title: Laparoscopic vs open abdominoperineal resection in the multimodality management of low rectal cancers.
abstract: OBJECTIVE
  To evaluate the safety and feasibility of laparoscopic abdominoperineal resection compared with the open procedure in multimodality management of rectal cancer.
  
  
  METHODS
  A total of 106 rectal cancer patients who underwent open abdominoperineal resection (OAPR) were matched with 106 patients who underwent laparoscopic abdominoperineal resection (LAPR) in a 1 to 1 fashion, between 2009 and 2013 at Fudan University Shanghai Cancer Center. Propensity score matching was carried out based on age, gender, pathological staging of the disease and administration of neoadjuvant chemoradiation. Data regarding preoperative staging, surgical technique, pathological results, postoperative recovery and complications were reviewed and compared between the LAPR and OAPR groups. Perineal closure around the stoma and pelvic floor reconstruction were performed only in OAPR, not in LAPR. Therefore, abdominoperineal resection procedure-specific surgical complications including parastomal hernia and perineal wound complications were compared between the open and laparoscopic procedure. Regular surveillance of the two cohorts was carried out to gather prognostic data. Disease-free survival was analyzed using Kaplan-Meier estimate and log-rank test. Subgroup analysis was performed in patients with locally advanced disease treated with preoperative chemoradiation followed by surgical resection.
  
  
  RESULTS
  No significant difference was found between the LAPR group and the OAPR group in terms of clinicopathological features. The operation time (180.8 ± 47.8 min vs 172.1 ± 49.2 min, P = 0.190), operative blood loss (93.9 ± 60.0 mL vs 88.4 ± 55.2 mL, P = 0.494), total number of retrieved lymph nodes (12.9 ± 6.9 vs 12.9 ± 5.4, P = 0.974), surgical complications (12.3% vs 15.1%, P = 0.549) and pathological characteristics were comparable between the LAPR and OAPR group, respectively. Compared with OAPR patients, LAPR patients showed significantly shorter postoperative analgesia (2.4 ± 0.7 d vs 2.7 ± 0.6 d, P < 0.001), earlier first flatus (57.3 ± 7.9 h vs 63.5 ± 9.2 h, P < 0.001), shorter urinary drainage time (6.5 ± 3.4 d vs 7.8 ± 1.3 d, P < 0.001), and shorter postoperative admission (11.2 ± 4.7 d vs 12.6 ± 4.0 d, P = 0.014). With regard to APR-specific complications (perineal wound complications and parastomal hernia), there were no significant differences between the two groups. Similar results were found in the 26 pairs of patients administered neoadjuvant chemoradiation in subgroup analysis. During the follow-up period, no port site recurrences were observed.
  
  
  CONCLUSIONS
  Laparoscopic abdominoperineal resection for multidisciplinary management of rectal cancer is safe, and is associated with earlier recovery and shorter admission time in combination with neoadjuvant chemoradiation.
authors.affiliation: Yu-Wei Wang, Li-Yong Huang, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li, Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai 200032, China.
authors.forename: Yu-Wei
authors.initials: YW
authors.lastname: Wang
authors.affiliation: Yu-Wei Wang, Li-Yong Huang, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li, Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai 200032, China.
authors.forename: Li-Yong
authors.initials: LY
authors.lastname: Huang
authors.affiliation: Yu-Wei Wang, Li-Yong Huang, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li, Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai 200032, China.
authors.forename: Cheng-Li
authors.initials: CL
authors.lastname: Song
authors.affiliation: Yu-Wei Wang, Li-Yong Huang, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li, Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai 200032, China.
authors.forename: Chang-Hua
authors.initials: CH
authors.lastname: Zhuo
authors.affiliation: Yu-Wei Wang, Li-Yong Huang, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li, Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai 200032, China.
authors.forename: De-Bing
authors.initials: DB
authors.lastname: Shi
authors.affiliation: Yu-Wei Wang, Li-Yong Huang, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li, Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai 200032, China.
authors.forename: Guo-Xiang
authors.initials: GX
authors.lastname: Cai
authors.affiliation: Yu-Wei Wang, Li-Yong Huang, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li, Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai 200032, China.
authors.forename: Ye
authors.initials: Y
authors.lastname: Xu
authors.affiliation: Yu-Wei Wang, Li-Yong Huang, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li, Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai 200032, China.
authors.forename: San-Jun
authors.initials: SJ
authors.lastname: Cai
authors.affiliation: Yu-Wei Wang, Li-Yong Huang, De-Bing Shi, Guo-Xiang Cai, Ye Xu, San-Jun Cai, Xin-Xiang Li, Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Fudan University, Shanghai 200032, China.
authors.forename: Xin-Xiang
authors.initials: XX
authors.lastname: Li
mesh_terms: D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical; D018279:Carcinoma, Signet Ring Cell / Q000473:pathology / Q000601:surgery*; D059186:Chemoradiotherapy, Adjuvant; D002681:China; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D018572:Disease-Free Survival; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D010535:Laparoscopy / Q000009:adverse effects; D008297:Male; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Abdominoperineal resection; Laparoscopy; Neoadjuvant chemoradiation; Rectal cancer; Total mesorectal excision