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BACKGROUND: Minimally invasive, laparoscopically assisted
surgery
Minimally invasive, laparoscopically assisted surgery
was first considered in 1990 for patients undergoing colectomy
for cancer. Concern that this approach would compromise survival
by failing to achieve a proper oncologic resection or adequate
staging or by altering patterns of recurrence (based on frequent
reports of tumor recurrences within surgical wounds) prompted
a controlled trial evaluation.
Summary: Laparoscopic
Surgery a Good Alternative for Some Colon Cancer Patients:
The study reported that patients with colon cancer experienced
similar rates of cancer recurrence whether they were treated
with laparoscopically assisted surgery or conventional open
abdominal surgery (open colectomy) in a large randomized clinical
trial. The trial’s investigators concluded that laparoscopically
assisted surgery is an acceptable, less invasive alternative.
However, they caution that not all patients with colon cancer
will be appropriate candidates for the laparoscopic operation.
Source: New England Journal
of Medicine, May 13, 2004.
Minimally Invasive,
Laparoscopically Assisted Surgery Overview
Laparoscopic surgery, an alternative to conventional open
surgical procedures, is widely used to treat noncancerous
abdominal diseases such as appendicitis, hiatal hernia, and
gall bladder disease. A laparoscope, attached to a video camera,
is inserted through a small cut or incision in the abdomen
to guide the surgery. Surgical instruments are then inserted
through other small abdominal incisions and used to perform
the surgical procedure.
For the patient, the potential advantages of laparoscopic
surgery include less pain after surgery, a shorter hospital
stay, and a shorter recovery period. However, laparoscopic
surgery for colon cancer was considered experimental because
it was not known whether the technique removed tumors as effectively
as the conventional, open surgical operation called a colectomy.
Inadequate surgical removal of tumors increases the risk that
the cancer will come back.
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The Study
The primary aim of this phase III study was to find out whether
colon cancer was more likely to come back in patients treated
with laparoscopically assisted surgery. A total of 872 patients
at 48 centers in the United States and Canada were randomly
assigned to receive either a conventional open colectomy or
a laparoscopic colectomy. Patients were followed up for a
median of 4.4 years.
The study was conducted by the Clinical Outcomes of Surgical
Therapy Study Group, a collaboration among researchers affiliated
with the National Cancer Institute’s (NCI’s) Clinical
Trial Cooperative Groups program. The principal investigator
was Heidi Nelson, M.D., of the Mayo Clinic in Rochester, Minnesota.
Results
Rates of cancer recurrence were not significantly different
in the two groups of patients. In addition, overall survival
was very similar in both groups.
Patients who had laparoscopic surgery recovered more quickly
than those who had conventional surgery. They were hospitalized
for a median of five days and took non-oral pain medications
for a median of three days. By contrast, patients who had
an open colectomy were hospitalized for a median of six days
and took non-oral pain medications for a median of four days.
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Limitations
Patients with colon cancer that had spread to other tissues
were not included in this study. One in every five patients
randomly assigned to receive laparoscopic surgery was switched
to open colectomy on the operating table when surgeons found
that their disease had spread or when other complications
were encountered making it difficult to perform the surgery
laparoscopically.
All surgeons participating in the study had performed at
least 20 laparoscopic surgeries for colon cancer and their
surgical techniques were scrutinized on videotape. Surgeons
with less expertise with the procedure than this might not
achieve the same results, cautions Meg Mooney, M.D., a surgical
oncologist with NCI’s Cancer Therapy Evaluation Program.
Laparoscopic surgery took longer to perform – 2½
hours, compared with 1 hour 35 minutes for the conventional
open colectomy. However, this time difference may diminish
in the future, says Mooney, as both surgical instruments and
surgeons’ expertise with the procedure improve.
The study was not designed to show that laparoscopic colectomy
is better than open colectomy, only that it is not worse –
that is, that the risk of cancer coming back was not significantly
greater using the laparoscopic procedure.
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Comments
“This trial has laid to rest most of the concerns that
existed about laparoscopic surgery for patients with colon
cancer that can be removed with surgery,” says Mooney.
“As a result of these findings, surgeons will feel more
comfortable that laparoscopic surgery is an acceptable alternative
to an open procedure for many patients with colon cancer.”
Because laparoscopic colorectal surgery requires extensive
and highly specialized training, few surgeons are qualified
to perform these procedures.
Be sure to find a surgeon certified to use laparoscopic
surgery in the treatment of colon conditions including diverticulitis,
colon cancer, Crohn's disease (occurring in the small intestine
as well as the colon), chronic ulcerative colitis, constipation,
sigmoid volvulus, and endometriosis.
Find a facility that is equipped with the latest
laparoscopic technology, including three-dimensional imaging
equipment and the most advanced ultrasound instruments.
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