title: Laparoscopic versus open total mesorectal excision for rectal cancer.
abstract: BACKGROUND
  Colorectal cancer including rectal cancer is the third most common cause of cancer deaths in the western world. For colon carcinoma, laparoscopic surgery is proven to result in faster postoperative recovery, fewer complications and better cosmetic results with equal oncologic results. These short-term benefits are expected to be similar for laparoscopic rectal cancer surgery. However, the oncological safety of laparoscopic surgery for rectal cancer remained controversial due to the lack of definitive long-term results. Thus, the expected short-term benefits can only be of interest when oncological results are at least equal.
  
  
  OBJECTIVE
  To evaluate the differences in short- and long-term results after elective laparoscopic total mesorectal excision (LTME) for the resection of rectal cancer compared with open total mesorectal excision (OTME).
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2013, Issue 2), MEDLINE (January 1990 to February 2013), EMBASE (January 1990 to February 2013), ClinicalTrials.gov (February 2013) and Current Controlled Trials (February 2013). We handsearched the reference lists of the included articles for missed studies.
  
  
  METHODS
  Only randomised controlled trials (RCTs) comparing LTME and OTME, reporting at least one of our outcome measures, was considered for inclusion.
  
  
  METHODS
  Two authors independently assessed study quality according to the CONSORT statement, and resolved disagreements by discussion. We rated the quality of the evidence using GRADE methods.
  
  
  RESULTS
  We identified 45 references out of 953 search results, of which 14 studies met the inclusion criteria involving 3528 rectal cancer patients. We did not consider the risk of bias of the included studies to have impacted on the quality of the evidence. Data were analysed according to an intention-to-treat principle with a mean conversion rate of 14.5% (range 0% to 35%) in the laparoscopic group.There was moderate quality evidence that laparoscopic and open TME had similar effects on five-year disease-free survival (OR 1.02; 95% CI 0.76 to1.38, 4 studies, N = 943). The estimated effects of laparoscopic and open TME on local recurrence and overall survival were similar, although confidence intervals were wide, both with moderate quality evidence (local recurrence: OR 0.89; 95% CI 0.57 to1.39 and overall survival rate: OR 1.15; 95% CI 0.87 to1.52). There was moderate to high quality evidence that the number of resected lymph nodes and surgical margins were similar between the two groups.For the short-term results, length of hospital stay was reduced by two days (95% CI -3.22 to -1.10), moderate quality evidence), and the time to first defecation was shorter in the LTME group (-0.86 days; 95% CI -1.17 to -0.54). There was moderate quality evidence that 30 days morbidity were similar in both groups (OR 0.94; 95% CI 0.8 to 1.1). There were fewer wound infections (OR 0.68; 95% CI 0.50 to 0.93) and fewer bleeding complications (OR 0.30; 95% CI 0.10 to 0.93) in the LTME group.There was no clear evidence of any differences in quality of life after LTME or OTME regarding functional recovery, bladder and sexual function. The costs were higher for LTME with differences up to GBP 2000 for direct costs only.
  
