Background: Previous studies indicated that the oncologic results of total mesorectal excision with abdominoperineal resection were poorer than those of total mesorectal excision with sphincter-preserving procedure for the treatment of low rectal cancer. However, previous studies were conducted in the era of traditional open surgery. Recently, more and more total mesorectal excisions were performed by laparoscopic approach. Therefore, it is mandatory to re-scrutinize if the same conclusion could be drawn when both surgical procedures were performed laparoscopically.
Methods: We enrolled 344 eligible patients with low rectal cancer for the present study, 170 of whom underwent preoperative chemoradiation therapy followed by laparoscopic total mesorectal excision, whereas 174 patients directly underwent laparoscopic total mesorectal excision without chemoradiation. Patients with or without chemoradiation were further stratified according to the pathologic tumor-node-metastasis stage (stage II or III disease) and surgical strategy (abdominoperineal resection or sphincter-preserving operation). The surgical procedures are presented in attached multimedia supplemental materials. All patients were prospectively followed (median: 40 months, range: 4-88 months) and the treatment outcomes were compared.
Results: In patients with preoperative chemoradiation, the estimated recurrence rate were similar between total mesorectal excision with abdominoperineal resection and total mesorectal excision with sphincter-preserving operation with 18.5%, n=5/27 versus 10.6%, n=7/66 in stage II disease (p=0.811, log-rank test); and 20%, n=4/20 versus 19.3%, n=11/57 in stage III disease (p=0.980). In patients without preoperative chemoradiation, the recurrence rate was significantly higher in total mesorectal excision with abdominoperineal resection than in total mesorectal excision with sphincter-preserving operation group of patients in stage III disease (45%, n=9/20 versus 19.3%, 16/83, p=0.025), whereas the recurrence rate of the two procedures was similar (21.4%, n=3/14 versus 17.5%, n=10/57, p=0.702) in stage II disease.
Conclusion: In the context that total mesorectal excision was performed laparoscopically, the poorer prognosis of abdominoperineal resection than that of sphincter-preserving operation was only seen in stage III patients without preoperative chemoradiation.
Key words: rectal cancer, laparoscopic surgery, total mesorectal excision(TME), abdominoperineal resection(APR), sphincter-preserving operation(SPO)
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