Surgical and Oncological Outcomes of Laparoscopic Colon Resection for Colorectal Cancer.

doi:10.21203/rs.3.rs-3215077/v1

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Surgical and Oncological Outcomes of Laparoscopic Colon Resection for Colorectal Cancer.

https://doi.org/10.21203/rs.3.rs-3215077/v1

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Background: Laparoscopy is one of the major advances in surgery in the last 30 years with many benefits including a lower incidence of postoperative ileus, less postoperative pain, shortened hospital stay, quicker return to daily activity, less wound-related complications and improved cosmetic results. Although initially laparoscopy was used for colon resection for benign cases, it’s now widely used for colorectal cancer resections after strong evidence has confirmed its safety and efficacy. We aim to report both surgical and oncological outcomes of our first series of laparoscopic colorectal cancer resections.

Methods: Laparoscopic colorectal resection service was set up in 2013. Data of all consecutive colorectal cancers were collected prospectively. Patients with locally advanced diseases and who required emergency operations for bowel obstruction or perforation were excluded. We analysed demographic, operative, postoperative and histopathological data for all patients who were included in the study.

Results: A total of 124 patients were presented to our unit between January 2013 and January 2023. Only 112 patients fulfilled the inclusion criteria and underwent laparoscopic resections. The median age of patients was 54.5 ( 19-92) years. Majority of patients were men, 55.4% of them. In 35% of cases, the cancer was located in the sigmoid and in the rectum in 33.5%. Laparoscopic anterior resection was the commonest procedure, 45%, followed by right hemicolectomy in 15% of cases. The conversion rate to open surgery was 8%. The commonest cause to convert to open were dilated bowel loops and tumour adherence to other structures. The mean operative time was 190 minutes (130-280). The mean hospital stay was 3 (2-7) days. No complication has been reported in 84% of patients. Among the complications, wound infection was the most common one, 6.3%. There were 6 anastomotic leaks (5.4%). The mean lymph node number harvested was 13 (3 – 66). In 62.5% lymph node count was 12 or more. The distal resection margin was over 2 cm in 89.3%. The 5 years disease-free survival rate was 87.3%.

Conclusion: This study showed that initiation of laparoscopic colorectal resection is feasible and safe both surgically and oncologically with the benefits of short hospital stay, adequate resection margins and lymph node harvested

Laparoscopy

Colorectal cancer

Oncological outcome

Surgical outcomes

Colorectal cancer is one of the commonest cancers in the Western world and the second commonest cause of cancer-related death (1). The overall 5-year relative survival rate approaches as high as 45%. Despite the progress with neoadjuvant chemoradiotherapy for rectal cancer and adjuvant chemotherapy for colon cancer, surgical resection remains the mainstay in the treatment of colorectal cancer (2). For so long, laparotomy and resection has been the procedure of choice for benign and malignant diseases of the colon and rectum. This is known to achieve curative oncological resections with clear margins and adequate lymph node count. Laparoscopy is one of the major advances in surgery in the last 30 years. The benefits of laparoscopy include lower incidence of postoperative ileus, less postoperative pain and a reduction in the need for analgesics, earlier tolerance of diet, shortened hospital stay, quicker return to daily activity, less wound-related morbidity, improved cosmetic results and a possible reduction in adhesion formation (3). These benefits are offset by prolonged operative time, cost, and the long learning curve associated with this technically challenging procedure (4). Initially, laparoscopy was reserved for benign cases and small and early colon cancers. The application of laparoscopy in cancer was opposed based on fear of the high incidence of port site seeding and metastases (5).

The first colorectal laparoscopic resection was reported by Jacobs et al. in 1991 (6). while Watanabe et al. (7) were the first to report the results of laparoscopic colorectal resection for colon cancer in 1993. Since then, multicentric randomized trials have shown that laparoscopy is safe in colorectal cancer resection in terms of 5-year overall and disease-free survival rates compared to open surgery (8–10). Further evidence strongly suggests that there are no statistically significant differences between open and laparoscopic surgery regarding the incidence of tumour local recurrence, distant metastases or disease-free survival (11–14). Currently, Laparoscopic resection for even large tumours is recognised as equally effective to open resection (15, 16). These led to wide acceptance of laparoscopy even for larger and advanced tumours. There is an obvious trend toward laparoscopy. In Great Britain, 40% of colorectal resections were performed laparoscopically in 2012 compared to only 5% in 2005 (17).