  
  CONCLUSIONS
  We have found moderate quality evidence that laparoscopic total mesorectal excision (TME) has similar effects to open TME on long term survival outcomes for the treatment of rectal cancer. The quality of the evidence was downgraded due to imprecision and further research could impact on our confidence in this result. There is moderate quality evidence that it leads to better short-term post-surgical outcomes in terms of recovery for non-locally advanced rectal cancer. Currently results are consistent in showing a similar disease-free survival and overall survival, and for recurrences after at least three years and up to 10 years, although due to imprecision we cannot rule out superiority of either approach. We await long-term data from a number of ongoing and recently completed studies to contribute to a more robust analysis of long-term disease free, overall survival and local recurrence.
authors.affiliation: Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ.
authors.forename: Sandra
authors.initials: S
authors.lastname: Vennix
authors.forename: Loeki
authors.initials: L
authors.lastname: Pelzers
authors.forename: Nicole
authors.initials: N
authors.lastname: Bouvy
authors.forename: Geerard L
authors.initials: GL
authors.lastname: Beets
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Pierie
authors.forename: Theo
authors.initials: T
authors.lastname: Wiggers
authors.forename: Stephanie
authors.initials: S
authors.lastname: Breukink
mesh_terms: D061887:Conversion to Open Surgery / Q000706:statistics & numerical data; D017558:Elective Surgical Procedures; D006801:Humans; D010535:Laparoscopy; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D016896:Treatment Outcome
references.citation: Ann Oncol. 2013 Oct;24 Suppl 6:vi81-8
references.pmid: 24078665
references.citation: Ann Surg. 2011 Jan;253(1):35-43
references.pmid: 21294286
references.citation: Zhonghua Wei Chang Wai Ke Za Zhi. 2007 May;10(3):253-6
references.pmid: 17520385
references.citation: Eur J Surg Oncol. 2008 Oct;34(10):1135-42
references.pmid: 18191529
references.citation: J Laparoendosc Adv Surg Tech A. 2011 Jun;21(5):381-5
references.pmid: 21395453
references.citation: Br J Cancer. 2006 Jul 3;95(1):6-12
references.pmid: 16755298
references.citation: Int J Colorectal Dis. 2008 Aug;23(8):795-800
references.pmid: 18465136
references.citation: Surg Endosc. 2002 Apr;16(4):558-62
references.pmid: 11972187
references.citation: Int J Colorectal Dis. 2006 Oct;21(7):652-6
references.pmid: 16463181
references.citation: J Int Med Res. 2010 May-Jun;38(3):916-22
references.pmid: 20819427
references.citation: Ann Surg. 2000 Apr;231(4):506-11
references.pmid: 10749610
references.citation: Zhonghua Wei Chang Wai Ke Za Zhi. 2009 May;12(3):236-8
references.pmid: 19434528
references.citation: Br J Surg. 2010 Jan;97(1):70-8
references.pmid: 20013936
references.citation: Jpn J Clin Oncol. 2005 Aug;35(8):475-7
references.pmid: 16006574
references.citation: Zhonghua Wai Ke Za Zhi. 2002 Dec;40(12):899-901
references.pmid: 12654204
references.citation: Int J Colorectal Dis. 2011 Apr;26(4):415-21
references.pmid: 21174107
references.citation: Surg Endosc. 1998 Sep;12(9):1131-6
references.pmid: 9716766
references.citation: Ann Surg Oncol. 2008 Sep;15(9):2418-25
references.pmid: 18392659
references.citation: Surg Endosc. 2004 Aug;18(8):1211-5
references.pmid: 15457380
references.citation: Rev Hosp Clin Fac Med Sao Paulo. 2003 May-Jun;58(3):133-40
references.pmid: 12894309
references.citation: Cancer Treat Rev. 2008 Oct;34(6):498-504
references.pmid: 18468803
references.citation: Int J Colorectal Dis. 2011 Jan;26(1):53-9
references.pmid: 20922542
references.citation: Lancet. 1986 Jun 28;1(8496):1479-82
references.pmid: 2425199
references.citation: Lancet Oncol. 2010 Jul;11(7):637-45
references.pmid: 20610322
references.citation: J Gastrointest Surg. 2011 Aug;15(8):1375-85
references.pmid: 21557014
references.citation: Surg Endosc. 2007 Aug;21(8):1301-7
references.pmid: 17522936
references.citation: Dis Colon Rectum. 1995 Jun;38(6):600-3
references.pmid: 7774470
