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| Journal of the New Zealand Medical Association,
08-June-2012, Vol 125 No 1356
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|
Short-term outcomes of laparoscopic resection for
colon cancer in a provincial New Zealand hospital
Josese Turagava, Tarik Sammour, Fadhel Al-Herz, Chris
Daynes, Mike Young
Laparoscopic colectomy for has been shown to be a safe
procedure with equivalent oncological outcomes compared with open
surgery.1–5 In addition, the laparoscopic
approach is associated with modest short-term benefits including less post
operative pain, improved pulmonary function, shorter length of stay, and a
decreased rate of postoperative
ileus.6–8
The Australasian Laparoscopic Colon Cancer Surgical trial
(ALCCaS) is the only published randomized controlled trial in an Australasian
setting that compares laparoscopic and open surgical treatments for colon
cancer.9 The study showed significantly quicker
return of gastrointestinal function and shorter hospital stay favouring the
laparoscopic group, with no difference in reoperation rates or in-hospital
mortality.9 However, as in the ALCCaS trial
most, most published data on laparoscopic colectomy comes from specialist
colorectal units and tertiary
hospitals,10–13 with sparse literature
from non-tertiary settings.14–16 The
issue of wider applicability of these results has been
raised.17
The aim of this study is to evaluate short-term outcomes of
laparoscopic colectomy performed in a single provincial secondary-level hospital
in New Zealand and to compare them to those of tertiary Australasian specialist
colorectal units, specifically with published ALCCaS trial results.
Materials and MethodsHospital and region—Palmerston
North Hospital (PNH) is the only public secondary level hospital in the Manawatu
region of the lower central North Island of New Zealand, with a base drainage
population of approximately 160,000 people. PNH is also one of six national
Regional Cancer Treatment Service centres, providing specialist intensive care,
medical and surgical subspecialty services for a larger population of up to
500,000.18
Patients—All patients who
underwent laparoscopic colectomy at PNH between March 2001 (clinical records
dating more than 10 years are destroyed) and April 2010 were screened for
inclusion in the study. Patients were eligible for inclusion if they were 18
years or older and had a laparoscopic colectomy for a single adenocarcinoma of
the left or right colon.
Exclusion criteria were similar to those of the ALCCaS
trial.9,19,20 These were: advanced local
disease (tumour size greater than 8 cm on radiologic imaging); metastatic
disease; rectal cancer (defined as <15 cm from the dentate line on rigid
sigmoidoscopy); emergency presentation; morbid obesity defined as body mass
index greater than 35 kg/m2; an American
Society of Anaesthesiologists’ (ASA) physical status classification IV or
V; associated gastrointestinal disease that required extensive operative
evaluation or intervention; pregnancy; or malignant disease in the past 5 years
(except superficial squamous or basal cell carcinoma of the skin or in situ
cervical cancer).
Data collection—Retrospective
review of patient clinical records, the Otago Audit System electronic
database21 (prospectively maintained by the
Department of General Surgery since 1993), as well as Operating Theatre and
Department of Pathology electronic records was performed by a single
investigator (JT). Institutional board approval was gained. Data collected
included demographic data, intraoperative parameters, postoperative outcome
data, and pathological histological data. All collected data were defined as per
the published definitions of the ALCCaS
trial.9,19,20
Statistics—Data from the PNH
cohort were tabulated for comparison alongside equivalent results from the
ALCCaS Trial.9 Results were analysed using
SPSS® for Windows® version 17.0 (Lead Technologies Inc, Chicago,
Illinois, USA). The student t test was used to analyse continuous parametric
data, and the Fisher’s exact test for categorical data. P<0.05 was
considered statistically significant.
ResultsIn total, 536 colonic operations were performed between
March 2001 and April 2010. Of these 138 were laparoscopic colonic resections and
76 satisfied criteria for inclusion in the study (Figure 1). Fifty of the
included laparoscopic colectomies were performed by a single surgeon (MY), who
is likely to be past his learning curve having performed his first laparoscopic
assisted right hemicolectomy in 1992.
