|Year : 2018 | Volume
| Issue : 4 | Page : 321-334
Short- and long-term outcomes of laparoscopic-assisted surgery, mini-laparotomy and conventional laparotomy in patients with Stage I-III colorectal cancer
Chin-Fan Chen1, Yi-Chieh Lin2, Hsiang-Lin Tsai3, Ching-Wen Huang3, Yung-Sung Yeh4, Cheng-Jen Ma5, Chien-Yu Lu6, Huang-Ming Hu6, Hsiang-Yao Shih7, Ying-Ling Shih8, Li-Chu Sun8, Herng-Chia Chiu9, Jaw-Yuan Wang10
1 Department of Surgery, Division of Trauma and Critical Care, Kaohsiung Medical University Hospital; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
2 Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan
3 Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital; Faculty of Medicine, College of Medicine; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
4 Department of Surgery, Division of Trauma and Critical Care; Division of Colorectal Surgery; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
5 Department of Surgery, Division of Colorectal Surgery; Division of General and Digestive Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Kaohsiung, Taiwan
6 Department of Internal Medicine, Division of Gastroenterology, Kaohsiung Medical University Hospital; College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
7 Department of Internal Medicine, Division of Gastroenterology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
8 Department of Surgery, Nutrition Support Team; Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
9 Research Education and Epidemiology Centre, Changhua Christian Hospital, Changhua; Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
10 Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University; Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University; Department of Surgery, Division of General and Digestive Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University; Center for Biomarkers and Biotech Drugs, Kaohsiung Medical University; Research Center for Environmental Medicine, Kaohsiung Medical University; Research Center for Natural Products and Drug Development, Kaohsiung Medical University, Kaohsiung, Taiwan
|Date of Submission||12-Aug-2017|
|Date of Acceptance||15-Oct-2017|
|Date of Web Publication||3-Sep-2018|
Prof. Herng-Chia Chiu
Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, No. 100, Tzyou 1st Road,
Dr. Jaw-Yuan Wang
Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung 807
Source of Support: None, Conflict of Interest: None
Background: Three operative techniques have been used for colorectal cancer (CRC) resection: Conventional laparotomy (CL) and the mini-invasive techniques (MITs)– laparoscopic-assisted surgery (LAS) and mini-laparotomy (ML). The aim of the study was to compare the short- and long-term outcomes of patients undergoing the three surgical approaches for Stage I–III CRC resection.
Patients and Methods: This study enrolled 688 patients with Stage I–III CRC undergoing curative resection. The primary endpoints were perioperative quality and outcomes. The secondary endpoints were oncological outcomes including disease-free survival (DFS), overall survival (OS) and local recurrence (LR).
Results: Patients undergoing LAS had significantly less blood loss (P < 0.001), earlier first flatus (P = 0.002) and earlier resumption of normal diet (P = 0.025). Although post-operative complication rates were remarkably higher in patients undergoing CL than in those undergoing MITs (P = 0.002), no difference was observed in the post-operative mortality rate (P = 0.099) or 60-day re-intervention rate (P = 0.062). The quality of operation as assessed by the number of lymph nodes harvested and rates of R0 resection did not differ among the groups (all P > 0.05). During a median follow-up of 5.42 years, no significant difference was observed among the treatment groups in the rates of 3-year late morbidity, 3-year LR, 5-year LR, 5-year OS or 5-year DFS (all P > 0.05).
Conclusions: Patients undergoing CL had higher post-operative morbidities. Moreover, the study findings confirm the favourable short-term and comparable long-term outcomes of LAS and ML for curative CRC resection. Therefore, both MITs may be feasible and safe alternatives to CL for Stage I-III CRC resection.
Keywords: Colorectal cancer, conventional laparotomy, laparoscopic-assisted surgery, mini-laparotomy
|How to cite this article:|
Chen CF, Lin YC, Tsai HL, Huang CW, Yeh YS, Ma CJ, Lu CY, Hu HM, Shih HY, Shih YL, Sun LC, Chiu HC, Wang JY. Short- and long-term outcomes of laparoscopic-assisted surgery, mini-laparotomy and conventional laparotomy in patients with Stage I-III colorectal cancer. J Min Access Surg 2018;14:321-34
|How to cite this URL:|
Chen CF, Lin YC, Tsai HL, Huang CW, Yeh YS, Ma CJ, Lu CY, Hu HM, Shih HY, Shih YL, Sun LC, Chiu HC, Wang JY. Short- and long-term outcomes of laparoscopic-assisted surgery, mini-laparotomy and conventional laparotomy in patients with Stage I-III colorectal cancer. J Min Access Surg [serial online] 2018 [cited 2021 Jan 16];14:321-34. Available from: https://www.journalofmas.com/text.asp?2018/14/4/321/225850
| ¤ Introduction|| |
To date, surgery remains the mainstay of treatment for patients with colorectal cancer (CRC). Since the introduction of laparoscopic surgery (LS), mini-invasive techniques (MITs, which are performed through small incisions) have been widely applied for colorectal disease. Accumulating evidence indicates that compared with the convention open approach, these techniques have potential benefits for short-term outcomes (i.e. faster recovery).,,,,,,,,,,,,,,,,, However, LS might have limitations in CRC patients with intra-abdominal adhesions following prior abdominal surgery (PAS). Previous studies have demonstrated that a small incision is associated with earlier recovery in patients with colorectal disease. However, to date, few studies have simultaneously compared the short- and long-term outcomes of three surgical approaches, namely, laparoscopic-assisted surgery (LAS), mini-laparotomy (ML) and conventional laparotomy (CL), for CRC treatment. The present study analysed prospectively collected data of patients with Stage I–III CRC who were treated at a university hospital. The primary endpoints were perioperative outcomes, safety and late morbidity. The secondary endpoints were oncological outcomes including disease-free survival (DFS), overall survival (OS) and local recurrence (LR) in the patients with CRC undergoing radical resection through the three mentioned surgical approaches.
