Laparoscopy-assisted colectomy for the treatment of colon cancer
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《中华医药杂志》英文版
[Abstract] Objective To explore the feasibility of laparoscopy-assisted colectomy to treat colon cancer. Methods Twenty patients with colon cancer underwent the treatment with current laparoscopic devices and techniques. Results With laparoscopy operated successfully in all patients without any complications, laparoscopic-assisted right hemicolectomy was performed in 12 cases, laparoscopic-assisted left hemicolectomy was performed in 8 cases. Pathologic diagnosis was confirmed as well-differentiated adenocarcinoma in 6 cases, moderately-differentiated adenocarcinoma in 6 cases, poorly-differentiated adenocarcinoma in 4 cases, mucinous adenocarcinoma in 3 cases, signet-ring cell carcinoma in 1 case. Ten patients were followed-up ranging from 6 months to 3 years.One patient was dead in 2 years and 4 months after the operation because of metastatic hepatic carcinoma, the others didn't incurred with port-site matastases and relapse. Conclusions In Dukes stage A, B and C1 colon cancers, radical operation with laparoscopy is feasibile, and laparoscopy-assisted colectomy for the treatment of colon cancer is worthy to be popularized and applied.
[Key words] laparoscopy；colon ic neoplasms；colectomy
INTRODUCTION Laparoscopic surgery has led to great progress in the treatment of many gastrointestinal diseases. In this article, the authors reported the results of laparoscopy-assisted colectomy in 20 patients with colon cancer aiming to evaluate the laparoscopy-assisted colon cancer resection.
MATERIALS AND METHODS
Patients
Since June 1997, 20 patients have undergone laparoscopic-assisted colectomies due to colon cancer,including 12 males and 8 females, aged from 45 to 68 years. All the patients were diagnosed by fibro-colonoscopy and pathological biopsy. The cancer located at the right colon in 12 cases(the ascending colon in 9 cases, hepatic flexure of colon in 1 case, proximal transverse colon in 2 cases), the left colon in 8 cases(descending colon in 3 cases, sigmoid colon in 5 cases). Pathologic diagnosis was well-differentiated adenocarcinoma in 6 cases, moderately-differentiated adenocarcinoma in 6 cases, poorly-differentiated adenocarcinoma in 4 cases, mucinous adenocarcinoma in 3 cases, signet-ring cell carcinoma in 1 case. All the patients didn't suferred from distant metastasis and intestinal obstruction. Dukes stage was as stage B in 9 cases, stage C1 in 11 cases.
Operative Procdures
Patients' preoperative preparation were the same as conventional open procedure. Procedures were performed under general anaesthesia, dorsal position. Viewing port was located at inferior margin of umbilicus, 3 or 4 manipulation ports were selected according to the positon of the lesions. Generally, manipulation ports were separately located at midpoint between xiphoid process and umbilicus, the right or left upper quadrant, the right or left Mcburney's point. A pneumoperitoneum with intraabdominal pressure between 10 mmHg and 14 mmHg was maintained throughout the operation. The average length of the incision for colonic extraction was 6.0 cm, located at the right upper quadrant for right-sided tumors or the left lower quadrant for left-sided lesions by use of a wound edge protective cover or protector.
Laparoscopy-assisted right hemicolectomy：Mobilization from the mesentery, transection of the ileocolic lymphovascular pedicle, mobilization of the ileocecum, ascending colon,hepatic flexure,and proximale
Department of General Surgery, The Affiliated Hospital of North University of China, Taiyuan 030051,Shanxi Province,China
Correspondance to SUN Xiao-Lin, E-mail：iamsun@tom. comtransversum,and then enlargement of one of the trocar incisions (located at the right upper quadrant) to 6. 0 cm length, the exteriorized ileocecum and colon segment involved was resected and an extracorporeal ileotransversostomy was performed in the standard manner.
Laparoscopy-assisted left hemicolectomy：Using the methods mentioned above, mobilization of the sigmoid colon, descending colon, splenic flexure, and distal transversum, and then enlargement of one of the trocar incisions (located at the left lower quadrant) to 6.0 cm length, the exteriorized colon segment involved was resected and an extracorporeal colosigmoidostomy or coloproctostomy was performed in the standard manner.
