Open Surgery For Colorectal Cancer Research Articles

Clinical analysis of open and laparoscopy-assisted surgery for colorectal cancer

Clinical analysis of open and laparoscopy-assisted surgery for colorectal cancer

The Postoperative Analgesic Efficacy of Preperitoneal Continuous Wound Infusion Compared to Epidural Continuous Infusion with Local Anesthetics After Colorectal Cancer Surgery

Open colorectal cancer (CRC) surgery induces severe and prolonged postoperative pain. The optimal method of postoperative analgesia in CRC surgery has not been established. We evaluated the efficacy of preperitoneal continuous wound infusion (CWI) of ropivacaine for postoperative analgesia after open CRC surgery in a multicenter randomized controlled trial. Candidates for open CRC surgery randomly received preperitoneal CWI analgesia or continuous epidural infusion (CEI) analgesia with ropivacaine 0.2% 10 mL/h for 48 hours after surgery. Fifty-three patients were allocated to each group. All patients received patient-controlled IV morphine analgesia. Over the 72-hour period after the end of surgery, CWI analgesia was not inferior to CEI analgesia. The difference of the mean visual analog scale score between CEI and CWI patients was 1.89 (97.5% confidence interval = -0.42, 4.19) at rest and 2.76 (97.5% confidence interval = -2.28, 7.80) after coughing. Secondary end points, morphine consumption and rescue analgesia, did not differ between groups. Time to first flatus was 3.06 ± 0.77 days in the CWI group and 3.61 ± 1.41 days in the CEI group (P = 0.002). Time to first stool was shorter in the CWI than the CEI group (4.49 ± 0.99 vs 5.29 ± 1.62 days; P = 0.001). Mean time to hospital discharge was shorter in the CWI group than in the CEI group (7.4 ± 0.41 and 8.0 ± 0.38 days, respectively). More patients in the CWI group reported excellent quality of postoperative pain control (45.3% vs 7.6%). Quality of night sleep was better with CWI analgesia, particularly at the postoperative 72-hour evaluation (P = 0.009). Postoperative nausea and vomiting was significantly less frequent with CWI analgesia at 24 hours (P = 0.02), 48 hours (P = 0.01), and 72 hours (P = 0.007) after surgery evaluations. Preperitoneal CWI analgesia with ropivacaine 0.2% continuous infusion at 10 mL/h during 48 hours after open CRC surgery provided effective postoperative pain relief not inferior to CEI analgesia.

Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer

Laparoscopic resection is used widely in the management of colorectal cancer; however, the data on long-term outcomes, particularly those related to rectal cancer, are limited. The results of long-term follow-up of the UK Medical Research Council trial of laparoscopically assisted versus open surgery for colorectal cancer are presented. A total of 794 patients from 27 UK centres were randomized to laparoscopic or open surgery in a 2:1 ratio between 1996 and 2002. Long-term follow-up data were analysed to determine differences in survival outcomes and recurrences for intention-to-treat and actual treatment groups. Median follow-up of all patients was 62·9 (interquartile range 22·9 - 92·8) months. There were no statistically significant differences between open and laparoscopic groups in overall survival (78·3 (95 per cent confidence interval (c.i.) 65·8 to 106·6) versus 82·7 (69·1 to 94·8) months respectively; P = 0·780) and disease-free survival (DFS) (89·5 (67·1 to 121·7) versus 77·0 (63·3 to 94·0) months; P = 0·589). In colonic cancer intraoperative conversions to open surgery were associated with worse overall survival (hazard ratio (HR) 2·28, 95 per cent c.i. 1·47 to 3·53; P < 0·001) and DFS (HR 2·20, 1·31 to 3·67; P = 0·007). In terms of recurrence, no significant differences were observed by randomized procedure. However, at 10 years, right colonic cancers showed an increased propensity for local recurrence compared with left colonic cancers: 14·7 versus 5·2 per cent (difference 9·5 (95 per cent c.i. 2·3 to 16·6) per cent; P = 0·019). Long-term results continue to support the use of laparoscopic surgery for both colonic and rectal cancer.

