ADVANCES IN CANCER TREATMENT
This month's topic: LAPAROSCOPIC COLECTOMY FOR COLORECTAL CANCER
| Arch Surg. 2004 Jan;139(1):39-42. |
Kiran RP, Delaney CP, Senagore AJ, Millward BL, Fazio VW.
Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
HYPOTHESIS: Blood loss, measured by estimated blood loss, drop in hemoglobin levels, and transfusion requirements, is lower in patients undergoing laparoscopic colectomy compared with patients undergoing conventional open colectomy. DESIGN: Case-matched study. SETTING: A university hospital. PATIENTS: Patients undergoing laparoscopic colectomy between January 2000 and December 2001 were matched in a prospective database for age, sex, comorbidity, and surgical procedure with patients undergoing open colectomy during the same period. MAIN OUTCOME MEASURES: Estimated blood loss, drop in hemoglobin levels, and transfusion requirements after surgery were compared. RESULTS: One hundred forty-seven patients undergoing the same operation using either an open or laparoscopic approach could be matched for age, sex, and diagnosis related grouping. There was no significant difference in American Society of Anesthesiologists class, body mass index, or preoperative and postoperative hemoglobin levels, but the open colectomy group required significantly more units of blood (P =.003) to maintain similar hemoglobin levels after surgery. Estimated blood loss (P<.001) and the number of patients who received transfusions on the day of surgery (P =.002), during the first 48 hours after surgery (P =.005), and during the entire hospital stay (P =.003) were significantly higher in the open colectomy group. CONCLUSION: A laparoscopic approach for colorectal surgery led to significantly less blood loss than matched open colectomy cases.
| Dis Colon Rectum. 2003 May;46(5):601-11. |
Prospective comparison of laparoscopic vs. open resections for colorectal adenocarcinoma over a ten-year period.
Patankar SK, Larach SW, Ferrara A, Williamson PR, Gallagher JT, DeJesus S, Narayanan S.
The Colon and Rectal Clinic of Orlando, 110 West Underwood Street, Orlando, Florida 32806, USA.
PURPOSE: The aim of this study was to define the long-term oncologic outcomes of laparoscopic resections for colorectal cancer. METHODS: We analyzed our experience via a prospective, nonrandomized, longitudinal cohort study. The period of study extended from April 1991 to May 2001. Laparoscopic resection was offered selectively in the absence of a large mass, invasion into abdominal wall or adjacent organs, and multiple prior abdominal operations. Every laparoscopic resection performed with curative intent for adenocarcinoma was included. Twenty percent of patients whose procedures were converted to open resection were included in the laparoscopic-resection group because of intention to treat. Oncologic outcome measures of this group were compared with a computerized, case-matched, open-resection group, the case-matching variables being age, gender, site of primary tumor (colon vs. rectum), and TNM stage. The laparoscopic-resection group was followed up prospectively, and data were updated regularly. The follow-up techniques consisted of a combination of office visits, telephone calls, and the United States Social Security Death Index database. RESULTS: The laparoscopic-resection group consisted of 172 patients with a mean age of 67 (range, 27-85) years. The open-resection group consisted of 172 patients with a mean age of 69 (range, 30-90) years. Mean follow-up was 52 (range, 3-128) months. Complete (100 percent) follow-up data were available. The TNM stage distribution was 63 Stage I (37 percent), 51 Stage II (30 percent), 47 Stage III (27 percent), and 11 Stage IV (6 percent) tumors for the laparoscopic-resection group and 65 Stage I (38 percent), 48 Stage II (28 percent), 51 Stage III (29 percent), and 8 Stage IV (5 percent) tumors for patients in the open-resection group (P = 0.75, not significant). Thirty-day mortality was 1.2 percent (2 deaths) in the laparoscopic-resection group and 2.4 percent (4 deaths) in the open-resection group (P > 0.05, not significant). Early and late complication incidences were comparable. Local recurrence was observed in three patients (1.7 percent) in the laparoscopic resection group with the primary tumor in the colon and in three patients (1.7 percent) with the primary tumor in the rectum, for a total incidence of local recurrence in the laparoscopy group of 3.5 percent (6 patients). In the open-resection group, local recurrence was observed in two patients (1.2 percent) among those with primary tumor site in the colon and in three patients (1.7 percent) in the group with primary tumor in the rectum, for a total incidence of local recurrence in the open-resection group of 2.9 percent (5 patients). One of the local recurrences in the laparoscopy group occurred in the port/extraction site, for an incidence of 0.6 percent. Metastasis occurred in 18 patients (10.5 percent) in the open group and in 21 (12.2 percent) in the laparoscopy group. Stage-for-stage overall five-year survival rates were similar in the two groups. The Kaplan-Meier statistical analysis performed for colonic vs. rectal primary adenocarcinoma confirmed that TNM stage for stage-overall survival was similar in the laparoscopic and open-resection groups (log-rank P = 0.22). CONCLUSIONS: Notwithstanding the drawbacks of a nonrandomized study, no adverse long-term oncologic outcomes of laparoscopic resections for colorectal cancer were observed in a single center's experience during a ten-year period.
