Current Status of Laparoscopy for Colon and Rectal Cancer
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Transcript of Current Status of Laparoscopy for Colon and Rectal Cancer
Current Status of Laparoscopy Current Status of Laparoscopy for Colon and Rectal Cancerfor Colon and Rectal CancerSteven D Wexner, MD, FACS, FRCS, FRCS Steven D Wexner, MD, FACS, FRCS, FRCS
(Ed)(Ed)Chairman, Department of Colorectal SurgeryChairman, Department of Colorectal Surgery
21st Century Oncology Chair in Colorectal Surgery21st Century Oncology Chair in Colorectal SurgeryChief of StaffChief of Staff
Cleveland Clinic FloridaCleveland Clinic FloridaProfessor of Surgery, Ohio State UniversityProfessor of Surgery, Ohio State University
Health Sciences Center at theHealth Sciences Center at theCleveland Clinic FoundationCleveland Clinic FoundationClinical Professor of Surgery,Clinical Professor of Surgery,
University of South Florida College of MedicineUniversity of South Florida College of MedicineClinical Professor of Biomedical ScienceClinical Professor of Biomedical Science
Department of Biomedical ScienceDepartment of Biomedical ScienceFlorida Atlantic University College of MedicineFlorida Atlantic University College of Medicine
Dan Enger Ruiz, MDDan Enger Ruiz, MDDavid Vivas, MDDavid Vivas, MD
Clinical Research FellowsClinical Research Fellows
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancer
Short term benefitsShort term benefits– Bowel function recoveryBowel function recovery– Quality of life (including pain)Quality of life (including pain)– Hospital stayHospital stay
CostsCosts Long term benefitsLong term benefits
– RecurrenceRecurrence– SurvivalSurvival
AuthorAuthor YearYear N of patientsN of patients Bowel function Bowel function (mean/median n of days)(mean/median n of days)
LapLap OpenOpen LapLap OpenOpen
MilsomMilsom 19981998 5454 5353 3 4
CuretCuret 20002000 1818 1818 2.7 4.4
LacyLacy 20022002 111111 108108 1.5 2.3
HasegawaHasegawa 20032003 2929 3030 2 3.3
KaiserKaiser 20042004 2929 2020 3 4
p<0.05p<0.05
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerBowel Function RecoveryBowel Function Recovery
RandomizedRandomized
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerBowel Function RecoveryBowel Function Recovery
The evidence that laparoscopy offers faster The evidence that laparoscopy offers faster bowel function recovery than the traditional bowel function recovery than the traditional open approach may be considered high open approach may be considered high (Level I)(Level I)
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerQuality of Life - PainQuality of Life - Pain
AuthorAuthor YearYear N of patientsN of patients Less pain/analgesic Less pain/analgesic requirement (days)?requirement (days)?
LapLap OpenOpen LapLap p valuep value
StageStage 19971997 1515 1414 YesYes < 0.05< 0.05
SchwenkSchwenk 19981998 3030 3030 YesYes < 0.01< 0.01
MilsomMilsom 19981998 5454 5353 YesYes 0.020.02
WeeksWeeks 20022002 168168 221221 YesYes 0.030.03
HasegawaHasegawa 20032003 2929 3030 YesYes 0.0020.002
RandomizedRandomized
KaiserKaiser 20042004 2929 2020 Yes < 0.05< 0.05
NelsonNelson 20042004 435435 425425 YesYes <0.001<0.001
Randomized trial (COST trial)Randomized trial (COST trial) 449 patients 449 patients 228 Laparoscopy (Lap) , 221Open228 Laparoscopy (Lap) , 221Open Pain, hospital stayPain, hospital stay Quality of life (2 days, 2 weeks, 2 months)Quality of life (2 days, 2 weeks, 2 months)
– Symptom distress scale Symptom distress scale – Quality of life indexQuality of life index– Global rating scale (1-100)Global rating scale (1-100)
Weeks, JAMA 2002
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerQuality of lifeQuality of life
ResultsResultsLap Lap
n = 228n = 228
Open Open
n = 221n = 221
Age (years)Age (years) 68.268.2 69.469.4
Gender M:FGender M:F 108:120108:120 108:113108:113
Tumor stageTumor stage
I I
II II
III III
IVIV
88 88
77 77
57 57
55
69 69 78 78
62 62
11 11
ASA classificationASA classification
I or II I or II
IIIIII
198 198
32 32
189 189
3232P = N.S.
Weeks, JAMA 2002
ResultsResultsLap (n = 228)Lap (n = 228) Open (n = 221)Open (n = 221) P valueP value
Oral analgesicsOral analgesics 1.91.9 2.22.2 0.030.03
IV narcotics/analgesicsIV narcotics/analgesics 3.23.2 4.04.0 <0.001<0.001
Hospital stayHospital stay 5.65.6 6.46.4 <0.001<0.001
Weeks, JAMA 2002
Patients in the Lap group had only greater mean global rate Patients in the Lap group had only greater mean global rate scores at 2 weeks after surgery (76.9 vs. 74.4; p=.0009)scores at 2 weeks after surgery (76.9 vs. 74.4; p=.0009) No other differences in quality of lifeNo other differences in quality of life
Values are means
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancer
The superiority of laparoscopy in reducing pain The superiority of laparoscopy in reducing pain during the same length of the postoperative period during the same length of the postoperative period seems evident (Level I)seems evident (Level I)
Other aspects of quality of life warrant further Other aspects of quality of life warrant further investigationinvestigation
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerHospital StayHospital Stay
AuthorAuthor YearYear N of patientsN of patients Hospital Stay (days) Hospital Stay (days)
Lap Open Lap Open
Stage 1997 15 14 5 8
Schwenk 1998 30 30 10.1 11.6
Milsom 1998 54 53 6 7
Curet 2000 18 18 5.2 7.3
Lacy 2002 111 108 5.2 7.9
Weeks 2002 168 221 5.6 6.4
Hasegawa 2003 29 30 7.1 12.7
Kaiser 2004 29 20 5 6
Nelson 2004 435 425 5 6
RandomizedRandomized
p<0.05p<0.05
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerHospital stayHospital stay
There is high evidence (Level I) that There is high evidence (Level I) that laparoscopy for malignancy is associated with laparoscopy for malignancy is associated with an earlier discharge compared to laparotomyan earlier discharge compared to laparotomy
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerCostCost
Randomized, prospective trialRandomized, prospective trial Subset of patients from the Swedish COLOR trialSubset of patients from the Swedish COLOR trial Study period – 12 weeks after surgeryStudy period – 12 weeks after surgery Analysis of direct medical cost (hospital and Analysis of direct medical cost (hospital and
outpatient) and indirect cost (loss of productivity)outpatient) and indirect cost (loss of productivity)
Janson, BJS 2004
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerCostCost
Janson, BJS 2004
LCR LCR (n=98)(n=98)
OCR OCR (n=112)(n=112)
DifferDiffer
OR time (min)OR time (min) 155155 122122 3333
Length of stay (days)Length of stay (days) 9.09.0 9.19.1 --
Conversion Conversion 14%14% -- --
Total cost first admissionTotal cost first admission 69316931 53755375 15561556
Total cost of care after discharge Total cost of care after discharge (readmissions/reoperations)(readmissions/reoperations)
25482548 18601860 688688
Total cost Total cost excludingexcluding productivity lost productivity lost 94799479 72377237 22442244
Productivity lossProductivity loss 21812181 25792579 -398-398
Total costTotal cost 1166011660 98149814 18461846
Prospective, Randomized - COLORProspective, Randomized - COLOR
All costs in Euros
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerCostCost
Janson, BJS 2004
LCR (n=98)LCR (n=98) OCR (n=112)OCR (n=112)
First admissionFirst admission
ComplicationsComplications 21%21% 16%16%
ReoperationsReoperations 8%8% 4%4%
After dischargeAfter discharge
ComplicationsComplications 12%12% 7%7%
ReoperationsReoperations 6%6% 3%3%
Prospective, Randomized - COLORProspective, Randomized - COLOR
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerCostCost
Total cost to society similar in both groupsTotal cost to society similar in both groups Direct costs to healthcare system much higher for LCRDirect costs to healthcare system much higher for LCR
