Current Status of Laparoscopy for Colon and Rectal Cancer

Current Status of Laparoscopy Current Status of Laparoscopy for Colon and Rectal Cancerfor Colon and Rectal CancerSteven D Wexner, MD, FACS, FRCS, FRCS Steven D Wexner, MD, FACS, FRCS, FRCS

(Ed)(Ed)Chairman, Department of Colorectal SurgeryChairman, Department of Colorectal Surgery

21st Century Oncology Chair in Colorectal Surgery21st Century Oncology Chair in Colorectal SurgeryChief of StaffChief of Staff

Cleveland Clinic FloridaCleveland Clinic FloridaProfessor of Surgery, Ohio State UniversityProfessor of Surgery, Ohio State University

Health Sciences Center at theHealth Sciences Center at theCleveland Clinic FoundationCleveland Clinic FoundationClinical Professor of Surgery,Clinical Professor of Surgery,

University of South Florida College of MedicineUniversity of South Florida College of MedicineClinical Professor of Biomedical ScienceClinical Professor of Biomedical Science

Department of Biomedical ScienceDepartment of Biomedical ScienceFlorida Atlantic University College of MedicineFlorida Atlantic University College of Medicine

Dan Enger Ruiz, MDDan Enger Ruiz, MDDavid Vivas, MDDavid Vivas, MD

Clinical Research FellowsClinical Research Fellows

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancer

Short term benefitsShort term benefits– Bowel function recoveryBowel function recovery– Quality of life (including pain)Quality of life (including pain)– Hospital stayHospital stay

CostsCosts Long term benefitsLong term benefits

– RecurrenceRecurrence– SurvivalSurvival

AuthorAuthor YearYear N of patientsN of patients Bowel function Bowel function (mean/median n of days)(mean/median n of days)

LapLap OpenOpen LapLap OpenOpen

MilsomMilsom 19981998 5454 5353 3 4

CuretCuret 20002000 1818 1818 2.7 4.4

LacyLacy 20022002 111111 108108 1.5 2.3

HasegawaHasegawa 20032003 2929 3030 2 3.3

KaiserKaiser 20042004 2929 2020 3 4

p<0.05p<0.05

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerBowel Function RecoveryBowel Function Recovery

RandomizedRandomized

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerBowel Function RecoveryBowel Function Recovery

The evidence that laparoscopy offers faster The evidence that laparoscopy offers faster bowel function recovery than the traditional bowel function recovery than the traditional open approach may be considered high open approach may be considered high (Level I)(Level I)

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerQuality of Life - PainQuality of Life - Pain

AuthorAuthor YearYear N of patientsN of patients Less pain/analgesic Less pain/analgesic requirement (days)?requirement (days)?

LapLap OpenOpen LapLap p valuep value

StageStage 19971997 1515 1414 YesYes < 0.05< 0.05

SchwenkSchwenk 19981998 3030 3030 YesYes < 0.01< 0.01

MilsomMilsom 19981998 5454 5353 YesYes 0.020.02

WeeksWeeks 20022002 168168 221221 YesYes 0.030.03

HasegawaHasegawa 20032003 2929 3030 YesYes 0.0020.002


KaiserKaiser 20042004 2929 2020 Yes < 0.05< 0.05

NelsonNelson 20042004 435435 425425 YesYes <0.001<0.001

Randomized trial (COST trial)Randomized trial (COST trial) 449 patients 449 patients 228 Laparoscopy (Lap) , 221Open228 Laparoscopy (Lap) , 221Open Pain, hospital stayPain, hospital stay Quality of life (2 days, 2 weeks, 2 months)Quality of life (2 days, 2 weeks, 2 months)

– Symptom distress scale Symptom distress scale – Quality of life indexQuality of life index– Global rating scale (1-100)Global rating scale (1-100)

Weeks, JAMA 2002

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerQuality of lifeQuality of life

ResultsResultsLap Lap

n = 228n = 228

Open Open

n = 221n = 221

Age (years)Age (years) 68.268.2 69.469.4

Gender M:FGender M:F 108:120108:120 108:113108:113

Tumor stageTumor stage

I I

II II

III III

IVIV

88 88

77 77

57 57

55

69 69 78 78

62 62

11 11

ASA classificationASA classification

I or II I or II

IIIIII

198 198

32 32

189 189

3232P = N.S.

Weeks, JAMA 2002

ResultsResultsLap (n = 228)Lap (n = 228) Open (n = 221)Open (n = 221) P valueP value

Oral analgesicsOral analgesics 1.91.9 2.22.2 0.030.03

IV narcotics/analgesicsIV narcotics/analgesics 3.23.2 4.04.0 <0.001<0.001

Hospital stayHospital stay 5.65.6 6.46.4 <0.001<0.001

Weeks, JAMA 2002

Patients in the Lap group had only greater mean global rate Patients in the Lap group had only greater mean global rate scores at 2 weeks after surgery (76.9 vs. 74.4; p=.0009)scores at 2 weeks after surgery (76.9 vs. 74.4; p=.0009) No other differences in quality of lifeNo other differences in quality of life

Values are means

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancer

The superiority of laparoscopy in reducing pain The superiority of laparoscopy in reducing pain during the same length of the postoperative period during the same length of the postoperative period seems evident (Level I)seems evident (Level I)

Other aspects of quality of life warrant further Other aspects of quality of life warrant further investigationinvestigation

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerHospital StayHospital Stay

AuthorAuthor YearYear N of patientsN of patients Hospital Stay (days) Hospital Stay (days)

Lap Open Lap Open

Stage 1997 15 14 5 8

Schwenk 1998 30 30 10.1 11.6

Milsom 1998 54 53 6 7

Curet 2000 18 18 5.2 7.3

Lacy 2002 111 108 5.2 7.9

Weeks 2002 168 221 5.6 6.4

Hasegawa 2003 29 30 7.1 12.7

Kaiser 2004 29 20 5 6

Nelson 2004 435 425 5 6


p<0.05p<0.05

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerHospital stayHospital stay

There is high evidence (Level I) that There is high evidence (Level I) that laparoscopy for malignancy is associated with laparoscopy for malignancy is associated with an earlier discharge compared to laparotomyan earlier discharge compared to laparotomy

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerCostCost

Randomized, prospective trialRandomized, prospective trial Subset of patients from the Swedish COLOR trialSubset of patients from the Swedish COLOR trial Study period – 12 weeks after surgeryStudy period – 12 weeks after surgery Analysis of direct medical cost (hospital and Analysis of direct medical cost (hospital and

outpatient) and indirect cost (loss of productivity)outpatient) and indirect cost (loss of productivity)

Janson, BJS 2004


Janson, BJS 2004

LCR LCR (n=98)(n=98)

OCR OCR (n=112)(n=112)

