Laparoscopic Management of Colorectal Cancer

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					  L a p a r o s c o p i c       M a n a g e m e n t      o f   C o l o r e c t a l   C a n c e r




Laparoscopic Management of
Colorectal Cancer
Frederick L. Greene, MD


Abstract                                               mid-1980s when the first laparoscopic
Laparoscopic treatment of colorectal can-              cholecystectomy was successfully com-
cer has emerged as a result of the technical           pleted. This technique was facilitated by
advances that have been made since the in-             the development of the three-chip cam-
troduction of laparoscopic cholecystecto-              era and the ability to display intra-ab-
my. The minimal-access approach to treat-              dominal anatomy on monitors in the op-
ment of benign disease results in smaller              erating room.
incisions, reduced length of hospital stay,                 During the past 10 years, the devel-
and a faster return to productive life.                opment of new accessory equipment has
      Laparoscopic approaches to colon                 led to successful laparoscopic bile duct
cancer must take into consideration the                exploration, gastroenterostomy, anti-re-
potential effects of the technique on tumor            flux procedures, and splenectomy. These
dissemination at the time of the surgical              procedures were facilitated by the cre-
procedure, as well as rates of recurrence              ation of a pneumoperitoneum using car-
and overall survival. Several technical ap-            bon dioxide, which expands the intra-ab-
proaches to laparascopic colon resection               dominal space. This technique allows the
have now become possible, utilizing either             surgeon to explore the intra-abdominal
total intra-abdominal maneuvers or la-                 contents and perform surgical procedures
paroscopic-assisted techniques. Margins                in an inert environment where electro-
of resection and lymph node removal with               cautery can be safely applied.
the minimal-access techniques compare                       In addition to use in many benign
favorably with those of open colectomy.                diseases, laparoscopic assessment tech-
Several series now show that early results             niques can be used for preoperative stag-
utilizing laparoscopic resection for col-              ing, confirmation of imaging studies with
orectal cancer are favorable but that rou-             biopsy, and therapeutic or curative resec-
tine implementation of this procedure                  tion in patients with cancer.1
should await confirmatory outcomes gen-
erated by well-done prospective clinical
trials. (CA Cancer J Clin 1999;49:221-
                                                       Laparoscopic Colon Procedures
228.)                                                  Laparoscopic approaches to the colon
                                                       were initially conceived in the late 1980s
                                                       when laparoscopic appendectomy began
Introduction                                           to show promise. The laparoscopic ap-
The revolution known in general surgery                proach to the appendix involved the mo-
as the “Laparoscopic Era” began in the                 bilization of the right colon, especially in
                                                       patients with retrocecal appendicitis.
                                                            Reports of colonic and rectal resec-
Dr. Greene is Chairman and Director of Surgical
Education in the Department of Surgery at the
                                                       tion for both benign and malignant dis-
Carolinas Medical Center, Charlotte, NC.               ease began to appear in the early 1990s.2-4
                                                       These procedures were described as
This article is also available online at http://www.   either “laparoscopic-assisted” or totally
ca-journal. org.                                       performed in the peritoneal cavity using a

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                                Table 1
       Colonic Procedures Performed by Laparoscopic Techniques


     1. Hemicolectomy

     2. Anterior (sigmoid) and low anterior (sigmoid and rectum) resections

     3. Abdominal-perineal resection (laparoscopic-assisted)

     4. Primary anastomosis (laparoscopic-assisted and totally intraperitoneal)

     5. Creation of colostomy and ileostomy



laparoscope and intracorporeal stapling               abdominal abscess, and postoperative
or suturing (Table 1).                                colonic stricture are similar in patients
      The laparoscopic-assisted approach,             undergoing laparoscopic and open pro-
with the creation of an extracorporeal                cedures.
anastomosis, is most commonly used                         As is the case with laparoscopic
when right colectomy and ileo-transverse              cholecystectomy, some patients may re-
anastomosis are performed. Although                   quire conversion from a laparoscopic to an
adhesions from earlier abdominal surg-                open procedure. This is usually secondary
eries can increase the difficulty of per-             to identifying significant adhesions or ad-
forming laparoscopic procedures, laparo-              ditional unexpected pathology. The rate of
scopic colectomy can be performed in                  conversion in laparoscopic colectomy has
patients who have previously undergone                continued to decrease over the past sever-
open procedures. Nevertheless, when la-               al years as surgeons have become more
paroscopic procedures are used, the in-               facile with these techniques. Early studies
ability to palpate the colonic lesion, a rou-         reported a conversion rate of 30% to 40%,
tine aspect of open operations, can cause             whereas more recent studies indicate that
difficulty with respect to locating the pri-          only 7% to 10% of patients need conver-
mary colonic lesion or can increase the               sion to open procedures.9,10
chance of missing synchronous tumors in
the colon.5 To prevent these problems,                BENEFITS OF LAPAROSCOPIC
preoperative colonoscopy with tattooing               PROCEDURES
of the colonic wall or intraoperative                 The expected benefits of any laparoscop-
colonoscopy is recommended.                           ic procedure are to reduce the need for a
                                                      large abdominal incision, lessen postop-
                                                      erative pain, and decrease the time to re-
Laparoscopic Versus Open                              turn to work and normal activity (Table
Procedures                                            2). Several studies have reported a re-
Several series have reported that short-              duced hospital stay following laparoscop-
term outcomes with laparoscopic colon                 ic colonic resection;6 others, however,
resection are similar to those achieved               while noting a reduction in ileus and the
with open procedures in patients with be-             need for postoperative narcotics, did not
nign colorectal disease.6-8 Likewise, the             find differences in overall length of stay
incidences of anastomotic leakage, intra-             compared with open procedures.11

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                               Table 2
        Advantages of Laparoscopic Colonic Resection for Cancer


      1. Limited abdominal wall trauma

      2. Reduced postoperative pain

      3. Possible more rapid return of bowel function

      4. Possible reduced length of hospital stay

      5. Possible hastened postoperative recovery

      6. Similar staging opportunities compared with open procedures

      7. Short-term outcomes similar to traditional procedures

      8. Possible protection of immune function



                                Table 3
       Possible Causes of Trocar Site Implantation Associated with
                Laparoscopic Colon Resection for Cancer


      1. Tumor spillage secondary to manipulation

      2. Disbursement of cells secondary to carbon dioxide pneumoperitoneum

      3. Mechanical disruption of peritoneum

      4. Entrapment of tumor cells secondary to trocar-site hematoma

      5. Tumor spillage secondary to specimen removal


     Although several well-done studies                 whether patients undergoing laparoscop-
from individual institutions have been re-              ic colectomy have recurrence rates simi-
ported, comprehensive assessment of la-                 lar to those of patients undergoing open
paroscopic techniques for patients with                 colectomy.
colorectal cancer will require results of
randomized clinical trials, such as studies             SURGICAL CHALLENGES
currently being conducted by the Nation-                A controversial issue with respect to
al Cancer Institute and the Clinical Out-               performing minimal access procedures
comes of Surgical Therapy study group.12                for cancer is the possibility that tumor
It is hoped that these prospective ran-                 cells may be implanted in the percuta-
domized studies will help determine                     neous (trocar) sites (Table 3). A large

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                                     Table 4
                    Principles of Colorectal Cancer Resection


