We reviewed the long-term results and patient survival for laparoscopic-assisted resection of colorectal malignancies. The place of laparoscopic colectomy for colorectal carcinomas is controversial. The techniques and expected surgical outcomes for patients undergoing laparoscopic and laparoscopic-assisted colectomies are being defined as these procedures become more acceptable and reach parity with, or even surpass, results of traditional operations. Anecdotal reports in the literature describe port-site and incisional tumor implantation in patients undergoing laparoscopic-assisted colectomies for colorectal malignancies. This raises concerns about whether these incisional tumor sites are more common in these patients and whether their survival is compromised by the laparoscopic technique.
The authors reviewed data from 110 patients who underwent laparoscopic-assisted colectomies for colorectal cancer to determine the long-term results and survival and to compare the safety and efficacy of laparoscopic-assisted colectomy to the safety and efficacy of open colectomy. Between July 1991 and June 1999, 350 patients underwent laparoscopic-assisted colectomies. Of these, 110 patients had colorectal malignancies. Survival rates and patterns of recurrence were compared within the various TNM stages and compared with conventional data after open surgery. The American Joint Committee on Cancer staging for colorectal carcinomas and the Kaplan-Meier method were used to determine the survival curves.
Laparoscopic-assisted colon resections for colorectal malignancies were performed in 110 patients. Fifty-one percent of the patients were women, and 49% percent were men, with a mean age of 78.17 years. The mean follow-up was 43 months. Thirteen patients were converted to open operation due to various difficulties encountered during the procedure. Mean operative time was 128.16 minutes, and mean hospital stay was 6.91 days. Perioperative mortality was 2.77%. There were 4 local recurrences. The ten-year survival rates for the various stages were 78% for stage I, 33% for stage II, 30% for stage III, and 0% for stage IV. No port-site implantations occurred.
Laparoscopic-assisted colon resection of colorectal carcinomas is technically feasible and safe. It allows earlier postoperative recovery and a shorter hospital stay. The long-term survival is also satisfactory. The incidence of port-site implants is no more than that with the conventional open technique. Determination of any benefits over the conventional open technique, however, still await prospective randomized trials.
Laparoscopic colon resections; Laparoscopic-assisted colon resections; Colorectal malignancies
Several multi-institutional prospective randomized trials have demonstrated short-term benefits using laparoscopy. Now the laparoscopic approach is accepted as an alternative to open surgery for colon cancer. However, in prior trials, the transverse colon was excluded. Therefore, it has not been determined whether laparoscopy can be used in the setting of transverse colon cancer. This study evaluated the peri-operative clinical outcomes and oncological quality by pathologic outcomes of laparoscopic surgery for transverse colon cancer.
Materials and methods
Analysis of the medical records of patients who underwent laparoscopic colorectal resection from August 2004 to November 2007 was made. Computed tomography, barium enema, and colonoscopy were performed to localize the tumor preoperatively. Extended right hemicolectomy, transverse colectomy, and extended left hemicolectomy were performed for transverse colon cancer. Surgical outcomes and pathologic outcomes were compared between transverse colon cancer (TCC) and other site colon cancer (OSCC).
Of the 312 colorectal cancer patients, 94 patients underwent laparoscopic surgery for OSCC, and 34 patients underwent laparoscopic surgery for TCC. Patients with TCC were similar to patients with OSCC in age, gender, body mass index, operating time, blood loss, time to pass flatus, start of diet, hospital stay, tumor size, distal resection margin, proximal resection margin, number of lymph nodes, and radial margin. One case in TCC and three cases in OSCC were converted to open surgery.
Laparoscopic surgery for transverse colon cancer and OSCC had similar peri-operative clinical and acceptable pathological outcomes.
Laparoscopy; Transverse colon; Colon cancer
Laparoscopy was introduced more than 15 years ago into clinical practice. However, its role in colorectal surgery was not well established for want of better skills and technology. This coupled with high incidences of port site recurrences, prevented laparoscopic surgery from being incorporated into mainstream colorectal cancer surgery. A recent increase in the number of reports, retrospective analyses, randomized trials and multicentric trials has now provided sufficient data to support the role of laparoscopy in colorectal cancer surgery. We, thus, present a review of the published data on the feasibility, safety, short - and long-term outcomes following laparoscopic surgery for colorectal cancers. While the data available strongly favors the use of laparoscopic surgery in colonic cancer, larger well powered studies are required to prove or disprove its role in rectal cancer.
