Evidence-Based Laparoscopic Surgery For Colorectal Cancer Ahmed M. Hussein, DrCh, PhD Professor of Colon & Rectal Surgery University of Alexandria, EGYPT
Pain Postop. Ileus Adhesions Incisional hernias Epithelial progenitor cell mobilization Cosmesis Reconvalescence Respiratory function Immune function Pro Minimal Invasive Surgery
GastroIntestinal QOL - Index n = 30 Chir Gastroenterol 2001; 17(suppl 2) : 34 - 38.
Issues under Discussion • Immune response ? • Tumor cell mobilization ? • Port-site metastasis ? • Technical feasibility ? • Oncologic radicality ?
Immune Function After Laparoscopic Surgery • Lap Surgery diminishes • Tissue damage • Degree of activation of pro-inflamatory cytokines • Leucocytosis & neutrophilia • No difference in phagocytic or enzymatic activities of neutrophils Hussein et al., Med Sci Res 1997
Is immune response positively influenced by laparoscopic surgery? • Reduction of trauma • Less immunosuppression ? • Impact on prognosis ?
Laparoscopy in CRC New aspects in the future? Percent of endothelial progenitor cells in the bone marrow Percent of endothelial progenitor cells in peripheral blood Condon ET et al, Surg Endosc 2007
Port-site Metastasis: What is reality in 2007? • Actual rate of port-site metastasis is much lower than initially reported (<1%) • No difference to wound recurrence after laparotomy • Influence of the learning curve • => Surgeon is the causative factor
Principals of Colorectal Surgery • Identification of the ureter • Protection of the autonomic nerves • Ligature of the supplying vessels • Lymphadenectomy • Intraabdominal mobilization and resection Laparoscopic = Open surgery
Laparoscopic Surgery for CRC Oncologic Radicality ?
“..I never once had a patient ask me about the size of the incision, but rather, what are the chances of survival ?” Prof. Henri Bismuth Paris
Clinical Question • Can laparoscopic surgery be recommended as an alternative to conventional open surgery for patients with curable colorectal cancer based on a comparison of outcomes? • Primary outcomes: • Survival • Recurrence • Adverse event rates • Secondary outcomes: • Operating time • Hospital stay
CLASSIC-Study (Great Britain) • LS vs. OS for CRC n=794 • OR time increased • Shorter hospital stay • Comparable QOL • Mortality & oncologic outcome comparable Guillou, Lancet 2005
COLOR-Study (Europe) • LS vs. OS for CRC n=1248 • OR time increased • Shorter hospital stay • Faster oral nutrition • Less postoperative pain • Mortality & oncologic outcome comparable Lancet Oncol 2005
COST Study Group (USA) • LS vs. OS for CRC n=872 median FU 4.1 yrs • Comparable local recurrence rate • OR time increased • Shorter hospital stay • Faster oral nutrition • Comparable QOL • Mortality & oncologic outcome comparable N Engl J Med 2004
Meta-analysis Survival Recurrence Cancer Care Ontario (CCO); 2005
Meta-analysis(12 RCTs) • LS vs. OS for CRC n=2512 • OR time increased • Postop. Ileus, analgesics, reconvalescence & hospital stay decreased • Less impairment of pulmonary function • Complications decreased (wound infection) • Mortality & oncologic outcome comparable Abraham et al., Br J Surg 2004
Meta-analysis (26 RCTs) Mortality Anastomotic Leakage Morbidity Böhm, Chir Allg, 2007
Meta-analysis (26 RCTs) OR - Time Bowel Movement Hospital Stay Böhm, Chir Allg, 2007
Lymph Node Harvest RCT: LC vs. OC
TME: Laparoscopic vs. Open 48 studies, 4224 Pts 33 prospective studies 8 retrospective studies 7 not classified studies 33 patient series 15 cohort studies => Currently no prospective randomized studies Breukink, Cochrane Library, 2007
TME: Laparoscopic vs. Open Oncological Results Advantages of laparoscopic TME: Blood loss, oral nutrition, postoperative pain and immune response No significant difference for: Disease-free survival, local recurrence, mortality, morbidity, resection margins, lymph node harvest, anastomotic leakage Breukink, Cochrane Library, 2007
TME: Laparoscopic vs. Open Pathological Results => No significant difference for macroscopic and pathological quality Breukink, Surg Endosc, 2005
Laparoscopic TME for Rectal Cancer • No differences in oncologic radicality (specimen length, radial margins, No. lymph node) • Lap. TME provides adequate survival & recurrence • Lap. APR with TME does not compromise cancer-specific prognosis outcome Hartley et al., DCR 2002 Poulin et al., Surg Endosc 2002 Baker et al., DCR 2002
Laparoscopic Surgery for CRC Summary & Conclusions • Laparoscopy • Reduction of trauma • Patients` comfort • For Colon Cancer: • Laparoscopic surgery adequate (Ia level evidence) • For Rectal Cancer: • Randomized multicenter studies missing
ASCRS & SAGES Position Statement: Lap Colectomy for Curable Colon Cancer • Laparoscopic colectomy for curable cancer results in equivalent cancer related survival to open colectomy when performed by experienced surgeons • Adherence to standard cancer resection techniques including but not limited to: • Complete exploration of the abdomen • Adequate proximal and distal margins • Ligation of the major vessels at their respective origins • Containment & careful tissue handling • En bloc resection with negative tumor margins The COST Study Group. N Engl J Med 2004 Endorsed by SAGES
ASCRS & SAGES Position Statement: Lap Proctectomy for Curable Rectal Cancer • ASCRS & SAGES recognize that laparoscopic proctectomy may be an alternative to traditional resection of benign disease involving the rectum • The absence of five-year survival data makes it premature to endorse laparoscopic proctectomy for curable cancer Guidelines for Laparoscopic Resection of Curable Colon and Rectal Cancer. SAGES publication #32 ASCRS Practice Parameters for the Management of Rectal Cancer (Revised). Dis Colon Rectum 2005
Professional Practice Question • What is the recommended experience & training for surgeons who perform laparoscopic surgeries for CRC?
Lap Colectomy for Curable Colon Cancer • COST* trial, pre-requisite experience • At least 20 laparoscopic colorectal resections with anastomosis for benign disease or metastatic colon cancer before using the technique to treat curable cancer • Hospitals credentials for lap colectomy for cancer based on: • Experience gained by formal graduate medical educational training • Advanced laparoscopic experience • Participation in hands-on training courses • Outcomes * The COST Study Group. N Engl J Med 2004 Endorsed by SAGES
Lap Proctectomy for Curable Rectal Cancer • It is only appropriate to perform laparoscopic proctectomy for curable cancer in an environment where the outcomes can be meaningfully evaluated • The ASCRS & SAGES consider laparoscopic proctectomy to be within the expertise of trained surgeons who focus on the treatment of rectal cancer Guidelines for Laparoscopic Resection of Curable Colon and Rectal Cancer. SAGES publication #32 ASCRS Practice Parameters for the Management of Rectal Cancer (Revised). Dis Colon Rectum 2005
Institutional Question • What are the recommended criteria for institutions performing laparoscopic surgeries for cancer of the colon?
Institutional Recommendations • LCCSEP recommendationsall eligible institutions should show a commitment to advanced laparoscopic surgery by providing • Appropriate equipment • Operating room time • Human resources • Developing a team approach • Optimal results in laparoscopic surgery for CRC depend on a commitment to appropriate equipment & resources