| ¤ Patients and Methods|| |
Patients and data sources
The study included consecutive patients who underwent elective resection of primary CRC at a single institution from August 2005 to December 2012. The institutional review board of our hospital approved this study. Patients who did not consent to the procedure, those with Stage IV disease at diagnosis, those undergoing only local or palliative resection, those undergoing abdominoperineal resection for rectal cancer, and those receiving urgent surgery were excluded because they almost exclusively underwent open surgery. Details of the eligibility criteria, pre-operative studies, preparation and operative procedures have been published previously., For CRC resection, all included patients underwent a standard resection through a LAS, an ML or a CL approach. The ML approach for CRC treatment was defined as resection performed through a skin incision ≤8 cm in length. All procedures were undertaken with curative intent (i.e., R0 resection).
The choice of operative procedure was based on a joint decision by the patients and the surgical team in clinical practice. Written informed consent was obtained from each patient regarding the choice of surgical approach. The surgical approach was converted from LAS to open resection when there was a necessity to interrupt the laparoscopic procedure and execute the surgical procedure using the conventional technique because of technical difficulties or the presence of associated intraoperative complications. Converted cases were allocated to the CL group because the key procedural steps of resection were executed through the CL approach.
The clinical data were entered prospectively into an electronic hospital-based surgical database. Demographic characteristics and perioperative outcomes were recorded. Post-operative morbidities and late complications (occurring during the 2nd month after surgery) were also recorded. Thereafter, the clinical data of the patients were obtained from the database. Post-operative morbidity was defined as a complication that led to additional treatment or procedures, therefore contributing to prolonged post-operative length of stay (PLOS). Incisional surgical site infection (ISSI) was diagnosed according to the criteria of the Centers for Disease Control and Prevention. Prolonged post-operative ileus (PPOI) was defined as ileus that persisted for more than 7 days following surgery. Prolonged PLOS was defined as a length of a post-operative inpatient stay longer than the median PLOS observed in the study. Post-operative mortality was defined as deaths occurring during the same hospitalisation or within 30 days of the primary surgery. Prospective data collection by the treating clinicians and dedicated data managers ensured the accuracy of the data.
The three groups received post-operative care following similar principles. Diet was resumed post-operatively as soon as bowel function recovered clinically. Post-operative narcotics were used according to policy of the surgical team. Patients with Stage III CRC received adjuvant chemotherapy according to the guideline of the cancer centre of the institution. Post-operative surveillance consisted of medical history, physical examination and laboratory studies of parameters including serum carcinoembryonic antigen levels. Such surveillance was conducted every 3 months for the first 2 years and then every 6 months for the subsequent 3 years. Abdominal ultrasonography was performed every 6 months. Computed tomography, chest radiography and colonoscopy were performed annually. Confirmation of recurrence required imaging studies or pathological reports. We intensively followed up these enrolled patients until April 2017, loss to follow-up, or death.
All data were analysed using the Statistical Package for the Social Sciences, version 19.0 (IBM SPSS Inc., Chicago, IL, USA). Continuous data are expressed as mean ± standard deviation. One-way analysis of variance was used to compare of continuous variables in the treatment groups. The Pearson χ2 test was used to analyse categorical data. OS was defined as the time from the date of the primary treatment to the date of death from any cause or to the date of the last follow-up. DFS was defined as the time from the date of the primary treatment to the date of recurrence or metastatic disease or the date of the last follow-up. DFS and OS were evaluated using the Kaplan–Meier method and time-to-event distributions were compared using the log-rank test. Multivariate analysis was performed with binary logistic regression or Cox regression. P < 0.05 was considered statistically significant.