DifferDiffer

OR time (min)OR time (min) 155155 122122 3333

Length of stay (days)Length of stay (days) 9.09.0 9.19.1 --

Conversion Conversion 14%14% -- --

Total cost first admissionTotal cost first admission 69316931 53755375 15561556

Total cost of care after discharge Total cost of care after discharge (readmissions/reoperations)(readmissions/reoperations)

25482548 18601860 688688

Total cost Total cost excludingexcluding productivity lost productivity lost 94799479 72377237 22442244

Productivity lossProductivity loss 21812181 25792579 -398-398

Total costTotal cost 1166011660 98149814 18461846

Prospective, Randomized - COLORProspective, Randomized - COLOR

All costs in Euros


Janson, BJS 2004

LCR (n=98)LCR (n=98) OCR (n=112)OCR (n=112)

First admissionFirst admission

ComplicationsComplications 21%21% 16%16%

ReoperationsReoperations 8%8% 4%4%

After dischargeAfter discharge

ComplicationsComplications 12%12% 7%7%

ReoperationsReoperations 6%6% 3%3%

Prospective, Randomized - COLORProspective, Randomized - COLOR


Total cost to society similar in both groupsTotal cost to society similar in both groups Direct costs to healthcare system much higher for LCRDirect costs to healthcare system much higher for LCR

– Higher OR costHigher OR cost

– Cost of complications and reoperation which happened more Cost of complications and reoperation which happened more often in LCRoften in LCR

Same length of stay in both (9 days)Same length of stay in both (9 days) Faster recovery and return to work offset higher Faster recovery and return to work offset higher

healthcare system costhealthcare system cost

Janson, BJS 2004

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerCostsCosts

The data available do not provide adequate The data available do not provide adequate evidence on whether total costs significantly evidence on whether total costs significantly differ between laparoscopy and laparotomy in the differ between laparoscopy and laparotomy in the treatment of malignancy. Costs may significantly treatment of malignancy. Costs may significantly vary depending on the healthcare systemvary depending on the healthcare system

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerRandomized Controlled TrialRandomized Controlled Trial

111 Laparoscopy vs. 106 Laparotomy111 Laparoscopy vs. 106 Laparotomy Non metastatic colon cancerNon metastatic colon cancer Median follow-up time: 43 (27-85) monthsMedian follow-up time: 43 (27-85) months Postoperative chemotherapy for all suitable Postoperative chemotherapy for all suitable

patients with Stage II or III rectal cancerpatients with Stage II or III rectal cancer Intention-to-treat analysisIntention-to-treat analysis

Lacy et al, The Lancet 2002Lacy et al, The Lancet 2002

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerRecurrenceRecurrence


LaparoscopyLaparoscopy

(n=106)(n=106)

OpenOpen

(n=102)(n=102)

Hazard RatioHazard Ratio

(95% CI)(95% CI)P valueP value

Tumor recurrenceTumor recurrence 18 (17%)18 (17%) 28 (27%)28 (27%) 0.72 (0.49-1.06)0.72 (0.49-1.06) 0.070.07

Type of recurrenceType of recurrence

Distant metastasis Distant metastasis

Locoregional relapse Locoregional relapse

Peritoneal seeding Peritoneal seeding

Port-site metastasisPort-site metastasis

77

77

33

11

99

1414

55

00

----

----

----

----

0.570.57

Time to recurrence (months)Time to recurrence (months) 15 (14)15 (14) 17 (12)17 (12) ---- 0.660.66

Surgical treatment of Surgical treatment of recurrence with curative recurrence with curative intentionintention

6 (33%)6 (33%) 9 (32%)9 (32%) ---- 1.001.00

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerSurvivalSurvival


LaparoscopyLaparoscopy

(n=106)(n=106)

OpenOpen

(n=102)(n=102)

Hazard ratioHazard ratio


Overall mortalityOverall mortality 19 (18%)19 (18%) 27 (26%)27 (26%) 0.77 (0.53-1.12)0.77 (0.53-1.12) 1.041.04

Cancer-related mortalityCancer-related mortality 10 (9%)10 (9%) 21 (21%)21 (21%) 0.68 (0.50-0.90)0.68 (0.50-0.90) 0.030.03

Causes of deathCauses of death

Perioperative mortalityPerioperative mortality

Tumor progressionTumor progression

OthersOthers

11

99

99

33

1818

66

----

----

----

0.190.19

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerPredictive factorsPredictive factors


Hazard ratioHazard ratio


Probability of being free of recurrenceProbability of being free of recurrence

Lymph node metastasis (presence or absence)Lymph node metastasis (presence or absence)

Surgical procedure (Open vs. Lap)Surgical procedure (Open vs. Lap)

Preoperative serum CEA (Preoperative serum CEA (>> ng/ml vs. < 4 ng/ml) ng/ml vs. < 4 ng/ml)

0.31 (0.16-0.60)0.31 (0.16-0.60)

0.39 (0.19-0.82)0.39 (0.19-0.82)

0.43 (0.22-0.87)0.43 (0.22-0.87)

0.00060.0006

0.0120.012

0.0180.018

Overall survivalOverall survival

Surgical procedure (open vs. Lap)Surgical procedure (open vs. Lap)

Lymph-node metastasis (presence vs. absence)Lymph-node metastasis (presence vs. absence)

0.48 (0.23-1.01)0.48 (0.23-1.01)

0.49 (0.25-0.98)0.49 (0.25-0.98)

0.0520.052

0.0440.044

Cancer-related survivalCancer-related survival

Lymph-node metastasis (presence vs. absence)Lymph-node metastasis (presence vs. absence)

Surgical procedure (open vs. Lap)Surgical procedure (open vs. Lap)

0.29 (0.12-0.67)0.29 (0.12-0.67)

0.38 (0.16-0.91)0.38 (0.16-0.91)

0.0040.004

0.0290.029

Cox’s regression modelCox’s regression model

Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerOverall survivalOverall survival


Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerCancer-related survivalCancer-related survival


Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerRecurrence free – by StageRecurrence free – by Stage


Laparoscopic Colectomy: CancerLaparoscopic Colectomy: Cancer

Laparoscopic resection of colorectal malignancies Laparoscopic resection of colorectal malignancies a systematic reviewa systematic review

English languageEnglish language Randomized controlled trialsRandomized controlled trials Controlled clinical trialsControlled clinical trials Case series/reportsCase series/reports

Chapman et al. Ann Surg 2001Chapman et al. Ann Surg 2001

Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer

• 52 papers met inclusion criteria52 papers met inclusion criteria– ““Little high level evidence was available”Little high level evidence was available”– ““The evidence base for laparoscopic-assisted reection of The evidence base for laparoscopic-assisted reection of

colorectal malignancies is inadequate to determine the colorectal malignancies is inadequate to determine the procedures safety and efficacy”procedures safety and efficacy”


Laparoscopic Colectomy : CancerLaparoscopic Colectomy : CancerDisadvantages vs. Open ColectomyDisadvantages vs. Open Colectomy

