ORIGINAL ARTICLE Laparoscopic Total Mesorectal Excision With Coloanal Anastomosis for Rectal Cancer Quentin Denost, MD, PhD, Jean-Philippe Adam, MD, Arnaud Pontallier, MD, Bertrand Celerier, MD, Christophe Laurent, MD, PhD, and Eric Rullier, MD Objective: Oncologic and functional outcomes were compared between transanal and transabdominal specimen extraction after laparoscopic coloanal anastomosis for rectal cancer. Background: Laparoscopic coloanal anastomosis is an attractive new sur- gical option in patients with low rectal cancer because laparotomy is not necessary due to transanal specimen extraction. Risks of tumor spillage and fecal incontinence induced by transanal extraction are not known. Methods: Between 2000 and 2010, 220 patients with low rectal cancer un- derwent laparoscopic rectal excision with hand-sewn coloanal anastomosis. The rectal specimen was extracted transanally in 122 patients and transab- dominally in 98 patients. End points were circumferential resection margin, mesorectal grade, local recurrence, survival, and functional outcome. Results: The mortality rate was 0.5% and surgical morbidity rate was 17%. The rate of positive circumferential resection margin was 9% and the mesorec- tum was graded complete in 79%, subcomplete in 12%, and incomplete in 9%. After a follow-up of 51 months (range, 1–151), the local recurrence rate was 4% and overall survival and disease-free survival rates were 83% and 70% at 5 years, respectively. The continence score was 6 (range, 0–20). There was no difference of mortality rate, morbidity rate, circumferential resection margin, mesorectal grade, local recurrence (4% vs 5%, P = 0.98), and disease-free survival rate (72% vs 68%, P = 0.63) between transanal and transabdominal extraction groups. Continence score was also similar (6 vs 6, P = 0.92). Conclusions: Transanal extraction of the rectal specimen did not compromise oncologic and functional outcome after laparoscopic surgery for low rectal cancer and seems as a safe option to preserve the abdominal wall. Keywords: coloanal anastomosis, laparoscopy, low rectal cancer, sphincter preservation, transanal extraction (Ann Surg 2015;261:138–143) L aparoscopic surgery is validated in treatment of colon cancer. 1–5 The advantages are improved short-term outcome with no differ- ence of survival at 5 years. In contrast, the laparoscopic approach in rectal cancer is still debated. Only 1 randomized trial is available for long-term outcome, suggesting similar survival rates between laparo- scopic and open surgery at 5 years, 6 but a higher morbidity rate 7 and a lower survival rate in the subgroup of converted patients. 6 One of the main restrictions for developing laparoscopic surgery in rectal cancer are the difficulties for stapling the distal rectum to achieve a low anterior resection. 8,9 This may translate to From the Department of Surgery, Colorectal Unit, CHU Bordeaux, Saint-Andre Hospital, France; and Universit´ e Bordeaux Segalen, Bordeaux, France. Disclosure: The authors report no financial or other conflicts of interest relevant to the subject of this article. Presented at the Congress of European Society of Coloproctology (ESCP), as oral communication, September 26–28, 2012, Vienne, France. Reprints: Eric Rullier, MD, Service de Chirurgie Digestive, Hopital Saint-Andre, 33075 Bordeaux, France. E-mail: eric.rullier@chu-bordeaux.fr. Copyright C  2014 by Lippincott Williams & Wilkins ISSN: 0003-4932/14/26101-0138 DOI: 10.1097/SLA.0000000000000855 a higher rate of APR in laparoscopic procedures, 10 the necessity to use hybrid procedures for rectal transection 11 or to perform a hand-sewn coloanal anastomosis. There are few data of full laparo- scopic coloanal anastomosis for rectal cancer, 12–14 including small series 12 and short follow-up. 13,14 Moreover, the risk of anastomotic or perineal recurrence induced by transanal extraction of the rec- tal specimen is not known. In the United Kingdom trial comparing laparoscopic versus open colorectal surgery, 9 extraction-site recur- rences have been reported in the laparoscopic group compared with one in the open group. 6 Moreover, functional outcomes of laparo- scopic coloanal anastomosis have never been reported, and therefore the potential risk of anal incontinence related to transanal specimen extraction has never been discussed. The objective of our large monocenter series was to report long-term outcome of laparoscopic coloanal anastomosis for rectal cancer, with the aim to solve the oncologic and functional impact of transanal extraction. METHODS Patients All patients operated on between 2000 and 2010 at Saint-Andre Hospital by laparoscopic total mesorectal excision with hand-sewn coloanal anastomosis for low rectal cancers were considered. During this period, 871 patients were treated for rectal cancer, 244 received open surgery for T4 (tumor fixation) or M1 (metastatic disease) le- sions, 277 had a laparoscopic low anterior resection with endoscopic rectal stapling for high and midrectal tumors, 30 were treated by laparoscopic abdominoperineal excision for a very low rectal can- cer infiltrating the external sphincter or the levator ani muscles, and 100 underwent local excision for early (T1) low rectal cancer or downstaged T2–T3 after radiochemotherapy. 15 The population study included 220 patients with laparoscopic total mesorectal excision and coloanal anastomosis for rectal cancer. There were 139 males and 81 females with a median age of 64 (range, 20–90) years. The ASA score was 1 in 136 patients, 2 in 73 patients, and 3 in 11 patients. The body mass index was 25 (range, 17–38). Tumors were staged after colonoscopy, CT scan, endorectal ultrasound and pelvic magnetic resonance imaging according to the TNM/UICC classification 16 as follows: uT1 in 13 patients, uT2 in 26 patients, uT3 in 175 patients, and uT4 in 6 patients; 130 were uN+ and 13 M1 (synchronous metastases). The tumors were 4 cm (range, 1–6 cm) from the anal verge and 1 cm (range, −2 to 3 cm) from the anal ring. Neoadjuvant and Adjuvant Treatments Neoadjuvant radiochemotherapy was used in patients with lo- cally advanced disease, that is, T3 and T4 or N1 disease. Preopera- tive radiotherapy consisted in 45 Gy during 5 weeks and was given in 192 patients (87%), in association with concomitant neoadjuvant chemotherapy (5 fluorouracil and capecitabine) in 164 patients. Postoperative adjuvant chemotherapy (5 fluorouracil and capecitabine and oxaliplatine) was given for 6 months in patients Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 138 | www.annalsofsurgery.com Annals of Surgery  Volume 261, Number 1, January 2015