Laparoscopic Total Mesorectal Excision for Middle and Low Rectal Adenocarcinoma with or Without Sphincter Preservation: A Prospective Study

Background: Reports on laparoscopic total mesorectum excision (TME) for cancer are often retrospective and contain heterogeneous patients who had several types of resection (i.e., anterior resection, low anterior resection, all or partially laparoscopic). The goal of this study was to assess the feasibility, safety, and effectiveness with respect to perioperative and oncological outcomes in two prospective series of all laparoscopic total mesorectal excision for rectum adenocarcinoma, one with, the other without anal sphincter preservation.

Patients and Methods:
Between November 2000 and July 2008, 104 unselected patients had laparoscopic TME for rectal adenocarcinoma. Patients with locally advanced rectal carcinoma (uN+/uT4) occasionally underwent preoperative radiation or chemoradiation. Postoperatively, adjuvant treatment was administered to patients with UICC stage II/III disease. All patients were followed up prospectively. Survival probability analysis was performed using the Kaplan-Meier method.

Results : There were 51 women and 52 men of a mean age of 58 years (range, 21-86). Conversion to laparotomy was necessary in 6 cases (5.7 %). Average operative time was 210 min (range, 120-550). One patient required blood transfusion (0.9 %). Intra-operative complications occurred in 5 patients (4.8 %) (2 left ureteral injuries, 2 splenic injuries, 1 vaginal tear, and 1 deferent duct section). There was one postoperative death (0.9 %). The most common postoperative complication was deep abscess in 9 patients (8.6 %) associated with anastomotic leakage in 7 patients (6.7 %) and with wound infection in 6 patients (5.7 %). Other complications included pneumonia (5 patients), urinary infection (5 patients), intestinal obstruction (2 patients), and miscellaneous (4 patients).
There were 71 sphincter-preserving procedures and 23 abdominoperineal resections. All but one resection margins were uninvolved. Among the former, 22 were performed for very low tumors, located within 4 cm of the dentate line. The average length of distal margins was 5.5 cm (range, 0-11). The mean number of harvested lymph nodes removed was 15 (range, 0-45) and mean length of the resected specimen was 28 cm (range, 20-101). Although resection was intended to be curative in all 84 patients, the distal margin (dentate line) was considered to be positive in one patient (0.9 %).
All patients were followed-up for an average of 62 months (range, 12-112). The most common late complications were incisional hernia in 8 patients (7.7 %) and intestinal obstruction in 4 patients (3.8 %). No port-site metastases occurred. Recurrence developed in 49 patients (47.1 %) including distant or peritoneal metastases (32 patients) and loco-regional recurrence (11 patients). Four patients had both local and distant metastases. Overall local recurrence rate was 10.6 %.

Conclusions: Laparoscopic total mesorectal excision for rectal cancer is a feasible and safe procedure. Oncological appropriateness is respected. However, large scale randomized studies are still needed in order to more accurately evaluate its efficacy and efficiency.

Session: Poster

Program Number: P131

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