Colorectal cancer; colorectal surgery; laparoscopic surgery
Compared to the open approach, randomized trials have shown that laparoscopic colectomy is associated with a shorter hospitalization without increases in morbidity or mortality rates. With broader adoption of laparoscopic colectomy for cancer in the United States, it is unclear if laparoscopic colectomy continues to be associated with shorter hospitalization and comparable morbidity.
To determine if hospitals where a greater proportion of colon resections for cancer are approached laparoscopically (laparoscopy rate) achieve improved short-term outcomes compared to hospitals with lower laparoscopy rates.
From the 2008–2009 Nationwide Inpatient Sample, we identified hospitals where ≤12 colon resections for cancer where reported with ≥1 approached laparoscopically. We assessed the correlation between a hospital’s laparoscopy rate and risk-standardized outcomes (intra- and post-operative morbidity, in-hospital mortality rates, and average length of stay).
Overall, 6,806 colon resections were performed at 276 hospitals. Variation was noted in hospital laparoscopy rates (median=52.0%, range=3.8–100%) and risk-standardized intra- (2.7%, 1.8–8.6%) and post-operative morbidity (27.8%, 16.4–53.4%), in-hospital mortality (0.7%, 0.3–42.0%), and average length of stay (7.0 days, 4.9–10.3 days). While no association was noted with in-hospital mortality, higher laparoscopy rates were correlated with lower post-operative morbidity (correlation coefficient [r]=−0.12, p=0.04) and shorter hospital stays (r=−0.23, p<0.001), but higher intra-operative morbidity (r=0.19, p<0.001) rates. This was not observed among hospitals with high procedure volumes.
Higher laparoscopy rates were associated with only slightly lower post-operative morbidity rates and modestly shorter hospitalizations.
Laparoscopic colectomy; surgical outcomes
Laparoscopic colectomy for colon cancer has been compared with open colectomy in randomized controlled trials, but these studies may not be generalizable because of strict enrollment and exclusion criteria which may explicitly or inadvertently exclude older individuals due to associated comorbidities. Previous studies of older patients undergoing laparoscopic colectomy have generally focused on short-term outcomes. The goals of this cohort study were to identify predictors of laparoscopic colectomy in an older population in the United States and to compare short-term and long-term outcomes.
Patients aged 65 years or older with incident colorectal cancer diagnosed 1996-2002 who underwent colectomy within 6 months of cancer diagnosis were identified from the linked Surveillance, Epidemiology, and End Results-Medicare database. Laparoscopic and open colectomy patients were compared with respect to length of stay, blood transfusion requirements, intensive care unit monitoring, complications, 30-day mortality, and long-term survival. We adjusted for potential selection bias in surgical approach with propensity score matching.
Laparoscopic colectomy cases were associated with left-sided tumors; areas with higher population density, income, and education level; areas in the western United States; and National Cancer Institute-designated cancer centers. Laparoscopic colectomy cases had shorter length of stay and less intensive care unit monitoring. Although laparoscopic colectomy patients (n = 424) had fewer complications (21.5% versus 26.3%), lower 30-day mortality (3.3% versus 5.8%), and longer median survival (6.6 versus 4.8 years) compared with open colectomy patients (n = 27,012), after propensity score matching these differences disappeared.
In this older population, laparoscopic colectomy practice patterns were associated with factors which likely correlate with tertiary referral centers. Although short-term and long-term survival are comparable, laparoscopic colectomy offers shorter hospitalizations and less intensive care.
The utility of lymph node mapping to improve staging in colon cancer is still under evaluation. Laparoscopic colectomy for colon cancer has been validated in multi-centric trials. This study assessed the feasibility and technical aspects of lymph node mapping in laparoscopic colectomy for colon cancer.
A total of 42 patients with histologically proven colon cancer were studied from January 2006 to September 2007. Exclusion criteria were: advanced disease (clinical stage III), rectal cancer, previous colon resection and contraindication to laparoscopy. Lymph-nodal status was assessed preoperatively by computed tomography (CT) scan and intra-operatively with the aid of laparoscopic ultrasound. Before resection, 2–3 ml of Patent Blue V dye was injected sub-serosally around the tumour. Coloured lymph nodes were marked as sentinel (SN) with metal clips or suture and laparoscopic colectomy with lymphadenectomy completed as normal. In case of failure of the intra-operative procedure, an ex vivo SN biopsy was performed on the colectomy specimen after resection.
A total number of 904 lymph nodes were examined, with a median number of 22 lymph nodes harvested per patient. The SN detection rate was 100%, an ex vivo lymph node mapping was necessary in four patients. Eleven (26.2%) patients had lymph-nodal metastases and in five (45.5%) of these patients, SN was the only positive lymph node. There were two (18.2%) false-negative SN. In three cases (7.1%) with aberrant lymphatic drainage, lymphadenectomy was extended. The accuracy of SN mapping was 95.2% and negative predictive value was 93.9%.
