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Table of Contents
Vol. 25, No. 1, 2007
Issue release date: March 2007
Section title: Original Article
Dig Dis 2007;25:94–99
(DOI:10.1159/000099176)

Lymph Node Clearance after Total Mesorectal Excision for Rectal Cancer: Laparoscopic versus Open Approach

Pechlivanides G.a · Gouvas N.b · Tsiaoussis J.c · Tzortzinis A.d · Tzardi M.b · Moutafidis M.a · Dervenis C.e · Xynos E.b
aFirst Department of General Surgery, Athens Naval Hospital, bMedical School, University of Crete, cDepartment of Surgery, ‘Metropolitan Hospital’, dDepartment of General Surgery, Naval Hospital of Crete, and eFirst Department of General Surgery, ‘Agia Olga’ Hospital of Athens, Greece
email Corresponding Author

Abstract

Background: Laparoscopic resection of the rectum is still under scrutiny for its adequacy of oncological clearance. Aim: To assess lymph node yield after laparoscopic total mesorectal excision (TME) for rectal cancer as compared to the open approach. Methods: 74 patients with middle and low rectal cancer were prospectively randomized in two groups. Group A included 39 patients who had an open TME (35 with low anterior resection of the rectum (LARR) and 4 with abdominoperineal resection of the rectum (APR)). In group B, there were 34 patients who had a laparoscopic TME (27 with LARR and 7 with APR). 10 of the LARR patients in group A and 14 of the LARR patients in group B had a defunctioning ileostomy. All operations were performed by one surgeon or under his supervision. Results: Gender and age distribution were similar for both groups (group A: 23 males; mean age 69 (41–85); group B: 20 males; mean age 72 (31–84)). The mean distance of the tumor from the dentate line was 7.6 cm (1–12 cm) for group A and 6.1 cm (1–12 cm) for group B. Anastomosis was formed at a mean distance of 5.5 cm (1.5–8.5 cm) from the dentate line in group A and 3.5 cm (1–4.5 cm) in group B. At histology, in group A there were 5 T4 tumors, 9 T3, 10 T3+ (<1 mm distance from the circumferential resection margin), 13 T2 and 2 T1. In group B, there were 3 T4 tumors, 14 T3, 8 T3+, 7 T2 and 2 T1. Differences between groups were not significant.The mean number of lymph nodes retrieved in group A specimens was 19.2 (5–45) and in group B 19.2 (8–41) (p = 0.2). In group A, 3.9 (1–9) regional, 13.9 (3–34) intermediate and 1.5 (1–3) apical lymph nodes were retrieved. The respective values in group B were 3.7 (3–7), 14.4 (4–33) and 1.3 (1–3). Differences between groups were not significant. Also, the incidence of lymph node involvement by the tumor was not significantly different between groups (group A: 23; group B: 19). Conclusions: Laparoscopic resection of the rectum can achieve similar lymph node clearance to the open approach. Also, distribution of the lymph nodes along the resected specimens is similar between the two approaches.

© 2007 S. Karger AG, Basel


  

Key Words

  • Laparoscopy
  • Rectal cancer
  • Total mesorectal excision
  • Lymph node harvesting
  • Lymph node clearance

