Laparoscopic Versus Open Total Mesorectal Excision for Rectal Cancer

Background: Because definitive long-term results are not yet available, the oncological safety of laparoscopic surgery for treatment of rectal cancer remains controversial. However, laparoscopic total mesorectal excision (LTME) for rectal cancer has been proposed to have several short-term advantages in comparison with open total mesorectal excision (OTME).

Objectives: To evaluate whether there are any relevant differences in safety and efficacy after elective LTME, for the resection of rectal cancer, compared with OTME.

Search Strategy: We searched MEDLINE, EMBASE, Cochrane Central register of Controlled Trials (CENTRAL), and Current Contents from 1990 to December 2005. Searches were conducted using MESH terms: "laparoscopy", "minimally invasive","colorectal neoplasms". Furthermore we used the following text words: laparoscopy, surgical procedures, minimally invasive, rectal cancer, rectal carcinoma, rectal adenocarcinoma, rectal neoplasms, anterior resection, abdominoperineal resection, total mesorectal excision.

Selection Criteria: We included randomised controlled trials (RCTs), controlled clinical trials and case series comparing LTME versus OTME. Furthermore case reports which describe LTME were also included.

Data Collection And Analysis: Two reviewers independently assessed study quality. All relevant studies have been categorized according to the evidence they provide according to the guidelines for "Levels of Evidence and Grades of Recommendation" supplied by the "Oxford Centre for Evidence-based Medicine". Disagreements were solved by discussion.

Main Results: 80 studies were identified of which 48 studies, representing 4224 patients, met the inclusion criteria. Methodological quality of most of the included studies was poor; three studies were grade 1b (individual randomised trial), 12 grade 2b (individual cohort study), 5 grade 3b (individual case-control study) and 28 grade 4 (case-series). As only one RCT described primary outcome, 3-year and 5-year disease-free survival rates, no meta-analyses could be performed. No significant differences in terms of disease-free survival rate, local recurrence rate, mortality, morbidity, anastomotic leakage, resection margins, or recovered lymph nodes were found. There is evidence that LTME results in less blood loss, quicker return to normal diet, less pain, less narcotic use and less immune response. It seems likely that LTME is associated with longer operative time and higher costs. No results of quality of life were reported.

Authors' Conclusions: Based on evidence mainly from non-randomized studies, LTME appears to have clinically measurable short-term advantages in patients with primary resectable rectal cancer. The long-term impact on oncological endpoints awaits the findings from large on-going randomized trials.