After colectomy, extensive cleaning with 5-Fluorouracil and thermal physiological saline solution (40℃～42 ℃ ) for 30 minutes were employed routinely. Then a rubber drainage-tube was put into the abdominal cavity.
RESULTS
All laparoscopic procedures were carried out smoothly.The operative time were 210～360 minutes,meaning 280 minutes. The paracolic lymph-node metastasis were found in 11 cases. The urinary catheters were removed the next day after operation, peristalsis was detected in 48 hours after operation(peristalsis was assessed every 4 hours for 3 or over times 3 a minute), the nasogastric tube was found remove after that peristalsis was detected, abdominal suction tube was removed in 48 ~72 hours after surgery when no exudates was effused. Because of slight incisional pain, one dose analgesic used in 5 patients after surgery. The inhospital time was 7～12 days after surgery, with the mean of 9 days. All the patients were discharged after their incision healed by first intention without perioperative mortality, viscera injury, operative complications and so on. Ten patients were followed-up ranging from 6 months to 3 years, 1 patient was in 2 years and 4 months after the operation because of metastatic hepatic carcinoma, the others didn't incurred with port-site matastases and relapse.
DISCUSSION
It has been 15 years since laparoscopic surgery was first employed in colon cancer treatment[1]. Early reports suggested that laparoscopy-assisted colectomy in colon cancer may favour tumour dissemination[2], thus its further development was restricted. The results of more recent series laparoscopic studies showed[3~6] that laparoscopic colectomy can be performed safely and effectively for the treatment of colon cancer, and can offer equivalent effects when compared to the open procedure. Laparoscopic colectomy is associated with decreased postoperative pain, faster ileus resolution, shorter hospitalization, decreased adhesive formation and subsequent bowel obstruction, and improved cosmesis when compared with open colectomy.
The most common controversial contention that laparoscopic approach to colon cancer were port-site metastasis and small wound tumours relapse after laparoscopic colorectal cancer resection[7, 8]. The cause and mechanism of port-site metastases and small wound tumours relapse are unknown, which may be associated with many factors such as carbon dioxide pneumoperitoneum, contaminated port-site or surgical instruments, exteriorized colon resected through narrow and small incision by force, ischemia, exfoliated tumour cell implantation metastasis, surgical trauma and so on. The results of more recent laparoscopic series presented figures regarding the incidence of port-site metastases range from 0 to 1.3%[9, 10], which is not quite high. The incisional tumour recurrences after open procedures do occur, albeit infrequently, which should be kept in mind. Two retrospective reviews[11, 12], each involving over 1 000 patients, reported a 0.6% to 0.68% of incidence of incisional tumours and an overall abdominal wall tumour incidence of 1%. Therefore, on the basis of available data, the incidence of wound tumours after either open or closed colorectal cancer resection seems to be similar. To prevent port-site metastasis, following measures had been taken：nontouch technique with initial vascular ligation, use of a wound-edge protective cover or protector, exteriorized the colonic segment involved through the protective cover or protector, avoiding the bigger tumour through the non-protective small incision, avoidance to grasping the tumour and to prevent the split tumour implanted metastases, reduction of intra-abdominal pressure before turnout extraction, and extensive cleansing with 5-Fluorouracil and thermal physiological saline solution ( 40℃～42℃ ) and so on. All the patients of our study did not find port-site metastases and incisional tumour recurrences.
Laparoscopic colon cancer resection which can or not achieve the radical operation depends on the same conditions：pathological grading of tumour, stages of tumour, whether or not radical operation, perioperative treatment and care, and so on. The laparoscopic procedure is performed by experienced surgeons, reducting the duration of pneumoperitoneum, avoidance to grasping tumours unnecessarily, nontouch isolation techniques and established oncological principles are other important factors to prevent or reduce port-site metastasis, tumour recurrence and implanted metastases. In Dukes stage A, B and C1 tumours, radical operation with laparoscopy is feasibility so long as the surgeon strictly implement the oncological principles of the operation.
