Randomized clinical trial of the effect of open versus laparoscopically assisted colectomy on systemic immunity in patients with colorectal cancer

Influence of Laparoscopic Surgery on Cellular Immunity in Colorectal Cancer: A Systematic Review and Meta-Analysis

Colorectal cancer (CRC) is the third most common cancer worldwide. The main treatment options are laparoscopic (LS) and open surgery (OS), which might differ in their impact on the cellular immunity so indispensable for anti-infectious and antitumor defense. MEDLINE, Embase, Web of Science (SCI-EXPANDED), the Cochrane Library, Google Scholar, ClinicalTrials.gov, and ICTRP (WHO) were systematically searched for randomized controlled trials (RCTs) comparing cellular immunity in CRC patients of any stage between minimally invasive and open surgical resections. A random effects-weighted inverse variance meta-analysis was performed for cell counts of natural killer (NK) cells, white blood cells (WBCs), lymphocytes, CD4+ T cells, and the CD4+/CD8+ ratio. The RoB2 tool was used to assess the risk of bias. The meta-analysis was prospectively registered in PROSPERO (CRD42021264324). A total of 14 trials including 974 participants were assessed. The LS groups showed more favorable outcomes in eight trials, with lower inflammation and less immunosuppression as indicated by higher innate and adaptive cell counts, higher NK cell activity, and higher HLA-DR expression rates compared to OS, with only one study reporting lower WBCs after OS. The meta-analysis yielded significantly higher NK cell counts at postoperative day (POD)4 (weighted mean difference (WMD) 30.80 cells/µL [19.68; 41.92], p < 0.00001) and POD6-8 (WMD 45.08 cells/µL [35.95; 54.21], p < 0.00001). Although further research is required, LS is possibly associated with less suppression of cellular immunity and lower inflammation, indicating better preservation of cellular immunity.

Laparoscopic-Assisted Colorectal Resection Can Reduce the Inhibition of Immune Function Compared with Conventional Open Surgery: A Retrospective Clinical Study

Background: Immune function is an important indicator for assessing postoperative recovery and long-term survival in patients with malignancy, and laparoscopic surgery is thought to have a less suppressive effect on the immune response than open surgery. This study aimed to investigate this effect in a retrospective clinical study. Methods: In this retrospective clinical study, we enrolled 63 patients with colorectal cancer in the Department of General Surgery of the First Affiliated Hospital of Soochow University and assessed the changes in their postoperative immune function by measuring CD3+T, CD4+T, CD8+T lymphocytes, and CD4+/CD8+ ratio. Results: Compared with open surgery, laparoscopic colorectal surgery was effective in improving the postoperative decline in immune function. We determined that the number of CD4+, CD8+T lymphocytes, and the CD4+/CD8+ ratio was not significantly reduced in the laparoscopic group. Conclusion: Laparoscopic-assisted colorectal resection can reduce the inhibition of immune functions compared with conventional open surgery.

Laparoscopic Radical Resection versus Routine Surgery for Colorectal Cancer

For patients with colorectal cancer, minimally invasive surgical methods, particularly laparoscopic methods, are now the preferred course of therapy. This research is performed to investigate the effects of laparoscopic radical resection on patients with colorectal cancer. A total of 100 colorectal cancer patients treated in our hospital from January 2017 to January 2019 were enrolled. The subjects were divided into observation (n = 50) and control (n = 50) groups and treated with laparoscopic surgery and laparotomy, respectively. As well as postoperative complications and survival rates, the levels of inflammatory substances, stress response, immunological function, and perioperative markers were compared between the two groups. There was no significant difference in the postoperative exhaust time between the two groups (P > 0.05). Compared with the control group, the observation group showed longer operation time, faster recovery of intestinal function, shorter hospital stay, and less intraoperative bleeding amount (P < 0.05). The serum contents of hs-CRP, TNF-α, IL-6, norepinephrine, adrenaline, and cortisol at 1 d, 3 d, and 5 d after surgery were significantly higher than before in both groups (P < 0.05). Moreover, the serum contents of hs-CRP, TNF-α, IL-6, norepinephrine, adrenaline, and cortisol in the observation group were significantly lower than that in the control group (P < 0.05). At 10 days following surgery, immune index levels had dramatically increased in both groups, with noticeably higher immune index levels in the observation group than in the control group (P < 0.05). There were no appreciable differences in the two groups' 2-year survival rates (P > 0.05), but the complication rate was much greater in the control group (P < 0.05). To sum up, after laparoscopic surgery, patients had fewer complications, shorter hospital stay, lower inflammatory factor expression, less stress response, better immune function, less trauma, faster recovery, and improved quality of life.

Immunophenotype Rearrangement in Response to Tumor Excision May Be Related to the Risk of Biochemical Recurrence in Prostate Cancer Patients

Background: Prostate cancer (PCa) is known to exhibit a wide spectrum of aggressiveness and relatively high immunogenicity. The aim of this study was to examine the effect of tumor excision on immunophenotype rearrangements in peripheral blood and to elucidate if it is associated with biochemical recurrence (BCR) in high risk (HR) and low risk (LR) patients. Methods: Radical prostatectomy (RP) was performed on 108 PCa stage pT2–pT3 patients. Preoperative vs. postoperative (one and three months) immunophenotype profile (T- and B-cell subsets, MDSC, NK, and T reg populations) was compared in peripheral blood of LR and HR groups. Results: The BCR-free survival difference was significant between the HR and LR groups. Postoperative PSA decay rate, defined as ePSA, was significantly slower in the HR group and predicted BCR at cut-off level ePSA = −2.0% d⁻¹ (AUC = 0.85 (95% CI, 0.78–0.90). Three months following tumor excision, the LR group exhibited a recovery of natural killer CD3 − CD16+ CD56+ cells, from 232 cells/µL to 317 cells/µL (p < 0.05), which was not detectable in the HR group. Prostatectomy also resulted in an increased CD8+ population in the LR group, mostly due to CD8+ CD69+ compartment (from 186 cells/µL before surgery to 196 cells/µL three months after, p < 001). The CD8+ CD69+ subset increase without total T cell increase was present in the HR group (p < 0.001). Tumor excision resulted in a myeloid-derived suppressor cell (MDSC) number increase from 12.4 cells/µL to 16.2 cells/µL in the HR group, and no change was detectable in LR patients (p = 0.12). An immune signature of postoperative recovery was more likely to occur in patients undergoing laparoscopic radical prostatectomy (LRP). Open RP (ORP) was associated with increased MDSC numbers (p = 0.002), whereas LRP was characterized by an immunity sparing profile, with no change in MDSC subset (p = 0.16). Conclusion: Tumor excision in prostate cancer patients results in two distinct patterns of immunophenotype rearrangement. The low-risk group is highly responsive, revealing postoperative restoration of T cells, NK cells, and CD8+ CD69+ numbers and the absence of suppressor MDSC increase. The high-risk group presented a limited response, accompanied by a suppressor MDSC increase and CD8+ CD69+ increase. The laparoscopic approach, unlike ORP, did not result in an MDSC increase in the postoperative period.

Laparoscopic surgery reduces the incidence of surgical site infections compared to the open approach for colorectal procedures: a meta-analysis

BACKGROUND

Surgical site infections (SSI) are the commonest healthcare associated infections. They severely compromise patient safety, are a significant burden on healthcare resources and have an adverse impact on patient quality of life. The incidence of SSIs can be as high as 10% after colorectal procedures. The laparoscopic approach is being increasingly used to undertake colorectal procedures. It provides advantages over the traditional open approach with smaller incisions, shorter hospital stay and equal oncological outcomes. The aim of this meta-analysis was to evaluate whether the laparoscopic approach for colorectal procedures reduces the incidence of SSI compared to the open approach.

METHODS

Randomised controlled trials (RCTs) comparing the two approaches published since 2000 were included in the review. Revman 5.3 software was used to carry out the review. Data were pooled and the results were shown as risk ratios with 95% confidence intervals using the fixed effects model.

