Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial

Laparoscopic anatomic liver resection

BACKGROUND

Liver resection is reputed to be one of the most difficult procedures embraced in laparoscopy. This report shows that with adequate training, anatomical liver resection including major hepatectomies can be performed.

METHODS

This is a retrospective study.

RESULTS

From 1995 to 2004, among 84 laparoscopic liver resections, 46 (54%) anatomical laparoscopic hepatectomies were performed in our institution by laparoscopy. Nine (20%) patients had benign disease while 37 (80%) had malignant lesions. Among those with malignant lesions, 14 patients had hepatocellular carcinoma (HCC), 18 had colorectal metastasis (CRM), while 5 had miscellaneous tumours. For benign disease, minor (two Couinaud's segments or less) and major anatomic hepatectomies were performed in five and four patients, respectively. For malignant lesions, minor and major anatomic hepatectomies were performed in 15 and 22 patients, respectively. Overall, conversion to laparotomy was necessary in 7 (15%) patients. Blood transfusion was required in five (10%) patients. One patient died of cerebral infarction 8 days after a massive peroperative haemorrhage. The overall morbidity rate was 34% whatever the type of resection. Three patients required reoperation, either for haemorrhage (n=1) and/or biliary leak (n=2). For CRM (n=18), overall and disease-free survival at 24 months (mean follow-up of 17 months) were 100% and 56%, respectively. For HCC (n=14), overall and disease-free survival at 36 months (mean follow-up of 29 months) were 91% and 65%, respectively. No port site metastasis occurred in patients with malignancy.

CONCLUSIONS

After a long training with limited liver resection in superficial segments, laparoscopic anatomical minor and major resections are feasible. Short-term carcinological results seem to be similar to those obtained with laparotomy.

Excisional surgery for cancer cure: therapy at a cost

Excisional surgery is one of the primary treatment modalities for cancer. Minimal residual disease (MRD) is the occult neoplastic disease that remains in situ after curative surgery. There is increasing evidence that tumour removal alters the growth of MRD, leading to perioperative tumour growth. Because neoplasia is a systemic disease, this phenomenon may be relevant to all patients undergoing surgery for cancer. In this review we discuss the published work that addresses the effects of tumour removal on subsequent tumour growth and the mechanisms by which tumour excision may alter residual tumour growth. In addition, we describe therapeutic approaches that may protect patients against any oncologically adverse effects of tumour removal. On the basis of the evidence presented, we propose a novel therapeutic paradigm; that the postoperative period represents a window of opportunity during which the patient may be further protected against the oncological effects of tumour removal.

[Laparoscopic pancreatic resections]

The feasibility of laparoscopic pancreatic resection has been demonstrated. However, the real clinical benefit for the patients remains questioned. The best indication for a laparoscopic approach appears to be the resection of benign or neuro-endocrine tumors without a need for pancreato-enteric reconstruction (i.e enucleation or distal pancreatectomy). The use of the laparoscopic approach for malignant tumors still remains controversial. The benefits of minimally invasive surgery are clearly correlated with the successful management of the pancreatic stump. Pancreatic related complication rate (fistula and collection) is 15% when using pancreatic transection with a laparoscopic endostappler.

Comparison of robotically performed and traditional laparoscopic colorectal surgery

INTRODUCTION

Robotic laparoscopic surgery is postulated to result in better surgical results by allowing improved instrument manipulation and three-dimensional vision. The authors' experience performing robot-assisted laparoscopic colorectal surgery is reported.

METHOD

Standard laparoscopic procedures with robot-assisted laparoscopic colon mobilization and vascular ligation were performed. Data relating to the operative procedure, hospital stay, and direct costs were collected. Results were compared with age, gender, and procedure case-matched controls taken from a prospective laparoscopic colorectal surgery database.

RESULTS

Six robot-assisted laparoscopic surgeries (2 right hemicolectomies, 3 sigmoid colectomies, and 1 Wells rectopexy) were performed between December 2001 and June 2002. There was no associated morbidity. Operative time was increased from a median time of 108 minutes for standard laparoscopic colorectal surgery to 165 minutes for robot-assisted laparoscopic surgeries (P = 0.0313; Wilcoxon matched-pairs signed-rank test for nonparametric data). This was primarily a result of the time required for robot set-up. Blood loss, length of stay, and hospital cost were not significantly different between groups. Additional direct equipment costs for RAC cases included robotic laparoscopic instruments and sterile drapes (approximately US $350 per case), without including acquisition and maintenance costs for the robot.

