Laparoscopic surgery in Crohn's disease

In a prospective study the feasibility and safety of laparoscopic-assisted ileocaecal resection for Crohn's disease was studied and compared with 16 patients who had open ileocaecal resection, and the value of laparoscopic stoma surgery was assessed. From January to November 1995 laparoscopic-assisted ileocaecal resection for Crohn's disease was undertaken in 7 patients, laparoscopic-assisted stoma formation in 10 patients. In 1 patient laparoscopic ileocaecal resection was converted to open surgery due to an unrecognised ileocolic fistula. Operating time in laparoscopic-assisted ileocaecal resections was longer than in open ileocaecal resection (150 vs. 127 min, P=0.7). Blood loss (386 vs. 445 ml, P=0.7), first bowel movement (3.5 vs. 4.9 postoperative days, P=0.07) and postoperative time to discharge (5.2 vs. 9.9 days, P<0.01) in patients who had a laparoscopic-assisted ileocaecal resection were less than in patients who had open surgery. In all 10 patients laparoscopic formation of a stoma was possible. Operating time was 62 min. Oral solids were restored on the 1.5 postoperative day. Mean postoperative stay was 8.8 days, prolonged due to time needed for stoma-care training. These preliminary results indicate that laparoscopic-assisted ileocaecal resection and stoma surgery for Crohn's disease are feasible and safe. Both procedures are characterised by rapid recovery and superior cosmetic results.     

Better preservation of immune function after laparoscopic-assisted<Emphasis Type="Italic">vs</Emphasis>. open bowel resection in a murine model

PURPOSE: We evaluated cell-mediated immune function after laparoscopic-assisted and open bowel resection in rats by measuring delayed-type hypersensitivity responses to keyhole limpet hemocyanin (KLH) and phytohemagglutinin (PHA). METHODS: Male Sprague-Dawley rats (n=120) were sensitized to 1 mg of KLH ten days before investigations. Rats were challenged preoperatively, immediately postoperatively, and on postoperative day (POD) 2 with an intradermal injection of 0.3 mg of KLH and 0.2 mg of PHA (at different sites). Averages of two measures of perpendicular diameters (taken 24 and 48 hours postchallenge) were used to calculate the area of induration using the formula for the area of an ellipse, A=(D₁/2×D₂/2)×π. Anesthesia control animals underwent no procedure (n=40). Open resection group underwent ligation and resection of the cecum (length=2 cm) through a 7 cm midline incision (n=40). In the laparoscopic-assisted resection group, under CO₂ pneumoperitoneum (4–6 mmHg), the cecum was identified, dissected free, and exteriorized through a 4 mm port. The cecum was then ligated and resected extracorporeally (n=40). RESULTS: Preoperative responses to both KLH and PHA were the same in all three groups. Furthermore, within each group, postoperative responses were similar. When groups were compared, the anesthesia group responses were significantly greater than the open resection group responses at all time points (P<0.05 for all comparisons). Laparoscopic-assisted resection group responses differed from control at only two of eight postoperative measures. Laparoscopic resection group responses were significantly greater than open resection group responses to challenge with both KLH and PHA on POD1 (P<0.02, for both comparisons) and POD 4 (P<0.05, for both comparisons). CONCLUSIONS: Postoperative cell-mediated immune function is better preserved after laparoscopic-assisted bowel resection than after open resection as assessed by skin antigen testing.     

Laparoscopic-assisted colorectal surgery

PURPOSE: To audit the development and outcomes of laparoscopic colorectal surgery at the Royal Brisbane Hospital. METHODS: Since July 1991, laparoscopic-assisted colectomy for benign and malignant colorectal disease has been performed on more than 300 patients at the Royal Brisbane Hospital. This paper summarizes the outcome for the first 240 patients who underwent a laparoscopic colorectal procedure. All laparoscopic data were collected prospectively, and for selected studies, data were compared with open surgical controls. RESULTS: Nineteen patients required open conversion (7.9 percent). There was a significant decrease in wound infection rates in patients having a laparoscopic-assisted colectomy (3.6 percent) compared with historical controls (7.9 percent) (P<0.05; chisquared). There were five anastomotic leaks, five laparotomies for postoperative adhesive obstruction, and four perioperative deaths. A total of 103 patients had a procedure for colorectal cancer. Of the 79 potentially curative procedures, there have been 5 (6.3 percent) recurrences to date. CONCLUSION: The overall morbidity and mortality in this series seem to be acceptable compared with that of open procedures.     

