Laparoscopic surgery for Colo-rectal cancer
Laparoscopic surgery for curable colorectal cancer has until very recently proved very controversial, particularly in the UK. Things however are changing. There is now a good level of evidence suggesting that the laparoscopic approach should be used if there is sufficient surgical expertise.
"Laparoscopic colectomy for curable cancer results in equivalent cancer related survival to open colectomy when performed by experienced surgeons. Based upon the COST trial, pre requisite experience should include at least 20 laparoscopic resections with anastomosis for benign disease or metastatic colon cancer before using the technique to treat curable cancer. Hospitals may base credentialing for laparoscopic colectomy for cancer on experience gained by formal graduate medical educationl training or advanced laparoscopic experience, participation in hands on training courses and outcomes".
Clinical Outcomes of Surgical Therapy Study Group N. Engl.J.Med 2204; 350: 2050-2059
Endorsed by the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) & European Association of Endoscopic Surgery (EAES)
Bristol Laparoscopic Associates believe that laparoscopic cancer surgery can be offered to the majority of patients. We believe that age and relative obesity are no longer contraindications to laparoscopic resection. Laparoscopic surgery in the hands of an expert takes no longer to perform than a conventiuonal open operation. In our experience this type of surgery is actually quicker to perform.
In our current practice a preoperative CT scan will be requested to check on the size/position of the cancer and for any sign of the cancer having invaded other local structures or already spread. This could affect the decision for surgery as the finding of metastases/spread decreases the chance of cure. In this case symptoms and patient choice affect the final decision.
When surgery is performed, the section of bowel containing the tumour is removed along with the surrounding blood vessels and lymph nodes (this resection is exactly the same as in open surgery). These lymph nodes and will be checked for signs of cancer.
The depth of tumour invasion of the bowel wall (Dukes' stage A or B), the presence of lymph node metastases (Dukes' C) and/or the presence of distant metastases (Stage D) will provide information on prognosis/survival. The survival curves beolow are based upon our 10 years experience of treating 1,260 patients with colorectal cancer.
Recently, Lacey et al., published the results of their single centre randomised trial on laparoscopic curative resection. In this study of 219 patients, 111 underwent laparoscopoc colectomy. A significantly better 3-year cancer related survival was found in the laparoscopic group (91% vs 79%). Follow-up data of large multicentre trials eg CLASSIC, COST & COLOR will provide a more definitive assessment of survival. We believe that ultimately, laparoscopic results will be shown to be superior.
Lacey AM et al., Laparoscopy assisted colectomy v open colectomy for treatment of non metastatic colon cancer: a randomised trial. Lancer 2002; 359: 2224-2229.