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Use of Laparoscopy for Rectal Cancer: A Word of Caution

Department of Surgical Oncology, Ghent University Hospital, Ghent, Belgium

To the Editor:

I have read with interest the paper from Jayne et al presenting the 3-year results of the CLASICC (Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer) trial comparing open with laparoscopic assisted resection of colorectal cancer, and the authors should be commended for overcoming the many challenges associated with successful completion of a surgical outcome study.¹ While the data confirm the oncological safety of laparoscopic assisted resection of colon cancer, a word of caution might be appropriate regarding the author's conclusion that this finding can be extended to laparoscopic resection of rectal cancer. First, obviously the reported outcome data for rectal cancer concern a subgroup analysis without formal sample size or power calculation, and as such, the results should be regarded as hypothesis generating. Second, one of the major improvements in rectal cancer therapy has been the introduction of total mesorectal excision (TME), as evidenced by the results of expert series as well as nationwide training programs in several European countries. Rather than giving in to pressure from the devices industry or from ill-advised patient organizations, it seems wiser to further invest resources in adequate open TME training in the pursuit of excellence, especially given the fact that no obvious advantages in quality of life were associated with the laparoscopic approach. In this regard, it would be interesting to know just in how many of the laparoscopic anterior resections TME and subsequent low anastomosis were performed using the laparoscope, and in how many patients laparoscopy was limited to mobilization of the proximal bowel followed by TME via a small suprapubic incision. There is no doubt that the latter approach would jeopardize adequate removal of the entire mesorectum in low-lying cancers. Finally, even though the reported double incidence of an involved circumferential resection margin after laparoscopic anterior resection did not translate into a higher local recurrence rate, neither the short follow-up time nor the design of the study can definitely rule out a true difference. In conclusion, I feel that, outside the context of rigorous trials, the author's original conclusion² that routine laparoscopic anterior resection for rectal cancer is not justified still stands.

AUTHOR'S 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 laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): Multicentre, randomised controlled trial. Lancet 365 : 1718 -1726, 2005[CrossRef][Medline]

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  David G. Jayne, Pierre J. Guillou, Julia M. Brown, and Helen C. Thorpe
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