Laparoscopic Versus Open Surgery For Colorectal Carcinoma

TME for rectal cancer: consecutive 70 patients treated with laparoscopic and robotic technique-cumulative experience in a single centre

From January 2011 to December 2015, 70 consecutive patients underwent either laparoscopic surgery (LS) or robotic surgery (RS) total mesorectal excision (TME) for malignancy. Data were prospectically recorded in a dedicated local database including ASA score, age, operative time, conversion rate, re-operation rate, early complications, length of stay, and pathological results. We enrolled 70 consecutive patients, 35 treated with LS (18 M, 17 F), 35 treated with RS (23 M, 12 F). Median total operative time was 225 min in LS group (IQR 194-255) and 252.5 min for RS group (IQR 214-300). Median first flatus time was 2 days for LS group (IQR 1-3) and 1 day for RS group (IQR 1-2). Stool discharge time (median) was 4 days for LS group (IQR 2-5) and 2 days for RS group (IQR 1-3). Length of stay (median) was 8 days in LS group (IQR 7-10) and 7 days in RS group (IQR 5-8). It was not found any statistically significant difference between the two groups when we analyzed the number nodes harvested the postoperative complications. The 30 day mortality was 0% in both two groups. The conversion rate for LS group was 23% (8/35 pts) and that for RS group was 0% (0/35). The RS may overcome technical limitations of LS. In our experience, it is a feasible and safe technique, it achieves better clinical outcomes due to the lower conversion rate compared to LS, although with higher costs.

Right colectomy: consecutive 100 patients treated with laparoscopic and robotic technique for malignancy. Cumulative experience in a single centre

Robotic-assisted resections prove beneficial in overcoming potential limitation of laparoscopy, but clear evidences on patient's benefits are still lacking. We report our experience on 100 consecutive patients who underwent right colectomy with either robotic or laparoscopic approaches. Data were prospectively collected on a dedicated database (ASA score, age, operative time, conversion rate, re-operation rate, early complications, length of stay, and pathological results). Median total operative time was 160 min in LS group (IQR = 140-180) and 204 min for RS group (IQR = 180-230). Median time to first flatus was 2.5 days for LS group (IQR = 2 - 3) and 2 days for RS group (IQR = 1-2). Length of stay (median) was 8 days in LS group (IQR = 6-10) and 5 days in RS group (IQR = 5-7). No statistically significant difference was found between the 2 groups when the number of harvested nodes, the anastomotic leakage and the postoperative bleeding were analyzed. The 30-day mortality was 0% in LS and RS groups. Conversion rate for LS group was 14% (7/50 pts) and for RS group was 0% (0/50). Minimally invasive surgery is a feasible and safe technique. The RS may overcome some technical limitations of laparoscopic surgery and it achieves the same oncological results compared to LS but with higher costs. The lower conversion rate allows to expect better clinical outcomes and lower complication rate.

Meta-analysis of the risk of small bowel obstruction following open or laparoscopic colorectal surgery

Background

One of the potential advantages of laparoscopic compared with open colorectal surgery is a reduction in postoperative bowel obstruction events. Early reports support this proposal, but accumulated evidence is lacking.

Methods

A systematic review and meta-analysis was performed of randomized clinical trials and observational studies by searching the PubMed and Cochrane Library databases from 1990 to August 2015. The primary outcomes were early and late postoperative bowel obstruction following laparoscopic and open colorectal surgery. Both ileus and bowel obstruction were defined as a postoperative bowel obstruction. Subgroup and sensitivity analyses were performed, and a random-effects model was used to account for the heterogeneity among the studies.

Results

Twenty-four randomized clinical trials and 88 observational studies were included in the meta-analysis; 106 studies reported early outcome and 12 late outcome. Collectively, these studies reported on the outcomes of 148 392 patients, of whom 58 133 had laparoscopic surgery and 90 259 open surgery. Compared with open surgery, laparoscopic surgery was associated with reduced rates of early (odds ratio 0·62, 95 per cent c.i. 0·54 to 0·72; P < 0·001) and late (odds ratio 0·61, 0·41 to 0·92; P = 0·019) postoperative bowel obstruction. Weighted mean values for early postoperative bowel obstruction were 8 (95 per cent c.i. 6 to 10) and 5 (3 to 7) per cent for open and laparoscopic surgery respectively, and for late bowel obstruction were 4 (2 to 6) and 3 (1 to 5) per cent respectively.

