Laparoscopic surgery of the colon and rectum

Impact of circulating tumor cells in colorectal cancer patients undergoing laparoscopic surgery

Laparoscopic surgery has recently been widely used for various benign colorectal diseases as well as colorectal cancer. Although laparoscopic surgery has been shown to be with similar prognostic results for certain groups of colorectal cancer patients. The influence of laparoscopic procedures on the oncologist results, especially free tumor cell spreading is still a concern for some surgeons. Tumor cells found in the peripheral blood of patients with cancer are termed circulating tumor cells (CTCs). Presence of CTCs in the peripheral blood of patients with colorectal cancer has been reported to be associated with disease stage, poor prognosis, tumor progression, response to therapy, and drug resistance. Whether laparoscopic procedure enhances tumor spreading during operation remains unknown. Significantly less CTC detected during laparoscopic surgery than open surgery for colorectal cancer has been reported. In our previous experience, no significant elevation in CTC level was found in most patients during laparoscopic resection of colorectal cancer. We have shown that laparoscopic surgery had no significantly deleterious effect on CTCs in colorectal cancer patients. In this review, we aim at the impact of CTCs in patients with colorectal cancer undergoing laparoscopic surgery. The prognostic significance of CTCs in patients with colorectal cancer will also be addressed.

Laparoscopic right hemicolectomy: a comparison of natural orifice versus transabdominal specimen extraction

BACKGROUND

Conventional laparoscopic right hemicolectomy (LRH) involves making an abdominal incision to remove the specimen and perform the anastomosis. Totally laparoscopic right hemicolectomy with natural orifice specimen extraction (NOSE) may lead to better outcomes compared to LRH.

STUDY DESIGN

Forty consecutive female patients total were reviewed: 20 LRH and 20 NOSE. The two groups were matched for sex, age, race, American Society of Anesthesiologist score, benign and malignant disease, tumor stage, lymph node number, tumor size, specimen length, body mass index, previous abdominal surgeries, and comorbidities.

RESULTS

The two groups were comparable for all categories. Follow-up was available on all patients (100%). The mean follow-up was 38.93 months (range 15-63 months). There was no difference between postoperative pain score between the two groups on postoperative day (POD) 1, POD 2, and POD day 14 (p = 0.571), (p = 0.861), (p = 0.688), respectively. There was no difference in the postoperative in-hospital morphine equivalents (p = 0.963). The NOSE group had no postoperative hernia formation or wound infections compared to the LRH, however, the difference was not significant (p = 0.439) and (p = 0.267), respectively. There was no difference in postoperative ileus (p = 0.192), septic complications (p = 1.000), readmission rate (p = 0.394), time interval for postoperative chemotherapy (p = 0.645), SDS (p = 0.446) or QLI (p = 0.175). There was no difference in length of hospital stay with 5.3 days for the LRH group and 7.7 days for the NOSE group (p = 0.183). The NOSE group had statistically significant better cosmetic scores (p = 0.018).

CONCLUSION

NOSE is comparable LRH with regard to postoperative outcomes and quality of life. NOSE is safe and maintains strict oncologic standards. NOSE is associated with a better cosmetic outcome compared to LRH.

Intraoperative localization of occult colorectal tumors during laparoscopic surgery by magnetic ring markers-a pilot study

PURPOSE

Intraoperative localization of small tumors or malignant polyps has been an important issue in laparoscopic colon surgery. We have developed a new method for preoperative endoscopic tumor marking using a ring-shaped magnetic marker.

METHODS

In a pilot study, 28 patients with small colonic (n = 23) or rectal tumors (n = 5) underwent endoscopic magnetic clipping prior to laparoscopic resection. A cap carrying a high-power neodymium ring magnet was mounted on the tip of a colonoscope. Near the lesion, the ring magnet was released and clipped to the colorectal wall. Standard laparoscopic instruments were used to find the magnet intraoperatively.

RESULTS

Endoscopic fixation of a ring magnet next to the tumor by clipping was technically feasible in all 28 patients. Intraoperative localization of the marked lesions was successful in 27 of 28 patients (96 %). All patients underwent magnet-guided radical laparoscopic resection of the tumor with an average proximal and distal resection margin of 101 and 63 mm, respectively. In one case, the magnet could not be found due to preoperative migration. Surgical complications related to magnetic clip application or intraoperative tumor localization were not observed. However, there was one case with an intraoperative perforation of the colon by the magnet, which was obviously caused by unchecked action with a laparoscopic instrument.

CONCLUSIONS

Preoperative endoscopic labeling of colonic lesions with on-the-scope magnetic markers is simple and safe. Intraoperative tumor localization during laparoscopic colorectal surgery can be achieved reliably without additional equipment such as ultrasound or fluoroscopy.

Laparoscopic versus open colectomy for TNM stage III colon cancer: results of a prospective multicenter study in Italy

BACKGROUND AND PURPOSE

There is still debate about the practicality of performing laparoscopic colectomy instead of open colectomy for patients with curable cancer, although laparoscopic surgery is now being performed even for patients with advanced colon cancer. We compared the long-term results of laparoscopic versus open colectomy for TNM stage III carcinoma of the colon in a large series of patients followed up for at least 3 years.

METHODS

The subjects of this prospective non-randomized multicentric study were 290 consecutive patients, who underwent open surgery (OS group; n = 164) or laparoscopic surgery (LS group; n = 126) between 1994 and 2005, at one of the four surgical centers. The same surgical techniques were used for the laparoscopic and open approaches to right and left colectomy. The distribution of TNM substages (III A, III B, IIIC) as well as the grading of carcinomas (G1, G2, G3) were similar in each arm of the study. The median follow-up periods were 76.9 and 58.0 months after OS and LS, respectively.

RESULTS

There were 10 (6.1 %) versus 9 (7.1 %) deaths unrelated to cancer, 15 (9.1 %) versus 5 (4 %) cases of local recurrence, 7 (4.2 %) versus 5 (4 %) cases of peritoneal carcinosis, and 37 (22.5 %) versus 14 (11.1 %) cases of metastases in the OS and LS groups, respectively. There was also one case of port-site recurrence after LS (0.8 %). The OS group had a significantly higher probability of local recurrence and metastases (p < 0.001) with a significant higher probability of cancer-related death (p = 0.001) than the LS group.

CONCLUSIONS

These findings support that LS is safe and effective for advanced carcinoma of the colon. Although the LS group in this study had a significantly better long-term outcome than the OS group, further investigations are needed to draw a definitive conclusion.

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.

Short-term and medium-term clinical outcomes of laparoscopic-assisted and open surgery for colorectal cancer: a single center retrospective case-control study

Background

Laparoscopic procedure is a rapid developed technique in colorectal surgery. In this investigation we aim at assessing the diversities of short-term and medium-term clinical outcomes of laparoscopic-assisted versus open surgery for colorectal cancer.

