Laparoscopic surgery for colon cancer

Acceptance of laparoscopy for the management of oncological disease has been slow due to the increased complexity of the technique, requirement of technological advances, and fears for the oncological safety of the approach. Laparoscopic oncological surgery has a role in the management of oncological patients at all stages of disease. Good evidence exists for the laparoscopic approach being a viable option for colon cancer patients. Current large multicenter trials will report the true outcomes of laparoscopic colon cancer surgery and how it compares with open surgery. This article examines some of the parameters by which laparoscopic colectomy will be judged.     

Laparoscopic surgery for colon diverticulitis

BACKGROUND: Laparoscopic surgery is used with increasing frequency to treat colorectal pathologies and some groups have also attempted to treat the complicated forms of diverticulitis (abscesses and/or fistulas). The results reported in the international literature are still controversial, especially in terms of the duration of surgery, the frequency of laparotomic conversions and postoperative morbidity. The aim of this study was to analyse the results of laparoscopic or laparotomic treatment of diverticular disease of the colon in patients admitted to the Department of Colorectal Surgery at the Cleveland Clinic in Florida over a three-year period. METHODS: A retrospective analysis was made of 57 patients with diverticular disease of the colon who were admitted to CCF (Cleveland Clinic Florida) between January 1996 and December 1998 and underwent elective laparoscopic or laparotomic surgery. A comparative analysis was made of the results in the two groups. RESULTS: Of the 57 patients treated only 15 underwent laparoscopic surgery; the majority were treated for uncomplicated diverticulitis. 22 out of 42 patients (53%) undergoing laparotomic surgery presented complicated diverticulitis (abscesses, fistulas or stenosis), whereas 12 out of 15 patients undergoing laparoscopic surgery (80%) were treated for uncomplicated diverticulitis. Statistically significant differences were found in relation to the duration of surgery: 152 min in the laparotomic group vs 209 in the laparoscopic group. No differences were found in the frequency of intraoperative complications, transfusions and the number of drainages inserted (p=0.66). The postoperative period showed significant differences in terms of the reappearance of intestinal peristalsis, use of PCA and postoperative stay. CONCLUSIONS: This retrospective study confirms that the laparoscopic treatment of colon diverticulitis offers a number of advantages: reduced postoperative pain, more rapid recovery of intestinal peristalsis and shorter postoperative stay. Laparoscopic sigma colectomy represents the treatment of choice for diverticulitis in uncomplicated cases.     

Laparoscopic surgery of colon cancer

Laparoscopic technologies have been used for the treatment of 184 patients with cancer of colon. Use of electrosurgical and suturing mechanical devices with linear and circular sutures is the essential part of laparoscopic and laparoscopy-assisted operations. Laparoscopic lymphadenectomy at patients with cancer of colon permits to perform required radical surgery that guarantees positive short- and long-term results of treatment.     

Laparoscopic surgery for stage I colorectal cancer

Background: This study analyzed the short- and long-term outcomes of laparoscopic surgery (LS) in patients with stage I colorectal cancer. Methods: A total of 130 patients with stage I colorectal cancer underwent LS between 1992 and 1999. Median follow-up was 61 months (range, 30–114). Results: Oral intake was started on median postoperative day 1, and the median postoperative hospital stay was 8 days. Postoperative complications included wound sepsis in eight patients (6.2%), anastomotic leakage in four patients (3.1%), and bowel obstruction in three patients (2.3%). Five patients developed recurrences. No port site recurrences were observed. The calculated 5-year survival rate was 97.9%. Conclusion: LS was shown to be technically feasible and oncologically sound for the treatment of patients with stage I colorectal cancer, and favorable short- and long-term outcomes were obtained.     

Laparoscopic surgery for stage IV colorectal cancer

Background  

The role of laparoscopic surgery in the management of stage IV colorectal cancer remains uncertain.     

