Laparoscopic resections for colorectal cancer: does conversion survival?

Post-operative outcomes in patients with locally advanced colon cancer: a comparison of operative approach

INTRODUCTION

Surgeons may choose an open approach to locally advanced colon cancer (LACC) because of the elevated conversion rate (minimally invasive to open) in these patients (resulting in part from a judgment of the technical feasibility of a minimally invasive approach). Poorer outcomes have been suggested in those requiring conversion from a minimal access to an open approach; however, the influence of conversion has not been studied in LACC. We sought to compare perioperative outcomes in patients with T4aN2 colon cancer undergoing minimally invasive surgery (MIS), planned open (PO), and converted (CN) procedures to evaluate the influence of conversion in this subgroup.

METHODS

A retrospective cohort study was conducted using the NSQIP database. Patients with T4aN2 colon cancer undergoing elective resection were included; rectal/unknown tumor location, and T4b disease were excluded (to ensure homogeneity in surgical management). Patients were divided into cohorts based on approach: PO, MIS, and CN. Summary statistics were compared between groups. Multivariable analysis was conducted for mortality and morbidity outcomes.

RESULTS

1286 cases were included (313 PO, 842 MIS, 131 CN); 10.2% underwent conversion. Those undergoing MIS had a shorter length of stay than those undergoing PO or CN (p < 0.0001). On univariable analysis, CN resulted in increased rates of any complication (p < 0.0001). CN also had a greater rate of anastomotic leak (p = 0.0046) and death (p = 0.05). On multivariable analysis, significant predictors of any complication included age, ASA class, M stage, and approach; however, CN did not increase the risk of complication compared with MIS, whereas PO nearly doubled the risk of complication (OR = 1.98, p = 0.0083). The only significant predictor of mortality on multivariable analysis was age (HR = 1.09, p = 0.0002)-approach was not associated with mortality.

CONCLUSION

PO confers the greatest risk of suffering any complication. Surgical approach was not associated with death. Results of our study challenge the notion that conversion is associated with the worst perioperative outcomes and an MIS approach should be considered in patients with LACC.

"Peek port": avoiding conversion during laparoscopic colectomy-an update

PURPOSE

To assess the efficacy of a method to avoid conversion to laparotomy in patients considered for laparoscopic colectomy. Patients considered being at high risk for conversion to formal laparotomy were initially approached via a small midline incision ("peek port") with the laparoscopic equipment readily available but unopened. If intraperitoneal conditions were favorable, the procedure was performed using hand-assisted laparoscopy (HALS); if intraperitoneal conditions were unfavorable, the incision was extended to a formal laparotomy.

METHODS

Data from 664 patients from a single surgeon brought to the operating room with the intention of proceeding with laparoscopic colectomy (either via straight laparoscopy or HALS) were retrieved from a prospective database. Comparison of conversion rates between groups was performed using χ² analysis.

RESULTS

The study population consisted of 361 men and 303 women with a mean age of 61 years. Inflammatory conditions accounted for 40% of the diagnoses and enteric fistulas were present in 12%. Of the 79 patients who underwent initial "peek port" exploration, 38 (48%) underwent immediate extension to formal laparotomy, whereas 41 (52%) underwent HALS colectomy, with one subsequent conversion from HALS to formal laparotomy. Of the 585 patients initially approached laparoscopically, 14 (2%) required conversion to laparotomy. Of the 626 patients from both groups who underwent laparoscopy, the overall conversion to laparotomy rate was 15/626 (2%).

DISCUSSION

The "peek port" approach to the patients with a potentially hostile abdomen allows for prompt assessment of intraperitoneal conditions and is associated with an overall low rate of conversion from laparoscopy to laparotomy during colectomy. This technique may reduce expense and morbidity for patients who ultimately require laparotomy, while allowing some patients with complex disease to be managed laparoscopically who would not normally be considered for a minimally invasive procedure.

The Short- and Long-Term Feasibility of Laparoscopic Surgery in Colon Cancer Patients with Bulky Tumors

BACKGROUND

Compared to open surgery for colon cancer, randomized controlled trials have shown that laparoscopic approaches have equivalent short- and long-term outcomes. However, the feasibility of laparoscopy for removal of bulky tumors has not been evaluated. The aim of our study was to determine the short- and long-term feasibility of laparoscopic surgery for bulky (> 8 cm) colon cancer.

METHODS

A total of 80 patients with bulky tumors (defined as greater than 8 cm in diameter) underwent curative resection from July 2004 to July 2014. Short- and long-term outcomes were compared between patients undergoing laparoscopic (n = 48) and open (n = 32) resection.

RESULTS

Compared to open, the operative time was significantly longer (213 vs. 148 min, p < 0.001), return of bowel function quicker (time to oral intake; 2 vs. 5 days, p < 0.001), and length of stay shorter (10 vs. 13 days, p < 0.001) in the laparoscopic group. Five-year cancer-specific and relapse-free survival was similar with no patients developing local recurrence in either group.

CONCLUSIONS

Laparoscopic resection of colon cancers greater than 8 cm in diameter is feasible and oncologically safe with better short-term and equivalent long-term outcomes compared to open surgery.

Impact of Conversion from Laparoscopy to Open Surgery in Patients with Right Colon Cancer

Conversion to open surgery is reported in up to 20 per cent of laparoscopic colectomies for cancer. This study aims to compare postoperative outcomes and survival between converted and successful laparoscopic right colectomy for cancer. Records of patients who underwent laparoscopic right colectomy for cancer between 2005 and 2015 were retrieved from the CLermontFerrand Ircad Mondor Hopital European Tours (CLIMHET) database. Perioperative, postoperative, and survival outcomes were evaluated. Multivariate analysis was performed to identify predictive factors for conversion. Overall, 445 patients underwent a successfully completed laparoscopic right colectomy and 28 (5.9%) were converted to open surgery. A higher rate of minor complications was found in the conversion group, whereas patient recovery outcomes were similar. Previous open and laparoscopic surgeries were significant predictors of conversion. No significant difference was found in overall and disease-free survival rates between converted and nonconverted procedures. In the setting of laparoscopic right colectomy for cancer, the conversion rate is low and does not have an impact on patient survival. Conversion is associated with higher rates of minor postoperative complications but recovery and survival outcomes are comparable with successful laparoscopic colectomies. The present results support the use of laparoscopy for right colon resection even in patients at risk of conversion.

Short- and Long-term Outcomes of Minimally Invasive Versus Open Multivisceral Resection for Locally Advanced Colorectal Cancer

BACKGROUND

Colorectal cancer invading the adjacent organs/structures is detected in 5% to 20% of all surgical interventions performed for the management of colorectal cancer.

OBJECTIVE

Our purpose is to verify the safety and feasibility of laparoscopic surgery for the treatment of locally advanced colorectal cancer invading the adjacent organs.

DESIGN

This is a retrospective study.

SETTINGS

The study was conducted at a single institution in Japan.

PATIENTS

We compared the morbidity, appropriate oncological resection, and disease-free survival of laparoscopic and open multivisceral resection in patients with colorectal carcinoma in the period between 2007 and 2015.

MAIN OUTCOME MEASURES

The primary outcome measures were curative resection rate, morbidity rate, and recurrence of laparoscopic and open multivisceral resection in patients with colorectal cancer.

RESULTS

Thirty-one patients received laparoscopic surgery, and 50 received open surgery. The amount of blood loss was smaller in the laparoscopic group than in the open group (60 vs 595 mL, p < 0.01). Curative surgery was performed in 46 patients of the open group (92.0%) and in 30 patients of the laparoscopic group (96.8%). Days until oral intake (5 vs 7 days, p < 0.01) and postoperative hospital stay (14 vs 19 days, p < 0.01) were shorter in the laparoscopic group. Overall morbidity was not different between the groups (22.5% vs 40.0%). Three-year disease-free survival rates were 62.7% in the open group and 56.7% in the laparoscopic group (p = 0.5776).

LIMITATION

This study was a retrospective small study conducted at a single institute.

CONCLUSION

Laparoscopic multivisceral resection may be a safe, less invasive alternative to open surgery, with less blood loss and shorter hospital stay, and was not inferior to open surgery based on long-term oncological end points. See Video Abstract at http://links.lww.com/DCR/A785.

