Page 28 - World Journal of Laparoscopic Surgery

Laparoscopy in Colorectal Malignancies: Current Concepts

The trial confirms and extends previous studies reporting After a median follow-up of 4.4 years, 160 patients had
that for any stage 3-year survival and disease free intervals a recurrence of tumor (84 in the open colectomy group and
are no worse than in patients undergoing laparoscopic 76 in the laparoscopic surgery group) and 186 had died (95
colorectal surgery as compared to open surgery. The DFS, and 91 respectively). The cumulative incidence of recurrence
OS, and local recurrences in patients undergoing among patients treated with the laparoscopic procedure did
laparoscopic resection of colorectal cancer are as good with not differ significantly from the open group. The overall
laparoscopic surgery as with open surgery. survival was also very similar in the two groups as was the
Overall, 10 wound or port-site recurrences occurred in disease free survival rate. These findings held true for any
639 patients randomly assigned who had curative colorectal stage of cancer; there were no significant differences
cancer surgery (1.9%). Of these, only one (0.2%) was between treatment groups in the time to recurrence, disease
reported as a true port-site recurrence, with the remainder free survival or overall survival. Tumor recurred in surgical
being retrieval site recurrences. The majority of retrieval wounds in 3 patients-2 in laparoscopy and 1 in open group.
site recurrences occurred in patients with larger tumors or Other multi-institutional randomized controlled trials like
more advanced disease, emphasizing the need for adequate the Barcelona trial, COST trial, and COLOR trial have level
wound protection during specimen extraction. Port-site 1 evidence to support the advantages of and refute the
recurrences in the Barcelona and Clinical Outcomes of disadvantages of laparoscopic curable colon cancer
Surgery Therapy (COST) trials were 0.94% and 0.5% surgery. 18,19
respectively. 15 Previous studies investigating immune Although clinical trials establish the safety and feasibility
dysfunction after laparoscopic surgery have failed to of laparoscopic colectomy in colon cancer, less evidence
demonstrate any difference in comparision to open exists for the same in rectal cancer. Laparotomy and
surgery. 16 meticulous total mesorectal excision as advocated by Herald
In long-term observations, the Quality of Life (QOL) et al is currently the accepted standard of care for carcinoma
after laparoscopic surgery is no worse than conventional rectum; a technique associated with low recurrence and
20
open surgery. In a previous subgroup analysis of rectal optimal survival. Laparoscopic surgery in rectal cancers
cancer surgery, a nonsignificant trend for worse sexual requires to duplicate these oncologic results. Many authors
function in males was reported after laparoscopic have published significant case-series studies establishing
resection. 17 The long-term QOL analysis presented here the safety of laparoscopic rectal cancer surgery with >1200
emphasizes the decline in male sexual function after rectal patients. Feliciotti et al prospectively studied laparoscopic
resection was present in both arms. assisted and open resections and found both methods to
Another randomized trial conducted by the clinical respect oncologic principles with similar long-term
outcomes of surgical therapy study group (COST) between outcomes. 21 Prospective studies have revealed that
August, 94 and August, 2001 of 872 patients was carried laparoscopic resection compared with open surgery did not
out where a total of 428 patients underwent open colectomy worsen survival or disease control in patients with
and 435 were treated laparoscopically. Operative times were rectosigmoid cancer. 2 recent meta-analysis reviewed the
significantly longer in the laparoscopic surgery group than current literature on the laparoscopic resection of rectal
in the open colectomy group (150 vs 95 minutes). The extent cancer. 22,23 Gao et al analyzed 11 studies (1995-2005),
of resection was similar in both groups; bowel margins which included 285 patients who had undergone
were less than 5 cm in 6% of patients in the open colectomy laparoscopic resection for rectal cancer. The authors found
group and 5 % in laparoscopic group. Perioperative recovery that laparoscopic surgery was associated with lower
was faster in the laparoscopic surgery group than in the morbidity but longer operating time. Wound infection,
open colectomy group, reflected by shorter hospital stay anastomotic leakage, and mortality were similar in the open
and briefer use of parenteral narcotics and oral analgesics. and laparoscopic groups. Aziz et al analyzed 20 studies
There were no statistical differences between the groups in (1993-2004) including 909 patients who had undergone
the rates of intraoperative complications (2% in the open laparoscopic rectal cancer resection and 1162 who had
colectomy group and 4% in the laparoscopic group), 30 undergone open surgery. Reduction in length of stay and
day postoperative mortality rates and severity of post- time to first bowel movement and stomal function in patients
operative complications at discharge at 60 days and rates who underwent laparoscopic surgery was revealed. In the
of readmission or reoperation (< 2% in each group). set of abdominoperineal resection, laparoscopic patients

World Journal of Laparoscopic Surgery, January-April 2010;3(1):27-30 29