Journal of the New Zealand Medical Association, 08-June-2012, Vol 125 No 1356
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.
Hospital 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.
In 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.
We 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.
In 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: email@example.com
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