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O’Donohue et al. Mini-invasive Surg 2018;2:24 I http://dx.doi.org/10.20517/2574-1225.2018.34 Page 5 of 8

The evidence from these landmark trials has highlighted the improvement in oncological outcomes as ex-
perience and expertise with laparoscopic rectal surgery increases.

LONGER TERM ONCOLOGICAL OUTCOMES FOR RECTAL SURGERY
At present, there is only limited published data available for the longer term oncological data that compares
laparoscopic and open approaches to rectal cancer. Currently, available datasets include the 10-year data
from the MRC CLASICC trial, the 3-year data from the COREAN and COLOR II trials. The initial 2-year
longer term oncological outcomes are still awaited from ALaCaRT and ACOSOG Z6051 trials.

The MRC CLASICC trial has revealed quite promising outcomes in terms of locoregional recurrence,
disease free survival and overall survival after 10 years. There was no difference in the overall survival,
disease free survival or local recurrence on subgroup analysis. The median disease-free survival was
70.6 months (open 67.1 months, laparoscopic 70.8 months; P = 0.925) with the median overall survival be-
[19]
ing 73.6 months (65.8 months open group, 82.7 months laparoscopic group; P = 0.147) .
In the COREAN trial the 3-year disease free survival was 79.2% for laparoscopic surgery and 72.5% for the
[20]
open resection group , which was not statistically significant. There was also no significant difference in
the rates of local recurrence or overall survival (disease free survival P = 0.34). These results were similar
to the results of the COLOR II trial in which 3-year disease free survival was 74.8% in the laparoscopic
[18]
surgery group and 70.8% in the open group, which did not result in a statistically significant difference .
The 3-year overall survival of the laparoscopic and open TME groups was 86.7% and 83.6% respectively.
This was not statistically significant. Both groups in the COLOR II trial had a 5% locoregional recurrence
[18]
rate . In both studies, the authors concluded that laparoscopic rectal surgery was comparable to that of
the open resection group.

EVIDENCE FROM META-ANALYSES FOR RECTAL CANCER
[30]
The most recent meta-analysis was published by Arezzo et al. in 2015. This included all RCTs and non-
randomised control trials published between 2000 and 2013 (therefore not including the ALaCaRT and
ACOSOG Z6051 trials). Their ultimate primary end point was CRM positivity, but they also analysed
DRM, quality of TME and local recurrence at 5 years. Essentially this revealed no significant differ-
ence in any of these outcome measures. The authors concluded that there was some evidence to support
laparoscopic rectal resection in terms of short term outcomes, pathological outcomes and longer-term
[30]
outcomes .
Moreover, there was a Cochrane review article published in 2014 that evaluated the short and longer-term
outcomes of laparoscopic and open rectal surgery. This review only reviewed RCTs. The conclusion was
that there was moderate strength evidence to support laparoscopic resection. It revealed similar outcomes
for disease free survival, overall survival and local recurrence. In addition, it also noted that there was a
[1]
decrease in hospital length of stay and time to first defection in the laparoscopic resection group .
Even though the evidence is not considered to be as strong, the general impression is that laparoscopic rec-
tal surgery is not non-inferior to open rectal resection.

SHIFTING OF FOCUS
Should the focus of these noninferiority studies shift focus from immediate oncologic analysis and focus
more upon the long-term survival data? In an experienced surgeon’s hands there appears to be a definite
[29]
short-term benefit regarding reduced post-operative morbidity and hospital length of stay . This cannot
be accepted if the long-term survival data is not equivalent to that of the open surgical group.