Laparoscopic vs. Conventional Resections for Colorectal Carcinoma

1
Laparoscopic vs. Conventional Resections for
Colorectal Carcinoma

• 2LT Pil (Pete) Kang
• New York University School of Medicine
• 28 September 2000

2
Colorectal Cancer Epidemiology

• Second leading cause of death from cancer in the
  United States
• Estimated 138,000 new cases (70 in colon and 30
  in rectum) per year
• 55,000 related deaths per year
• Risk factors personal/family hx, IBD, HNPCC,
  FAP, diet (high fat, low fiber)

3
Clinical Signs Symptoms

• Right Colon
• Unexplained weakness/anemia
• Occult blood in feces
• Dyspeptic symptoms
• Persistent right abdominal discomfort
• Palpable abdominal mass

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Clinical Signs Symptoms

• Left Colon
• Change in bowel habits
• Gross blood in stool
• Obstructive symptoms
• Rectum (20-30 of CR Ca)
• Rectal bleeding
• Change in bowel habits
• Sensation of incomplete evacuation
• Palpable tumor during rectal exam

5
Colorectal Cancer Diagnosis

• Physical Exam
• Rectal exam with test for occult blood
• Labs
• CBC, LFTs (AlkPhos), Calcium
• Carcinoembryonic antigen (CEA)

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Colorectal Cancer Diagnosis

• Barium enema
• Apple core lesions
• Filling defect

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Colorectal Cancer Diagnosis

• Colonoscopy
• Allows biopsy
• Invasive

• Future
• virtual colonoscopy?

Fenlon et al., NEJM Nov 1999 341 (20)
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Staging of Colorectal Cancer
Dukes Stage T N M
0 Tis N0 M0
A I T1 N0 M0
A I T2 N0 M0
B1 II T3 N0 M0
B2 II T4 N0 M0
C III Any T N1 M0
C III Any T N2/3 M0
D IV Any T Any N M1
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Stage I II Colorectal Cancers

• Treatment Surgical resection
• Colectomy
• Low Anterior Resection (gt12cm from AV)
• Abdominoperineal Resection (lt7-8cm from AV)
• Stage I II (T1 T2) surgical resection only
• Stage II (T3 T4) surgery clinical trials of
  systemic chemotherapy
• Stage II rectal post-op radiation therapy

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Stage III Colorectal Cancers

• Treatment Surgical resection
• Adjuvant therapy
• 5-FU and levamisole
• Clinical trials
• Radiation therapy for rectal cancer

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Stage IV Colorectal Cancers

• Palliative resection to prevent
  obstruction/perforation
• Diversion if unresectable
• Resection of solitary liver metastasis
• Chemotherapy

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Outcome of Patients with Colorectal Cancer
Sabiston, Textbook of Surgery, 15th ed.
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Colorectal Cancer Survival by Stage
Survival () Survival () Survival ()
Stage Crude 5-year1 Mayo 2-year2 Australia 2-year2
I 80 100 85
II 60 92/88 82
III 30 65 55
IV 5 18 22
1 Way, LW. Current Surgical Diagnosis
Treatment, 10 ed. 2 Poulin, et al. Ann Surg
1999229(4)
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Oncologic Principles of Colorectal Resection

• Evaluation of abdominal cavity for local/distant
  metastases
• Wide excision of tumor with at least 5cm and 2cm
  proximal and distal margins
• Control/resection of lymphovascular pedicle(s)
  and involved soft tissues

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Anatomical Considerations
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Laparoscopic Colon Surgery

• Natural extension of experience gained in
  laparoscopic cholecystectomy
• Benign diseases
• colorectal polyps, rectal prolapse
• diverticular disease, stomas
• cecal/sigmoid volvulus
• IBD

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Laparoscopic Colorectal Cancer Surgery (LCCS)
A Port sites for right-sided lesions B
Umbilical extraction site, extracorporeal
ligation of vessels and resection of bowel,
extraction through wound protector C
Extracorporeal anastomosis
Poulin, et al. Ann Surg 1999229(4)
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Laparoscopic Colorectal Cancer Surgery (LCCS)
A Port sites for left-sided lesions B
Intracorporeal ligation of vessels and bowel
resection, specimen bagged C Intracorporeal
anastomosis
Poulin, et al. Ann Surg 1999229(4)
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Laparoscopic SurgeryPotential Advantages

• Overall cost-effectiveness, better short-term
  outcomes (immediate post-op)
• Lower postoperative mortality rate
• (ptsgt70 y.o. pts w/ comorbid factors pts w/
  metastases)
• Better biologic response to injury/SIRS
• Better long term survival (???)

