Laparoscopic colorectal surgery for cancer: Is it ready for prime time?
Weiser, MD, Martin R.



Article by Martin R. Weiser, M.D.

Dr. Weiser is an Attending Surgeon at Memorial
Sloan Kettering Cancer Center and specializes in colorectal cancer.



INTRODUCTION


Minimally invasive surgery has gained tremendous popularity after the
success of laparoscopic cholecystectomy. With the promise of smaller
incisions, less pain, and quicker recovery, minimally invasive techniques
have been applied to an increasing variety of surgical procedures.
Laparoscopic appendectomy, splenectomy, and adrenalectomy have been accomplished,
and attempts at more complex procedures such as colon and rectal resection
have been explored.

Laparoscopic intestinal resection is a challenge. It requires
dissection in multiple parts of the abdomen, isolation and ligation of
major arteries and veins, division of colonic attachments, identification
and preservation of critical retroperitoneal structures, intestinal division,
and reconstruction of bowel continuity. Laparoscopic colorectal surgery
is now being performed routinely for benign processes such as inflammatory
bowel disease, rectal prolapse, benign polyps, and diverticular disease.
In the setting of cancer, however, there has been considerably more caution
in using these newer surgical techniques. Concerns over the adequacy
of tumor resection, tumor spillage and the possibility of earlier tumor
recurrence have been raised.

This review will discuss our current experience with laparoscopic
colectomy for malignant disease. Results from prospective randomized
trials (in which patients are assigned by chance to either a laparoscopic
or an open colectomy) as well as from well-constructed prospective non-randomized
trials, will be reviewed. Finally, our limited experience with
minimally invasive resection for rectal cancer will be discussed.


LAPAROSCOPIC TECHNIQUES AND DEFINITIONS


Minimally invasive surgery involves insufflating the abdomen with carbon
dioxide gas, which pushes the abdominal wall away from the intestine and
allows the surgeon to work (figure 1).





Figure 1: The abdomen is insufflated with gas. Thin
specially designed instruments and a magnifying video camera is placed
into the abdomen and used for dissection.



Dissection is performed with specially constructed thin instruments
that are placed into the abdomen through small incisions, referred to as
ports. A miniature magnifying video camera is inserted into the abdomen,
and the surgeon and assistants view the procedure on monitors in the operating
room (Figure 2).





Figure 2: The surgeon and assistants perform
the operation with the aid of video monitors.



A small incision, often less than one-third the length normally required
in open colectomy, is utilized to remove the specimen at the end of the
procedure (Figure 3).



Figure 3: (A) In open surgery for colorectal cancer, a
midline incision is often used.




(B) In laparoscopic colorectal surgery multiple small incision
are used for instruments and camera. The specimen is removed by enlarging
one of the incisions.





There is considerable variability in laparoscopic techniques for colon
resection. Some surgeons perform only a portion of the procedure
laparoscopically, and then make an incision to complete the resection (laparoscopic
assisted colectomy). Others perform the complete resection laparoscopically.
Still others perform hand-assisted laparoscopic surgery, in which the surgeonís
hand is used along with laparoscopic equipment to perform the dissection.

When a minimally invasive procedure cannot be completed via the laparoscopic
approach, a larger-than-anticipated incision is created to complete the
surgery. This is referred to as a conversion from the laparoscopic
to an open procedure. The reasons for conversion include: intraoperative
complication such as bleeding; the discovery of more advanced disease than
anticipated; the presence of adhesions or scar tissue from previous surgery;
and an inability to visualize key anatomic structures. In general,
the benefits of laparoscopic surgery are fewer or, in some instances, completely
negated in converted cases(1).



FEASIBILITY OF LAPAROSCOPIC COLECTOMY FOR CANCER


A sound oncologic resection is defined as complete tumor removal, with
an adequate intestinal surgical margin and removal of the draining lymph
nodes. Many prospective randomized studies have compared the size
of the resection margin and the number of lymph nodes removed, following
open or laparoscopic colectomy for cancer. No difference is seen,
indicating that laparoscopic colectomy for cancer is feasible from a technical
standpoint(2-4).

In the early experience of laparoscopic colectomy for cancer, a few
reports described immediate tumor recurrence at the laparoscopic incision
sites, referred to as port site recurrences. It was hypothesized
such early cancer recurrence happened after laparoscopy due to tumor shedding
and/or accelerated tumor growth, secondary to the presence of gas in the
peritoneal cavity. However, multiple reviews have indicated that
this is not the case. In one such study, which included over 2600
cases, the rate of port site recurrence was approximately 1%, which is
similar to that noted in open colorectal surgery {56}. It is not
currently believed that laparoscopic colectomy is associated with early
wound recurrences.


ADVANTAGES OF LAPAROSCOPIC COLECTOMY FOR CANCER


What are the advantages to this approach? The benefits of minimally
invasive colectomy for cancer are similar to those seen for benign disease,
and are related to less surgical trauma. The small incisions utilized
in laparoscopic surgery are associated with considerably less pain, as
reflected in the patientís reduced postoperative need for narcotic medication.
Related benefits include earlier resolution of postoperative ileus (bowel
obstruction caused by temporary intestinal paralysis), quicker resumption
of diet, and shorter hospitalization. Some studies have noted fewer complications
and overall quicker convalescence following the laparoscopic approach.

Most postoperative pain is related to the size of the abdominal incision.
Therefore, it makes sense that the laparoscopic approach, which uses small
incisions, is associated with less pain and less need for postoperative
narcotics than the conventional open approach. Many prospective randomized
studies have noted that those patients assigned to the laparoscopic colectomy
group needed less pain medication for a shorter period of time{72}{244}{228}.

Patients who undergo a laparoscopic colectomy can resume an oral
diet earlier than those undergoing an open colectomy(2;5;6). The
ability to tolerate an oral diet following surgery is related to the return
of normal intestinal (peristaltic) activity. Following surgery, the
intestines become paralyzed, referred to as postoperative ileus.
This is caused by many factors, including intraoperative intestinal manipulation,
pain, and narcotic usage. It is thought that all these factors are
reduced in laparoscopic surgery, and that this accounts for the earlier
resolution of ileus following minimally invasive surgery.

Although minimally invasive surgery does not allow for direct manipulation
or visualization of tissues, there has not been an increased rate of complication
following laparoscopic colectomy for cancer. In fact some prospective
randomized trials have noted a lower complication rate with the laparoscopic
approach(6;7). The reasons for this may be related to quicker return
of pulmonary function(2), less operative blood loss(2;3;6), and increased
ambulation following minimally invasive surgery. This difference
is most noticeable in the elderly patient, who is more prone to postoperative
complications. In one cohort study of patients over the age of 75
years, those undergoing laparoscopic colectomy had half the complication
rate of those undergoing open colectomy(8).

Laparoscopic colectomy is associated with earlier postoperative recovery.
Patients are generally discharged from the hospital after they can tolerate
an oral diet, when their bowel function returns, and when their postoperative
discomfort can be controlled with oral pain medication. Most studies
have shown that patients who undergo laparoscopic colectomy are discharged
from the hospital 1-3 days earlier than patients who undergo open colectomy
(1;5;6). Long-term convalescence also appears to be quicker
following laparoscopic surgery. One cohort study compared the time
it took for patients to return to their usual activity following either
laparoscopic or open colectomy. Patients who underwent laparoscopic
colectomy returned to their usual activity, on average, two weeks after
surgery, whereas patients who underwent open colectomy reported returning
to their usual activity seven weeks after surgery(9). Another study
investigated the ability of elderly patients (>75 years) to resume an independent
lifestyle following colectomy. After open colectomy, close to 25%
of these patients required admission to some type of assisted living facility,
while only 5% of the laparoscopic patients required admission to an assisted
living facility(8).

