Laparoscopy and Colon Cancer
Is the Port Site at Risk? A Preliminary Report
Jose M. Ramos, MD; Sagar Gupta; Gary J. Anthone, MD; Adrian E. Ortega, MD;
Anthony J. Simons, MD; Robert W. Beart, Jr, MD
Purpose: To quantify the magnitude of the risk for port/ the patients had a Dukes' stage C tumor at the time of
extraction site recurrence of laparoscopically resected co- initial surgery.
lon cancer in a defined study population.
Conclusions: The incidence of port/extraction site
Methods: The data from a prospective laparoscopic recurrence following laparoscopic colon cancer
bowel surgery registry was used to identify cases of co- surgery is low. All the recurrences were in patients
lon cancer that were resected laparoscopically, with a mini- with Dukes' stage C tumors, and there was diffuse
mum follow-up of 1 year. A questionnaire was sent to peritoneal carcinomatosis in two of the three cases,
the surgeons who performed the procedures. suggesting that port/extraction site recurrence may be
attributable to the advanced nature of the disease
Results: A total of 252 identified from the
cases were rather than the laparoscopic technique. Longer
registry. Questionnaires were returned in 208 of those follow-up and more cases are required to confirm
cases, a response rate of 82.5%. Three cases of port or these findings.
extraction site recurrence were noted, two of them
associated with diffuse peritoneal carcinomatosis. All (Arch Surg. 1994;129:897-899)
THE RELATIVELY short time since As laparoscopic techniques are ap¬
laparoscopy first used thera-
was plied tocolon and rectal cancer surgery,
peutically in general surgery, its an early and critical examination of the op¬
use has spread beyond cholecys- erative results is imperative. In laparos-
tectomy and been applied to nu¬ copy for colon cancer, the malignant neo¬
merous other abdominal and thoracic op¬ plasm is removed through either a port site
erations. Laparoscopic colectomy is a or small incision or transrectally. There is
natural extension of the experience gained a theoretical risk of contaminating these
in laparoscopic cholecystectomy and in¬ sites with tumor. Dragging the tumor
guinal hernia operations. It is a substan¬ through a small incision may result in im¬
tially more complex procedure but one that plantation of tumor cells at the extrac¬
has been shown to be efficacious.1 Re¬ tion site. A further possibility is that dis¬
ported benefits of laparoscopic surgery spe¬ tant port sites are contaminated by
cifically related to cholecystectomy are exfoliated tumor cells during the proce¬
fewer pulmonary complications, more rapid dure. Following initial reports of port site
return of gastrointestinal tract function, recurrences of gall bladder carcinoma,'1
shorter postoperative stay, decreased cost, several cases of colon cancer port site re¬
less postoperative pain and disability, bet¬ currence have now been published in the
From the Department of
ter cosmesis, and more rapid return to
Surgery, University of the
Witwatersrand, Johannesburg, work.2'6 Initial results of laparoscopic co¬
South Africa (Dr Ramos), and lon resections appear to be comparable to
the Department of Surgery, those of operations performed in the tra¬
University of Southern See Invited Commentary
ditional open manner and have been used
for patients with cancer, but long-term re¬
at end of article
(Mr Gupta and Drs Anthone,
Ortega, Simons, and Beart). sults are not yet available.1-7"10
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Details of Port/Extraction Site Recurrence
MATERIALS AND METHODS Site of
Case Dukes' i-1 Peritoneal Interval,
A laparoscopic bowel surgery registry was pro- No. Stage Port Extraction Carcinomatosis mot
spectively initiated and then approved by the
American Society of Colon and Rectal Surgery,
Arlington Heights, 111, in 1991. The registry con¬
tains such information as the patients' identifiers,
characteristics of the bowel pathologic features,
"-Indicates Dukes' stage of tumor at the time of operation.
type of laparoscopic procedure performed, preop- t Indicates interval from initial curative resection to appearance of
erative, intraoperative, and postoperative compli¬ recurrence.
cations, and length of hospital stay. In an effort to
promote broad compliance, the American College
of Surgery Commission on Cancer, Chicago, 111, RESULTS
consented to house and analyze the data accumu¬
lated. The Society of American Gastrointestinal A total of 208 follow-up reports were received, giving a
and Endoscopie Surgeons, Santa Monica, Calif, response rate of 82.5%. There were three cases of port
endorsed the registry and has promoted it since its or extraction site recurrences reported (Table), giving
inception. The registry was promoted through pre¬ an overall incidence of 1.44%. Of the three cases, two were
sentations at meetings and advertisements in associated with diffuse peritoneal carcinomatosis, both
national peer-reviewed surgical journals. Registry the port and extraction sites being involved with the re¬
data forms were available through the American currences. These occurred 6 and 8 months after the ini¬
College of Surgeons, the Society of American Gas¬ tial surgery, respectively. The third case, reported at 21
trointestinal and Endoscopie Surgeons, and the
months, involved the extraction site alone, with no other
American Society of Colon and Rectal Surgery.
