LAUSR

Withthepromiseofreducedsurgicaltraumaandquickerrecovery,laparoscopic surgery has gained popularity over the past 2 decades. However, the recent publication of the Australasian Laparoscopic Cancer of the Rectum Randomized Clinical Trial (ALaCaRT)1 questions whether it is appropriate for rectal cancer. The study randomized 475 patients with rectal adenocarcinomas located within 15 cm of the analvergetolaparoscopicoropen proctectomy. Stage T4 tumors, and tumors involving the circumferential radial margin (CRM) on preoperativeimaging,wereexcluded.Fiftypercentofpatientsreceivedpreoperative radiotherapy; 35% had low tumors (within 5 cm of the anal verge); 8% underwent abdominoperineal resection. Participating surgeons were required to provide evidence of expertise in laparoscopic colorectal surgery. Hybrid procedures, in which the abdominal dissection is performed laparoscopically and the pelvic dissection performed through a small incision, were permitted in the open group. Thestudyendpointcomprisedpathologicalfactorsthoughttorepresent adequate resection, defined as meeting all of the following criteria:(1)completetotalmesorectalexcision,basedonvisualassessment of the specimen, (2) clear CRM ( 1 mm), (3) clear distal resection margin ( 1 mm). This novel end point permitted early analysis, based on retrospective studies correlating these factors with recurrence. Successful resection was achieved in 194 patients (82%) in the laparoscopic group and 208 (89%) in the open surgery group (difference, −7.0%; 1-sided 95% CI, −12.4% to ; P for noninferiority = .38). This difference did not meet the prespecified noninferiority margin of 8%; noninferiority could not be established based on the composite end point. Post hoc analysis showed trends of less successful laparoscopic resection in patients with advanced T stage disease, those JAMA