Laparoscopic surgery minimizes the surgical manipulation of isolated tumor cells leading to decreased metastasis compared to open surgery for colorectal cancer

We focused on the possible benefits of laparoscopic surgery to protect against isolated tumor cells (ITC) generated by surgical manipulation in comparison to open surgery. We performed conventional open surgery and laparoscopic surgery for 25 and 8 cases of colorectal cancer (CRC), respectively. We compared the presence of ITC in the peripheral blood (PB) immediately after surgery via quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) for a representative epithelial marker, carcinoembryonic antigen (CEA). In the 25 patients who underwent open surgery, 8 of the 10 cases with metastasis were positive for ITC in PB, while 13 of the 15 cases without metastasis were negative for ITC. Therefore, we validated that there was a significant clinical usefulness for the detection of ITC in the prediction of metastasis (p = 0.0024). We limited our subsequent analysis to the CRC cases with a Dukes stage of B or C to avoid differences due to the background, and we found that the positive ITC rate for metastasis was higher in the 19 patients who underwent open surgery (42.1 %) than in the 8 who underwent laparoscopic surgery (37.5 %). The short observation period, especially in the laparoscopic surgery group, and the inadequate number of cases limit the ability to draw any definitive conclusions; however, laparoscopic surgery appears to minimize the surgical manipulation, thus leading to reduced ITC from primary CRC compared with open surgery.

Laparoscopic-Assisted Versus Open Surgery for Colorectal Cancer: Short- and Long-Term Outcomes Comparison

Despite the theoretical advantages of laparoscopic surgery, it is still not considered the standard treatment for colorectal cancer patients because of criticism concerning oncologic stability. This study aimed at examining the short- and long-term follow-up results of laparoscopic surgery versus open surgery for colorectal cancer and at investigating clinical outcomes, oncologic safety, and any potential advantages of laparoscopic colorectal cancer resection. We retrospectively analyzed a database containing the information about patients who underwent surgery for stage I-III colorectal cancer from January 2004 to January 2012 at our institution. The patients who underwent the laparoscopic-assisted procedure showed a significantly faster recovery than those who underwent open surgery, namely, less time to first passing flatus (P=.041), time of first bowel motion (P=.04), time to resume normal diet (P=.043), and time to walk independently (P=.031). Laparoscopic colorectal surgery caused less pain for patients, leading to lower need of analgesic (P=.002) and less hospital recovery time (P=.034), compared with patients who underwent open surgery. No differences were found in 3- and 5-year overall and disease-free survival rates. Our results suggested that the laparoscopic approach was as safe as the open alternative. Laparoscopic-assisted surgery has been shown to be a favorable surgical option with better short-term outcomes and similar long-term oncological control compared with open resection.

The selective use of splenic flexure mobilization is safe in both laparoscopic and open anterior resections

Splenic flexure mobilization (SFM) is standard practice in anterior resections. No previous studies have compared outcomes with and without SFM in laparoscopic and open colorectal cancer surgery. This study aimed to determine whether routine or selective SFM should be advised. Data were collected prospectively on all elective anterior resections for cancer in our unit between October 2006 and November 2009. Of 263 resections, SFM data were recorded in 216; 138 were laparoscopic (32% with SFM, 3.6% converted) and 78 open (68% with SFM). Eighty-eight were low anterior resections (LARs) for mid-low rectal cancers, with 54 laparoscopic (50% with SFM) and 34 open (91% with SFM). Comparing laparoscopic with SFM to without, differences were found in the proportion of LARs (61%vs 29%, P<0.001), defunctioning ileostomy rates (75%vs 46%, P=0.001) and operative time (median 255 vs 185 min, P<0.001), with no differences in age, gender, body mass index, American Society of Anesthesiology score, preoperative treatment, length of stay, lymph node yield, conversion rate, mortality, anastomotic leakage, reoperation, readmission and R0 resection. No differences in outcomes were seen between laparoscopic LARs with and without SFM or between open resections with and without SFM. Our results show no disadvantage in short-term clinical or oncological outcomes when SFM was avoided. Laparoscopic anterior resections with SFM take longer. A selective approach to SFM is safe during anterior resection (open or laparoscopic), including mid-low rectal cancers.