Conclusion

The reduction in postoperative bowel obstruction demonstrates an advantage of laparoscopic surgery in patients with colorectal disease.

Retraction techniques in laparoscopic colorectal surgery: a literature-based review

AIM

To systematically review the published literature and describe the various techniques of bowel and mesentery retraction available for use in laparoscopic colorectal resection.

METHOD

A comprehensive search of the literature was undertaken using MESH terms 'retraction', 'laparoscopic' and 'colorectal'. All articles describing methods of retraction in laparoscopic colorectal surgery were included.

RESULTS

Twelve methods of retraction in laparoscopic colorectal surgery were described. Five case-based series and three case studies were reported on 108 patients. Techniques were classified into those offering retraction of the small or large bowel or according to the mode of retraction.

CONCLUSION

Many retraction methods are available to the surgeon varying in cost, invasiveness and complexity. Adequate retraction remains a challenge for optimal exposure and dissection during laparoscopic colorectal surgery.

Minimally invasive surgery and cancer: controversies part 1

Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the pro-con debate format.

Laparoscopic versus Open Total Mesorectal Excision: A Nonrandomized Comparative Prospective Trial in a Tertiary Center in Mexico City

Because definitive long-term results are not yet available, the oncologic safety of laparoscopic surgery in rectal cancer remains controversial. Laparoscopic total mesorectal excision (LTME) for rectal cancer has been proposed to have several short-term advantages in comparison with open total mesorectal excision (OTME). However, few prospective randomized studies have been performed. The main purpose of our study was to evaluate whether relevant differences in safety and efficacy exist after elective LTME for the treatment of rectal cancer compared with OTME in a tertiary referral medical center. This comparative nonrandomized prospective study analyzes data in 56 patients with middle and lower rectal cancer treated with low anterior resection or abdominoperineal resection from November 2005 to November 2007. Follow-up was determined through office charts or direct patient contact. Statistical analysis was performed using χ2 test and Student's t test. Twenty-eight patients underwent LTME and 28 patients were in the OTME group. No conversion was required in the LTME group. Mean operating time was shorter in the laparoscopic group (LTME) (181.3 vs 206.1 min, P < 0.002). Less intraoperative blood loss and fewer postoperative complications were seen in the LTME group. Return of bowel motility was observed earlier after laparoscopic surgery. There was no 30-day mortality and the overall morbidity was 17 per cent in the LTME group versus 32 per cent in the OTME group. The mean number of harvested lymph nodes was greater in the laparoscopic group than in the OTME group (12.1 ± 2 vs 9.3 ± 3). Mean follow-up time was 12 months (range 9-24 months). No local recurrence was found. LTME is a feasible procedure with acceptable postoperative morbidity and low mortality, however it is technically demanding. This series confirms its safety, although oncologic results are at present comparable with the OTME published series with the limitation of a short follow-up period. Further randomized studies are necessary to evaluate long-term clinical outcome.

Prophylactic ureteric catheters in laparoscopic colorectal surgery

BACKGROUND

The purpose of this study was to evaluate the use of ureteric catheter placement in laparoscopic colorectal surgery and to assess the morbidity related to this procedure.

METHODS

Between 1994 and 2001, 313 elective laparoscopic colorectal surgeries were performed. Patients with and without ureteric catheters were retrospectively analyzed.

RESULTS

Catheter placement was attempted in 149 patients (catheter group) and was not attempted in 164 (controls). There were no significant differences between groups in the number of patients with prior colorectal resection (p=0.286) or other abdominal surgery (p=0.074). Crohn's disease and diverticulitis were more common in the catheter group than among controls (p<0.001). Concomitant intra-abdominal fistula or abscess was present in 29 patients (19.5%) in the catheter group vs. 14 (8.5%) in the control group (p=0.005). The duration of surgery was longer in the catheter group (p=0.001). There were no significant differences in conversion, duration of bladder catheter placement, or length of hospital stay. Urinary tract infection occurred in 3 patients (2.0%) in the catheter group and 7 (4.3%) in the control group (p=0.257) and urinary retention occurred in 3 patients (2.0%) and 11 patients (6.7%), respectively (p=0.045). No intraoperative ureteric injuries occurred in either group.

