Laparoscopic surgery for colorectal cancer was first reported in 1991. However, early experiences with laparoscopic colectomy were unfavorable, with higher than expected rates of port-site recurrence and concerns about compromised long-term oncologic outcomes. These concerns have been resolved by the results of several large-scale European and American multicenter randomized controlled trials (RCTs) that reported no difference in oncologic clearance and survival between laparoscopic and open colectomy for colon cancer. / The role of laparoscopic surgery for rectal cancer, on the other hand, still remains controversial. Because laparoscopic surgery for rectal cancer is technically more difficult and has a higher morbidity rate than laparoscopic colectomy for colon cancer, most of the published large-scale multicenter RCTs comparing laparoscopic and open colorectal cancer did not include patients with rectal cancer. To date, good-quality data comparing laparoscopic and open surgery for rectal cancer are still scarce in the literature. The main objective of this thesis is to provide additional evidence to justify the role of laparoscopic surgery for rectal cancer. / To be justified, laparoscopic surgery for rectal cancer should have equal or better clinical outcomes than open surgery and improve quality of life. Furthermore, oncologic clearance as well as long-term survival should not be adversely affected by the laparoscopic approach. / In this thesis, a series of RCTs and comparative studies with long-term follow-up were conducted to address the above issues. Our results demonstrate that laparoscopic surgery for rectal cancer is associated with earlier postoperative recovery, better preservation of urosexual function and quality of life, and less late morbidity when compared with open surgery. Oncologic clearance in terms of resection margins and number of lymph nodes harvested are comparable between the laparoscopic and open groups. Most importantly, laparoscopic surgery does not adversely affect disease control or jeopardize long-term survival of rectal cancer patients. The benefits of the laparoscopic over the open approach remain the same regardless of the types of rectal cancer surgery (laparoscopic-assisted anterior resection, total mesorectal excision, or abdominoperineal resection) or the location of the tumor. It is therefore concluded that laparoscopic surgery for rectal cancer is safe and justified. Based on our results, we believe that laparoscopic surgery can be regarded as an acceptable alternative to open surgery for treating curable rectal cancer. / Ng, Siu Man Simon. / Thesis (M.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 323-366). / Dedication --- p.1 / Declaration of Originality --- p.2 / Abstract --- p.3 / Table of Contents --- p.5 / List of Tables --- p.8 / List of Figures --- p.10 / List of Abbreviations --- p.13 / PRÉCIS TO THE THESIS --- p.15 / Chapter PART I --- BACKGROUND --- p.37 / Chapter Chapter 1 --- Management of Colorectal Cancer: From Open to Laparoscopic Surgery --- p.38 / Chapter 1.1 --- Introduction to Colorectal Cancer --- p.39 / Chapter 1.2 --- A Brief History of Laparoscopic Surgery --- p.51 / Chapter 1.3 --- Laparoscopic Colorectal Surgery: The Beginning --- p.58 / Chapter 1.4 --- Evidence for the Safety and Efficacy of Laparoscopic Surgery for Colon Cancer --- p.62 / Chapter Chapter 2 --- Laparoscopic Surgery for Rectal Cancer: A Critical Appraisal of Published Literature --- p.71 / Chapter 2.1 --- Introduction --- p.72 / Chapter 2.2 --- Evidence from Single-Center Trials --- p.76 / Chapter 2.3 --- Evidence from Multicenter Trials --- p.82 / Chapter 2.4 --- Ongoing Trials --- p.89 / Chapter 2.5 --- Discussion --- p.92 / Chapter Chapter 3 --- Laparoscopic Surgery for Rectosigmoid and Rectal Cancer: Experience at The Prince of Wales Hospital, Hong Kong --- p.97 / Chapter 3.1 --- The Beginning of Laparoscopic Era in Hong Kong --- p.98 / Chapter 3.2 --- Early Experience of Laparoscopic Colorectal Surgery --- p.102 / Chapter 3.3 --- Nonrandomized Comparative Studies --- p.105 / Chapter 3.4 --- The Hong Kong Trial --- p.110 / Chapter PART II --- HYPOTHESES AND CLINICAL STUDIES --- p.116 / Chapter Chapter 4 --- Research Hypotheses and Objectives --- p.117 / Chapter 4.1 --- Research Hypotheses --- p.118 / Chapter 