Laparoscopic Versus Open Resection

Steve Wexner

Powerpoint File

Introduction:

Since the first minimally invasive colon resection 17 years ago, laparoscopic colectomy has been implemented as techniques have evolved. Like the laparoscopic approach for other operations, minimally invasive colectomy has potential benefits of improved short-term outcomes – postoperative pain, postoperative ileus, morbidity, short-term quality of life, hospital stay - and cosmesis. Questions have been raised, however, regarding its use for colorectal cancer resection. Until recently, it was unclear whether minimally invasive surgery for colonic malignancies would achieve adequate oncologic resection. The role of laparoscopy as a safe and adequate technique in rectal cancer surgery was also a debatable issue, but supporting data in its favor are slowly accumulating.

Laparoscopy for colon cancer:
Numerous studies have compared the laparoscopic and open approaches in the surgical treatment of colon cancer, but the two studies that were instrumental in shifting the paradigm in favor of the laparoscopic approach were the COST and COLOR studies (1,2). The COLOR study emphasized the short-term advantages of laparoscopy, and the COST study established the oncologic adequacy of laparoscopy.

The COST study:

This trial was a multi-institutional North-American (US and Canada) trial conducted in 48 centers. 872 patients with adenocarcinoma of the colon were randomly assigned to undergo open or laparoscopically assisted colectomy performed by credentialed surgeons. The median follow-up was 4.4 years. The primary end point was the time to tumor recurrence. At three years, the rates of recurrence were similar in the two groups -16% among patients in the group that underwent laparoscopically assisted surgery and 18% among patients in the open-colectomy group (p=0.32). Recurrence rates in surgical wounds were less than 1% in both groups (p=0.50). The overall survival rate at three years was also very similar in the two groups (86% in the laparoscopic-surgery group and 85% in the open-colectomy group; p=0.51), with no significant difference between groups in the time to recurrence or overall survival for patients with any stage of cancer. Perioperative recovery was faster in the laparoscopic-surgery group than in the open-colectomy group, as reflected by a shorter median hospital stay (five days vs. six days, p<0.001) and shorter use of parenteral narcotics (three days vs. four days, p<0.001) and oral analgesics (one day vs. two days, p=0.02). The rates of intraoperative complications, 30-day postoperative mortality, complications at discharge and 60 days, hospital readmission, and reoperation were very similar between the 2 groups. The investigators concluded that the laparoscopic approach is an acceptable alternative to open surgery for colon cancer.

The COLOR study:

This study was a multi-institutional European trial conducted in 29 centers. 627 patients were randomly assigned to laparoscopic surgery and 621 patients to open surgery. The primary endpoint was cancer-free survival 3 years after surgery. Secondary outcomes were short-term morbidity and mortality, number of positive resection margins, local recurrence, port-site or wound-site recurrence, metastasis, overall survival, and blood loss during surgery. Patients who underwent laparoscopic resections had less blood loss compared with patients who underwent open resection (p<0.0001), although laparoscopic surgery lasted 30min longer than did open surgery (p<0.0001). Conversion to open surgery was needed for 91 (17%) patients undergoing the laparoscopic procedure. Laparoscopic colectomy was associated with earlier recovery of bowel function (p<0.0001), need for fewer analgesics, and with a shorter hospital stay (p<0.0001) compared with open colectomy. Morbidity and mortality 28 days after colectomy did not differ between groups. The investigators concluded that laparoscopic surgery can be used for safe and radical resection of cancer in the right, left, and sigmoid colon.
The short-term advantages of laparoscopic surgery for colorectal cancer were further demonstrated in a meta-analysis of 25 randomized controlled trials (3). Operative time was longer in laparoscopic surgery, but intraoperative blood loss was less than in conventional surgery. Intensity of postoperative pain and duration of postoperative ileus was shorter after laparoscopic colorectal resection and pulmonary function was improved after a laparoscopic approach. Total morbidity and local (surgical) morbidity was decreased in the laparoscopic groups. General morbidity and mortality was not different between both groups. Until the 30th postoperative day, quality of life was better in laparoscopic patients. Postoperative hospital stay was shorter after laparoscopic surgery than after laparotomy.

Laparoscopy for rectal cancer:

Because definitive long-term results are not yet available, the oncological safety of laparoscopic surgery for treatment of rectal cancer remains controversial. However, laparoscopic total mesorectal excision (TME) for rectal cancer has been proposed to have several short-term advantages in comparison with open TME. These advantages were assessed in a recent meta-analysis (4). Randomized controlled trials (RCT), controlled clinical trials and case series were included; 48 studies, representing 4224 patients were analyzed. As only one RCT described primary outcome, 3-year and 5-year disease-free survival rates, no meta-analyses could be performed. No significant differences in terms of disease-free survival rate, local recurrence rate, mortality, morbidity, anastomotic leakage, resection margins, or recovered lymph nodes were found. There is evidence that laparoscopic TME results in less blood loss, quicker return to normal diet, less pain, less narcotic use and less immune response. It seems likely that laparoscopic TME is associated with longer operative time and higher costs. The authors concluded that based on evidence mainly from non-randomized studies, laparoscopic TME appears to have clinically measurable short-term advantages in patients with primary resectable rectal cancer.
The long-term impact on oncological endpoints awaits the findings from large, on-going international, randomized trials. In the meantime the technique continues to be employed.

References:

Clinical Outcomes of Surgical Therapy (COST) study group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004 May 13;350(20):2050-9.
Colon Cancer Laparoscopic or Open Resection (COLOR) study group. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol. 2005 Jul;6(7):477-84.
Schwenk W, Haase O, Neudecker J, Müller JM. Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD003145.
Breukink S, Pierie J, Wiggers T. Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005200.