W. Schwenk

Long‐term results of laparoscopic colorectal cancer resection

BACKGROUNDnAlthough 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.nnnOBJECTIVESnTo determine long-term outcome after laparoscopically-assisted versus open surgery for non-metastasised colorectal cancer.nnnSEARCH STRATEGYnThe Cochrane library, EMBASE, Pub med and Cancer Lit were searched for published and unpublished randomised controlled trials.nnnSELECTION CRITERIAnRandomised clinical trials comparing laparoscopically-assisted and open surgery for non-metastasised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.nnnDATA COLLECTION AND ANALYSISnTwo reviewers independently assessed the studies and extracted data. RevMan 4.2 was used for statistical analysis.nnnMAIN RESULTSnThirty-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).nnnAUTHORS CONCLUSIONSnLaparoscopic 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.

Laparoscopic versus conventional colorectal resection: a prospective randomised study of postoperative ileus and early postoperative feeding

Background: A shorter duration of postoperative ileus and earlier oral alimentation of patients may be a clinically relevant benefit of laparoscopic compared with conventional colorectal resection. Patients/Methods: A total of 60 patients were randomised to either laparoscopic (n=30) or conventional (n=30) resection of colorectal tumours. Major endpoints were the postoperative time to the first bowel movement and the time until oral feeding without parenteral alimentation was tolerated. Minor endpoints were the postoperative interval to the first peristalsis and first passage of flatus, the distribution of radio-opaque markers in abdominal radiographs on day 3 and day 5 and the incidence of postoperative vomiting. Results: Age, gender, ASA-classification and type of resection were comparable in thetwo groups. Peristalsis was first noticed 26±9 h after laparoscopic and 38±17 h after conventional colorectal resection (P<0.01). First flatus occurred 50±19 h after laparoscopic and 79±21 h after conventional surgery (P<0.01). The incidence of postoperative vomiting was similar in both groups. Three days after surgery radio-opaque markers were found more often in the right colon (P<0.01) and less often in the small intestine (P<0.05) in laparoscopic compared with conventional patients. Five days after laparoscopic surgery, more markers had reached the left colon (P<0.05). The first bowel movement occurred 70±32 h after laparoscopic and 91±22 h after conventional resection (P<0.01). Oral feeding without additional parenteral alimentation was tolerated 3.3±0.7 days after laparoscopic and 5.0±1.5 days after conventional surgery (P<0.01). Conclusion: The shorter duration of postoperative ileus allows earlier restoration of oral feeding after laparoscopic compared with conventional colorectal resection and therefore increases quality of life immediately after resection of colorectal tumours.

Fast-track multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: A controlled prospective evaluation

BackgroundLaparoscopic colorectal resection improves patient outcome by reducing pain, postoperative pulmonary dysfunction, gastrointestinal paralysis, and fatigue. A multimodal rehabilitation program (“fast-track”) with epidural analgesia, early oral feeding, and enforced mobilization may further improve the excellent results of laparoscopic colorectal resection, enabling early ambulation of these patients.MethodsFifty two consecutive patients underwent laparoscopic sigmoidectomy with standardized regular perioperative treatment (standard) or multimodal rehabilitation program (“fast-track”). Outcome measures included pulmonary function, duration of postoperative ileus, pain perception, fatigue, morbidity, and mortality.ResultsTwenty nine standard-care patients (19 men and 10 women) and 23 fast-track patients (15 men and eight women) were evaluated. Demographic and operative data were similar for the two groups. On the 1st postoperative day, pulmonary function was improved (p = 0.01) in fast-track patients. Oral feeding was achieved earlier (p < 0.01) and defecation occurred earlier (p < 0.01) in the fast-track group. Visual analogue scale scores for pain were similar for the two groups (p > 0.05), but fatigue was increased in the standard-care group on the 1st (p = 0.06) and 2nd (p < 0.05) postoperative days. Morbidity was not different for the two groups. Fast-track patients were discharged on day 4 (range, 3–6) and standard-care patients on day 7 (range, 4–14) (p < 0.001).ConclusionMultimodal rehabiliation can improve further on the excellent results of laparoscopic sigmoidectomy and decrease the postoperative hospital stay.