     1. Full intra-abdominal assessment

     2. Identification and confirmation of visceral metastases

     3. Full mesenteric and nodal dissection

     4. Adequate margins of resection (longitudinal and radial)

     5. Safe creation of anastomosis or stoma where applicable


number of animal studies have suggest-                5)2-4,6-9,17-21 and length of tumor margins
ed that the pneumoperitoneum neces-                   are similar, regardless of whether open
sary for laparoscopic colorectal surgery              or laparoscopic maneuvers are used.
may, in fact, enhance cell disbursement                     It is interesting to note that an aver-
and the development of trocar site re-                age of 13 lymph nodes are obtained using
currence.13-15 Additional studies suggest             either the laparoscopic or the traditional,
that surgical technique, especially the               open-colon procedures. The identifica-
handling of the bowel tumor, may be the               tion of nodal metastatic disease currently
initiating event in port site recurrence.16           depends on histologic evaluation, which
If pneumoperitoneum is the culprit, the               may miss small foci of tumor, causing pa-
use of abdominal wall lift devices, which             tients to be understaged using the TNM
allow gasless laparoscopic techniques,                classification. In the future, use of tech-
may represent a solution. These gasless               nology such as polymerase chain reaction
techniques have not become popular,                   may better identify metastatic disease in
however, and probably will not replace                lymph nodes removed by open and la-
the use of carbon dioxide pneumoperi-                 paroscopic techniques.22
toneum in the forseeable future.                            Although several recent reports in-
      Unfortunately, traditional celioto-             dicate that node retrieval has been ample
my used by surgeons for many decades in               in laparoscopically resected patients,
the treatment of patients with colorectal             other investigators have observed that
cancer has not been standardized (Table               lymph node retrieval during laparoscopic
4). This prohibits accurate comparison of             colon resection is inadequate when com-
outcomes among surgeons. Certain prin-                pared with open traditional approaches.
ciples, such as careful handling of the tis-          Additionally, although node dissection
sue, adequate surgical margins, wide re-              may be satisfactory with laparoscopic re-
section of colonic mesentery to include               section of the right colon, the retrieval of
nodal drainage regions, and appropriate               nodes in patients having left colon or rec-
anastomotic technique, are all important              tal excisions has been sub-optimal.17
to the performance of safe and effective
colonic resection for cancer. Generally,
these principles can be similarly satisfied
                                                      Future Role for Laparoscopic
by laparoscopic colonic resection. Sever-             Techniques
al investigators have reported, for in-               Any eventual role of laparoscopic re-
stance, that lymph node retrieval (Table              section for treatment of colorectal can-

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                                    Table 5
                   Comparison of Lymph Node Harvest in Open
                         and Laparoscopic Colectomy

                                                              Number of Nodes (Average)
Published Report                      Year                    Open         Laparoscopic

Bleday et al2                         1993                    9.5               10.5

Peters et al19                        1993                    8.5                7.9

Tate et al3                           1993                    10.0              13.0

Musser et al20                        1994                    7.9               10.6

Hoffman et al9                        1994                    8.0                6.1

Darzi et al17                         1995                    11.0               8.0

Franklin et al7                       1995                    14.7              15.8

Tucker et al4                         1995                    6.4                8.7

Lacy et al18                          1995                    12.5              13.0

Lord et al21                          1996                    8.9                7.8

Franklin et al6                       1996                    13.0              15.3

Milsom et al8                         1998                    25.0              19.0


 cer will have to be confirmed by re-           cancer-related deaths were equal in
 ports from well-done, prospective se-          both groups.
 ries. Fortunately, several of these are             Despite the favorable short-term
 now in progress.                               outcome, these authors correctly pointed
      Recent reports from single-institu-       out that results from a single institution
 tion, prospective, randomized studies          study do not have the statistical power
 provide results of at least the short-         provided by a multi-institutional study.
 term outcomes of patients undergoing           Statistical power is especially important
 laparoscopic procedures. Milsom et al,8        with regard to port site recurrence, which
 for instance, recently compared 42 pa-         has been estimated to occur in 1% to
 tients with cancer who underwent la-           1.5% of patients in some series. Large
 paroscopic resection with 38 patients          numbers of patients must be fully as-
 who had conventional open proce-               sessed to completely address the criticism
 dures. These patients were followed for        that tumor implantation may be in-
 a median of 1.5 and 1.7 years, respec-         creased in patients undergoing laparo-
 tively. No port site recurrences were re-      scopic colectomy.14
 ported in the laparoscopic group, and

