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Oncologic Outcomes of Laparoscopic Versus Open Radical Protectomy for Rectal Cancer After Preoperative Chemoradiation in 132 Patients
Lauren Kosinski*, John Marks, David Heinsch, Hsiao-Ling Shen, Gerald Marks
Lankenau Hospital and Institute for Medical Research, Wynnewood, PA

Background: To date, there is little data specific to laparoscopic proctectomy for cancer to guide surgical treatment. We report our experience with open and laparoscopic approaches and analyze short-term oncologic outcomes.
Methods: A consecutive series of rectal cancer patients treated with high dose neoadjuvant chemoradiation then radical proctectomy between 1/97-11/05 were selected from a prospectively maintained, 670-patient database. Patients with metastases at the time of surgery were excluded. Patients were prospectively staged clinically and with CT, MRI, and, when appropriate, endorectal ultrasound. All patients were treated with 4500-7000 cGy and concurrent 5-FU or Xeloda. >T3 cancers and T1/T2 cancers in the distal 6-cm of the rectum post-radiation were further treated with either proctosigmoid colectomy with hand sewn coloanal anastomosis or low anterior resection (LAR); abdominoperineal resection (APR) was reserved for fixed cancers in the distal 3-cm. Operations were performed by open or laparoscopic approach. All data were tabulated and analyzed.
Results: 132 patients met inclusion criteria (78 Lap, 55 Open). Lap and Open groups were equivalent with respect to age (median 59 yrs Lap, 58 yrs Open), gender (67% male, both), and median radiation dose (5400 cGy Lap vs 5580 cGy Open). In both groups, 71% of tumors were in the distal 3-cm of the rectum. 76.9% of the Lap, 84% of the Open (p > 0.05) pretreated tumors were stage T3. The overall local recurrence rate was 1.7% with a mean follow-up of 34.2 months (range 1.8-99.9 mos). Three patients in each group (4.3% Lap, 6.3% Open, p > 0.05) developed metastases. 89.9% (Lap) and 81.3% (Open) (N.S.) are without evidence of disease. 87% (Lap) and 91% (Open) (N.S.) had sphincter preservation. Groups were also equivalent with respect to distal margin length (median cm 2.7 Lap, 2.5 Open), lymph node harvest (median 10 in both groups, range 2-93), R0 resection (97% Lap, 98% Open).
Discussion: In our group, local recurrence and distant failure rates are very low and independent of Lap vs. Open technique. Despite the predominance of advanced stage tumors in the distal third of the rectum, sphincter preservation was achieved in the vast majority of cases. Longer follow-up is needed, especially in the setting of neoadjuvant treatment. Laparoscopic proctectomy is technically challenging and should be performed by experienced laparoscopic colorectal surgeons.

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