CONCLUSION

Ureteric catheter placement was successful in most cases and was not associated with intraoperative injuries. The increased length of surgery in patients with ureteric catheter placement may attest to the increased severity of pathology in these patients.

Can community surgeons perform laparoscopic colorectal surgery with outcomes equivalent to tertiary care centers?

BACKGROUND

Laparoscopic colorectal surgery (LCS) performed in tertiary care centers has been well studied. It has been shown to provide improved short-term outcomes and comparable long-term outcomes to the conventional open approach. However, LCS performed in a community hospital setting has not been well studied. In a previous paper, we presented the short-term outcomes of 100 LCS performed by two community surgeons with no formal training in LCS. In this follow-up study, we present both short- and longer-term outcomes for 250 patients who underwent LCS.

METHODS

This is a prospective study of 250 consecutive patients who underwent LCS at the North Bay District Hospital (a 200-bed community hospital located 350 km away from the nearest tertiary care center).

RESULTS

Between October 2000 and October 2006, 250 consecutive patients (130 women and 120 men, mean age of 64.4 +/- 13.7 years) underwent LCS for benign (N = 129) and malignant (N = 121) disease. Median operating time was 215.0 min (58.0-475.0 min) and the conversion rate was 7.2%. The intraoperative complication rate was 2.8%. There were 20 (8.0%) major postoperative complications and 42 (16.8%) minor postoperative complications. There was no intraoperative mortality. There were six 30-day mortalities due to ischemic bowel (1), stroke (1), myocardial infarction (3), and pneumonia (1). The median length of stay was 4.0 days (2.0-55.0 days). Disease-free survival for stages I-IV colorectal cancer (CRC) was 100, 97.2, 71.4, and 10% for a mean follow-up time of 36.9, 29.3, 27.9, and 21.1 months, respectively. The mean number of resected lymph nodes was 11.5 +/- 8.6.

CONCLUSION

We note that both our short and longer-term outcomes are similar to tertiary care centers. We therefore conclude that LCS can be performed in a community hospital setting with both short- and longer-term outcomes similar to tertiary care centers.

Does the extraction-site location in laparoscopic colorectal surgery have an impact on incisional hernia rates?

BACKGROUND

Incisional hernias are a common postoperative complication with abdominal surgery. The major risk factors for their development include wound infection, obesity, and age. This study aimed to evaluate the impact of extraction-site location and technique on incisional hernia rates in laparoscopic colorectal surgery.

METHODS

A prospective study of 208 consecutive patients who underwent laparoscopic colorectal surgery between March 2002 and July 2006 was performed. The study included only patients who had an extraction site on the abdominal wall. Patients were excluded if they were lost to follow-up evaluation or underwent conversion to open procedure. For the 166 patients included in the study, the mean follow-up period was 20.2 +/- 14.4 months. Extraction-site incisions were classified into two groups: midline or off-midline. Midline wounds involved sharp division of the linea alba and were closed with a single layer of no.1 Vicryl. Off-midline incisions involved sharp division of the anterior and posterior sheaths with blunt spreading of the muscular layers and were closed in two layers with no. 1 Vicryl. Risk factors including wound infection, body mass index (BMI), age, and diabetes were analyzed.

RESULTS

The incisional hernia rate for the entire series was 7.8%. The incisional hernia rate was 17.6% for the midline group (n = 74) and 0% for the off-midline group (n = 92) (p = 0.0002, statistically significant). There was no statistically significant difference in age, BMI, diabetes, follow-up time, or wound infection rate between the two groups.

CONCLUSION

In this series, the midline extraction site resulted in a significantly higher incisional hernia rate statistically than the off-midline extraction sites. The authors therefore have adopted an off-midline blunt muscle-splitting extraction site when performing laparoscopic colorectal surgery.

Does the extraction-site location in laparoscopic colorectal surgery have an impact on incisional hernia rates?