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                                 Table 6
              Possible Disadvantages of Laparoscopic Colonic
                           Resection for Cancer


    1. Reduced ability to explore peritoneum

    2. Reduced ability to palpate and localize colonic lesion

    3. Mechanical manipulation of tumor leading to cellular disbursement

    4. Increased operating room time and cost

    5. Possibility of port-site tumor seeding

    6. Possible detrimental effects of conversion to open procedures

    7. Questionable detrimental effect on recurrence rates and survival


COLORECTAL SURGERY
                                                       rable survival and disease-free intervals
While it is clear that laparoscopic colorec-           (Table 7). The mean follow-up for the la-
tal surgery can be performed safely, the               paroscopic group was 22 months. Recur-
question remains whether laparoscopic                  rent disease was noted in 7% of patients
colorectal surgery can be performed safe-              after open resection and in 8% after la-
ly for patients with large bowel cancer                paroscopic resection.
(Table 6).                                                  A randomized study from Spain per-
     Franklin et al 6 addressed this issue             formed by Lacey and colleagues18
with a non-randomized, prospective mul-                showed no differences in lymph node re-
                                                       moval, pathological staging, or margins of
                                                       resection when patients who underwent
     Laparoscopic colon                                laparoscopic or open colectomy were
                                                       compared. These authors noted fewer
   resection for benign and                            complications, in fact, in their laparoscop-
   malignant disease is safe                           ic patients. It is expected that similar
                                                       studies will be published in the next sev-
   and comparable, in the                              eral years that will confirm equivalent
 short-term, to conventional,                          short-term outcomes for the two surgical
       open procedures.                                techniques.

                                                       Recommendations
ticenter study of 194 patients undergoing              What should we recommend to our pa-
laparoscopic or open colon resection.                  tients who have colorectal cancer and
They reported that laparoscopic surgery                which surgical techniques should we use
allowed a similar resection with an equal              in caring for these patients? The ultimate
number of mesenteric nodes removed,                    answer depends on the training and expe-
similar margins of resection, and compa-               rience of the individual surgeon in recom-


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                                     Table 7
                    Outcomes Following Laparoscopic Colectomy

                          Follow-up                                     Converted           Recurrence
 Study                    (Months)       Number of Patients            (Number, %)         (Number, %)

 Fielding et al10             33                    149                   26 (7)               10 (7)

 Lacy et al18            11.5 - 21.4                31                    4 (13)               5 (16)

 Milsom et al8                18                    42                      —                   3 (7)

 Franklin et al6              33                    191                    8 (4)              25 (13)


mending an operation that is both safe                   open, conventional techniques, as com-
and effective for a patient with a particu-              plete resection and full assessement of
lar disease process.                                     the intra-abdominal cavity can be per-
      A review of all available reports                  formed. Preoperative laparoscopy for the
clearly shows that laparoscopic colon re-                assessment of metastases from colon and
section for benign and malignant disease                 rectal cancer is not associated with the
is safe and comparable, in the short-term,               same overall benefit as is laparoscopy for
to conventional, open procedures. Pa-                    pancreatic or esophageal cancer, as most
tients with small right-sided malignancies               patients with colonic malignancy require
can be effectively treated with laparo-                  resection, even when disease has metasta-
scopic-assisted right colectomy and cre-                 sized to the liver or other organs.
ation of an extracorporeal anastomosis.                       Patients who request laparoscopic
These patients will require close follow-                resection of colorectal cancer or those
up for possible port site recurrence. It is              deemed to have disease appropriate for
the obligation of surgeons performing                    the technique should be considered for
these procedures to report unusual mani-                 surgical clinical trials under Institutional
festations of tumor recurrence in their pa-              Review Board guidelines. These trials
tient populations.                                       may finally determine whether “open”
      The resection of bulky or advanced                 and “minimal-access” techniques are tru-
colon cancer is still best performed using               ly equal.                                CA




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Vol. 49 No. 4 july/august 1999                                                                             228
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