Current Status of Current Status of Laparoscopy for Colon Laparoscopy for Colon and Rectal Cancer and Rectal Cancer Steven D Wexner, MD, FACS, Steven D Wexner, MD, FACS, FRCS, FRCS (Ed) FRCS, FRCS (Ed) Chairman, Department of Colorectal Surgery Chairman, Department of Colorectal Surgery 21st Century Oncology Chair in Colorectal Surgery 21st Century Oncology Chair in Colorectal Surgery Chief of Staff Chief of Staff Cleveland Clinic Florida Cleveland Clinic Florida Professor of Surgery, Ohio State University Professor of Surgery, Ohio State University Health Sciences Center at the Health Sciences Center at the Cleveland Clinic Foundation Cleveland Clinic Foundation Clinical Professor of Surgery, Clinical Professor of Surgery, University of South Florida College of Medicine University of South Florida College of Medicine Clinical Professor of Biomedical Science Clinical Professor of Biomedical Science Department of Biomedical Science Department of Biomedical Science Florida Atlantic University College of Medicine Florida Atlantic University College of Medicine Dan Enger Ruiz, MD Dan Enger Ruiz, MD David Vivas, MD David Vivas, MD Clinical Research Fellows Clinical Research Fellows
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Current Status of Laparoscopy for Colon and Rectal Cancer
Current Status of Laparoscopy for Colon and Rectal Cancer. Chairman, Department of Colorectal Surgery 21st Century Oncology Chair in Colorectal Surgery Chief of Staff Cleveland Clinic Florida Professor of Surgery, Ohio State University Health Sciences Center at the - PowerPoint PPT Presentation
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Current Status of Laparoscopy Current Status of Laparoscopy for Colon and Rectal Cancerfor Colon and Rectal CancerSteven D Wexner, MD, FACS, FRCS, FRCS Steven D Wexner, MD, FACS, FRCS, FRCS
(Ed)(Ed)Chairman, Department of Colorectal SurgeryChairman, Department of Colorectal Surgery
21st Century Oncology Chair in Colorectal Surgery21st Century Oncology Chair in Colorectal SurgeryChief of StaffChief of Staff
Cleveland Clinic FloridaCleveland Clinic FloridaProfessor of Surgery, Ohio State UniversityProfessor of Surgery, Ohio State University
Health Sciences Center at theHealth Sciences Center at theCleveland Clinic FoundationCleveland Clinic FoundationClinical Professor of Surgery,Clinical Professor of Surgery,
University of South Florida College of MedicineUniversity of South Florida College of MedicineClinical Professor of Biomedical ScienceClinical Professor of Biomedical Science
Department of Biomedical ScienceDepartment of Biomedical ScienceFlorida Atlantic University College of MedicineFlorida Atlantic University College of Medicine
Dan Enger Ruiz, MDDan Enger Ruiz, MDDavid Vivas, MDDavid Vivas, MD
Clinical Research FellowsClinical Research Fellows
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancer
Short term benefitsShort term benefits– Bowel function recoveryBowel function recovery– Quality of life (including pain)Quality of life (including pain)– Hospital stayHospital stay
CostsCosts Long term benefitsLong term benefits
– RecurrenceRecurrence– SurvivalSurvival
AuthorAuthor YearYear N of patientsN of patients Bowel function Bowel function (mean/median n of days)(mean/median n of days)
LapLap OpenOpen LapLap OpenOpen
MilsomMilsom 19981998 5454 5353 3 4
CuretCuret 20002000 1818 1818 2.7 4.4
LacyLacy 20022002 111111 108108 1.5 2.3
HasegawaHasegawa 20032003 2929 3030 2 3.3
KaiserKaiser 20042004 2929 2020 3 4
p<0.05p<0.05
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerBowel Function RecoveryBowel Function Recovery
RandomizedRandomized
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerBowel Function RecoveryBowel Function Recovery
The evidence that laparoscopy offers faster The evidence that laparoscopy offers faster bowel function recovery than the traditional bowel function recovery than the traditional open approach may be considered high open approach may be considered high (Level I)(Level I)
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerQuality of Life - PainQuality of Life - Pain
AuthorAuthor YearYear N of patientsN of patients Less pain/analgesic Less pain/analgesic requirement (days)?requirement (days)?
Patients in the Lap group had only greater mean global rate Patients in the Lap group had only greater mean global rate scores at 2 weeks after surgery (76.9 vs. 74.4; p=.0009)scores at 2 weeks after surgery (76.9 vs. 74.4; p=.0009) No other differences in quality of lifeNo other differences in quality of life
Values are means
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancer
The superiority of laparoscopy in reducing pain The superiority of laparoscopy in reducing pain during the same length of the postoperative period during the same length of the postoperative period seems evident (Level I)seems evident (Level I)
Other aspects of quality of life warrant further Other aspects of quality of life warrant further investigationinvestigation
There is high evidence (Level I) that There is high evidence (Level I) that laparoscopy for malignancy is associated with laparoscopy for malignancy is associated with an earlier discharge compared to laparotomyan earlier discharge compared to laparotomy
Randomized, prospective trialRandomized, prospective trial Subset of patients from the Swedish COLOR trialSubset of patients from the Swedish COLOR trial Study period – 12 weeks after surgeryStudy period – 12 weeks after surgery Analysis of direct medical cost (hospital and Analysis of direct medical cost (hospital and
outpatient) and indirect cost (loss of productivity)outpatient) and indirect cost (loss of productivity)
Total cost to society similar in both groupsTotal cost to society similar in both groups Direct costs to healthcare system much higher for LCRDirect costs to healthcare system much higher for LCR
– Higher OR costHigher OR cost
– Cost of complications and reoperation which happened more Cost of complications and reoperation which happened more often in LCRoften in LCR
Same length of stay in both (9 days)Same length of stay in both (9 days) Faster recovery and return to work offset higher Faster recovery and return to work offset higher
The data available do not provide adequate The data available do not provide adequate evidence on whether total costs significantly evidence on whether total costs significantly differ between laparoscopy and laparotomy in the differ between laparoscopy and laparotomy in the treatment of malignancy. Costs may significantly treatment of malignancy. Costs may significantly vary depending on the healthcare systemvary depending on the healthcare system
111 Laparoscopy vs. 106 Laparotomy111 Laparoscopy vs. 106 Laparotomy Non metastatic colon cancerNon metastatic colon cancer Median follow-up time: 43 (27-85) monthsMedian follow-up time: 43 (27-85) months Postoperative chemotherapy for all suitable Postoperative chemotherapy for all suitable
patients with Stage II or III rectal cancerpatients with Stage II or III rectal cancer Intention-to-treat analysisIntention-to-treat analysis
Lacy et al, The Lancet 2002Lacy et al, The Lancet 2002
Lacy et al, The Lancet 2002Lacy et al, The Lancet 2002
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerRecurrence free – by StageRecurrence free – by Stage
Lacy et al, The Lancet 2002Lacy et al, The Lancet 2002
Laparoscopic Colectomy: CancerLaparoscopic Colectomy: Cancer
Laparoscopic resection of colorectal malignancies Laparoscopic resection of colorectal malignancies a systematic reviewa systematic review
English languageEnglish language Randomized controlled trialsRandomized controlled trials Controlled clinical trialsControlled clinical trials Case series/reportsCase series/reports
Chapman et al. Ann Surg 2001Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
• 52 papers met inclusion criteria52 papers met inclusion criteria– ““Little high level evidence was available”Little high level evidence was available”– ““The evidence base for laparoscopic-assisted reection of The evidence base for laparoscopic-assisted reection of
colorectal malignancies is inadequate to determine the colorectal malignancies is inadequate to determine the procedures safety and efficacy”procedures safety and efficacy”
Chapman et al. Ann Surg 2001Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : CancerDisadvantages vs. Open ColectomyDisadvantages vs. Open Colectomy
• Significantly longer operative timesSignificantly longer operative times
• Possibly more expensivePossibly more expensive
• Possibly worse short term immune effectsPossibly worse short term immune effects
Chapman et al. Ann Surg 2001Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
• ““Laparoscopic resection of colorectal malignancy was Laparoscopic resection of colorectal malignancy was more expensive and time-consuming”more expensive and time-consuming”
• The new procedure’s advantages revolve around early The new procedure’s advantages revolve around early recovery from surgery and reduced pain”recovery from surgery and reduced pain”
Chapman et al. Ann Surg 2001Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : CancerAdvantages vs. Open ColectomyAdvantages vs. Open Colectomy
• Improved cosmesis (no data but appears uncontentious)Improved cosmesis (no data but appears uncontentious)
• Less narcotic use, though possibly larger benefits for certain Less narcotic use, though possibly larger benefits for certain types of colectomy (low colonic)types of colectomy (low colonic)
• Possibly less pain at rest, at least for patients who have Possibly less pain at rest, at least for patients who have uncovered proceduresuncovered procedures
• Possibly earlier return of bowel function and resumption of Possibly earlier return of bowel function and resumption of normal dietnormal diet
Chapman et al. Ann Surg 2001Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
Short term Quality-of-Life outcomes Following Short term Quality-of-Life outcomes Following Laparoscopic-Assisted Colectomy vs Open Laparoscopic-Assisted Colectomy vs Open Colectomy for Colon Cancer (COST Study)Colectomy for Colon Cancer (COST Study)
AIMSAIMS– Are disease free and overall survival equivalent ?Are disease free and overall survival equivalent ?– Is laparoscopic approach associated with better QOL ?Is laparoscopic approach associated with better QOL ?
Weeks et al. JAMA 2002Weeks et al. JAMA 2002
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
Randomized control trial Randomized control trial 449 patients 449 patients
– Adenocarcinoma of single segment of colonAdenocarcinoma of single segment of colon– Excluded: Acute presentation, rectal and transverse Excluded: Acute presentation, rectal and transverse
colon cancers, advanced local disease, those lesions colon cancers, advanced local disease, those lesions with evidence of metastatic disease, ASA IV or Vwith evidence of metastatic disease, ASA IV or V
Quality of surgery:Quality of surgery:– All surgeons with > 20 cases; Random audit of casesAll surgeons with > 20 cases; Random audit of cases
Weeks et al. JAMA 2002Weeks et al. JAMA 2002
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
Outcomes:Outcomes:– Survival: still pendingSurvival: still pending– QOL at 2days, 2 weeks and 2 months using: QOL at 2days, 2 weeks and 2 months using:
» Symptom Distress Scale, Global QOL Scale, QOL indexSymptom Distress Scale, Global QOL Scale, QOL index
Results: Intention to Treat AnalysisResults: Intention to Treat Analysis– Shorter use of narcoticsShorter use of narcotics– Shorter length of stay by 0.8 days (p<0.01)Shorter length of stay by 0.8 days (p<0.01)– Quality of life: no differenceQuality of life: no difference
Weeks et al. JAMA 2002Weeks et al. JAMA 2002
Laparoscopic Colectomy : CancerLaparoscopic Colectomy : Cancer
ConclusionsConclusions– ““The modest benefits in short term QOL measures we The modest benefits in short term QOL measures we
observed are not sufficient to justify the use of this observed are not sufficient to justify the use of this procedure in the routine care setting”procedure in the routine care setting”
Unresolved Issues:Unresolved Issues:– Blunting of QOL differences via analgesic use Blunting of QOL differences via analgesic use – QOL differences between POD 2 and POD 14QOL differences between POD 2 and POD 14– Recurrence and survival outcomesRecurrence and survival outcomes– Incidence of small bowel obstruction Incidence of small bowel obstruction
No difference between: No difference between: – Time to recurrenceTime to recurrence
– Disease-free survival Disease-free survival