• Significantly longer operative timesSignificantly longer operative times

• Possibly more expensivePossibly more expensive

• Possibly worse short term immune effectsPossibly worse short term immune effects



• ““Laparoscopic resection of colorectal malignancy was Laparoscopic resection of colorectal malignancy was more expensive and time-consuming”more expensive and time-consuming”

• The new procedure’s advantages revolve around early The new procedure’s advantages revolve around early recovery from surgery and reduced pain”recovery from surgery and reduced pain”


Laparoscopic Colectomy : CancerLaparoscopic Colectomy : CancerAdvantages vs. Open ColectomyAdvantages vs. Open Colectomy

• Improved cosmesis (no data but appears uncontentious)Improved cosmesis (no data but appears uncontentious)

• Quicker hospital dischargeQuicker hospital discharge

• Less narcotic use, though possibly larger benefits for certain Less narcotic use, though possibly larger benefits for certain types of colectomy (low colonic)types of colectomy (low colonic)

• Possibly less pain at rest, at least for patients who have Possibly less pain at rest, at least for patients who have uncovered proceduresuncovered procedures

• Possibly earlier return of bowel function and resumption of Possibly earlier return of bowel function and resumption of normal dietnormal diet



Short term Quality-of-Life outcomes Following Short term Quality-of-Life outcomes Following Laparoscopic-Assisted Colectomy vs Open Laparoscopic-Assisted Colectomy vs Open Colectomy for Colon Cancer (COST Study)Colectomy for Colon Cancer (COST Study)

AIMSAIMS– Are disease free and overall survival equivalent ?Are disease free and overall survival equivalent ?– Is laparoscopic approach associated with better QOL ?Is laparoscopic approach associated with better QOL ?

Weeks et al. JAMA 2002Weeks et al. JAMA 2002


Randomized control trial Randomized control trial 449 patients 449 patients

– Adenocarcinoma of single segment of colonAdenocarcinoma of single segment of colon– Excluded: Acute presentation, rectal and transverse Excluded: Acute presentation, rectal and transverse

colon cancers, advanced local disease, those lesions colon cancers, advanced local disease, those lesions with evidence of metastatic disease, ASA IV or Vwith evidence of metastatic disease, ASA IV or V

Quality of surgery:Quality of surgery:– All surgeons with > 20 cases; Random audit of casesAll surgeons with > 20 cases; Random audit of cases



Outcomes:Outcomes:– Survival: still pendingSurvival: still pending– QOL at 2days, 2 weeks and 2 months using: QOL at 2days, 2 weeks and 2 months using:

» Symptom Distress Scale, Global QOL Scale, QOL indexSymptom Distress Scale, Global QOL Scale, QOL index

Results: Intention to Treat AnalysisResults: Intention to Treat Analysis– Shorter use of narcoticsShorter use of narcotics– Shorter length of stay by 0.8 days (p<0.01)Shorter length of stay by 0.8 days (p<0.01)– Quality of life: no differenceQuality of life: no difference



ConclusionsConclusions– ““The modest benefits in short term QOL measures we The modest benefits in short term QOL measures we

observed are not sufficient to justify the use of this observed are not sufficient to justify the use of this procedure in the routine care setting”procedure in the routine care setting”

Unresolved Issues:Unresolved Issues:– Blunting of QOL differences via analgesic use Blunting of QOL differences via analgesic use – QOL differences between POD 2 and POD 14QOL differences between POD 2 and POD 14– Recurrence and survival outcomesRecurrence and survival outcomes– Incidence of small bowel obstruction Incidence of small bowel obstruction


Laparoscopic Colectomy : Laparoscopic Colectomy : Prospective, Randomized, ControlledProspective, Randomized, Controlled

48 institutions, 872 patients48 institutions, 872 patients

Prospective, randomizedProspective, randomized

Follow-up 4.4 yearsFollow-up 4.4 years

Conversion 21%Conversion 21%

End point was time to tumor recurrenceEnd point was time to tumor recurrence

Nelson, NEJM 2004Nelson, NEJM 2004

Prospective, Randomized, ControlledProspective, Randomized, Controlled

LaparoscopicLaparoscopic

(n=435)(n=435)

OpenOpen

(n=425)(n=425)

AgeAge 7070 6969

FemaleFemale 212212 220220

LocationLocation

RightRight

LeftLeft

SigmoidSigmoid

237237

3232

166166

232232

3232

164164

TNM StageTNM Stage

00

11

22

33

44

UnknownUnknown

2020

153153

136136

112112

1010

44

3333

112112

146146

121121

1616

00


Prospective, Randomized, Prospective, Randomized, Controlled: Outcome at Surgery Controlled: Outcome at Surgery


(n=435)(n=435)

OpenOpen

(n=425)(n=425)P valueP value

Bowel margins (cm)Bowel margins (cm) 10-1310-13 11-1211-12 0.4-0.90.4-0.9

Lymph nodesLymph nodes 1212 1212 1.01.0

Surgery time (min)Surgery time (min) 150 150 9090 <0.001<0.001

ConversionConversion 9090 -- --

Intraoperative Intraoperative complicationscomplications

88 1515 NSNS

Length of incision (cm)Length of incision (cm) 66 1818 <0.001<0.001


Prospective, Randomized, Prospective, Randomized, Controlled: Post-operativeControlled: Post-operative


(n=435)(n=435)

Open Open


IV narcotics (days)IV narcotics (days) 33 44 <0.001<0.001

PO narcotics (days)PO narcotics (days) 11 22 0.020.02

Length of StayLength of Stay 55 66 <0.001<0.001

30-day mortality30-day mortality 22 44 NSNS

ComplicationsComplications 9292 8585 NSNS

Rates of readmissionRates of readmission 1010 1212 NSNS

Rates of reoperationRates of reoperation <2%<2% <2%<2% NSNS


Prospective, Randomized, Prospective, Randomized, Controlled: Outcome Controlled: Outcome


(n=435)(n=435)

OpenOpen


Recurrence* (4.4yrs)Recurrence* (4.4yrs) 7676 8484 0.830.83

Wound recurrenceWound recurrence 1%1% 1%1% P=0.50 NSP=0.50 NS

3-yr survival3-yr survival 86%86% 85%85% P=0.51 NSP=0.51 NS


**Laparoscopic procedure not significantlyLaparoscopic procedure not significantly inferior to Open Procedure.inferior to Open Procedure.

