Laparoscopic resection of rectosigmoid carcinoma: prospective randomised trial

Minimally invasive pancreatic surgery: the new frontier?

Recent advances in minimally invasive pancreatic surgery encompass laparoscopic, retroperitoneoscopic, endoscopic, thoracoscopic, and percutaneous approaches. Applications of endoscopic pancreatic surgery include laparoscopic resection, necrosectomy, drainage of pseudocysts, gastric and biliary bypass, and thoracoscopic splanchnotomy. This review provides an update on laparoscopic pancreatic resections. Over 400 cases of laparoscopic distal pancreatectomy (LDP) and enucleation (LEn) have been reported in the English literature, largely for benign disease. LDP and LEn have been associated with reductions in blood loss, morbidity, and hospital stay and a greater rate of splenic preservation compared with open surgery. Laparoscopic ultrasound is essential for intraoperative localization of insulinomas because failure of localization is the most common cause for conversion to laparotomy. The role of LDP with en bloc splenectomy and laparoscopic pancreaticoduodenectomy (LPD) for malignancy remains controversial. The majority of LPDs have been performed for malignancy. The short-term results of the limited world experience of 34 reported LPDs appear favorable.

[Implementation of laparoscopic rectal cancer surgery]

INTRODUCTION

The integration of laparoscopic surgery for rectal cancer in clinical practice is one of the challenges faced by surgical societies. The aim of the present study was to analyze the results obtained during the implementation phase of this technique.

PATIENTS AND METHOD

From January 2003 to June 2005, 40 patients with rectal carcinoma underwent laparoscopic surgery in our center. Clinical and pathological variables were prospectively collected for statistical analyses.

RESULTS

A total of 27 men and 13 women underwent surgery: 11 high (HAR) and 20 low anterior resections (LAR) and 9 abdominoperineal resections (APR) were performed. Operative time was 240.4 +/- 200 min and was greater in the LAR group (259.7 vs 201.5 min; p=.02). The intraoperative complication rate was 22.5% (9% HAR vs 25% LAR; p=NS). The mean length of hospital stay was 8.7 +/- 4.8 days. The rate of postoperative complications was 32.5%. The conversion rate was 15% (6 patients), and was greater in the LAR group (25% vs 0% HAR vs 11.1% APR; p=0.02). The most common intraoperative complication and the most frequent cause of conversion consisted of stapling problems (4 patients). Surgery was considered curative in 34 patients (85%). One case of positive radial margins was encountered (3.3%). The mean distal and radial margins were 3.6 +/- 2.7 cm and 1.1 +/- 0.9 cm respectively.

CONCLUSIONS

The overall results during the implementation stage of laparoscopic surgery for rectal surgery were satisfactory. Conversion rates were highest in LAR, which proved to be the most demanding procedure.

Laparoscopic-assisted versus open ileocolic resection for Crohn's disease: a randomized trial

OBJECTIVE

The aim of the study was to compare laparoscopic-assisted and open ileocolic resection for primary Crohn's disease in a randomized controlled trial.

METHODS

Sixty patients were randomized for laparoscopic-assisted or open surgery. Primary outcome parameter was postoperative quality of life (QoL) during 3 months of follow-up, measured by SF-36 and GIQLI questionnaire. Secondary parameters were operating time, morbidity, hospital stay, postoperative morphine requirement, pain, and costs.

RESULTS

Patient characteristics were not different. Conversion rate was 10% (n=3). Median operating time was longer in laparoscopic compared with open surgery (115 versus 90 minutes; P<0.003). Hospital stay was shorter in the laparoscopic group (5 versus 7 days; P=0.008). The number of patients with postoperative morbidity within the first 30 days differed between the laparoscopic and open group (10% versus 33%; P=0.028). There was no statistically significant difference in QoL between the groups during follow-up. Significant time effects were found on all scales of the SF-36 (P<0.001) and the GIQLI score (P<0.001). QoL declined in the first week, returned to baseline levels after 2 weeks, and was improved 4 weeks and 3 months after surgery. Median overall costs during the 3 months follow-up were significantly different: euro6412 for laparoscopic and euro8196 for open surgery (P=0.042).

CONCLUSIONS

Although QoL measured by SF-36 and GIQLI questionnaires was not different for laparoscopic-assisted compared with the open ileocolic resection, morbidity, hospital stay, and costs were significantly lower.

Ressecção laparoscópica pós terapia neo-adjuvante no tratamento do câncer no reto médio e baixo

Desde o início da década de 90, diversas publicações têm reportado equivalência de resultados entre as ressecções colorretais laparoscópicas e convencionais de neoplasias, seja quanto ao número de linfonodos, extensão da ressecção, margens e implantes parietais. Quanto às neoplasias colônicas, séries recentes demonstraram não haver alteração dos índices de recidiva e sobrevida. Entretanto, a avaliação dos resultados oncológicos nas ressecções retais ainda suscita controvérsias. Este trabalho visou apresentar a experiência do Hospital de Câncer de Barretos no tratamento vídeo-laparoscópico do câncer do reto e discutir o impacto do tratamento neo-adjuvante nos resultados intra e pós-operatórios imediatos. PACIENTES E MÉTODOS: a presente casuística é constituída por série de pacientes operados consecutivamente no período de janeiro de 2000 a janeiro de 2003, submetidos a ressecções pretensamente curativas para tumores T3 ou T4 no reto médio e baixo. Esses pacientes receberam tratamento neoadjuvante e foram operados por videolaparoscopia (LAP) ou laparotomia (CONV) 4 a 6 semanas após. Analisaram-se dados clínicos, cirúrgicos, patológicos, recidiva e sobrevida após seguimento mínimo de 24 meses. RESULTADOS: foram computados 43 pacientes (20 LAP, 23 CONV), que não apresentaram diferença em relação ao gênero, IMC, estadio clínico, tipo de procedimento, tempo de internação, morbidade pós-operatória, linfonodos, tamanho de espécime e margens. A recidiva global foi semelhante entre os grupos (35% LAP vs. 26% CONV, p = 0,43). A curva de sobrevida avaliada pelo método de Kaplan Meier para um período de seguimento médio de 45,6 meses no grupo LAP e 39,8 meses no grupo CONV (p = 0,86) mostrou sobrevida global de 76,7% (85% LAP e 70% CONV; p = 0,761) sem diferença entre os grupos. CONCLUSÕES: Os dados apresentados indicam equivalência nos índices de recidiva e sobrevida de pacientes portadores de câncer no reto médio e distal, tratados pelas vias de acesso laparoscópica e convencional. A realização de terapia neoadjuvante parece não dificultar a dissecação laparoscópica do reto extra-peritonial, favorecendo a obtenção de resultados oncológicos adequados.