Effect of cancer characteristics and oncological outcomes associated with laparoscopic colorectal resection converted to open surgery: A meta-analysis

BACKGROUND

Although laparoscopic colorectal cancer resection is an oncologically safe procedure equivalent to open resection,the effects of conversion of a laparoscopic approach to an open approach remain unclear.This study evaluated the cancer characteristic and oncological outcomes associated with conversion of laparoscopic colorectal resection to open surgery.

METHOD

We conducted searches on PubMed, EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials. We included the literature published until 2018 that examined the impact of laparoscopic conversion to open colorectal resection. Only randomized control trials and prospective studies were included. Each study was reviewed and the data were extracted. Fixed-effects methods were used to combine data, and 95% confidence intervals (CIs) were used to evaluate the outcomes.

RESULTS

Twelve studies with 5427 patients were included. Of these, 4672 patients underwent complete laparoscopic resection with no conversion (LAP group), whereas 755 underwent conversion to an open resection (CONV group). The meta-analysis showedsignificant differences between the LAP group and converted (CONV) group with respect to neoadjuvant therapy (P = .002), location of the rectal cancer (P = .01), and recurrence (P = .01). However, no difference in local recurrence (P = .17) was noted between both groups.

CONCLUSION

Conversion of laparoscopic to open colorectal cancer resection is influenced by tumor characteristics. Conversion of laparoscopic surgery for colorectal cancer is associated with a worse oncological outcome.

Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery

Several patients' and pathological characteristics in rectal surgery can significantly complicate surgical loco regional tumor clearance. The main factors are obesity, short tumor distance from anal verge, bulky tumors, and narrow pelvis, which have been shown to be associated to poor surgical results in open and laparoscopic approaches. Minimally invasive surgery has the potential to reduce perioperative morbidity with equivalent short- and long-term oncological outcomes compared to conventional open approach. Achilles' heel of laparoscopic approaches is conversion to open surgery. High risk for conversion is evident for patients with bulky and low tumors as well as male gender and narrow pelvis. Hence, patient's characteristics represent challenges in rectal cancer surgery especially in minimally invasive approaches. The available surgical techniques increased remarkably with recently developed and implemented improvements of minimally invasive rectal cancer surgery. The controversial discussions about sense and purpose of these novel approaches are still ongoing in the literature. Herein, we evaluate, if latest technical advances like transanal approach or robotic assisted surgery have the potential to overcome known challenges and pitfalls in rectal cancer surgery in demanding surgical cases and highlight the role of current minimally invasive approaches in rectal cancer surgery.

Laparoscopic treatment of rectal cancer and lateral pelvic lymph node dissection: are they obsolete?

Laparoscopic surgery for rectal cancer offers favorable short-term results without compromising long term oncological outcomes so far, according to the data from major trials. For this reason, it is currently considered as a standard option for rectal cancer surgery. The learning curve of laparoscopic rectal cancer surgery is generally longer compared to colon cancer. Appropriate standardization and training of laparoscopic rectal cancer surgery is required. Several RCTs suggested the potential negative effect on quality of resected specimen, which can increase local recurrence. The long-term outcomes - especially local recurrence rate - of these RCTs are awaited. Lateral pelvic lymph node dissection (LPLND) has a certain effect of reducing local recurrence of rectal cancer even after neoadjuvant radiotherapy. Since LPLND is associated with postoperative morbidity, we should carefully select the candidate to maximize the effect of LPLND and minimize the morbidity caused by LPLND. Recent advancements in imaging study such as CT and MRI enable us to find the suitable candidates for LPLND. The morbidity caused by LPLND could be reduced by minimally invasive surgeries such as laparoscopic surgery and robotic surgery. We have to improve oncological outcomes and reduce morbidity by the multidisciplinary strategy for rectal cancer including total mesorectal excision, neoadjuvant chemoradiotherapy and LPLND together with laparoscopic surgery.

Lower Gastrointestinal Surgery: Robotic Surgery versus Laparoscopic Procedures

Introduction

For a long time, the comprehensive application of minimally invasive techniques in lower gastrointestinal (GI) surgery was substantially impaired by inherent anatomical and technical complexities. Recently, several new techniques such as robotic operating platforms and transanal total mesorectal excision (taTME) have revolutionized the minimally invasive approach. This review aims to depict the current state of the art and evaluates the advantages and drawbacks in regard to perioperative outcome and quality of oncological resection.

Methods

A systematic literature search was performed using the search terms 'colorectal cancer', 'rectal cancer', 'minimally invasive surgery', 'laparoscopic surgery', and 'robotic' to identify relevant studies reporting on robotic surgery (RS) either alone or in comparison to laparoscopic surgery (LS). Publications on taTME were analyzed separately.

Results

69 studies reporting on RS with a total of 20,872 patients, and 17 articles on taTME including 881 patients, were identified.

Conclusion

Both RS and taTME can facilitate a minimally invasive approach for lower GI surgery in an increasing number of patients. Furthermore, combining both techniques might become an auspicious approach in selected patients; further prospective and randomized trials are needed to verify its benefits over conventional laTME.

Outcomes of laparoscopic surgery in pathologic T4 colon cancers compared to those of open surgery

INTRODUCTION

Despite the oncologic safety of laparoscopic surgery in colon cancer management, laparoscopy is not regarded as a standard treatment for T4 colon cancer. The aim of this study was to investigate the short-term and long-term oncologic outcomes of laparoscopic surgery in patients with locally advanced colon cancer.

MATERIAL AND METHOD

From March 2003 to June 2013, a total of 109 consecutive patients with proven pathologic T4 colon cancer were enrolled. These patients were divided into the laparoscopy group (LG, n = 52) and the open group (OG, n = 57). Perioperative and long-term oncologic outcomes were compared between the two groups.

RESULTS

In the LG, open conversion occurred in four patients (7.6%). Combined resection was less commonly performed in the LG (13.5%) than in the OG (36.8%, P = 0.005). Operation time was similar between the two groups. In the LG, blood loss (129 mL vs. 437 mL, P < 0.001) and overall complication rate (13.5 vs. 36.8%, P = 0.005) were lower and length of hospital stay was shorter (median 7 vs. 17 days, P < 0.001) than in the OG. The 5-year overall survival rate was 60.7% for the LG and 61.9% for the OG (P = 0.817). Local recurrence-free survival did not differ between the groups (88.9% in LG vs. 88.1% in OG, P = 0.725).

CONCLUSION

Considering the benefits of early recovery and similar oncologic outcomes, laparoscopic surgery in T4 colon cancer could be a viable option in selected patients.

Surgical Outcomes After Open, Laparoscopic, and Robotic Gastrectomy for Gastric Cancer

BACKGROUND

In contrast to the significant advantages of laparoscopic versus open gastrectomy, robotic gastrectomy has shown little benefit over laparoscopic gastrectomy. This study aimed to compare multi-dimensional aspects of surgical outcomes after open, laparoscopic, and robotic gastrectomy.

METHODS

Data from 915 gastric cancer patients who underwent gastrectomy by one surgeon between March 2009 and May 2015 were retrospectively reviewed. Perioperative parameters were analyzed for short-term outcomes. Surgical success was defined as the absence of conversion to open surgery, major complications, readmission, positive resection margin, or fewer than 16 retrieved lymph nodes.

RESULTS

This study investigated 241 patients undergoing open gastrectomy, 511 patients undergoing laparoscopic gastrectomy, and 173 patients undergoing robotic gastrectomy. For each approach, the respective incidences were as follows: conversion to open surgery (not applicable, 0.4%, and 0%; p = 0.444), in-hospital major complications (5.8, 2.7, and 1.2%; p = 0.020), delayed complications requiring readmission (2.9, 2.0, and 1.2%; p = 0.453), positive resection margin (1.7, 0, and 0%; p = 0.003), and inadequate number of retrieved lymph nodes (0.4, 4.1, and 1.7%; p = 0.010). Compared with open and laparoscopic surgery, robotic gastrectomy had the highest surgical success rate (90, 90.8, and 96.0%). Learning-curve analysis of success using cumulative sum plots showed success with the robotic approach from the start. Multivariate analyses identified age, sex, and gastrectomy extent as significant independent parameters affecting surgical success. Surgical approach was not a contributing factor.

CONCLUSIONS

Open, laparoscopic, and robotic gastrectomy exhibited different incidences and causes of surgical failure. Robotic gastrectomy produced the best surgical outcomes, although the approach method itself was not an independent factor for success.

