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10.1245/ASO.2006.05.045
Annals of Surgical Oncology 13:413-424 (2006)
© 2006 Society of Surgical Oncology
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Original Article

Laparoscopic Versus Open Surgery for Rectal Cancer: A Meta-Analysis

Omer Aziz, MRCS, BSc, Vasilis Constantinides, MBBS, Paris P. Tekkis, MD, FRCS, Thanos Athanasiou, PhD, FECTS, Sanjay Purkayastha, MRCS, BSc, Paraskevas Paraskeva, PhD, FRCS, Ara W. Darzi, FRCS, KBE and Alexander G. Heriot, MD, FRCS

Department of Surgical Oncology & Technology, Imperial College London, St. Mary’s Hospital, 10th Floor QEQM Wing, Praed Street, London W2 1NY, United Kingdom

Correspondence: Address correspondence and reprint requests to: Alexander G. Heriot, MD, FRCS; E-mail: a.heriot{at}imperial.ac.uk.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: Laparoscopic rectal cancer surgery aims to provide patients with curative resection while minimizing postoperative morbidity and mortality. This study used meta-analytical techniques to compare laparoscopic and open surgery as the primary treatment for patients with rectal cancer with regard to short-term and long-term outcomes.

Methods: A literature search was performed on all studies between 1993 and 2004 comparing laparoscopic and open surgery for rectal cancer. Subgroup analysis was performed on patients undergoing abdominoperineal excision of the rectum. The following end points were evaluated: operative outcomes, postoperative recovery, and early and late adverse events.

Results: Twenty studies matched the selection criteria and reported on 2071 subjects, of whom 909 (44%) underwent laparoscopic and 1162 (56%) underwent open surgery for rectal cancer. Time to stomal function (weighted mean difference [WMD], –1.52; 95% confidence interval [95% CI], –2.20, –1.01), first bowel movement (WMD, –.72; 95% CI, –1.21,–.22), feeding solids (WMD, –.92; 95% CI, –1.35,–.50), and length of hospital stay (WMD, –2.67; 95% CI, –3.81, –1.54) were all significantly reduced after laparoscopic surgery. In patients who underwent abdominoperineal excision of the rectum, wound infection (odds ratio, .15; 95% CI, .03, .73) and requirement for postoperative parenteral analgesia (WMD, –.63; 95% CI, –1.22,–.04) were also significantly reduced. There was no difference between groups in the extent of oncological clearance.

Conclusions: Laparoscopic rectal cancer surgery results in an earlier postoperative recovery and a resected specimen that is oncologically comparable to open surgery. Results from randomized trials reporting long-term outcomes such as cancer recurrence (local and metastatic) and 5-year survival are eagerly awaited.

Key Words: Laparoscopic • Rectal cancer • Curative resection • Comparative


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Laparoscopic surgery for rectal cancer aims to provide patients with curative resection while minimizing postoperative morbidity and mortality. Adequacy of resection margins and total mesorectal excision for mid and low rectal tumors are important requirements of rectal resections for cancer, because they have been shown to be crucial in reducing local recurrence and ultimately improving survival during open surgery.1 Adjuvant treatments such as preoperative radiotherapy have also been suggested for downstaging of rectal cancers and reducing local recurrence and may therefore be used together with a surgical resection as part of a multidisciplinary approach to the treatment of rectal cancer.2 Although oncological radicality and survival are the primary outcomes that determine success from rectal cancer resections, secondary outcomes such as a reduction in postoperative complications, time taken to recover from surgery, urinary continence, and sexual function are all important determinants of quality of life after surgery3–5 and have been suggested to be improved by a laparoscopic approach.