– Overall survivalOverall survival
Oncologic outcome of laparoscopic resection is similar to Oncologic outcome of laparoscopic resection is similar to that of open resectionthat of open resection
Laparoscopic approach is associated with less pain and a Laparoscopic approach is associated with less pain and a shorter hospital stay than conventional surgeryshorter hospital stay than conventional surgery
Laparoscopy for colon cancer has shown to be potentially Laparoscopy for colon cancer has shown to be potentially superior to laparotomy in regard to short-term benefits superior to laparotomy in regard to short-term benefits and equivalent with regard to long term benefitsand equivalent with regard to long term benefits
Available data appear to support that laparoscopic Available data appear to support that laparoscopic colectomy and conventional open colectomy have either colectomy and conventional open colectomy have either similar or superior long-term outcomes (Level 1 similar or superior long-term outcomes (Level 1 evidence)evidence)
Surgeons with sufficient expertise and ongoing peer-Surgeons with sufficient expertise and ongoing peer-reviewed data collection may offer this therapy to reviewed data collection may offer this therapy to appropriately selected patientsappropriately selected patients
Laparoscopy vs. Open Colectomy in Laparoscopy vs. Open Colectomy in Cancer PatientsCancer Patients
AdvantagesAdvantages Amplification of planes of Amplification of planes of
mesorectum and pelvic mesorectum and pelvic fasciafascia
30 degree laparoscope better 30 degree laparoscope better visibility in narrow pelvisvisibility in narrow pelvis
Easier identification of Easier identification of pelvic autonomic nerve pelvic autonomic nerve plexusplexus
DisadvantagesDisadvantages Technically demandingTechnically demanding Absence of tactile sensationAbsence of tactile sensation Difficulty in assessing Difficulty in assessing
surgical marginssurgical margins Difficulty in ultralow cross-Difficulty in ultralow cross-
clampingclamping Learning curveLearning curve
Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME)Excision (TME)
Prospective review – 58 monthsProspective review – 58 months Control group – open rectal resectionsControl group – open rectal resections
– Second consultantSecond consultant– Same unitSame unit
(21 vs. 22)(21 vs. 22)
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME)Excision (TME)
42 Attempted Laparoscopic Rectal Mobilizations
14 Early Conversions
28 Laparoscopic Rectal Dissections
21 Laparoscopic TME – Study Group
7 AP Resections
1 Non CurativeResection
6 Total Laparoscopic AP
21 Anterior Resections
6 Partial OpenDissection
15 Total Laparoscopic AR
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Excision (TME)Laparoscopy: Total Mesorectal Excision (TME)Completed Laparoscopic Completed Laparoscopic
Values are medians (interquartile ranges)* p=0.02, Mann-Whitney test for nonparametric data vs. open group† n=19 because two patients not resected;includes the one palliative lap. APR‡ Both known palliative
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Excision (TME)Laparoscopy: Total Mesorectal Excision (TME)
* Median follow-up was 38 (range, 6-53) months† p=1 and † P=0.736, Fisher’s exact test
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME)Excision (TME)
Feasible in 50% of patients where possibleFeasible in 50% of patients where possible
Yields histologic and early survival and Yields histologic and early survival and recurrence figures comparable to open surgeryrecurrence figures comparable to open surgery
Hartley et al. DCR 2001Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Laparoscopy: Total Mesorectal Excision (TME) case control studyExcision (TME) case control study
Breukink, Int J Colorectal Dis 2005Breukink, Int J Colorectal Dis 2005
VARIABLE/GROUPVARIABLE/GROUP LAPAROSCOPICLAPAROSCOPIC OPENOPEN P valueP value
Mean operative time 170.4 minMean operative time 170.4 min Mean anastomotic distance from anal verge 3.9 cmMean anastomotic distance from anal verge 3.9 cm Mean circumferential margin 17.1 mmMean circumferential margin 17.1 mm Mean distal margin 3.4 cmMean distal margin 3.4 cm