Laparoscopic vs Open Colonic Surgery: Long Term Survival Tarik Sammour

Laparoscopic colectomy is increasingly being utilized for the treatment of colon cancer worldwide, and in many centres is now the primary procedure offered.

Laparoscopic Colectomy PROS CONS Reduced day stay (1 day) Less pain / ileus Better cosmesis Longer OT time Higher cost Learning curve Unresolved Issue And with good reason: Level one evidence for improved short term outcome. Oncological outcomes and overall long-term survival have also been shown to be equivalent, but this is primarily in the setting of tightly controlled randomised trials that enrolled highly selected patients. Excluded patients with transverse colon, synchronous or large tumours; advanced local disease, patients with a higher body mass index (BMI) or comorbidities, and even patients who have had any other malignant disease in the past. Prospective data from large institutional databases need to be reported, to further interrogate the oncological safety of laparoscopic colectomy. Long term oncological outcomes? Equivalence in RCTs / Cochrane review 2012 But…patients (and surgeons) very highly selected Remains a need for real world clinical data

So far only administrative data has been published.

Methods Prospectively collected clinical data 2003 – 2009 Linkage + analysis resources of BioGrid Australia 5 year follow-up Inclusions: Patients > 15 years Colon cancer resections Exclusions: Emergency resections (most performed open)

Statistics Cox regression survival analysis, using the Enter method (SPSS v20) Covariates controlled: Age, sex, BMI, ASA Hospital site, operation ACPS stage, post-op chemotherapy Year surgery performed Conversions analysed as intention to treat

Results 1387 patients underwent resection for colon cancer 226 emergency resection 55 no access method recorded 1106 patients included in analysis 560 (50.6%) laparoscopic (conversion rate 11%) 546 (49.4%) open Proportion of cases done laparoscopically increased over time

7% in 2003 to 67% in 2009

Baseline characteristics   Laparoscopic (n = 560) Open (n = 546) P Value Age Median years (IQR) 71 (16) 69 (17) 0.828 Sex Male Female 51.6% 48.4% 53.1% 46.9% 0.630 BMI Median (IQR) 27.0 (6.1) 26.4 (6.6) 0.262 ASA score I II III IV 11.4% 33.6% 3.4% 13.2% 55.5% 28.2% 3.1% 0.249 Hospital funding Public Private 74.5% 25.5% 71.4% 28.6% 0.279 Procedure R hemicolectomy Extended R hemicolectomy Transverse colectomy Left hemicolectomy High Anterior resection Hartmann’s Total colectomy 39.1% 5.0% 0.5% 8.4% 42.0% 1.3% 3.8% 39.6% 11.2% 0.9% 6.6% 33.1% 2.2% 6.4% <0.0001 Stoma performed Loop ileostomy End colostomy End ileostomy 5.8% 4.3% 0.2% 9.7% 2.4% 0.7% 0.071

Post-op parameters Laparoscopic (n = 560) Open (n = 546) P Value   Laparoscopic (n = 560) Open (n = 546) P Value Length of Hospital Stay Median days (IQR) 7 (4) 8 (5) <0.0001 Post-operative Complication Total per patient Total events Anastomotic leak Prolonged ileus Wound infection Cardiopulmonary DVT / PE Urinary tract infection / retention Other 34.1% 45.6% 3.2% 6.6% 5.0% 11.8% 1.1% 7.7% 5.9% 38.8% 53.8% 2.9% 11.0% 4.8% 12.5% 1.3% 7.5% 8.4% 0.105 0.007 0.862 0.011 0.890 0.782 0.787 1.000 0.262 ACPS stage A B C D 25.2% 31.8% 31.3% 19.4% 37.0% 25.6% 27.9% 0.001 Number of nodes examined Median (IQR) 14 (8) 0.142 Adjuvant chemotherapy Yes No 30.5% 69.5% 28.8% 71.2% 0.554 5 year survival 30 day Overall Cancer specific 0.71% 75.9% 82.7% 1.6% 69.2% 78.3% 0.172 0.015 0.074 5 year local recurrence 5.1 vs 6.6%, P = 0.357

5 year Overall Survival (Corrected) χ2 1.302 P 0.254

5 year Cancer Specific Survival (Corrected) χ2 0.028 P 0.866

Conclusion This study validates the results of previous randomised controlled trials. Confirms no difference in survival outcome between laparoscopic and open surgery for colon cancer using real world unselected clinical data. In conclusion, this study constitutes the largest prospectively collected clinical data set on this topic and it confirms the results of previous randomised controlled trials on real world unselected data. There is no difference in 5 year survival between lap and open colectomy. Admin data: variable coding, inaccurate cancer staging, and lack of meaningful data on adjuvant treatment.