Safety and feasibility of an enhanced recovery pathway after a liver resection: prospective cohort study

BackgroundIn contrast to colorectal surgery, enhanced recovery pathways (ERPs) have not yet become standard practice after major upper abdominal surgery. The aim of this study was to assess the feasibility and outcomes after implementation of an ERP after liver a resection.MethodsPatients who underwent a liver resection in two consecutive 6-month periods before (July–December 2013) and after (January–June 2014) implementation of an ERP were included in a prospective study. Patients who underwent live donation, ALPPS (associating liver partition with portal vein ligation for staged hepatectomy) or concomitant procedures were excluded. Peri-operative outcomes were compared between groups, and multivariate analysis of factors influencing the length of hospital stay (LOS) was performed.ResultsTwo hundred and eleven patients (93 pre-ERP and 91 post-ERP patients) underwent a liver resection during the study period. There was no significant difference in the median LOS (P = 0.907) and 30-day readmission rates (P = 0.645) between the groups. Severe (Clavien grade III–V) complications were reduced in ERP patients (13.9% versus 4.3%; P = 0.039). On multivariate analysis, an increased age (< 0.001), open resection (< 0.001) and complications (< 0.001) were associated with an increased LOS.ConclusionEnhanced recovery after a liver resection appears to be safe, feasible and may reduce severe complications. However, the LOS was significantly influenced by patient age, open surgery and post-operative complications, but not by an ERP.     

Laparoscopic- <Emphasis Type="Italic">vs.</Emphasis> Hand-Assisted Ultralow Anterior Resection: A Prospective Study

Purpose A standard laparoscopic-assisted operation can be conducted with colorectal anastomosis performed after extraction of specimen and insertion of a pursestring via a small left iliac fossa or suprapubic incision, or completed via hand-assisted laparoscopic technique with a 7-cm to 8-cm suprapubic incision. This study compares the short-term outcomes of either technique. Methods Sixty-three consecutive patients undergoing laparoscopic-assisted ultralow anterior resection or total mesorectal excision for rectal cancer were examined. The laparoscopic-assisted group (n = 31) had standard laparoscopic-assisted resection, whereas the hand-assisted laparoscopic group (n = 32) had a 7-cm to 8-cm suprapubic incision to allow an open colorectal anastomosis. In patients who were obese or have had multiple abdominal surgeries, the hand-assisted approach was generally favored. All patients had a diverting ileostomy. Results There was no conversion in either group. Mean operating time was significantly longer in the laparoscopic-assisted group (188.2 vs. 169.8 minutes; P < 0.0001). Mean duration for narcotic analgesia (1.65 vs. 3.38 days, P < 0.0001), mean time to flatus (1.97 vs. 3.19 days, P < 0.0001), and mean duration of intravenous hydration (2.45 vs. 3.88 days, P < 0.0001) were longer in the hand-assisted laparoscopic group. However, the mean length of hospital stay (5.8 vs. 5.9 days, P = 0.379) was similar. There was no major surgical complication in either group; chest infection, wound infection, and thrombophlebitis were similar between the laparoscopic-assisted group and the hand-assisted laparoscopic group. Adequacy of specimen harvest (distal tumor margins, P = 0.995; circumferential resection margin, P = 0.946; number of lymph nodes, P = 0.845) was similar. Conclusions Although both laparoscopic-assisted and hand-assisted laparoscopic surgeries are safe and feasible for ultralow anterior resection, the hand-assisted technique significantly shortens operating time. †Deceased. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007.     

Total mesorectal excision: Assessment of the laparoscopic approach

PURPOSE: Total mesorectal excision offers the lowest reported rates of local recurrence for rectal cancer; however, the ability to perform total mesorectal excision laparoscopically remains unproven. The aim of this study was to assess the feasibility and adequacy of a totally laparoscopic total mesorectal excision for rectal cancer. METHODS: A prospective review of all patients undergoing laparoscopic-assisted surgery for rectal cancer by a single surgeon was undertaken. These were compared with a control group undergoing open rectal resections by another colorectal consultant in the unit (n=22). Comparison of total specimen length, longitudinal and radial excision margins, and lymph node yield was made between groups. RESULTS: Of 42 laparoscopic-assisted rectal resections attempted, 14 (33 percent) were converted to open procedures and six had their dissection completed open. One resection was considered noncurative. Twenty-one total mesorectal excisions (50 percent) were completed totally laparoscopically. No significant difference was detected between groups for specimen length, radial margin, or lymph node yield. Longitudinal margin of excision was longer in the laparoscopic group (4 (3.5–5)vs. 2.5 (1.05–3.5) cm;P=0.02, Mann-Whitney). Operating time was significantly longer in the laparoscopic group (180 (168–218)vs. 125 (104–144) minutes;P=0.003, Mann-Whitney). Data are medians (inter-quartile ranges). Four patients in the laparoscopic-assisted group had clinical anastomotic leakagevs. one in the open group (P=0.329, Fisher's exact test). At median follow-up of 38 (range, 6–53) months, one local recurrence had occurred in each group and crude mortality rates were 29 and 23 percent in the laparoscopic-assisted and open groups, respectively (P=0.736, Fisher's exact test). CONCLUSION: Totally laparoscopic excision of the mesorectum is feasible in 50 percent of patients and where possible yields histologic parameters comparable to open surgery. Early survival and recurrence figures also appear to be comparable.Drs. Hartley and Mehigan are University Research Fellows supported by Autosuture UK.Read at the meeting of The American Society of Colon and Rectal Surgeons, Washington, D.C., May 1 to 6, 1999.     

Simultaneous laparoscopic multi-organ resection combined with colorectal cancer: comparison with non-combined surgery

AIM: To access the short-term outcomes of simultaneous laparoscopic surgery combined with resection for synchronous lesions in patients with colorectal cancer.METHODS: Between March 1996 and April 2010 prospectively collected data were reviewed from 93 consecutive patients who had colorectal cancer and underwent simultaneous multiple organ resection (combined group) and 1090 patients who underwent conventional laparoscopic right hemicolectomy or laparoscopic low/anterior resection for colorectal cancer (non-combined group). In the combined group, there were nine gastric resections, three nephrectomies, nine adrenalectomies, 56 cholecystectomies, and 21 gynecologic resections. In addition, five patients underwent simultaneous laparoscopic resection for three organs. The patient demographics, intra-operative outcomes, surgical morbidity, and short-term outcomes were compared between the two groups (the combined and non-combined groups).RESULTS: There were no significant differences in the clinicopathological variables between the two groups. The operating time was significantly longer in the combined group than in the non-combined group, regardless of tumor location (laparoscopic right hemicolectomy and laparoscopic low/anterior resection groups; P = 0.048 and P < 0.001, respectively). The other intra-operative outcomes, such as the complications and open conversion rate, were similar in both groups. The rate of post-operative morbidity in the combined group was similar to the non-combined group (combined vs non-combined, 15.1% vs 13.5%, P = 0.667). Oncological safety for the colon and synchronous lesions were obtained in the combined group.CONCLUSION: Simultaneous laparoscopic multiple organ resection combined with colorectal cancer is a safe and feasible option in selected patients.     

Laparoscopic Colorectal Resection in Octogenarian Patients: Is it Safe? A Systematic Review and Meta-Analysis

The population older than 80 years has been increasing. A significant proportion of colorectal diseases that require colorectal resection occur in very elderly patients. However, the benefits of laparoscopy remain controversial in octogenarians. A systematic review and meta-analysis of observational study was performed to compare clinical outcomes between laparoscopic versus open colorectal resection in octogenarians.The PubMed, EMBASE, Ovid, Web of Science, and Cochrane databases from the years 1990 to 2015 were searched for studies that compare surgical outcomes between laparoscopic and open colorectal resection in octogenarians (≥80 years old).Seven eligible studies including 528 laparoscopic and 484 open colorectal resections were identified. Laparoscopic approach was associated with lower rate of mortality (odds ratio [OR] 0.48, P = 0.03), overall complications (OR 0.54, P < 0.001), and prolonged ileus (OR 0.56, P = 0.009), quicker bowel function return (standardized mean difference [SMD] −0.50, P < 0.001), and shorter length of hospital stay (SMD −0.47, P = 0.007). No differences were found in anastomotic leak (OR 1.16, P = 0.72), respiratory complication (OR 0.60, P = 0.07), and reoperation (OR 0.85, P = 0.69).Laparoscopic colorectal resection is as safe as open approach, and the short-term outcomes appear to be more favorable in octogenarians.     