Laparoscopic lymphatic mapping and SN removal is feasible in laparoscopic colectomy for colon cancer. The ex vivo technique is useful as a salvage technique in case of failure of the intra-operative procedure. Prospective studies are justified to determine the real accuracy and false-negative rate of the technique.
At present time, there is evidence from randomized controlled studies of the success of laparoscopic resection for the treatment of colon cancer with reported smaller incisions, lower morbidity rate and earlier recovery compared to open surgery. Technical limitations and a steep learning curve have limited the wide application of mini-invasive surgery for rectal cancer. The present article discusses the current status of laparoscopic resection for rectal cancer. A review of the more recent retrospective, prospective and randomized controlled trial (RCT) data on laparoscopic resection of rectal cancer including the role of trans-anal endoscopic microsurgery and robotics was performed. A particular emphasis was dedicated to mid and low rectal cancers. Few prospective and RCT trials specifically addressing laparoscopic rectal cancer resection are currently available in the literature. Improved short-term outcomes in term of lesser intraoperative blood loss, reduced analgesic requirements and a shorter hospital stay have been demonstrated. Concerns have recently been raised in the largest RCT trial of the oncological adequacy of laparoscopy in terms of increased rate of circumferential margin. This data however was not confirmed by other prospective comparative studies. Moreover, a similar local recurrence rate has been reported in RCT and comparative series. Similar findings of overall and disease free survival have been reported but the follow-up time period is too short in all these studies and the few RCT trials currently available do not draw any definitive conclusions. On the basis of available data in the literature, the mini-invasive approach to rectal cancer surgery has some short-term advantages and does not seem to confer any disadvantage in term of local recurrence. With respect to long-term survival, a definitive answer cannot be given at present time as the results of RCT trials focused on long-term survival currently ongoing are still to fully clarify this issue.
Postoperative complications; Recurrence rate; Transanal endoscopic microsurgery; Robotics; Long-term outcome; Prognosis; Rectal cancer; Laparoscopy
Large comparative studies and multiple prospective randomized control trials (RCTs) have reported equivalence in short and long-term outcomes between the open and laparoscopic approaches for the surgical treatment of colon cancer which has heralded widespread acceptance for laparoscopic resection of colon cancer. In contrast, laparoscopic total mesorectal excision (TME) for the treatment of rectal cancer has been welcomed with significantly less enthusiasm. While it is likely that patients with rectal cancer will experience the same benefits of early recovery and decreased postoperative pain from the laparoscopic approach, whether the same oncologic clearance, specifically an adequate TME can be obtained is of concern. The aim of the current study is to review the current level of evidence in the literature on laparoscopic rectal cancer surgery with regard to short-term and long-term oncologic outcomes. The data from 8 RCTs, 3 meta-analyses, and 2 Cochrane Database of Systematic Reviews was reviewed. Current data suggests that laparoscopic rectal cancer resection may benefit patients with reduced blood loss, earlier return of bowel function, and shorter hospital length of stay. Concerns that laparoscopic rectal cancer surgery compromises short-term oncologic outcomes including number of lymph nodes retrieved and circumferential resection margin and jeopardizes long-term oncologic outcomes has not conclusively been refuted by the available literature. Laparoscopic rectal cancer resection is feasible but whether or not it compromises short-term or long-term results still needs to be further studied.
Rectal cancer; Laparoscopy; Total mesorectal excision; Anterior resection; Abdominoperineal resection
For some time now, there has been significant interest in understanding and defining the role of minimally invasive surgery in colorectal cancer. Laparoscopic surgery has been shown to have similar or better outcomes compared with open surgery. Recently, prospective randomized trials have demonstrated oncologic outcomes of laparoscopic colon surgery equivalent to those for open surgery. However, the technical challenges of performing laparoscopic resection of rectal cancers and the uncertainty of the oncologic quality of the surgical resection have hindered the growth of minimally invasive rectal surgery. Robotic rectal surgery has recently emerged as an attractive alternative to laparoscopic surgery because it allows for superior visualization within a narrow pelvic field and more precise dissection. Studies of robotic rectal resection have suggested similar or potentially improved short-term oncologic outcomes when compared with laparoscopic rectal resection. Ongoing randomized studies will provide additional insight into the role of laparoscopic and minimally invasive robotic surgery for rectal cancer.
Recent developments in large bowel surgery are the introduction of laparoscopic surgery and the implementation of multimodal fast track recovery programs. Both focus on a faster recovery and shorter hospital stay.