| Surg Endosc. 2003 Apr;17(4):636-40. Epub 2003 Feb 10. |
Randomized controlled trial of laparoscopic versus open colectomy for advanced colorectal cancer.
Hasegawa H, Kabeshima Y, Watanabe M, Yamamoto S, Kitajima M.
Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
BACKGROUND: After confirming a favorable outcome of laparoscopic surgery for early colorectal cancer, we conducted a randomized controlled trial to compare short-term outcomes of laparoscopic and open colectomy for advanced colorectal cancer. METHODS: Fifty-nine patients with T2 or T3 colorectal cancer were randomized to undergo laparoscopic (n = 29) or open (n = 30) colectomy. Median follow-up was 20 months (range, 6-34 months). RESULTS: Operative time was longer (p <0.0001) and blood loss (p = 0.0034) and postoperative analgesic requirement were less in the laparoscopic group than in the open group. An earlier return of bowel motility and earlier discharge from the hospital (p = 0.0164) were observed after laparoscopic surgery. Serum C-reactive protein levels on postoperative days 1 (p <0.0001) and 4 (p = 0.0039) were lower in the laparoscopic group than in the open group. Postoperative complications did not differ between the two groups. CONCLUSION: Laparoscopic surgery for advanced colorectal cancer is feasible, with favorable short-term outcome.
| Surg Clin North Am. 2002 Oct;82(5):1019-33. |
The role of laparoscopy in the multimodality treatment of colorectal cancer.
Hartley JE, Monson JR.
The University of Hull, Academic Surgical Unit, Castle Hill Hospital, Cottingham, East Yorkshire Y016 5JQ, United Kingdom.
Ten years after the first reports of laparoscopic techniques in colorectal surgery the precise role for these approaches in future colorectal practice as still to be defined. However, it seems most unlikely that the application is going to disappear. Laparoscopic colectomy is undoubtedly a complex. time-consuming procedure and it is clear that the technique is intolerant of difficult cases and will likely remain thus. Therefore. the potential advantages of laparoscopy do not as yet appear to be attainable across the board in colorectal resection. Such generalized advantage may, however, be tantalizingly close. Although many studies have failed to show major benefits for laparoscopy in terms of postoperative recovery, it must be remembered that most of these have been of insufficient statistical power to settle the issue. What is clear to all involved in the field is that very many patients do gain major benefit from the minimally invasive approach. The challenge for the future lies in developing the technology to such a point that these benefits for patients are more reproducible. The requirement for a significant abdominal incision to deliver an intact specimen represents a significant hurdle in this regard. The importance of pathological staging for colorectal cancer at present mandates retrieval of an intact specimen. It is of course possible that radiological staging may develop to such a point that surgeons need only remove the lesion with minimal attention to lymphadenectomy. Alternatively, new adjuvant therapies may arrive that, by virtue of increased efficacy and low side-effect profiles, may be applicable to all but the earliest lesions. Finally, increasing health awareness and application of screening programs may lead to a preponderance of large polyps and preinvasive lesions for which a more limited resection may be appropriate. Obviously these scenarios remain almost entirely speculative. However, the trend towards less invasive local therapy for colorectal cancer seems inexorable, and we firmly believe that laparoscopy will come to play an increasing role. Finally, we suggest that the oncological safety of laparoscopy is of less concern than was the case some years ago. The specter of port-site metastasis, once so alarming, has faded. It is now apparent from all of the larger scale studies that port-site metastases are not a significant issue in the presence of adequate training and laparoscopic skills. Almost without exception, the accumulating evidence seems to point to equivalence in terms of disease-specific recurrence and survival between patients treated using conventional and laparoscopic techniques. We foresee these findings being confirmed by the North American and European trials.