Cumulative Incidence of Recurrence at Any SatgeCumulative Incidence of Recurrence at Any Satge

Overall Survival at Any StageOverall Survival at Any Stage

Prospective, Randomized, Prospective, Randomized, Controlled: ConclusionsControlled: Conclusions

No difference between: No difference between: – Time to recurrenceTime to recurrence

– Disease-free survival Disease-free survival

– Overall survivalOverall survival

Oncologic outcome of laparoscopic resection is similar to Oncologic outcome of laparoscopic resection is similar to that of open resectionthat of open resection

Laparoscopic approach is associated with less pain and a Laparoscopic approach is associated with less pain and a shorter hospital stay than conventional surgeryshorter hospital stay than conventional surgery


Laparoscopic Colectomy : Laparoscopic Colectomy : CLASICC Trial CLASICC Trial

Colon and Rectal CancerColon and Rectal Cancer

27 UK institutions, 794 patients27 UK institutions, 794 patients

Prospective, randomized, controlledProspective, randomized, controlled

Follow-up at 1 and 3 monthsFollow-up at 1 and 3 months

29% conversion rate29% conversion rate

Guillou, Lancet 2005Guillou, Lancet 2005

Laparoscopic ColectomyLaparoscopic ColectomyCLASICC Trial CLASICC Trial

Colon and Rectal CancerColon and Rectal Cancer


Primary Primary EndpointsEndpoints

Positivity rates of circumferential and Positivity rates of circumferential and

longitudinal resection marginslongitudinal resection margins

Proportion of Dukes’ C2 tumorsProportion of Dukes’ C2 tumors

In-Hospital mortalityIn-Hospital mortality

SecondarySecondaryEndpointsEndpoints

Complication rates Complication rates

Quality of lifeQuality of life

Transfusion requirmentsTransfusion requirments


CLASICC Trial Profile CLASICC Trial Profile

Prospective, Randomized, ControlledProspective, Randomized, ControlledOpen (n=276)Open (n=276) Laparoscopic (n=345)Laparoscopic (n=345) Conversion (n=143)Conversion (n=143)

AgeAge 6969 6969 6868

FemaleFemale 121 (44%)121 (44%) 167 (48%)167 (48%) 49 (34%)49 (34%)

ColonColon

RectumRectum

144 (52%)144 (52%)

132 (48%)132 (48%)

185 (52%)185 (52%)

160 (46%)160 (46%)

61 (43%)61 (43%)

82 (18%)82 (18%)

TNM Stage TNM Stage

T 0T 0

T 1T 1

T 2T 2

T 3T 3

T 4T 4

----

9 (4%)9 (4%)

36 (16%)36 (16%)

141 (64%)141 (64%)

33 (15%)33 (15%)

----17 (6%) 17 (6%)

48 (17%)48 (17%)175 (63%)175 (63%)36 (13%)36 (13%)

----

4 (3%)4 (3%)

16 (13%)16 (13%)

71 (60%)71 (60%)

28 (24%)28 (24%)

N0N0

N1N1

N2N2

Not InvestigatedNot Investigated

130 (59%)130 (59%)

51 (23%)51 (23%)

38 (17%)38 (17%)

----

159 (58%)159 (58%)

70 (25%)70 (25%)

46 (17%)46 (17%)

1 1

63 (53%)63 (53%)

33 (28%)33 (28%)

21 (18%)21 (18%)

2 (2%)2 (2%)

M0M0

M1M1

Not investigatedNot investigated

MissingMissing

96 (44%)96 (44%)

8 (4%)8 (4%)

107(49%)107(49%)

8 (4%)8 (4%)

98 (36%)98 (36%)

4 (1%)4 (1%)

159 (58%)159 (58%)

15 (5%)15 (5%)

57 (48%)57 (48%)

7 (6%)7 (6%)

52 (44%)52 (44%)

3 (3%)3 (3%)


CLASICC: Outcome at Surgery CLASICC: Outcome at Surgery

OpenOpen

(n=276)(n=276)


(n=345)(n=345)

ConversionConversion

(n=143)(n=143)

Time to first bowel Time to first bowel movement (days)movement (days)

6 (4.5-7) colon6 (4.5-7) colon

6 (4-7) rectum6 (4-7) rectum

5 (4-6.5) colon5 (4-6.5) colon


5 (4-6.5) colon5 (4-6.5) colon


Time to normal dietTime to normal diet6 (5-8) colon6 (5-8) colon


5 (4-7) colon5 (4-7) colon


6 (5-8) colon6 (5-8) colon


Anaesthetic time (min)Anaesthetic time (min) 135 (100-175)135 (100-175) 180 (140-220)180 (140-220) 180 (135-223)180 (135-223)

Length of incision (mm)Length of incision (mm) 228 (180-300)228 (180-300) 70 (55-100)70 (55-100) 200 (150-285)200 (150-285)


All data are medianAll data are median

CLASICC: PathologyCLASICC: Pathology

LaparoscopicLaparoscopic OpenOpen ConvertedConverted

Lymph-nodeLymph-node

Duke’s C2Duke’s C2

12 ( 8-17)12 ( 8-17)

34 (6%)34 (6%)

13.5 (8-1913.5 (8-19

18 (7%)18 (7%)

----

16 (12%)16 (12%)

ColonColon

Distance from tumor to mesenteric Distance from tumor to mesenteric resection marginresection margin

Circumferential resection margin +Circumferential resection margin +

8cm (6.5-10)8cm (6.5-10)

16 (7%)16 (7%)

9cm (7-11)9cm (7-11)

6 (5%)6 (5%)

RectumRectum

Circumferential resection margin +Circumferential resection margin + 30 (16%)30 (16%) 14 (14%)14 (14%)


P>0.05P>0.05

CLASICC: ComplicationsCLASICC: Complications

Intraoperative Intraoperative complicationscomplications


(intention to treat)(intention to treat)OpenOpen

GeneralGeneral 54 (10%) 27 (10%)

(Colon) Haemorrhage(Colon) Haemorrhage

Cardiac/PulmonaryCardiac/Pulmonary

Bowel InjuryBowel Injury

Ureteric InjuryUreteric Injury

OtherOther

2 (1%)

10 (4%)

6 ( 2%)

2 (1%)

2 (1%)

5 (4%)

4 (3%)

--

--

2 (1%)

(Rectum) Haemorrhage(Rectum) Haemorrhage

Cardiac/PulmonaryCardiac/Pulmonary

Bowel InjuryBowel Injury

Ureteric InjuryUreteric Injury

OtherOther

17 (7%)

11 (4%)

3 ( 1%)

--

9 (4%)

7 (5%)

4 (3%)

1 (1%)

4 (3%)

2 (2%)


P > 0.05P > 0.05

CLASICC: ComplicationsCLASICC: Complications

30 days post op30 days post op LaparoscopicLaparoscopic Open Open ConvertedConverted

Total ComplicationsTotal Complications 133 (39%)133 (39%) 115 (42%)115 (42%) 99 (69%)99 (69%)

(Colon) wound infection(Colon) wound infection

chest infectionchest infection

anastomotic dehiscenceanastomotic dehiscence

DVTDVT

OtherOther

8 (4%)8 (4%)

10 (5%)10 (5%)

7 (4%)7 (4%)

5 (3%)5 (3%)

32 (17%)32 (17%)

7 (5%)7 (5%)

5 (3%)5 (3%)

5 (3%)5 (3%)

----

31 (22%)31 (22%)

5 (8%)5 (8%)

6 (10%)6 (10%)

