The influence of a pneumoperitoneum on the peritoneal implantation of free intraperitoneal colon cancer cells

Successful resection of port site recurrence of pancreatic ductal adenocarcinoma after laparoscopic distal pancreatectomy

BACKGROUND

There are many reports of port site recurrence after laparoscopic surgery for various types of cancer. However, only two cases of port site recurrence after laparoscopic pancreatectomy have been reported to date. We herein report a case of port site recurrence after laparoscopic distal pancreatectomy.

CASE PRESENTATION

A 73-year-old woman was diagnosed with pancreatic tail cancer and underwent laparoscopic distal pancreatectomy with splenectomy. Histopathological examination revealed pancreatic ductal carcinoma (pT1N0M0 pStage I). The patient was discharged on postoperative day 14 with no complications. However, 5 months after surgery, computed tomography showed a small tumor at the right abdominal wall. No distant metastasis had appeared after 7 months of follow-up. Under the diagnosis of port site recurrence without any other metastases, we resected this abdominal tumor. Histopathological examination showed port site recurrence of pancreatic ductal carcinoma. No recurrence was observed 15 months postoperatively.

CONCLUSIONS

This is the report of successful resection of port site recurrence of pancreatic cancer.

Port site recurrence of esophageal adenocarcinoma after minimally invasive esophagectomy: a case report

BACKGROUND

Port site recurrence has been observed after a variety of oncologic resection procedures. However, few have reported port site recurrence of esophageal cancer.

CASE PRESENTATION

A 51-year-old man underwent minimally invasive esophagectomy for pT3(AD)N3M0 adenocarcinoma of the esophagus. One year after surgery, he presented with a rapidly growing tumor on the right thoracic wall. Contrast computed tomography demonstrated an enhancing tumor with uptake on positron emission tomography. We performed resection of the thoracic wall, including the skin and subcutis. The pathologic diagnosis was poorly differentiated adenocarcinoma, consistent with metastasis of esophageal origin.

CONCLUSION

This was the first report on thoracic port site recurrence of esophageal adenocarcinoma. We recommend elimination of leakage around the thoracoscopic ports to prevent such recurrence. We should provide prudent postoperative clinical surveillance.

Port-Site Metastases and Chimney Effect of B-Ultrasound-Guided and Laparoscopically-Assisted Hyperthermic Intraperitoneal Perfusion Chemotherapy

PURPOSE

CO₂ leakage along the trocar (chimney effect) has been proposed to be an important factor underlying port-site metastasis after laparoscopic surgery. This study aimed to test this hypothesis by comparing the incidence of port-site metastasis between B-ultrasound-guided and laparoscopically-assisted hyperthermic intraperitoneal perfusion chemotherapy (HIPPC).

MATERIALS AND METHODS

Sixty-two patients with malignant ascites induced by gastrointestinal or ovarian cancer were divided into two groups to receive either B-ultrasound-guided or laparoscopically-assisted HIPPC. Clinical efficacy was assessed from the objective remission rate (ORR), the Karnofsky Performance Status (KPS) score, and overall survival. The incidence of port-site metastasis was compared between the two groups.

RESULTS

Patients in the B-ultrasound (n=32) and laparoscopy (n=30) groups were comparable in terms of age, sex, primary disease type, volume of ascites, and free cancer cell (FCC)-positive ascites. After HIPPC, there were no significant differences between the B-ultrasound and laparoscopy groups in the KPS score change, ORR, and median survival time. The incidence of port-site metastasis after HIPPC was not significantly different between the B-ultrasound (3 of 32, 9.36%) and laparoscopy (3 of 30, 10%) groups, but significantly different among pancreatic, gastric, ovarian, and colorectal cancer (33.33, 15.79, 10.00, and 0.00%, p<0.001).

CONCLUSION

The chimney effect may not be the key reason for port-site metastasis after laparoscopy. Other factors may play a role, including the local microenvironment at the trocar site and the delivery of viable FCCs (from the tumor or malignant ascites) to the trauma site during laparoscopic surgery.

Does carbon dioxide pneumoperitoneum enhance wound metastases following laparoscopic abdominal tumor surgery? A meta-analysis of 20 randomized control studies

The mechanisms involved in the development of wound metastasis following laparoscopic abdominal tumor surgery remain unclear. The aim of this study was to accurately assess whether the duration of carbon dioxide pneumoperitoneum (CDP) during laparoscopic abdominal tumor surgery enhances wound metastases. We conducted a systematic review of PubMed, Cochrane Library, and Embase through December 2013 to identify animal experiments comparing wound recurrence between laparoscopic and gasless laparoscopic procedures or open procedures. The outcome of interest was the number of animals with a wound tumor. Meta-regression was used to assess whether heterogeneity was explained by study level covariates (animal model, study size, CDP pressure, duration, and evaluated time). Twenty randomized control studies involving 1,229 animals were included. Wound recurrence was not significant in the laparoscopic surgery (LP) vs. gasless laparoscopic surgery (GLP) subgroups [odds ratio (OR), 2.23; 95 % confidence interval (CI), 0.90-5.55; P = 0.08) or the LP vs. laparotomy (LA) subgroups (OR, 0.97; 95 % CI, 0.31-3.00; P = 0.08). Overall postoperative wound recurrence results were not significantly different between the study groups and controls (OR, 1.47; 95 % CI, 0.74-2.92; P = 0.28). A meta-regression analysis showed that the outcome was not correlated with the covariates (animal model: P = 0.82; evaluated time: P = 0.30; pressure of CDP: P = 0.12; duration time: P = 0.80). Current evidence suggests that CDP does not enhance wound metastases following laparoscopic abdominal tumor surgery. Additional large sample, well-designed, randomized, controlled trials are needed to further confirm whether CDP duration in laparoscopic abdominal tumor surgery significantly enhances wound recurrence.