references.citation: Surg Endosc. 2003 Oct;17(10):1530-5
references.pmid: 12874687
references.citation: Dis Colon Rectum. 2001 Feb;44(2):217-22
references.pmid: 11227938
references.citation: Br J Surg. 2006 Mar;93(3):300-8
references.pmid: 16363014
references.citation: World J Surg. 2011 May;35(5):1130-6
references.pmid: 21416172
references.citation: Br J Surg. 2013 Jan;100(1):75-82
references.pmid: 23132548
references.citation: Lancet. 2004 Apr 10;363(9416):1187-92
references.pmid: 15081650
references.citation: Br J Surg. 2005 Sep;92(9):1124-32
references.pmid: 15997446
references.citation: Br J Surg. 2002 Dec;89(12):1551-6
references.pmid: 12445065
references.citation: BMC Surg. 2006 Nov 29;6:16
references.pmid: 17134506
references.citation: BMC Med Res Methodol. 2005 Apr 20;5:13
references.pmid: 15840177
references.citation: Lancet Oncol. 2009 Jan;10(1):44-52
references.pmid: 19071061
references.citation: Dis Colon Rectum. 2009 Apr;52(4):558-66
references.pmid: 19404053
references.citation: Colorectal Dis. 2012 Jun;14(6):e277-96
references.pmid: 22330061
references.citation: J Laparoendosc Adv Surg Tech A. 2008 Oct;18(5):679-85
references.pmid: 18699750
references.citation: Br J Surg. 2001 Jun;88(6):801-7
references.pmid: 11412248
references.citation: Br J Surg. 2009 Sep;96(9):982-9
references.pmid: 19644973
references.citation: Dis Colon Rectum. 2007 Apr;50(4):464-71
references.pmid: 17195085
references.citation: Surg Endosc. 2003 Aug;17(8):1305-10
references.pmid: 12728374
references.citation: J Clin Oncol. 2007 Jul 20;25(21):3061-8
references.pmid: 17634484
references.citation: Jpn J Clin Oncol. 2008 Jul;38(7):497-500
references.pmid: 18586667
references.citation: Ann Surg. 2011 Dec;254(6):868-75
references.pmid: 21597360
references.citation: Br J Surg. 2009 Dec;96(12):1458-67
references.pmid: 19918852
references.citation: Cochrane Database Syst Rev. 2005 Jul 20;(3):CD003145
references.pmid: 16034888
references.citation: Dis Colon Rectum. 2005 Dec;48(12):2217-23
references.pmid: 16228828
references.citation: Lancet Oncol. 2013 Mar;14(3):210-8
references.pmid: 23395398
references.citation: World J Surg. 2013 Aug;37(8):1789-98
references.pmid: 23754141
references.citation: Lancet. 2005 Aug 27-Sep 2;366(9487):713; author reply 713-4
references.pmid: 16125582
references.citation: Br J Surg. 2011 Feb;98(2):299-307
references.pmid: 20981742
references.citation: Dis Colon Rectum. 1999 Mar;42(3):327-32; discussion 332-3
references.pmid: 10223751
references.citation: J Am Coll Surg. 1998 Jul;187(1):46-54; discussion 54-5
references.pmid: 9660024
references.citation: Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005200
references.pmid: 17054246
references.citation: Ann Surg Oncol. 2006 Mar;13(3):413-24
references.pmid: 16450220
references.citation: Br J Surg. 2010 Nov;97(11):1638-45
references.pmid: 20629110
references.citation: Cancer Control. 2010 Jan;17(1):16-24
references.pmid: 20010515
references.citation: Dis Colon Rectum. 2013 May;56(5):535-50
references.pmid: 23575392
references.citation: Ann Surg. 2002 Dec;236(6):759-66; disscussion 767
references.pmid: 12454514
references.citation: Ann Surg. 2007 Oct;246(4):655-62; discussion 662-4
references.pmid: 17893502
references.citation: Lancet. 2005 May 14-20;365(9472):1718-26
references.pmid: 15894098
references.citation: Ann Surg. 2005 Jul;242(1):83-91
references.pmid: 15973105
references.citation: J Clin Epidemiol. 2010 Aug;63(8):834-40
references.pmid: 20346629
references.citation: Crit Rev Oncol Hematol. 2000 Feb;33(2):99-103
references.pmid: 10737371
references.citation: Surgeon. 2011 Feb;9(1):38-43
references.pmid: 21195330
references.citation: Dis Colon Rectum. 1998 Aug;41(8):971-8
references.pmid: 9715151
references.citation: Ann Surg. 2014 Jan;259(1):139-47
references.pmid: 23598381
references.citation: Dis Colon Rectum. 1999 Jul;42(7):930-9
references.pmid: 10411441
references.citation: Dig Dis. 2007;25(1):94-9
references.pmid: 17384514
references.citation: Ann Surg Oncol. 2009 Nov;16(11):3038-47
references.pmid: 19641971
references.citation: BMJ. 2003 Sep 6;327(7414):557-60
references.pmid: 12958120