When long-term quality of life is measured with questionnaires, little
difference is seen between laparoscopic and open colectomy(1). One
reason for this is that most quality of life questionnaires were developed
for patients with advanced cancer, on chemotherapy, and not for postoperative
patients. These questionnaires do not adequately measure the improvements
seen after laparoscopic surgery such as reduced narcotic requirement, shorter
postoperative ileus, and faster recovery(1;10). Newer questionnaires
are being developed to study the effects of laparoscopy of quality of life.



DISADVANTAGES OF LAPAROSCOPIC COLECTOMY


The major disadvantage of laparoscopic colectomy is increased operative
time. Most studies report a 30 to 75 minute increase in surgical
time using the minimally invasive approach(2;5;6). The surgeonís
experience is important, and there is a significant learning curve for
laparoscopic colectomy. A recent report notes that operative time
decreases significantly the greater the number of procedures performed
by the operating surgeon(10).




LONG-TERM RECURRENCE AND SURVIVAL


A recently reported prospective randomized trial has published their
long-term tumor recurrence and survival data. This study notes that
patients that underwent laparoscopic colectomy had fewer tumor recurrences
and were less likely to die from colon cancer compared with patients that
underwent open colectomy(6). The reasons for this are unclear, but
the authors speculate that laparoscopic colectomy is may be associated
with less surgical trauma and reduced immune suppression. This
study is relatively small, with a total of 219 randomized patients, and
before there is wide acceptance of laparoscopy for colon cancer these results
need to be verified by larger, multicenter trials. One such
trial, sponsored by the National Cancer Institute, has recently completed
accrual of more than 900 patients and tumor recurrence and survival data
should be available in the next few years.



RECTAL CANCER


Laparoscopic rectal resection is considerably more difficult than colon
resection, due to the narrow confines of the bony pelvis, and the need
to identify retroperitoneal structures such as the nerves that control
sexual and bladder function(11). The few studies concerning
minimally invasive rectal resection for cancer indicate that the procedure
is safe and feasible; however, more often than not, it cannot be entirely
performed laparoscopically, and an incision is required to complete dissection
low in the pelvis(12). This is referred to as the hybrid approach
in which a portion of the procedure is performed laparoscopically followed
by a small incision to complete the resection and reconstruction(13).
One prospective study noted that patients who undergo hybrid-type rectal
resection have an incision half the size, quicker return of bowel function,
and significantly shorter hospitalization than patients who undergo open
rectal resection(13). Laparoscopic rectal resection is currently
an active field of research.



CONCLUSION AND FUTURE DIRECTIONS


Minimally invasive colectomy for cancer is feasible in experienced hands.
The laparoscopic approach to colon cancer is associated with smaller incisions,
reduced pain, less postoperative narcotic requirement, shorter hospitalization,
and quicker recovery. There is no increased complication rate, and
some studies have noted fewer complications with the laparoscopic approach.
In most studies, the laparoscopic procedure does take longer than an open
procedure; and there is a surgeon learning curve. At this time, there is
no indication that the laparoscopic procedure is associated with worse
long-term outcome, and one report indicates that patients have improved
survival following laparoscopic colectomy for cancer. However before
laparoscopic colectomy can be advocated routinely for colorectal cancer,
recurrence and survival data from larger, multicenter randomized trials,
such as the one sponsored by the National Cancer Institute must be analyzed.

Minimally invasive surgery for colorectal cancer is an evolving field.
Patients undergoing laparoscopic colectomy for cancer should be monitored
in a research setting, with data collection and analysis.
Areas of active research include: patient selection to reduce conversion
rates; the immunologic benefit of minimally invasive surgery; and the application
of laparoscopy to rectal cancer surgery. With further
research, the appropriateness of minimally invasive surgery for colorectal
cancer patients will be further defined.



