Long-term results of laparoscopic colorectal cancer resection.

BACKGROUND: Although minimally invasive surgery has been accepted for a variety of disorders, laparoscopic resection of colorectal cancer is performed by few. Concern about oncological radicality and long term outcome has limited the adoption of laparoscopic surgery for colorectal cancer. OBJECTIVES: To determine long-term outcome after laparoscopically-assisted versus open surgery for non-metastasised colorectal cancer. SEARCH STRATEGY: The Cochrane library, EMBASE, Pub med and Cancer Lit were searched for published and unpublished randomised controlled trials. SELECTION CRITERIA: Randomised clinical trials comparing laparoscopically-assisted and open surgery for non-metastasised colorectal cancer were included. Studies that did not report any long-term outcomes were excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the studies and extracted data. RevMan 4.2 was used for statistical analysis. MAIN RESULTS: Thirty-three randomised clinical trials (RCT) comparing laparoscopically-assisted versus open surgery for colorectal cancer were identified. Twelve of these trials, involving 3346 patients, reported long-term outcome and were included in the current analysis. No significant differences in the occurrence of incisional hernia, reoperations for incisional hernia or reoperations for adhesions were found between laparoscopically assisted and open surgery (2 RCT, 474 pts, 7.9% vs 10.9%;P = 0.32 and 2 RCT, 474 pts, 4.0% vs 2.8%; P = 0.42 and 1 RCT, 391 pts, 1.1% vs 2.5%;P = 0.30, respectively). Rates of recurrence at the site of the primary tumor were similar (colon cancer: 4 RCT, 938 pts, 5.2% vs 5.6%; OR (fixed) 0.84 (95% CI 0.47 to 1.52)(P = 0.57); rectal cancer: 4 RCT, 714 pts, 7.2% vs 7.7%; OR (fixed) 0.81 (95% CI 0.45 to 1.43) (P = 0.46). No differences in the occurrence of port-site/wound recurrences were observed (P=0.16). Similar cancer-related mortality was found after laparoscopic surgery compared to open surgery ( colon cancer: 5 RCT, 1575 pts, 14.6% vs 16.4%; OR (fixed) 0.80 (95% CI 0.61 to 1.06) (P=0.15); rectal cancer: 3 RCT, 578 pts, 9.2% vs 10.0%; OR (fixed) 0.66 (95% CI 0.37 to 1.19) (P=0.16). Four studies were included in the meta-analyses on hazard ratios for tumour recurrence in laparoscopic colorectal cancer surgery. No significant difference in recurrence rate was observed between laparoscopic and open surgery (hazard ratio for tumour recurrence in the laparoscopic group 0.92; 95% CI 0.76-1.13). No significant difference in tumour recurrence between laparoscopic and open surgery for colon cancer was observed (hazard ratio for tumour recurrence in the laparoscopic group 0.86; 95% CI 0.70-1.08). AUTHORS' CONCLUSIONS: Laparoscopic resection of carcinoma of the colon is associated with a long term outcome no different from that of open colectomy. Further studies are required to determine whether the incidence of incisional hernias and adhesions is affected by method of approach. Laparoscopic surgery for cancer of the upper rectum is feasible, but more randomised trials need to be conducted to assess long term outcome.

Open or endoscopic total extraperitoneal inguinal hernia repair? A systematic review.

BACKGROUND: Although a large number of surgeons currently perform endoscopic hernia surgery using a total extraperitoneal (TEP) approach, reviews published to date are based mainly on trials that compare laparoscopic transabdominal preperitoneal (TAPP) repair with various types of open inguinal hernia repair. METHODS: A qualitative analysis of randomized trials comparing TEP with open mesh or sutured repair. RESULTS: In this review, 4,231 patients were included in 23 trials. In 10 of 15 trials, TEP repair was associated with longer surgery time than open repair. A shorter postoperative hospital stay after TEP repair than after open repair was reported in 6 of 11 trials. In 8 of 9 trials, the time until return to work was significantly shorter after TEP repair. Hospital costs were significantly higher for TEP than for open repair in all four trials that included an economic evaluation. Most trials (n = 14) reported no differences in subsequent recurrence rates between TEP and open repair. CONCLUSIONS: The findings showed that endoscopic TEP repair is associated with longer surgery time, shorter postoperative hospital stay, earlier return to work, and recurrence rates similar to those for open inguinal hernia repair. The procedure involves greater expenses for hospitals, but appears to be cost effective from a societal perspective. The TEP technique is a serious option for mesh repair of primary hernias.

