Laparoscopic resection of rectal cancer in the elderly

Abstract

Recent published trials have failed to demonstrate that laparoscopic resection is not inferior to open resection of rectal cancer in terms of pathologic outcomes. However, there have been numerous studies showing the benefit of laparoscopic resection in terms of short-term complications and quality of life. Fewer complications and shorter hospital stays improve the chance of maintaining functional status, which is very important for the elderly population. Thus, laparoscopic resection of rectal cancer remains a viable option for the elderly.

While surgical resection remains the cornerstone of treatment for stage II or III colorectal cancer, there is some debate regarding the efficacy of a laparoscopic technique in patients with rectal cancer. The recently published ACOSOG Z6051 trial failed to demonstrate that laparoscopic resection of rectal cancer was not inferior to open resection in terms of pathologic outcomes. The concern is that while laparoscopic surgery might be beneficial in terms of short-term complications, it might sacrifice long-term recurrence prevention and survival. Since the incidence and death rates for colorectal cancer increase with age (1), determining the best approach to resection in elderly patients with rectal cancer is particularly important.

The Z6051 trial asked, “Is laparoscopic resection noninferior to open resection for the treatment of rectal cancer?” The trial consisted of 462 patients with clinical stage II or III rectal cancer within 12 cm of the anal verge who were randomized to laparoscopic or open low anterior or abdominoperineal resection of the rectum after receiving neoadjuvant therapy. Successful resection was defined as a negative distal margin, a circumferential radial margin (CRM) >1 mm between the deepest extent of tumor invasion into the mesorectal fat and inked surface on the fixed specimen, and a complete or nearly complete total mesorectal excision (TME). A 6% noninferiority margin was chosen for the study.¹

A successful resection was achieved in 81.7% of the laparoscopic cases compared with 86.9% of the open cases. While the difference in success rates was less than the preset noninferiority margin of 6%, the 95% confidence limits extended to a possible difference of up to 10.8%, forcing the authors to acknowledge possible inferiority of the laparoscopic technique. While the authors admitted to using a “novel composite measure of resection quality,” tumor pathologic staging has been shown to be the most important prognostic determinant for the development of recurrent rectal cancer (2). The importance of negative margins also extends to survival data; the 5-year survival of patients with stage III rectal cancer decreased to 42% in those with CRM involvement compared with 81% in those with negative CRM (3). Because the Z6051 trial failed to show that laparoscopic resection was not inferior to open resection, the authors concluded that the data do not support the use of laparoscopic resection of rectal cancer (4).

The ALaCaRT trial from Australia and New Zealand was similar to Z6051, in which 402 patients with T1 to T3 rectal adenocarcinoma <15 cm from the anal verge were randomized to laparoscopic or open laparotomy for rectal resection. The noninferiority margin was set at 8%. A successful resection was accomplished in 82% of laparoscopic cases and 89% of open resections, but similarly, the confidence limits did not allow this study to reject inferiority (5).

The CLASICC trial from the United Kingdom studied 737 patients with colorectal cancer who were randomized to receive laparoscopic-assisted or open resection; this trial included both colon and rectal cancer and randomized patients at a 2-to-1 ratio in terms of laparoscopic or open resection to account for expected conversion rates to open surgery. A nonsignificant increase in CRM positivity was seen in patients who underwent laparoscopic anterior resection of the rectum. The small subset of patients (160) undergoing laparoscopic resection of rectal cancer and the high conversion rate (82) in the subset make the data difficult to interpret. The concern regarding laparoscopic anterior resection was lessened when long-term data were later published demonstrating no difference in overall survival, disease-free survival, and local and distant recurrences between the two groups (6, 7).

The COREAN trial involved 340 patients with mid to low rectal cancer resected after chemoradiotherapy and actually found higher rates of complete TME and CRM negativity in laparoscopic proctectomy (92% and 97%, respectively) when compared with open surgery (88% and 96%). The 3-year local recurrence rate was 2.6% in patients who underwent laparoscopic resection and 4.9% in those who had open surgery. The average body mass index was <25 kg/m², which somewhat decreases the difficulty of the procedure. Furthermore, the noninferiority margin was set at 15%, which gave the study more leeway to establish a statistical difference (8). This study, however, supported the use of laparoscopic surgery for rectal cancer.

These trials with somewhat contradictory conclusions do not definitively define the role of laparoscopic resection for rectal cancer. It is reasonable to consider this option, especially in the right patient population. The elderly represent a high-risk surgical group due to the usual presence of multiple medical comorbidities, decrease in reserve, and diminished functional capacity (9). Numerous studies have shown the benefit of laparoscopic resection in terms of short-term complications and quality of life. Furthermore, studies have shown that prolonged hospital stay is independently associated with a large reduction in functional status (10, 11). Therefore, fewer complications and shorter hospital stays improve the chance of maintaining functional status, which is very important for the elderly population.

A review of the Nationwide Inpatient Sample from 2008 to 2011 of 3,191 patients undergoing elective laparoscopic or open abdominoperineal resection showed that the laparoscopic resection group had lower in-hospital complication rates and a shorter length of stay when compared with the open resection group. The complication rates were 19% in the laparoscopic group and 29% in the open group, and the length of stay was 5.3 vs. 7 days for patients undergoing laparoscopic and open resections, respectively (12).

Boutros et al followed 234 patients who received open or laparoscopic TME for rectal cancer for almost 5 years. This study also showed less blood loss in the laparoscopic group as well as a 1-day shorter hospital stay. Thirty-day general morbidity, specifically the presence of surgical site infections, was less for patients undergoing laparoscopy (13).

Li and colleagues confirmed that the short-term benefits of laparoscopic surgery are also seen in the elderly population. Laparoscopic surgery reduced the length of hospital stay, intraoperative blood loss, time to return of bowel function, and incidence of postoperative pneumonia, wound infection, and postoperative ileus in their review of laparoscopic colorectal resection versus open surgery in octogenarians. Data were collected from 11 comparative studies that included a total of 1066 laparoscopic and 1034 open colorectal resections (9).

Many studies have reported better short-term quality of life in patients after laparoscopic versus open resection. Ng et al reported that Chinese patients with rectal cancer undergoing laparoscopic resection had better physical and cognitive function at 8 months, fewer micturition problems at 4 to 8 months, and fewer male sexual problems from 8 months onward than those undergoing open resection (14). Another study by Li et al specifically looked at the quality of life in patients with rectal cancer after laparoscopic resection and found that patients in the laparoscopic group had less pain, better global health status, and better body image (15).

The above benefits of laparoscopic surgery must be weighed against the potential reduction in cure. While 100% of patients undergoing laparoscopic resection stand to benefit from a faster recovery, up to 11% of patients might have an anticipated 5-year survival rate of approximately 42% instead of 81%, based on data from the Z6051 trial and survival data from the study by Luna-Perez. It is important to relay this concern for a potential decrease in cure rate to the elderly patient considering laparoscopic resection. Because laparoscopic surgery has shown a benefit in short-term complications and quality of life, it remains a viable option for the properly selected elderly patient. High-risk elderly patients may favor the known short-term and quality-of-life benefits of laparoscopic resection over concerns regarding the uncertainty surrounding oncologic outcomes. It is appropriate to discuss this approach with the elderly patient despite the uncertainty around the role of laparoscopic resection for the general population.