Laparoscopic Colectomy for Curable Colon Cancer

by Michael Tarnoff, MD, Surgeon, Tufts-New England Medical Center

Colon cancer is the third most common type of cancer in the western world. Over 135,000 new cases are diagnosed each year in the United States. The incidence is highest in African Americans, who are also more likely to die of the disease. The likelihood of developing colon cancer increases after age 50, but younger individuals can be affected as well. Risk factors for colon cancer include a personal history of colon cancer or polyps, inherited colon cancer syndromes such as Familial Adenomatous Polyposis or Hereditary Non-Polyposis Colon Cancer, ulcerative colitis or Crohn's disease, and lifestyle factors such as high fat diets, smoking and alcohol consumption. Family history is also an important component of assessing risk. For example, a patient with one first degree relative (parent, sibling or child) with colon cancer is two-to-three times as likely to develop the cancer as someone who does not have an affected relative. Despite this association, roughly 80 percent of new colon cancer cases are diagnosed in people who do not possess any of these identifiable risks. Fortunately, with screening, early detection and surgery, the majority of patients afflicted with colon cancer can be cured.

Laparoscopic Colectomy
The surgical treatment of colon cancer has traditionally been open resection of the involved colonic segment, also known as a “segmental colectomy” (see figure 1). While effective in achieving local tumor control, open segmental colectomy usually requires large abdominal incisions. This is particularly true for lesions or tumors of the left and sigmoid colon. The larger incisions required by “open” approaches can be associated with complications including prolonged postoperative hospital stays and narcotic use, which in turn can lead to longer convalescence and delays in resumption of normal activities. Further, larger incisions compromise the cosmetic result and increase the possibility for wound infection and incisional hernia. Minimally invasive (laparoscopic) surgery offers the opportunity for improvement.

Laparoscopic colectomy has been utilized to treat benign colon diseases for nearly a decade. In fact, laparoscopic colectomy for sigmoid diverticulitis is rapidly becoming a gold standard approach. Regardless of the condition being treated, laparoscopic colectomy generally involves four small incisions (three less than one cm and one approximately five cm). This minimally invasive approach permits access to the abdomen, where resection can be performed with the same technique applied through larger “open” incisions. A recent case-matched comparison study of 300 patients undergoing laparoscopic colectomy at the Cleveland Clinic found that laparoscopic colectomy for benign disease afforded a shorter length of stay and reductions in inpatient pharmacy costs when compared with an open approach (Annuals of Surgery, US, July 2003, 238 1 p. 67-72). The benefit so significant that the reduced post-operative hospital costs offset the increased operating room costs associated with the laparoscopic approach.

Despite the enthusiasm for minimally invasive colectomy for benign disease, there has been significant caution over its use in the treatment of curable colon cancer. Early experience with laparoscopic colectomy in colon cancer yielded alarmingly high rates of recurrent tumors at laparoscopic port sites (NEJM, 2004; 350;2050-9). There was also skepticism over whether or not a minimally invasive approach could yield as effective a cancer operation, i.e. lymph node dissection, tumor free margins, etc. This raised concerns over the ability of surgeons to adhere to time-honored oncologic principles when removing tumors using laparoscopic techniques. Lastly, laparoscopic colectomy still requires a small incision to remove the specimen, which raised questions as to whether or not this approach truly yielded any benefit over conventional open approaches.

The results from a multi-center National Institutes of Health clinical trial have recently been published, and offer scientific insight into each of these debated points. In this trial, investigators from 48 centers across the United States randomized eligible colon cancer patients to either laparoscopic colectomy or standard open segmental colectomy. There were 428 patients who underwent conventional open colectomy and 435 who underwent laparoscopic colectomy. At three-year follow-up, rates of port site and local tumor recurrence – as well as survival – were similar in both groups, while length of hospital stay and duration of narcotic use were significantly lower for those who underwent the laparoscopic approach.

Several other randomized prospective trials have reported similar results. A 2002 Lancet publication on a 219-patient randomized prospective trial suggested that laparoscopic colectomy yielded equivalent local tumor control, improved post-operative convalescence and improved survival over open resection (Lancet 359:224, 2002). These authors proposed that the minimally invasive nature of the laparoscopic approach may allow for higher immune system function, which could explain their results.

About Tufts-New England Medical Center
Founded in 1796 as the Boston Dispensary to care for sick and needy Bostonians, Tufts-New England Medical Center is the oldest health care facility in New England. It serves as the primary clinical and teaching affiliate of Tufts University School of Medicine. Tufts-NEMC is a world-class, academic medical institution that is home to both a full-service hospital for adults and the Floating Hospital for Children and has long been recognized as a leader in cancer care, cardiology, organ transplantation and pediatrics. Surgeons in Tufts-New England Medical Center’s Division of Bariatric Surgery have extensive experience performing laparascopic colectomies for both benign and metastatic disease. For more information on Tufts-NEMC, access our web site, .


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