Safety and efficacy of endoscopic retroperitoneal adrenalectomy.

BACKGROUND: Minimally invasive adrenalectomy has replaced open surgery in the treatment of benign adrenal tumours. Transperitoneal and retroperitoneal approaches have been advocated. However, long-term outcome data are rare. METHODS: Over a period of 8 years, 123 patients underwent surgery for benign adrenal lesions using the endoscopic retroperitoneal approach. Data were analysed retrospectively by review of medical charts. Long-term results were obtained by sending questionnaires to patients and contacting their primary physicians. RESULTS: One hundred and twenty-three patients underwent 126 endoscopic retroperitoneal adrenalectomies. Mean operating time for unilateral adrenalectomy was 115 min, whereas that for bilateral adrenalectomy was 208 min. The conversion rate was 4.8 per cent. Complications occurred after 15.9 per cent of adrenalectomies. One patient died during the postoperative period. Long-term results were obtained in 80 patients (74.8 per cent). Nine patients (11 per cent) reported chronic incisional pain and six patients (8 per cent) had chronic abdominal pain. Addisonian crisis after bilateral adrenalectomy occurred in three patients. Most patients (86 per cent) were satisfied with the cosmetic results. CONCLUSION: Endoscopic retroperitoneal adrenalectomy is a safe and effective procedure. Long-term outcome is acceptable and the procedure has excellent cosmetic results.

Impact of hospital case volume on short-term outcome after laparoscopic operation for colonic cancer.

BACKGROUND: High hospital case volume has been associated with improved outcome after open operation for colorectal malignancies. METHODS: To assess the impact of hospital case volume on short-term outcome after laparoscopic operation for colon cancer, we conducted an analysis of patients who underwent laparoscopic colon resection within the COlon Cancer Laparoscopic or Open Resection (COLOR) trial. RESULTS: A total of 536 patients with adenocarcinoma of the colon were included in the analysis. Median operating time was 240, 210 and 188 min in centers with low, medium, and high case volumes, respectively (p < 0.001). A significant difference in conversion rate was observed among low, medium, and high case volume hospitals (24% vs 24% vs 9%; p < 0.001). A higher number of lymph nodes were harvested at high case volume hospitals (p < 0.001). After operation, fewer complications (p = 0.006) and a shorter hospital stay (p < 0.001) were observed in patients treated at hospitals with high caseloads. CONCLUSIONS: Laparoscopic operation for colon cancer at hospitals with high caseloads appears to be associated with improved short-term results.

Effect of laparoscopy on the immune system.

Surgery induces alterations in local and systemic immune responses. These changes appear to be associated with an increase in postoperative morbidity. Minimally invasive techniques are considered to improve the preservation of immune function compared with open surgery and may therefore be beneficial for patient recovery. As laparoscopic techniques are increasingly used in abdominal surgery, more research has focussed on the immunologic consequences of these techniques. Nevertheless, the changes that occur in response to trauma are still not completely understood. The immunologic benefits of laparoscopic surgery are the most obvious for minor surgical procedures such as cholecystectomy and antireflux surgery. For more complex procedures such as colorectal surgery for cancer, the benefits are not immediately obvious. Although laparoscopic surgery for colorectal malignancies may be associated with higher survival rates and lower recurrence rates because of improved immune function, it has also been related to high incidences of port-site metastases. Reviews in the literature have now shown that incidences of port-site metastases are comparable to incidences of wound metastases after open surgery. However, it will be necessary to wait for the long-term results of randomized, clinical trials to provide further clarification of how immune function is altered after laparoscopic and open surgery for colorectal cancer.