– Higher OR costHigher OR cost
– Cost of complications and reoperation which happened more Cost of complications and reoperation which happened more often in LCRoften in LCR
Same length of stay in both (9 days)Same length of stay in both (9 days) Faster recovery and return to work offset higher Faster recovery and return to work offset higher
healthcare system costhealthcare system cost
Janson, BJS 2004
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerCostsCosts
The data available do not provide adequate The data available do not provide adequate evidence on whether total costs significantly evidence on whether total costs significantly differ between laparoscopy and laparotomy in the differ between laparoscopy and laparotomy in the treatment of malignancy. Costs may significantly treatment of malignancy. Costs may significantly vary depending on the healthcare systemvary depending on the healthcare system
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerRandomized Controlled TrialRandomized Controlled Trial
111 Laparoscopy vs. 106 Laparotomy111 Laparoscopy vs. 106 Laparotomy Non metastatic colon cancerNon metastatic colon cancer Median follow-up time: 43 (27-85) monthsMedian follow-up time: 43 (27-85) months Postoperative chemotherapy for all suitable Postoperative chemotherapy for all suitable
patients with Stage II or III rectal cancerpatients with Stage II or III rectal cancer Intention-to-treat analysisIntention-to-treat analysis
Lacy et al, The Lancet 2002Lacy et al, The Lancet 2002
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerRecurrenceRecurrence
Lacy et al, The Lancet 2002Lacy et al, The Lancet 2002
LaparoscopyLaparoscopy
(n=106)(n=106)
OpenOpen
(n=102)(n=102)
Hazard RatioHazard Ratio
(95% CI)(95% CI)P valueP value
Tumor recurrenceTumor recurrence 18 (17%)18 (17%) 28 (27%)28 (27%) 0.72 (0.49-1.06)0.72 (0.49-1.06) 0.070.07
Type of recurrenceType of recurrence
Distant metastasis Distant metastasis
Locoregional relapse Locoregional relapse
Peritoneal seeding Peritoneal seeding
Port-site metastasisPort-site metastasis
77
77
33
11
99
1414
55
00
----
----
----
----
0.570.57
Time to recurrence (months)Time to recurrence (months) 15 (14)15 (14) 17 (12)17 (12) ---- 0.660.66
Surgical treatment of Surgical treatment of recurrence with curative recurrence with curative intentionintention
6 (33%)6 (33%) 9 (32%)9 (32%) ---- 1.001.00
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerSurvivalSurvival
Lacy et al, The Lancet 2002Lacy et al, The Lancet 2002
LaparoscopyLaparoscopy
(n=106)(n=106)
OpenOpen
(n=102)(n=102)
Hazard ratioHazard ratio
(95% CI)(95% CI)P valueP value
Overall mortalityOverall mortality 19 (18%)19 (18%) 27 (26%)27 (26%) 0.77 (0.53-1.12)0.77 (0.53-1.12) 1.041.04
Cancer-related mortalityCancer-related mortality 10 (9%)10 (9%) 21 (21%)21 (21%) 0.68 (0.50-0.90)0.68 (0.50-0.90) 0.030.03
Causes of deathCauses of death
Perioperative mortalityPerioperative mortality
Tumor progressionTumor progression
OthersOthers
11
99
99
33
1818
66
----
----
----
0.190.19
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerPredictive factorsPredictive factors
Lacy et al, The Lancet 2002Lacy et al, The Lancet 2002
Hazard ratioHazard ratio
(95% CI)(95% CI)P valueP value
Probability of being free of recurrenceProbability of being free of recurrence
Lymph node metastasis (presence or absence)Lymph node metastasis (presence or absence)
Surgical procedure (Open vs. Lap)Surgical procedure (Open vs. Lap)
Preoperative serum CEA (Preoperative serum CEA (>> ng/ml vs. < 4 ng/ml) ng/ml vs. < 4 ng/ml)
0.31 (0.16-0.60)0.31 (0.16-0.60)
0.39 (0.19-0.82)0.39 (0.19-0.82)
0.43 (0.22-0.87)0.43 (0.22-0.87)
0.00060.0006
0.0120.012
0.0180.018
Overall survivalOverall survival
Surgical procedure (open vs. Lap)Surgical procedure (open vs. Lap)
Lymph-node metastasis (presence vs. absence)Lymph-node metastasis (presence vs. absence)
0.48 (0.23-1.01)0.48 (0.23-1.01)
0.49 (0.25-0.98)0.49 (0.25-0.98)
0.0520.052
0.0440.044
Cancer-related survivalCancer-related survival
Lymph-node metastasis (presence vs. absence)Lymph-node metastasis (presence vs. absence)
Surgical procedure (open vs. Lap)Surgical procedure (open vs. Lap)
0.29 (0.12-0.67)0.29 (0.12-0.67)
0.38 (0.16-0.91)0.38 (0.16-0.91)
0.0040.004
0.0290.029
Cox’s regression modelCox’s regression model
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerOverall survivalOverall survival
Lacy et al, The Lancet 2002Lacy et al, The Lancet 2002
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerCancer-related survivalCancer-related survival
Lacy et al, The Lancet 2002Lacy et al, The Lancet 2002
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerRecurrence free – by StageRecurrence free – by Stage
Lacy et al, The Lancet 2002Lacy et al, The Lancet 2002
Laparoscopic Colectomy: CancerLaparoscopic Colectomy: Cancer
Laparoscopic resection of colorectal malignancies Laparoscopic resection of colorectal malignancies a systematic reviewa systematic review
English languageEnglish language Randomized controlled trialsRandomized controlled trials Controlled clinical trialsControlled clinical trials Case series/reportsCase series/reports
Chapman et al. Ann Surg 2001Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
• 52 papers met inclusion criteria52 papers met inclusion criteria– ““Little high level evidence was available”Little high level evidence was available”– ““The evidence base for laparoscopic-assisted reection of The evidence base for laparoscopic-assisted reection of
colorectal malignancies is inadequate to determine the colorectal malignancies is inadequate to determine the procedures safety and efficacy”procedures safety and efficacy”
Chapman et al. Ann Surg 2001Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : CancerDisadvantages vs. Open ColectomyDisadvantages vs. Open Colectomy
• Significantly longer operative timesSignificantly longer operative times
• Possibly more expensivePossibly more expensive
• Possibly worse short term immune effectsPossibly worse short term immune effects
Chapman et al. Ann Surg 2001Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
• ““Laparoscopic resection of colorectal malignancy was Laparoscopic resection of colorectal malignancy was more expensive and time-consuming”more expensive and time-consuming”
• The new procedure’s advantages revolve around early The new procedure’s advantages revolve around early recovery from surgery and reduced pain”recovery from surgery and reduced pain”
Chapman et al. Ann Surg 2001Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : CancerAdvantages vs. Open ColectomyAdvantages vs. Open Colectomy
• Improved cosmesis (no data but appears uncontentious)Improved cosmesis (no data but appears uncontentious)
• Quicker hospital dischargeQuicker hospital discharge
• Less narcotic use, though possibly larger benefits for certain Less narcotic use, though possibly larger benefits for certain types of colectomy (low colonic)types of colectomy (low colonic)
• Possibly less pain at rest, at least for patients who have Possibly less pain at rest, at least for patients who have uncovered proceduresuncovered procedures
• Possibly earlier return of bowel function and resumption of Possibly earlier return of bowel function and resumption of normal dietnormal diet
Chapman et al. Ann Surg 2001Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
Short term Quality-of-Life outcomes Following Short term Quality-of-Life outcomes Following Laparoscopic-Assisted Colectomy vs Open Laparoscopic-Assisted Colectomy vs Open Colectomy for Colon Cancer (COST Study)Colectomy for Colon Cancer (COST Study)
AIMSAIMS– Are disease free and overall survival equivalent ?Are disease free and overall survival equivalent ?– Is laparoscopic approach associated with better QOL ?Is laparoscopic approach associated with better QOL ?
