Assessment of laparoscopic colectomy as the standard treatment of cancer colon

Assessment of laparoscopic colectomy as the standard treatment of cancer colon

EmadAbdelateef, MD; Ahmed Kamal, MD; Hamed Abo Steit, MD;

Hisham Omran, MD; Ahmed Elnabil, MD; Haitham Elmaleh, MRCS, MD Department of General Surgery, Ain Shams University, Cairo, Egypt.

Background &  objectives:  Laparoscopic  colectomy  had  become  a  popular  choice   for treatment of cancer colon, as it is feasible, safe and provides many advantages to the patients in comparison to open colectomy  However, the adoption of the technique as the routine treatment for patients with cancer colon is still a subject of clinical trials.

Methods: 60 patients with cancer colon were randomly dividedinto 2 equal groups.  Group A patients underwent open surgery, and group B patients had laparoscopic surgery.The results of both groups were compared and statistically analyzed to identify the advantage and limitations of the laparoscopic approach.

Results:   Laparoscopic  colectomy  was associated  with longer  operative times  than  open colectomy  The outcomes of patients of the laparoscopic group  was comparable  {oncological results & recovery of bowel functions) or better (postoperative pain, wound complications and hospital stay) than the open group.

Conclusions:  Laparoscopic  resection   for cancer  colon is safe,  feasible and  has  better

recovery and comparable  oncological results than open colectomy  More analysis is needed before implementation of the technique in routine practice and training.

Introduction:

Colorectal cancer   is  the  second   leading cause of death from malignancy in the industrialized  world,   accounting  for   more than  10  per  cent  of  all  cancer  deaths.l   The only curative  treatment is operative  excision. Traditionally, this  has involved  open surgery (OS)  and  complete resection  of the  primary tumor;  however,  since  1991 laparoscopic surgery  (LS) has also been used in this context_2,3  Several    studies   have   reported the short-term advantages of LS  over  OS in the treatment of colorectal cancer, such as reduced  blood loss, a reduction in pain, more rapid recovery of bowel function, shorter hospital  stay  and  better  cosmetic results.4-6

Other clinical trials emphasized the improved long-term survival. This had led to a general agreement on laparoscopic surgery  as an alternative to  conventional open  surgery  for

colon cancer.2,7-9

However,    despite    the   theoretical advantages  of   laparoscopic  surgery,   it   is still  not  considered the  standard treatment for     colorectal   cancer     patients     due    to technical limitations or characteristics of the patients that may affect short and long-term outcomes.1o

The aim of this study is to evaluate  the utilization of laparoscopic surgery  as the standard   treatment  for   elective    cases   of cancer colon.

Methods:

The study was carried  out in Ain Shams University  Hospitals  during  the  period between   August   2011   and   October   2013. It was  a  prospective  randomized  study   in which   patients   referred   to   our  department and diagnosed as resectable  cancer  colon  on elective  base were included  in the study. The

study excluded patients who werenot candidate

Am-Shams] Surg 2014; 7(16):1-10

for laparoscopic approach as patients with extensive intraperitoneal adhesions (previous extensive abdominal surgery or previous attacks of generalized peritonitis) and patients with contraindications for insufflation (sever restrictive pulmonary diseases). The patients were assigned  randomly  to  either  Group  A (will be operated upon using open approach), or Group B (will be operated upon using laparoscopic approach).

Preoperative   preparation   of  all  patients

included complete clinical evaluation (history taking  and  physical  examination  including per  rectal  examination  (PR),  Routine laboratory investigations (CBC, coagulation profile, serum electrolytes, blood sugar level, renal and liver functions), Tumor markers (carcino-embryonic antigen (CEA) & Cancer Antigen (CA19.9)), ECG, Chest x-ray, Pelvi­ abdominal CT with contrast and colonoscopy with tissue biopsy. All patients were prepared preoperatively with prophylactic parenteral broad-spectrum antibiotics. Prophylactic measures against venous thrombosis were taken. Standard mechanical cathartic bowel preparation 2 days prior to surgery was done only in left sided or rectal tumor.