| ¤ Results|| |
A total of 1005 patients underwent curative resection at the institution between August 2005 and December 2012. Of these patients, 688 were finally included in this study [Figure 1]. The study population included 406 men (59.0%) and the median age was 67 years (range, 20–103 years). A total of 233 (33.9%) and 208 resections (30.2%) were performed through the ML and CL approaches, respectively, and 247 patients (35.9%) were initially treated with the LAS approach. During surgery, 8 patients (3.2%) initially undergoing LAS were finally converted to CL. The reasons for conversion were adhesions (n = 4), advanced tumours invading adjacent organs (n = 3) and bleeding (n = 1). Although not statistically significant, the rate of conversion to open surgery was higher in the patients with a history of PAS compared with those without PAS (7.8% vs. 2.0%, P = 0.059). [Table 1] shows the baseline data of the patients. The groups showed similar demographic characteristics and pre-operative condition. However, the CL group had a higher mean body mass index, and a higher proportion of the patients in the CL group underwent PAS (all P < 0.05).
|Table 1: Demographics characteristics of the patients undergoing three surgical approaches|
Click here to view
Details of surgical approaches and histological results
As shown in [Table 2], the surgical approaches in the three groups were performed using similar procedures. The proportion of patients undergoing low anterior resection was 27.6% in the LAS group, 31.3% in the ML group and 26.9% in the CL group (P = 0.526). The mean operating times (minutes) were significantly longer in the LAS group than in the open surgery group (LAS vs. ML vs. CL, 268.91 ± 89.13 vs. 191.48 ± 63.02 vs. 197.43 ± 73.48, P < 0.001; for the patients with PAS, 259.57 ± 92.72 vs. 190.14 ± 59.77 vs. 199.14 ± 76.54, P < 0.001). The mean intraoperative blood loss (mL) during LAS was significantly less than that during open colectomy (176.07 ± 224.56 vs. 226.57 ± 212.39 vs. 276.88 ± 278.93, P < 0.001). However, no difference was observed in intraoperative transfusion requirements (12.6% vs. 13.7% vs. 13.4%, P = 0.926) or intraoperative complication rates among the groups (2.1% vs. 1.3% vs. 2.3%, P = 0.698).
|Table 2: Operation details, perioperative outcomes and histopathologic results|
Click here to view
Stage distribution and histopathologic results were comparable among the three groups [Table 2]. The proportions of patients having Stage III CRC were similar in all three groups (33.9% vs. 36.5% vs. 38.4%, P = 0.600). Furthermore, the median numbers of lymph nodes (LNs) harvested from specimens were identical in the groups (14 in each group). A positive circumferential resection margin (CRM) following rectal cancer resection was achieved in 1.4%, 0% and 0% of the patients in the LAS, ML and CL groups, respectively (P = 0.404).
The details of post-operative recovery are shown in [Table 2]. Perioperative recovery was faster in the LAS group, as reflected by the shorter PLOS (11.12 ± 13.19 days vs. 10.72 ± 5.18 days vs. 12.47 ± 7.99 days, P = 0.125). Moreover, patients undergoing LAS had a shorter time to first flatus passage, earlier resumption of normal diet, earlier return to urination and earlier ambulation achievement.
Post-operative short-term outcomes are shown in [Table 3]. Post-operative complications occurred in 185 patients (26.9%). The observed complication rates did not differ significantly between the patients undergoing rectal procedures and those undergoing colonic procedures (30.2% vs. 25.5%, P = 0.207). However, the CL group exhibited a higher incidence of overall post-operative complications (LAS vs. ML vs. CL, 25.1% vs. 21.0% vs. 35.2%; P = 0.002; for the patients with PAS, 38.3% vs. 23.3% vs. 40.0%, P = 0.073), as well as a significantly higher incidence of complications after colon cancer surgery (21.0% vs. 20.6% vs. 35.2%, P = 0.003). In addition, the converted patients had a higher post-operative complication rate than those who underwent successful LAS (62.5% vs. 25.1%, P = 0.032). After sequential analysis, no differences were observed in the occurrence of ISSI, intra-abdominal sepsis, PPOI, pulmonary or cardiac events, urinary tract infection, gastrointestinal bleeding or wound dehiscence among the groups (all P > 0.05). In this study, the most common post-operative complication was PPOI (10.8%), followed by ISSI (8.7%).
|Table 3: Post-operative morbidities, late complications and survival data|
Click here to view
No significant difference was observed in the rates of readmission for complications within 30 days of discharge (4.3% vs. 3.0% vs. 6.6%, P = 0.190) or re-intervention within 60 days of surgery (5.9% vs. 1.7% vs. 3.7%, P = 0.062). Eight re-interventions were needed for intra-abdominal sepsis, four for failure of conservative treatment for PPOI, three for wound dehiscence, three for mesenteric bleeding, three for tracheostomy for prolonged mechanical ventilation, one for a malfunctioning ileostomy, one for a colovaginal fistula, one for a perforated peptic ulcer, one for pleural effusion in the pulmonary sepsis and one for a thrombosed femoral artery.