BACKGROUND

Incisional hernias are a common postoperative complication with abdominal surgery. The major risk factors for their development include wound infection, obesity, and age. This study aimed to evaluate the impact of extraction-site location and technique on incisional hernia rates in laparoscopic colorectal surgery.

METHODS

A prospective study of 208 consecutive patients who underwent laparoscopic colorectal surgery between March 2002 and July 2006 was performed. The study included only patients who had an extraction site on the abdominal wall. Patients were excluded if they were lost to follow-up evaluation or underwent conversion to open procedure. For the 166 patients included in the study, the mean follow-up period was 20.2 +/- 14.4 months. Extraction-site incisions were classified into two groups: midline or off-midline. Midline wounds involved sharp division of the linea alba and were closed with a single layer of no.1 Vicryl. Off-midline incisions involved sharp division of the anterior and posterior sheaths with blunt spreading of the muscular layers and were closed in two layers with no. 1 Vicryl. Risk factors including wound infection, body mass index (BMI), age, and diabetes were analyzed.

RESULTS

The incisional hernia rate for the entire series was 7.8%. The incisional hernia rate was 17.6% for the midline group (n = 74) and 0% for the off-midline group (n = 92) (p = 0.0002, statistically significant). There was no statistically significant difference in age, BMI, diabetes, follow-up time, or wound infection rate between the two groups.

CONCLUSION

In this series, the midline extraction site resulted in a significantly higher incisional hernia rate statistically than the off-midline extraction sites. The authors therefore have adopted an off-midline blunt muscle-splitting extraction site when performing laparoscopic colorectal surgery.

Economic evaluation of laparoscopic surgery for colorectal cancer

OBJECTIVES

The aim of this study was to assess the cost-effectiveness of laparoscopic surgery compared with open surgery for the treatment of colorectal cancer.

METHODS

A Markov model was developed to model cost-effectiveness over 25 years. Data on the clinical effectiveness of laparoscopic and open surgery for colorectal cancer were obtained from a systematic review of the literature. Data on costs came from a systematic review of economic evaluations and from published sources. The outcomes of the model were presented as the incremental cost per life-year gained and using cost-effectiveness acceptability curves to illustrate the likelihood that a treatment was cost-effective at various threshold values for society's willingness to pay for an additional life-year.

RESULTS

Laparoscopic surgery was on average pounds 300 more costly and slightly less effective than open surgery and had a 30 percent chance of being cost-effective if society is willing to pay pounds 30,000 for a life-year. One interpretation of the available data suggests equal survival and disease-free survival. Making this assumption, laparoscopic surgery had a greater chance of being considered cost-effective. Presenting the results as incremental cost per quality-adjusted life-year (QALY) made no difference to the results, as utility data were poor. Evidence suggests short-term benefits after laparoscopic repair. This benefit would have to be at least 0.01 of a QALY for laparoscopic surgery to be considered cost-effective.

CONCLUSIONS

Laparoscopic surgery is likely to be associated with short-term quality of life benefits, similar long-term outcomes, and an additional pounds 300 per patient. A judgment is required as to whether the short-term benefits are worth this extra cost.

Meta-analysis of non-randomized comparative studies of the short-term outcomes of laparoscopic resection for colorectal cancer