Abdominoperineal Resection without an Abdominal Incision for Rectal Cancer Has the Advantage of No Abdominal Wound Complication and Easier Stoma Care

Abdominoperineal resection has been used for years for the management of low rectal cancer. However, the abdominal incision is associated with many complications and causes interference of the stoma care. If the abdominal incision can be avoided, it would be beneficial to the patient. The aim of the study is to evaluate the possibility and safety of performing abdominoperineal resection and the oncology result without an abdominal incision. From September 2001 to May 2010, 40 patients with rectal malignancies received excision of the rectum, anus, and perineum through a perineal incision and a skin hole created for stomy. No harmonic scalpel or laser was used during surgery. No laparoscope or hand port was used in the procedure. There were 19 males and 21 females. Age ranged from 31 to 87 years old (average, 62.9 years). There were 39 adenocarcinomas and one malignant gastrointestinal stromal cell tumor. There was no operative mortality. Six patients had postoperative complications; three patients had intestinal obstructions; and one patient each had bleeding, urinary tract infection, and colostomy separation from the skin. The lymph nodes in the specimens ranged from 9 to 33 cm (average, 16.8 cm). The survival is similar to the traditional abdominoperineal resection. This limited experience suggests that an abdominal incision is not necessary for radical resection of the rectum, anus, and perineum in patients with low-lying rectal cancer. It also offers the patient easier care of stoma without interference of the abdominal incision.

Technical innovation, standardization, and skill qualification for pediatric minimally invasive surgery in Japan

This is a presentation of sharing endeavors at modifying and standardizing surgical procedures as well as establishing endoscopic surgical skill qualification in the field of pediatric surgery in Japan.

The port site recurrence after a thoracoscopic and video-assisted esophagectomy for advanced esophageal cancer

INTRODUCTION

Thoracoscopic or video-assisted thoracic esophagectomies have been performed for the last 10 years. Nevertheless, some reports have showed a risk of dissemination with endoscopic or video-assisted surgery for malignant disease. This institute experienced three cases of port site recurrence after a thoracoscopic esophagectomy for advanced esophageal cancer. Following those cases, induction chemo-radiation therapy was performed for patient with advanced esophageal cancer before thoracoscopic or video-assisted esophagectomy. Since introducing induction chemo-radiation therapy, no patients have experienced port site recurrence after a thoracoscopic or video-assisted esophagectomy for advanced esophageal cancer. In this study, the two patients groups are compared before and after the introduction of induction chemo-radiation therapy.

PATIENTS AND METHODS

Between November 1995 and December 2005, thoracoscopic and video-assisted esophagectomies were performed on 112 (72.7%) patients out of 154 who underwent a surgical resection for thoracic and abdominal esophageal cancer. The histologic type of cancer was squamous cell carcinoma in 109 (97.4%) patients and adenocarcinoma in 3 (2.6%). Ninety-one patients were men and 21 were women. The tumor was located in the upper thoracic esophagus in 22 (19.6%) patients, the middle thoracic esophagus in 49 (43.8%), the lower thoracic esophagus in 34 (30.4%), and the abdominal esophagus in 7 (6.2%).

RESULTS

Before December 1999, port site recurrence occurred in three cases of those of 29 patients with clinical T2-T4 esophageal cancer from 3 to 6 months after surgery, and pleural dissemination was observed in two of those patients. Since January 2000, induction chemo-radiation therapy (low-dose fluorouracil and platinum + 40 Gy radiation) has been performed to 31 patients with clinical T2-T4 disease, and port site recurrence has not occurred in any patients who received trimodality therapy.

CONCLUSIONS

We think that the trend toward less port site recurrences with induction therapy should be examined in future studies of video-assisted thoracic surgery esophagectomy to confirm our findings.

Intra-Abdominal Lesions Could be Missed by Inadequate Laparoscopy

Laparoscopic resection has become one of the choices for colectomy for various colon and rectal diseases in recent years. Despite some uncertainties of laparoscopic procedures, especially during cancer surgery, its popularity has forced surgeons to pursue the approach. One of the concerns is inadequate examination of the intra-abdominal organs with a laparoscope. This study is a retrospective analysis of a single surgeon's experience of the frequencies of unexpected findings during laparotomies. From July 1990 to November 2005, 2775 patients with various colorectal diseases receiving laparotomies by a single surgeon were analyzed. Among them, 2282 patients were operated for primary colorectal cancer. Excluded were patients who did not receive a formal laparotomy, who had a recent laparotomy, who had peritoneal and omental metastasis, and whose pathology did not attract attention for management. Exploration of the entire peritoneal cavity was performed for all cases in the series. There were 1423 males and 1352 females. Ages ranged from 12 to 94 years, averaging 62.6-years-old. Forty-six patients (1.7%) were found to have unexpected intra-abdominal lesions during laparotomies. Eleven patients were found to have synchronous colorectal cancers; five patients were found to have unexpected liver metastases; three patients each were found to have gastric cancers, stromal tumors of the small bowel, and ectopic pancreas; two patients each were found to have gastric leiomyosarcomas, pancreatic cancers, mucoceles of the appendix, ulcers of the small intestine, bleeding Meckel's diverticula, pancreatitis, and perforations of the ileum; one patient each was found to have gall bladder cancer, malignant carcinoid tumor, pheochromocytoma, diverticulitis of the jejunum, diverticulitis of the colon, duplication of the colon, and aortic aneurysm larger than 6 cm. Forty-one of the lesions were likely to be missed by laparoscope. This experience suggests that incomplete laparotomies might miss various pathologies. Laparoscopy is not a complete form of laparotomy because of loss of tactile sensation. Laparoscopy might result in an inadequate or inappropriate management due to misdiagnosis.

Recurrence of cholangiogenous carcinoma in port-sites two years after laparoscopic removal of noncancerous gallbladder

We present a unique case of carcinoma diagnosed in port-site, two years after uncomplicated laparoscopic cholecystectomy for benign cholecystitis. Analysis of morphology and cytokeratin profile (CK19+ and CK20+/-) of resected port-site tumor allows us to establish the diagnosis of tubular carcinoma with probable cholangiogenic origin. The primary carcinoma was not diagnosed in archival gallbladder tissue, despite repeated histological examination. No other primary tumor was identified during follow-up. Patient history and histological/immunohistochemical picture of the recurrent tumor suggested that primary carcinoma was probably located in the gallbladder, but was not detected during initial and repeated histological examinations of postoperative specimen. The patient is still alive, 12 months after the first port-site recurrence and 36 months after initial laparoscopy.

Oncologic results of laparoscopic versus conventional open surgery for stage II or III left-sided colon cancers: a randomized controlled trial

INTRODUCTION

Minimal invasive surgical approach can achieve quick functional recovery. However, the oncologic outcome for cancer is still a concern. This study aims to compare the oncologic outcome between laparoscopic and open methods in the curative resection of Stage II or III left-sided colon cancers.

