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Laparoscopic vs. Conventional Resections for Colorectal Carcinoma

Laparoscopic vs. Conventional Resections for Colorectal Carcinoma. 2LT Pil (Pete) Kang New York University School of Medicine 28 September 2000. Colorectal Cancer: Epidemiology. Second leading cause of death from cancer in the United States

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Laparoscopic vs. Conventional Resections for Colorectal Carcinoma

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  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

  4. 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)

  6. Colorectal Cancer: Diagnosis Barium enema • “Apple core” lesions • Filling defect

  7. Colorectal Cancer: Diagnosis Future: • virtual colonoscopy? Colonoscopy • Allows biopsy • Invasive Fenlon et al., NEJM Nov 1999; 341 (20)

  8. Staging of Colorectal Cancer

  9. Stage I & II Colorectal Cancers Treatment: Surgical resection • Colectomy • Low Anterior Resection (>12cm from AV) • Abdominoperineal Resection (<7-8cm 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

  10. Stage III Colorectal Cancers Treatment: Surgical resection Adjuvant therapy: • 5-FU and levamisole • Clinical trials • Radiation therapy for rectal cancer

  11. Stage IV Colorectal Cancers • Palliative resection to prevent obstruction/perforation • Diversion if unresectable • Resection of solitary liver metastasis • Chemotherapy

  12. Outcome of Patients with Colorectal Cancer Sabiston, Textbook of Surgery, 15th ed.

  13. Colorectal Cancer: Survival by Stage 1: Way, LW. Current Surgical Diagnosis & Treatment, 10 ed. 2: Poulin, et al. Ann Surg 1999;229(4)

  14. 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

  15. Anatomical Considerations

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

  17. 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 1999;229(4)

  18. 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 1999;229(4)

  19. Laparoscopic Surgery:Potential Advantages • Overall cost-effectiveness, better short-term outcomes (immediate post-op) • Lower postoperative mortality rate (pts>70 y.o.; pts w/ comorbid factors; pts w/ metastases) • Better biologic response to injury/SIRS • Better long term survival (???)

  20. Laparoscopic Surgery:Potential 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)

  21. 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?

  22. Hartley et al., Ann Surg 2000 Aug;232(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

  23. Disease Recurrence Rates: 24 months Differences between groups not statistically significant

  24. Overall Survival: 24 months LAP: solid CON: dotted (+’s are censored data) Hartley et al., Ann Surg 2000 Aug;232(2)

  25. Survival rates at 24 months Differences between groups not statistically significant

  26. Psaila et al., Br J Surg 1998 May;85(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 (P=0.001) • Mean morphine requirements: LAP<CON • Adequate margins achieved • Number of lymph nodes harvested similar • No port site or wound recurrence

  27. Milsom et al., J Am Coll Surg 1998 Jul;187(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 (P=0.01) • Morphine requirements up to POD#2 (mg/kg/d): LAP 0.78 ± 0.32 CON: 0.92 ± 0.34 (P=0.02) • Flatus (POD): LAP: 3 CON: 4 (P=0.006)

  28. Milsom et al., J Am Coll Surg 1998 Jul;187(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 (P=0.16) • Tumor margins clear in all patients • No port-site recurrence in LAP group

  29. 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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