Long-term Outcomes of Laparoscopic versus Open Surgery for Rectal Cancer: A Single-center Retrospective Analysis

Jae Hyun Kim; Byung Kwon Ahn; Seun Ja Park; Moo In Park; Sung Eun Kim; Sung Uhn Baek; Seung Hyun Lee; Si Sung Park

doi:10.4166/kjg.2015.65.5.273

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Kim, Ahn, Park, Park, Kim, Baek, Lee, and Park: Long-term Outcomes of Laparoscopic versus Open Surgery for Rectal Cancer: A Single-center Retrospective Analysis

Original Article

Korean J Gastroenterol 2015;65(5):273-282.

Published online: 4 October 2015

DOI: https://doi.org/10.4166/kjg.2015.65.5.273

Long-term Outcomes of Laparoscopic versus Open Surgery for Rectal Cancer: A Single-center Retrospective Analysis

Jae Hyun Kim, Byung Kwon Ahn¹, Seun Ja Park, Moo In Park, Sung Eun Kim, Sung Uhn Baek¹, Seung Hyun Lee¹, Si Sung Park²

Department of Gastroenterology, Kosin University Gospel Hospital, Busan, Korea

¹Department of Colorectal Surgery, Kosin University Gospel Hospital, Busan, Korea

²Department of Neuropsychiatry, Kosin University Gospel Hospital, Busan, Korea

Correspondence to: Byung Kwon Ahn, Department of Surgery, Kosin University College of Medicine, 262 Gamcheon-ro, Seo-gu, Busan 602-702, Korea. Tel: +82-51- 990-6462, Fax: +82-51-246-6093, E-mail: gsabk@hotmail.com

Received 3 December 20147 March 2015 Accepted 22 March 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

Laparoscopic surgery has been proven to be an effective alternative to open surgery in patients with colon cancer. However, data on laparoscopic surgery in patients with rectal cancer are insufficient. The aim of this study was to compare the long-term outcomes of laparoscopic and open surgery in patients with rectal cancer.

Methods

A total of 307 patients with rectal cancer who were treated by open and laparoscopic curative resection at Kosin University Gospel Hospital (Busan, Korea) between January 2002 and December 2011 were reviewed retrospectively.

Results

Regarding treatment, 176 patients underwent an open procedure and 131 patients underwent a laparoscopic procedure. The local recurrence rate after laparoscopic resection was 2.3%, compared with 5.7% after open resection (p=0.088). Distant metastases occurred in 6.9% of the laparoscopic surgery group, compared with 24.4% in the open surgery group (p<0.001). In univariate analysis, age (≥75 years vs. ≤60 years), preoperative staging, surgical approach (open vs. laparoscopic), elevated initial CEA level, elevated follow-up CEA level, number of positive lymph nodes, and postoperative chemotherapy affected overall survival and disease free survival. However, in multivariate analysis, the surgical approach apparently did not affect long-term oncologic outcome.

Conclusions

In this study, long-term outcomes after laparoscopic surgery for rectal cancer were not inferior to those after open surgery. Therefore, laparoscopic surgery would be an alternative operative tool to open resection for rectal cancer, although further investigation is needed.

Keywords: Rectal neoplasms, Conversion to open surgery, Laparoscopy

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Fig. 1.

Comparison of overall survival (OS) and disease-free survival (DFS) according to preoperative staging between open surgery group and laparoscopic surgery group. (A) Stage 1. (B) Stage 2. (C) Stage 3.

Fig. 2.

Comparison of overall survival (OS) and disease-free survival (DFS) according to tumor location between open surgery group and laparoscopic surgery group. (A) Upper (11–15 cm from anal verge). (B) Middle (6–10 cm from anal verge). (C) Lower (≤5 cm from anal verge).

Table 1.

Patient Characteristics

Characteristic	Open (n=176)	Laparoscopy (n=131)	p-value
Gender			0.153
Male	89 (50.6)	77 (58.8)
Female	87 (49.4)	54 (41.2)
Age (yr)	59 (22–85)	61 (33–88)	0.252
Location			0.002
Lower (≤5 cm from anal verge)	45 (25.6)	26 (19.8)
Middle (6–10 cm from anal verge)	84 (47.7)	45 (34.4)
Upper (11–15 cm from anal verge)	47 (26.7)	60 (45.8)
Preoperative staging			0.056
I	33 (18.8)	40 (30.5)
II	45 (25.6)	29 (22.1)
III	98 (55.7)	62 (47.3)
Neoadjuvant CCRT			0.293
Yes	26 (14.8)	14 (10.7)
No	150 (85.2)	117 (89.3)
Adjuvant chemotherapy			0.008
Yes	130 (73.9)	78 (59.5)
No	46 (26.1)	53 (40.5)

Values are presented as n (%) or mean (range).

CCRT, concurrent chemoradiotherapy.

Table 2.

Pathological Data

Variable	Open (n=176)	Laparoscopy (n=131)	p-value
Completeness of resection			0.304
Complete	163 (92.6)	126 (96.2)
Partially complete	12 (6.8)	4 (3.1)
Incomplete	1 (0.6)	1 (0.8)
Histology			0.846
Well differentiated	44 (28.0)	36 (27.5)
Moderately differentiated	118 (63.0)	88 (67.2)
Poorly differentiated	10 (6.6)	5 (3.8)
Mucinous	4 (2.4)	2 (1.5)
Circumference resection margin			0.951
Positive	7 (4.0)	4 (3.1)
Negative	122 (69.3)	67 (51.1)
Missing data	47 (26.7)	60 (45.8)
Number of harvested lymph nodes
Total group	13.0 (0–48.0)	12.0 (0–83.04)	0.946
Missing data	4	5
Number of positive lymph nodes
Total group	2.62±4.45	1.39±2.52	0.003
Missing data	4	4
Distance to proximal resection margin (cm)
Total group	13.5 (1.5-40.0)	10.0 (0.8-33.0)	<0.001
Missing data	11	5
Distance to distal resection margin (cm)
Total group	2.0 (0–10.0)	3.0 (0–8.5)	0.181
Missing data	11	5

Values are presented as n (%), median (range), n only, or mean±SD.

Table 3.

Postoperative Recurrence according to Surgical Procedure

	Total (n=307)	Open (n=176)	Laparoscopy (n=131)	p-value
Period of performance of operation				<0.001
January 2002-December 2004	47 (15.3)	43 (24.4)	4 (3.0)
January 2005-December 2007	99 (32.2)	85 (48.3)	14 (10.7)
January 2008-December 2011	161 (52.5)	48 (27.3)	113 (86.3)
Duration of follow-up (mo)	44 (8–142)	51 (8–142)	40 (11–135)	<0.001
Time to recurrence (mo)	18 (5–136)	20 (5–136)	11 (5–37)	0.076
Recurrence after operation				<0.001
Local recurrence	13 (4.3)	10 (5.7)	3 (2.3)	0.088
Distant recurrence	52 (16.9)	43 (24.4)	9 (6.9)	<0.001
No recurrence	242 (78.8)	123 (69.9)	119 (90.8)
Site of distant recurrence				0.958
Liver	13 (4.2)	10 (5.7)	3 (2.3)
Lungs	20 (6.5)	17 (9.7)	3 (2.3)
Bone	3 (1.0)	3 (1.7)	0 (0)
Lymph nodes	2 (0.7)	2 (1.1)	0 (0)
Peritoneum	4 (1.3)	3 (1.7)	1 (0.8)
Ovary	1 (0.4)	1 (0.6)	0 (0)
Multiple organ involvement	9 (2.9)	7 (4.0)	2 (1.5)

Values are presented as n (%) or median (range).

Table 4.

