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Current Status of Laparoscopy for Colon and Rectal Cancer. Chairman, Department of Colorectal Surgery 21st Century Oncology Chair in Colorectal Surgery Chief of Staff Cleveland Clinic Florida Professor of Surgery, Ohio State University Health Sciences Center at the

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current status of laparoscopy for colon and rectal cancer

Current Status of Laparoscopy for Colon and Rectal Cancer

Chairman, Department of Colorectal Surgery

21st Century Oncology Chair in Colorectal Surgery

Chief of Staff

Cleveland Clinic Florida

Professor of Surgery, Ohio State University

Health Sciences Center at the

Cleveland Clinic Foundation

Clinical Professor of Surgery,

University of South Florida College of Medicine

Clinical Professor of Biomedical Science

Department of Biomedical Science

Florida Atlantic University College of Medicine

Steven D Wexner, MD, FACS, FRCS, FRCS (Ed)

Dan Enger Ruiz, MD

David Vivas, MD

Clinical Research Fellows

laparoscopy colorectal cancer
Laparoscopy: Colorectal cancer
  • Short term benefits
    • Bowel function recovery
    • Quality of life (including pain)
    • Hospital stay
  • Costs
  • Long term benefits
    • Recurrence
    • Survival
laparoscopy colorectal cancer bowel function recovery1
Laparoscopy: Colorectal cancerBowel Function Recovery
  • The evidence that laparoscopy offers faster bowel function recovery than the traditional open approach may be considered high (Level I)
laparoscopy colorectal cancer quality of life
Laparoscopy: Colorectal cancerQuality of life
  • Randomized trial (COST trial)
  • 449 patients
  • 228 Laparoscopy (Lap) , 221Open
  • Pain, hospital stay
  • Quality of life (2 days, 2 weeks, 2 months)
    • Symptom distress scale
    • Quality of life index
    • Global rating scale (1-100)

Weeks, JAMA 2002

results
Results

P = N.S.

Weeks, JAMA 2002

results1
Results

Values are means

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

Weeks, JAMA 2002

laparoscopy colorectal cancer1
Laparoscopy: Colorectal cancer
  • The superiority of laparoscopy in reducing pain during the same length of the postoperative period seems evident (Level I)
  • Other aspects of quality of life warrant further investigation
laparoscopy colorectal cancer hospital stay1
Laparoscopy: Colorectal cancerHospital stay
  • There is high evidence (Level I) that laparoscopy for malignancy is associated with an earlier discharge compared to laparotomy
laparoscopy colorectal cancer cost
Laparoscopy: Colorectal cancerCost
  • Randomized, prospective trial
  • Subset of patients from the Swedish COLOR trial
  • Study period – 12 weeks after surgery
  • Analysis of direct medical cost (hospital and outpatient) and indirect cost (loss of productivity)

Janson, BJS 2004

laparoscopy colorectal cancer cost1
Laparoscopy: Colorectal cancerCost

Prospective, Randomized - COLOR

Janson, BJS 2004

All costs in Euros

laparoscopy colorectal cancer cost2
Laparoscopy: Colorectal cancerCost

Prospective, Randomized - COLOR

Janson, BJS 2004

laparoscopy colorectal cancer cost3
Laparoscopy: Colorectal cancerCost
  • Total cost to society similar in both groups
  • Direct costs to healthcare system much higher for LCR
    • Higher OR cost
    • Cost of complications and reoperation which happened more often in LCR
  • Same length of stay in both (9 days)
  • Faster recovery and return to work offset higher healthcare system cost

Janson, BJS 2004

laparoscopy colorectal cancer costs
Laparoscopy: Colorectal cancerCosts
  • The data available do not provide adequate evidence on whether total costs significantly differ between laparoscopy and laparotomy in the treatment of malignancy. Costs may significantly vary depending on the healthcare system
laparoscopy colorectal cancer randomized controlled trial
Laparoscopy: Colorectal cancerRandomized Controlled Trial
  • 111 Laparoscopy vs. 106 Laparotomy
  • Non metastatic colon cancer
  • Median follow-up time: 43 (27-85) months
  • Postoperative chemotherapy for all suitable patients with Stage II or III rectal cancer
  • Intention-to-treat analysis

Lacy et al, The Lancet 2002

laparoscopy colorectal cancer recurrence
Laparoscopy: Colorectal cancerRecurrence