Methods

A total number of 519 patients with non-metastatic colorectal cancer were enrolled for this study. The patients underwent either laparoscopic-assisted surgery (LAP) (n = 254) or open surgery (OP) (n = 265). Surgical techniques, perioperative managements and clinical follow-ups were standardized. Short-term perioperative data and medium-term recurrence and survival were compared and analyzed between the two groups.

Results

There were no differences in perioperative parameters between the two groups except in regards to a trend of faster recovery in laparoscopic procedures. There was no statistically significant difference in postoperative complications, reoperation rate, or perioperative mortality. Statistically significant differences in a faster return of gastrointestinal function and shorter hospital stay were identified in favor of laparoscopic-assisted resection. In colon and rectal cancer cases separately, the overall survival, cancer-free survival and recurrence rate were similar in two groups. There was also no tendency of significant differences in overall survival, cancer-free survival and recurrence in stage I-II and stage III patients in two cancer categories between the two groups, respectively. pT, lymph node metastasis, and clinical stage were independent predictors of overall death risk, while pT, pN, lymph node metastasis and clinical stage were found to be the independent predictors of recurrence risk in enrolled patients database.

Conclusions

Laparoscopic-assisted procedure has more benefits on postoperative recovery, while has the same effects on medium-term recurrence and survival compared with open surgery in the treatment of non-metastatic colorectal cancer.

Short-term Outcomes of a Laparoscopic Left Hemicolectomy for Descending Colon Cancer: Retrospective Comparison with an Open Left Hemicolectomy

Purpose

Many randomized clinical trials have been performed to treat a colorectal neoplasm with the exclusion of descending colon cancer. The aim of the present study was to investigate the difference in surgical outcomes between a laparoscopic left hemicolectomy and a conventional open left hemicolectomy for descending colon cancer.

Methods

A retrospective study of ninety patients with descending colon cancer, who underwent a laparoscopic (LAP) or open left hemicolectomy (OS) between May 1998 and December 2009 at Kyungpook National University Hospital, was performed. Clinicopathological and surgical outcomes were compared between the LAP and the OS for descending colon cancer.

Results

The baseline characteristics, including age, gender, body mass index, history of prior abdominal surgical history and tumor location, were similar between the two groups. The mean operation time was 156.2 minutes for the LAP group and 223.2 minutes for the OS group (P < 0.001). Intraoperative blood loss was significantly greater in the OS group (37.5 mL vs. 80.4 mL; P = 0.039). The postoperative recovery in the LAP group was faster, as reflected by the shorter time to pass gas and the shorter hospital stay. Pathological examinations showed the surgery to be equally radical in the two groups. The median follow-up was 21 months and there were 3 distant metastases (8.5%) during follow-up in the LAP group, but no port-site or local recurrence.

Conclusion

A laparoscopic left hemicolectomy is a technically safe and feasible procedure for treating descending colon cancer. Prospective multi-center trials are necessary to establish the LAP as the standard treatment for descending colon cancer.

Is laparoscopic colorectal cancer surgery equal to open surgery? An evidence based perspective

Laparoscopic colorectal surgery (LCS) is an evolving subject. Recent studies show that LCS can not only offer safe surgery but evidence is growing that this new technique can be superior to classical open procedures. Fewer perioperative complications and faster postoperative recovery are regularly mentioned when studies of LCS are presented. Even though the learning curve of LCS is frequently debated when limitations of laparoscopic surgeries are reviewed, studies show that in experienced hands LCS can be a safe procedure for colorectal cancer treatment. The learning curve however, is associated with high conversion rates and economical aspects such as higher costs and prolonged hospital stay. Nevertheless, laparoscopic colorectal cancer surgery (LCCR) offers several advantages such as less co-morbidity and less postoperative pain in comparison with open procedures. Furthermore, the good exposure of the pelvic cavity by laparoscopy and the magnification of anatomical structures seem to facilitate pelvic dissection laparoscopically. Moreover, recent studies describe no difference in safety and oncological radicalness in LCCR compared to the open total mesorectal excision (TME). The oncological adequacy of LCCR still remains unproven today, because long-term results do not yet exist. To date, only a few studies have described the results of laparoscopic TME combined with preoperative adjuvant treatment for colorectal cancer. The aim of this review is to examine the various areas of development and

controversy of LCCR in comparison to the conventional open approach.

Safety and feasibility of laparoscopic intersphincteric resection for very low rectal cancer

BACKGROUND

Laparoscopic surgery has been reported to be one of the approaches for total mesorectal excision (TME) in rectal cancer surgery. Intersphincteric resection (ISR) has been reported as a promising method for sphincter-preserving operation in selected patients with very low rectal cancer.

METHODS

From July 2005 to December 2008, 35 patients with very low rectal cancer underwent laparoscopic TME with ISR. The results were compared retrospectively with those of previous open TME with ISR.

RESULTS

Conversion to open surgery was necessary in one (3%) patient. The median operation time was 293 min and median estimated blood loss was 40 ml. The pelvic plexus was completely preserved in 32 patients. There was no mortality. Postoperative complications occurred in three (9%) patients. The median length of postoperative hospital stay was 17 days. Macroscopic complete mesorectal excision was achieved in all cases. Complete resection (R0) was achieved in 34 patients. Clinical lymph node stage, operation time, and blood loss were significantly different between the laparoscopic group and open group, but the differences of other factors were not statistically significant.

CONCLUSIONS

Laparoscopic TME with ISR is technically feasible and a safe alternative to laparotomy with favorable short-term postoperative outcomes.

Clinical evidences of laparoscopic versus open surgery for colorectal cancer

Laparoscopic surgery has widely spread in the treatment of colorectal cancer. In Japan, a nation-wide survey has shown that a rate of advanced colorectal cancer has increased gradually and reached 65% of the total cases for colorectal cancer in 2007. For colon cancer, many randomized controlled trials regarding short-term outcome demonstrate that laparoscopic surgery is feasible, safe and has many benefits including reduction in a peri-operative mortality. In terms of long-term outcome, four randomized controlled trials insist that there are no differences in both laparoscopic and open surgeries. However, there are still more important issues including long-term oncological outcome for advanced colon cancer, cost effectiveness and the impact on quality of life of patients. Meanwhile, for rectal cancer, a controversy persists with regard to the appropriateness of laparoscopic surgery because of concerns over the safety of the procedure and a necessity of lateral lymph node dissection for lower rectal cancer. At present, laparoscopic surgery is acceptable for Stage I colon cancer, whereas there are controversies for Stage II/III colon cancer and each staged rectal cancer because of inadequate clinical evidences. Whether laparoscopic surgery further spreads to be applied for colorectal cancer or not, it would be confirmed by Japanese large-scale phase III trial (JCOG0404) estimating oncological outcome for Stage II/III colon cancer and a Phase II trial estimating the feasibility for Stage 0/I rectal cancer in near future.

Is laparoscopic surgery acceptable for advanced colon cancer?

Laparoscopic surgery is widespread in the treatment of colorectal cancer. In Japan, a nationwide survey has shown that the rate of advanced colorectal cancer has increased gradually to 65% of total laparoscopic surgeries in 2007. Many randomized controlled trials have demonstrated that in the short term, laparoscopic surgery is feasible, safe, and has many benefits, including reduction of peri-operative mortality. In terms of long-term outcomes, four randomized controlled trials suggest that there are no differences in laparosupic and open surgery for colon cancer. However, important issues, including long-term oncological outcome, cost effectiveness, and the impact on the quality of life of patients, should be addressed in well-designed large-scale trials. In Japan, a retrospective multicenter study has demonstrated that the short-term outcomes of laparoscopic surgery are beneficial, and the long-term outcomes are the same as for open surgery. In 2004, a prospective large-scale randomized controlled trial (JCOG0404) to compare laparoscopic surgery with open surgery was started to evaluate oncological outcomes for advanced colon cancer. This trial is supported in part by a Grant-in-Aid for Cancer Research from the Japanese Ministry of Health, Labour, and Welfare. In the present study, laparoscopic surgery is found to be acceptable for stage I disease of colon cancer, whereas it is controversial for stage II/III disease because of inadequate clinical evidence. Whether laparoscopic surgery is acceptable for advanced colon cancer or not should be confirmed by the Japanese large-scale prospective randomized controlled trial (JCOG0404) in the near future.

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.

Colorectal cancer: the role of laparoscopy

Since the first report in 1991 the laparoscopic resection of colon cancer is progressing slowly and just in the last 2-3 years is becoming more popular. The resistance to its use by some general and colo-rectal surgeons is receding. The explanations are that technology is evolving quickly and there is a worldwide diffusion of more sophisticated surgical instruments. Moreover several randomized trials have been published showing that the outcomes of laparoscopic colon surgery are similar or better than those of conventional surgery and the early reports suggesting the tumour dissemination were not confirmed. The revolution in oncological surgery that we are observing in these last decades with the introduction and diffusion of mini-invasive approach is comparable to that regarding conventional surgery during the period of Halsted. Therefore the principles of surgery accepted during the years must not be forgotten.

Implantación de la cirugía laparoscópica de colon en un servicio de cirugía general

OBJECTIVE

To evaluate the viability, safety and short-term results of laparoscopic colon surgery during the first few years after its introduction in our department.

METHOD

Between January 2002 and December 2005, laparoscopic surgery was performed in patients with surgical indication for benign colon disease. After 2003, patients with malignant disease were also included. A database was created and demographic data, surgical indication, technique, conversion rate, morbidity and postoperative length of stay were recorded. All patients were operated on by the same team of three surgeons.

RESULTS

Ninety consecutive patients, with a mean age of 59.2 years (20-88) underwent laparoscopic surgery. Of these, 53 were men (59%). In total, 32 patients had previously undergone one or more open laparotomies (35.5%). Surgery was indicated for benign disease in 60 patients (66%). Distribution was left colon in 79 patients and right colon in 11 patients. The most frequent technique was sigmoidectomy (67.7%). The conversion rate was 12.2%. Operating time was 199 min. (120-340) and length of postoperative stay was 7.5 days (4-57). Morbidity was 18.8% and mortality was 1.1%.

CONCLUSIONS

Laparoscopic surgery of the colon is safe and reproducible. Our short-term results are similar to those of previous studies. We believe that prior experience of laparoscopic surgery is important and that a stable surgical team minimizes the effect of the learning curve.

Operative Behandlung von Rektumkarzinomen im Vergleich

BACKGROUND

The laparoscopic resection of rectal cancer shows morbidity and oncological safety comparable to the open approach, but morbidity increases after conversion to open resection. No oncological long-term results are available for the latter patients.

METHODS

From 01/01/2000-31/12/2002, patients with curatively resected rectal cancer enrolled in a observational study were evaluated for morbidity, mortality, tumor- and local recurrence rate, paying attention to patients with conversion from laparoscopic to open resection.

RESULTS

237 (3.3%) of 7,189 patients underwent laparoscopic resection (ITT). These patients showed significantly more T1/2 tumors (P<0.001) in earlier UICC stages (P<0.001) than open resected patients. 35 (14.8%) of 237 laparoscopic procedures were converted. Compared with patients receiving complete laparoscopic or open resection, these patients showed significantly higher frequencies of intraoperative (P<0.001) and general postoperative complications (P=0.003) as well as the highest overall morbidity (P=0.031). After a median follow-up of 30.1 months, the highest 5-year local recurrence rate was found in the converted group (16.0%). The laparoscopically resected patients showed a local recurrence rate of 3.3%, patients with open resection of 12.4% (P=0.082). The disease-free survival rate did not differ between the groups (P=0.585).

CONCLUSION

Laparoscopic resection of rectal cancer provides oncological results similar to open resection. After conversion, the short and oncological long-term outcomes were worse. Considering a conversion rate of 15%, only a strict indication for the laparoscopic approach can be allowed, and laparoscopic resection should be performed at centers.

Systematic review on the short-term outcome of laparoscopic resection for colon and rectosigmoid cancer

OBJECTIVE

Several large randomized controlled trials on laparoscopic resection for colon and rectosigmoid cancer have recently been published. There is a need to provide an up-to-date systematic review in this subject.

METHODS

A literature search of all published randomized trials in English between January 1991 and September 2005 was obtained, from Ovid MEDLINE, EMBASE, CINAHL, and All EBM Reviews (Cochrane Central Register of Controlled Trial, Cochrane Database of Systemic Review, and Database of Abstracts of Reviews of Effects), including e-links to the related articles. Two independent assessors reviewed the trials using a standardized protocol. Where means and standard deviations were available, meta-analysis was performed using the Forest plot review. Studies where medians and ranges were presented were separately analysed.

RESULTS

A total of 17 randomized controlled trials with 4013 procedures were reviewed. The conversion rate varied widely between studies and was lowest in single-Centre trials. There were no significant differences in overall and surgical complication rate, anastomotic leak rate, re-operation rate and oncological clearance. However, laparoscopic resection has a significantly lower peri-operative mortality (odds ratio 0.33; P = 0.005), lower wound complications (odds ratio 0.65; P = 0.01), less blood loss (weighted mean difference 0.11 l; P < 0.00001) and reduced postoperative pain scores by 12.6% with reduction of requirements for narcotic analgesia by 30.7%. After laparoscopic surgery, patients passed flatus 38.8% earlier (weighted mean difference 27.6 h; P < 0.00001) and had bowel movement 21.0% earlier (weighted mean difference 23.9 h; P < 0.00001) and resumed oral diet 28.3% sooner than patients in the open group (weighted mean difference 27.3 h; P < 0.00001). Patients were discharged 19.1% earlier after laparoscopic surgery than open surgery (weighted mean difference 1.7 days; P < 0.00001). Laparoscopic resection took 28.7% longer (weighted mean difference 40.1 min; P < 0.00001) to perform.

CONCLUSIONS

Laparoscopic resection for colon and rectosigmoid cancer is feasible, safe and has many short-term benefits.

Three-dimensional computed tomography in laparoscopic surgery for colorectal carcinoma

AIM

To evaluate the usefulness of three-dimensional computed tomography (3DCT) in laparoscopic surgery for colorectal carcinoma.

METHODS

Seventy-two patients with colorectal cancer who underwent curative operation at our hospital were enrolled in this study. They were classified into two groups by operative procedures. Sixteen patients underwent laparoscopic surgery, laparoscopic group (LG), while 56 patients underwent conventional open surgery, open group (OG). At our institution, contrast-enhanced CT is routinely performed as part of intra-abdominal screening and the 3D images of the major regional vessels are described. We have previously described about the preoperative visualization of the inferior mesenteric artery (IMA) by 3DCT. This time we newly acquired 3D images of the superior mesenteric artery (SMA)/superior mesenteric vein (SMV), ileocecal artery (ICA), middle colic artery (MCA), and inferior mesenteric vein (IMV). We have compared our two study groups with regard to five items, including clinical anastomotic leakage. We have discussed here the role of 3DCT in laparoscopic surgery for colorectal carcinoma.

RESULTS

The mean length of the incision in LG was 4.625+/-0.89 cm, which was significantly shorter than that in OG (P<0.001). The association between ICA and SMV and SMA was described in the right-sided colectomy. The preoperative imaging of IMA and IMV was created in the rectosigmoidectomy. There was no significant difference in anastomotic leakage between the two groups, but no patients in LG experienced anastomotic leakage.

CONCLUSION

Most of the patients are satisfied with the shorter incisional length following laparoscopic surgery. Preoperative visualization of the major regional vessels may be helpful for the secure treatment of the anastomosis in laparoscopic surgery for colorectal carcinoma.

Long-term results of laparoscopic versus open colorectal resections for cancer in 235 patients with a minimum follow-up of 5 years

BACKGROUND

Laparoscopic resection for cure of colorectal cancer is controversial. More investigations on long-term results are required. This study aimed to compare the long-term outcome with a minimum follow-up of 5 years between laparoscopic or open approach for the treatment of colo-rectal cancer.

METHODS

The treatment modality (laparoscopic or open) was related to the patients (pts) choice. The following parameters between the two groups (laparoscopic and open) were assessed: wound recurrences rate, local recurrences rate, incidence of distant metastases and survival probability analysis.

RESULTS

We report the long term outcome of 149 pts with colon cancer of which 85 treated by Laparoscopic Surgery (LS) and 64 by Open Surgery (OS) and of 86 patients with rectal cancer of which 52 treated by LS and 34 by OS. In the pts with colonic cancer, mean follow-up was 82.8 months. No Statistically Significant Difference (SSD) was observed in the local recurrences rate (3.5% after LS and 6.2% after OS) and in the incidence of distant metastases (10.5% after LS and 10.9% after OS). Cumulative survival probability in LS was 0.882 as compared to 0.859 after OS. In the pts with rectal cancer, mean follow-up was 78.5 months. No SSD was observed in the local recurrences rate (19.2% after LS and 17.6% after OS) and in the incidence of distant metastases (15.3% after LS and 20.5% after OS). Cumulative survival probability in LS was 0.711 as compared to 0.617 after OS. We report an interesting data about the time of recurrences between LS and OS: the recurrences were delayed after LS, both after colonic (22.6 months vs 6.5) and rectal (25.7 months vs 13.0) resections, respectively.

CONCLUSION

We suppose that laparoscopic surgery in the treatment of colo-rectal cancer is quite safe. However, further investigation is needed.

LAPAROSCOPIC AND OPEN COLORECTAL SURGERY IN EVERYDAY PRACTICE: RETROSPECTIVE STUDY

BACKGROUND

Most studies available on laparoscopic colorectal surgery focus on highly selected patient groups. The aim of the present study was to review short- and long-term outcome of everyday patients treated in a general surgery department.

METHODS

Retrospective review was carried out of a prospective database of all consecutive patients having undergone primary laparoscopic (LAP) or open colorectal surgery between March 1993 and December 1997. Follow-up data were completed via questionnaire.

RESULTS

A total of 187 patients underwent LAP resection and 215 patients underwent open surgery. Follow up was complete in 95% with a median of 59 months (range, 1-107 months) and 53 months (range, 1-104 months), respectively. There were 28 conversions (15%) in the LAP group and these remained in the LAP group in an intention-to-treat analysis. The LAP operations lasted significantly longer for all types of resections (205 vs 150 min, P < 0.001) and hospital stay was shorter (8 vs 13 days, P < 0.001). Recovery of intestinal function was faster in the LAP group, but only after left-sided procedures (3 vs 4 days, P < 0.01). However, preoperative patient selection (more emergency operations and patients with higher American Society of Anesthesiologists (ASA) score in the open group) had a major influence on these elements and favours the LAP group. Surprisingly, the overall surgical complication rate (including long-term complications such as wound hernia) was 20% in both groups with rates of individual complications also being comparable in both groups.

CONCLUSION

Despite a patient selection favourable to the laparoscopy group, only little advantage in postoperative outcome could be shown for the minimally invasive over the open approach in the everyday patient.

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.

Does laparoscopic colorectal resection for diverticular disease impair male urinary and sexual function?

BACKGROUND

Laparoscopic colorectal resection may induce bladder and sexual dysfunction secondary to injury to the autonomic nervous system. The aim of this study was to evaluate urinary and sexual function in male patients after laparoscopic colorectal resection for diverticular disease.

METHODS

From January 1997 to March 2002, we performed a retrospective analysis of urinary and sexual function in 56 consecutive male patients who had undergone laparoscopic colorectal resection for diverticular disease. Preoperative and 6-month postoperative assessment was carried out using data collected via standardized postal questionnaires.

RESULTS

Three patients were excluded (one had a prior prostatectomy, one had Peyronie's disease, and one was treated with neuroleptics). Fifty-three patients with a mean age of 54 A+/- 2 years were included in the study. There were no conversions. The morbidity rate was 9.4%. Mean follow-up was 27 A+/- 2 months. There was no significant difference in preoperative and postoperative urinary function. Fifty-one patients (96%) were sexually active preoperatively and were still sexually active postoperatively. Compared with the preoperative period, postoperative impairment of libido, erection, ejaculation, and orgasm were not significant. Every patient was able to achieve ejaculation after the intervention, and no retrograde ejaculations were reported. One patient was unable to have an erection after the intervention.

CONCLUSION

Laparoscopic colorectal resection for diverticular disease does not significantly impair urinary and sexual function.

Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer

BACKGROUND

The safety and efficacy of laparoscopic resection (LR) for colorectal cancer remains to be established.

