title: Postoperative morbidity and mortality after mesorectal excision with and without lateral lymph node dissection for clinical stage II or stage III lower rectal cancer (JCOG0212): results from a multicentre, randomised controlled, non-inferiority trial.
abstract: BACKGROUND
  Mesorectal excision is the international standard surgical procedure for lower rectal cancer. However, lateral pelvic lymph node metastasis occasionally occurs in patients with clinical stage II or stage III rectal cancer, and therefore mesorectal excision with lateral lymph node dissection is the standard procedure in Japan. We did a randomised controlled trial to confirm that the results of mesorectal excision alone are not inferior to those of mesorectal excision with lateral lymph node dissection.
  
  
  METHODS
  This study was undertaken at 33 major hospitals in Japan. Eligibility criteria included histologically proven rectal cancer of clinical stage II or stage III, with the main lesion located in the rectum with the lower margin below the peritoneal reflection, and no lateral pelvic lymph node enlargement. After surgeons had confirmed macroscopic R0 resection by mesorectal excision, patients were intraoperatively randomised to mesorectal excision alone or with lateral lymph node dissection. The groups were balanced by a minimisation method according to clinical N staging (N0 or N1, 2), sex, and institution. Allocated procedure was not masked to investigators or patients. This study is now in the follow-up stage. The primary endpoint is relapse-free survival and will be reported after the primary analysis planned for 2015. Here, we compare operation time, blood loss, postoperative morbidity (grade 3 or 4), and hospital mortality between the two groups. Analysis was by intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT00190541.
  
  
  RESULTS
  351 patients were randomly assigned to mesoretcal excision with lateral lymph node dissection and 350 to mesorectal excision alone, between June 11, 2003, and Aug 6, 2010. One patient in the mesorectal excision alone group underwent lateral lymph node dissection, but was analysed in their assigned group. Operation time was significantly longer in the mesorectal excision with lateral lymph node dissection group (median 360 min, IQR 296-429) than in the mesorectal excision alone group (254 min, 210-307, p<0·0001). Blood loss was significantly higher in the mesorectal excision with lateral lymph node dissection group (576 mL, IQR 352-900) than in the mesorectal excision alone group (337 mL, 170-566; p<0·0001). 26 (7%) patients in the mesorectal excision with lateral lymph node dissection group had lateral pelvic lymph node metastasis. Grade 3-4 postoperative complications occurred in 76 (22%) patients in the mesorectal excision with lateral lymph node dissection group and 56 (16%) patients in the mesorectal excision alone group. The most common grade 3 or 4 postoperative complication was anastomotic leakage (18 [6%] patients in the mesorectal excision with lateral lymph node dissection group vs 13 [5%] in the mesorectal excision alone group; p=0·46). One patient in the mesorectal excision with lateral lymph node dissection group died of anastomotic leakage followed by sepsis.
  
  
  CONCLUSIONS
  Mesorectal excision with lateral lymph node dissection required a significantly longer operation time and resulted in significantly greater blood loss than mesorectal excision alone. The primary analysis will help to show whether or not mesorectal excision alone is non-inferior to mesorectal excision with lateral lymph node dissection.
  
  
  BACKGROUND
  National Cancer Center, Ministry of Health, Labour and Welfare of Japan.
authors.affiliation: Colorectal Surgery Division, National Cancer Center Hospital, Tokyo, Japan. sfujita@ncc.go.jp
authors.forename: Shin
authors.initials: S
authors.lastname: Fujita
authors.forename: Takayuki
authors.initials: T
authors.lastname: Akasu
authors.forename: Junki
authors.initials: J
authors.lastname: Mizusawa
authors.forename: Norio
authors.initials: N
authors.lastname: Saito
authors.forename: Yusuke
authors.initials: Y
authors.lastname: Kinugasa
authors.forename: Yukihide
authors.initials: Y
authors.lastname: Kanemitsu
authors.forename: Masayuki
authors.initials: M
authors.lastname: Ohue
authors.forename: Shoichi
authors.initials: S
authors.lastname: Fujii
authors.forename: Manabu
authors.initials: M
authors.lastname: Shiozawa
authors.forename: Takashi
authors.initials: T
authors.lastname: Yamaguchi
authors.forename: Yoshihiro
authors.initials: Y
authors.lastname: Moriya
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D000273:Adipose Tissue / Q000601:surgery; D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical / Q000401:mortality / Q000503:physiopathology; D003082:Colectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007564:Japan; D053208:Kaplan-Meier Estimate; D008197:Lymph Node Excision / Q000379:methods*; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D011183:Postoperative Complications / Q000401:mortality / Q000473:pathology; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery*; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult