Minimally Invasive Procedures in Colon & Rectal Surgery

1. Minimally Invasive Procedures in Colon & Rectal Surgery Alan E. Harzman, M.D.

2. Outline • Endoscopy • TEM • Combined approaches • Colonic Stents • Laparoscopy • “Pure” laparoscopy vs. Hand-assisted • NOTES • Laparoscopic Techniques

3. Goals of Minimally Invasive Techniques • Equivalent or improved outcomes • Equivalent or improved oncologic outcomes • Avoid excessive cost

4. Learning New TechniquesTraining Issues • Learning Curve (20-50 cases) • ABS Recertification Reports (General Surgeons) • Mean 11 colectomies/year • 90th percentile – 23/year • I did about 40 laparoscopic colectomies as a fellow.

5. Rewards of Minimally Invasive Techniques Risk/Effects Of Anesthesia, Trauma, Etc. Benefits of New Techniques Operative Time

6. Endoscopy

7. Transanal Endoscopic Microsurgery (TEM)

8. Transanal Endoscopic Microsurgery (TEM) Richard Wolf Medical Instruments Corporation

9. Transanal Endoscopic Microsurgery (TEM) • Suggested uses • Benign tumors mid to upper rectum • 5% recurrence • T1 low-risk lesions • 3% recurrence • Palliation or high-risk patients • Overall 8% recurrence • Large, long-term, randomized numbers lacking (Bemelman, 2005) (Middleton et al, 2005)

10. Transanal Excision • Similar indications • Similar results • Lower lesions only Nova Plastics

11. How do you apply principles of local resection to the rest of the colon? • Step 1 – Combine laparoscopic and endoscopic resection • Step 2 – Under development (OmicronLab, 2007)

12. Combined Laparoscopy and Colonoscopy (Bemelman, 2005)

13. Colonic Stentsfor Obstructing Tumors

14. Colonic Stents • As a bridge to surgery, in hopes of avoiding a colostomy • Possibly as a definitive measure in patients with widespread disease • 84-96% clinical success rate • Complications (~25%) include perforation, stent migration, fistula, reobstruction, tenesmus (if too low), stool impaction, bleeding (Wolff, 2007)

15. Colonic Stents (Camunez et al, 2000)

16. Colonic Stents Camúñez Study • Placement in 70 of 80 patients • Resolved obstruction in 67 • 2 perforated, 1 died • 33 patients had surgery after 7 days • Used as final treatment in 35 • Estimated primary patency of 91% at 6 months (Camunez et al, 2000)

17. Laparoscopy

18. Laparoscopy • Laparoscopic – “Pure” • Hand-Assisted Laparoscopic • Is not “lap converted to open”

19. Laparoscopic ApproachConsideration of Cost • Time - Per Minute Charge  Standard - O.R. Care Time $43.00 • Equipment • Energy devices • Ligasure • Harmonic Scalpel • Electrocautery • Staplers • Access devices • Trocars • Hand ports

20. ACGME Competency-Based Goals and Objectives • Surg 2 Chief Resident • Systems-based Practice • Will refine operative skills including cost-effective utilization of equipment.

21. Laparoscopy • Goal - Do the same (oncologic) resection • 12 lymph nodes • Ligate feeding vessel at its origin • Currently little data on RECTAL resection for cancer • Societies currently discourage laparoscopic proctectomy outside clinical trials

22. Preoperative Considerations • Site (Right and sigmoid easier) • Tumor size/invasion • Obesity • Previous surgery • Almost always get a pre-op CT (cancer) • Must talk with patient about need for conversion to open • Must be able to find tumor/polyp (tattoo!, 0.5cc India ink in 3-4 sites)

23. Tattoo

24. Preoperative ConsiderationsContinued • Can also locate with BE • Having to do intraoperative colonoscopy is a flail • CO2 colonoscopy may be better • Bowel Preparation • Utility is debatable, but with laparoscopy it makes bowel easier to handle

25. Conversion to Open • 10-25% • Obesity • Prior surgery • Acute inflammation • Fistula – 50% conversion • Tumor bulk • Not a failure • Early conversion preserves good outcomes (Wolff, 2007)