RESULTS

Sixteen RCT's were included in the analysis comprising 5797 patients. These covered a range of colorectal pathologies including colon cancer, rectal cancer, inflammatory bowel disease and familial adenomatous polyposis syndrome. Analysis showed significantly lower wound infection rates (RR: 0.72, 95% confidence interval: 0.60-0.88, p = 0.001) and lower abdominal abscess rates (RR: 0.88, 95% CI 0.62-1.27, p = 0.51). The combined SSI rate was significantly lower in laparoscopic compared to open surgery (RR: 0.76, 95% CI 0.64-0.90, p = 0.001).

CONCLUSIONS

Laparoscopic colorectal surgery significantly lowers the incidence of SSI compared to open surgery.

Rivaroxaban for extended antithrombotic prophylaxis after laparoscopic surgery for colorectal cancer. Design of the PRO-LAPS II STUDY

BACKGROUND

The clinical benefit of extending prophylaxis for venous thromboembolism (VTE) beyond hospital discharge after laparoscopic surgery for cancer is undefined. Extended prophylaxis with rivaroxaban is effective in reducing post-operative VTE after major orthopedic surgery without safety concern.

METHODS

PROLAPS II is an investigator-initiated, randomized, double-blind study aimed at assessing the efficacy and safety of extended antithrombotic prophylaxis with rivaroxaban compared with placebo after laparoscopic surgery for colorectal cancer in patients who had received antithrombotic prophylaxis with low molecular-weight heparin for 7 ± 2 days (NCT03055026). Patients are randomized to receive rivaroxaban (10 mg once daily) or placebo for 3 weeks (up to day 28 ± 2 from surgery). The primary study outcome is a composite of symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT or VTE-related death at 28 ± 2 days from laparoscopic surgery. The primary safety outcome is major bleeding defined according to the International Society of Thrombosis and Haemostasis. Symptomatic objectively confirmed VTE, asymptomatic ultrasonography-detected DVT, major bleeding or death by day 28 ± 2 and by day 90 from surgery are secondary outcomes. Assuming an 8% event rate with placebo and 60% reduction in the primary study outcome with rivaroxaban, 323 patients per group are necessary to show a statistically significant difference between the study groups.

DISCUSSION

The PROLAPS II is the first study with an oral anti-Xa agent in cancer surgery. The study has the potential to improve clinical practice by answering the question on the clinical benefit of extending prophylaxis after laparoscopic surgery for colorectal cancer.

A meta-analysis of laparoscopic surgery versus conventional open surgery in the treatment of colorectal cancer

BACKGROUND

This meta-analysis aimed to explore the overall effect and safety of anterior laparoscopic surgery versus conventional open surgery for patients with colorectal cancer based on eligible randomized controlled trials (RCTs), especially the difference in the postoperative incidence of deep venous thrombosis (DVT).

METHODS

PubMed, Cochrane, and Embase were searched based on keywords to identify eligible studies before February 2018. Only RCTs were eligible. We analyzed the main outcomes using the relative risk (RR) or mean difference (MD) along with 95% confidence interval (95% CI).

RESULTS

In this meta-analysis, we analyzed a total of 24 studies with 4592 patients in the laparoscopic surgery group and 3865 patients in the open surgery group. The results indicated that compared with the open surgery, laparoscopic surgery significantly decreased estimated blood loss (SMD: -1.14, 95%CI: -1.70 to -0.57), hospital stay (SMD: -1.12, 95%CI: -1.76 to -0.47), postoperative mortality (RR: 0.60, 95%CI: 0.41-0.86) and postoperative complication (RR: 0.83, 95%CI: 0.72-0.95). However, the operative time (WMD: 40.46, 95%CI: 35.94-44.9) was statistically higher in the laparoscopic surgery group than the open surgery group, and there was no significant difference in the incidence of DVT between the 2 groups (RR: 0.96, 95%CI: 0.46-2.02).

CONCLUSION

Laparoscopic surgery is superior to open surgery for patients with colorectal cancer. But the 2 surgeries showed no significant difference in the incidence of DVT.

Does a laparoscopic approach attenuate the body weight loss and lean body mass loss observed in open distal gastrectomy for gastric cancer? a single-institution exploratory analysis of the JCOG 0912 phase III trial

BACKGROUND

Laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer may prevent the loss of body weight and lean body mass resulting from reduced surgical stress in comparison to open distal gastrectomy (ODG). A multicenter phase III trial conducted by the Japan Clinical Oncology Group (JCOG0912 trial) was performed to confirm the non-inferiority of LADG to ODG for stage I gastric cancer in terms of relapse-free survival.

METHODS

This study was performed as a single-institution exploratory analysis using the data of the patients from our hospital who were enrolled in the JCOG0912 phase III trial. Body weight and lean body mass were evaluated using a bioelectrical impedance analyzer within 1 week before and at 1 week, 1 month, and 3 months after surgery.

RESULTS

One-hundred six patients were randomized to undergo ODG (54 patients) or LADG (51 patients). Body weight loss at 1 week, 1 month, and 3 months was -3.0%, -4.9%, and -5.4%, respectively, in the ODG group and -2.7%, -4.3%, and -5.7%, respectively, in the LADG group; the differences were not statistically significant (p = 0.330, 0.166, and 0.656, respectively). Lean body mass loss at 1 week, 1 month, and 3 months was -2.8%, -4.1%, and -2.3%, respectively, in the ODG group and -2.7%, -2.9%, and -3.0%, respectively, in the LADG group; the differences were not statistically significant (p = 0.610, 0.413, and 0.925, respectively).

CONCLUSIONS

The laparoscopic approach did not attenuate the loss of body weight and lean body mass in comparison to patients who underwent open distal gastrectomy for gastric cancer.

Enhanced recovery after gastro-intestinal surgery: The scientific background

Enhanced recovery programs (ERP) are without any doubt a major innovation in the care of surgical patients. This multimodal approach encompasses elements of both medical and surgical care. The goal of this in-depth review is to analyze the surgical aspects of ERP, underlining the scientific rationale behind each element of ERP after surgery and in particular, the role of mechanical bowel preparation before colorectal surgery, the place of minimal access surgery, the utility of nasogastric tube, abdominal drainage, bladder catheters and early re-feeding. Publication of factual data has allowed many dogmas to be discarded.

Laparoscopically assisted colorectal surgery provides better short-term clinical and inflammatory outcomes compared to open colorectal surgery

INTRODUCTION

Changes in immune function after surgery may influence overall outcome, length of hospital stay, susceptibility to infection and perioperative tumour dissemination in cancer patients. Our aim was to elaborate on postoperative differences in the immune status and the intensity of the systemic inflammatory response between two groups of prospectively enrolled patients with colorectal cancer, namely patients undergoing laparoscopically assisted or open colorectal surgery.

MATERIAL AND METHODS

Blood samples from 77 patients were taken before surgery and then 3 h, 24 h and 4 days after surgery. The inflammatory response was determined by leukocyte counts, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and procalcitonin levels (PCT). Immune status was determined by phenotypic analysis of lymphocyte populations and the activation of mononuclear cells. CD64 expression and cytokine expression were also determined.

RESULTS

Patients undergoing laparoscopically assisted surgery had less intraoperative blood loss (p = 0.002), earlier resumption of diet (p = 0.002) and shorter hospital stay (p = 0.02). Numbers of total leukocytes (p = 0.12), CRP (p = 0.002) and PCT (p = 0.23) were remarkably higher 4 days after surgery in patients who underwent an open colorectal procedure. There was an important decrease in monocyte HLA-DR expression 3 h after surgery in patients undergoing laparoscopically assisted surgery (p = 0.03).

CONCLUSIONS

Our study suggests that minimally invasive surgery provides better short-term clinical outcomes for patients with resectable colorectal cancer. The acute inflammatory response is less pronounced. Post-surgical immunological disturbance in both groups is similar, but we observed a divergent effect of different surgical approaches on the expression of HLA-DR on monocytes. However, our results corroborate the results of previous studies.