Cancer recurrence following conversion during laparoscopic colorectal resections: a meta-analysis

INTRODUCTION

Evidence regarding long-term oncological outcomes following conversion to open surgery (COS) during laparoscopic colorectal resection (LCR) is controversial. The aim of this study is to assess the impact on cancer recurrence of a failed laparoscopic attempt.

METHODS

MEDLINE, Scopus and ISI Web of Knowledge databases were searched for articles reporting data on cancer recurrence in patients undergoing completed LCR and COS. Data were pooled by fixed or random effect modeling, according to the presence of heterogeneity. Primary outcomes were local recurrence (LR) and distance recurrence (DR).

RESULTS

Seven studies involving 2493 patients (completed LCR, n 2201 and COS, n 292) were included. The pooled analysis showed that COS resections have an higher risk of LR (OR 1.97, 95% CI 1.14-3.42, p = 0.1); no difference was found in DR (OR 1.09, 95% CI 0.67-1.77, p = 0.71). However, an higher rate of T4 tumor was present in the converted group (OR 2.62, 95% CI 1.71-4, p = 0.0). Subgroup analysis including studies with T stage matched populations showed no significant statistical difference in LR rate; however, a trend toward higher recurrence was still clear.

CONCLUSION

There is no consistent evidence that a failed laparoscopic attempt does not result in a poorer oncological outcome; therefore, a careful selection of patients for LCR for cancer is required.

Impact of Timing of Conversion to Open Surgery on Short-Term and Oncologic Outcomes in Patients Undergoing Minimally Invasive Surgery for Colorectal Cancer

To evaluate the influence of timing of open conversion on short-term and oncologic outcomes after minimally invasive surgery for colorectal cancer. Six hundred forty-six consecutive patients were enrolled. All patients converted to open surgery were classified into early (n = 10) or late (n = 67) groups based on conversion timing using a 60-minute cutoff. A comparison of early conversion and nonconverted groups showed that history of prior abdominal surgery and pT4 tumor was more common in the early conversion group. Mean operative time was longer in the early conversion group. Rates of 30-day postoperative complications (30% vs 27%), time to soft diet (5 days vs 5 days), and hospital stay (12 days vs 12 days) were not different. A comparison of the late and nonconverted groups showed that history of prior abdominal surgery was more common in the late conversion group. Mean operative time was longer in the late conversion. Rates of 30-day postoperative complications (42% vs 27%), Clavien–Dindo score ≥3 (22% vs 11%), intensive care unit care (31% vs 15%), and transfusion (37% vs 21%) were significantly higher in the late conversion group. Time to soft diet (6 days vs 5 days) and hospital stay (15 days vs 12 days, P = 0.037) were longer in the late conversion group. Cancer-specific and recurrence-free survival rates did not differ among the early, late conversion, and nonconverted groups. Decisions about open conversion need be made within 60 minutes of the beginning of surgery as early conversion does not worsen short-term and oncologic outcomes.

Conversion of laparoscopic colorectal resection for cancer: What is the impact on short-term outcomes and survival?

Laparoscopic resection for colon and rectal cancer is associated with quicker return of bowel function, reduced postoperative morbidity rates and shorter length of hospital stay compared to open surgery, with no differences in long-term survival. Conversion to open surgery is reported in up to 30% of patients enrolled in randomized control trials comparing open and laparoscopic colorectal resection for cancer. In this review, reasons for conversion are anatomical-related factors, disease-related-factors and surgeon-related factors. Body mass index, local tumour extension and co-morbidities are independent predictors of conversion. The current evidence has shown that patients with converted resection for colon cancer have similar outcomes compared to patients undergoing a laparoscopic completed or open resection. The few studies that have assessed the outcomes after conversion of laparoscopic rectal resection reported significantly higher rates of complications and longer length of hospital stay in converted patients compared to laparoscopically treated patients. No definitive conclusions can be drawn when converted and open rectal resections are compared. Early and pre-emptive conversion appears to have more favourable outcomes than reactive conversion; however, further large studies are needed to better define the optimal timing of conversion. With regard to long-term oncologic outcome, overall and disease-free survival in the case of conversion in laparoscopic colorectal cancer surgery seems to be worse than those achieved in patients in whom resection was successfully completed by laparoscopy. Although a worse long-term oncologic outcome has been suggested, it remains difficult to draw a proper conclusion due to the heterogeneity of the long-term outcomes as well as the inclusion of both colon and rectal cancer patients in most of the studies. Therefore, we discuss the currently available evidence of the impact of conversion in laparoscopic resection for colon and rectal cancer on both short-term outcomes and long-term survival.

Does Conversion in Laparoscopic Colectomy Portend an Inferior Oncologic Outcome? Results from 104,400 Patients

BACKGROUND

Limited data exist regarding the effect of conversion from laparoscopic to open colectomy on perioperative and oncologic outcomes in colon cancer.

STUDY DESIGN

The National Cancer Data Base was used to identify patients who underwent colectomy for non-metastatic colon cancer (2010-2012). Patients were stratified into three groups: laparoscopic/robotic-assisted colectomy (MIC), converted colectomy (CC), and open colectomy (OC). Multivariable modeling was applied to compare outcomes from CC and MIC to OC while adjusting for patient, clinical, and tumor characteristics.

RESULTS

Of 104,400 patients, 40,328 (38.6 %) underwent MIC, 57,928 (55.5 %) OC, and 6144 (5.9 %) CC. After adjustment, the rate of positive surgical margins was not significantly different between CC and OC (p = 0.44). However, with adjustment, CC versus OC was associated with shorter hospital length of stay (4 % decrease, 95 % CI 2-5 %, p < 0.0001) and lower odds of 30-day mortality (OR 0.77, 95 % CI 0.64-0.94, p = 0.0112). Adjusted overall survival was similar between CC and OC (p = 0.34).

CONCLUSIONS

Conversion from laparoscopic to open colectomy was not associated with compromised oncologic outcomes, while maintaining improved short-term outcomes despite being attempted in only 45 % of patients. This data suggests that utilization of laparoscopic colectomy should be attempted for patients with colon cancer.

How to reduce the laparoscopic colorectal learning curve

Background:

The laparoscopic approach for colorectal pathologies is becoming more widely used, and surgeons have had to learn how to perform this new technique. The purpose of this work is to study the indicators of the learning curve for laparoscopic colectomy in a community hospital and to find when the group begins to improve.

Methodology:

From January 1 2005 to December 31 2012, 313 consecutive laparoscopic colorectal surgeries were performed (105 rectal and 208 colonic) by at least 60% of the same surgical team (6 members) in each operation. We evaluate the learning curve by moving averages and cumulative sums (CUSUM) for different variables related to the surgery outcomes.

Results:

Moving average curves for postoperative stay, fasting, and second step analgesia show a stabilizing trend toward improvement as we get more experience. However, intensive care unit stay, number of lymph nodes achieved, and operating time did not show a clear decreasing tendency. CUSUM curves of conversion, specimens <12 lymph nodes, and complications all show a clear turning point marked on all the charts around the procedure 60, accumulating a positive trend toward improvement. The CUSUM curve of the “learning variable” shows this improvement point at procedure 70.

Conclusions:

The laparoscopic colectomy learning curve accelerates with a collective team involvement in each procedure. The CUSUM and moving average curves are useful for initial and ongoing monitoring of new surgical procedures. The markers of the learning curve evidenced in our study are the conversion rate, postoperative surgical morbidity, and the number of patients with a lymph node count <12.

What is new in this paper?

The significance of this study is the evaluation of the learning curve, in laparoscopic colorectal surgery, of a surgical team in a community hospital, using moving average and CUSUM curves. This study demonstrated that the number of patients needed to achieve skilful practice decreased when there is collective team involvement in each procedure.

Conversion during laparoscopic colorectal resections: a complication or a drawback? A systematic review and meta-analysis of short-term outcomes

PURPOSE

Several studies compared the outcomes of laparoscopically completed colorectal resections (LCR) to those requiring conversion to open surgery (COS). However, a comparative analysis between COS patients and patients undergoing planned open surgery (POS) would be useful to clarify if the conversion can be considered a simple drawback or a complication, being cause of additional postoperative morbidity. The aim of this study is to perform a meta-analysis of current evidences comparing postoperative outcomes of COS patients to POS patients.