During the laparoscopy procedures,if suspected tumour invasion of adjacent organs, distant metastasis such as hepatic metastases, intra-abdominal implantation metastases occurred,the procedures should be converted to open surgery. The patients with obstructive colon cancer or required emergency operation should be converted to open surgery, for their intestinal tracts were not preoperatively prepared with prevention to increase incidence of postoperative pyogenic infection, and incidence of tumour recurrences and metastases. Our initial results show that laparoscopy-assisted colectomy for the treatment of colon cancer is worthy to be popularized and applied.
REFERENCES
1. Jacobs M, Wedeja JC, Goldstein HS, et al. Minimally invasive colon resection ( Laparoscopic colectomy ). Surg Laparo Endosc,1991,1(2)：144-150.
2. Vukasin P, Ortega AE, Greene FL, et al. Wound recurrence following laparoscopic colon cancer resection：results of the American Society of Colon and Rectal Surgeons Laparoscopic Registry. Dis Colon Rectum,1996,39(6)：520-523.
3. Jacob BP, Salky B. Laparoscopic colectomy for colon adenocarcinoma：an 11-year retrospective review with 5-year survival rates. Surg Endoc,2005,19(5)：643-649.
4. Baca I, Perko Z, Bokan I, et al. Technique and survival after laparoscopically assisted right hemicolectomy. Surg Endoc,2005,19(5)：650-655.
5. Franklin ME Jr, Gonzalez JJ Jr, Miter DB, et al. Laparoscopic right hemicolectomy for cancer：11-year experience. Rev Gastroenterol Mex,2004,69 Suppl 1：65-72.
6. Barlehner E, Benhidjeb T, Anders S, et al. Laparoscopic surgery for colon and rectal cancer. Surg Technol Int,2004,13：93-99.
7. Poulin EC, Mamazza J, Schlachta CM, et al. Laparoscopic resection does not adversely affect early survival curves in patients undergoing surgery for colorectal adenocarcinoma. Ann Surg, 1999, 229(4)：487-492.
8. Franklin ME, Kazantsev B, Abrego D, et al. Laparoscopic surgery for stage Ⅲ colon cancer：long term follow up. Surg Endosc,2000,14(7)：612-616.
9. Hartley JE, Mehigan BJ, MacDonald AW, et al. Patterns of recurrence and survival after laparoscopic and conventional resections for colorectal carcinoma. Ann Surg,2000,232(2)：181-186.
10. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer：A randomised trial. Lancet,2002,359(7)：2224-2229.
11. Reilly WT, Nelson H, Schroeder G, et al. Wound recurrence following conventional treatment of colorectal cancer. Dis Colon Rectum,1996,39(3)：200-207.
12. Hughes ESR, Mc Dermott FT, Polglase AL, et al. Tumor recurrence in the abdominal wall scar after large-bowel cancer surgery. Dis Colon Rectum,1983,26(6)：571-572.
(Editor Emilia)(SUN Xiao-lin, LOU Shan-hu)
[Key words] laparoscopy；colon ic neoplasms；colectomy
INTRODUCTION Laparoscopic surgery has led to great progress in the treatment of many gastrointestinal diseases. In this article, the authors reported the results of laparoscopy-assisted colectomy in 20 patients with colon cancer aiming to evaluate the laparoscopy-assisted colon cancer resection.
MATERIALS AND METHODS
Patients
Since June 1997, 20 patients have undergone laparoscopic-assisted colectomies due to colon cancer,including 12 males and 8 females, aged from 45 to 68 years. All the patients were diagnosed by fibro-colonoscopy and pathological biopsy. The cancer located at the right colon in 12 cases(the ascending colon in 9 cases, hepatic flexure of colon in 1 case, proximal transverse colon in 2 cases), the left colon in 8 cases(descending colon in 3 cases, sigmoid colon in 5 cases). Pathologic diagnosis was well-differentiated adenocarcinoma in 6 cases, moderately-differentiated adenocarcinoma in 6 cases, poorly-differentiated adenocarcinoma in 4 cases, mucinous adenocarcinoma in 3 cases, signet-ring cell carcinoma in 1 case. All the patients didn't suferred from distant metastasis and intestinal obstruction. Dukes stage was as stage B in 9 cases, stage C1 in 11 cases.