Multimedia article. Laparoscopic abdominoperineal resection for lower rectal cancers: how do we do it?

BACKGROUND

The appropriateness of the laparoscopic approach for the resection of rectal cancer has been controversial, although it is well established in colon cancer. This is a phase II study of laparoscopic abdominoperineal resection (APR) in the treatment of lower rectal cancers.

METHODS

Patients with lower rectal adenocarcinoma located within 6 cm above the anal verge were recruited and subjected to laparoscopic APR. The surgical principle included en bloc resection with high ligation of inferior mesenteric vessels by no-touch isolation and total mesorectal excision. Details of the surgical procedures are presented in the video. The technical efficiency and outcome of this surgical approach were evaluated prospectively. This study was approved by the institutional review board of National Taiwan University Hospital (NTUH).

RESULTS

A total of 22 patients were enrolled in the study from January 2003 to December 2004 under the ethical guidelines of clinical trials in NTUH. There were 12 females and 10 males, with an age distribution of 62.5 +/- 10.4 years. The body mass index was 24.8 +/- 4.0 kg/m2. Physical status (American Society of Anesthesiology classification) was class I in 12, class II in eight, and class III in two patients. Tumor size was 44.0 +/- 12.0 mm in diameter. Two patients were in pathologic TNM stage I, 14 in stage II, and six in stage III. The operation time was 214.0 +/- 28.4 min. Blood loss was 54.0 +/- 14.0 ml. Because the tumor specimen was retrieved from a perineal wound, the five 5 to 12 mm working ports constituted the abdominal wound. There were no major complications. However, wound infection of port sites was detected in one patient. The patients had a quick convalescence, as evaluated by the length of postoperative ileus (48.0 +/- 12.0 h), length of hospitalization (8.0 +/- 2.0 days), and degree of postoperative pain (3.5 +/- 0.5 visual analogue scale). Return to partial activity, full activity, and work was 2.0 +/- 0.5, 4.0 +/- 0.8, and 6.0 +/- 0.5 weeks, respectively. The number of cleared lymph nodes was 14.0 +/- 2.0. During follow-up (median, 18 months; range, 6-30), lung metastasis and local pelvic recurrence developed in one and two patients, respectively. Besides the expenses covered by the National Bureau of Health Insurance of Taiwan, the additional payment by patients undergoing laparoscopic procedures was NTD 24,000 +/- 3000 (1 U.S. dollar = 32 NTD).

CONCLUSIONS

In our clinical setting, laparoscopic APR can be performed with good technical efficiency, quick functional recovery, and mild disability. The short-term oncologic results of laparoscopic APR seem to be acceptable, but further long-term follow-up for these patients is mandatory to define the oncologic outcomes of this approach.

Palliative laparoscopic resections for Stage IV colorectal cancer

PURPOSE

Issues surrounding the safety and efficacy of palliative laparoscopic resections for patients with Stage IV colorectal cancer have not been explicitly examined in the literature. This article describes our experience with laparoscopic procedures for patients with Stage IV colorectal cancer and compares their perioperative outcomes to a contemporaneous group of patients with clinically curable (Stages I-III) disease.

METHODS

A prospective database of laparoscopic resections for colorectal cancer performed between 1991 and 2002 was reviewed. Data regarding patient demographics, perioperative morbidity and mortality, operative times, conversion rates, and length of stay were extracted. Statistical analysis included chi-squared and Student's t-tests as required and P<or=0.05 was considered significant.

RESULTS

A total of 375 cases were identified, of these 49 (13 percent) underwent laparoscopic palliative resections while 326 (87 percent) patients had resections for cure. When comparing palliative to curative procedures, there were no differences in intraoperative (4 percent vs. 9 percent) or postoperative complications (14 percent vs. 12 percent), perioperative mortality (8 percent vs. 4 percent), or length of hospital stay. Patients with Stage IV disease had larger tumors (5.4+/-2.3 cm vs. 4.6+/-2.6 cm, P=0.04) which contributed to an increased rate of conversion (22 percent vs. 11 percent, P=0.05) with most conversions secondary to tumor fixation or bulk (64 percent) preventing determination of resectability.

CONCLUSIONS

A palliative laparoscopic resection is a safe and feasible option and presents acceptable morbidity and mortality in patients with Stage IV colorectal cancer. Importantly, in this difficult group of patients, our results compare favorably with those from previously published series of open procedures.

Laparoscopic resection of gastrointestinal stromal tumors: not all tumors are created equal

BACKGROUND

Laparoscopic resection has become an accepted approach to gastrointestinal stromal tumors (GISTs), with acceptable early results published in the literature. Long-term recurrence rates, however, are still unclear, and the management of tumors in challenging locations requires exploration.