Colorectal and extracolonic cancer variations in MLH1/MSH2 hereditary nonpolyposis colorectal cancer kindreds and the general population

PURPOSE: This clinical case review aimed to identify phenotypic variations in colorectal and extracolonic cancer expression between hereditary nonpolyposis colorectal cancer (HNPCC) families with MLH1 and MSH2 germline mutations and the general population. METHODS: Colorectal cancer onset and site distribution were compared among 67 members of MLH1 kindreds, 45 members of MSH2 kindreds, and 1,189 patients from the general population. Synchronous and metachronous cancer rates, tumor stage, extracolonic cancer incidence, and survival were also compared. RESULTS: Mean ages of colorectal cancer onset were 44, 46, and 69 years for MLH1, MSH2, and the general population, respectively (P<0.001). More proximal and fewer distal colon cancers were noted in HNPCC than the general population (P<0.001,P=0.04). Site distribution showed disparity of rectal cancers (8 percent MLH1vs. 28 percent MSH2;P=0.01) based on genotypes. Overall, synchronous colorectal cancer rates were 7.4, 6.7, and 2.4 percent for MLH1, MSH2, and the general population, respectively (P=0.016). Annual metachronous colorectal cancer rates were 2.1, 1.7, and 0.33 percent for MLH1, MSH2, and the general population, respectively (P=0.041). Colorectal cancer stage presentation was lower in HNPCC than the general population (P=0.0028). Extracolonic cancers were noted in 33 percent of MSH2 patients, compared with 12 percent of MLH1 patients and 7.3 percent of the general population with colorectal cancers (P<0.001). Combined MLH1 and MSH2 ten-year survival was 68.7 percent compared with 47.8 percent for the general population (P=0.009 stage stratified, hazard ratio 0.57). CONCLUSION: The presence of rectal cancer should not preclude the diagnosis of HNPCC, because the incidence of rectal cancer in MSH2 was comparable with that in the general population. Phenotypic variations, including the preponderance of extracolonic cancers in MSH2 patients, did not result in survival differences between genotypic subgroups. These phenotypic features of HNPCC genotypes may have clinical significance in the design of specific screening, surveillance, and follow-up for affected individuals.     

Laparoscopicvs. open resection for colorectal adenocarcinoma

PURPOSE: To compare the outcome after laparoscopicversus open resection for colorectal adenocarcinoma. METHODS: A retrospective cohort analysis of all patients undergoing elective resection for colorectal adenocarcinoma between November 1992 and June 1999 at a university-affiliated hospital. These included 219 open (mean age, 68.3 years) and 98 laparoscopic (mean age, 70.3 years) resections. Data from converted cases (n=12) were included in the laparoscopic group using the intention-to-treat principle. RESULTS: Operative time, lymph node yield, resection margins and postoperative morbidity and mortality were similar between laparoscopic and open technique. Parenteral analgesic use was less in the laparoscopic group (laparoscopic, 2.7; open, 3.2 days;P=0.021). Time to first flatus (laparoscopic, 1.8; open, 3 days;P<0.0001) and first bowel movement (laparoscopic, 3.5; open, 4.9 days;P<0.0001) was shorter in the laparoscopic group. Resumption of an oral liquid diet (laparoscopic, 2.1; open, 4 days;P<0.0001) and solid diet (laparoscopic, 5.2; open, 7.1 days;P<0.0001) was also quicker in the laparoscopic patients. Length of hospitalization was significantly shorter in the laparoscopic patients (laparoscopic, 6.9; open, 10.9 days;P<0.001). There were less minor complications in the laparoscopic group (laparoscopic, 11.2; open, 21.5 percent;P=0.029) but no difference in major complications or perioperative mortality. Recurrence, disease-free and overall survival were similar between the two groups. No port site recurrences ocurred in the laparoscopic group but there were three wound recurrences in the open group. CONCLUSIONS: Laparoscopic resection for colorectal cancer can be performed safely and effectively in tertiary centers. Earlier discharge from hospital, quicker resumption of oral feeds and less postoperative pain are clear advantages. No adverse effect on recurrence or survival was noted, but results of prospective, randomized trials, currently underway, are needed before laparoscopic resection for colorectal cancer becomes the standard of practice.Presented at The Society of American Gastrointestinal and Endoscopic Surgeons 2000 Scientific Session, Atlanta, Georgia, March 29 to April 1, 2000.     

