Download Laparoscopic vs. Conventional Resections for Colorectal

Laparoscopic vs. Conventional
Resections for Colorectal Carcinoma
2LT Pil (Pete) Kang
New York University School of Medicine
28 September 2000
Colorectal Cancer: Epidemiology
Second leading cause of death from
cancer in the United States
Estimated 138,000 new cases (70% in
colon and 30% in rectum) per year
55,000 related deaths per year
Risk factors: personal/family hx, IBD,
HNPCC, FAP, diet (high fat, low fiber)
Clinical Signs & Symptoms
Right Colon:
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Unexplained weakness/anemia
Occult blood in feces
Dyspeptic symptoms
Persistent right abdominal discomfort
Palpable abdominal mass
Clinical Signs & Symptoms
Left Colon:
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Change in bowel habits
Gross blood in stool
Obstructive symptoms
Rectum (20-30% of CR Ca):
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Rectal bleeding
Change in bowel habits
Sensation of incomplete evacuation
Palpable tumor during rectal exam
Colorectal Cancer: Diagnosis
Physical Exam
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Rectal exam with test for occult blood
Labs
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CBC, LFTs (AlkPhos), Calcium
Carcinoembryonic antigen (CEA)
Colorectal Cancer: Diagnosis
Barium enema
 “Apple core” lesions
 Filling defect
Colorectal Cancer: Diagnosis
Colonoscopy
Allows biopsy
Invasive
Future:
 virtual colonoscopy?
Fenlon et al., NEJM Nov 1999; 341 (20)
Staging of Colorectal Cancer
Dukes
Stage
T
N
M
0
Tis
N0
M0
A
I
T1
N0
M0
A
I
T2
N0
M0
B1
II
T3
N0
M0
B2
II
T4
N0
M0
C
III
Any T
N1
M0
C
III
Any T
N2/3
M0
D
IV
Any T
Any N
M1
Stage I & II Colorectal Cancers
Treatment: Surgical resection
 Colectomy
 Low Anterior Resection (>12cm from AV)
 Abdominoperineal Resection (<7-8cm from
AV)
Stage I & II (T1 & T2): surgical resection only
Stage II (T3 & T4): surgery + clinical trials of
systemic chemotherapy
Stage II rectal: post-op radiation therapy
Stage III Colorectal Cancers
Treatment: Surgical resection
Adjuvant therapy:
 5-FU and levamisole
 Clinical trials
 Radiation therapy for rectal cancer
Stage IV Colorectal Cancers
Palliative resection to prevent
obstruction/perforation
 Diversion if unresectable
 Resection of solitary liver metastasis
 Chemotherapy
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Outcome of Patients with
Colorectal Cancer
Sabiston, Textbook of Surgery, 15th ed.
Colorectal Cancer: Survival by Stage
Survival (%)
Stage
Crude
5-year1
Mayo
2-year2
Australia
2-year2
I
80
100
85
II
60
92/88
82
III
30
65
55
IV
5
18
22
1: Way, LW. Current Surgical Diagnosis & Treatment, 10 ed.
2: Poulin, et al. Ann Surg 1999;229(4)
Oncologic Principles of
Colorectal Resection
Evaluation of abdominal cavity for
local/distant metastases
Wide excision of tumor with at least 5cm
and 2cm proximal and distal margins
Control/resection of lymphovascular
pedicle(s) and involved soft tissues
Anatomical Considerations
Laparoscopic Colon Surgery
Natural extension of experience gained
in laparoscopic cholecystectomy
 Benign diseases
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colorectal polyps, rectal prolapse
diverticular disease, stomas
cecal/sigmoid volvulus
IBD
Laparoscopic Colorectal Cancer
Surgery (LCCS)
A: Port sites for right-sided lesions
B: Umbilical extraction site, extracorporeal
ligation of vessels and resection of bowel,
extraction through wound protector
C: Extracorporeal anastomosis
Poulin, et al. Ann Surg 1999;229(4)
Laparoscopic Colorectal Cancer
Surgery (LCCS)
A: Port sites for left-sided lesions
B: Intracorporeal ligation of vessels and
bowel resection, specimen bagged
C: Intracorporeal anastomosis
Poulin, et al. Ann Surg 1999;229(4)
Laparoscopic Surgery:
Potential Advantages
Overall cost-effectiveness, better shortterm outcomes (immediate post-op)
 Lower postoperative mortality rate
(pts>70 y.o.; pts w/ comorbid factors;
pts w/ metastases)
 Better biologic response to injury/SIRS
 Better long term survival (???)
