Medical Articles

Laparoscopic Colorectal Surgery – Is this the Future?

Laparoscopic Colon Surgery

  • First laparoscopic cholecystectomy 1987 (France)
  • First lap right hemicolectomy 1991
  • Slow to take off
    • Long learning curve
    • Unique complications
    • Advantages less clear
    • Oncological concerns
      • Port site metastases
    • Given away by many surgeons by late 1990’s
    • Now enjoying a strong renaissance
      • Equipment manufacturers

Indications

  • Benign Disease
    • Diverticulosis
    • Crohn’s
    • Ulcerative Colitis
    • Rectal prolapse
    • Endometriosis
  • Neoplastic
    • Polyps
    • Colon Carcinoma
    • Rectal carcinoma

Laparoscopic colorectal surgery

  • Potential benefits:
    • Smaller wounds
    • Less pain
    • Early return of bowel function
    • Early discharge
    • Early return to normal activities
    • Improved long term outcome?
  • Not as universally accepted as:
    • Cholecystectomy
    • Fundoplication
    • Adrenalectomy

Why?

  • Complex procedures
    • Learning curve
    • Long procedures
    • Expensive instruments
    • New complications
  • Most colorectal procedures are for malignancy
    • Oncological safety debated
      • Port site recurrences
      • Long-term survival

Laparoscopic Surgery

Laparoscopic Colorectal Surgery

What really matters?

  • Operative death rate
  • Major complications
  • Long term survival
  • Tumour recurrence
  • Length of incision
  • Pain scores during first week
  • Return of bowel function
  • Hospital stay
  • Cost

Evidence to Support Laparoscopic Colorectal Surgery

  • Clinical Effectiveness
    • Shorter length of stay
    • Fewer complications
    • Less blood loss & use of blood products
    • Less pain & analgesia
    • Quicker return to normal activities
    • Better cosmesis
    • Incidence of port site metastases is 1%
    • Equivalent to open surgery

COST trial

  • 872 patients
  • 428 open, 435 lap
  • 66 surgeons at 48 institutions
  • R & L colon ca only
  • Primary end point – tumour recurrence
  • Recurrence att 3 years
    • 16% laparoscopic vs 18% open
  • Surviivall att 3 years
    • 86% laparoscopic vs 85% open
  • Laparoscopic benefits:
    • Shorter LOS ( 5 vs 6 days)
    • Reduced use of narcotics (3 vs 4 days)
    • Reduced use of oral analgesia (1 vs 2 days)

CLASICC trial

  • 794 patients
  • 526 laparoscopic, 268 open
  • 32 surgeons (83% of patients recruited from surgeons >20 patients)
  • Colon and rectal cancer

CLASICC trial - uniqueness

  • Central pathology analysis
  • Pathological endpoints
  • Inclusion of rectal cancer cases
  • LR as effective as OR for collon cancer
  • Pathological features after LR “do not yet justify routine use in rectal cancer”

Summary of the evidence to date

  • Randomised controlled trials 4
  • Non-RCT with contemporaneous controls 11
  • Non-RCT with historical controls 4

Duration of operation (mins)

LAP: OPEN: p
Hewitt et al : 165 : 107 : .02
Stage et al : 150 : 95
Lacy et al : 149 : 111
Milsom et al : 200 : 125 : .001

Post-operative Pain

  • Hewiitt et all RCT morphine use in 48 hours: 27 vs 62mg p=0.04, but intention to treat violation
  • Non-RCTs
  • Consistent difference in favour of laparoscopy

Return of bowel function

  • Lacy et al RCT retturn to solid food: 51 vs 99 hours p<0..01
  • Non-RCTs 2 favoured laparoscopy 2 no difference

Hospital stay (days)

  • LAP: OPEN : p
  • Hewitt et al : 6 : 7
  • Lacy et el 5.2 : 8.1 : .006
  • Stage et el 5 : 8 : .01

Quality of life

  • 428 patients
  • Quality of life questionnaires at:
  • Baseline
    • 2 days
    • 2 weeks
    • 2 months
    • Only significant difference was global score at 2 weeks

Peri-operative death rate

  • 0% in all RCTs
  • 0% – 7% reported for laparoscopic procedures
  • 0% - 6% reported for open procedures

No significant differences No obvious trends

Operative complications

  • RCTs no meaningful data
  • Non-RCTs 1trial - fewer complications in lap group
    3 trial - more complications in lap group
  • Trend towards more complications in laparoscopic group.

