Baiju Senadhipan
Holy Cross Hospital, Kollam

Corresponding Author: Dr. Baiju Senadhipan, MS, MNAMS, MCh (Gastro), Consultant Surgical Gastroenterologist and Laparoscopic Surgeon, Holy Cross Hospital, Kollam. Phone 9847572355. Email: senadhipan@gmail.com

ABSTRACT

Though laparoscopy was introduced decades ago, its role in colorectal surgery was not well established for want of better skills and technology. This article examines the advantages of laparoscopy in the management of colorectal cancer. The safety, oncologic clearance, long term effects of laparoscopic surgery were compared with that of conventional surgical procedures.

Though laparoscopy was introduced decades ago, its role in colorectal surgery was not well established for want of better skills and technology. This coupled with high incidences of port site recurrences prevented laparoscopic surgery from being incorporated into the mainstream colorectal cancer surgery. A recent increase in the number of reports, retrospective analyses, randomized trials and multicentric trials have now provided sufficient data to support the role of laparoscopy in colorectal cancer surgery.

The problems associated with laparoscopic surgery for colorectal cancers are

  • Steeper learning curve
  • Early reports of port site recurrence
  • Fear about adequate oncological clearance

Safety of the Procedure

When we consider a surgical procedure with a new approach, the new method should be as safe as the existing one. As far as safety of laparoscopy is concerned, many studies in the literature1-3 show that it is as safe as the open surgery and moreover, it has got short-term benefits like

  • Decreased pain
  • Short hospital stay period
  • Early return to work
  • Reduced usage of drugs

Numerous large trials have shown that laparoscopic colectomy is comparable to open in terms of postoperative morbidity and mortality.

Oncological Clearance

The next concern regarding laparoscopic colectomy is whether we can achieve satisfactory oncological clearance in terms of two important parameters:

  • LN Clearance
  • Resection Margins

One meta- analysis of 3935 patients, in multiple trials of Lap. Assisted Colectomy with Open Colectomy has shown that more number of LNs could be extracted laparoscopically (2.1) than by open surgery (0.3).

The same meta- analysis has looked at distal marginal clearance. Distal margin is not a concern when we do colectomy, where we visually get adequate margin. Distal margin is a concern when one is dealing with rectal cancer, where the surgeons aim to achieve a margin of 2 cm distally, which is the accepted distal margin of oncological safety. In the above mentioned meta-analysis the mean distal margin was 4.6 cm in Laparoscopy group and 5.3 cm in Open group. But this 4.6 cm is more than adequate for the acceptable margin of safety.

Effect on the Immune System

Are There Immune Benefits to Laparoscopic Surgery?

It is well known that surgery leads to transient immunosuppression, though the underlying etiology remains unclear. A well-known cascade of physiologic and immunologic responses occurs after surgery. Inflammation involves the recruitment of macrophages and neutrophils at sites of tissue injury, release of pro-inflammatory cytokines and growth factors to promote wound healing (and that may also stimulate tumor growth), and activation of T cell (cellular) and B cell (humoral) immunity. Surgery has been shown to dampen each of these responses, leading to varying degrees of immunosuppression. Laparoscopic surgery, which is associated with less patient trauma through smaller incisions and less postoperative pain, may be associated with less immunosuppression, compared with open surgery, though the data remain a subject of debate and the clinical significance of this effect remains unclear.14

In a study by Belizon et al, patients who underwent surgery for colon cancer had further elevations in serum vascular endothelial growth factor levels during the early postoperative period.15 The increase occurred earlier, and was more profound, in patients having open surgery compared with laparoscopically treated patients. Levels also increased in proportion to incision length. Insulin and insulin-like growth factor are also associated with tumor growth; elevated levels may place patients at increased risk for the development of colon cancer

To date, no survival differences have been found comparing cancer patients treated by the open method and those treated laparoscopically; however, some intriguing trends have been seen in smaller studies. Systemic immune function and tumor growth may be differentially regulated by the degree of surgical trauma. Though the clinical impact of these findings is uncertain, the concept certainly warrants further study.

Long -Term Results
Port Site Metastasis

Many surgeons questioned whether there was a novel risk for tumor cell dissemination during laparoscopy compared to open, or conventional surgery. Proposed mechanisms included cancer cell implantation during there lease of pneumoperitoneum, direct tumor implantation from a contaminated instrument or during extraction of the specimen through a small incision, stimulation of tumor growth by the insufflating gas, and the laparoscopic technique itself.

Döbrönte et al, first described port-site metastasis in 1978 after an ovarian cancer operation.5 Though the underlying etiology is still unclear, the development of recurrent cancer at a previous surgical site is not unique to laparoscopic surgery but occurs after open surgery as well.

