Laparoscopic surgery for colorectal cancer

Traditionally open surgical resection has been recommended for colorectal tumours, but recently, laparoscopic surgery has gained popularity. This review summarizes the published data on laparoscopic colorectal cancer surgery with emphasis on recently published trials. For colon cancer laparoscopic resection appears to be associated with the same outcome as open surgery. However, whilst short‐term outcome was better in the laparoscopic group in most of the randomized trials, when comparing laparoscopic with fast‐track open surgery, no differences could be demonstrated in a randomized control trial. For rectal cancer the data are less clear. It seems that it may be feasible to resect at least small rectal cancers laparoscopically. Clearly the role of the laparoscopic technique needs to be better defined in rectal cancer. It has been well documented that short‐ and long‐term outcome of colorectal cancer surgery depends on the quality and experience of the team treating the patient. Therefore, the major future challenge in laparoscopic colorectal cancer surgery will be to provide and structure adequate training and introduce quality control measures.     

Laparoscopic colorectal surgery

Background: This study was performed to prospectively assess the results of our first 140 consecutive patients who underwent laparoscopic or laparoscopic-assisted colorectal operations. Methods: The parameters studied included the type and length of procedure, intra- and postoperative complications, conversion to open surgery, and length of ileus and hospitalization. Results: 140 laparoscopic and laparoscopic-assisted procedures were performed between May 1991 and January 1995. The mean patient age was 48 (range 12–88) years; there were 78 males and 62 females. Indications for surgery included inflammatory bowel disease in 47, colorectal carcinoma in 19, diverticular disease in 17, polyps in 16, familial polyposis in 7, colonic inertia in 7, fecal incontinence in 11, sigmoidocele in 3, irradiation proctitis in 3, rectal prolapse in 2, intestinal lymphoma in 2, and miscellaneous conditions in 6. The procedures included 38 total abdominal colectomies (TAC) (ileoanal reservoir 28, ileorectal anastomosis 8 and end ileostomy 2); 70 segmental resections of the colon, small bowel, and rectum; 18 diverting stoma creations; 10 reversal of Hartmann's procedures; and 4 other procedures. In 15 cases, the laparoscopic procedure was converted to a laparotomy (11%); 31 patients (22%) sustained 37 complications, which included: enterotomies (7), hemorrhage (10), intraabdominal abscess (4), prolonged ileus (6), wound infection (4), intestinal obstruction (2), anastomotic leak (1), aspiration (1), cardiac arrhythmia (1), and upper intestinal bleeding (1); there was no mortality. The overall complication rate in TAC cases was significantly higher (42%) when compared to that of all other procedures (segmental resection 17%, others 9%), P<0.05. The mean length of operating time was 4 (range 2.5–6.5) h for TAC, 2.6 (range 1.5–5.5) h for segmental colonic resections, and 1.7 (range 0.7–4) for all other procedures. The length of ileus was 3.5 (range 2–7) days after TAC, 3 (range 2–7) after the segmental resections and 2 (range 1–4) after the other procedures. The mean length of hospital stay was 6.8 (2–40) days (8.4, 6.5, and 6.3 days for the TAC, segmental resections, and other procedures, respectively). Conclusion: The feasibility of laparoscopic colorectal surgery has been well established. TAC is associated with a higher complication rate compared to other laparoscopic colorectal procedures.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Laparoscopic colorectal surgery in elderly patients: a case-control study of 15 years of experience

Introduction

The aim of this study was to review the impact of age (≥75 years) on the short-term outcomes of laparoscopic colorectal surgery.

Methods

Three hundred seventy-nine patients under 70 years of age and 91 patients 75 years and older were analyzed. Quantification of comorbidities was performed using the Charlson Weighted Comorbidity Index. Outcome measures were postoperative complications and 30-day mortality.

Results

There was no difference in the occurrence of postoperative complications between the younger and older patients. Bivariate analysis revealed that patient age was not a risk factor of major complications (odds ratio = 1.2; 95% confidence interval, .6–2.3). Although bivariate analysis revealed that older age had a statistically significant odds ratio for 30-day mortality (odds ratio = 12.8; 95% confidence interval, 1.3–125.4), multivariate analysis revealed that it was a weighted comorbidity index score of 5 or more (P = .02) and long operative time (P = .01) that were independent predictors of 30-day mortality and not age per se.

Conclusions

Age is not an independent predictor of morbidity and mortality in laparoscopic colorectal cancer surgery.     

Laparoscopic palliative surgery for complicated colorectal cancer

Background The aim of this study was to evaluate the feasibility and outcomes of the laparoscopic approach for the palliation of advanced complicated colorectal cancer (CRC).Methods We reviewed 21 laparoscopic palliative procedures for emergent complications of advanced CRC between 1994 and 2002. Intraoperative complications, estimated blood loss, transfusions, operative times, time to first bowel movement, length of hospital stay, and postoperative complications were assessed.Results Indications for surgery included perforation (n = 10), bleeding (n = 7), and obstruction (n = 4). A proximal diverting procedure was performed in all patients, and a concomitant colon resection was performed in 18 patients (86%). The mean operative time was 181 ± 22 min. Estimated blood loss was 283 ± 48 cc, with three patients (14%) requiring transfusions. The average length of hospital stay was 8.6 ± 2 days, and time to first bowel movement was 61 ± 9 h. The complication rate and the 30-day mortality rate were 33% and 0%, respectively.Conclusion A laparoscopic approach to address advanced CRC is safe and effective and should be considered part of the surgeons armamentarium for the palliation of advanced complicated CRC.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, 13–15, March 2003     

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 colorectal surgery in Great Britain and Ireland – Where are we now?

OBJECTIVE: We aimed to gather information from the members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) to assess trends in the current practice of laparoscopic colorectal surgery. METHODS: A postal questionnaire survey of the members of ACPGBI. RESULTS: The response rate was 37% (200/540). Only 45 surgeons currently perform laparoscopic colorectal work in Great Britain and Ireland mainly right hemicolectomy and laparoscopic stoma formation, of these about one third practiced laparoscopy for benign colorectal conditions only. The majority (68%) of surgeons had enough resources at their place of work, but further training seemed to be a major issue. Nearly 22% of surgeons had not had any formal training. Only 50% of surgeons trained their specialist registrars. The incidence of conversion rate was not different for benign or malignant conditions and also did not appear to be related to the duration of experience. Only four surgeons had noted port a site recurrence during the past 10 years. Seventy-five percent (150/200) felt that laparoscopic colorectal work could be carried out safely in a District General Hospital. CONCLUSION: Laparoscopic colorectal surgery was being performed by a small minority of members of the ACPGBI although more surgeons had started to work in this field in recent years. The main areas of concern appeared to be a wide variation in the range of experience as indicated by the number of operations performed and limited formal training for consultants.     

Laparoscopic colorectal resection

Background. The aim of the present study was to evaluate retrospectively the experience of six surgical units currently performing laparoscopic colorectal surgery. Methods. From November 1991 to January 1994, 200 patients (103 male, 97 female; mean age 62.5 years) were candidates for, and received, laparoscopic colorectal resection for benign (54) or malignant (196) lesions. All the units excluded patients with locally advanced organ tumors and all cases with suspected perforation and ascites. One center submitted to laparoscopic resection only stage I and IV adenocarcinoma. All surgeons considered obesity a relative contraindication.The following data were analyzed: indications, conversion rate to open surgery, operative time, morbidity and mortality, resumption of gastrointestinal function, number of lymph nodes harvested, hospital stay. Results. Twenty-one out of 200 patients were converted to open surgery (10.5%); 37 patients had a complete laparoscopic procedure (17.1%); 137 had an assisted resection (68.5%); and the remaining 5 patients had a facilitated resection. The mean operative time was 208 min (90–480) for assisted resection and 275 min (54–550) for complete laparoscopic resection. The mortality rate was 1.7%; the overall morbidity was 19.6% (major complications 11.2%). All patients quickly became ambulatory and showed a prompt resumption of gastrointestinal functions, and less postoperative pain if compared with converted cases. The average number of lymph nodes was 12.1 (range 1–32). The mean hospital stay was 8.6 days (range 5–14.5). The mean follow-up was 16 months (range 6–24). The recurrence rate 11.7%. Conclusions: Laparoscopy seems to offer the possibility of minimally invasive treatment, but long-term follow-up is needed to evaluate the efficacy of laparoscopic surgery in the treatment of colorectal cancer.     