Although evidence from randomized trials suggests that freedom from recurrence and cancer-related survival rates are comparable after laparoscopic as compared with open surgery for colorectal cancer,6,7 such evidence is at present missing for laparoscopic rectal cancer surgery. Concerns that the technical difficulties of laparoscopic rectal cancer resection might limit the application of laparoscopic techniques with respect to oncological outcomes have been raised, and this contributed to the exclusion of rectal cancer resections from the Clinical Outcomes of Surgical Therapy (COST) trial.7 With regard to short-term postoperative outcomes, a recent meta-analysis of 12 randomized trials that compared laparoscopic versus open surgery for colonic cancer demonstrated a reduction in postoperative morbidity, time to recovery, and length of stay, with no evidence of compromise to oncological clearance.8 Laparoscopic rectal cancer surgery would be expected to have similar benefits when compared with open surgery, but this has been impossible to quantify, mainly because of the presence of limited prospective randomized trials specifically comparing laparoscopic with open surgery for rectal cancer.9–11

Meta-analysis can be used to evaluate the existing literature in both a qualitative and quantitative way by comparing and integrating the results of different studies and taking into account variations in characteristics that can influence the overall estimate of the outcome of interest.12,13 This study uses meta-analytical techniques to compare laparoscopic and open surgery for rectal cancer with regard to operative outcomes, early postoperative complications, postoperative recovery, and late complications.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study Selection
A MEDLINE, EMBASE, OVID, and Cochrane database search was performed on all studies between 1993 and 2004 to compare laparoscopic and open surgery for rectal cancer. The following Medical Subject Headings were used: "laparoscopy," "rectal neoplasms/*pathology/*surgery," "comparative study," and "treatment outcome". The "related articles" function was used to broaden the search, and all abstracts, studies, and citations scanned were reviewed.

Data Extraction
Three reviewers (O.A., A.G.H., and V.C.) independently extracted the following from each study: first author, year of publication, study population characteristics, study design, inclusion and exclusion criteria, number of subjects operated on with each technique, male:female ratio, conversion rate, and time of follow-up.

Inclusion Criteria
To enter the analysis, studies had to (1) compare laparoscopic and open techniques in patients undergoing rectal cancer resection, (2) report on at least one of the outcome measures mentioned below, and (3) clearly document rectal cancer surgery as either an "anterior resection" or "abdominoperineal resection" and clearly document technique as "laparoscopic" or "open." When two studies were reported by the same institution, either the one of better quality or the most recent publication was included in the analysis.

Exclusion Criteria
Studies were excluded from the analysis if (1) the outcomes of interest were not reported for the two techniques or it was impossible to calculate these from the published results, (2) they reported on rectal surgery for benign lesions and inflammatory bowel disease and did not contain a distinct group of patients with rectal cancer, or (3) they reported on a patient group undergoing palliative treatment (non-curative surgical intent).

Outcomes of Interest and Definitions
The following outcomes were used to compare the laparoscopic rectal cancer surgery group with the open rectal cancer surgery group in surgery for rectal cancer:

  1. Operative outcomes included operative time, the presence of positive radial margins, and the number of lymph nodes harvested in the specimen.
  2. Early postoperative complications included postoperative mortality, hemorrhage, anastomotic leak, perianal wound complications (infection or hematoma), wound infection, chest infection, prolonged ileus, incidence of deep vein thrombosis (DVT)/pulmonary embolus (PE), and urinary retention.
  3. Postoperative recovery included time to stomal function, time to first bowel movement, time to feeding liquids, time to feeding solids, time requiring parenteral analgesia, and length of hospital stay.
  4. Late complications included bowel obstruction and the incidence of abdominal wound hernia at follow-up.

Statistical Analysis
Meta-analysis was performed in line with recommendations from the Cochrane Collaboration and the Quality of Reporting of Meta-Analyses guidelines. 14,15 Statistical analysis for categorical variables was performed by using the odds ratio (OR) as the summary statistic. This ratio represents the odds of an adverse event occurring in the laparoscopic group compared with the open group. Subgroup analysis was also performed for the above-mentioned outcomes in patients undergoing abdominoperineal excision of the rectum for low rectal cancers.

The Mantel-Haenszel method was used to combine the ORs for the outcomes of interest by using a random-effects meta-analytical technique. Yates’ correction was used for studies that contained a 0 in one cell for the number of events of interest in one of the two groups.16,17 These "zero cells" created problems with the computation of the ratio measure and its standard error of the treatment effect. This was resolved by adding the value .5 in each cell of the 2 x 2 table for the study in question, and if there were no events for either the laparoscopic or open group, then the study was discarded from the meta-analysis.

For continuous variables such as the number of lymph nodes harvested, statistical analysis was performed by using the weighted mean difference (WMD) as the summary statistic.18 For studies that presented continuous data as means and range values, the standard deviations were calculated by using statistical algorithms and checked by using bootstrap resampling techniques. Thus, all continuous data were standardized for analysis.

