T2 and 2 T1. Differences between groups were not significant.The mean number of lymph nodes retrieved in group A specimens was 19.2 (5–45) and in group B 19.2 (8–41) (p = 0.2). In group A, 3.9 (1–9) regional, 13.9 (3–34) intermediate and 1.5 (1–3) apical lymph nodes were retrieved. The respective values in group B were 3.7 (3–7), 14.4 (4–33) and 1.3 (1–3). Differences between groups were not significant. Also, the incidence of lymph node involvement by the tumor was not significantly different between groups (group A: 23; group B: 19). Conclusions: Laparoscopic resection of the rectum can achieve similar lymph node clearance to the open approach. Also, distribution of the lymph nodes along the resected specimens is similar between the two approaches.

Laparoscopic versus open surgery for the treatment of colorectal cancer: a literature review and recommendations from the Comité de l’évolution des pratiques en oncologie

“…For rectal cancer, 9 phase III randomized clinical trials 11,20,21,[33][34][35][36][37][38][39][40][41][42] and 7 meta-analyses were selected. 28,29,[43][44][45][46][47] No meeting abstracts satisfied the inclusion criteria.…”

A comparison of resection margins and lymph node clearance in laparoscopic vs open anterior and abdomino-perineal resections for carcinoma of rectum

“…Pechlivanides G, et al has shown in their study that laparoscopic resection of the rectum can achieve similar lymph node clearance to the open approach (8).…”

“…In most of the studies it is proven that the resection is comparable with open surgery achieving acceptable oncological requirements (7,8) whilst providing benefits of reduced morbidity (1-7). The criteria to assess oncologically acceptable resection, is the number of lymph nodes harvested and tumour free distal resection margin.…”

“…The postoperative morbidity is reduced allowing early mobilization, early feeding and discharge (1,7). Oncologically acceptable resection margins and satisfactory lymph node clearance have also been reported (7,8). This study was designed to evaluate resection margins and lymph node clearance of laparoscopic anterior resections and abdominoperineal resections performed in our unit.…”

Ultrasonically activated scalpel versus monopolar electrocautery shovel in laparoscopic total mesorectal excision for rectal cancer

“…Since the successful introduction of laparoscopic colectomy by Jacobs et al [1] , laparoscopic surgery, especially laparoscopic rectal surgery has been developed considerably [2][3][4][5][6] . Laparoscopic total mesorectal excision (TME) for rectal cancer whether hand-assisted, laparoscopy-assisted or robotic-assisted laparoscopic technique can offer advantages over open TME, such as greater comfort and an earlier return to daily activities while preserving the oncologic radicality of the procedure [7][8][9][10] .…”