AIM: This study was designed to compare the outcomes of laparoscopic right hemicolectomy (LRH) with open right hemicolectomy (ORH) in the treatment of colon carcinoma.
METHODS: Between September 2001 and March 2005, 57 patients with colon cancer who underwent LRH were evaluated and compared with 65 controls treated by ORH in the same period. All patients were evaluated with respect to the surgery-related complications, postoperative recovery, recurrence and metastasis rate, and survival.
RESULTS: 57 LRH, 4 (7.0%) were converted to open procedure. No significant differences were observed in terms of mean operation time, blood loss, post-operative complications, and hospital stay between LRH and ORH groups. Mean time to flatus passage, to liquid diet, to semiliquid diet and duration of urinary drainage in the LRH group were significantly shorter than those of ORH group (3.2±1.6 vs 4.7±2.1 d, 4.3±4.6 vs 6.7±3.6 d, 5.9±1.9 vs 8.8±2.3 d , 3.2±2.0 vs 5.7±2.9 d respectively, P<0.05). As to the lymph node yield and the specimen length, there was no significant difference between these two groups (LRH vs ORH: 17.0±11.8 vs 15.0±5.2, 20.60±6.97 vs 23.15±6.86 cm, P>0.05). Local recurrence rate and metachronous metastases rate had no marked difference between the two groups. Cumulative survival probability at 40 months in LRH group (78.9%) was not obviously different compared to the ORH group (74.5%).
CONCLUSION: LRH in patients with colon cancer has statistically and clinically significant advantages over ORH. Thus, LRH can be regarded as a safe and efficacious procedure.
Since the successful introduction of laparoscopic colectomy by Jacobs et al1, laparoscopic surgery for the treatment of colorectal cancer, especially laparoscopic rectal surgery, has been developed considerably2-14. We previously reported that laparoscopic rectosigmoid colon resection for malignant disease allowed earlier recovery than open surgery without jeopardizing oncological clearance3. The results of that study, however, could not extrapolate to right-sided colon cancer because of the wider range of resection, more complicated regional anatomy and more advanced requirements of technique in laparoscopic right hemicolectomy than those of the traditional procedure for rectosigmoid cancer4. In this study, we reviewed the results of laparoscopic-assisted resection of right colon carcinoma and compared with a matched group of patients with resection by conventional open procedure carried out during the same period.
Between September 2001 and March 2005, 57 patients with colon cancer who underwent laparoscopic-assisted right hemicolectomy (LRH) were evaluated and compared with 65 controls treated by open right hemicolectomy (ORH) in the same period. All patients were preoperatively identified to be malignant tumor through colonoscopy and pathological biopsy. The demographic data of the patients are shown in Table 1. The oncological criteria of LRH was the same as that of conventional surgery. The LRH procedure was performed as described previously5. The following parameters were measured prospectively: operation time; blood loss; analgesic requirement; time to flatus passage, time to resume normal diet and duration of hospitalization; morbidity and mortality; specimen length and lymph node yield; pathological staging (Duke’s staging); local recurrence rate and metachronous metastases rate and cumulative survival probability. The data was expressed as mean ± SD. Student’s t test and Mann-Whitney U-test were used to analyze quantitative variables and chi-square test was used to analyze qualitative variables. Survival was calculated by the Kaplan-Meier method, and difference between the groups was compared with the log-rank test. P<0.05 was considered statistically significant. All the statistical analyses were performed using SPSS 11.0 software.
The demographic data of the two groups of patients are shown in Table 1. There was no significant difference in gender, age, Duke’s staging, previous abdominal operation and tumor site between LRH and ORH groups. Four patients in LRH group required conversion to open surgery because of unexpected bulky tumor and severe adhesion in abdominal cavity.
Surgical safety and postoperative recovery
No operative death occurred in the both groups. Mean operation time of LRH and ORH groups was 148.6±42.4 and 162.7±47.0 min, respectively, with no significant difference (Table 2). The blood loss in LRH group (108.6±85.7 mL) was less than that in ORH group (258.1±284.0 mL), but the difference was not significant (P=0.094, Table 2). Nine patients (15.8%) in LRH group experienced postoperative complications: two with anastomotic leak three with pulmonary infections, three with wound infections and one with incomplete intestinal obstruction, while 15 patients with postoperative complications were found in ORH group (Table 2). The morbidity results were shown in Table 2.
The data are shown in Table 2. Time for flatus passage, and time to liquid diet, to semiliquid diet and duration of urinary drainage in the LRH group were significantly shorter than those of ORH group (P<0.05). Mean time for duration of abdominal drainage and hospital stay in LRH group were similar to ORH group.
Oncological clearance and follow-up results
The length of the specimens in LRH and ORH group was 20.60±6.97 cm and 23.15±6.86 cm respectively (Table 3). The number of total lymph node yield in LRH group were 17.0±11.8, which had no significant difference compared to those in ORH group (Table 3).
All the patients were followed-up. The mean follow-up time was: 19 mo (range 8-53 mo) for LRH group and 20 mo (range 9-59 mo) for ORH group. One patients (1.8%) in LRH group developed local recurrence, 3 cases (5.3%) and 2 case (3.5%) case died from hepatic metastasis and pulmonary metastasis, respectively. The local recurrence rate and metachronous metastases rate of the two groups were similar. There was no port site or wound recurrence in either group. Cumulative survival probabilities at 40 mo in LRH group and ORH group were 78.9% and 74.5%, respectively, and no significant difference were found between the two groups (Figure 1).