Cellular and humoral inflammatory response after laparoscopic and conventional colorectal resections

Background: Surgical trauma and anesthesia are known to cause transient postoperative suppression of the immune system. In randomized controlled trials, it has been shown that laparoscopic colorectal resections have short-term benefits not observed with conventional colorectal resections. We hypothesized that these benefits were due to the reduction in surgical trauma, leading to a diminished cytokine response and less depression of cell-mediated immunity after laparoscopy. Methods: In a prospective randomized trial, colorectal cancer patients without evidence of metastatic disease underwent either laparoscopic (n = 20) or conventional (n = 20) tumor resection. Postoperative immune function was assessed by measuring the white blood cell (WBC) count, the CD4+ and CD8+ lymphocytes, the CD4+/CD8+/ratio, and the HLA-DR expression of CD14+ monocytes. In addition, the production of interleukin-6 (IL = 6) and TNF-a were measured after ex vivo stimulation of mononuclear blood cells with lipopolysaccharide (LPS) and compared to the plasma levels of these cytokines. Postoperative mean levels of the immunologic parameters for the two groups were calculated and compared using the Mann-Whitney U test. Results: Preoperatively, there were no differences between the two groups in terms of patient characteristics or immunologic parameters. Although the postoperative peak concentrations of white blood cells were significant lower in the laparoscopic group than the conventional group (p < 0.05), there were no differences between the two groups in the subpopulation of lymphocytes (CD4+, CD8+). HLA-DR expression of CD14+ monocytes was lower in the conventional group on the 4th postoperative day (p < 0.05). The laparoscopic group showed higher values in cytokine production of mononuclear blood cells after LPS stimulation. Postoperative plasma peak concentrations of IL-6 and TNF-a were lower after laparoscopic resection. Conclusion: Postoperative cell-mediated immunity was better preserved after laparoscopic than after conventional colorectal resection. Cellular cytokine production was preserved only in the laparoscopic group, while cytokine plasma levels were significantly higher in the conventional group. These findings may have important implications for the use of laparoscopic colorectal resection, especially in patients with malignant disease.

Fast-track rehabilitation after rectal cancer resection.

Background and aims:After rectal cancer surgery, postoperative general complications occur in 25–35% of all patients and postoperative hospital stay is 14–21xa0days. “Fast-track” rehabilitation has been shown to accelerate recovery, reduce general morbidity and decrease hospital stay after elective colonic surgery. Because the feasibility of “fast-track” rehabilitation in patients undergoing rectal cancer surgery has not been demonstrated yet, we demonstrate our initial results of “fast-track” rectal cancer surgery.Patients and methods:Seventy consecutive unselected patients undergoing rectal cancer resection by one surgeon underwent a perioperative “fast-track” rehabilitation. Demographic and operative data, pulmonary function, pain and fatigue, local and general complications and mortality were assessed prospectively.Results and findings:Thirty-six female and 34 male patients aged 65 (34–77)xa0years underwent open (n=31) or laparoscopic (n=39) anterior resection with partial mesorectal excision (PME 27), anterior resection with total mesorectal excision and protective loop ileostomy (TME 29) or abdominoperineal excision with colostomy (APR 14). Overall, pulmonary function returned to >80% of preoperative value on dayxa02 (1–4) and the first bowel movement occurred on dayxa01 (0–3) after surgery. The incidence of local and general complications was 27 and 18%, respectively. Postoperative hospital stay was 8 (3–50)xa0days overall, but shorter after PME [5 (3–47)] than TME [10 (5–42)] or APR [9 (5–50)] (p<0.01).Interpretation and conclusion:“Fast-track” rehabilitation was feasible in patients undergoing rectal cancer resection. Local morbidity was not increased, while general morbidity and postoperative hospital stay compared favourably to other series with “traditional” perioperative care.

Intermittent pneumatic sequential compression (ISC) of the lower extremities prevents venous stasis during laparoscopic cholecystectomy. A prospective randomized study.

AbstractBackground: Fifty patients were included in a prospective randomized trial to evaluate the efficacy of intermittent sequential compression (ISC) of the lower extremities in preventing venous stasis during laparoscopic cholecystectomy.n Methods: We treated 25 patients with (+ISC) and 25 without (–ISC) intermittent sequential compression. Peak flow velocity (PFV) and cross-sectional area (CSA) of the right femoral vein were measured by Doppler ultrasound before, during, and after capnopneumoperitoneum with 14 mm Hg.n Results: PFV was 26.4 (8.4) cm/s and CSA was 1.03 (0.23) cm2 before pneumoperitoneum was induced. During abdominal insufflation, PFV decreased to 61% of the baseline value in the (–ISC) group but remained unchanged in the (+ISC) group (t = 5.17, df = 42.8, p < 0.01). CSA was 1.06 (0.22) cm2 before insufflation. It increased to 118% of the baseline in the (–ISC) group and to 108% in the (+ISC) group (t =–1.55, df = 47.1, p= 0.13). PFV and CSA returned to baseline values within 5 min after abdominal desufflation.n Conclusions: ISC effectively neutralizes venous stasis during laparoscopic surgery and may decrease the risk of postoperative thromboembolic complication. Therefore, it is recommended for all prolonged laparoscopic procedures.

Immunomodulatory changes in patients with colorectal cancer.

