ORIGINAL ARTICLE
Short-term Outcome of Laparoscopic Surgery for Rectal Cancer
Nobuyoshi Miyajima

Gastroenterological and General Surgery, School of Medicine,
St. Marianna University, Toyoko Hospital, Kawasaki, Japan(Received for publication on October 30, 2007)(Revised for publication on March 4, 2008)(Accepted for publication on March 27, 2008)

Abstract: Although laparoscopic surgery for colorectal cancer improves post operative recovery, its use for curative treatment especially for rectal cancer is still controversial. The
present study is an attempt to analyze the results of the safety and feasibility of laparoscopic surgery including short-term results for rectal cancer.
Methods: This study accumulated 109 patients with rectal cancer retrospectively who underwent laparoscopic surgery. Patients with rectosigmoid colon cancer were excluded fromthis study. Patients’ data, perioperative data including morbidity and mortality, surgical data
were analyzed, and the 3-year disease-free survival data were calculated by Kaplan-Meiermethod, according to the location of the tumor and the UICC stage.
Results: There were 71 males and 38 females who underwent laparoscopic surgery forrectal cancer. Mean age of them was 63.7±12.5 years. The mean BMI was 22.6±2.8 kg/m2.
The operative procedure was low anterior resection (LAR) in 80 cases, abdominoperineal
resection (APR) in 14 cases, intersphincteric resection (ISR) in 14 cases, and Hartmann’s
procedure in one case. The operation time was 237.0±71.6 minutes. Blood loss was 165.0±
163.8. The postoperative morbidity was 22.9%. The postoperative mortality within 30 days
after surgery was not experienced. The 3-year disease-free survival rate was 94.2% after
curative surgery. According to the UICC stage, the 3-year disease survival rate was 100% instage 0/I, 89.1% in stage II, and 84.6% in stage III.
Conclusions: Laparoscopic surgery for rectal cancer was safe and feasible including postoperative morbidity, mortality and postoperative short-term results. Further study is necessary to clarify the quality of laparoscopic surgery including the postoperative long-term results. (Keio J Med 57 (3) : 150 －154, September 2008)
Key words: rectal cancer, laparoscopic surgery, short-term outcome, disease-free survival

Introduction
Colorectal cancer is one of the commonest malignant
diseases in our country, and laparoscopic surgery forcolorectal cancer has been reported since 1991.1 Laparoscopic surgery for colon and rectal diseases has been
performed increasingly in many institutions with the advances in techniques and instruments, and many studies
have reported the usefulness of laparoscopic surgery forcolorectal malignancy.2-7 Lacy et al. reported that laparoscopic colectomy is superior to open surgery in termsof cancer-related survival.8 However, cases with rectal

cancer were excluded in their study. In Japan, laparoscopic surgery for colorectal cancer was introduced in
1992. Individual institutions have reported the satisfactory short-term results, but there have been few studies focused on rectal cancer.9-11
This present article analyzes the perioperative course,
oncologic radicality and the short-term outocomes oflaparoscopic surgery for rectal cancer.
Materials and Methods
From May, 1994 to February, 2006, cases which were

Corresponding Author : Nobuyoshi Miyajima, M.D. Gastroenterological and General Surgery, School of Medicine, St. Marianna University, Toyoko Hospital,
3-435 Kosugi-cho Nakahara-ku Kawasaki 211-0063, Japan, E-mail: miyajima@mariannna-u.ac.jp150Keio J Med 2008; 57 (3): 150－154

151

Table 1 Data of patients
Patients
Male/Female
Mean Age
Mean BMI (kg/m2)
Tumor location
upper rectum
lower rectum
Distance from anal verge (cm)upper rectum
lower rectum
Preoperative chemotherapy

Table 2 Surgical data
109
71/38
63.7±12.5
22.6±2.85455
7.5±2.99.1±1.3
5.1±1.9
1

BMI: Body mass index

Surgical procedures (%)
LAR
APR
ISR
Hartmann

80(73.4)
14(12.8)
14(12.8)1(0.9)

Conversion (%)

3(2.8)

Mean operation time (minutes)
LAR
APR
ISR

237.0±71.6
217.5±61.4
302.5±72.3*
278.8±41.7**

Mean blood loss (ml)
LAR
APR
ISR

165.0±163.8
117.6±156.0
275.7±167.1***
232±148.2****

Diverting stoma (%)

diagnosed as rectal cancer and underwent laparoscopic
surgery were accumulated. Operation was performed at
my institute or several related hospitals where the author
attended and performed the operation. The location of
the tumor was determined by means of pelvic CT scan,colonoscopy, and/or barium enema before surgery andconfirmed during surgery. We excluded the following
cases; (1) those with tumor larger than 7 cm, (2) thosewith tumor infiltration to the adjacent organs in upper
rectal cancer, (3) those with tumor penetrated the adventitia in lower rectal cancer, (4) those with intestinal obstruction or perforation.
Patients took a standard mechanical bowel preparation
before surgery. The extent of lymphadenectomy and was
decided according to the General Rules for Clinical andPathological Studies on Cancer of the Colon, Rectumand Anus edited by the Japanese Society for Cancer of
the Colon and Rectum. 1 2 Total mesorectal excision(TME) or tumor specific mesorectal excision (TSME)
was performed by keeping proper plane. Adequate distal
margin was secured according to the extent of the clinical stage of the tumor. Surgery was defined as conversion when the skin incision was longer than 8 cm. In the
low anteior resection (LAR), rectum was transected laparoscopically or through a small laparotomy, and the decision depended on the situation of the operation.
The data including demographic data, operation time,
blood loss, passage of the first flatus, time until resumption of oral intake, morbidity, and 30-day mortality wereaccumulated and analyzed.
In the case of curative resection, additional detailed
data including histopathology, International Union
Against Cancer (UICC) TNM stage, and the number oflymph nodes harvested were obtained.
Cancer follow-up consisted of measurement of the serum carcinoembryonic antigen level 3-6 months during
the first year, every 6 months during the next 2 years,stage

20(21.3 of AR+ISR)
0
I
II
III
IV

10
41
31
16
11

LAR: Low anterior resection
APR: Abdominoperineal resection
ISR: Intersphincteric resection*: p<0.01 vs LAR***: p<0.01 vs LAR**: p=0.01 vs LAR****: p=0.01 vs LAR

and annually during the next 5 years, and abdominal andpelvic computed tomography scanning, chest x-ray weretaken at least every 6 months.
Statistical differences in categorical variables were analyzed by the chi-square test, and differences in continuous variables were analyzed by the Student’s t-test. The
Kaplan-Meier method was used to calculate survival
rates.
Results
Between May 1994 and February 2006, 109 patientswith rectal cancer underwent laparoscopic surgery at myinstitute and several related hospitals. The majority of
the interventions were completed with curative intent totreat a lower rectal cancer, whereas in 11 patients theprocedure was palliative .
The data of the patients who underwent laparoscopic
surgery for rectal cancer are summarized in Table 1.
There were 71 males and 38 females. Mean age was 63.7
±12.5 years. The mean BMI was 22.6±2.8 kg/m2. All theoperations were performed for adenocarcinoma of therectum. Tumor was located at the upper rectum in 54 patients and at the lower rectum in 55 patients. The mean
distance from anal verge to the lower edge of the tumor
was 7.5±2.9 cm, 9.1±1.3 cm in the upper rectal cancer,

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Miyajima N: Laparoscopic rectal cancer outcomes

Table 3 Postoperative course
Oral intake (days)

Table 5 Three-year disease-free survival rate
5.4±6.8
12.0±14.2
4.1±2.5

Complication (+)
Complication ( - )First stool (days)

4.3±2.2

Postoperative hospital stay (days)
Complication (+)
Complication ( - )30.6±20.5
59.4±25.8
24.9±13.3

Table 4 Morbidity and mortality
Morbidity (%)

Mortality

25 (22.9)

Anastomotic leakage (%)

8 (8.5 of AR+ISR)

Wound infection (%)

8 (8.5)Abscess (%)

2 (1.8)Ileus (%)

2 (1.8)

Pulmonary (%)

2 (1.8)Urinary tract infection (%)

1 (0.9)Others (%)

2 (1.8)0

and 5.1±1.9 cm in the lower rectal cancer. One patient
received preoperative chemotherapy. Laparoscopic cholecystectomy was performed in 2 cases at the same time.
The surgical data are shown in Table 2. Low anterior
resection (LAR) was the most common procedure forrectal cancer and was performed in 80 cases. Abdominoperineal resection (APR) was performed in 14 cases, intersphincteric resection (ISR) in 14 cases and Hartmann’s procedure in one case. Conversion to open surgery was necessary in 3 cases of all patients (2.8%). The
cause of conversion was the invasion of the tumor to theurinary bladder in one case, the invasion of the tumor to
the uterus in one case, and massive adhesion because of
the previous gastrectomy. Diverting stoma was createdin 20 cases.
Mean operation time was 237.0±71.6minutes. Operation time was shorter in LAR than in APR (p<0.001) andISR (p=0.01). Mean blood loss was 165.0±163.8 ml.
Blood loss was smaller in LAR than in APR (p<0.001)
and ISR (p=0.01).
According to UICC stage, 10 cases were stage 0, 41
cases stage I, 31 cases stage II, 16 cases stage III, and 11
cases stage IV.

Curative resection (%)
uper rectum (%)
lower rectum (%)
stage 0/I (%)
stage II (%)
stage III (%)

94.2
91.2
97.4
100
89.1*
84.6*

*: p=<0.05 vs stage 0/I

The postoperative course is shown in Table 3. Oral intake started on day 5.4±6.8 after surgery. However, theday of oral intake prolonged in patients with complications. First stool appeared on 4.3±2.2 days after surgery.
Postoperative hospital stay was 30.6±20.5 days after surgery. Postoperative hospital stay prolonged markedly inpatients with complications.
Morbidity was shown in Table 4. Intraoperatively,
bleeding, injury of other organ and anastomotic trouble
occurred in each case. Postoperative complications wereseen in 25 cases of 18 patients. Anastomotic leakage rate
was 8.5%. Wound infection occurred in 8 cases. Intraabdominal abscess developed in 2 cases, ileus in 2 cases,
pulmonary disorder in 2 cases, urinary tract infection in
1 case, and others in 2 cases.
The mean number of lymph nodes harvested was 16.1
±7.2. There was no significant difference between upper
rectal cancer and lower rectal cancer in terms of thenumber of the lymph nodes harvested (p=0.09). Curative
surgery was performed in 98 patients (90.0%). Other 11cases underwent palliative surgery because of liver metastasis in 8 cases, lung metastasis in 2 cases, and peritoneal dissemination in one case.
Mean follow up period is 1020±917.5 days. Recurrence developed in 5 cases. The first recurrent site wasliver in 2 cases, lung in one case, peritoneum in one caseand ovary in one case. The 3-year disease-free survival
rate was 94.2% after curative resection. According to thelocation of the tumor, the 3-year disease-free survival
rate was 91.2% in upper rectal cancer patients and 97.4%
in lower rectal cancer patients. There was no significant
difference between upper rectal cancer and lower rectal
cancer patients. The 3-year disease-free survival rate was
100% in stage 0/I, 89.1% in stage II, and 84.6% in stage
III. The 3-year disease-free survival rate in stage 0/I was
significantly higher than that in stage II and stage III.
The difference between stage II and stage III was not
significant (Table 5).
Discussion
This study analyzes the safety and feasibility of laparoscopic surgery for rectal cancer including the short-termKeio J Med 2008; 57 (3): 150－154

results. Numerous studies have demonstrated that laparoscopic techniques have many advantages in colorectal
surgery compared with open surgery.13-15 However, it isstill controversial to perform laparoscopic surgery forrectal cancer because of the difficulty in understanding
the accurate anatomy of the small pelvic cavity, in dissecting the TME or TSME plane, and in transecting thelower rectum safely. This study demonstrated that laparoscopic surgery for rectal cancer was safe and feasible,
and the 3-year disease-free survival rate was acceptable.
Laparoscopic surgery did not jeopardize the perioperative outcomes and the short-term results compared withthe results reported in the literature. A series reported by
Lacy and colleagues showed that the laparoscopic approach had survival advantages over the conventional
approach, 8 but they excluded the rectal cancer. This
study analyzed only rectal cancer.
Conversion from laparoscopic surgery to open surgery
occurred because of technical difficulties, the presenceof associated conditions such as obesity and unexpected
adhesion, or findings of locally advanced disease. Conversion to open surgery should not be hesitated for thepatients’ safety. In our series, conversion rate was verylow.
The reported morbidity rates for laparoscopic colorectal surgery vary between 6 and 39 percent. 1 6- 2 6 The
postoperative morbidity in this study was mainly due toanastomotic leakage and wound infection, which was thesame as reported in open surgery. The mortality rate
within 30 days after surgery, which is one of the mostimportant factors to analyze the safety of laparoscopic
surgery, was not experienced in this study.
Low conversion rate and the acceptable morbidity andmortality rate shows that laparoscopic surgery itself was
performed safely and feasibly
The postoperative hospital stay was not short in thisstudy especially in cases with complications. Owing to
the specifics of the health insurance system in our country, the duration of postoperative hospital stay can not becompared with the data in the international literature.
Adequate tumor resection and lymphadenectomy are
major problems of cancer surgery. The number of lymph
nodes harvested in this study was comparable with thestudies so far published on laparoscopic resection.26-30
The 3-year disease free survival rate was 100% instage 0/I patients, 89.1% in stage II and 84.6% in stage
III. This result was acceptable and extremely favorable
compared with that reported in the literature.31-34
This study concentrated on the lesions at the rectum
because rectum was one of the commonest sites ofcolorectal cancer which we encountered and we hadmany experiences in open surgery. Laparoscopic surgery
has been reported to have a magnified view and get better visual fields than open surgery. However, in cases oflower rectal cancer it is sometimes difficult to grasp the153

correct dissecting plane and dissect the rectum in the pelvic cavity because of obesity, narrow pelvic space, andthe tumor extension. This study clarified that the morbidity rate was acceptable, the mortality was not experienced, and short-term outcome was quite acceptablecompared with open surgery.
This study analyzed only small number of laparoscopic
surgery retrospectively. Large number of cases with rectal cancer operated laparoscopically should be accumulated by multi-center study, and safety and feasibility oflaparoscopic surgery for lower rectal cancer should bemade sure. Based on the results of multi-center study,
randomized control study is essential.
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