METHODS

A retrospective analysis of all patients undergoing a laparoscopic resection of gastric GIST in our institution between November 1997 and July 2004 was performed.

RESULTS

A total of 14 patients with 15 tumors were evaluated, 5 of which were located high on the lesser curve. All the patients had an attempted laparoscopic approach, with the following procedures performed: stapled wedge excision (n = 8), excision and manual sewing technique (n = 4), and distal gastrectomy (n = 1). Overall, there was a 15% (n = 2) conversion rate. Lesions found in the fundus and greater curvature areas were easily resected via simple stapled wedge excision. High lesser curve tumors were more difficult to manage and required a combination of methods for complete excision and preservation of the gastrointestinal junction including intraoperative gastroscopy, excision and manual sewing technique, and reconstruction over an esophageal bougie. There were no postoperative complications, and the length of hospital stay was 4.6 +/- 1.9 days. At a median follow-up period of 46.5 months (mean, 37.4 +/- 26 months), one patient experienced a recurrence (18 months postoperatively), with eventual disease-related death.

CONCLUSION

The laparoscopic approach to gastric GIST tumors is safe and associated with acceptable short- and intermediate-term results. High lesser curve GISTs can be safely approached laparoscopically using various techniques to ensure an adequate resection margin without compromise of the GE junction.

Hand-assisted laparoscopic sigmoid resection for diverticular disease: 100 consecutive cases

BACKGROUND

Hand-assisted laparoscopic surgery (HALS) has been proposed as a useful alternative to conventional laparoscopic and open surgery. As compared with conventional laparoscopic surgery, it offers the advantages of tactile feedback, better exposure, and a shorter learning curve. There is increasing evidence that HALS retains the advantages of minimal-access surgery. The aim of this study was to analyze the feasibility as well as the short- and medium-term outcomes of HALS sigmoid resection for diverticular disease.

METHODS

The study included 100 consecutive patients between July 1999 and August 2004. Data were prospectively recorded. Follow-up evaluation was performed by standardized telephone interview after a mean postoperative period of 19 months (range, 2-55 months).

RESULTS

Two major intraoperative complications occurred: splenic laceration requiring splenectomy and ureteral injury requiring suture. There were only three conversions: one case of pararectal incision and two cases of extended lower Pfannestiel incision. There was no single case of conversion to midline laparotomy. One patient died postoperatively of myocardial infarction. The postoperative complications included intraabdominal hematoma (2%), anastomotic leakage (3%), wound infection (11%) and bladder dysfunction (1%). The reoperation rate was 5%. The median hospital stay was 8 days. In terms of satisfaction with the results, 97% of patients would choose HALS again.

CONCLUSIONS

When used for diverticular disease, HALS sigmoid resection has a low intra- and postoperative complication rate. The satisfaction rate among patients is high. Even in technically difficult cases, conversion to midline laparotomy can be avoided.

Laparoscopic versus open colorectal surgery: cost-benefit analysis in a single-center randomized trial

SUMMARY BACKGROUND DATA

Studies comparing the costs of colorectal resection by laparoscopic (LPS) and open approaches are small sized or not randomized. The main purpose of this study is to compare the hospital costs of LPS and open colorectal surgery in a large series of randomized patients.

METHODS

A total of 517 patients with colorectal disease were randomly assigned to LPS (n = 258) or open (n = 259) resection. The following costs were calculated: surgical instruments, operative room (OR) occupation, routine care, postoperative morbidity, and length of hospital stay (LOS). Follow-up for postoperative morbidity was carried out for 30 days after hospital discharge.

RESULTS

Operative time was 37 minutes longer in the LPS group. Overall morbidity rate was 18.2% (47 of 258) in the LPS versus 34.7% (90 of 259) in the open group (P = 0.0005). The mean LOS was 9.9 (2.6) days in the LPS group and 12.4 (3.9) days in the open group (P < 0.0001). The additional OR charge in the LPS group was 1171 per patient randomized (864 due to surgical instruments and 307 due to longer time). The saving in the LPS group was 1046 per patient randomized (401 due to shorter LOS and 645 due to the lower cost of postoperative complications). The net balance resulted in 125 extra cost per patient allocated to the LPS group.

CONCLUSIONS

The present cost-benefit analysis showed a slight additional cost in the LPS group. The better postoperative short-term outcome in patients receiving LPS had a key role to nearly balance the operative room charges due to laparoscopy.

Laparoscopic vs. open colectomy in cancer patients: long-term complications, quality of life, and survival

PURPOSE

This study was designed to evaluate long-term complications, quality of life, and survival rate in a series of colorectal cancer patients randomized to laparoscopic or open surgery.

METHODS

A total of 391 patients with colorectal cancer were randomly assigned to laparoscopic (n = 190) or open (n = 201) resection. Long-term follow-up was performed every six months by office visits. Quality of life was assessed at 12, 24, and 48 months after surgery by a modified version of Short Form 36 Health Survey questionnaire. All patients were analyzed on an intention-to-treat basis.

RESULTS

Eight (4.2 percent) laparoscopic group patients needed conversion to open surgery. Overall long-term morbidity rate was 6.8 percent (13/190) in the laparoscopic vs. 14.9 percent (30/201) in the open group (P = 0.018). Overall quality of life was significantly better in the laparoscopic group in the first 12 months after surgery, whereas at 24 months, patients of the laparoscopic group reported a significant advantage only in social functioning. No difference was found in both overall and disease-free survival rates by comparing laparoscopic vs. open group.

