Long-term results of laparoscopic colorectal cancer resection: current knowledge and what remains unclear. Surg Today. 2010;40:97-101. [PMID: 20107946 DOI: 10.1007/s00595-009-4133-3]

Long-term oncologic outcomes of laparoscopic vs open surgery for stages II and III rectal cancer: A retrospective cohort study

AIM: To evaluate the 5-year survival after laparoscopic surgery vs open surgery for stages II and III rectal cancer.

METHODS: This study enrolled 406 consecutive patients who underwent curative resection for stages II and III rectal cancer between January 2000 and December 2009 [laparoscopic rectal resection (LRR), n = 152; open rectal resection (ORR), n = 254]. Clinical characteristics, operative outcomes, pathological outcomes, postoperative recovery, and 5-year survival outcomes were compared between the two groups.

RESULTS: Most of the clinical characteristics were similar except age (59 years vs 55 years, P = 0.033) between the LRR group and ORR group. The proportion of anterior resection was higher in the LRR group than that in the ORR group (81.6% vs 66.1%, P = 0.001). The LRR group had less estimated blood loss (50 mL vs 200 mL, P < 0.001) and a lower rate of blood transfusion (4.6% vs 11.8%, P = 0.019) compared to the ORR group. The pathological outcomes of the two groups were comparable. The LRR group was associated with faster recovery of bowel function (2.8 d vs 3.7 d, P < 0.001) and shorter postoperative hospital stay (11.7 d vs 13.7 d, P < 0.001). The median follow-up time was 63 mo in the LRR group and 65 mo in the ORR group. As for the survival outcomes, the 5-year local recurrence rate (16.0% vs 16.4%, P = 0.753), 5-year disease-free survival (DFS) rate (63.0% vs 63.1%, P = 0.589), and 5-year overall survival (OS) rate (68.1% vs 63.5%, P = 0.682) were comparable between the LRR group and the ORR group. Stage by stage, there were also no statistical differences between the LRR group and the ORR group in terms of the 5-year local recurrence rate (stage II: 6.3% vs 8.7%, P = 0.623; stage III: 26.4% vs 23.2%, P = 0.747), 5-year DFS rate (stage II: 77.5% vs 77.6%, P = 0.462; stage III: 46.5% vs 50.9%, P = 0.738), and 5-year OS rate (stage II: 81.4% vs 74.3%, P = 0.242; stage III: 53.9% vs 54.1%, P = 0.459).

CONCLUSION: LRR for stages II and III rectal cancer can yield comparable long-term survival while achieving short-term benefits compared to open surgery.

Uptake and outcomes of laparoscopically assisted resection for colon and rectal cancer in Australia: a population-based study

BACKGROUND

Meta-analyses of randomized controlled trials support the use of laparoscopically assisted resection for colon cancer. The evidence supporting its use in rectal cancer is weak.

OBJECTIVE

The purpose of this work was to investigate the uptake of laparoscopically assisted resection for colon and rectal cancer and to compare short- and long-term outcomes using population data.

DESIGN

This was a retrospective cohort study using linked administrative health data.

SETTINGS

The study encompassed all of the public and private hospitals in New South Wales, Australia, between 2000 and 2008.

PATIENTS

A total of 27,947 patients with colon or rectal cancer undergoing surgery with curative intent were included in the study.

MAIN OUTCOME MEASURES

We summarized the proportion of resections performed laparoscopically. Short-term outcomes were extended stay, 28-day readmission, 28-day emergency readmission, 30- and 90-day mortality, and 90-day readmission with pulmonary embolism or deep-vein thrombosis. Long-term outcomes were all-cause and cancer-specific death and admission with obstruction or incisional hernia repair.

RESULTS

Laparoscopic procedures increased between 2000 and 2008 for colon (1.5%-20.7%) and rectal cancer (0.6%-15.5%). Laparoscopic procedures reduced rates of extended stay (OR, 0.60; 95% CI, 0.49-0.72) and 28-day readmission (OR, 0.86; 95% CI, 0.74-0.99) for colon cancer. For rectal cancer, laparoscopic procedures had lower rates of 28-day readmission (OR, 0.58; 95% CI, 0.42-0.78) and 28-day emergency readmission (OR, 0.54; 95% CI, 0.34-0.85). Laparoscopic procedures improved cancer-specific survival for rectal cancer (HR, 0.71; 95% CI, 0.51-1.00). Survival benefits were observed for laparoscopically assisted colon resection in higher-caseload hospitals but not lower-caseload hospitals.

LIMITATIONS

It was not possible to identify laparoscopically assisted resections converted to open procedures because of the claims-based nature of the data.