The randomized controlled multicenter LAFA-trial (LAparoscopy and/or FAst track multimodal management versus standard care) was conceived to determine whether laparoscopic surgery, fast track perioperative care or a combination of both is to be preferred over open surgery with standard care in patients having segmental colectomy for malignant disease.
The LAFA-trial is a double blinded, multicenter trial with a 2 × 2 balanced factorial design. Patients eligible for segmental colectomy for malignant colorectal disease i.e. right and left colectomy and anterior resection will be randomized to either open or laparoscopic colectomy, and to either standard care or the fast track program. This factorial design produces four treatment groups; open colectomy with standard care (a), open colectomy with fast track program (b), laparoscopic colectomy with standard care (c), and laparoscopic surgery with fast track program (d). Primary outcome parameter is postoperative hospital length of stay including readmission within 30 days. Secondary outcome parameters are quality of life two and four weeks after surgery, overall hospital costs, morbidity, patient satisfaction and readmission rate.
Based on a mean postoperative hospital stay of 9 +/- 2.5 days a group size of 400 patients (100 each arm) can reliably detect a minimum difference of 1 day between the four arms (alfa = 0.95, beta = 0.8). With 100 patients in each arm a difference of 10% in subscales of the Short Form 36 (SF-36) questionnaire and social functioning can be detected.
The LAFA-trial is a randomized controlled multicenter trial that will provide evidence on the merits of fast track perioperative care and laparoscopic colorectal surgery in patients having segmental colectomy for malignant disease.
The laparoscopic surgery in gastric cancer is applied with increasing frequency nowadays; noticeable reports come mainly from Korea and Japan with satisfactory results. This review presents briefly the issue by evaluating its role. A PubMed search of relevant articles published up to 2010 was performed to identify current information. Most data come from Far East, where gastric cancer occurs more often, and the proportion of early gastric cancer is high. Laparoscopic approach includes both the diagnostic laparoscopy and laparoscopic resection. Laparoscopic gastrectomy has currently limited application for gastric cancer in the West; it is not widely accepted and raises important considerations necessitating the planning of multicentre randomised control trials based mainly on the long-term results.
Advanced laparoscopic surgery; diagnostic laparoscopy; gastric cancer; laparoscopic gastrectomy; stomach carcinoma
A prospective case series of single incision multiport laparoscopic colorectal resections for malignancy using conventional laparoscopic trocars and instruments is described.
MATERIALS AND METHODS:
Eleven patients (seven men and four women) with colonic or rectal pathology underwent single incision multiport laparoscopic colectomy/rectal resection from July till December 2010. Four trocars were placed in a single transumblical incision. The bowel was mobilized laparoscopically and vessels controlled intracorporeally with either intra or extracorporeal anastomosis.
Three patients had carcinoma in the caecum, one in the hepatic flexure, two in the rectosigmoid, one in the descending colon, two in the rectum and two had ulcerative pancolitis (one with high grade dysplasia and another with carcinoma rectum). There was no conversion to standard multiport laparoscopy or open surgery. The median age was 52 years (range 24-78 years). The average operating time was 130 min (range 90-210 min). The average incision length was 3.2 cm (2.5-4.0 cm). There were no postoperative complications. The average length of stay was 4.5 days (range 3-8 days). Histopathology showed adequate proximal and distal resection margins with an average lymph node yield of 25 nodes (range 16-30 nodes).
Single incision multiport laparoscopic colorectal surgery for malignancy is feasible without extra cost or specialized ports/instrumentation. It does not compromise the oncological radicality of resection. Short-term results are encouraging. Long-term results are awaited.
Laparoscopic colectomy; single incision laparoscopic surgery; single incision
Colorectal cancer is the second leading cause of cancer-related death in western countries. The objective of this systematic review was to show that laparoscopic-assisted colon resection for cancer is not inferior to open colectomy with respect to cancer survival and perioperative outcomes.
We performed a comprehensive literature review. Inclusion criteria were adults aged over 16 years with a colon resection for documented colon cancer and randomized controlled trials with laparoscopic-assisted or open resections. We excluded studies that did not document colon cancer recurrence in their article. We assessed data extraction and study quality and performed a quantitative data analysis.
Six published and 4 unpublished studies fulfilled our inclusion criteria, with a total of 1262 patients. All primary and secondary outcomes showed good homogeneity, except for morbidity, which was described heterogeneously between the studies. There was no disadvantage to laparoscopic colon resection in any of these primary and secondary outcomes, compared with the conventional open technique.