The quality of the studies was assessed by using the Newcastle-Ottawa Scale with some modifications to match the needs of this meta-analysis.19,20 This scoring system uses three aspects of study design to assess quality: namely, patient selection, comparability of study groups, and assessment of outcome. It is important to appreciate that such scoring systems are used in the quality comparison of nonrandomized research because simple quality grading according to levels of evidence does not provide adequate stratification. In this study, studies that achieved five or more stars on the modified Newcastle-Ottawa Scale were considered high quality.

Three strategies were used to quantitatively assess heterogeneity. First, data were reanalyzed by using both random- and fixed-effects models. Second, graphical exploration with funnel plots was used to evaluate publication bias.21,22 Third, sensitivity analysis was undertaken by using the following subgroups: (1) studies of high quality with 5 or more stars, (2) studies with a year of publication inclusive of and greater than 2000, and (3) studies containing more than 20 patients in each group. In a random-effects model, it is assumed that there is variation between studies, and the calculated OR thus has a more conservative value.18,21 In surgical research, meta-analysis with the random-effects model is preferable, particularly because patients who undergo operation in different centers have varying risk profiles and selection criteria for each surgical technique. Analysis was conducted by using the statistical software Intercooled Stata version 8.0 for Windows (Stata Corporation, College Station, TX) and Review Manager Version 4.2 (The Cochrane Collaboration, Software Update, Oxford).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Studies Selected
The literature search identified 22 studies that compared the results of laparoscopic and open rectal cancer surgery for rectal cancer.9–11,23–41 Of these, one study was excluded from the analysis because it did not provide adequate results for the outcomes of interest,40 and another was excluded because it contained a patient group that had already been included in this analysis.39 Twenty studies published between 1993 and 2004 that matched the selection criteria and compared laparoscopic rectal cancer surgery with open rectal cancer surgery for rectal cancer were therefore included in this meta-analysis. These included a combined total of 2071 subjects, of which 909 (44%) underwent laparoscopic rectal cancer surgery and 1162 (56%) underwent open rectal cancer surgery as the primary operative intervention for rectal cancer. On review of the data extraction, there was 100% agreement among the three reviewers.

The characteristics of these 20 studies are listed in Table 1Go. Fourteen studies contained groups that were fully matched for age and sex, whereas six studies had groups matched for age, sex, length of follow-up, tumor type, and tumor stage. One study contained laparoscopic and open groups matched for the grade of tumor.35 Eight studies scored 5 or more stars on the modified Newcastle-Ottawa Scale, 11 studies had a year of publication equal to or greater than 2000, and 13 studies contained 20 or more patients in both the laparoscopic and open groups. Fin ally, seven studies followed up their patients for ≥24 months. It is interesting to note that the rate of conversion ranged from 0% to 34%. The outcomes of interest reported by each of the 19 studies are listed in Table 2Go. The trial by Guillou et al.11 gave median and interquartile range values for "time to first bowel movement," "resuming normal diet," and "length of stay" and therefore could not be used in the meta-analysis of these outcomes.


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  		TABLE 1. Study characteristics
 

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  		TABLE 2. Studies reporting outcomes after laparoscopic versus open surgery for rectal cancer
 
Results from meta-analysis of the studies with regard to operative outcomes, early postoperative complications, postoperative recovery, and late complications are listed in Table 3Go. The table displays the number of studies reporting each outcome, the total number of patients in both the laparoscopic and open groups, the summary statistic of OR or WMD, the 95% confidence intervals (CI)s, a test of heterogeneity between the studies, and the calculated P values. Figure 1Go is a Forest plot displaying the results of the meta-analysis of measures of postoperative recovery after laparoscopic rectal cancer surgery versus open rectal cancer surgery for rectal cancer: namely, time to feeding solids, stomal function, and first bowel movement. Figure 2Go is a Forest plot displaying the results of the meta-analysis of length of stay and measures of postoperative recovery after laparoscopic abdominoperineal resections (LAPRs) versus open abdominoperineal resections (OAPRs) for rectal cancer: namely, time to feeding solids, stoma function, and requirement for parenteral analgesia.


