There is sufficient level I evidence to support and even recommend laparoscopy as the surgical modality of choice for colon cancer resection. Laparoscopy offers improved short-term outcomes and at least equivalent long-term oncologic outcomes when compared with open resection. Laparoscopic rectal cancer surgery remains investigational. Short-term results from a large multinational randomized trial suggest that laparoscopy is not inferior to open total mesorectal excision with regard to completeness of resection and short-term morbidity and mortality. It is necessary to await the long-term oncologic results of current studies before embracing laparoscopic proctectomy for rectal cancer.
Key points
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Laparoscopic surgery should be offered to appropriate patients undergoing colectomy for colon cancer, as oncologic outcomes are equivalent to those following open surgery.
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Laparoscopy for colon cancer offers faster gastrointestinal recovery and shorter duration of hospital stay compared with open surgery.
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Laparoscopic proctectomy for rectal cancer is being studied. Oncologic data are not yet available, but short-term outcomes are at least equivalent to open proctectomy.
Introduction
Colorectal cancer is the third most common malignancy and the third most common cause of cancer-related death in the United States. Surgical resection remains the primary treatment modality for resectable disease, and the surgical management of colon and rectal cancer has evolved over the past 2 decades. Laparoscopy for colon surgery was originally reported in 1991 by Fowler and White. Since that time, considerable controversy has surrounded the application of laparoscopic techniques for colon and rectal cancer. Despite an abundance of randomized trial evidence that laparoscopy is oncologically equivalent to and offers short-term benefits over open colectomy for colon cancer, laparoscopy remains underused. Early data suggest that short-term benefits are also realized for rectal cancer, but robust long-term oncologic data are not yet available. Laparoscopy in the pelvis is technically challenging and whether laparoscopic proctectomy for rectal cancer is ready for prime time remains to be determined. Robotic rectal dissection may overcome many of the challenges of laparoscopy.
It has been suggested that only approximately 9% of colectomies for colon cancer were being performed laparoscopically in the United States between 2005 and 2007. An administrative review of 48 hospitals in the northwest United States showed that there was no increase in the percentage of colon cancer operations performed laparoscopically between 2005 and 2010. Similar findings were reported recently using data from the National Inpatient Sample in which only 6.7% of colon cancer cases were being done laparoscopically. The reasons for this perceived lack of acceptance are not known. Lack of training and/or experience with the technique, as well as persistent concerns about the oncologic adequacy of the technique are likely the 2 major contributing factors. There is also evidence that database reviews underestimate the percentage of patients undergoing laparoscopy for colon cancer. With improved coding, Fox and colleagues reviewed data from the National Inpatient Sample and determined that more than 40% of colon cancer operations are now done laparoscopically. We review the available evidence for the laparoscopic technique for colon and rectal cancer.
Introduction
Colorectal cancer is the third most common malignancy and the third most common cause of cancer-related death in the United States. Surgical resection remains the primary treatment modality for resectable disease, and the surgical management of colon and rectal cancer has evolved over the past 2 decades. Laparoscopy for colon surgery was originally reported in 1991 by Fowler and White. Since that time, considerable controversy has surrounded the application of laparoscopic techniques for colon and rectal cancer. Despite an abundance of randomized trial evidence that laparoscopy is oncologically equivalent to and offers short-term benefits over open colectomy for colon cancer, laparoscopy remains underused. Early data suggest that short-term benefits are also realized for rectal cancer, but robust long-term oncologic data are not yet available. Laparoscopy in the pelvis is technically challenging and whether laparoscopic proctectomy for rectal cancer is ready for prime time remains to be determined. Robotic rectal dissection may overcome many of the challenges of laparoscopy.
It has been suggested that only approximately 9% of colectomies for colon cancer were being performed laparoscopically in the United States between 2005 and 2007. An administrative review of 48 hospitals in the northwest United States showed that there was no increase in the percentage of colon cancer operations performed laparoscopically between 2005 and 2010. Similar findings were reported recently using data from the National Inpatient Sample in which only 6.7% of colon cancer cases were being done laparoscopically. The reasons for this perceived lack of acceptance are not known. Lack of training and/or experience with the technique, as well as persistent concerns about the oncologic adequacy of the technique are likely the 2 major contributing factors. There is also evidence that database reviews underestimate the percentage of patients undergoing laparoscopy for colon cancer. With improved coding, Fox and colleagues reviewed data from the National Inpatient Sample and determined that more than 40% of colon cancer operations are now done laparoscopically. We review the available evidence for the laparoscopic technique for colon and rectal cancer.
Colon cancer
Operative and Short-Term Outcomes
Level I evidence from 4 large multicenter (often multinational) randomized trials consistently suggest that patients undergoing laparoscopic and open colon cancer surgery have equivalent rates of perioperative morbidity and mortality. The operative outcomes and short-term results of these 4 trials are reported in Tables 1 and 2 .
| Trial | Assigned Group | No. of Patients | Conversion Rate (%) | Operative Time (min) | Estimated Blood Loss (mL) | Lymph Node Count |
|---|---|---|---|---|---|---|
| COST | Laparoscopy | 437 | 21 | 150 | — | 12 |
| Open | 435 | 95 | — | 12 | ||
| CLASICC | Laparoscopy | 273 | 29 | 180 | — | 12 |
| Open | 140 | 135 | — | 14 | ||
| COLOR I | Laparoscopy | 621 | 17 | 145 | 100 | 10 |
| Open | 627 | 115 | 175 | 10 | ||
| ALCCaS | Laparoscopy | 298 | 15 | 158 | 100 | 13 |
| Open | 294 | 107 | 100 | 13 |
| Trial | Assigned Group | No. of Patients | Time to 1st BM (d) | Duration of Hospital Stay (d) | 30-d Morbidity (%) | 30-d or In-Hospital Mortality (%) |
|---|---|---|---|---|---|---|
| COST | Laparoscopy | 437 | 3 | 5 | 21 | 0.5 |
| Open | 435 | 4 | 6 | 20 | 0.9 | |
| CLASICC | Laparoscopy | 273 | 5 | 9 | 26 | 4 |
| Open | 140 | 6 | 9 | 27 | 5 | |
| COLOR I | Laparoscopy | 621 | 3.6 | 8 | 21 | 1 |
| Open | 627 | 4.6 | 9 | 20 | 2 | |
| ALCCaS | Laparoscopy | 298 | 4 | 10 | 38 | 1.4 |
| Open | 294 | 5 | 11 | 45 | 0.7 |
Multiple meta-analyses and systematic reviews have been performed to combine the short-term outcomes of available randomized controlled trials (RCTs) for laparoscopic versus open colon cancer resection. Tjandra and Chan evaluated 17 randomized trials with a combined 4013 patients. They found no significant differences in overall and surgery-specific morbidity, anastomotic leak rates, reoperation rates, and quality of oncologic resection. Operative times were prolonged in the laparoscopic group. Additionally, laparoscopy was associated with lower 30-day mortality, fewer wound complications, lower surgical blood loss, and decreased pain scores, with an associated lower requirement for narcotic analgesia. Bowel function and oral diet were earlier, and duration of hospital stay was shorter by 1.7 days in the laparoscopic group. A Cochrane database review included 25 randomized trials. They found an increased operative time in the laparoscopic group; the open group had higher blood loss, higher pain scores, longer duration of ileus, and longer length of stay. Overall morbidity and surgery-specific morbidity were also improved in the laparoscopic group. Nonsurgical morbidity and mortality were not different. An additional systematic review of 19 trials showed no difference in the number of lymph nodes harvested or in the completeness of surgical resection.
Long-Term Oncologic Outcomes
All 4 of the major randomized trials have reported long-term oncologic outcomes for a minimum of 3 years. There were no differences in overall or disease-free survival ( Table 3 ).
| Trial | Assigned Group | No. of Patients | Recurrence (%) | Port-Site Recurrence (%) | Disease-Free Survival (%) | Overall Survival (%) |
|---|---|---|---|---|---|---|
| COST | Laparoscopy | 437 | 19 a | 0.9 a | 69 a | 76 a |
| Open | 435 | 22 | 0.5 | 68 | 76 | |
| CLASICC | Laparoscopy | 273 | 11 a | 2.4 a | 58 a | 56 a |
| Open | 140 | 9 | 0.5 | 64 | 63 | |
| COLOR I | Laparoscopy | 621 | — | 1.3 b | 74 b | 82 b |
| Open | 627 | — | 0.4 | 76 | 84 | |
| ALCCaS | Laparoscopy | 298 | 14 a | — | 72 a | 78 a |
| Open | 294 | 15 | — | 72 | 76 |
Bonjer and colleagues confirmed no difference in survival outcomes when the Clinical Outcomes of Surgical Therapy (COST), Colon Cancer Laparoscopic or Open Resection (COLOR I), and Conventional Versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC) trials were combined in a meta-analysis. Other meta-analyses and systematic reviews have combined data from additional single-institution randomized trials and have come to the same conclusion.
