Laparoscopic vs. Conventional Resections for Colorectal Carcinoma 2LT Pil (Pete) Kang New York University School of Medicine 28 September 2000

Colorectal Cancer: Epidemiology Second leading cause of death from cancer in the United States Estimated 138,000 new cases (70% in colon and 30% in rectum) per year 55,000 related deaths per year Risk factors: personal/family hx, IBD, HNPCC, FAP, diet (high fat, low fiber)

Clinical Signs & Symptoms Right Colon: n Unexplained weakness/anemia n Occult blood in feces n Dyspeptic symptoms n Persistent right abdominal discomfort n Palpable abdominal mass

Clinical Signs & Symptoms Left Colon: n Change in bowel habits n Gross blood in stool n Obstructive symptoms Rectum (20-30% of CR Ca): n Rectal bleeding n Change in bowel habits n Sensation of incomplete evacuation n Palpable tumor during rectal exam

Colorectal Cancer: Diagnosis Physical Exam n Rectal exam with test for occult blood Labs n CBC, LFTs (AlkPhos), Calcium n Carcinoembryonic antigen (CEA)

Colorectal Cancer: Diagnosis Barium enema n “Apple core” lesions n Filling defect

Colorectal Cancer: Diagnosis Future: n virtual colonoscopy? Colonoscopy n Allows biopsy n Invasive Fenlon et al., NEJM Nov 1999; 341 (20)

Staging of Colorectal Cancer DukesStage T NM 0TisN0M0 AIT1N0M0 AIT2N0M0 B1IIT3N0M0 B2IIT4N0M0 CIIIAny TN1M0 CIIIAny TN2/3M0 DIVAny TAny NM1

Stage I & II Colorectal Cancers Treatment: Surgical resection n Colectomy n Low Anterior Resection (>12cm from AV) n Abdominoperineal Resection (<7-8cm from AV) Stage I & II (T1 & T2): surgical resection only Stage II (T3 & T4): surgery + clinical trials of systemic chemotherapy Stage II rectal: post-op radiation therapy

Stage III Colorectal Cancers Treatment: Surgical resection Adjuvant therapy: n 5-FU and levamisole n Clinical trials n Radiation therapy for rectal cancer

Stage IV Colorectal Cancers n Palliative resection to prevent obstruction/perforation n Diversion if unresectable n Resection of solitary liver metastasis n Chemotherapy

Outcome of Patients with Colorectal Cancer Sabiston, Textbook of Surgery, 15 th ed.

Colorectal Cancer: Survival by Stage Survival (%) Stage Crude 5-year 1 Mayo 2-year 2 Australia 2-year 2 I II6092/8882 III IV : Way, LW. Current Surgical Diagnosis & Treatment, 10 ed. 2: Poulin, et al. Ann Surg 1999;229(4)

Oncologic Principles of Colorectal Resection Evaluation of abdominal cavity for local/distant metastases Wide excision of tumor with at least 5cm and 2cm proximal and distal margins Control/resection of lymphovascular pedicle(s) and involved soft tissues

Anatomical Considerations

Laparoscopic Colon Surgery n Natural extension of experience gained in laparoscopic cholecystectomy n Benign diseases – colorectal polyps, rectal prolapse – diverticular disease, stomas – cecal/sigmoid volvulus – IBD

Laparoscopic Colorectal Cancer Surgery (LCCS) A: Port sites for right-sided lesions B: Umbilical extraction site, extracorporeal ligation of vessels and resection of bowel, extraction through wound protector C: Extracorporeal anastomosis Poulin, et al. Ann Surg 1999;229(4)

Laparoscopic Colorectal Cancer Surgery (LCCS) A: Port sites for left-sided lesions B: Intracorporeal ligation of vessels and bowel resection, specimen bagged C: Intracorporeal anastomosis Poulin, et al. Ann Surg 1999;229(4)

Laparoscopic Surgery: Potential Advantages n Overall cost-effectiveness, better short- term outcomes (immediate post-op) n Lower postoperative mortality rate (pts>70 y.o.; pts w/ comorbid factors; pts w/ metastases) n Better biologic response to injury/SIRS n Better long term survival (???)

Laparoscopic Surgery: Potential Drawbacks n Inadequate for tumor localization, identification of anatomy, mesentery resection, high vessel ligation, resection margins n Tumor cell seeding (port-site, wound) n Embolization of exfoliated cells (related to pneumoperitoneum)

Current Issues n Is laparoscopic resection for colorectal cancer oncologically sound? –Adequate margins & lymph node assessment –Comparable recurrence/survival rates n Do laparoscopic resection techniques have any short-term advantages?

Hartley et al., Ann Surg 2000 Aug;232(2) n Prospective comparative trial; UK n 114 pts  minimum 2-year follow-up of 109 pts n Recurrent disease: 25% of pts total LAP: 16/57 (28%)CON: 11/52 (21%) n Crude death rates: LAP: 26/57 (46%)CON: 24/52 (46%) n Wound metastases: LAP: 1CON: 3 No port metastases

Disease Recurrence Rates: 24 months StageLAP (57)CON (52) Overall1012 I0/12 (0%)0/10 (0%) II2/20 (10%)3/15 (20%) III7/22 (32%)9/21 (43%) IV1/3 (33%)0/6 (0%) Differences between groups not statistically significant

Overall Survival: 24 months LAP: solid CON: dotted (+’s are censored data) Hartley et al., Ann Surg 2000 Aug;232(2)

Survival rates at 24 months StageLAP (57)CON (52) Overall4335 I11/12 (92%) 10/10 (100%) II16/20 (80%) 12/15 (80%) III15/22 (68%) 10/21 (48%) IV1/3 (33%)3/6 (50%) Differences between groups not statistically significant

Psaila et al., Br J Surg 1998 May;85(5) n Prospective comparative trial n 54 pts; LAP 25, CON 29  median follow-up of 28 months n Mean hospital stay (days): LAP: 10.7CON: 17.8(P=0.001) n Mean morphine requirements: LAP<CON n Adequate margins achieved n Number of lymph nodes harvested similar n No port site or wound recurrence

Milsom et al., J Am Coll Surg 1998 Jul;187(1) n Prospective, randomized trial in one surgery department (Cleveland Clinic) n Patients: LAP: 55 (42 w/ Ca)CON: 54 (38 w/ Ca) Median follow-up: 1.5/1.7 years n Recovery of 80% of FEV1, FVC (POD): LAP: 3CON: 6(P=0.01) n Morphine requirements up to POD#2 (mg/kg/d): LAP 0.78 ± 0.32CON: 0.92 ± 0.34(P=0.02) n Flatus (POD): LAP: 3CON: 4(P=0.006)

Milsom et al., J Am Coll Surg 1998 Jul;187(1) n Cancer-related deaths: LAP: 3CON: 4 n Postoperative complications: 15% in both groups LAP: pneumonia (1), peritonitis, PE (1), MI (1), CHF(2), death (1) CON: dehiscence (1), pneumonia (1), PE (1), Afib (1), death (1) n Hospital length of stay: LAP: 6.0CON: 7.0(P=0.16) n Tumor margins clear in all patients n No port-site recurrence in LAP group

Summary n Recurrence/survival of both LAP and CON groups at 2 years of follow-up to be equivalent n Equivocal data on possible short-term advantages n Need randomized, controlled multi- center study with larger number of pts and longer follow-up period