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Laparoscopic SurgeryPotential Drawbacks

• Inadequate for tumor localization, identification
  of anatomy, mesentery resection, high vessel
  ligation, resection margins
• Tumor cell seeding (port-site, wound)
• Embolization of exfoliated cells (related to
  pneumoperitoneum)

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Current Issues

• Is laparoscopic resection for colorectal cancer
  oncologically sound?
• Adequate margins lymph node assessment
• Comparable recurrence/survival rates
• Do laparoscopic resection techniques have any
  short-term advantages?

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Hartley et al., Ann Surg 2000 Aug232(2)

• Prospective comparative trial UK
• 114 pts ? minimum 2-year follow-up of 109 pts
• Recurrent disease 25 of pts total
• LAP 16/57 (28) CON 11/52 (21)
• Crude death rates
• LAP 26/57 (46) CON 24/52 (46)
• Wound metastases
• LAP 1 CON 3
• No port metastases

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Disease Recurrence Rates 24 months
Stage LAP (57) CON (52)
Overall 10 12
I 0/12 (0) 0/10 (0)
II 2/20 (10) 3/15 (20)
III 7/22 (32) 9/21 (43)
IV 1/3 (33) 0/6 (0)
Differences between groups not statistically
significant
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Overall Survival 24 months
LAP solid CON dotted (s are censored
data) Hartley et al., Ann Surg 2000 Aug232(2)
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Survival rates at 24 months
Stage LAP (57) CON (52)
Overall 43 35
I 11/12 (92) 10/10 (100)
II 16/20 (80) 12/15 (80)
III 15/22 (68) 10/21 (48)
IV 1/3 (33) 3/6 (50)
Differences between groups not statistically
significant
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Psaila et al., Br J Surg 1998 May85(5)

• Prospective comparative trial
• 54 pts LAP 25, CON 29 ? median follow-up of 28
  months
• Mean hospital stay (days)
• LAP 10.7 CON 17.8 (P0.001)
• Mean morphine requirements LAPltCON
• Adequate margins achieved
• Number of lymph nodes harvested similar
• No port site or wound recurrence

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Milsom et al., J Am Coll Surg 1998 Jul187(1)

• Prospective, randomized trial in one surgery
  department (Cleveland Clinic)
• Patients
• LAP 55 (42 w/ Ca) CON 54 (38 w/ Ca)
• Median follow-up 1.5/1.7 years
• Recovery of 80 of FEV1, FVC (POD)
• LAP 3 CON 6 (P0.01)
• Morphine requirements up to POD2 (mg/kg/d)
• LAP 0.78 0.32 CON 0.92 0.34 (P0.02)
• Flatus (POD)
• LAP 3 CON 4 (P0.006)

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Milsom et al., J Am Coll Surg 1998 Jul187(1)

• Cancer-related deaths
• LAP 3 CON 4
• Postoperative complications 15 in both groups
• LAP pneumonia (1), peritonitis, PE (1), MI (1),
  CHF(2), death (1)
• CON dehiscence (1), pneumonia (1), PE (1), Afib
  (1), death (1)
• Hospital length of stay
• LAP 6.0 CON 7.0 (P0.16)
• Tumor margins clear in all patients
• No port-site recurrence in LAP group

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Summary

• Recurrence/survival of both LAP and CON groups at
  2 years of follow-up to be equivalent
• Equivocal data on possible short-term advantages
• Need randomized, controlled multi-center study
  with larger number of pts and longer follow-up
  period

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