One randomized study from Barcelona, Spain, compared 111 patients undergoing laparoscopy for colon cancer with 108 undergoing open colectomy. The investigators found that patients in the laparoscopic group had better oncologic outcomes, including lower recurrence rates and improved overall and cancer-specific survival. The differences in this trial were primarily attributable to patients with stage III disease, and these results were not duplicated in larger RCTs.
A Cochrane review of 12 RCTs (3346 patients) comparing laparoscopic and open resection for colorectal cancer reported that in addition to comparable survival and local recurrence rates between groups, there were no differences in the number of reoperations for hernias or adhesions.
Initial concerns were raised about the possibility of higher numbers of port-site and wound recurrences in laparoscopic resections. Long-term follow-up studies have shown no difference in the rate of port-site recurrences between patients undergoing laparoscopic and open colon cancer surgery. The rate of port-site recurrence was estimated to be 0.6% in a large retrospective study.
It should be noted that most of the RCTs included surgeons with vast laparoscopic experience in high-volume hospitals. Some of the trials used technical credentialing techniques before surgeon approval to enroll patients. Whether the noncredentialed surgeon can achieve the same results is still debated, but recent literature suggests that the answer is yes. McKay and colleagues described short-term outcomes following laparoscopic versus open surgery for colon and rectal cancers in a population-based study in the western zone of Sydney, Australia. The catchment area encompassed 6 hospitals and 36 surgeons. This was a consecutive, nonrandomized series that included 1938 patients undergoing operations over an 8-year period. Specimen adequacy was similar between the open and laparoscopic groups. Conversion rates were low at 6.5% for colon and 8.3% for rectal resection. There were no differences between the open and laparoscopic groups with regard to anastomotic leak, sepsis, reoperation rates, and 30-day mortality. Duration of hospital stay was 7 days in the laparoscopic group and 10 days in the open group. Overall complication rates were lower in the laparoscopic group (32% vs 57%). This study suggests that the benefits seen in the large randomized trials at specialized centers can be translated to the general population of surgeons who have been adequately trained in laparoscopic colon and rectal surgery.
To summarize, data from randomized trials and from single institutions confirms the safety and oncologic adequacy of laparoscopic surgery for the treatment of colon cancer. In view of the easier and faster recovery, laparoscopic resection should be the preferred approach for colon cancer.
Rectal cancer
Short-Term Outcomes
The CLASICC trial also included patients with rectal cancer. The investigators found no differences in short-term morbidity or mortality, and the laparoscopic group had a shorter length of hospital stay (by 2 days). Positive circumferential radial margins (CRMs) occurred in 12% of the laparoscopic anterior resection group versus 6% of the open group; for abdominoperineal resections, positive CRMs occurred in 20% of the laparoscopic group and 26% of the open group. The conversion rate to open surgery was high at 34%. It should be noted that preoperative pelvic imaging was not routinely performed in this trial, and this may have influenced the conversion rate.
The European COLOR II trial recently reported their short-term outcomes. The trial was performed at 30 hospitals across 8 countries between 2004 and 2010. A total of 1103 patients were randomized to laparoscopic (n = 739) or open surgery (n = 364). No significant differences were seen in completeness of resection, positive CRM rates, morbidity, or mortality. The laparoscopic group experienced lower blood loss, longer operative times, faster return of bowel function, and shorter length of stay. The oncologic results are pending and will likely be reported in the next 2 years.
Systematic reviews and meta-analyses have shown advantages for the laparoscopic groups with regard to wound infection rates, overall morbidity, and length of stay. Aziz and colleagues found no difference in CRM positivity between the laparoscopic and open groups. Multiple authors have reported no difference in lymph node counts when comparing laparoscopic and open rectal cancer resection.
The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) study evaluated 5240 patients undergoing proctectomy for rectal cancer (19.2% were performed laparoscopically and the remainder were performed open). Laparoscopy resulted in fewer blood transfusions, longer operative times, shorter length of hospital stay (by 2 days), and less morbidity (21% vs 29%). Obese patients had more complications in both groups.
The largest single-institution retrospective review of 579 patients undergoing laparoscopic proctectomy for cancer showed a CRM positivity rate of 2%. Two randomized trials comparing laparoscopic and open proctectomy have found CRM positivity rates of 2.6% to 4.0% in the laparoscopic arms. Others have reported a more complete mesorectal fascia following laparoscopic total mesorectal excision (TME) than those undergoing open TME.
Tables 4 and 5 summarize the short-term and operative outcomes for the major randomized trials and meta-analyses.
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