All the patients were  operated on by the

same surgical team. The goal ofthe operation in either group was to achieve radical resection with proper lymphadenectomy, so the same oncological principles were applied in both laparoscopic and open approaches. In both groups, lesions of the ascending colon were treated by Rt. Hemicolectomy, lesions of the hepatic flexure were treated by extended  Rt. Hemicolectomy, lesions of the splenic flexure were treated by Lt. hemicolectomy without resection of the sigmoid colon, and lesions of the distal descending or sigmoid colon were treated  by Lt. hemicolectomy  with resection of the sigmoid colon. Also, in both groups ligation of the vascular pedicle was done as close as possible to their origins to achieve proper nodal dissection.

The     procedure     was     performed     with

the patients under general anesthesia with endotracheal  intubation.  A nasogastric  tube was inserted to decompress the stomach and a Foley's catheter was inserted to the bladder.

The patient was put in the supine position with a 20° head-up tilt (reversed Trendelenburg position).

In group B (laparoscopic  group):  A-For Rt. or extended Rt. hemicolectomy:  The surgeon  on the  left side of the  patient with the   1st assistant   on  his  left  and  the   2nd assistant  on the opposite  side of the patient. After   establishment   of  pneumoperitonium and   insertion   of   the   ports   Figure (la), thorough exploration ofthe abdominal cavity was  done.  The omentum  was  lifted  to  the upper  part  of  the  abdomen.  Key  steps  of the procedure involved (1) Identification of Iliocolic pedicle and division after ligation using clips, (2) Medial dissection  ventral to the superior mesenteric vessels and lateral to the duodenum was done up to the transverse colon, (3) Mobilization of the hepatic flexure, (4) Lateral dissection of the ascending colon (dissection was done mainly by the LigaSure

10 mm instrument), (5) Resection of the colon

and small intestine using a linear stapler (Endo GIA), (6) Extraction of specimen through an enlargement of the camera port incision, (7) Extracorporeal    iliotransverse    anastomosis, (8) Insertion of a drain, (9) Closure of the extraction incision and port sites.

B-  For  Lt hemicolectomy:  The  surgeon stod  on the  rt. side  of the  patient  with the

1st assistant  on his left and the  2nd assistant

on  the  opposite  side  of  the  patient.  After establishment            of         pneumoperitonium                           and insertion  of the ports  Figure (2a),  thorough exploration  of the abdomen  was done.  Key steps  of the  procedure  involved  (1)  Medial dissection   under   inferior   mesenteric   vein (IMV)  up  to  the  level  of  transvers  colon, then  the  vein  was  clipped  and divided  (2) Dissection of inferior mesenteric artery, then it was clipped and divided (3) Mobilization of the splenic flexure, (4) Division of gastro colic ligament,  (5) Lateral  dissection  of the descending  colon  (and  sigmoid  if  needed) (dissection was done mainly by the LigaSure

10  mm  instrument),   (6)  Resection   of  the

colon using  a linear  stapler  (EndoGIA),  (7) Extraction  of  specimen  through  a left  iliac or suprapubic incision, (8) Extracorporeal iliotransverse   anastomosis  and  in  cases  of

Figure {1): Rt. Hemicolectomy: a- port sites, b- extraction incision, c- extracted specimen. d- after closure of the port sites.

Site of the Lesion

Figure   {2):  Lt.  Hemicolectomy:  a-   port sites, b & c- extraction incision & extracted specimen. d- after closure of the port sites.

Post Opertative Complication Rate

16

14

12

10

8

4

2

0

Group A                                         Group 8

aRt.Colon   aLt.Colon

Type of Operation

16

14

12

10

8

6

0

GroupA                                           GroupS

25

20

15

10

0

4

3.5

3

2.5

1.5

1

0.5

0

GroupA                                          GroupS

aNone •Yes

Post Operative Complications Types

GroupA                                           GroupS

a Rt. hemicolectomy  a ExtendedRt. hemkolectomy   aLt.hoemiccfe<:tomy

Figures {3,4): The distribution of the site of lesion and operative management in the study group.

sigmoid resection it was done by circular stapler, (9) Insertion of a drain, (10) Closure of the extraction incision and pmt sites.

lngroupA(opengroup): lt. hemicolectomy,

awoundInfection  aWounddehiscence •leakage     aChestinfe«ion

Figures {5,6): The rate and types of postoperative complications in the study group.