Interleukin-6, C-Reactive Protein,and Expression of Human Leukocyte Antigen-DR on Peripheral Blood Mononuclear Cells in Patients After Laparoscopic <Emphasis Type="Italic">vs.</Emphasis> Conventional Bowel Resection

PURPOSE: The aim of the study was to investigate the effect of surgical trauma in terms of approach (laparoscopic vs. conventional surgery) and extent of bowel resection (ileocolic resection vs. colectomy) on interleukin-6 level, C-reactive protein level, and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells. Second, the length of the incision was correlated with the inflammatory response. METHODS: Thirty-four patients were analyzed as part of a randomized trial comparing laparoscopically assisted vs. open bowel resection for Crohns disease, ulcerative colitis, and familial adenomatous polyposis. C-reactive protein levels and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells were measured preoperatively and one day after surgery. Interleukin-6 was measured preoperatively and on Days 1 and 7 postoperatively. RESULTS: Four of the 34 patients were excluded because of blood transfusion after surgery. One day postoperatively, the interleukin-6 level peaked significantly within the laparoscopic and conventional group. There was no significant difference between the conventional and laparoscopic groups at Day 1 postoperatively. At Day 7 postoperatively, interleukin-6 levels were similar in both groups and returned to baseline levels. There was a higher C-reactive protein level in the conventional group one day after surgery than in the laparoscopic group, although the difference was not significant. Preoperative and postoperative human leukocyte antigen-DR expression on monocytes and postoperative percentage of lymphocytes expressing human leukocyte antigen-DR did not differ between the conventional and laparoscopic groups. No differences in immune response with respect to the measured parameters were noticed in patients with a large or small bowel resection segment or in patients with a small (8 cm) or large (>8 cm) incision. CONCLUSIONS: These data suggest that surgical trauma did not significantly affect the immune status of patients with respect to the measured parameters in terms of either the approach or the extent of bowel resection.     

Defunctioning of the anorectum

BACKGROUND: Creating a defunctioning stoma for anorectal disease in patients in whom no resection or anastomosis is required appears eminently suited for laparoscopic techniques, with the intended advantages of early recovery, reduced pain, and avoidance of a laparotomy. OBJECTIVES: The study contained herein was undertaken to determine the feasibility of laparoscopic defunctioning stoma formation using a three-port technique (including one at the stoma site) and to compare initial results with a historical control group. METHODS: Duration of operation (anesthetic plus surgery), the time to tolerance of a liquid and then a solid diet, time to passage of flatus and feces, patient morphine requirements in the first 48 hours, and day of discharge were documented. RESULTS: Nineteen laparoscopic stomas were attempted (3 converted to open) and 23 open stomas were formed in the control group. The laparoscopic stoma group had lower morphine requirements (mean, 47.7vs. 89.9 mg;P<0.01), an earlier tolerance of both liquid (mean, 2.1vs. 3.7 days; P<0.01) and solid diets (mean, 3.6vs. 5.5 days;P<0.001), and an earlier time to passage of both flatus (mean, 2.2vs. 3.6 days;P<0.001) and feces (mean, 3.7vs. 5.6 days;P<0.001). Operating time was longer for the laparoscopic group (mean, 176vs. 104 minutes;P<0.001), whereas median time to discharge from hospital was shorter (median, 8vs. 11 days;P=0.014). Postoperative 30-day morbidity occurred in 1 of 19 laparoscopic group patients and 4 of 23 open group patients. CONCLUSIONS: In this select group of patients requiring defunctioning stoma only, laparoscopic surgery is feasible and safe and may have advantages over open procedures of less pain, earlier tolerance of diet, earlier return of bowel function, and a shorter median length of stay.     

Effectiveness of Radical Surgery after Incomplete Endoscopic Mucosal Resection for Early Colorectal Cancers: A Clinical Study Investigating Risk Factors of Residual Cancer