METHODS

A meta-analysis of randomized clinical trials comparing the short-term outcomes of laparoscopic with those of open resection for colorectal cancer was undertaken. A literature search was performed for relevant articles published by the end of 2002. Two reviewers independently appraised the trials using a predetermined protocol. Results were analysed using Comprehensive Meta-analysis.

RESULTS

The outcomes of 2512 procedures from 12 trials were analysed. LR took on average 32.9 per cent longer to perform than open resection but was associated with lower morbidity rates. Specifically, wound infection rates were significantly lower (odds ratio 0.47 (95 per cent confidence interval 0.28 to 0.80); P = 0.005). In patients undergoing LR, the average time to passage of first flatus was reduced by 33.5 per cent, that to tolerance of a solid diet by 23.9 per cent and that to 80 per cent recovery of peak expiratory flow by 44.3 per cent. Early narcotic analgesia requirements were also reduced by 36.9 per cent, pain at rest by 34.8 per cent and during coughing by 33.9 per cent, and hospital stay by 20.6 per cent. There were no significant differences in perioperative mortality or oncological clearance.

CONCLUSION

LR for colorectal cancer is associated with lower morbidity, less pain, a faster recovery and a shorter hospital stay than open resection, without compromising oncological clearance.

Laparoscopic total mesorectal excision (TME) for rectal cancer surgery: long-term outcomes

BACKGROUND

Total mesorectal excision (TME) offers the lowest reported rates of local recurrence and the best survival results in patients with rectal cancer. However, the laparoscopic approach to resection for colorectal cancer remains controversial due to fears that oncologic principles will be compromised. We assessed the feasibility, safety and long-term outcome of laparoscopic rectal cancer resections following the principles of TME. The aim of this study was to evaluate the perioperative outcome and long-term results of laparoscopic TME.

METHODS

We reviewed the prospective database of 102 consecutive unselected patients undergoing laparoscopic TME for rectal cancer between November 1991 and December 2000. Follow-up was done through office charts or direct patient contact. Recurrence and survival curves were generated by the Kaplan-Meier method.

RESULTS

Laparoscopic TME was completed successfully in 99 patients, whereas conversion to an open approach was required in three cases (3%). The overall morbidity and mortality rates were 27% and 2%, respectively, with an overall anastomotic leak rate of 17%. Of the 102 patients, four were excluded from the oncologic evaluation because final pathology was not confirmatory (two had anal canal squamous cell carcinoma and two had villous adenoma with dysplasia). In 90 of the 98 remaining patients (91.8%), the resection was considered curative. The remainder had a palliative resection due to synchronous metastatic disease or locally advanced disease. Mean follow-up was 36 months (range, 6-96). There were no trocar site recurrences. The local recurrence rate was 6%, and the cancer-specific survival of all curatively resected patients was 75% at 5 years. The overall survival rate of all curatively resected patients was 65% at 5 years; mean survival time was 6.23 years (95% confidence interval [CI], 5.39-7.07).

CONCLUSION

Laparoscopic TME is feasible and safe. The laparoscopic approach to the surgical treatment of operable rectal cancer does not seem to entail any oncologic disadvantages.

Long-term results of laparoscopic versus open resections for rectal cancer for 124 unselected patients

BACKGROUND

Controversy continues to surround laparoscopic rectal resection for malignancy. A longer follow-up period is required to evaluate the long-term efficacy of the procedure and its impact on survival. Furthermore, no data from ongoing randomized controlled trials are yet available. The aims of this study were to compare long-term outcomes for unselected patients undergoing either laparoscopic or open rectal resection for cancer.

METHODS

A series of 124 unselected consecutive patients with rectal cancer, who underwent surgery by the same surgical team, have been included in this study. Patients with T1N0 tumors underwent local excision, and emergency cases were excluded from the study. Written consent was submitted by each patient, and inclusion in either group (laparoscopic or open) was left to the patient's choice. The laparoscopic approach was chosen by 81 patients, and 43 patients chose open surgery. All the patients underwent preoperative radiotherapy (5,040 cGy), performed in selected cases with chemotherapy (for patients younger than 70 years). The following parameters were compared between the two groups: length of the surgical specimen, clearance of the margins of the specimen, number of lymph nodes identified, local recurrence rate, incidence of distant metastases, and survival probability analysis. The mean follow-up period for both groups was 43.8 months (range, l-9 years).

RESULTS

We performed 60 laparoscopic and 27 open anterior resections, as well as 21 laparoscopic and 16 open abdomino perineal resections, respectively. No mortality occurred in either group. The mean length of the resected specimens was 24.3 cm in the laparoscopic group and 23.8 cm in the open group ( p = 0.47). The mean tumor-free margin was 3.0 cm in the laparoscopic group and 2.8 cm in the open group ( p = 0.57), and the mean number of lymph nodes identified was 10.3 in the laparoscopic group and 9.8 in the open group ( p = 0.63). Of the 124 patients, 86 (52 laparoscopic and 34 open) were included in out study. We excluded patients who underwent a palliative resection (6 laparoscopic and 6 open patients) or conversion to open surgery ( n = 10) and patients who had undergone surgery in the past year ( n = 16). One laparoscopic patient was lost to follow-up evaluation, whereas three laparoscopic patients and one open patient died of causes not related to cancer. No wound recurrence was observed. The local recurrence rate after laparoscopic resection was 20.8%, as compared with 16.6% after open resection ( p = 0.687). Distant metastases occurred in 18.2% of the patients in the laparoscopic group, as compared with 21.2% in the open group ( p = 0.528). Cumulative survival probability was 0.709 after laparoscopic resection after LR and 0.606 after open resection ( p = 0.162), whereas for Dukes' stages A, B, and C in the laparoscopic group versus the open group, it was 0.875 vs 0.889 ( p = 0.392), 0.722 vs 0.584 ( p = 0.199), and 0.500 vs 0.417 ( p = 0.320), respectively. At this writing 20 laparoscopic patients (62.5%) and 20 open patients (60.6%) are disease free ( p = 0.623).

CONCLUSIONS

Oncologic surgical principles were respected. Long-term outcome after laparoscopic resection of rectal cancer was comparable with that after conventional resection. We should wait to draw conclusive scientific statements until the completion of ongoing international randomized controlled trials.

Staging of colonic neoplasms by colonoscopic miniprobe ultrasonography

BACKGROUND AND AIMS

In contrast to the situation in the upper gastrointestinal tract staging of colonic neoplasm by endoscopic ultrasonography (EUS) has not gained importance because until yet preoperative staging is without any clinical consequences. This may change with the introduction of minimally invasive surgical procedures and endoscopic resection techniques as an alternative to conventional (open) surgery.

