Transcript Laparoscopic Colorectal Surgery

Current Status of Laparoscopy
for Colon and Rectal Cancer
Steven D Wexner, MD, FACS, FRCS, FRCS
(Ed)
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
Cleveland Clinic Foundation
Clinical Professor of Surgery,
University of South Florida College of Medicine
Clinical Professor of Biomedical Science
Department of Biomedical Science
Florida Atlantic University College of Medicine
Dan Enger Ruiz, MD
David Vivas, MD
Clinical Research Fellows
Laparoscopy: Colorectal cancer
 Short term benefits
– Bowel function recovery
– Quality of life (including pain)
– Hospital stay
 Costs
 Long term benefits
– Recurrence
– Survival
Laparoscopy: Colorectal cancer
Bowel Function Recovery
Randomized
Author
Year
N of patients
Lap
Bowel function
(mean/median n of days)
Open
Lap
Open
Milsom
1998
54
53
3
4
Curet
2000
18
18
2.7
4.4
Lacy
2002
111
108
1.5
2.3
Hasegawa
2003
29
30
2
3.3
Kaiser
2004
29
20
3
4
p<0.05
Laparoscopy: Colorectal cancer
Bowel Function Recovery
 The evidence that laparoscopy offers faster
bowel function recovery than the traditional
open approach may be considered high
(Level I)
Laparoscopy: Colorectal cancer
Quality of Life - Pain
Randomized
Author
Year
N of patients
Open
14
30
Less pain/analgesic
requirement (days)?
Lap
p value
Yes
< 0.05
Yes
< 0.01
Stage
Schwenk
1997
1998
Lap
15
30
Milsom
Weeks
1998
2002
54
168
53
221
Yes
Yes
0.02
0.03
Hasegawa
2003
29
30
Yes
0.002
Kaiser
Nelson
2004
2004
29
435
20
425
Yes
Yes
< 0.05
<0.001
Laparoscopy: Colorectal cancer
Quality of life





Randomized trial (COST trial)
449 patients
228 Laparoscopy (Lap) , 221Open
Pain, hospital stay
Quality of life (2 days, 2 weeks, 2 months)
– Symptom distress scale
– Quality of life index
– Global rating scale (1-100)
Weeks, JAMA 2002
Results
Age (years)
Gender M:F
Tumor stage
I
II
III
IV
ASA classification
I or II
III
Lap
n = 228
68.2
Open
n = 221
69.4
108:120
108:113
88
77
57
5
69
78
62
11
198
32
189
32
P = N.S.
Weeks, JAMA 2002
Results
Lap (n = 228) Open (n = 221)
Oral analgesics
IV narcotics/analgesics
Hospital stay
1.9
3.2
5.6
2.2
4.0
6.4
P value
0.03
<0.001
<0.001
Values are means
 Patients in the Lap group had only greater mean global rate
scores at 2 weeks after surgery (76.9 vs. 74.4; p=.0009)
 No other differences in quality of life
Weeks, JAMA 2002
Laparoscopy: Colorectal cancer
 The superiority of laparoscopy in reducing pain
during the same length of the postoperative period
seems evident (Level I)
 Other aspects of quality of life warrant further
investigation
Laparoscopy: Colorectal cancer
Hospital Stay
Randomized
Author
Year
N of patients
Hospital Stay (days)
Lap
Open
Lap
Open
Stage
1997
15
14
5
8
Schwenk
1998
30
30
10.1
11.6
Milsom
1998
54
53
6
7
Curet
2000
18
18
5.2
7.3
Lacy
2002
111
108
5.2
7.9
Weeks
2002
168
221
5.6
6.4
Hasegawa
2003
29
30
7.1
12.7
Kaiser
2004
29
20
5
6
Nelson
2004
435
425
5
6
p<0.05
Laparoscopy: Colorectal cancer
Hospital stay
 There is high evidence (Level I) that
laparoscopy for malignancy is associated
with an earlier discharge compared to
laparotomy
Laparoscopy: Colorectal cancer
Cost




Randomized, prospective trial
Subset of patients from the Swedish COLOR trial
Study period – 12 weeks after surgery
Analysis of direct medical cost (hospital and
outpatient) and indirect cost (loss of productivity)
Janson, BJS 2004
Laparoscopy: Colorectal cancer
Cost
Prospective, Randomized - COLOR
LCR
(n=98)
OCR
(n=112)
Differ
OR time (min)
155
122
33
Length of stay (days)
9.0
9.1
-
Conversion
14%
-
-
Total cost first admission
6931
5375
1556
Total cost of care after discharge
(readmissions/reoperations)
2548
1860
688
Total cost excluding productivity lost
9479
7237
2244
Productivity loss
2181
2579
-398
Total cost
11660
9814
1846
All costs in Euros
Janson, BJS 2004
Laparoscopy: Colorectal cancer
Cost
Prospective, Randomized - COLOR
First admission
Complications
Reoperations
After discharge
Complications
Reoperations
LCR (n=98)
OCR (n=112)
21%
8%
16%
4%
12%
6%
7%
3%
Janson, BJS 2004
Laparoscopy: Colorectal cancer
Cost
 Total cost to society similar in both groups
 Direct costs to healthcare system much higher for LCR
