Laparoscopy in colorectal cancer (CRC) surgery has gained worldwide acceptance and many patients are being operated using this minimally invasive approach. All surgeons agree with the advantages of laparoscopy over open surgery. Less pain, earlier first oral intake, faster recovery, lower rate of surgical site infections, lower rate of incisional hernias are some of the most common advantages. In that setting some questions need answers. Is laparoscopic approach frequently used? Did laparoscopy overcome open surgery?
Germany is traditionally one of the European countries that uses laparoscopy more often. So, we need to compare our country with the best ones and that is Germany. In 2018 a retrospective analyzes of laparoscopic CRC surgery in Germany was published in Scientific Reports. We all must know these numbers before talking about our own data.
According to Tarik Ghadban et al 345.913 elective CRC surgeries were performed between 2005 and 2015 (61% colon and 39% rectum). In 2005 only 6,4% were performed by laparoscopy and in 2015 laparoscopic approach was used in 28,5% of CRC patients. For the entire period of the study the minimally invasive surgery rate was 16%. Meaning that open surgery was used more often (84%) than laparoscopy for elective CRC procedures for that 10 years period. During 2015, from all CRC procedures, sigmoid and rectal resections were the most frequently performed by laparoscopy (38,3% and 39,2%). This is interesting to know, since according to worldwide studies laparoscopic surgery for rectal cancer may not have the same oncological results as open. Since open rectal surgery is many times difficult to perform due to anatomic reasons, it is understandable the initial euphoria to use laparoscopy for rectal cancer treatment. Nowadays, robotic surgery seems to be the best option, followed by open surgery, with laparoscopy in the bottom of oncological outcomes for rectal cancer resections. More studies will allow us to define the best approach, but that is another issue…
In 2015 laparoscopic approach was used in 28,5% of elective CRC procedures.
There was an increase in laparoscopic procedures over the years, probably because more patients were included as indications for minimally invasive surgery, as expertise increased. However, we must "not go with the flow" and use laparoscopy without clinical criteria. There are patients not suitable for laparoscopy. Open surgery will always have a place in CRC surgery. Remember: we work for the patient and not for our ego. Surgeons must work to have excellent oncological results and low morbidity, and not to have “medals” on the wall.
The authors report a conversion rate of 14,4% (higher in transverse colon and left-sided), and that rate did not decrease over time. Does this data means expertise and number of procedures do not influence conversion rate? Were more difficult cases included over time? Probably both… Surgical site infection (SSI) was lower with laparoscopy. Anastomotic leak rate was lower for right-sided and left-sided colectomies. For rectal surgery anastomotic leak rate was identical in both approaches. Mortality was significantly lower in laparoscopic group (1,8% vs 4,7%, p<0,001).
In many countries laparoscopy is not the most frequently used approach.
I believe it is interesting to know that in 2014 and 2015 open surgery for CRC was used in 75% and 71,5%, respectively. There was a 4,5 fold increase in laparoscopy from 2014 to 2015, but laparoscopy is still far way of being the most frequently used approach in Germany. This is true also for other countries. In Norway, laparoscopic approach between 2007 and 2010 was only 27%. In France only 26% of CRC procedures were performed by laparoscopy between 2006 and 2008. In these “front–line” countries of minimally invasive surgery and innovation I thought numbers were totally different. Why should Portugal be different? Are we different? Do not know…
Across the Atlantic the picture is similar… In NCCN centers (USA) only 36% of colon cancer patients were submitted to laparoscopic surgery between 2005 and 2010. However, laparoscopy increased over the years and 51% of stage I-III colon cancer patients were operated by laparoscopy in 2010 in NCCN centers. For rectal cancer stage I-III laparoscopy was used in 37% of patients (there is no indication for laparoscopy in locally advanced rectal cancer according to NCCN guidelines). Read post: “NCCN centers and laparoscopic colorectal surgery numbers. You may not like this.” – published in “Surgical Thoughts”, 15 September 2019.
Laparoscopy for CRC has lower morbidity, lower mortality, and the same oncological outcomes than open surgery.
You may say these are old numbers, and in fact they are. However, they may also tell us we are as good as they are. Although I could not find the same data for Portugal, I believe our numbers shall be similar for laparoscopic CRC surgery. I believe Portugal is not inferior to these countries. In fact we may be better, or at least we can. However, if we want to take conclusions about our numbers, first we must know our real numbers and second we must compare them with other colleagues and countries numbers. This is the only way to know if we are good or bad. Even though, if we are equal to others in laparoscopic numbers, it shall not be a reason to celebrate. On the contrary, it shall be a reason to think about what we are doing wrong. Remember that Dr. Tarik Ghadban et al conclude that there was an increase “in the use of the laparoscopic approach in Germany over the time span investigated; however, the rate remains low.”
Answering the initial questions: laparoscopic surgery is not frequently used but has overcome open surgery (less morbidity and mortality with the same oncological results). So… Why is it not used more often? “National health policies should aim at promoting training programs and standardization of laparoscopic surgery in the future.” I believe the picture is exactly the same in Portugal… but there is no public investment in health services. There is a lot to improve in a global scale. Each country must find its own pace in search for excellence. Portugal is no exception.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon
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