Laparoscopy-assisted pancreaticoduodenectomy as minimally invasive surgery for periampullary tumors: a comparison of short-term clinical outcomes of laparoscopy-assisted pancreaticoduodenectomy and open pancreaticoduodenectomy

BACKGROUND

Few reports have described laparoscopy-assisted pancreaticoduodenectomy (LAPD) as an alternative to the conventional open approach for periampullary tumors. The safety and feasibility of this procedure remain to be determined. In this study, we compared the short-term clinical outcomes of LAPD with those of open pancreaticoduodenectomy (OPD).

METHODS

A retrospective review of patients who had undergone pancreaticoduodenectomy for periampullary tumors between June and December 2014 was conducted. Patient demographic data and their pathological and short-term clinical parameters were compared between the LAPD and OPD groups.

RESULTS

Fifty-two patients were included in the study: 18 had undergone LAPD and 34 had undergone OPD. The mean operation time was longer for LAPD than for OPD (531.1 vs. 383.2 min, P < 0.001). The estimated blood loss, rate of blood transfusion, surgical resection margin status, and number of lymph nodes retrieved were similar in both groups. Overall morbidity and the incidence of pancreatic fistula did not differ significantly between the two groups. However, the mean length of hospital stay was significantly shorter in the LAPD group (12.6 vs. 18.6 days, P = 0.001).

CONCLUSION

LAPD is a technically safe and feasible alternative treatment for periampullary tumors, with short-term clinical outcomes equivalent to those of OPD, with a shorter hospital stay.

The Peto odds ratio viewed as a new effect measure

Meta-analysis has generally been accepted as a fundamental tool for combining effect estimates from several studies. For binary studies with rare events, the Peto odds ratio (POR) method has become the relative effect estimator of choice. However, the POR leads to biased estimates for the OR when treatment effects are large or the group size ratio is not balanced. The aim of this work is to derive the limit of the POR estimator for increasing sample size, to investigate whether the POR limit is equal to the true OR and, if this is not the case, in which situations the POR limit is sufficiently close to the OR. It was found that the derived limit of the expected POR is not equivalent to the OR, because it depends on the group size ratio. Thus, the POR represents a different effect measure. We investigated in which situations the POR is reasonably close to the OR and found that this depends only slightly on the baseline risk within the range (0.001; 0.1) yet substantially on the group size ratio and the effect size itself. We derived the maximum effect size of the POR for different group size ratios and tolerated amounts of bias, for which the POR method results in an acceptable estimator of the OR. We conclude that the limit of the expected POR can be regarded as a new effect measure, which can be used in the presented situations as a valid estimate of the true OR.

Laparoscopy-assisted posterior low anterior resection of rectal cancer

Background

Laparoscopy-assisted low anterior resection (LAR) of colorectal cancer, using a posterior surgical approach, is a difficult and controversial procedure to perform. We report successful operations on 13 patients with clear surgical margins and no serious complications.

Methods

Thirteen patients [10 males and three females, age range: 48 to 69 years (median: 61 years)] with low adenocarcinoma confirmed by preoperative colonoscopic biopsy (four stage T1; nine stage T2) were resected. The distance from inferior edge of tumor to dentate line was 2 ~ 5 cm (average: 3.4 cm). Intraperitoneal laparoscopy was performed to isolate rectosigmoid and mesocolon moving toward distal end of the tumor. Perineal operation was performed in the prone clasp-knife position.

Results

The circumferential resection margin (CRM) was negative in all cases. No serious postoperative complications occurred. There were four cases of perineal wound infection, two cases with superficial perineal wound dehiscence, and two cases with persistent postoperative sacral pain. All 13 patients passed the Wexner continence test and had satisfactory anal function during a mean 18-month postoperative follow-up period.

Conclusion

Laparoscopic posterior LAR of colorectal cancer is a safe and reliable treatment for patients with low colorectal cancer, increasing the chance of anal functional recovery.

Trial registration

Chinese Clinical Trial Register ChiCTR-ONC-14005145. Registered 19 August 2014.

Perioperative advantages of modified laparoscopic vs open splenectomy and azygoportal disconnection

AIM: To investigate perioperative outcomes in patients undergoing modified laparoscopic splenectomy or open splenectomy and azygoportal disconnection for portal hypertension.

METHODS: This study included 44 patients who underwent modified laparoscopic splenectomy and azygoportal disconnection (MLSD) and 71 who underwent open procedures for portal hypertension. Blood samples were collected before surgery and on days 1, 3, and 7 after surgery. Markers of liver and renal function, C-reactive protein (CRP), interleukin-6 (IL-6), and procalcitonin (PCT) were measured, and perioperative variables were compared between the two groups.

RESULTS: The modified laparoscopic group showed significantly better and faster recovery, better liver and renal function, and fewer complications than the open group. CRP, IL-6, and PCT concentrations on postoperative days 1, 3, and 7 were significantly lower in the modified laparoscopic group than in the open group.

CONCLUSION: MLSD was associated with lower inflammatory immune responses, less impairment of liver and renal function, and faster and better recovery.

[Guidelines for enhanced recovery after elective colorectal surgery]

Early recovery after surgery provides patients with all means to counteract or minimize the deleterious effects of surgery. This concept is suitable for a surgical procedure (e.g., colorectal surgery) and comes in the form of a clinical pathway that covers three periods (pre-, intra- and postoperative). The purpose of this Expert panel guideline is firstly to assess the impact of each parameter usually included in the rehabilitation programs on 6 foreseeable consequences of colorectal surgery: surgical stress, postoperative ileus, water and energy imbalance, postoperative immobility, sleep alterations and postoperative complications; secondly, to validate the usefulness of each as criteria of efficiency criteria for success of rehabilitation programs. Two main criteria were selected to evaluate the impact of each parameter: the length of stay and frequency of postoperative complications. Lack of information in the literature forced experts to assess some parameters with criteria (duration of postoperative ileus or quality of analgesia) that mainly surrogate a positive impact for the implementation of an early recovery program. After literature analysis, 19 parameters were identified as potentially interfering with at least one of the foreseeable consequences of colorectal surgery. GRADE® methodology was applied to determine a level of evidence and strength of recommendation. After synthesis of the work of experts using GRADE® method on 19 parameters, 35 recommendations were produced by the organizing committee. The recommendations were submitted and amended by a group of reviewers. After three rounds of Delphi quotes, strong agreement was obtained for 28 recommendations (80%) and weak agreement for seven recommendations. A consensus was reached among anesthesiologists and surgeons on a number of approaches that are likely not sufficiently applied for rehabilitation programs in colorectal surgery such as: preoperative intake of carbohydrates; intraoperative hemodynamic optimization; oral feeding resume before ha24; gum chewing after surgery; patient out of bed and walking at D1. The panel also clarified the value and place of such approaches such as: patient information; preoperative immunonutrition; laparoscopic surgery; antibiotic prophylaxis; prevention of hypothermia; systematic prevention of nausea and vomiting; morphine-sparing analgesic techniques; indications and techniques for bladder catheterization. The panel also confirmed the futility of approaches such as: bowel preparation for colon surgery; maintain of the nasogastric tube; surgical drainage for colonic surgery.

Laparoscopic versus open total mesorectal excision for rectal cancer

BACKGROUND

Colorectal cancer including rectal cancer is the third most common cause of cancer deaths in the western world. For colon carcinoma, laparoscopic surgery is proven to result in faster postoperative recovery, fewer complications and better cosmetic results with equal oncologic results. These short-term benefits are expected to be similar for laparoscopic rectal cancer surgery. However, the oncological safety of laparoscopic surgery for rectal cancer remained controversial due to the lack of definitive long-term results. Thus, the expected short-term benefits can only be of interest when oncological results are at least equal.