Expert Opinion on Laparoscopic Surgery for Colorectal Cancer Parallels Evidence from a Cumulative Meta-Analysis of Randomized Controlled Trials

BackgroundThis study sought to synthesize survival outcomes from trials of laparoscopic and open colorectal cancer surgery, and to determine whether expert acceptance of this technology in the literature has parallel cumulative survival evidence.Study DesignA systematic review of randomized trials was conducted. The primary outcome was survival, and meta-analysis of time-to-event data was conducted. Expert opinion in the literature (published reviews, guidelines, and textbook chapters) on the acceptability of laparoscopic colorectal cancer was graded using a 7-point scale. Pooled survival data were correlated in time with accumulating expert opinion scores.ResultsA total of 5,800 citations were screened. Of these, 39 publications pertaining to 23 individual trials were retained. As well, 414 reviews were included (28 guidelines, 30 textbook chapters, 20 systematic reviews, 336 narrative reviews). In total, 5,782 patients were randomized to laparoscopic (n = 3,031) and open (n = 2,751) colorectal surgery. Survival data were presented in 16 publications. Laparoscopic surgery was not inferior to open surgery in terms of overall survival (HR = 0.94, 95% CI 0.80, 1.09). Expert opinion in the literature pertaining to the oncologic acceptability of laparoscopic surgery for colon cancer correlated most closely with the publication of large RCTs in 2002–2004. Although increasingly accepted since 2006, laparoscopic surgery for rectal cancer remained controversial.ConclusionsLaparoscopic surgery for colon cancer is non-inferior to open surgery in terms of overall survival, and has been so since 2004. The majority expert opinion in the literature has considered these two techniques to be equivalent since 2002–2004. Laparoscopic surgery for rectal cancer has been increasingly accepted since 2006, but remains controversial. Knowledge translation efforts in this field appear to have paralleled the accumulation of clinical trial evidence.

The quality of research synthesis in surgery: the case of laparoscopic surgery for colorectal cancer

BackgroundSeveral systematic reviews and meta-analyses populate the literature on the effectiveness of laparoscopic surgery for colorectal cancer. The utility of this body of work is unclear. The objective of this study was to synthesize all such systematic reviews in terms of clinical effectiveness, to appraise their quality, and to determine whether areas of duplication exist across reviews.MethodsSystematic reviews comparing laparoscopic and open surgery for colorectal cancer were identified using a comprehensive search protocol (1991 to 2008). The primary outcome was overall survival. The methodological quality of reviews was appraised using the Assessment of Multiple Systematic Reviews (AMSTAR) instrument. ion and quality appraisal was carried out by two independent reviewers. Reviews were synthesized, and outcomes were compared qualitatively. A citation analysis was carried out using simple matrices to assess the comprehensiveness of each review.ResultsIn total, 27 reviews were included; 13 reviews included only randomized controlled trials. Rectal cancer was addressed exclusively by four reviews. There was significant overlap between review purposes, populations and, outcomes. The mean AMSTAR score (out of 11) was 5.8 (95% CI: 4.6 to 7.0). Overall survival was evaluated by ten reviews, none of which found a significant difference. Three reviews provided a selective meta-analysis of time-to-event data. Previously published systematic reviews were poorly and highly selectively referenced (mean citation ratio 0.16, 95% CI: 0.093 to 0.22). Previously published trials were not comprehensively identified and cited (mean citation ratio 0.56, 95% CI: 0.46 to 0.65).ConclusionsNumerous overlapping systematic reviews of laparoscopic and open surgery for colorectal cancer exist in the literature. Despite variable methods and quality, survival outcomes are congruent across reviews. A duplication of research efforts appears to exist in the literature. Further systematic reviews or meta-analyses are unlikely to be justified without specifying a significantly different research objective. This works lends support to the registration and updating of systematic reviews.