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  		TABLE 3. Results of a meta-analysis comparing laparoscopic versus open surgery for rectal cancer
 

Figure 1
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  		FIG. 1. Forest plot displaying the results of the meta-analysis of measures of postoperative recovery after laparoscopic rectal cancer surgery versus open rectal cancer surgery for rectal cancer: time to feeding solids, time to stomal function, and time to first bowel movement. WMD, weighted mean difference; CI, confidence interval.

 

Figure 2
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  		FIG. 2. Forest plot displaying the results of the meta-analysis of length of stay and measures of postoperative recovery after laparoscopic abdominoperineal resections (LAPR) versus open abdominoperineal resections (OAPR) for rectal cancer: namely, time to feeding solids, stoma function, and requirement for parenteral analgesia. WMD, weighted mean difference; CI, confidence interval.

 
Meta-Analysis of Operative Outcomes
Operative time was significantly increased in the laparoscopic as compared with the open group, with a WMD of 40.18 (95% CI, 26.46–56.13), although there was no significant difference between the two groups in the proportion of patients with positive radial margins or the number of lymph nodes found in the harvested specimen.

Meta-Analysis of Early Postoperative Complications
There was no significant difference between the laparoscopic and open groups in postoperative mortality rates, hemorrhage, anastomotic leak, perianal wound complications, wounds, or chest infections. There was also no significant difference in the incidence of prolonged ileus, postoperative DVT/PE, or urinary retention.

Meta-Analysis of Outcomes of Postoperative Recovery
In cases in which a stoma was required, the time to stomal function was significantly shorter in the laparoscopic as compared with the open surgery group (WMD, –1.52; 95% CI, –2.20, –1.01), as was the time to first bowel movement (WMD,–.72; 95% CI, –1.21,–.22) and the time to feeding solids (WMD,–.92; 95% CI, –1.35,–.50), as shown in Fig. 1Go. The length of hospital stay was also significantly reduced in the laparoscopic as compared with the open group (WMD, –2.67; 95% CI, –3.81, –1.54). There was no significant difference between groups in the time taken to tolerate fluids and the requirement for parenteral analgesia.

Meta-Analysis of Late Complications
There was no significant difference between the laparoscopic and open groups in the incidence of postoperative bowel obstruction or postoperative hernia at follow-up.

Subgroup Analysis of Abdominoperineal Resections
Meta-analysis of studies that reported on patients undergoing laparoscopic rectal cancer surgery versus OAPR (Table 4Go) revealed a significantly longer operative time in the laparoscopic as compared with the open group (WMD, 35.94; 95% CI, 19.9, 51.99). There was no significant difference between groups in the proportion of patients with positive radial margins or the number of lymph nodes harvested in the specimen. With regard to early postoperative complications, the incidence of wound infection was 0% after LAPR versus 14% after OAPR: a finding that was significant (CI, .15; 95% CI, .03, .73). There was no difference between groups in perianal wound complications or the incidence of urinary retention. Measures of postoperative recovery were all significantly better in the LAPR group: namely, time to stomal function (WMD, –1.76; CI, –2.62,–.90), time to feeding solids (WMD, –1.52; 95% CI, –2.68,–.37), requirement for parenteral analgesia (WMD,–.63; 95% CI, –1.22,–.04), and length of hospital stay (WMD, –4.74; 95% CI, –6.75, –2.74). There was no significant difference between groups in the incidence of bowel obstruction.


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  		TABLE 4. Results of a meta-analysis comparing laparoscopic versus open abdominoperineal resection for rectal cancer
 
Publication Bias
A funnel plot of the studies used in the meta-analysis reporting on wound infection after laparoscopic rectal cancer surgery as compared with open rectal cancer surgery is shown in Fig.3Go. This is a scatter plot of the treatment effects estimated from individual studies plotted on the horizontal axis (OR) against the standard error of the estimate shown on the vertical axis. None of the studies lay outside the limits of the 95% CIs, and there was no evidence of publication bias (all studies were equally distributed around the vertical axis) or heterogeneity among the studies (P = .63). When only studies of high quality (five or more stars) were considered, however, the studies became distributed more closely together, as indicated in Fig.4Go.


Figure 3
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  		FIG. 3. Funnel plot for the results from all studies comparing wound infection in patients undergoing laparoscopic versus open surgery for rectal cancer. Lap, laparoscopic; OR, odds ratio; SE, standard error.