Our study aimed to report the initial experience of our centre and to evaluate the surgical and oncological results of laparoscopic colorectal cancer resections.

We started our first laparoscopic colorectal resection service for both malignant and benign conditions at Zheen Hospital in Erbil-Iraq in 2013. From January 2013 to December 2022, all consecutive patients with malignant colorectal tumours who were referred to or seen in our centre and underwent laparoscopic or laparoscopic-assisted colorectal resection were included in this study. All data were collected prospectively using a computerized database. This included preoperative demographic data, cancer staging, intraoperative, postoperative surgical and oncological data.

Exclusion criteria for laparoscopy were as follows: surgical colorectal emergencies, for example, large bowel obstruction by cancer or colon perforation and peritonitis, locally advanced T4 tumours confirmed by preoperative CT scan requiring extra anatomical dissection, large recurrent cancer and when there were medical contraindications to laparoscopy.

Preoperative workup

All patients had colonoscopy and tissue histology. A staging CT scan of the chest, abdomen and pelvis was done to detect any distant spread. For local staging of rectal cancer, a pelvic MRI was performed. Tumours were localised using both colonoscopy and CT scan. The procedure and possibility of a stoma were fully explained to all patients and informed consent was obtained. All patients were given a 4000 or 6000 IU Enoxaparin Sodium subcutaneously on the evening before surgery and continued for 5 days after the operation. No mechanical bowel preparation was used in any patient except for a single phosphate rectal enema 30 minutes before surgery in cases of rectal cancer. The rectal tumour was defined by location within 15 cm from the anal verge. Because of lower capacity than the volume of cases, not all patients with rectal cancer were able to receive neoadjuvant treatment.

Procedure

At the induction of anaesthesia, a single dose of 1 gm Ceftriaxone and 500 mg of metronidazole were administered and continued for 1 week postoperative. All patients had thromboembolic prevention stocking and intermittent pneumatic compression of the calf during surgery. Ports were placed in standard positions. Pneumoperitoneum was achieved with direct vision port insertion. Left and right colon segments were mobilised by medial to lateral dissection using Ligasure® (Covidien Inc.). The procedure routinely involved a proximal division of vessels (inferior mesenteric artery for the left colon and rectum, ileocolic and right branch of the middle colic artery for the right colon). The right Hemicolectomy specimen was delivered through a 5 cm transverse incision right to the umbilicus. Continuity was restored by a stapled functional side to side anastomosis using linear stapling devices. Left-sided and total colectomy specimens were delivered through a 5 cm suprapubic incision. Splenic flexure was mobilised when deemed necessary. Reconstruction was done with a circular stapling device to perform a colorectal anastomosis after anterior resections or ileorectal anastomosis following total colectomy. For mid and lower rectal lesions, Total Mesorectal Excision (TME) was performed via the same suprapubic incision that was used to deliver the specimen. None of the patients had a nasogastric tube. A pelvic drain was used only after rectal surgery and removed after 24 hours.

The conversion was defined as stopping the laparoscopy and continuing the dissection via a laparotomy wound larger than the incision used to extract the specimen. Conversion to open surgery was required in case of difficulty to proceed with laparoscopy in the presence of dilated bowel loops, T4 tumours attached to other organs requiring extra-anatomical dissection which was not shown on preoperative CT scan or patient’s characteristics such as thick mesentery and omentum in cases of obesity.