Audit of definitive colorectal surgery in patients with early and advanced colorectal cancer

Background : The role of surgery in patients with advanced colorectal cancer may be questioned in the era of specialized intensive palliative care. Should patients with advanced disease be advised against surgery because of the risks of the surgery itself? In this study, the perioperative outcomes in patients undergoing definitive surgery for early (Dukes’ stages A, B and C) and advanced colorectal cancer (stage D) were examined. Methods : All patients undergoing definitive surgery for colorectal cancer during a 15‐year period were identified. Details of tumour site and stage, surgery performed, perioperative complications and postoperative mortality were compared. Results : A total of 374 patients underwent definitive surgery. There were 193 men, a male : female ratio of 1:0.9. Seventy‐one patients had advanced disease. There were no differences between the early and advanced groups in perioperative requirements for either blood or total parenteral nutrition. In the advanced group, more operations were performed as emergencies than in the early group (32.4 vs 17.5%; P < 0.01) and more patients presented with bowel obstruction in the advanced group (23.9 vs 10.2%; P < 0.01). There were no site differences between the early and advanced groups and no differences between the operations performed except that endo‐anal destruction was not performed in advanced patients. There were no differences in perioperative morbidity or mortality in the groups studied. Conclusion : Resection rates, operation type and postoperative morbidity and mortality were similar in patients with both early and advanced colorectal cancers. In terms of perioperative outcome, the presence of advanced cancer, per se, should not, therefore, be a justification to decline surgery.     

Outcomes of laparoscopic surgery for colorectal cancer in elderly patients

Objective:

To evaluate the short-term outcomes of laparoscopic colorectal surgery for cancer in the elderly compared with younger patients.

Methods:

We retrospectively considered a consecutive unselected series of 159 patients who underwent elective laparoscopic procedures for colorectal cancer at our institution between January 2007 and December 2009. Of these patients, 101 (63.5%) were ≤70 years of age (Group A), and 58 (36.5%) were >70 (Group B). Operative steps and instrumentation were standardized. Demographics, disease-related, operative, and short-term data were analyzed for each group, and an appropriate statistical comparison was made. Comorbidity was quantified by using the Charlson Comorbidity Index.

Results:

We reviewed right colectomies (29.5%), left colectomies (44.7%), rectal resections (19.5%), and other procedures (6.3%). There was no significant difference in sex ratio, body mass index, American Society of Anesthesiology score, type of surgical procedures, and tumor stage between Group A and Group B. A statistically higher comorbidity according to the Charlson index characterized Group B (2.2 vs 3.8; P=.034). Median operative time (228±78.1min vs 224.3±97.6min; NS), estimated blood loss (50.0±94.8mL vs 31.2±72.7mL; NS), conversion rate (2.0% vs 1.7%; NS), and timing to canalization (4.5±1.7dd vs 4.4±1.3dd; NS) were statistically comparable in both Groups. Group B was associated with a significantly longer length of hospital stay compared with Group A (8.1±2.8dd vs 10.8±6.6dd; P<.01) There was no statistically significant difference in major postoperative complications (3.8% vs 3.4%; NS), reoperations (0.9% vs 1.7%; NS), and 30-day mortality (0% vs 1.7%; NS).

Conclusions:

Laparoscopic colorectal surgery appears feasible and safe in elderly patients with increased comorbidity.     

腹腔镜与开腹手术在结直肠癌治疗中的应用对比分析

目的比较腹腔镜与开腹结直肠癌切除术临床疗效,探讨腹腔镜结直肠癌切除术的临床价值。 方法选择2009年6月至2012年1月中山大学孙逸仙纪念医院胃肠外科收治的结直肠癌患者98例作为研究对象,其中52例接受腹腔镜手术,46例接受开腹手术,比较两组结直肠癌患者的手术时间、术中出血量、淋巴结清扫范围、术后腹腔（或盆腔）引流量、术中术后并发症、肛门恢复排气排便时间、术后住院时间等指标。 结果腹腔镜组与开腹组清扫淋巴结数目、术中出血量、术中术后并发症发生率差异均无统计学意义;手术时间、术后腹腔（或盆腔）引流量、术后肛门恢复排气排便时间、术后住院时间等方面差异有统计学意义（P<0.05）。 结论腹腔镜结直肠癌切除术是可行和安全有效的,与开腹手术对比有较多优点,适合在临床进一步推广应用。     

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目的评价腹腔镜及开腹手术治疗浆膜浸润结直肠癌病人的预后。方法回顾性分析2003年6月至2007年6月南方医科大学附属南方医院收治的浆膜浸润结直肠癌病人的临床、病理资料及随访数据。对两组病人生存及复发情况进行比较。结果腹腔镜组和开腹组病人的基线数据及随访时间差异无统计学意义。腹腔镜组总死亡率为20.7%,开腹组为28.9%,两组之间差异无统计学意义(P=0.234);腹腔镜组肿瘤相关死亡率为17.2%,开腹组为26.8%,两组之间差异无统计学意义(P=0.105);腹腔镜组复发率为12.1%,开腹组为26.8%,差异有统计学意义(P=0.024)。生存分析显示腹腔镜组病人累积无复发率高于开腹组(P=0.035),两组病人累积总存活率(P=0.159)及肿瘤相关存活率(P=0.083)差异无统计学意义。结论对于浆膜侵润的结直肠癌,腹腔镜组病人复发率明显低于开腹组,因此可以获得部分优于开腹手术的结果。     

快速康复外科对肥胖结直肠癌腹腔镜根治术的近期疗效及应激反应的影响

目的:探讨快速康复外科(FTS)对肥胖结直肠癌患者腹腔镜根治术的近期疗效及应激反应的作用.方法:选择2017年1月-2019年3月在我院行腹腔镜结直肠癌根治术的肥胖患者60例作为研究对象,采用随机数字表法分为观察组和对照组各30例.观察组在FTS理念指导下行腹腔镜根治术,对照组采用传统围手术期处理方式行腹腔镜手术.对比...     

Prognostic factors in survival of colorectal cancer patients after surgery

Objective  To determine the factors affecting survival, following resection of large bowel for colorectal carcinoma.
Method  From the cancer database of a single referral institution, a total of 1090 patients who had undergone colorectal resection between 1999 and 2002 were identified. Cases with recurrent colorectal cancer or previous history of neoadjuvant chemotherapy were excluded. Survival curves were plotted using the Kaplan–Meier method. Univariate analysis of factors thought to influence survival was then made using Logrank test. Criteria studied consisted of age, sex, TNM stage, T-status, nodal status, distant metastasis, histological grade, lymphatic and vascular invasion, tumour location, preoperative carcinoembryonic antigen (CEA) level and liver function tests. Multivariate analysis was conducted using Cox regression analysis.
Results  The mean survival time for all patients was 42.8 (SEM = 2.8) months. The overall 1-, 3- and 5-year survival rates were 72%, 54% and 47%, respectively. In univariate analysis, patients' age ( P  < 0.0001), TNM stage ( P  < 0.0001), T-status ( P  = 0.015), nodal status ( P  = 0.016), distant metastasis ( P  < 0.0001), grade ( P  = 0.005), lymphatic and vascular invasion ( P  < 0.0001) and presurgery CEA level > 5 ng/ml ( P  = 0.021) were found to be predictors that could affect survival. In Cox regression analysis, age ( P  < 0.0001), TNM stage ( P  = 0.001) and grade ( P  = 0.008) were determined as independent prognostic factors of survival.
Conclusion  Age, TNM stage, T-status, nodal status, distant metastasis, grade, lymphatic and vascular invasion and presurgery CEA level can predict the postsurgical survival rate in patients with colorectal cancer.     

Laparoscopic anti-reflux surgery is effective in obese patients with gastro-oesophageal reflux disease

INTRODUCTION

Obesity has long been regarded as a risk factor for the development of gastro-oesophageal reflux disease (GORD). It has been claimed that surgical efficacy of laparoscopic anti-reflux operations is decreased in obese patients. The aim of this study was to assess whether laparoscopic anti-reflux surgery is effective in obese patients with GORD compared to non-obese patients.

PATIENT AND METHODS

A total of 366 patients (mean age 44 years; range, 12–86 years) underwent laparoscopic anti-reflux surgery between 1997–2003. Of these, 74 patients were considered obese; 58 patients had a body mass index (BMI) of 30–34 kg/m² and 16 were classified as morbidly obese with a BMI ≥ 35 kg/m². Pre-operative symptomatic scoring, indications for surgery, pH studies, operative times and complications were compared between obese and non-obese patients. Symptomatic outcome and Visick score between the two groups were assessed at 6 weeks, 6 months and 1 year following surgery.

RESULTS

Failure of medical treatment was the main reason for surgery in all groups. Operative time was longer in obese patients (mean time 93 min compared to 81 min; P = 0.0007), the main difficulty being gaining access because of their body habitus. All groups found the procedure to be effective in symptomatic outcome, 91% of obese patients compared to 92% of non-obese patients scored Visick I or II at 6 weeks'' postoperatively. Similar Visick scoring was shown between the two groups at 6 months and 1 year, and in the morbidly obese group.

CONCLUSIONS

The outcome of laparoscopic anti-reflux surgery is similar between obese and non-obese patients with no trend towards a worse outcome in the obese or morbidly obese. Obesity should not be seen as a contra-indication, although it may be more technically challenging in this group of patients. Good results can be achieved in obese patients.     