Operative Procdures
Patients' preoperative preparation were the same as conventional open procedure. Procedures were performed under general anaesthesia, dorsal position. Viewing port was located at inferior margin of umbilicus, 3 or 4 manipulation ports were selected according to the positon of the lesions. Generally, manipulation ports were separately located at midpoint between xiphoid process and umbilicus, the right or left upper quadrant, the right or left Mcburney's point. A pneumoperitoneum with intraabdominal pressure between 10 mmHg and 14 mmHg was maintained throughout the operation. The average length of the incision for colonic extraction was 6.0 cm, located at the right upper quadrant for right-sided tumors or the left lower quadrant for left-sided lesions by use of a wound edge protective cover or protector.
Laparoscopy-assisted right hemicolectomy：Mobilization from the mesentery, transection of the ileocolic lymphovascular pedicle, mobilization of the ileocecum, ascending colon,hepatic flexure,and proximale
Department of General Surgery, The Affiliated Hospital of North University of China, Taiyuan 030051,Shanxi Province,China
Correspondance to SUN Xiao-Lin, E-mail：iamsun@tom. comtransversum,and then enlargement of one of the trocar incisions (located at the right upper quadrant) to 6. 0 cm length, the exteriorized ileocecum and colon segment involved was resected and an extracorporeal ileotransversostomy was performed in the standard manner.
Laparoscopy-assisted left hemicolectomy：Using the methods mentioned above, mobilization of the sigmoid colon, descending colon, splenic flexure, and distal transversum, and then enlargement of one of the trocar incisions (located at the left lower quadrant) to 6.0 cm length, the exteriorized colon segment involved was resected and an extracorporeal colosigmoidostomy or coloproctostomy was performed in the standard manner.
After colectomy, extensive cleaning with 5-Fluorouracil and thermal physiological saline solution (40℃～42 ℃ ) for 30 minutes were employed routinely. Then a rubber drainage-tube was put into the abdominal cavity.
RESULTS
All laparoscopic procedures were carried out smoothly.The operative time were 210～360 minutes,meaning 280 minutes. The paracolic lymph-node metastasis were found in 11 cases. The urinary catheters were removed the next day after operation, peristalsis was detected in 48 hours after operation(peristalsis was assessed every 4 hours for 3 or over times 3 a minute), the nasogastric tube was found remove after that peristalsis was detected, abdominal suction tube was removed in 48 ~72 hours after surgery when no exudates was effused. Because of slight incisional pain, one dose analgesic used in 5 patients after surgery. The inhospital time was 7～12 days after surgery, with the mean of 9 days. All the patients were discharged after their incision healed by first intention without perioperative mortality, viscera injury, operative complications and so on. Ten patients were followed-up ranging from 6 months to 3 years, 1 patient was in 2 years and 4 months after the operation because of metastatic hepatic carcinoma, the others didn't incurred with port-site matastases and relapse.
DISCUSSION
It has been 15 years since laparoscopic surgery was first employed in colon cancer treatment[1]. Early reports suggested that laparoscopy-assisted colectomy in colon cancer may favour tumour dissemination[2], thus its further development was restricted. The results of more recent series laparoscopic studies showed[3~6] that laparoscopic colectomy can be performed safely and effectively for the treatment of colon cancer, and can offer equivalent effects when compared to the open procedure. Laparoscopic colectomy is associated with decreased postoperative pain, faster ileus resolution, shorter hospitalization, decreased adhesive formation and subsequent bowel obstruction, and improved cosmesis when compared with open colectomy.
The most common controversial contention that laparoscopic approach to colon cancer were port-site metastasis and small wound tumours relapse after laparoscopic colorectal cancer resection[7, 8]. The cause and mechanism of port-site metastases and small wound tumours relapse are unknown, which may be associated with many factors such as carbon dioxide pneumoperitoneum, contaminated port-site or surgical instruments, exteriorized colon resected through narrow and small incision by force, ischemia, exfoliated tumour cell implantation metastasis, surgical trauma and so on. The results of more recent laparoscopic series presented figures regarding the incidence of port-site metastases range from 0 to 1.3%[9, 10], which is not quite high. The incisional tumour recurrences after open procedures do occur, albeit infrequently, which should be kept in mind. Two retrospective reviews[11, 12], each involving over 1 000 patients, reported a 0.6% to 0.68% of incidence of incisional tumours and an overall abdominal wall tumour incidence of 1%. Therefore, on the basis of available data, the incidence of wound tumours after either open or closed colorectal cancer resection seems to be similar. To prevent port-site metastasis, following measures had been taken：nontouch technique with initial vascular ligation, use of a wound-edge protective cover or protector, exteriorized the colonic segment involved through the protective cover or protector, avoiding the bigger tumour through the non-protective small incision, avoidance to grasping the tumour and to prevent the split tumour implanted metastases, reduction of intra-abdominal pressure before turnout extraction, and extensive cleansing with 5-Fluorouracil and thermal physiological saline solution ( 40℃～42℃ ) and so on. All the patients of our study did not find port-site metastases and incisional tumour recurrences.