CONCLUSIONS

Laparoscopic colorectal resection was associated with a lower incidence of long-term complications and a better quality of life in the first 12 months after surgery compared with open surgery. No difference between groups was found in overall and disease-free survival rates.

Internal hernia through the mesenteric opening after laparoscopy-assisted transverse colectomy

We report a case of a rare complication in laparoscopic colectomy. A 55-year-old woman underwent a laparoscopy-assisted transverse colectomy for transverse colon cancer. On the 5th postoperative day, she developed bowel obstruction. Decompression by a long intestinal tube failed to resolve the bowel obstruction. She underwent operative intervention. Abdominal exploration showed jejunal loop caused by a strangulation forming on an internal hernia through the mesenteric opening at the anastomotic colonic stumps, which had not been sutured during the previous operation. Our experience might indicate the need for closure of small mesenteric opening after laparoscopic colectomy.

Laparoscopic versus open surgery for extraperitoneal rectal cancer: a prospective comparative study

BACKGROUND

The role of laparoscopic resection (LR) in the management of extraperitoneal rectal cancer still is unclear. This study aimed to compare perioperative and long-term results of laparoscopic and open resection (OR) for low and midrectal cancer.

METHODS

A prospective nonrandomized trial comparing patients submitted to OR or LR for low and midrectal cancer at a single institution was conducted.

RESULTS

The study included 191 consecutive patients: 98 patients who underwent LR and 93 who underwent OR. The mean follow-up period was 46.3 months for LR and 49.7 months for OR. The conversion rate for LR was 18.4%. With the use of LR, the mean time for complete patient mobilization was shorter (1.7 vs 3.3 days; p < 0.001) and patients were earlier in passing flatus (2.6 vs 3.9 days; p < 0.001) and stools (3.8 vs 4.7 days; p < 0.01), and in resuming oral intake (3.4 vs 4.8 days; p < 0.001). The mean hospital stay was shorter for LR, but the difference did not reach significance (11.4 vs 13 days). Morbidity and mortality rates were similar: LR (24.4% and 1%) and OR (23.6% and 2.2%). Laparoscopic patients presented a higher rate of anastomotic fistulas (13.5% vs 5.1%) and reoperations (6.1% vs 3.2%) but the difference was statistically nonsignificant. Laparoscopic resection presented a significantly lower local recurrence rate (3.2% vs 12.6%; p < 0.05). The cumulative survival and disease-free rates at 5 years were, respectively, 80% and 65.4% after LR and 68.9% and 58.9% after OR (nonsignificant difference). Stage-by-stage comparison showed prolonged cumulative survival for stages III and IV cancer in LR (82.5% vs 40.5%; p = 0.006 and 15.8% vs 0%; p = 0.013, respectively) and a reduced rate of cancer-related death for stage III in LR (11.4% vs 51.9%; p = 0.001).

CONCLUSIONS

As compared with conventional open surgery, LR for low and midrectal cancer is characterized by a faster recovery and similar overall morbidity (but a higher rate of anastomotic leakages), and does not present any adverse oncologic effect.

Laparoscopic Colectomy for Cancer

Since the first minimally invasive colon resection 15 years ago, laparoscopic colectomy has been implemented as techniques have evolved. Like the laparoscopic approach for other operations, minimally invasive colectomy has potential benefits of improved short-term outcomes. Questions have been raised, however, regarding its use for colorectal cancer resection. Until recently, it was unclear whether minimally invasive surgery for colonic malignancies would achieve adequate oncologic resection. This review provides an overview of laparoscopic colectomy and techniques and examines recent data from randomized, controlled trials that report the short- and long-term outcomes after laparoscopic colectomy for cancer.

Laparoscopic colectomy

Minimally invasive surgical techniques are preferred for a variety of surgical disorders and result in improved outcomes. Laparoscopic colectomy is associated with decreased postoperative pain, faster ileus resolution, shorter hospitalization, and improved cosmesis when compared with open colectomy. The laparoscopic technique is now often preferred for benign disease, but concerns over oncologic adequacy have limited its availability for cancer. The Clinical Outcomes of Surgical Therapy randomized trial of laparoscopic versus open colectomy for cancer recently validated the efficacy of laparoscopy for colon cancer. Limitations include the technical requirements of advanced laparoscopic skills and training, increased operative time, and equipment costs. Surgeons performing laparoscopic colectomy should be adequately experienced and certified to ensure successful outcomes. Despite these limitations, patient recovery benefits may offset the increased operative costs and result in improved cost-effectiveness overall.

Thoracotomy is associated with significantly more profound suppression in lymphocytes and natural killer cells than video-assisted thoracic surgery following major lung resections for cancer

Major surgery is immunosuppressive, and this could have an impact on postoperative tumor immunosurveillance and, therefore, long-term survival in cancer patients. Video-assisted thoracic surgery (VATS) lung resection is a new alternative surgical approach to thoracotomy for patients with early lung cancer. This is a pilot study to examine the postoperative changes in leukocytes, lymphocyte subsets, B cells, T cells, and natural killer (NK) cells in non-small-cell lung cancer (NSCLC) patients undergoing lung resection with VATS versus thoracotomy approaches. Twenty-one consecutive patients with resectable primary NSCLC were assigned to VATS or thoracotomy approach over a 3-month period. Blood samples were collected preoperatively and at postoperative days (POD) 1, 3, and 7 for flow cytometry determination of total leucocytes, B cells, NK cells, lymphocytes, total T cells, and T4 and T8 cell numbers. There were no demographic differences between the two groups. Compared with the preoperative values, significantly increased total white cell numbers were detected at POD 1, 3, and 7 in all patients. At POD 1, although T8 cells and NK cells were reduced in both groups, total T cell, T4 cell, and lymphocyte numbers were significantly reduced only in the thoracotomy group. At POD 7, NK cell numbers were significantly lower in the thoracotomy group than that in the VATS group. No significant intra- or intergroup differences were seen with B cells. No significant differences in survival or disease-free survival were found between the two groups. Thus, VATS major lung resection for NSCLC is associated with less, as well as quicker recovery from, postoperative immunosuppression compared with the thoracotomy approach. The clinical relevance of better preserved cellular immunity in the early postoperative period warrants confirmation from large randomized trials.

