Laparoscopic Surgery After Preoperative Chemoradiation Therapy Is a Safe and Feasible Option for T3 and T4 Rectal Cancer

Tomohiko Miyatani, MD, Mitsuo Shimada, phD, Nobuhiro Kurita, phD, Takashi Iwata, phD, Masanori Nishioka, phD, Shinya Morimoto, phD, Kouzou Yoshikawa, phD, Jun Higashijima, phD, Hideya Kashihara, MD, Chie Mikami, MD. The University of Tokushima

Introduction: Preoperative chemoradiation therapy (CRT) for low rectal cancer reduces local recurrence and increases anal sphincter preservation rate. On the other hand, Laparoscopic surgery for advanced colon cancer has been widely accepted. A few studies have shown that there are advantages of laparoscopic over open TME surgery for rectal cancer. However, the feasibility of laparoscopic surgery for T3 and T4 rectal cancer has not been clearly defined specifically in cases following preoperative CRT.
Purpose: The aim of this study was to investigate the feasibility of laparoscopic surgery after preoperative CRT for T3 and T4 rectal cancer.
Methods: May 2003 and June 2009, 57 patients (T3: n=50, T4: n=7) who underwent preoperative CRT for rectal cancer were identified. Forty-three patients with laparoscopic surgery (Lap group) were compared with 14 patients with open surgery (Open group). Peri-operative data including post-operative morbility were assessed between the two groups.
Results: Except for age there was no difference between the two groups based on gender, BMI, tumor size, tumor distance from the anal verge, T stage, N stage and procedure. All patients underwent complete laparoscopic operations and none were converted to laparotomy. Operating time was longer in the Open group (331 versus 375 min, p<0.01). Blood loss during the operation decreased in the Lap group (160 versus 316 min, p<0.01). Lymph node harvest (10 versus 11) and morbility rate (21 versus 29) were similar in both groups. The distal tumor margin was negative in all patients. No patients had peri-operative mortality associated with surgery after CRT. Postoperative hospital stay was shorter in the Lap group (28 versus 38 days, p<0.01).
Laparoscopic prosedures: Our video will show knack and pitfalls of laparoscopic surgery after preoperative CRT. First point is the tension between rectum and sacrum by operator’s left hand for total mesorectal excision. Secondary point is the complete preservation of neurovascular bundle to avoid bleeding. Third point is the careful attention to edema and adhesion by CRT for keeping accurate dissected layer.
Conclusions: Laparoscopic surgery after preoperative CRT is a feasible and a safe option for T3 and T4 rectal cancer compared to conventional open surgery.