Summary of short term outcomes

  • Longer operations
  • Less pain
  • Early return to bowel function
  • Shorter hospital stay
  • Improved global quality of life at 2 weeks
  • No difference in death rate
  • No significant difference in complications

Long-term data

  • Port site recurrences
  • Survival
  • Disease free survival
  • Recurrence
  • (Lymph node harvest)

Port site recurrence

  • Early reports 1.5% - 21%
  • Mechanical contaminatiin
    • Direct tumour contamination
    • Seeding on instruments
    • Seeding during specimen removal
    • Aerosol effect
  • Metabolic/immunological factors
  • Haematogenous spread
  • Allardyce 1999
    1769 laparoscopiic cases
    .85%
  • Reilly et al 1996
    1711 conventional open cases
    64 wound recurrence
  • Avoidance of traumatic tumour handling
  • Protected tumour extraction
  • Responsible for reluctance to embrace laparoscopic colorectal surgery for cancer in UK

Long-term survival rates

  • Lacy et al RCT 1.61 odds ratio (0.47-51)
  • Leung et al non-RCT
    5 year survival
    Laparoscopic 90.9%
    Open 55.6%
  • No significant difference due to selection bias

Lacy et. Al (Lancet 2002)

  • Randomized trial non-metastatic colon cancer (recttal excluded)
  • Aim: Assess differences in cancer-related survival between laparoscopiic and open collectomy

Laparoscopic Colorectal Surgery

Figure 3. Kaplan-Meier estimates of cancer-related survival LAC=laparoscopy-assisted colectomy; OC=open colectomy.

Recurrence rates

  • Little meaningful data
  • 4% tto 16% recurrence rates reported
  • No major differences between laparoscopic and open

Summary of long-term data

  • Port site recurrences probably not a major issue
  • Very little data on survival and tumour recurrence, but no major differences apparentt
  • More large, long follow up RCT’s awaited

Markers of oncological quality

  • Lymph node harvestt 2 RCTs, 7 non-RCTS no differences in node harvest rate blinded

Potential other benefits of laparoscopic colorectal surgery

  • Less immunosuppresiion
    • Wu et al 2003: no differences in peritoneal and systemic immune response
  • Reduced adhesions formation
    • Beck et al 1999: reduced episodes of small bowel obstruction

Cost analysis

Open vs llaparoscopiic siigmoiid resecttiion (diiverttiicullar diisease)

  • Lap costt per case - $3458 +//- 437
  • Open costt per case - $4321 +//- 501

Patients’ perceptions

“Patients intuitively perceive that laparoscopic procedures are more advantageous tthan open operations”

Other minimal invasive options in colorectal disease

  • Colonic stenting
  • Transanall endoscopiic Microsurgery

COLONIC STENTS

  • Treatment of malignant large bowel obstruction
    • Inserted by colonoscopy under endoscopic or fluoroscopic control (or both)
    • Avoid emergency laparotomy with colostomy
  • Best for left sided cancers
    • Right and transverse colon cancers can be treated by resection and anastomosis
    • Rectal cancers rarely obstruct (and stent migrates out)
  • Two situations
    • Palliative
    • ‘Bridge’ to definitive curative surgery

TEM RESULTS

  • Excellent results for polyps
    • Low recurrence rate
    • Avoidance of major resection and permanent or temporary stoma
    • Probably gold standard of care
  • ? Role in malignant disease
  • Recurrence rate (T1 and T2 on endoulltrasound)
    • Mellegren 2000 28%
    • Floyd 2006 7.5% (T1 only)
    • Bregahol 2007 15%
    • Whithouse 2008 26%
    • Winde 1996 4.1% (T1 only)

The future

  • Robotic surgery
  • Natural orifice surgery

The da Vinci surgical robot

Laparoscopic Colorectal Surgery