The Landmark Series: Minimally Invasive (Laparoscopic and Robotic) Colorectal Cancer Surgery
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CONTINUING EDUCATION– COLORECTAL CANCER
The Landmark Series: Minimally Invasive (Laparoscopic and Robotic) Colorectal Cancer Surgery Marco E. Allaix, MD, PhD1, Fabrizio Rebecchi, MD1, and Alessandro Fichera, MD, FACS, FASCRS2 Department of Surgical Sciences, University of Torino, Turin, Italy; 2Department of Surgery, Division of Colorectal Surgery, Baylor University Medical Center, Dallas, TX 1
ABSTRACT Current high-quality evidence supports the routine use of the laparoscopic approach for patients with colon cancer. Laparoscopic colectomy is associated with earlier resumption of gastrointestinal function and shorter hospital stay, with no increased morbidity or mortality. Pathology and long-term oncologic outcomes are similar to those achieved with open surgery. The absolute benefits of laparoscopic resection for rectal cancer are still under evaluation. While its safety in terms of early postoperative clinical outcomes has been confirmed, two recent randomized controlled trial (RCTs) have questioned its routine use even in expert hands, since its non-inferiority has not been demonstrated when compared with the gold standard of open surgery. Furthermore, the impact of robotic technology is still unclear, since the only RCT available so far failed to demonstrate any benefits compared with standard laparoscopic rectal resection.
Surgical resection is the standard of care for the treatment of colorectal cancer. The last three decades have witnessed several major advancements, including the concept of total mesorectal excision (TME), multidisciplinary management, laparoscopic approach, and lastly, robotic technology. Starting in the early 1990s, several nonrandomized comparative studies have shown improved postoperative recovery after laparoscopic colectomy, with no increase in
Ó Society of Surgical Oncology 2020 First Received: 1 March 2020 Accepted: 19 June 2020 A. Fichera, MD, FACS, FASCRS e-mail: [email protected]
morbidity and mortality. However, reports of high recurrence rates at the port sites raised concerns regarding the oncologic safety of this approach. To better define the impact of laparoscopic surgery on patients with colorectal cancer, several randomized controlled trials (RCTs) have been conducted during the last 20 years, showing clear benefits in colon cancer patients (Table 1). Based on these encouraging data, some RCTs were then undertaken also in rectal cancer patients, with mixed results (Table 2). More recently, robotic technology has been introduced to overcome perceived limitations of standard laparoscopy. The aim of this review is to critically assess the outcomes of large RCTs comparing open and minimally invasive surgery in colon and rectal cancer patients. LITERATURE SEARCH A literature search was performed in MEDLINE and EMBASE databases for RCTs published between January 2000 and April 2020. Only multicenter RCTs or RCTs with more than 100 patients per arm were considered for inclusion in this review. Methodological quality of the RCTs was evaluated following the Coc
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