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Defining the Role of Minimally Invasive Proctectomy for Locally Advanced Rectal Adenocarcinoma

Sujatha-Bhaskar, Sarath MD; Jafari, Mehraneh D. MD; Gahagan, John V. MD; Inaba, Colette S. MD; Koh, Christina Y. MD; Mills, Steven D. MD; Carmichael, Joseph C. MD; Stamos, Michael J. MD; Pigazzi, Alessio MD, PhD

doi: 10.1097/SLA.0000000000002357
PAPERS OF THE 137TH ASA ANNUAL MEETING
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Objective: National examination of open proctectomy (OP), laparoscopic proctectomy (LP), and robotic proctectomy (RP) in pathological outcomes and overall survival (OS).

Background: Surgical management for rectal adenocarcinoma is evolving towards utilization of LP and RP. However, the oncological impacts of a minimally invasive approach to rectal cancer have yet to be defined.

Methods: Retrospective review of the National Cancer Database identified patients with nonmetastatic locally advanced rectal adenocarcinoma from 2010 to 2014, who underwent neoadjuvant chemoradiation, surgical resection, and adjuvant therapy. Cases were stratified by surgical approach. Multivariate analysis was used to compare pathological outcomes. Cox proportional-hazard modeling and Kaplan–Meier analyses were used to estimate long-term OS.

Results: Of 6313 cases identified, 53.8% underwent OP, 31.8% underwent LP, and 14.3% underwent RP. Higher-volume academic/research and comprehensive community centers combined to perform 80% of laparoscopic cases and 83% of robotic cases. In an intent-to-treat model, multivariate analysis demonstrated superior circumferential margin negativity rates with LP compared with OP (odds ratio 1.34, 95% confidence interval 1.02–1.77, P = 0.036). Cox proportional-hazard modeling demonstrated a lower death hazard ratio for LP compared with OP (hazard ratio 0.81, 95% confidence interval 0.67–0.99, P = 0.037). Kaplan–Meier analysis demonstrated a 5-year OS of 81% in LP compared with 78% in RP and 76% in OP (P = 0.0198).

Conclusion: In the hands of experienced colorectal specialists treating selected patients, LP may be a valuable operative technique that is associated with oncological benefits. Further exploration of pathological outcomes and long-term survival by means of prospective randomized trials may offer more definitive conclusions regarding comparisons of open and minimally invasive technique.

Department of Surgery, University of California, Irvine School of Medicine, Irvine, CA.

Reprints: Alessio Pigazzi MD, PhD, University of California, Irvine, Department of Surgery, 333 City Blvd. W. Ste. 850, Orange, CA 92868. E-mail: apigazzi@uci.edu.

Author contributions: Dr Mehraneh D. Jafari assisted with design of the study plan, interpretation of results, and drafting of the manuscript with addition of critical intellectual content. She has given final approval. Dr John V. Gahagan has assisted in designing of the NCDB study protocol, acquisition of data, analysis of data, and manuscript revisions. He has given final approval. Dr Colette S. Inaba has assisted by reviewing our NCDB data retrieval and analysis protocol and drafting and revisions of the manuscript. She has given final approval. Dr Christina Y. Koh has assisted by reviewing our NCDB data retrieval and analysis protocol as well as manuscript revision. She has given final approval. Dr Steven D. Mills has assisted with design of the study plan and manuscript revisions. He has given final approval. Dr Joseph C. Carmichael has assisted with design of study plan, manuscript revisions, assistance with result interpretation, and recommendations on study statistics. He has assisted with study revisions. He has given final approval. Dr Michael J. Stamos has assisted with design of study plan, interpretation of results, drafting and revision of the manuscript. He has given final approval. Dr Alessio Pigazzi has assisted in facilitating usage of the NCDB database, design of the study plan, drafting of our NCDB data analysis protocol, interpretation of results, and drafting/revisions of our manuscript. He has given final approval.

The authors report no conflicts of interest.

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