Postoperative and follow-up

All patients started an oral soft and liquid diet and mobilisation from the first postoperative day. Urinary catheter and pelvic drains were removed on the first postoperative day unless indicated otherwise. After discharge from hospital patients were seen on postoperative days 5 and 10 to record progress and presence of morbidity. All patients were referred to oncology for assessment to decide on adjuvant chemotherapy. Patients thereafter were scheduled for regular bi-annual follow-ups. Local recurrence was defined as any recurrence diagnosed or suspected at the site of the surgery or abdominal wound. Distant metastasis was defined when a new lesion appeared in the liver, lung, brain or bone during follow-up assessments.

The statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 28.0 (SPSS, IBM, Armonk, NY). The study has gained approval by the Ethics committee at the College of Medicine-Hawler Medical University.

A total of 124 patients underwent laparoscopic resection for cancer during the period of the study. Of those, 12 patients were decided not suitable for laparoscopic resection after preoperative assessment. Eight patients had colonic obstruction, 2 had colon perforation and 2 had locally advanced cancer. The characteristics of the remaining 112 patients included for analysis are shown in Table 1. There were 62 men and 50 women with a median age of 54.5 (19–92) years. According to the American Society of the Anaesthesiologists (ASA) grade, the health status was considered as ASA I in the majority of the patients, 56 patients (50%) while 46 (41%) patients were ASA II. Only 10 patients (9%) were ASA III. About 79 patients (70.5%) had the primary tumour located in the colon and 33 patients (29.5%) in the rectum. Among those with colon cancer, sigmoid was the most common (35%). Among the 33 rectal cancers, only 11 patients (9.7%) had neoadjuvant radiotherapy (5 patients) or chemoradiotherapy (6 patients), whereas only 3 (2.6%) with colon cancer received preoperative chemotherapy.

Table 1

Patients’ Demographic and clinical characteristics
	n (%)
Median Age (Range)	54.5 (19–92) years
Male Female	62 (55.4) 50 (44.6)
ASA Score I II III	56 (50) 46 (41) 10 (9)
Tumours location Right colon Left colon Sigmoid Rectum	21 (18.25) 19 ( 17) 39 (35) 33 ( 29.5)
Neoadjuvant therapy in Rectal cancer Short course Long course Neoadjuvant therapy in colon cancer	5 (4.4) 6 (5.3) 3 (2.6)

Table 2 outlines the intraoperative details. Anterior resection was the most frequent procedure in this period, being 50 procedures (45%), followed by right Hemicolectomy in 17 patients (15%), left hemicolectomy in 14 patients (12.5%), total colectomy in 12 patients (10.7%) and sigmoid colectomy in 9 patients (8%). Two patients (1.8%) had Hartmann’s procedure.

Among all the procedures, 9 (8%) were converted to open procedures either because of a locally invading tumour or dilated bowel loops in 6 (5.4%) and 3 (2.6%) patients respectively. The median operative time for all procedures was 190 minutes. After splitting the duration of 9 years of this study into 3 sections of 3 years each, there was a significant difference (p = 0.034) between the operation time of the first 3 years period (mean 230 minutes) and the subsequent 2 periods (mean 190 minutes). While conversions to open surgery were distributed throughout all three periods.

Table 2

Operative details
Intraoperative details	n (%)
Surgical resection type Right Hemicolectomy Left Hemicolectomy Total colectomy Anterior resection Sigmoid colectomy Abdominoperineal resection Hartmann’s procedure	17 (15) 14 (12.5) 12 (10.7) 50 (45) 9 (8) 8 (7) 2 (1.8)
Conversion into open surgery	9 (8)
Causes for conversion Dilated bowel loops Tumour invasion	3 (2.6) 6 (5.4)
Median operative time (Range)	190 min (130–280)

Postoperative details are shown in Table 3. The mean hospital stay was 3 (2–7) days. The 30-day mortality rate was 1 (0.9%), this was because of myocardial infarction. The overall morbidity rate was 16% (18/112). 6 patients (5.4%) had a clinical anastomotic leak. Four leaks were following rectal cancer resection and were treated conservatively as they had a diversion ileostomy during the initial operation. The 2 other leaks were following colon resection, both of whom required readmission and reoperation. Only 4 patients (3.6%) had delayed bowel movement after surgery and were diagnosed as paralytic. Both of them were treated conservatively. The mean length of hospital stay of the patients with complications was 4 days which was significantly higher than those with no complications, 2.9 days. (p < 0.001).