Weeks et al. JAMA 2002Weeks et al. JAMA 2002
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
Randomized control trial Randomized control trial 449 patients 449 patients
– Adenocarcinoma of single segment of colonAdenocarcinoma of single segment of colon– Excluded: Acute presentation, rectal and transverse Excluded: Acute presentation, rectal and transverse
colon cancers, advanced local disease, those lesions colon cancers, advanced local disease, those lesions with evidence of metastatic disease, ASA IV or Vwith evidence of metastatic disease, ASA IV or V
Quality of surgery:Quality of surgery:– All surgeons with > 20 cases; Random audit of casesAll surgeons with > 20 cases; Random audit of cases
Weeks et al. JAMA 2002Weeks et al. JAMA 2002
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
Outcomes:Outcomes:– Survival: still pendingSurvival: still pending– QOL at 2days, 2 weeks and 2 months using: QOL at 2days, 2 weeks and 2 months using:
» Symptom Distress Scale, Global QOL Scale, QOL indexSymptom Distress Scale, Global QOL Scale, QOL index
Results: Intention to Treat AnalysisResults: Intention to Treat Analysis– Shorter use of narcoticsShorter use of narcotics– Shorter length of stay by 0.8 days (p<0.01)Shorter length of stay by 0.8 days (p<0.01)– Quality of life: no differenceQuality of life: no difference
Weeks et al. JAMA 2002Weeks et al. JAMA 2002
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
ConclusionsConclusions– ““The modest benefits in short term QOL measures we The modest benefits in short term QOL measures we
observed are not sufficient to justify the use of this observed are not sufficient to justify the use of this procedure in the routine care setting”procedure in the routine care setting”
Unresolved Issues:Unresolved Issues:– Blunting of QOL differences via analgesic use Blunting of QOL differences via analgesic use – QOL differences between POD 2 and POD 14QOL differences between POD 2 and POD 14– Recurrence and survival outcomesRecurrence and survival outcomes– Incidence of small bowel obstruction Incidence of small bowel obstruction
Weeks et al. JAMA 2002Weeks et al. JAMA 2002
Laparoscopic Colectomy : Laparoscopic Colectomy : Prospective, Randomized, ControlledProspective, Randomized, Controlled
48 institutions, 872 patients48 institutions, 872 patients
Prospective, randomizedProspective, randomized
Follow-up 4.4 yearsFollow-up 4.4 years
Conversion 21%Conversion 21%
End point was time to tumor recurrenceEnd point was time to tumor recurrence
Nelson, NEJM 2004Nelson, NEJM 2004
Prospective, Randomized, ControlledProspective, Randomized, Controlled
LaparoscopicLaparoscopic
(n=435)(n=435)
OpenOpen
(n=425)(n=425)
AgeAge 7070 6969
FemaleFemale 212212 220220
LocationLocation
RightRight
LeftLeft
SigmoidSigmoid
237237
3232
166166
232232
3232
164164
TNM StageTNM Stage
00
11
22
33
44
UnknownUnknown
2020
153153
136136
112112
1010
44
3333
112112
146146
121121
1616
00
Nelson, NEJM 2004Nelson, NEJM 2004
Prospective, Randomized, Prospective, Randomized, Controlled: Outcome at Surgery Controlled: Outcome at Surgery
LaparoscopicLaparoscopic
(n=435)(n=435)
OpenOpen
(n=425)(n=425)P valueP value
Bowel margins (cm)Bowel margins (cm) 10-1310-13 11-1211-12 0.4-0.90.4-0.9
Lymph nodesLymph nodes 1212 1212 1.01.0
Surgery time (min)Surgery time (min) 150 150 9090 <0.001<0.001
ConversionConversion 9090 -- --
Intraoperative Intraoperative complicationscomplications
88 1515 NSNS
Length of incision (cm)Length of incision (cm) 66 1818 <0.001<0.001
Nelson, NEJM 2004Nelson, NEJM 2004
Prospective, Randomized, Prospective, Randomized, Controlled: Post-operativeControlled: Post-operative
LaparoscopicLaparoscopic
(n=435)(n=435)
Open Open
(n=425)(n=425)P valueP value
IV narcotics (days)IV narcotics (days) 33 44 <0.001<0.001
PO narcotics (days)PO narcotics (days) 11 22 0.020.02
Length of StayLength of Stay 55 66 <0.001<0.001
30-day mortality30-day mortality 22 44 NSNS
ComplicationsComplications 9292 8585 NSNS
Rates of readmissionRates of readmission 1010 1212 NSNS
Rates of reoperationRates of reoperation <2%<2% <2%<2% NSNS
Nelson, NEJM 2004Nelson, NEJM 2004
Prospective, Randomized, Prospective, Randomized, Controlled: Outcome Controlled: Outcome
LaparoscopicLaparoscopic
(n=435)(n=435)
OpenOpen
(n=425)(n=425)P valueP value
Recurrence* (4.4yrs)Recurrence* (4.4yrs) 7676 8484 0.830.83
Wound recurrenceWound recurrence 1%1% 1%1% P=0.50 NSP=0.50 NS
3-yr survival3-yr survival 86%86% 85%85% P=0.51 NSP=0.51 NS
Nelson, NEJM 2004Nelson, NEJM 2004
**Laparoscopic procedure not significantlyLaparoscopic procedure not significantly inferior to Open Procedure.inferior to Open Procedure.