Lacy et al, The Lancet 2002

laparoscopy colorectal cancer survival
Laparoscopy: Colorectal cancerSurvival

Lacy et al, The Lancet 2002

laparoscopy colorectal cancer predictive factors
Laparoscopy: Colorectal cancerPredictive factors

Cox’s regression model

Lacy et al, The Lancet 2002

slide24

Laparoscopic Colectomy: Cancer

  • Laparoscopic resection of colorectal malignancies
    • a systematic review
  • English language
  • Randomized controlled trials
  • Controlled clinical trials
  • Case series/reports

Chapman et al. Ann Surg 2001

slide25

Laparoscopic Colectomy : Cancer

  • 52 papers met inclusion criteria
    • “Little high level evidence was available”
    • “The evidence base for laparoscopic-assisted reection of colorectal malignancies is inadequate to determine the procedures safety and efficacy”

Chapman et al. Ann Surg 2001

slide26

Laparoscopic Colectomy : CancerDisadvantages vs. Open Colectomy

  • Significantly longer operative times
  • Possibly more expensive
  • Possibly worse short term immune effects

Chapman et al. Ann Surg 2001

slide27

Laparoscopic Colectomy : Cancer

  • “Laparoscopic resection of colorectal malignancy was more expensive and time-consuming”
  • The new procedure’s advantages revolve around early recovery from surgery and reduced pain”

Chapman et al. Ann Surg 2001

slide28

Laparoscopic Colectomy : CancerAdvantages vs. Open Colectomy

  • Improved cosmesis (no data but appears uncontentious)
  • Quicker hospital discharge
  • Less narcotic use, though possibly larger benefits for certain types of colectomy (low colonic)
  • Possibly less pain at rest, at least for patients who have uncovered procedures
  • Possibly earlier return of bowel function and resumption of normal diet

Chapman et al. Ann Surg 2001

laparoscopic colectomy cancer
Laparoscopic Colectomy : Cancer
  • Short term Quality-of-Life outcomes Following Laparoscopic-Assisted Colectomy vs Open Colectomy for Colon Cancer (COST Study)
  • AIMS
    • Are disease free and overall survival equivalent ?
    • Is laparoscopic approach associated with better QOL ?

Weeks et al. JAMA 2002

laparoscopic colectomy cancer1
Laparoscopic Colectomy : Cancer
  • Randomized control trial
  • 449 patients
    • Adenocarcinoma of single segment of colon
    • Excluded: Acute presentation, rectal and transverse colon cancers, advanced local disease, those lesions with evidence of metastatic disease, ASA IV or V
  • Quality of surgery:
    • All surgeons with > 20 cases; Random audit of cases

Weeks et al. JAMA 2002

laparoscopic colectomy cancer2
Laparoscopic Colectomy : Cancer
  • Outcomes:
    • Survival: still pending
    • QOL at 2days, 2 weeks and 2 months using:
      • Symptom Distress Scale, Global QOL Scale, QOL index
  • Results: Intention to Treat Analysis
    • Shorter use of narcotics
    • Shorter length of stay by 0.8 days (p<0.01)
    • Quality of life: no difference

Weeks et al. JAMA 2002

laparoscopic colectomy cancer3
Laparoscopic Colectomy : Cancer
  • Conclusions
    • “The modest benefits in short term QOL measures we observed are not sufficient to justify the use of this procedure in the routine care setting”
  • Unresolved Issues:
    • Blunting of QOL differences via analgesic use
    • QOL differences between POD 2 and POD 14
    • Recurrence and survival outcomes
    • Incidence of small bowel obstruction

Weeks et al. JAMA 2002

laparoscopic colectomy prospective randomized controlled
Laparoscopic Colectomy : Prospective, Randomized, Controlled
  • 48 institutions, 872 patients
  • Prospective, randomized
  • Follow-up 4.4 years
  • Conversion 21%
  • End point was time to tumor recurrence

Nelson, NEJM 2004

prospective randomized controlled outcome
Prospective, Randomized, Controlled: Outcome

*Laparoscopic procedure not significantlyinferior to Open Procedure.

