Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group. Laparoscopic resection for rectal cancer: outcomes in 194 patients and review of the literature. Laparoscopically assisted colon resection for colon carcinoma: perioperative results and long-term outcome. Long-term outcomes following laparoscopically assisted versus open ileocolic resection for Crohn's disease. Retromuscular sutured incisional hernia repair: a randomized controlled trial to compare open and laparoscopic approach. Wound complications of laparoscopic vs open colectomy. Laparoscopic vs. open colectomy in cancer patients: long-term complications, quality of life, and survival. Prospective evaluation of laparoscopic surgery for rectosigmoidal and rectal carcinoma. Randomized controlled trial of laparoscopic versus open colectomy for advanced colorectal cancer. A case-control-study comparing laparoscopic versus open surgery for rectosigmoidal and rectal cancer. Laparoscopic-assisted approach in rectal cancer patients: lessons learned from >200 patients.
The aim of the current study is to report the long-term outcomes after laparoscopic-assisted surgery compared with conventional open surgery within the context of the UK MRC CLASICC trial. Results from randomized trials have indicated that laparoscopic surgery for colon cancer is as effective as open surgery in the short term. Few data are available on rectal cancer, and long-term data on survival and recurrence are now required.
                The United Kingdom Medical Research Council Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (UK MRC CLASICC; clinical trials number ISRCTN 74883561) trial study comparing conventional versus laparoscopic-assisted surgery in patients with cancer of the colon and rectum. The randomization ratio was 2:1 in favor of laparoscopic surgery. Long-term outcomes (3-year overall survival [OS], disease-free survival [DFS], local recurrence, and quality of life [QoL]) have now been determined on an intention-to-treat basis.
                Seven hundred ninety-four patients were recruited (526 laparoscopic and 268 open). Overall, there were no differences in the long-term outcomes. The differences in survival rates were OS of 1.8% (95% CI, -5.2% to 8.8%; P = .55), DFS of -1.4% (95% CI, -9.5% to 6.7%; P = .70), local recurrence of -0.8% (95% CI, -5.7% to 4.2%; P = .76), and QoL (P > .01 for all scales). Higher positivity of the circumferential resection margin was reported after laparoscopic anterior resection (AR), but it did not translate into an increased incidence of local recurrence.
                Successful laparoscopic-assisted surgery for colon cancer is as effective as open surgery in terms of oncological outcomes and preservation of QoL. Long-term outcomes for patients with rectal cancer were similar in those undergoing abdominoperineal resection and AR, and support the continued use of laparoscopic surgery in these patients. There are few reports on laparoscopic rectum resection demonstrating its feasibility and efficacy in patients with rectal cancer. Most patient series are small, and results must be considered preliminary and medium-term. Our large prospective conducted study aimed to assess the effectiveness of a totally laparoscopic resection for rectum carcinoma with emphasis on perioperative and long-term oncological outcomes.
                Between November 1992 and July 2003, 194 unselected patients were resected laparoscopically for rectal carcinoma. Patients with locally advanced rectum carcinoma (uT3/uT4) and no evidence of distant metastases were candidates for neoadjuvant chemoradiation. Adjuvant treatment was administered to patients with UICC stage II/III disease. All patients were followed up prospectively to evaluate complications and late outcomes. Survival probability analysis was performed using the Kaplan-Meier method. Study selection was made by Medline search using the following key words: rectal cancer, rectal neoplasms, laparoscopy, and resection. Single case reports and abstracts were excluded. When surgical series were reported more than once, only the most recent reports were considered and listed.
