Pathologic Outcomes of Laparoscopic vs Open Mesorectal Excision for Rectal Cancer A Systematic Review and Meta-analysis
Por:
Martínez-Pérez A, Carra MC, Brunetti F and de'Angelis N
Publicada:
1 abr 2017
Ahead of Print:
8 feb 2017
Categoría:
Surgery
Resumen:
IMPORTANCE Rectal resection with mesorectal excision is the mainstay
treatment for rectal cancer.
OBJECTIVE To review and analyze the evidence concerning the pathologic
outcomes of laparoscopic (LRR) vs open (ORR) rectal resection for rectal
cancer.
DATA SOURCES The Cochrane Central Register of Controlled Trials, MEDLINE
(through PubMed), EMBASE, Scopus databases, and clinicaltrials. gov were
searched for randomized clinical trials (RCTs) comparing LRR vs ORR.
STUDY SELECTION Only RCTs published in English from January 1, 1995, to
June 30, 2016, that compared LRR with ORR for histologically proven
rectal cancer in adult patients and reported pathologic outcomes (eg,
positive circumferential resection margin, and complete mesorectal
excision) were eligible for inclusion. Of 369 records screened, 14 RCTs
were selected for the qualitative and quantitative analyses.
DATA EXTRACTION AND SYNTHESIS Two independent reviewers performed the
study selection and quality assessment. Random-effects models were used
to summarize the risk ratio (RR) and mean differences.
MAIN OUTCOMES AND MEASURES The rate of positive circumferential
resection margin (CRM), defined as 1 mm or less from the closest tumor
to the cut edge of the tissue, and the quality of mesorectal excision
(complete, nearly complete, or incomplete).
RESULTS Themeta-analysis included 14 unique RCTs with 4034 unique
patients. Of 2989 patients undergoing rectal resection, a positive CRM
was found in 135 (7.9%) of 1697 patients undergoing LRR and 79 (6.1%) of
1292 patients undergoing ORR (RR, 1.17; 95% CI, 0.89-1.53; P = .26; I-2
= 0%) in 9 studies. A noncomplete (nearly complete and incomplete)
mesorectal excision was reported in 179 (13.2%) of 1354 patients
undergoing LRR and 104 (10.4%) of 998 patients undergoing ORR (RR, 1.31;
95% CI, 1.05-1.64; P = 02; I-2 = 0%) in 5 studies. The distal resection
margin involvement (RR, 1.12; 95% CI, 0.34-3.67; P = .86), the mean
number of lymph nodes retrieved (mean difference, 0.05; 95% CI, -0.77 to
0.86; P = .91), the mean distance to the distal margin (mean difference,
0.01 cm; 95% CI, -0.12 to 0.15 cm; P = .87), and the mean distance to
radial margins (mean difference, -0.67 mm; 95% CI, -2.16 to 0.83 mm; P =
.38) were not significantly different between LRR and ORR. The risk for
bias was assessed as low in 10 studies, high in 3, and unknown in 1. The
overall quality of the evidence emerging from the literature was rated
as high.
CONCLUSIONS AND RELEVANCE Based on the available evidence, the risk for
achieving a noncomplete mesorectal excision is significantly higher in
patients undergoing LRR compared with ORR. These findings question the
oncologic safety of laparoscopy for the treatment of rectal cancer.
However, long-term results of the ongoing RCTs are awaited to assess
whether these pathologic results have an effect on disease-free and
overall patient survival.
Filiaciones:
:
Department of Digestive, Hepatobiliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Est-Créteil, Créteil, France2Department of General and Digestive Surgery, Hospital Universitario Doctor Peset, Valencia, Spain
Carra MC:
Rothschild Hospital, AP-HP, Université Paris 7, Paris, France
Brunetti F:
Department of Digestive, Hepatobiliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Est-Créteil, Créteil, France
de'Angelis N:
Department of Digestive, Hepatobiliary Surgery and Liver Transplantation, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Est-Créteil, Créteil, France
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