Nelson, NEJM 2004

prospective randomized controlled conclusions
Prospective, Randomized, Controlled: Conclusions
  • No difference between:
    • Time to recurrence
    • Disease-free survival
    • Overall survival
  • Oncologic outcome of laparoscopic resection is similar to that of open resection
  • Laparoscopic approach is associated with less pain and a shorter hospital stay than conventional surgery

Nelson, NEJM 2004

laparoscopic colectomy clasicc trial colon and rectal cancer
Laparoscopic Colectomy : CLASICC Trial Colon and Rectal Cancer
  • 27 UK institutions, 794 patients
  • Prospective, randomized, controlled
  • Follow-up at 1 and 3 months
  • 29% conversion rate

Guillou, Lancet 2005

laparoscopic colectomy clasicc trial colon and rectal cancer1
Laparoscopic ColectomyCLASICC Trial Colon and Rectal Cancer
  • Positivity rates of circumferential and

longitudinal resection margins

  • Proportion of Dukes’ C2 tumors
  • In-Hospital mortality

Primary Endpoints

  • Complication rates
  • Quality of life
  • Transfusion requirments

Secondary

Endpoints

Guillou, Lancet 2005

slide43

CLASICC Trial Profile

Guillou, Lancet 2005

clasicc outcome at surgery
CLASICC: Outcome at Surgery

All data are median

Guillou, Lancet 2005

clasicc pathology
CLASICC: Pathology

P>0.05

Guillou, Lancet 2005

clasicc complications
CLASICC: Complications

P > 0.05

Guillou, Lancet 2005

clasicc complications1
CLASICC: Complications

P>0.05

Guillou, Lancet 2005

clasicc conversions
CLASICC: Conversions

Guillou, Lancet 2005

laparoscopic colectomy prospective randomized controlled1
Laparoscopic Colectomy : Prospective, Randomized, Controlled

Outcome at 3 years

Equivalent in terms of recurrence and survival

Kaiser, J Lap and Advanced Surg Tech 2004

laparoscopy vs open colon cancer
Laparoscopy vs. Open: Colon Cancer

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

Abraham, BJS 2004

laparoscopy vs open colon cancer1
Laparoscopy vs Open: Colon Cancer

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

Abraham, BJS 2004

laparoscopy vs open colon cancer2
Laparoscopy vs Open: Colon Cancer

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

Abraham, BJS 2004

laparoscopy colon cancer conclusion
Laparoscopy: Colon CancerConclusion
  • Laparoscopy for colon cancer has shown to be potentially superior to laparotomy in regard to short-term benefits and equivalent with regard to long term benefits
  • Available data appear to support that laparoscopic colectomy and conventional open colectomy have either similar or superior long-term outcomes (Level 1 evidence)
  • Surgeons with sufficient expertise and ongoing peer-reviewed data collection may offer this therapy to appropriately selected patients
laparoscopy vs open colectomy in cancer patients2
Laparoscopy vs. Open Colectomy in Cancer Patients

Five-Year Survival by Cancer Stage

Braga, DCR 2005

laparoscopy vs open colectomy in cancer patients3
Laparoscopy vs. Open Colectomy in Cancer Patients

Five-year Disease-Free Survival

Braga, DCR 2005

laparoscopy vs open colectomy in cancer patients4
Laparoscopy vs. Open Colectomy in Cancer Patients

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

Braga, DCR 2005

laparoscopy rectal cancer total mesorectal excision
Advantages

Amplification of planes of mesorectum and pelvic fascia

30 degree laparoscope better visibility in narrow pelvis

Easier identification of pelvic autonomic nerve plexus

Disadvantages

Technically demanding

Absence of tactile sensation

Difficulty in assessing surgical margins

Difficulty in ultralow cross-clamping

Learning curve

Laparoscopy: Rectal CancerTotal Mesorectal Excision
laparoscopy total mesorectal excision tme
Laparoscopy: Total Mesorectal Excision (TME)
  • Prospective review – 58 months
  • Control group – open rectal resections
    • Second consultant
    • Same unit(21 vs. 22)

Hartley et al. DCR 2001

laparoscopy total mesorectal excision tme1
Laparoscopy: Total Mesorectal Excision (TME)

42 Attempted Laparoscopic Rectal Mobilizations

14 Early Conversions

28 Laparoscopic Rectal Dissections

7 AP Resections

21 Anterior Resections

1 Non CurativeResection

6 Partial OpenDissection

6 Total Laparoscopic AP

15 Total Laparoscopic AR

21 Laparoscopic TME – Study Group

Hartley et al. DCR 2001

laparoscopy total mesorectal excision tme2
Laparoscopy: Total Mesorectal Excision (TME)

