Controversies in Surgical Oncology: Does the Minimally Invasive Approach for Rectal Cancer Provide Equivalent Oncologic Outcomes Compared with the Open Approach?

BACKGROUND: Compared with open surgery, minimally invasive surgery for colon cancer has been shown to improve short-term outcomes and yield equivalent long-term oncologic results. It remains to be seen if oncologic outcomes for the minimally invasive approach for rectal cancer are equivalent to traditional open rectal resection.

METHODS: We conducted a systematic review of Medline, SCOPUS, and Cochrane databases. Relevant studies were selected using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five key questions comparing minimally invasive and open oncologic outcomes for rectal cancer were specifically analyzed. A meta-analysis was not done due to heterogeneity of studies.

RESULTS: Forty-five studies met inclusion criteria, including six randomized controlled trials. The laparoscopic approach to rectal resection was not more likely than the traditional open approach to have clear circumferential and distal margins, a complete total mesorectal excision grade, ≥ 12 lymph nodes in the resected specimen, reduced local recurrence rates, or reduced overall survival rates. Two randomized trials revealed that successful laparoscopic resection was not noninferior to open.

CONCLUSIONS: Caution should be exercised when choosing surgical options for rectal cancer. Results of randomized trials could not prove that short-term oncologic outcomes of laparoscopic surgery were equivalent to those after open surgery even when performed by surgeons with laparoscopic expertise. However, reported long-term data have not shown a difference in outcomes between laparoscopic and open surgery. Future advances in minimally invasive technology may improve oncologic margins but these will require careful study and scrutiny.