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Journal of Minimal Access Surgery, Vol. 2, No. 4, October-December, 2006, pp. 205-210 Review Article Laparoscopic surgery for colorectal cancers: Current status Shukla ParulJ, Barreto George, Gupta Piyush, Shrikhande ShaileshV Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai Code Number: ma06040 Abstract Laparoscopy was introduced more than 15 years ago into clinical practice. However, its role in colorectal surgery was not well established for want of better skills and technology. This coupled with high incidences of port site recurrences, prevented laparoscopic surgery from being incorporated into mainstream colorectal cancer surgery. A recent increase in the number of reports, retrospective analyses, randomized trials and multicentric trials has now provided sufficient data to support the role of laparoscopy in colorectal cancer surgery. We, thus, present a review of the published data on the feasibility, safety, short - and long-term outcomes following laparoscopic surgery for colorectal cancers. While the data available strongly favors the use of laparoscopic surgery in colonic cancer, larger well powered studies are required to prove or disprove its role in rectal cancer. Keywords: Colorectal cancer, colorectal surgery, laparoscopic surgery The morbidity and mortality associated with surgical procedures performed on the colon and rectum have plagued surgeons since time immemorial. As surgeons began to perform open colorectal surgery with increasing confidence these very same problems assumed high significance until the principles of antisepsis and the refinements in surgical technique began to make a considerable dent in these negative outcomes. At this same time, surgeons had already explored the role of minimal invasiveness in treating colorectal problems, viz. the use of the sigmoidoscope to deflate a sigmoid volvulus, perineal procedures for prolapse in elderly persons, etc. The laparoscopic cholecystectomy in 1987 in France, performed by Philipe Mouret for the first time during a laparoscopic gynecologic surgery, rapidly established its role in place of open surgery.[1] However, laparoscopic large bowel surgery did not, for a long time, receive the same degree of acceptance by the surgical community although a few of the initial series had shown promising results. We thus review the problems that were and are still associated with laparoscopic surgery for colorectal cancer while finally attempting to provide an evidence-based review of literature to suggest as to where laparoscopic surgery stands today in the field of colorectal cancers. Problems associated with laparoscopic surgery Laparoscopy for colorectal cancers has not gained universal acceptance for a number of reasons[2],[3]
Historical discoveries in the advancement of laparoscopy for colorectal surgery[10] Advances in techniques of laparoscopy that have paved the way for a shift in the role of laparoscopic surgery in colorectal diseases from the initial intended role of an adjunct to open surgery, to an important operative modality have been, firstly, the realization of the benefit of such a procedure in elderly patients where the morbidity of the large incision of open surgery can be overcome by the reduction in pain and overall bacterial contamination. Videolaparoscopic techniques in colorectal surgery were used for the first time in 1990 by Moises Jacobs in Miami, Florida while performing a right hemicolectomy.[11] The development of a circular stapling device for colostomy closure permitted the first laparoscopic colostomy closure to be performed by in 1990 by Joseph Uddo. The development of a laparoscopic intestinal stapler meant that for the first time, the bowel could be transected intraperitoneally. Dennis Fowler successfully demonstrated this in 1990 when he performed the first laparoscopic sigmoid resection. Subsequent years witnessed more technical innovations that could now make laparoscopic surgeries on the colon and rectum feasible. Contraindications to laparoscopic colorectal surgery [Table - 1][12] Results Extent of oncological resection in laparoscopy versus open surgery The most important aspect if the feasibility of laparoscopy has to be assessed in case of colorectal malignancies is to unconditionally prove that the oncological resection, i.e., the margins of resection - proximal, distal and circumferential and the number of nodes harvested are comparable, if not better than in open surgery. Numerous studies[2],[3],[13] in the 1990s had shown that the number of lymph nodes harvested was comparable between open and laparoscopic surgery. Melotti et al also concluded that the distance of the tumor from resection margins and the number of lymph nodes harvested with the operative specimen did not vary from those obtained in open surgery.