The results of this study suggest that, although there is no definitive answer, present evidence indicates that laparoscopic colon cancer resection is as safe and efficacious as the conventional open technique.
Laparoscopic colectomy has not been accepted as quickly as laparoscopic cholecystectomy. This is because of its steep learning curve, concerns with oncological outcomes, lack of randomised controlled trials (RCTs) and initial reports on port-site recurrence after curative resection. The aim of this review is to summarise current evidence on laparoscopic colorectal surgery.
PATIENTS AND METHODS
Review of literature following Medline search using key words ‘laparoscopic’, ‘colorectal’ and ‘surgery’.
Laparoscopic colorectal surgery proved to be safe, cost-effective and with improved short-term outcomes. However, further studies are needed to assess the role of laparoscopic rectal cancer surgery and the value of enhanced recovery protocols in patients undergoing laparoscopic colorectal resections.
Laparoscopy; Colorectal surgery; Colectomy
Liver metastasis of colorectal cancer is common. Resection of solitary tumors of primary and metastatic colorectal cancer can have a favorable outcome. Open resection of primary colorectal tumor and liver metastasis in one operation or in separate operations is currently common practice. Reports have shown that synchronous resections do not jeopardize short or long-term surgical outcomes and that this is a safe and effective approach in open surgery. The development of laparoscopic colorectal surgery and laparoscopic hepatectomy has made a minimally invasive surgical approach to treating colorectal cancer with liver metastasis feasible. Synchronous resections of primary colorectal tumor and liver metastasis by laparoscopy have recently been reported. The efficacy and safety of laparoscopic colorectal resection and laparoscopic hepatectomy have been proven separately but synchronous resections by laparoscopy are in hot debate. As it has been shown that open resection of primary colorectal tumor and liver metastasis in one operation results in an equally good short-term outcome when compared with that done in separate operations, laparoscopic resection of the same in one single operation seems to be a good option. Recent evidence has shown that this new approach is a safe alternative with a shorter hospital stay. Large scale randomized controlled trials are needed to demonstrate the effectiveness of this minimally invasive approach.
Colorectal cancer; Hepatectomy; Laparoscopic; Liver resection; Simultaneous; Synchronous
These authors found that conversion in laparoscopic surgery for curable colorectal cancer is associated with a worse peri-operative outcome and worse disease-free survival.
Long-term outcome of patients following conversion during laparoscopic surgery for colorectal cancer is not often reported. Recent data suggest a negative impact of conversion on long-term survival. This study aimed to evaluate the impact of conversion on the perioperative outcome and on long-term survival in patients who underwent laparoscopic resection for curable colorectal cancer.
Evaluation of our prospective in-hospital collected data of patients who underwent laparoscopic surgery for curable colorectal cancer over a 5-year period. Long-term data were collected from our outpatient's clinic data and personal contact when necessary.
During the study period, 175 patients were operated on laparoscopically for curable colon cancer (stage I-III). Mean follow-up was 33±18 months with a minimum follow-up of 12 months. For various reasons, 25 patients (14.4%) had to be converted to open surgery. Short-term outcome revealed a trend towards longer operations, a higher rate of surgical complications, and a longer hospital stay in the converted group. Five-year, Kaplan-Meier, disease-free analysis was worse for converted patients. Overall survival did not differ between the 2 groups. Cox proportional hazards regression analysis revealed that conversion and AJCC stage were independent risk factors for recurrence.
Conversion in laparoscopic surgery for curable colorectal cancer is associated with a worse perioperative outcome and worse disease-free survival.
Colorectal cancer; Conversion; Laparoscopy; Survival
After over a decade of debate and controversy, it is now well established that laparoscopic colon surgery for cancer when compared with open surgery, results in short-term benefits while maintaining at least equivalent long-term outcomes. Consequently, more and more patients are undergoing laparoscopic colon surgery, but the adoption rate still remains relatively low in the United States. Similarly, there are many potential benefits to performing rectal surgery laparoscopically. Although not well documented, laparoscopic rectal surgery is under active investigation and may result in the usual short-term benefits associated with laparoscopic surgery. In this article, short- and long-term outcomes of patients undergoing laparoscopic colorectal surgery for cancer are reviewed. In addition, different technical options for laparoscopic approaches to colon and rectal cancer are compared.