Post-operative mortality did not differ among the three groups [Table 3]. The mortality rates of the LAS, ML and CL groups were 2.1%, 0% and 1.4%, respectively, (P = 0.099). No mortality was noted in the eight converted patients. Eight patients died in the post-operative period (6–30 days), and the overall post-operative mortality rate was 1.2%. The main cause of death was gastrointestinal bleeding (37.5%), followed by cardiovascular disease (25.0%) and pulmonary sepsis (25.0%).
Late complications during the first 3 years following surgery
During a median follow-up of 5.42 years, 105 of the 680 patients (15.3%) developed late morbidities during the first 3 years of follow-up. The overall rate of 3-year late complications did not differ among the groups (LAS vs. ML vs. CL, 15.8% vs. 13.7% vs. 16.9%, P = 0.640). Among 116 patients with late morbidities during outpatient follow-up, incisional or trocar site herniation (40.5%) was the most frequent event, followed by adhesion-related small bowel obstruction (SBO, 32.8%), anastomotic stenosis (19.8%) and fistula (9.5%).
Recurrence and survival
As presented in [Figure 2], no significant difference was observed in the OS for all stages, Stage I, Stage II or Stage III of CRC. The overall 5-year OS rate was 67.1% [Table 3], (LAS vs. ML vs. CL, 64.5% vs. 71.0% vs. 65.8%, P = 0.343). In patients with Stage II, Stage III and all stages of CRC, the DFS rates were comparable among the treatment groups. However, in patients with stage I, the DFS rate in the CL group was superior to those in the other two groups (P = 0.025). During the first 5 years of follow-up, 253 patients experienced CRC recurrence or died, accounting for the 5-year DFS rates of 54.6% (LAS), 60.8% (ML) and 58.9% (CL) (P = 0.428). For colon cancer, patients in the ML group have higher 3-year OS/DFS and 5-year OS rates than patients in the other two groups (both P < 0.05). Moreover, separate analyses for colon (P = 0.177) and rectal cancer (P = 0.415) revealed no significant differences in the 5-year DFS rate among the groups. On completion of the study, CRC recurred in 28.4% (193/680) of the patients. The 3- and 5-year recurrence rates were similar in the 3 groups (3-year rate, P = 0.716; 5-year rate, P = 0.951).
|Figure 2: Kaplan–Meier survival curve of overall survival and disease-free survival|
Click here to view
In this study, LR was the most common site of recurrence after surgery for CRC. The 3- and 5-year LR rates were 9.9% and 14.6% for the LAS group, 12.9% and 16.6% for the ML group and 12.5% and 16.4% for the CL group (3-year rate, P = 0.570; 5-year rate, P = 0.860), respectively. Similarly, the rates of incisional and trocar site recurrence were comparable among the groups (2.1% vs. 1.7% vs. 2.3%, P = 0.891).
As shown in [Table 4], multivariate analysis of post-operative morbidities revealed that the independent risk factors were Eastern Cooperative Oncology Group (ECOG) performance status (PS) 2–3 (odds ratio [OR] = 2.090, 95% confidence interval [CI], 1.037–4.211, P = 0.039), comorbidity of hypertension (OR = 1.577, 95% CI, 1.012–2.459, P = 0.044), PAS (OR = 1.892, 95% CI, 1.210–2.959, P = 0.005), hypoalbuminaemia at admission (OR = 1.786, 95% CI, 1.108–2.878, P = 0.017), CL approach (OR = 1.702, 95% CI, 1.106–2.620, P = 0.016), more intraoperative blood loss (OR = 1.991, 95% CI, 1.298–3.055, P = 0.002) and presence of intraoperative complications (OR = 10.071, 95% CI, 2.395–42.348, P = 0.002). Second, the risk factors for prolonged PLOS were a diagnosis of ileus at admission (OR = 3.422, 95% CI, 1.375–8.512, P = 0.008), ECOG PS 2–3 (OR = 2.676, 95% CI, 1.159–6.178, P = 0.021), CL approach (OR = 2.519, 95% CI, 1.630–3.891, P < 0.001) and presence of the post-operative morbidities (OR = 17.531, 95% CI, 9.897–31.050, P < 0.001). Third, multivariate analysis demonstrated that ECOG PS 2–3 (hazard ratio [HR] = 2.959, 95% CI, 1.256–6.972, P = 0.013), anaemia at admission (HR = 2.345, 95% CI, 1.005–5.470, P = 0.049), longer operating time (HR = 2.116, 95% CI, 1.066–4.201, P = 0.032) and presence of the post-operative morbidities (HR = 3.318, 95% CI, 1.660–6.633, P = 0.001) were the risk factors significantly affecting mortality during the first post-operative year. Finally, in multivariate analysis, the significant risk factors for CRC recurrence or death during the first 3 post-operative years included ECOG PS 2–3 (HR = 1.977, 95% CI, 1.303–2.999, P = 0.001), a diagnosis of ileus at admission (HR = 2.215, 95% CI, 1.380–3.555, P = 0.001), neoadjuvant chemotherapy (HR = 1.712, 95% CI, 1.092–2.684, P = 0.019), more intraoperative blood loss (HR = 1.688, 95% CI, 1.244–2.291, P = 0.001) and presence of LN metastasis (HR = 1.986, 95% CI, 1.472–2.679, P < 0.001).
