Is the jury here? Survival advantage with lap surgery for rectal cancer

Laparoscopic surgery may improve long-term overall survival (OS) compared to open surgery for patients with rectal cancer, according to results from a large meta-analysis.

The estimated 5-year OS rate for patients who underwent laparoscopic surgery was 76.2%, compared with 72.7% for those who underwent open surgery.

“The survival benefit of laparoscopic surgery is encouraging and supports the routine use of laparoscopic surgery for adult patients with rectal cancer in the era of minimally invasive surgery,” write the authors, led by Leping Li, MD, from the Department of Gastrointestinal Surgery, Shandong Provincial Hospital, Shandong, China

The article was published online in Open JAMA Network.

Surgery is an essential part in the treatment of rectal cancer, but the advantages of laparoscopic surgery over open surgery are unclear. Over the past 15 years, randomized clinical trials (RCTs) have shown comparable long-term results for laparoscopic and open surgery. However, in most meta-analyses that have assessed the evidence more broadly, researchers have used an “inappropriate” method for pooled analysis.

Li and her colleagues wanted to perform their own meta-analysis to better understand whether the long-term outcome evidence supports or opposes the use of laparoscopic surgery for rectal cancer.

In the present study, the authors conducted a meta-analysis of individual participant data using time-to-event data and focused on long-term survival outcomes after laparoscopic or open surgery for adult patients with rectal cancer.

A total of 10 articles involving 12 RCTs and 3709 participants were included. In these, 2097 patients were randomly assigned to undergo laparoscopic surgery, and 1612 were randomly assigned to undergo open surgery. The studies focused on a global population, with participants from Europe, North America and East Asia.

In a one-step analysis, the authors found that disease-free survival was slightly better in patients who underwent laparoscopic surgery, but the results were statistically similar (relative risk [HR]0.92; P = 0.26).

However, with regard to OS, those who had undergone laparoscopic surgery fared significantly better (HR, 0.85; P = .02).

These results held in the two-step analysis for disease-free survival (HR, 0.92; P = 0.25) and OS (RR, 0.85; P = .02). A sensitivity analysis conducted with large RCTs yielded similar pooled effect sizes for disease-free survival (HR, 0.91; P = 0.20) and OS (RR, 0.84; P = .03).

The authors highlight several reasons why laparoscopic surgery may be associated with better survival. First, the authors note, the faster recovery from the minimally invasive procedure could allow patients to start adjuvant therapy sooner. Additionally, reduced stress responses and higher levels of immune function in patients undergoing minimally invasive surgery may contribute to a long-term survival benefit.

“These findings address concerns about the efficacy of laparoscopic surgery,” the authors write. However, “further studies are needed to explore the specific mechanisms underlying the positive effect of laparoscopic surgery on OS.”

No external source of funding has been identified. The authors did not disclose any relevant financial relationship.

JAMA Netw Open. Published online May 9, 2022. Full text

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