E. F. Midura2, D. J. Hanseman2, R. S. Hoehn2, B. R. Davis2, D. E. Abbott2, S. A. Shah2, I. M. Paquette2 2University Of Cincinnati,General Surgery,Cincinnati, OH, USA
Introduction: The oncologic safety of minimally invasive surgery for colon cancer has been well established, however the role for a minimally invasive approach to rectal cancer has yet to be fully defined. Though current evidence to support the use of laparoscopic and robotic approaches is limited, these approaches are being adopted broadly into clinical practice. We sought to describe national practice patterns in different surgical approaches and operative outcomes for rectal cancer in the US.
Methods: The 2010 National Cancer Database (NCDB) was queried for surgical cases of rectal cancer. Surgical approach was classified as open, laparoscopic, or robotic. Patient, tumor, and hospital characteristics were examined for variation in approach. Oncologic efficacy was studied by examining whether harvest of ≥ 12 lymph nodes (controlling for radiation use) and negative surgical margins were achieved. We used propensity-score matching to compare laparoscopic or robotic surgery to open surgery, while controlling for case-mix differences.
Results: We identified 9,253 patients, of which 68.6% had open, 26.4% laparoscopic, and 5.0% robotic surgery. Patients who underwent a minimally invasive approach were more likely to have private insurance, higher income, and be operated on in higher volume, urban hospitals. Patients who underwent open operations were more likely to have elevated CEA levels, higher histologic grade and more advanced pathologic stage. Patients who had robotic surgery were more likely to receive preoperative radiation compared to other approaches (p = 0.01). In unadjusted analysis, patients who had a minimally invasive approach had a lower incidence of positive resection margin, a shorter length of stay and a lower readmission rate compared to open surgery, however there were no differences in lymph nodes harvested or 30-day mortality (Table 1). After propensity score matching on age, gender, radiation use, tumor grade, and pathologic T and N stage, the laparoscopic approach was associated with a 2.6% decrease in the incidence of positive margin when compared to open surgery (p = 0.02), whereas the robotic approach was not associated with a difference in margin status when compared to open surgery.
Conclusion: Minimally invasive approaches for rectal cancer resections are more commonly performed in high volume, urban, academic centers on privately insured patients. Patients with more advanced tumors are being resected by an open approach. Examination of a matched cohort of patients indicates that the laparoscopic approach may lead to improvements in resection margin status, though longer follow-up will be needed to determine whether this translates into better long-term survival.