|Table 4: Multivariate analysis of factors associated with (a) post-operative morbidity, (b) prolonged post-operative length of stay, (c) mortality during the first post-operative year, (d) recurrence or death during the first three post-operative years|
Click here to view
| ¤ Discussion|| |
Formation of intra-abdominal adhesions is a common consequence of abdominal surgery. In the present study, a total of 190 patients (27.6%) have a history of PAS. Consequently, adhesiolysis is a frequent part of surgery in the management of these CRC patients. However, previous studies have shown that adhesiolysis by laparoscopy can be technically difficult under certain circumstances, and can lead to inadvertent bowel injury., Therefore, open surgery (ML/CL) still plays an indispensable role in the treatment of CRC. The current study investigated the short- and long-term outcomes of three surgical approaches, namely, LAS, ML and CL. The findings support the safety and efficacy of MITs (LAS/ML) for CRC. Because of the similar distribution of CRC stages among the three groups, no bias in favour of early-stage disease was indicated. In addition, following the policy of using the same surgical team, the operative techniques were executed using the same standard procedures.
Safety of surgical approaches
This study showed that the operating time of LAS was longer than that of open surgery. Moreover, intraoperative blood loss and blood transfusion requirements during LAS were significantly less than those during open surgery. The results are consistent with those reported previously.,,,,,,,,,,,,, Because the effect of surgical experience on the operating time of LAS has been well documented, the authors believe that as surgeons gain experience, the operating time of the laparoscopic approach can be reduced gradually. Thus, the operating time of LAS can eventually be close to that of open surgery.
Although no significant difference was observed in the rates of intraoperative complications among the groups, the rates of post-operative morbidities were significantly lower in the patients undergoing MIT than in those undergoing CL. The favourable post-operative complication rate following laparoscopic resection for CRC has been well documented over the past decade.,,,,,,,,,,,,,, However, only a few studies have compared the morbidity outcome following ML and CL approaches for CRC. The present study demonstrated a superior morbidity profile after ML compared with that after CL. Therefore, this finding supports the feasibility of ML for CRC. In multivariate analysis, patients undergoing CL had a higher likelihood of developing post-operative morbidities and prolonged PLOS [Table 4]. This finding is supported by another study conducted by Bilimoria et al.
The post-operative mortality rates determined in the present study were within the reported range.,,,,,,,,,,,,,,,,,, Moreover, the three groups did not differ in terms of the post-operative mortality rate. The finding is consistent with those of previous studies [Table 5]. Our study results show that the overall 1-year mortality rate after surgery was higher in the LAS group than in the ML group. Considering the efficacy of surgical treatment for CRC, however, the 1-year mortality rates after CRC recurrence did not differ among the three groups (P = 0.488). The majority of mortalities occurring within 1 year of surgery were attributed to medical causes.
|Table 5: Comparison of perioperative outcomes and disease-free survival rate after resection of colorectal cancer through laparoscopic surgery, conventional laparotomy or mini-laparotomy approach|
Click here to view
The safety of surgical approaches for CRC resection can be measured based on the occurrence of late morbidities. There is a paucity of data pertaining to long-term complications following the three approaches for radical CRC resection. Our study revealed no difference in the rates of incisional hernia, adhesion-related SBO and overall 3-year complication among the groups. When the data for colon and rectal cancer were analysed individually, no significant difference was observed in the 3-year morbidity rates among the groups [Table 3], (colon, P = 0.225; rectum, P = 0.336). However, notably, patients with rectal cancer were more likely to develop late complications in the first 3 years following surgery than patients with colon cancer (29.5% vs. 9.6%, P < 0.001). Research has demonstrated the equivocal effects of laparoscopy on incisional hernias and adhesion-related SBO,, Our findings are consistent with the long-term results of other studies., Therefore, the results confirm that for radical resection of CRC, the safety of MIT is comparable to that of CL.