OBJECTIVES

To evaluate the differences in short- and long-term results after elective laparoscopic total mesorectal excision (LTME) for the resection of rectal cancer compared with open total mesorectal excision (OTME).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2013, Issue 2), MEDLINE (January 1990 to February 2013), EMBASE (January 1990 to February 2013), ClinicalTrials.gov (February 2013) and Current Controlled Trials (February 2013). We handsearched the reference lists of the included articles for missed studies.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) comparing LTME and OTME, reporting at least one of our outcome measures, was considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality according to the CONSORT statement, and resolved disagreements by discussion. We rated the quality of the evidence using GRADE methods.

MAIN RESULTS

We identified 45 references out of 953 search results, of which 14 studies met the inclusion criteria involving 3528 rectal cancer patients. We did not consider the risk of bias of the included studies to have impacted on the quality of the evidence. Data were analysed according to an intention-to-treat principle with a mean conversion rate of 14.5% (range 0% to 35%) in the laparoscopic group.There was moderate quality evidence that laparoscopic and open TME had similar effects on five-year disease-free survival (OR 1.02; 95% CI 0.76 to1.38, 4 studies, N = 943). The estimated effects of laparoscopic and open TME on local recurrence and overall survival were similar, although confidence intervals were wide, both with moderate quality evidence (local recurrence: OR 0.89; 95% CI 0.57 to1.39 and overall survival rate: OR 1.15; 95% CI 0.87 to1.52). There was moderate to high quality evidence that the number of resected lymph nodes and surgical margins were similar between the two groups.For the short-term results, length of hospital stay was reduced by two days (95% CI -3.22 to -1.10), moderate quality evidence), and the time to first defecation was shorter in the LTME group (-0.86 days; 95% CI -1.17 to -0.54). There was moderate quality evidence that 30 days morbidity were similar in both groups (OR 0.94; 95% CI 0.8 to 1.1). There were fewer wound infections (OR 0.68; 95% CI 0.50 to 0.93) and fewer bleeding complications (OR 0.30; 95% CI 0.10 to 0.93) in the LTME group.There was no clear evidence of any differences in quality of life after LTME or OTME regarding functional recovery, bladder and sexual function. The costs were higher for LTME with differences up to GBP 2000 for direct costs only.

AUTHORS' CONCLUSIONS

We have found moderate quality evidence that laparoscopic total mesorectal excision (TME) has similar effects to open TME on long term survival outcomes for the treatment of rectal cancer. The quality of the evidence was downgraded due to imprecision and further research could impact on our confidence in this result. There is moderate quality evidence that it leads to better short-term post-surgical outcomes in terms of recovery for non-locally advanced rectal cancer. Currently results are consistent in showing a similar disease-free survival and overall survival, and for recurrences after at least three years and up to 10 years, although due to imprecision we cannot rule out superiority of either approach. We await long-term data from a number of ongoing and recently completed studies to contribute to a more robust analysis of long-term disease free, overall survival and local recurrence.

Randomized comparison of surgical stress and the nutritional status between laparoscopy-assisted and open distal gastrectomy for gastric cancer

BACKGROUND

Laparoscopy-assisted distal gastrectomy (LADG) for gastric cancer may prevent the development of an impaired nutritional status due to reduced surgical stress compared with open distal gastrectomy (ODG).

METHODS

This study was performed as an exploratory analysis of a phase III trial comparing LADG and ODG for stage I gastric cancer during the period between May and December of 2011. All patients received the same perioperative care via fast-track surgery. The level of surgical stress was evaluated based on the white blood cell count and the interleukin-6 (IL-6) level. The nutritional status was measured according to the total body weight, amount of lean body mass, lymphocyte count, and prealbumin level.

RESULTS

Twenty-six patients were randomized to receive ODG (13 patients) or LADG (13 patients). The baseline characteristics and surgical outcomes were similar between the two groups. The median IL-6 level increased from 0.8 to 36.3 pg/dl in the ODG group and from 1.5 to 53.3 pg/dl in the LADG group. The median amount of lean body mass decreased from 48.3 to 46.8 kg in the ODG group and from 46.6 to 46.0 kg in the LADG group. There are no significant differences between two groups.

CONCLUSIONS

The level of surgical stress and the nutritional status were found to be similar between the ODG and LADG groups in a randomized comparison using the same perioperative care of fast-track surgery.

Incidence of postoperative venous thromboembolism after laparoscopic versus open colorectal cancer surgery: a meta-analysis

The objective of this study was to systematically compare the incidence of postoperative venous thromboembolism (VTE; deep vein thrombosis and/or pulmonary embolism) in patients with colorectal cancer after laparoscopic surgery and conventional open surgery. A systematic search of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted. Eleven randomized control trials involving 3058 individuals who reported VTE outcomes were identified, of whom 1677 were treated with laparoscopic therapy and 1381 underwent open surgery. The combined results of the individual trials showed no statistically significant difference in the odds ratio for overall VTE (odds ratio 0.64, 95% confidence interval, 0.33-1.23, P=0.18), as well as in subgroups of deep vein thrombosis and anticoagulant prophylaxis between these 2 approaches. In conclusion, laparoscopic resection could achieve similar outcomes in terms of the incidence of VTE, which are associated with long-term benefits of the patients.

[Comparison of initial results with robotic-assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy]

OBJECTIVE

To investigate the superiority in 2 radical prostatectomies, we compared the initial results of robotic-assisted radical prostatectomy (RARP) to those of retropubic radical prostatectomy (RRP) performed during the same period at Nagakubo hospital.

PATIENTS AND METHODS

The study was conducted on a total of 160 patients having undergone radical prostatectomy from April 2009 to March 2012 (92 patients with RARP and 68 with RRP). We investigated surgical stress, cancer control, functional outcomes and complications in both groups.

RESULTS

Surgical stress; operation time was significantly shorter with RRP; however, blood loss and serum total protein loss were significantly less with RARP. White blood cell count at 2 days after surgery was significantly less with RARP. The rates of analgesic use and SIRS were similar. Although the date on which taking solid meals resumed did not differ, the duration of indwelling urethral catheter and admission period were significantly shorter with RARP. Cancer control; the rates of positive surgical margin were 27.2% and 19.1% with RARP and RRP, respectively (p = 0.24), and biochemical recurrence was seen in 12.0% and 19.1% with RARP and RRP, respectively (p = 0.73), which were not significantly different. Continence; urinary continence outcomes with RARP and RRP were 17% and 4% for urinary continence at discharge (p = 0.01), 1.8 and 3.3 months for no more than one pad per day (p < 0.01), and 4.3 and 6.2 months for pad free (p = 0.03), respectively. Sexual function; erection recovery within 6 mo was only observed with RARP; however, overall recovery rate of erection was 65% and 75% with RARP and RRP, respectively (p = 0.69).

COMPLICATIONS

1 case with a rectal injury was seen in both groups, but complication rates were 8.7% and 16.2% with RARP and RRP, respectively (p = 0.22).

CONCLUSION

In spite of our initial experience of RARP, surgical stress and complications with RARP were considered to be superior to that with RRP. Cancer control and sexual function showed no significant difference between RARP and RRP, however, urinary continence outcome is significantly superior with RARP. Our data suggest that treatment outcome after initial experience with RARP is not inferior to that with RRP, and better results are expected by improving surgical techniques.

[Not Available]

The term “robot” was coined by the Czech playright Karel Capek in 1921 in his play Rossom's Universal Robots. The word “robot” is from the check word robota which means forced labor. The era of robots in surgery commenced in 1994 when the first AESOP (voice controlled camera holder) prototype robot was used clinically in 1993 and then marketed as the first surgical robot ever in 1994 by the US FDA. Since then many robot prototypes like the Endoassist (Armstrong Healthcare Ltd., High Wycombe, Buck, UK), FIPS endoarm (Karlsruhe Research Center, Karlsruhe, Germany) have been developed to add to the functions of the robot and try and increase its utility. Integrated Surgical Systems (now Intuitive Surgery, Inc.) redesigned the SRI Green Telepresence Surgery system and created the daVinci Surgical System^® classified as a master-slave surgical system. It uses true 3-D visualization and EndoWrist^®. It was approved by FDA in July 2000 for general laparoscopic surgery, in November 2002 for mitral valve repair surgery. The da Vinci robot is currently being used in various fields such as urology, general surgery, gynecology, cardio-thoracic, pediatric and ENT surgery. It provides several advantages to conventional laparoscopy such as 3D vision, motion scaling, intuitive movements, visual immersion and tremor filtration. The advent of robotics has increased the use of minimally invasive surgery among laparoscopically naïve surgeons and expanded the repertoire of experienced surgeons to include more advanced and complex reconstructions.

Factors that influence lymph node retrieval in the surgical treatment of colorectal cancer: a comparison of the laparoscopic versus open approach

BACKGROUND

The purpose of this study was to determine whether surgical approach and patient demographics are important factors that influence lymph node retrieval.

METHODS

This was a retrospective review of patients receiving surgical treatment for colorectal cancer at a single institution.

RESULTS

Two hundred three patients underwent resection for colorectal cancer. The total number of lymph nodes recovered and the number of lymph nodes involved were similar in both the laparoscopic group and the open group. Patients who had right-sided colon resection had a higher total number of lymph nodes recovered. There was no effect of age, sex, race, or body mass index (BMI) on the total number of lymph nodes harvested or on the number of positive lymph nodes.

CONCLUSIONS

Adequate regional lymphadenectomy for colorectal cancer can be successfully performed using a laparoscopic approach. Patient demographics did not make a difference in the number of total or positive lymph nodes recovered.

Effects of hybrid minimally invasive oesophagectomy on major postoperative pulmonary complications

BACKGROUND

Morbidity after oesophageal cancer surgery remains high, mainly due to major postoperative pulmonary complications (MPPCs). The aim of this study was to test the hypothesis that hybrid minimally invasive oesophagectomy (HMIO) decreases the 30-day MPPC rate without compromising oncological outcomes.

METHODS

Consecutive patients undergoing curative oesophagectomy for cancer by laparoscopic gastric mobilization and open thoracotomy (HMIO) between January 2004 and December 2009 were matched to randomly selected patients undergoing a totally open approach during the same study interval. Matching variables were age, sex, cancer stage, location of the primary tumour, histological subtype, American Society of Anesthesiologists grade, malnutrition, neoadjuvant chemoradiation and epidural analgesia.

RESULTS

MPPCs at 30 days were significantly less frequent after HMIO compared with open surgery (15·7 versus 42·9 per cent; P < 0·001). Postoperative in-hospital mortality and overall morbidity rates were 4·3 and 47·5 per cent respectively, again significantly lower in the HMIO group: 1·4 versus 7·1 per cent (P = 0·018) and 35·7 versus 59·3 per cent (P < 0·001). In multivariable analysis, HMIO, adenocarcinoma subtype, epidural analgesia and surgery after 2006 were independent protective factors against MPPCs, and HMIO was independently protective against acute respiratory distress syndrome (ARDS). Lymph node yields and survival were similar in the two groups.

CONCLUSION

HMIO for oesophageal cancer, using laparoscopic gastric mobilization and open right thoracotomy, offered a substantial and independent protective effect against MPPCs, including ARDS, without compromising oncological outcomes.

Immunologic response after laparoscopic colon cancer operation within an enhanced recovery program

OBJECTIVE

It has been demonstrated that colon operation combined with fast-track (FT) surgery and laparoscopic technique can shorten the length of hospital stay, accelerate recovery of intestinal function, and reduce the occurrence of post-operative complications. However, there are no reports regarding the combined effects of FT colon operation and laparoscopic technique on humoral inflammatory cellular immunity.

METHODS

This was a prospective, controlled study. One hundred sixty-three colon cancer patients underwent the traditional protocol and open operation (traditional open group, n=42), the traditional protocol and laparoscopic operation (traditional laparoscopic group, n=40), the FT protocol and open operation (FT open group, n=41), or the FT protocol and laparoscopic operation (FT laparoscopic group, n=40). Blood samples were taken prior to operation as well as on days 1, 3, and 5 after operation. The number of lymphocyte subpopulations was determined by flow cytometry, and serum interleukin-6 and C-reactive protein levels were measured. Post-operative hospital stay, post-operative morbidity, readmission rate, and in-hospital mortality were recorded.

RESULTS

Compared with open operation, laparoscopic colon operation effectively inhibited the release of post-operative inflammatory factors and yielded good protection via post-operative cell immunity. FT surgery had a better protective role with respect to the post-operative immune system compared with traditional peri-operative care. Inflammatory reactions, based on interleukin-6 and C-reactive protein levels, were less intense following FT laparoscopic operation compared to FT open operation; however, there were no differences in specific immunity (CD3+ and CD4+ counts, and the CD4+/CD8+ ratio) during these two types of surgical procedures. Post-operative hospital stay in patients randomized to the FT laparoscopic group was significantly shorter than in the other three treatment groups (P<0.01). Post-operative complications in patients who underwent FT laparoscopic treatment were less than in the other three treatment groups (P<0.05). There were no significant differences between the four treatment groups regarding readmission rate and in-hospital mortality.

CONCLUSIONS

The laparoscopic technique and FT surgery rehabilitation program effectively inhibited release of post-operative inflammatory factors with a reduction in peri-operative trauma and stress, which together played a protective role on the post-operative immune system. Combining two treatment measures during colon operation produced better protective effects via the immune system. The beneficial clinical effects support that the better-preserved post-operative immune system may also contribute to the improvement of post-operative results in FT laparoscopic patients.

Effects of surgical stress on early nonspecific immune response in children

Surgery alters the body's homeostatic balance and defense mechanisms. In adults transient postoperative cellular and humoral immunosuppression after different degrees of operative stress has been reported. In children the immunologic consequences of operations are not elaborated. This study investigates the effect of minor and major surgery on early nonspecific immune response in terms of neutrophil counts and function. Forty-three children undergoing minor and major elective procedures were studied. Blood samples were collected before, immediately after, and 72 h after surgery. Total white cell count, differential neutrophil count, and neutrophil phagocytic function were studied using nitroblue tetrazolium test. Children were divided into two groups-group 1 underwent minor surgery and group 2 major surgery. In group 1 there was a significant drop in total counts after surgery, but in group 2 total counts were not affected. In both groups, the percentage of neutrophils increased immediately after surgery but fell to near or less than preoperative levels 72 h after surgery. However, the assessment of neutrophil functions by nitroblue tetrazolium test in both unstimulated and stimulated forms revealed it to be unchanged in group 1. In group 2 the unstimulated neutrophil function was elevated 72 h after surgery, whereas stimulated function was elevated immediately after surgery. Minor surgery does not alter the early nonspecific immune response. However, major surgery seems to induce a transient increase in neutrophil phagocytic activity.

Laparoscopic proctectomy: oncologic considerations

The role of laparoscopic proctectomy in rectal cancer has not clearly been defined. Publications on long-term outcomes after laparoscopic proctectomy is lacking and there is a wide variation of practice patterns of rectal cancer management. Current data supports the feasibility of laparoscopic proctectomy for rectal cancer but due to surgeon, patient and tumor related factors open technique may be favored. Current series suggest that laparoscopic proctectomy can be performed with similar oncologic adequacy with regards to, circumferential resection margin, distal margin, local recurrence and quality of life. Ongoing trials will provide evidence clarifying the role of laparoscopic proctectomy in rectal cancer. Until then, high-level laparoscopic skills and meticulous preoperative evaluation of both patient and tumor can identify appropriate candidates.