Short term benefits for laparoscopic colorectal resection

BACKGROUND

Colorectal resections are common surgical procedures all over the world. Laparoscopic colorectal surgery is technically feasible in a considerable amount of patients under elective conditions. Several short-term benefits of the laparoscopic approach to colorectal resection (less pain, less morbidity, improved reconvalescence and better quality of life) have been proposed.

OBJECTIVES

This review compares laparoscopic and conventional colorectal resection with regards to possible benefits of the laparoscopic method in the short-term postoperative period (up to 3 months post surgery).

SEARCH STRATEGY

We searched MEDLINE, EMBASE, CancerLit, and the Cochrane Central Register of Controlled Trials for the years 1991 to 2004. We also handsearched the following journals from 1991 to 2004: British Journal of Surgery, Archives of Surgery, Annals of Surgery, Surgery, World Journal of Surgery, Disease of Colon and Rectum, Surgical Endoscopy, International Journal of Colorectal Disease, Langenbeck's Archives of Surgery, Der Chirurg, Zentralblatt für Chirurgie, Aktuelle Chirurgie/Viszeralchirurgie. Handsearch of abstracts from the following society meetings from 1991 to 2004: American College of Surgeons, American Society of Colorectal Surgeons, Royal Society of Surgeons, British Assocation of Coloproctology, Surgical Association of Endoscopic Surgeons, European Association of Endoscopic Surgeons, Asian Society of Endoscopic Surgeons.

SELECTION CRITERIA

All randomised-controlled trial were included regardless of the language of publication. No- or pseudorandomised trials as well as studies that followed patient's preferences towards one of the two interventions were excluded, but listed separately. RCT presented as only an abstract were excluded.

DATA COLLECTION AND ANALYSIS

Results were extracted from papers by three observers independently on a predefined data sheet. Disagreements were solved by discussion. 'REVMAN 4.2' was used for statistical analysis. Mean differences (95% confidence intervals) were used for analysing continuous variables. If studies reported medians and ranges instead of means and standard deviations, we assumed the difference of medians to be equal to the difference of means. If no measure of dispersion was given, we tried to obtain these data from the authors or estimated SD as the mean or median. Data were pooled and rate differences as well as weighted mean differences with their 95% confidence intervals were calculated using random effects models.

MAIN RESULTS

25 RCT were included and analysed. Methodological quality of most of these trials was only moderate and perioperative treatment was very traditional in most studies. Operative time was longer in laparoscopic surgery, but intraoperative blood was less than in conventional surgery. Intensity of postoperative pain and duration of postoperative ileus was shorter after laparoscopic colorectal resection and pulmonary function was improved after a laparoscopic approach. Total morbidity and local (surgical) morbidity was decreased in the laparoscopic groups. General morbidity and mortality was not different between both groups. Until the 30th postoperative day, quality of life was better in laparoscopic patients. Postoperative hospital stay was less in laparoscopic patients.

AUTHORS' CONCLUSIONS

Under traditional perioperative treatment, laparoscopic colonic resections show clinically relevant advantages in selected patients. If the long-term oncological results of laparoscopic and conventional resection of colonic carcinoma show equivalent results, the laparoscopic approach should be preferred in patients suitable for this approach to colectomy.

Mortality and morbidity after surgery of mid and low rectal cancer. Results of a French prospective multicentric study

BACKGROUND

The aim of the study was to assess both mortality and morbidity following resection of mid and low rectal cancers in a French prospective multicentric study.

PATIENTS

From June to September 2002, consecutive patients undergoing resection for cancer of the mid- or lower rectum were prospectively included in a multicentric study. Both postoperative mortality and morbidity were recorded. Multivariate statistical analysis was performed in order to assess risk factors predictive of postoperative morbidity.

RESULTS

238 patients with a mean age of 66 +/- 13 years (range: 26-88) were included. Neoadjuvant radiotherapy was performed in 68% of the patients. Total mesorectal excision was performed in 218 patients (92%), of whom 151 (63%) had a sphincter saving procedure. Six patients died (2.5%). Overall postoperative morbidity rate was 43%, including anastomotic leakage (11%) and reoperation (5%). Mean hospital-in-stay was 20 +/- 16 days (range: 3191). Four independent risk factors of morbidity were found: perioperative fecal contamination (OR = 3.9 [1.1; 13.5]), mean operating time longer than 6 hours (OR = 4.5 [1.7; 12.1]), ASA score > 2 (OR = 3.2 [1.6; 7.9]), and smocking (OR = 3.3 [1.2; 8.9]).

CONCLUSIONS

Resection of cancer involving the middle or lower rectum with sphincter saving procedures was possible in two-thirds of the patients and was associated with 2.5% mortality and 43% morbidity.

Randomized controlled trial to evaluate laparoscopic surgery for colorectal cancer: Japan Clinical Oncology Group Study JCOG 0404

A randomized controlled trial was started in Japan to evaluate whether laparoscopic surgery is the optimal treatment for colorectal cancer. Patients with T3 or deeper carcinoma in the colorectum without transverse and descending colons are pre-operatively randomized to either open or laparoscopic colorectal resection. Surgeons in 24 specialized institutions will recruit 818 patients. The primary end-point is overall survival. Secondary end-points are relapse-free survival, short-term clinical outcome, adverse events, the proportion of conversion from laparoscopic surgery to open surgery, and the proportion of completion of laparoscopic surgery.

Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial

BACKGROUND

The safety and short-term benefits of laparoscopic colectomy for cancer remain debatable. The multicentre COLOR (COlon cancer Laparoscopic or Open Resection) trial was done to assess the safety and benefit of laparoscopic resection compared with open resection for curative treatment of patients with cancer of the right or left colon.

METHODS

627 patients were randomly assigned to laparoscopic surgery and 621 patients to open surgery. The primary endpoint was cancer-free survival 3 years after surgery. Secondary outcomes were short-term morbidity and mortality, number of positive resection margins, local recurrence, port-site or wound-site recurrence, metastasis, overall survival, and blood loss during surgery. Analysis was by intention to treat. Here, clinical characteristics, operative findings, and postoperative outcome are reported.

FINDINGS

Patients assigned laparoscopic resection had less blood loss compared with those assigned open resection (median 100 mL [range 0-2700] vs 175 mL [0-2000], p<0.0001), although laparoscopic surgery lasted 30 min longer than did open surgery (p<0.0001). Conversion to open surgery was needed for 91 (17%) patients undergoing the laparoscopic procedure. Radicality of resection as assessed by number of removed lymph nodes and length of resected oral and aboral bowel did not differ between groups. Laparoscopic colectomy was associated with earlier recovery of bowel function (p<0.0001), need for fewer analgesics, and with a shorter hospital stay (p<0.0001) compared with open colectomy. Morbidity and mortality 28 days after colectomy did not differ between groups.

INTERPRETATION

Laparoscopic surgery can be used for safe and radical resection of cancer in the right, left, and sigmoid colon.

Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial

BACKGROUND

Laparoscopic-assisted surgery for colorectal cancer has been widely adopted without data from large-scale randomised trials to support its use. We compared short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer to predict long-term outcomes.

METHODS

Between July, 1996, and July, 2002, we undertook a multicentre, randomised clinical trial in 794 patients with colorectal cancer from 27 UK centres. Patients were allocated to receive laparoscopic-assisted (n=526) or open surgery (n=268). Primary short-term endpoints were positivity rates of circumferential and longitudinal resection margins, proportion of Dukes' C2 tumours, and in-hospital mortality. Analysis was by intention to treat. This trial has been assigned the International Standard Randomised Controlled Trial Number ISRCTN74883561.

FINDINGS

Six patients (two [open], four [laparoscopic]) had no surgery, and 23 had missing surgical data (nine, 14). 253 and 484 patients actually received open and laparoscopic-assisted treatment, respectively. 143 (29%) patients underwent conversion from laparoscopic to open surgery. Proportion of Dukes' C2 tumours did not differ between treatments (18 [7%] patients, open vs 34 [6%], laparoscopic; difference -0.3%, 95% CI -3.9 to 3.4%, p=0.89), and neither did in-hospital mortality (13 [5%] vs 21 [4%]; -0.9%, -3.9 to 2.2%, p=0.57). Apart from patients undergoing laparoscopic anterior resection for rectal cancer, rates of positive resection margins were similar between treatment groups. Patients with converted treatment had raised complication rates.

INTERPRETATION

Laparoscopic-assisted surgery for cancer of the colon is as effective as open surgery in the short term and is likely to produce similar long-term outcomes. However, impaired short-term outcomes after laparoscopic-assisted anterior resection for cancer of the rectum do not yet justify its routine use.

Liver metastasis and ICAM-1 mRNA expression in the liver after carbon dioxide pneumoperitoneum in a murine model

BACKGROUND

Liver metastasis of colorectal malignancies is an important prognostic factor. Several studies have demonstrated that carbon dioxide (CO2) pneumoperitoneum enhances liver metastasis in animal models. Little is known about intercellular adhesion molecule-1 (ICAM-1) and tumor necrosis factor-alpha (TNF-(alpha) mRNA expression in the liver after CO2 pneumoperitoneum.

METHODS

Forty-five male BALB/c mice were randomly divided into three groups after intra-splenic tumor cell (colon 26) inoculation and the following procedures were performed: CO2 pneumoperitoneum (n = 15), open laparotomy (n = 15), and anesthesia alone (n = 15). On day 7 after each procedure, the livers were excised and the number and diameter of the tumor nodules and the cancer index score were determined. Another 90 male BALB/c mice were randomly divided into three groups as described above, and they underwent each procedure (n = 30 each). After each procedure, the livers were excised on days 0, 1, 3, and ICAM-1 and TNF-alpha mRNA expression were examined by real-time RT-PCR using SYBR Green I.

RESULTS

The number of tumor nodules and the cancer index score were larger in the CO2 pneumoperitoneum group than in the control group (p < 0.05). The mean diameter of the tumor nodules was not different among the three groups. The expression of ICAM-1 in the CO2 pneumoperitoneum group was higher than that in the other groups on day 1 (p < 0.05), and the TNF-alpha mRNA was higher than that in the control group on day 1 (p < 0.05).

CONCLUSIONS

CO2 pneumoperitoneum enhances liver metastasis compared with anesthesia alone, and ICAM-1 expression in the liver after the pneumoperitoneum plays an important role in establishing liver metastasis in a murine model.

The oncological safety of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma

BACKGROUND

Although experience of laparoscopic treatment of rectal carcinoma has been reported, there is no evidence of its oncological safety because most procedures included partial mesorectal excision or abdominoperineal excision and quality of surgery is lacking. The aim of this study was to assess the oncological results of laparoscopic total mesorectal excision with sphincter preservation for rectal carcinoma.

