Editorials
Surgery Cancer
Volume 194 - Issue 9

Is laparoscopic resection for colorectal cancer the way to the future?

Author:  Ned S Abraham

Med J Aust 2011; 194 (9): 441-442. || doi: 10.5694/j.1326-5377.2011.tb03055.x
Published online: 2 May 2011
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Upcoming large studies may shed light on why this technique was not rapidly widely adopted like certain other laparoscopically assisted procedures

Laparoscopic “keyhole” surgery has been the gold standard for gall bladder surgery for a few decades. It has also been widely used for appendicectomies, a multitude of gynaecological procedures and, to various extents, for other procedures such as hernia repair, splenectomy and nephrectomy. However, the uptake of laparoscopically assisted resection in elective surgery for colorectal cancer (CRC) has been slow, both in Australia and overseas. This is the subject of the article by Thompson and colleagues in this issue of the Journal (→ National trends in the uptake of laparoscopic resection for colorectal cancer, 2000–2008).1

The authors searched the National Hospital Morbidity Database (NHMD), which uses codes based on Medicare Benefits Schedule item numbers, for elective laparoscopic resections for CRC. Their search was somewhat restricted and the internal validity was not tested, but Thompson and colleagues reported that, in about a quarter of elective CRC resections performed in Australia in the financial year 2007–08, an item number for a laparoscopy was included.

Reliance on databases may overestimate or underestimate outcomes. Three studies from the United States reported percentages of laparoscopic resections for cancers of the colon ranging from 3.3% to 5.2%2-4 in the period July 2003 to June 2004, based on the National Cancer Data Base and Nationwide Inpatient Sample. However, a fourth US study that used the Perspective Rx Comparative Database (Premier Inc, Charlotte, NC), which relies on procedure codes, reported a percentage of 33.7% for the period July 2004 to June 2006.5 Such an increase is far greater than what would be expected to be the result of the publication of the Clinical Outcomes of Surgical Therapy trial.6

The adoption of laparoscopic surgery for CRC has been slow despite the proven short-term benefits of laparoscopic compared with open resection, which include a shorter hospital stay.7,8 In line with other published articles, the Australasian Laparoscopic Colon Cancer Study (ALCCaS) — the largest Australasian study to date of laparoscopic resection for CRC — showed that the laparoscopic method was associated with a smaller number of patients with complications and a shorter length of stay than open resection.9 However, the ALCCaS group also reported that reviews show that the short-term advantages for laparoscopic resection for CRC are arguably relatively minor and often subjective, and that patients who benefit most from improved outcomes are patients who are aged 70 years or older whose procedures were completed laparoscopically.10 The median length of stay for patients younger than 70 years of age undergoing laparoscopic resection in the ALCCaS trial was 7 days (range, 1–30 days) compared with 8 days (range, 4–49 days) for open resections in the same age group — a difference of only 1 day.10 The average hospital stay for conventional open resection has been reported to be about 10 days (range, 7–12 days).7,11-13

It seems likely that authors of large series, trials and reviews report more conservative (and perhaps more realistic) results than earlier series reporting a new surgical procedure or innovation. The first published series of laparoscopic colorectal surgery in 1991 reported achieving the aim of a 5-day hospital stay in 14 out of 20 patients undergoing sigmoid resections (70%).14 Most subsequent larger studies, reviews and meta-analyses report lengths of stay of around 8 days for laparoscopic resection.7-9,11,12 Thompson and colleagues (→ National trends in the uptake of laparoscopic resection for colorectal cancer, 2000–2008) recommend exploring whether the short-term benefits of laparoscopic resection are experienced outside of the clinical trial environment.1

If we accept the limitation of using secondary data, such as those from the NHMD, in exploring the uptake of laparoscopic surgery for CRC, then a quarter of elective resections for CRC performed in Australia in 2007–08 were laparoscopic. That represents an increase from zero to 25% in more than 17 years. There are no comparable studies that used similar methods to assess the uptake of laparoscopic cholecystectomy in the late 1980s. However, many of us experienced first-hand the rapid uptake of laparoscopic gall bladder surgery. The first laparoscopic cholecystectomy was probably performed in France by Phillippe Mouriat of Lyons in 1987.15 There are published data that show that laparoscopic surgery was well and truly the gold standard for gall bladder surgery in 1992.16 That represents an increase from zero to close to 100% in less than 5 years. The contrast is stark.

In 1999, Kehlet and Mogensen introduced the concept of fast-track surgery to colorectal resections;17 this concept is now known as Enhanced Recovery After Surgery (ERAS). It involves a multimodal rehabilitation program that commences before surgery to optimise all aspects of care using evidence-based protocols that hasten recovery. Kehlet and Mogensen reported a median hospital stay of 2 days (range, 2–6 days) after 16 consecutive elective open sigmoid colectomies. Fifteen of the 16 patients resumed bowel function before discharge.17

The results of a systematic review of five studies comparing laparoscopic with open colorectal surgery using an ERAS rehabilitation program were inconclusive.18 Further, the authors of a meta-analysis of 11 studies (1021 patients) reported a 2.5-day shorter length of stay for patients on an ERAS rehabilitation program who had resections compared with those not on an ERAS program.19 These authors assumed an added benefit to the laparoscopic approach, but an advantage was not clearly demonstrated. They concluded that ERAS programs should become a mainstay of elective colorectal surgery.19

These later and larger series, trials and reviews have shown that an average length of stay of 5 days seems to be quite achievable within an ERAS protocol, regardless of whether the surgical approach is open or laparoscopic. Many of the aspects of the ERAS program are now included in “standard” care regardless of whether a structured protocol is in place or not.

It seems that, on the whole, laparoscopic surgery for CRC has probably not been successful in delivering the outstanding benefits suggested by early reports. This may be partly responsible for its slow uptake. Attention to a multimodal approach such as an ERAS program may, in fact, produce more clinical benefits for patients and cost benefits for hospitals. Whether the laparoscopic approach “adds” to these benefits or not has not been established.20

The Australasian Laparoscopic Cancer of the Rectum Trial (A La CaRT), with a target sample size of 470 patients, is expected to shed more light on the safety and efficacy of laparoscopic compared with conventional open resection for rectal cancer.21 The Dutch Laparoscopy and/or Fast Track Multimodal Management (LAFA) trial, with a target sample size of 400 patients, will examine laparoscopic versus open CRC surgery with or without an ERAS rehabilitation program.22

Author

  • Ned S Abraham MMed, FRACS, PhD1
  • 1. Faculty of Medicine, University of New South Wales (Coffs Harbour Campus), Coffs Harbour, NSW.

Correspondence: nedabraham@optusnet.com.au

References

Provenance: Commissioned; not externally peer reviewed.

View this article on Wiley Online Library