site of recurrence being apparent. The incidence of iso¬
Forms were entered in the Centers for Disease
Control and Prevention database EPI5, which was
lated port site recurrence in the absence of diffuse peri¬
also used to perform the data analysis. toneal carcinomatosis was 0.48%. In all three patients,
This particular study involved a subset of the initial Dukes' stage was C.
patients entered into the laparoscopic bowel sur¬
gery registry who had colon cancer that was COMMENT
resected laparoscopically. At the time of this study,
the registry contained 252 cases of cancer that As new procedures are developed, they should be
were operated on laparoscopically. A questionnaire monitored closely. An American Society of Colon and
was sent to each surgeon who entered the cancer Rectal Surgery registry was established to monitor
cases into theregistry. Based on the patients' iden¬
tifiers, the surgeon was asked to note which, if laparoscopic colectomy. The purpose of this commu¬
nication is to evaluate one issue contained in this reg¬
any, patients in whom port site recurrence of can¬
cer developed and if the recurrence was associated
istry and to share it in a timely manner with interested
with diffuse peritoneal carcinomatosis. Interviews surgeons. As laparoscopic techniques are applied to
with surgeons were conducted to supplement the colon and rectal cancer surgery, we must consider
information of those cases with recurrence. whether or not this is an adequate operation for can¬
Supplemental information included Dukes' stage, cer. It has been reported1 that pathologists have been
exact location of the recurrence (port or extraction unable to tell whether the specimen removed has been
site), and interval from the initial resection to port/ removed through laparoscopic or open techniques.
extraction site recurrence. The follow-up period The number of lymph nodes identified by the patholo¬
was a minimum of 1 year.
gist in both laparoscopically and openly removed cases
is not significantly different.7 It is clear that by ligating
the mesentery at the origin of the primary feeding ves¬
sels standard lymphatic resections can be performed.
literature, with others being presented at various meet¬ All these observations suggest that laparoscopic resec¬
ings.1216 Anecdotal, isolated reports may create levels of tion for cancer is as potentially curable as open sur¬
anxiety if the true incidence is not known. In this study, gery. Nevertheless, we must consider whether laparo¬
we attempted to quantify the magnitude of the risk for scopic extraction of cancer through a small incision or
port/extraction site recurrence in a defined study popu¬ port site will change the incidence or patterns of
lation. Furthermore, we attempted to answer the ques¬ recurrence.
tion of whether this is an inordinate risk of the opera¬ The development of an incisional recurrence of co¬
tion or a risk of the dise--" . lon cancer atthe extraction site or at distant port sites
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may be the sequela of isolated implantation of viable ex¬ ther numbers and longer follow-up are required, how¬
foliated tumor cells during the course of surgery or at the ever, to confirm these observations.
time of extraction. Experimentally, viable tumor cells have
been recovered at various sites following colon cancer CONCLUSION
surgery.171" Alternatively, the extraction site or distant
port sites may be involved as a manifestation of diffuse The incidence of port/extraction site recurrence follow¬
peritoneal carcinomatosis. ing laparoscopic colon cancer surgery is low, three cases
Hughes et allg reviewed 1603 patients who under¬ being reported in 208 patients. In these three patients,
went curative open surgery for colon cancer and found the initial Dukes' stage was C. Two of the three patients
grossly recognized incisional recurrences in 11 pa¬ in whom this complication developed had associated dif¬
tients, giving a rate of 0.69%. They suggested that inci¬ fuse peritoneal carcinomatosis. These findings suggest
sional recurrence is more likely to be a manifestation of that port/extraction site recurrence is more likely to be
incurable systemic malignant disease, as more than 50% a manifestation of widespread regional recurrence rather
of patients with incisional recurrences died of dissemi¬ than a complication of the laparoscopic technique, al¬
nated tumor within 6 months and all these patients died though longer follow-up and more cases are required to
of the disease within 4 years. confirm these findings.
Initial published12"'6 and unpublished reports that
port site recurrence of laparoscopically resected colon Reprint requests to 1510 San Pablo St, Suite 514, Los Angeles,
cancer may occur in the absence of diffuse carcinoma¬ CA 90033-4612 (Dr Beart).
tosis raised the question whether laparoscopy for colon
cancer is associated with a greater risk for abdominal wall
recurrence than the equivalent open procedure. Such an¬
ecdotal reports are prone to falsely reassure or frighten 1. Beart RW. Laparoscopic colectomy: status of the art. Dis Colon Rectum. 1994;
surgeons and therefore generate inappropriate re¬ 37(suppl):S47-S49.
sponses. This study, which analyzed only port/ 2. Berci G, Sackier JM. The Los Angeles experience with laparoscopic cholecys-
extraction site recurrences, shows that the 1-year inci¬ tectomy. Am urg.
