Commentary (Beart/Ortega): Role of Laparoscopic Techniques in Colorectal Cancer Surgery

The authors have nicely reviewed many of the issues surrounding laparoscopic colon cancer surgery. However, we would like to offer a slightly different perspective on several points which they make.

As the authors point out, laparoscopic colon resection is a new, evolving technology, the role of which is unclear. The fact that one can do this operation laparoscopically does not necessarily mean that it is a good idea. In general, most authors who have published papers on this issue have found technical advantages to performing the procedure laparoscopically [1-3]. When colon resection is performed laparoscopically, it would appear that most patients have less pain, more rapid return of bowel function, shorter hospital stay, and more rapid return to full and normal functioning. However, most of these series are not randomized and may have a strong selection bias. Therefore, a randomized prospective study needs to be carried out to confirm this impression.

Physiology of Laparoscopic Resection

The physiology of laparoscopic colon resection may differ substantially from that of the open procedure. There appears to be a greater stress response during laparoscopic surgery but a more rapid return to normal stress hormone levels in the postoperative period. In addition, hypercarbia alters peripheral perfusion and cardiac output. In general, cardiac patients may tolerate a laparoscopic procedure better than when an open procedure is performed. However, the use of carbon dioxide for insufflation may make it difficult for patients with pulmonary diffusion abnormalities to maintain an adequate acid-base balance during laparoscopic surgery.

Similarly, immune function may be better preserved by laparoscopic surgery. Initial studies by Senagore and others suggest that interleukin-6 levels are maintained in a more normal range and the acute immune reaction is much less intense when the colon is removed laparoscopically than when it is removed in an open procedure [3-8]. If laparoscopic resection does minimize immunosuppression, patients may have less recurrent cancer and lower infection rates.

No Inordinate or Unusual Risks

Concerns have been raised about port site recurrences [4,9]. Although a number of these complications have been reported in the literature, only one article offers a denominator by which to judge the probable incidence of port site recurrence [10]. In this article, with a minimum of 1 year of follow-up, the incidence of port site recurrence appears to be less than 2%. Therefore, although this is an issue that needs to be evaluated, at present there is no evidence to suggest that there are inordinate or unusual risks posed by removing colon cancer laparoscopically.

Several studies have evaluated the costs of laparoscopic colon resection. In all cases, the increased intraoperative costs have been at least balanced by the decreased length of stay of the patient population. In studies in which the surgeon is more experienced and operative time is decreased, laparoscopic surgery generally is less expensive than open surgery.

In summary, this is an interesting technology that deserves to be fully explored. It would be unfortunate if isolated observations or concerns were to compromise the complete evaluation of this procedure, which is critical to determining whether it offers any advantage to patients who traditionally would undergo an open resection. The randomized prospective studies outlined by the authors should be completed, and should enjoy the support of the entire medical community, so as to answer this question as quickly as possible.

References:

1. Beart RW: Laparoscopic colectomy. Dis Colon Rectum 37(suppl):S47-S49, 1994.

2. Frazee RC, Roberts JW, Symonds RE, et al: A prospective randomized trial comparing open versus laparoscopic appendectomy. Ann Surg 219:725-731, 1994.

3. Kwok SPY, Lau WY, Li AKC: Prospective comparison of laparoscopic and conventional anterior resection (reply). Br J Surg 81:625, 1994.

4. Cirocco WC, Schwartzman A, Golub RW: Abdominal wall recurrence after laparoscopic colectomy for colon ca. Surgery 116:842-846, 1994.

5. Colacchio TA, Yeager MP, Hildebrandt LW: Perioperative immunomodulation in cancer surgery. Am J Surg 167:174-179, 1994.

6. Harmon GD, Senagore AJ, Kilbride MJ, et al: Interleukin-6 response to laparoscopic and open colectomy. Dis Colon Rectum 37:754-759, 1994.

7. Kloosterman T, Von Blomberg ME, Borgstein P, et al: Unimpaired immune functions after laparoscopic cholecystectomy. Surgery 115:424-428, 1994.

8. Patel RT, Deen KI, Youngs D, et al: IL-6 is a prognostic indicator of outcome in severe intra-abdominal sepsis. Br J Surg 81:1306-1308, 1994.

9. Nelson H: Laparoscopic and colon cancer: Is the port site at risk? A preliminary report (invited commentary). Arch Surg 129:900, 1994.

10. Ramos JM, Gupta S, Anthone GJ, et al: Laparoscopic and colon cancer: Is the port site at risk? Arch Surg 129:897-899, 1994.