METHODS

In consideration of statistical power up to 90%, 286 eligible patients with curable left-sided colon cancer (Tumor-Node-Metastasis Stage II and Stage III disease) requiring the takedown of colonic splenic flexure to facilitate a curative left hemicolectomy were recruited randomly and equally allocated to the laparoscopic and open group. The primary endpoint was time-to-recurrence of tumor. Data was analyzed according to intention-to-treat principle.

RESULTS

Postrandomization exclusion occurred because of metastatic disease detected intraoperatively occurred in 13 patients and because of patient withdrawal from trial in 4. Therefore, 135 and 134 patients actually comprised the laparoscopic and open group, respectively. The median follow-up of patient was 40 months (range: 18-72 months). The oncologic results were similar (P = 0.362, one-sided log-rank test) in laparoscopic and open group of patients, with the estimated cumulative recurrence rate of 13.2% (9/68) versus 17.2% (11/64) in Stage II disease and 20.9% (14/67) versus 25.7% (18/70) in Stage III disease, respectively. The recurrence patterns were similar between the two groups. Both open and laparoscopic groups were comparable in the number of dissected lymph node (15.6 +/- 3.0 vs. 16.0 +/- 6.0, P = 0.489), various demographic and clinicopathologic parameters.

CONCLUSIONS

The estimated cumulative recurrence rate for the surgery of Stage II or III left-sided colon cancers was the same between laparoscopic and open methods.

ICAM-1 mediated peritoneal carcinomatosis, a target for therapeutic intervention

Development of peritoneal metastasis is a significant issue in the treatment of abdominal cancers. Primary interaction between tumour cells and the mesothelium is a vital step in initiating this process. Our aim was to determine the role of the intercellular adhesion molecule-1 (ICAM-1) in mesothelial-tumour adhesion and the effectiveness of therapeutic intervention. Mesothelial cells were derived from omental tissue. ICAM-1 expression in resting state, in the presence of TNF-alpha or after the application of heparin or hyaluronan was determined by flow cytometry. Functional effects on tumour adhesion to a mesothelial monolayer were determined via a Calcein-AM in vitro adhesion assay. In vivo studies were performed utilising 30 WAG/rij rats, which underwent mini-laparotomy with the injection of 1 x 10(5 )CC 513 tumour cells intraperitoneally. Tumour growth was assessed macroscopically and microscopically by two independent examiners. Mesothelial cells expressed high level of ICAM-1, which was up-regulated by the presence of TNF-alpha. The introduction of heparin caused a decrease in ICAM-1 expression, however hyaluronan did not affect the expression. A significant decrease in tumour-mesothelial cell adhesion in vitro and complete aberration of tumour growth in vivo was observed with heparin application. In vitro studies showed utilisation of high molecular weight hyaluronan, which was more limited in vivo. These data imply that heparin may be used as a potential therapeutic through a defined molecular mechanism both in vitro and in vivo. Hyaluronan appears to function as a barrier and hence may be unreliable in blocking peritoneal recurrence.

Feasibility of colectomy with mini-incision

BACKGROUND

Laparoscopic resection has been advocated as a method of colectomy for various colon and rectal disease. One advantage claimed by laparoscopy is its smaller incision size. The aim of the present study is to evaluate whether mini-incision is feasible along with the advantage of adequate exploration of the peritoneal cavity.

METHODS

From December 2000 to November 2003, 316 patients with various colorectal diseases receiving colectomies through a skin incision less than 7 cm were analyzed. All of the colectomies were performed by a single surgeon. Exploration of the entire peritoneal cavity was possible for all the cases. There were 153 men and 163 women. Ages ranged from 19 to 90 years, averaging 62.4 years. Two hundred ninety-five patients were operated on for carcinoma of the colon or rectum; 4 had operations for villous tumors with severe dysplasia; 3 each for radiation enterocolitis and diverticulitis; 2 each for malignant stromal tumor and rectal prolapse; and 1 each for lymphoma, actinomycosis, volvulus, angiodysplasia, Crohn's disease, ulcerative colitis, and ovarian cancer with rectal invasion. There were 15 abdominoperineal resections, 97 low anterior resection, 49 anterior resections, 64 sigmoidectomies, 7 left hemicolectomies, 81 right hemicolectomies, 2 subtotal colectomies, and 1 restorative proctocolectomy. No Harmonic scalpel or laser was used during surgery. No hand-port or laparoscope was used in the series.

RESULTS

Five patients died of acute respiratory failure, 2 patients died of terminal cancer, and 1 patient died of hypoglycemia due to poor control of diabetes mellitus. Complications included 11 urinary tract infections, 8 intestinal obstructions, 6 anastomotic leakages, 6 wound infections, 5 respiratory failures, 5 pelvic bleedings, 2 pneumonias, 2 gastrointestinal bleedings, and 1 pancreatitis. Small incisions did not prolong operation time.

CONCLUSION

This experience suggests that the majority of colectomies can be accomplished by an incision of less than 7 cm, which is no larger than the incision size used in a laparoscope colectomy if multiple incisions made for trocars are added to the main incision length. The advantages of mini-incision include lower cost, faster completion of procedure, reduced bulkiness of equipment, and the possibility of exploring the entire peritoneal cavity by hand without loss of tactile sensation.

Impact of taurolidin and octreotide on liver metastasis and lipid peroxidation after laparoscopy in chemical induced ductal pancreatic cancer

BACKGROUND

There is controversial discussion whether metastasis initiated by laparoscopy with carbon dioxide might be prevented by instillation of taurolidin or radical scavengers like the somatostatin analogue Octreotide. Therefore we evaluated the effects of laparoscopic lavage with taurolidin and Octreotide on liver metastasis after staging laparoscopy in ductal pancreatic cancer.

METHODS

In 60 Syrian hamsters pancreatic adenocarcinoma was induced by weekly subcutanous injection of 10 mg N-nitrosobis-2-oxopropylamin/kg body weight for 10 weeks. In the 16th week laparoscopic staging biopsy by use of carbon dioxide was performed. Finally animals underwent abdominal irrigation with saline (gr.1, n = 20), taurolidin (0.5%) (gr.2, n = 20) or Octreotide (gr.3, n = 20). In week 25 animals were sacrificed, pancreas and liver were analysed.