Lymph node harvested in laparoscopic versus open colorectal cancer approaches: a meta-analysis

Increasing researches have reported the safety and efficacy of laparoscopic versus open approach for colorectal cancer resection; however, the number of lymph nodes harvested in the 2 approaches is still unclear. This meta-analysis is to compare the number of lymph node harvested in these 2 methods. We searched the PUBMED, the EMBASE, and the Cochrane Library up to July 1, 2011 for relevant studies. Twenty-four randomized controlled trials, comprising 6264 participants, met our criterion. We found no difference in the number of lymph nodes harvested in these 2 approaches (weighted mean difference=-0.25; 95% confidence interval, -0.57 to 0.08; P=0.542), as well as in subgroups of colon cancer and of rectal cancer. Our meta-analysis suggests that laparoscopic surgery could achieve the same effectiveness with open surgery in relation to lymph node harvested. Surgeons should pay appropriate attention on the excision of lymph nodes, which are associated with long-term benefits of patients.

Laparoscopic surgery for colorectal cancer

BACKGROUND

Laparoscopic surgery for colorectal cancer has undergone tremendous advancement in the last two decades, with maturation of techniques and integration into current practice.

SOURCES OF DATA

Worldwide English-language literature on laparoscopic surgery for the management of colon and rectal cancer was reviewed.

AREAS OF AGREEMENT

A large body of evidence has attested to the improved short-term outcomes and long-term oncological safety of laparoscopic surgery for colon cancer. Laparoscopic colectomy can be recommended to suitable patients where expertise is available. Laparoscopic resection for rectal cancer is feasible, with good evidence of faster post-operative recovery and adequate surgical quality, but requires more data on long-term oncological outcomes. This review examines the evidence and current practice of laparoscopic surgery for colorectal cancer.

AREAS OF CONTROVERSY

Does laparoscopic surgery confer a survival advantage for colorectal cancer patients?

GROWING POINTS

The role of single-incision laparoscopic surgery and robotic surgery in colorectal cancer.

AREAS TIMELY FOR DEVELOPING RESEARCH

Barriers to the adoption of the laparoscopic technique.

Systemic inflammatory response after laparoscopic and conventional colectomy for cancer: a matched case-control study

BACKGROUND

Studies dealing with laparoscopic colectomy for cancer have reached conflicting results in regards to various inflammatory cytokines. Most of them have not examined potential differences with the open procedures at later postoperative days, when the immunologic advantage of laparoscopic surgery would be more demanding to demonstrate (for earlier administration of adjuvant treatment). The aim of this work is to detect differences of proinflammatory cytokines between conventional and laparoscopic colectomy for cancer.

PATIENTS AND METHODS

30 patients who underwent laparoscopic colectomy were age, sex, and preoperative stage-matched with 30 patients treated by open surgery. C-reactive protein (CRP), interleukin (IL)-1, -6, and -8, and interferon (IFN)-γ serum levels were measured preoperatively, at 24 h, and at the 7th postoperative day (POD).

RESULTS

CRP and IL-6 postoperative values (24 h and 7th POD) were significantly higher than baseline for both groups (p = 0.001), but the respective values at the 7th POD were less than at 24 h (p = 0.001). IL-1 and -8 levels did not show any differences between assessment timepoints. A higher IFN-γ measurement was demonstrated at 24 h compared with baseline for the laparoscopic group only (p = 0.03). This difference was not maintained at the 7th POD. IFN-γ levels at 24 h and the 7th POD were significantly less for the open compared with the laparoscopic group of patients (p = 0.001). No correlation was revealed between measured serum values and age, sex, tumor location, or stage.

CONCLUSIONS

This matched case-control study verifies the already reported lack of differences regarding IL-1. Controversy still exists on likely IL-6 differences. The inadequately studied IL-8 does not seem to play an important role in immunologic differences. The immunologically beneficial IFN-γ, produced by the principal effectors of cell-mediated immunity Th1 cells, seems to have a more active presence following laparoscopic colectomy, potentially contributing to an immunologic "advantage" by counteracting "harmful" cytokines, such as IL-1.

Comparison of survival of patients receiving laparoscopic and open radical resection for stage II colon cancer

BACKGROUND

The aim of the study was to compare the survival of patients receiving laparoscopic vs. open radical resection for stage II colon cancer.

PATIENTS AND METHODS

Two hundred and twenty patients with stage II colon cancer were enrolled from Beijing Chaoyang Hospital of Capital Medical University from January 2000 to December 2009, including 61 patients in the laparoscopic radical resection group and 159 patients in the open radical resection group. The survival data in both groups were compared using the log rank test based on Kaplan-Meier survival curves.

RESULTS

There was no statistically significant difference in the 3-year survival (88.5% vs. 80.5%; X(2)=1.98, P=0.159) and the 5-year survival (81.9% vs. 69.2%; X(2)=1.98, P=0.159) between both groups. However, statistically significant difference was found in median overall survival (mOS), which was 102.6 (95% CI: 76.8-122.7) months in the laparoscopic group and 90.0 (95% CI: 70.4-109.6) months in the open radical resection group (X(2)=4.183, P=0.041). mOS was 96 (95% CI: 68.6-111.4) months and 92.6 (95% CI: 56.8-107.2) months in those with and without postoperative chemotherapy, respectively (X(2)=6.389, P=0.011). For patients older than 75 years the mOS was 90.0 (95% CI: 25.3-105.0) months and 83.4 (95% CI: 13.1-96.9) months in the laparoscopic and open group, respectively. The difference between the both groups was statistically significant (X(2)=6.191, P=0.013).

CONCLUSIONS

The mOS of patients receiving laparoscopic radical resection was better than open radical resection for stage II colon cancer, especially for patients over 75 years old.

Laparoscopic pancreaticoduodenectomy combined with minilaparotomy

Laparoscopic pancreatic surgery is evolving rapidly; however, the surgical treatment of periampullary tumors is still fraught with challenges, such as technical difficulty and the appropriateness of oncologic treatment for these patients. We describe how we performed laparoscopic pancreaticoduodenectomy (LPD) combined with minilaparotomy successfully in six consecutive patients. This procedure consisted of two surgical phases: safe laparoscopic surgery, including the Kocher maneuver, tunneling behind the pancreatic neck, and dissecting along the uncinate process with magnified vision; and a secure open approach with complete skeletonization of the hepatoduodenal ligament and alimentary tract reconstruction, performed similarly to conventional pancreaticoduodenectomy, under direct visualization through the minilaparotomy. By performing this procedure, we combined a safe and secure minilaparotomy approach under direct vision with a less invasive laparoscopic approach providing a magnified image. Our experience demonstrates that LPD combined with minilaparotomy is technically feasible for selected patients with periampullary tumors.

Surgical treatment for colorectal cancer

The rapid in development of surgical technology has had a major effect in surgical treatment of colorectal cancer. Laparoscopic colon cancer surgery has been proven to provide better short-term clinical and oncologic outcomes. However this quickly accepted surgical approach is still performed by a minority of colorectal surgeons. The more technically challenging procedure of laparoscopic rectal cancer surgery is also on its way to demonstrating perhaps similar short-term benefits. This article reviews current evidences of both short-term and long-term outcomes of laparoscopic colorectal cancer surgery, including the overall costs comparison between laparoscopic surgery and conventional open surgery. In addition, different surgical techniques for laparoscopic colon and rectal cancer are compared. Also the relevant future challenge of colorectal cancer robotic surgery is reviewed.

Laparoscopic versus conventional open surgery for immune function in patients with colorectal cancer

OBJECTIVE

To systematically evaluate the immune function in patients with colorectal cancer after laparoscopic surgery (LS) and conventional open surgery (OS).

METHODS

PUBMED, EMBASE, and the Cochrane library were searched and randomized controlled trials (RCTs) comparing the immunological difference between LS and OS were included. Two authors extracted data and assessed trial quality.