CONCLUSIONS

Despite increases in laparoscopically assisted resections for colon and rectal cancer, the majority of resections are still treated by open procedures. Our data suggest that laparoscopic resection reduces the lengths of stay and rates of readmission and may result in improved cancer-specific survival for both colon and rectal resections.

Comparison of the clinical outcomes of laparoscopic-assisted versus open surgery for colorectal cancer

The present study aimed to compare the clinical outcomes of laparoscopic-assisted surgery versus open surgery for colorectal cancer and investigate the oncological safety and potential advantages and disadvantages of laparoscopic-assisted surgery for colorectal cancer. The medical records from a total of 160 patients who underwent surgery for colorectal cancer between January 2009 and January 2013 at The Second Hospital of Dalian Medical University (Dalian, China) were retrospectively analyzed. The patients who underwent laparoscopic-assisted surgery showed significant advantages due to the minimally invasive nature of the surgery compared with those who underwent open surgery, namely, less blood loss (P=0.002), shorter time to flatus (P<0.001), bowel movement (P=0.009) and liquid diet intake (P=0.015), earlier ambulation time (P=0.006), smaller length of incision (P<0.001) and a shorter post-operative hospital stay (P=0.007). However, laparoscopic-assisted surgery for colorectal cancer resulted in a longer operative time (P=0.015) and higher surgery expenditure (P=0.003) and total hospitalization costs (P<0.001) compared with open surgery. There were no statistically significant differences between the intraoperative and post-operative complications. There were no differences in the local recurrence (P=0.699) or distant metastasis (P=0.699) rates. In addition, no differences were found in overall survival (P=0.894) and disease-free survival (P=0.701). These findings indicated that laparoscopic-assisted surgery for colorectal cancer had the clear advantages of a minimally invasive surgery and relative disadvantages, including a longer surgery time and higher cost, and exhibited similar rates of recurrence and survival compared with open surgery.

Impact of surgical extent and sex on the hepatic metastasis of colon cancer

PURPOSE

Extensive oncological surgeries were previously suggested to increase cancer recurrence rates. We herein studied the impact of different surgical procedures and sex on colorectal cancer liver metastasis, employing several tumor inoculation approaches in BALB/c mice.

METHODS

Experimental hepatic metastases of the syngeneic CT26 colorectal cancer line were induced either by intra-portal inoculation or intra-splenic inoculation, employing different tumor loads. Following intra-splenic inoculation, the entire spleen or an injected hemi-spleen was removed. Additionally, the magnitude of the surgical trauma accompanying the injection procedure was manipulated.

RESULTS

Increasing the surgical trauma by adding laparotomy or extending the length of the surgery and hypothermia did not significantly affect the number of liver metastases or liver weight for any of the injection methods and tumor loads. The development of metastasis was significantly greater in males than in females under all conditions studied--a difference not explained by the direct effects of sex hormones on in vitro CT26 proliferation or vitality.

CONCLUSION

Concurring with less controlled clinical observations, the surgical extensiveness did not significantly affect CT26 hepatic metastasis, potentially due to a ceiling effect of the surgical trauma on the metastatic process. The sexual dimorphism observed for the CT26 metastasis should be investigated in the context of surgical stress and considering anti-CT26 immunoreactivity.

Potential value of sonazoid-enhanced intraoperative laparoscopic ultrasonography for liver assessment during laparoscopy-assisted colectomy

Purpose

Laparoscopy-assisted colectomy (LAC) has gained acceptance for the treatment of colorectal cancer. However, conventional palpation of the liver and adequate observation of the abdominal cavity are not achievable during LAC. The aim of this study was to assess the clinical value of using Sonazoid (contrast enhanced)-intraoperative laparoscopic ultrasonography (S-IOLUS) in patients with primary colorectal cancer.

Methods

From May 2005 to August 2008, 454 patients underwent 339 LACs and 115 open colectomies for colorectal cancer. One hundred forty-eight patients with clinical stage II or III colorectal cancer, as determined by preoperative imaging, who were undergoing LACs were prospectively enrolled.

Results

Although IOLUS did not detect any lesions, small hypoechoic lesions were detected by the S-IOLUS (n = 71) in the Kupffer-phase view of two patients (2.8 %). None of the 71 patients who underwent S-IOLUS showed liver metastases within 6 months after LAC. In the conventional IOLUS group (n = 77), metastatic lesions were identified in two patients (2.6 %). The new liver metastases in these two patients were detected within 6 months after LAC.

Conclusions

S-IOLUS of the liver during colorectal cancer surgery is useful for staging and as a diagnostic modality. It can identify lesions that are undetectable by preoperative imaging, and may be considered for routine use during LAC.