Cumulative Incidence of Recurrence at Any SatgeCumulative Incidence of Recurrence at Any Satge
Overall Survival at Any StageOverall Survival at Any Stage
Prospective, Randomized, Prospective, Randomized, Controlled: ConclusionsControlled: Conclusions
No difference between: No difference between: – Time to recurrenceTime to recurrence
– Disease-free survival Disease-free survival
– Overall survivalOverall survival
Oncologic outcome of laparoscopic resection is similar to Oncologic outcome of laparoscopic resection is similar to that of open resectionthat of open resection
Laparoscopic approach is associated with less pain and a Laparoscopic approach is associated with less pain and a shorter hospital stay than conventional surgeryshorter hospital stay than conventional surgery
Nelson, NEJM 2004Nelson, NEJM 2004
Laparoscopic Colectomy : Laparoscopic Colectomy : CLASICC Trial CLASICC Trial
Colon and Rectal CancerColon and Rectal Cancer
27 UK institutions, 794 patients27 UK institutions, 794 patients
Prospective, randomized, controlledProspective, randomized, controlled
Follow-up at 1 and 3 monthsFollow-up at 1 and 3 months
29% conversion rate29% conversion rate
Guillou, Lancet 2005Guillou, Lancet 2005
Laparoscopic ColectomyLaparoscopic ColectomyCLASICC Trial CLASICC Trial
Colon and Rectal CancerColon and Rectal Cancer
Guillou, Lancet 2005Guillou, Lancet 2005
Primary Primary EndpointsEndpoints
Positivity rates of circumferential and Positivity rates of circumferential and
longitudinal resection marginslongitudinal resection margins
Proportion of Dukes’ C2 tumorsProportion of Dukes’ C2 tumors
In-Hospital mortalityIn-Hospital mortality
SecondarySecondaryEndpointsEndpoints
Complication rates Complication rates
Quality of lifeQuality of life
Transfusion requirmentsTransfusion requirments
Guillou, Lancet 2005Guillou, Lancet 2005
CLASICC Trial Profile CLASICC Trial Profile
Prospective, Randomized, ControlledProspective, Randomized, ControlledOpen (n=276)Open (n=276) Laparoscopic (n=345)Laparoscopic (n=345) Conversion (n=143)Conversion (n=143)
AgeAge 6969 6969 6868
FemaleFemale 121 (44%)121 (44%) 167 (48%)167 (48%) 49 (34%)49 (34%)
ColonColon
RectumRectum
144 (52%)144 (52%)
132 (48%)132 (48%)
185 (52%)185 (52%)
160 (46%)160 (46%)
61 (43%)61 (43%)
82 (18%)82 (18%)
TNM Stage TNM Stage
T 0T 0
T 1T 1
T 2T 2
T 3T 3
T 4T 4
----
9 (4%)9 (4%)
36 (16%)36 (16%)
141 (64%)141 (64%)
33 (15%)33 (15%)
----17 (6%) 17 (6%)
48 (17%)48 (17%)175 (63%)175 (63%)36 (13%)36 (13%)
----
4 (3%)4 (3%)
16 (13%)16 (13%)
71 (60%)71 (60%)
28 (24%)28 (24%)
N0N0
N1N1
N2N2
Not InvestigatedNot Investigated
130 (59%)130 (59%)
51 (23%)51 (23%)
38 (17%)38 (17%)
----
159 (58%)159 (58%)
70 (25%)70 (25%)
46 (17%)46 (17%)
1 1
63 (53%)63 (53%)
33 (28%)33 (28%)
21 (18%)21 (18%)
2 (2%)2 (2%)
M0M0
M1M1
Not investigatedNot investigated
MissingMissing
96 (44%)96 (44%)
8 (4%)8 (4%)
107(49%)107(49%)
8 (4%)8 (4%)
98 (36%)98 (36%)
4 (1%)4 (1%)
159 (58%)159 (58%)
15 (5%)15 (5%)
57 (48%)57 (48%)
7 (6%)7 (6%)
52 (44%)52 (44%)
3 (3%)3 (3%)
Guillou, Lancet 2005Guillou, Lancet 2005
CLASICC: Outcome at Surgery CLASICC: Outcome at Surgery
OpenOpen
(n=276)(n=276)
LaparoscopicLaparoscopic
(n=345)(n=345)
ConversionConversion
(n=143)(n=143)
Time to first bowel Time to first bowel movement (days)movement (days)
6 (4.5-7) colon6 (4.5-7) colon
6 (4-7) rectum6 (4-7) rectum
5 (4-6.5) colon5 (4-6.5) colon
5 (3-7) rectum5 (3-7) rectum
5 (4-6.5) colon5 (4-6.5) colon
6 (4-8) rectum6 (4-8) rectum
Time to normal dietTime to normal diet6 (5-8) colon6 (5-8) colon
7 (5-8) rectum7 (5-8) rectum
5 (4-7) colon5 (4-7) colon
6 (5-7) rectum6 (5-7) rectum
6 (5-8) colon6 (5-8) colon
7 (5-9) rectum7 (5-9) rectum
Anaesthetic time (min)Anaesthetic time (min) 135 (100-175)135 (100-175) 180 (140-220)180 (140-220) 180 (135-223)180 (135-223)
Length of incision (mm)Length of incision (mm) 228 (180-300)228 (180-300) 70 (55-100)70 (55-100) 200 (150-285)200 (150-285)
Guillou, Lancet 2005Guillou, Lancet 2005
All data are medianAll data are median
CLASICC: PathologyCLASICC: Pathology
LaparoscopicLaparoscopic OpenOpen ConvertedConverted
Lymph-nodeLymph-node
Duke’s C2Duke’s C2
12 ( 8-17)12 ( 8-17)
34 (6%)34 (6%)
13.5 (8-1913.5 (8-19
18 (7%)18 (7%)
----
16 (12%)16 (12%)
ColonColon
Distance from tumor to mesenteric Distance from tumor to mesenteric resection marginresection margin
Circumferential resection margin +Circumferential resection margin +
8cm (6.5-10)8cm (6.5-10)
16 (7%)16 (7%)
9cm (7-11)9cm (7-11)
6 (5%)6 (5%)
RectumRectum
Circumferential resection margin +Circumferential resection margin + 30 (16%)30 (16%) 14 (14%)14 (14%)
Guillou, Lancet 2005Guillou, Lancet 2005
P>0.05P>0.05
CLASICC: ComplicationsCLASICC: Complications
Intraoperative Intraoperative complicationscomplications
LaparoscopicLaparoscopic
(intention to treat)(intention to treat)OpenOpen
GeneralGeneral 54 (10%) 27 (10%)
(Colon) Haemorrhage(Colon) Haemorrhage
Cardiac/PulmonaryCardiac/Pulmonary
Bowel InjuryBowel Injury
Ureteric InjuryUreteric Injury
OtherOther
2 (1%)
10 (4%)
6 ( 2%)
2 (1%)
2 (1%)
5 (4%)
4 (3%)
--
--
2 (1%)
(Rectum) Haemorrhage(Rectum) Haemorrhage
Cardiac/PulmonaryCardiac/Pulmonary
Bowel InjuryBowel Injury
Ureteric InjuryUreteric Injury
OtherOther
17 (7%)
11 (4%)
3 ( 1%)
--
9 (4%)
7 (5%)
4 (3%)
1 (1%)
4 (3%)
2 (2%)
Guillou, Lancet 2005Guillou, Lancet 2005
P > 0.05P > 0.05
CLASICC: ComplicationsCLASICC: Complications
30 days post op30 days post op LaparoscopicLaparoscopic Open Open ConvertedConverted
Total ComplicationsTotal Complications 133 (39%)133 (39%) 115 (42%)115 (42%) 99 (69%)99 (69%)
(Colon) wound infection(Colon) wound infection
chest infectionchest infection
anastomotic dehiscenceanastomotic dehiscence
DVTDVT
OtherOther
8 (4%)8 (4%)
10 (5%)10 (5%)
7 (4%)7 (4%)