3. Cuschieri A, Dubois F, Mouiel J, et al. The European experience with laparo-
dence of this complication appears to be low. We found
scopic cholecystectomy. Am J Surg. 1991;161:385-387.
the incidence of recurrence to be 0.48% (1/208 cases) in 4. Flowers JL, Bailey RW, Scovill WA, Zucker KA. The Baltimore experience with lapa-
the absence of diffuse peritoneal carcinomatosis, and roscopic management of acute cholecystitis. Am J Surg. 1991;161:388-392.
5. Arregui ME, Davis CJ, Arkush A, Nagan RF. In selected patients outpatient
1.44% overall. As the registry was initiated fairly re¬
laparoscopic cholecystectomy is safe and significantly reduces hospitalization
cently, follow-up is limited, although, in all the pa¬ charges. Surg Laparosc Endosc. 1991;1:240-245.
tients, it was at least 1 year. In the study by Hughes et al19 6. Peters JH, Ellison EC, Innes JT, et al. Safety and efficacy of laparoscopic cho-
of recurrence following open surgery, more than 50% of lecystectomy. Ann Surg. 1991;213:3-12.
7. Falk PM, Beart RW, Wexner SD, et al. Laparoscopic colectomy: a critical ap-
recurrences were within the first year. Further recur¬
praisal. Dis Colon Rectum. 1993;36:28-34.
rence in this study may become apparent with longer fol¬ 8. Phillips EH, Franklin M, Carroll BJ, et al. Laparoscopic colectomy. Ann Surg.
low-up, but the overall presumed recurrence should re¬ 1992;216:703-707.
main below 1%. 9. Bleday R, Babineau T, Forse RA. Laparoscopic surgery for colon and rectal
Semin Surg Oncol. 1993;9:59-64.
In all three cases the initial Dukes' stage was C, a
10. Monson JRT, Darzi A, Carey PD, Guillou PJ. Prospective evaluation of laparo-
stage associated with higher recurrence rates, either re¬ scopic-assisted colectomy in an unselected group of patients. Lancet. 1992;
gional or distant, than earlier stages. Abdominal wall re¬ 340:831-833.
currence in patients with more advanced tumor, such as 11. Pezet D, Fondrinier E, Rotman N, et al. Parietal seeding of carcinoma of the
Dukes' stage C tumors, could be a component of re¬ gallbladder after laparoscopic cholecystectomy. Br J Surg. 1992:79:230.
12. Fusco MA, Paluzzi MW. Abdominal wall recurrence after laparoscopic-assisted
gional recurrence or a consequence of tumor implanta¬ colectomy for adenocarcinoma of the colon. Dis Colon Rectum. 1993:36:858\x=req-\
tion at the time of surgery. The report by O'Rourke et 861.
al15 of two port site recurrences in one patient with Dukes' 13. Alexander RJT, Jaques BC, Mitchell KG. Laparoscopically assisted colectomy
and wound recurrence. Lancet. 1993;341:249-250.
stage B tumor at 10 postoperative weeks is more sugges¬ 14. Walsh DCA, Wattchow DA, Wilson TG. Subcutaneous metastases after lapa-
tive of tumor implantation during the laparoscopic pro¬ roscopic resection of malignancy. Aust NZJ Surg. 1993:63:563-565.
cedure. Port site recurrences in the setting of diffuse car¬ 15. O'Rourke N, Price PM, Kelly S, Sikora K. Tumor inoculation during laparos-
cinomatosis are less likely owing to the laparoscopic copy. Lancet. 1993;342:368.
16. Guillou PJ, Darzi A, Monson JR. Experience with laparoscopic colorectal sur-
technique, being rather more likely a manifestation of re¬ gery for malignant disease. Surg Oncol. 1993;2:43-49.
gional recurrence. 17. Umpleby HC, Fermor B, Symes MO, Williamson RCN. Viability of exfoliated
A review of the literature reveals that reports of in¬ colorectal carcinoma cells. Br J Surg. 1984;71:659-663.
cisional recurrences of colon cancer after open surgery 18. Fermor B, Umpleby HC, Lever JV, et al. Proliferative and metastatic potential
of exfoliated colorectal cancer cells. J Natl Cancer Inst. 1986:76:347-349.
are sparse, it being an unusual complication of curative
19. Hughes ESR, McDermott FT, Polglase AI, Johnson WR. Tumor recurrence in
resection. In the setting of laparoscopic colon cancer sur¬ the abdominal wall scar tissue after large-bowel cancer surgery. Dis Colon
gery, our results suggest that this risk remains low. Fur- Rectum. 1983;26:571-572.
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