RESULTS

Eleven studies including 695 patients were analysed. Immune-competent cells demonstrated no significant differences between LS and OS in six trials. Eight trials assessed various perioperative plasma cytokine concentrations with no significant differences in interleukin-6 (IL-6) and C-reactive protein (CRP) levels between LS and OS. However, meta-analysis showed higher T suppressor lymphocytes (CD8+) counts on postoperative days (POD) 1-3 and lower plasma levels of CRP on POD 0-1 in LS group compared with OS group.

CONCLUSION

Although LS groups displayed higher T suppressor lymphocyte (CD8+) counts on postoperative days (POD) 1-3 and lower plasma levels of CRP on POD 0-1, there is no sufficient evidence to support superior preservation of global immune function with LS compared to OS.

Comparison of short-term outcomes and perioperative systemic immunity of laparoscopy-assisted and open radical gastrectomy for gastric cancer

OBJECTIVE

To compare the perioperative systemic immunity of laparoscopy-assisted and open radical gastrectomy for gastric cancer.

METHODS

Patients with gastric adenocarcinoma proven by endoscopy and biopsy were eligible, while patients with preoperative staging of T4, N2-3, or M1 were excluded. Eligible patients willing to undertake laparoscopic surgery in the consecutive cohort were assigned to the laparoscopy-assisted gastrectomy (LAG) group, while concurrent patients were assigned to the conventional open gastrectomy (OG) group. All operations were performed with the intention of radical resection. Various immunological parameters were tested in peripheral venous blood collected at preoperative 1(st) day and postoperative 2(nd) day (POD2) and 7(th) day (POD7). SPSS 13.0 software was used for statistical analysis.

RESULTS

Thirty patients were included, 15 each in the LAG and OG groups. The general characteristics and short-term outcomes (harvested lymph nodes number, hospital stay, complications, and mortality rate) of the two groups were comparable, but the operation time was significantly longer in LAG (P = 0.001). Moreover, intergroup comparisons indicated no significant differences between the groups in levels of neutrophils, T-lymphocytes, natural killer cells, IgG, IgM, IgA, C3, C4, interleukin-6, or interleukin-10 at any time point (P>0.05). However, there was a gradual decrease in natural killer cell count in the LAG group up to POD7 (P = 0.008).

CONCLUSION

The changes in systemic immunity markers were comparable between laparoscopy-assisted and open gastrectomy for gastric cancer. However, there was a trend of suppression of natural killer cells in the laparoscopy-assisted gastrectomy group.

Laparoscopic surgery for colorectal cancers: Current status

Laparoscopy was introduced more than 15 years ago into clinical practice. However, its role in colorectal surgery was not well established for want of better skills and technology. This coupled with high incidences of port site recurrences, prevented laparoscopic surgery from being incorporated into mainstream colorectal cancer surgery. A recent increase in the number of reports, retrospective analyses, randomized trials and multicentric trials has now provided sufficient data to support the role of laparoscopy in colorectal cancer surgery. We, thus, present a review of the published data on the feasibility, safety, short - and long-term outcomes following laparoscopic surgery for colorectal cancers. While the data available strongly favors the use of laparoscopic surgery in colonic cancer, larger well powered studies are required to prove or disprove its role in rectal cancer.

Autostereoscopic three-dimensional viewer evaluation through comparison with conventional interfaces in laparoscopic surgery

In the near future, it is likely that 3-dimensional (3D) surgical endoscopes will replace current 2D imaging systems given the rapid spreading of stereoscopy in the consumer market. In this evaluation study, an emerging technology, the autostereoscopic monitor, is compared with the visualization systems mainly used in laparoscopic surgery: a binocular visor, technically equivalent from the viewer's point of view to the da Vinci 3D console, and a standard 2D monitor. A total of 16 physicians with no experience in 3D interfaces performed 5 different tasks, and the execution time and accuracy of the tasks were evaluated. Moreover, subjective preferences were recorded to qualitatively evaluate the different technologies at the end of each trial. This study demonstrated that the autostereoscopic display is equally effective as the binocular visor for both low- and high-complexity tasks and that it guarantees better performance in terms of execution time than the standard 2D monitor. Moreover, an unconventional task, included to provide the same conditions to the surgeons regardless of their experience, was performed 22% faster when using the autostereoscopic monitor than the binocular visor. However, the final questionnaires demonstrated that 60% of participants preferred the user-friendliness of the binocular visor. These results are greatly heartening because autostereoscopic technology is still in its early stages and offers potential improvement. As a consequence, the authors expect that the increasing interest in autostereoscopy could improve its friendliness in the future and allow the technology to be widely accepted in surgery.

Inflammatory and tumor stimulating responses after laparoscopic sigmoidectomy

PURPOSE

Laparoscopic colectomy has clinical benefits such as short hospital stay, less postoperative pain, and early return of bowel function. However, objective evidence of its immunologic and oncologic benefits is scarce. We compared functional recovery after open versus laparoscopic sigmoidectomy and investigated the effect of open versus laparoscopic surgery on acute inflammation as well as tumor stimulation.

MATERIALS AND METHODS

A total of 57 patients who were diagnosed with sigmoid colon cancer were randomized for elective conventional or laparoscopically assisted sigmoidectomy. Serum samples were obtained preoperatively and on postoperative day 1. C-reactive protein (CRP) and interleukin-6 (IL-6) were measured as inflammation markers, and vascular endothelial growth factor (VEGF) and insulin-like growth factor binding protein-3 (IGFBP-3) were used as tumor stimulation factors. Clinical parameters and serum markers were compared.

RESULTS

Postoperative hospital stay (p=0.031), the first day of gas out (p=0.016), and the first day of soft diet (p<0.001) were significantly shorter for the laparoscopic surgery group than the open surgery group. The levels of CRP, IL-6, and VEGF rose significantly, and the concentration of IGFBP-3 fell significantly after both open and laparoscopic surgery. However, there were no significant differences in the preoperative and postoperative levels of CRP, IL-6, VEGF, and IGFBP-3 between the two groups.

CONCLUSION

Our data suggest that both open and laparoscopic surgeries are accompanied by significant changes in IL-6, CRP, IGFBP-3, and VEGF levels. Acute inflammation markers and tumor stimulating factors may not reflect clinical benefits of laparoscopic surgery.

Immunological effects of laparoscopic and open cholecystectomy

This prospective, randomized, controlled study evaluated plasma levels of interleukin-18 (IL-18) and monocyte chemotactic protein-1 (MCP-l) in patients undergoing cholecystectomy. Forty patients were randomized to undergo laparoscopic cholecystectomy (LC) or open cholecystectomy (OC). Plasma concentrations of IL-18 and MCP-1 were measured before anaesthesia (T(0)), before operation (T(1)), 30 min after the start of the operation (T(2)) and at the end of the operation (T(3)). Compared with T(0), the IL-18 concentration was significantly increased at T(2) and T(3) in both groups. In addition, the MCP-1 concentration was significantly increased at T(3) compared with T(0) in the LC group. Both the IL-18 and MCP-1 concentrations were significantly lower in the OC group than in the LC group at T(3). It is suggested that carbon dioxide pneumoperitoneum may cause immunodepression, that epidural anaesthesia can attenuate the stress response, and that IL-18 and MCP-1 are sensitive markers for evaluating the patient's immune function.

Use of Jiangqi Hewei Tongfu method to improve gastrointestinal function and immune function in patients with intestinal tumors after surgery

AIM: To observe the clinical effect of acupuncture and traditional Chinese medicine in improving the gastrointestinal function and immune function in patients with intestinal tumors after surgery.

METHODS: One hundred and five patients were randomly and equally divided into three groups: control group, Chinese medicine group, and acupuncture group. The control group received only conventional therapy, while the Chinese medicine group underwent conventional therapy and treatment with Simotang Oral Liquid (three times daily for 10 d), and the acupuncture group underwent conventional therapy and acupuncture (once a day for 10 d).