It. or extended It. hemicolectomy were done according to the standard technique.

Postoperatively, the patients were observed for vital data, need of analgesia, return of

Table (1): Showing the preoperative characteristics of the study group.

DM: Diabetes mellitus, HTN: Hypertension, S: Significant, HS: Highly Significant, NS: None

Significant.

Tables (2&3): The type of operative management and the results of intraoperative parameters for each group.

Tables (4): Showing postoperative data.

Type of complication    Group A                       Group B                      P value

Frequency    Percent     Frequency   Percent

None                              21                 70            25                83.3         <0.05 (S)

Overall                          9                   30             5                   16.7 complications

Wound Infection           4                    13.3         2                  6.7           <0.01(HS) Wound dehiscence                      1                  3.3           0                   0

Leakage                         2                   6.7           2                  6.7           >0.05(NS)

Chest infection              2                   6.7           1                  3.3           >0.05(NS) Recurrence                    0                   0              0                  0              >0.05(NS) Total                              30                 100         30                100

Need for

Period of            Full oral           Hospital           parenteral      LNs harvested ileus(days)      intake(days)       stay(days)          analgesia           (number)

Variable

(days)

Group  Group  Group  Group  Group  Group  Group  Group  Group  Group

A          B           A           B         A           B           A          B         A           B

Mean                  2.6        2.1       3.9         3.2       9.6

Std. Deviation    0.7        0.9        1.6         1.1       1.8

7.1         3.5       2.3       12.6      11.1

0.5         0.8       0.5       0.7        0.9

Minimum           2           2          3            3          5           5          3           2           8          7

Maximum          6           5          8           7           15

9            7           5          26         25

P value               >0.05(NS)          >0.05(NS)         <0.01(HS)         <0.05 (S)           >0.05(NS)

bowel  functions  and  wound  complications. The patients were discharged  after return of normal  bowel functions,  drain removed  and any complication ruled out. The patients had follow up visits 1 week after discharge, one month and three months later. The oncological results     were      assessed     by     pathological examination  of  reception  margins,  number of harvested lymph nodes and any evidence of recurrence  after  3 months  using contrast enhanced CT scan of the abdomen and pelvis.

Analysis   of   data   was   done  by   SPSS (statistical program for social science version

21) as follows: Description of qualitative variables as number and percentage and quantitative ones as means ± standard deviation. Chi-square test was used to compare the groups as regard qualitative variable.  Fisher  exact  probability  test  was used instead of chi-square when one expected cell or more <5.

Unpaired   t-test   was   used   to   compare two  groups  as  regard  quantitative  variable

in  parametric  data  (SD<50%  mean).  Mann

Whitney  test  was used  instead  of  unpaired t-test  in  non-parametric   data  (SD>50% mean).

Results:

The study included 60 patients with cancer colon (30 in each group), all patients had there operative  management  done and  completed the follow-up period.

An analysis of the preoperative characteristics (age, gender, associated comorbidities,   BMI,   ASA  score   and   the site of the colonic lesion) of both open and laparoscopic groups was done at first to make sure that they did not affect the outcomes of the study. The analysis had shown that there was no statistically significant difference between the two groups regarding the preoperative characteristics. The preoperative characteristics of the patients in both groups are shown in Table (1).

The operation was carried using the open

Am-Shams] Surg 2014; 7(16):1-10

approach in group A and the laparoscopic approach in group B. All laparoscopic cases were  completed   without  conversion.  There were no intraoperative visceral injuries in all cases. Analysis ofthe intraoperative parameters between both groups had shown that there was a statistically significant difference between both groups regarding the operative time with open times being shorter than the laparoscopic ones (45-60 minutes). At same time, there was no statistically significant difference between both groups regarding the intraoperative blood loss  and  need  for  transfusion.  Tables (2,3) shows the type of operative management  and the  results  of  intraoperative  parameters  for each group.