Impact of conversion on outcome in laparoscopic colorectal cancer surgery.

IntroductionLong-term results after laparoscopic surgery with conversion to open surgery for colorectal cancer are seldom published.AimThe study analysed the impact of conversion of laparoscopic surgery to open resection for colorectal cancer on short- and long-term results.Material and methodsThe prospectively collected data of 469 patients with colorectal cancer in the period from 1 January 2001 to 31 December 2006 were analysed. Short- and long-term results were compared.ResultsThe relative frequency of conversion was 7%. The subgroups were statistically similar regarding age, gender, body mass index (BMI), localization of tumour, T stage, and TNM stage. We observed a lower frequency of previous surgery (p = 0.018) in the group of patients with conversions to open surgery as well as statistically significantly higher frequency of patients with American Society of Anesthesiologists (ASA) score II (p = 0.039). There was no statistical difference in morbidity, mortality, or the length of hospital stay between both the groups of patients. The operating time was significantly higher in the group of patients with conversion (p = 0.00001). There was a significantly higher blood loss in the patient groups with conversion to open surgery and in the group with primarily open surgery (p = 0.00023). There was no difference in the overall survival (p = 0.712), disease-free survival (p = 0.072) or in the local (p = 0.432) or distant (p = 0.957) recurrence.ConclusionsNo negative impact on short- or long-term results of conversion to open surgery was verified in patients with colorectal surgery.

Short-term and medium-term clinical outcomes of laparoscopic-assisted and open surgery for colorectal cancer: a single center retrospective case-control study

BackgroundLaparoscopic procedure is a rapid developed technique in colorectal surgery. In this investigation we aim at assessing the diversities of short-term and medium-term clinical outcomes of laparoscopic-assisted versus open surgery for colorectal cancer.MethodsA total number of 519 patients with non-metastatic colorectal cancer were enrolled for this study. The patients underwent either laparoscopic-assisted surgery (LAP) (n = 254) or open surgery (OP) (n = 265). Surgical techniques, perioperative managements and clinical follow-ups were standardized. Short-term perioperative data and medium-term recurrence and survival were compared and analyzed between the two groups.ResultsThere were no differences in perioperative parameters between the two groups except in regards to a trend of faster recovery in laparoscopic procedures. There was no statistically significant difference in postoperative complications, reoperation rate, or perioperative mortality. Statistically significant differences in a faster return of gastrointestinal function and shorter hospital stay were identified in favor of laparoscopic-assisted resection. In colon and rectal cancer cases separately, the overall survival, cancer-free survival and recurrence rate were similar in two groups. There was also no tendency of significant differences in overall survival, cancer-free survival and recurrence in stage I-II and stage III patients in two cancer categories between the two groups, respectively. pT, lymph node metastasis, and clinical stage were independent predictors of overall death risk, while pT, pN, lymph node metastasis and clinical stage were found to be the independent predictors of recurrence risk in enrolled patients database.ConclusionsLaparoscopic-assisted procedure has more benefits on postoperative recovery, while has the same effects on medium-term recurrence and survival compared with open surgery in the treatment of non-metastatic colorectal cancer.

Epidural Analgesia in Open Resection of Colorectal Cancer: Is there a Clinical Benefit? A Retrospective Study on 1,470 Patients

BackgroundEpidural analgesia (EA) is effective for postoperative pain relief and results in an earlier recovery from postoperative paralytic ileus. This study evaluated the influence of epidural analgesia on the postoperative 30-day mortality and morbidity after open colorectal cancer resection. MethodsA retrospective observational study was performed at a single, tertiary hospital. All patients with an open colorectal cancer surgery between 1991 and 2008 were identified from the hospital database. ResultsOf the 1,470 patients included in the study, 838 (57.0%) received an EA. Mortality was lower after EA (1.5% vs. 5.7%, p < 0.001). Risk of pneumonia was reduced after EA (odds ratio (OR), 0.45; 95% confidence interval (CI), 0.28–0.74; p = 0.001), but not the risk of anastomotic leakage (OR, 1.18; 95% CI, 0.76–1.81; p = 0.465) or surgical site infections (OR, 1.09; 95% CI, 0.74–1.60; p = 0.663). A subgroup analysis of 427 patients operated on after 2002 (reflecting improved perioperative management) yielded similar results. However, no significant reduction in mortality was observed in the subgroup analysis. ConclusionFor patients with open colorectal cancer surgery, the application of EA leads to a reduction in pneumonia. Although this is only a retrospective study, it strongly supports the use of EA.

