LAPAROSCOPIC VS. OPEN COLECTOMY FOR COLON CANCER
Laparoscopic colectomy for cancer was first considered in 1990, however several questions arose: • Could laparoscopy achieve a proper oncologic resection? • Is laparoscopic staging adequate? • Were patterns of tumor dissemination altered or enhanced by this technique? 1994: 3 out of 14 patients had port site metastases (compared with less than 1% for open) The COST Study – N Eng J Med, May 2004 872 patients undergoing surgery between 1994-2001 were prospectively randomized Exclusion criteria: • advanced local or metastatic disease • rectal or transverse colon cancer • acute obstruction or perforation • severe comorbidities • IBD, familial polyposis, pregnancy, concurrent or previous malignancy Median follow-up: 4.4 years End Points: Primary - time to tumor recurrence; Secondary – survival, complications, recovery and quality of life Results: • conversion rate: 21% • operative time: 150’ for laparoscopic vs. 95’ for open • 63 patients in the open undergone concurrent other organ resection vs. 34. Rates of malignant involvement were 22% vs. 17% respectively. • 6% inadequate bowel margins (<5cm) in the open group vs. 5% in the laparoscopic (no statistical significance). Median number of lymph nodes was 12 in both groups. • length of hospital stay was 6 days for the open vs. 5 days for the laparoscopic • no significant difference between the rates of intraoperative complications (2% in the open vs. 4% in the laparoscopic), 30-day post-op mortality, post-op complications, readmission rates (10% in the open vs. 12% in the laparoscopic) or the reoperation rates (<2% in both). • recurrence rates were 19.6% in the open vs. 17.4% after a median f/u of 4.4 yrs. • overall survival 78% for open vs. 79% for laparoscopic • surgical wound recurrence was 0.2% in open (1 pt) vs 0.5% (2 pts) in laparoscopic Surgeons’ experience, surgical technique and patient selction are highly important for success of laparoscopy 219 Patients in a Spanish prospective randomized study (Lancet, 2002): • improved outcome (tumor relapse, cancer free survival) in the laparoscopic group. • 17% tumor recurrence for laparoscopic colectomies vs. 27% for open ,over 4 yrs of f/u. • 9% vs. 21% cancer related mortality for laparoscopic vs. open • 18% vs. 26% overall mortality (not significant). • Possible suggested mechanisms: • reduced stress • reduced tumor handling
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References: 1. The COST study group. A comparison of laparoscopically assisted and open colectomy for colon cancer. The New Engl J Med 2004; 350(20): 2050-2059. 2. Lacy AM and others. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomised trial. Lancet 2002; 359(9325): 2224-2229. 3. Lacy AM and others. Colonic carcinoma implants at port sites. In Cueto-Garcia J and others: Laparoscopic Surgery. 2003 1/e McGraw-Hill; 321-327. 4. Chapman AE and others. Laparoscopic assisted resection of colorectal malignancies. A systematic review. Ann Surg 2001; 234(5):590-606. Chen Rubinstein, MD June 3, 2004
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