1 (2%)1 (2%)

----

11 (18%)11 (18%)

(Rectum) wound infection(Rectum) wound infection

chest infection chest infection

anastomotic dehiscenceanastomotic dehiscence

DVTDVT

OtherOther

16 (10%)16 (10%)

12 (8%)12 (8%)

13 (8%)13 (8%)

----

30 (19%)30 (19%)

16 (12%)16 (12%)

6 (5%)6 (5%)

10 (7%)10 (7%)

2 (2%)2 (2%)

33 (25%)33 (25%)

16 (20%)16 (20%)

12 (15%)12 (15%)

12 (15%)12 (15%)

1 (1%)1 (1%)

35 (43%)35 (43%)

DeathDeath 16 (1%)16 (1%) 15 (5%)15 (5%) 13 (9%)13 (9%)


P>0.05P>0.05

CLASICC: ConversionsCLASICC: Conversions

Conversion Rate (Colon)Conversion Rate (Colon)

61 (25%)61 (25%)

-Tumor fixity-Tumor fixity

-Uncertainty of tumor clearance-Uncertainty of tumor clearance

-Obesity-Obesity

37 (61%)37 (61%)

13 (21%)13 (21%)

5 (8%)5 (8%)

Conversion Rate (Rectum) Conversion Rate (Rectum)

82 (34%)82 (34%)

-Tumor fixity/Uncertainty of -Tumor fixity/Uncertainty of

tumor clearancetumor clearance

-Obesity-Obesity

-Anatomical uncertainty-Anatomical uncertainty

-Inaccessibility of tumor-Inaccessibility of tumor

34 (41%)34 (41%)

21 (26%)21 (26%)

17 (21%)17 (21%)

16 (20%)16 (20%)


Laparoscopic Colectomy : Prospective, Laparoscopic Colectomy : Prospective, Randomized, ControlledRandomized, Controlled

OpenOpen

N=20N=20

ConvertedConverted

N=13N=13


N=15N=15

Recurrence %Recurrence % 55 2323 00

Survival StatusSurvival Status

Alive without disease %Alive without disease % 9090 6262 9393

Alive with disease %Alive with disease % 55 2323 00

Died, Disease-related %Died, Disease-related % 55 88 77

Died, non-disease related %Died, non-disease related % 00 88 00

Outcome at 3 yearsOutcome at 3 years

Kaiser, J Lap and Advanced Surg Tech 2004Kaiser, J Lap and Advanced Surg Tech 2004

Equivalent in terms of recurrence and survivalEquivalent in terms of recurrence and survival

Laparoscopy vs. Open: Colon CancerLaparoscopy vs. Open: Colon CancerMeta-analysis of 12 randomized controlled trials (2512 patients)

Abraham, BJS 2004Abraham, BJS 2004

YearYear PatientsPatients

LacyLacy 20022002 219219

COSTCOST 20022002 428428

COLORCOLOR 20022002

NeudeckerNeudecker 20022002 3030

BragaBraga 20022002 269269

SingaporeSingapore 20012001 236236

SchwenkSchwenk 20002000 6060

LeungLeung 20002000 3434

CuretCuret 20002000 7373

HewittHewitt 19981998 2525

MilsomMilsom 19981998 113113

StageStage 19971997 2929

Laparoscopy vs Open: Colon CancerLaparoscopy vs Open: Colon CancerMeta-analysis of 12 randomized controlled trials (2512 patients)


Odds RatioOdds Ratio P valueP value

MortalityMortality 0.850.85 NSNS

MorbidityMorbidity 0.620.62 <0.003<0.003

All complicationsAll complications 0.600.60 <0.001<0.001

Local ComplicationsLocal Complications 0.510.51 <0.001<0.001

All wound complicationsAll wound complications 0.470.47 0.0030.003

All leakageAll leakage 0.840.84 NSNS

HemorrhageHemorrhage 0.710.71 NSNS

ReoperationReoperation 0.700.70 NSNS

Systemic, Cardiac, Respiratory, DVTSystemic, Cardiac, Respiratory, DVT 0.65-0.810.65-0.81 NSNS

Laparoscopy vs Open: Colon CancerLaparoscopy vs Open: Colon Cancer


Meta-analysis of 12 randomized controlled trials (2512 patients)Meta-analysis of 12 randomized controlled trials (2512 patients)

PatientsPatients ImprovementImprovement

First FlatusFirst Flatus 476476 33.5%33.5%

Tolerating Solid DietTolerating Solid Diet 406406 23.9%23.9%

80% Recovery of Peak Expiratory Flow80% Recovery of Peak Expiratory Flow 9494 44.3%44.3%

Pain 6-8hr postopPain 6-8hr postop

At restAt rest

During coughingDuring coughing

173173

173173

34.8%34.8%

33.9%33.9%

Narcotic Analgesia (first 48hrs)Narcotic Analgesia (first 48hrs) 269269 36.9%36.9%

Length of Hospital StayLength of Hospital Stay 12371237 20.6%20.6%

Laparoscopy: Colon CancerLaparoscopy: Colon CancerConclusionConclusion

Laparoscopy for colon cancer has shown to be potentially Laparoscopy for colon cancer has shown to be potentially superior to laparotomy in regard to short-term benefits superior to laparotomy in regard to short-term benefits and equivalent with regard to long term benefitsand equivalent with regard to long term benefits

Available data appear to support that laparoscopic Available data appear to support that laparoscopic colectomy and conventional open colectomy have either colectomy and conventional open colectomy have either similar or superior long-term outcomes (Level 1 similar or superior long-term outcomes (Level 1 evidence)evidence)

Surgeons with sufficient expertise and ongoing peer-Surgeons with sufficient expertise and ongoing peer-reviewed data collection may offer this therapy to reviewed data collection may offer this therapy to appropriately selected patientsappropriately selected patients

Laparoscopy vs. Open Colectomy in Laparoscopy vs. Open Colectomy in Cancer PatientsCancer Patients

Randomized Trial

Braga, DCR 2005Braga, DCR 2005

VariableVariableLaparoscopyLaparoscopy

(n = 190)(n = 190)OpenOpen

(n = 201)(n = 201)

Age (yr)Age (yr) 65 (13) 67 (11)

Male/female ratioMale/female ratio 115/75 121/80

ASA scoreASA score 1.9 (0.6) 2.0 (0.7)

Hemoglobin (g/l)Hemoglobin (g/l) 126 (19) 124 (22)

ObesityObesity 17 (8.9) 12 (6)

UndernutritionUndernutrition 22 (11.6) 24 (11.9)

Albumin (g/l)Albumin (g/l) 36.9 (5.3) 36.2 (6.5)

Laparoscopy vs. Open Colectomy in Laparoscopy vs. Open Colectomy in Cancer Patients:Cancer Patients:

