Abstract & Commentary
Synopsis: In a prospective, randomized trial, primary excision of colorectal carcinomas by laparoscopic surgery was compared with laparotomy. Disease recurrence and 5-year survival were not significantly different in the 2 groups. Operative time was greater for those receiving laparoscopic approach but post-operative recovery and hospital stays were shorter.
Source: Leung KL, et al. Lancet. 2004;363:1187-1192.
The primary surgical approach to colorectal carcinoma remains the single greatest chance of cure. Laparoscopic resection of this disease has been used since 1991 and it has been shown to improve post-operative recovery and reduce surgical stress. However, due to concerns regarding the adequacy of disease control and long-term survival, this procedure is only recommended for colorectal cancer as part of a clinical trial. Leung and colleagues from the Department of Surgery at the Chinese University of Hong Kong conducted a randomized controlled clinical trial with the goal of demonstrating that the survival rates are similar after laparoscopic and open resection for rectosigmoid carcinoma. Between 1993 and 2002, 403 patients with rectosigmoid cancer seen at the Prince of Wales Hospital and the United Christian Hospital in Hong Kong were randomized to receive either laparoscopic assisted (n = 203) or conventional open (n = 200) sigmoid colectomy. Disease-free interval and overall survival were analyzed post-operatively.
After curative resection, the 5-year survival rate for the laparoscopic group was slightly greater than that of the open resection group (76.1% vs 72.9%). However, patients in the laparoscopic resection group had a slightly lower probability of being disease free at 5 years than those in the open resection group (75.3% vs 78.3%), but neither of these findings was significant. The postoperative recovery for the laparoscopic group was significantly better, but the operative time for the laparoscopic procedure was significantly longer and the direct cost was greater. The overall morbidity and operative mortality was the same between the 2 groups.
Comment by William B. Ershler, MD
Laparoscopic surgical procedures have evolved dramatically over the past decade and, at many sites, have supplanted the need for open surgeries and the inherent associated costs in terms of postoperative morbidity and lengthy recovery. The concern that appropriate wide excision and regional node sampling would be compromised by the procedure has delayed its widespread use for primary colon cancer surgery. In the current randomized clinical trial the results of laparoscopic excision were analogous to open laparotomy in terms of disease recurrence and overall survival. Thus, it would seem perfectly reasonable to recommend this approach.
However, when it comes to changing standing surgical approaches in oncology, the pace is very slow. Take for example how long it took for surgeons to abandon the radical mastectomy in favor of the modified mastectomy or even lumpectomy (with axillary node sampling). Thus, despite this relatively large trial published in a first-line journal, it would be surprising to see surgeons abandon their standard approach. Furthermore, the results from this single institution at which the participating surgeons obviously have extensive experience in laparoscopic techniques cannot readily be translated to community practice where the experience may be limited. Thus, the report is of great interest. Hopefully, surgical oncology training programs will evolve in such a way that this methodology will be familiar to a greater number of practicing surgeons and laparoscopic procedures will be considered for patients in whom such an approach is considered appropriate.
Dr. Ershler is an oncologist at INOVA Fairfax Hospital Cancer Center, Fairfax, VA; Director, Institute for Advanced Studies in Aging, Washington, DC.