Short-term outcomes of laparoscopic total mesorectal excision compared to open surgery

AIM: To investigate the short-term outcome of laparoscopic total mesorectal excision (TME) in patients with mid and low rectal cancers.

METHODS: A consecutive series of 138 patients with middle and low rectal cancer were randomly assigned to either the laparoscopic TME (LTME) group or the open TME (OTME) group between September 2008 and July 2011 at the Department of Colorectal Cancer of Shanghai Cancer Center, Fudan University and pathological data, as well as surgical technique were reviewed retrospectively. Short-term clinical and oncological outcome were compared in these two groups. Patients were followed in the outpatient clinic 2 wk after the surgery and then every 3 mo in the first year if no adjuvant chemoradiation was indicated. Statistical analysis was performed using SPSS 13.0 software.

RESULTS: Sixty-seven patients were treated with LTME and 71 patients were treated with OTME (sex ratio 1.3:1 vs 1.29:1, age 58.4 ± 13.6 years vs 59.6 ± 9.4 years, respectively). The resection was considered curative in all cases. The sphincter-preserving rate was 65.7% (44/67) vs 60.6% (43/71), P = 0.046; mean blood loss was 86.9 ± 37.6 mL vs 119.1 ± 32.7 mL, P = 0.018; postoperative analgesia was 2.1 ± 0.6 d vs 3.9 ± 1.8 d, P = 0.008; duration of urinary drainage was 4.7 ± 1.8 d vs 6.9 ± 3.4 d, P = 0.016, respectively. The conversion rate was 2.99%. The complication rate, circumferential margin involvement, distal margins and lymph node yield were similar for both procedures. No port site recurrence, anastomotic recurrence or mortality was observed during a median follow-up period of 21 mo (range: 9-56 mo).

CONCLUSION: Laparoscopic TME is safe and feasible, with an oncological adequacy comparable to the open approach. Further studies with more patients and longer follow-up are needed to confirm the present results.

Laparoscopic versus open colectomy for TNM stage III colon cancer: results of a prospective multicenter study in Italy

BACKGROUND AND PURPOSE

There is still debate about the practicality of performing laparoscopic colectomy instead of open colectomy for patients with curable cancer, although laparoscopic surgery is now being performed even for patients with advanced colon cancer. We compared the long-term results of laparoscopic versus open colectomy for TNM stage III carcinoma of the colon in a large series of patients followed up for at least 3 years.

METHODS

The subjects of this prospective non-randomized multicentric study were 290 consecutive patients, who underwent open surgery (OS group; n = 164) or laparoscopic surgery (LS group; n = 126) between 1994 and 2005, at one of the four surgical centers. The same surgical techniques were used for the laparoscopic and open approaches to right and left colectomy. The distribution of TNM substages (III A, III B, IIIC) as well as the grading of carcinomas (G1, G2, G3) were similar in each arm of the study. The median follow-up periods were 76.9 and 58.0 months after OS and LS, respectively.

RESULTS

There were 10 (6.1 %) versus 9 (7.1 %) deaths unrelated to cancer, 15 (9.1 %) versus 5 (4 %) cases of local recurrence, 7 (4.2 %) versus 5 (4 %) cases of peritoneal carcinosis, and 37 (22.5 %) versus 14 (11.1 %) cases of metastases in the OS and LS groups, respectively. There was also one case of port-site recurrence after LS (0.8 %). The OS group had a significantly higher probability of local recurrence and metastases (p < 0.001) with a significant higher probability of cancer-related death (p = 0.001) than the LS group.

CONCLUSIONS

These findings support that LS is safe and effective for advanced carcinoma of the colon. Although the LS group in this study had a significantly better long-term outcome than the OS group, further investigations are needed to draw a definitive conclusion.

Single-incision laparoscopic surgery used to perform transanal endoscopic microsurgery (SILSTEM) for T1 rectal cancer under spinal anesthesia: report of a case

Transanal endoscopic surgery has slowly gained widespread acceptance among colorectal surgeons, despite the need for specific training and the high costs of specialized instrumentation. At the other extreme, some laparoscopic surgeons recommend single port access surgery using a single-incision laparoscopic surgery port. Single-incision laparoscopic surgery was applied to perform transanal endoscopic microsurgery in a patient with T1 rectal cancer under spinal anesthesia. The patient was a 74-year-old man who presented with a 2-cm elevated lesion in the right anterior portion of the rectum. Ordinary laparoscopic instruments were used to perform submucosal resection. The tumor was completely excised from the rectal wall with the use of an ultrasonic surgical scissors. The patient recovered uneventfully and was discharged 4 days after the operation. There was no fecal incontinence or soiling during the postoperative follow-up. Colonoscopy at 4 months after the operation showed no recurrence of either adenocarcinoma or adenoma.

Laparoscopy-assisted resection of an undiagnosed liver tumor and ascending colon cancer via mini median laparotomy: report of a case

We describe how we resected a hepatic angiomyolipoma and ascending colon cancer synchronously via laparoscopic left lateral segmentectomy and laparoscopic right colectomy, respectively. The patient was a 72-year-old man, admitted to our hospital after a liver tumor and ascending colon cancer were detected during a general health check. Computed tomography (CT) showed a hypervascular liver tumor mimicking hepatocellular carcinoma, 2 cm in diameter, in segment 3 of the liver. The ascending colon cancer was diagnosed as T2N0M0, Stage I. The left lateral liver and right colon were mobilized laparoscopically and hepatic transaction, followed by resection and anastomosis of the colon, were performed extracorporeally through the same 7-cm upper median incision. This type of laparoscopy-assisted combined resection is useful to obtain a pathological diagnosis of the liver tumor and to remove the entire tumor in a minimally invasive and cosmetic manner.

Short-term and medium-term clinical outcomes of laparoscopic-assisted and open surgery for colorectal cancer: a single center retrospective case-control study

Background

Laparoscopic procedure is a rapid developed technique in colorectal surgery. In this investigation we aim at assessing the diversities of short-term and medium-term clinical outcomes of laparoscopic-assisted versus open surgery for colorectal cancer.

Methods

A total number of 519 patients with non-metastatic colorectal cancer were enrolled for this study. The patients underwent either laparoscopic-assisted surgery (LAP) (n = 254) or open surgery (OP) (n = 265). Surgical techniques, perioperative managements and clinical follow-ups were standardized. Short-term perioperative data and medium-term recurrence and survival were compared and analyzed between the two groups.

Results

There were no differences in perioperative parameters between the two groups except in regards to a trend of faster recovery in laparoscopic procedures. There was no statistically significant difference in postoperative complications, reoperation rate, or perioperative mortality. Statistically significant differences in a faster return of gastrointestinal function and shorter hospital stay were identified in favor of laparoscopic-assisted resection. In colon and rectal cancer cases separately, the overall survival, cancer-free survival and recurrence rate were similar in two groups. There was also no tendency of significant differences in overall survival, cancer-free survival and recurrence in stage I-II and stage III patients in two cancer categories between the two groups, respectively. pT, lymph node metastasis, and clinical stage were independent predictors of overall death risk, while pT, pN, lymph node metastasis and clinical stage were found to be the independent predictors of recurrence risk in enrolled patients database.

Conclusions

Laparoscopic-assisted procedure has more benefits on postoperative recovery, while has the same effects on medium-term recurrence and survival compared with open surgery in the treatment of non-metastatic colorectal cancer.

Reduction in mortality after epidural anaesthesia and analgesia in patients undergoing rectal but not colonic cancer surgery: a retrospective analysis of data from 655 patients in central Sweden

BACKGROUND

There is some evidence that epidural analgesia (EDA) reduces tumour recurrence after breast and prostatic cancer surgery. We assessed whether EDA reduces long-term mortality after colorectal cancer surgery.

METHODS

All patients having colorectal cancer surgery between January 2004 and January 2008 at Linköping and Örebro were included. Exclusion criteria were: emergency operations, laparoscopic-assisted colorectal resection, and stage 4 cancer. Statistical information was obtained from the Swedish National Register for Deaths. Patients were analysed in two groups: EDA group or patient-controlled analgesia (PCA group) as the primary method of analgesia.

RESULTS

A total of 655 patients could be included. All-cause mortality for colorectal cancer (stages 1-3) was 22.7% (colon: 20%, rectal: 26%) after 1-5 yr of surgery. Multivariate regression analysis identified the following statistically significant factors for death after colon cancer (P<0.05): age (>72 yr) and cancer stage 3 (compared with stage 1). A similar model for rectal cancer found that age (>72 yr) and the use of PCA rather than EDA and cancer stages 2 and 3 (compared with stage 1) were associated with a higher risk for death. No significant risk of death was found for colon cancer when comparing EDA with PCA (P=0.23), but a significantly increased risk of death was seen after rectal cancer when PCA was used compared with EDA (P=0.049) [hazards ratio: 0.52 (0.27-1.00)].

CONCLUSIONS

We found a reduction in all-cause mortality after rectal but not colon cancer in patients having EDA compared with PCA technique.