Table 3

postoperative surgical and pathological outcomes
Postoperative data	n (%)
Mean postoperative hospital stay (range) days	3 (2–7)
30-day postoperative mortality	1 (0.9)
Complications Paralytic ileus Bleeding Cardiovascular Wound infection Leak Fistula	18 (16) 4 (3.6) 1 (0.9) 1 (0.9) 7 (6.3) 6 (5.4) 1 (0.9)
Reoperation rate	2 (1.8)
Histopathology Well–moderately differentiated Poorly differentiated and mucinous No residual tumour (neoadjuvant therapy)	97 (85.6) 13 (11.6) 2 (1.8)
Median Lymph node count (range) Lymph node yield < 12 > 12	13 (3–66) 42 (37.5) 70 (62.5)
Median distal resection margin ( range) cm Distal resection margin < 2 cm > 2 cm	5 (0.5–32) 12 (10.7) 100 (89.3)
Final postoperative tumour stage Stage I Stage II Stage III Stage IV	22 (20) 41 (37.3) 33 ( 30) 14 (12.7)

Tumour histopathology showed that 85.6% of the tumours were well–moderately differentiated adenocarcinomas. Two patients (1.8%) had complete resolution of the rectal tumour after receiving neoadjuvant chemoradiotherapy. The median lymph node number harvested was 13 lymph nodes. In 62.5%, the number of lymph nodes was over 12 lymph nodes. The median distal resection margin was 5 cm. In 100 (89.3%) cases, the distal resection margin was 12 cm and more. 33 patients had surgery for rectal cancer. In 60.6%, more than 12 lymph nodes were harvested. The distal resection margin was more than 2 cm in 20 of them (74%).

The mean period of follow-up was 28 months. During follow up 15 patients had confirmed recurrence of the tumour either locally or distally. The mortality rate during the period of follow-up was 8.9%, 10 patients died in total. Although, 8 patients (7.1%) out of the study group were lost to follow-up. The cause of death in 7 patients (6.3%) was directly related to the cancer while 3 patients (2.7%) died because of causes not related to their cancer.

The overall 5 years disease-free survival rate was 87.3% as shown in Fig. 1.

Disease free survival rate according to all cancer stages is shown in Fig. 2. There was a significant difference in disease-free survival between the tumour stages. (P = 0.001)

The current study reports the experience of trained surgeons in a single institution. The laparoscopic colon resection service was initiated for the first time after training a dedicated team and meeting the requirements. There was considerable fear from both the medical and patient sides that laparoscopy could jeopardise a complete resection of the tumour and adequate lymph node dissection. These fears, as well as port site metastasis, were the reasons behind the delay to apply laparoscopy in colon cancer management. What refuted these concerns were the conclusions of four major randomised controlled trials (COST, COLOR, Barcelona and MRC CLASSICC) which demonstrated that the oncological outcomes are similar to the open method (18–21). This minimally invasive technique is now widely adopted worldwide. Its efficacy and benefits were shown in literature with high-level evidence.

The mean age of patients at diagnosis of colorectal cancer in our study, 54.5 years, seems to be lower than many other series (26–28). This is because about 60% of patients were 60 years and younger. This in turn explains the fact that 50% of patients were ASA I and 41% were ASA II. It is well observed that less than 10% of rectal cancer patients had neoadjuvant treatment, which is very low compared to the standard management of rectal cancer. This might be attributed to the shortage of this service that cannot accommodate all cases.

Of all laparoscopic procedures, only 8% were converted to and completed by an open procedure. This is comparable with literature reports and even lower than some major studies reporting 21%, 25% and 17% conversion rates (15–21). These conversions were not influenced by the learning curve because they were spread throughout the period of the study. It is well known that Laparoscopic colon cancer resection has a long learning curve that varies between surgeons and is affected by patient and operative complexity (4, 32). There was a significant difference between the operative times of the first 3 years of the study and the following two periods of 3 years each.