| Ann Surg. 2002 Dec;236(6):759-66; disscussion 767. |
Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome.
Braga M, Vignali A, Gianotti L, Zuliani W, Radaelli G, Gruarin P, Dellabona P, Di Carlo V.
Department of Surgery, San Raffaele University, Milan Italy. braga.marco@hsr.it
OBJECTIVE: The primary endpoint was to compare the impact of laparoscopic and open colorectal surgery on 30-day postoperative morbidity. Lymphocyte proliferation to mitogens and gut oxygen tension were surrogate endpoints. SUMMARY BACKGROUND DATA: Evidence-based proof of the effect of laparoscopic colorectal surgery on immunometabolic response and clinically relevant outcome variables is scanty. Further randomized trials are desirable before proposing laparoscopy as a superior technique. METHODS: Two hundred sixty-nine patients with colorectal disease were randomly assigned to laparoscopic (n = 136) or open (n = 133) colorectal resection. Four trained members of the surgical staff who were not involved in the study registered postoperative complications. Lymphocyte proliferation to Candida albicans and phytohemagglutinin was evaluated before and 3 and 15 days after surgery. Operative gut oxygen tension was monitored continuously by a polarographic microprobe. RESULTS: In the laparoscopic group the conversion rate was 5.1%. The overall morbidity rate was 20.6% in the laparoscopic group and 38.3% in the open group. Postoperative infections occurred in 15 of the 136 patients in the laparoscopic group and 31 of the 133 patients in the open group. The mean length of hospital stay was 10.4 +/- 2.9 days in the laparoscopic group and 12.5 +/- 4.1 days in the open group. On postoperative day 3, lymphocyte proliferation was impaired in both groups. Fifteen days after surgery, the proliferation index returned to baseline values only in the laparoscopic group. Intraoperative gut oxygen tension was higher in the laparoscopic than in the open group. CONCLUSIONS: Laparoscopic colorectal surgery resulted in a significant reduction of 30-day postoperative morbidity. Lymphocyte proliferation and gut oxygen tension were better preserved in the laparoscopic group than in the open group.
| Surg Endosc. 2003 Feb;17(2):242-6. Epub 2002 Oct 29. |
Comparison of surgical stress between laparoscopic and open colonic resections.
Hildebrandt U, Kessler K, Plusczyk T, Pistorius G, Vollmar B, Menger MD.
Klinikum Salzgitter, Salzgitter, Germany. chuhil@med-rz.uni-sb.de
BACKGROUND: The magnitude of surgical trauma after laparoscopic and open colonic resection was evaluated by examining postoperative serum values of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and granulocyte elastase (GE) for further evidence of the benefit realized with minimally invasive approaches in colonic surgery. METHODS: Altogether, 42 patients with Crohn's disease (n = 20) or colon carcinomas/adenomas (n = 22) were matched by age, gender, body mass index (BMI), and Crohn's Disease Activity Index for either a laparoscopic (n = 21) or an open colonic resection (n = 21). In both groups the postoperative serum levels of IL-6, IL-10, C-RP, and granulocyte elastase were determined, as indicators of surgical stress. RESULTS: Laparoscopic and open colonic resection caused a significant increase in serum IL-6, IL-10, CRP, and granulocyte elastase levels. The comparison between laparoscopic and open colonic resections, however, showed significantly lower serum IL-6, IL-10, CRP, and granulocyte elastase levels after laparoscopic colonic resection, which was most evident for IL-6 and granulocyte elastase. CONCLUSIONS: Our study demonstrated that IL-6 and granulocyte elastase may be appropriated particularly to monitor surgical stress. By using these parameters, we found a significant reduction in surgical trauma after laparoscopic surgery, was compared with the open procedure. This supports the clinical findings of a clear benefit for patients undergoing laparoscopic colonic surgery.
| Surg Endosc. 2002 Jun;16(6):949-53. Epub 2002 Mar 18. |
COLOR: a randomized clinical trial comparing laparoscopic and open resection for colon cancer.