Long-Term ComplicationsLong-Term Complications


ComplicationComplicationLaparoscopyLaparoscopy

(n = 190)(n = 190)OpenOpen

(n = 201)(n = 201)P ValueP Value

OverallOverall 13 (6.8) 30 (14.9) 0.02

Incisional herniaIncisional hernia 9 (4.7) 18 (8.9) NS

Intestinal obstructionIntestinal obstruction 3 (1.6) 6 (3) NS

Abdominal abscessAbdominal abscess 0 (0) 1 (0.5) NS

Urinary dysfunctionUrinary dysfunction 0 (0) 3 (1.5) NS

Peristomal abscessPeristomal abscess 1 (0.5) 1 (0.5) NS

Anastomosis stenosisAnastomosis stenosis 0 (0) 1 (0.5) NS


Quality of Life



Five-Year Survival by Cancer Stage



Five-year Disease-Free Survival



Conclusion


Laparoscopic colorectal resection reduced longterm

complication rate, improved quality of life in the

first postoperative year, and did not adversely affect

survival in cancer patients

Laparoscopy for Rectal CancerLaparoscopy for Rectal Cancer

Laparoscopy: Rectal CancerLaparoscopy: Rectal CancerTotal Mesorectal ExcisionTotal Mesorectal Excision

AdvantagesAdvantages Amplification of planes of Amplification of planes of

mesorectum and pelvic mesorectum and pelvic fasciafascia

30 degree laparoscope better 30 degree laparoscope better visibility in narrow pelvisvisibility in narrow pelvis

Easier identification of Easier identification of pelvic autonomic nerve pelvic autonomic nerve plexusplexus

DisadvantagesDisadvantages Technically demandingTechnically demanding Absence of tactile sensationAbsence of tactile sensation Difficulty in assessing Difficulty in assessing

surgical marginssurgical margins Difficulty in ultralow cross-Difficulty in ultralow cross-

clampingclamping Learning curveLearning curve

Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME)Excision (TME)

Prospective review – 58 monthsProspective review – 58 months Control group – open rectal resectionsControl group – open rectal resections

– Second consultantSecond consultant– Same unitSame unit

(21 vs. 22)(21 vs. 22)

Hartley et al. DCR 2001Hartley et al. DCR 2001


42 Attempted Laparoscopic Rectal Mobilizations

14 Early Conversions

28 Laparoscopic Rectal Dissections

21 Laparoscopic TME – Study Group

7 AP Resections

1 Non CurativeResection

6 Total Laparoscopic AP

21 Anterior Resections

6 Partial OpenDissection

15 Total Laparoscopic AR


Laparoscopy: Total Mesorectal Excision (TME)Laparoscopy: Total Mesorectal Excision (TME)Completed Laparoscopic Completed Laparoscopic

(n=21)(n=21)Open (n=22)Open (n=22)

Laparoscopic Laparoscopic Conversions* (n=21)Conversions* (n=21)

Mean age (range)Mean age (range) 66 (37-82)66 (37-82) 65 (47-79)65 (47-79) 72 (58-90)72 (58-90)

Male:femaleMale:female 15:615:6 15:715:7 13:813:8

Dukes’ StageDukes’ Stage

AA 55 44 00

BB 1010 88 88

CC 66 1010 1313

DD 00 00 11

Tumor height ([number] cm above anal verge, mean (range))Tumor height ([number] cm above anal verge, mean (range))

Anterior resectionAnterior resection [15] 6.2 (4-9)[15] 6.2 (4-9) [16] 6.4 (4-10)[16] 6.4 (4-10) [16] 7 (5-10)[16] 7 (5-10)

Abdominoperineal resctn.Abdominoperineal resctn. [6] 2 (0-5)[6] 2 (0-5) [6] 1.66 (0-5)[6] 1.66 (0-5) [1] 1[1] 1

UnresectableUnresectable [0][0] [0][0] [2] 6 (4-8)[2] 6 (4-8)

Hartmann’s resectionHartmann’s resection [0][0] [0][0] [2] 9 (6-12)[2] 9 (6-12)

* Includes the one palliative lap. APRHartley et al. DCR 2001Hartley et al. DCR 2001


Reason for Conversion NumberReason for Conversion Number– Fixed tumorFixed tumor 22

– Doubtful resectabilityDoubtful resectability 44

– Gross obesityGross obesity 22

– Dense adhesionsDense adhesions 22

– Obstructed sigmoidObstructed sigmoid 11

– Ureter not identifiedUreter not identified 22

– Camera failureCamera failure 11

– TOTAL 14 (33%)TOTAL 14 (33%)


Laparoscopy: Total Mesorectal Excision (TME)Laparoscopy: Total Mesorectal Excision (TME)

GroupGroupSpecimen Specimen

Length (cm)Length (cm)Longitudinal Longitudinal Margin (cm)Margin (cm)

Radial Margin Radial Margin (cm)(cm)

No. Positive No. Positive MarginsMargins

Lymph Node Lymph Node YieldYield

LaparoscopicLaparoscopic(n=21)(n=21)

27.527.5(24-30)(24-30)

4*4*(3.5-5)(3.5-5)

0.650.65(0.33-1.5)(0.33-1.5)

0066

(3.25-9.5)(3.25-9.5)

Open (n=22)Open (n=22)26.526.5

(23.75-32)(23.75-32)2.52.5

(1.05-3.5)(1.05-3.5)0.80.8

(0.225-1.2)(0.225-1.2)00

7.07.0(4.5-10.5)(4.5-10.5)

ConvertedConvertedlaparoscopiclaparoscopic(n=19) (n=19) ††

28 (24-32)28 (24-32) 2 (1.5-3.5)2 (1.5-3.5) 0.6 (0.35-1)0.6 (0.35-1) 2 2 ‡‡77

(6-10)(6-10)

Values are medians (interquartile ranges)* p=0.02, Mann-Whitney test for nonparametric data vs. open group† n=19 because two patients not resected;includes the one palliative lap. APR‡ Both known palliative



GroupGroupOperating Time Operating Time

(min)(min)Duration of Ileus Duration of Ileus

(days)(days)

Analgesia Analgesia Requirements Requirements

(days)(days)

Hospital Stay Hospital Stay (days)(days)


180*180*(168-218)(168-218)

3.03.0(3.0-4.0)(3.0-4.0)

4.04.0(3.0-6.0)(3.0-6.0)

13.513.5(10.25-27.0)(10.25-27.0)

OpenOpen(n=22)(n=22)

125125(104-144)(104-144)

4.04.0(3.0-5.0)(3.0-5.0)

4.04.0(3.0-5.0)(3.0-5.0)

15.015.0(11.75-28.5)(11.75-28.5)

Converted Converted laparoscopiclaparoscopic(n=21)(n=21)††

146146(136.5-179.5)(136.5-179.5)

44(3.5-7)(3.5-7)

55(3.5-7)(3.5-7)

1616(11.5 – 33)(11.5 – 33)

Values are medians (interquartile ranges)* p=0.003, Mann-Whitney test for nonparametric data vs. open cases† Includes the one palliative lap. APR



