Colorectal cancer: The role of laparoscopy

ARTICLE IN PRESS Surgical Oncology (2007) 16, S65–S67

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REVIEW

Colorectal cancer: The role of laparoscopy F. Roveraa,, G. Dionigia, L. Bonia, P. Masciocchia, G. Carcanoa, A. Beneventob, M. Diurnia, R. Dionigia a

Department of Surgical Sciences, University of Insubria, 21100 Varese, Italy Chirurgia Generale, Multimedica, Castellanza, Varese, Italy

b

KEYWORDS Colorectal cancer; Minimally invasive surgery; Laparoscopy

Summary Since the first report in 1991 the laparoscopic resection of colon cancer is progressing slowly and just in the last 2–3 years is becoming more popular. The resistance to its use by some general and colo-rectal surgeons is receding. The explanations are that technology is evolving quickly and there is a worldwide diffusion of more sophisticated surgical instruments. Moreover several randomized trials have been published showing that the outcomes of laparoscopic colon surgery are similar or better than those of conventional surgery and the early reports suggesting the tumour dissemination were not confirmed. The revolution in oncological surgery that we are observing in these last decades with the introduction and diffusion of mini-invasive approach is comparable to that regarding conventional surgery during the period of Halsted. Therefore the principles of surgery accepted during the years must not be forgotten. & 2007 Elsevier Ltd. All rights reserved.

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Colorectal cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Port-site recurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conversion of laparoscopic procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conflict of Interest Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Introduction The pneumoperitoneum, also defined by Wegner as ‘‘abdominal emphysema’’ and the laparoscopic procedures Corresponding author. Tel.: +39 332278871; fax: +39 332260260.

E-mail address: [email protected] (F. Rovera). 0960-7404/$ - see front matter & 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.suronc.2007.10.044

S65 S66 S67 S67 S67 S67

originated from the experimental works of Georg Kelling [1], a german physician, who presented his work in 1902. Jacobaeus [2] and Kalk [3] first performed a true human celioscopy for the treatment of ascites, and for the evaluation of liver diseases. In the late 1960s and 1970s there have been the introductions and the development of endoscopy and the stapling devices with the possibility to manage less

ARTICLE IN PRESS S66 invasively the colon cancer, with decreased morbidity and mortality. Semm [4] in the 1980s first made an appendectomy laparoscopically. Many surgeons [4–8] have significantly contributed to develop the videoendoscopy and the laparoscopic surgery. Nowadays laparoscopic cholecystectomy is considered worldwide the preferred approach for removing the gallbladder; since its introduction in Europe, laparoscopic techniques have been applied virtually to several operations, such as fundoplication, appendectomy, splenectomy and nephrectomy. The progressive improvement of surgical and anaesthetic techniques observed in these last years allowed surgeons and anaesthesiologists to become more and more experienced with laparoscopic surgery for colorectal diseases and, on the other hand, to decrease the absolute contraindications to this procedure. Critical review of literature shows that there are two main fields of application of laparoscopic colorectal surgery: laparoscopic techniques in benign disease and laparoscopic surgery for colorectal carcinoma.

Colorectal cancer One of the most controversial area of application of laparoscopic approach is the resection of colorectal cancer. In 1991 during the annual convention of the American Society of the Colon and Rectal Surgeons (ASCRS), the following resolution was adopted: Resolved that the ASCRS regards the laparoscopic colectomy as an unproven technology, and that it is only appropriate to perform laparoscopic intestinal resection in an environment designed to meaningfully evaluate patients safety and efficacy of this techniques. In 2004 the Surgical Therapy Study Group published the results of a trial performed in 48 institutions in the US and the conclusions were that laparoscopic approach to the colon cancer is an acceptable alternative to open surgery [9]. In 2005 the Standard Practice Task Force of ASCRS made the following statement ‘‘Laparoscopic techniques for rectal cancer are established and feasible, meanwhile for colon cancer is safe and effective.’’ Level of evidence: Class II; Grade of recommendation: B [10]. The more frequent questions about the accuracy of this technique include if minimally invasive surgery compared to open resection could achieve a proper oncologic resection, with the same extension of information about lymph node staging and if patterns of tumour-cell dissemination are altered or enhanced by the use of laparoscopic techniques [9]. Moreover, the insemination of neoplastic cells reported in some studies [11] in the first years of application of this technique and the subsequent neoplastic growth in port sites induced some surgeons to abandon the possibility of laparoscopic resection of colorectal cancer. Several studies, some of them randomized and prospective, published in the recent literature, demonstrated the surgical feasibility of laparoscopical resections of colorectal cancer, reproducing endoscopically all those resections