Laparoscopic resection remains to be established as the procedure of first choice for operable colorectal cancer. The aim of the study was to conduct a systematic review of non-randomized comparative studies of laparoscopic resection for colorectal cancer. Published work in English was searched for relevant articles published by the end of 2003. The MOOSE statement was used to conduct the meta-analysis. Study quality was assessed by two investigators using the MINORS tool and the analysis was conducted using Comprehensive Meta-analysis software (Biostat, Englewood, NJ, USA) and Microsoft Excel (Microsoft, Redmond, WA, USA). One thousand two hundred and twenty abstracts were reviewed and 398 articles examined in detail. Out of 108 articles reporting the results of relevant studies, 75 were reports of 64 non-randomized comparative studies. Fifteen studies were excluded. Analysis of the outcomes of 6438 resections showed that the conversion rate was 13.3% with a statistically significant difference between studies with more than 50 versus those with 50 or less attempted resections (11.7 vs 16.5%; P<0.001). Laparoscopic resection took 27.6% (41 min) longer to carry out than open resection. There was no significant difference between the two groups in early mortality rates (1.2 vs 1.1%; P=0.787) or likelihood of re-operation (2.3 vs 1.5%; P=0.319). Laparoscopic resection was associated with a lower morbidity rate (24.05 vs 30.80%, odds ratio (95% confidence interval)=0.77 (0.63-0.95); P=0.014, n=4111, random-effects model). Time until passage of first flatus, passage of a bowel motion, tolerating oral fluids and a solid diet was 1.2-1.6 days (26 to 37%) shorter, measurements of pain and narcotic analgesic requirements were 16-35% lower and hospital stay was 3.5 days (18.8%) shorter following laparoscopic resection compared with open resection. The two approaches were 99% similar in terms of adequacy of oncological clearance. Meta-analysis of non-randomized comparative studies favours laparoscopic over open resection for colorectal cancer. The results were remarkably similar to those of a contemporaneous meta-analysis of randomized controlled trials published by the end of 2002.

Laparoscopic colon resection for cancer

LAC has become an acceptable alternative in the treatment of colon carcinoma. New data should elucidate better the potential advantages in postoperative recovery, QOL, and cost reduction. Appropriate credentialing for LAC remains essential for widespread application of LAC while preserving patient safety.

Long-term results of laparoscopic versus open colorectal resections for cancer in 235 patients with a minimum follow-up of 5 years

BACKGROUND

Laparoscopic resection for cure of colorectal cancer is controversial. More investigations on long-term results are required. This study aimed to compare the long-term outcome with a minimum follow-up of 5 years between laparoscopic or open approach for the treatment of colo-rectal cancer.

METHODS

The treatment modality (laparoscopic or open) was related to the patients (pts) choice. The following parameters between the two groups (laparoscopic and open) were assessed: wound recurrences rate, local recurrences rate, incidence of distant metastases and survival probability analysis.

RESULTS

We report the long term outcome of 149 pts with colon cancer of which 85 treated by Laparoscopic Surgery (LS) and 64 by Open Surgery (OS) and of 86 patients with rectal cancer of which 52 treated by LS and 34 by OS. In the pts with colonic cancer, mean follow-up was 82.8 months. No Statistically Significant Difference (SSD) was observed in the local recurrences rate (3.5% after LS and 6.2% after OS) and in the incidence of distant metastases (10.5% after LS and 10.9% after OS). Cumulative survival probability in LS was 0.882 as compared to 0.859 after OS. In the pts with rectal cancer, mean follow-up was 78.5 months. No SSD was observed in the local recurrences rate (19.2% after LS and 17.6% after OS) and in the incidence of distant metastases (15.3% after LS and 20.5% after OS). Cumulative survival probability in LS was 0.711 as compared to 0.617 after OS. We report an interesting data about the time of recurrences between LS and OS: the recurrences were delayed after LS, both after colonic (22.6 months vs 6.5) and rectal (25.7 months vs 13.0) resections, respectively.

CONCLUSION

We suppose that laparoscopic surgery in the treatment of colo-rectal cancer is quite safe. However, further investigation is needed.

LAPAROSCOPIC AND OPEN COLORECTAL SURGERY IN EVERYDAY PRACTICE: RETROSPECTIVE STUDY

BACKGROUND

Most studies available on laparoscopic colorectal surgery focus on highly selected patient groups. The aim of the present study was to review short- and long-term outcome of everyday patients treated in a general surgery department.

METHODS

Retrospective review was carried out of a prospective database of all consecutive patients having undergone primary laparoscopic (LAP) or open colorectal surgery between March 1993 and December 1997. Follow-up data were completed via questionnaire.

