Long Term Long Term Outcomes Outcomes following following

Laparoscopic Laparoscopic Colorectal SurgeryColorectal SurgeryPeter HewettPeter Hewett

The Queen Elizabeth HospitalThe Queen Elizabeth Hospital

AdelaideAdelaide

Long term outcomes Long term outcomes following Laparoscopic following Laparoscopic

Colorectal SurgeryColorectal Surgery

Malignant DiseaseMalignant Disease Colon and RectumColon and Rectum Oncological outcomesOncological outcomes Incisional Hernia ratesIncisional Hernia rates Small bowel obstruction ratesSmall bowel obstruction rates

Single series studiesSingle series studies

Case matched studies Case matched studies

Randomised Controlled TrialsRandomised Controlled Trials

Single series studiesSingle series studies

Jacob & Salky 11 year retrospective Jacob & Salky 11 year retrospective with 5 year survival rates with 5 year survival rates (Surg Endosc 2005 19 (Surg Endosc 2005 19 :643-649):643-649)

Law et al Comparison of two Law et al Comparison of two separate cohorts separate cohorts (Annals of Surgery Jan 2007 245 : 1-7)(Annals of Surgery Jan 2007 245 : 1-7)

Single series studiesSingle series studies

Jacob & Salky 11 year Jacob & Salky 11 year retrospective with 5 year survival retrospective with 5 year survival rates rates (Surg Endosc 2005 19 :643-649)(Surg Endosc 2005 19 :643-649)

Law et al Comparison of two Law et al Comparison of two separate cohorts separate cohorts (Annals of Surgery Jan 2007 245 : 1-7)(Annals of Surgery Jan 2007 245 : 1-7)

Overall survival and disease free survival after laparoscopic surgery for colon cancer is no worse and perhaps better than the previously reported rates for the same procedure done by an open technique.

81 patients

Single series studiesSingle series studies

Jacob & Salky 11 year retrospective Jacob & Salky 11 year retrospective with 5 year survival rates with 5 year survival rates (Surg Endosc 2005 19 (Surg Endosc 2005 19 :643-649):643-649)

Law et al Comparison of two Law et al Comparison of two separate cohorts separate cohorts (Annals of Surgery Jan 2007 245 (Annals of Surgery Jan 2007 245 : 1-7): 1-7)

Impact of Laparoscopic Impact of Laparoscopic Resection for Colorectal Resection for Colorectal

Cancer on Operative Cancer on Operative Outcomes and Survival Outcomes and Survival

Objective: This study aimed to compare Objective: This study aimed to compare the outcomes of patients who underwent the outcomes of patients who underwent laparoscopic and open resections for laparoscopic and open resections for colorectal cancer. Comparison of colorectal cancer. Comparison of colectomy in 2 consecutive periods colectomy in 2 consecutive periods (period 1: January 1996–May 2000; (period 1: January 1996–May 2000; period 2: June 2000–December 2004), period 2: June 2000–December 2004), with laparoscopic surgery being a with laparoscopic surgery being a surgical option in period 2, was also surgical option in period 2, was also performed.performed.

448 open 1996-2000

656 lap assisted 2000-2004

Colon & upper rectum

Overall survival

STAGE 3

Randomised TrialsRandomised Trials

Braga M et al. Colon Ca. Lap 190 Braga M et al. Colon Ca. Lap 190 Open 201 Open 201 (DCR 2005 48: 2217-2223)(DCR 2005 48: 2217-2223)

Leung KL, Kwok S, Lam S, Lee J Leung KL, Kwok S, Lam S, Lee J Rectosigmoid Ca Lap 203 Open 200 Rectosigmoid Ca Lap 203 Open 200 (Lancet 2004 363 1187-1193)(Lancet 2004 363 1187-1193)

Lacy A et al Colon Ca. Lap 111 Open Lacy A et al Colon Ca. Lap 111 Open 108 108 (Annals of Surgery 2008 248:1-7)(Annals of Surgery 2008 248:1-7)

Randomised TrialsRandomised Trials

Braga M et al. Colon Ca. Lap 190 Braga M et al. Colon Ca. Lap 190 Open 201 Open 201 (DCR 2005 48: 2217-2223)(DCR 2005 48: 2217-2223)

Leung KL, Kwok S, Lam S, Lee J Leung KL, Kwok S, Lam S, Lee J Rectosigmoid Ca Lap 203 Open 200 Rectosigmoid Ca Lap 203 Open 200 (Lancet 2004 363 1187-1193)(Lancet 2004 363 1187-1193)

Lacy A et al Colon Ca. Lap 111 Open Lacy A et al Colon Ca. Lap 111 Open 108 108 (Annals of Surgery 2008 248:1-7)(Annals of Surgery 2008 248:1-7)

Acturarial 5 year survival

Randomised TrialsRandomised Trials

Braga M et al. Colon Ca. Lap 190 Braga M et al. Colon Ca. Lap 190 Open 201 Open 201 (DCR 2005 48: 2217-2223)(DCR 2005 48: 2217-2223)

Leung KL, Kwok S, Lam S, Lee J Leung KL, Kwok S, Lam S, Lee J Rectosigmoid Ca Lap 203 Open Rectosigmoid Ca Lap 203 Open 200 200 (Lancet 2004 363 1187-1193)(Lancet 2004 363 1187-1193)

Lacy A et al Colon Ca. Lap 111 Open Lacy A et al Colon Ca. Lap 111 Open 108 108 (Annals of Surgery 2008 248:1-7)(Annals of Surgery 2008 248:1-7)