F. Rovera et al. usually performed with open abdomen, reporting low mortality and morbidity rates. However, the low number of enrolled patients and the low period of follow-up do not allow sure conclusions about the real effectiveness of this procedure [12,13]. Although its feasibility and good results in terms of less postoperative pain and decreased hospital stay are widely described, only controlled, randomized large studies, such as the CO.LO.R. trial (COlon cancer Laparoscopic or Open Resection) a European multicenter randomized trial that started in 1997 [14], could determine the definitive role regarding the real oncological efficacy and safety of such laparoscopically performed resections. As already cited, in 2004 the results in terms of cancer recurrence of a multi-institutional study were published in The New England Journal of Medicine [9]. In that study 872 patients with adenocarcinoma of the colon underwent randomly open or laparoscopically assisted colectomy performed by credentialed surgeons. They showed that the rates of recurrent cancer were similar after laparoscopically assisted colectomy and open surgery colectomy, suggesting that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer. Technically the main differences compared with other video-endoscopic procedures include operation over multiple quadrants, with the necessity to retract the small intestine away from the operative field, to expose and dissect large tissue planes and to remove a large, bacterialaden organ. Furthermore, an intestinal anastomosis must be performed, inside or outside the abdomen. Similarly to the indications for benign lesions, the role of laparoscopy in colorectal cancer includes

 the diagnostic purpose which allows a complete and



direct evaluation of all abdominal cavity, with a clear visualization of intestinal tract site of cancer, evaluating the fat closed to the neoplastic colon and a more precise staging and, finally, biopsy of abnormal tissue. This procedure may precede the curative surgical time, just with the scope to better stage the neoplastic disease, or in case of advanced colorectal carcinoma it permits palliative measures such as an intestinal bypass or a stoma diversion without the necessity of open abdomen. the resection of the neoplastic intestinal tract respecting all the oncologic principles applied in open resections. This implies complete cancer resection, including regional lymph nodes, with macroscopically free margins and with minimal manipulation of the neoplastic tract and with extraction of the tumour from the abdominal cavity through an endoscopic impermeable disk.

Also the laparoscopic resection of rectal tumours is technically safe and feasible in selected patients, although it is more difficult in cancer of the low rectum; the learning curve is longer than in other laparoscopic colorectal procedures and the surgical team has to be very trained. Anyway, the oncological and anatomical principles must be respected: total mesorectal excision and lymph node dissection, lateral mobilization of the circumferential margin together with the complete fascia propria, sparing the sympathetic and para-sympathetic nerves [15–17].

ARTICLE IN PRESS Colorectal cancer and laparoscopy

Port-site recurrence Port-site recurrence remains a leading concern regarding the widespread acceptance of laparoscopic resection for colorectal carcinoma. Since Alexander et al. [18] described the first case of an abdominal wall metastasis 3 months after curative laparoscopic-assisted right hemicolectomy for a Dukes C patient, several other studies were published in literature reporting cases of postlaparoscopic implants of neoplastic cells in abdominal wall. It is difficult to estimate the real incidence of port-site recurrence because most studies were not prospective and the criteria for patient selection and indication of surgery could be different among surgical centres. Tomita et al. [19] in a study published in 1999, after reviewing recent literature, suggested that the overall incidence of port-site recurrence after laparoscopic colorectal cancer surgery was approximately 1%, in contrast to the previously suggested 4% by Wexner and Cohen [20]. The comparison of these data to the reported incidence of wound recurrence after open colorectal resection (0.64–1.00%) [21,22] is difficult because wound recurrences after open colectomy often remain asymptomatic for a long period until the recurrence reaches an advance stage with widespread systemic neoplastic dissemination and the initial wound recurrence could not be recorded [23].

Conversion of laparoscopic procedure The conversion rate during laparoscopic colorectal resection varies from centre to centre and in relation to the surgical team’s experience, mainly due to the individual learning curve; this makes the data reported in literature difficult to compare between and within centres. It is reported that in large series the conversion rate ranges from 7% to 25%, while in smaller ones from 2% to 41% [24]. As demonstrated in a study recently published by Casillas et al. [25] the most frequent causes of conversion are technical, followed by the presence of severe adhesions, large infective process, bleeding or difficult identification of anatomical structures. It was suggested by several authors [26,27] that the conversion from a laparoscopic approach to laparotomy was associated with increased morbidity and higher hospital costs. On the contrary, Casillas et al. in their study conducted on 430 laparoscopic colectomies performed by two surgeons found a conversion rate of 12%; this group of patients with conversion in open surgery did not show an increased morbidity or length of hospital stay, nor higher hospital costs [25].

Conflict of Interest Statement The Authors do not have any potential or actual personal, political, or financial interest in the material, information, or techniques described in the paper.

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