Should laparoscopic colorectal surgery still be considered unsafe?

To the Editor: We read with interest the paper by Sammour and colleagues1 comparing laparoscopic to open colorectal surgery in terms of intraoperative complication rates.On the basis of their analysis, the authors concluded that their results “clearly indicate a significantly higher rate of intraoperative complications during laparoscopic colorectal surgery,” mainly due to an increased rate of intraoperative bowel injury. In spite of the unexceptionable methodology of the statistical analysis, the way the study was performed raises several concerns. First, even according to the stated inclusion criteria, study selection seems to have missed at least some consistent data as reported by other authors.2–4 Second, only 10 of 30 studies for which authors forwarded the missing data on intraoperative complications were included in the analysis. This might be comparable to an inappropriate selection bias as it meant the exclusion of more than onethird of cases potentially available. Finally, despite the inclusion of a variety of indications, heterogeneity was almost constantly low to moderate, which might be explained by the rarity of the events considered. From the clinical point of view, even though the total intraoperative complication rate was significantly lower in open surgery, the variables considered (ie, bowel injury defined as any hollow viscus injury requiring repair) lack both a clear clinical relevance and severity. How a difference of less than 1% in risk of bowel injury might affect a patient’s clinical course is questionable. There is now a consistent body of literatureshowing that laparoscopic colorectal surgery, although associated with longer operative times than open colorectal resection, is also associated with a shorter hospital stay, equivalent or improved morbidity, and in the early postoperative period, with better quality of life.5,6 Moreover,minor intraoperative bowel injuries can be more easily noticed or simply reported as significant, during a laparoscopic procedure than during open surgery. This observation is in accordance with Hewett and Frizelle,7 who declared that the recording of intraoperative complications in the Australasian Randomized Clinical Study Comparing Laparoscopic and Conventional Open Surgical Treatments for Colon Cancer (ALCCaS) trial relied upon an independent observer and that most of the smaller events in the Open Group might therefore have passed unnoticed. The other 2 large studies included in the analysis were the Conventional vs Laparoscopic Surgery in Colorectal Cancer (CLASICC)8 and Clinical Outcomes of Surgical Therapy (COST)9 trials. Both have already been criticized10 because the surgeons had not gone through thewhole learning curve before starting the studies, and the results of the intention-to-treat analysis might therefore be biased. For example, theCLASICC trial reported an initial phase with a conversion rate of 45%,which declined to 15% in the last year of the study. Different figures were reported when high-volume centers or the single experience of highly trained and experienced colorectal surgeons were considered.11 We agree with Sammour and colleagues about the need for more accurate reporting of intraoperative complications in future trials, and it seems evident that more strict definition criteria are needed for precise recording of such events. However, the negative impact of laparoscopy on the intraoperative complication rate and the clinical relevance of this finding are far from being demonstrated. A rigorous selection and inclusion of studies, including division by indication, would certainly help provide a more homogeneous and reliable data analysis. Accurate endpoints, that include an assessment of clinical implications, should be identified to increase the relevance of findings. REFERENCES 1. Sammour T, Kahokehr A, Srinivasa S, et al. Laparoscopic colorectal surgery is associated with a higher intraoperative complication rate than open surgery. Ann Surg. 2011;253:35–43. 2. Braga M, Frasson M, Vignali A, et al. Laparoscopic resection in rectal cancer patients: outcome and cost-benefit analysis. Dis Colon Rectum. 2007;50:464–471. 3. Ng SS, Leung KL, Lee JF, et al. Long-term morbidity and oncologic outcomes of laparoscopicassisted anterior resection for upper rectal cancer: ten-year results of a prospective, randomized trial. Dis Colon Rectum. 2009;52:558–566. 4. Gonz´alez QH, Rodr´ıguez-Zentner HA, Moreno- Berber JM, et al. Laparoscopic vs. open total mesorectal excision for treatment of rectal cancer. Rev Invest Clin. 2008;60:205–211. 5. Schwenk W, Haase O, Neudecker J, et al. Short termbenefits for laparoscopic colorectal resection. Cochrane Database Syst Rev. 2005;20:CD003145. 6. Dasari BV, McKay D, Gardiner K. Laparoscopic versus open surgery for small bowel Crohn’s disease. Cochrane Database Syst Rev. 2011;1:CD006956. 7. Hewett PJ, Frizelle F. Does Laparoscopic colectomy have a higher intraoperative complication rate than open colectomy?. Ann Surg. 2010;251:577–578. 8. Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopicassisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet. 2005;365:1718– 1726. 9. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004;350:2050–2059. 10. Curet MJ. Laparoscopic-assisted resection of colorectal carcinoma. Lancet. 2005;365:1666– 1668. 11. Kuhry E, Bonjer HJ, Haglind E, et al. Impact of hospital case volume on short-term outcome after laparoscopic operation for colonic cancer. Surg Endosc. 2005;19:687–692.