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Laparoscopic Surgery for Colorectal Cancer

Laparoscopic Surgery for Colorectal Cancer. Bruce D George John Radcliffe Hospital. First described 1991 Potential benefits: Smaller wounds Less pain Early return of bowel function Early discharge Early return to normal activities. Laparoscopic colorectal surgery.

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Laparoscopic Surgery for Colorectal Cancer

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  1. Laparoscopic Surgery for Colorectal Cancer Bruce D George John Radcliffe Hospital

  2. First described 1991 Potential benefits: Smaller wounds Less pain Early return of bowel function Early discharge Early return to normal activities Laparoscopic colorectal surgery

  3. Not as universally accepted as: Cholecystectomy Fundoplication Adrenalectomy Laparoscopic colorectal surgery

  4. Complex procedures Learning curve Long procedures Expensive instruments New complications Most colorectal procedures for malignancy Oncological safety debated Port site recurrences Long-term survival Why?

  5. Advanced disease Milsom et al (n=30) Stoma formation Staging CURE ? Potential indications in colorectal cancer

  6. Operative death rate Major complications Long term survival Tumour recurrence Length of incision Pain scores during first week Return of bowel function Hospital stay Cost What really matters?

  7. Randomised controlled trials 4 Non-RCT with contemporaneous controls 11 Non-RCT with historical controls 4 The evidence to date

  8. LAP OPEN p Hewitt et al 165 107 .02 Stage et al 150 95 Lacy et al 149 111 Milsom et al 200 125 ..001 Duration of operation (mins)

  9. Hewitt et al RCT morphine use in 48 hours: 27 vs 62mg p=0.04, but intention to treat violation Non-RCTs consistent difference in favour of laparoscopy Post-operative Pain

  10. Lacy et al RCT return to solid food: 51 vs 99 hours p<0.01 Non-RCTs 2 favoured laparoscopy 2 no difference Return of bowel function

  11. LAP OPEN p Hewitt et al 6 7 Lacy et el 5.2 8.1 .006* Stage et el 5 8 .01 *intention to treat violation Hospital stay (days)

  12. 428 patients Quality of life questionnaires at: Baseline 2 days 2 weeks 2 months Only significant difference was global score at 2 weeks Clinical Outcomes of Surgical Therapy (COST) studyH.Nelson JAMA 2002

  13. 0% in all RCTs 0% – 7% reported for laparoscopic procedures 0% - 6% reported for open procedures No significant differences No obvious trends Peri-operative death rate

  14. RCTs no meaningful data Non-RCTs 1 fewer complications in lap group 3 more complications in lap group Trend towards more complications in laparoscopic group, especially cardiac. Operative complications

  15. Longer operations Less pain Early return to bowel function Shorter hospital stay Improved global quality of life at 2 weeks No difference in death rate No significant difference in complications Summary of short term outcomes

  16. Port site recurrences Survival Disease free survival Recurrence (Lymph node harvest) Long-term data

  17. Early reports 1.5% - 21% Mechanical contamination Direct tumour contamination Seeding on instruments Seeding during desupplation Aerosol effect Metabolic/immunlogical factors Haematogenous spread Port site recurrence

  18. Allardyce 1999 1769 laparoscopic cases 0.85% Reilly et al 1996 1711 conventional open cases 0.64 wound recurrence Port site recurrence

  19. Avoidance of traumatic tumour handling Protected tumour extraction Responsible for reluctance to embrace laparoscopic colorectal surgery for cancer in UK NICE recommendations Port site recurrence

  20. Lacy et al RCT 1.61 odds ratio (0.47-51) Leung et al non-RCT 5 year survival Laparoscopic 90.9% Open 55.6% not significant difference ? Selection bias Long-term survival rates

  21. Little meaningful data 4% to 16% recurrence rates reported No major differences between laparoscopic and open Recurrence rates

  22. Port site recurrences probably not a major issue Very little data on survival and tumour recurrence, but no major differences apparant Summary of long-term data

  23. Lymph node harvest 2 RCTs, 7 non-RCTS no differences in node harvest rate ? blinded Markers of oncological quality

  24. Less immunosuppresion Wu et al 2003: no differences in peritoneal and systemic immune response Reduced adhesions formation Beck et al 1999: reduced episodes of small bowel obstruction Potential other benefits of laparoscopic colorectal surgery

  25. Oncological safety remains unproven Superiority rather than equivalence required Training and learning curve issues Large multi-centre RCTs awaited Conclusions

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