Laparoscopic Surgery in Colorectal Malignancy

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Laparoscopic Surgery in Colorectal Malignancy

• Mark Louie-Johnsun

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Introduction (1)

• Minimal invasive surgery wide acceptance.
• E.g. Laparoscopic cholecystectomy
• BDI lap. open after learning curve era
• Improved outcomes/ cost effective

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Introduction (2)

• Laparoscopic colorectal surgery for benign
  disease successful.
• (polyps, diverticulitis, rectal prolapse, IBD)
• Chen et. al 1998/ Panis et. al 2000.

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Introduction (3)

• Laparoscopic colorectal resection for cancer
  controversial
• Technically challenging - conversions
• Adequacy of oncological resection
• Improved convalescence
• Cost effective
• ? Recurrences- esp. port site
• ? Long term survival
• Weeks et. al 2002/ Stocchi et. al 2000
• Milsom et. al 1998/ Lacy et. al 1995

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Clinical Trials

• No long term multicentre prospective randomized
  trial results
• NCI (US) 900 pts/ CLASICC (UK) 787 pts/ COLOR
  trial
• Few single centre small prospective randomized
  trial
• Milsom et. al 109 pts
• Bohm et. al 60 pts
• Lacy et. al 219 pts (43 month FU)

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Lacy et. Al (Lancet 2002)

• Randomized trial non-metastatic colon cancer
  (rectal excluded)
• Aim Assess differences in cancer-related
  survival between laparoscopic and open colectomy

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Methods

• 11/93- 7/98 all pts ca colon
• Exclusion criteria
• Randomized 1 day pre-op
• Single GI surgical team
• TNM staging
• Adjuvant chemoRx
• Post-op surveillance
• Statistics Kaplan Meier

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Figure 1 Trial Profile
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Table 1 Baseline
characteristics                                   
                
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Table 2. Data related to surgical intervention
and morbidity                                  
                                                  
             
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Table 3. Tumour recurrence and mortality in
patients with non-metastatic colon cancer
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  Figure 3. Kaplan-Meier estimates of
cancer-related survival LAClaparoscopy-assisted
colectomy OCopen colectomy.
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  Figure 4. Kaplan-Meier estimates of
probability of being free of recurrence, overall
survival, and cancer-related survival after
stratifying patients according to TNM tumour
stage. LAClaparoscopy-assisted colectomy
OCopen colectomy.
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Conclusion (Lacy et al)

• LAC preferred Rx non metastatic colonic cancer
• dec. morbidity
• dec. LOS
• improved long term outcome (StageIII)
• Acceptable port-site recurrence (lt1)

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Discussion(1)

• 1st RCT show inc. survival
• But small no.s / FU lt4 yrs
• ?High recurrence rates
• ?Conversions

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Discussion(2)

• Low port-site recurrence(0.6)
• Initial reports 1.5-21
• 20 studies 1994-98 (gt2600 pts) 1.1
• Incisional recurrence open Sx 1
  
• Tomita et al 1999
• Stocchi et al 2000
• Hughes et al 1983

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Discussion(3)

• ?Long term complictns
• Adhesive SBO incisional hernia
• Lumley,Stitz et al Laparoscopic Colorectal
  Surgery for Cancer Intermediate to Long Term
  Outcomes Dis Colon Rectum 2002
• - 181 pts 71months FU (1991-2000)
• - Include rectal/metastatic
• - Recurrence(curative) 13.6
• - Port site recurrence 0.6
• - Conversions 6.6
• - Adhesive SBO 3
• - Incisional hernias 0.6

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Conclusion

• Results of small randomized trials for
  laparoscopic Mx colonic Ca promising with at
  least comparable intermediate/long term
  recurrence and survival rates
• Await multicentre trial results
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