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Ann Coloproctol > Volume 38(4); 2022 > Article
Oh: Advances in surgery for locally advanced rectal cancer
Rectal cancer, especially locally advanced rectal cancer (LARC), presents surgical technique challenges due to anatomical constraints. In the past, open surgery was considered the standard surgical treatment for rectal cancer, but there has been a more recent trend toward laparoscopic surgery. Laparoscopic surgery has favorable short-term outcomes such as less pain, rapid recovery, reduced blood loss, and fewer postoperative complications compared to open surgery [1]. Recently, results on long-term outcomes in terms of oncologic safety of laparoscopic surgery for rectal cancer have been published.
Nasir et al. [2] studied the feasibility of laparoscopic surgery for LARC by comparing surgical outcomes between LARC and non-LARC groups using propensity score matched analysis. They showed comparable short-term outcomes such as open conversion, reoperation, anastomotic leak, and 30-day mortality rate between LARC and non-LARC groups. Also, pathologic outcomes such as R0 resection and harvested lymph nodes were similar between the two groups. Several randomized controlled trials and observational studies have explored the outcomes of laparoscopic surgery for LARC. The COREAN (Comparison of Open versus laparoscopic surgery for mid and low REctal cancer After Neoadjuvant chemoradiotherapy) randomized controlled trial demonstrated the oncologic feasibility of laparoscopic surgery in LARC patients with preoperative chemoradiotherapy [3]. Recent, largecohort studies of LARC patients showed the feasibility of laparoscopic surgery based on short-term and long-term results [1, 4]. In contrast, the ACOSOG Z6051 randomized controlled trial comparing laparoscopic surgery and open surgery in LARC failed to demonstrate the non-inferiority of laparoscopic surgery for pathologic outcomes such as completeness of total mesorectal excision and negative resection margins [5]. Follow-up oncologic outcomes of the ACOSOG Z6051 trial did not find significant differences between laparoscopic surgery and open surgery in 2-year disease-free survival and recurrence [6]. Recently, results on the surgical feasibility and oncological safety of laparoscopic surgery for lateral pelvic lymph node dissection and pelvic exenteration beyond total mesorectal excision in LARC have also been reported [7, 8]. Advanced techniques such as robotic surgery and transanal minimally invasive surgery are being introduced, and studies on their feasibility in LARC are being conducted [9].
Minimally invasive surgery including laparoscopic surgery has become widespread, with better short-term outcomes and favorable oncologic safety reported in many studies. Although there are still technical hurdles and further research on long-term outcomes is needed, the application of minimally invasive surgery in LARC is expected to gradually expand. Therefore, it is necessary to define appropriate indications and standardize surgical techniques to establish the emerging roles of minimally invasive surgery in LARC.

CONFLICT OF INTEREST

No potential conflicts of interest relevant to this article were reported.

Notes

FUNDING

None.

REFERENCES

1. Nishizaki D, Hida K, Sumii A, Okamura R, Sakai Y, Konishi T, et al. Laparoscopic versus open surgery for locally advanced rectal cancer: five-year survival outcomes in a large, multicenter, propensity score-matched cohort study. Dis Colon Rectum 2022;65:1005–14.
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2. Nasir IU, Shah MF, Panteleimonitis S, Figueiredo N, Parvaiz A. Spotlight on laparoscopy in the surgical resection of locally advanced rectal cancer: multicenter propensity score match study. Ann Coloproctol Ann Coloproctol 2022;38:307–13.
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3. Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, et al. Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 2014;15:767–74.
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4. Hida K, Okamura R, Sakai Y, Konishi T, Akagi T, Yamaguchi T, et al. Open versus laparoscopic surgery for advanced low rectal cancer: a large, multicenter, propensity score matched cohort study in Japan. Ann Surg 2018;268:318–24.
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5. Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, et al. Effect of laparoscopic-assisted resection vs open resection of stage ii or iii rectal cancer on pathologic outcomes: the ACOSOG Z6051 randomized clinical trial. JAMA 2015;314:1346–55.
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6. Fleshman J, Branda ME, Sargent DJ, Boller AM, George VV, Abbas MA, et al. Disease-free survival and local recurrence for laparoscopic resection compared with open resection of stage ii to iii rectal cancer: follow-up results of the ACOSOG Z6051 randomized controlled trial. Ann Surg 2019;269:589–95.
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7. Tang J, Zhou S, Zhao W, Lou Z, Liang J, Feng B, et al. Short- and long-term outcomes of laparoscopic versus open selective lateral pelvic lymph node dissection for locally advanced middle-low rectal cancer: results of a multicentre lateral node study in China. Colorectal Dis 2022;Jun 17 [Epub]. https://doi.org/10.1111/codi.16223.
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8. Yamanashi T, Miura H, Tanaka T, Watanabe A, Goto T, Yokoi K, et al. Short- and long-term outcomes of robotic-assisted laparoscopic surgery for rectal cancer: a single-center retrospective cohort study. Asian J Endosc Surg 2022;Jun 16 [Epub]. https://doi.org/10.1111/ases.13095.
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9. Stitzenberg KB, Barnes E. Advances in rectal cancer surgery. Clin Colorectal Cancer 2022;21:55–62.
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