RESULTS

Size of pancreatic carcinomas was decreased in the taurolidin gr. compared to the other two groups. Furthermore the number of liver metastasis per animal was reduced after lavage with taurolidin (2 +/- 2) and Octreotide (2.5 +/- 2) compared to saline irrigation (4 +/- 4) (p < 0.05). Additionally the incidence of port site metastases was significantly reduced in the taurolidin group. Activity of antioxidative enzyme superoxide dismutase (SOD) was increased while concentration of products of lipidperoxidation was decreased in non-metastatic liver after taurolidin irrigation compared to saline or Octreotide irrigation.

CONCLUSIONS

Taurolidin irrigation during laparoscopy might be a new concept to reduce the number of liver metastasis and port site metastases in pancreatic cancer.

Peritoneal nebulizer: a novel technique for delivering intraperitoneal therapeutics in laparoscopic surgery to prevent locoregional recurrence

BACKGROUND

Peritoneal involvement is a significant issue in the treatment of gastrointestinal malignancies. Current statistics indicate that after surgical intervention, up to 20% of patients will present with locoregional metastasis. The ability to inhibit initial tumor adhesion to the mesothelial lining of the peritoneum may be considered critical in the inhibition of tumor development. This article describes, the use of a novel nebulizer system capable of delivering high-concentration, low-dose therapeutics to the peritoneal cavity.

METHODS

For this study, 30 male WAG rats were inoculated with CC531 colorectal tumor cells. The rats were randomized into three groups: control group (n = 10), heparin-treated group (n = 10), and high-molecular-weight hyaluronan-treated group (n = 10). A peritoneal cancer index was used to determine tumor burden at 15 days. Analysis of variance (ANOVA) was used to compare multiple group means.

RESULTS

Nebulization therapy was performed without any complication in the cohort. Heparin inhibited macroscopic intraperitoneal tumor growth completely (p = 0.0001) without affecting tumor cell viability. The introduction of hyaluronan attenuated both tumor size and distribution, was compared with the control group (p = 0.002).

CONCLUSION

Nebulized heparin and hyaluronic acid using a novel nebulization technique attenuates peritoneal tumor growth after laparoscopic surgery. The technique itself is easy to use and safe.

Increased peritoneal dissemination after laparotomy versus pneumoperitoneum in a mouse cecal cancer model

BACKGROUND

The effect of carbon dioxide (CO(2)) pneumoperitoneum on the liberation of cancer cells from the primary tumor is not clear. This study investigated the influence of laparotomy versus CO(2) pneumoperitoneum on the progression of colon cancer with serosal invasion in a mouse model.

METHODS

Pieces of human colon adenocarcinoma (HT29) tumor were implanted in the cecal wall of 45 BALB/c nude mice. Each mouse underwent one of three procedures: laparotomy, CO(2) pneumoperitoneum, or anesthesia (control). Three weeks later, the size and weight of cecal tumors, the number of nodules, and the tumor volume score of peritoneal dissemination were examined. Another 45 mice were treated in the same way. The cecal tumor was resected on days 1, 3, or 5 after treatment. Total RNA was isolated from the resected tumors. The expression of E-cadherin and beta-1 integrin messenger RNA (mRNA) was examined by semiquantitative real-time reverse transcriptase-polymerase chain reaction assay.

RESULTS

Significantly more nodules of peritoneal dissemination were found in the laparotomy group than in the control group (p < 0.05). The tumor volume score of peritoneal dissemination in the laparotomy group was significantly higher than in the other two groups (p < 0.05). The expression of E-cadherin mRNA at day 5 in the laparotomy group was significantly less than in the other two groups (p < 0.05). There were no differences in beta-1 integrin among three groups.

CONCLUSIONS

Peritoneal dissemination was more extensive after laparotomy than after CO(2) pneumoperitoneum in a mouse model of cecal cancer with serosal invasion. Decreased expression of E-cadherin mRNA in tumors after laparotomy, but not after CO(2) pneumoperitoneum, may be associated with the increase in peritoneal dissemination.

Effects of taurolidine and octreotide on tumor growth and lipid peroxidation after staging-laparoscopy in ductal pancreatic cancer

Irrigation with taurolidine after laparoscopy decreases tumor growth in colon carcinoma. In pancreatic cancer subcutaneous therapy with octreotide decreases oxidative stress and carcinogenesis as well. However, it is still unclear, whether irrigation with taurolidine or octreotide after laparoscopic pancreatic biopsy reduces tumor growth in pancreatic cancer as well. In 60 Syrian hamsters ductal pancreatic adenocarcinoma was induced by weekly injection of 10mg/kg body weight N-nitrosobis-2-oxopropylamine s.c. for 10 weeks. In week 16 laparoscopic pancreatic biopsy by use of carbon dioxide was performed (gr. 1, n = 20) with subsequent laparoscopic irrigation with taurolidine (gr. 2, n = 20) or octreotide (gr. 3, n = 20). In week 25 hamsters were sacrificed. Our results show that macroscopic visible primary tumors were found in only one animal of the taurolidine group (5.9%), compared to 42.1% in the saline and 62.5% in the octreotide group (P<0.05). Carcinomas were smaller after saline (6+/-23 mm(2)) than after octreotide irrigation (70+/-120 mm(2), P<0.05). In conclusion this study showed that laparoscopic irrigation with taurolidine after pancreatic biopsy inhibited tumor growth in ductal pancreatic adenocarcinoma.

The Incidence of Positive Peritoneal Cytology in Colon Cancer: A Prospective Randomized Blinded Trial

Many investigators have attempted to explain the suspected increased incidence of port site metastasis in patients undergoing laparoscopic colorectal resections for cancer with animal models in which cancer is simulated by injection of a tumor slurry into the peritoneal cavity. This approach makes the basic assumption that all patients with colorectal malignancies have viable cancer cells freely circulating within the peritoneal cavity. Recent reports in open colorectal resections have conflicting results. Some suggest that the true incidence is negligible and related to advanced-stage cancers whereas others implicate a much higher incidence. We initiated a prospective blinded trial to establish the true incidence of malignant peritoneal cytology in colorectal cancer. One hundred eight consecutive colon resections underwent conventional peritoneal cytologic evaluation. The patients included those with inflammatory conditions of the colon as well as malignant disease. The cytopathologist was blinded as to the indications for surgery as well as the final pathology result. In only one case—stage IV rectal cancer with peritoneal carcinomatosis—was the cytologic specimen positive. Malignant cytology appears to be an infrequent occurrence and is restricted to advanced-stage cancer.