4.2 --- Research Plan and Objectives --- p.120 / Chapter Chapter 5 --- Laparoscopic-Assisted Versus Open Anterior Resection for Upper Rectal Cancer: Short-Term Outcomes --- p.122 / Chapter 5.1 --- Abstract --- p.123 / Chapter 5.2 --- Introduction --- p.125 / Chapter 5.3 --- Patients and Methods --- p.128 / Chapter 5.4 --- Results --- p.133 / Chapter 5.5 --- Discussion --- p.144 / Chapter 5.6 --- Conclusions --- p.148 / Chapter Chapter 6 --- Laparoscopic-Assisted Versus Open Anterior Resection for Upper Rectal Cancer: Long-Term Morbidity and Oncologic Outcomes --- p.149 / Chapter 6.1 --- Abstract --- p.150 / Chapter 6.2 --- Introduction --- p.152 / Chapter 6.3 --- Patients and Methods --- p.154 / Chapter 6.4 --- Results --- p.158 / Chapter 6.5 --- Discussion --- p.173 / Chapter 6.6 --- Conclusions --- p.179 / Chapter Chapter 7 --- Laparoscopic-Assisted Versus Open Abdominoperineal Resection for Low Rectal Cancer --- p.180 / Chapter 7.1 --- Abstract --- p.181 / Chapter 7.2 --- Introduction --- p.183 / Chapter 7.3 --- Patients and Methods --- p.185 / Chapter 7.4 --- Results --- p.190 / Chapter 7.5 --- Discussion --- p.201 / Chapter 7.6 --- Conclusions --- p.207 / Chapter Chapter 8 --- Laparoscopic-Assisted Versus Open Total Mesorectal Excision with Anal Sphincter Preservation for Mid and Low Rectal Cancer --- p.208 / Chapter 8.1 --- Abstract --- p.209 / Chapter 8.2 --- Introduction --- p.211 / Chapter 8.3 --- Patients and Methods --- p.214 / Chapter 8.4 --- Results --- p.221 / Chapter 8.5 --- Discussion --- p.238 / Chapter 8.6 --- Conclusions --- p.246 / Chapter Chapter 9 --- Long-Term Oncologic Outcomes of Laparoscopic Versus Open Surgery for Rectal Cancer: A Pooled Analysis of Three Randomized Controlled Trials --- p.247 / Chapter 9.1 --- Abstract --- p.248 / Chapter 9.2 --- Introduction --- p.250 / Chapter 9.3 --- Patients and Methods --- p.254 / Chapter 9.4 --- Results --- p.258 / Chapter 9.5 --- Discussion --- p.272 / Chapter 9.6 --- Conclusions --- p.280 / Chapter Chapter 10 --- Prospective Comparison of Quality of Life Outcomes After Curative Laparoscopic Versus Open Sphincter-Preserving Resection for Rectal Cancer --- p.281 / Chapter 10.1 --- Abstract --- p.282 / Chapter 10.2 --- Introduction --- p.284 / Chapter 10.3 --- Patients and Methods --- p.287 / Chapter 10.4 --- Results --- p.292 / Chapter 10.5 --- Discussion --- p.308 / Chapter Chapter 11 --- Conclusions --- p.314 / Chapter 11.1 --- Conclusions --- p.315 / REFERENCES --- p.322 / LIST OF PUBLICATIONS RELATED TO THE THESIS --- p.367 / ACKNOWLEDGEMENTS --- p.373

A cirurgia ainda é o principal método de tratamento do câncer do reto. Recentemente a quimio e radioterapia neo-adjuvantes têm sido preconizadas, com freqüência cada vez maior, com o intuito de reduzir os índices de recidiva e mortalidade. O objetivo desse estudo foi avaliar, retrospectivamente a sobrevida e a recidiva tumoral de pacientes submetidos a quimioterapia adjuvante, com e sem quimio e radioterapia neoadjuvantes. Foram avaliados retrospectivamente 36 pacientes submetidos a ressecção anterior baixa por adenocarcinoma do reto. Subdivididos em três grupos: grupo I (N=11), submetidos exclusivamente a tratamento cirúrgico; grupo II (N=8), submetidos a tratamento cirúrgico, seguido de quimioterapia adjuvante; grupo III (N=17), submetidos a tratamento cirúrgico com quimio e radioterapia neo-adjuvantes. O período de seguimento foi de 36 meses. Seis pacientes (16,6%) apresentaram recidiva, sendo 1 paciente do grupo I, 3 pacientes do grupo II e 2 pacientes do grupo III. A sobrevida global foi de 88,9%, assim distribuída: grupo I, 80,0%; grupo II, 100,0% e grupo III, 87,5%. Não houve diferença significante nos índices de recidiva nem na sobrevida entre os grupos. Concluiu-se que na amostra estudada os métodos terapêuticos tiveram resposta equivalente, não tendo sido possível demonstrar a interferência da quimio e ou radioterapia nos índices de sobrevida ou recidiva / Surgery continues to be the principal method for treating cancer of the rectum. Recently, chemo and neo-adjuvant radiotherapy have been considered, with increasing frequency, with the intention of reducing the rates of recurrence and mortality. The objective of this study was to evaluate, retrospectively, survival and tumor recurrence in patients submitted to adjuvant