PATIENTS AND METHODS

We performed EUS with a miniprobe in 54 consecutive patients with colonic tumors who had been referred to our hospital for endoscopic resection or for laparoscopic resection of their lesions. Therefore patients with locally advanced tumors or systemic tumor spread were not included. After detection of the lesion during colonoscopy miniprobe EUS was performed with water-filling of the colonic lumen. The depth of invasion (T classification) and the local lymph node status (positive or negative) was ascertained. Lymph node-negative lesions staged as T1 underwent endoscopic resection whenever this was technically possible. In lymph node-negative T2-3 tumors laparoscopic resection was planned if they were localized at least 10 cm apart from the flexuras. All other lesions were resected by open surgery. The EUS findings were later compared with the final pathological results (pTN classification) of the resected specimen.

RESULTS

In 50 patients (93%) a sufficient EUS evaluation of the colonic tumor was possible. In one patient with a tumor at the left flexura the lesion could not be completely visualized, and in three patients a sufficient water filling of the colon was impossible. The infiltration depth was correctly classified in 17 adenomas, 16 T1, 8 T2, 5 T3, and one T4-carcinoma (EUS accuracy for T staging: 94%). Two T2 and one T3 carcinoma were overstaged by EUS while no understaging was recorded. The lymph node status was correctly classified in 42/50 patients (84%), and a false-negative lymph node status was found in only 4/50 cases (8%). The overall accuracy of EUS was 80%.

CONCLUSION

Miniprobe EUS is suitable and has a sufficient but not optimal accuracy for staging of colonic neoplasm. Its employment makes sense if minimally invasive resection techniques in patients with high-risk for open surgery are planned.

Laparoscopic intersphincteric resection with coloplasty and coloanal anastomosis for mid and low rectal cancer

BACKGROUND

The feasibility of laparoscopic rectal resection in patients with mid or low rectal cancer was studied prospectively with regard to quality of mesorectal excision, autonomic pelvic nerve preservation and anal sphincter preservation.

METHODS

Laparoscopic rectal excision was performed in 32 patients (21 men) with rectal carcinoma located 5 cm from the anal verge. Most patients had T3 disease and received preoperative radiotherapy. The surgical procedure was performed 6 weeks after radiotherapy and included total mesorectal excision, intersphincteric resection, transanal coloanal anastomosis with coloplasty and loop ileostomy.

RESULTS

Three patients needed conversion to a laparotomy. Postoperative morbidity occurred in ten patients, related mainly to coloplasty. Macroscopic evaluation showed an intact mesorectal excision in 29 of 32 excised specimens; microscopically, 30 of the 32 resections were R0. Sphincter preservation was achieved in 31 patients. The hypogastric nerves and pelvic plexuses were identified and preserved in 24 of the 32 patients. Sexual function was preserved in ten of 18 evaluable men.

CONCLUSION

A laparoscopic approach can be considered in most patients with mid or low rectal cancer.

Laparoscopic total mesorectal excision: a consecutive series of 100 patients

OBJECTIVE

To analyze total mesorectal excision (TME) for rectal cancer by the laparoscopic approach during a prospective nonrandomized trial.

SUMMARY BACKGROUND DATA

Improved local control and survival rates in the treatment of rectal cancer have been reported after TME.

METHODS

The authors conducted a prospective consecutive series of 100 laparoscopic TMEs for low and mid-rectal tumors. All patients had a sphincter-saving procedure. Case selection, surgical technique, and clinical and oncologic results were reviewed.

RESULTS

The distal limit of rectal neoplasm was on average 6.1 (range 3-12) cm from the anal verge. The mean operative time was 250 (range 110-540) minutes. The conversion rate was 12%. Excluding the patient who stayed 104 days after a severe fistula and reoperation, the mean postoperative stay was 12.05 (range 5-53) days. The 30-day mortality was 2% and the overall postoperative morbidity was 36%, including 17 anastomotic leaks. Of 87 malignant cases, 70 (80.4%) had a minimum follow-up of 12 months, with a median follow-up of 45.7 (range 12-72) months. During this period 18.5% (13/70) died of cancer and 8.5% (6/70) are alive with metastatic disease. The port-site metastasis rate was 1.4% (1/70): a rectal cancer stage IV presented with a parietal recurrence at 17 months after surgery. The locoregional pelvic recurrence rate was 4.2% (3/70): three rectal cancers stage III at 19, 13, and 7 postoperative months.

CONCLUSIONS

Laparoscopic TME is a feasible but technically demanding procedure (12% conversion rate). This series confirms the safety of the procedure, while oncologic results are at present comparable to the open published series with the limitation of a short follow-up period. Further studies and possibly randomized series will be necessary to evaluate long-term clinical outcome in cancer patients.

The effects of increased intraabdominal pressure on colonic anastomoses

BACKGROUND

This experimental, randomized, controlled study was designed to investigate the effects of increased intraabdominal pressure (IAP) on colocolic anastomoses. To our knowledge, this is the first study to address this important issue.

METHODS

For this study, 50 Wistar albino rats were randomized into five groups. The animals in all the groups underwent laparotomy and colocolic anastomosis. The rats in the control group were not subjected to increased IAP. Accordingly, IAP's of 14, 20, 25, and 30 mmHg were established by carbon dioxide insufflation and maintained for 60 min in study groups 1, 2, 3 and 4, respectively. Colocolic anastomosis was realized after these periods of IAP in the study groups. Half of the surviving rats in all the groups were sacrificed on postoperative days 7 and 14 to allow comparison between the control and study groups with respect to their mean body weights, mean anastomosis bursting pressures, and histopathologic characteristics of their anastomosis sites.

RESULTS

The mean body weights of all the groups were comparable at all times during the study. The anastomosis bursting pressures of the animals subjected to increased IAP were lower than that of the control group, with the differences reaching statistical relevance for the animals subjected to an IAP of 20 mmHg or higher on postoperative day 7 (p <0.0005 for study groups 2, 3, and 4 vs the control group) and becoming more pronounced by the day 14 (p <0.0005 for study groups 2, 3, and 4 vs the control group). The anastomosis bursting pressure showed an inverse correlation with IAP. The adequacy of mucosal layer formation at the anastomosis line was lower and the degree of inflammation was higher in the groups exposed to an IAP of 20 mmHg or higher in the control group (p <0.05 for both comparisons among study groups 2, 3 and 4 vs the control group).

CONCLUSIONS

An IAP increased to 20 mmHg and higher was found to result in impaired strength and wound healing in colocolic anastomoses, as reflected by the decreased bursting pressure and mucosal layer formation, and by the increased inflammation at the anastomosis sites of animals subjected to high IAP values.

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.

Laparoscopic vs open hemicolectomy for colon cancer

BACKGROUND

The role of laparoscopic resection in the management of colon cancer is still a subject of debate. In this clinical study, we compared the perioperative results and long-term outcome for two unselected groups of patients undergoing either laparoscopic or open hemicolectomy for colon cancer.