5 (3%)5 (3%)
32 (17%)32 (17%)
7 (5%)7 (5%)
5 (3%)5 (3%)
5 (3%)5 (3%)
----
31 (22%)31 (22%)
5 (8%)5 (8%)
6 (10%)6 (10%)
1 (2%)1 (2%)
----
11 (18%)11 (18%)
(Rectum) wound infection(Rectum) wound infection
chest infection chest infection
anastomotic dehiscenceanastomotic dehiscence
DVTDVT
OtherOther
16 (10%)16 (10%)
12 (8%)12 (8%)
13 (8%)13 (8%)
----
30 (19%)30 (19%)
16 (12%)16 (12%)
6 (5%)6 (5%)
10 (7%)10 (7%)
2 (2%)2 (2%)
33 (25%)33 (25%)
16 (20%)16 (20%)
12 (15%)12 (15%)
12 (15%)12 (15%)
1 (1%)1 (1%)
35 (43%)35 (43%)
DeathDeath 16 (1%)16 (1%) 15 (5%)15 (5%) 13 (9%)13 (9%)
Guillou, Lancet 2005Guillou, Lancet 2005
P>0.05P>0.05
CLASICC: ConversionsCLASICC: Conversions
Conversion Rate (Colon)Conversion Rate (Colon)
61 (25%)61 (25%)
-Tumor fixity-Tumor fixity
-Uncertainty of tumor clearance-Uncertainty of tumor clearance
-Obesity-Obesity
37 (61%)37 (61%)
13 (21%)13 (21%)
5 (8%)5 (8%)
Conversion Rate (Rectum) Conversion Rate (Rectum)
82 (34%)82 (34%)
-Tumor fixity/Uncertainty of -Tumor fixity/Uncertainty of
tumor clearancetumor clearance
-Obesity-Obesity
-Anatomical uncertainty-Anatomical uncertainty
-Inaccessibility of tumor-Inaccessibility of tumor
34 (41%)34 (41%)
21 (26%)21 (26%)
17 (21%)17 (21%)
16 (20%)16 (20%)
Guillou, Lancet 2005Guillou, Lancet 2005
Laparoscopic Colectomy : Prospective, Laparoscopic Colectomy : Prospective, Randomized, ControlledRandomized, Controlled
OpenOpen
N=20N=20
ConvertedConverted
N=13N=13
LaparoscopicLaparoscopic
N=15N=15
Recurrence %Recurrence % 55 2323 00
Survival StatusSurvival Status
Alive without disease %Alive without disease % 9090 6262 9393
Alive with disease %Alive with disease % 55 2323 00
Died, Disease-related %Died, Disease-related % 55 88 77
Died, non-disease related %Died, non-disease related % 00 88 00
Outcome at 3 yearsOutcome at 3 years
Kaiser, J Lap and Advanced Surg Tech 2004Kaiser, J Lap and Advanced Surg Tech 2004
Equivalent in terms of recurrence and survivalEquivalent in terms of recurrence and survival
Laparoscopy vs. Open: Colon CancerLaparoscopy vs. Open: Colon CancerMeta-analysis of 12 randomized controlled trials (2512 patients)
Abraham, BJS 2004Abraham, BJS 2004
YearYear PatientsPatients
LacyLacy 20022002 219219
COSTCOST 20022002 428428
COLORCOLOR 20022002
NeudeckerNeudecker 20022002 3030
BragaBraga 20022002 269269
SingaporeSingapore 20012001 236236
SchwenkSchwenk 20002000 6060
LeungLeung 20002000 3434
CuretCuret 20002000 7373
HewittHewitt 19981998 2525
MilsomMilsom 19981998 113113
StageStage 19971997 2929
Laparoscopy vs Open: Colon CancerLaparoscopy vs Open: Colon CancerMeta-analysis of 12 randomized controlled trials (2512 patients)
Abraham, BJS 2004Abraham, BJS 2004
Odds RatioOdds Ratio P valueP value
MortalityMortality 0.850.85 NSNS
MorbidityMorbidity 0.620.62 <0.003<0.003
All complicationsAll complications 0.600.60 <0.001<0.001
Local ComplicationsLocal Complications 0.510.51 <0.001<0.001
All wound complicationsAll wound complications 0.470.47 0.0030.003
All leakageAll leakage 0.840.84 NSNS
HemorrhageHemorrhage 0.710.71 NSNS
ReoperationReoperation 0.700.70 NSNS
Systemic, Cardiac, Respiratory, DVTSystemic, Cardiac, Respiratory, DVT 0.65-0.810.65-0.81 NSNS
Laparoscopy vs Open: Colon CancerLaparoscopy vs Open: Colon Cancer
Abraham, BJS 2004Abraham, BJS 2004
Meta-analysis of 12 randomized controlled trials (2512 patients)Meta-analysis of 12 randomized controlled trials (2512 patients)
PatientsPatients ImprovementImprovement
First FlatusFirst Flatus 476476 33.5%33.5%
Tolerating Solid DietTolerating Solid Diet 406406 23.9%23.9%
80% Recovery of Peak Expiratory Flow80% Recovery of Peak Expiratory Flow 9494 44.3%44.3%
Pain 6-8hr postopPain 6-8hr postop
At restAt rest
During coughingDuring coughing
173173
173173
34.8%34.8%
33.9%33.9%
Narcotic Analgesia (first 48hrs)Narcotic Analgesia (first 48hrs) 269269 36.9%36.9%
Length of Hospital StayLength of Hospital Stay 12371237 20.6%20.6%
Laparoscopy: Colon CancerLaparoscopy: Colon CancerConclusionConclusion
Laparoscopy for colon cancer has shown to be potentially Laparoscopy for colon cancer has shown to be potentially superior to laparotomy in regard to short-term benefits superior to laparotomy in regard to short-term benefits and equivalent with regard to long term benefitsand equivalent with regard to long term benefits
Available data appear to support that laparoscopic Available data appear to support that laparoscopic colectomy and conventional open colectomy have either colectomy and conventional open colectomy have either similar or superior long-term outcomes (Level 1 similar or superior long-term outcomes (Level 1 evidence)evidence)
Surgeons with sufficient expertise and ongoing peer-Surgeons with sufficient expertise and ongoing peer-reviewed data collection may offer this therapy to reviewed data collection may offer this therapy to appropriately selected patientsappropriately selected patients
Laparoscopy vs. Open Colectomy in Laparoscopy vs. Open Colectomy in Cancer PatientsCancer Patients
Randomized Trial
Braga, DCR 2005Braga, DCR 2005
VariableVariableLaparoscopyLaparoscopy
(n = 190)(n = 190)OpenOpen
(n = 201)(n = 201)
Age (yr)Age (yr) 65 (13) 67 (11)
Male/female ratioMale/female ratio 115/75 121/80
ASA scoreASA score 1.9 (0.6) 2.0 (0.7)
Hemoglobin (g/l)Hemoglobin (g/l) 126 (19) 124 (22)
ObesityObesity 17 (8.9) 12 (6)
UndernutritionUndernutrition 22 (11.6) 24 (11.9)
Albumin (g/l)Albumin (g/l) 36.9 (5.3) 36.2 (6.5)
Laparoscopy vs. Open Colectomy in Laparoscopy vs. Open Colectomy in Cancer Patients:Cancer Patients:
Long-Term ComplicationsLong-Term Complications
Braga, DCR 2005Braga, DCR 2005
ComplicationComplicationLaparoscopyLaparoscopy
(n = 190)(n = 190)OpenOpen
(n = 201)(n = 201)P ValueP Value
OverallOverall 13 (6.8) 30 (14.9) 0.02