AKNOWLEDGMENTS:

The author would like to acknowledge the significant editorial assistance
of Jenifer Levin.


Additional Authors:

Works Cited:
1. Weeks, J. C., Nelson, H., Gelber, S., Sargent, D., and Schroeder, G. Short-Term Quality-of-Life Outcomes Following Laparoscopic-Assisted Colectomy Vs Open Colectomy for Colon Cancer: a Randomized Trial. JAMA 1-16-2002;287(3):321-8.
2. Milsom, J. W., Bohm, B., Hammerhofer, K. A., Fazio, V., Steiger, E., and Elson, P. A Prospective, Randomized Trial Comparing Laparoscopic Versus Conventional Techniques in Colorectal Cancer Surgery: a Preliminary Report. J.Am.Coll.Surg. 1998;187(1):46-54.
3. Delgado, S., Lacy, A. M., Filella, X., Castells, A., Garcia-Valdecasas, J. C., Pique, J. M., Momblan, D., and Visa, J. Acute Phase Response in Laparoscopic and Open Colectomy in Colon Cancer: Randomized Study. Dis.Colon Rectum 2001;44(5):638-46.
4. Stocchi, L. and Nelson, H. Laparoscopic Colectomy for Colon Cancer: Trial Update. J.Surg.Oncol. 1998;68(4):255-67.
5. Delgado, S., Lacy, A. M., Garcia Valdecasas, J. C., Balague, C., Pera, M., Salvador, L., Momblan, D., and Visa, J. Could Age Be an Indication for Laparoscopic Colectomy in Colorectal Cancer? Surg.Endosc. 2000;14(1):22-6.
6. Lacy, A. M.; Garcia-Valdecasas, J. C.; Delgado, S.; Castells, A.; Taura, P.; Pique, J. M.; Visa, J. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet. 2002;359(9325), 2224-9.
7. Lacy, A. M., Garcia-Valdecasas, J. C., Pique, J. M., Delgado, S., Campo, E., Bordas, J. M., Taura, P., Grande, L., Fuster, J., Pacheco, J. L. Short-Term Outcome Analysis of a Randomized Study Comparing Laparoscopic Vs Open Colectomy for Colon Cancer. Surg.Endosc. 1995;9(10):1101-5.
8. Stocchi, L., Nelson, H., Young-Fadok, T. M., Larson, D. R., and Ilstrup, D. M. Safety and Advantages of Laparoscopic Vs. Open Colectomy in the Elderly: Matched-Control Study. Dis.Colon Rectum 2000;43(3):326-32.
9. Franklin, M. E., Jr., Rosenthal, D., Abrego-Medina, D., Dorman, J. P., Glass, J. L., Norem, R., and Diaz, A. Prospective Comparison of Open Vs. Laparoscopic Colon Surgery for Carcinoma. Five-Year Results. Dis.Colon Rectum 1996;39(10 Suppl):S35-S46.
10. Marescaux, J., Rubino, F., Leroy, J., and Henri, M. Laparoscopic-Assisted Surgery for Colon Cancer. JAMA 4-17-2002;287(15):1938-9.
11. Weiser, M. R. and Milsom, J. W. Laparoscopic Total Mesorectal Excision With Autonomic Nerve Preservation. Semin.Surg.Oncol. 2000;19(4):396-403.
12. Hartley, J. E., Mehigan, B. J., Qureshi, A. E., Duthie, G. S., Lee, P. W., and Monson, J. R. Total Mesorectal Excision: Assessment of the Laparoscopic Approach. Dis.Colon Rectum 2001;44(3):315-21.
13. Vithiananthan, S., Cooper, Z., Betten, K., Stapleton, G. S., Carter, J., Huang, E. H., and Whelan, R. L. Hybrid Laparoscopic Flexure Takedown and Open Procedure for Rectal Resection Is Associated With Significantly Shorter Length of Stay Than Equivalent Open Resection. Dis.Colon Rectum 2001;44(7):927-35.

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