[14] A recent meta-analysis[15] showed that the number of lymph nodes harvested was higher in the laparoscopic group although the differences did not attain statistical significance. Korolija et al , however, noted that the difference in distal resection margins (4.6 cm in the lap group versus 5.3 cm in the open group) were statistically significant in favor of open surgery. On the basis of correlation they concluded that laparoscopic surgery was as adequate as the conventional approach. Bretagnol et al , have shown that R0 resections could be achieved in 93% of patients undergoing laparoscopic low colorectal and coloanal surgeries.[16] Safety and complications The introduction of laparoscopy into the armamentarium of surgery for colorectal cancer has brought, along with the novel idea of minimal access, a novel set of complications associated with the creation of pneumoperitoneum, port placement and diathermy use that require a considerable amount of skill as well as specialized training if they have to be prevented. [Table - 2] lists a few of the specific complications associated with laparoscopic colorectal surgery.[17] Six randomized controlled trials[18],[19],[20],[21],[22],[23] comparing complication rates did not find any significant difference between laparoscopic and open surgery. In fact, a few did show a lower morbidity in favor of the laparoscopy group. Lacy et al[18] concluded that while the operative time was consistently longer in the laparoscopic arm, the peri-operative blood loss as well as morbidity were significantly lower in the laparoscopic arm. Conversion rates vary from 1%[24] to 29%.[25] The conclusion is clear - laparoscopic surgery, if performed by a trained, skillful surgeon, will produce results comparable to open surgery. Poor technique is responsible for the complications encountered and does not reflect an inherent errant potential in laparoscopic surgery. Conversion is not a complication and must be resorted to whenever required.[17] Short-term outcomes [Table - 3] shows a comparison between various randomized trials comparing short-term outcomes viz, blood loss, analgesic requirement and operative time. Braga et al ,[29] in their randomized study on short-term outcomes in laparoscopic and open surgery, while analyzing parameters such as wound infection rates, anastomotic leak rates, operative time, blood loss, lymphocyte proliferation in response to Candida albicans and phytohemagglutinin and return to full activity, found that the laparoscopic arm had a significant decrease in the 30-day postoperative morbidity rates compared with the open arm. They also concluded that laparoscopic-assisted colorectal surgeries are associated with better preservation of lymphocyte proliferation indices and gut oxygen tension. Tang et al ,[30] have shown that there is no difference in the systemic immune response of patients having laparoscopically assisted colectomy and those undergoing conventional open surgery for colorectal cancer. The Cochrane review[31] on the short-term benefits for laparoscopic colorectal resections which analyzed 22 trials and 2965 participants, concluded that whilst the results available favored laparoscopic colorectal resection, only seven of the trials had more than 100 patients. The reviewers believed that the final verdict could only be given after the multicenter trials viz, COLOR, MRC CLASICC and LAPKON II (Germany). The results of the COLOR study[23] have been summarized in [Table - 3], while the MRC CLASICC[25] has concluded that laparoscopic-assisted surgery for colon cancer is as effective as open surgery and is likely to produce similar long-term outcomes. However, impaired short-term outcomes after laparoscopic-assisted anterior resection (including CRM positivity) for cancer of the rectum do not justify its routine use. Long-term outcomes Laparoscopic colorectal surgeries have constantly been under scrutiny with respect to the long-term outcomes - survival data and recurrence rates. The data available[32],[33],[34],[35] has shown long-term survival comparable to conventional open surgery. Local recurrence rates vary from 0-6.6%.[18],[36],[37] Capusotti et al ,[33] have even found a better outcome for node - positive patients treated by laparoscopy. Jacob et al,[34] have in fact shown better results in the patients undergoing laparoscopic resections. A recent systematic review[38] has shown no difference between laparoscopy and open surgery with regard to the long-term outcome. Other, less powered studies,[39],[40] have shown a better outcome for the laparoscopy arm patients. However, multicenter randomized trials are needed to confirm or refute these results. Port site recurrence After the first reported port site metastasis in 1978,[41] numerous studies have been carried out to determine whether laparoscopy is actually associated with an increased incidence of port site recurrences / metastasis. Initial reports showed a high incidence of port site recurrence.