Hazebroek EJ; Color Study Group.
BACKGROUND: Laparoscopic surgery has proven to be safe and effective. However, the value of laparoscopic resection for malignancy in terms of cancer outcome can only be assessed by large prospective randomized clinical trials with sufficient follow-up. METHODS: COLOR (COlon carcinoma Laparoscopic or Open Resection) is a European multicenter randomized trial that began in 1997. In 27 hospitals in Sweden, The Netherlands, Germany, France, Italy, Spain, and the United Kingdom, 1200 patients will be included. The primary endpoint of the study is cancer-free survival after 3 years. RESULTS: In <3.5 YEARS, >850 patients have been randomized for right hemicolectomy (47%), left hemicolectomy (11%), and sigmoidectomy (42%). Fifty seven patients were excluded after randomization. Forty six months after the start of the trial, the overall recurrence rate is 6.8%. The distribution of stage of disease is as follows: stage I, 25%; stage II, 41%; stage III, 32%; stage IV, 2%. CONCLUSION: Although laparoscopic surgery appears to be of value in the treatment of colorectal cancer, the final, results of randomized trials need to be considered to determine its definitive role. Given the current accrual rate, the COLOR study will be completed in 2002.
Publication Types:
- Clinical Trial
- Multicenter Study
- Randomized Controlled Trial
| 8: Surg Endosc. 2002 Oct;16(10):1409-12. Epub 2002 Jul 29. |
Five-year results of 206 laparoscopic left colectomies for cancer.
Lechaux D, Trebuchet G, Le Calve JL.
Departement de Chirurgie Viscerale, Hopital Pontchaillou, Rue Henri Le Guilloux 35033 Rennes, France. david.lechaux@chu-rennes.fr
BACKGROUND: The purpose of this study was to evaluate the 5-year survival of 206 consecutive patients with left colon carcinoma operated with a laparoscopic procedure between March 1992 and December 2000. METHODS: Patients with obstructing or bulky cancers were excluded from this study. Tumor stage was defined according to the Dukes modified classification. The laparoscopic-assisted technique included primary high vascular ligation, centrifugal dissection of the mesentery, and "no touch" technique. The survival rates were calculated with the Kaplan-Meier test. RESULTS: There were 109 males and 97 females, median age 67 (range 34-91). There were 30 left hemicolectomies (15%) and 177 sigmoid colectomies (85%). 22 patients required open conversion (11%). Overall operative mortality (1 month) was 1% and morbidity 12% (surgical and medical). There were 56 Dukes A carcinomas (27%), 69 Dukes B (34%), 54 Dukes C (26%), and 27 Dukes D (13%). 125 patients (61%) are alive and disease free, 22 (11%) are alive with disease recurrence, and 59 patients (28%) are deceased. None have been lost to follow-up. Only 1 case of trocar site implantation occurred after curative resections. Three-year observed survival rate were 93% for Dukes A + B (node negative tumors confined to the bowel wall), 78% for Dukes C, and 15% for Dukes D. The 5-year survival rates were 85% for Dukes A + B, 61% for Dukes C, and 8% for Dukes D. CONCLUSION: Laparoscopic colectomy for cancer seems to be a safe procedure. The long-term results are comparable to those of open surgery. Further randomized trials will be necessary to confirm the value of this technique.
| Dis Colon Rectum. 2002 Jul;45(7):867-72; discussion 872-5. |
Laparoscopic colorectal surgery for cancer: intermediate to long-term outcomes.
Lumley J, Stitz R, Stevenson A, Fielding G, Luck A.
Royal Brisbane Hospital, Herston, Queensland, Australia.