                The most common procedures were low anterior resection with total mesorectum excision in 65.5% of patients and high anterior resection in 25.3%. Average operative time was 174 min. Average number of lymph nodes removed was 25.4 and length of specimen resected was 27.6 cm. Resection was curative in 145 patients and palliative in 49 cases. UICC tumor stages were as follows: stage I: 25.2%, stage II: 27.3%, stage III: 30.4%, and stage IV: 17%. Intraoperative complications were <1% for lesions of the ureter, urinary bladder, and deferent duct. Conversion to conventional surgery was necessary in two cases (1%). The most common postoperative complication was anastomotic leakage in 13.5% of patients. There was no postoperative mortality. Follow-up evaluation ranged from 1 to 128 months with a mean of 46.1 months. The most common late complication was incisional hernia in 3.6% of patients. Port-site metastases occurred in one patient (0.5%). Tumor recurrence developed in 23 of the 145 curative resected patients (11.7% distant metastases and 4.1% local recurrence). Overall local recurrence rate was 6.7% (4.1% after curative resection and 14.3% after palliative resection). Overall survival rate was 90.6% at 1 year, 74.5% at 3 years, and 66.3% at 5 years. Overall 5-year survival rate was 76.9% after curative resection and 31.8% after palliative resection. Cancer-related survival rate was 94% at 1 year, 82.4% at 3 years, and 78.9% at 5 years. At 5 years it was 87.7% after curative resection and 48.5% after palliative resection. At 5 years, the survival rate was 100% for stage I, 94.4% for stage II, 66.6% for stage III, and 44.6% for stage IV.
                Our results and the literature review clearly demonstrate that laparoscopic resection for rectal cancer is not associated with higher morbidity and mortality. Established oncological and surgical principles are respected and long-term outcomes are at least as good as those after open surgery. The role of laparoscopic colon resection in the management of colon cancer is unclear. The aims of this study were to compare perioperative results and long-term outcomes in patients randomized to either open (O) or laparoscopically assisted (LA) colon resection for colon cancer.
                A prospective randomized trial comparing O to LA colon resection was conducted from January 1993 to November 1995. Preoperative workup, intraoperative results, complications, length of stay, pathologic findings, and long-term outcomes were compared between the two groups. Statistical analysis was performed with t-test. Follow-up periods ranged from 3.5 to 6.3 years (mean, 4.9 years).
                No port-site or abdominal wall recurrences were noted in any patients. [table: see text]
                These results suggest that laparoscopically assisted colon resection for malignant disease can be performed safely, with morbidity, mortality, and en bloc resections comparable with those of open laparotomy. Long-term (5-year) follow-up assessment shows similar outcomes in both groups of patients, demonstrating definite perioperative advantages with LA surgery and no perioperative or long-term disadvantages. Long-term results of laparoscopically assisted versus open ileocolic resection for Crohn's disease were evaluated in a randomized trial.
                Sixty patients who underwent ileocolic resection between 1999 and 2003 were followed prospectively. Primary outcomes were reoperation, readmission and repeat resection rates for recurrent Crohn's disease. Secondary outcomes were quality of life (QOL), body image and cosmesis.
                Five patients were lost to follow-up. Median follow-up was 6.7 (interquartile range 5.7-7.9) years. Sixteen of 29 and 16 of 26 patients remained relapse free after ileocolic resection in the laparoscopic and open groups respectively (risk difference 6 (95 per cent confidence interval - 20 to 32) per cent). Resection of recurrent Crohn's disease was necessary in two of 29 versus three of 26 patients (risk difference 5 (-11 to 20) per cent). Overall reoperation rates for recurrent Crohn's disease, incisional hernia and adhesion-related problems were two of 29 versus six of 26 (risk difference 16 (-3 to 35) per cent). QOL was similar, whereas body image and cosmesis scores were significantly higher after laparoscopy (P = 0.029 and P < 0.001 respectively).
                Laparoscopically assisted ileocolic resection results in better body image and cosmesis, whereas open surgery is more likely to produce incisional hernia and obstruction.
                Copyright (c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. To compare the early and intermediate results of the open and laparoscopic tension-free repair of incisional hernia, 24 patients were randomized prospectively to undergo laparoscopic or open repair of incisional hernia with retromuscular placement of the prosthesis using transabdominal sutures for mesh fixation. All the procedures were completed as planned. The mean duration of surgery was not significantly different between the 2 groups (P=0.15). Time to oral solid food intake was longer in the open group (P=0.002). The analgesic requirement was lower in the laparoscopic group (P=0.05). One patient after open surgery and 2 in the laparoscopic group suffered postoperative complications (P=0.71). Postoperative stay was shorter in the laparoscopic group (P=0.006). No readmission or recurrence was registered within 6 months from surgery in either group. Laparoscopic incisional hernia repair, based on the Rives-Stoppa technique, is a safe, feasible alternative to open techniques. However, larger studies and long-term follow-up are required to further evaluate the true effectiveness of this operation. This study was conducted to determine if laparoscopic colon surgery has changed the incidence of wound complications after colon resection.
                Eighty-three patients were randomized to undergo either laparoscopic (LCR) or open colon resection (OCR) for cancer at our institution as part of a multicenter trial. Data were tabulated from review of the prospective database and physician records.
                Thirty-seven patients were randomized to LCR and 46 to OCR. Seven patients in the LCR group were converted to OCR. LCR was performed using a limited midline incision for anastomosis and specimen extraction. Incision length was significantly greater (p <0.001) in the OCR group (19.4 +/- 5.6 cm) compared to the LCR extraction site (6.3 +/- 1.4 cm). Wound infections occurred in 13.5% of patients after LCR (2.7% trocar, 10.8% extraction sites) and in 10.9% of patients after OCR. Over a mean follow-up period of 30.1 +/- 17.8 months, incisional hernias developed in 24.3% of patients after LCR and 17.4% after OCR. In the LCR group, extraction sites accounted for 85.7% of all wound complications.
                The extraction site for LCR is associated with a high incidence of complications, comparable to open colectomy. Strategies to alter operative technique should be considered to reduce the incidence of these complications. This study was designed to evaluate long-term complications, quality of life, and survival rate in a series of colorectal cancer patients randomized to laparoscopic or open surgery.
                A total of 391 patients with colorectal cancer were randomly assigned to laparoscopic (n = 190) or open (n = 201) resection. Long-term follow-up was performed every six months by office visits. Quality of life was assessed at 12, 24, and 48 months after surgery by a modified version of Short Form 36 Health Survey questionnaire. All patients were analyzed on an intention-to-treat basis.
                Eight (4.2 percent) laparoscopic group patients needed conversion to open surgery. Overall long-term morbidity rate was 6.8 percent (13/190) in the laparoscopic vs. 14.9 percent (30/201) in the open group (P = 0.018). Overall quality of life was significantly better in the laparoscopic group in the first 12 months after surgery, whereas at 24 months, patients of the laparoscopic group reported a significant advantage only in social functioning. No difference was found in both overall and disease-free survival rates by comparing laparoscopic vs. open group.
                Laparoscopic colorectal resection was associated with a lower incidence of long-term complications and a better quality of life in the first 12 months after surgery compared with open surgery. No difference between groups was found in overall and disease-free survival rates. This study was designed to examine the short-term results of laparoscopy in the treatment of curative cases of rectosigmoidal and rectal carcinoma.
                A review was performed of a prospective registry of 70 patients who underwent curative laparoscopic resection for rectosigmoidal and rectal carcinoma between July 1993 and April 2001. Before 1997, only patients with early (Tis or T1) cancers located in the rectosigmoid and upper rectum that required bowel resection were candidates for laparoscopy. In 1997, we expanded the application of laparoscopy to include T2 cancers located anywhere in the rectum. Mesorectal transection was performed at least 5 cm below the tumor for rectosigmoidal and upper rectal lesions, and total mesorectal excision was performed for lower tumors. Primary anastomosis was performed by a double-stapling technique, or a handsewn coloanal anastomosis was performed. Patient demographics and outcomes were recorded prospectively.
                The median follow-up was 23 months. An anastomosis was performed in 92.9 percent of the operations. Oral intake was started on median postoperative Day 1, and the median length of hospitalization was 8 days. Two patients needed conversion to conventional open surgery. A total of 15 postoperative complications occurred in 13 patients (18.6 percent), including anastomotic leakage in 6 (8.6 percent) and bowel obstruction in 3 (4.3 percent). Reoperation was required in six patients. Two patients developed recurrence of cancer at the anastomotic site. The expected 5-year survival and disease-free survival rates were 100 and 92.1 percent, respectively.
                The findings of the present study demonstrate the feasibility and safety of laparoscopic surgery for selected patients with rectal carcinoma. Morbidity and mortality rates and oncologic outcome appear to be comparable with conventional surgery. After confirming a favorable outcome of laparoscopic surgery for early colorectal cancer, we conducted a randomized controlled trial to compare short-term outcomes of laparoscopic and open colectomy for advanced colorectal cancer.
                Fifty-nine patients with T2 or T3 colorectal cancer were randomized to undergo laparoscopic (n = 29) or open (n = 30) colectomy. Median follow-up was 20 months (range, 6-34 months).
                Operative time was longer (p <0.0001) and blood loss (p = 0.0034) and postoperative analgesic requirement were less in the laparoscopic group than in the open group. An earlier return of bowel motility and earlier discharge from the hospital (p = 0.0164) were observed after laparoscopic surgery. Serum C-reactive protein levels on postoperative days 1 (p <0.0001) and 4 (p = 0.0039) were lower in the laparoscopic group than in the open group. Postoperative complications did not differ between the two groups.
                Laparoscopic surgery for advanced colorectal cancer is feasible, with favorable short-term outcome. This study compared laparoscopic with open surgery for the cure of cancer of the rectosigmoid and rectum. Results of surgery, postoperative recovery, and oncological follow-up were compared between 32 laparoscopic curative procedures (19 laparoscopic-assisted anterior resections for cancer of the rectosigmoid or upper rectum and 13 laparoscopic abdominoperineal resections for low rectal cancer) and 32 controls matched for age, UICC stage, tumor site, and type of resection who underwent open surgery during the same observation period. Morbidity was identical after laparoscopic and open resection (31.3%). Surgery was equally radical in the two groups regarding yield of lymph nodes and lateral and distal margins. Survival, recurrence, and cancer-related mortality showed no statistical differences. There was no port-site recurrence. The benefits of laparoscopic surgery were shown with a reduction in perioperative blood transfusion and earlier return of bowel function. However, the operative time was significantly increased in the laparoscopic group. This study shows that laparoscopic surgery for the cure of colorectal cancer is technically feasible, and that oncological short-term outcome does not differ from the results achieved by open techniques. However, prospective randomized trials are mandatory to evaluate the definite role of laparoscopic surgery for malignancy. The applicability of laparoscopic surgery in the treatment of colorectal diseases is still controversial. Early reports on laparoscopic-assisted colectomy in patients with colon cancer suggested that it minimizes surgical trauma, decreases perioperative complications, and leads to a more rapid recovery. To our knowledge, no previous studies have compared the laparoscopic vs the open approach in rectal cancer. The aim of this paper was to assess the results of laparoscopic techniques in patients with rectal cancer.
                From March 1998 to February 2003, all patients admitted to our unit with adenocarcinoma of the rectum were evaluated for surgery by the laparoscopic approach.
                A total of 220 patients with a mean age of 67.3 years were included in the study. One hundred thirty patients (59%) were treated with neoadjuvant chemoradiotherapy. In >75% of the patients, a surgical procedure with sphincter preservation was performed. The rate of conversion to the open approach was 20%. Ten patients had intraoperative complications. Fifty-eight patients (26.3%) developed postoperative complications. The length of hospital stay was 6.8 days. The distribution of tumor stages was as follows: stage I, 16.81%; stage II, 33.6%; stage III, 26.36%; stage IV, 19.09%. The mean number of lymph nodes was 13.8. The incidence of local relapse was 5.3%, with a follow-up of 18 months.
                Laparoscopic surgery can be safely performed in patients with adenocarcinoma of the rectum with good short-term results. Randomized controlled trials are needed to confirm these results.
Laparoscopic 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.