Laparoscopic Versus Open Resection for Rectal Cancer: A Meta-Analysis of Reconstructed Individual Data on 3060 Patients Treated in Randomized Controlled Trials

Abstract

Background and Aims: The role of laparoscopic rectal cancer resection remains controversial. Previous meta-analyses of survival outcomes have utilized a standard meta-analytical approach less amenable to the incorporation of flexible and robust survival models. Thus, we aimed to conduct a one-stage meta-analysis with reconstructed patient-level data using randomized trial data to compare long-term oncologic efficacy of laparoscopic and open surgical resection for rectal cancer. Methods: Medline, EMBASE and Scopus were searched for articles comparing laparoscopic with open surgery for rectal cancer. Primary outcome was disease free survival (DFS) while secondary outcome was overall survival (OS). One-stage meta-analysis was conducted using patient-level survival data reconstructed from Kaplan-Meier curves with Web Plot Digitizer. Shared-frailty and stratified Cox models were fitted to compare survival endpoints. Results: Seven randomized trials, with a median follow-up of six years, involving 1,767 laparoscopic and 1,293 open resections for rectal cancer in 3,060 patients were included. There were no significant differences between both groups for DFS and OS with respective hazard ratio estimates of 0.91 (95% CI: 0.78 – 1.06, p =0.241) and 0.86 (95% CI: 0.73 - 1.02, p = 0.090). Sensitivity analysis for non-metastatic patients and patients with mid and lower rectal cancer showed no significant differences in OS and DFS between both surgical approaches. In the laparoscopic arm, improved DFS was noted for stage II (HR: 0.73, 95% CI: 0.54 - 0.98, p = 0.036) and stage III rectal cancers (HR: 0.74, 95% CI: 0.55 - 0.99, p =0.041). Conclusions: This meta-analysis concludes that laparoscopic rectal cancer resection does not compromise long-term oncologic outcomes compared with open surgery with potential survival benefits for a minimal access approach in patients with stage II and III rectal cancer. Funding: No funding was required for this work. Declaration of Interest: None to declare.