Two retrospective reviews of open colectomy for colorectal cancer, each with more than 1500 patients, demonstrated an incidence of 0.6% to 0.68% of incisional tumors, with overall abdominal wall tumors having an incidence of 1%. Multiple studies have now demonstrated that the incidence of port-site metastasis after laparoscopic surgery is low. A prospective evaluation by the Laparoscopic Bowel Surgery Registry, which was initiated in 1992 by the American Society of Colon and Rectal Surgeons, the American College of Surgeons,  and  the  Society of American Gastrointestinal Endoscopic Surgeons, reported the rate of this complication to be at 1.1%,8 similar to the results for open surgery. Recent trials evaluating the outcomes of laparoscopic colectomy for cancer have also reported a similarly low incidence of port-site metastasis.

With the extra precautions of preventing the PSM while doing surgery, we can still bring down the incidence of port site metastasis to negligible level. The precautions like avoiding tumor manipulations, securing port sites to prevent air leak, evacuating the pneumoperitoneum only through the ports, protecting the wound while delivering the specimen and irrigating the wound with cytotoxic agents, will help in reducing the port site recurrence.

Several large uncontrolled trials with comparison to historical controls are available in the literature, showing equal or comparable 3 to 5 years survival results.

Barcelona Trial

Lacy et al, in a randomized trial in Lancet2002 showed better survival at 48 months in stage III colon cancers. The 48 months survival in Stage I and II were similar. This was a single center trial from the University of Barcelona for a period of 4 years from 1993 to 1996. 219 patients were randomized (109 patients in the open group and 111 patients in the lap group) Barcelona trial concluded that Lap. Assisted Colectomy is more effective than Open Colectomy for the treatment of colon cancer in terms of morbidity, hospital stay, tumor recurrence and cancer related survival.

Similar results were observed by other authors in the subsequent publications.10-13

Cost Trial (Clinical Outcomes  of Surgical Therapy Study Group)3

Another prospective randomized trial was initiated by National Cancer Institute and NCI co- operative group. This trial included 66 experienced surgeons from 48 centers in USA for a period of 1994 to 2001.  872 patients were randomized (428 in the open group and 435 in the laparoscopic group). They summarized the  results  as Laparoscopic Colectomy for cancer was associated with equivalent morbidity and mortality, equivalent oncologic outcomes, equivalent recurrence rates, overall and disease free survival rates. There were short-term benefits of reduced pain and short-term hospital stay.

Color Trial (Colon Cancer Laparoscopic or Open Resection Study Group)4

Another Randomized Controlled Trial, the COLOR Trial (sponsored by Ethicon Endo Surgery) included 29 centers in Europe. 1248 patients were randomized (627 patients in the Laparoscopic group and 621 patients in the Open group). They excluded transverse colon and rectal cancers. Their conclusions were Short-term outcomes (blood loss, return of bowel functions, pain control and hospital stay) are improved by Laparoscopy.

Short-term oncological parameters are (LN clearance and margin clearance) preserved. Preoperative morbidity and mortality were equivalent.

MRC Clasicc Trial

It is a prospective randomized trial sponsored by UK Medical Research Council, which included 32 surgeons from 27 centers in UK. 794 patients were randomized. The trial included both colon and rectal cancers in the study.

Early results17 of the trial were:

  • No observed differences between Open & Lap. Assisted surgery for both colon and rectal cancers in terms of tumor and nodal status, short term morbidity and mortality and quality of life.
  • There was a trend towards shorter hospital stay after laparoscopic procedures.
  • Laparoscopic surgery for rectal cancer may be associated with more frequent positive margins.
  • For colon cancer, laparoscopic resection is oncologically safe, with equivalent pathologic results.
  • For  rectal  cancer,  equivalency  of laparoscopic resection is not yet proven.

The long-term results18 were:

The local recurrence rate in anterior resection was 7%  in Open group and 7.8% in Lap group. The difference in possibility of circumferential resection, which was observed in short-term study, did not translate into a difference in 3 years local recurrence rate, overall survival rate or disease-free survival rates. Taking into consideration of the long-term results, MRC Clasicc Trial supported the continued use of laparoscopic surgery in rectal cancer patients.

Nice Guidance (National Institute for Health& Clinical Excellence and professional experts, UK)

At the guidance committee meeting reported that the consensus among clinicians is that there is no difference in long-term outcomes between Lap& Open Colorectal surgery provided lap procedure is performed by adequately trained surgeons

Conclusion

If the Laparoscopic approach for Colorectal  Cancer  has  equivalent Morbidity and Mortality, equivalent Oncological clearance and equivalent long term survival in comparison to Open Surgery, why not offer our patients the added benefits of decreased pain, reduced hospital stay, less disability, early return to work and better cosmetic results.

End Note

Author Information

Dr. Baiju Senadhipan, MS, MNAMS, MCh (Gastro),
Consultant Surgical Gastroenterologist and
Laparoscopic Surgeon,
Holy Cross Hospital, Kollam   

Conflict of Interest: None declared

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