METHODS

This prospective nonrandomized study was based on a series of 248 consecutive patients operated on by the same surgical team using the same type of surgical technique for right (RHC) and left (LHC) hemicolectomy, excluding segmental resections; the only difference was the type of access, which was either laparoscopic or open. The choice of type of access was left up to the patient after he or she had read the informed consent form. Operative time, length of stay, complications, and long-term outcome for the two groups were compared. Follow-up time ranged between 12 and 92 months (mean, 42).

RESULTS

Between March 1992 and January 2000, 140 patients underwent a laparoscopic hemicolectomy (55 RHC and 86 LHC); at the same time, 107 patients (44 RHC and 63 LHC) were treated via an open approach. There were no conversions to open surgery in the laparoscopic RHC group, but six patients (7%) in the laparoscopic LHC group were converted. The mean operative time for laparoscopic surgery was significantly longer than the time for open surgery (190 vs 140 min for RHC, 240 vs 190 min for LHC,); however, with increasing experience, this time decreased significantly. The mean hospital stay for the patients who underwent laparoscopic procedures was significantly shorter in both the RHC and the LHC groups (9.2 vs 13.2 days for RHC, 10.0 vs 13.2 days for LHC). No statistically significant difference between the two laparoscopic and open groups was observed for the major complication rate (1.9% vs 2.3% for RHC, 7.5% vs 6.3% for LHC). The patient in the laparoscopic RHC group were lost to follow-up. The local recurrence rate was lower after laparoscopic surgery in both arms (5.4% vs 9% for RHC, 1.5% vs 7.5% for LHC), but the differences were not statistically significant. Two port site recurrences were observed in the laparoscopic groups, one after RHC (2.7%) and one after LHC (1.5%). Metachronous metastases rates were similar for the two groups (16.2% vs 15.1% for RHC, 4.4% vs 5.7% for LHC). Cumulative survival probability at 48 months after laparoscopic RHC was 0.865, as compared to 0.818 after open surgery, and 0.971 after laparoscopic LHC, as compared to 0.887 after open surgery.

CONCLUSION

These results suggest that laparoscopic hemicolectomy for colonic cancer can be performed safely, with morbidity, mortality, and long-term results comparable to those of open surgery.

Laparoscopic colonic resection

BACKGROUND AND PURPOSE

In the last decade, laparoscopy has dramatically changed colonic surgery. Laparoscopic procedures are applied to the treatment of almost all colonic diseases, including both benign and malignant lesions. Focusing our attention on the laparoscopic oncologic operative technique, we compared the perioperative results and the long-term outcome of laparoscopic surgery (LS) with those of conventional open surgery (OS) in a series of 360 unselected consecutive patients.

PATIENTS AND METHODS

Between 1992 and 2001, excluding 102 patients with rectal tumors, 207 patients underwent laparoscopic colonic resection (72.5% for malignant lesions), whereas 153 (71.9% with malignant lesions) were treated by OS. The treatment modality was selected by the patients after reading the informed consent form. The statistical significance of differences in the morbidity and mortality rates, local recurrence rate, and incidence of distant metastases in the two groups was assessed by chi2 test. The survival probability analysis was performed by the Kaplan-Meier method. Significant differences in survival probability between groups were assessed by the log-rank test. A level of 5% was used as the criterion of statistical significance.

RESULTS

Laparoscopic surgery was technically feasible in 95.7% of the patients. No statistically significant difference was observed in the major complication rate (3.5% after LS and 3.3% after OS; P = 0.870) or in perioperative mortality (1.5% v 1.3%; P = 0.769). The mean follow-up in the patients with malignant disease was 42.2 months, during which time, we observed 2 cases of abdominal wall metastases (1.9%) in patients with advanced disease. The local recurrence rate was lower after LS than OS: 2.8% v 8.1%; P = 0.223). Distant metastases occurred in 8.6% of patients after LS and 9.3% after OS (P = 0.926). At 48 months of follow-up, the cumulative survival probability in the LS-completed malignant group was 0.934 compared with 0.860 after OS (P = 0.781).

CONCLUSION

Laparoscopic colonic resection for both benign and malignant lesions is technically feasible, without additional risks for the patients. However, oncologic outcomes have not been determined because no data from the ongoing randomized controlled trials are yet available.

Laparoscopic-assisted resection of colorectal malignancies: a systematic review

OBJECTIVE

To compare the safety and efficacy of laparoscopic-assisted resection of colorectal malignancies with open colectomy.

METHODS

Two search strategies were devised to retrieve literature from the Medline, Current Contents, Embase, and Cochrane Library databases until July 1999. Inclusion of papers was determined using a predetermined protocol, independent assessments by two reviewers, and a final consensus decision. English language papers were selected. Acceptable study designs included randomized controlled trials, controlled clinical trials, case series, or case reports. Fifty-two papers met the inclusion criteria. They were tabulated and critically appraised in terms of methodology and design, outcomes, and the possible influence of bias, confounding, and chance.

RESULTS

Little high-level evidence was available. Laparoscopic resection of colorectal malignancy was more expensive and time-consuming, but little evidence suggests high rates of port site recurrence. The new procedure's advantages revolve around early recovery from surgery and reduced pain.

CONCLUSIONS

The evidence base for laparoscopic-assisted resection of colorectal malignancies is inadequate to determine the procedure's safety and efficacy. Because of inadequate evidence detailing circumferential marginal clearance of tumors and the necessity of determining a precise incidence of cardiac and other major complications, along with wound and port site recurrence, it is recommended that a controlled clinical trial, ideally with random allocation to an intervention and control group, be conducted. Long-term survival rates need to be a primary aim of such a trial.

CO2 pneumoperitoneum does not enhance tumor growth and metastasis: study of a rat cecal wall inoculation model

INTRODUCTION

Although many studies have evaluated the effects of carbon dioxide pneumoperitoneum on port site recurrence, little is known about its outcome on tumor growth and metastasis. The effect of pneumoperitoneum with carbon dioxide on cecal tumor growth and metastasis was compared with laparotomy using a rat colon cancer cell line.

METHODS

Time Course Study: Fifty WF/BN F1 hybrid rats were inoculated with 2,000,000 WB2054M5 tumor cells into the cecal wall and explored two to ten weeks after injection. Main Study: 152 rats were randomly assigned either to 6-mmHg CO2 pneumoperitoneum (30 minutes) or 4-cm laparotomy (30 minutes) two weeks after tumor inoculation and were explored four weeks after treatment.

RESULTS

Time Course Study: Thirty-seven (95 percent) of the surviving rats developed a cecal wall tumor, and there was progressive tumor growth and metastasis over the ten-week period. At six weeks, metastasis occurred to the liver in 25 percent, to the lung in 38 percent, and to the lymph node in 63 percent, and peritoneal seeding occurred in 38 percent; this time period was chosen for the main study. Main Study: At the time of treatment (2 weeks), 124 rats were eligible for randomization. One hundred two rats survived the six-week period (50 pneumoperitoneum, 52 laparotomy) and were killed. There were no differences between the CO2 pneumoperitoneum and laparotomy groups regarding cecal tumor growth (1.043 vs. 0.894 g) and metastases to the liver (32 vs. 37 percent), lung (34 vs. 17 percent), lymph node (84 vs. 77 percent), and wound or port (20 vs. 23 percent).

