Gastrointestinal
Laparoscopic colon resection for colon cancer

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Abstract

Introduction

Laparoscopic colon resection for cancer is as yet an unproven operation. This review article summarizes current data on the topic.

Methods

A Medline review identified articles published since 1990 summarizing patients with potentially curable colon cancer who underwent a laparoscopic-assisted colon resection. Only articles that were randomized or had a control group with historical or matched open cases were used.

Results

Very few prospective randomized controls exist. Several clinical trials are under way with one completed. Data thus far support some patient benefits with a laparoscopic approach. No differences in morbidity, oncologic data, or survival appear to exist.

Conclusions

The results of ongoing clinical trials are still needed to further evaluate the role of laparoscopic assisted colon resection in patients with potentially curable colon cancer.

Introduction

The advantages of a minimally invasive approach to many traditional open operations have been proven, including shorter hospital stay, quicker return of gastrointestinal function, less pain, less wound complications, and quicker recovery [1], [2], [3], [4], [5], [6], [7], [8], [9]. Laparoscopic assisted colon resection was first described in 1991 [10], [11], [12]. Despite over a decade of experience with the operation, laparoscopic colon resection has not been met with uniform enthusiasm such as has been seen with laparoscopic cholecystectomy or fundoplication. Numerous reasons exist, including the technical challenges associated with operating in several quadrants, the fact that the colon is not a fixed organ, the need to divide major blood vessels, the need to create an anastomosis, the need to extract a bulky specimen, the diversity of operations performed, and the longer learning curve. There have been many multiple advances made in videolaparoscopic imaging, instruments, staplers, and surgeon experience, making the operation technically more feasible with acceptable operating times and morbidity. The benefits of a laparoscopic approach to benign colonic disease have been proven. However, concerns still persist about the role of laparoscopy in patients with malignant colon disease. Specifically, concerns about oncologic principles, recurrence, port-site metastases, and survival are unanswered. Unfortunately, very few prospective randomized trials exist. Those that have been performed are small with short follow-up. Other studies to date have been limited, unrandomized, evaluated small numbers of patients with uncontrolled selection of patients, and had varied surgeon experience, varied indications, and incorporated various operations. Therefore, the answer as to whether patients with potentially curable colonic malignancy should be offered a laparoscopic resection is not as yet known.

One problem in analyzing the current data is the wide variety of operations included under the term “laparoscopic colon resection.” Totally laparoscopic, laparoscopic-assisted, and laparoscopic-facilitated techniques have been described [13]. For this review article, only data on laparoscopic-assisted techniques will be evaluated. The major focus will be on data evaluating patients operated on with curative intent. For this review article, only articles that compare open to laparoscopic operations through randomized trials, prospective trials, historical, or matched controls will be evaluated. Feasibility studies are not summarized.

Section snippets

Clinical trials

There are currently several multi-institutional, large-scale prospective, randomized trials comparing laparoscopic assisted to open colon resection in patients with colon cancer [1], [8], [14], [15], [16], [17]. The National Institutes of Health trial, begun in 1995, proposes to study 1200 patients randomly assigned to laparoscopic or open colectomy for curable colon cancer with a follow-up of 8 years [1], [8]. Forty centers are participating. The primary outcome measures for this study are

Prospective, randomized studies

Stage et al. [9] prospectively randomized 34 patients with potentially curable colon cancer to laparoscopic (n = 18) or open surgery (n = 16). Five patients were excluded, three because of conversion secondary to extensive tumor growth, leaving 15 in the laparoscopic group and 14 in the open. The two groups were comparable with respect to demographics, estimated blood loss, and operative procedure performed. Conversion rate was 16.7%. Patients in the laparoscopic surgery group experienced

Patient benefits

The advantages of laparoscopic surgery, proven in multiple operations such as cholecystectomy and fundoplication, include less pain, earlier return of gastrointestinal function, shorter hospital stay, and faster recovery. These short-term benefits have been experienced by patients undergoing laparoscopic assisted colon resection for cancer as well. Several of the prospective randomized studies have demonstrated these benefits [2], [9], [16], [18], [19], [20], [22], [23]. Delgado et al. found

Cost

Unfortunately, there are not much data available on cost or cost effectiveness of laparoscopic colon resection. Several of the multi-institutional clinical trials are analyzing cost effectiveness as a secondary end point so additional information will be forthcoming. Information currently available includes data on colectomies performed for benign disease as well as malignant. As with other laparoscopic cases, several authors have found that intraoperative costs are higher with the laparoscopic

Inflammatory response

The inflammatory and immune responses to laparoscopic colectomy have been studied in both animal and human trials. Many authors feel that surgery suppresses the immune response and that the degree of suppression is related to the degree of surgical trauma [23], [44], [45]. As stated by Hewitt et al., cancer patients may already have a suppressed immune system and therefore any further attenuation may be potentially harmful [23]. Immune suppression is mediated by a number of factors, and

Oncologic issues

One of the major concerns about laparoscopic colon resection for colon cancer is whether oncologic principles are followed. Included in these concerns are issues regarding lymph node dissection, adequacy of staging, and port-site metastases. The prospective, randomized trials currently underway are evaluating overall survival and cancer-free survival as primary end-points. In the meantime, other studies have evaluated length of resected specimen, margins and number of resected lymph nodes as

Port-site metastases

Concerns over port-site metastases have limited the application of laparoscopic techniques for resection of intra-abdominal malignancies. The first report of port-site metastatic disease occurred in 1978 in a patient who underwent diagnostic laparoscopy for ovarian cancer [65]. The first reports in colorectal cancer occurred in 1993, one in a patient who underwent a curative right hemicolectomy for a Duke’s C cancer [66] and one in a patient with a Duke’s B cancer who presented 8 weeks

Recurrent disease and survival

Several authors have studied local and distant recurrence (Table 8). None have found significant differences in locoregional recurrence or distant recurrence in the laparoscopic and open groups. Patterns of metastatic disease have also been similar in the two groups. Likewise, overall survival and disease free survival have not differed significantly between the 2 groups (Table 9). The results are similar to the SEER data, both stage for stage and overall [7], [41] and to the data obtained

Conclusions

Laparoscopic colon resection has been performed for over 10 years. The safety and feasibility of the operation has been proven. When applied to patients with potentially curable cancer, it appears that there exist some patient benefits, especially in regards to pain, return of gastrointestinal function, and recovery. It is not clear yet that length of stay is significantly shortened with the minimally invasive approach. This is clearly a technically difficult operation, as evidenced by the

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