Incisional herniaIncisional hernia 9 (4.7) 18 (8.9) NS
Intestinal obstructionIntestinal obstruction 3 (1.6) 6 (3) NS
Abdominal abscessAbdominal abscess 0 (0) 1 (0.5) NS
Urinary dysfunctionUrinary dysfunction 0 (0) 3 (1.5) NS
Peristomal abscessPeristomal abscess 1 (0.5) 1 (0.5) NS
Anastomosis stenosisAnastomosis stenosis 0 (0) 1 (0.5) NS
Laparoscopy vs. Open Colectomy in Laparoscopy vs. Open Colectomy in Cancer PatientsCancer Patients
Quality of Life
Braga, DCR 2005Braga, DCR 2005
Laparoscopy vs. Open Colectomy in Laparoscopy vs. Open Colectomy in Cancer PatientsCancer Patients
Five-Year Survival by Cancer Stage
Braga, DCR 2005Braga, DCR 2005
Laparoscopy vs. Open Colectomy in Laparoscopy vs. Open Colectomy in Cancer PatientsCancer Patients
Five-year Disease-Free Survival
Braga, DCR 2005Braga, DCR 2005
Laparoscopy vs. Open Colectomy in Laparoscopy vs. Open Colectomy in Cancer PatientsCancer Patients
Conclusion
Braga, DCR 2005Braga, DCR 2005
Laparoscopic colorectal resection reduced longterm
complication rate, improved quality of life in the
first postoperative year, and did not adversely affect
survival in cancer patients
Laparoscopy for Rectal CancerLaparoscopy for Rectal Cancer
Laparoscopy: Rectal CancerLaparoscopy: Rectal CancerTotal Mesorectal ExcisionTotal Mesorectal Excision
AdvantagesAdvantages Amplification of planes of Amplification of planes of
mesorectum and pelvic mesorectum and pelvic fasciafascia
30 degree laparoscope better 30 degree laparoscope better visibility in narrow pelvisvisibility in narrow pelvis
Easier identification of Easier identification of pelvic autonomic nerve pelvic autonomic nerve plexusplexus
DisadvantagesDisadvantages Technically demandingTechnically demanding Absence of tactile sensationAbsence of tactile sensation Difficulty in assessing Difficulty in assessing
surgical marginssurgical margins Difficulty in ultralow cross-Difficulty in ultralow cross-
clampingclamping Learning curveLearning curve
Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME)Excision (TME)
Prospective review – 58 monthsProspective review – 58 months Control group – open rectal resectionsControl group – open rectal resections
– Second consultantSecond consultant– Same unitSame unit
(21 vs. 22)(21 vs. 22)
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME)Excision (TME)
42 Attempted Laparoscopic Rectal Mobilizations
14 Early Conversions
28 Laparoscopic Rectal Dissections
21 Laparoscopic TME – Study Group
7 AP Resections
1 Non CurativeResection
6 Total Laparoscopic AP
21 Anterior Resections
6 Partial OpenDissection
15 Total Laparoscopic AR
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Excision (TME)Laparoscopy: Total Mesorectal Excision (TME)Completed Laparoscopic Completed Laparoscopic
(n=21)(n=21)Open (n=22)Open (n=22)
Laparoscopic Laparoscopic Conversions* (n=21)Conversions* (n=21)
Mean age (range)Mean age (range) 66 (37-82)66 (37-82) 65 (47-79)65 (47-79) 72 (58-90)72 (58-90)
Male:femaleMale:female 15:615:6 15:715:7 13:813:8
Dukes’ StageDukes’ Stage
AA 55 44 00
BB 1010 88 88
CC 66 1010 1313
DD 00 00 11
Tumor height ([number] cm above anal verge, mean (range))Tumor height ([number] cm above anal verge, mean (range))
Anterior resectionAnterior resection [15] 6.2 (4-9)[15] 6.2 (4-9) [16] 6.4 (4-10)[16] 6.4 (4-10) [16] 7 (5-10)[16] 7 (5-10)
Abdominoperineal resctn.Abdominoperineal resctn. [6] 2 (0-5)[6] 2 (0-5) [6] 1.66 (0-5)[6] 1.66 (0-5) [1] 1[1] 1
UnresectableUnresectable [0][0] [0][0] [2] 6 (4-8)[2] 6 (4-8)
Hartmann’s resectionHartmann’s resection [0][0] [0][0] [2] 9 (6-12)[2] 9 (6-12)
* Includes the one palliative lap. APRHartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME)Excision (TME)
Reason for Conversion NumberReason for Conversion Number– Fixed tumorFixed tumor 22
– Doubtful resectabilityDoubtful resectability 44
– Gross obesityGross obesity 22
– Dense adhesionsDense adhesions 22
– Obstructed sigmoidObstructed sigmoid 11
– Ureter not identifiedUreter not identified 22
– Camera failureCamera failure 11
– TOTAL 14 (33%)TOTAL 14 (33%)
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Excision (TME)Laparoscopy: Total Mesorectal Excision (TME)
GroupGroupSpecimen Specimen
Length (cm)Length (cm)Longitudinal Longitudinal Margin (cm)Margin (cm)
Radial Margin Radial Margin (cm)(cm)
No. Positive No. Positive MarginsMargins
Lymph Node Lymph Node YieldYield
LaparoscopicLaparoscopic(n=21)(n=21)
27.527.5(24-30)(24-30)
4*4*(3.5-5)(3.5-5)
0.650.65(0.33-1.5)(0.33-1.5)
0066
(3.25-9.5)(3.25-9.5)
Open (n=22)Open (n=22)26.526.5
(23.75-32)(23.75-32)2.52.5
(1.05-3.5)(1.05-3.5)0.80.8
(0.225-1.2)(0.225-1.2)00
7.07.0(4.5-10.5)(4.5-10.5)
ConvertedConvertedlaparoscopiclaparoscopic(n=19) (n=19) ††
28 (24-32)28 (24-32) 2 (1.5-3.5)2 (1.5-3.5) 0.6 (0.35-1)0.6 (0.35-1) 2 2 ‡‡77
(6-10)(6-10)
Values are medians (interquartile ranges)* p=0.02, Mann-Whitney test for nonparametric data vs. open group† n=19 because two patients not resected;includes the one palliative lap. APR‡ Both known palliative
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Excision (TME)Laparoscopy: Total Mesorectal Excision (TME)
GroupGroupOperating Time Operating Time
(min)(min)Duration of Ileus Duration of Ileus
(days)(days)
Analgesia Analgesia Requirements Requirements
(days)(days)
Hospital Stay Hospital Stay (days)(days)
LaparoscopicLaparoscopic(n=21)(n=21)
180*180*(168-218)(168-218)
3.03.0(3.0-4.0)(3.0-4.0)
4.04.0(3.0-6.0)(3.0-6.0)
13.513.5(10.25-27.0)(10.25-27.0)
OpenOpen(n=22)(n=22)
125125(104-144)(104-144)
4.04.0(3.0-5.0)(3.0-5.0)
4.04.0(3.0-5.0)(3.0-5.0)
15.015.0(11.75-28.5)(11.75-28.5)
Converted Converted laparoscopiclaparoscopic(n=21)(n=21)††
146146(136.5-179.5)(136.5-179.5)
44(3.5-7)(3.5-7)
55(3.5-7)(3.5-7)
1616(11.5 – 33)(11.5 – 33)
