Multicenter Comparison of Laparoscopic vs Conventional Surgery for Colorectal Cancer
Multicenter Comparison of Laparoscopic vs Conventional Surgery for Colorectal Cancer
Abstract & Commentary
William B. Ershler, MD, INOVA Fairfax Hospital Cancer Center, Fairfax, VA; Director, Institute for Advanced Studies in Aging, Washington, DC, is Editor for Clinical Oncology Alert.
Synopsis: Laparoscopic surgery is rapidly becoming more commonly used for colorectal cancer resection. The current study reports the short-term findings of a relatively large, randomly assigned comparison of laparoscopic surgery vs standard open procedure for patients with newly diagnosed colon or rectal cancer. With the exception of laparoscopic anterior resection for rectal cancer, short term markers of success were comparable. This data set, as it matures, will provide additional information that will help define the role for laparoscopically assisted surgical procedures for this disease.
Source: Guillou PJ, et al. Lancet. 2005;365:1718-1726.
Laparoscopic-assisted surgery offers a theoretical advantage of more rapid recovery, fewer complications, and shorter duration of hospital stay. Accordingly, there has been an increased adaptation of this approach for a wide variety of procedures, including the potentially curative resection of colon or rectal carcinoma. Yet, there remain little data from large-scale prospective randomized trials that would support such an approach. The current report is that of short-term results from one such trial.
Guillou and colleagues report from the UK Medical Research Council (MRC) trial of conventional vs laparoscopic-assisted surgery in colorectal cancer (CLASICC) is a randomized, controlled study undertaken by surgeons at 27 UK centers. Eligible patients were candidates for hemicolectomy (right or left), sigmoid colectomy, anterior resection, or abdominoperitoneal resection for newly discovered colon cancer. Patients were excluded if their carcinoma was in the transverse colon, if they had bowel obstruction, synchronous carcinomas, or pulmonary or cardiac disease for which pneumoperitoneum or prolonged anesthesia would introduce unacceptable additional operative risks. Using a 2:1 randomization scheme, patients were allocated to receive laparoscopic-assisted (n = 526) or open surgery (n = 268). Primary short-term end points were positivity rates of circumferential and longitudinal resection margins, proportion of Dukes’ C2 tumors, and in-hospital mortality. Analysis was by intention to treat.
The treatment groups were well balanced and the proportion of patients with Dukes C2 tumors was nearly identical (7% open, 6% laparoscopic). Similarly, in-hospital mortality was not different (5% vs 4%) and with the exception of patients undergoing laparoscopic anterior resection for rectal cancer, rates of positive resection margins were similar between treatment groups. For rectal cancer in general, positive margins were identified in 14% with open surgery and 16% with laparoscopically assisted surgery. However, for those undergoing anterior resection laparoscopically, margin positivity was greater (12% vs 6%; a trend, but not statistically significant) (95% confidence interval, -2.1 to 14.4%; P = 0.019).
In those assigned to laparoscopic surgery, 29% required intraoperative conversion to an open procedure. For the purposes of analysis, these individuals were included in the laparoscopic treatment arm (intention to treat analysis). However, they were also examined separately. Individuals who had converted procedures had a higher percentage of Dukes C2 tumors (P = 0.19, NS). The most common causes for conversion were excessive tumor fixity (ie, difficulty in removal), uncertainty of tumor clearance, and obesity. In addition, for rectal cancers specifically, some cases were converted because of anatomic uncertainty and others for inaccessibility of tumor.
In summary, Guillou et al concluded that laparoscopically assisted surgery for cancer of the colon is as safe and effective as open surgery in the short term, and likely in the long term as well. However, impaired short-term outcomes after laparoscopic-assisted anterior resection for cancer of the rectum raised enough concern that Guillou et al felt that routine use was not warranted at present.
Comment by William B. Ershler, MD
Randomized, prospective studies of laparoscopic surgery for colorectal carcinoma have been limited in number and scope. That stated, the current report, which is an early analysis of a series that will generate important long-term results in years to come, is large and well designed. Furthermore, the inclusion of patients with rectal cancer and the suggestion that those treated by laparoscopic anterior resection had a worrisome trend for increased unclear margins is an important finding, even at this preliminary stage.
The data thus far for colon cancers are quite similar to that for smaller series, for which survival data have been published. For example, Leung and colleagues just last year1 reported experience from their Hong Kong centers on 403 colon cancer patients who were randomly assigned to either laparoscopic procedure or open surgery. The 5-year survival rate for the laparoscopic group was slightly greater than that of the open resection group (76.1% vs 72.9%). However, patients in the laparoscopic resection group had a slightly lower probability of being disease free at 5 years than those in the open resection group (75.3% vs 78.3%), but neither of these findings were significant. The postoperative recovery for the laparoscopic group was significantly better, but the operative time for the laparoscopic procedure was significantly longer and the direct cost was greater. The overall morbidity and operative mortality was the same between the 2 groups. Thus, the UK experience is quite similar and Guillou et al’s prediction—that the lack of difference observed in early markers (such as tumor margins) will ultimately reflect comparable cure rates—is likely to be true. Nonetheless, although the numbers are somewhat larger, the UK trial itself will be inadequate to definitively declare equivalence.
Thus, the issue will ultimately come down to weighing the benefits of laparoscopic surgery against the risks and added costs, which may include longer periods of anesthesia and the additional training required to become procedurally competent. Regarding the benefits, short-term complications and quality of life may actually be comparable, as demonstrated in the UK trial. So, the real difference may be that of cost reduction as a result of reduced hospital stay. To this reviewer, it seems that this technical advance may ultimately be considered modest at best.
Reference
1. Leung KL, et al. Lancet. 2004;363:1187-1192.
Laparoscopic surgery is rapidly becoming more commonly used for colorectal cancer resection. The current study reports the short-term findings of a relatively large, randomly assigned comparison of laparoscopic surgery vs standard open procedure for patients with newly diagnosed colon or rectal cancer.Subscribe Now for Access
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