Laparoscopic Versus Open Resection For T
Laparoscopic Versus Open Resection For T
Laparoscopic Versus Open Resection For T
ORIGINAL ARTICLE
Keywords: Abstract
Descending colon cancer; laparoscopic
surgery; transverse colon cancer Introduction: Previous randomized controlled trials demonstrated similar
oncological outcomes between laparoscopic and open colectomies, except for
Correspondence cases involving transverse colon and splenic flexure colon cancer. The objective
Shigeki Yamaguchi, Department of of this study was to confirm the oncological safety and advantages of the
Gastroenterological Surgery, Saitama
short-term results of laparoscopic surgery for transverse and descending colon
Medical University International Medical
Center, 1397-1 Yamane, Hidaka, Saitama
cancer in comparison with open surgery.
350-1298, Japan. Methods: The study data were retrospectively collected from the databases of 45
Tel: +81 42 984 4111 hospitals. Patients with transverse or descending colon cancer who underwent
Fax: +81 42 984 4741 laparoscopic or open R0 resection were registered. The primary end-points were
Email [email protected] the 3-year overall survival and relapse-free survival rates according to
pathological stage. The secondary end-points were the short-term results,
Received 7 January 2017; accepted 13
including blood loss, operative time, diet intake, hospital stay, and postoperative
February 2017
complications.
DOI: 10.1111/ases.12373 Results: Of the 1830 eligible patients, 872 underwent open colectomy and 958
underwent laparoscopic colectomy. The median follow-up period was
38.4 months. The conversion rate to open resection was 4.5%. The 3-year overall
survival rate of the laparoscopic group was significantly higher than that of the
open group for stage I patients (96.2% vs 99.2%; P = 0.04); it was also higher
for stage II (94.0% vs 95.5%) and stage III (87.4% vs 90.2%) patients, but there
were no significant differences. The 3-year relapse-free survival rate of the
laparoscopic group was significantly higher than that of the open group for stage
I patients; there were no differences between the open and laparoscopic groups
among the stage II and III patients. In the multivariate analyses, laparoscopic
resection was a significant factor in relapse-free survival. Laparoscopic patients
had significantly lower blood loss and a significantly longer operative time than
the open groups. Also, postoperative hospital stay was significantly shorter and
postoperative morbidity was significantly lower in the laparoscopic group.
Conclusion: Although this retrospective study has limitations, we can conclude
that laparoscopic surgery for transverse and descending colon cancer is
oncologically safe and yields better short-term results than open surgery.
Procedures
Laparoscopic resection was performed by member surgeons
of the Japan Society of Laparoscopic Colorectal Surgery.
Under pneumoperitoneum, mobilization of the colon
was performed laparoscopically in all patients. Vascular
ligation was performed in accordance with the
lymphadenectomy for each patient. In some institutions,
the vessels were ligated directly from a small skin incision
via an open method. Finally, the specimen was removed,
and anastomosis was performed extracorporeally via Figure 1 CONSORT diagram of the study.
statistically significant. All statistical analyses were performed The two study groups were well balanced in terms of sex,
by one author (R.A.) using SAS version 9.1.3 SP4 (SAS comorbidity, and primary cancer lesion; age, BMI, and
Institute, Cary, USA) and SAS JMP 11.0.0 (SAS Institute). previous laparotomy were statistically different. D3 lymph
node dissection and lymph node harvests were significantly
more frequent in the open group (8). Intraoperative
Results complications were similar in both groups. Regarding the
Patient characteristics TNM stage distribution, there were more patients with stage
I in the laparoscopic group and more patients with stage II in
From March 2011 to March 2012, 1926 patients were
the open group. The number of patients with stages 0 and III
registered. Of these patients, 96 were excluded because of
was almost equivalent in both groups. The histological grade
stage IV cancer (n = 37), R1 or R2 resection (n = 3), or
of differentiation was also significantly different (Table 1).
incomplete data (n = 56). Among the 1830 patients who
The conversion rate of laparoscopic to open resection was
were available for analysis, 872 patients underwent open
4.5% (Table 2). Severe adhesion was the most common
colectomy and 958 patients underwent laparoscopic
reason (n = 14), and advanced cancer status, such as
colectomy (Figure 1). The median follow-up period of all
invasion to other organs, and bleeding were the secondary
analyzed patients was 38.4 months.
reasons for conversion to open surgery.