RESULTS

A total of 187 patients underwent LAP resection and 215 patients underwent open surgery. Follow up was complete in 95% with a median of 59 months (range, 1-107 months) and 53 months (range, 1-104 months), respectively. There were 28 conversions (15%) in the LAP group and these remained in the LAP group in an intention-to-treat analysis. The LAP operations lasted significantly longer for all types of resections (205 vs 150 min, P < 0.001) and hospital stay was shorter (8 vs 13 days, P < 0.001). Recovery of intestinal function was faster in the LAP group, but only after left-sided procedures (3 vs 4 days, P < 0.01). However, preoperative patient selection (more emergency operations and patients with higher American Society of Anesthesiologists (ASA) score in the open group) had a major influence on these elements and favours the LAP group. Surprisingly, the overall surgical complication rate (including long-term complications such as wound hernia) was 20% in both groups with rates of individual complications also being comparable in both groups.

CONCLUSION

Despite a patient selection favourable to the laparoscopy group, only little advantage in postoperative outcome could be shown for the minimally invasive over the open approach in the everyday patient.

Laparoscopic resection of low rectal cancer with a mean follow-up of seven years

The role of laparoscopic surgery in the management of cancer of the rectum remains controversial. The main concern is the risk of port-site metastasis and neoplastic dissemination. The aim of this study was to evaluate prospectively 29 patients who underwent laparoscopic resection with total mesorectum excision for lower rectal carcinoma with a mean follow-up of 7 years. From January 1993 to December 1998, 29 patients with proven low (<10 cm from the anal verge) rectal cancer were operated by a laparoscopic approach. They were followed up at 1-, 3-, and then every 6-month intervals, postoperatively for an average of 7 years. Mean operative time was 157 +/- 46 minutes. The conversion rate was 13.7% (4 cases): 1 for tumor invasion of adjacent structures, 2 for inadequate margins of resection, and 1 for locally advanced cancer. First flatus occurred after 37.3 +/- 11.5 hours, and oral feeding started at 48.3 +/- 23 hours postoperatively. The length of the suprapubic incision for extraction of the specimen was 5.6 +/- 1.7 cm. Hospital stay was 7.2 +/- 3.0 days. There were no deaths. The morbidity rate was 14.8%. Length of the specimen, lateral and distal margins, and the number of lymph nodes resected were comparable to those of an open surgical approach. The average postoperative follow-up was 7 years (5-10 years). The late complication rate was 3.7%. There were no port-site metastases. Five-year recurrence rates were 0%, 22%, and 37% for Duke's A, B, and C cancers, respectively. The 5-year survival rate was 100% for Duke's A, 89% for B, and 50% for C. Laparoscopic resection for low rectal cancer with total mesorectum excision can be performed with the same oncologic principles, low morbidity, and long-term complications. Five-year survival and recurrence rates are comparable to those of open surgery.

Laparoscopic hepatic resection for hepatocellular carcinoma

AIMS

To assess the results of laparoscopic liver resection for hepatocellular carcinoma.

PATIENTS AND METHODS

From 1998 to 2003, 12 laparoscopic liver resections for hepatocellular carcinoma were performed.

RESULTS

There were no operative complications and no deaths. Conversion to laparotomy was required in one patient (8%) and transfusion in three patients (25%). One patient died of liver failure. Postoperative complications occurred in three patients (25%): trocar site bleeding, cardiac failure and biliary collection. The mean hospital stay was 5 days. No ascites and no transient liver failure occurred. During the mean follow up of 15 months the recurrence rate was 45.5%. No port site or peritoneal metastases were observed. Treatment of recurrence was second resection in two patients and microwave coagulation therapy in two other patients. Mean survival was 24 months.

CONCLUSION

Laparoscopic liver resection is feasible in hepatocellular carcinoma if the tumor is unique, smaller than 5 centimeters and located in the left lateral segments or in the anterior or inferior segments of the right liver. Postoperative morbidity is low and long-term results seem to be similar to laparotomy.

Minimally invasive treatment of colon cancer

The advantages of laparoscopy in the treatment of benign diseases have been well demonstrated. Compared with laparotomy, the laparoscopic approach is associated with a shorter hospitalization period, shorter duration of ileus, decreased postoperative pain, earlier return to work, and improved cosmesis. The role of laparoscopy for the treatment of gastrointestinal malignancy has had a slower evolution and been the subject of considerable debate over the past decade. Since 1991, several concerns have limited the widespread use of laparoscopy for attempted cure of colorectal carcinoma. This review aims to analyze the results of several studies published to date on short and long term outcome of laparoscopy for colorectal carcinoma, based on levels of evidence. From the least to the most convincing data, the hierarchy of study designs progresses through a spectrum ranging from retrospective reviews to prospective series, to case-controlled, cohort, and ultimately randomized controlled trials.