ComplicationComplicationLaparoscopicLaparoscopic

(n=21)(n=21)OpenOpen

(n=22)(n=22)

Converted Converted LaparoscopicLaparoscopic

(n=21)(n=21)††

Wound infectionWound infection 00 11 22

Respiratory tract infectionRespiratory tract infection 11 11 22

Wound hematomaWound hematoma 11 00 00

Clinical anastomotic leakageClinical anastomotic leakage 4*4* 11 11

Bowel obstructionBowel obstruction 00 11 00

* P = 0.329 Fisher’s exact test vs. open group† Includes the one palliative lap. APR



Follow-up for Patients Having Curative Laparoscopic and Open ResectionsFor Rectal Cancer, Including Complete Mesorectal Excision


OpenOpen(n=22)(n=22)

Local recurrenceLocal recurrence 1 (5%)1 (5%) 1 (4.5%)*1 (4.5%)*

Death (all causes)Death (all causes) 6 (29%)6 (29%) 5 (23%)5 (23%)††

* Median follow-up was 38 (range, 6-53) months† p=1 and † P=0.736, Fisher’s exact test



Feasible in 50% of patients where possibleFeasible in 50% of patients where possible

Yields histologic and early survival and Yields histologic and early survival and recurrence figures comparable to open surgeryrecurrence figures comparable to open surgery


Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME) case control studyExcision (TME) case control study

Breukink, Int J Colorectal Dis 2005Breukink, Int J Colorectal Dis 2005

VARIABLE/GROUPVARIABLE/GROUP LAPAROSCOPICLAPAROSCOPIC OPENOPEN P valueP value

OPERATIVE TIME(min)OPERATIVE TIME(min) 200200 180180 0.060.06

BLOOD LOSS(ml)BLOOD LOSS(ml) 250250 10001000 <0.001<0.001

>1000 ml FLUID INTAKE>1000 ml FLUID INTAKE 33 66 0.0020.002

SOLID DIET (days)SOLID DIET (days) 44 77 0.0460.046

HOSPITALIZATION (days)HOSPITALIZATION (days) 1212 1919 0.0070.007

MORBIDITYMORBIDITY 37%37% 51%51% N/AN/A

ANASTOMOTIC LEAK (n)ANASTOMOTIC LEAK (n) 22 22 N/AN/A

MORTALITY(n)MORTALITY(n) 00 11 N/AN/A

NN Conversion Conversion OR OR

TimeTime

(mins)(mins)

AnastomoticAnastomotic

TechniqueTechnique

Goh, 97Goh, 97 OLAROLAR

LLARLLAR

2020

2020

--

0%0%

7373

9090

Partial TME with double Partial TME with double staplestaple

Leung, 97Leung, 97 OLAROLAR

LLARLLAR

5050

5050

--

16%16%

150150

196196

Partial TME with double Partial TME with double staplestaple

Schwander, 99Schwander, 99 OLA/prOLA/pr

LLA/prLLA/pr

3232

3232

--

NSNS

209209

281281

LAR 19 Lap 19 Open, LAR 19 Lap 19 Open,

APR 13 Lap 13 OpenAPR 13 Lap 13 Open

Hartley, 01Hartley, 01 OLA/prOLA/pr

LLA/prLLA/pr

2222

4242

--

50%50%

125125

180180

LAR, APR, HartmannLAR, APR, Hartmann

Anthuber, 03Anthuber, 03 OLA/prOLA/pr

LLA/prLLA/pr

334334

101101

--

11%11%

219219

218218

TME with colonic J if <6cmTME with colonic J if <6cm

Breukink, 05Breukink, 05 LARLAR

APRAPR

1010

3131NSNS 195195

225225

Double stapled anastomosisDouble stapled anastomosis

Laparoscopy: Rectal Cancer

Case controlled series for LAR

Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME) case control studyExcision (TME) case control study

VARIABLE/GROUPVARIABLE/GROUP LAPAROSCOPICLAPAROSCOPIC OPENOPEN

CIRCUMFERENTIAL CIRCUMFERENTIAL MARGIN(mm)MARGIN(mm)

3 (2-31)3 (2-31) 5 (2-31)5 (2-31)

DISTAL MARGIN mmDISTAL MARGIN mm 35 (10-100)35 (10-100) 10 (1-30)10 (1-30)

NUMBER OF NODESNUMBER OF NODES 8 (1-25)8 (1-25) 8 (2-20)8 (2-20)

FOLLOW UP (months)FOLLOW UP (months) 14 (2-31)14 (2-31) 19 (2-31)19 (2-31)

LOCAL RECURRENCELOCAL RECURRENCE 00 00

DISTANT METASTASISDISTANT METASTASIS 55 55

Breukink, Int J Colorectal Dis 2005Breukink, Int J Colorectal Dis 2005

Length of Length of StayStay

LRMLRM DRMDRM MorbidityMorbidity MorbidityMorbidity LeakLeak

Goh, 97 Goh, 97 OLAROLAR

LLARLLAR

5.55.5

55

clearclear

clearclear

44

4.54.5

5%5%

20%20%

NSNS 00

00

Leung, 97Leung, 97 OLAROLAR

LLARLLAR

88

66

clearclear

clearclear

NSNS 30%30%

26%26%

6%6%

2%2%

2%2%

0%0%

Schwander, 99Schwander, 99 OLA/prOLA/pr

LLA/prLLA/pr

2121

1515

clearclear clearclear 31%31%

31%31%

0%0%

3%3%

00

3%3%

Hartley, 01*Hartley, 01* OTMEOTME

LTMELTME

1515

13.513.5

0.80.8

0.650.65

2.52.5

44

18%18%

26%26%

0%0%

0%0%

11

44

Anthuber, 03Anthuber, 03 OLA/prOLA/pr

LLA/prLLA/pr

1919

1414

DNDN DNDN 54%54%

31%31%

1%1%

0%0%

7%7%

9%9%

Breukink, 05Breukink, 05 LARLAR

APRAPR1111

2121

NSNS 3.53.5 37%37% 00 5%5%


Case controlled series for LAR

NN Conversion Conversion OR TimeOR Time

(mins)(mins)

