Laparoscopic sphincter-preserving rectal cancer surgery: a highly demanding procedure

Abstract

Most patients with potentially curable middle or lower rectal cancer at diagnosis prefer or require a sphincterpreserving surgical procedure. Currently, laparoscopic low anterior resection (LLAR) is thought to offer the best possible postoperative quality of life (QOL) [1, 2]. However, what are the risks of postoperative complications and local or locoregional failures? Are there standardized criteria for a safe and effective LLAR? Is preoperative (neoadjuvant) chemoradiotherapy beneficial to all patients or only in selected cases? To evaluate these questions, Fukunaga et al. [3] performed a retrospective analysis which was reported in the January 2010 issue of this journal. Clinicopathologic treatment and follow-up data of 98 patients with middle (n = 51) or low-lying rectal cancer (n = 47) who underwent laparoscopic rectal surgery were studied. Depending on the distal distance of the distal tumor border to the anal verge, the patients were classified as having lower (\8 cm) or middle (C8 cm) rectal cancer. Total mesorectal excision (TME) was performed in all patients. Pelvic anatomy was accurately visualized by endoscopic magnification so autonomic nerves could be preserved. Conversion to open surgery was necessary in five patients because of difficulties with rectal transection in three early cases and a large tumor and adhesions in the other two. Overall, the postoperative complication rate was 32.2%, with an anastomotic leakage rate of 13.1%. Recurrence occurred in 12 patients: 3 local, 2 lymph nodes, and 7 distant failures. Although the Fukunaga et al. study is limited by its retrospective nature and small number of patients, it provides precise data on short-term and long-term risks associated with LLAR. Anastomotic leakage and locoregional recurrence are substantial and should be seriously considered when preparing to perform this surgical procedure. Can these risks be prevented? For evidence-based good clinical practice, when performing a LLAR certain criteria should be kept in mind. In contrast to the conclusive evidence associated with laparoscopic colectomy [4], there is no such evidence for LLAR. Although six randomized controlled trials of LLAR have been published, they have several limitations [1]. The oncological principles of open surgery also should be kept in mind for sphincter-saving resection: Because of a better view of the pelvis via the laparoscopic technique, a more accurate and precise TME can be achieved laparoscopically (LTME) [1, 2, 5, 6]. The distal distance from the tumor for preventing local recurrence has been an important topic. Currently, there is consensus that at least 2-cm distal tumor-free surgical margins are required. Adequate lymphadenectomy is also crucial to avoid nodal failures and to obtain accurate nodal staging which is important for deciding on adjuvant treatment. There is currently agreement on high ligation of the inferior mesenteric artery and splenic flexure mobilization [1, 2]. A trend in favor of laparoscopic surgery also expands the indications for other common gastrointestinal tumors, including gastric cancer [5, 7–9]. It appears that the quality of the surgery affects the patient’s oncological and QOL outcomes. Standardized LLAR can be performed probably more safely and efficiently by high-volume surgeons. However, there are several questions and controversies. For example, there is limited evidence that LLAR improves local control by C. G. Katsios (&) G. Baltogiannis Department of Surgery, University of Ioannina, School of Medicine, 451 10 Ioannina, Greece e-mail: chkatsios@gmail.com