Values are medians (interquartile ranges)* p=0.003, Mann-Whitney test for nonparametric data vs. open cases† Includes the one palliative lap. APR
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Excision (TME)Laparoscopy: Total Mesorectal Excision (TME)
ComplicationComplicationLaparoscopicLaparoscopic
(n=21)(n=21)OpenOpen
(n=22)(n=22)
Converted Converted LaparoscopicLaparoscopic
(n=21)(n=21)††
Wound infectionWound infection 00 11 22
Respiratory tract infectionRespiratory tract infection 11 11 22
Wound hematomaWound hematoma 11 00 00
Clinical anastomotic leakageClinical anastomotic leakage 4*4* 11 11
Bowel obstructionBowel obstruction 00 11 00
* P = 0.329 Fisher’s exact test vs. open group† Includes the one palliative lap. APR
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Excision (TME)Laparoscopy: Total Mesorectal Excision (TME)
Follow-up for Patients Having Curative Laparoscopic and Open ResectionsFor Rectal Cancer, Including Complete Mesorectal Excision
LaparoscopicLaparoscopic(n=21)(n=21)
OpenOpen(n=22)(n=22)
Local recurrenceLocal recurrence 1 (5%)1 (5%) 1 (4.5%)*1 (4.5%)*
Death (all causes)Death (all causes) 6 (29%)6 (29%) 5 (23%)5 (23%)††
* Median follow-up was 38 (range, 6-53) months† p=1 and † P=0.736, Fisher’s exact test
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME)Excision (TME)
Feasible in 50% of patients where possibleFeasible in 50% of patients where possible
Yields histologic and early survival and Yields histologic and early survival and recurrence figures comparable to open surgeryrecurrence figures comparable to open surgery
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME) case control studyExcision (TME) case control study
Breukink, Int J Colorectal Dis 2005Breukink, Int J Colorectal Dis 2005
VARIABLE/GROUPVARIABLE/GROUP LAPAROSCOPICLAPAROSCOPIC OPENOPEN P valueP value
OPERATIVE TIME(min)OPERATIVE TIME(min) 200200 180180 0.060.06
BLOOD LOSS(ml)BLOOD LOSS(ml) 250250 10001000 <0.001<0.001
>1000 ml FLUID INTAKE>1000 ml FLUID INTAKE 33 66 0.0020.002
SOLID DIET (days)SOLID DIET (days) 44 77 0.0460.046
HOSPITALIZATION (days)HOSPITALIZATION (days) 1212 1919 0.0070.007
MORBIDITYMORBIDITY 37%37% 51%51% N/AN/A
ANASTOMOTIC LEAK (n)ANASTOMOTIC LEAK (n) 22 22 N/AN/A
MORTALITY(n)MORTALITY(n) 00 11 N/AN/A
NN Conversion Conversion OR OR
TimeTime
(mins)(mins)
AnastomoticAnastomotic
TechniqueTechnique
Goh, 97Goh, 97 OLAROLAR
LLARLLAR
2020
2020
--
0%0%
7373
9090
Partial TME with double Partial TME with double staplestaple
Leung, 97Leung, 97 OLAROLAR
LLARLLAR
5050
5050
--
16%16%
150150
196196
Partial TME with double Partial TME with double staplestaple
Schwander, 99Schwander, 99 OLA/prOLA/pr
LLA/prLLA/pr
3232
3232
--
NSNS
209209
281281
LAR 19 Lap 19 Open, LAR 19 Lap 19 Open,
APR 13 Lap 13 OpenAPR 13 Lap 13 Open
Hartley, 01Hartley, 01 OLA/prOLA/pr
LLA/prLLA/pr
2222
4242
--
50%50%
125125
180180
LAR, APR, HartmannLAR, APR, Hartmann
Anthuber, 03Anthuber, 03 OLA/prOLA/pr
LLA/prLLA/pr
334334
101101
--
11%11%
219219
218218
TME with colonic J if <6cmTME with colonic J if <6cm
Breukink, 05Breukink, 05 LARLAR
APRAPR
1010
3131NSNS 195195
225225
Double stapled anastomosisDouble stapled anastomosis
Laparoscopy: Rectal Cancer
Case controlled series for LAR
Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME) case control studyExcision (TME) case control study
VARIABLE/GROUPVARIABLE/GROUP LAPAROSCOPICLAPAROSCOPIC OPENOPEN
CIRCUMFERENTIAL CIRCUMFERENTIAL MARGIN(mm)MARGIN(mm)
3 (2-31)3 (2-31) 5 (2-31)5 (2-31)
DISTAL MARGIN mmDISTAL MARGIN mm 35 (10-100)35 (10-100) 10 (1-30)10 (1-30)
NUMBER OF NODESNUMBER OF NODES 8 (1-25)8 (1-25) 8 (2-20)8 (2-20)
FOLLOW UP (months)FOLLOW UP (months) 14 (2-31)14 (2-31) 19 (2-31)19 (2-31)
LOCAL RECURRENCELOCAL RECURRENCE 00 00
DISTANT METASTASISDISTANT METASTASIS 55 55
Breukink, Int J Colorectal Dis 2005Breukink, Int J Colorectal Dis 2005
Length of Length of StayStay
LRMLRM DRMDRM MorbidityMorbidity MorbidityMorbidity LeakLeak
Goh, 97 Goh, 97 OLAROLAR
LLARLLAR
5.55.5
55
clearclear
clearclear
44
4.54.5
5%5%
20%20%
NSNS 00
00
Leung, 97Leung, 97 OLAROLAR
LLARLLAR
88
66
clearclear
clearclear
NSNS 30%30%
26%26%
6%6%
2%2%
2%2%
0%0%
Schwander, 99Schwander, 99 OLA/prOLA/pr
LLA/prLLA/pr
2121
1515
clearclear clearclear 31%31%
31%31%
0%0%
3%3%
00
3%3%
Hartley, 01*Hartley, 01* OTMEOTME
LTMELTME
1515
13.513.5
0.80.8
0.650.65
2.52.5
44
18%18%
26%26%
0%0%
0%0%
11
44
Anthuber, 03Anthuber, 03 OLA/prOLA/pr
LLA/prLLA/pr
1919
1414
DNDN DNDN 54%54%
31%31%
1%1%
0%0%
7%7%
9%9%
Breukink, 05Breukink, 05 LARLAR
APRAPR1111
2121
NSNS 3.53.5 37%37% 00 5%5%
Laparoscopy: Rectal Cancer
Case controlled series for LAR
NN Conversion Conversion OR TimeOR Time
(mins)(mins)
AnastomoticAnastomotic
TechniqueTechnique
Seow-Chen, 97Seow-Chen, 97 OAPROAPR
LAPRLAPR
1111
1616
--
NSNS
100100
110110
TMETME
Ramos, 97Ramos, 97 OAPROAPR
LAPRLAPR
1818
1818
--
10%10%
208208
229229
TMETME
Fleshman, 99Fleshman, 99 OAPROAPR
LAPRLAPR
4242
152152
--
21%21%
209209
234234
Lap APR with TMELap APR with TME
Leung, 00Leung, 00 OAPROAPR
LAPRLAPR
3434
2525
--
NSNS
166166
216216
TMETME
Baker, 02Baker, 02 OAPROAPR
LAPRLAPR
6161
2828
--
25%25%
NSNS
NSNS
?TME?TME
Laparoscopy: Rectal Cancer
Case controlled series for APR
Length of Length of StayStay
LRMLRM DRMDRM MorbidityMorbidity MortalityMortality
Seow-Chen, 97Seow-Chen, 97 OAPROAPR
LAPRLAPR
88
6.56.5
clearclear
clearclear
33
22
55%55%
25%25%
0%0%
0%0%
Ramos, 97Ramos, 97 OAPROAPR
LAPRLAPR
12.912.9
7.47.4
NSNS NSNS 66%66%
44%44%
5.5%5.5%
0%0%
Fleshman, 99Fleshman, 99 OAPROAPR
LAPRLAPR
1212
77
+ in 5+ in 5
+ in 19+ in 19
NSNS 27%27%
33%33%
0%0%
0%0%
Leung, 00Leung, 00 OAPROAPR
LAPRLAPR
1616
2525
NSNS 11
22
48%48%
61%61%
0%0%
0%0%
Baker, 02Baker, 02 OAPROAPR
LAPRLAPR
1818
1313
+ in 1 + in 1 3.23.2
4.54.5
-/3%-/3%
-/4%-/4%