Laparoscopic colorectal surgery, especially for rectosigmoid cancer, is becoming increasingly popular and has got decent initial results2,3,6-10. But due to relatively complicated anatomy and much higher advanced requirements for surgery technique, laparoscopic right colectomy developed relatively slowly when compared with laparoscopic rectomy11. Our study showed that in LRH group patients, the time to resume normal gastrointestinal function and early activity, and the duration of urinary drainage were shorter as compared with the ORH group, which was in agreement with the results of some previous studies11-13. Compared with laparoscopic rectal cancer surgery, LRH was more difficult in technique demanding and need much more operation time, so the learning curve was much longer[15,16]. In comparison with ORH group, less blood loss and comparable postoperative complications in LRH group suggested the similar surgery safety in both groups.
Laparoscopic colectomy does not change the oncologic surgical principles, including en bloc resection, no-touch isolation technique, proximal lymphovascular ligation, complete lymphadenectomy, wound protection, and adequate margin of resection11. A large amount of clinical study confirmed that laparoscopic surgery for colorectal cancer had the same oncological clearance as in open procedure2-13. In this study, we also got the similar conclusion. Under the condition that no difference in tumor location and Duke’s staging, the pathological parameters, concerning the specimen length and lymph node yield did not reveal any statistical differences between the two groups. Follow-up results showed that the local recurrence rate, metachronous metastases rate, and short-term (40 months) survival rate between the two groups were comparable, which were in agreement with the previous clinical studies11-13. In fact, considering that most local recurrence and distant metastases occurred within the first 3 years17-18, it clearly showed that the laparoscopic approach does not increase the risk of local and distant recurrence in a long-term period of follow-up.
LRH for right-sided colon cancer can apply the same oncological clearance, surgical safety, and patient survival as ORH. In addition, patients can benefit from quicker postoperative recovery of laparoscopic surgery.
Figure 1 Cumulative survival probability of LRH group and ORH group.
1 Jacobs M, Verdeja JC, Goldstein HS. Minimally invasive colon resection (laparoscopic colectomy). Surg Laparosc Endosc 1991;1:144-150 [PMID: 1688289]
2 Khalili TM, Fleshner PR, Hiatt JR, et al.. Colorectal cancer: comparison of laparoscopic with open approaches. Dis Colon Rectum 1998;41:832-838 [PMID: 9678367]
3 Zheng MH, Cai JL, Lu AG, et al. Clinical study on the security of laparoscopic radical operation for malignant tumor of the large bowel. J Surg Concepts Pract 2003;8:361-364
4 Leung KL, Meng WC, Lee JF, et al. Laparoscopic-assisted resection of right-sided colonic carcinoma: a case-control study. J Surg Oncol 1999;71:97-100 [PMID: 10389865]
5 Zheng MH, Feng B, Lu AG, et al. Laparoscopic versus open right hemicolectomy with curative intent for colon carcinoma. World J Gastroenterol. 2005; 11(3): 323-326
6 Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med,2004,350(20):2050-2059.
7 Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet. 2005;365(9472):1718-26.
8 Scheidbach H, Schneider C, Hugel O, et al. Oncological quality and preliminary long-term results in laparoscopic colorectal surgery. Surg Endosc 2003;17:903-910 [PMID: 12632133]
9 Degiuli M, Mineccia M, Bertone A, et al. Outcome of laparoscopic colorectal resection. Surg Endosc 2004;18:427-432 [PMID: 14752626]
10 Braga M, Vignali A, Gianotti L, et al. Laparoscopic versus open colorectal surgery: a randomized trial on short-term outcome. Ann Surg 2002;236:759-766 [PMID: 12454514]
11 Fujita J, Uyama I, Sugioka A, et al. Laparoscopic right hemicolectomy with radical lymph node dissection using the no-touch isolation technique for advanced colon cancer. Surg Today 2001;31:93-96 [PMID: 11213054]
12 Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopy-assisted colectomy versus open colectomy for treatment of non-metastatic colon cancer: a randomized trial. Lancet 2002;359:2224-2229 [PMID: 12103285]
13 Hasegawa H, Kabeshima Y, Watanabe M, et al. Randomized controlled trial of laparoscopic versus open colectomy for advanced colorectal cancer. Surg Endosc 2003;17:636-640 [PMID: 12574925]
14 Rockall TA, Darzi A. Robot-assisted laparoscopic colorectal surgery. Surg Clin North Am 2003;83:1463-1468 [PMID: 14712879]
15 Zheng MH, Li JW, Lu AG, et al. Learning curve of laparoscopic-assisted colorectal surgery. J Surg Concepts Pract 2002;7:187-189
16 Dincler S, Koller MT, Steurer J, et al. Multidimensional analysis of learning curves in laparoscopic sigmoid resection: eight-year results. Dis Colon Rectum 2003;46:1371-1378 [PMID: 14530677]
17 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;229:487-492 [PMID: 10203080]
18 Feliciotti F, Paganini AM, Guerrieri M, et al. Results of laparoscopic vs open resections for colon cancer in patients with a minimum follow-up of 3 years. Surg Endosc 2002;16:1158-1161 [PMID: 11984684]