Laparoscopic colon surgery in community practice

BACKGROUND: The benefits of laparoscopic colon surgery have been shown in the literature. More recently, the oncologic outcomes have been shown to be similar in the laparoscopic group when compared with open colon surgery for colon cancer. However, most of the published literature is from university/academic institutions. There is limited literature on laparoscopic colon surgery from a community hospital. METHODS: A retrospective chart review was conducted of 62 laparoscopic colon surgeries from a single surgeon's practice in a community hospital from October 27, 2003, to August 31, 2006. The laparoscopic approach was performed on patients with benign and curative colon cancer. The primary outcome measures were length of operating room times, pathologic results, length of hospital stay, and complication rates. RESULTS: Of the 62 laparoscopic patients, there were 9 converted patients (14% conversion rate). There were no perioperative deaths, and no anastomotic leaks. The average length of operating room time was 190 minutes (range, 96-295 min). The median length of hospital stay was 4 days (range, 3-17 d). There were 40 laparoscopic patients for colon cancer. The resection margins all were negative, and the mean number of lymph nodes in the resected specimen was 17 (range, 5-37). The overall complication rate was 18%. CONCLUSIONS: This study showed that laparoscopic colon surgery is technically feasible in a community hospital. The results from this study are similar to the published literature from university/academic institutions.     

Laparoscopic surgery for colon cancer: a systematic review

INTRODUCTION: Colorectal cancer is the second leading cause of cancer-related death in western countries. The objective of this systematic review was to show that laparoscopic-assisted colon resection for cancer is not inferior to open colectomy with respect to cancer survival and perioperative outcomes. METHOD: We performed a comprehensive literature review. Inclusion criteria were adults aged over 16 years with a colon resection for documented colon cancer and randomized controlled trials with laparoscopic- assisted or open resections. We excluded studies that did not document colon cancer recurrence in their article. We assessed data extraction and study quality and performed a quantitative data analysis. RESULTS: Six published and 4 unpublished studies fulfilled our inclusion criteria, with a total of 1262 patients. All primary and secondary outcomes showed good homogeneity, except for morbidity, which was described heterogeneously between the studies. There was no disadvantage to laparoscopic colon resection in any of these primary and secondary outcomes, compared with the conventional open technique. CONCLUSION: The results of this study suggest that, although there is no definitive answer, present evidence indicates that laparoscopic colon cancer resection is as safe and efficacious as the conventional open technique.     

Laparoscopic colon surgery in a rat model

The effects of laparoscopic colectomy on immune function require further study. Because the rat has been widely used to investigate the immune system we studied the feasibility of laparoscopic sutured colon anastomoses in a rat model. We used a low-pressure CO₂ pneumoperitoneum, a 2.7-mm 30° wide-angle arthroscope and video system, and microotologic forceps and scissors to perform two-handed dissection and suturing of the rat colon. The procedures included laparoscopic division of the colon and colostomy (group A,n=3), laparoscopic closure of a colotomy (group B,n=4), and complete laparoscopic division and reanastomosis of the colon (group C,n=4). One anesthetic death occurred in group C. Necropsy performed 1–15 days postoperatively revealed no anastomotic leaks and two anastomotic strictures. Laparoscopic sutured colon anastomosis in the rat is feasible and may provide a new model for the physiologic study of laparoscopic colon surgery.     

Laparoscopic versus open colectomy for TNM stage III colon cancer: results of a prospective multicenter study in Italy

Background and Purpose

There is still debate about the practicality of performing laparoscopic colectomy instead of open colectomy for patients with curable cancer, although laparoscopic surgery is now being performed even for patients with advanced colon cancer. We compared the long-term results of laparoscopic versus open colectomy for TNM stage III carcinoma of the colon in a large series of patients followed up for at least 3?years.

Methods

The subjects of this prospective non-randomized multicentric study were 290 consecutive patients, who underwent open surgery (OS group; n?=?164) or laparoscopic surgery (LS group; n?=?126) between 1994 and 2005, at one of the four surgical centers. The same surgical techniques were used for the laparoscopic and open approaches to right and left colectomy. The distribution of TNM substages (III A, III B, IIIC) as well as the grading of carcinomas (G1, G2, G3) were similar in each arm of the study. The median follow-up periods were 76.9 and 58.0?months after OS and LS, respectively.