The remaining operations performed by one of five other
surgeons at various stages in the early part of the learning curve for
laparoscopic colectomy. All of the surgeons in these series were general
surgeons, who have had no specific sub-specialty training in laparoscopic
colectomy.
Figure 1. Diagram of patient inclusion and
exclusion
 Patient demographics—The mean age,
sex, BMI, and rates of previous abdominal surgery were similar in both groups
(see Table 1). There was a significantly higher percentage of ASA 3 patients in
the PNH group compared to the ALCCaS group.
Table 1. Baseline patient
parameters
SD: Standard Deviation.
Intraoperative parameters—More left
sided resections were performed in the PNH group (55% vs 40%), and a much higher
percentage of anterior resections were de-functioned with a covering loop
ileostomy (76% vs 4%), see Table 2. There were no significant differences in the
rates of blood transfusion or conversions to laparotomy between the two groups.
Reasons for conversion in the PNH group included colonic
tears (2), inability to visualize critical structures (3), adhesions (1) and
inability to mobilise colon (1). There was no significant difference in the
conversion rate in the PNH group in the first half of the study vs the second
half (11.1% vs 8.6%, P=0.667). The number of patients with at least 1
intraoperative complication was significantly lower in the PNH group (2.6% vs
10.5%, P=0.039). Both complications were colonic tears that required conversion
to open (1 was managed conservatively and 1 required open suture repair).
Table 2. Intraoperative
parameters
R: Right, L: Left
Postoperative parameters—Patients
tolerated fluids one day earlier in the PNH group (P=0.0001), but mean days to
passage of flatus, passage of bowel motion, and discharge were nearly identical
in both groups (Table 3). There were no statistically significant differences in
the number of patients with at least 1 postoperative complication, the
re-operation rate, or the in-hospital mortality rate (Table 4). The single death
in the PNH group was due to a postoperative aspiration pneumonia complicated by
multiorgan failure.
Table 3. Postoperative
parameters
SD: Standard Deviation.
Table 4. Total mortality
(all-cause)
* Statistical analysis could not be performed as raw
data from the ALCCaS trial was not available.
n = number of patients with confirmed follow-up.
Pathology—There was a higher
percentage of rectosigmoid tumours in the PNH group compared to the ALCCaS
group, which had a much higher recorded rate of purely sigmoid tumours (Table
5). The tumours in the PNH group were better differentiated overall.
Reporting of tumour clearance margins and operative specimen
metastases was not standardised in the PNH pathology data in the earlier part of
the series. As such, a comparable dataset to that of the ALCCaS trial could not
be generated for this parameter. However, TNM staging, and lymph node counts
were reliably reported and these are presented (Table 5).
The median number of lymph nodes harvested was lower in the
PNH group (11 vs 13), but statistical significance could not be established.
There were fewer stage II cancers (26% vs 45%) and relatively more stage III
cancers (33% vs 27%) in the PNH group.
Table 5. Pathological parameters
*Statistical analysis could
not be performed as raw data from the ALCCaS trial was not available.
DiscussionWe have conducted a retrospective study looking at the
short-term outcomes of laparoscopic colonic resection for neoplasia in a
non-tertiary setting. This is the first published study to directly compare
outcomes with published data from tertiary institutions.
Patients in the PNH group had a higher ASA score at baseline
and were more likely to have undergone an anterior resection for a rectosigmoid
tumour with a covering ileostomy compared to patients in the ALCCaS trial. There
were also some pathological differences with a statistically significant worse
stage, but conversely better tumour differentiation. However, intraoperative and
short-term postoperative outcomes were comparable between the two groups.
