ARTHUR P. FINE, MD, FACS
Over the past year, the percentage of colon surgeries performed laparoscopically has increased yet still remains a small fraction of all large bowel procedures performed. It has been estimated that last year 5% of all colon procedures were performed laparoscopically. This year, industry analysts estimate that 8% are accomplished laparoscopically and 7-9% by hand-assisted laparoscopic technique . Despite an increasing body of literature suggesting an equivalency for cancer surgery, feasibility for resection of benign disease, and an improvement of recovery of physical and GI tract activity with a decreased length of hospital stay, most colon surgery is performed by open technique. The reasons may be multiple, including the technical difficulty of the procedure, the fact that most colon resections are performed for malignancy (and that the results of the large multi-institutional studies are pending), and the lack of demand by the public which, as much as any other factor, drove the rapid availability of laparoscopic cholecystectomy. It will be the eventual findings of the effectiveness of laparoscopic surgery for curative resection of colon cancer that will dictate its acceptance.
Multiple studies of laparoscopic colon cancer surgery have been released this year. Most have not been both randomized and prospective nor had sufficient numbers to reach statistical significance. The follow-up periods for these studies have varied between 3 and 5 years.
A study by Franco-Osario  of 140 laparoscopic patients showed 3-year survivals for stages I, II, and III of 3.4%, 92.4% and 77.8% respectively. Bertolino  also evaluated 3-year survival for curative resection finding survivals of 100% for stage I and 87.7% and 76% for stage II and III. Feliciotti  compared 102 rectal cancer patients having both open and laparoscopic surgery. Survival probability for laparoscopic versus open procedures was 80.9% and 75.6% overall, 79% and 75% for stage II, and 69.2% and 66.7% for stage III. The same group  also compared 156 colon cancer patients who underwent either laparoscopic surgery or open procedures at 69 months. The cumulative survival probability was 89.7% for laparoscopic surgery and 86.1% open procedures. Lezoche  studied a group of 300 patents, still not enough to reach statistical significance; however, there was a trend toward a survival advantage for laparoscopic surgery (cumulative survival probability of 93.4% for laparoscopic versus 86% for open procedures). Lujon’s study  of 102 patients, however, compared their results with a benchmark. The results for laparoscopic versus open versus benchmark were 73%, 75%, 70% for stage I; 64%, 65%, 60% for stage II; 55%, 46%, 44% for stage III; and 0%, 11%, 7% for stage IV. While again not statistically significant, there was a trend for improved stage III survival for laparoscopic surgery. A study by Champault  also showed equivalence between the two procedures without reaching significance (cumulative survival probability of 63.1% for laparoscopic versus 59.1% for open procedures).
Lezoche’s data broken down by site seems to show a definite benefit for laparoscopic surgery (right colectomy: 86.5% for laparoscopic versus 81.8% for open and left colectomy: 97.1% for laparoscopic versus 88.7% for open). Even more interesting is when this group looked at their stage III survival. In a separate report of stage III patients, survival probability for right colectomy was 81.2% for laparoscopic surgery versus 66.7% for open procedures and was 95.0% for laparoscopic surgery versus 72.3% for open procedures for left colectomy.
The most significant paper of the past year was by Lacy . It was a prospective, randomized study of 219 patients and did reach statistical significance at 43 months. The cancer related mortality for laparoscopic surgery was 9% and for open surgery 21% (p = 0.02). The statistical significance was entirely due to the improved stage III patient survival for laparoscopic patients.
The findings in Lacy’s paper are unique in this year’s significant studies in that they reached statistical significance; however, they are similar to the trends towards improved overall survival at 3-5 years for laparoscopic surgery primarily reflected in the stage III population. Is there significance for this?
Most patients who succumb to malignant disease do so because of metastatic tumor burden. There have been many studies on local or port site recurrences in laparoscopic colon cancer surgery which have as their most consistent finding that surgical technique is the greatest contributor to whether or not local disease recurrence is kept to a minimum. If local and port site recurrence is controlled, and that is painting with a rather broad brush, then these studies at least suggest that laparoscopic surgery may have a more favorable effect on the occult micrometastasis present in stage III malignancy than a comparable open procedure.
Rocca et al  evaluated levels of vascular endothelial growth factor (VEGF) in patients undergoing open colon cancer surgery. VEGF is a potent stimulator of tumor angiogenesis , without which micrometastasis cannot grow beyond several millimeters in size to become a clinically significant and detectable metastasis. Their data shows circulating levels of VEGF increasing from pre-op levels of 1.32 to 1.61 on postoperative day 2 and 2.43 on postoperative day 5.
A study by Fine (unpublished data) compared an unselected group of patients undergoing colon surgery either by laparoscopic or open technique and evaluated the data for a correlation between total incision length and pre- and postoperative levels of VEGF (The difference in the appearance of the data reflects Rocca’s dividing the VEGF level in pg/cc by the patient’s platelet count). In patients with a total incision length of 12 cm or greater, pre- and postoperative levels were 70 pg/cc and 625 pg/cc respectively. If less than 12 cm, the levels were 44 pg/cc and 90 pg/cc. Data in neither study had sufficient volume to teach statistical significance; however in Fine’s study, multivariate analysis revealed that in the subgroup of patients receiving perioperative blood transfusions, incision length alone accounted for 50% of the pre- and postoperative rise in VEGF.
While the large multi-institutional studies have yet to report what will be regarded as the greatest body of evidence to judge the relative effectiveness of laparoscopic colon cancer surgery, this year, as in the past few years, studies have consistently shown a rough, albeit usually a not significant benefit for this procedure. The consistent finding of improved stage III survival raises the question of whether “wounding” is a factor in how quickly solid tumors and their metastasis recur and whether open surgery hastens the appearance of distant occult metastasis compared to laparoscopic surgery.
This article is a synopsis of Dr Fine’s presentation at Endo Expo 2002.
Address reprint requests to: Arthur P. Fine, MD, FACS, Jefferson Regional Medical Center, South Hills Medical Building, 575 Coal Valley Rd, Ste 372, Jefferson Hills, PA 15025, Telephone: 412 469 7035, Fax: 412 469 7037, E-mail: email@example.com
Arthur P. Fine, MD, trained in general surgery at McKeesport Hospital in Pennsylvania. Before entering private practice, Dr Fine joined the US Air Force where he served as Chief of Surgery at Laughlin Air Force Base until he was discharged, and he began his private practice. He first performed laparoscopic colon surgery in 1992. Since then he has continued clinical research and has reported on the results of laparoscopic surgery in a variety of clinical settings as well as the biochemical changes that may be responsible for the improvements demonstrable to the patient.
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