* Includes the one palliative lap. APR

Hartley et al. DCR 2001

laparoscopy total mesorectal excision tme3
Laparoscopy: Total Mesorectal Excision (TME)
  • Reason for Conversion Number
    • Fixed tumor 2
    • Doubtful resectability 4
    • Gross obesity 2
    • Dense adhesions 2
    • Obstructed sigmoid 1
    • Ureter not identified 2
    • Camera failure 1
    • TOTAL 14 (33%)

Hartley et al. DCR 2001

laparoscopy total mesorectal excision tme4
Laparoscopy: Total Mesorectal Excision (TME)

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

Hartley et al. DCR 2001

laparoscopy total mesorectal excision tme5
Laparoscopy: Total Mesorectal Excision (TME)

Values are medians (interquartile ranges)

* p=0.003, Mann-Whitney test for nonparametric data vs. open cases

† Includes the one palliative lap. APR

Hartley et al. DCR 2001

laparoscopy total mesorectal excision tme6
Laparoscopy: Total Mesorectal Excision (TME)

* P = 0.329 Fisher’s exact test vs. open group

† Includes the one palliative lap. APR

Hartley et al. DCR 2001

laparoscopy total mesorectal excision tme7
Laparoscopy: Total Mesorectal Excision (TME)

Follow-up for Patients Having Curative Laparoscopic and Open Resections

For Rectal Cancer, Including Complete Mesorectal Excision

* Median follow-up was 38 (range, 6-53) months

† p=1 and † P=0.736, Fisher’s exact test

Hartley et al. DCR 2001

laparoscopy total mesorectal excision tme8
Laparoscopy: Total Mesorectal Excision (TME)
  • Feasible in 50% of patients where possible
  • Yields histologic and early survival and recurrence figures comparable to open surgery

Hartley et al. DCR 2001

laparoscopy total mesorectal excision tme case control study
Laparoscopy: Total Mesorectal Excision (TME) case control study

Breukink, Int J Colorectal Dis 2005

slide73

Laparoscopy: Rectal Cancer

Case controlled series for LAR

laparoscopy total mesorectal excision tme case control study1
Laparoscopy: Total Mesorectal Excision (TME) case control study

Breukink, Int J Colorectal Dis 2005

slide75

Laparoscopy: Rectal Cancer

Case controlled series for LAR

slide76

Laparoscopy: Rectal Cancer

Case controlled series for APR

slide77

Laparoscopy: Rectal Cancer

Case controlled series for APR

laparoscopy rectal cancer
Laparoscopy: Rectal Cancer

Prospective, Randomized, Controlled – Short-term outcome

of TME with anal sphincter preservation (ASP)

Zhou, Surg Endosc 2004

laparoscopy rectal cancer1
Laparoscopy: Rectal Cancer

Zhou, Surg Endosc 2004

laparoscopy rectal cancer2
Laparoscopy: Rectal Cancer

Zhou, Surg Endosc 2004

laparoscopic sphincter preserving tme with colonic j pouch reconstruction
Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstruction
  • 105 patients
  • Mean follow up time 26.9 (1.3-65.6) months

Tsang WWC, Ann Surg 2006

laparoscopic sphincter preserving tme with colonic j pouch reconstruction1
Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstruction
  • Mean operative time 170.4 min
  • Mean anastomotic distance from anal verge 3.9 cm
  • Mean circumferential margin 17.1 mm
  • Mean distal margin 3.4 cm

Tsang WWC, Ann Surg 2006

laparoscopic sphincter preserving tme with colonic j pouch reconstruction2
Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstruction
  • 5-year cancer-specific survival rate 81.3%
  • Local recurrence rate 8.9%

Tsang WWC, Ann Surg 2006

laparoscopic sphincter preserving tme with colonic j pouch reconstruction3
Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstruction

Conclusion

Lap TME with colonic J-pouch is a safe procedure with reasonable operating time and does not appear to pose any threat to the oncologic and functional outcomes

Tsang WWC, Ann Surg 2006

laparoscopic vs open surgery for extraperitoneal rectal cancer
Laparoscopic vs. Open Surgery for Extraperitoneal Rectal Cancer
  • 191 consecutive patients
  • 98 patients underwent lap resection
  • 93 patients underwent open resection

Morino M, Surg Endosc 2005

laparoscopic vs open surgery for extraperitoneal rectal cancer3
Laparoscopic vs. Open Surgery for Extraperitoneal Rectal Cancer

Conclusion

Laparoscopic resection for low and midrectal cancer is characterized by faster recovery and similar overall morbidity with no adverse oncologic effect

Morino M, Surg Endosc 2005