Laparoscopic Colectomy For Cancer Research Articles

Feasibility and safety of laparoscopic colorectal surgeries for patients with left ventricular assist device.

There is limited literature regarding the feasibility and safety of laparoscopic procedures in patients having mechanical circulatory support, especially colonic resections. The aim of this study is to present the case of a laparoscopic colectomy for cancer undergone in a 69-year-old patient having a HeartWare II at our institution without any postoperative major complications and to describe the perioperative management and outcome of these patients according to the literature, regarding the hemodynamic, hemorrhagic, and infectious risks and the safety of this procedure. There was no 90-day postoperative morbidity or death. A total of six patients including ours were identified in the study. This study has a limited number of patients and relatively short follow-up time. Even though the management of patients having a LVAD is challenging and needs a multidisciplinary approach, reported literatures have shown the safety and feasibility of laparoscopic interventions for colorectal surgeries.

Trainee-associated outcomes in laparoscopic colectomy for cancer: propensity score analysis accounting for operative time, procedure complexity and patient comorbidity.

Surgical trainee association with operative outcomes is controversial. Studies are conflicting, possibly due to insufficient control of confounding variables such as operative time, case complexity, and heterogeneous patient populations. As operative complications worsen long-term outcomes in oncologic patients, understanding effect of trainee involvement during laparoscopic colectomy for cancer is of utmost importance. Here, we hypothesized that resident involvement was associated with worsened 30-day mortality and 30-day overall morbidity in this patient population. Patients undergoing laparoscopic colectomy for oncologic diagnosis from 2005 to 2012 were assessed using the American College of Surgeons National Surgical Quality Improvement Program dataset. Propensity score matching accounted for demographics, comorbidities, case complexity, and operative time. Attending only cases were compared to junior, middle, chief resident, and fellow level cohorts to assess primary outcomes of 30-day mortality and 30-day overall morbidity. A total of 13,211 patients met inclusion criteria, with 4075 (30.8%) cases lacking trainee involvement and 9136 (69.2%) involving a trainee. Following propensity matching, junior (PGY 1-2) and middle level (PGY 3-4) resident involvement was not associated with worsened outcomes. Chief (PGY 5) resident involvement was associated with worsened 30-day overall morbidity (15.5 vs. 18.6%, p=0.01). Fellow (PGY>5) involvement was associated with worsened 30-day overall morbidity (16.0 vs. 21.0%, p<0.001), serious morbidity (9.3 vs. 13.5%, p<0.001), minor morbidity (9.8 vs. 13.1%, p=0.002), and surgical site infection (7.9 vs. 10.5%, p=0.006). No differences were seen in 30-day mortality for any resident level. Following propensity-matched analysis of cancer patients undergoing laparoscopic colectomy, chief residents, and fellows were associated with worsened operative outcomes compared to attending along cases, while junior and mid-level resident outcomes were no different. Further study is necessary to determine what effect the PGY surgical trainee level has on post-operative morbidity in cancer patients undergoing laparoscopic colectomy in the context of multiple collinear factors.

Impact of radiofrequency energy on intraoperative outcomes of laparoscopic colectomy for cancer in obese patients.

Nowadays laparoscopic approach is accepted as a valid alternative to open surgery for the treatment of colorectal cancer. Several studies consider this approach to be safe and feasible also in obese patients, even if dissection in these patients may require a longer operative time and involve higher blood loss. To facilitate laparoscopic approach, more difficult in these patients, several energy sources for laparoscopic dissection and sealing, has been adopted recently. The aim of this study is to investigate the possible intraoperative advantages of radiofrequency energy in terms of blood loss and operative time in obese patients undergoing laparoscopic resection for cancer. All patients who underwent laparoscopic surgery for colorectal cancer from January 2010 to December 2015 were registered in a prospective database. Patients with a body mass index BMI (kg/m2)≥30 were defined as obese, and patients with a BMI (kg/m2)<30 were defined as non-obese. All 136 obese patients observed were divided retrospectively into 2 groups according to the devices used for dissection: 83 patients (Historical group: B) on whom dissection and coagulation were performed using other energy sources (monopolar electrocautery scissors, bipolar electrical energy, ultrasonic coagulating shears) and 53 patients who were treated with electrothermal bipolar vessel sealing (Caiman group: A). In group A, the Laparoscopic Caiman 5 (Aesculap AG, Tuttlingen, Germany) was the only instrument employed in the whole procedure. The study examined only three types of operation: right colectomy (RC), left colectomy (LC), and anterior resection (AR). Preoperative data were similar for RC, LC, and AR in both groups (A and B). The mean operative time was statistically shorter in the Caiman group than in the Historical group [104 vs 124min (p 0.004), 116 vs 140min (p 0.004), and 125 vs 151min (p 0.003) for RC, LC, and AR between group A and B, respectively]. Also intraoperative blood loss results significantly lower in the Caiman group than in the historical one [52ml vs 93 for RC (p 0.003); 65 vs 120ml for LC (p 0.001); 93 vs 145ml for AR (p 0.002) between group A and B, respectively]. No intraoperative complications were recorded in either group. The mean conversion rate was 4.4% (6 patients). There were no statistical differences in intensive care unit (ICU) stay, functional outcomes, mean hospital stay and overall morbidity rate between the two groups. There was no mortality in either group. The use of the Caiman EBVS instrument shows significant advantages with respect to a small number of intraoperative parameters. We can conclude that use of this radiofrequency device, in the laparoscopic approach, offers advantages in terms of lower intraoperative blood loss and shorter operative time in obese patients with colorectal cancer.

Laparoscopic colectomy for cancer: Improved compliance with guidelines for chemotherapy and survival

Laparoscopic surgery for colon cancer has been demonstrated in clinical trials to have short-term benefits when compared to the open surgical approach. Guidelines of the National Comprehensive Cancer Network recommend that patients with stage III or high-risk stage II colon cancer undergo adjuvant chemotherapy. We hypothesized that laparoscopic colectomy is associated with increased compliance to recommendations for chemotherapy, a lesser time to start of chemotherapy, and increased overall survival. The National Cancer Data Base was queried to identify patients with stage III or high-risk stage II colon cancer (T4, positive margins, <12 lymph nodes, or high tumor grade) diagnosed 2010-2012. Patients were divided into laparoscopic colectomy and open colectomy groups. Intent-to-treat analysis was used with converted cases included in the laparoscopic colectomy group. Rates of receiving adjuvant chemotherapy, time from diagnosis and date of operation to start of chemotherapy, and overall survival were compared. A total of 48,257 patients were included for analysis; 18,801 patients underwent laparoscopic colectomy and 29,456 underwent open colectomy. Laparoscopic colectomy patients received adjuvant chemotherapy at a somewhat greater rate than open colectomy (66.2% vs 59.4%, P<.01). Among patients who received chemotherapy, mean time to start of chemotherapy after definitive resection was somewhat less for laparoscopic colectomy than open colectomy (48.7 vs 52.7days, P<.01). Two-year overall survival was greater for laparoscopic colectomy than open colectomy (81.9% vs 73.2%, P<.01). Compared to open colectomy, laparoscopic colectomy is associated with somewhat greater rates of compliance with guidelines for adjuvant chemotherapy for stage III and high-risk stage II colon cancer, as well as a slightly lesser time to start of chemotherapy and improved overall survival.

"Ultra" E.R.A.S. in laparoscopic colectomy for cancer: discharge after the first flatus? A prospective, randomized trial.

Enhanced Recovery After Surgery (E.R.A.S.) programs are now widely accepted in colonic laparoscopic resections because of faster recovery and less perioperative complications. The aim of this study was to assess safety and feasibility of discharging patients operated on by laparoscopic colectomy on postoperative day 2, so long as the first flatus has passed and in the absence of complication-related symptoms. This study was a non-inferiority, open-label, single-center, prospective, randomized study comparing "Ultra" to Classic E.R.A.S. with discharge on POD 2 and 4, respectively. Seven hundred and sixty-five patients with resectable non-metastatic colonic cancer were analyzed: 384 patients were assigned to "Ultra" E.R.A.S. and 381 to Classic E.R.A.S. Primary end-point was mortality; secondary end-points were morbidity, readmission and reoperation rate. Limitations are: it is a single-center experience; it is not double-blind, with the intrinsic risk of intentional or unconscious bias; exclusion criteria because of "non-compliance" may be considered arbitrary. Mortality was 0.89% in "Ultra" E.R.A.S. group and 0.59% in Classic E.R.A.S. (p=0.571). Morbidity was 34.1% for "Ultra" E.R.A.S. arm and 35.4% for Classic E.R.A.S. (p=0.753). Readmissions were 5.6% for "Ultra" E.R.A.S. and 5.9% for Classic E.R.A.S. (p=0.359). Reoperation rate was 3.8% for "Ultra" ERAS and 4.7% for Classic E.R.A.S. (p=0.713). Multivariate regression analyses using Cox's proportional hazard model showed that mortality (primary end-point), morbidity, reoperation and readmission (secondary end-points) were not significantly influenced by the two different perioperative regimens; conversely, the global cost of "Ultra" E.R.A.S. regimen was more economically effective. "Ultra" E.R.A.S. showed to be safe, actual and effective; discharge on postoperative day 2 after the first flatus passage, in the absence of complication-related symptoms, should be actively considered in a modern, multidisciplinary, multimodal laparoscopic management of colonic cancer.

Quality of life after laparoscopic colectomy for cancer.

Background and Objectives:This review focuses on health-related quality-of-life (HRQoL) assessment questionnaires and the influence of various parameters on HRQoL at distinct time points after laparoscopic colectomy for cancer.Methods:A PubMed electronic database literature search was conducted.Results:Twenty studies (7 prospective randomized, 5 nonrandomized, 2 retrospective, 1 matched, and 3 observational studies) used the following HRQoL tools: European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)–C30 (8 studies), EORTC QLQ-CR38 (6 studies), EORTC QLQ-CR29 (1 study), Short Form 36 (8 studies), Gastrointestinal Quality Life Index (2 studies), EuroQoL-5D (1 study), Symptoms Distress Scale (2 studies), Quality of Life Index (2 studies), and global quality of life (1 study). Long-term beneficial effects on patient HRQoL after laparoscopic colectomy for cancer have not been clearly shown compared with “open” resections. A physical function deterioration and emotional function improvement are observed during the first month. Most patients have recovered at 12 months. Distinct HRQoL domains may be affected in older, female, and chemotherapy-treated patients. HRQoL-related parameters of pain and cosmesis have been assessed in few of the current studies on hand-assisted and single-incision laparoscopic colectomy.Conclusion:Studies' heterogeneity in terms of assessment tools and time points remains as the main obstacle to establish robust conclusions. The addition of more patients and extension of the follow-up period will improve our knowledge on HRQoL changes after laparoscopic colectomy for cancer.

Immune response after laparoscopic colectomy for cancer: a review.

Background and aim: Colorectal cancer (CRC) is the third leading cause of cancer mortality worldwide and laparoscopic colectomy has been established as equivalent to the open approach in terms of oncological results and patients’ safety. Survival benefits have been reported in favor of laparoscopic colectomy (LC) in stage III CRC patients. Different immune responses after surgery, in terms of innate and cellular immunity, may potentially explain some of the reported differences. This review summarizes the literature on differences in immune response after the laparoscopic and the open approach for CRC.Materials and Methods: A literature search of electronic databases was conducted and all studies published on ‘colorectal cancer’, ‘laparoscopic and open colectomy’ ‘immune response’ and ‘surgical stress laparoscopy versus open’ were collected. Among these, the ones referring to CRC and those that had any clinical relevance offering information on perioperative parameters were used.Results: Despite the heterogeneity of studies, they support the view that innate immune response is activated to a greater degree in open colectomy (OC), which may be related to the more extensive trauma and surgical stress. On the other hand, cellular immunity is better preserved after LC. These differences are more pronounced in the immediate postoperative period.Conclusions: LC has been related to decreased up-regulation of innate immunity and better-preserved cellular immunity. The latter may be related to better anti-tumor activity and may be beneficial in terms of oncological survival in a subgroup of LC patients.

Comparative analysis of open and laparoscopic colectomy for malignancy in a developing country

To compare the short-term, including oncologic, outcomes of open vs laparoscopic colectomy for cancer in a developing country. The records of patients who underwent elective open and laparoscopic colectomies for cancer at the University Hospital of the West Indies between January 2005 and December 2010 were retrospectively reviewed. Demographic (age, gender, Charlson comorbidity index score), peri-operative, post-operative and oncologic data were collected for each patient. Specific oncologic variables included lymph node yield, pathologic stage, grade, proximal, distal and circumferential margin involvement. Fisher's exact, Mann-Whitney, and binary logistic regression tests were used for analysis. Significance level was set at P < 0.05. There were 87 cases for open colectomy (OC) and 17 cases for laparoscopic colectomy (LC). Demographics did not significantly differ between OC and LC groups. Intra-operative blood loss and post-operative analgesic requirements did not significantly differ between groups. There was a trend towards longer operating times in OC group and shorter hospital stay in the LC group. Lymph node yield (14 vs 14, P = 0.619), proximal (10 cm vs 7 cm, P = 0.353) and distal (8 cm vs 8 cm, P = 0.57) resection margin distance and circumferential margin involvement (9 vs 0, P = 0.348) did not significantly differ between groups. Thirty-day morbidity was equivalent between groups (22 vs 6, P = 0.774). There were 6 deaths within 30 d of initial procedure, all in the OC group (6.9%). Laparoscopic colectomy in a developing country is oncologically safe and represents a option for colonic malignancies in these regions. Such data encourage the continued laparoscopic development.

Single-Incision Laparoscopic Colectomy for Cancer: Short-Term Outcomes and Comparative Analysis

Introduction. Single-incision laparoscopic colectomy (SILC) is a viable and safe technique; however, there are no single-institution studies comparing outcomes of SILC for colon cancer with well-established minimally invasive techniques. We evaluated the short-term outcomes following SILC for cancer compared to a group of well-established minimally invasive techniques. Methods. Fifty consecutive patients who underwent SILC for colon cancer were compared to a control group composed of 50 cases of minimally invasive colectomies performed with either conventional multiport or hand-assisted laparoscopic technique. The groups were paired based on the type of procedure. Demographics, intraoperative, and postoperative outcomes were assessed. Results. With the exception of BMI, demographics were similar between both groups. Most of the procedures were right colectomies (n = 33) and anterior resections (n = 12). There were no significant differences in operative time (127.9 versus 126.7 min), conversions (0 versus 1), complications (14% versus 8%), length of stay (4.5 versus 4.0 days), readmissions (2% versus 2%), and reoperations (2% versus 2%). Oncological outcomes were also similar between groups. Conclusions. SILC is an oncologically sound alternative for the management of colon cancer and results in similar short-term outcomes as compared with well-established minimally invasive techniques.

Systemic inflammatory response after laparoscopic and conventional colectomy for cancer: a matched case–control study

Studies dealing with laparoscopic colectomy for cancer have reached conflicting results in regards to various inflammatory cytokines. Most of them have not examined potential differences with the open procedures at later postoperative days, when the immunologic advantage of laparoscopic surgery would be more demanding to demonstrate (for earlier administration of adjuvant treatment). The aim of this work is to detect differences of proinflammatory cytokines between conventional and laparoscopic colectomy for cancer. 30 patients who underwent laparoscopic colectomy were age, sex, and preoperative stage-matched with 30 patients treated by open surgery. C-reactive protein (CRP), interleukin (IL)-1, -6, and -8, and interferon (IFN)-γ serum levels were measured preoperatively, at 24 h, and at the 7th postoperative day (POD). CRP and IL-6 postoperative values (24 h and 7th POD) were significantly higher than baseline for both groups (p = 0.001), but the respective values at the 7th POD were less than at 24 h (p = 0.001). IL-1 and -8 levels did not show any differences between assessment timepoints. A higher IFN-γ measurement was demonstrated at 24 h compared with baseline for the laparoscopic group only (p = 0.03). This difference was not maintained at the 7th POD. IFN-γ levels at 24 h and the 7th POD were significantly less for the open compared with the laparoscopic group of patients (p = 0.001). No correlation was revealed between measured serum values and age, sex, tumor location, or stage. This matched case-control study verifies the already reported lack of differences regarding IL-1. Controversy still exists on likely IL-6 differences. The inadequately studied IL-8 does not seem to play an important role in immunologic differences. The immunologically beneficial IFN-γ, produced by the principal effectors of cell-mediated immunity Th1 cells, seems to have a more active presence following laparoscopic colectomy, potentially contributing to an immunologic "advantage" by counteracting "harmful" cytokines, such as IL-1.

Laparoscopic colectomy for colonic carcinoma

The aim of this study is to present our experience with the laparoscopic treatment approach for colonic carcinoma. Between 2005 and 2010, laparoscopic colectomy was performed in 13 patients; 9 patients underwent laparoscopic right hemicolectomy, 3 sigmoidectomy and 1 patient underwent laparoscopic caecectomy. With regards to the right hemicolectomies, the average operative time was 168 min and the average hospital stay 5.3 days. In patients who underwent laparoscopic sigmoidectomy, the average operative time was 176 min, while the average hospital stay was 10.2 days. Finally, the laparoscopic caecectomy was performed in 85 min. There was one conversion (7.7%) to an open procedure, as well as one case (7.7%) of anastomotic leakage, which was treated with re-laparotomy and a Hartmann's procedure. Up to today, all patients remain healthy with no signs of tumor recurrence. Laparoscopic colectomy for cancer, in the hands of an experienced laparoscopic surgeon, is a safe and efficient procedure.

Assessing superiority: intracorporeal versus extracorporeal anastomosis for laparoscopic colon resection

Laparoscopic colectomy for cancer or benign disease has become increasingly popular. Compared with open surgery, laparoscopic colon resection improves quality of life (QOL). With a rapid progression in laparoscopic technology and increasing surgeon’s experience, there is now a trend toward intracorporeal anastomosis during laparoscopic colectomy. Is this an evidence-based approach and does it provide significant benefits compared with conventional extracorporeal anastomosis? This question is highlighted in a report by Grams and colleagues [1] in the August issue of Surgical Endoscopy. The authors compared the short-term outcomes of 54 patients who underwent intracorporeal anastomosis with that of 51 patients in whom an extracorporeal anastomosis was performed by a single surgeon. In this retrospective study, although postoperatively, there was no significant difference in time to bowel movement between the intraand extracorporeal anastomosis groups; length of stay and perioperative morbidity were significantly reduced in the intracorporeal anastomosis group. The authors concluded that further studies will be needed to verify their findings. Indeed, the retrospective comparison of short-term QOL by small numbers of patients in each group requires further evaluation. It is likely that intracorporeal anastomosis after colon resection improves QOL outcomes, but randomized, controlled trials are the best tool for treatment decisionsmaking. In the evidence-based medicine era, requirements and rules for approving new diagnostic and therapeutics have become more intensive [2]. Compared with open surgery, laparoscopic surgery for colon cancer has been proved to improve significantly QOL outcomes by equal safety and effectiveness when it is performed by high-volume surgeons [3]. Although the level of evidence is still not as high as for colectomy, the findings in favor of laparoscopic surgery for other gastrointestinal cancers, including rectal cancer and gastric cancer, are encouraging [4–9]. Despite rapid advances in improving short-term outcomes by using the latest laparoscopic or robotic technology for patients with solid cancers [3–9], the big challenge is how to improve long-term survival or even cure these patients particularly when diagnosis is late at advanced stages of disease. Advances in cancer biology and molecular oncology and the advent of next-generation sequencing technology provide now promises for new therapeutic strategies, including both new robust biomarkers for selecting the right patients and novel targeted drugs. These biologic agents added to standard surgery, radiotherapy, and modern chemotherapy will further improve the oncological outcomes of patients with solid tumors [10–31].

Enhanced recovery program in laparoscopic colectomy for cancer

IntroductionBoth laparoscopic colectomy and application of enhanced recovery program (ERP) in open colectomy have been demonstrated to enable early recovery and to shorten hospital stay. This study evaluated the impact of ERP on results of laparoscopic colectomy and comparison was made with the outcomes of patients prior to the application of ERP.MethodsAn ERP was implemented in the authors’ center in December 2006. Short-term outcomes of consecutive 84 patients who underwent laparoscopic colonic cancer resection 23 months before (control group) and 96 patients who were operated within 13 months; after application of ERP (ERP group) were compared.ResultsBetween the ERP and control groups, there was no statistical difference in patient characteristics, pathology, operating time, blood loss, conversion rate or complications. Compared to the control group, patients in the ERP group had earlier passage of flatus [2 (range: 1–5) versus 2 (range: 1–4) days after operation respectively; p = 0.03)] and a lower incidence of prolonged post-operative ileus (6% versus 0 respectively; p = 0.02). There was no difference in the hospital stay between the two groups [4 (range: 2–34) days in control group and 4 (range: 2–23) days in ERP group; p = 0.4)]. The re-admission rate was also similar (7% in control group and 5% in ERP group; p = 0.59).ConclusionsIn laparoscopic colectomy for cancer, application of ERP was associated with no increase in complication rate but significant improvement of gastrointestinal function. ERP further hastened patient recovery but resulted in no difference in hospital stay.

Laparoscopic Total Mesorectal Excision for Rectal Cancer

Laparoscopic colectomy for cancer has been shown to be equivalent to open colectomy. Laparoscopic total mesorectal excision is feasible but remains investigational. Improvement in equipment and training for rectal dissection should result in similar outcomes to open operation for cancer in the future.

Laparoscopic anterior resection

Laparoscopic colectomy for cancer is increasingly practiced worldwide in the last 2 decades. However, due to procedural complexity, laparoscopic rectal cancer excision had not proceeded at a similar pace. This article deals with the technique of laparoscopic anterior resection. Resection of rectosigmoid or upper rectal tumors is first described, followed by the more difficult sphincter-saving total mesorectal excision. We have been using and modifying this technique of laparoscopic anterior resection for rectal cancer since 1990 s. In our recent review, the local recurrence rate was 7.4%, and the overall 5-year survival was 70%. Our data suggest laparoscopic resection for rectal cancer is safe and is the procedure of choice in selected patients.

Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial

Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial

The controversy regarding hand-assisted colorectal resection

The technique of hand-assisted colectomy was introduced in the 1990s but initially was not widely embraced by the minimally invasive community [1, 2]. However, in the past 4–6 years the popularity of hand-assisted methods has increased considerably. One reason for the surge in interest was the publication of the Clinical Outcomes of Surgical Therapy (COST) findings, which suggested that laparoscopic colectomy for cancer was associated with comparable oncological outcome and improved short-term results [3]. Many surgeons who had not been performing laparoscopic colectomy now felt it was safe to do so and, thus, began utilizing minimally invasive methods. Another important reason for the increased utilization of handassisted methods in recent years was the introduction of secondand third-generation devices that are far easier to use and are more versatile than the initial devices. As the use of hand-assisted techniques has increased, a rift has developed in the minimally invasive world regarding the appropriateness and need for hand-assisted methods. Strong proponents believe that hand-assisted methods are appropriate for all left-sided colorectal resections whereas others feel strongly that, for an experienced minimally invasive surgeon, there is no need for hand-assisted methods at all. Until recently, the relatively sparse published literature on the subject has been insufficient to settle the dispute. However, the recent multicenter randomized study presented at the 2007 American Society of Colon and Rectal Surgeons (ASCRS) meeting sheds further light on the subject. This study suggested that handassisted colectomy is associated with time savings of 33 and 57 min for left segmental colectomy and total abdominal colectomy, respectively. Importantly, the shortterm clinical outcomes of hand-assisted procedures were comparable to those obtained using straight laparoscopic methods [4]. The mean incision length for the hand-assisted group was 8.2 cm as opposed to 6.1 cm for the laparoscopic group. Despite these findings, the controversy continues. Laparoscopic ‘‘purists’’ believe that there is little or no place for hand-assisted methods because the straight laparoscopic approach results in a smaller final incision. Since the whole point of laparoscopy is to minimize abdominal wall trauma, they can find no acceptable rationale for ‘‘giving back’’ incision length to accommodate hand methods. Some feel that the abdominal wall trauma incurred with hand-assisted operations more resembles an open rather than a minimally invasive operation. They maintain that, with the proper skills and training, straight laparoscopic resections are feasible and clearly preferable to hand-assisted approaches. Straight laparoscopic proponents also worry that surgeons who exclusively learn handassisted methods will never master the two-handed technique and are not likely to cross the bridge to straight laparoscopic resection. Thus, a cadre of hand-assisted surgeons is likely to arise who will be doing a second best type of resection. Hand-assisted proponents believe that, clinically, for the majority, the recovery and morbidity of hand-assisted patients is very close to if not the same as patients that undergo straight laparoscopic resection. Further, they point out that the difference in overall incision size between the two approaches is not that great. Supporters also believe S. Stein New York Presbyterian Hospital, New York, NY, United States

Laparoscopic Colectomy for Cancer Is Not Inferior to Open Surgery Based on 5-Year Data From the COST Study Group Trial

Oncologic concerns from high wound recurrence rates prompted a multi-institutional randomized trial to test the hypothesis that disease-free and overall survival are equivalent, regardless of whether patients receive laparoscopic-assisted or open colectomy. Eight hundred seventy-two patients with curable colon cancer were randomly assigned to undergo laparoscopic-assisted or open colectomy at 1 of 48 institutions by 1 of 66 credentialed surgeons. Patients were followed for 8 years, with 5-year data on 90% of patients. The primary end point was time to recurrence, tested using a noninferiority trial design. Secondary endpoints included overall survival and disease-free survival. (Kaplan-Meier) As of March 1, 2007, 170 patients have recurred and 252 have died. Patients have been followed a median of 7 years (range 5-10 years). Disease-free 5-year survival (Open 68.4%, Laparoscopic 69.2%, P=0.94) and overall 5-year survival (Open 74.6%, Laparoscopic 76.4%, P=0.93) are similar for the 2 groups. Overall recurrence rates were similar for the 2 groups (Open 21.8%, Laparoscopic 19.4%, P=0.25). These recurrences were distributed similarly between the 2 treatment groups. Sites of first recurrence were distributed similarly between the treatment arms (Open: wound 0.5%, liver 5.8%, lung 4.6%, other 8.4%; Laparoscopic: wound 0.9%, liver 5.5%, lung 4.6%, other 6.1%). Laparoscopic colectomy for curable colon cancer is not inferior to open surgery based on long-term oncologic endpoints from a prospective randomized trial.

Laparoscopically Assisted vs Open Colectomy for Colon Cancer

To perform a meta-analysis of trials randomizing patients with colon cancer to laparoscopically assisted or open colectomy to enhance the power in determining whether laparoscopic colectomy for cancer is oncologically safe. The databases of the Barcelona, Clinical Outcomes of Surgical Therapy (COST), Colon Cancer Laparoscopic or Open Resection (COLOR), and Conventional vs Laparoscopic-Assisted Surgery in Patients With Colorectal Cancer (CLASICC) trials were the data sources for the study. Patients who had at least 3 years of complete follow-up data were selected. Patients who had undergone curative surgery before March 1, 2000, were studied. Three-year disease-free survival and overall survival were the primary outcomes of this analysis. Of 1765 patients, 229 were excluded, leaving 796 patients in the laparoscopically assisted arm and 740 patients in the open arm for analysis. Three-year disease-free survival rates in the laparoscopically assisted and open arms were 75.8% and 75.3%, respectively (95% confidence interval [CI] of the difference, -5% to 4%). The associated common hazard ratio (laparoscopically assisted vs open surgery with adjustment for sex, age, and stage) was 0.99 (95% CI, 0.80-1.22; P = .92). The 3-year overall survival rate after laparoscopic surgery was 82.2% and after open surgery was 83.5% (95% CI of the difference, -3% to 5%). The associated hazard ratio was 1.07 (95% CI, 0.83-1.37; P = .61). Disease-free and overall survival rates for stages I, II, and III evaluated separately did not differ between the 2 treatments. Laparoscopically assisted colectomy for cancer is oncologically safe.

Laparoscopic Colectomy for Cancer

Laparoscopic Colectomy for Cancer