Abstract.Background and aims: Solid tumors are frequently accompanied by a depressed cellular and humoral immunity. This study analyzed changes these factors in colorectal cancer patients. Patients and methods: We compared cellular (leukocytes, lymphocytes, HLA-DR expression on monocytes) and humoral immune parameters (interleukin-6, interleukin-10, tumor necrosis factor α) in 40 patients with colorectal cancer and in 18 healthy controls. Results: Leukocytes were in the normal range in patients and controls. However, tumor patients showed significant lymphopenia in comparison to controls. HLA-DR antigen expression on CD14+ monocytes was reduced in the cancer patients while IL-6 and IL-10 plasma levels were increased. Patients with UICC stage III had IL-6 and IL-10 concentrations were significantly increased as well. Conclusions: These findings suggest that colorectal tumor establishment and progression results in a malfunction of the immune system, and underline the importance of elucidating in detail the mechanisms of immune modulation in cancer patients.

Réhabilitation rapide en chirurgie colique : résultats d'une étude prospective

Objective. – In elective large bowel surgery the incidence of general complications with standard perioperative care is up to 27%. Hospital discharge occurs 10 to 15 days after a conventional or laparoscopic colonic resection. The aim of a fast track management is to reduce the number of general complications and the length of hospital stay. n nMaterial and methods. – We prospectively evaluated a multimodal protocol in our service utilizing a combined thoracic epidural analgesia, an early mobilization and oral nutrition to accelerate postoperative recovery after elective colonic surgery. n nResults. – One hundred thirty-two consecutive patients aged an average of 66 years (range 22–88) were operated by laparotomy (n =71) or laparoscopy (n =61) and treated with the fast track rehabilitation protocol. Surgical complications occurred in 15 patients (11 %), four of these had an anastomotique leakage (3%). General complications occurred in 11 patients (8 %), the mortality was 1 %. The median length of hospital stay was four days (range 3–77) and 14 patients (11%) had to be readmitted. n nConclusion. – Application of a fast track rehabilitation protocol lowered the number of general complications and reduced the duration of hospital stay in our study.

Effect of laparoscopic and conventional colorectal resection on peritoneal fibrinolytic capacity: a prospective randomized clinical trial

Background and aims: Reduced fibrinolytic activity of the peritoneum seems to be the main cause of postoperative adhesions. This prospective randomized trial compared the peritoneal fibrinolytic activity between laparoscopic and conventional colorectal resection. Methods: Parietal peritoneal biopsy specimens were taken in standardized elective laparoscopic (n=14) and conventional (n=16) colorectal resections at the beginning and at the end of surgery. Activities and concentrations of tissue-plasminogen activator (tPA), plasminogen activator (PAI) type 1, and tPA/PAI complex were determined by ELISA kits. Results: There was no difference in age, sex, or body mass index between the two groups. Perioperative tPA activity decreased in both groups without differences between the groups. Concentrations and activities of tPA, PAI-1, and tPA/PAI complex did not differ between the groups at any time. Conclusion: Peritoneal concentrations and activities of tPA, PAI-1, and tPA/PAI complex are similar during laparoscopic and conventional colorectal resections. A capnoperitoneum of 12xa0mmHg over 3xa0h did not affect the peritoneal fibrinolytic activity

Prospective randomized trial to determine the influence of laparoscopic and conventional colorectal resection on intravasal fibrinolytic capacity.

Background: Although the pneumoperitoneum decreases venous reflux from the lower extremities, the rate of thromboembolic complcations seems to be lower after laparoscopic than after conventional procedures. Therefore, it has been assumed that laparoscopic surgery better preserves the intravasal fibrinolytic capacity. The aim of this study was to determine the influence of the operative technique on intravasal fibrinolytic capacity in colorectal resection. Methods: Randomized controlled trial conducted in parallel with the multicenter trial LAPKON II comparing the long-term effects of elective laparoscopic (group I) and conventional (group II) resections for colorectal cancer. Blood samples were taken from 30 patients preoperatively, at the beginning and end of surgery as well as 2, 8, and 24 hr postoperatively. Activities and concentrations of tissue plasminogen activator (tPA), plasminogen activator inhibitor type 1 (PAI-1), tPA/PAI complex, fibrinogen, and D-dimers were determined in all specimen with ELISA tests. Area under the curve values (AUC) were calculated for all parameters. Results: Patient characteristics and indication for surgery were not different between both groups. Preoperative values of fibrinolytic parameters were similar in both groups. Postoperatively, tPA activity decreased significantly in both groups, but AUC values for tPA and PAI-1 activity (p = 0.23; p = 0.68); concentration of tPA, PAI-1, and tPA/PAI complex (p = 0.52; p = 0.78; p = 0.95); and concentration of fibrinogen and D-dimers (p = 0.67; p = 0.71) did not differ between the groups. Conclusions: An intravasal fibrinolytic shutdown occurs not only after conventional but also after laparoscopic colorectal resection. Both operative techniques had similar effects on postoperative intravasal fibrinolytic capacity. Therefore, the lower incidence of thromboembolic complications after laparoscopic colorectal resections does not seem to be caused by a lesser depression of the intravasal fibrinolytic capacity.n