RESULTS: On day 10 after treatment, the recovery of gastrointestinal function was significantly different among the three groups (F = 18.98, P < 0.05). Compared with the control group and traditional Chinese medicine group, the acupuncture group showed more rapid recovery of gastrointestinal function (both P < 0.05). Compared with the control group and traditional Chinese medicine group, the counts of leukocytes, lymphocytes and neutrophils were significantly improved in the acupuncture group (all P < 0.05). The percentages of CD3, CD4, CD4/CD8 and NK cells differed significantly among the three groups (CD3: 69.44% ± 6.37% vs 57.62% ± 8.08%, 56.57% ± 8.90%, F = 31.25; CD4: 35.63% ± 6.26% vs 30.28% ± 6.66%, 30.89% ± 6.25%, F = 7.42; CD4/CD8: 1.27% ± 0.44% vs 1.01% ± 0.45%, 1.03% ± 0.64%, F = 5.64; NK: 13.29% ± 3.45% vs 11.88% ± 3.89%, 10.64% ± 2.64%, χ² = 10.39, all P < 0.05). The score of digestive system symptoms and ZPS were also significantly different among the three groups (all P < 0.05).

CONCLUSION: Jiangqi Hewei Tongfu method can promote the recovery of gastrointestinal function and immune function, bidirectionally modulate the numbers of leukocytes, lymphocytes and neutrophils, and thereby improve the score of digestive system symptoms and ZPS in patients with intestinal tumor after surgery.

Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer

INTRODUCTION

The UK Medical Research Council CLASICC trial assessed the safety and efficacy of laparoscopically assisted surgery in comparison with open surgery for colorectal cancer. The results of the 5-year follow-up analysis are presented.

METHODS

Five-year outcomes were analysed and included overall and disease-free survival, and local, distant and wound/port-site recurrences. Two exploratory analyses were performed to evaluate the effect of age (70 years or less, or more than 70 years) on overall survival between the two groups, and the effect of the learning curve.

RESULTS

No differences were found between laparoscopically assisted and open surgery in terms of overall survival, disease-free survival, and local and distant recurrence. Wound/port-site recurrence rates in the laparoscopic arm remained stable at 2.4 per cent. Conversion to open operation was associated with significantly worse overall but not disease-free survival, which was most marked in the early follow-up period. The effect of surgery did not differ between the age groups, and surgical experience did not impact on the 5-year results.

CONCLUSION

The 5-year analyses confirm the oncological safety of laparoscopic surgery for both colonic and rectal cancer. The use of laparoscopic surgery to maximize short-term outcomes does not compromise the long-term oncological results.

REGISTRATION NUMBER

ISRCTN74883561 (http://www.controlled-trials.com).

A meta-analysis of laparoscopy compared with open colorectal resection for colorectal cancer

The aim of this study was to compare the outcome of the overall complication, mortality, and recurrence rate between laparoscopic resection and open surgery for colorectal cancer. We searched the Medline, Embase, and Cochrane Library and systematically reviewed the randomized controlled trials by comparing the overall complication, mortality, and recurrence rate between laparoscopic resection and open surgery for colorectal cancer. Fifteen trials with 4,207 patients who reported long-term outcomes of the overall complication, mortality, and recurrence rate were included. The combined results of the individual trials showed no statistically significant difference in the odds ratio (OR) for overall recurrence (OR 0.92, 95% CI, 0.77-1.11, P=0.34), local recurrence (OR 0.81, 95% CI, 0.59-1.12, P=0.20), distant metastasis (OR 1.01, 95% CI, 0.78-1.30, P=0.95), wound-site recurrence (OR 1.97, 95% CI, 0.77-5.02, P=0.16), colorectal cancer-related mortality (OR 0.82, 95% CI, 0.66-1.02, P=0.07), colon cancer-related mortality (OR 0.85, 95% CI, 0.66-1.09, P=0.20), rectal cancer-related mortality (OR 0.76, 95% CI, 0.53-1.11, P=0.16), and overall mortality (OR 0.87, 95% CI, 0.73-1.73, P=0.11) between the laparoscopic surgery and open surgery groups. The overall complications in the laparoscopic surgery group were much lower than that in the open surgery group (OR 0.71, 95% CI, 0.58-0.87, P=0.001). This meta-analysis showed that the successful laparoscopic colorectal resection for colorectal cancer was as effective as open surgery in terms of the oncological outcomes, thereby suggesting that laparoscopic surgery can be continued in patients with colorectal cancer.

Comparison of immunologic outcomes of laparoscopic vs open approaches in clinical stage III colorectal cancer

PURPOSE

Improved survival in patients with stage III colon cancer after a laparoscopic colectomy (LC) has been reported by Lacy et al. (Lancet 359:2224-2229, 6), and preserved immunity was suggested as the reason for the survival advantage. The aim of our study was to clarify the existence of an immunological benefit after laparoscopic colon cancer surgery (LC) compared to open colon surgery (OC).

METHODS

From January 2006 to November 2007, 74 patients with clinical stage III colon cancer were prospectively assigned to undergo a LC (n = 35) or an OC (n = 39). The immune factors were examined preoperatively, and on the first and fifth days postoperatively (POD1 and POD5).

RESULTS

The cellular immune factors were significantly decreased; however, there was no significant difference between the LC and OC groups except for the mHLA-DR. The LC group had a better preserved mHLA-DR on POD5 than did the OC group (p = 0.015), in addition to a faster recovery (p < 0.005).

CONCLUSION

The mHLA-DR on POD5 was affected less by the LC compared to the OC. The LC demonstrated minimal immunological advantage when compared to the OC. However, further study is required to clarify the immunological benefits of the LC on colorectal cancer prognosis.

Laparoscopic TME in rectal cancer--electronic supplementary: op-video

Background

Laparoscopic total mesorectal excision (TME) for rectal cancer has been proved in various studies. The minimal invasive procedure is feasible and safe which was demonstrated in many studies. However, the results of prospective, randomized studies providing valuable evidence are still not available. Compared to conventional surgery, the laparoscopic technique has short-term advantages including less pain, shorter duration of postoperative ileus, less fatigue, better pulmonary function, and less blood loss (Leung et al., Lancet 363:1187–1192, 2004; Braga et al., Dis Colon Rectum 48:217–223, 2005; Jayne et al., J Clin Oncol 25:3061–3068, 2007; Agha et al., Surg Endosc 22:2229–2237, 2008).

Methods

The autonomic nerve sparing TME technique is the gold standard in rectal cancer resection even in conventional or laparoscopic procedure. With regard of the oncological dimension, the laparoscopic TME technique is not different compared to the open procedure. However, a standardized laparoscopic step-by-step procedure may simplify the operation and can reduce operation time.

Results

There are no studies available which compare different types of TME procedures. Most surgeons start the operation left laterally mobilizing the sigmoid colon first. In the laparoscopic technique, we recommend the medial to lateral approach starting the operation at the right side of the rectum and sigmoid colon. A nerve sparing TME technique can be performed easier, and the identification of the left ureter may be simplified. After multiple workshops and extensive discussion with national and international experts, we developed a standardized laparoscopic “10 step TME procedure.” Reviewing the results of laparoscopic TME the studies do not allow firm conclusions as to the questions of whether the safety and efficacy of laparoscopic TME is equal or superior to open TME (Breukink et al. 2006). Actually, we are waiting for large prospective randomized studies comparing laparoscopic TME with the traditional open procedure (Bonjer et al., Dan Med Bull 56:89–91, 2009).

Conclusion

Laparoscopic TME appears to have clinically measurable short-term advantages in patients with primary resectable rectal cancer based on evidence mainly from nonrandomized studies (Breukink et al. 5). In nearly all published studies, the efficacy and technical feasibility of laparoscopic surgery for rectal cancer could be demonstrated regarding perioperative morbidity and oncological outcome. A standardized laparoscopic TME technique can be strongly recommended.

Electronic supplementary material

The online version of this article (doi:10.1007/s00423-009-0556-y) contains supplementary material, which is available to authorized users.