Abdominal wall recurrences after colorectal resection for cancer: results of the Italian registry of laparoscopic colorectal surgery

PURPOSE

The purpose of the present study was to evaluate prospectively the abdominal wall recurrence rate after laparoscopic resection for colorectal cancer, to analyze the impact of the learning curve on abdominal wall recurrence, and to assess the outcome of those patients.

METHODS

The Italian Registry of Laparoscopic Colorectal Surgery database was analyzed to obtain data on cancer patients with abdominal wall recurrence, concomitant local or distant metastases, and interval between initial surgery and diagnosis of trocar site or minilaparotomy recurrences. The records of the initial procedures and the technique of specimen removal were reviewed.

RESULTS

From January 1992 to July 2000, 2,583 patients (1,753 cases of carcinomas and 830 cases of benign diseases) were recorded. The malignant lesions were located on the right colon in 19 percent, the left colon in 48.8 percent, and rectum in 32.2 percent. Sixteen patients with histologic evidence of colorectal adenocarcinoma recurrences at the abdominal wall were observed (0.9 percent). Ten patients presented an advanced stage (III for 7 patients and IV for 3 patients). Eleven cases occurred during the learning curve period (the first 50 consecutive cases). The median survival time after abdominal wall recurrence diagnosis was 16 (range, 12-60) months. By July 2000 only two patients were alive.

CONCLUSIONS

The results of the Italian prospective Registry of Laparoscopic Colorectal Surgery confirm that the incidence of abdominal wall recurrences is similar to that reported in open studies (<1 percent). Most abdominal wall recurrences occurred in the learning curve period, suggesting that surgical experience may play a role in the development of this outcome. The prognosis of these patients is very poor.

A proteinase inhibitor decreases tumor growth in a laparoscopic rat model

BACKGROUND

The balance between proteolysis and protease inhibition in the formation and breakdown processes of the extracellular matrix plays a major role in tumor cell invasion. An understanding of this relationship gave rise to the therapeutic concept of lowering tumor cell invasion by inhibiting protease activity. Phosphoramidon is an unspecific proteinase inhibitor. This experimental study investigated the effect of intraperitoneal phosphoramidon administration on tumor growth in a laparoscopic rat model.

METHODS

In the first phase of the study, we investigated the influence of phosphoramidon on tumor cell invasion in a collagen matrix gel chamber in vitro. In a second experiment, a suspension of colon carcinoma cells (CC531) was introduced into the peritoneal cavity of male WAG rats. Prior to laparoscopy (at 6 mmHg for 20 min), the animals were randomized to two groups. At the start of laparoscopy, the test substance was applied intraperitoneally (group 1: controls, 1 ml 0.9% NaCl; group 2: 250 mg phosphoramidon in 1 ml 0.9% NaCl). Three weeks after the injection of tumor cells, the animals were autopsied and the tumor mass determined.

RESULTS

In comparison with the control group (tumor weight 7.42 +/- 1.01 g), intraperitoneal tumor growth in the experimental group was significantly (p < 0.001) reduced by the application of phosphoramidon (tumor weight, 3.22 +/- 1.06 g). Phosphoramidon also significantly (p < 0.05) reduced tumor cell invasion through the matrix gel.

CONCLUSION

The proteinase inhibitor phosphoramidon reduced tumor cell invasion in vitro and tumor cell growth in vivo in this laparoscopic rat model.

Experimental assessment of tumor growth and dissemination of a microscopic peritoneal carcinomatosis after CO2 peritoneal insufflation or laparotomy

BACKGROUND

Based on clinical observations and previous animal studies, laparoscopic surgery for malignant disease is regarded as controversial. We used a rat model to measure and compare the tumor growth, proliferation, and dissemination of a microscopic peritoneal carcinomatosis after CO(2) intraperitoneal insufflation or laparotomy.

METHODS

Peritoneal carcinomatosis was induced in three groups of 27 BD IX rats each with intraperitoneal injections of 106 DHD/K12 cells, an aneuploid tumor cell line. At 48 h after tumor cell injection, the animals were randomly divided into three groups to undergo different types of intervention. All animals were anesthetized for 20 min (Halothane). The control group had no surgical intervention (group C), group I had CO(2) insufflation (7 mmHg),and group L had a midline laparotomy (5-cm). Neither bowel manipulation nor any other traumatic action was performed. Two weeks later, the rats were killed and the incidence, type, and dissemination of carcinomatosis were evaluated. We also measured the tumor's weight. Malignant omentum was sampled for flow cytometry analysis (DNA ploidy, S-phase fraction).

RESULTS

The incidence of carcinomatosis did not differ among the groups. The mean score of macroscopic characteristics of the carcinomatosis was 2.8 +/- 1.9 in group L, 2.9 +/- 1.9 in group I, and 3 +/- 1.9 in group C (NS). The location of the implants did not differ, except for parietal peritoneum location, which was more frequent in group L (p < 0.01). The tumor weight was 4.96 g +/- 3.2 in group L, 5.55 g +/- 3.2 in group C, and 5.75 g +/- 3.4 in group I (NS). The percentage of aneuploid cells and S-phase fraction did not differ statistically among the groups.

CONCLUSION

These results indicate that CO(2) insufflation does not cause more effects than laparotomy when tumors cells are present before the beginning of the surgery. Further studies are needed to determine the influence of other steps in laparoscopic surgery on tumor growth and dissemination.

Trocar site recurrence in laparoscopic surgery for colorectal cancer

BACKGROUND

Laparoscopic colorectal surgery has been associated with less postoperative pain, an early return of bowel function, a shorter period of hospitalization and disability, and better cosmetic results. However, the application of laparoscopic techniques to the curative resection of colorectal cancer is still controversial, owing to reports of cancer recurrence at the port site wounds. The accumulation of numerous such reports in a relatively short period raised concern that there might be an extraordinary high rate of port site metastases after laparoscopic colorectal surgery. This concern has led to intense clinical and basic research aimed at determining the incidence and causes of wound recurrence and developing preventative measures to address this problem. Despite these efforts, it is still not clear whether port site metastasis is really an inherent drawback to laparoscopic cancer surgery.

METHODS

In this review of the literature on port site metastasis, we gathered data from clinical series of laparoscopic surgery for colorectal cancer. We eliminated series of <50 patients, since they may be flawed by the learning curve required for this technically demanding procedure.