Laparoscopic colon cancer resection which can or not achieve the radical operation depends on the same conditions：pathological grading of tumour, stages of tumour, whether or not radical operation, perioperative treatment and care, and so on. The laparoscopic procedure is performed by experienced surgeons, reducting the duration of pneumoperitoneum, avoidance to grasping tumours unnecessarily, nontouch isolation techniques and established oncological principles are other important factors to prevent or reduce port-site metastasis, tumour recurrence and implanted metastases. In Dukes stage A, B and C1 tumours, radical operation with laparoscopy is feasibility so long as the surgeon strictly implement the oncological principles of the operation.
During the laparoscopy procedures,if suspected tumour invasion of adjacent organs, distant metastasis such as hepatic metastases, intra-abdominal implantation metastases occurred,the procedures should be converted to open surgery. The patients with obstructive colon cancer or required emergency operation should be converted to open surgery, for their intestinal tracts were not preoperatively prepared with prevention to increase incidence of postoperative pyogenic infection, and incidence of tumour recurrences and metastases. Our initial results show that laparoscopy-assisted colectomy for the treatment of colon cancer is worthy to be popularized and applied.
REFERENCES
1. Jacobs M, Wedeja JC, Goldstein HS, et al. Minimally invasive colon resection ( Laparoscopic colectomy ). Surg Laparo Endosc,1991,1(2)：144-150.
2. Vukasin P, Ortega AE, Greene FL, et al. Wound recurrence following laparoscopic colon cancer resection：results of the American Society of Colon and Rectal Surgeons Laparoscopic Registry. Dis Colon Rectum,1996,39(6)：520-523.
3. Jacob BP, Salky B. Laparoscopic colectomy for colon adenocarcinoma：an 11-year retrospective review with 5-year survival rates. Surg Endoc,2005,19(5)：643-649.
4. Baca I, Perko Z, Bokan I, et al. Technique and survival after laparoscopically assisted right hemicolectomy. Surg Endoc,2005,19(5)：650-655.
5. Franklin ME Jr, Gonzalez JJ Jr, Miter DB, et al. Laparoscopic right hemicolectomy for cancer：11-year experience. Rev Gastroenterol Mex,2004,69 Suppl 1：65-72.
6. Barlehner E, Benhidjeb T, Anders S, et al. Laparoscopic surgery for colon and rectal cancer. Surg Technol Int,2004,13：93-99.
7. Poulin EC, Mamazza J, Schlachta CM, et al. Laparoscopic resection does not adversely affect early survival curves in patients undergoing surgery for colorectal adenocarcinoma. Ann Surg, 1999, 229(4)：487-492.
8. Franklin ME, Kazantsev B, Abrego D, et al. Laparoscopic surgery for stage Ⅲ colon cancer：long term follow up. Surg Endosc,2000,14(7)：612-616.
9. Hartley JE, Mehigan BJ, MacDonald AW, et al. Patterns of recurrence and survival after laparoscopic and conventional resections for colorectal carcinoma. Ann Surg,2000,232(2)：181-186.
10. Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer：A randomised trial. Lancet,2002,359(7)：2224-2229.
11. Reilly WT, Nelson H, Schroeder G, et al. Wound recurrence following conventional treatment of colorectal cancer. Dis Colon Rectum,1996,39(3)：200-207.
12. Hughes ESR, Mc Dermott FT, Polglase AL, et al. Tumor recurrence in the abdominal wall scar after large-bowel cancer surgery. Dis Colon Rectum,1983,26(6)：571-572.
(Editor Emilia)(SUN Xiao-lin, LOU Shan-hu)