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.

Robotic and laparoscopic surgery for treatment of colorectal diseases

PURPOSE

In the last ten years, several robotic systems have been developed to overcome the loss of the three-dimensional view and dexterity characteristic of laparoscopic surgery. The aim of this study was to compare the traditional laparoscopic approach and robotic techniques in the treatment of colorectal diseases.

METHODS

The study compares a consecutive series of patients treated surgically for colorectal disease from June 2001 to May 2003 with the da Vinci robotic system (Intuitive Surgical) and a matched number of patients who underwent conventional laparoscopy during the same time interval. The factors analyzed were the time required to prepare the patient and the room, total time of surgery, length of specimens, number of lymph nodes retrieved, blood loss, complications, and postoperative results.

RESULTS

The study included 106 patients (53 in each group). No differences were observed in total time of surgery (laparoscopic group, 222 +/- 77 minutes vs. robotic group, 240 +/- 61 minutes), specimen length (laparoscopic group, 29 +/- 11 cm vs. robotic group, 27 +/- 13 cm), or number of lymph nodes retrieved (laparoscopic group, 16 +/- 9 vs. robotic group, 17 +/- 10). It took significantly longer to prepare the operating room and patient in the robotic group (24 +/- 12 minutes) than in the laparoscopic group (18 +/- 7 minutes). There were three conversions to laparotomy in the laparoscopic group; in the robotic group, two cases were converted to laparoscopy and three to hand-assisted laparoscopy. No significant differences were observed between the two groups in terms of recovery of bowel function and postoperative hospital stay.

CONCLUSIONS

Robot-assisted surgery proved to be as safe and effective as laparoscopic techniques in the treatment of colorectal diseases. Because of its dexterity and three-dimensional view, the da Vinci system was particularly useful in specific stages of the procedure, e.g., takedown of the splenic flexure, dissection of a narrow pelvis, identification of nervous plexus, and handsewn anastomosis. The cost-effectiveness of the procedure still needs to be evaluated.

Laparoscopic adrenalectomy for malignancy

Laparoscopic adrenalectomy for primary malignancies and tumors metastatic to the adrenal is controversial. Most studies demonstrate that results of laparoscopic adrenalectomy for malignant lesions are similar to those of open adrenalectomy, without its morbidity. The results of laparoscopic adrenalectomy for tumor metastases suggest that it may benefit patients who have a metachronous metastasis from any of a variety of primary tumors. Selective laparoscopic adrenalectomy for potentially malignant tumors requires seeking signs of local invasion, lymphadenopathy, or distant metastasis; there are no other reliable preoperative criteria of malignancy. Diagnostic laparoscopy may be useful, and in some cases, may establish a diagnosis. Laparoscopic adrenalectomy should be cautiously performed, with the goals of achieving complete tumor resection without disruption of the adrenal capsule.

Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer

BACKGROUND

The Laparoscopic approach has been applied to colorectal surgery for many years; however, there are only a few reports on laparoscopic low and ultralow anterior resection with construction of coloanal anastomosis. This study compares open versus laparoscopic low and ultralow anterior resections, assesses the feasibility and efficacy of the laparoscopic approach of total mesorectal excision (TME) with anal sphincter preservation (ASP), and analyzes the short-term results of patients with low rectal cancer.

METHODS

We analyzed our experience via a prospective, randomized control trail. From June 2001 to September 2002, 171 patients with low rectal cancer underwent TME with ASP, 82 by the laparoscopic procedure and 89 by the open technique. The lowest margin of tumors was below peritoneal reflection and 1.5-8 cm above the dentate line (1.5-4.9 cm in 104 cases and 5-8 cm in 67 cases). The grouping was randomized.