RESULTS

The rate of port site recurrences in the 1737 patients who participated in these series was 1%. Although the methods and criteria for patient selection in these studies varied, this figure appears to be comparable to the incidence reported for other malignancies and for laparotomies performed to treat colorectal cancer.

CONCLUSION

This review suggests that wound recurrence may actually be the result of an unfortunate learning curve, rather than an inherent concern. However, we must await the final results of large randomized studies before drawing any definitive conclusions.

Effect of Pneumoperitoneal Pressure on Tumor Dissemination and Tumor Recurrence at Port-Site and Midline Incisions

Over the past several years numerous cases of port site tumor recurrence after laparoscopic resection of a cancerous tissue have been reported. Possible mechanisms for tumor seeding include tumor removal, contaminated instruments, pneumoperitoneum, and aerosolization of tumor cells. This experiment examined the relationship among trocar contamination, aerosolization, and tumor recurrence with increasing pneumoperitoneal pressure using a hamster model. Increased pneumoperitoneal pressure significantly increased both instrument contamination and tumor recurrence at midline and port site incisions. Interestingly, increasing pneumoperitoneal pressure had no significant effect on the number of aerosolized tumor cells. The results reaffirm that the use of a reduced pneumoperitoneum or gasless laparoscopy may significantly lower port site tumor recurrence.

Laparoscopic colectomy

The unique challenges of a laparoscopic approach to colorectal surgery have delayed its widespread adoption into clinical practice. Advances in instrumentation, modifications of technique, and an unequivocal demonstration of its safety undoubtedly will increase its popularity in the future.

Cancer and laparoscopy, experimental studies: a review

OBJECTIVE

To review the experimental studies on laparoscopy and cancer and to propose guidelines for the clinical management of gynecologic cancer.

METHODS

The literature in MEDLINE was searched from January 1992 to December 1998 using the terms 'cancer', 'laparoscopy' and 'experimental or animal study'. Cross-referencing identified additional publications. Abstracts and letters to the editor were excluded. All the relevant papers were reviewed.

RESULTS

Depending on the model used, controversial results have been reported on the incidence of trocar site metastasis when comparing CO(2) laparoscopy and laparotomy. In contrast, the following conclusions can be proposed: (i) tumour growth after laparotomy is greater than after endoscopy; (ii) tumour dissemination is worse after CO(2) laparoscopy than after laparotomy; (iii) some of the disadvantages of CO(2) laparoscopy may be treated using local or intravenous treatments or avoided using other endoscopic exposure methods, such as gasless laparoscopy.

CONCLUSIONS

The laparoscopic treatment of gynecologic cancer has potential advantages and disadvantages, and may only be performed in prospective clinical trials. The risk of dissemination appears high when a large number of malignant cells are present. Adnexal tumours with external vegetations, and bulky lymph nodes should be considered as contra-indications to CO(2) laparoscopy.

A prospective, randomized comparison of port wound and culdotomy for extracting mature teratomas laparoscopically

STUDY OBJECTIVE

To compare removing teratomas through a culdotomy opening or through an enlarged port wound.

DESIGN

Prospective, randomized trial (Canadian Task Force classification I).

SETTING

Veterans Hospital.

PATIENTS

Thirty-one women with mature teratomas identified by ultrasound examination and biochemical markers.

INTERVENTION

Laparoscopic cystectomy.

MEASUREMENTS AND MAIN RESULTS

Patients were randomly assigned to have the cysts removed intact in a cellulose bag through an enlarged port site (15, group A) or through a culdotomy opening (16, group B). Inclusion criteria were history of vaginal delivery, no previous abdominal surgery, no history of pelvic inflammatory disease, no medical illness, and no symptoms. Operating time in group B (90 +/- 18 min) was significantly longer than that in group A (70 +/- 22 min, p = 0. 0113). Blood loss was 79 and 49 ml, respectively (p = 0.0010). There was no significant differences in tumor size, patient age, and postoperative recovery between groups.

CONCLUSION

It is possible to remove intact ovarian dermoid cysts and prevent rupture and spillage of cyst contents during laparoscopic surgery by both approaches. We prefer the enlarged port because operating time is shorter and blood loss is less.

Effects of laparoscopy on intraperitoneal tumor growth and distant metastases in an animal model

BACKGROUND AND AIMS

Laparoscopic surgery for colorectal cancer is currently being evaluated in humans. The aim of this study was to examine the effect of laparoscopy on intraperitoneal tumor growth and distant metastases in an animal model. We also examined the effect of combining laparotomy with laparoscopy and on infusing the peritoneal cavity with normal saline solution (NaCl), water, and sodium hypochlorite after laparoscopy on intraperitoneal tumor growth.

MATERIAL AND METHODS

Female Fischer rats were given MtLn3 adenocarcinoma cells by intraperitoneal injection to produce intraperitoneal tumor growth and by tail vein injection to produce lung metastases. A pneumoperitoneum was then induced to a pressure of 8 mm Hg with carbon dioxide (CO2), helium, or room air. After this, animals were allowed to either recover or underwent laparotomy or infusion of NaCl, water, or sodium hypochlorite before recovery, depending on the experiment. At 21 days all animals were killed and intraperitoneal tumor growth was assessed by counting the number of peritoneal and serosal nodules and by weighing the omental pad of tumor. Lung metastases were assessed by counting the number of metastases after fixation.

RESULTS

Laparoscopy caused a marked intraperitoneal dissemination of tumor with a median of 17 (10 to 20) peritoneal and serosal nodules for CO2, 19.5 (12.5 to 25) for helium, and 15.0 (9.5 to 17.7) for room air compared with 0 (0 to 1) for controls (P < .0001). The weight of omental tumor was also significantly increased (P < .02) in the CO2, helium, and room air groups. Infusion with NaCl, water, or sodium hypochlorite had no effect on tumor dissemination after laparoscopy. The combination of laparoscopy and laparotomy caused a significant reduction (P < .05) in the number of peritoneal nodules but had no significant effect on omental tumor growth. Laparoscopy also had no effect on the number of pulmonary metastases induced compared with controls.

CONCLUSIONS

This study shows that laparoscopy promotes intraperitoneal dissemination of tumor. This effect is independent of the insufflating gas used and is not affected by use of a cytotoxic agent. The use of gasless laparoscopy should be encouraged by those undertaking curative laparoscopic surgery for colorectal cancer.