CONCLUSION

Robot-assisted laparoscopic colectomy is a feasible and safe procedure. Although three-dimensional vision and dexterity are facilitated, operative time is increased and the overall additional expense of robotics is of concern. Robot-assisted laparoscopic colectomy requires further evaluation to establish clinical and financial benefits before introduction to routine practice. Such techniques may, in the future, facilitate complex laparoscopic techniques.

Laparoscopy and its current role in the management of colorectal disease

OBJECTIVE

To evaluate the current place of laparoscopy in the management of colorectal disease.

METHOD

A literature search was undertaken on Medline between the period 1991 and 2002.

RESULTS

From the literature there is good evidence that the laparoscopic approach is associated with at least some short-term advantages. Improved cosmesis and better patient's satisfaction are also evident. Because of this laparoscopy has been widely employed in various benign conditions. Among others, laparoscopic stoma formation, laparoscopic resection for diverticular disease and Crohn's disease, laparoscopic rectopexy, as well as laparoscopic assisted reversal of Hartmann's procedure were commonly reported. As port site recurrence and oncological safety are of less concern, there have been increasing reports on laparoscopic resection for colorectal cancer. Although long-term follow up data is still limited, results of large prospective studies as well as various randomized trials show that recurrence and survival rates of the laparoscopic approach were at least comparable to open surgery. As experience and confidence accumulates, there are also increasing reports on technically demanding, laparoscopic sphincter-saving rectal excision. Articles on functional aspects following this type of resection also start to appear, which might be one of the future directions.

CONCLUSION

The applicability of laparoscopy to colorectal disease continues to expand. Laparoscopic approach should be considered for patients with benign conditions. For colorectal cancer, results from randomized trials so far have been favourable. Hence, the authors suggest the utility of laparoscopy in potentially curable cancer can also be judiciously relaxed.

Effect of laparotomy and CO(2) pneumoperitoneum on tumor growth of human colon carcinoma and expression pattern of tumor-associated proteins in the SCID mouse

BACKGROUND AND AIMS

The impact of laparoscopy on tumor progression is still unclear. This study investigated the effect of CO(2) pneumoperitoneum on the intra-abdominal growth of human colon carcinoma independently of the effect of the immune system.

METHODS

SCID mice underwent either median laparotomy or laparoscopy. Human colon carcinoma cells were implanted into the upper abdomen. The control group was not operated on following cell injection. Tumor growth and the protein expression pattern of proliferation marker Ki67, cell-cell adhesion molecules E-cadherin, alpha- and beta-catenin, and cell-extracellular matrix adhesion molecules CD44 v5 and v6 in tumor tissue were analyzed on postoperative day 14.

RESULTS

Total tumor volume in the laparoscopy group significantly exceeded that in the laparotomy group. Immunohistochemistry revealed reduced expression of alpha-catenin and elevated expression on beta-catenin and CD44 v5 in the tumor tissue of the laparoscopy group.

CONCLUSION

The expression pattern of proteins associated with tumor progression and the increase in tumor growth suggest an increased risk of laparoscopy at least for the growth of advanced human colon carcinoma.

Laparoscopic-assisted cecectomy is associated with decreased formation of postoperative pulmonary metastases compared with open cecectomy in a murine model

BACKGROUND

It was shown in a murine model that sham laparotomy is associated with a higher incidence of postoperative lung metastases when compared with results seen after carbon dioxide pneumoperitoneum. Using the same tumor model, the present study was undertaken to determine if the addition of bowel resection to the operative procedure would impact the results.

METHODS

Sixty mice underwent anesthesia alone (anesthesia control [AC]), laparoscopic-assisted cecectomy (LC), or open cecectomy (OC). After surgery, all animals received tail vein injections of 105 TA3-Ha tumor cells. On postoperative day 14, the lungs and trachea were excised en bloc and processed, and surface lung metastases were counted and recorded by a blinded observer.

RESULTS

The mean number of surface lung metastases in the AC, LC, and OC groups was 30.9, 76.3, and 134.5, respectively. Significantly more metastases were documented after OC (P<.001) and LC (P<.05) than after anesthesia alone. Mice in the LC group had significantly fewer lung metastases (43% less) than mice in the OC group (P<.01).