Colorectal cancer; laparoscopy; hand-assisted colectomy; straight laparoscopy
This study was a systematic review of the available evidence on quality of life in patients after laparoscopic or open colorectal surgery. A systematic review was performed of all randomized clinical trials (RCTs) that compared laparoscopic with open colorectal surgery. Study selection, quality assessment and data extraction were carried out independently by two reviewers. Primary endpoint was quality of life after laparoscopic and open colorectal surgery, as assessed by validated questionnaires. The search resulted in nine RCTs that included 2263 patients. Short- and long-term results of these RCTs were described in 13 articles. Postoperative follow-up ranged from 2 d to 6.7 years. Due to clinical heterogeneity, no meta-analysis could be conducted. Four RCTs did not show any difference in quality of life between laparoscopic or open colorectal surgery. The remaining five studies reported a better quality of life in favor of the laparoscopic group on a few quality of life scales at time points ranging from 1 wk to 2 years after surgery. In conclusion, based on presently available high-level evidence, this systematic review showed no clinically relevant differences in postoperative quality of life between laparoscopic and open colorectal surgery.
Quality of life; Colorectal surgery; Laparoscopy; Colonic neoplasms; Colonic diseases; Inflammatory bowel diseases
Examine effects of HMO penetration, hospital competition, and patient severity on the uptake of laparoscopic colectomy and its price relative to open surgery for colon cancer.
We used 2002-2007 the MarketScan Database to identify admissions for privately insured colorectal cancer patients undergoing laparoscopic or open partial colectomy (n=1,035 and n=6,389, respectively). Patient and health plan characteristics were retrieved from these data; HMO market penetration rates and an index of hospital market concentration, Herfindahl-Hirschman Index (HHI), were derived from national databases. Logistic and logarithmic regressions were used to examine the odds of having laparoscopic colectomy, effect of covariates on colectomy prices, and the differential price of laparoscopy.
Adoption of laparoscopy was highly sensitive to market forces, with a 10% increase in HMO penetration leading to a 10.3% increase in the likelihood of undergoing laparoscopic colectomy (Adjusted Odds Ratio (AOR): 1.109, 95% Confidence Interval: 1.062, 1.158), and a 10% increase in HHI resulting in 6.6% lower likelihood (AOR: 0.936 (0.880, 0.996)). Price models indicated that the price of laparoscopy was 7.6% lower than for open surgery (transformed coefficient (Coeff): 0.927 (0.895, 0.960)). A 10% increase in HMO penetration was associated with 1.6% lower price (Coeff: 0.985 (0.977, 0.992)), while a 10% increase in HHI was associated with 1.6% higher price (Coeff: 1.016 (1.006, 1.027), p < 0.001 for all comparisons).
Laparoscopy was significantly associated with lower hospital prices. Moreover,
Laparoscopic surgery may result in cost savings, while market pressures contribute to its adoption.
Colon Cancer; Surgery; Laparoscopy, Medical Prices
Colorectal cancer is one kind of frequent malignant tumors of the digestive tract which gets high morbidity and mortality allover the world. Despite the promising clinical results recently, less information is available regarding the perioperative immunological effects of laparoscopic surgery when compared with the open surgery. This study aimed to compare the cellular immune responses of patients who underwent laparoscopic(LCR) and open resections(OCR) for colorectal cancer.
Between Mar 2009 and Sep 2009, 35 patients with colorectal carcinoma underwent LCR by laparoscopic surgeon. These patients were compared with 33 cases underwent conventional OCR by colorectal surgeon. Clinical data about the patients were collected prospectively. Comparison of the operative details and postoperative outcomes between laparoscopic and open resection was performed. Peripheral venous blood samples from these 68 patients were taken prior to surgery as well as on postoperative days(POD) 1, 4 and 7. Cell counts of total white blood cells, neutrophils, lymphocyte subpopulations, natural killer(NK) cells as well as CRP were determined by blood counting instrument, flow cytometry and hematology analyzer.
There was no difference in the age, gender and tumor status between the two groups. The operating time was a little longer in the laparoscopic group (P > 0.05), but the blood loss was less (P = 0.039). Patients with laparoscopic resection had earlier return of bowel function and earlier resumption of diet as well as shorter median hospital stay (P < 0.001). Compared with OCR group, cell numbers of total lymphocytes, CD4+T cells and CD8+T cells were significant more in LCR group (P < 0.05) on POD 4, while there was no difference in the CD45RO+T or NK cell numbers between the two groups. Cellular immune responds were similar between the two groups on POD1 and POD7.
Laparoscopic colorectal resection gets less surgery stress and short-term advantages compared with open resection. Cellular immune respond appears to be less affected by laparoscopic colorectal resection when compared with open resection.
Laparoscopic colorectal surgery is being widely practiced with an excellent short-term and equal long-term results for colorectal diseases including cancer. However, it is widely believed that as the experience of the surgeon/unit improves the results get better. This study aims to assess the pattern of case selection and short-term results of laparoscopic colorectal surgery in a high volume centre in two different time frames.
