Retrospective Study
Copyright ©The Author(s) 2016.
World J Gastrointest Surg. Jun 27, 2016; 8(6): 452-460
Published online Jun 27, 2016. doi: 10.4240/wjgs.v8.i6.452
Table 1 Demographic characteristics of study cohort
VariablesLap (%) n = 200Converted (%) n = 25Open (%) n = 408P value
GenderMale128 (64)15 (60)243 (60)0.570
Female72 (36)10 (40)165 (40)
Median age (yr)596366< 0.001
Ethnic groupChinese172 (86)22 (88)352 (86.3)0.368
Malay9 (4.5)019 (4.7)
Indian4 (2)2 (8)18 (4.4)
Others15 (7.5)1 (4)19 (4.7)
ASA175 (37.5)4 (16)84 (20.6)0.002
2105 (52.5)20 (80)267 (65.4)
320 (10)1 (4)55 (13.5)
4002 (0.4)
Location of tumorLower rectum68 (34)8 (32)131 (32.1)0.381
Middle rectum90 (45)10 (40)212 (52)
Upper rectum42 (21)7 (28)65 (15.9)
Type of surgeryHAR30 (15)4 (16)24 (5.9)0.067
LAR (w/stoma)27 (13.5)4 (16)82 (20.1)
LAR (w/o stoma)32 (16)5 (20)76 (18.6)
ULAR98 (49)12 (48)193 (47.3)
APR13 (6.5)033 (8.1)
Neo-adjuvant therapy statusChemo-therapy5 (2.5)014 (3.4)< 0.001
Radio-therapy3 (1.5)012 (2.9)< 0.001
Adjuvant therapy statusChemo-therapy65 (32.5)15 (60)134 (32.8)0.071
Radio-therapy28 (14)7 (28)82 (20.1)0.271
Table 2 Reasons for laparoscopic conversion to open surgery
Reason for conversionNo. of patients (% within converted patients)
Excessive adhesions12 (48)
Advanced tumor or excessive tumor fixation3 (12)
Difficult anatomy3 (12)
Intraoperative complications (e.g., bleeding, ureteric/urinary tract injury, bowel perforation/injury)4 (16)
Intolerant of tilt and pneumoperitoneum3 (12)
Table 3 Oncologic characteristics and perioperative outcomes of study cohort
VariablesLap (%) n = 200Converted (%) n = 25Open (%) n = 408P value
Tumor gradeWell-differentiated20 (10)3 (12)38 (9.3)0.339
Mod-differentiated173 (86.5)21 (84)349 (85.6)
Poorly-differentiated7 (3.5)1 (4)21 (5.1)
Median lesion size (cm)3.94.14.30.275
T stageT118 (9)3 (12)23 (5.6)0.151
T243 (21.5)4 (16)73 (17.9)
T3126 (63)9 (36)265 (65)
T413 (6.5)9 (36)47 (11.5)
Nodal statusN095 (47.5)10 (40)188 (46.1)0.77
N+105 (52.5)15 (60)320 (53.9)
TNM stageStage I47 (23.5)3 (12)69 (16.9)0.086
Stage II51 (25.5)4 (16)111 (27.2)
Stage III75 (37.5)9 (36)162 (39.7)
Stage IV27 (13.5)9 (36)66 (16.2)
Perineural invasion+38 (19)8 (32)90 (22.1)0.652
-162 (81)17 (68)318 (77.9)
Vascular invasion+61 (30.5)11 (44)135 (33.1)0.617
-139 (69.5)14 (56)275 (66.9)
Median lymph nodes harvested (range)14 (4-90)15 (4-55)14 (3-56)0.447
Proximal margin (cm)9.9 (0-30)10 (2-22)12 (0-39)0.004
Distal margin (cm)2.1 (1-15)1.8 (1-15)2 (1-14)0.55
CRM < 2 mm29 (14.5)5 (20)75 (18.4)0.494
Median duration of surgery (min)162147119< 0.001
Length of hospitalization7 (3-159)7 (5-16)8 (3-78)< 0.001
Table 4 Distribution of long-term and short-term outcomes across three surgery groups
Laparoscopic surgery n = 200Converted surgery n = 25Open surgery n = 408P value
No. of patients (%)No. of patients (%)No. of patients (%)
Short-term outcomes
Anastomotic leaks13 (6.5)0 (0)17 (4.2)0.233