chemotherapy, with and without neo-adjuvant chemo and radiotherapy. A retrospective evaluation of 36 patients submitted to lower anterior resection for adenocarcinoma of the rectum was conducted, subdivided into three groups: Group I (n=11), submitted exclusively to surgical treatment; Group II (n=8), submitted to surgical treatment followed by adjuvant chemotherapy; Group III (n=17), submitted to surgical treatment with chemo and neo-adjuvant radiotherapy. The time period was 36 months. Six patients (16.6%) presented recurrence: 1 patient from Group I, 3 patients from Group II and 2 patients from Group III. Overall survival was 88.9%, distributed in the following way: Group I, 80.0%; Group II, 100.0% and Group III, 87.5%. No significant differences in the rates of recurrence and survival were observed between the groups. It is therefore concluded that within the sample the therapeutic methods had similar response, not having been possible to demonstrate the interference of chemo and radiotherapy in the rates of survival or recurrence

A cirurgia ainda é o principal método de tratamento do câncer do reto. Recentemente a quimio e radioterapia neo-adjuvantes têm sido preconizadas, com freqüência cada vez maior, com o intuito de reduzir os índices de recidiva e mortalidade. O objetivo desse estudo foi avaliar, retrospectivamente a sobrevida e a recidiva tumoral de pacientes submetidos a quimioterapia adjuvante, com e sem quimio e radioterapia neoadjuvantes. Foram avaliados retrospectivamente 36 pacientes submetidos a ressecção anterior baixa por adenocarcinoma do reto. Subdivididos em três grupos: grupo I (N=11), submetidos exclusivamente a tratamento cirúrgico; grupo II (N=8), submetidos a tratamento cirúrgico, seguido de quimioterapia adjuvante; grupo III (N=17), submetidos a tratamento cirúrgico com quimio e radioterapia neo-adjuvantes. O período de seguimento foi de 36 meses. Seis pacientes (16,6%) apresentaram recidiva, sendo 1 paciente do grupo I, 3 pacientes do grupo II e 2 pacientes do grupo III. A sobrevida global foi de 88,9%, assim distribuída: grupo I, 80,0%; grupo II, 100,0% e grupo III, 87,5%. Não houve diferença significante nos índices de recidiva nem na sobrevida entre os grupos. Concluiu-se que na amostra estudada os métodos terapêuticos tiveram resposta equivalente, não tendo sido possível demonstrar a interferência da quimio e ou radioterapia nos índices de sobrevida ou recidiva / Surgery continues to be the principal method for treating cancer of the rectum. Recently, chemo and neo-adjuvant radiotherapy have been considered, with increasing frequency, with the intention of reducing the rates of recurrence and mortality. The objective of this study was to evaluate, retrospectively, survival and tumor recurrence in patients submitted to adjuvant chemotherapy, with and without neo-adjuvant chemo and radiotherapy. A retrospective evaluation of 36 patients submitted to lower anterior resection for adenocarcinoma of the rectum was conducted, subdivided into three groups: Group I (n=11), submitted exclusively to surgical treatment; Group II (n=8), submitted to surgical treatment followed by adjuvant chemotherapy; Group III (n=17), submitted to surgical treatment with chemo and neo-adjuvant radiotherapy. The time period was 36 months. Six patients (16.6%) presented recurrence: 1 patient from Group I, 3 patients from Group II and 2 patients from Group III. Overall survival was 88.9%, distributed in the following way: Group I, 80.0%; Group II, 100.0% and Group III, 87.5%. No significant differences in the rates of recurrence and survival were observed between the groups. It is therefore concluded that within the sample the therapeutic methods had similar response, not having been possible to demonstrate the interference of chemo and radiotherapy in the rates of survival or recurrence