CONCLUSIONS

A cecal wall inoculation model mimics the natural cascade of colon cancer growth and metastasis. CO2 pneumoperitoneum did not affect the tumor growth and metastasis to the liver and other organs when compared with laparotomy in this model.

Surgical aspects and future developments of laparoscopy

Laparoscopy has revolutionized surgery and in the process influenced the practice of anesthesiology. This article reviews several minimal access procedures that have been accepted into practice, are gaining acceptance, or remain investigational. Absolute contraindications to laparoscopy have been emphasized. As the threshold for primary care physicians to refer sicker and sicker patients for surgery decreases, it is crucial for the anesthesiologist to understand physiologic stresses of pneumoperitoneum and the nuances of laparoscopic surgery. The anesthesiologist also can be recruited to adjust insufflation pressures, tweak images on monitors, rotate and position the patient, or pass balloons and bougies. With patient and surgeon expectation of no pain or nausea and early discharge, anesthetic choices become vital for the ultimate success of the procedure.

Laparoscopic total mesorectal excision with autonomic nerve preservation

Laparoscopy has greatly influenced abdominal surgery. We hypothesize that the benefits of minimally invasive surgery are applicable to rectal cancer. A cadaver model of laparoscopic rectal resection with total mesorectal excision (TME) and autonomic nerve preservation was utilized to explore this hypothesis. The principles of TME were followed, including high vascular ligation, sharp mesorectal dissection, and identification and preservation of the autonomic pelvic nerves. After proving feasibility in the cadaver model, a clinical study was performed on patients with mid to low rectal cancers. We observed acceptable morbidity with this minimally invasive technique of rectal resection and TME. We conclude that there is growing evidence that laparoscopic methods can be applied to patients with rectal cancer.

Rapid rehabilitation in elderly patients after laparoscopic colonic resection

BACKGROUND

Introduction of the laparoscopic surgical technique has reduced hospital stay after colonic resection from about 8-10 to 4-6 days. In most studies, however, specific attention has not been paid to changes in perioperative protocols required to maximize the advantages of the minimally invasive procedure. In the present study the laparoscopic approach was combined with a perioperative multimodal rehabilitation protocol.

METHODS

After laparoscopically assisted colonic resection, patients were treated with epidural local anaesthesia for 2 days, early mobilization and enteral nutrition. Routine use of morphine and traditional tubes, drains and prolonged bladder catheterization was avoided.

RESULTS

Laparoscopic resection was intended in 50 consecutive patients, of median age 81 years. The conversion rate to open resection was 22 per cent. In patients in whom the procedure was completed laparoscopically the median hospital stay was 2.5 days; defaecation occurred in 92 per cent of patients within 3 days. Patients were mobilized for more than 8 h daily from day 2.

CONCLUSION

Recovery after colonic surgery was improved considerably by combining the use of a laparoscopic technique with a multimodal rehabilitation protocol of pain relief, early mobilization and oral nutrition.

A Case-Control Study of Laparoscopic versus Open Sigmoid Colectomy for Diverticulitis

Laparoscopic sigmoid colectomy (LSC) for diverticular disease accounts for a limited number of laparoscopic colon cases performed nationally because of the technical challenge it presents. Our objective was to determine the feasibility and impact of the laparoscopic approach in elective sigmoid colectomy for diverticular disease and to compare these results with those of the open approach. Twenty elective laparoscopic sigmoid colectomies (LSCs) were performed for diverticulitis between April 1992 and July 1999 at a university-affiliated urban hospital. A case-control study was performed comparing LCS with a matched control group of conventional open sigmoidectomies. Fourteen of 20 sigmoidectomies were successfully completed laparoscopically. The mean operative time for LSC was similar to that for open sigmoid colectomy (251 vs 243 minutes). There was earlier return to oral intake in the LSC group (1 vs 5 days; P < 0.001). The mean length of stay was significantly shorter ( P = 0.029) in LSC (4.8 days) versus open sigmoid colectomy (7.8 days). Conversion to open sigmoidectomy extended hospital stay to 8.16 days. The overall complication rate was 10 per cent in both groups. We conclude that LSC can be performed effectively and with a low complication rate for diverticular disease. LSC provides the benefit of quicker return of bowel function and shorter hospitalization.

Laparoscopic adrenalectomy for large-volume (> or = 5 cm) adrenal masses

BACKGROUND AND PURPOSE

Laparoscopic adrenalectomy has emerged as the standard of care at many centers for small surgical adrenal masses. However, the role of laparoscopic adrenalectomy in the treatment of large adrenal masses has not been specifically addressed. Our aim was to evaluate the outcome of laparoscopic v open adrenalectomy for large-volume (> or =5 cm) adrenal masses and to compare laparoscopic adrenalectomy for large- and small-volume (<5 cm) masses.

PATIENTS AND METHODS

Data from 14 patients with large adrenal masses undergoing laparoscopic adrenalectomy between February 1998 and March 1999 (Group I) were retrospectively compared with 14 contemporary large-volume open adrenalectomies between December 1992 and May 1998 (Group II) and 45 small-volume laparoscopic adrenalectomies between July 1997 and November 1998 (Group III).

RESULTS

In Group I and Group II, the mean surgical time (205 min v 216 min) and blood loss (400 mL v 584 mL) were similar. Although the mean adrenal size was also comparable (8 cm v 7.8 cm), the specimen weight of the en bloc adrenal gland and periadrenal fat was greater in Group I (168 g v 106 g). The hospital stay was shorter in Group I (2.4 days v 7.7 days). Minor complications occurred in 21.4% of Group I and 50% of Group II patients. On comparing Group I and Group III (laparoscopic <5 cm), Group I had larger specimen weight (168 g v 51.4 g), longer surgical time (205 min v 158 min), greater blood loss (400 mL v 113 mL), longer hospital stay (2.4 days v 1.5 days), a higher complication rate (21.4% v 8.9%), and a higher incidence of open surgical conversion (14.3% v 2.2%). Over a mean follow-up of 9.9 months, no local or port-site recurrences have been noted in Group I.

CONCLUSIONS

Laparoscopic adrenalectomy for large-volume adrenal masses is technically feasible and seems to replicate open surgical oncologic principles of achieving a wide-margin, en bloc excision of the adrenal gland and periadrenal fat. Successful laparoscopic resection is not impacted by the large size of the adrenal mass per se but rather by the presence of local invasion and poorly defined tissue planes that may be encountered in adrenal malignancy. As such, laparoscopic adrenalectomy for large masses should be attempted only by experienced laparoscopic surgeons and then with a low threshold for open conversion.