The aim of this study was to determine the need for additional treatment following endoscopic mucosal resection for early colorectal cancer. Risk factors for residual carcinoma were investigated using specimens of curative surgical resection performed after endoscopic mucosal resection. A total of 44 patients who had received imperfect endoscopic mucosal resection initially for early colorectal cancers and, therefore, had undergone subsequent surgical resection were enrolled in this study. Of these, 39 (88.6%) were resected completely by endoscopic mucosal resection based on gross inspection, while the other five cases (11.4%) were incompletely resected. Histopathological examination of specimens of endoscopic mucosal resection revealed that microscopic lateral resection margin was positive in 11 cases (25.0%) and vertical resection margin was positive in 16 cases (36.4%). However, after curative surgery, residual cancer within colorectal tissue was found in only five cases (11.4%), while lymph node metastases were found in three cases (6.8%). Gross incomplete resection (P < 0.001) and microscopic vertical margin positivity (P = 0.031) were found to be risk factors of residual cancer within the colorectal tissue, whereas lymphovascular invasion was a risk factor for lymph node metastasis (P = 0.040). However, no residual cancer cells were found after supplementary surgery in the microscopic lateral resection margin-positive cases. In conclusion, grossly incomplete resection, microscopic vertical resection margin positivity, or the presence of lymphovascular invasion after endoscopic mucosal resection for early colorectal cancer indicate the need for further treatment with surgical resection and lymph node dissection. However, microscopic lateral margin positivity without gross remnant tumor and deep submucosal invasion might not indicate residual cancer. This needs to be further validated by a large scale, prospective study with long-term follow-up.     

Depletion of Circulating Insulin-Like Growth Factor Binding Protein 3 After Open Surgery is Associated With High Interleukin-6 Levels

PURPOSE: We have previously shown that plasma from open, but not laparoscopic-assisted, surgery patients has increased mitogenic activity for colon cancer cells. Decreased insulin-like growth factor binding protein 3 levels, most likely the result of an open surgery-induced proteolytic activity, may account for this finding. Plasma proteases are activated by interleukin-6. This study was designed to investigate plasma insulin-like growth factor binding protein 3 and interleukin-6 levels after major open or laparoscopic-assisted surgery.METHODS: EDTA plasma was obtained from 24 patients undergoing resection for colonic adenocarcinoma. Insulin-like growth factor binding protein 3 was detected by Western blot analysis and enzyme-linked immunosorbent assay. Interleukin-6 levels were determined by enzyme-linked immunosorbent assay. The effect of insulin-like growth factor binding protein 3 on tumor growth was tested using HCT116 cells.RESULTS: In patients undergoing open surgery, enzyme-linked immunosorbent assay revealed a significant decrease in total insulin-like growth factor binding protein 3 levels on postoperative Day 1 (915.6 ± 378.5 ng/ml) compared with preoperative levels (1,267.5 ± 407.9 ng/ml; P < 0.001). Western blots revealed a decrease in the levels of intact insulin-like growth factor binding protein 3. In patients undergoing laparoscopic-assisted surgery, levels of total and intact insulin-like growth factor binding protein 3 before surgery (1,088.9 ± 232.5 ng/ml) and on postoperative Day 1 (1,202.3 ± 285.6 ng/ml) were comparable with no significant changes in Western blot analysis. Interleukin-6 levels were undetectable preoperatively. On postoperative Day 1, interleukin-6 concentration was higher in open surgery group (434.8 ± 506.6 pg/ml) compared with laparoscopic-assisted surgery group (100.9 ± 60.2 pg/ml; P < 0.0001), and correlated significantly with a decrease in plasma insulin-like growth factor binding protein 3 after open surgery (r = 0.81; P < 0.0001).CONCLUSIONS: A significant decrease in both total and free insulin-like growth factor binding protein 3 occurs after open but not laparoscopic colectomy. There is an associated increase in the levels of interleukin-6. It remains to be proven that the interleukin-6 elevations are responsible for the low insulin-like growth factor binding protein 3 level seen after open surgery.Supported by grants from Minimal Access Surgery Center at the New York-Presbyterian Hospital.Read at the meeting of The American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, June 21 to 26, 2003.     

Improving treatment and survival: a population‐based study of current outcomes after a hepatic resection in patients with metastatic colorectal cancer

BackgroundPopulation‐based studies historically report underutilization of a resection in patients with colorectal metastases to the liver. Recent data suggest limitations of the methods in the historical analysis. The present study examines trends in a hepatic resection and survival among Medicare recipients with hepatic metastases.MethodsMedicare recipients with incident colorectal cancer diagnosed between 1991 and 2009 were identified in the SEER(Surveillance, Epidemiology and End Results)‐Medicare dataset. Patients were stratified into historical (1991–2001) and current (2002–2009) cohorts. Analyses compared treatment, peri‐operative outcomes and survival.ResultsOf 31 574 patients with metastatic colorectal cancer to the liver, 14 859 were in the current cohort treated after 2002 and 16 715 comprised the historical control group. The overall proportion treated with a hepatic resection increased significantly during the study period (P< 0.001) with pre/post change from 6.5% pre‐2002 to 7.5% currently (P < 0.001). Over time, haemorrhagic and infectious complications declined (both P ≤ 0.047), but 30‐day mortality was similar (3.5% versus 3.9%, P = 0.660). After adjusting for predictors of survival, the use of a hepatic resection [hazard ratio (HR) = 0.40, 95% confidence interval (CI): 0.38–0.42, P < 0.001] and treatment after 2002 (HR = 0.88, 95% CI: 0.86–0.90, P < 0.001) were associated with a reduced risk of death.ConclusionsCase identification using International Classification of Diseases, 9th Revision (ICD‐9) codes is imperfect; however, comparison of trends over time suggests an improvement in multimodality therapy and survival in patients with colorectal metastases to the liver.     