PURPOSE: Since 1991, a laparoscopic-assisted resection has been used at the Royal Brisbane Hospital selectively for patients with colorectal cancer. This article audits the intermediate to long-term postoperative complications and cancer follow-up data. METHODS: All patients undergoing a laparoscopic resection for cancer were prospectively followed up with regard to long-term outcomes. RESULTS: One hundred eighty-one patients have been studied. One hundred fifty-four patients had potentially curative procedures performed in the study period. Median follow up was 71 (range, 7-108) months. The overall recurrence rate in this group was 6 percent (21 recurrences). There was one port site recurrence after a potentially curative procedure (0.6 percent) and one port site recurrence after a palliative resection. Perioperative mortality was 1 percent (2 patients). Only six patients suffered an adhesive small-bowel obstruction postoperatively. There was one incisional hernia. Unadjusted five-year median survival data for Australian Clinico-pathological Staging A was 91 percent (3.5 percent recurrence); for Australian Clinico-pathological Staging B, 83 percent (15 percent recurrence); and for Australian Clinico-pathological Staging C, 74 percent (26 percent recurrence). CONCLUSION: In selected patients a laparoscopic resection for colorectal cancer produces acceptable intermediate to long-term oncologic outcomes and a low long-term complication rate.
| J Am Coll Surg. 2002 Jul;195(1):30-2. |
Comment in:
Gum
chewing enhances early recovery from postoperative ileus after laparoscopic
colectomy.
Asao T, Kuwano H, Nakamura J, Morinaga N, Hirayama I, Ide M.
Department of Surgery I, Gunma University School of Medicine, Maebashi,
Japan.
BACKGROUND: Postoperative ileus limits early hospital discharge for patients
who have undergone laparoscopic procedures. Sham feeding has been reported
to enhance bowel motility. Here, the effect of gum chewing is evaluated as a
convenient method to enhance postoperative recovery from ileus after
laparoscopic colectomy. STUDY DESIGN: A total of 19 patients who underwent
elective laparoscopic colectomy for colorectal cancer participated in the
study. Each patient was randomly assigned to one of two groups: a
gum-chewing group (n = 10, mean age 58.6 years, range 50 to 71 years) or a
control group (n = 9, mean age 60.6 years, range 45 to 80 years). The
patients in the gum-chewing group chewed gum three times a day from the
first postoperative AM until oral intake. The times of the first passage of
flatus and defecation were recorded precisely. RESULTS: The first passage of
flatus was seen, on average, on postoperative day 2.1 in the gum-chewing
group and on day 3.2 in the control group (p < 0.01). The first
defecation was 2.7 days sooner in the gum-chewing group (postoperative day
3.1) than in the control group (5.8 days; p< 0.01). All patients
tolerated gum chewing on the first operative AM. The postoperative hospital
stays for the gum-chewing and control groups were 13.5+/-3.0 days and
14.5+/-6.1 days, respectively. CONCLUSIONS: Gum chewing aids early recovery
from postoperative ileus and is an inexpensive and physiologic method for
stimulating bowel motility. Gum chewing should be added as an adjunct
treatment in postoperative care because it might contribute to shorter
hospital stays.
| Dis Colon Rectum. 2002 Apr;45(4):491-501. |
Long-term survival after laparoscopic colon resection for cancer: complete five-year follow-up.
Lujan HJ, Plasencia G, Jacobs M, Viamonte M 3rd, Hartmann RF.
Laparoscopic Center of South Florida, HEALTHSOUTH Doctors' Hospital, Miami, Florida 33173, USA.
