Lower Anterior Resections for Rectal Cancer– Minimally Invasive Better Than Open in a Non-Academic Setting?

Abstract

Research question: In patients with rectal cancer undergoing lower anterior resections (LAR), are the operative approaches (open versus laparoscopic versus robotic) statistically significant in terms of complications and outcomes? Further, do the outcomes from a large private-practice group compare to data published by large, tertiary care academic institutions?

Background, Significance, and rationale for the question: There remains uncertainty as to which surgical approach for lower anterior resections is best suited for rectal cancer. Open and laparoscopic surgical approaches have traditionally been the backbone of surgical treatment for rectal cancer; however, the robot offers a relatively new operative approach that adds more complexity to the situation. Larger academic institutions have often compared two different surgical techniques at a time, and few have compared all three surgical approaches at once. There is an especially notable lack of data related to rectal cancer resections in a community setting.

Materials and Methods: This is a retrospective study from a large group of private-practice colorectal surgeons in a large metropolitan area. A prospectively maintained database was used, and data was queried for low anterior resections using robotic, open, and laparoscopic, approaches in the resection of rectal cancer. Further, data on morbidity and mortality, along with postoperative complications such as acute blood loss anemia, anastomotic leak, and surgical site infection, were evaluated.

Results: From 2016 to January 2020, a total of 130 patients underwent robotic, open, or laparoscopic oncologic lower anterior resections for rectal cancer. Length of stay was noted to be statistically significant (p<0.005) when comparing the open (8.08 days), laparoscopic (7.04 days), and robotic (4.96 days) approaches, respectively. When comparing all three surgical approaches, it was determined that there was no statistical significance for estimated blood loss, operating time, or other postoperative complications including pneumonia, ileus, pulmonary embolism, urinary tract infection, surgical site infection, or anastomotic leak. When the two minimally invasive surgical approaches were combined (laparoscopic low anterior resection and robotic low anterior resection) and compared directly with the open surgical approach, both estimated blood loss and length of stay were statistically significant (p = 0.021 and p=0.005, respectively). There were no perioperative or postoperative mortalities.

Conclusions: This study shows that minimally invasive surgical low anterior resections have a noteworthy advantage over the open approach in terms of length of stay and estimated blood loss. However, it was unexpected, and significant, to note that robotic surgery offered better outcomes when compared to laparoscopic low anterior resections. This experience in the private practice world raises the question as to whether the robotic approach should be considered the standard of care for patients undergoing low anterior resection for rectal cancer.