Laparoscopic total mesorectal excision: a consecutive series of 100 patients

Abstract

Objective: To analyze total mesorectal excision (TME) for rectal cancer by the laparoscopic approach during a prospective nonrandomized trial.

Summary background data: Improved local control and survival rates in the treatment of rectal cancer have been reported after TME.

Methods: The authors conducted a prospective consecutive series of 100 laparoscopic TMEs for low and mid-rectal tumors. All patients had a sphincter-saving procedure. Case selection, surgical technique, and clinical and oncologic results were reviewed.

Results: The distal limit of rectal neoplasm was on average 6.1 (range 3-12) cm from the anal verge. The mean operative time was 250 (range 110-540) minutes. The conversion rate was 12%. Excluding the patient who stayed 104 days after a severe fistula and reoperation, the mean postoperative stay was 12.05 (range 5-53) days. The 30-day mortality was 2% and the overall postoperative morbidity was 36%, including 17 anastomotic leaks. Of 87 malignant cases, 70 (80.4%) had a minimum follow-up of 12 months, with a median follow-up of 45.7 (range 12-72) months. During this period 18.5% (13/70) died of cancer and 8.5% (6/70) are alive with metastatic disease. The port-site metastasis rate was 1.4% (1/70): a rectal cancer stage IV presented with a parietal recurrence at 17 months after surgery. The locoregional pelvic recurrence rate was 4.2% (3/70): three rectal cancers stage III at 19, 13, and 7 postoperative months.

Conclusions: Laparoscopic TME is a feasible but technically demanding procedure (12% conversion rate). This series confirms the safety of the procedure, while oncologic results are at present comparable to the open published series with the limitation of a short follow-up period. Further studies and possibly randomized series will be necessary to evaluate long-term clinical outcome in cancer patients.

Figures

Figure 1. Trocar positions for laparoscopic total mesorectal excision; dotted lines represent possible sites of minilaparotomy. The numbers represent the size of trocars (5 or 10 mm).

Figure 2. Laparoscopic view at the end of total mesorectal excision before division of the rectum.

Figure 3. Laparoscopic-assisted end-to-end colorectal anastomosis with a double-stapled technique.

Figure 4. Survival rate by stage evaluated using Kaplan-Meier statistical analysis. Time represented in postoperative months.

Figure 5. Disease-free rate by stage evaluated using Kaplan-Meier statistical analysis. Time represented in postoperative months.