References

  1. Heald RJ, Husband EM, Ryall RDH: The mesorectum in rectal cancer surgery: the clue to pelvic recurrence? Br J Surg 1982;69:613–616.
  2. Heald RJ, Karanjia ND: Results of radical surgery for rectal cancer. World J Surg 1992;16: 848–857.
  3. Dahlberg M, Glimelius B, Pahlman L: Changing strategy for rectal cancer is associated with improved outcome. Br J Surg 1999;86:379–384.
  4. Aziz O, Constantinides V, Tekkis PP, et al: Laparoscopic versus open surgery for rectal cancer: a meta-analysis. Ann Surg Oncol 2006;13:413–424.
  5. Gao F, Cao YF, Chen LS: Meta-analysis of the short-term outcomes after laparoscopic resection for rectal cancer. Int J Colorectal Dis 2006;7:1–5.
  6. Quah HM, Jayne DG, Eu KW, Seow-Choen F: Bladder and sexual dysfunction following laparoscopically assisted and conventional open mesorectal resection for rectal cancer. Br J Surg 2002;89:1551–1556.
  7. Araujo SE, da Silva e Sousa AH Jr, de Campos FG, et al: Conventional approach versus laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial. Rev Hosp Clin Fac Med São Paolo 2003;58:133–140.
  8. Breukink SO, Grond AJK, Pierie JPEN, Hoff C, Wiggers T, Meijerink WJHJ: Laparoscopic vs. open total mesorectal excision for rectal cancer. An evaluation of the mesorectum’s macroscopic quality. Surg Endosc 2005;19:307–310.
  9. Guillou PJ, Quirke P, Thorpe H, et al: Short-term endpoints of conventional versus laparoscopic assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005;365:1718–1726.
  10. Tate JJ, Kwok S, Dawson JW, et al: Prospective comparison of laparoscopic and conventional anterior resection. Br J Surg 1993;80:1396–1398.
  11. Darzi A, Lewis C, Menzies-Gow N, et al: Laparoscopic abdominoperineal excision of the rectum. Surg Endosc 1995;9:414–417.
  12. Goh YC, Eu KW, Seow-Choen F: Early postoperative results of a prospective series of laparoscopic vs. open anterior resections for rectosigmoid cancers. Dis Colon Rectum 1997;40:776–780.
  13. Leung KL, Kwok SP, Lau WY, et al: Laparoscopic-assisted resection of rectosigmoid carcinoma. Immediate and medium-term results. Arch Surg 1997;132:761–764.
  14. Seow-Choen F, Eu KW, Ho YH, Leong AF: A preliminary comparison of a consecutive series of open versus laparoscopic abdomino-perineal resection for rectal adenocarcinoma. Int J Colorectal Dis 1997;12:88–90.
  15. Ramos JR, Petrosemolo RH, Valory EA, et al: Abdominoperineal resection: laparoscopic versus conventional. Surg Laparosc Endosc 1997;7:148–152.
  16. Iroatulam AJ, Agachan F, Alabaz O, et al: Laparoscopic abdominoperineal resection for anorectal cancer. Am Surg 1998;64:12–18.
  17. Fleshman JW, Wexner SD, Anvari M, et al: Laparoscopic vs. open abdominoperineal resection for cancer. Dis Colon Rectum 1999;42:930–939.
  18. Schwandner O, Schiedeck TH, Killaitis C, Bruch HP: A case-control-study comparing laparoscopic versus open surgery for rectosigmoidal and rectal cancer. Int J Colorectal Dis 1999;14:158–163.
  19. Leung KL, Kwok SP, Lau WY, et al: Laparoscopic-assisted abdominoperineal resection for low rectal adenocarcinoma. Surg Endosc 2000;14:67–70.
  20. Hartley JE, Mehigan BJ, Qureshi AE, et al: Total mesorectal excision: assessment of the laparoscopic approach. Dis Colon Rectum 2001;44: 315–321.
  21. Baker RP, White EE, Titu L, et al: Does laparoscopic abdominoperineal resection of the rectum compromise long-term survival? Dis Colon Rectum 2002;45:1481–1485.
  22. Anthuber M, Fuerst A, Elser F, et al: Outcome of laparoscopic surgery for rectal cancer in 101 patients. Dis Colon Rectum 2003;46:1047–1053.
  23. Feliciotti F, Guerrieri M, Paganini AM, et al: Long-term results of laparoscopic versus open resections for rectal cancer for 124 unselected patients. Surg Endosc 2003;17:1530–1535.
  24. Vorob’ev GI, Shelygin IuA, Frolov SA, et al: Laparoscopic surgery of rectal cancer (comparative results of laparoscopic and open abdominal resection) (in Russian). Khirurgiia (Mosk) 2003;3:36–42.

    External Resources

  25. Wu WX, Sun YM, Hua YB, Shen LZ: Laparoscopic versus conventional open resection of rectal carcinoma: a clinical comparative study. World J Gastroenterol 2004;10:1167–1170.

    External Resources

  26. Radcliffe A: Can the results of anorectal (abdominoperineal resection) be improved: are circumferential resection margins too often positive? Colorectal Dis 2006;8:160–167.
  27. Morino M, Parini U, Giraudo G, Salval M, Brachet Contul R, Garonne C: Laparoscopic total mesorectal excision: a consecutive series of 100 patients. Ann Surg 2003;237:335–342.
  28. Leroy J, Jamali F, Forbes L, et al: Laparoscopic total mesorectal excision for rectal cancer surgery: long-term outcomes. Surg Endosc 2004;18:281–289.
  29. Jass JR, Morson BC: Reporting colorectal cancer. J Clin Pathol 1987;40:1016–1023.
  30. Carolyn C, Compton CA: The staging of colorectal Cancer: 2004 and beyond. Cancer J Clin 2004;54:295–308.
  31. Nagtegaal ID, van de Velde CJ, van der Worp E, Kapiteijn E, Quirke P, van Krieken JH, Cooperative Clinical Investigators of the Dutch Colorectal Cancer Group: Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol 2002;20:1729–1734.

