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2012 - Memon
2012 - Memon
2012 - Memon
DOI 10.1245/s10434-012-2270-1
1
Department of Colorectal Surgery, Division of Cancer Surgery, Peter MacCallum Cancer Centre, East Melbourne,
Australia; 2Department of Surgery, St. Vincent’s Hospital, University of Melbourne, Melbourne, Australia; 3Division of
Cancer Surgery, Department of Urology, Peter MacCallum Cancer Centre, East Melbourne, Australia; 4Department of
Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, East Melbourne, Australia
despite an increased circumferential resection margin heterogeneity was high, a sensitivity analysis was per-
(CRM) involvement in the laparoscopic group in the initial formed to by repeating the meta-analysis with any outlying
report.1,7 There are a number of reports examining RALS studies excluded.13 In meta-analysis, the random-effects
for rectal resection, and two multicentre randomized con- method was used. For dichotomous variables, meta-anal-
trolled trials: Robotic versus laparoscopic assisted ysis of risk ratios was performed. In such analyses, if one
resection for rectal cancer (ROLARR) and American col- of the studies reported no events in any treatment group,
lege of surgeons oncology group (ACOSOG)-Z6051 are meta-analysis of risk difference was performed. For con-
now recruiting. However, it will be a number of years until tinuous variables, meta-analysis of the differences between
the results are available.9,10 means was performed by the inverse variance method.
The aim of this study was to undertake a meta-analysis Meta-analyses and graphical representation of the results
of studies comparing RALS with laparoscopic surgery for were undertaken by Review Manager (RevMan) software
rectal cancer to compare the safety and efficacy of each version 5.0 (The Nordic Cochrane Centre, Copenhagen,
approach. Denmark). Risk ratio, risk difference and mean differences
are presented with 95 per cent confidence intervals. A result
MATERIALS AND METHODS was considered significance if P B 0.050.
extraction and evaluation, the results of Patriti et al.21 Operation Time Mean differences in operation time
appeared noticeably different to the other studies. However, varied widely among the studies (I2 = 95%). The Forest
because it met the eligibility criteria, it was included in the plot shows two clusters: one with studies reporting a
analysis, which was then repeated, excluding the study, as a shorter operation time for CLS proctectomy and the other
sensitivity analysis. cluster showing no difference (Fig. 3).15–20 Patriti et al. 21
Park22 Korea RALS: 41 TME 23.4 24:17 5.7 9 34 Hybrid Yes 5 9.7
CLS: 82 TME 23.4 49:33 5.9 14 21 5 7.3
18
Kim Korea RALS: 100 TME 23.6 70:30 14 30 8.2
CLS: 100 TME 23.5 57:30 7 27 11.1
Kwak19 Korea RALS: 59 TME 24.3 39:20 8.0 14 Total 37% 42 13.6
CLS: 58 TME, 1 APR 23.8 42:17 8.0 9 31% 44 10.2
Baek15 USA RALS: 35 TME, 6 APR 25.7 25:16 24 83 Hybrid 94 8.6
CLS: 35 TME, 6 APR 26.7 25:16 44 44 40 2.9
Bianchi17 Italy RALS: 18 TME, 7 APR 24.6 18:7 52 Total (75%), Yes 55 5.5
hybrid (25%)
CLS: 19 TME, 6 APR 26.5 17:8 40 26 10.5
16
Baik Korea RALS: 56 TME 23.4 37:19 9.6 2 9 Hybrid No 0 1.8
CLS: 57 TME 23.2 34:23 9.5 9 12 7
Patriti21 Italy RALS: 26 TME, 5 APR 24 1:1.6 5.9 62 24 Hybrid Yes 0 8.3%
CLS: 34 TME, 3 APR 25.4 1:2 11.0 30 5.4 2.9%
BMI body mass index, Preop CRT preoperative chemoradiotherapy, APR abdominoperineal resection, TME restorative low anterior resection or
ultralow anterior resection
2098 S. Memon et al.
Park22 Prospectively collected data, case-matched study Yes No Yes No Yes Yes
18 a
Kim Prospectively collected data, comparative study Yes No Yes No Yes Yes
Kwak19 Prospectively collected data, case- matched study Yes No Yes No Yes Yes
Baek15 Prospectively collected data, comparative study Yes No Yes No Yesb Yes
Bianchii17 Prospectively collected data, comparative study Yes No Yes No Yes Yes
Baik16 Prospectively collected data, comparative study Yes No Yes No Yes Yes
21 a
Patriti Prospectively collected data, comparative study Yes No Yes No Yes Yes
a
More patients received chemoradiotherapy and there were more low cancers in the RALS group
b
More patients received chemoradiotherapy in the RALS group
FIG. 2 Forest plot showing a meta-analysis of conversion rates for rectal RALS versus CLS. Risk differences are shown with 95% CIs
FIG. 3 Forest plot showing a meta-analysis of operation times for rectal RALS versus CLS. Mean differences are shown with 95% CIs
were the only ones to show a mean operating time favoring did not report the duration of the hospital stay. The studies by
the robot. The standard deviation of mean operation times Baik et al. and by Kim and Kang were the only to find a
for Patriti et al. was notably smaller compared to the other significant difference, both favoring shorter stay in the RALS
studies, which resulted in over 80% of the weight of the group.16,18 The result of the meta-analysis shows no difference
meta-analysis given to this study. A reason for their narrow between the two methods: mean difference -0.57 days (95%
range of operating times could not be established. Meta- CI -1.83 to 0.69) favoring RALS proctectomy, P = 0.38.
analysis of all studies revealed no significant difference in
the operating times between the techniques. Analysis after Complications There was a similar incidence of
excluding the data from Patriti et al. demonstrated a complications among all studies, with low heterogeneity
statistically significant difference in operating time of (I2 = 29%). All studies showed no difference in the overall
43 min (95% CI 32–53) favoring CLS. However, the complication rate except for that by Baik et al. 16 which
heterogeneity still remained high (I2 = 90%). showed a difference favoring the robotic technique. Meta-
analysis indicates no evidence of a difference in the
Hospital Stay There is high heterogeneity among the number of complications between the two methods: risk
studies regarding hospital stay (I2 = 68%). Kwak et al. 19 ratio = 0.93 (95% CI 0.67–1.29), P = 0.67.