Results

There were 10 (6.1?%) versus 9 (7.1?%) deaths unrelated to cancer, 15 (9.1?%) versus 5 (4?%) cases of local recurrence, 7 (4.2?%) versus 5 (4?%) cases of peritoneal carcinosis, and 37 (22.5?%) versus 14 (11.1?%) cases of metastases in the OS and LS groups, respectively. There was also one case of port-site recurrence after LS (0.8?%). The OS group had a significantly higher probability of local recurrence and metastases (p?<?0.001) with a significant higher probability of cancer-related death (p?=?0.001) than the LS group.

Conclusions

These findings support that LS is safe and effective for advanced carcinoma of the colon. Although the LS group in this study had a significantly better long-term outcome than the OS group, further investigations are needed to draw a definitive conclusion.     

Laparoscopic colon surgery for benign disease: a comparison to open surgery.

BACKGROUNDS AND OBJECTIVES: There remains a debate in the literature about the advisability of laparoscopic surgery for malignant disease of the colon. Current prospective studies will hopefully answer this question. However, for benign diseases of the colon, we believe laparoscopic surgery offers many advantages including decreased postoperative pain, early discharge from the hospital, and early return to normal activities. We retrospectively reviewed our experience with laparoscopic colectomies for benign disease to see whether these procedures could be done safely and if the proposed advantages could be realized. METHODS: Thirty-eight laparoscopic colon resections performed for benign disease were compared to 39 open colon resections with respect to operating times, length of hospital stay, estimated blood loss, days until first postoperative bowel movement, and complications. RESULTS: The laparoscopic colon resection group had decreased length of stay, less blood loss, earlier return of bowel function, and an equivalent number of complications. Laparoscopic cases did take an average of 24 minutes longer. CONCLUSION: The use of laparoscopic colon surgery for benign disease not only affords the patient the advantage of the laparoscopic approach, but also allows the surgeon to gain experience while awaiting the results of ongoing trials for laparoscopic colon surgery in malignant disease.     

Laparoscopic colon resection for colon cancer

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.     

腹腔镜辅助与开腹结直肠癌根治术临床对比研究

目的对比研究腹腔镜辅助与开腹结直肠癌根治术的安全性及根治疗效。方法选取2010年2月至2012年2月结直肠的患者252例,前瞻性非随机(根据患者意愿)将入选病例分为腹腔镜组(143例)及开腹组109例。将所得数据采用SPSS 19.0软件检验分析。术前、术后指标、肿瘤大小、结肠标本的大小、直肠标本的大小、直肠下切端距离及淋巴结清扫枚数采用x珋±s表示并用t检验,近期并发症、复发率、转移率及远期并发症采用率表示并用χ~2检验,检验标准α=0.05,P0.05则具有统计学意义。结果腹腔镜的手术时间长于开腹组[(156.8±52.3)min比(143.5±41.9)min,t=2.187,P0.05]。腹腔组的术中失血、术后排气时间、术后下床时间、术后进食流食时间及术后住院时间的指标优于开腹组[(83.8±26.7)ml比(173.2±39.5)ml,(2.2±0.7)d比(3.9±0.9)d,(2.4±0.6)d比(3.2±1.1)d,(3.0±0.8)d比(4.3±0.9)d,(6.8±1.3)d比(8.9±1.6)d,t=21.368,t=16.867,t=7.349,t=12.123,t=11.496,P0.05]。两组术后近期并发症、切除的肿瘤大小、结肠标本的大小、直肠标本的大小、直肠下切端距离及淋巴结清扫枚数、局部复发率、远处转移率、术后远期并发症发生率及3年生存率差异无统计学意义(P0.05)。结论本研究腹腔镜结直肠癌手术具有开腹手术相同的手术安全性及肿瘤根治效果,近期疗效优于开腹手术,远期疗效与开腹手术无显著差异。     

