Page 57 - Read Online

Page 6 of 8 O’Donohue et al. Mini-invasive Surg 2018;2:24 I http://dx.doi.org/10.20517/2574-1225.2018.34

Of note, there is overwhelming data supporting that there are improved outcomes with the increasing
quality of TME excision. However, this evidence was collected in the open operation era. Is quality of
[31]
the TME the only predictor in overall survival? Bouvy et al. published an article in 1997 which sug-
gested that laparoscopic surgery was associated with less tumour growth when compared to conventional
open surgery because of the reduced operative trauma. They believed that reduced operative stress lead
[31]
to decreased production of growth factors and therefore decreased stimulation of tumour cell growth .
More recently, endocrine and metabolic markers have been studied in attempt to quantify this operative
stress. Human leukocyte antigen (HLA) and the pro-inflammatory marker interleukin 6 (IL-6) have been
proposed potential surrogates to measure the surgical stress response. The evidence suggests that there is
preserved immune function and less inflammation in laparoscopy as compared to the conventional open
[32]
resections .

Could this be the reason that despite current trials being unable to show non-inferiority, early survival data
appears equivalent? To answer this, we await the survival data from the more recent trials with great interest.

Should the next focus be more on the quality of the TME using minimally invasive techniques (robotics or
trans-anal TME)? If we are currently obtaining equivalence in survival outcomes with lower grade TME
quality, surely survival will improve with the development of higher quality minimally invasive TME.

[33]
Kim et al. have recently published their experience with robotic TME. They retrospectively compared
732 patients (robotic n = 272; laparoscopic n = 460) aiming to evaluate the long term oncological outcomes
between the robotic and laparoscopic TME. Ultimately, they were able to show that the overall 5-year sur-
vival for robotic TME and laparoscopic TME was 90.5% and 78% respectively, with the 5-year disease free
survival being 72.6% and 68% respectively. Despite the limitations of this study, it does reveal that robotic
TME may have a meaningful impact on long term outcomes (in regard to overall survival and disease free
[33]
survival) . Long-term oncological outcomes from the prospective trials Robotic versus Laparoscopic Re-
section for Rectal Cancer (ROLARR) and Comparison of Laparoscopic versus Robotic-Assisted Surgery for
Rectal Cancer (COLRAR) trials are awaited.

CONCLUSION
Currently there is conflicting evidence for the role of laparoscopic TME for rectal cancer patients. The evi-
dence from recent well executed RCTs would suggest that the short term oncological outcome of the lapa-
roscopic TME has failed to reach noninferiority. The long-term survival data from the limited literature
is promising and is showing equivalence between the 2 groups. However more evidence from recent trials
needs to publish to further evaluate this.

It is our belief that in experienced hands laparoscopic rectal resection is not non-inferior but is equivalent
to open resection. In saying this, it is important that whichever modality is chosen, that the surgeon is
comfortable and well trained in that technique. Ultimately the quality of the surgery will facilitate the out-
comes for the patient and hopefully the desired long-term outcome.

DECLARATIONS
Authors’ contributions
Design, manuscript editing, manuscript revision: O’Donohue PF, Warren CD, Chow CFK
Literature research, data analysis, manuscript writing: O’Donohue PF, Warren CD

Availability of data and materials
Not applicable.