Does epidural anesthesia and analgesia reduce mortality following open surgery for colo-rectal cancer? A retrospective analysis of data from 655 patients

Does epidural anesthesia and analgesia reduce mortality following open surgery for colo-rectal cancer? A retrospective analysis of data from 655 patients

Equivalency of Lymph Node Harvest in Laparoscopic Versus Open Colorectal Cancer Procedures

To compare the number of lymph nodes harvested in laparoscopic versus open colorectal cancer surgery early in a surgeon's career. We reviewed the data of 80 patients operated upon with a primary diagnosis of colorectal cancer between September 2006 and June 2008. All data were from a single fellowship trained colorectal surgeon. The effects of laparoscopic versus open surgery, and neoadjuvant radiation were examined to assess lymph node harvest. There was no statistically significant difference between the lymph nodes harvested during laparoscopic versus open surgery (17.4 vs 18.5; P=0.5920). The amount of lymph nodes harvested decreased with increasing American Society of Anesthesiology grade (22.4, 17.1, 19.2, 7.0 for American Society of Anesthesiology grade I, II, III, IV, respectively; P=0.0412) and with neoadjuvant radiotherapy (18.7 vs 13.2; P=0.0151). Laparoscopic colorectal cancer surgery results in the same number of lymph nodes being harvested as in open surgery.

A Meta-Analysis of the Short- and Long-Term Results of Randomized Controlled Trials That Compared Laparoscopy-Assisted and Conventional Open Surgery for Colorectal Cancer

We conducted a meta-analysis to evaluate and compare the short- and long-term results of laparoscopic colorectal surgery (LCRS) and conventional open surgery (OCRS) for colorectal cancer (CRC). We searched relevant papers published between January 1990 and May 2011. We analyzed the outcomes of each type of surgery over the short- and long-term periods. In the short-term period, we found no significant differences in overall perioperative complications and anastomotic leakage between LCRS and OCRS groups. We found no significant differences in overall, distant, local and wound-site recurrence, overall mortality, 3 and 5 year disease-free survival rate, and cancer-related mortality between the 2 groups. LCRS has the benefits of reducing intraoperative blood loss, earlier resumption of oral intake, and shorter duration of hospital stay in the short-term. The long-term outcomes of LCRS seem to be similar to those of OCRS.

Angiogenic cells, macroparticles and RNA transcripts in laparoscopic vs open surgery for colorectal cancer

Background:Angiogenesis is crucial for tissue repair and cancer progression. We investigated a panel of angiogenic cells, macroparticles and RNA transcripts before, during and after laparoscopic colectomy or open colectomy for colorectal cancer.Results:Viable and apoptotic circulating endothelial cells were significantly increased after open but not after laparoscopic colectomy (p

Outcomes after laparoscopic techniques in major gastrointestinal surgery

Despite the benefits of minimally invasive surgery, its use in oncological resections has been adopted slowly. We highlight the differences in short-term and long-term outcomes between laparoscopic and open surgery for colorectal and gastric cancer. Furthermore, we review the relevance of postoperative fast-track methodologies in improving surgical outcomes after laparoscopic resections. Numerous randomized controlled trials demonstrate equivalent short-term and long-term outcomes (including oncologic outcomes) after laparoscopic colon resection. Though recent retrospective studies demonstrate its safety in rectal and gastric cancer resection, large-scale randomized controlled trials demonstrating its safe use in this setting are pending. Additionally, evidence to support the use of fast-track postoperative care modalities in gastrointestinal surgery continues to increase. These fast-track protocols should be implemented in conjunction with laparoscopic techniques to enhance patient recovery, reduce postoperative ileus and length of hospital stay. Laparoscopic techniques are safe and at least equivalent to open surgery for colon cancer resections. Studies evaluating the role of laparoscopic techniques in rectal and gastric cancer resection are ongoing. Additionally, fast-track postoperative care methodologies improve recovery after surgery and should be applied to the clinical setting to enhance outcomes after laparoscopic surgery.

