When Ernest Miles performed abdomino-perineal excision for rectal cancer in the early 1900s, the operative mortality was around 50% and long term cancer outcomes were not even mentioned! With improved postoperative care, cancer outcomes became more important – and there was an increasing awareness of the role of surgical technique in achieving cure. In fact, traditional surgical technique for rectal cancer (not so much of an issue for the relatively easier surgery needed for colon cancer) was found to be wanting with the incidence of local recurrence in the pelvis (almost always a fatal development) occurring in 30-50% of patients.
In the 1980s, surgeons in Britain, the USA and New Zealand described a technique of surgery for rectal cancer that came to be known as Total Mesorectal Excision (TME) and were able to demonstrate a huge improvement in surgical cure. In Sweden, surgeons practising TME reduced local recurrence in their patients from over 30% to less than 10%. In Australia, colorectal surgeons began introducing these techniques in the late 1980s and as an example, the Colorectal Surgery Unit at Royal Melbourne Hospital has a local recurrence rate of less than 5%.
In more recent times, laparoscopic assisted surgery for colon cancer has been introduced and good cancer outcomes were observed, so it was not surprising that these techniques were then extended to rectal cancer. However, as described above, surgical technique for more difficult rectal cancers has a far more critical impact on patient outcome and it is surprising (and disappointing) that it has taken so long before laparoscopic surgery for rectal cancer was subjected to scrutiny.
Recently, two very well conducted randomized clinical trials, undertaken here and in the US by surgeons with excellent laparoscopic skills, were unable to show that laparoscopic rectal cancer surgery was as good as traditional open surgery using TME techniques (JAMA October 2015) and has resulted in a reappraisal of laparoscopic surgery for rectal cancer. For example, if these studies had been conducted by surgeons with fewer laparoscopic skills than the expert surgeons who conducted these trials, the results may have been even more concerning. If nothing else, it reinforces the need for new techniques, no matter how impressive they might seem to be at first sight, to be carefully evaluated by well conducted clinical trials.
As one of my colleagues said after reading these papers, he would be happy to have a laparoscopic operation for colon cancer but would want open TME surgery by an experienced colorectal surgeon if he had rectal cancer.