Wound complications8 (4)2 (8.0)31 (7.6)0.227
Bleeding complications5 (2.5)1 (4.0)9 (2.2)0.840
Ileus3 (1.5)2 (8.0)18 (4.4)0.097
Pneumonia1 (0.5)0 (0)8 (2)0.298
Cardiac events7 (3.5)2 (8)17 (4.2)0.562
30 d mortality2 (1)0 (0)8 (2.0)0.545
Long-term
Intestinal obstruction23 (11.5)5 (20)59 (14.5)0.396
Incisional hernia9 (4.5)1 (4)33 (8.1)0.218
Local recurrence9 (4.5)1 (4.0)36 (8.8)0.126
Distant recurrence45 (22.5)6 (24)106 (26)0.644
Table 5 Prognostic factors of overall survival: Univariate and multivariate analysis
Variable5 yr overall survival (%)Univariate P valueOverall survival HR (95%CI)Multivariate P value
Age ≥ 65 vs < 6550.9 vs 68.3< 0.00111.4557 (1.083-1.9568)0.0032
Gender (male vs female)60.6 vs 600.921--
Lap vs converted vs open70.5 vs 61.8 vs 52.70.0161-0.148
ASA 1/2 vs 3/462.6 vs 45.70.0161-0.131
NeoadjChemo (yes vs no)59.5 vs 60.40.36--
NeoadjRT (yes vs no)66.7 vs 60.20.654--
AdjChemo (yes vs no)40.8 vs 70.5< 0.0011-0.06
AdjRT (yes vs no)53.2 vs 62.30.206--
TNM stage (I-IV)< 0.0011< 0.0012
Stage I77.2Reference
Stage II73.81.04 (0.58-1.84)0.907
Stage III60.31.52 (0.89-2.58)0.124
Stage IV13.95.80 (3.26-10.33)< 0.001
Tumor grade0.00210.0152
Well differentiated75Reference
Moderately differentiated60.12.10 (1.00-4.40)0.049
Poorly differentiated39.11.18 (0.54-2.54)0.682
CRM < 2 mm vs > 2 mm40.1 vs 63.5< 0.00111.66 (1.19-2.32)0.0032
No. of lymph nodes ≥ 12 vs < 1262.2 vs 56.10.08--
Perineural invasion36.2 vs 67.3< 0.0011-0.276
Vascular emboli46.2 vs 68.5< 0.0011-0.14
Clinical symptoms of obstruction at presentation (yes vs no)35.3 vs 64.6< 0.00111.95 (1.39-2.74)< 0.0012
Table 6 Summary of studies reporting at least 5 year survival outcomes of laparoscopic vs open rectal resection
Ref.Type of studyNo. of patients with rectal cancer5 yr overall survivalRemarks
Lujan et al[4]Randomized Controlled Trial204 (103 open, 101 lap)75.3% (open) vs 72.1% (lap) P = 0.980Middle and low rectal cancers only
Green et al[26], (MRC CLASICC trial)Randomized Controlled Trial381 (128 open, 253 lap)52.9% (open) vs 60.3% (lap) P = 0.132
Ng et al[29]Pooled Analysis of 3 RCT278 (142 open, 136 lap)61.1% (open) vs 63.0% (lap) P = 0.50510 yr overall survival
Laurent et al[6]Retrospective Comparative Study471 (233 open, 239 lap)79% (open) vs 82% (lap) P = 0.52Cancer free survival main outcome measure
Day et al[25]Retrospective222 (133 open, 89 lap)58% (open) vs 75% (lap) P = 0.014Laparoscopic group had better survival on multivariate analysis as well
Baik et al[24]Case-matched Controlled Analysis162 (108 open, 54 lap)88.5% (open) vs 90.8% (lap) P = 0.261
Li et al[28]Retrospective238 (123 open, 113 lap)78.9% (open) vs 77.9% (lap) P = 0.913Middle and low rectal cancers only
Lim et al[21]Retrospective191 (91 open, 100 lap)72.6% (open) vs 74.7% (lap) P = 0.54
Zhong et al[30]Retrospective514 (238 open, 186 lap)61.3% (open) vs 69.4% (lap) P = 0.067
Agha et al[23]Retrospective225 (all laparoscopic)50.5% (lap)10 yr overall survival