Five-year follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer

The UK Medical Research Council CLASICC trial assessed the safety and efficacy of laparoscopically assisted surgery in comparison with open surgery for colorectal cancer. The results of the 5-year follow-up analysis are presented. Five-year outcomes were analysed and included overall and disease-free survival, and local, distant and wound/port-site recurrences. Two exploratory analyses were performed to evaluate the effect of age (70 years or less, or more than 70 years) on overall survival between the two groups, and the effect of the learning curve. No differences were found between laparoscopically assisted and open surgery in terms of overall survival, disease-free survival, and local and distant recurrence. Wound/port-site recurrence rates in the laparoscopic arm remained stable at 2.4 per cent. Conversion to open operation was associated with significantly worse overall but not disease-free survival, which was most marked in the early follow-up period. The effect of surgery did not differ between the age groups, and surgical experience did not impact on the 5-year results. The 5-year analyses confirm the oncological safety of laparoscopic surgery for both colonic and rectal cancer. The use of laparoscopic surgery to maximize short-term outcomes does not compromise the long-term oncological results. ISRCTN74883561 (http://www.controlled-trials.com).

A meta-analysis of laparoscopy compared with open colorectal resection for colorectal cancer

The aim of this study was to compare the outcome of the overall complication, mortality, and recurrence rate between laparoscopic resection and open surgery for colorectal cancer. We searched the Medline, Embase, and Cochrane Library and systematically reviewed the randomized controlled trials by comparing the overall complication, mortality, and recurrence rate between laparoscopic resection and open surgery for colorectal cancer. Fifteen trials with 4,207 patients who reported long-term outcomes of the overall complication, mortality, and recurrence rate were included. The combined results of the individual trials showed no statistically significant difference in the odds ratio (OR) for overall recurrence (OR 0.92, 95% CI, 0.77-1.11, P=0.34), local recurrence (OR 0.81, 95% CI, 0.59-1.12, P=0.20), distant metastasis (OR 1.01, 95% CI, 0.78-1.30, P=0.95), wound-site recurrence (OR 1.97, 95% CI, 0.77-5.02, P=0.16), colorectal cancer-related mortality (OR 0.82, 95% CI, 0.66-1.02, P=0.07), colon cancer-related mortality (OR 0.85, 95% CI, 0.66-1.09, P=0.20), rectal cancer-related mortality (OR 0.76, 95% CI, 0.53-1.11, P=0.16), and overall mortality (OR 0.87, 95% CI, 0.73-1.73, P=0.11) between the laparoscopic surgery and open surgery groups. The overall complications in the laparoscopic surgery group were much lower than that in the open surgery group (OR 0.71, 95% CI, 0.58-0.87, P=0.001). This meta-analysis showed that the successful laparoscopic colorectal resection for colorectal cancer was as effective as open surgery in terms of the oncological outcomes, thereby suggesting that laparoscopic surgery can be continued in patients with colorectal cancer.

Authors' reply: Short-term outcomes from a prospective randomized trial comparing laparoscopic and open surgery for colorectal cancer (Br J Surg 2009; 96: 1458–1467)

Authors' reply: Short-term outcomes from a prospective randomized trial comparing laparoscopic and open surgery for colorectal cancer (<i>Br J Surg</i> 2009; 96: 1458–1467)

Letter 2: Short-term outcomes from a prospective randomized trial comparing laparoscopic and open surgery for colorectal cancer (Br J Surg 2009; 96: 1458–1467)

Letter 2: Short-term outcomes from a prospective randomized trial comparing laparoscopic and open surgery for colorectal cancer (<i>Br J Surg</i> 2009; 96: 1458–1467)