Laparoscopic resection does not adversely affect early survival curves in patients undergoing surgery for colorectal adenocarcinoma

OBJECTIVE

To determine the survival curves for laparoscopic resection (LR) of colorectal cancer.

SUMMARY BACKGROUND DATA

Laparoscopic resection for cure of colorectal cancer is controversial, and survival curves have not been determined.

METHODS

A prospective database of 177 consecutive LRs of colorectal cancers performed between November 1991 and 1997 was reviewed. The TNM classification (stage 0, I, II, III, and IV) for colorectal cancers and the Kaplan-Meier method were used to determine survival curves.

RESULTS

Of the 177 patients, 5 were excluded for not having adenocarcinomas. Twenty-five patients (14.5%) had conversion to open surgery; most of these patients had rectal cancer or tumor invasion to adjacent organs. Twelve patients were lost to follow-up. All 135 remaining patients had follow-up. Overall, 28 deaths occurred during the follow-up period, 15 of which were cancer-related. The median follow-up was 24 months for patients with stage I, II, and III disease and 9 months for patients with stage IV disease. Observed 2-year survival rates were 100% stage I, 88.7% stage II, 80.6% stage III, and 28.6% stage IV. Survival rates at 4 years were 100% stage I, 79.5% stage II, 53.7% stage III, and 0% stage IV. No trocar site recurrence was observed.

CONCLUSIONS

Early survival curves for patients with colorectal cancer who underwent LR do not differ negatively from historical controls for conventional surgery. Further validation is needed.

Experimental study of the effect of intraperitoneal heparin on tumour implantation following laparoscopy

BACKGROUND

Conclusions drawn from clinical reports of port site metastases following laparoscopic resection of intra-abdominal malignancy are now supported by a burgeoning experimental literature which suggests that laparoscopy promotes tumour metastasis to wounds. This study investigated the effect of intraperitoneal blood and heparin on the incidence of tumour cell implantation and port site metastasis.

METHODS

Twenty-four Dark Agouti rats underwent laparoscopy with carbon dioxide insufflation and the instillation of a tumour cell suspension and/or blood into the peritoneal cavity. Rats were allocated randomly to one of the following study groups (six rats per group): (1) controls; (2) intraperitoneal blood (2 ml blood introduced from a syngeneic donor rat); (3) intraperitoneal heparin; (4) intraperitoneal blood and heparin. Rats were killed 7 days after the procedure, and the peritoneal cavity and port sites were examined for the presence of tumour.

RESULTS

Tumour implantation and port site metastases were reduced by the intraperitoneal administration of heparin, but increased by the presence of intraperitoneal blood.

CONCLUSION

The results of this study suggest that tumour implantation following laparoscopy is promoted by the presence of intraperitoneal blood and that this effect may be reduced by the use of intraperitoneal heparin.

Risk factors contributing to early occurrence of port site metastases of laparoscopic surgery for malignancy

In this article, the authors present an up-to-date review of our experience and that of the medical literature encompassing all important aspects of port site metastases after laparoscopic surgery for malignancy and to search for potential risks with contribution to early occurrence of port site metastases after laparoscopic surgery. We used a Medline computer database search to conduct for pertinent articles through September 1996. Cross-referencing identified additional publications. We found that the majority of recurrences were in patients with adenocarcinoma cell type, advanced stage (far-advanced disease), and often with diffuse peritoneal carcinomatosis, suggesting that port site metastases may contribute to the highly aggressive nature of the disease. Risk factors that contributed to early occurrence of port site metastases were ovarian cancers, presence of ascites, and diagnostic or palliative procedures for malignancy (P < 0.0001, P = 0.008, and P < 0.001, respectively). Practitioners should exercise extreme caution when using laparoscopic techniques to manage the care of these patients.

CT of abdominal wall implantation metastases after abdominal percutaneous procedures

PURPOSE

Our goal was to report the CT manifestations of abdominal wall implantation metastases occurring after abdominal percutaneous procedure.

METHOD

CT scans and clinical data of six patients with abdominal wall implantation metastases at the puncture site following abdominal percutaneous procedure were reviewed. The abdominal percutaneous procedures included drainage of intraperitoneal abscess in patients with colon or gastric cancer (n = 2), transhepatic biliary drainage in a patient with hilar cholangiocarcinoma (n = 1), biopsy of intrahepatic hepatocellular carcinoma (n = 1), biopsy of a metastatic left adrenal gland (n = 1), and laparoscopic cholecystectomy in a patient with unsuspected gallbladder cancer (n = 1).

RESULTS

CT enabled the diagnosis of abdominal wall implantation metastasis in all six patients and showed coexisting intraabdominal tumor sites in five patients. All abdominal wall implantation metastases were homogeneous before intravenous administration of iodinated contrast material and became moderately heterogeneous on contrast-enhanced CT scan with marked enhancement relative to adjacent tissues.

CONCLUSION

Abdominal wall implantation metastases are moderately heterogeneous on contrast-enhanced CT scan with marked enhancement relative to adjacent tissues. In most cases of abdominal wall implantation metastasis following abdominal percutaneous procedure, CT shows additional intraabdominal tumor sites. This complication may occur following a variety of abdominal percutaneous procedures (either radiological or surgical).

Detection of aerosolized cells during carbon dioxide laparoscopy

Laparoscopic surgery for malignancy has been complicated by port-site recurrences. The exact mechanism has yet to be defined. In vitro studies suggest that carbon dioxide-induced tumor cell aerosolization may play a role. We have attempted to document this in a human model. Patients scheduled for elective laparoscopy underwent port placement and abdominal insufflation with carbon dioxide. A suction trap was then filled with 40 cc of normal saline solution and attached to an insufflation site on the port. The carbon dioxide effluent was directed through the saline. The specimen was concentrated, resuspended, and transferred to a slide. A Papanicolaou stain was used. Thirty-five specimens were obtained. Fifteen patients (37%) had malignant disease, which was metastatic in eight. Five patients had carcinomatosis. In two of those with carcinomatosis, staining revealed a large number of malignant cells. Malignant cells were not found in any other patients. In two patients, however, aerosolized mesothelial cells were identified. Follow-up ranged from 2 to 7 months. One patient who displayed cellular aerosolization developed a port-site recurrence. We conclude that malignant cells are aerosolized but only during laparoscopy in the presence of carcinomatosis. It is unlikely that tumor cell aerosolization contributes significantly to port-site metastasis.