Impact of hepatic lymph node metastasis on survival of patients with synchronous resectable or unresectable liver metastases of colorectal cancer

Background

The goals of this retrospective study were to comprehensively evaluate the impact of hepatic lymph node (HLN) involvement on survival in patients with synchronous resectable or unresectable liver metastases from colorectal cancer and to highlight how to deal with such cases in the light of recent advances in chemotherapy.

Methods

The impact of HLN involvement on survival, along with various clinical, pathological, and therapeutic factors, was retrospectively evaluated in 61 patients with synchronous liver metastases from colorectal cancer (resectable, 26; unresectable, 35), undergoing resection of the primary tumor and histopathological evaluation between July 2000 and April 2008.

Results

The proportion with HLN metastasis was 11.5 % in resectable cases and 28.6 % in unresectable cases. On multivariate analysis using the Cox proportional hazards model, HLN metastasis (P < 0.001), along with non-resection of hepatic lesions (P < 0.001), larger metastatic tumor volume (P < 0.001), non-use of oxaliplatin-based chemotherapy (P < 0.001), involvement of 4 or more regional lymph nodes (P < 0.001), and excessive lymphatic invasion (P = 0.02), was identified as an independent risk factor for shorter survival.

Conclusions

To establish a new therapeutic strategy for synchronous liver metastasis of colorectal cancer, the HLNs should be examined histologically in patients undergoing resection of their primary colon and rectal cancer.     

Metabolic and functional results after laparoscopic colorectal surgery: a randomized,controlled trial

PURPOSE: This study was designed to compare metabolic and functional results after laparoscopic and open colorectal resection. METHODS: Seventy-nine patients were randomly assigned to laparoscopic (n = 40) or open (n = 39) colorectal resection. Before and after operation, the following parameters were determined: respiratory function (spirography and blood gas); serum level of cortisol, lactate, and C-reactive protein; total lymphocyte count; and CD4 and CD8 lymphocyte subsets. Intraoperative core temperature was measured by a bladder probe. Postoperative pain and analgesic consumption were also monitored. RESULTS: Mild operative hypothermia, a trend to postoperative reduction of total lymphocyte count, and significant impairment of respiratory function early after surgery were found in both groups. Laparoscopy showed a higher CD4/CD8 ratio (P = 0.01) on postoperative Day 1 and a faster return of C-reactive protein to preoperative values (P = 0.01) than in the open colorectal resection group. Morphine consumption in the first 48 hours after surgery was lower in the laparoscopic than in the open group (P = 0.02). CONCLUSIONS: Laparoscopy was associated with a less pronounced immunosuppression and inflammatory response and a lower consumption of analgesic drugs than open surgery. Moreover, our data did not show any additional detrimental effect of laparoscopy on either operative core temperature or early postoperative respiratory function.     

Totally laparoscopic resection with natural orifice specimen extraction (NOSE) has more advantages comparing with laparoscopic-assisted resection for selected patients with sigmoid colon or rectal cancer

Purpose

The purposes of this study were to compare the short-term outcomes of natural orifice specimen extraction (NOSE) and laparoscopic-assisted resection for sigmoid colon cancer or rectal cancer and to appraise whether totally laparoscopic resection with NOSE had more advantages compared with conventional laparoscopic-assisted resection.

Methods

Sixty-five patients who underwent totally laparoscopic resection with NOSE were assigned to NOSE group, and 132 patients who underwent laparoscopic-assisted resection were assigned to laparoscopic-assisted (LA) group. Data of all 197 cases were reviewed. Short-term outcomes (including operative outcomes, gastrointestinal recovery, hospital stay, and complication) of the two groups were compared.