METHODS

A systematic search of Medline, ISI Web of Knowledge, and Scopus was performed to identify studies reporting short-term outcomes of COS and POS patients. Primary outcomes were 30-day overall morbidity and length of postoperative hospital stay. Data were analyzed with fixed-effect modeling, and sensitivity analyses were performed to test the robustness of the results.

RESULTS

Twenty studies involving 30,656 patients undergoing POS and 1935 COS patients were selected. The mean conversion rate was 0.17. Similar 30-day overall morbidity and length of postoperative hospital stay were found in COS and POS patients. Wound infection (OR 1.43, 95 % CI 1.12 to 1.83, p < 0.01) was higher in the COS group. Other results were robust. Outcomes were comparable for patients undergoing resection for different natures of the disease (benign vs. malignant) and at different sites (colon vs. rectum).

CONCLUSION

Conversions from laparoscopic to open procedure during colorectal resection are not associated with a poorer postoperative outcome compared to patients undergoing planned open surgery, except for a higher risk of wound infection.

A meta-analysis to determine the oncological implications of conversion in laparoscopic colorectal cancer surgery

AIM

Laparoscopic colon and rectal cancer surgery is oncologically equivalent to open resection, but the impact of conversion is undetermined. The aim of this study was to assess the oncological outcome and predictive factors associated with conversion.

METHOD

A comprehensive search for published studies examining the associated factors and outcome of conversion from laparoscopic to open colorectal cancer resection was performed adhering to PRISMA (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Only randomized control trials and prospective studies were included. Each study was reviewed and the data extracted. Random effects methods were used to combine data.

RESULTS

Fifteen studies, including 5293 patients, met the inclusion criteria. Of these 4391 patients had a completed laparoscopic resection and 902 were converted to an open resection. The average conversion rate of the studies was 17.9 ± 10.1%. Meta-analysis showed completed laparoscopic surgery favoured lower 30-day mortality (OR 0.134, 95% CI 0.047-0.385, P < 0.0001), lower long-term disease recurrence (OR 0.634, 95% CI 0.421-0.701, P < 0.023) and lower overall mortality (OR 0.512, 95% CI 0.417-0.629, P < 0.0001). Factors negatively associated with completion of laparoscopic surgery were male gender (P = 0.011), rectal tumour (P = 0.017), T3/T4 tumour (P = 0.009) and node-positive disease (P = 0.009). Completed laparoscopic surgery was also associated with a lower body mass index (BMI; mean difference -0.93 kg/m(2) , P = 0.004).

CONCLUSION

The results suggest that conversion from laparoscopic to open colorectal cancer resection is influenced by patient and tumour characteristics and is associated with an adverse perioperative outcome. Although confounding factors such as advanced tumour stage and elevated BMI are present, unsuccessful laparoscopic surgery appears to be associated with an adverse long-term oncological outcome.

The impact of laparoscopic converted to open colectomy on short-term and oncologic outcomes for colon cancer

PURPOSE

This study was designed to evaluate the impact of laparoscopic converted to open colectomy on short-term and oncologic outcomes and to identify risk factors for long-term survival in patients undergoing colectomy for non-metastatic colon cancer.

METHODS

A prospective database of consecutive operations for non-metastatic colon cancer was reviewed. Patients were grouped as conversion (CONV) group, completed laparoscopic resection (LAP) group, or open resection (OPEN) group. The clinical and perioperative parameters, pathologic features, and oncologic outcomes were collected. Univariate analysis was performed for comparing these data. Patients without evidence of recurrence at last follow-up or still alive at the end of study period were censored. Kaplan-Meier curves were utilized to analyze survival. A multivariate analysis was performed to identify predictors of poor disease-free survival (DFS) and overall survival (OS).

RESULTS

The conversion rate was 15.2 %. The most common reason for conversion was locally advanced cancer (45.5 %). Converted patients were associated with a longer operative time (188 ± 29.1 min, P < 0.001), greater blood loss (147 ± 14 mL, P < 0.001), and a higher rate of intra-operative complications (15.2 %, P = 0.042) compared to the completely laparoscopic or open patients. Days to flatus, early ambulation, and length of hospitalization were significantly shorter in completed laparoscopic resection (LAP) group (P < 0.001); however, the outcomes were comparable between conversion (CONV) and open resection (OPEN) groups. The incidence of wound infection was significantly higher in the OPEN group than in the LAP group (P = 0.005), whereas there were no significant differences observed between the CONV group and the OPEN group (P = 1.000) or between the LAP group and the CONV group (P = 0.073). The 5-year DFS in CONV patients (46.5 %) was comparable to LAP patients (55.5 %, P = 0.138) and OPEN patients (59.1 %, P = 0.113). Moreover, there were no significant differences noted in terms of the 5-year OS in the CONV group (56.7 %) compared to the LAP group (67.3 %, P = 0.317) or the OPEN group (66.3 %, P = 0.420). The multivariate analysis showed that pT3-4 cancer (P < 0.001) and poor differentiation (P < 0.001) were independent predictors of both lower OS and lower DFS, whereas leakage (P = 0.008) and lack of adjuvant chemotherapy (P = 0.023) were independent risk factors only of lower DFS.

CONCLUSION

Conversion to open colectomy from an initial laparoscopic approach does not worsen the long-term survival in patients with non-metastatic colon cancer.

Laparoscopic versus open resection for colon cancer: 10-year outcomes of a prospective clinical trial

BACKGROUND

Laparoscopic resection (LR) and open resection (OR) for colon cancer have similar oncologic outcomes at 5-year follow-up. However, results from studies with longer follow-up are limited. This study aimed to compare 10-year oncologic outcomes of LR and OR for non-metastatic colon cancer.

METHODS

A prospective non-randomized trial comparing patients undergoing LR or OR for non-metastatic colon cancer at a single institution was conducted. Statistical analyses were performed on an ''intention-to-treat'' basis and by actual treatment. Kaplan-Meier curves were compared to analyze overall survival (OS) and disease-free survival (DFS). A multivariate analysis was performed to identify predictors of poor survival.

RESULTS

The study included 304 colon cancer patients: 154 patients underwent LR and 150 underwent OR. Fifteen (9.7 %) had LR converted to OR. During a median follow-up period of 138 (range, 120-220) months, no significant differences were observed between LR and OR patients in 10-year OS and DFS rates: 87.2 % versus 78.7 % (P = 0.182) and 80.9 % versus 76.8 % (P = 0.444), respectively. Conversion to open surgery was associated with a non-significant reduction in OS and DFS. Stage-by-stage comparison showed no significant differences between the two groups. Both OS and DFS were similar between right colon and left-sided colon cancer patients. On multivariate analysis, pT4 cancer and a lymph node ratio of 0.20 or more were the only independent predictors of both OS and DFS.

CONCLUSIONS

The 10-year follow-up results confirm the oncological effectiveness of the laparoscopic approach to non-metastatic colon cancer.

The influence of obesity on short- and long-term outcomes after laparoscopic surgery for colon cancer: a case-matched study of 152 patients

BACKGROUND

Despite the increasing prevalence of obesity and colonic diseases, the impact of obesity on short-term and oncologic outcomes of laparoscopic colorectal surgery still remains unclear.

STUDY DESIGN

Seventy-six consecutive obese patients with body mass index (BMI) ≥30 kg/m(2) who underwent laparoscopic colectomy were matched with 76 nonobese patients with BMI <30 kg/m(2). Perioperative parameters and oncologic outcomes were analyzed in the two groups.

RESULTS

Obesity was associated with greater operative time (obese vs nonobese, 182 ± 59 vs 157 ± 55 min, P = .0084) and multivariate analysis identified BMI (hazard ratio 2.11, 95% confidence interval 0.64-3.56, P = .0049) as an independent predicting factor for operative time together with cancer location (hazard ratio 28.6, 95% confidence interval 14.62-42.51, P < .0001). Obesity had no adverse influence on overall morbidity (25 vs 21%, P = .563), however, or postoperative duration of stay (median 6.0 vs 5.5 days, P = .22). Furthermore, the rate of conversion to open procedure was similar between the two groups (9 vs 9%, P > .99). Regarding oncologic outcomes, there was no statistical difference in overall and disease-free survival between the two groups (5-year overall survival rate 86 vs 89%, P = .72, 5-year disease survival rate 70 vs 77%, P = .70).