[5],[6],[7],[8],[9] The possible mechanisms which lead to port site metastasis have been summarized in [Table - 4].[42] In the review published in 1998, Neuhaus et al[42] had strongly suggested an increased incidence of port site metastases due to laparoscopic surgery, warning that in view of the findings, laparcoscopic surgery for colorectal malignancies should occur only within the context of clinical trials. In a prospective randomized controlled trial, Lacy et al ,[43] found no port site recurrences in the 91 patients studied by them, neither in the laparoscopic nor open surgical arms. Many studies[17],[44],[45],[46] found a lesser prevalence of port site recurrence than previously shown and realized that the incidence corresponds with wound recurrence seen in open surgery. According to Melotti et al ,[14] the incidence of port site metastases varies from 0, in the recent studies, to 21.4% in other limited series.[7] Data in support of laparoscopic surgery have steadily increased blaming the initial reports of poor outcome on poor surgical technique. Some policies advised are to avoid contact between laparoscopic instruments and the tumor by bagging and the use of "no - touch" isolation technique suggested by RB Turnbull Jr,[14] meticulous lavage of all wounds with a cytocidal agent,[2] widening the port of extraction of the specimen and use of wound protectors.[17] Quality of life issues While the operative time for laparoscopic surgery is obviously more than that for open surgery, there are several beneficial outcomes resulting directly from the use of laparoscopy as compared with open surgery. As there is no large abdominal incision, the corresponding postoperative pain and the ensuing need for analgesia is reduced.[20],[23],[27],[47],[48] As the wound is smaller, the likelihood of wound infection is less.[29],[49] This attains significance when the patient is a candidate for adjuvant chemotherapy at which time, a wound infection can delay institution of the chemotherapy. The COST study has shown better short-term quality of life. The recurrence and survival rates were equivalent for both groups and for all tumor stages.[27] The median hospital stay and the need for parenteral antibiotics were also shown to be lower in the laparoscopy group. The validity of this shortened hospital stay, though, has been questioned in the light of the stay also being affected by the presence of an anastomosis and the age of the patient. The incidence of small bowel related problems postoperatively including adhesive obstruction and the incidence of postoperative ventral hernias have also been seen to be on the lower side in the laparoscopically resected group of patients.[50] The incidence of injuries to the pelvic autonomic nerves during dissection in rectal cancers has been associated with bladder and sexual dysfunction. An increased rate has been noted in some studies.[51],[52],[53] This has been attributed possibly to the higher proportion of complete TMEs done by laparoscopy. More trials are required in this aspect. Laparoscopy in early lower GI cancers Laparoscopy has been shown to have an important role in early colonic carcinomas viz, laparoscopic-assisted colonoscopic polypectomy, laparoscopic wedge resection and laparoscopic colostomies with a 67-100% success rate for avoiding a formal bowel resection. This can be achieved by preoperative colonoscopic tattooing for localization.[54] Conclusion According to the data available, laparoscopic surgery definitely appears to have a role in colonic malignancies. The short- term and long-term outcomes clearly favor this approach. It should be realized, though, that the benefits of laparoscopic surgery can be obtained only when performed by persons trained in the art of laparoscopy so as to avoid unnecessary morbidity and even the risk of mortality. As for rectal cancer, the present data on the role of laparoscopy is not mature enough, especially for anterior resections. At present, laparoscopic anterior resection should only be considered within the context of clinical trials.References
Copyright 2006 - Journal of Minimal Access Surgery The following images related to this document are available:Photo images[ma06040t2.jpg] [ma06040t1.jpg] [ma06040t4.jpg] [ma06040t3.jpg] |
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