Although not statistically significant, a trend suggesting that the mean PLOS was shorter in patients undergoing MIT than in those undergoing CL (P = 0.125) was observed in this study. Furthermore, patients undergoing LAS had a first flatus, tolerated normal diet intake, and started an ambulation earlier than did those undergoing open surgery (ML/CL). The findings are supported by those of other studies,,,,,, Multivariate analysis demonstrated that the CL approach, ECOG PS 2–3, a diagnosis of ileus at admission and post-operative morbidity are the independent parameters correlated with prolonged PLOS. However, after analysing PS 0–1 patients without a diagnosis of ileus at admission or detectable post-operative complications, we still found a significantly longer mean PLOS in the open surgery group (7.39 ± 5.11 days vs. 8.92 ± 1.97 days vs. 9.49 ± 2.28 days, P < 0.001). Our findings are consistent with evidence reported by de Campos-Lobato et al., who linked open surgery with a prolonged hospital stay after analysing the data of 12269 patients. A previous study indicated that hospital stay is one of the leading cost items in surgical treatment for CRC. Therefore, a shorter LOS is expected to increase the cost efficiency within the health-care system.
Oncological quality of three surgical approaches
In this study, the distribution, stage and almost all histopathologic characteristics of the resected tumours did not differ significantly among the three approaches. For colon cancer, a slight difference may exist among the groups on the basis of the positive rates of surgical resection margins. For rectal cancer, no significant difference was observed in the risk of a positive CRM among the groups. Moreover, the three groups had identical median numbers of LNs (14 in each group) sampled during coloproctectomy [Table 2]. A study suggested that the removal of at least 12 LNs could determine the LN status reliably. Therefore, the results demonstrate that from a surgical perspective, the resection outcomes of MIT (LAS/ML) are favourable and comparable to those of CL.
Analysis of survival and local recurrence data
During a median follow-up of 5.42 years, the oncologic outcomes after surgery were similar among the groups. The efficacy of curative resection for CRC can be measured in terms of DFS. In this study, the DFS rate was higher in patients with Stage I CRC who underwent CL [Figure 2], (P = 0.025). However, no significant differences were observed among patients with all stages, stage II or stage III of CRC. The number of the Stage I cases was lower in the CL group than in the other two groups in this non-randomised study (LAS vs. ML vs. CL, 71 vs. 63 vs. 42), and this may affect the results of this study. Additional randomised controlled studies are required to identify the differences in CRC stage-specific survival. Both 5-year DFS rates and 5-year recurrence rates were comparable among the three groups in this study [Table 3]. Therefore, there was no trend toward a higher rate of recurrence among patients with stage III CRC in the LAS or ML group. This result suggests that the presence of undetected nodal metastases due to inadequate nodal resection is not a limitation of the MITs. Our finding is consistent with those of other studies, which supported the equivalence of oncologic outcomes among the different approaches for CRC.,,,,,,,,,,,,,,,
A study reported that more than 80% of LRs in patients undergoing curative resection of CRC occur within the first 3 years following surgery. This study found no significant difference in 3- or 5-year LR rates among the groups, and our finding is consistent with previous findings., Consequently, we confirm that both LAS and ML are qualified oncological approaches for CRC.
Selection bias was certainly difficult to avoid in this study. The major limitation of the study is that the patients were not blinded to the surgical approach they were allocated to receive, and the non-random assignment could have affected subjective outcomes. Second, the eight patients who required intraoperative conversion to open coloproctectomy were assigned to the CL group, and this allocation is debatable because it may affect the perioperative and long-term outcomes in the CL group.
| ¤ Conclusions|| |
Our finding demonstrates the safety of the MITs (LAS/ML) for curative resection of CRC. The study finding confirms the benefits of MITs for stage I–III CRC, as indicated by the favourable short-term outcomes, comparable oncological quality, and similar long-term outcomes. Therefore, both MITs can be feasible alternatives to CL for curative resection of CRC. Besides, ML surgery might remain some advantage in CRC patients with a history of PAS.
We would like to thank the cancer centre of Kaohsiung medical university hospital for providing the database for this research. This research was supported by grants from the Excellence for Cancer Research Center Grant through funding by the Ministry of Science and Technology (MOST-101-2314-B-037-050-MY3), and grants from Kaohsiung Medical University Hospital (KMUH99-9M07, KMUH106-6R32, KMUHS10601, KMUHS10608). The research was also supported by Kaohsiung Medical University for the Grant of Biosignature in Colorectal Cancers, Academia Sinica, Taiwan, R.O.C.(grant no.T107-001). And aim for the top University Grant, grant no. KMU-S10511.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
Nakagoe T, Sawai T, Tsuji T, Ayabe H. Use of minilaparotomy in the treatment of colonic cancer. Br J Surg 2001;88:831-6.
Leung KL, Kwok SP, Lam SC, Lee JF, Yiu RY, Ng SS, et al.
Laparoscopic resection of rectosigmoid carcinoma: Prospective randomised trial. Lancet 2004;363:1187-92.
Clinical Outcomes of Surgical Therapy Study Group, Nelson H, Sargent DJ, Wieand HS, Fleshman J, Anvari M, et al.
