Jury Is In? Survival Benefit With Lap Surgery for Rectal Cancer

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

The estimated 5-year OS rate for patients who underwent laparoscopic surgery was 76.2%, vs 72.7% for those who had 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 JAMA Network Open.

Surgery is an essential component in treating rectal cancer, but the benefits of laparoscopic vs open surgery are not clear. Over the past 15 years, randomized clinical trials (RCTs) have shown comparable long-term outcomes for laparoscopic and open surgery. However, in most meta-analyses that assessed the evidence more broadly, researchers used an “inappropriate” method for the pooled analysis.

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

In the current study, the authors conducted an individual participant data meta-analysis using time-to-event data and focused on the 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 covered a global population, with participants from Europe, North America, and East Asia.

In a one-stage analysis, the authors found that disease-free survival was slightly better among patients who underwent laparoscopic surgery, but the results were statistically similar (hazard ratio [HR], 0.92; P = .26).

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

These results held up in the two-stage analysis for both disease-free survival (HR, 0.92; P = .25) and OS (HR, 0.85; P = .02). A sensitivity analyses conducted with large RCTs yielded similar pooled effect sizes for disease-free survival (HR, 0.91; P = .20) and OS (HR, 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 begin adjuvant therapy earlier. In addition, the reduced stress responses and higher levels of immune function among patients undergoing minimally invasive surgery may contribute to a long-term survival advantage.

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

No outside funding source was noted. The authors have disclosed no relevant financial relationships.

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

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