Robotic versus Laparoscopic Proctectomy 2099
Oncologic Outcomes cosmesis and faster convalescence over the open approach.
However, CLS has been slow to gain popularity in the
CRM Status The risk difference in CRM status was management of rectal cancer, largely as a result of the
similar for all studies (I2 = 0%). None of the studies technical difficulties associated with extensive dissection in
showed a difference between the RALS and CLS the pelvis.4 The da Vinci surgical system has been popu-
approaches (Fig. 4). The result of the meta-analysis larized in urology for performing robot-assisted
shows no risk difference for CRM involvement between laparoscopic radical prostatectomy because it offers tech-
the two methods (P = 0.77). nical features which help overcome such difficulties. As
robotic surgical systems have become increasingly com-
Lymph Nodes Collected The studies showed high monplace, there has been growing interest among
heterogeneity in the differences between the number of colorectal surgeons in the use of this device to perform
lymph nodes collected, between the two techniques RALS proctectomy.
(I2 = 57%). Two studies found a significant difference in The results of this meta-analysis suggest some benefits
the number of nodes collected both favoring RALS for RALS over CLS proctectomy. The findings support the
proctectomy.17,22 The result of the meta-analysis shows safety and oncologic quality of RALS proctectomy as
no difference between the two methods in the mean equivalent to CLS but do need to be interpreted with some
number of lymph nodes collected: mean difference = - caution. Although the overall quality of the studies was
0.90 nodes (95% CI -1.94 to 1.80) favoring RALS good, selection bias may have affected outcomes as none
proctectomy, (P = 0.94). of the studies were randomized or blinded and preoperative
patient characteristics were not equal in all studies, tending
Distal Resection Margin (DRM) Mean DRM distances to favor the CLS patients. High heterogeneity for some of
comparing the two methods were similar among the the outcomes analyzed may preclude useful meta-analysis
studies, except for the findings of Patriti et al. who of these outcomes. However, it indicates the significant
reported a high standard deviation for CLS proctectomy impact of factors other than the surgical method that affect
(7.2 cm) and who also were the only group to find a these outcomes which needs to be acknowledged when
significant difference between the two techniques, favoring interpreting multicentre trials.
CLS proctectomy.21 The six other studies found no RALS was associated with a significantly lower con-
difference between DRMs and all reported small standard version rate with an absolute risk reduction of 7%. A
deviations (\2.2 cm). Despite the discrepant findings of number of aspects of RALS may influence this. RALS
Patriti et al., because of its low weighting it has minimal increases the technical ease and dexterity with which the
impact on the meta-analysis result. Meta-analysis showed surgeon can perform dissection: articulated instruments
no difference in mean DRM distances between the two with seven degrees-of-freedom; motion scaling and tremor
methods: mean difference -0.03 cm, 95% CI -0.30 to filtration; a magnifiable, steady, high definition 3-dimen-
0.24), P = 0.84. sional operator controlled image; stable retraction, and
reduced postural strain and fatigue all may contribute to a
DISCUSSION more achievable minimally invasive proctectomy.
The differences in mean hospital stay between operative
As with many other procedures, the application of approaches varied between studies and in most studies
minimally invasive surgery to the management of rectal confidence intervals were wide also indicating significant
cancer is attractive to both surgeons and patients because of variation in outcomes within studies. Factors that account
the possible benefits of reduced morbidity, improved for variability between study groups may include
FIG. 4 Forest plot showing a meta-analysis of CRM status for rectal RALS vs. CLS. Risk differences are shown with 95% CIs
2100 S. Memon et al.
differences in discharge criteria or differences in operative demonstration of further benefits may make RALS a more
complications as a result of differences in surgical tech- economically viable alternative in the future.
niques used such as defunctioning ileostomy. Factors There is limited functional outcome data available for
which account for the wide confidence intervals observed assessment, and data regarding the long-term oncologic
for some studies may include confounding factors such as outcome of RALS proctectomy is not yet mature. These
complications or social factors delaying discharge in a potentially valuable benefits of RALS proctectomy will
proportion of patients. require assessment in future studies.
The heterogeneity in mean differences in operation On the basis of the limited number of patients in the
times between studies was very high (I2 = 95%). How- studies eligible for inclusion in this meta-analysis and the
ever, the Forest plot suggests two distinct groups, each absence of randomized data, the current evidence suggests
within which the heterogeneity appears to be significantly that robotic surgery decreases the conversion rate com-
less, which may indicate two separate effects of RALS on pared to CLS. Other clinical and oncologic outcomes
operating times between these patient groups. Three Kor- appear equivalent. The benefits of robotic rectal cancer
ean studies report mean operating times favoring surgery may differ between population groups. Future
CLS.18,19,22 In these studies, the times reported for RALS larger randomized controlled studies assessing clinical,
proctectomy are similar to the RALS times reported in the functional and oncologic outcomes are required to establish
four other series. The reason for this difference is not clear. the true role of RALS in the minimally invasive manage-
One explanation could be uncontrolled variations in the ment of rectal cancer.
RALS or CLS operative approaches between the two
clusters of studies. Variations in RALS approach can
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