It is difficult to determine whether the differences in ASA
scores and disease distribution between patients in the PNH and ALCCaS groups
were due to different population characteristics at baseline, or a variation in
patient selection.22, 23 These differences may
have had an impact on reported pathological parameters, including the number of
lymph nodes harvested (although variation between pathologists is also a
contributing factor).24–26
There were some important intraoperative differences between
the two groups. The frequent use of a covering ileostomy in the PNH group was
largely due to surgeon preference, although the higher percentage of
rectosigmoid lesions requiring anterior resection, and the preponderance of ASA
3 patients may have also influenced this.
The use of diverting stomas in colorectal resections is
controversial.27–29 The evidence suggests
that diversion reduces the clinical impact of an anastomotic leak in low rectal
resections,30–32 however a benefit in
colonic and high rectal resections has not been convincingly demonstrated.
Secondly, the intraoperative complication rate was significantly lower in the
PNH group, although the difference may well be due to under-reporting bias
resulting from retrospective data collection. It is notable, however, that the
complication rate in the laparoscopic arm of the ALCCaS trial was significantly
higher than in the open arm (10.5% versus 3.7%,
P=0.001).9,17
The only difference in postoperative outcome was that
patients in the PNH group tolerated oral fluids one day earlier. We postulate
that this may be due to the early oral intake resumption policy in PNH, with
patients routinely allowed free oral fluids immediately after surgery.
Otherwise, postoperative recovery parameters were very similar in the two
groups. The 5-year all-cause mortality was 64.3%, although only 15 patients had
been followed up for >5 years at the time of data collection.
There have been a few published studies from non-tertiary
institutions, reporting generally favourable
outcomes.14–16 The largest series
included 250 consecutive patients undergoing laparoscopic colectomy for benign
and malignant disease.16 The authors concluded
that the short and longer term results were comparable to those from tertiary
centers, however, comparisons were observational and no formal statistical
comparisons were performed.
A smaller case-control study from Australasia comparing
laparoscopic and open colectomy, demonstrated earlier recovery of
gastrointestinal function and a reduction in hospital stay when the surgeons
moved from the open to the laparoscopic
approach.14 However, there was considerable
selection bias in this early phase with patients in the laparoscopic group being
younger, and more likely to have benign disease and smaller
tumours.14 Nevertheless, these published
results appear to be consistent with our own, and support the use of the
laparoscopic approach in a non-tertiary setting.
The main limitation of the current study is the
retrospective nature of the data collection. In addition, the majority of
operations were performed by a single surgeon who has wide experience with
laparoscopic surgery (albeit in a non-tertiary setting) and this may limit
applicability to other centres where laparoscopic colonic surgery is not
routinely practiced. Another limitation is that, like the ALCCaS trial, the data
presented is from a highly selected patient group, and therefore results cannot
be generalised to all patients with colonic neoplasia (such as patients with
synchronous lesions, with a tumour size greater than 8 cm, obese patients, or
patients who present acutely with haemorrhage or obstruction). Also the
non-contemporaneous timeline of the two data sets being compared may have
influenced the comparison.
ConclusionIn selected patients, short-term outcomes of laparoscopic
colonic surgery for neoplasia in a secondary level provincial setting are
equivalent to those from specialist colorectal units.
Competing interests: None.
Author information: Josese Turagava,
Registrar, Department of Surgery, Palmerston North Hospital; Tarik Sammour,
Research Fellow, Department of Surgery, South Auckland Clinical School, Faculty
of Medical and Health Sciences, University of Auckland; Fadhel Al-Herz,
Registrar, Department of Surgery, Palmerston North Hospital; Chris Daynes,
General Surgeon, Department of Surgery, Palmerston North Hospital; Mike Young,
General Surgeon, Department of Surgery, Palmerston North Hospital, Palmerston
North
Correspondence and reprint requests: Dr
Tarik Sammour, Research Fellow, Department of Surgery, South Auckland Clinical
School, Private Bag 93311, Middlemore Hospital, Otahuhu, Auckland, New Zealand.
Fax: +64 (0)9 6264558; email: sammour@xtra.co.nz
References:
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