Laparoscopic colon and rectal surgery at a VA hospital

Background: Laparoscopic techniques were utilized for all colon and rectal procedures undertaken by a single surgeon at the West Haven VA Hospital beginning in August of 1991. Methods: All patients were entered into a registry, and data was gathered prospectively. This report comprises the first 50 patients. These patients were compared with 34 consecutive patients undergoing open operations during the same time period. Results: Overall, 33 patients (66%) were completed laparoscopically. This increased to 87% after the first 20 patients. Patients undergoing laparoscopic procedures showed significant improvement over the open and converted patients in several areas. Operative blood loss was decreased. They ate sooner (3.7 days) and required less postoperative pain medication. Major complications were less common after laparoscopic operations. Average length of stay was 8.3 days, compared with 13.9 days and 14.5 days in the converted and open groups, respectively. There was no difference in the operative time between laparoscopic and open cases; time for converted cases was significantly longer. There was no difference in lymph node counts among the three groups in patients with resections for cancer. Conclusions: Laparoscopic colorectal surgery is safe and effective, although its efficacy in malignant disease is uncertain. Patients enjoy the same benefits derived from other laparoscopic procedures. Although there appears to be a longer learning curve associated with the procedure, minimally invasive techniques should become utilized more frequently for patients with colorectal disease.     

Laparoscopic colon surgery: past, present and future

Since its first described case in 1991, laparoscopic colon surgery has lagged behind minimally invasive surgical methods for solid intra-abdominal organs in terms of acceptability, dissemination, and ease of learning. In colon cancer, initial concerns over port site metastases and adequacy of oncologic resection have considerably dampened early enthusiasm for this procedure. Only recently, with the publication of several large, randomized controlled trials, has the incidence of port site metastases been shown to be equivalent to that of open resection. Laparoscopic surgery for colon cancer has also been demonstrated to be at least equivalent to traditional laparotomy in terms of adequacy of oncologic resection, disease recurrence, and long-term survival. In addition, numerous reports have validated short-term benefits following laparoscopic resection for cancer, including shorter hospital stay, shorter time to recovery of bowel function, and decreased analgesic requirements, as well as other postoperative variables. In benign colonic disease, much less high-quality literature exists supporting the use of laparoscopic methods. Two recent randomized controlled trials have demonstrated some short-term benefits to laparoscopic ileocolic resection for CD, in addition to evident cosmetic advantages. On the other hand, the current evidence on laparoscopic surgery for UC does not support its routine use among nonexpert surgeons outside of specialized centers. Laparoscopic colonic resection for diverticular disease appears to provide several short-term benefits, although these advantages may not translate to cases of complicated diverticulitis. Despite the increasing acceptability of minimally invasive methods for the management of benign and malignant colonic pathologies, laparoscopic colon resection remains a prohibitively difficult technique to master. Numerous technological innovations have been introduced onto the market in an effort to decrease the steep learning curve associated with laparoscopic colon surgery. Good evidence exists supporting the use of second-generation, sleeveless, hand-assist devices in this context. Similarly, new hemostatic devices such as the ultrasonic scalpel and the electrothermal bipolar vessel sealer may be particularly helpful for extensive colonic mobilizations, in which several vascular pedicles must be taken. The precise role of these hemostatic technologies has yet to be established, particularly in comparison with stapling devices and significantly cheaper laparoscopic clips. Finally, recent advances in camera systems are promising to improve the ease with which difficult colonic dissections can be performed.     

Primary lung cancer surgery in stage II and stage III

We reviewed 100 operations performed on 95 consecutive patients with stage II (n = 7) and stage III (n = 88) primary lung cancer. The five-year survival of patients with N1 involvement was 58% and with N2 disease was 21%. Of 13 patients with Pancoast or chest wall involvement, 58% survived five years. The entire group had a 34% five-year survival and a median survival of 32 months. Preoperative and/or postoperative radiotherapy, in the presence of nodal disease, appears to improve local control, but an effective chemotherapy program is needed for unrecognized visceral metastases. In the absence of contraindications, surgical excision offers the best likelihood of survival and quality of life.     

