1. Laparoscopic vs Open Colonic Surgery: Long Term Survival
Tarik Sammour

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

3. 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

4. So far only administrative data has been published.

5. 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)

6. 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

7. 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

8. 7% in 2003 to 67% in 2009

9. 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

10. 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

11. 5 year Overall Survival (Corrected)χ
P 0.254

13. 5 year Cancer Specific Survival (Corrected)χ
P 0.866

15. 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.