Comparing outcomes of open versus minimally invasive total mesorectal excision after total neoadjuvant therapy in rectal cancer: a national cancer database analysis
DOI:
https://doi.org/10.18203/2349-2902.isj20261995Keywords:
Lymph node retrieval, Rectal cancer, Total neoadjuvant therapy, Total mesorectal excisionAbstract
Background: Total neoadjuvant therapy (TNT), in which systemic chemotherapy and pelvic radiation are delivered before surgery, improves pathological complete response, disease-free survival and treatment compliance in locally advanced rectal cancer. Large-scale data comparing open and minimally invasive surgery (MIS) approaches to total mesorectal excision (TME) specifically after TNT are lacking.
Methods: The national cancer database was queried (2010–2020) for adults with clinical stage II–III rectal adenocarcinoma who received chemoradiotherapy and at least two chemotherapeutic agents before TME. Stage I or IV disease, primary resection without neoadjuvant therapy and MIS converted to open were excluded. Univariate analysis and multivariable logistic regression were performed. The primary outcome was inadequate lymph node retrieval (<12 nodes); the secondary outcome was 90-day postoperative mortality.
Results: A total of 5,962 patients were included; 3,111 (52.2%) underwent MIS and 2,851 (47.8%) underwent open TME. Inadequate lymph node retrieval was less frequent with MIS (27.1%) than open surgery (33.2%) (OR 0.80; 95% CI 0.71–0.90; p<0.001). 90-day mortality was lower with MIS (0.8%) than open surgery (2.2%) (OR 2.46 for open; 95% CI 1.51–4.03; p<0.001).
Conclusions: After TNT for rectal cancer, an MIS approach to TME was associated with a higher likelihood of adequate lymph node harvest and lower 90-day mortality than open surgery. These differences may reflect improved pelvic exposure, although selection bias toward more advanced tumors in the open cohort cannot be excluded. Prospective studies are warranted.
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