Laparoscopic colorectal surgery in the irradiated pelvis

BACKGROUND: Heightened interest in minimally invasive surgery and the expanding use of radiation therapy presents surgeons with new challenges. While conventional surgery in the irradiated pelvis represents a significant technical obstacle, indications for laparoscopic colorectal surgery are currently being defined. The purpose of this study is to examine the efficacy of laparoscopic surgery in the irradiated field. METHODS: Forty-two patients underwent laparoscopic colorectal surgery after preoperative radiation therapy, mean dose of 5,644 cGy. All patients were assessed according to intraoperative issues and perioperative events. RESULTS: Eleven patients underwent diverting stoma formation whereas 31 patients underwent resections. The overall conversion rate was 7% (n = 3). Average blood loss was 378 mL. There were no perioperative deaths. Overall morbidity was 19% (n = 8). 78% of patients tolerated clear liquids by postoperative day 2, and 73% tolerated a house diet by postoperative day 4. Average length of stay was 5.5 days. CONCLUSIONS: With proper patient selection and laparoscopic experience, laparoscopic colorectal surgery can be performed in the irradiated pelvis without undue morbidity and mortality.     

Laparoscopic resection for rectal cancer in patients with previous abdominal surgery: A comparative study

Objective: In laparoscopic colorectal procedures, the presence of peritoneal adhesions caused by previous surgery is one of the most common reasons for conversion and is often associated with increased postoperative morbidity. However, improvements in laparoscopic technique and instruments might, to some extent, help to overcome the adverse effects of peritoneal adhesions. Therefore, the present study was designed to compare and evaluate laparoscopic rectal cancer excision in patients who had had and who had not had previous abdominal surgery. Methods: The present study was a non‐randomized comparison of patients who have had and have not had previous abdominal surgery. Data were extracted from a prospective cohort of patients who had undergone laparoscopic anterior resection for rectal cancer in one particular unit between January 1996 and May 2000. For the purpose of standardization, data on laparoscopic low anterior resection and laparoscopic abdomino‐perineal resection were not used for analysis. The measured outcomes included operation time, blood loss and length of hospital stay as well as complications and conversions. Results: Of the 91 patients recruited for analysis, 26 patients had had previous abdominal surgery (study group), whereas 65 patients had not had previous abdominal surgery (control group). The two groups had a similar age and gender distribution as well as tumour staging. The median operating times of the study group and control group (115 vs 123 min, P = 0.34), their blood loss (122 vs 144 mL, P = 0.30) and lengths of hospital stay (10 vs 11 days, P = 0.66) were similar. The complication rates (23 vs 23%, P = 0.79) and conversion rates (15.4 vs 7.7%, P = 0.55) were also similar between the two groups. Conclusion: Laparoscopic resection for rectal cancer in patients who have had previous abdominal surgery is technically safe and produces similar results to those who have not had previous abdominal surgery.      

肥胖患者腹腔镜结直肠癌根治术中实时食管压监测下呼气末正压通气对肺通气的影响

目的探讨实时食管压监测指导下设定呼气末正压(positive end expiratory pressure,PEEP)通气参数对肥胖腹腔镜结直肠癌根治术患者的临床价值。方法选择2016年1—12月收治的拟行腹腔镜结直肠癌根治术的肥胖患者90例,男50例,女40例,年龄40~65岁,BMI30kg/m2,ASAⅡ或Ⅲ级,采用随机数字表法将患者随机分为三组:P组、PEEP5组和PEEP10组,设置VT8ml/kg,分别在肺复张后给予个体化PEEP(采用实时食管压监测通过计算呼气末跨肺压=0cmH_2O和吸气末跨肺压=25cmH_2O确定最佳PEEP)、PEEP 5cmH_2O和10cmH_2O。观察气腹建立前(T0)、气腹建立后10min(T1)、气腹后头低40.5°足高位20 min(T2)和气腹结束(T3)时的呼吸力学指标。结果T1—T3时P组Ppeak、SBP明显低于,PaO_2/FiO_2明显高于PEEP5组和PEEP10组(P0.05);T2时P组Pplat、Raw明显低于PEEP5组(P0.05);T2、T3时P组Cst明显高于PEEP5组(P0.05);T1、T2时P组DBP明显低于PEEP5组和PEEP10组(P0.05)。结论实时食管压监测应用于PEEP通气的肥胖腹腔镜结肠癌手术患者,能够有效改善患者呼吸和循环功能。