 

Figure 4
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  		FIG. 4. Funnel plot for results from high-quality studies comparing wound infection in patients undergoing laparoscopic versus open surgery for rectal cancer. Lap; laparoscopic; OR, odds ratio; SE, standard error.

 
Sensitivity Analysis
The results for sensitivity analysis performed for studies comparing laparoscopic rectal cancer surgery versus open rectal cancer surgery are listed in (Table 5Go). With regard to wound infection, when all studies were considered (Table 3Go), heterogeneity was 8.88 (P = .63). This was reduced when high-quality studies (heterogeneity, 2.02; P = .85), those with a year of publication after and including 2000 (heterogeneity, 1.69; P = .79), and those with >20 patients in each group (heterogeneity, 1.61; P = .95) were considered. With regard to length of stay, significant heterogeneity existed between groups during both overall and subgroup analyses, although this was lowest when only recent studies were considered (heterogeneity, 16.05; P = .01). This was also the case with the time taken to resume a solid diet, for which heterogeneity was lowest and not significant when only recent studies were considered (heterogeneity, .87; P = .35). These findings highlight the paramount importance of accounting for good study design, adequate sample size, and, finally, the effects of time when comparing new surgical techniques.


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  		TABLE 5. Sensitivity analysis performed for studies comparing LRS versus ORS
 
Power Calculation for Outcomes of Interest
The incidence of postoperative complications between studies in the open rectal cancer surgery group ranged from 1.9% for DVT/PE (a relatively rare event) to 16.2% for perianal wound complications (a more common event). In the laparoscopic group, the incidence of these complications was .6% and 2.3%, respectively. To rule out a 50% relative risk reduction with a 5% significance level and 80% power, a traditional randomized controlled trial would require approximately 2649 patients in each arm for rare events and 280 for the more common ones. The sample size in our study was adequately powered to detect such changes in the most common complications: namely, hemorrhage, wound infection, anastomotic leak, chest infection, postoperative ileus, and death.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The results of this meta-analysis of 2071 patients have shown that there was no significant difference in the proportion of patients with "positive radial margins" and the "number of lymph nodes harvested" when considering the laparoscopic rectal cancer surgery, open rectal cancer surgery, LAPR, and OAPR groups. This finding suggests that specimens from laparoscopic and open surgery were comparable in terms of their adequacy of resection and oncological clearance. Because these operative factors strongly influence the likelihood of curative resection and ultimately, survival after laparoscopic surgery for rectal cancer, this is an important confirmatory finding. The operative time was significantly longer with laparoscopic rectal cancer surgery as compared with open rectal cancer surgery—a finding that has been consistent in laparoscopic colorectal surgery.

Postoperative recovery was significantly better for patients who underwent laparoscopic resection in terms of bowel function and shortened hospital stay. This was also true for abdominoperineal resections, for which the requirement for parenteral analgesia was also significantly reduced in the laparoscopic group. It is important to note that time to feeding solids is a measure of recovery that is prone to bias, because surgeons with an interest in laparoscopic rectal cancer surgery are likely to feed their patients earlier than for open rectal cancer surgery. Time to first bowel movement is a better measure, but it may also be affected by the decision to commence oral intake. Improvement in the return of bowel function and reduced hospital stay has been shown by both the COST and Conventional versus Laparoscopic-Assisted Surgery Inpatients with Colorectal Cancer (CLASICC) trials for laparoscopic colorectal cancer surgery, although neither has demonstrated an improvement in quality of life.11,42

The results of this study on early and late postoperative complications after laparoscopic and open rectal cancer surgery did not reveal any significant difference between groups, although subgroup analysis comparing LAPR and OAPR showed a significantly lower rate of wound infection in the laparoscopic (0%) as compared with the open (13.9%) group. The fact that the other postoperative complications were not significantly different between laparoscopic and open surgery is interesting to note because this is often considered to be one of the potential benefits of laparoscopic surgery. Results from the power calculation suggest that for common adverse events (such as perianal wound complications), the sample size was adequate. It is more difficult to comment on rarer complications, such as DVT, for which the sample size was small. Several studies have identified a potential reduction in long-term complications after laparoscopic colonic resection, including a reduction in ventral hernias43 and a reduced incidence of adhesional small-bowel obstruction.43,44 Although these findings were not confirmed for laparoscopic rectal resection within this meta-analysis, these are areas that require further examination within a future trial.