CONCLUSION

Laparoscopic colonic resection, when performed for selected patients, appears to be a safe and reasonable option in obese patients with colon cancer resulting in similar short-term and oncologic outcomes as nonobese patients.

Mini-invasive surgery for colorectal cancer

Laparoscopic techniques have been extensively used for the surgical management of colorectal cancer during the last two decades. Accumulating data have demonstrated that laparoscopic colectomy is associated with better short-term outcomes and equivalent oncologic outcomes when compared with open surgery. However, some controversies regarding the oncologic quality of mini-invasive surgery for rectal cancer exist. Meanwhile, some progresses in colorectal surgery, such as robotic technology, single-incision laparoscopic surgery, natural orifice specimen extraction, and natural orifice transluminal endoscopic surgery, have been made in recent years. In this article, we review the published data and mainly focus on the current status and latest advances of mini-invasive surgery for colorectal cancer.

Laparoscopic and converted approaches to rectal cancer resection have superior long-term outcomes: a comparative study by operative approach. Surg Endosc. 2014;28:1940-1948. [PMID: 24515259 DOI: 10.1007/s00464-014-3419-8]

BACKGROUND AND OBJECTIVES

The goal of this study was to evaluate outcomes for rectal cancer resection by operative approach. Our hypothesis is that laparoscopic (LAP) and LAP converted to open (OPEN) rectal cancer resections have excellent patient and oncologic outcomes.

METHODS

Review of a prospective database identified curative rectal cancer resections. Patients were stratified by operative approach: LAP, OPEN, or CONVERTED. Oncologic and clinical outcomes data was examined for each operative approach.

RESULTS

Overall, 294 patients were analyzed-116 LAP (39.5%), 153 OPEN (52.0%), and 25 (8.5%) CONVERTED. Groups were comparable in demographics. Mean distal margin, circumferential resection margin, and lymph nodes harvested were comparable. The median length of stay was 4 days (range 1-20) LAP, 6 days (range 3-13) CONVERTED, and 8 days (range 1-35) OPEN (p < 0.01). More OPEN had postoperative complications (p < 0.01)-complication rates were 43.8% OPEN, 32.0% CONVERTED, and 21.5 % LAP. Unplanned readmissions and reoperations were similar (21.6% OPEN, 16.0% CONVERTED, 12.1% LAP). Overall 3-year disease-free survival (DFS) was 98.3%, and local recurrence rate was 2.0%. By approach, DFS was 100% CONVERTED, 93.1% LAP, and 87.6% OPEN (p = 0.31). Overall survival (OS) was 100 % CONVERTED, 99.1% LAP, and 97.4%. OPEN. Local recurrence was 0% CONVERTED, 2% OPEN, and 2.6% LAP. 3-year DFS for LAP and CONVERTED was superior to OPEN (p = 0.05), with comparable local recurrence (p = 0.07) and OS rates (0.43).

CONCLUSIONS

LAP and converted procedures have comparable or superior clinical and oncologic outcomes. More procedures should be approached through a LAP approach. If the procedure cannot be completed laparoscopically, outcomes are not compromised for converted patients.

Does conversion affect short-term and oncologic outcomes after laparoscopy for colorectal cancer?

BACKGROUND

Conversion of laparoscopic colorectal resection (LCR) for cancer has been associated with adverse short-term and oncologic outcomes. However, most studies have had small sample sizes and short follow-up periods. This study aimed to evaluate the impact of conversion to open surgery on early postoperative outcomes and survival among patients undergoing LCR for nonmetastatic colorectal cancer.

METHODS

A prospective database of consecutive LCRs for nonmetastatic colorectal cancer was reviewed. Patients who required conversion (CONV group) were compared with those who had completed laparoscopic resection (LAP group). Only patients with a minimum 5-year follow-up period were included in the oncologic analysis. Kaplan-Meier curves were compared to analyze survival. A multivariate analysis was performed to identify predictors of poor survival.

RESULTS

The conversion rate was 10.9%. The most common reason for conversion was a locally advanced tumor (48.4%). Conversion was associated with a significantly longer operative time and a greater blood loss. No differences were observed in terms of postoperative morbidity, mortality, or hospital stay between the CONV and LAP patients. During a median follow-up period of 120 months (range, 60-180 months), the CONV group had a significantly worse 5-year overall survival (OS) (79.4 vs 87.4%; p = 0.016) and disease-free survival (DFS) (65.4 vs 79.6%; p = 0.013). Univariate analysis showed that conversion to open surgery, postoperative complications, anastomotic leakage, pT4 cancer, stage 3 disease, and adjuvant chemotherapy were significant risk factors for OS and DFS. On multivariate analysis, pT4 cancer and a lymph node ratio (LNR) of 0.25 or greater were the only independent predictors of DFS and OS, whereas a LNR of 0.01 to 0.24 showed a trend that did not reach statistical significance.

CONCLUSION

Conversion to open surgery per se is not associated with worse early postoperative outcomes and does not adversely affect long-term survival per se.

Population-based study of laparoscopic colorectal cancer surgery 2006-2008

Background

Clinical guidelines recommend that, where clinically appropriate, laparoscopic tumour resections should be available for patients with colorectal cancer. This study aimed to examine the introduction of laparoscopic surgery in the English National Health Service.

Methods

Data were extracted from the National Cancer Data Repository on all patients who underwent major resection for a primary colorectal cancer diagnosed between 2006 and 2008. Laparoscopic procedures were identified from codes in the Hospital Episode Statistics and National Bowel Cancer Audit Project data in the resource. Trends in the use of laparoscopic surgery and its influence on outcomes were examined.

Results

Of 58 135 resections undertaken over the study period, 10 955 (18·8 per cent) were attempted laparoscopically. This increased from 10·0 (95 per cent confidence interval (c.i.) 8·1 to 12·0) per cent in 2006 to 28·4 (25·4 to 31·4) per cent in 2008. Laparoscopic surgery was used less in patients with advanced disease (modified Dukes' stage ‘D’ versus A: odds ratio (OR) 0·45, 95 per cent c.i. 0·40 to 0·50), rectal tumours (OR 0·71, 0·67 to 0·75), those with more co-morbidity (Charlson score 3 or more versus 0: OR 0·69, 0·58 to 0·82) or presenting as an emergency (OR 0·15, 0·13 to 0·17). A total of 1652 laparoscopic procedures (15·1 per cent) were converted to open surgery. Conversion was more likely in advanced disease (modified Dukes' stage ‘D’ versus A: OR 1·56, 1·20 to 2·03), rectal tumours (OR 1·29, 1·14 to 1·46) and emergencies (OR 2·06, 1·54 to 2·76). Length of hospital stay (OR 0·65, 0·64 to 0·66), 30-day postoperative mortality (OR 0·55, 0·48 to 0·64) and risk of death within 1 year (hazard ratio 0·60, 0·55 to 0·65) were reduced in the laparoscopic group.

Conclusion

Laparoscopic surgery was used more frequently in low-risk patients. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Outcome of laparoscopic surgery in colorectal cancer: a critical appraisal

Despite the wide application of laparoscopic surgery for various common surgical conditions, the development of laparoscopic colorectal surgery has been slow. The obstacle for its advancement is formed by a steep learning curve and concerns about the oncologic safety in cases of malignant diseases. With refinement in instrumentation and improvement in surgical techniques in recent years, laparoscopic colectomy has become a safe and feasible procedure. The short-term advantages in terms of quicker recovery of bowel function, less postoperative pain and shorter hospital stay of laparoscopic colectomy over conventional treatment seem to be indisputable. Results from large prospective randomized trials revealed the oncologic outcome to be comparable between the two treatments. Furthermore, the incidence of port-site metastasis was shown to be similar between the two approaches. For rectal cancer, laparoscopic-assisted total mesorectal excision has been shown to be a safe and feasible procedure. The incidence of postoperative morbidity including anastomotic leakage appears to be comparable between the two treatments. However, the long-term outcome especially for local recurrence and overall survival remains uncertain. Prospective randomized study with long follow-up is required to elucidate this issue.

Postoperative morbidity after fast-track laparoscopic resection of rectal cancer

AIM

Analysis was carried out of the nature and chronological order of early complications after fast-track laparoscopic rectal surgery with a view to optimizing the short-time outcome of rectal cancer surgery.

METHOD

A total of 102 consecutive patients who underwent elective fast-track laparoscopic rectal cancer surgery were analysed prospectively from the Danish Colorectal Cancer Database supplemented by data from the medical records. We studied in detail the nature and chronological order of postoperative morbidity and reason for prolonged stay (> 5 days).

RESULTS

Twenty-five patients (25%) had one or more complications. Surgical complications occurred in 19 patients, while six patients had medical complications as the primary event. Fifteen patients underwent reoperation, three died, and eight were readmitted within 30 days. The median length of stay was 5 days (range 2-42).

CONCLUSION

Postoperative morbidity remains a significant problem in the fast-track era, even in experienced surgical hands. Our results suggest that besides improvement of surgical technique further improvement of outcome lies in early recognition and proper treatment of complications and the perioperative optimization of organ function.

Laparoscopic colorectal resection for cancer: effects of conversion on long-term oncologic outcomes. Surg Endosc. 2012;26:1971-1976. [PMID: 22237758 DOI: 10.1007/s00464-011-2137-8]

BACKGROUND

The effects of conversion to open surgery during laparoscopic resection for colorectal cancer on long-term oncologic outcomes still are unclear.

METHODS

All 450 laparoscopic colorectal resections for cancer performed at a single center between 1994 and 2008 and included in a prospectively maintained database were considered. Patients who required conversion to open surgery (CONV) were matched 1:2 with laparoscopically completed cases (LAP) and 1:5 with open surgery cases (OPEN) for age, American Society of Anesthesiologists (ASA) score, year of surgery, tumor location, and tumor stage. Fisher's exact, chi-square, and Wilcoxon tests were used as appropriate. Kaplan-Meier curves were compared to analyze survival.

RESULTS

In this study, 31 CONV cases were independently compared with 62 LAP and 155 OPEN cases. Compared with the LAP and OPEN patients, the CONV patients were characterized by a numerically higher rate of preoperative comorbidity (61.3% vs LAP, 51.6; P = 0.4 and OPEN, 48.4%; P = 0.2), male gender (77.4% vs LAP, 59.7%; P = 0.09 and OPEN, 58.1%; P = 0.05), and a significantly higher mean body mass index (29.6 vs LAP, 26.8; P = 0.012 and OPEN, 28.8; P = 0.3). The pathologic tumor stage, location, and chemotherapy and radiotherapy rates were comparable among the groups. After a median follow-up period of 4.1, 4.2, and 4.6 years, the 5-year disease-free survival rate was significantly lower for the CONV patients (40.2%) than for the LAP (70.7%, P = 0.01) or the OPEN (63.3%, P = 0.04) patients. However, the 5-year cancer-specific survival rates were similar among the CONV (94.4%), LAP (86.1%, P = 0.36), and OPEN (84.9%, P = 0.14) patients.

CONCLUSIONS

Conversion to open surgery does not affect oncologic outcomes, although CONV patients have increased comorbidity rates affecting long-term mortality.

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.

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.

Impact of conversion on outcome in laparoscopic colorectal cancer surgery

INTRODUCTION

Long-term results after laparoscopic surgery with conversion to open surgery for colorectal cancer are seldom published.

AIM

The study analysed the impact of conversion of laparoscopic surgery to open resection for colorectal cancer on short- and long-term results.

MATERIAL AND METHODS

The prospectively collected data of 469 patients with colorectal cancer in the period from 1 January 2001 to 31 December 2006 were analysed. Short- and long-term results were compared.

RESULTS

The relative frequency of conversion was 7%. The subgroups were statistically similar regarding age, gender, body mass index (BMI), localization of tumour, T stage, and TNM stage. We observed a lower frequency of previous surgery (p = 0.018) in the group of patients with conversions to open surgery as well as statistically significantly higher frequency of patients with American Society of Anesthesiologists (ASA) score II (p = 0.039). There was no statistical difference in morbidity, mortality, or the length of hospital stay between both the groups of patients. The operating time was significantly higher in the group of patients with conversion (p = 0.00001). There was a significantly higher blood loss in the patient groups with conversion to open surgery and in the group with primarily open surgery (p = 0.00023). There was no difference in the overall survival (p = 0.712), disease-free survival (p = 0.072) or in the local (p = 0.432) or distant (p = 0.957) recurrence.

CONCLUSIONS

No negative impact on short- or long-term results of conversion to open surgery was verified in patients with colorectal surgery.

Conversion in laparoscopic colorectal cancer surgery: impact on short- and long-term outcome

INTRODUCTION

Despite the well-documented safety and effectiveness of laparoscopic colorectal surgery in curative intention, the role of conversion and its impact on short- and long-term outcome after resection of a carcinoma are unclear and continue to give rise to controversial discussion.

METHODS

Within the framework of a prospective, multicenter observational study (Laparoscopic Colorectal Surgery Study Group), into which a total of 5,863 patients from 69 hospitals were recruited over a period of 10 years, a subgroup of all patients who had undergone curative resection was analyzed with regard to the effects of conversion.

RESULTS

Of the 1409 patients who had undergone curative resection for colorectal carcinoma, conversion had to be performed in 80 (5.7%) cases for the most diverse reasons. The duration of surgery (median: 183 vs. 241 minutes; P<.001) was significantly longer in the conversion group. Perioperatively, significant disadvantages were noted in converted patients in terms of intraoperative blood loss (median: 243 vs. 573 mL, P<.001), need for perioperative blood transfusion (10.8% vs. 33.8%; P<.001), and resumption of bowel movement (median: after 3 vs. 4 days; P<.001). With regard to postoperative morbidity, significant disadvantages were observed in converted patients, in particular in terms of specific surgical complications, including a higher rate of anastomotic insufficiency (5.0% vs. 13.8%; P=.003) and a higher reoperation rate (4.9% vs. 15.0%; P=.001). In the long term, conversion was associated with lower overall survival, but not with poorer disease-free survival.

CONCLUSION

Significantly higher postoperative morbidity was observed in patients after conversion, in particular in terms of specific surgical complications. In addition, conversion is associated with overall lower survival but not with poorer disease-free survival.

Impact of conversion on short and long-term outcome in laparoscopic resection of curable colorectal cancer

These authors found that conversion in laparoscopic surgery for curable colorectal cancer is associated with a worse peri-operative outcome and worse disease-free survival.

Introduction:

Long-term outcome of patients following conversion during laparoscopic surgery for colorectal cancer is not often reported. Recent data suggest a negative impact of conversion on long-term survival. This study aimed to evaluate the impact of conversion on the perioperative outcome and on long-term survival in patients who underwent laparoscopic resection for curable colorectal cancer.

Methods:

Evaluation of our prospective in-hospital collected data of patients who underwent laparoscopic surgery for curable colorectal cancer over a 5-year period. Long-term data were collected from our outpatient's clinic data and personal contact when necessary.

Results:

During the study period, 175 patients were operated on laparoscopically for curable colon cancer (stage I-III). Mean follow-up was 33±18 months with a minimum follow-up of 12 months. For various reasons, 25 patients (14.4%) had to be converted to open surgery. Short-term outcome revealed a trend towards longer operations, a higher rate of surgical complications, and a longer hospital stay in the converted group. Five-year, Kaplan-Meier, disease-free analysis was worse for converted patients. Overall survival did not differ between the 2 groups. Cox proportional hazards regression analysis revealed that conversion and AJCC stage were independent risk factors for recurrence.

Conclusions:

Conversion in laparoscopic surgery for curable colorectal cancer is associated with a worse perioperative outcome and worse disease-free survival.

Minimally invasive surgery for colorectal cancer: past, present, and future

A rapid progression from conventional open surgery to minimally invasive approaches in the surgical management of colorectal cancer has occurred over the last 2 decades. Initial concerns that this new approach was oncologically inferior to open surgery were ultimately refuted when several prospective randomized trials concluded that laparoscopic colectomy could achieve similar oncologic outcomes to open surgery. On the contrary, level 1 data has not yet matured regarding the oncologic safety of minimally invasive approaches for rectal cancer. We review the published literature pertaining to the evolution of minimally invasive techniques used to treat colorectal cancer surgery, including barriers to adoption, and the prospects for future advances related to innovative techniques.

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).

Intraoperative technical difficulty during laparoscopy-assisted surgery as a prognostic factor for colorectal cancer

BACKGROUND

Laparoscopy-assisted surgery has technical drawbacks compared with open surgery, although laparoscopic surgery has become widely adopted with evidence of oncological safety for colon cancer treatment. The oncological risk of technical difficulties during laparoscopic surgery for colorectal cancer has not been previously reported. We aimed to investigate whether a technical difficulty encountered during laparoscopic surgery can be considered a recurrence-related factor for colorectal cancer.

