Nowadays, laparoscopy is the gold standard approach for colon cancer. The same is not true for rectal cancer, but that is another story. All surgeons know that using minimally invasive surgery to treat colon cancer offers a faster recovery, less pain, less incisional hernias, less surgical site infection and less in-hospital stay. These advantages of laparoscopy were easily accepted by the worldwide surgical community and colon cancers of all stages are now been operated by laparoscopy. Is this the correct approach? Although laparoscopy was considered inappropriate for locally advanced colon cancers and increased risk of postoperative peritoneal metastases was suggested, laparoscopy was considered ontologically feasible for T4 tumors.
Surgeons are the possible reason for this denial and insistence on minimally invasive surgery even in the presence of doubts about its benefits for the patients. In fact, in the present day many surgeons use laparoscopy as a “circus ability” trying to present themselves before the medical community as a “surgeon with great skills”. Some surgeons are using surgery to seek notoriety. This is not the correct path to follow, since medicine must use knowledge to better treat patients and not to fulfil a surgeon’s ego.
I personally do not use laparoscopy in all cases. Patients’ characteristics, tumor size and staging dictate my decision: open vs laparoscopy. Soon I will present my results of colo-rectal laparoscopy.
Trying to clarify the effects of laparoscopic surgery on postoperative peritoneal recurrence after treating T4 tumors, Nagata et al from Tokyo, Japan, published a retrospective study in Surgery. A total of 272 patients were analyzed, comparing 146 submitted to open colectomy with 126 patients submitted to laparoscopic colectomy. All patients were submitted to R0 resection for adenocarcinoma T4a without distant metastasis at time of diagnosis. Both groups were similar according to age, ASA score, tumor size, location, N stage. Patients were treated according to the Japanese Society for Cancer of the Colon and Rectum Guidelines. Surveillance included a CT scan every 6 months and peritoneal recurrence was diagnosed based on imaging findings. Peritoneal cancer index (PCI) was used to define extension of peritoneal metastases.
“...laparoscopic surgery may increase the risk of peritoneal recurrence in patients with pT4a colon cancer.” Nagata et al.
After propensity score matching results are clear. The incidence of postoperative peritoneal metastases was found to be significantly higher in the laparoscopic group than in the open group (28.1% vs 12.1%, p=0.003). PCI was similar between both groups. Lung and liver metastases were also similar. There was no statistical difference in the 5y survival and relapse-free survival comparing laparoscopic with open surgery. These results led the authors to state that “laparoscopic surgery may increase the risk of peritoneal recurrence in patients with pT4a colon cancer”. They say “may increase” because this is a one single-center study and a retrospective one. More studies are necessary to validate this conclusion. In the meanwhile, surgeons must take these results into account while deciding which approach to use.
The authors present some reasons to justify the worse oncological outcome of minimally invasive surgery for T4 colon cancers. One possible reason is the dehumidification of the peritoneum by dry CO2 which can damage the mesothelial lining and facilitate tumor cell adhesion. This is not well accepted. A second possible reason is the apparent failure of laparoscopic intraperitoneal inspection to find peritoneal metastases, meaning some peritoneal nodules may be misdiagnosed as recurrence. A third reason is related to intraoperative toilet, which tends to be less extensive in laparoscopy. For me this is the harder hypothesis to accept. The authors say that more cancer cells may remain in abdominal cavity after laparoscopic surgery because mechanical washing is technically difficult. This is only theory, but studies are being prepared.
Nagata et al say there are studies going on to find strategies to prevent postoperative peritoneal recurrence in T4a disease. One strategy is a second-look surgery and the other is HIPEC. I hope surgeons will not offer a second-look surgery just to force laparoscopy as first line approach. Patient’s benefit is more important than doctor’s ego.
In conclusion, this study presents laparoscopy as an independent risk factor for peritoneal recurrence after laparoscopic colon resection for T4a cancer. Laparoscopic surgery has advantages, but it is not a “to use in all cases” approach. Laparoscopic surgery is not suitable for all patients. Not individualizing indications and approaches may be the reason why some surgeons present increased conversion rates. Surgery is science and art, and surgeons must be able to recognize when to use or not to use minimally invasive surgery. In Surgery there cannot be a strict standard for indications.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon