It is well known by all surgeons that laparoscopic colectomy for colon cancer has several short-term benefits when compared to open surgery: decreased surgical site infection (SSI); decreased postoperative pain; earlier return of bowel function; faster recovery and return to normal activity; lesser in-hospital stay. However these benefits were realized without long-term benefits on oncologic outcomes. This is about to change!
Roger Kim et al. from the Louisiana State University Health Sciences Center-Shreveport, and the Feist-Weiller Cancer Center, Shreveport, LA, hypothesized that laparoscopic colectomy could increase adjuvant chemotherapy (QT) compliance, decrease time to initiation of QT, and increase survival. For colon cancer the NCCN guidelines indicate adjuvant QT for Stage III patients and Stage II patients with high-risk factors (T4 tumour, perforation, bowel obstruction, poorly differentiated, lymphovascular invasion, positive margins, <12 lymph nodes examined).
In this setting, the authors retrospectively studied all Stage III patients and Stage II patients with high-risk factors operated between 2010 and 2012, registered in the National Cancer Data Base (NCDB) of the United States of America. A total of 48.257 patients were collected. Laparoscopic colectomy (LC) was performed in 18.801 (39%) and open colectomy (OC) in 29.456 (61%).
From data analysis LC has several advantages comparing to OC:
decreases 30-day and 90-day mortality (p<0,01);
decreases in-hospital length of stay (p<0,01);
increases rate of patients receiving QT (p<0,01);
lessens time gap to initiation of QT after surgery (p<0,01);
increases proportion of patients receiving QT within the first 8 weeks post colectomy (p<0,01);
increases the 2-year survival rate (p<0,01).
One result is presented which I assume to be a possible disadvantage: LC increases the time from diagnosis to colectomy. Why? Waiting to have a surgical team available to perform laparoscopy? Probably...
Several trials show that the delay in QT increases mortality, and for each week of delay after the 6 weeks mark, mortality increases about 7%. In the presented study, LC increased the number of patients receiving QT and decreased the time gap from surgery to QT. That is why the authors found laparoscopic approach to be an independent predictor of improved survival. Additionally this study confirms that the receipt of QT is a factor with the highest impact on mortality.
The authors cannot justify the QT delay after OC from the data collected in the NCDB. Even so, less complications after LC (eg. SSI) comparing to OC is pointed out by Roger Kim as a possible reason.
There are two drawbacks in this study. First, only 2-year overall survival is presented, which means that these data must be review after 5 years follow-up. Secondly, indications for operative approach (laparoscopic vs open) are not available in NCDB, such as emergency operations due to perforation or obstruction, which are associated with decreased survival.
The authors state that being a study based on the National Cancer Data Base it may represent a good estimation of the current practice. However, because of the large sample size some differences are unlikely to be of clinical significance given the small magnitude, even being statiscally significant. This is a well known problem in the research area, the so-called p mania.
So... Think about what you read before you accept it as a possible dogma.
A final comment on the 39% of laparoscopic colectomies versus the 61% open. This is a huge difference in the era of minimally invasive surgery. The authors thought exactly the same as they wrote: "The majority of colectomies for cancer are still performed by open surgery. This represents another area for quality improvement". However, we must not turn into laparoscopy fanatics and use laparoscopy in all patients, as there are contraindications and different patients. At the end the authors conclude that laparoscopic approach has the "potential to benefit colon cancer patients".
As we can see, in the United States of America there is still a long road to walk to perfection in this area, and laparoscopy still needs to gain acceptance among some sceptic surgeons.
Questions to the reader:
What is your opinion about the 2-year overall survival benefit from laparoscopy?
What is your current practice on laparoscopic approach for colon cancer?
Exchanging ideas makes you stronger! Please comment below...
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon