Laparoscopic colorectal cancer surgery: panacea, placebo or just good fun?

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Date: July 2013
Publisher: Expert Reviews Ltd.
Document Type: Editorial
Length: 1,922 words
Lexile Measure: 1440L

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Author(s): Craig A Harris 1 , Prashant Sharma 2 , Frank A Frizelle 3



ALCAS; colorectal cancer; laparoscopic surgery; randomized controlled trials; surgical outcomes

The timely collision of technological development of miniature video cameras, on-screen display and surgical opportunities led to the emergence of minimally invasive surgery, which has been met with open arms by surgeons and patients alike. Ever since the first laparoscopic cholecystectomy in 1987, the surgical world has been fascinated with broadening the potential indications for laparoscopic surgery. In the early 1990s, laparoscopic colorectal surgery was an emerging technique with unproven outcomes. Case reports documenting port site tumor recurrence raised concerns in the medical community, questioning the oncological outcomes and potential sacrifices that were being made in order to perform the resection in a minimally invasive manner.

The initially steep learning curve and evolving technology meant longer operating times and higher costs compared with open surgery, with perhaps minimal gains in terms of length of stay, opiate use and return of bowel function. Early adapters looked for the potential advantages of laparoscopic surgery and continued to refine techniques, thus reducing operating times and subsequent associated costs. However, issues still remain as surgeons moved from 'what can we do?' to 'what should we do?'; the question arose as to whether laparoscopic colectomy could achieve an oncologically sound resection with an equivalent extent of dissection and lymph node yield without creating new patterns of disease recurrence. It has taken almost 20 years from the initial trial designs to publication of the long-term results to clarify this. There are four landmark trials that have helped map the path forward. Interestingly, none of these trials were designed to determine whether or not laparoscopic surgery was superior to open surgery.

The first substantive results to be published were from the COST study group and were reported in the New England Journal of Medicine in 2004 [1] . This was a noninferiority designed randomized controlled trial that recruited 872 patients from 48 institutions between August 1994 and August 2001. After a median follow-up of 4.4 years, the results showed no difference in overall survival or local recurrence.

The COLOR trial group reported their noninferiority design study in Lancet Oncology in 2009 [2] . They had recruited patients from March 1997 to March 2003. Exclusion criteria included those with a BMI over 30 - a somewhat interesting exclusion given the modern day obesity epidemic. They randomized 627 patients to laparoscopic surgery and 621 to open surgery with the primary end point being cancer-free survival at 3 years. The median follow-up was 53 months (range: 0.03-60 months). This study showed a trend towards increased disease-free survival in patients undergoing an open operation. The difference in overall survival at 3 years was 2.4% (95% CI: 2.1-7.0; hazard ratio: 0.95 [0.74-1.22]).

In January 2013, the UK Medical Research Council CLASICC trial long-term results were published in the British Journal of...

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Gale Document Number: GALE|A339495924