Results

Mean numbers of lymph nodes harvested were 17.0?±?8.3 and 18.9?±?11.6 in NOSE group and LA group, respectively, (P?=?0.248); mean operative times were 111.6?±?25.4 min and 115.3?±?23.0 min in the two groups (P?=?0.384); and the mean blood losses in these two groups were 70.2?±?66.1 ml and 126.3?±?58.6 ml, respectively, (P?P?P?=?0.002) in NOSE group and LA group, respectively. Hospital stay in NOSE group were 9.0?±?1.9 and 9.9?±?2.0 days in LA group. Incidences of peri-operative complications were 6.2 and 17.2 % in the two groups, respectively (P?=?0.031).

Conclusions

Without compromising oncologic outcome, totally laparoscopic resection with NOSE had more advantages including less blood loss, less pain, faster recovery of intestinal function and shorter hospital stay compared with laparoscopic-assisted resection for selected patients with sigmoid colon cancer or rectal cancer.     

Open liver resection for colorectal metastases: better short- and long-term outcomes in patients potentially suitable for laparoscopic liver resection

Background:

There is no prospective randomized data comparing laparoscopic to open hepatectomy. This study compared short- and long-term outcomes in patients undergoing hepatectomy for colorectal metastases (CRM), who were suitable for either laparoscopic or open surgery.

Methods:

Data were prospectively collected from consecutive patients undergoing hepatic resection of CRM at a single centre (1987–2007). Patients who were suitable for laparoscopic resection (Group 1) were compared with patients whose tumour characteristics would best be considered for open resection (Group 2).

Results:

Out of 1152 hepatectomies, 266 (23.1%) were deemed suitable for a laparoscopic approach. The median (IQR) number of metastases was greater in Group 2 [2(1–20) vs. 1(1–10), P < 0.001], as was the mean (SD) tumour size [5.3(3.6) cm vs. 3.3(1.2) cm, P < 0.001]. The median (IQR) operation time [210 (70) min vs. 240 (90) min, P < 0.001] and blood loss [270 (265) ml vs. 355 (320) ml, P < 0.001] were less in Group 1. There was no difference in length of stay, morbidity or mortality. Patients in Group 2 had a higher R1 resection rate (14.9%) compared with Group 1 (4.5%, P < 0.001) and lower 5-year survival (37.8% vs. 44.2%, P= 0.005).

Discussion:

Current criteria for laparoscopic hepatectomy selects patients who have more straight-forward surgery, with less risk of an involved resection margin and better long-term survival, compared with patients unsuited to a laparoscopic approach. Clearly defined criteria for laparoscopic hepatectomy are essential to allow meaningful analysis of outcomes and the results of unrandomized series of laparoscopic hepatectomies must be interpreted with caution.     

Laparoscopic-assisted versus open surgery for rectal cancer: a meta-analysis of randomized controlled trials on oncologic adequacy of resection and long-term oncologic outcomes

Background

Whether laparoscopic-assisted surgery (LS) can achieve the same oncologic outcomes compared with open surgery (OS) for rectal cancer remains controversial. The aim of this meta-analysis of randomized controlled trials (RCTs) is to compare oncologic adequacy of resection and long-term oncologic outcomes of LS with OS in the treatment of rectal cancer.

Methods

Literature searches of electronic databases (Pubmed, Embase, Web of Science, and Cochrane Library) and manual searches were performed to identify RCTs comparing values of oncologic adequacy of resection, recurrence, and survival following LS and OS.

Results

Six RCTs enrolling 1,033 participants were included in the meta-analysis. LS was associated with similar number of lymph nodes harvested and a similar distal tumor-free margin. LS was associated with a slightly high circumferential resection margin (CRM) positive rate with no significant difference (7.94% vs. 5.37%; risk ratio [RR], 1.13; P?=?0.63). There was no significant difference between the two groups in local recurrence (RR, 0.55; P?=?0.21). The 3-year overall survival advantage for LS over OS was not statistically significantly different (hazard ratio [HR], 0.76; P?=?0.11). The 3-year disease-free survival was not significantly different between the two groups (HR, 1.16; P?=?0.64).

Conclusions

The meta-analysis suggests that there are no differences between laparoscopic-assisted and open surgery in terms of number of lymph nodes harvested, involvement of CRM, local recurrence, 3-year overall survival, and disease-free survival for rectal cancer. However, more high-quality studies are needed for further analysis due to the small number of included studies.