  

Author Contacts

Evaghelos Xynos
19, Michelidaki Street
GR–712 02 Heraklion (Greece)
Tel. +30 2810 280 002, Fax +30 2810 280 009
E-Mail exynos@med.uoc.gr

  

Article Information

Number of Print Pages : 6
Number of Figures : 0, Number of Tables : 3, Number of References : 31

  

Publication Details

Digestive Diseases (Clinical Reviews)

Vol. 25, No. 1, Year 2007 (Cover Date: March 2007)

Journal Editor: Malfertheiner, P. (Magdeburg)
ISSN: 0257–2753 (print), 1421–9875 (Online)

For additional information: http://www.karger.com/DDI


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Background: Laparoscopic resection of the rectum is still under scrutiny for its adequacy of oncological clearance. Aim: To assess lymph node yield after laparoscopic total mesorectal excision (TME) for rectal cancer as compared to the open approach. Methods: 74 patients with middle and low rectal cancer were prospectively randomized in two groups. Group A included 39 patients who had an open TME (35 with low anterior resection of the rectum (LARR) and 4 with abdominoperineal resection of the rectum (APR)). In group B, there were 34 patients who had a laparoscopic TME (27 with LARR and 7 with APR). 10 of the LARR patients in group A and 14 of the LARR patients in group B had a defunctioning ileostomy. All operations were performed by one surgeon or under his supervision. Results: Gender and age distribution were similar for both groups (group A: 23 males; mean age 69 (41–85); group B: 20 males; mean age 72 (31–84)). The mean distance of the tumor from the dentate line was 7.6 cm (1–12 cm) for group A and 6.1 cm (1–12 cm) for group B. Anastomosis was formed at a mean distance of 5.5 cm (1.5–8.5 cm) from the dentate line in group A and 3.5 cm (1–4.5 cm) in group B. At histology, in group A there were 5 T4 tumors, 9 T3, 10 T3+ (<1 mm distance from the circumferential resection margin), 13 T2 and 2 T1. In group B, there were 3 T4 tumors, 14 T3, 8 T3+, 7 T2 and 2 T1. Differences between groups were not significant.The mean number of lymph nodes retrieved in group A specimens was 19.2 (5–45) and in group B 19.2 (8–41) (p = 0.2). In group A, 3.9 (1–9) regional, 13.9 (3–34) intermediate and 1.5 (1–3) apical lymph nodes were retrieved. The respective values in group B were 3.7 (3–7), 14.4 (4–33) and 1.3 (1–3). Differences between groups were not significant. Also, the incidence of lymph node involvement by the tumor was not significantly different between groups (group A: 23; group B: 19). Conclusions: Laparoscopic resection of the rectum can achieve similar lymph node clearance to the open approach. Also, distribution of the lymph nodes along the resected specimens is similar between the two approaches.

© 2007 S. Karger AG, Basel


  

Author Contacts

Evaghelos Xynos
19, Michelidaki Street
GR–712 02 Heraklion (Greece)
Tel. +30 2810 280 002, Fax +30 2810 280 009
E-Mail exynos@med.uoc.gr

  

Article Information

Number of Print Pages : 6
Number of Figures : 0, Number of Tables : 3, Number of References : 31

  

Publication Details

Digestive Diseases (Clinical Reviews)

Vol. 25, No. 1, Year 2007 (Cover Date: March 2007)

Journal Editor: Malfertheiner, P. (Magdeburg)
ISSN: 0257–2753 (print), 1421–9875 (Online)

For additional information: http://www.karger.com/DDI


Article / Publication Details

First-Page Preview
Abstract of Original Article

Published online: 3/29/2007
Issue release date: March 2007

Number of Print Pages: 6
Number of Figures: 0
Number of Tables: 3

ISSN: 0257-2753 (Print)
eISSN: 1421-9875 (Online)

For additional information: http://www.karger.com/DDI


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Heald RJ, Husband EM, Ryall RDH: The mesorectum in rectal cancer surgery: the clue to pelvic recurrence? Br J Surg 1982;69:613–616.
  2. Heald RJ, Karanjia ND: Results of radical surgery for rectal cancer. World J Surg 1992;16: 848–857.
  3. Dahlberg M, Glimelius B, Pahlman L: Changing strategy for rectal cancer is associated with improved outcome. Br J Surg 1999;86:379–384.
  4. Aziz O, Constantinides V, Tekkis PP, et al: Laparoscopic versus open surgery for rectal cancer: a meta-analysis. Ann Surg Oncol 2006;13:413–424.
  5. Gao F, Cao YF, Chen LS: Meta-analysis of the short-term outcomes after laparoscopic resection for rectal cancer. Int J Colorectal Dis 2006;7:1–5.
  6. Quah HM, Jayne DG, Eu KW, Seow-Choen F: Bladder and sexual dysfunction following laparoscopically assisted and conventional open mesorectal resection for rectal cancer. Br J Surg 2002;89:1551–1556.
  7. Araujo SE, da Silva e Sousa AH Jr, de Campos FG, et al: Conventional approach versus laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial. Rev Hosp Clin Fac Med São Paolo 2003;58:133–140.
  8. Breukink SO, Grond AJK, Pierie JPEN, Hoff C, Wiggers T, Meijerink WJHJ: Laparoscopic vs. open total mesorectal excision for rectal cancer. An evaluation of the mesorectum’s macroscopic quality. Surg Endosc 2005;19:307–310.
  9. Guillou PJ, Quirke P, Thorpe H, et al: Short-term endpoints of conventional versus laparoscopic assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005;365:1718–1726.
  10. Tate JJ, Kwok S, Dawson JW, et al: Prospective comparison of laparoscopic and conventional anterior resection. Br J Surg 1993;80:1396–1398.
  11. Darzi A, Lewis C, Menzies-Gow N, et al: Laparoscopic abdominoperineal excision of the rectum. Surg Endosc 1995;9:414–417.
  12. Goh YC, Eu KW, Seow-Choen F: Early postoperative results of a prospective series of laparoscopic vs. open anterior resections for rectosigmoid cancers. Dis Colon Rectum 1997;40:776–780.
  13. Leung KL, Kwok SP, Lau WY, et al: Laparoscopic-assisted resection of rectosigmoid carcinoma. Immediate and medium-term results. Arch Surg 1997;132:761–764.
  14. Seow-Choen F, Eu KW, Ho YH, Leong AF: A preliminary comparison of a consecutive series of open versus laparoscopic abdomino-perineal resection for rectal adenocarcinoma. Int J Colorectal Dis 1997;12:88–90.
  15. Ramos JR, Petrosemolo RH, Valory EA, et al: Abdominoperineal resection: laparoscopic versus conventional. Surg Laparosc Endosc 1997;7:148–152.
  16. Iroatulam AJ, Agachan F, Alabaz O, et al: Laparoscopic abdominoperineal resection for anorectal cancer. Am Surg 1998;64:12–18.
  17. Fleshman JW, Wexner SD, Anvari M, et al: Laparoscopic vs. open abdominoperineal resection for cancer. Dis Colon Rectum 1999;42:930–939.
  18. Schwandner O, Schiedeck TH, Killaitis C, Bruch HP: A case-control-study comparing laparoscopic versus open surgery for rectosigmoidal and rectal cancer. Int J Colorectal Dis 1999;14:158–163.
  19. Leung KL, Kwok SP, Lau WY, et al: Laparoscopic-assisted abdominoperineal resection for low rectal adenocarcinoma. Surg Endosc 2000;14:67–70.
  20. Hartley JE, Mehigan BJ, Qureshi AE, et al: Total mesorectal excision: assessment of the laparoscopic approach. Dis Colon Rectum 2001;44: 315–321.
  21. Baker RP, White EE, Titu L, et al: Does laparoscopic abdominoperineal resection of the rectum compromise long-term survival? Dis Colon Rectum 2002;45:1481–1485.
  22. Anthuber M, Fuerst A, Elser F, et al: Outcome of laparoscopic surgery for rectal cancer in 101 patients. Dis Colon Rectum 2003;46:1047–1053.
  23. Feliciotti F, Guerrieri M, Paganini AM, et al: Long-term results of laparoscopic versus open resections for rectal cancer for 124 unselected patients. Surg Endosc 2003;17:1530–1535.
  24. Vorob’ev GI, Shelygin IuA, Frolov SA, et al: Laparoscopic surgery of rectal cancer (comparative results of laparoscopic and open abdominal resection) (in Russian). Khirurgiia (Mosk) 2003;3:36–42.

    External Resources

  25. Wu WX, Sun YM, Hua YB, Shen LZ: Laparoscopic versus conventional open resection of rectal carcinoma: a clinical comparative study. World J Gastroenterol 2004;10:1167–1170.

    External Resources

  26. Radcliffe A: Can the results of anorectal (abdominoperineal resection) be improved: are circumferential resection margins too often positive? Colorectal Dis 2006;8:160–167.
  27. Morino M, Parini U, Giraudo G, Salval M, Brachet Contul R, Garonne C: Laparoscopic total mesorectal excision: a consecutive series of 100 patients. Ann Surg 2003;237:335–342.
  28. Leroy J, Jamali F, Forbes L, et al: Laparoscopic total mesorectal excision for rectal cancer surgery: long-term outcomes. Surg Endosc 2004;18:281–289.
  29. Jass JR, Morson BC: Reporting colorectal cancer. J Clin Pathol 1987;40:1016–1023.
  30. Carolyn C, Compton CA: The staging of colorectal Cancer: 2004 and beyond. Cancer J Clin 2004;54:295–308.
  31. Nagtegaal ID, van de Velde CJ, van der Worp E, Kapiteijn E, Quirke P, van Krieken JH, Cooperative Clinical Investigators of the Dutch Colorectal Cancer Group: Macroscopic evaluation of rectal cancer resection specimen: clinical significance of the pathologist in quality control. J Clin Oncol 2002;20:1729–1734.