The incidences of complications after Laparoscopy is not statistically different from that after open surgery (22, 23). Overall 30-day postoperative morbidity was reported in 16% of patients. Of 6 patients who had anastomotic leaks, only 2 patients required readmission and reoperation. The other 4 patients had a long course of neoadjuvant chemoradiotherapy and had a defunctioning ileostomy at initial resection and were managed conservatively. The other complications were mild and treated conservatively. The 30-day mortality was 1 (0.9%). This patient was ASA III and had an acute myocardial infection 1 day postoperative. These findings partly coincide with other reported morbidities ranging from 7%-30% (24–27). Earlier larger studies reported even higher morbidities of 60–80% (19–21).

Our mean length of stay of 4 days compares favourably with other series. It is lower than the ACPGBI figure of 10 days for open elective colon resection (28). Some studies reported 5 and 6.6 days (27, 29). Longer hospital stays in some reports may be attributed to an aging population and the presence of comorbidities. We tended to discharge patients as soon as possible and schedule 2 or 3 postoperative outpatient reviews within 10 days after the operation. Morbidity had a negative influence on the length of hospital stay. Patients stayed significantly longer when they had complications.

Our oncological outcomes are acceptable in the form of clear resection margins and nodal yield. The distal resection margin was < 2 cm in 10.7% of cases. The mean lymph node yield of 13 is more than the recommended 12 lymph nodes (30). In 37.5% the lymph node count was < 12. The lowest nodal yield was 3 lymph nodes. Such low counts were in cases who had resection of recurrent tumours or after neoadjuvant chemoradiotherapy (30). Our pathologists harvest lymph nodes by palpation method only which can miss small nodes (31) without using any (fat-clearing method) to maximise nodal count. Unfortunately, circumferential resection margin is not done routinely by every pathologist. This is why we lack some data. Only one patient with poorly differentiated Mucinous adenocarcinoma had surgical wound recurrence. Only 2 patients had a pelvic recurrence. No anastomotic recurrence has been reported in this series.

About 7.1% of the patients were lost to follow-up. The fact that we receive patients from other counties makes it more difficult for some patients to travel and attend regular follow-ups.

We acknowledge that this series is limited in some aspects, most importantly, the small number of patients and the absence of resources to meet international guidelines such as neoadjuvant treatment and histopathology resources. Yet, this study shows acceptable oncological outcomes while supporting the benefits of Laparoscopy.

Our study shows that initiation of laparoscopic colorectal resection for cancer is feasible with acceptable outcomes. The study showed comparable low complications, short hospital stays, adequate resection margin, adequate lymph node yield and comparable survival rates. It shows that laparoscopic colon resection for cancer can be safely completed without compromising surgical or oncological outcomes.

Competing interests: The authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.
Ethics approval and consent to participate: The current study has gained approval from the Ethics Committee at the College of Medicine, Hawler Medical University. Written informed consent was obtained from the patients for the performance of the surgical procedure, participation in the study and publication of the results and any images. All procedures performed in the study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments.
Consent for publication: Not applicable, the study doesn’t include any detail or image related to an individual person. The raw data used in this study, which may be shared on request, do not include any image or detail related to any individual person
Availability of data and materials: The dataset used and analysed during the current study is available from the corresponding author upon reasonable request.
Funding: The study and the authors have not received any funding in any form.
Authors’ contributions: M. Reviewed data and wrote the methods and the discussion N.A. Collected and updated data A.M.D wrote the introduction and prepared references B.S.A. wrote the results and prepared the tables A.A. checked the contents and the language of the manuscript All authors reviewed the manuscript.
Acknowledgements: Not applicable.

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No competing interests reported.

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Surgical and Oncological Outcomes of Laparoscopic Colon Resection for Colorectal Cancer.

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Abstract

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Introduction

Patients and methods

Preoperative workup

Procedure

Postoperative and follow-up

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

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