INTRODUÇÃO: A microcirurgia endoscópica transanal (TEM) é uma técnica minimamente invasiva segura e eficiente para o tratamento de neoplasia retal benigna e maligna precoce. As complicações pós operatórias podem ser graves. Existe controvérsia na literatura a respeito da sua incidência e gravidade. OBJETIVOS: Avaliar os fatores de risco relacionados a incidência e gravidade das complicações pós operatórias e seu comportamento temporal em pacientes com neoplasia retal tratados por TEM. MÉTODOS: Estudo prospectivo das complicações pós-operatórias usando a classificação e graduação de Clavien-Dindo. As características estudadas dos pacientes foram: idade, sexo, risco cirúrgico dado pela Associação Americana de Anestesiologia (ASA), quimiorradioterapia neoadjuvante, altura e tamanho da lesão, margens patológicas, histologia do tumor e tipo de sutura: por TEM ou por afastador anal convencional. RESULTADOS: Dentre os cinquenta e três pacientes tratados, a morbidade geral foi de 50%. Incontinência foi a complicação mais frequente (17,3%). Apenas uma paciente teve incontinência persistente. As taxas de complicações pós-operatórias grau I e grau II (GII) foram ambas 21,1%; para grau III (GIII) e IV também foram ambas: 3,8%. Não houve mortalidade. Dos pacientes que tiveram complicações pós-operatórias, 61,54% tinham lesões abaixo da primeira válvula retal, comparado com 38,46% dos pacientes com lesões acima da primeira válvula (p=0.039). Pacientes submetidos à quimiorradioterapia neoadjuvante tiveram 24 vezes mais chance de apresentarem complicações pós-operatórias GII (p=0,002), e 7,03 vezes mais chance de GIII (p=0,098). Quando a sutura da ferida cirúrgica foi realizada por TEM, houve 16 vezes menos chance de ocorrerem complicações pós-operatórias GIII (p=0,043). 53% das complicações pós-operatórias ocorreram em 10 dias e 95%, em 20 dias. CONCLUSÕES: Complicações pós-operatórias pós TEM são frequentes, aceitáveis e geralmente controladas com medicamentos. Pacientes com lesões mais distais têm mais complicações pós-operatórias. Pacientes que receberam quimiorradioterapia neoadjuvante e submetidos a sutura com afastador de ânus convencional tiveram complicações pós operatórias que requereram intervenção médica - cirúrgica ou endoscópica sobre sedação. O comportamento temporal das complicações é progressivo e inespecífico, a maioria ocorrendo nos primeiros 20 dias / INTRODUCTION: Transanal endoscopic microsurgery (TEM) is a safe and efficient minimally invasive treatment for rectal benign and early malignant neoplasia. Postoperative complications may be severe. Controversy exists with regard to incidence and severity. OBJECTIVES: Evaluate risk factors related to incidence and severity of postoperative complications, and time course, in patients with rectal neoplasia treated by TEM. METHODS: Prospective study of postoperative complications using the Clavien-Dindo classification and grading system. Patients\' characteristics included age, sex, ASA score, neoadjuvant chemoradiotherapy (CRT), lesion height and size, pathologic margins, tumor histology, and suture type: through TEM or conventional retractor. RESULTS: Among fifty-three patients treated,overall morbidity rate was 50%. Incontinence was the most frequent complication (17.3%). One patient had persistent incontinence. Grade I and Grade II (GII) postoperative complication rates were both 21.1%, and Grade III (GIII) and IV rates were both 3.8%. There was no mortality. Of the patients with postoperative complications, 61.54% had lesions under the first rectal valve, compared with 38.46% of patients with lesions over the first valve (p=0.039). Patients submitted to CRT had a 24-fold greater chance of presenting GII complications (p=0.002), and a 7.03-fold greater chance of GIII (p=0.098). When the surgical defect was treated using the TEM device to perform the suture, there was a 16-fold less chance of having GIII complications (p=0.043). Fifty-three percent of complications occurred in the first 10 days, and 95% within 20 days. CONCLUSIONS: Postoperative complications after TEM for the treatment of rectal neoplasia are frequent, acceptable, and usually controllable with pharmacologic treatment. Patients with more distal lesions have more postoperative complications. Patients receiving neoadjuvant CRT and submitted to suture with a conventional anal retractor have more postoperative complications that require intervention under sedation. Over time the nature of complications is progressive and nonspecific, with most occurring within the first 20 days

