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In Reply

Academic Surgical Unit, St James's University Hospital, Leeds, United Kingdom

Julia M. Brown, Helen C. Thorpe

Clinical Trials and Research Unit, University of Leeds, Leeds, United Kingdom

The authors thank W.P. Ceelen for his comments and note his concern regarding the support for laparoscopic rectal cancer surgery, drawn from the 3-year CLASICC data analysis.¹

Indeed, concerns were expressed by the authors in a short-term analysis of CLASICC (Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer) regarding an observed increase in circumferential resection margin (CRM) positivity following laparoscopic as compared to open anterior resection (AR), although this did not reach statistical significance.² The same was not observed following abdominoperineal resection, where rates of CRM involvement were comparable. This led to the cautious recommendation that routine laparoscopic anterior resection for rectal cancer was not justified at that time.

The CLASICC data have now matured and at 3 years' follow-up the observed difference in CRM positivity following anterior resection has not translated into a difference in local recurrence rates. It is accepted that CLASICC was not designed to detect a difference in outcomes for rectal cancer and that the data presented are from subgroup analysis. However, the CIs around the difference in local recurrence rates (difference in local recurrence rates = –0.8%; 95% CI, –8.8% to 7.2%) suggest that there is unlikely to be a clinically relevant difference between the arms. As 95% of recurrences present within 3 years of surgery, it might have been expected that, at least, a nonsignificant trend to increased local recurrence would have been observed in the laparoscopic arm, had this been the case.

We acknowledge that the number of anterior resections with a positive CRM was small (laparoscopic AR: 16 of 129; open AR: four of 64) and that further follow-up is required to ensure that a difference does not emerge in the longer term. However, until other randomized trials of laparoscopic rectal cancer surgery are reported, the CLASICC study remains the largest randomized trial from which any conclusions can be drawn.

The authors share W.P. Ceelen's enthusiasm for total mesorectal excision (TME) and have previously highlighted the importance of performing high-quality laparoscopic TME, particularly in the preservation of postoperative sexual and bladder function.³ However, we believe that it is time to embrace the advantages of new technology, and to complement training in open TME with similar high quality training in laparoscopic TME. If this can be achieved, it is likely that the previously high conversion rates observed with laparoscopic rectal cancer surgery can be reduced with corresponding improvements in quality of life.

We confirm our support for laparoscopic rectal cancer surgery, with the caveat that surgeons must be suitably trained in the performance of high-quality laparoscopic TME.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Jayne DG, Guillou PJ, Thorpe H, et al: Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-Year results of the UK MRC CLASICC Trial Group. J Clin Oncol 25 : 3061 -3068, 2007[Abstract/Free Full Text]

2. Guillou PJ, Quirke P, Thorpe H, et al: Short-term endpoints of conventional versus laparoscopicassisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 365 : 1718 -1726, 2005[CrossRef][Medline]

3. Jayne DG, Brown JM, Thorpe H, et al: Bladder and sexual function following resection for rectal cancer in a randomized clinical trial of laparoscopic versus open technique. Br J Surg 92 : 1124 -1132, 2005[CrossRef][Medline]

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