PURPOSE: The role of laparoscopic surgery in the cure of colorectal cancer is controversial. The aim of this study was to evaluate long-term survival after curative, laparoscopic resection of colorectal cancer. Specifically, we wanted to review those patients who now had complete five-year follow-up. METHODS: One hundred two consecutive patients (March 1991 to March 1996) underwent laparoscopic colon resections for cancer at one institution and now have complete five-year survival data. Charts were retrospectively reviewed and results compared with conventional surgery, i.e., open colectomy at our institution, and with the National Cancer Data Base during a similar time period. RESULTS: Fifty-nine male and 43 female patients with an average age of 70 (range, 34-92) years made up the study. Complications occurred in 23 percent of patients, and one patient died (1 percent). Forty-four laparoscopic right colectomies, 2 transverse colectomies, 36 laparoscopic left or sigmoid colectomies, 15 laparoscopic low anterior resections, and 5 laparoscopic abdominoperineal resections were performed. The average number of lymph nodes harvested was 6.6 +/- 0.61 (range, 0-22). Eight cases (7.8 percent) were "converted to open"; i.e., the typical 6-cm extraction site was lengthened to complete mobilization, devascularization, resection, or anastomosis, or a separate incision was required to complete the procedure. There was one extraction-site recurrence and one port-site recurrence; both occurred before the routine use of plastic-sleeve wound protection. The mean follow-up for laparoscopic colon resection patients was 64.4 +/- 2.8 (range, 1-111) months. According to the TNM classification system, 27 patients had Stage I cancer, 37 had Stage II, 23 had Stage III, and 15 had Stage IV. Similar five-year survival rates for laparoscopic and conventional surgery for cancer were noted. The five-year relative survival rates in the laparoscopic colon resection group were 73 percent for Stage I, 61 percent for Stage II, 55 percent for Stage III, and 0 percent for Stage IV. The five-year relative survival rates for the open colectomy and National Cancer Data Base groups were 75 and 70 percent, respectively, for Stage I, 65 and 60 percent for Stage II, 46 and 44 percent for Stage III, and 11 and 7 percent for Stage IV. CONCLUSIONS: Laparoscopic colon resection for cancer is safe and feasible in a private setting. Our data suggest that long-term survival after laparoscopic colon resection for cancer is similar to survival after conventional surgery. Prospective, randomized trials presently under way will likely confirm these results.
| 12: Surg Endosc. 2002 Aug;16(8):1158-61. Epub 2002 May 03. |
Results of laparoscopic vs open resections for colon cancer in patients with a minimum follow-up of 3 years.
Feliciotti F, Paganini AM, Guerrieri M, Sanctis A, Campagnacci R, Lezoche E.
Department of General Surgery, University of Ancona, "Umberto I" Hospital, Largo Cappelli 1, 60121, Ancona, Italy.
BACKGROUND: Laparoscopic resection for colon cancer is still a controversial procedure, the major cause of concern being the lack of long-term results. The aims of this study was to compare long-term outcome in unselected patients undergoing either laparoscopic (LH) or open hemicolectomy (OH) for colonic cancer. METHODS: From March 1992 to August 1997, 197 elective patients were included in this prospective nonrandomized study. The patients were operated on by the same surgical team following the same type of surgical technique for both right and left hemicolectomy, excluding segmental resections; the only difference was the type of access, which was either laparoscopic or open. Each patient gave a written consent, and the allocation to each group (laparoscopic or open) was done on the basis of the patient's choice. The long-term outcomes of the two groups were compared. Follow-up for both groups ranged from 36 to 96 months (mean, 48.9). RESULTS: In all, 149 (74 LH, 75 OH) of 197 patients were studied, excluding palliative resections, conversions to open surgery, perioperative deaths, and deaths not related to cancer. Only two patients in the laparoscopic group were lost to follow-up. The local recurrence after LH was 1.3% vs 2.7% after OH (p = 0.105). Metachronous metastases rates were similar for the two groups (10.8% for LH and 10.7% for OH). Cumulative survival probability (CSP) in the LH group vs the OH group was 0.892 vs 0.867 (p = 0.513), respectively. CSP for Duke's stage B and C in the LH group vs the OH group was 0.910 vs 0.895 (p = 0.506) and 0.800 vs 0.734 (p = 0.544) respectively. Sixty-four LH patients (86.5%) and 65 OH patients (86.7%) are disease-free. CONCLUSION: In our series of patients, no statistically significant difference was found between the two groups in terms of long-term survival rate.
| Surg Endosc. 2002 Apr;16(4):596-602. Epub 2002 Jan 09. |
Laparoscopic vs open hemicolectomy for colon cancer.