Long-term prognosis after surgery for pathological stage III lung cancer

OBJECTIVE: We studied for the purpose of revealing the long-term prognosis of the surgical treatment for pathological stage III lung cancer. METHOD: Two hundred fifty-four patients with pathological stage III disease who underwent surgical procedures in our hospital from 1981 to 2000 were investigated retrospectively. RESULTS: The 5- and 10-year survival rates of 144 patients with stage IIIA disease were 35 and 25%, while those of 110 patients with IIIB disease were 30 and 16%. The 5- and 10-year survival rates were 40 and 27% for 52 patients with T1N2 disease, 33 and 23% for 70 patients with T2N2 disease, 34 and 0% for 9 patients with T3N1 disease, and 33 and 26% for 13 patients with T3N2 disease, respectively. In the patients with IIIB disease, the 5- and 10-year survival rates of 56 patients only with pml were 47 and 26%, those of the other patients were 9 and 0%. There is significant difference among them (p < 0.0001). In 54 patients with IIIB disease in addition to pm1, the 5-year survival rates of 19 patients with exploration only and the other patients were 7 and 14%, respectively. There were no 10-year survivors in both groups. CONCLUSION: The long-term prognosis of pathological stage III disease was still not satisfactory. Therefore, we should make efforts to get a sufficient informed-consent before the surgery for the patients with stage III disease.     

Laparoscopic colectomy for colon cancer

Surgical resection is the primary treatment for colon cancer. The introduction and acceptance of laparoscopic colectomy for cancer has been gradual for a number of reasons including the fact that it is technically challenging, has less than dramatic patient benefits, and perhaps most significantly it could theoretically represent a compromise as an oncologic procedure. Preliminary evidence suggests that laparoscopic colectomy for colon cancer is safe, feasible, and can be performed with acceptable operative times and conversion rates. Furthermore, it may offer important patient-related advantages and the same extent of resection as in open surgery can be achieved. It may result in improved outcomes when performed by experienced surgeons. The early experience with high rates of wound recurrences has not been realized in current reports. Ongoing prospective, randomized trials should establish whether laparoscopic colectomy is as effective as open colectomy in preventing recurrence and death from colon cancer; until then this procedure is not considered standard for patients with curable colon cancer.     

Laparoscopic colon surgery: unreliability of end-tidal CO2 monitoring

Background: The relatively good haemodynamic and respiratory tolerance to abdominal CO₂ insufflation has mostly been observed in healthy patients during short‐lasting laparoscopic procedures. End‐tidal CO₂ pressure (PetCO₂) has been shown to be a reliable method to assess arterial CO₂ (PaCO₂) in the absence of cardio‐respiratory disease in this setting. However, no study has investigated whether PetCO₂ is accurately related to PaCO₂ during laparoscopic colon surgery. Indeed, these procedures last longer, prolonging the pneumoperitoneum and requiring a Trendelenburg position. The aim of the present study was to measure the PaCO₂–PetCO₂ difference over time in patients undergoing laparoscopic colon surgery and to determine whether PaCO₂ is reliably assessed by PetCO₂. Methods: Forty consecutive patients (ASA I and II) scheduled for laparoscopic colon surgery were anaesthetized and ventilated to obtain a PetCO₂ between 4.0 and 5.5 kPa. After initiation of CO₂ insufflation, PaCO₂ and PetCO₂ were recorded every 30 min during surgery. Results: No complication was observed during anaesthesia. The mean arterial pressure increased significantly after CO₂ insufflation and remained steady up to the end of pneumoperitoneum. The heart rate remained stable over time. The relation between PaCO₂ and PetCO₂ was not constant among patients and increased over time within the same patients. The R² values fluctuated and did not show a constant correlation between PaCO₂ and PetCO₂. Conclusion: The correlation between PaCO₂ and PetCO₂ during laparoscopic colon surgery is inconsistent mainly due to inter‐ and intra‐individual variability.