The incidence of urinary retention was not significantly different when laparoscopic rectal cancer surgery, open rectal cancer surgery, LAPR, and OAPR were compared, although concerns have been raised over the potential risk of increased pelvic nerve damage after laparoscopic rectal resection. Quah et al.10 assessed longer-term bladder and sexual dysfunction retrospectively in 40 patients who had undergone laparoscopic rectal cancer surgery as compared with another 40 who had open rectal cancer surgery. They found a significantly higher rate of sexual dysfunction in men after laparoscopic surgery: 47% of men who underwent laparoscopic rectal cancer surgery reported impotence or impaired ejaculation, compared with 5% of men who had open rectal cancer surgery. There was no difference between laparoscopic rectal cancer surgery and open rectal cancer surgery in bladder dysfunction or female sexual function. It is uncertain whether this morbidity is secondary to iatrogenic disruption of pelvic innervation resulting from laparoscopic surgery, but it clearly requires further study.

In deciding the best operative strategy for patients with rectal cancer, the risks of recurrence and long-term survival are the most important factors to consider. Only five studies reported on local and metastatic recurrence,9,30,31,35,37 whereas only four reported long-term survival.29,31,33,35 The fact that none of these was matched for tumor grade, use of adjuvant oncological therapy, or duration of follow-up, as well as the small number of patients (166 laparoscopic rectal cancer surgery vs.179 open rectal cancer surgery patients) for whom recurrence and survival were documented, makes comparison of long-term survival with the two techniques impossible.

Meta-analytical research such as this study has several limitations that must be taken into account when its results are considered. Despite the efforts for standardization, outcome measures were less well defined, and this therefore limited the proportion of studies for which outcomes were comparable. It was not possible to match all patient groups for tumor grade, stage, and adjuvant treatment, all of which are factors known to affect outcome for patients with rectal cancer. Neither the allocation of treatment nor the assessment of outcome was blinded, and it is important to bear in mind publication bias, particularly in meta-analytical research based on published studies, as well as variations in inclusion criteria, treatment protocols, operative technique, and outcome assessment between studies. It is also important to note that only three of the studies included in this meta-analysis had a prospective randomized design,9–11 and only one of these (CLASICC) focused on a group of patients undergoing laparoscopic resection for rectal cancer.11 Although the lack of randomized data available is important to acknowledge, it is in such situations that meta-analysis does allow comparison of the two surgical approaches.

This study could not account for the learning curve associated with the technique and its effect on postoperative outcome, and this is an important consideration because it has been suggested that laparoscopic resection of the rectum is more technically demanding and is associated with a longer learning curve than other laparoscopic colonic resections.45 The studies included in this meta-analysis did have surgeons of varying experience with laparoscopic rectal cancer surgery. This is illustrated by the conversion rate, which was as high as 34% in the recently published multicenter CLASICC trial by Guillou et al.,11 which is the largest comparative randomized trial thus far to report specifically on a group of patients undergoing laparoscopic surgery for rectal cancer. The inclusion criteria for the large randomized trials of laparoscopic colorectal surgery, such as COST7 and CLASICC,11 have been for the operating surgeon to have performed >20 laparoscopic resections before submitting patients onto the trial. It has been suggested that the learning curve may actually be bimodal, with improvement continuing to >100 cases.46 It is possible, therefore, that the outcomes could be better for surgeons with more experience with laparoscopic rectal cancer surgery, and this necessitates further close examination.

This article highlights the individual merits and weaknesses of laparoscopic as compared with open surgery as the primary treatment of rectal cancer. Although the result of this meta-analysis suggest that laparoscopic rectal cancer surgery results in an earlier postoperative recovery and a resected specimen that is oncologically comparable to those with open surgery, more long-term data on cancer recurrence and survival at 3 and 5 years after surgery are eagerly awaited from studies such as the CLASICC trial.11 This will ultimately determine the suitability of laparoscopic surgery as the primary treatment for rectal cancer.

Received for publication June 14, 2005. Accepted for publication September 2, 2005.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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