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Laparoscopic Surgery:
Potential Drawbacks
Inadequate for tumor localization,
identification of anatomy, mesentery
resection, high vessel ligation, resection
margins
 Tumor cell seeding (port-site, wound)
 Embolization of exfoliated cells (related
to pneumoperitoneum)
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Current Issues
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Is laparoscopic resection for colorectal
cancer oncologically sound?
– Adequate margins & lymph node assessment
– Comparable recurrence/survival rates
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Do laparoscopic resection techniques
have any short-term advantages?
Hartley et al., Ann Surg 2000 Aug;232(2)
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Prospective comparative trial; UK
114 pts  minimum 2-year follow-up of 109 pts
Recurrent disease: 25% of pts total
LAP: 16/57 (28%) CON: 11/52 (21%)
Crude death rates:
LAP: 26/57 (46%) CON: 24/52 (46%)
Wound metastases:
LAP: 1
CON: 3
No port metastases
Disease Recurrence Rates: 24 months
Stage
Overall
LAP (57)
CON (52)
10
12
I
0/12 (0%)
0/10 (0%)
II
2/20 (10%) 3/15 (20%)
III
7/22 (32%) 9/21 (43%)
IV
1/3 (33%)
0/6 (0%)
Differences between groups not statistically significant
Overall Survival: 24 months
LAP: solid
CON: dotted
(+’s are
censored data)
Hartley et al.,
Ann Surg 2000
Aug;232(2)
Survival rates at 24 months
Stage
Overall
I
II
III
IV
LAP (57)
CON (52)
43
35
11/12
(92%)
16/20
(80%)
15/22
(68%)
1/3 (33%)
10/10
(100%)
12/15
(80%)
10/21
(48%)
3/6 (50%)
Differences between groups not statistically significant
Psaila et al., Br J Surg 1998 May;85(5)
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Prospective comparative trial
54 pts; LAP 25, CON 29  median follow-up of 28
months
Mean hospital stay (days):
LAP: 10.7
CON: 17.8 (P=0.001)
Mean morphine requirements: LAP<CON
Adequate margins achieved
Number of lymph nodes harvested similar
No port site or wound recurrence
Milsom et al., J Am Coll Surg 1998
Jul;187(1)
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Prospective, randomized trial in one surgery
department (Cleveland Clinic)
Patients:
LAP: 55 (42 w/ Ca) CON: 54 (38 w/ Ca)
Median follow-up: 1.5/1.7 years
Recovery of 80% of FEV1, FVC (POD):
LAP: 3
CON: 6
(P=0.01)
Morphine requirements up to POD#2 (mg/kg/d):
LAP 0.78 ± 0.32
CON: 0.92 ± 0.34 (P=0.02)
Flatus (POD):
LAP: 3
CON: 4
(P=0.006)
Milsom et al., J Am Coll Surg 1998
Jul;187(1)
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Cancer-related deaths:
LAP: 3
CON: 4
Postoperative complications: 15% in both groups
LAP: pneumonia (1), peritonitis, PE (1), MI (1),
CHF(2), death (1)
CON: dehiscence (1), pneumonia (1), PE (1), Afib (1),
death (1)
Hospital length of stay:
LAP: 6.0
CON: 7.0
(P=0.16)
Tumor margins clear in all patients
No port-site recurrence in LAP group
Summary
Recurrence/survival of both LAP and
CON groups at 2 years of follow-up to
be equivalent
 Equivocal data on possible short-term
advantages
 Need randomized, controlled multicenter study with larger number of pts
and longer follow-up period
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