Univariate Analysis of Overall Survival and Disease-free Survival

Factor	Overall Survival		Disease-free Survival
Factor	Hazard ratio (95% CI)	p-value	Hazard ratio (95% CI)	p-value
Age (yr)
60-74 vs. ≤60	1.46 (0.88-2.44)	0.144	1.51 (0.94-2.44)	0.091
≥75 vs. ≤60	2.47 (1.08-5.67)	0.033	3.79 (1.85-7.77)	<0.001
Male vs. female	1.21 (0.78-1.89)	0.404	1.31 (0.84-2.04)	0.232
Open vs. laparoscopic surgery	1.94 (1.14-3.28)	0.014	2.09 (1.24-3.52)	0.006
Tumor location
Middle vs. lower	1.62 (0.89-2.92)	0.114	1.60 (0.89-2.90)	0.120
Upper vs. lower	1.08 (0.57-2.08)	0.807	1.04 (0.54-1.99)	0.910
Stage 2 vs. stage 1	3.29 (1.22-8.93)	0.019	3.45 (1.27-9.36)	0.015
Stage 3 vs. stage 1	6.19 (2.48-15.45)	<0.001	5.59 (2.24-13.97)	<0.001
Histology (well/moderate vs. poorly/mucinous)	0.94 (0.38-2.32)	0.887	0.85 (0.34-2.11)	0.727
Completeness of resection (R1/R2 vs. R0)	2.00 (0.96-4.16)	0.063	1.98 (0.95-4.12)	0.067
Positive CRM	0.86 (0.67-1.10)	0.234	0.83 (0.64-1.06)	0.138
Number of harvested LNs	0.99 (0.97-1.02)	0.787	1.00 (0.97-1.03)	0.983
Number of positive LNs	1.17 (1.12-1.23)	<0.001	1.15 (1.11-1.20)	<0.001
Distance to proximal RM	0.99 (0.96-1.02)	0.558	0.99 (0.96-1.02)	0.622
Distance to distal RM	1.01 (0.89-1.14)	0.861	0.99 (0.88-1.12)	0.882
Elevated initial CEA level	3.12 (1.97-4.95)	<0.001	2.91 (1.84-4.60)	<0.001
Elevated follow-up CEA level	3.46 (2.59-4.61)	<0.001	3.69 (2.76-4.93)	<0.001
Preoperative CCRT	0.82 (0.44-1.51)	0.519	0.93 (0.50-1.72)	0.810
Postoperative chemotherapy	0.18 (0.08-0.39)	<0.001	0.19 (0.09-0.41)	<0.001

CRM, circumferential resection margin; LNs, lymph nodes; RM, resection margin; CCRT, concurrent chemoradiotherapy.

Table 5.

Multivariate Analysis of Overall Survival and Disease-free Survival

Factor	Overall Survival		Disease-free Survival
Factor	Hazard ratio (95% CI)	p-value	Hazard ratio (95% CI)	p-value
Age (yr)
60-74 vs. ≤60	1.46 (0.88-2.44)	0.144	1.41 (0.85-2.35)	0.186
≥75 vs. ≤60	2.47 (1.08-5.67)	0.033	3.30 (1.43-7.63)	0.005
Open vs. laparoscopic surgery	1.06 (0.57-1.98)	0.845	1.49 (0.78-2.85)	0.222
Stage 2 vs. stage 1	0.73 (0.12-4.48)	0.732	0.43 (0.07-2.73)	0.369
Stage 3 vs. stage 1	0.99 (0.17-6.05)	0.998	0.46 (0.07-2.92)	0.412
Number of positive LNs	1.19 (1.12-1.27)	<0.001	1.14 (1.07-1.21)	<0.001
Elevated initial CEA level	2.16 (1.29-3.60)	0.003	1.76 (1.06-2.91)	0.029
Elevated follow-up CEA level	3.68 (2.59-5.23)	<0.001	3.72 (2.63-5.26)	<0.001
Postoperative chemotherapy	0.29 (0.13-0.67)	0.004	0.20 (0.09-0.49)	<0.001

LNs, lymph nodes.

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