MATERIALS AND METHODS:
This study was done from the prospective data of 265 elective laparoscopic colorectal resections performed in a single unit from December 2005 to April 2011. The group was subdivided into initial 132 patients (Group 1) from December 2005 to December 2008 and next 133 patients (Group 2) between December 2008 and April 2011 who underwent laparoscopic colorectal resections for cancer. The groups were compared for intraoperative and perioperative parameters, type of surgery, and the stage of the disease.
The age of patients was similar in Groups 1 and 2 (57.7 and 56.9, respectively). Patients with co-morbid illness were significantly more in Group 2 than in Group 1 (63.2% vs. 32.5%, respectively, P≤0.001). There were significantly more cases of right colonic cancers in Group 1 than in Group 2 (21.9% vs. 11.3%, respectively, P<0.02) and less number of low rectal lesions (20.4% vs. 33.8%, respectively, P≤0.02). The conversion rates were 3.7% and 2.2% in Groups 1 and 2, respectively. The operating time and blood loss were significantly more in Group 1 than in Group 2. The ICU stay was significantly different in Groups 1 and 2 (31.2± 19.1 vs. 24.7± 18.7 h, P≤0.005). The time for removal of the nasogastric tube was significantly earlier (P=0.005) in Group 2 compared to Group 1 (1.37± 1.1 vs. 2.63±1.01 days). The time to pass first flatus, resumption of oral liquids, semisolid diet, and complications were similar in both groups. The hospital stay was more in Group 1 than in Group 2 ( P≤0.01). The numbers of lymph nodes retrieved was similar in both groups. The T stage of the disease in Groups 1 and 2 were similar, however, the number of T4 lesions was significantly more in Group 2 (8.3% vs. 18.7%, respectively, P<0.01).
This study shows that with increasing experience, laparoscopic colorectal surgery can be practiced safely with minimal conversion rates and morbidity. As the units experience improves, there is a trend towards selecting advanced cases and performing complex laparoscopic colorectal procedures. With increasing experience, there is a trend towards better short-term outcome after laparoscopic colorectal surgeries.
Case selection; laparoscopic colectomy; learning curve; short-term results
The long-term results of a laparoscopic resection for colorectal cancer have been reported in several studies, but reports on the results of laparoscopic surgery for rectal cancer are limited. We investigated the long-term outcomes, including the five-year overall survival, disease-free survival and recurrence rate, after a laparoscopic resection for colorectal cancer.
Using prospectively collected data on 303 patients with colorectal cancer who underwent a laparoscopic resection between January 2001, and December 2003, we analyzed sex, age, stage, complications, hospital stay, mean operation time and blood loss. The overall survival rate, disease-free survival rate and recurrence rate were investigated for 271 patients who could be followed for more than three years.
Tumor-node-metastasis (TNM) stage I cancer was present in 55 patients (18.1%), stage II in 116 patients (38.3%), stage III in 110 patients (36.3%), and stage IV in 22 patients (7.3%). The mean operative time was 200 minutes (range, 100 to 535 minutes), and the mean blood loss was 97 mL (range, 20 to 1,200 mL). The mean hospital stay was 11 days and the mean follow-up period was 54 months. The mean numbers of resected lymph nodes were 26 and 21 in the colon and the rectum, respectively, and the mean distal margins were 10 and 3 cm. The overall morbidity rate was 26.1%. The local recurrence rates were 2.2% and 4.4% in the colon and the rectum, respectively, and the distant recurrence rates were 7.8% and 22.5%. The five-year overall survival rates were 86.1% in the colon (stage I, 100%; stage II, 97.6%; stage III, 77.5%; stage IV, 16.7%) and 68.8% in the rectum (stage I, 90.2%; stage II, 84.0%; stage III, 57.6; stage IV, 13.3%). The five-year disease-free survival rates were 89.8% in the colon (stage I, 100%; stage II, 97.7%; stage III, 74.2%) and 74.5% in the rectum (stage I, 90.0%; stage II, 83.9%; stage III, 59.2%).
Laparoscopic surgery for colorectal cancer is a good alternative method to open surgery with tolerable oncologic long-term results.
Long-term outcome; Laparoscopy; Colorectal neoplasms
This study aimed to compare the overall and disease specific survivals of patients who underwent laparoscopic and open resection of colorectal cancer in a high volume tertiary center.
Consecutive patients who underwent elective resection for colorectal cancer (open resection, n = 1,197; laparoscopic resection, n = 814) from January 2000 to December 2009 were included. The operative details, postoperative complications, postoperative outcomes, and survival data were collected prospectively. Comparison was made between patients who had laparoscopic and open surgery.