AnastomoticAnastomotic

TechniqueTechnique

Seow-Chen, 97Seow-Chen, 97 OAPROAPR

LAPRLAPR

1111

1616

--

NSNS

100100

110110

TMETME

Ramos, 97Ramos, 97 OAPROAPR

LAPRLAPR

1818

1818

--

10%10%

208208

229229

TMETME

Fleshman, 99Fleshman, 99 OAPROAPR

LAPRLAPR

4242

152152

--

21%21%

209209

234234

Lap APR with TMELap APR with TME

Leung, 00Leung, 00 OAPROAPR

LAPRLAPR

3434

2525

--

NSNS

166166

216216

TMETME

Baker, 02Baker, 02 OAPROAPR

LAPRLAPR

6161

2828

--

25%25%

NSNS

NSNS

?TME?TME


Case controlled series for APR

Length of Length of StayStay

LRMLRM DRMDRM MorbidityMorbidity MortalityMortality

Seow-Chen, 97Seow-Chen, 97 OAPROAPR

LAPRLAPR

88

6.56.5

clearclear

clearclear

33

22

55%55%

25%25%

0%0%

0%0%

Ramos, 97Ramos, 97 OAPROAPR

LAPRLAPR

12.912.9

7.47.4

NSNS NSNS 66%66%

44%44%

5.5%5.5%

0%0%

Fleshman, 99Fleshman, 99 OAPROAPR

LAPRLAPR

1212

77

+ in 5+ in 5

+ in 19+ in 19

NSNS 27%27%

33%33%

0%0%

0%0%

Leung, 00Leung, 00 OAPROAPR

LAPRLAPR

1616

2525

NSNS 11

22

48%48%

61%61%

0%0%

0%0%

Baker, 02Baker, 02 OAPROAPR

LAPRLAPR

1818

1313

+ in 1 + in 1 3.23.2

4.54.5

-/3%-/3%

-/4%-/4%

3%3%

4%4%

Laparoscopy: Rectal CancerCase controlled series for APR

Laparoscopy: Rectal CancerLaparoscopy: Rectal CancerProspective, Randomized, Controlled – Short-term outcome of TME with anal sphincter preservation (ASP)

Zhou, Surg Endosc 2004Zhou, Surg Endosc 2004

OpenOpen LaparoscopicLaparoscopic

PatientsPatients 8989 8282

Mean age (years)Mean age (years) 4545 4444

Dukes’ StageDukes’ Stage

AA

BB

CC

DD

66

88

6868

77

55

1010

6363

44

Laparoscopy: Rectal CancerLaparoscopy: Rectal CancerResults of SurgeryResults of Surgery

OpenOpen

(n=89)(n=89)


(n=82)(n=82)

Distance of Tumor from Dentate (cm)Distance of Tumor from Dentate (cm)

1.5-4cm1.5-4cm

4.1-7cm4.1-7cm

5656

3333

4848

3434

Distal MarginDistal Margin 1.5-3.51.5-3.5 1.5-4.01.5-4.0

Sphincter preservationSphincter preservation 100%100% 100%100%

Anastomotic heightAnastomotic height

Low anterior (>2cm from dentate)Low anterior (>2cm from dentate)

Ultralow anterior (<2cm from dentate)Ultralow anterior (<2cm from dentate)

Coloanal (at or below dentate)Coloanal (at or below dentate)

3535

2727

2727

3030

2727

2525

Diverting ileostomyDiverting ileostomy 00 00


Laparoscopy: Rectal CancerLaparoscopy: Rectal CancerOpenOpen LaparoscopicLaparoscopic P P

valuevalue

Operative time (min)Operative time (min) 106106 120120 NSNS

Blood loss (ml)Blood loss (ml) 9292 2020 0.020.02

Parenteral analgesics (days)Parenteral analgesics (days) 4.14.1 3.93.9 NSNS

Solid intake (days)Solid intake (days) 4.54.5 4.34.3 NSNS

Hospitalization (days)Hospitalization (days) 13.313.3 8.18.1 0.0010.001

MorbidityMorbidity

Anastomotic leakAnastomotic leak

12.4%12.4%

33

6.1%6.1%

11

0.0160.016

MortalityMortality 00 00 NSNS

Follow-up 1-16 monthsFollow-up 1-16 months

Port site metsPort site mets NANA 22

Pelvic recurrencePelvic recurrence 33 00


105 patients105 patients

Mean follow up time 26.9 (1.3-65.6) monthsMean follow up time 26.9 (1.3-65.6) months

Laparoscopic Sphincter-Preserving TME Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstructionwith Colonic J-Pouch Reconstruction

Tsang WWC, Ann Surg 2006Tsang WWC, Ann Surg 2006

Mean operative time 170.4 minMean operative time 170.4 min Mean anastomotic distance from anal verge 3.9 cmMean anastomotic distance from anal verge 3.9 cm Mean circumferential margin 17.1 mmMean circumferential margin 17.1 mm Mean distal margin 3.4 cmMean distal margin 3.4 cm



5-year cancer-specific survival rate 81.3%5-year cancer-specific survival rate 81.3% Local recurrence rate 8.9%Local recurrence rate 8.9%




ConclusionConclusion

Lap TME with colonic J-pouch is a safe procedure with Lap TME with colonic J-pouch is a safe procedure with

reasonable operating time and does not appear to pose reasonable operating time and does not appear to pose

any threat to the oncologic and functional outcomesany threat to the oncologic and functional outcomes


Laparoscopic vs. Open Surgery for Laparoscopic vs. Open Surgery for Extraperitoneal Rectal CancerExtraperitoneal Rectal Cancer

191 consecutive patients191 consecutive patients 98 patients underwent lap resection 98 patients underwent lap resection 93 patients underwent open resection93 patients underwent open resection

Morino M, Surg Endosc 2005Morino M, Surg Endosc 2005


n = 98n = 98

OpenOpen

n = 93n = 93PP

Mean follow up (months)Mean follow up (months) 46.3 46.3 49.749.7 NSNS

Conversion rate (%)Conversion rate (%) 18.418.4

Mobilization (days)Mobilization (days) 1.71.7 3.33.3 < 0.001< 0.001

Flatus (days)Flatus (days) 2.62.6 3.93.9 < 0.001< 0.001

Stool (days)Stool (days) 3.83.8 4.74.7 < 0.01< 0.01

Oral intake (days)Oral intake (days) 3.43.4 4.84.8 < 0.001< 0.001

Hospital stay (days)Hospital stay (days) 11.411.4 13.013.0 NSNS




n = 98n = 98

OpenOpen

n = 93n = 93

PP

Morbidity (%)Morbidity (%) 24.424.4 23.623.6 NSNS

Mortality (%)Mortality (%) 1.01.0 2.22.2 NSNS

Anastomotic leakage (%)Anastomotic leakage (%) 13.513.5 5.15.1 NSNS

Reoperation (%)Reoperation (%) 6.16.1 3.23.2 NSNS

Local recurrence (%)Local recurrence (%) 3.23.2 12.612.6 < 0.05< 0.05

Cumulative 5-year survival rate (%)Cumulative 5-year survival rate (%) 80.080.0 68.968.9 NSNS

Disease-free 5-year survival rate (%)Disease-free 5-year survival rate (%) 65.465.4 58.958.9 NSNS





ConclusionConclusion

Laparoscopic resection for low and midrectal cancer is Laparoscopic resection for low and midrectal cancer is

characterized by faster recovery and similar overall characterized by faster recovery and similar overall

morbidity with no adverse oncologic effectmorbidity with no adverse oncologic effect

Documents

Current Status of Laparoscopy for Colon and Rectal Cancer