– Higher OR cost
– Cost of complications and reoperation which happened more
often in LCR
 Same length of stay in both (9 days)
 Faster recovery and return to work offset higher
healthcare system cost
Janson, BJS 2004
Laparoscopy: Colorectal cancer
Costs
 The data available do not provide adequate
evidence on whether total costs significantly
differ between laparoscopy and laparotomy in the
treatment of malignancy. Costs may significantly
vary depending on the healthcare system
Laparoscopy: Colorectal cancer
Randomized Controlled Trial




111 Laparoscopy vs. 106 Laparotomy
Non metastatic colon cancer
Median follow-up time: 43 (27-85) months
Postoperative chemotherapy for all suitable
patients with Stage II or III rectal cancer
 Intention-to-treat analysis
Lacy et al, The Lancet 2002
Laparoscopy: Colorectal cancer
Recurrence
Tumor recurrence
Type of recurrence
Distant metastasis
Locoregional relapse
Peritoneal seeding
Port-site metastasis
Laparoscopy
(n=106)
Open
(n=102)
Hazard Ratio
(95% CI)
P value
18 (17%)
28 (27%)
0.72 (0.49-1.06)
0.07
0.57
7
7
3
1
9
14
5
0
-----
Time to recurrence (months)
15 (14)
17 (12)
--
0.66
Surgical treatment of
recurrence with curative
intention
6 (33%)
9 (32%)
--
1.00
Lacy et al, The Lancet 2002
Laparoscopy: Colorectal cancer
Survival
Laparoscopy
(n=106)
Open
(n=102)
Hazard ratio
(95% CI)
P value
Overall mortality
19 (18%)
27 (26%)
0.77 (0.53-1.12)
1.04
Cancer-related mortality
10 (9%)
21 (21%)
0.68 (0.50-0.90)
0.03
Causes of death
Perioperative mortality
Tumor progression
Others
0.19
1
9
9
3
18
6
----
Lacy et al, The Lancet 2002
Laparoscopy: Colorectal cancer
Predictive factors
Hazard ratio
(95% CI)
P value
Probability of being free of recurrence
Lymph node metastasis (presence or absence)
Surgical procedure (Open vs. Lap)
Preoperative serum CEA (> ng/ml vs. < 4 ng/ml)
0.31 (0.16-0.60)
0.39 (0.19-0.82)
0.43 (0.22-0.87)
0.0006
0.012
0.018
Overall survival
Surgical procedure (open vs. Lap)
Lymph-node metastasis (presence vs. absence)
0.48 (0.23-1.01)
0.49 (0.25-0.98)
0.052
0.044
Cancer-related survival
Lymph-node metastasis (presence vs. absence)
Surgical procedure (open vs. Lap)
0.29 (0.12-0.67)
0.38 (0.16-0.91)
0.004
0.029
Cox’s regression model
Lacy et al, The Lancet 2002
Laparoscopy: Colorectal cancer
Overall survival
Lacy et al, The Lancet 2002
Laparoscopy: Colorectal cancer
Cancer-related survival
Lacy et al, The Lancet 2002
Laparoscopy: Colorectal cancer
Recurrence free – by Stage
Lacy et al, The Lancet 2002
Laparoscopic Colectomy: Cancer
 Laparoscopic resection of colorectal malignancies
 a systematic review
 English language
 Randomized controlled trials
 Controlled clinical trials
 Case series/reports
Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : Cancer
• 52 papers met inclusion criteria
– “Little high level evidence was available”
– “The evidence base for laparoscopic-assisted reection of
colorectal malignancies is inadequate to determine the
procedures safety and efficacy”
Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : Cancer
Disadvantages vs. Open Colectomy
• Significantly longer operative times
• Possibly more expensive
• Possibly worse short term immune effects
Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : Cancer
• “Laparoscopic resection of colorectal malignancy was
more expensive and time-consuming”
• The new procedure’s advantages revolve around early
recovery from surgery and reduced pain”
Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : Cancer
Advantages vs. Open Colectomy
• Improved cosmesis (no data but appears uncontentious)
• Quicker hospital discharge
• Less narcotic use, though possibly larger benefits for certain
types of colectomy (low colonic)
• Possibly less pain at rest, at least for patients who have
uncovered procedures
• Possibly earlier return of bowel function and resumption of
normal diet
Chapman et al. Ann Surg 2001
Laparoscopic Colectomy : Cancer
 Short term Quality-of-Life outcomes Following
Laparoscopic-Assisted Colectomy vs Open
Colectomy for Colon Cancer (COST Study)
 AIMS
– Are disease free and overall survival equivalent ?
– Is laparoscopic approach associated with better QOL ?
Weeks et al. JAMA 2002
Laparoscopic Colectomy : Cancer
 Randomized control trial
 449 patients
– Adenocarcinoma of single segment of colon
– Excluded: Acute presentation, rectal and transverse
colon cancers, advanced local disease, those lesions
with evidence of metastatic disease, ASA IV or V
 Quality of surgery:
– All surgeons with > 20 cases; Random audit of cases
Weeks et al. JAMA 2002
Laparoscopic Colectomy : Cancer
 Outcomes:
– Survival: still pending
– QOL at 2days, 2 weeks and 2 months using:
» Symptom Distress Scale, Global QOL Scale, QOL index
 Results: Intention to Treat Analysis
– Shorter use of narcotics
– Shorter length of stay by 0.8 days (p<0.01)
– Quality of life: no difference
Weeks et al. JAMA 2002
Laparoscopic Colectomy : Cancer
 Conclusions
– “The modest benefits in short term QOL measures we
observed are not sufficient to justify the use of this
procedure in the routine care setting”
 Unresolved Issues:
–
–
–
–
Blunting of QOL differences via analgesic use
QOL differences between POD 2 and POD 14
Recurrence and survival outcomes
Incidence of small bowel obstruction
Weeks et al. JAMA 2002
Laparoscopic Colectomy :
Prospective, Randomized, Controlled
 48 institutions, 872 patients
 Prospective, randomized
 Follow-up 4.4 years
 Conversion 21%
 End point was time to tumor recurrence
Nelson, NEJM 2004
Prospective, Randomized, Controlled
Laparoscopic
(n=435)
Open
(n=425)
Age
70
69
Female
212
220
Location
Right
Left
Sigmoid
237
32
166
232
32
164
TNM Stage
0
1
2
3
4
Unknown
20
153
136
112
10
4
33
112
146
121
16
0
Nelson, NEJM 2004
Prospective, Randomized,
Controlled: Outcome at Surgery
Laparoscopic
(n=435)
Open
(n=425)
P value
10-13
11-12
0.4-0.9
Lymph nodes
12
12
1.0
Surgery time (min)
150
90
<0.001
Conversion
90
-
-
Intraoperative
complications
8
15
NS
Length of incision (cm)
6
18
<0.001
Bowel margins (cm)
Nelson, NEJM 2004
Prospective, Randomized,
Controlled: Post-operative
Laparoscopic
(n=435)
Open
(n=425)
P value
IV narcotics (days)
3
4
<0.001
PO narcotics (days)
1
2
0.02
Length of Stay
5
6
<0.001
30-day mortality
2
4
NS
Complications
92
85
NS
Rates of readmission
10
12
NS
Rates of reoperation
<2%
<2%
NS
Nelson, NEJM 2004
Prospective, Randomized,
Controlled: Outcome
Laparoscopic
(n=435)
Open
(n=425)
P value
Recurrence* (4.4yrs)
76
84
0.83
Wound recurrence
1%
1%
P=0.50 NS
3-yr survival
86%
85%
P=0.51 NS
*Laparoscopic procedure not significantly inferior to Open Procedure.
Nelson, NEJM 2004
Cumulative Incidence of Recurrence at Any Satge
Overall Survival at Any Stage
Prospective, Randomized,
Controlled: Conclusions
 No difference between:
– Time to recurrence
– Disease-free survival
– Overall survival
 Oncologic outcome of laparoscopic resection is similar to
that of open resection
 Laparoscopic approach is associated with less pain and a
shorter hospital stay than conventional surgery
Nelson, NEJM 2004
Laparoscopic Colectomy :
CLASICC Trial
Colon and Rectal Cancer
 27 UK institutions, 794 patients
 Prospective, randomized, controlled
 Follow-up at 1 and 3 months
 29% conversion rate
Guillou, Lancet 2005
Laparoscopic Colectomy
CLASICC Trial
Colon and Rectal Cancer
Positivity
Primary
Endpoints
rates of circumferential and
longitudinal resection margins
Proportion
of Dukes’ C2 tumors
In-Hospital
mortality
Complication
Secondary
Endpoints
Quality
rates
of life
Transfusion
requirments
Guillou, Lancet 2005
CLASICC Trial Profile
Guillou, Lancet 2005
Prospective, Randomized, Controlled
Open (n=276)
Laparoscopic (n=345)
Conversion (n=143)
69
69
68
Female
121 (44%)
167 (48%)
49 (34%)
Colon
Rectum
144 (52%)
132 (48%)
185 (52%)
160 (46%)
61 (43%)
82 (18%)
T0
T1
T2
T3
T4
-9 (4%)
36 (16%)
141 (64%)
33 (15%)
-17 (6%)
48 (17%)
175 (63%)
36 (13%)
-4 (3%)
16 (13%)
71 (60%)
28 (24%)
N0
N1
N2
Not Investigated
130 (59%)
51 (23%)
38 (17%)
--
159 (58%)
70 (25%)
46 (17%)
1
63 (53%)
33 (28%)
21 (18%)
2 (2%)
M0
M1
Not investigated
Missing
96 (44%)
8 (4%)
107(49%)
8 (4%)
98 (36%)
4 (1%)
159 (58%)
15 (5%)
57 (48%)
7 (6%)
52 (44%)
3 (3%)
Age
TNM Stage
Guillou, Lancet 2005
CLASICC: Outcome at Surgery
Open
(n=276)
Laparoscopic
(n=345)
Conversion
(n=143)
Time to first bowel
movement (days)
6 (4.5-7) colon
6 (4-7) rectum
5 (4-6.5) colon
5 (3-7) rectum
5 (4-6.5) colon
6 (4-8) rectum
Time to normal diet
6 (5-8) colon
7 (5-8) rectum
5 (4-7) colon
6 (5-7) rectum
6 (5-8) colon
7 (5-9) rectum
Anaesthetic time (min)
135 (100-175)
180 (140-220)
180 (135-223)
Length of incision (mm)
228 (180-300)
70 (55-100)
200 (150-285)
All data are median
Guillou, Lancet 2005
CLASICC: Pathology
Laparoscopic
Open
Converted
12 ( 8-17)
34 (6%)
13.5 (8-19
18 (7%)
-16 (12%)
Colon
Distance from tumor to mesenteric
resection margin
8cm (6.5-10)
9cm (7-11)
Circumferential resection margin +
16 (7%)
6 (5%)
Rectum
Circumferential resection margin +
30 (16%)
14 (14%)
Lymph-node
Duke’s C2
P>0.05
Guillou, Lancet 2005
CLASICC: Complications
Laparoscopic
(intention to treat)
Open
General
54 (10%)
27 (10%)
(Colon) Haemorrhage
Cardiac/Pulmonary
Bowel Injury
Ureteric Injury
Other
2 (1%)
10 (4%)
6 ( 2%)
2 (1%)
2 (1%)
5 (4%)
4 (3%)
--2 (1%)
(Rectum) Haemorrhage
Cardiac/Pulmonary
Bowel Injury
Ureteric Injury
Other
17 (7%)
11 (4%)
3 ( 1%)
-9 (4%)
7 (5%)
4 (3%)
1 (1%)
4 (3%)
2 (2%)
Intraoperative
complications
P > 0.05
Guillou, Lancet 2005
CLASICC: Complications
30 days post op
Laparoscopic
Open
Converted
Total Complications
133 (39%)
115 (42%)
99 (69%)
(Colon) wound infection
chest infection
anastomotic dehiscence
DVT
Other
8 (4%)
10 (5%)
7 (4%)
5 (3%)
32 (17%)
7 (5%)
5 (3%)
5 (3%)
-31 (22%)
5 (8%)
6 (10%)
1 (2%)
-11 (18%)
(Rectum) wound infection
chest infection
anastomotic dehiscence
DVT
Other
16 (10%)
12 (8%)
13 (8%)
-30 (19%)
16 (12%)
6 (5%)
10 (7%)
2 (2%)
33 (25%)
16 (20%)
12 (15%)
12 (15%)
1 (1%)
35 (43%)
Death
16 (1%)
15 (5%)
13 (9%)
P>0.05
Guillou, Lancet 2005
CLASICC: Conversions
Conversion Rate (Colon)
61 (25%)
-Tumor fixity
37 (61%)
-Uncertainty of tumor clearance
13 (21%)
-Obesity
5 (8%)
-Tumor fixity/Uncertainty of
tumor clearance
34 (41%)
Conversion Rate (Rectum)
-Obesity
82 (34%)
-Anatomical uncertainty
21 (26%)
-Inaccessibility of tumor
16 (20%)
17 (21%)
Guillou, Lancet 2005
Laparoscopic Colectomy : Prospective,
Randomized, Controlled
Outcome at 3 years
Open
N=20
Converted
N=13
Laparoscopic
N=15
5
23
0
Alive without disease %
90
62
93
Alive with disease %
5
23
0
Died, Disease-related %
5
8
7
Died, non-disease related %
0
8
0
Recurrence %
Survival Status
Equivalent in terms of recurrence and survival
Kaiser, J Lap and Advanced Surg Tech 2004
Laparoscopy vs. Open: Colon Cancer
Meta-analysis of 12 randomized controlled trials (2512 patients)
Year
Patients
Lacy
2002
219
COST
2002
428
COLOR
2002
Neudecker
2002
30
Braga
2002
269
Singapore
2001
236
Schwenk
2000
60
Leung
2000
34
Curet
2000
73
Hewitt
1998
25
Milsom
1998
113
Stage
1997
29
Abraham, BJS 2004
Laparoscopy vs Open: Colon Cancer
Meta-analysis of 12 randomized controlled trials (2512 patients)
Odds Ratio
P value
Mortality
0.85
NS
Morbidity
0.62
<0.003
All complications
0.60
<0.001
Local Complications
0.51
<0.001
All wound complications
0.47
0.003
All leakage
0.84
NS
Hemorrhage
0.71
NS
Reoperation
0.70
NS
0.65-0.81
NS
Systemic, Cardiac, Respiratory, DVT
Abraham, BJS 2004
Laparoscopy vs Open: Colon Cancer
Meta-analysis of 12 randomized controlled trials (2512 patients)
Patients
Improvement
First Flatus
476
33.5%
Tolerating Solid Diet
406
23.9%
80% Recovery of Peak Expiratory Flow
94
44.3%
Pain 6-8hr postop
At rest
During coughing
173
173
34.8%
33.9%
Narcotic Analgesia (first 48hrs)
269
36.9%
Length of Hospital Stay
1237
20.6%
Abraham, BJS 2004
Laparoscopy: Colon Cancer
Conclusion
 Laparoscopy for colon cancer has shown to be potentially
superior to laparotomy in regard to short-term benefits
and equivalent with regard to long term benefits
 Available data appear to support that laparoscopic
colectomy and conventional open colectomy have either
similar or superior long-term outcomes (Level 1
evidence)
 Surgeons with sufficient expertise and ongoing peerreviewed data collection may offer this therapy to
appropriately selected patients
Laparoscopy vs. Open Colectomy in
Cancer Patients
Randomized Trial
Variable
Laparoscopy
(n = 190)
Open
(n = 201)
Age (yr)
65 (13)
67 (11)
Male/female ratio
115/75
121/80
ASA score
1.9 (0.6)
2.0 (0.7)
Hemoglobin (g/l)
126 (19)
124 (22)
Obesity
17 (8.9)
12 (6)
Undernutrition
22 (11.6)
24 (11.9)
Albumin (g/l)
36.9 (5.3)
36.2 (6.5)
Braga, DCR 2005
Laparoscopy vs. Open Colectomy in
Cancer Patients:
Long-Term Complications
Laparoscopy
(n = 190)
Open
(n = 201)
P Value
Overall
13 (6.8)
30 (14.9)
0.02
Incisional hernia
9 (4.7)
18 (8.9)
NS
Intestinal obstruction
3 (1.6)
6 (3)
NS
Abdominal abscess
0 (0)
1 (0.5)
NS
Urinary dysfunction
0 (0)
3 (1.5)
NS
1 (0.5)
1 (0.5)
NS
0 (0)
1 (0.5)
NS
Complication
Peristomal abscess
Anastomosis stenosis
Braga, DCR 2005
Laparoscopy vs. Open Colectomy in
Cancer Patients
Quality of Life
Braga, DCR 2005
Laparoscopy vs. Open Colectomy in
Cancer Patients
Five-Year Survival by Cancer Stage
Braga, DCR 2005
Laparoscopy vs. Open Colectomy in
Cancer Patients
Five-year Disease-Free Survival
Braga, DCR 2005
Laparoscopy vs. Open Colectomy in
Cancer Patients
Conclusion
 Laparoscopic colorectal resection reduced longterm
complication rate, improved quality of life in the
first postoperative year, and did not adversely affect
survival in cancer patients
Braga, DCR 2005
Laparoscopy for Rectal Cancer
Laparoscopy: Rectal Cancer
Total Mesorectal Excision
Advantages
 Amplification of planes of
mesorectum and pelvic
fascia
 30 degree laparoscope better
visibility in narrow pelvis
 Easier identification of
pelvic autonomic nerve
plexus
Disadvantages
 Technically demanding
 Absence of tactile sensation
 Difficulty in assessing
surgical margins
 Difficulty in ultralow crossclamping
 Learning curve
Laparoscopy: Total Mesorectal
Excision (TME)
 Prospective review – 58 months
 Control group – open rectal resections
– Second consultant
– Same unit
(21 vs. 22)
Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal
Excision (TME)
42 Attempted Laparoscopic Rectal Mobilizations
14 Early Conversions
28 Laparoscopic Rectal Dissections
7 AP Resections
21 Anterior Resections
1 Non Curative
Resection
6 Partial Open
Dissection
6 Total Laparoscopic AP
15 Total Laparoscopic AR
21 Laparoscopic TME – Study Group
Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Excision (TME)
Completed Laparoscopic
(n=21)
Open (n=22)
Laparoscopic
Conversions* (n=21)
66 (37-82)
65 (47-79)
72 (58-90)
15:6
15:7
13:8
A
5
4
0
B
10
8
8
C
6
10
13
D
0
0
1
[15] 6.2 (4-9)
[16] 6.4 (4-10)
[16] 7 (5-10)
[6] 2 (0-5)
[6] 1.66 (0-5)
[1] 1
Unresectable
[0]
[0]
[2] 6 (4-8)
Hartmann’s resection
[0]
[0]
[2] 9 (6-12)
Mean age (range)
Male:female
Dukes’ Stage
Tumor height ([number] cm above anal verge, mean (range))
Anterior resection
Abdominoperineal resctn.
* Includes the one palliative lap. APR
Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal
Excision (TME)
Reason for Conversion
–
–
–
–
–
–
–
–
Fixed tumor
Doubtful resectability
Gross obesity
Dense adhesions
Obstructed sigmoid
Ureter not identified
Camera failure
TOTAL
Number
2
4
2
2
1
2
1
14 (33%)
Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Excision (TME)
Group
Specimen
Length (cm)
Longitudinal Radial Margin
Margin (cm)
(cm)
No. Positive
Margins
Lymph Node
Yield
Laparoscopic
(n=21)
27.5
(24-30)
4*
(3.5-5)
0.65
(0.33-1.5)
0
6
(3.25-9.5)
Open (n=22)
26.5
(23.75-32)
2.5
(1.05-3.5)
0.8
(0.225-1.2)
0
7.0
(4.5-10.5)
Converted
laparoscopic
(n=19) †
28 (24-32)
2 (1.5-3.5)
0.6 (0.35-1)
2‡
7
(6-10)
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 2001
Laparoscopy: Total Mesorectal Excision (TME)
Operating Time
(min)
Duration of Ileus
(days)
Analgesia
Requirements
(days)
Hospital Stay
(days)
Laparoscopic
(n=21)
180*
(168-218)
3.0
(3.0-4.0)
4.0
(3.0-6.0)
13.5
(10.25-27.0)
Open
(n=22)
125
(104-144)
4.0
(3.0-5.0)
4.0
(3.0-5.0)
15.0
(11.75-28.5)
146
(136.5-179.5)
4
(3.5-7)
5
(3.5-7)
16
(11.5 – 33)
Group
Converted
laparoscopic
(n=21)†
Values are medians (interquartile ranges)
* p=0.003, Mann-Whitney test for nonparametric data vs. open cases
† Includes the one palliative lap. APR
Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Excision (TME)
Complication
Laparoscopic
(n=21)
Open
(n=22)
Converted
Laparoscopic
(n=21)†
Wound infection
0
1
2
Respiratory tract infection
1
1
2
Wound hematoma
1
0
0
4*
1
1
0
1
0
Clinical anastomotic leakage
Bowel obstruction
* P = 0.329 Fisher’s exact test vs. open group
† Includes the one palliative lap. APR
Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal Excision (TME)
Follow-up for Patients Having Curative Laparoscopic and Open Resections
For Rectal Cancer, Including Complete Mesorectal Excision
Laparoscopic
(n=21)
Open
(n=22)
Local recurrence
1 (5%)
1 (4.5%)*
Death (all causes)
6 (29%)
5 (23%)†
* Median follow-up was 38 (range, 6-53) months
† p=1 and † P=0.736, Fisher’s exact test
Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal
Excision (TME)
 Feasible in 50% of patients where possible
 Yields histologic and early survival and
recurrence figures comparable to open surgery
Hartley et al. DCR 2001
Laparoscopy: Total Mesorectal
Excision (TME) case control study
VARIABLE/GROUP
LAPAROSCOPIC
OPEN
P value
OPERATIVE TIME(min)
200
180
0.06
BLOOD LOSS(ml)
250
1000
<0.001
>1000 ml FLUID INTAKE
3
6
0.002
SOLID DIET (days)
4
7
0.046
HOSPITALIZATION (days)
12
19
0.007
37%
51%
N/A
ANASTOMOTIC LEAK (n)
2
2
N/A
MORTALITY(n)
0
1
N/A
MORBIDITY
Breukink, Int J Colorectal Dis 2005
Laparoscopy: Rectal Cancer
Case controlled series for LAR
N
Conversion
OR
Time
(mins)
Anastomotic
Technique
Goh, 97
OLAR
LLAR
20
20
0%
73
90
Partial TME with double
staple
Leung, 97
OLAR
LLAR
50
50
16%
150
196
Partial TME with double
staple
Schwander, 99
OLA/pr
LLA/pr
32
32
NS
209
281
LAR 19 Lap 19 Open,
APR 13 Lap 13 Open
Hartley, 01
OLA/pr
LLA/pr
22
42
50%
125
180
LAR, APR, Hartmann
Anthuber, 03
OLA/pr
LLA/pr
334
101
11%
219
218
TME with colonic J if <6cm
Breukink, 05
LAR
APR
10
31
NS
195
225
Double stapled anastomosis
Laparoscopy: Total Mesorectal
Excision (TME) case control study
VARIABLE/GROUP
LAPAROSCOPIC
OPEN
CIRCUMFERENTIAL
MARGIN(mm)
3 (2-31)
5 (2-31)
DISTAL MARGIN mm
35 (10-100)
10 (1-30)
NUMBER OF NODES
8 (1-25)
8 (2-20)
FOLLOW UP (months)
14 (2-31)
19 (2-31)
LOCAL RECURRENCE
0
0
DISTANT METASTASIS
5
5
Breukink, Int J Colorectal Dis 2005
Laparoscopy: Rectal Cancer
Case controlled series for LAR
Length of
Stay
LRM
DRM
Morbidity
Morbidity Leak
Goh, 97
OLAR
LLAR
5.5
5
clear
clear
4
4.5
5%
20%
NS
0
0
Leung, 97
OLAR
LLAR
8
6
clear
clear
NS
30%
26%
6%
2%
2%
0%
Schwander, 99
OLA/pr
LLA/pr
21
15
clear
clear
31%
31%
0%
3%
0
3%
Hartley, 01*
OTME
LTME
15
13.5
0.8
0.65
2.5
4
18%
26%
0%
0%
1
4
Anthuber, 03
OLA/pr
LLA/pr
19
14
DN
DN
54%
31%
1%
0%
7%
9%
Breukink, 05
LAR
APR
11
21
NS
3.5
37%
0
5%
Laparoscopy: Rectal Cancer
Case controlled series for APR
N
Conversion
OR Time
(mins)
Anastomotic
Technique
Seow-Chen, 97
OAPR
LAPR
11
16
NS
100
110
TME
Ramos, 97
OAPR
LAPR
18
18
10%
208
229
TME
Fleshman, 99
OAPR
LAPR
42
152
21%
209
234
Lap APR with TME
Leung, 00
OAPR
LAPR
34
25
NS
166
216
TME
Baker, 02
OAPR
LAPR
61
28
25%
NS
NS
?TME
Laparoscopy: Rectal Cancer
Case controlled series for APR
Length of
Stay
LRM
DRM
Morbidity
Mortality
Seow-Chen, 97
OAPR
LAPR
8
6.5
clear
clear
3
2
55%
25%
0%
0%
Ramos, 97
OAPR