The age, gender, medical morbidity, and American Society of Anesthesiologists status were similar in the two groups. Laparoscopic resection was associated with significantly less blood loss and a shorter hospital stay. The operating mortality and morbidity were significantly lower in the laparoscopic group. The qualities of the specimens in terms of the distal resection margin and the number of lymph nodes examined were not inferior in the laparoscopic group. With the median follow-up of 40.3 months, the 5-year overall survival (74.1% vs. 65.5%, p < 0.001) and disease specific survival (81.9% vs. 75.2%, p = 0.002) were significantly better in patients with non-disseminated disease in the laparoscopic group. The operative approach was an independent prognostic factor in the overall (risk ratio 1.36, 95% CI 1.093–1.700, p = 0.006) and disease specific (risk ratio 1.32, 95% CI 1.005–1.738, p = 0.048) survivals in multivariate analysis.
Laparoscopic resection for colorectal cancer is associated with more favorable overall and disease specific survivals when compared with open resection in a high volume tertiary center.
Outcomes of laparoscopic colorectal resection
As a result of the obvious benefits of laparoscopic cholecystectomy, minimally invasive techniques have been applied to more complex gastrointestinal procedures, including colorectal resections. The goal in adapting laparoscopic techniques for colorectal surgery is to offer an operation that results in less pain, shorter hospital stay, more rapid return to normal activities, and improved cosmesis compared with conventional operation. The challenge has been to show that this can be done safely and efficiently and that for cancer patients there is no detrimental oncologic effect. The major issues that have been and continue to be addressed are (1) whether an adequate resection can be performed laparoscopically, (2) whether there is a high rate of wound or port site recurrence following these operations, and (3) whether, by using these techniques, we are trading short-term benefits for a poor long-term oncologic outcome. To answer these fundamental questions, several prospective randomized trials have been conducted and several more are under way. The results of these trials indicate that, in terms of cancer outcome, there is no difference in overall survival, disease-free survival, and wound recurrences in patients treated using laparoscopic techniques compared with conventional operation. In addition, there are short-term benefits associated with the use of these techniques. It can now be said that from an oncologic standpoint, in experienced hands, laparoscopic colectomy for curable colon cancer is equivalent to conventional therapy, and it is superior to conventional operation regarding short-term outcomes. Laparoscopic colectomy for colon cancer should be offered to appropriately selected patients.
Laparoscopy; colon cancer; laparoscopic colectomy
During the last two decades the use of laparoscopic resection and a multimodal approach known as an enhanced recovery programme, have been major changes in colorectal perioperative care. Clinical outcome improves using laparoscopic surgery to resect colorectal cancer but until recently no multicentre trial evidence had been reported regarding whether the benefits of laparoscopy still exist when open surgery is optimized within an enhanced recovery programme. The EnROL trial (Enhanced Recovery Open versus Laparoscopic) examines the hypothesis that laparoscopic surgery within an enhanced recovery programme will provide superior postoperative outcomes when compared to conventional open resection of colorectal cancer within the same programme.
EnROL is a phase III, multicentre, randomised trial of laparoscopic versus open resection of colon and rectal cancer with blinding of patients and outcome observers to the treatment allocation for the first 7 days post-operatively, or until discharge if earlier. 202 patients will be recruited at approximately 12 UK hospitals and randomised using minimization at a central computer system in a 1:1 ratio. Recruiting surgeons will previously have performed >100 laparoscopic colorectal resections and >50 open total mesorectal excisions to minimize conversion. Eligible patients are those suitable for elective resection using either technique. Excluded patients include: those with acute intestinal obstruction and patients in whom conversion from laparoscopic to open procedure is likely. The primary outcome is physical fatigue as measured by the physical fatigue domain of the multidimensional fatigue inventory 20 (MFI-20) with secondary outcomes including postoperative hospital stay; complications; reoperation and readmission; quality of life indicators; cosmetic assessments; standardized performance indicators; health economic analysis; the other four domains of the MFI-20. Pathological assessment of surgical quality will also be undertaken and compliance with the enhanced recovery programme will be recorded for all patients.
Should this trial demonstrate that laparoscopic surgery confers a significant clinical and/or health economic benefit this will further support the transition to this type of surgery, with implications for the training of surgeons and resource allocation.
Laparoscopy; Colon cancer; Rectal cancer; Enhanced recovery programme; Fast track surgery; Health economics; Cosmetic assessment; Fatigue; Randomised controlled trial; EnROL