Randomised TrialsRandomised Trials

Braga M et al. Colon Ca. Lap 190 Braga M et al. Colon Ca. Lap 190 Open 201 Open 201 (DCR 2005 48: 2217-2223)(DCR 2005 48: 2217-2223)

Leung KL, Kwok S, Lam S, Lee J Leung KL, Kwok S, Lam S, Lee J Rectosigmoid Ca Lap 203 Open 200 Rectosigmoid Ca Lap 203 Open 200 (Lancet 2004 363 1187-1193)(Lancet 2004 363 1187-1193)

Lacy A et al Colon Ca. Lap 111 Lacy A et al Colon Ca. Lap 111 Open 108 Open 108 (Annals of Surgery 2008 248:1-7)(Annals of Surgery 2008 248:1-7)

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Multicentered Randomised Multicentered Randomised Controlled TrialsControlled Trials

COSTCOST

COLORCOLOR

CLASSIC CLASSIC

ALCCaSALCCaS

Multicentered Randomised Multicentered Randomised Controlled TrialsControlled Trials

COSTCOST

COLORCOLOR

CLASSIC CLASSIC

ALCCaSALCCaS

COSTCOST

872 patients872 patients 5 year data on 90% of patients5 year data on 90% of patients Primary endpoint : time to Primary endpoint : time to

recurrencerecurrence Secondary endpoints : overall Secondary endpoints : overall

survival and disease free survival.survival and disease free survival. Noninferiority trial designNoninferiority trial design

Conclusion. Laparoscopic colectomy for cancer is not inferior to open surgery.

Multicentered Randomised Multicentered Randomised Controlled TrialsControlled Trials

COSTCOST

COLORCOLOR

CLASSICCLASSIC

ALCCaSALCCaS

CLASSIC TRIAL CLASSIC TRIAL 3 year survival figures3 year survival figures

3 year overall survival similar3 year overall survival similar Colon and rectal cancerColon and rectal cancer Lap assisted vs openLap assisted vs open Anterior resection local recurrence Anterior resection local recurrence

rate 7.0% open & 7.8% lap assistedrate 7.0% open & 7.8% lap assisted Wound/port site recurrence 9 lap:1 Wound/port site recurrence 9 lap:1

openopen QOL. No differenceQOL. No difference Jayne et al J Clin Oncology 2007 25(21) 2996-8Jayne et al J Clin Oncology 2007 25(21) 2996-8

Multicentered Randomised Multicentered Randomised Controlled TrialsControlled Trials

COSTCOST

COLORCOLOR

CLASSICCLASSIC

ALCCaSALCCaS

Transantlantic Transantlantic Laparoscopically Assisted Laparoscopically Assisted vs Open Colectomy Trials vs Open Colectomy Trials

Study GroupStudy Group Combined analysis of data of the Combined analysis of data of the

Barcelona Trial, COST, CLASSIC & Barcelona Trial, COST, CLASSIC & COLOR trials. COLOR trials.

Overall & Disease free survival @ 3 Overall & Disease free survival @ 3 yearsyears

Curative surgery for colon cancer Curative surgery for colon cancer before March 2000.before March 2000.

796 lap assisted & 740 open796 lap assisted & 740 open

*

Long Term Outcomes Long Term Outcomes following Laparoscopic following Laparoscopic

Colorectal SurgeryColorectal SurgeryStudy InterpretationStudy Interpretation

Study biasStudy bias Subgroup errorSubgroup error Patient SelectionPatient Selection Site SelectionSite Selection Surgeon SelectionSurgeon Selection Investigator bias (Hawthorne effect)Investigator bias (Hawthorne effect)

Long Term Outcomes Long Term Outcomes following Laparoscopic following Laparoscopic

Colorectal Surgery Colorectal Surgery Equipoise?Equipoise?

3 year disease and overall survival is the 3 year disease and overall survival is the same between lap assisted and open same between lap assisted and open colectomy.colectomy.

For surgeons and patients globally the For surgeons and patients globally the current standard of care has not changed.current standard of care has not changed.

Surgeons can continue to offer Surgeons can continue to offer laparoscopic assisted colectomy while laparoscopic assisted colectomy while awaiting 5 year survival statistics.awaiting 5 year survival statistics.

Different skills & experience to perform Different skills & experience to perform lap rectal resectionlap rectal resection

ALCCaS TrialALCCaS Trial Short-Term Outcomes of the Australasian Short-Term Outcomes of the Australasian

Randomized Clinical Study Comparing Randomized Clinical Study Comparing Laparoscopic and Conventional Open Surgical Laparoscopic and Conventional Open Surgical Treatments for Colon Cancer: The ALCCaS Trial.Treatments for Colon Cancer: The ALCCaS Trial.

Hewett, Peter J. FRACS ; Allardyce, Randall A. Hewett, Peter J. FRACS ; Allardyce, Randall A. PhD ; Bagshaw, Philip F. FRCS ; Frampton, PhD ; Bagshaw, Philip F. FRCS ; Frampton, Christopher M. PhD [S]; Frizelle, Francis A. Christopher M. PhD [S]; Frizelle, Francis A. FACS ; Rieger, Nicholas A. FRACS *; Smith, J FACS ; Rieger, Nicholas A. FRACS *; Smith, J Shona MA(Hons) ; Solomon, Michael J. FRACS ; Shona MA(Hons) ; Solomon, Michael J. FRACS ; Stephens, Jacqueline H. MPH ; Stevenson, Stephens, Jacqueline H. MPH ; Stevenson, Andrew R. L. FRACS Andrew R. L. FRACS

Annals of Surgery 2008 Vol 248 No 5Annals of Surgery 2008 Vol 248 No 5 5 year survival figures available April 20105 year survival figures available April 2010