CONCLUSIONS

OC was associated with significantly more lung metastases than either LC or AC. Surgery-related immune suppression or trophic tumor cell stimulation occurring after surgery may contribute to this phenomenon.

Laparoscopic vs open hepatic resection: a comparative study

BACKGROUND

Although the feasibility of minor laparoscopic liver resections (LLR) has been demonstrated, data comparing the open vs the laparoscopic approach to liver resection are lacking.

METHODS

We compared 30 LLR with 30 open liver resections (OLR) in a pair-matched analysis. The indications for resection were malignant disease in 47% of the LLR and 83% of the OLR. The average size of the lesions was 42 mm for LLR and 41 mm for OLR. Five wedge resections, 12 segmentectomies, and 13 bisegmentectomies were performed in each group.

RESULTS

The conversion rate for LLR was nil. The mean operative time was 148 min for LLR and 142 min for OLR. Mean blood loss was minimal in the LLR group (320 vs 479 ml; p < 0.05). Postoperative complications occurred in 6.6% of the patients in each group; there were no deaths. The mean postoperative hospital stay was shorter for LLR patients (6.4 vs 8.7 days; p < 0.05). In tumors, the resection margin was <1 cm in 43% of the LLR patients and 40% of the OLR patients ( p = NS).

CONCLUSIONS

Minor LLR of the anterior segments has the same rates of mortality and morbidity as OLR. However, the laparoscopic approach reduces blood loss and postoperative hospital stay.

Laparoscopic resection of colonic cancer

Laparoscopic resection of colonic cancer can be regarded as a safe and efficacious procedure. Short-term outcome is better after laparoscopic colectomy than after open colectomy. Long-term results of the first published randomized clinical trial indicate improved cancer related survival following laparoscopic resection of colonic cancer. However, patients included in this single center study were operated on by highly experienced laparoscopic surgeons and included relative small numbers of patients. Results of other large randomized controlled trials have to be awaited before laparoscopic resection can be recommended for colonic cancer. Higher in-hospital costs and a long learning curve hinder rapid implementation of laparoscopic colectomy into general surgical practice. Integration of laparoscopic surgery into surgical training programs is mandatory.

Laparoscopic colorectal cancer surgery

Colorectal cancer remains the second most common cause of cancer death in the USA and western Europe, with more than 34,000 new cases per year in the UK alone. Annual expenditure is in excess of pounds sterling 300 million, required for surgical, adjuvant and palliative treatment. Laparoscopic colorectal surgery has yet to gain the widespread support observed with gallbladder surgery. Randomized controlled trials are ongoing, evaluating the short- and long-term risks and benefits of laparoscopic versus conventional open surgery. Although long-term results are awaited, there is evidence of short-term benefits and no obvious evidence of laparoscopic techniques conferring any additional harm in terms of tumor recurrence or disease-free survival. This review explores the likely benefits and areas of continued concern. Information resources provide a background to colorectal cancer for nonclinicians and new strategies and a 5-year view are presented.

Recent randomised trials in colorectal disease

Progress in colorectal surgery over the last few years is evident by the growing number of randomised controlled trials reported. We have scrutinised such trials reported over the last year across the entire spectrum of colorectal disease and have presented the significant findings in this trials report.

Surgeon experience with laparoscopic-assisted colorectal surgery in Washington State

PURPOSE

To describe the current practice and opinions held by surgeons performing colorectal surgery in Washington regarding laparoscopic colorectal surgery.

METHODS

After attempting to identify all surgeons with hospital privileges in colorectal surgery in Washington, a survey was sent to 303 surgeons. The survey asked about the surgeon's practice, volume of colon surgery in the preceding year, the number of laparoscopic colon resections ever performed, the surgeon's opinion on the future practice of laparoscopic colorectal surgery, and whether faced with the personal need to undergo colon resection at the present time, would the surgeon elect to have laparoscopic or open colon resection.

RESULTS

In all 170 surveys were returned; 154 returned surveys were from surgeons who had performed at least one colon resection in the preceding year; 53 (34%) respondents had experience with fewer than 20 laparoscopic resections and 83 (55%) have never performed laparoscopic-assisted colectomy (LAC). Only 4 (3%) surgeons had performed more than 50 laparoscopic colon resections. Forty-five percent of respondents indicated that they would currently seek a laparoscopic resection for themselves to treat either a benign condition or an incurable malignancy, and 84% of respondents indicated they would have an open colectomy for a curable malignancy.

