Page 38 - Journal of WALS

WJOLS

Laparoscopic Surgery for Colorectal Cancers: Current Status

body, using it for sensory perception and to guide the surgical It is often dependent upon bowel function recovery and
instruments. He manipulates with his other hand while severity of postoperative pain. There is high level of evidence
observing the entire procedure on a TV screen overhead. With suggesting laparoscopic group has shorter stay compared with
both hand and laparoscopic instruments doing the work, the laparotomy group.
surgeon has more control over the operation and sense of depth
and sensation of touch that cannot be gained through the lens COST
of a camera.
Experience with laparoscopy for the treatment of benign disease
has suggested that the short-term benefits gained with the
POSTOPERATIVE PAIN
laparoscopic approach may compensate for the higher costs
Numerous randomized controlled trials have demonstrated a related to a laparoscopic procedure. Although laparoscopy was
significant reduction in pain or analgesic requirements in the associated with increased operating times and increased costs
immediate postoperative period. In a meta-analysis, Abraham associated with disposable equipment, the total overall cost
et al found significant advantages for the laparoscopic was less than for the open group. The most convincing evidence
colectomy group in pain levels at rest and during coughing. comes from a recent prospective, randomized study, in which
cost analysis was performed on a subset of patients
QUALITY OF LIFE (98 laparoscopic, 111 open) participating in the Swedish colon
Quality of life (QOL) has primarily focused on postoperative cancer laparoscopic or open resection. The study period
pain and intravenous analgesic requirements. While it may be included 12 weeks after surgery and the analysis examined direct
expected that laparoscopy results in decreased pain and medical costs (hospital costs and cost of outpatient care) and
consequently less intravenous analgesic use, this assessment indirect costs, such as loss of productivity, because of time
may be subject to bias in nonrandomized trials since patients absent from work. The authors found that the total cost to
undergoing laparoscopy tend to start oral feeding/analgesics society was similar for laparoscopic and open procedures but
earlier. The few case control and cohort studies that addressed the total cost to the health care system was significantly higher
postoperative pain have reported inconsistent results possibly for the laparoscopic group. The main contributors of this higher
due to the small number of patients in these studies. In contrast, cost included higher operating room costs, costs resulting from
randomized trials have shown laparoscopy to be associated complications and reoperations which occurred more frequently
with less pain at some point in the postoperative recovery period, in the laparoscopic group. However, it is critical to note that in
pain with coughing and fatigue were significant less in the this study there was no difference in hospital length of stay to
laparoscopy group up to postoperative days. Exact QOL offset the higher costs of short-term care. However, early
between two groups is difficult to measure because of lack of recovery resulted in less loss of productivity such that the two
more sensitive and appropriate instruments. approaches did not differ in economic impact.

RECOVERY OF BOWEL FUNCTION LONG-TERM OUTCOMES
Faster recovery of bowel function is another significant Long-term outcomes among the various studies may be impaired
advantage seen in the laparoscopic group. Schwenk et al found due to the lack of homogeneity in patient selection, radiation
that first passage of flatus was 1 day earlier in the laparoscopic therapy, site and stage of the tumor, time of follow-up and
colectomy group (p < 0.0001) and the first bowel movement was violation of the “intent-to-treat principle” in some trials, which
0.9 days earlier (p < 0.0001). Lacy et al demonstrated faster can impact recurrence and reported survival rates. Additionally,
initiation of peristalsis and oral intake in laparoscopic group. most of these studies are non-controlled, non-randomized trials
with a short-term follow-up and/or a small number of patients.
LENGTH OF HOSPITAL STAY
DISEASE-FREE SURVIVAL AND
Length of hospital stay is a common variable assessed in most
laparoscopic studies. It reflects the rapidity of physiologic OVERALL SURVIVAL
recovery and has economic implications with regard to operative Different studies have reported 3 to 5 years survival (Kaplan-
and hospital costs. Meier curve) data. Retrospective and prospective reviews have
Results from numerous retrospective and prospective series demonstrated a 5-year survival rate ranging from 72 to 80.9%,
demonstrate a mean duration of hospitalization of 10.5 days, after curative resection with better outcomes associated with
with one series reporting a mean as high as 16.6 days. However, early stage carcinomas.
it is difficult to make sense of this data as the length of Comparative case control and cohort studies have not
hospitalization is significantly influenced by the health care demonstrated any differences in 5-year survival between
system in which the patient is treated as by the condition of the patients who underwent laparoscopy and those individuals
patient himself. who had laparotomy with rates ranging from 64 to 93% in both

World Journal of Laparoscopic Surgery, May-August 2011;4(2):103-108 105