Similar Outcomes For Minimally Invasive, Open Surgery In Colon Cancer

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Large, open incisions that cause pain and require lengthy healing times might be unnecessary to treat colorectal cancer patients successfully, according to a new review of studies.

"For a long time, many surgeons have been afraid that laparoscopy might impair survival in colorectal cancer patients and cause metastases in the skin openings that are used to insert the instruments, but this has proven not to be the case," said lead reviewer Esther Kuhry, M.D., a general surgery resident at Namsos Hospital in Norway.

Colorectal cancer is one of the most common types of cancer in the United States. According to the National Cancer Institute, there will be 148,810 new diagnoses of colorectal cancer in 2008.

In a meta-analysis that combined the results of 12 trials involving 3,346 patients, the reviewers compared outcomes of laparoscopic and open surgeries used in colorectal cancer treatment and found no significant differences between the two types of surgeries when it came to long-term survival and cancer recurrence rates.

Five studies took place in the United States; the others occurred in China, Taiwan, Portugal, Italy, Spain and the United Kingdom.

The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

In laparoscopic procedures, the surgeon conducts the surgery through small holes in the abdomen and uses a camera to visualize the person's abdominal contents. These procedures have revolutionized the operating room, leading to smaller incisions, less pain and quicker recovery times for patients requiring gallbladder removal, appendectomies, gastric bypass and other common gastrointestinal surgeries.

Still, because of a lack of information about laparoscopic surgery's long-term outcomes, surgeons have traditionally relied on open surgery to treat colon cancer patients. In open surgery, surgeons cut through the abdominal wall and use longer incisions to directly view the patient's colon and remove cancerous tissue.

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Based on the review results, "laparoscopic surgery for colon cancer is associated with survival and mortality rates that are equal to open surgery," Kuhry said. The review found no significant differences between the two groups in terms of cancer metastasis, short-term and five-year survival rates and deaths caused by cancer.

The reviewers also evaluated the incidence of adhesions -- bands of scar tissue that form between organs and tissue -- and hernias at the incision site, two common complications after colorectal cancer surgery. They found no significant differences in the rates of these complications between the laparoscopic and open surgery groups.

However, for rectal cancer, not enough evidence is available to draw reliable conclusions about whether laparoscopic surgery safely compares to open surgery, Kuhry said. Only two included studies evaluated patients with rectal cancer separately.

"More studies are emerging that suggest the laparoscopic approach to colorectal cancer resection is equivalent in terms of cancer control. However, more long-term data is needed to verify that and more thorough data is required before anyone can say it is better or preferred," said Janice Rafferty, M.D., chief of the division of colon and rectal surgery at the University of Cincinnati College of Medicine.

Rafferty, who was not involved with the review, said that it includes "only a few studies and the numbers therefore become quite small to be overwhelmingly powerful."

"It is true that it appears that laparoscopic outcomes in cancer surgery are equivalent, but that is not a strong enough argument to say it must be offered to all cancer patients, which [the authors] say in the conclusion," she said.

The authors fail to discuss surgical experience and the learning curve necessary for laparoscopic colon cancer resection, and whether or not this influenced results, Rafferty said: "After all, if every abdominal surgeon is going to hang their hat on these results, there have to be guidelines established about who is qualified to do this 'equivalent' cancer resection."

Before laparoscopy can be widely used to treat colorectal cancer, surgeons must have adequately training to perform these minimally invasive colorectal cancer surgical procedures, Kuhry said in an interview. Until recently, surgeons have mainly performed laparoscopic surgery for colorectal cancer treatment within the framework of clinical studies, she noted.

When it comes to evaluating colorectal cancer treatments, it is vital for patients to remember that laparoscopy is a technique, not a science, Rafferty said.

"It's not for every patient," she said. "Sometimes it is in the best interest of the patient to have an expeditious traditional approach to cancer removal, because -- what is getting lost here -- is that the whole patient needs to be considered, not just the size of their incision."

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