A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050-9.
Fleshman J, Sargent DJ, Green E, Anvari M, Stryker SJ, Beart RW Jr., et al.
Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST study group trial. Ann Surg 2007;246:655-62.
Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, et al.
Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): Multicentre, randomised controlled trial. Lancet 2005;365:1718-26.
Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AM, et al.
Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC trial group. J Clin Oncol 2007;25:3061-8.
Law WL, Lee YM, Choi HK, Seto CL, Ho JW. Impact of laparoscopic resection for colorectal cancer on operative outcomes and survival. Ann Surg 2007;245:1-7.
Hewett PJ, Allardyce RA, Bagshaw PF, Frampton CM, Frizelle FA, Rieger NA, et al.
Short-term outcomes of the Australasian randomized clinical study comparing laparoscopic and conventional open surgical treatments for colon cancer: The ALCCaS trial. Ann Surg 2008;248:728-38.
Bagshaw PF, Allardyce RA, Frampton CM, Frizelle FA, Hewett PJ, McMurrick PJ, et al.
Long-term outcomes of the Australasian randomized clinical trial comparing laparoscopic and conventional open surgical treatments for colon cancer: The australasian laparoscopic colon cancer study trial. Ann Surg 2012;256:915-9.
Kellokumpu IH, Kairaluoma MI, Nuorva KP, Kautiainen HJ, Jantunen IT. Short- and long-term outcome following laparoscopic versus open resection for carcinoma of the rectum in the multimodal setting. Dis Colon Rectum 2012;55:854-63.
McKay GD, Morgan MJ, Wong SK, Gatenby AH, Fulham SB, Ahmed KW, et al.
Improved short-term outcomes of laparoscopic versus open resection for colon and rectal cancer in an area health service: A multicenter study. Dis Colon Rectum 2012;55:42-50.
Wang XD, Huang MJ, Yang CH, Li K, Li L. Minilaparotomy to rectal cancer has higher overall survival rate and earlier short-term recovery. World J Gastroenterol 2012;18:5289-94.
Boutros M, Hippalgaonkar N, Silva E, Allende D, Wexner SD, Berho M, et al.
Laparoscopic resection of rectal cancer results in higher lymph node yield and better short-term outcomes than open surgery: A large single-center comparative study. Dis Colon Rectum 2013;56:679-88.
Kang SB, Park JW, Jeong SY, Nam BH, Choi HS, Kim DW, et al.
Open versus laparoscopic surgery for mid or low rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): Short-term outcomes of an open-label randomised controlled trial. Lancet Oncol 2010;11:637-45.
Jeong SY, Park JW, Nam BH, Kim S, Kang SB, Lim SB, et al.
Open versus laparoscopic surgery for mid-rectal or low-rectal cancer after neoadjuvant chemoradiotherapy (COREAN trial): Survival outcomes of an open-label, non-inferiority, randomised controlled trial. Lancet Oncol 2014;15:767-74.
Zhou T, Zhang G, Tian H, Liu Z, Xia S. Laparoscopic rectal resection versus open rectal resection with minilaparotomy for invasive rectal cancer. J Gastrointest Oncol 2014;5:36-45.
van der Pas MH, Haglind E, Cuesta MA, Fürst A, Lacy AM, Hop WC, et al.
Laparoscopic versus open surgery for rectal cancer (COLOR II): Short-term outcomes of a randomised, phase 3 trial. Lancet Oncol 2013;14:210-8.
Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES, et al.
A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med 2015;372:1324-32.
Kim IY, Kim BR, Kim YW. Impact of prior abdominal surgery on rates of conversion to open surgery and short-term outcomes after laparoscopic surgery for colorectal cancer. PLoS One 2015;10:e0134058.
Fleshman JW, Fry RD, Birnbaum EH, Kodner IJ. Laparoscopic-assisted and minilaparotomy approaches to colorectal diseases are similar in early outcome. Dis Colon Rectum 1996;39:15-22.
Tsai HL, Chen MJ, Yeh YS, Chen CW, Sun LC, Lu CY, et al.
Comparison of mini laparotomy with conventional laparotomy as the surgical approach in stage I-III CRC patients: Appealing outcomes. Hepatogastroenterology 2012;59:2132-6.
Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Centers for disease control and prevention (CDC) hospital infection control practices advisory committee. Am J Infect Control 1999;27:97-132.
Artinyan A, Nunoo-Mensah JW, Balasubramaniam S, Gauderman J, Essani R, Gonzalez-Ruiz C, et al.
Prolonged postoperative ileus-definition, risk factors, and predictors after surgery. World J Surg 2008;32:1495-500.
Chiu HC, Lin YC, Hsieh HM, Chen HP, Wang HL, Wang JY, et al.
The impact of complications on prolonged length of hospital stay after resection in colorectal cancer: A retrospective study of Taiwanese patients. J Int Med Res 2017;45:691-705.