Lezoche E, Feliciotti F, Paganini AM, Guerrieri M, De Sanctis A, Minervini S, Campagnacci R.
Department of Surgery "Paride Stefanini," II Clinica Chirurgica, University "La Sapienza," Viale del Policlinico, 00161 Rome, Italy.
BACKGROUND: The role of laparoscopic resection in the management of colon cancer is still a subject of debate. In this clinical study, we compared the perioperative results and long-term outcome for two unselected groups of patients undergoing either laparoscopic or open hemicolectomy for colon cancer. METHODS: This prospective nonrandomized study was based on a series of 248 consecutive patients operated on by the same surgical team using the same type of surgical technique for right (RHC) and left (LHC) hemicolectomy, excluding segmental resections; the only difference was the type of access, which was either laparoscopic or open. The choice of type of access was left up to the patient after he or she had read the informed consent form. Operative time, length of stay, complications, and long-term outcome for the two groups were compared. Follow-up time ranged between 12 and 92 months (mean, 42). RESULTS: Between March 1992 and January 2000, 140 patients underwent a laparoscopic hemicolectomy (55 RHC and 86 LHC); at the same time, 107 patients (44 RHC and 63 LHC) were treated via an open approach. There were no conversions to open surgery in the laparoscopic RHC group, but six patients (7%) in the laparoscopic LHC group were converted. The mean operative time for laparoscopic surgery was significantly longer than the time for open surgery (190 vs 140 min for RHC, 240 vs 190 min for LHC,); however, with increasing experience, this time decreased significantly. The mean hospital stay for the patients who underwent laparoscopic procedures was significantly shorter in both the RHC and the LHC groups (9.2 vs 13.2 days for RHC, 10.0 vs 13.2 days for LHC). No statistically significant difference between the two laparoscopic and open groups was observed for the major complication rate (1.9% vs 2.3% for RHC, 7.5% vs 6.3% for LHC). The patient in the laparoscopic RHC group were lost to follow-up. The local recurrence rate was lower after laparoscopic surgery in both arms (5.4% vs 9% for RHC, 1.5% vs 7.5% for LHC), but the differences were not statistically significant. Two port site recurrences were observed in the laparoscopic groups, one after RHC (2.7%) and one after LHC (1.5%). Metachronous metastases rates were similar for the two groups (16.2% vs 15.1% for RHC, 4.4% vs 5.7% for LHC). Cumulative survival probability at 48 months after laparoscopic RHC was 0.865, as compared to 0.818 after open surgery, and 0.971 after laparoscopic LHC, as compared to 0.887 after open surgery. CONCLUSION: These results suggest that laparoscopic hemicolectomy for colonic cancer can be performed safely, with morbidity, mortality, and long-term results comparable to those of open surgery.
| Surg Laparosc Endosc Percutan Tech. 2002 Apr;12(2):88-95. |
Laparoscopic versus open surgery for colorectal carcinoma: a prospective clinical trial involving 157 cases with a mean follow-up of 5 years.
Champault GG, Barrat C, Raselli R, Elizalde A, Catheline JM.
Department of Digestive Surgery, Paris University Hopital J. Verdier, Paris, France. gerard.champault@jvr.ap-hop-paris.fr
The role of laparoscopic resection in the management of colorectal cancer is still unclear. It has been shown that laparoscopic colectomies can be accomplished with acceptable morbidity. Major concerns are port-site recurrences and neoplastic dissemination. The aims of this study were to compare perioperative results and long-term outcomes in a prospective, nonrandomized study of patients treated by laparoscopic versus open colorectal resection for cancer. In particular, the effects of an initial laparoscopic approach on survival and recurrence were examined. One hundred fifty-seven patients with colorectal carcinoma were included in the prospective trial: 74 underwent laparoscopic resection and 83 underwent conventional open surgery. The two groups were comparable in terms of characteristics, demographic data, stage of disease, and use of adjuvant or palliative chemoradiotherapy. All patients were observed at 1.3- and 6-month intervals. The median duration of follow-up was 60 months (range, 10-125 months). The mean operating time was significantly longer in the laparoscopic group. Six conversions (8.1%) were necessary. The passage of flatus and the restarting of oral intake (P = 0.0001) occurred earlier in the laparoscopic surgery group than in the open conventional surgery group. The mean postoperative stay was significantly shorter in the former group (P = 0.005), as was the length of the scar (P = 0.001). There were no deaths in either group. The overall morbidity was significantly lower (13% versus 33.7%; P = 0.001) in patients treated laparoscopically. No significant differences were observed between the groups in the length of specimens, the size of the tumor, or the number of nodes removed. Late complications were more frequent after open resection (12% versus 5.4%; P = 0.01). Two port-site metastases (2.6%) were seen in stage III and IV locally advanced carcinoma. There was no significant difference in recurrent disease between the groups (24.3% versus 25%) during the 60-month follow-up. Stage-for-stage comparisons showed that disease recurrence rates and crude death rates were comparable.