METHODS

Data from 427 patients who underwent laparoscopic surgery for colorectal cancer between May 2003 and December 2007 were analyzed. An intraoperative technical difficulty was defined as a significant deviation from the ordinary surgical procedure. All conversions to open surgery and iatrogenic bowel perforation during laparoscopic surgery were included as technical difficulties. The Cox proportional-hazards regression model was used to evaluate the recurrence-related factor in the various risk factors including technical difficulty.

RESULTS

Technical difficulties were found in 44 (10.3%) patients, which included 17 (3.9%) conversions to open surgery and 10 (2.4%) with iatrogenic bowel injury. Technical difficulties were encountered more frequently in men compared with women (13.5% vs 6.0%, P = .013), and for cancers located in the mid and low rectum, splenic flexure, and descending colon. The recurrence rates were higher in patients with technical difficulties (local recurrence, 2.6% vs 6.7%, P < .05; systemic recurrence, 6.3% vs 13.6%, P < .05) with a mean follow-up duration of 45.9 months. Multivariate analysis by the Cox proportional-hazards regression model showed that a technical difficulty was an independent factor related to recurrence after laparoscopic surgery (odds ratio, 2.374; 95% CI, 1.006-5.600; P = .048).

CONCLUSIONS

This study has demonstrated that a technical difficulty during laparoscopy-assisted surgery jeopardizes oncological safety. It is suggested that surgeons should be prepared to minimize technical difficulties during laparoscopy-assisted surgery.

Conversion in laparoscopic-assisted colectomy for right colon cancer: risk factors and clinical outcomes

PURPOSE

Laparoscopic colon resection is technically challenging, and conversion to open surgery is sometimes unavoidable. The impact of conversion may vary among different types of colorectal resection and pathology. Our present study aims at evaluating the risk factors and clinical outcomes of conversion in laparoscopic resection for right colon cancer.

METHODS

Between the periods April 1992 to July 2007, 183 consecutive patients undergoing laparoscopic-assisted right colon resection for carcinoma of colon were identified from our database. Data pertaining demographic information, operative details, postoperative course, complications, length of stay, 30-day mortality, and follow-up status were analyzed.

RESULTS

The overall conversion rate was 12% (22 patients). Stage IV disease, tumor length >5 cm, and surgery performed in an earlier time period (before year 2002) were independent risk factors for conversion. Although the median operative time was comparable (195 vs 180 min, p = 0.074), more blood loss was recorded among the conversion group (350 vs 20 ml, p < 0.001). Conversion was also associated with higher wound infection rate (27.3% vs 5%, p = 0.002) and 30-day mortality (9.1% vs 0.62%, p = 0.039). After potential curative resection, the 5-year overall survival rate of the conversion and no conversion group was 53.8% and 72.6%, respectively (p = 0.039).

CONCLUSIONS

Our results showed that conversion increased the intraoperative blood loss, wound related morbidities, and the 30-day mortality. Moreover, it had negative impact on overall survival.

Laparoscopic colon surgery: does operative time matter?

PURPOSE

The purpose was to determine if the perioperative benefits associated with laparoscopic colectomies are maintained as operative time increases.

METHODS

A retrospective review was performed of a database that was prospectively collected from April 1991 to May 2005. Since operative time distributions were different, patients were divided into three groups: laparoscopic right colectomy or ileocecal resection, sigmoid resection, and total abdominal colectomy. The following outcomes were assessed: intraoperative and postoperative complications, days to surgical diet, length of stay, 30-day mortality, and the presence of a learning curve.

RESULTS

Following exclusions, there were 231 right colon and ileocecal resections, 210 sigmoid colectomies, and 46 total abdominal colectomies. With increasing operative time in both right/ileocecal and sigmoid resections, logistic regression demonstrated no significant association between intraoperative and postoperative complications, days to surgical diet, or length of stay. Weight was significantly correlated with increasing operative time in the right/ileocecal and sigmoid resection groups. In the total abdominal colectomy group, significant relationships between increased operative time and postoperative complications (P = 0.04), days to surgical diet (P = 0.02), and hospital stay (P = 0.03) were found. An operative time cut-point was determined in the total abdominal colectomy group. Patients with operative times >270 minutes were more likely to have postoperative complications (P = 0.024), longer ileus (five vs. three median days to surgical diet, P = 0.003), and longer length of stay (seven vs. five days, P = 0.04). This increased risk remained significant after adjusting for weight and diagnosis. No significant learning curve was identified.

CONCLUSION

Increasing operative time does not appear to adversely affect perioperative outcomes in segmental colectomies. Total abdominal colectomies lasting more than 270 minutes were associated with increased postoperative complications, days to surgical diet, and length of stay.

Laparoscopic resection for rectal cancer: a review

Despite increasing evidence on the success of laparoscopic resection in colorectal diseases, clinicians remain skeptical about the application of laparoscopic resection in rectal cancer, although it may benefit patients by resulting in early return of bowel function, reduced postoperative pain, and shorter hospital stay. Rectal cancer surgery has been regarded as a technically demanding procedure. Deviation from the oncologic principle of mesrectal dissection will lead to a higher local recurrence rate. Therefore, rectal cancer was not included in earlier studies on laparoscopic versus open resection for colorectal cancer. However, many colorectal surgeons who practice laparoscopic surgery soon appreciated that the improved optics of laparoscopy can provide a much better view of the pelvis, and the Heald principle of meticulous sharp dissection for total mesorectal excision could be performed without compromise. In recent years, there has been increasing number of reports on laparoscopic resection of rectal cancers. Apart from the issues on postoperative outcomes and long-term results, laparoscopic resection has generated interest in its impact on the preservation of sexual and bladder function. We summarize the current evidence on laparoscopic resection for rectal cancer.

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.

Impact of conversion on surgical outcomes after laparoscopic operation for rectal carcinoma: a retrospective study of 1,073 patients

BACKGROUND

In laparoscopic operations for rectal carcinoma, only a few multicenter studies of a large number of patients have examined the impact of conversion on outcomes and determined risk factors for conversion. This study was designed to evaluate short-term outcomes and risk factors for conversion to open operation in laparoscopic operations for rectal carcinoma.

STUDY DESIGN

A total of 1,073 patients with carcinoma of the rectum and anus who underwent laparoscopic operations were reviewed retrospectively. Patients were collected from 28 institutions. Patients who required conversion during laparoscopic operation were compared with those with completed laparoscopic resection.

RESULTS

Conversion rate was 7.3% (n = 78), and patients requiring conversion were considerably heavier (mean body mass index 24.6 versus 22.7) and had a substantially higher rate of low anterior resection (94.9% versus 83.5%). Conversion was also associated with longer operation time (median 295 minutes versus 270 minutes), greater blood loss (median 265 mL versus 80 mL), longer median postoperative hospital stay (20 days versus 14 days), and higher rates of intraoperative (32.1% versus 3.5%) and postoperative (43.6% versus 21.1%) complications. In multivariate analysis, body mass index and rate of low anterior resection were predictive of conversion.

CONCLUSIONS

Conversion to open operation is associated with greater morbidity than completed laparoscopic resection. Body mass index and the particular laparoscopic procedure are risk factors for conversion, indicating that appropriate patient selection is essential in laparoscopic operations for rectal carcinoma.

What is the definition of "conversion" in laparoscopic colorectal surgery?

BACKGROUND

A web-based survey was conducted among colorectal surgeons who represented members of both SAGES and ASCRS to find out how they define conversion for laparoscopic colorectal surgery.

METHODS

Questionnaires were designed based on MCQs, including three parts: surgeon information, different definitions for conversion, and four different clinical scenarios. Surgeons were asked to choose the best definition(s).