RESULTS

Results of operation, postoperative recovery, and short-term oncological follow-up were compared between 82 laparoscopic procedures and 89 controls who underwent open surgery during the same period. In the laparoscopic group, 30 patients in whom low anterior resection was performed had the anastomosis below peritoneal reflection and more than 2 cm above the dentate line, 27 patients in whom ultralow anterior resection was performed had anastomotic height within 2 cm of the dentate line, and 25 patients in whom coloanal anastomosis was performed had the anastomosis at or below the dentate line. In the open group, the numbers were 35, 27, and 27, respectively. There was no statistical difference in operation time, administration of parenteral analgesics, start of food intake, and mortality rate between the two groups. However, blood loss was less, bowel function recovered earlier, and hospitalization time was shorter in the laparoscopic group.

CONCLUSION

Totally laparoscopic TME with ASP is feasible, and it is a minimally invasive technique with the benefits of much less blood loss during operation, earlier return of bowel function, and shorter hospitalization.

Laparoscopy as a prognostic factor in curative resection for node positive colorectal cancer: results for a single-institution nonrandomized prospective trial

BACKGROUND

Several studies reporting preliminary long-term survival data after laparoscopic resections for colonic adenocarcinoma did not show any detrimental effect in comparison with historic studies of laparotomies. A previous randomized study has reported an unforeseen better long-term survival for node-positive patients treated by laparoscopic colectomy.

METHODS

A single-institution prospective nonrandomized trial compared short- and long-term results of laparoscopic and open curative resection for adenocarcinoma of the left colon or rectum in 255 consecutive patients from January 1996 to December 2000.

RESULTS

In this study, 34 left hemicolectomy, 202 anterior resections, and 19 abdominoperineal resections were performed. A total of 74 patients underwent a laparoscopic resection (LR), and 181, an open resection (OR). The tumor site was the descending colon in 32 cases, the sigmoid colon in 98 cases, and the rectum in 125 cases, including 87 mid-low rectal cancers. Ten LR procedures (13.5%) were converted to open surgery. The hospital mortality was 0.08%, and in hospital morbidity was 16.2% for LR and 13.3% for OR (p = 0.56). The median postoperative stay was 1 day shorter for LR (9 days) than for OR (10 days) (p = 0.09). The mean number of lymph nodes retrieved were 13.8 +/- 5.7 for OR and 12.7 +/- 5; for LR (p = 0.23). Age exceeding 70 years, T stage, N stage, grading, mid-low rectal site, and laparoscopy were found by multivariate analysis to be significant prognostic factors for disease-free and cancer-related survival. When patients were stratified by stage, a trend toward a better disease-free and cancer-related survival was identified in stage III patients undergoing LR.

CONCLUSIONS

Laparoscopic colonic resection is a safe procedure in terms of postoperative outcome and long-term survival. Multivariate analysis showed that laparoscopy is a positive prognostic factor for disease-free and cancer-related survival. The current data agrees with the data for the only randomized study reported so far. Both suggest a better outcome for node-positive patients treated by laparoscopy.

Laparoscopic versus conventional open resection of rectal carcinoma: A clinical comparative study

AIM: To evaluate the feasibility of laparoscopic resection of rectal carcinoma and to compare the short-term outcome of laparoscopic procedure with conventional open surgery for rectal cancer.

METHODS: Thirty-eight patients with rectal cancer were included in a prospective non-randomized study. The patients were assigned to laparoscopic (n = 18) or open (n = 18) colorectal resection. Case selection, surgical technique, and clinical and pathological results were reviewed.

RESULTS: The operative time was longer in laparoscopic resection group (LAP) than in open resection group (189 ± 18 min vs 146 ± 22 min, P < 0.05). Intraoperative blood loss and postoperative complications were less in LAP resection group than in open resection group. An earlier return of bowel motility was observed after laparoscopic surgery. The overall postoperative morbidity was 5.6% in the LAP resection group and 27.8% in open resection group (P < 0.05). No anastomotic leakage was found in both groups. The pathologic examination showed that the length of the resected specimen, the mean number of harvested lymph nodes in laparoscopic resection group were comparable to those in open resection group.

CONCLUSION: Laparoscopic total mesorectal excision (TME) for rectal cancer is a feasible but technically demanding procedure. The present study demonstrates the safety of the procedure, while oncologic results are comparable to the open surgery, with a favorable short-term outcome.