Farinella E, Cirocchi R, La Mura F, Morelli U, Cattorini L, Delmonaco P, et al.
Feasibility of laparoscopy for small bowel obstruction. World J Emerg Surg 2009;4:3.
Tekkis PP, Senagore AJ, Delaney CP, Fazio VW. Evaluation of the learning curve in laparoscopic colorectal surgery: Comparison of right-sided and left-sided resections. Ann Surg 2005;242:83-91.
Sammour T, Jones IT, Gibbs P, Chandra R, Steel MC, Shedda SM, et al.
Comparing oncological outcomes of laparoscopic versus open surgery for colon cancer: Analysis of a large prospective clinical database. J Surg Oncol 2015;111:891-8.
Cianchi F, Trallori G, Mallardi B, Macrì G, Biagini MR, Lami G, et al.
Survival after laparoscopic and open surgery for colon cancer: A comparative, single-institution study. BMC Surg 2015;15:33.
Fleshman J, Branda M, Sargent DJ, Boller AM, George V, Abbas M, et al.
Effect of laparoscopic-assisted resection vs. open resection of stage II or III rectal cancer on pathologic outcomes: The ACOSOG Z6051 randomized clinical trial. JAMA 2015;314:1346-55.
Bilimoria KY, Bentrem DJ, Merkow RP, Nelson H, Wang E, Ko CY, et al.
Laparoscopic-assisted vs. Open colectomy for cancer: Comparison of short-term outcomes from 121 hospitals. J Gastrointest Surg 2008;12:2001-9.
Veldkamp R, Kuhry E, Hop WC, Jeekel J, Kazemier G, Bonjer HJ, et al.
Laparoscopic surgery versus open surgery for colon cancer: Short-term outcomes of a randomised trial. Lancet Oncol 2005;6:477-84.
Colon Cancer Laparoscopic or Open Resection Study Group, Buunen M, Veldkamp R, Hop WC, Kuhry E, Jeekel J, et al.
Survival after laparoscopic surgery versus open surgery for colon cancer: Long-term outcome of a randomised clinical trial. Lancet Oncol 2009;10:44-52.
Deijen CL, Vasmel JE, de Lange-de Klerk ESM, Cuesta MA, Coene PLO, Lange JF, et al.
Ten-year outcomes of a randomised trial of laparoscopic versus open surgery for colon cancer. Surg Endosc 2017;31:2607-15.
Liu Z, Zhou T, Yang G, Zhang G. Comparison of clinical outcomes between laparoscopic-assisted and minilaparotomy approaches for colon cancer. J Gastrointest Cancer 2017 Feb 3;doi:10.1007/s12029-017-9923-z.
Taylor GW, Jayne DG, Brown SR, Thorpe H, Brown JM, Dewberry SC, et al.
Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial. Br J Surg 2010;97:70-8.
Bartels SA, Vlug MS, Hollmann MW, Dijkgraaf MG, Ubbink DT, Cense HA, et al.
Small bowel obstruction, incisional hernia and survival after laparoscopic and open colonic resection (LAFA study). Br J Surg 2014;101:1153-9.
Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer J. Long-term outcome of laparoscopic surgery for colorectal cancer: A cochrane systematic review of randomised controlled trials. Cancer Treat Rev 2008;34:498-504.
Naguib N, Rafique H, Dhruva Rao PK, Longworth T, Soukias JM, Masoud A, et al.
A review of the incidence of iatrogenic hernia in both laparoscopic and open colorectal surgery: Using CT as the gold standard of detection, cohort study. Int J Surg 2015;19:87-90.
de Campos-Lobato LF, Alves-Ferreira PC, Wickc EC, Kiran RP, Remzi FH, Kalady MF, et al
. Risk factors for prolonged length of stay after colorectal surgery. J Coloproctol 2013;33:22-7.
Berto P, Lopatriello S, Aiello A, Corcione F, Spinoglio G, Trapani V, et al.
Cost of laparoscopy and laparotomy in the surgical treatment of colorectal cancer. Surg Endosc 2012;26:1444-53.
Tsai HL, Huang CW, Yeh YS, Ma CJ, Chen CW, Lu CY, et al.
Factors affecting number of lymph nodes harvested and the impact of examining a minimum of 12 lymph nodes in stage I-III colorectal cancer patients: A retrospective single institution cohort study of 1167 consecutive patients. BMC Surg 2016;16:17.
Yun HR, Lee LJ, Park JH, Cho YK, Cho YB, Lee WY, et al.
Local recurrence after curative resection in patients with colon and rectal cancers. Int J Colorectal Dis 2008;23:1081-7.
Ma Y, Yang Z, Qin H, Wang Y. A meta-analysis of laparoscopy compared with open colorectal resection for colorectal cancer. Med Oncol 2011;28:925-33.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]