[Laparoscopic resection of the colon for adenocarcinoma. Report of a series of 218 cases]

STUDY AIM

The aim of this retrospective study was to report the results of a series of 218 laparoscopic resections for adenocarcinoma of the colon by the same surgical team over a 6-year period.

PATIENTS AND METHODS

Laparoscopic procedures included, for the right and the left colon, at first a ligature of the vascular pedicles, secondarily a dissection of the mesocolons, and were almost identical to the conventional procedures. A conversion to open laparotomy was necessary in 8.3% of the patients. Among 218 patients, there were 117 men and 101 women; the mean age was 69 years. Twenty nine per cent of the patients had already undergone open laparotomy. Mean ASA grade was 2.1. An emergency operation was necessary for 9% of the patients in relation with colonic obstruction (n = 20) or peritonitis (n = 3).

RESULTS

Colonic resections were considered curative in 180 patients (82.6%). The mean duration of surgery was 157 minutes for the right colectomies and 148 for the left. The proportion of A, B, C, D Dukes stage tumours was respectively 19.3%, 38.5%, 27.5% and 14.7%. There was one post-operative death related to a serious epileptic seizure due to unknown cerebral metastases. The morbidity rate was 5.5% and the early reintervention rate 2.8%. There was no lost to follow-up. With a mean 35-month follow-up. 82.2% of the patients were alive after curative surgery. Abdominal wall recurrence at port sites occurred in four patients operated on for a Dukes C cancer before 1994. Prognosis was significantly dependent on cellular differentiation, lymph node extension, pericolic extension and Dukes stage. The 5-year actuarial survival rate, according to Kaplan-Meier method was 65.36%.

CONCLUSION

Laparoscopic colon cancer resection was used by the authors in 92% of patients during 1997. The conversion rate to open laparotomy has been lower than 5% since 1995. Post-operative mortality was 0.4% and post-operative morbidity 5.5%. After curative colonic cancer resection, the 5-year actuarial survival rate was 65%.

Port-site metastases following laparoscopic surgery

BACKGROUND

Application of laparoscopy to the resection of malignancy has been followed by a literature describing cases of metastatic involvement at laparoscopic port sites. These include patients who underwent surgery for early stage carcinoma and instances following laparoscopic procedures during which tumours were not dissected.

METHODS

Recently published clinical and experimental studies, and case reports related to this problem are reviewed; their relevance is discussed.

RESULTS

Experimental studies incorporating bench top and large animal models have confirmed that tumour cells may be redistributed to port sites during laparoscopic surgery either directly from contaminated instruments or indirectly via the insufflation gas. Small animal models suggest that the incidence of wound metastasis is increased following conventional laparoscopic surgery, and that it may be decreased by gasless laparoscopy or helium insufflation. This evidence suggests that the development of port-site metastases depends not only on the physical redistribution of tumour cells but also on the specific insufflation gas used, possibly because of influences on local metabolic or immune factors acting at the wound site.

CONCLUSION

Further research in this area is urgent. Until the issue is better understood, patients undergoing laparoscopic surgery for malignancy should be entered into clinical trials.

Mechanism and prevention of port-site tumor recurrence after laparoscopy in a murine model

BACKGROUND/PURPOSE

Although minimally invasive surgery (MIS) has been broadly applied in patients with cancer of the gastrointestinal tract, the etiology of port-site tumor recurrence (PSR) after laparoscopic cancer surgery remains unclear. The authors report here an analysis of PSR in a model of murine neuroblastoma after laparoscopic tumor biopsy and propose a mechanism for this complication as well as a potential treatment.

METHODS

Immature 5- to 7-week old male A/J mice (18-23 g) were subcutaneously inoculated with the minimally immunogenic TBJ-neuroblastoma (TBJ-NB) in the left flank and divided into three treatment groups. The following operations were performed 14 days after tumor inoculation: group 1, additional intraperitoneal or intravenous injection of TBJ-NB during CO2 pneumoperitoneum; group 2, simulated transperitoneal tumor biopsy using MIS techniques during either CO2 pneumoperitoneum or gasless suspension; Group 3, intraperitoneal (IP) or intravenous (IV) administration of cyclophosphamide on postoperative days 0 and 3 to prevent PSR after simulated tumor biopsy during CO2 pneumoperitoneum.

RESULTS

In group 1, the incidence of PSR was 0% in the intravenously injected mice versus 63% in mice injected intraperitoneally with TBJ-NB. In group 2, no significant difference in the incidence of PSR was seen between simulated tumor biopsy (89%) animals with CO2 pneumoperitoneum versus animals with gasless suspension (81%). In group 3, mice that did not receive any chemotherapy had an 89% incidence of PSR. Administration of cyclophosphamide via either the IP or IV route effectively prevented PSR, although there was no difference in the incidence of PSR between the two routes (IP 12% versus IV 13%).

CONCLUSIONS

The data suggest that PSR in tumor-bearing hosts may be caused by direct seeding of exfoliated tumor cell, and not by hematogenous metastases. Contrary to the other reports, CO2 pneumoperitoneum was not found to be essential for the development of PSR. Furthermore, the authors conclude that postoperative chemotherapy may be useful in preventing PSR after MIS in patients bearing chemotherapy-sensitive tumors such as neuroblastoma.

Colorectal carcinoma and the relationship of peritoneal cytology

BACKGROUND

This study was designed to investigate the frequency of the association between colorectal cancer and peritoneal cytology as well as the impact of surgical resection on conversion of cytology from benign to malignant cells being present. Furthermore, increasingly frequent reports of port site recurrences with laparoscopic colectomy for limited stage colon carcinoma prompted us to evaluate the incidence of tumor cell spillage with traditional "open" colonic surgery.

METHODS

Fifty random patients undergoing surgery for colorectal carcinoma were prospectively evaluated with peritoneal washings prior to and following colon resection.

RESULTS

Five patients (10%) were found to have malignant cytology, with no patients converting from negative to positive cytology. All five positive cytologies were associated with stage IV disease and poorly differentiated colon cancer.

CONCLUSION

Intraoperative peritoneal cancer dissemination could not be demonstrated by cytologic washings of the abdominal cavity before and after colorectal resection utilizing standard cytomorphological criteria.