Analysis  of  the  postoperative  parameters was done. There was a statically significant difference   between   both   groups   regarding the overall postoperative complication rate. Analysis ofthe individual complication types showed a highly significant  difference  in the rate of wound related complications (infection and dehiscence)  in the favor  of laparoscopic group. At the same time, there was no statistically   significant   difference   between both groups regarding the rest of complication types   (leakage  and  chest  infection).  There was no statistically significant difference between both groups regarding the period of postoperative ileus and the time needed to achieve full oralintake. There was a statistically significant difference between both groups regarding the need of postoperative analgesia (in favor oflaparoscopic group), and there was a highly significant difference between both groups  regarding the  period  of hospital  stay (in  favor  of laparoscopic  group).  Regarding the oncological results, resection free margins were achieved in all cases of both groups and there  was no detectable  cases  of recurrence in both groups through the study. There was no statistically significant difference between both groups regarding the number of resected lymph nodes. Postoperative parameters are shown in Table (4).

Discussion:

Since its introduction, laparoscopic colorectal  surgery, started to gain acceptance

and it is gradually becoming the preferable approach  for  performing  colonic  resections in many centers.9  However, despite the theoretical advantages oflaparoscopic surgery, it is still not considered the standard treatment for colorectal cancer patients due to technical limitations  or  characteristics  of  the  patients that may affect short and longterm outcomes.l o This had made the adoption of laparoscopic colorectal surgery as the standard approach under many investigation and trials. Our study aims to address the question if laparoscopic approach can be used as standard operative approach for colonic cancer in our hospital.

Our   study   included   only   patients   who

are candidate for both approaches. It is well documented that some patients are not suitable for the laparoscopic approach (e.g. those with extensive intraabdominal  adhesions and those with contraindications for insufflation),ll and eliminating them from the study helps to avoid any bias in the study group, which may affect the  results.  The  statistical   analysis  of  our study groups revealed no difference regarding the preoperative characteristics of the study groups, this also makes the study results more accurate and representative.

Regarding  the  operative  parameters,  we

found    no    significant   difference    between open and laparoscopic groups regarding intraoperative  blood  loss  or  requirement  of blood transfusion. The available literature revealed that laparoscopic colectomy is associated with the same or less intraoperative blood loss than open surgery.l2 The operative time recorded  in the  laparoscopic  group was significantly  longer  than  in the  open  group. Most published studies had reported the same trend  although  recent  studies  had  reported no difference or a less significant difference, mostly due to the growing experience and familiarity with the technique.l3,14

Regarding   the   postoperative    outcomes, our  study   showed  a  significant   difference in  postoperative   complications   in  favor  of laparoscopic group mainly due to the increase in  wound   related   complications,   although there  was  no  difference   in  other  types  of complications. Regarding recovery, there was

shorter hospital stay mainly due to less need

in-   ams     urg       ;

for  analgesia  and  less  wound  complications in the laparoscopic group, but there was no difference   regarding the  period  of  ileus  or time taken to achieve full oral intake. These results  are consistent with the published literature  which  had  highlighted that laparoscopic  colectomy  is  associated  with less  post-operative pain,  earlier  resumption of normal  diet, shorter hospitalstay and better overall  recovery_l5 Oncological outcomes were comparable between both groups, tumor free resection  was achieved  in all cases, there were  no  recorded cases   of  recurrence  and no difference  in number  in harvested lymph nodes between  both groups.  The same results were  shown   previously  in  literature   which stated  that  laparoscopic colectomy achieved a comparable result to open  colectomy regarding the outcomes.l6

The results of our study shows that laparoscopic  colectomy  has   short-term results  that are comparable or better to  open colectomy in cases of cancer colon. However, our study did not include cost analysis,  which needs  to  be investigated, and  leaves  a lot to be  addressed regarding the  implementation of laparoscopic colectomy in routine  practice and training programs.

Conclusion:

Our results show that laparoscopic resection for  cancer  colon  is safe, technically feasible and has better recovery and comparable oncological results  to open colectomy. More analysis  is needed to address the cost benefit, long-term results  and  implementation of the technique to routine  practice  and training.

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