3%3%
4%4%
Laparoscopy: Rectal CancerCase controlled series for APR
Laparoscopy: Rectal CancerLaparoscopy: Rectal CancerProspective, Randomized, Controlled – Short-term outcome of TME with anal sphincter preservation (ASP)
Zhou, Surg Endosc 2004Zhou, Surg Endosc 2004
OpenOpen LaparoscopicLaparoscopic
PatientsPatients 8989 8282
Mean age (years)Mean age (years) 4545 4444
Dukes’ StageDukes’ Stage
AA
BB
CC
DD
66
88
6868
77
55
1010
6363
44
Laparoscopy: Rectal CancerLaparoscopy: Rectal CancerResults of SurgeryResults of Surgery
OpenOpen
(n=89)(n=89)
LaparoscopicLaparoscopic
(n=82)(n=82)
Distance of Tumor from Dentate (cm)Distance of Tumor from Dentate (cm)
1.5-4cm1.5-4cm
4.1-7cm4.1-7cm
5656
3333
4848
3434
Distal MarginDistal Margin 1.5-3.51.5-3.5 1.5-4.01.5-4.0
Sphincter preservationSphincter preservation 100%100% 100%100%
Anastomotic heightAnastomotic height
Low anterior (>2cm from dentate)Low anterior (>2cm from dentate)
Ultralow anterior (<2cm from dentate)Ultralow anterior (<2cm from dentate)
Coloanal (at or below dentate)Coloanal (at or below dentate)
3535
2727
2727
3030
2727
2525
Diverting ileostomyDiverting ileostomy 00 00
Zhou, Surg Endosc 2004Zhou, Surg Endosc 2004
Laparoscopy: Rectal CancerLaparoscopy: Rectal CancerOpenOpen LaparoscopicLaparoscopic P P
valuevalue
Operative time (min)Operative time (min) 106106 120120 NSNS
Blood loss (ml)Blood loss (ml) 9292 2020 0.020.02
Parenteral analgesics (days)Parenteral analgesics (days) 4.14.1 3.93.9 NSNS
Solid intake (days)Solid intake (days) 4.54.5 4.34.3 NSNS
Hospitalization (days)Hospitalization (days) 13.313.3 8.18.1 0.0010.001
MorbidityMorbidity
Anastomotic leakAnastomotic leak
12.4%12.4%
33
6.1%6.1%
11
0.0160.016
MortalityMortality 00 00 NSNS
Follow-up 1-16 monthsFollow-up 1-16 months
Port site metsPort site mets NANA 22
Pelvic recurrencePelvic recurrence 33 00
Zhou, Surg Endosc 2004Zhou, Surg Endosc 2004
105 patients105 patients
Mean follow up time 26.9 (1.3-65.6) monthsMean follow up time 26.9 (1.3-65.6) months
Laparoscopic Sphincter-Preserving TME Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstructionwith Colonic J-Pouch Reconstruction
Tsang WWC, Ann Surg 2006Tsang WWC, Ann Surg 2006
Mean operative time 170.4 minMean operative time 170.4 min Mean anastomotic distance from anal verge 3.9 cmMean anastomotic distance from anal verge 3.9 cm Mean circumferential margin 17.1 mmMean circumferential margin 17.1 mm Mean distal margin 3.4 cmMean distal margin 3.4 cm
Laparoscopic Sphincter-Preserving TME Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstructionwith Colonic J-Pouch Reconstruction
Tsang WWC, Ann Surg 2006Tsang WWC, Ann Surg 2006
5-year cancer-specific survival rate 81.3%5-year cancer-specific survival rate 81.3% Local recurrence rate 8.9%Local recurrence rate 8.9%
Laparoscopic Sphincter-Preserving TME Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstructionwith Colonic J-Pouch Reconstruction
Tsang WWC, Ann Surg 2006Tsang WWC, Ann Surg 2006
Laparoscopic Sphincter-Preserving TME Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstructionwith Colonic J-Pouch Reconstruction
ConclusionConclusion
Lap TME with colonic J-pouch is a safe procedure with Lap TME with colonic J-pouch is a safe procedure with
reasonable operating time and does not appear to pose reasonable operating time and does not appear to pose
any threat to the oncologic and functional outcomesany threat to the oncologic and functional outcomes
Tsang WWC, Ann Surg 2006Tsang WWC, Ann Surg 2006
Laparoscopic vs. Open Surgery for Laparoscopic vs. Open Surgery for Extraperitoneal Rectal CancerExtraperitoneal Rectal Cancer
191 consecutive patients191 consecutive patients 98 patients underwent lap resection 98 patients underwent lap resection 93 patients underwent open resection93 patients underwent open resection
Morino M, Surg Endosc 2005Morino M, Surg Endosc 2005
LaparoscopicLaparoscopic
n = 98n = 98
OpenOpen
n = 93n = 93PP
Mean follow up (months)Mean follow up (months) 46.3 46.3 49.749.7 NSNS
Conversion rate (%)Conversion rate (%) 18.418.4
Mobilization (days)Mobilization (days) 1.71.7 3.33.3 < 0.001< 0.001
Flatus (days)Flatus (days) 2.62.6 3.93.9 < 0.001< 0.001
Stool (days)Stool (days) 3.83.8 4.74.7 < 0.01< 0.01
Oral intake (days)Oral intake (days) 3.43.4 4.84.8 < 0.001< 0.001
Hospital stay (days)Hospital stay (days) 11.411.4 13.013.0 NSNS
Morino M, Surg Endosc 2005Morino M, Surg Endosc 2005
Laparoscopic vs. Open Surgery for Laparoscopic vs. Open Surgery for Extraperitoneal Rectal CancerExtraperitoneal Rectal Cancer
LaparoscopicLaparoscopic
n = 98n = 98
OpenOpen
n = 93n = 93
PP
Morbidity (%)Morbidity (%) 24.424.4 23.623.6 NSNS
Mortality (%)Mortality (%) 1.01.0 2.22.2 NSNS
Anastomotic leakage (%)Anastomotic leakage (%) 13.513.5 5.15.1 NSNS
Reoperation (%)Reoperation (%) 6.16.1 3.23.2 NSNS
Local recurrence (%)Local recurrence (%) 3.23.2 12.612.6 < 0.05< 0.05
Cumulative 5-year survival rate (%)Cumulative 5-year survival rate (%) 80.080.0 68.968.9 NSNS
Disease-free 5-year survival rate (%)Disease-free 5-year survival rate (%) 65.465.4 58.958.9 NSNS
Morino M, Surg Endosc 2005Morino M, Surg Endosc 2005
Laparoscopic vs. Open Surgery for Laparoscopic vs. Open Surgery for Extraperitoneal Rectal CancerExtraperitoneal Rectal Cancer
Morino M, Surg Endosc 2005Morino M, Surg Endosc 2005
Laparoscopic vs. Open Surgery for Laparoscopic vs. Open Surgery for Extraperitoneal Rectal CancerExtraperitoneal Rectal Cancer
ConclusionConclusion
Laparoscopic resection for low and midrectal cancer is Laparoscopic resection for low and midrectal cancer is
characterized by faster recovery and similar overall characterized by faster recovery and similar overall
morbidity with no adverse oncologic effectmorbidity with no adverse oncologic effect