Comparison Between TME and LPLD in Surgical Treatment of Rectal Cancer

Although some studies on LPLD show a tendency of oncologic results to improve [2, 16, 31], the technique did not earn wide consent because of the lack of incontrovertible data about its effectiveness [1, 4, 5, 9,12].

Recently, Moreira et al. [36], comparing the patients who were operated on with or without LPLD, observed that relapses, metastasis and survival are connected with adverse pathologic factors (such as venous and perineural invasion), and not with the extension of lymphadenectomy.

Among the various arguments against the routine use of LPLD are the relatively low number of cases presenting involvement of lateral lymph nodes (6-15% of the total number of patients having rectal cancer) [3, 12, 30], consistent increase of surgical time and complications [4, 8], severe damage to the genito-urinary function [12, 30], and the negative prognostic outcome of lateral lymphatic metastases (5-year survival 7.1-26%) [3,12, 30].

The most consistent criticism of the Japanese results is the lack of a clinical perspective and randomised evaluation that can definitively clarify the various debates that have arisen [4, 5, 9, 25, 37].

From a practical point of view the adoption of TME in various European centres as well as in the United States contributed to decreases in local relapses to considerably below 10% [4, 37, 38]. Both McFarlane [11] and Enker [4] report local relapses of 5-8% and a 5-year survival free of illness in 74-78% of "high risk" patients (T3N0M0, T3N1-2M0), results which equal those obtained with LPLD [4, 9]; however it must be pointed out that Western series report cases of tumours above the peritoneal reflection [1, 39, 40], where lateral lymph nodal metastases are very rare [17, 35].

Further benefits of TME are represented by a considerable decrease of abdominoperineal amputations [1,38], preservation of bladder function in almost all patients and preservation of sexual function in over 80% of cases (autonomic nerve preserving TME) [38, 39]. In Heald's [1] and Enker's [4] opinion, TME and LPLD, even though different, obtain similar results because they are based on a thorough dissection down well defined anatomic-embryologycal planes, and both ensure undamaged circumferential resection margins in over 90% of cases [37], which is a prerequisite for the local control of rectal cancer [15].

We must not overlook the recent Japanese experiences showing survivals much higher than 50% at 5 years after LPLD in patients with lateral lymph nodal metastases [17,41,42].

Takahashi's remarks [17] about the bad results reported by Heald and Enker in patients with cancer within a 5 cm limit from the anal margin who underwent abdominoperineal amputations (33% local relapses and 42% long-term survival), and the data of the CKVO 95-04 Dutch trial of 20% local relapses after TME in stage III patients [43], would seem to be indirect proof that a considerable amount of neo-plasias in the low rectum spread beyond the reach of the TME alone [17, 44].

When neoplastic involvement is lower than 4 lymph nodes [42], or if it is exclusive of the lateral lymph nodes [17], 5-year survival is 75%, compared with 65% of cases with metastasis of mesorectal lymph nodes (17%). It is then possible that some specific subgroup of patients may benefit from LPLD [41, 42]. The problem, which is still unsolved, is how to select the patients pre-operatively [4,42].

It has been widely confirmed, in the Western side of the world, that pre-operative radiotherapy considerably reduces local relapses both associated with ordinary surgery and with TME (especially in N+ patients) [44, 45].

The effectiveness of pre-operative RT associated with nerve-sparing surgery in the case of advanced rectal cancer in terms of local control and preservation of urinary function was also recently confirmed by Japanese surgeons [46]. Moreover Watanabe et al. [47] compared the patients who underwent LPLD or ordinary lymphadenectomy preceded by RT (50 Gy), without finding any difference in terms of global and illness-free survival and local relapses, suggesting that pre-operative RT may be a good alternative to LPLD because of the cytotoxic effect on regional lymph nodes, including lateral lymph nodes as well.

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