between the two groups. The 3-year RFS rate for stage I was 2: HR: 3.81, 95%CI: 2.34–6.55, P < 0.001; 2 and 3: HR:
significantly better in the laparoscopic group (open 92.7% vs 2.22, 95%CI: 1.69–2.95, P < 0.001) were significant factors
laparoscopic 97.8%, P = 0.001). There were no statistically in the univariate analysis. In the multivariate analysis of
significant differences in the 3-year RFS rate for stages II RFS, the type of procedure was also a significant factor (HR:
and III (II: open 86.2% vs laparoscopic 89.4%, P = 0.21; III: 0.69, 95%CI: 0.53–0.91, P = 0.007) (Table 4).
open 71.4% vs laparoscopic 77.5%, P = 0.13) (Figure 3).
A univariate analysis was performed regarding the OS.
The type of procedure (laparoscopic and open) (hazard Short-term results
ratio [HR]: 0.52, 95% confidence interval [CI]: 0.35– Blood loss in the laparoscopic group was significantly lower
0.79, P = 0.002) and TNM stage (1 and 2: HR: 3.49, 95% than that in the open group for the overall stage and stages I
CI: 1.70–8.10, P < 0.001; 2 and 3: HR: 2.11, 95%CI: 1.38– to III. Operative time in the laparoscopic group was
3.26, P < 0.001) were significantly different. Only the TNM significantly longer than that in the open group for the
stage was a significant factor in the multivariate analysis overall stage and each stage. Both postoperative solid diet
(Table 3). Regarding the RFS, the type of procedure (HR: intake start and postoperative hospital stay were shorter in
0.53, 95%CI: 0.41–0.69, P < 0.001) and TNM stage (1 and the laparoscopic group (Table 5). No postoperative mortality
Univariate Multivariate
CI, confidence interval; D, descending colon; F, female; HR, hazard ratio; Lap, laparoscopic; M, male; T, transverse colon.
Univariate Multivariate
CI, confidence interval; D, descending colon; F, female; HR, hazard ratio; Lap, laparoscopic; M, male; T, transverse colon.
other sites of colon cancer. Previous retrospective studies in the present study was generally lower than that of
have reported that laparoscopic transverse colectomy patients in Western countries. However, transverse
showed better short-term results than open surgery with colectomy is still technically demanding and has been
acceptable oncologic outcomes (10–12). However, all these reported as a significant risk factor for conversion to open
studies were single-center analyses with relatively few surgery (13). In this study, adhesion was the most frequent
cases. Therefore, we conducted a multicenter retrospective reason for conversion to open surgery. Therefore, further
study to evaluate large numbers of patients. improvements are required for a safe and skillful
The 3-year OS rate for all stages was statistically better in laparoscopic surgery.
the laparoscopic group because of staging bias. Because this In this study, all short-term results, except for the
study was a retrospective cohort study, stage distribution operative time of each TNM stage, were more favorable in
bias was expected in the operation period. As a result, the the laparoscopic group than in the open group, especially
distribution of stages 0–I was 19% in the open group and in comparison with those of prior study outcomes
48% in the laparoscopic group. The number of cases with (2,3,14). There was significantly less bleeding in the
stage III was around 30% and comparable in both groups. laparoscopic group; however, blood loss in the open group
Therefore, we assessed each survival rate separately in was small compared with previous results (3,6). Blood loss
accordance with the TNM stage. The OS curves were similar is generally measured by the weight of the gauze and
in each stage from stages I to III, and there were no suction volume in Japan. Therefore, previous results using
significant differences between stages II and III. The the estimated blood loss were different from the counted
laparoscopic group had a statistically better 3-year OS rate blood loss in this study.
for stage I, but the laparoscopic procedure was not a A longer operative time has always been an issue in
statistically significant factor in the multivariate analysis of laparoscopic procedures. Recently, the operative time of
OS. The OS rates of the laparoscopic and open resections laparoscopic colectomy has been shortened, and the
were considered almost equivalent from these results. The learning curve for laparoscopic surgery has become faster.
3-year RFS rate for each stage had a similar relationship Technical improvements and further education in
with the OS rate and was statistically better in the transverse colectomy are still important. D3 lymph node
laparoscopic group for stage I; there was no significant dissection is particularly technically demanding (7). The
difference between stages II and III. Furthermore, skeletonization and division of the middle colic vessels are
laparoscopic resection was a significant factor in the complicated techniques because of the diverse anatomy of
univariate and multivariate analyses of RFS in this study. the vessels (15). Therefore, the relatively longer operative
Therefore, there were no OS and RFS rates indicating that time in this study may have been caused by the
the laparoscopic group’s inferiority to the open group. lymphadenectomy used in the Japanese-style D3
Most large randomized trials have suggested that dissection. Both postoperative solid diet intake start and
laparoscopic and open colectomies have no difference in hospital stay were shorter in the laparoscopic group. The
survival, even with regard to the TNM stage (4,6), although fast recovery after laparoscopic surgery is one of its greatest
the Barcelona trial resulted in a better survival rate after advantages, with other trials having shown similar results
laparoscopic colectomy for stage III patients (2). In this trial, (2–4,14).
a significant difference was observed in stage I patients, and Postoperative complications after laparoscopic surgery
it is unclear why the laparoscopic group showed better occurred less frequently than or at a similar rate to those
results for stage I. However, there were many T1 patients reported in previous studies (2,4,6,14). In this study, the
in the laparoscopic group; it is possible that the laparoscopic overall morbidity rate and wound infection rate in the
group included more T1a patients than the open group. laparoscopic group were significantly lower than in the
Lacy et al. suggested that immunity and surgical stress open group. A recent survey of over 27 000 patients
may reduce cancer recurrence after laparoscopic re suggested similar results (16).
section (2). Further studies are necessary to assess this Several issues are noted in this study. Given that this
favorable outcome, but at least an almost equivalent study had a retrospective cohort design and was not a
survival rate is expected for laparoscopic resection from randomized trial, there were likely biases with regard to
this study. several factors such as the hospital, surgeons, indication
The rate of conversion to open surgery was 4.5% in this for laparoscopic surgery, and operation date. Randomized
study, which is lower than the rates observed in the Clinical trials are the gold standard to establish clinical evidence.
Outcomes of Surgical Therapy trial (21%) and in the Colon However, the frequency of transverse and descending
Cancer Laparoscopic or Open Resection trial (19%) (4,6). colon cancer is relatively low. Therefore, a planned
After these trials, the surgical techniques and devices randomized trial for transverse colectomy would take a
improved. Furthermore, the BMI of the Japanese patients long time. A very large number of patients—more than
1900—were registered in this study. All participating 6. The Colon Cancer Laparoscopic or Open Resection Study
surgeons were on staff at teaching hospitals and were Group. Survival after laparoscopic surgery versus open surgery
members of the Japan Society of Laparoscopic Colorectal for colon cancer: Long-term outcome of a randomised clinical
Surgery. We believe that this study could serve as a trial. Lancet Oncol 2009; 10: 44–52.
reference for future studies. 7. Watanabe T, Itabashi M, Shimada Y et al. Japanese Society for
Despite these limitations, the results of this study of more Cancer of the Colon and Rectum (JSCCR) guidelines 2010 for
than 1800 patients demonstrate that laparoscopic surgery the treatment of colorectal cancer. Int J Clin Oncol 2012; 17: 1–29.
for transverse and descending colon cancer is oncologically 8. Japanese Society for Cancer of the Colon and Rectum. General
Rules for Clinical and Pathological Studies on Cancer of the Colon,
safe and has better short-term outcomes than those in
Rectum and Anus, 7th edn. Tokyo: Kanehara-Syuppan, 2006
previous trials on right and sigmoid colon cancer.
(in Japanese).
9. Sobin LH & Wittekind C. TNM classification of malignant tumors,
6th edn. New York: Wiley-Liss, 2002.
Acknowledgments 10. Yamamoto M, Okuda J, Tanaka K et al. Clinical outcomes of
This trial was funded by the Japanese Society for Cancer of laparoscopic surgery for advanced transverse and descending
the Colon and Rectum. The authors have no conflicts of colon cancer: A single-center experience. Surg Endosc 2012;
interest to declare in association with this study. Further, 26: 1566–1572.
we thank the members of the Japanese Society of 11. Kim HJ, Lee IK, Lee YS et al. A comparative study on the
short-term clinicopathologic outcomes of laparoscopic surgery
Laparoscopic Colorectal Surgery for supporting this trial.
versus conventional open surgery for transverse colon cancer.
Surg Endosc 2009; 23: 1812–1817.
12. Fernández-Cebrián JM, Gil Yonte P, Jimenez-Toscano M et al.
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