CONCLUSIONS

The majority of surgeons performing colorectal resections in Washington have limited experience with LAC. Surgeon opinion regarding the role of laparoscopic colorectal surgery in clinical practice is mixed. We suggest a model for proctoring of LAC for surgeons interested in implementing laparoscopic colorectal resection into their practice.

Laparoscopic liver resection

certainly feasible; possibly effective

Laparoscopic intersphincteric resection with coloplasty and coloanal anastomosis for mid and low rectal cancer

BACKGROUND

The feasibility of laparoscopic rectal resection in patients with mid or low rectal cancer was studied prospectively with regard to quality of mesorectal excision, autonomic pelvic nerve preservation and anal sphincter preservation.

METHODS

Laparoscopic rectal excision was performed in 32 patients (21 men) with rectal carcinoma located 5 cm from the anal verge. Most patients had T3 disease and received preoperative radiotherapy. The surgical procedure was performed 6 weeks after radiotherapy and included total mesorectal excision, intersphincteric resection, transanal coloanal anastomosis with coloplasty and loop ileostomy.

RESULTS

Three patients needed conversion to a laparotomy. Postoperative morbidity occurred in ten patients, related mainly to coloplasty. Macroscopic evaluation showed an intact mesorectal excision in 29 of 32 excised specimens; microscopically, 30 of the 32 resections were R0. Sphincter preservation was achieved in 31 patients. The hypogastric nerves and pelvic plexuses were identified and preserved in 24 of the 32 patients. Sexual function was preserved in ten of 18 evaluable men.

CONCLUSION

A laparoscopic approach can be considered in most patients with mid or low rectal cancer.

Gastrointestinal diseases in the elderly

PURPOSE OF REVIEW

The subject of gastrointestinal disorders in the elderly is timely and important because of the demographic reality that soon over 20% of our population will be older than 65 years of age, utilizing perhaps 50% of our total healthcare costs. The purpose of this review is to draw attention to some areas of clinical information that point in the direction of better clinical care for the elderly. Medicine is finally advancing from the era when most symptoms in older patients were ascribed to the aging process itself. Indeed, within gastroenterology there are few changes that occur inevitably as part of aging.

RECENT FINDINGS

Progress has been made in several areas of gastrointestinal pathophysiology. These include: the pathophysiology of swallowing and evacuation disorders and the beginning of the application of techniques derived from physiological studies to improve function; recognizing the importance of reflux esophagitis and its complications and improving treatment; understanding the importance of disorders of malabsorption and their impact upon nutrition in the elderly; major issues in the diagnosis and management of inflammatory bowel disease in this age group; and approaches to the prevention and treatment of gastrointestinal cancer, particularly colorectal cancer.

SUMMARY

As we pay more attention to these areas and encourage clinical research we expect to improve the treatment of older patients with these diseases and to reduce the burden of morbidity in this population.

Breast models: a useful tool for instruction

Background

In the late '80s the successes of the laparoscopic surgery for gallbladder disease laid the foundations on the modern use of this surgical technique in a variety of diseases. In the last 20 years, laparoscopic colorectal surgery had become a popular treatment option for colorectal cancer patients.

Discussion

Many studies emphasized on the benefits stating the significant advantages of the laparoscopic approach compared with the open surgery of reduced blood loss, early return of intestinal motility, lower overall morbidity, and shorter duration of hospital stay, leading to a general agreement on laparoscopic surgery as an alternative to conventional open surgery for colon cancer. The reduced hospital stay may also decrease the cost of the laparoscopic surgery for colorectal cancer, despite th higher operative spending compared with open surgery. The average reduction in total direct costs is difficult to define due to the increasing cost over time, making challenging the comparisons between studies conducted during a time range of more than 10 years. However, despite the theoretical advantages of laparoscopic surgery, it is still not considered the standard treatment for colorectal cancer patients due to technical limitations or the characteristics of the patients that may affect short and long term outcomes.

Conclusions

The laparoscopic approach to colectomy is slowly gaining acceptance for the management of colorectal pathology. Laparoscopic surgery for colon cancer demonstrates better short-term outcome, oncologic safety, and equivalent long-term outcome of open surgery. For rectal cancer, laparoscopic technique can be more complex depending on the tumor location. The advantages of minimally invasive surgery may translate better care quality for oncological patients and lead to increased cost saving through the introduction of active enhanced recovery programs which are likely cost-effective from the perspective of the hospital health-care providers.