INTRODUÇÃO: A microcirurgia endoscópica transanal (TEM) é uma técnica minimamente invasiva segura e eficiente para o tratamento de neoplasia retal benigna e maligna precoce. As complicações pós operatórias podem ser graves. Existe controvérsia na literatura a respeito da sua incidência e gravidade. OBJETIVOS: Avaliar os fatores de risco relacionados a incidência e gravidade das complicações pós operatórias e seu comportamento temporal em pacientes com neoplasia retal tratados por TEM. MÉTODOS: Estudo prospectivo das complicações pós-operatórias usando a classificação e graduação de Clavien-Dindo. As características estudadas dos pacientes foram: idade, sexo, risco cirúrgico dado pela Associação Americana de Anestesiologia (ASA), quimiorradioterapia neoadjuvante, altura e tamanho da lesão, margens patológicas, histologia do tumor e tipo de sutura: por TEM ou por afastador anal convencional. RESULTADOS: Dentre os cinquenta e três pacientes tratados, a morbidade geral foi de 50%. Incontinência foi a complicação mais frequente (17,3%). Apenas uma paciente teve incontinência persistente. As taxas de complicações pós-operatórias grau I e grau II (GII) foram ambas 21,1%; para grau III (GIII) e IV também foram ambas: 3,8%. Não houve mortalidade. Dos pacientes que tiveram complicações pós-operatórias, 61,54% tinham lesões abaixo da primeira válvula retal, comparado com 38,46% dos pacientes com lesões acima da primeira válvula (p=0.039). Pacientes submetidos à quimiorradioterapia neoadjuvante tiveram 24 vezes mais chance de apresentarem complicações pós-operatórias GII (p=0,002), e 7,03 vezes mais chance de GIII (p=0,098). Quando a sutura da ferida cirúrgica foi realizada por TEM, houve 16 vezes menos chance de ocorrerem complicações pós-operatórias GIII (p=0,043). 53% das complicações pós-operatórias ocorreram em 10 dias e 95%, em 20 dias. CONCLUSÕES: Complicações pós-operatórias pós TEM são frequentes, aceitáveis e geralmente controladas com medicamentos. Pacientes com lesões mais distais têm mais complicações pós-operatórias. Pacientes que receberam quimiorradioterapia neoadjuvante e submetidos a sutura com afastador de ânus convencional tiveram complicações pós operatórias que requereram intervenção médica - cirúrgica ou endoscópica sobre sedação. O comportamento temporal das complicações é progressivo e inespecífico, a maioria ocorrendo nos primeiros 20 dias / INTRODUCTION: Transanal endoscopic microsurgery (TEM) is a safe and efficient minimally invasive treatment for rectal benign and early malignant neoplasia. Postoperative complications may be severe. Controversy exists with regard to incidence and severity. OBJECTIVES: Evaluate risk factors related to incidence and severity of postoperative complications, and time course, in patients with rectal neoplasia treated by TEM. METHODS: Prospective study of postoperative complications using the Clavien-Dindo classification and grading system. Patients\' characteristics included age, sex, ASA score, neoadjuvant chemoradiotherapy (CRT), lesion height and size, pathologic margins, tumor histology, and suture type: through TEM or conventional retractor. RESULTS: Among fifty-three patients treated,overall morbidity rate was 50%. Incontinence was the most frequent complication (17.3%). One patient had persistent incontinence. Grade I and Grade II (GII) postoperative complication rates were both 21.1%, and Grade III (GIII) and IV rates were both 3.8%. There was no mortality. Of the patients with postoperative complications, 61.54% had lesions under the first rectal valve, compared with 38.46% of patients with lesions over the first valve (p=0.039). Patients submitted to CRT had a 24-fold greater chance of presenting GII complications (p=0.002), and a 7.03-fold greater chance of GIII (p=0.098). When the surgical defect was treated using the TEM device to perform the suture, there was a 16-fold less chance of having GIII complications (p=0.043). Fifty-three percent of complications occurred in the first 10 days, and 95% within 20 days. CONCLUSIONS: Postoperative complications after TEM for the treatment of rectal neoplasia are frequent, acceptable, and usually controllable with pharmacologic treatment. Patients with more distal lesions have more postoperative complications. Patients receiving neoadjuvant CRT and submitted to suture with a conventional anal retractor have more postoperative complications that require intervention under sedation. Over time the nature of complications is progressive and nonspecific, with most occurring within the first 20 days