MINIMALLY INVASIVE PROCTECTOMY IS ASSOCIATED WITH IMPROVED SURVIVAL
Andrea M. Mesiti*, Alessio Pigazzi
Weill Cornell Medicine, New York, NY
Introduction:
Multiple randomized control trials have evaluated laparoscopic (LP) and open proctectomy (OP) for rectal cancer, with mixed results. COREAN, CLASICC and COLOR II supported the use of LP, while ALaCaRT and Z6051 did not. Additionally, there is limited data on long-term oncologic outcomes for robotic proctectomy (RP). The aim of this study is to examine the effect of surgical approach on oncologic factors and survival for patients undergoing open, laparoscopic and robotic proctectomies.
Methods:
Patients in the National Cancer Database with locally advanced rectal cancer were stratified based on surgical approach from 2010-2018. Patient demographics and tumor characteristics were compared with univariate analysis. Intent to treat multivariable analysis and survival analysis with Cox proportional hazard ratios and Kaplan-Meier method were performed. Data analysis was performed using STATA v.17 and R v.4.0.2.
8,293 patients were identified. 3,991 (48.1%) underwent OP, 2,101 (25.3%) underwent LP, 1,666 (20.1%) underwent RP. Conversion rates were 7% for RP and 20% for LP. No clinically significant difference in age or sex was noted between groups. Differences in distribution of race were noted, with those who were Black more likely to have open compared to LP or RP (p-value < 0.001). MIS approaches appear to be more common at academic and comprehensive cancer centers (p-value<0.001). And patients with private insurance are more likely to undergo LP or RP (p-value<0.001). On multivariable analysis, patients who underwent LP (OR 0.760; 95% CI 0.611-0.946; p-value=0.014) or RP (OR 0.660; 95% CI 0.511-0.853; p-value=0.002) were less likely to have positive margins compared to OP. Patients who underwent LP (OR 0.842; 95% CI 0.738-0.961; p-value=0.011) and RP (OR 0.712; 95% CI 0.615-0.825; p-value<0.001) were less likely to have positive lymph nodes compared to those who underwent OP. No difference in 30-day or 90-day mortality was noted. On adjusted survival analysis a reduction in overall survival (OS) for OP compared to LP (HR 0.811; 95% CI:0.725-0.907; p-value<0.01) and RP (HR 0.78; 95% CI:0.67-0.905; p-value=0.01) was demonstrated. There was no difference in OS between LP and RP (HR 0.96; 95% CI: 0.820-1.13; p-value=0.654).
Conclusion:
MIS proctectomy is associated with improved survival compared to open technique. Importantly, there was no difference in survival between a robotic and laparoscopic approach. This suggests that robotic assisted proctectomies are a safe option.
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