| JAMA. 2002 Jan 16;287(3):321-8. |
Short-term quality-of-life outcomes following laparoscopic-assisted colectomy vs open colectomy for colon cancer: a randomized trial.
Weeks JC, Nelson H, Gelber S, Sargent D, Schroeder G; Clinical Outcomes of Surgical Therapy (COST) Study Group.
Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115, USA. jane_weeks@dfci.harvard.edu
CONTEXT: Laparoscopic-assisted colectomy (LAC) has emerged as the preferred minimally invasive surgical strategy for diseases of the colon. The safety and efficacy of LAC for colon cancer are unknown, and the nature and magnitude of any quality-of-life (QOL) benefit resulting from LAC for colon cancer is also unknown. OBJECTIVE: To compare short-term QOL outcomes after LAC vs open colectomy for colon cancer. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized controlled trial (Clinical Outcomes of Surgical Therapy [COST]). Between September 1994 and February 1999, 37 of 48 centers provided data for the QOL component of the trial for 449 consecutive patients with clinically resectable colon cancer. MAIN OUTCOME MEASURES: Scores on the Symptoms Distress Scale (SDS), Quality of Life Index, and a single-item global rating scale at 2 days, 2 weeks, and 2 months postoperative; duration of postoperative in-hospital analgesic use; and length of stay. RESULTS: Of 449 patients, 428 provided QOL data. In an intention-to-treat analysis comparing SDS pain intensity, SDS summary, QOL Index summary, and global rating scale scores at each time point, the only statistically significant difference observed between groups was the global rating scale score for 2 weeks postsurgery. The mean (median) global rating scale scores for 2 weeks postsurgery were 76.9 (80) for LAC vs 74.4 (75) for open colectomy (P =.009). While in the hospital, patients assigned to LAC required fewer days of both parenteral analgesics compared with patients assigned to open colectomy (mean [median], 3.2 [3] vs 4.0 [4] days; P<.001) and oral analgesics (mean [median], 1.9 [1] vs 2.2 [2] days; P =.03). CONCLUSION: Only minimal short-term QOL benefits were found with LAC for colon cancer compared with standard open colectomy. Until ongoing trials establish that LAC is as effective as open colectomy in preventing recurrence and death from colon cancer, this procedure should not be offered to patients with colon cancer.
| Surg Oncol Clin N Am. 2001 Jul;10(3):639-53. |
Update on prospective randomized trials of laparoscopic surgery for colorectal cancer.
Pikarsky AJ.
Department of General Surgery, Hadassah University Medical Center, Jerusalem, Israel.
Cosmetic improvement is perhaps the only conclusive advantage of laparoscopic colectomy for cancer. Previous retrospective studies repeatedly have demonstrated the feasibility and safety of this procedure. Although short-term prospective studies showed adequate cancer resection, comparable complication rates, and no increase in recurrence, issues of port site implantation, immune response and cost-efficiency remain unsolved. The ongoing clinical trials mentioned currently are evaluating the benefits and the potential risks of this technique as a cancer operation. Four trials will have completed accrual and three will be able to offer early analysis of the results by the year 2001. Until then, laparoscopic surgery for colorectal cancer should be considered investigational to be performed only as part of these above-mentioned trials.