26. Evaluating Outcomes • Tracking Outcomes • Current national push • To be included in “Maintenance of Certification” • “Intention to Treat” • If you started laparoscopically and had to open, it’s not fair to put that patient’s outcome in “open” group. (Wolff, 2007)

27. What difference does it make? Laparoscopic Colectomy

28. What difference does it make? • It helps you get a job • Patients like it (thanks to the internet) • Referring doctors like it • But what difference does it really make Laparoscopic Colectomy

29. Outcomes • Ileus – average 1-2 days shorter with laparoscopy • Less need for narcotics • Quicker return of pulmonary function • Length of stay ~1 day less • May be influenced by biased expectations • Who cares? (Wolff, 2007)

30. Outcomes – Page 2 • Return to work and quality of life • No statistical change • Anecdotally improved • Cost • Equipment costs and OR time are greater • May be balanced or outpaced by shorter hospital stay • Time – Average 30-60 minutes longer (Wolff, 2007)

31. Port-Site Metastasis • Initial concern greatly slowed development of laparoscopic colectomy • Not born out in major trials

32. Specific Trials • Antonio Lacy • COST • COLOR • MRC CLASSIC

33. Antonio Lacy, et al 2002 • 219 patients (Lacy et al, 2002)

34. Antonio Lacy, et al Overall Survival p=0.16 Cancer Related Survival p=0.02 (Lacy et al, 2002)

35. Antonio Lacy, et al 2008 (Lacy et al, 2008)

36. COST TrialClinical Outcomes of Surgical Therapy Study Group • 872 patients with colonic adenocarcinoma • Recurrence • 16% lap • 18% open • Survival • 86% lap • 85% open • Post-operative stay • 5 days lap • 6 days open (COST Study, 2004)

37. COST TrialClinical Outcomes of Surgical Therapy Study Group • 5 year data published October 2007 • Disease-free 5 year survival • 68.4% Open • 69.2% Laparoscopic • Overall survival • 74.6% Open • 76.4% Laparoscopic • Recurrence • 21.8% Open • 19.4% Laparoscopic (COST Study, 2007)

38. COLOR TrialCOlon cancer Laparoscopic or Open Resection • 1248 patients • 17% conversion to open • BMI>30 excluded (because started in 1997) • Pathologic criteria no different • Time to GI recovery, 1st BM, hospital stay all one day less • Complications were equivalent (COLOR Trial, 2005)

39. MRC CLASSICCMedical Research Council trial of Conventional versus Laparoscopic-ASsisted Surgery In Colorectal Cancer • 794 patients • Pathologic specimens, complications were similar • Time to 1st BM 1 day shorter • Time to diet and discharge similar between groups (Guillou et al, 2005)

40. Hand Assisted Laparoscopy vs.“Pure” Laparoscopy • May reduce learning curve • May be used “up front” or as a “pseudo-conversion” • Need to make an incision large enough for the specimen anyway • Outcomes similar to laparoscopy, with operative times usually shorter

41. Hand-assist vs. Laparoscopy (Targarona et al, 2002)

42. Hand-assist vs. Laparoscopy (Targarona et al, 2002)

43. Hand-assist vs. LaparoscopyMarcello et al • 95 patients - left or total colectomy • Randomized to HA vs LAP • Left colectomy • 175 minutes HA, 208 LAP (p=0.021) • Flatus 2.5 vs 3 days (p=0.64) • Length of stay 5 vs 4 days (p=0.55) • Total colectomy • 127 vs 184 minutes (p=0.015) (Marcello et al, 2008)

44. In a comparison of “pure” laparoscopy and HALS, what does no significant difference mean? It means that if you can do it more easily with one hand in, why not do it?

45. Robotic Assisted So far not advantageous, encumbered by time and cost (Minimally Invasive Robotics Association, 2002)

46. NOTESNatural Orifice Transluminal Endoscopic Surgery

47. (Pai et al, 2006)

48. (Pai et al, 2006)

49. Techniques in Laparoscopic Colon and Rectal Surgery

50. Laparscopic HemicolectomyTechnique • Access • Takedown of previous adhesions • Mobilization and vascular division • Intestinal division • Anastomosis • Closure of mesenteric defect • Usually skipped • Closure