LAPR
12.9
7.4
NS
NS
66%
44%
5.5%
0%
Fleshman, 99
OAPR
LAPR
12
7
+ in 5
+ in 19
NS
27%
33%
0%
0%
Leung, 00
OAPR
LAPR
16
25
NS
1
2
48%
61%
0%
0%
Baker, 02
OAPR
LAPR
18
13
+ in 1
3.2
4.5
-/3%
-/4%
3%
4%
Laparoscopy: Rectal Cancer
Prospective, Randomized, Controlled – Short-term outcome
of TME with anal sphincter preservation (ASP)
Open
Laparoscopic
Patients
89
82
Mean age (years)
45
44
Dukes’ Stage
A
B
C
D
6
8
68
7
5
10
63
4
Zhou, Surg Endosc 2004
Laparoscopy: Rectal Cancer
Results of Surgery
Open
(n=89)
Laparoscopic
(n=82)
56
33
48
34
Distal Margin
1.5-3.5
1.5-4.0
Sphincter preservation
100%
100%
Anastomotic height
Low anterior (>2cm from dentate)
Ultralow anterior (<2cm from dentate)
Coloanal (at or below dentate)
35
27
27
30
27
25
Diverting ileostomy
0
0
Distance of Tumor from Dentate (cm)
1.5-4cm
4.1-7cm
Zhou, Surg Endosc 2004
Laparoscopy: Rectal Cancer
Open
Laparoscopic
P
value
Operative time (min)
106
120
NS
Blood loss (ml)
92
20
0.02
Parenteral analgesics (days)
4.1
3.9
NS
Solid intake (days)
4.5
4.3
NS
Hospitalization (days)
13.3
8.1
0.001
Morbidity
Anastomotic leak
12.4%
3
6.1%
1
0.016
Mortality
0
0
NS
Port site mets
NA
2
Pelvic recurrence
3
0
Follow-up 1-16 months
Zhou, Surg Endosc 2004
Laparoscopic Sphincter-Preserving TME
with Colonic J-Pouch Reconstruction
 105 patients
 Mean follow up time 26.9 (1.3-65.6) months
Tsang WWC, Ann Surg 2006
Laparoscopic Sphincter-Preserving TME
with Colonic J-Pouch Reconstruction
 Mean operative time 170.4 min
 Mean anastomotic distance from anal verge 3.9 cm
 Mean circumferential margin 17.1 mm
 Mean distal margin 3.4 cm
Tsang WWC, Ann Surg 2006
Laparoscopic Sphincter-Preserving TME
with Colonic J-Pouch Reconstruction
 5-year cancer-specific survival rate 81.3%
 Local recurrence rate 8.9%
Tsang WWC, Ann Surg 2006
Laparoscopic Sphincter-Preserving TME
with Colonic J-Pouch Reconstruction
Conclusion
Lap TME with colonic J-pouch is a safe procedure with
reasonable operating time and does not appear to pose
any threat to the oncologic and functional outcomes
Tsang WWC, Ann Surg 2006
Laparoscopic vs. Open Surgery for
Extraperitoneal Rectal Cancer
 191 consecutive patients
 98 patients underwent lap resection
 93 patients underwent open resection
Morino M, Surg Endosc 2005
Laparoscopic vs. Open Surgery for
Extraperitoneal Rectal Cancer
Laparoscopic
n = 98
Open
n = 93
P
Mean follow up (months)
46.3
49.7
NS
Conversion rate (%)
18.4
Mobilization (days)
1.7
3.3
< 0.001
Flatus (days)
2.6
3.9
< 0.001
Stool (days)
3.8
4.7
< 0.01
Oral intake (days)
3.4
4.8
< 0.001
Hospital stay (days)
11.4
13.0
NS
Morino M, Surg Endosc 2005
Laparoscopic vs. Open Surgery for
Extraperitoneal Rectal Cancer
Laparoscopic
n = 98
Open
n = 93
P
Morbidity (%)
24.4
23.6
NS
Mortality (%)
1.0
2.2
NS
Anastomotic leakage (%)
13.5
5.1
NS
Reoperation (%)
6.1
3.2
NS
Local recurrence (%)
3.2
12.6
< 0.05
Cumulative 5-year survival rate (%)
80.0
68.9
NS
Disease-free 5-year survival rate (%)
65.4
58.9
NS
Morino M, Surg Endosc 2005
Laparoscopic vs. Open Surgery for
Extraperitoneal Rectal Cancer
Conclusion
Laparoscopic resection for low and midrectal cancer is
characterized by faster recovery and similar overall
morbidity with no adverse oncologic effect
Morino M, Surg Endosc 2005