Laparoscopic Colectomy May Prove Equivalent to Open Surgery

CHICAGO—Laparoscopic colec-tomy increasingly is being performed for colorectal cancer, and, despite concerns about wound tumor implantation, it may be only a matter of time before this type of minimally invasive surgery is shown to be equivalent to open surgical resection, said Heidi Nelson, MD, associate professor of surgery, Mayo Clinic, at the annual scientific meeting of the American College of Surgeons.

Laparoscopic colectomy for colorectal cancer is becoming more common because it causes less postoperative pain and ileus, and reduces the length of hospitalization and total charges. In Dr. Nelson’s practice, laparoscopic right colectomy has reduced postoperative requirements for narcotics by 50% and cut the hospital stay by 3.1 days.

The procedure also, however, has been associated with a high rate of cancer recurrence at the trocar site in some studies. In fact, Dr. Nelson said, “the most alarming issue that has caused concern with the introduction of laparoscopic surgery is in the area of colorectal cancer treatment.”

The incidence of recurrence of colorectal cancer at the trocar site, or wound tumor implantation, following laparoscopic colectomy ranges from 0% to 21% in the surgical literature.

“It is not clear whether this is a lasting issue and is intrinsic to the process of doing minimally invasive surgery or a consequence of the learning curve,” she said. The fact that some surgeons can perform the procedure with a 0% to 1% wound tumor implantation rate, which is comparable to that accomplished with open surgery, “gives us hope this is something we can work on and reduce with time,” she added.

To ensure that it was safe to proceed with their trial of laparoscopy vs open colectomy, Dr. Nelson’s group conducted a retrospective pretrial survey of 372 colon cancer patients who had been treated by the consortium of surgeons involved in the trial. The survey uncovered only a 1.1% rate of colorectal cancer recurrence at the trocar site, which is comparable to the recurrence rate with open surgery, and an overall local recurrence rate of 3.5% after a 22-month follow-up.

Five other international trials currently are assessing the rates and types of colorectal cancer recurrence, short- and long-term outcomes, overall safety, quality of life, and cost of laparoscopic and open colectomy. Until the results of these trials are reported in 2001, the effect of laparoscopic colectomy on the frequency of recurrence of colorectal cancer will not be known.

Dr. Nelson nevertheless predicts that laparoscopic colectomy may eventually be proved to be just as good as open surgery. “Data in 1997 are conclusive that laparoscopic colectomy for benign conditions is feasible, safe, and reasonable. It is a viable alternative to the open procedure, and there is no doubt about the patient-related benefits that can be realized,” she said.

She noted that although it isn’t possible as yet to draw firm conclusions, there is mounting evidence from uncontrolled trials that laparoscopic colectomy and open surgery are probably going to be equivalent, “and that is the information that the current trials will provide.”