RESULTS

325 (28.5%) of 1,140 surgeons, 28.5% responded; approximately half of them were part of private-based practices. Fifty-three percent had more than 10 years experience; 35.9% performed more than 50 laparoscopic colon cases per year, 12% performed more than 25 laparoscopic rectal cases per year, and 60% less than 10. The majority (68.4%) agreed that any incision made earlier than planned is conversion. Whereas 81.4% felt that incision >5 cm is not a conversion, only 53.4% considered incision >10 cm a conversion, and 37% did not. Neither extracorporeal vessel ligation (73.8%), bowel resection (81.2%), anastomosis (77%), or incision made for specimen retrieval (91.1%) was counted as conversion. In clinical case scenarios, 62% found an incision made to facilitate phlegmon dissection after laparoscopically mobilizing the left colon up to and around the splenic flexure to be laparoscopic-assisted. A 10-cm incision required for fistula take down after finishing laparoscopic dissection was defined as conversion (55.6%). A 10-cm incision made for the rectal dissection in rectopexy was described as conversion in 51% and laparoscopic-assisted in 48%. Increasing a 5-12-cm for specimen extraction, 49.3% was declared a laparoscopic-assisted case.

CONCLUSIONS

It was considered clear that any incision made earlier than planned a conversion, whereas extra corporeal vessel ligation, bowel resection and anastomosis were not. However, there seem to be many views of conversion regarding incision length, and some clinical situations that might influence outcome among different centers.

Laparoscopic rectal resection for cancer: effects of conversion on short-term outcome and survival

BACKGROUND

Laparoscopic rectal resection (LRR) is an oncologically safe procedure. The impact of conversion to open surgery on outcomes has not been fully elucidated. The aim of the study is to compare short- and long-term outcomes of converted (CR) and not converted (NCR) patients undergoing LRR.

METHODS

Data were drawn from a prospective database of LRR performed between 1999 and 2008. Statistical analysis employed the chi-squared or Wilcoxon test and Kaplan-Meier estimation.

RESULTS

Of 173 patients undergoing LRR, 26 (15%) required conversion. No differences in age, gender, American Society of Anesthesiologists (ASA) score, and T and N stages were observed between CR and NCR patients. Conversion was associated with higher body mass index (BMI) (27.3 versus 24.9 kg/m(2), P < 0.001) and American Joint Committee on Cancer (AJCC) stage IV (26.9% versus 4.8%, P < 0.001), and resulted in longer operative time (342 versus 285 min, P = 0.006) and increased intraoperative complication rate (31% versus 5%, P < 0.001). No differences were observed in postoperative outcome between CR and NCR patients. After a mean follow-up of 46 and 36 months, 5-year disease-free survival was 55.7% in CR group and 79.2% in NCR group (P = 0.007). After exclusion of stage IV patients from the analysis, 5-year disease-free survival was 71.1% in CR group and 85.3% in NCR group (P = 0.17), while the overall recurrence rate was 26.3% in CR patients and 11.4% in NCR patients (P = 0.07).

CONCLUSIONS

Our study suggests that conversion to open surgery does not affect postoperative outcome, but could have a negative impact on long-term overall recurrence rate. LRR should be performed by experienced surgeons in selected patients.

[Clinical value of laparoscopic surgery for colon cancer]. Chirurg. 2008;79:1145-1150. [PMID: 18685819 DOI: 10.1007/s00104-008-1585-8]

BACKGROUND

Using data and analysis compiled in the nationwide German Colon/Rectal Cancer qualitative multicenter study, the aim of this study was to determine the value of laparoscopic surgery for colon cancer in clinical routine.

METHODS

From 1 January 2000 to 31 December 2003, patients with colon cancer resections were evaluated for short-term postoperative and long-term oncologic results associated with operative approach (laparoscopic vs conversion vs open).

RESULTS

Of 21,721 patients with colon cancer, 949 (4.4%) underwent laparoscopic resection. These patients were younger (P<0.001) with lower ASA risk factors (P<0.001) and earlier UICC tumor stages (P<0.001) than open resected patients. They also showed reduced overall morbidity (P<0.001), in-hospital mortality (P=0.001), and shorter hospital stays (P<0.001). The rates of intraoperative and specific complications remained unchanged. Nineteen percent of the patients had resections converted to open approaches. These had the highest overall morbidity and longest hospital stays. Their mortality was three times that of the group with complete laparoscopic resection.

CONCLUSIONS

The open approach remained the standard of surgical care in colon cancer for the study duration. Laparoscopic surgery was used in only a small number of patients. By virtue of preferential patient selection, better early postoperative and long-term results could be achieved for the laparoscopic group than with the open approach. Conversions were shown to be associated with inferior results at the high rate of 19%. To ensure optimal results, laparoscopic surgery for colon carcinoma should be conducted by an experienced surgeon in an appropriately selected patient pool.

Laparoscopy in gastrointestinal malignancies

This paper presents an update of the role of minimally invasive surgery (MIS) in gastrointestinal malignancy. A review of indications, surgical technique, and radicality of laparoscopy in the field of gastrointestinal cancer surgery is discussed. The feasibility and safety of laparoscopic procedures are compared with established and implemented standards in the diagnosis and treatment of oncological disorders. It is important to appreciate that only the "access" is different with all its attendant advantages. The use of laparoscopy in tumor staging and palliative and curative resection is evaluated on review of the literature, and special indications for a laparoscopic approach in gastrointestinal malignancy in different organs are discussed. In conclusion, MIS is safe and feasible, with many short-term advantages; long-term results should be further assessed in randomized controlled studies. Until the outcomes of such studies are available MIS for malignant disease should be performed by experienced surgeons in specialized centers.

A multivariate analysis of potential risk factors for intra- and postoperative complications in 1316 elective laparoscopic colorectal procedures. Ann Surg. 2008;248:259-265. [PMID: 18650636 DOI: 10.1097/sla.0b013e31817bbe3a]

OBJECTIVE

To identify predictive risk factors for intra- and postoperative complications in patients undergoing laparoscopic colorectal surgery.

BACKGROUND DATA

In emergency situations or in elective open and laparoscopic colorectal surgery, there are many risk factors that should be recognized by the surgeon to reduce complications and initiate adequate treatment. Most available data, thus far, refer to open colorectal surgery and literature that focuses mainly on a laparoscopic approach is still rare.

METHODS

Univariate and multivariate analyses of a prospectively gathered database (1993-2006) were performed on a consecutive series of patients (1316) undergoing laparoscopic colorectal surgery who were operated at a single institution (first referral center). Patients were assessed for demographic data, operative indications, type of resection, and intra- and postoperative complications. Altogether, we analyzed 20 potential risk factors to identify significant influence on the intra- and postoperative outcome.

RESULTS

Significant risk factors that led to intraoperative complications consisted of age > or = 75 years and malignant neoplasia. Increased postoperative rate of surgical complications was significantly influenced by male gender, age > or = 75 years, American Society of Anesthesiology class > or = III, malignant neoplasia, and the experience of the surgeon. The analysis of specific medical postoperative complications revealed even more significant predictive risk factors. In addition, our analysis showed that specific risk factors predict specific complications such as postoperative bleeding, anastomotic leakage, and surgical site infections. The type of surgical procedure performed also influenced patient outcome.

CONCLUSION

This large single center study provides the first evidence of the significance of predictive risk factors for intra- and postoperative complications in laparoscopic colorectal surgery.

Laparoscopic resection for colorectal cancer

BACKGROUND

This study examined one surgeon's practice to determine the place of laparoscopic colorectal cancer surgery.

METHODS

Some 365 patients undergoing elective colorectal cancer resection (219 colonic, 146 rectal) were studied prospectively. Early (1994-1997; 104 patients), middle (1998-2001; 112) and late (2002-2005; 149) cohorts were analysed with respect to suitability for laparoscopic surgery, conversion and outcome.

RESULTS

Forty-six of 135 patients undergoing open resection were suitable for laparoscopic surgery but randomized to open surgery. The proportion of attempted laparoscopic resections (35.6, 65.2 and 80.6 per cent in early, middle and late cohorts) and patients thought suitable for laparoscopic resection (37.5, 87.5 and 94.0 per cent respectively; P = 0.001) increased over time. Independent predictors of conversion were rectal cancer surgery (odds ratio (OR) 3.12 versus colonic surgery) and body mass index 28 kg/m(2) or more (OR 3.87). Conversion was necessary in all five patients with a threatened margin predicted by preoperative magnetic resonance imaging. After exclusion of these patients the conversion rate in the late cohort was 8.7 per cent. During the same period, inclusion of 20 patients who were suitable for laparoscopic surgery but underwent open resection meant that 135 (90.6 per cent) of 149 patients were actually suitable for laparoscopic resection.

CONCLUSION

With experience, laparoscopic surgery is feasible in around 90 per cent of elective colorectal cancer resections.