Long term Results of Laparoscopic Surgery Following Long Course Chemoradiotherapy for Locally Advanced Rectal Cancer

Omer Jalil, Dr, Thanjakumar Arulampalam, Dr, Bruce Sizer, Dr, Darren Boone, Dr, Roger Motson, Professor. ICENI Centre

Objectives: The treatment of locally advanced rectal cancer (LARC) has undergone significant change over the last 20 years. Although surgical resection remains the mainstay of treatment, neoadjuvant radiotherapy (CRT) may render LARC operable and enable sphincter preservation. In parallel, laparoscopic rectal cancer surgery (LRS) has developed so that it is feasible to utilize this technique with its proven short term benefits for pelvic dissection. This study assesses the outcome of patients who have undergone laparoscopic surgery following CRT for LARC.

Methods: Between January 2004 and June 2012 consecutive patients undergoing LRS following CRT for LARC at our institution were entered into a prospective database. All surgery was performed in a specialist laparoscopic surgical unit with surgery carried out by trained attending surgeons. Patients underwent standard CRT if poor risk features were identified on MRI and the decision to treat was ratified by the colorectal multidisciplinary team (MDT). All MRI protocols were standardized. CRT consisted of oral Tegafur–uracil (UFT) and two-phase, conformal, external beam radiotherapy of 45–50.4 Gy in 25–28 fractions over 5 weeks. Clinical assessment was carried out twice weekly from 4 weeks post completion of CRT and MRI was repeated at 6-7 weeks and 10 weeks with the median time to surgery being 12 weeks. Patients underwent standard technique laparoscopic resection of the rectum.  Data was collected on demographics, treatment regime, ASA grade, BMI, operative data, length of stay, complications defined by Dindo, mortality and overall and disease free survival.

Results: 112 patients underwent CRT of whom 103 underwent surgical resection. Median follow up was 42 months. Laparoscopic TME was carried in 89 (86.4%) patients with 11 (12.4%) conversions to open surgery. 11 patients underwent open surgery and 3 patients underwent local resection. 30 day post operative mortality occurred in 3 (2.9%) patients. Major complications occurred in 33% patients and minor complications in 13% patients. Anastomotic leaks occurred in 14/59 (24%) patients of whom 7 patients required surgical intervention. R0 resection was achieved in 92% of patients and complete pathological response was seen in 21 (19%). The local recurrence rate was 11%.  The overall, disease free and relapse free survival were 57%, 49% and 67%.

Discussion: This study demonstrates the feasibility and safety of the laparoscopic approach for surgical resection of rectal cancer following CRT in a specialist unit with structured training. Delaying surgery following CRT does not seem to have an adverse oncological outcome.