METHODS

From 2000 to 2003, 144 patients underwent laparoscopic total mesorectal excision with low colorectal or coloanal anastomosis for mid and low rectal adenocarcinoma. There were 88 men and 56 women, with a median age of 65 years. The tumor was located at 5.5 cm (range 1-12) from the anal verge and was classified uT1T2 in 25 cases and uT3 in 119 cases. One hundred twenty patients received preoperative radiotherapy.

RESULTS

Postoperative mortality and morbidity were 1% and 34% respectively. Conversion was 14% (n = 20). Macroscopic assessment of the specimen (n = 92) showed an intact mesorectum in 88% of the cases. The distal margin and the circumferential margin were safe in 98% and 94% of the cases, respectively. A complete microscopic excision, i.e., R0 resection, was achieved in 134 cases (93%). Pathological data were similar to those of an open match group. With a median follow-up of 18 months, there was no port-site recurrence and two patients had local recurrence (1.4%). The 3-year overall and disease- free survival rates were 89% and 77%, respectively.

CONCLUSIONS

A high quality of surgical excision can be achieved by the laparoscopic dissection, suggesting that this approach in treatment of rectal carcinoma is oncologically safe.

Laparoscopic resection for rectal cancer: outcomes in 194 patients and review of the literature

BACKGROUND

There are few reports on laparoscopic rectum resection demonstrating its feasibility and efficacy in patients with rectal cancer. Most patient series are small, and results must be considered preliminary and medium-term. Our large prospective conducted study aimed to assess the effectiveness of a totally laparoscopic resection for rectum carcinoma with emphasis on perioperative and long-term oncological outcomes.

METHODS

Between November 1992 and July 2003, 194 unselected patients were resected laparoscopically for rectal carcinoma. Patients with locally advanced rectum carcinoma (uT3/uT4) and no evidence of distant metastases were candidates for neoadjuvant chemoradiation. Adjuvant treatment was administered to patients with UICC stage II/III disease. All patients were followed up prospectively to evaluate complications and late outcomes. Survival probability analysis was performed using the Kaplan-Meier method. Study selection was made by Medline search using the following key words: rectal cancer, rectal neoplasms, laparoscopy, and resection. Single case reports and abstracts were excluded. When surgical series were reported more than once, only the most recent reports were considered and listed.

RESULTS

The most common procedures were low anterior resection with total mesorectum excision in 65.5% of patients and high anterior resection in 25.3%. Average operative time was 174 min. Average number of lymph nodes removed was 25.4 and length of specimen resected was 27.6 cm. Resection was curative in 145 patients and palliative in 49 cases. UICC tumor stages were as follows: stage I: 25.2%, stage II: 27.3%, stage III: 30.4%, and stage IV: 17%. Intraoperative complications were <1% for lesions of the ureter, urinary bladder, and deferent duct. Conversion to conventional surgery was necessary in two cases (1%). The most common postoperative complication was anastomotic leakage in 13.5% of patients. There was no postoperative mortality. Follow-up evaluation ranged from 1 to 128 months with a mean of 46.1 months. The most common late complication was incisional hernia in 3.6% of patients. Port-site metastases occurred in one patient (0.5%). Tumor recurrence developed in 23 of the 145 curative resected patients (11.7% distant metastases and 4.1% local recurrence). Overall local recurrence rate was 6.7% (4.1% after curative resection and 14.3% after palliative resection). Overall survival rate was 90.6% at 1 year, 74.5% at 3 years, and 66.3% at 5 years. Overall 5-year survival rate was 76.9% after curative resection and 31.8% after palliative resection. Cancer-related survival rate was 94% at 1 year, 82.4% at 3 years, and 78.9% at 5 years. At 5 years it was 87.7% after curative resection and 48.5% after palliative resection. At 5 years, the survival rate was 100% for stage I, 94.4% for stage II, 66.6% for stage III, and 44.6% for stage IV.

CONCLUSIONS

Our results and the literature review clearly demonstrate that laparoscopic resection for rectal cancer is not associated with higher morbidity and mortality. Established oncological and surgical principles are respected and long-term outcomes are at least as good as those after open surgery.

Why We Need Confidence Intervals

The estimation approach to statistical analysis aims to quantify the effect of interest as an "estimate" of a clinically relevant quantity and to quantify the uncertainty in this estimate by means of a confidence interval (CI). As such, results expressed in this form are much more informative than results presented just as p values. This article focuses on the principles rather than the mathematics of CIs and discusses interpretation of CIs and some common misuses. CIs can be constructed for almost all analyses. They are especially useful for avoiding misinterpretation of nonsignificant results of small studies. CIs should be provided routinely for the main results of trials and observational studies.

Safety of Laparoscopic Intracorporeal Rectal Transection With Double-Stapling Technique Anastomosis

To assess the feasibility and analyze the short-term outcomes of laparoscopic intracorporeal rectal transection with double-stapling technique anastomosis, a review was performed of a prospective registry of 67 patients who underwent laparoscopic sigmoidectomy and anterior resection with intracorporeal rectal transection and double-stapling technique anastomosis between July 2001 and January 2004. Patients were divided into 3 groups: sigmoid colon/rectosigmoid carcinoma, upper rectal carcinoma, and middle/lower rectal carcinoma. A comparison was made of the short-term outcomes among the groups. The number of cartridges required in bowel transection was significantly increased in patients with middle/lower rectal carcinoma, and significant differences were observed in the length of the first stapler cartridge fired for rectal transection. Furthermore, mean operative time and blood loss were also significantly greater in the middle/lower rectum group; however, complication rates and postoperative course were similar among the 3 groups. No anastomotic leakage was observed. Laparoscopic intracorporeal rectal transection with double-stapling technique anastomosis can be performed safely without increased morbidity or mortality.

Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study

BACKGROUND

Laparoscopic colonic surgery has been claimed to hasten recovery and reduce hospital stay compared with open operation. Recently, enforced multimodal rehabilitation (fast-track surgery) has improved recovery and reduced hospital stay in both laparoscopic and open colonic surgery. Since no comparative data between laparoscopic and open colonic resection with multimodal rehabilitation are available, the value of laparoscopy per se is unknown.

METHODS

In a randomized, observer-and-patient, blinded trial, 60 patients (median age 75 years) underwent elective laparoscopic or open colonic resection with fast-track rehabilitation and planned discharge after 48 hours. Functional recovery was assessed in detail during the first postoperative month.

RESULTS

Median postoperative hospital stay was 2 days in both groups, with early and similar recovery to normal activities as assessed by hours of mobilization per day, computerized monitoring of motor activity assessed, pulmonary function, cardiovascular response to treadmill exercise, pain, sleep quality, fatigue, and return to normal gastrointestinal function. There were no significant differences in postoperative morbidity, mortality, or readmissions, although 3 patients died in the open versus nil in the laparoscopic group.

CONCLUSION

Functional recovery after colonic resection is rapid with a multimodal rehabilitation regimen and without differences between open and laparoscopic operation. Further large-scale studies are required on potential differences in serious morbidity and mortality.

Practice parameters for the management of rectal cancer (revised)

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Minimally invasive surgery for rectal cancer

The present scarcity of literature on laparoscopic rectal cancer surgery makes it premature to determine whether laparoscopic surgery should be the standard of care for rectal cancer. Notwithstanding that, the available evidence proves its safety and adequate oncological clearance. Moreover, current data do not suggest any detrimental effect on the postoperative and early oncological outcomes. On the contrary, there is level three evidence showing that laparoscopic technique results in less blood loss, shorter length of stay, and reduced abdominal wound disorders and pulmonary complications, albeit the overall morbidity remains similar to that of open surgery. Long-term survival outcomes remain largely unclear, however. Hence, it is high time that laparoscopic technique should be further evaluated, preferably by means of large-scale randomized trials, to define its exact role in the treatment of rectal cancer.

Update on the role of laparoscopy in the treatment of gynaecological malignancy

PURPOSE OF REVIEW

To update the available information and to report on how the recent literature has better defined the role of laparoscopy for the management of gynaecological malignancies.

RECENT FINDINGS

When compared with laparotomy, laparoscopy provides a similar outcome with a shorter hospitalization, an earlier recovery, and an improved quality of life for the treatment of endometrial cancer. Recent reports in the literature on cervical cancer management now include follow-up data; however, only one study included a control group. These studies confirm the feasibility of radical hysterectomy by laparoscopy. The 2-year disease-free and overall survivals were similar in patients treated by laparoscopy and laparotomy in the study that included a control group. The role of laparoscopy for early ovarian cancer is limited by the absence of available data on upstaging. For advanced ovarian carcinoma, new applications of laparoscopy, such as laparoscopic fluorescence detection after intraperitoneal application of 5-aminolevulinic acid, have been reported but the real utility needs further investigation. One of the challenges for the development of laparoscopic surgery is the difficulty for physicians of acquiring advanced laparoscopic surgical skills.

SUMMARY

The feasibility and safety of laparoscopy for most of the surgical procedures that are used for gynaecological malignancies are now established from cohort or case-control analytical studies. The absence of large phase III studies needs to be balanced by the relatively low incidence of cervical and ovarian cancer.

Colorectal cancer

Every year, more than 945000 people develop colorectal cancer worldwide, and around 492000 patients die. This form of cancer develops sporadically, in the setting of hereditary cancer syndromes, or on the basis of inflammatory bowel diseases. Screening and prevention programmes are available for all these causes and should be more widely publicised. The adenoma-carcinoma sequence is the basis for development of colorectal cancer, and the underlying molecular changes have largely been identified. Prognosis depends on factors related to the patient, treatment, and tumour, and the expertise of the treatment team is one of the major determinants of outcome. New information on the molecular basis of this cancer have led to the development of targeted therapeutic options, which are being tested in clinical trials. Further clinical progress will largely depend on the broader implementation of multidisciplinary treatment strategies following the principles of evidence-based medicine.

Current status of laparoscopic therapy of colorectal cancer

Laparoscopic colorectal resections offer several benefits postoperatively, including minimal impairment of gastrointestinal and pulmonary function, less immunosuppression, shorter hospital stay and improved reconvalescence. Since the introduction of laparoscopic surgery for the therapy of curable colorectal cancer, some concern was voiced in terms of oncologic radicality, the issue of port-site metastases and tumor cell distribution. However, the clinical reality has demonstrated that oncologic radicality is equivalent to open surgery, and the incidence of port-site metastases is not increased when compared to wound recurrence at the laparotomy site. Focusing on colon and rectum, various indications of laparoscopic-endoscopic 'rendezvous' procedures exist including laparoscopic-assisted endoscopic transluminal resection, endoscopic-assisted wedge or anatomical resections, and, finally, intraoperative tumor location by colonoscopy to achieve oncologic resection margins in laparoscopic curative resections. In terms of colorectal curative resections, long-term results provide level I evidence that laparoscopic surgery for colon cancer is oncologically adequate and can be performed with equivalent morbidity and mortality rates when compared to conventional surgery. In terms of rectal cancer, no level I evidence is available. However, short-term data from experienced centers do not report inferior oncologic outcome particularly related to laparoscopic total mesorectal excision.