CURRENT STATUS OF CURRENT STATUS OF LAPAROSCOPY FOR COLORECTAL LAPAROSCOPY FOR COLORECTAL DISORDERS DISORDERS Steven D. Wexner, M.D., FACS, FRCS, Steven D. Wexner, M.D., FACS, FRCS, FRCS(Ed) FRCS(Ed) Cleveland Clinic Florida Cleveland Clinic Florida Chairman, Department of Colorectal Surgery Chairman, Department of Colorectal Surgery Professor of Surgery, Ohio State University Professor of Surgery, Ohio State University Health Sciences Center at the Cleveland Clinic Health Sciences Center at the Cleveland Clinic Foundation Foundation Clinical Professor of Surgery, University of Clinical Professor of Surgery, University of South Florida South Florida
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CURRENT STATUS OF LAPAROSCOPY FOR COLORECTAL DISORDERS Steven D. Wexner, M.D., FACS, FRCS, FRCS(Ed) Cleveland Clinic Florida Chairman, Department of Colorectal.
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CURRENT STATUS OF CURRENT STATUS OF LAPAROSCOPY FOR LAPAROSCOPY FOR
COLORECTAL DISORDERSCOLORECTAL DISORDERS
Steven D. Wexner, M.D., FACS, FRCS, FRCS(Ed)Steven D. Wexner, M.D., FACS, FRCS, FRCS(Ed)Cleveland Clinic FloridaCleveland Clinic Florida
Chairman, Department of Colorectal SurgeryChairman, Department of Colorectal SurgeryProfessor of Surgery, Ohio State University Health Sciences Center at the Professor of Surgery, Ohio State University Health Sciences Center at the
Cleveland Clinic FoundationCleveland Clinic FoundationClinical Professor of Surgery, University of South Florida Clinical Professor of Surgery, University of South Florida
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
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancer
I Evidence obtained from at least one properly randomized controlled trial
II-1 Evidence obtained from well-designed controlled trials without randomization
II-2 Evidence obtained from well-designed cohort or case control analytic studies, preferable from more than one center or research group
II-3 Evidence obtained from comparisons between times or places with or without the intervention; dramatic results in uncontrolled experiments were also included in this category
III Opinion of respected authorities based on clinical experience, descriptive studies, or reports of expert committees
Levels of evidence*Levels of evidence*
*Can Med Assoc, 1979*Can Med Assoc, 1979
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerBowel Function RecoveryBowel Function Recovery
AuthorAuthor YearYear N ofN of
patientspatients
Bowel function recoveryBowel function recovery
(mean/median n of days)(mean/median n of days)
RetrospectiveRetrospective
MelottiMelotti 19991999 163163 2.92.9
SchiedeckSchiedeck 20002000 399399 33
ZhouZhou 20032003 8282 1-21-2
ProspectiveProspective
MorinoMorino 20032003 100100 2.92.9
TsangTsang 20032003 4444 22
AuthorAuthor YearYear N of patientsN of patients Bowel function Bowel function (mean/median n of days)(mean/median n of days)
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerBowel Function RecoveryBowel Function Recovery
p<0.05p<0.05
Case-control/CohortCase-control/Cohort
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
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 bowel The evidence that laparoscopy offers faster bowel function recovery than the traditional open function recovery than the traditional open approach may be considered high (Level I)approach may be considered high (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)?
LapLap OpenOpen LapLap p valuep value
Seow-ChoenSeow-Choen 19971997 1616 1111 NoNo --
RamosRamos 19971997 1818 1818 YesYes <0.005<0.005
GohGoh 19971997 2020 2020 NoNo --
PsailaPsaila 19981998 2929 2525 YesYes 0.0020.002
SchwandnerSchwandner 19991999 3232 3232 NoNo --
Case-control/CohortCase-control/Cohort
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 Patients in the Lap group had only greater mean global rate scores at 2 weeks after surgery (76.9 vs. 74.4; rate scores at 2 weeks after surgery (76.9 vs. 74.4; p=.0009)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 investigation investigation
There is high evidence (Level I) that laparoscopy There is high evidence (Level I) that laparoscopy for malignancy is associated with an earlier for malignancy is associated with an earlier discharge compared to laparotomy discharge compared to laparotomy
The data available does not provide adequate The data available does not provide adequate evidence on whether total costs differ between evidence on whether total costs differ between laparoscopy and laparotomy in the treatment of laparoscopy and laparotomy in the treatment of malignancy malignancy
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
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerOverall survival- by StageOverall survival- by Stage
Lacy et al, The lancet 2002Lacy et al, The lancet 2002
Laparoscopy: Colorectal cancerLaparoscopy: Colorectal cancerCancer related survival – by StageCancer related survival – 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 colorectal cancer has shown to be Laparoscopy for colorectal cancer has shown to be potentially superior to laparotomy in regard to short-term potentially superior to laparotomy in regard to short-term benefits and equivalent with regard to long term benefitsbenefits and 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 Surgeons with sufficient expertise and ongoing peer-reviewed data collection may offer this peer-reviewed data collection may offer this therapy to appropriately selected patientstherapy to appropriately selected patients
International Colorectal Disease SymposiumInternational Colorectal Disease Symposium
16th Annual
An International Exchange of Medical and Surgical Concepts