Clinical outcomes of laparoscopic right hemicolectomy for colon cancer

Min-Hua Zheng, Bo Feng, Jun-Jun Ma. Ai-Guo Lu, Jian-Wen Li, Ming-Liang Wang, Zhi-Hai Mao, Feng Dong, Lu Zang ,Ya-Ping Zong Department of General Surgery, Ruijin Hospital, Shanghai Minimally Invasive Surgery Center China

ABSTRACT

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.

INTRODUCTION

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.

MATERIALS AND METHODS

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.

RESULTS

Demographic data
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).

DISCUSSION

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.

Table-1 Demographic data of LRH and ORH group

  • Parameters
  •  
  • Mean age (yr)
  • Gender (ratio)
  • Male
  • Female
  • Previous abdominal operation (%)
  • Yes
  • No
  • Tumor site (%)
  • Cecum
  • Ascending colon
  • Hepatic flexure
  • Dukes' stage (%)
  • A
  • B
  • C
  • D
  • LRH(n=57)
  •  
  • 65 (28-94)
  • (1: 1.04)
  • 28
  • 29
  •  
  • 15(26.3)
  • 42 (73.7)
  •  
  • 16 (28.1)
  • 23 (40.4)
  • 18 (31.6)
  •  
  • 7
  • 27
  • 19
  • 4
  • ORH(n=65)
  •  
  • 64 (32-84)
  • (1: 1.17)
  • 30
  • 35
  •  
  • 18 (27.7)
  • 47 (72.3)
  •  
  • 17 (26.2)
  • 26 (40.0)
  • 22 (33.8)
  •  
  • 9
  • 29
  • 21
  • 6
  • P
  •  
  • 0.308
  •  
  • 0.743
  •  
  •  
  • 0.864
  •  
  •  
  • 0.956
  • 0.960
  •  
  •  
  •  
  •  
  •  
  •  

 

Table 2 Comparison of surgical safety and postoperative recovery

  • Parameters
  •  
  • Surgery-related
  • Operating time (min)
  • Blood loss (ml)
  • Postoperative recovery
  • Flatus (d)
  • Time to liquid diet (d)
  • Time to semiliquid diet (d)
  • Duration of urinary drainage (d)
  • Duration of abdominal drainage (d)
  • Hospital stay (d)
  • Major complications(%)
  • Massive haemorrhage
  • Anastomotic leak
  • Pulmonary infection
  • Urinary tract infection
  • Wound infection
  • Ileus
  • LRH(n=57)
  •  
  • 148.6±42.4
  • 108.6±85.7
  •  
  • 4.3±4.6
  • 4.3±4.6
  • 5.9±1.9
  • 3.2±2.0
  • 3.6±7.7
  • 13.4±3.3
  • 9 (15.8)
  •  
  • 0
  • 2
  • 3
  • 0
  • 3
  • 1
  • ORH(n=65)
  •  
  • 162.7±47.0
  • 258.1±284.0
  •  
  • 4.7±2.1
  • 6.7±3.6
  • 8.8±2.3
  • 5.7±2.9
  • 3.5±5.0
  • 13.7±4.9
  • 15 (23.1)
  •  
  • 1
  • 1
  • 5
  • 1
  • 5
  • 2
  • P
  •  
  • 0.200
  • 0.094
  •  
  • <0.01
  • <0.01
  • <0.01
  • <0.01
  • 0.459
  • 0.550
  • 0.312

 

Table 3 Comparison of oncological clearance and follow-up results

  • Parameters
  •  
  • Oncological clearance
  • Length of specimen (cm)
  • Lymph node yield
  •  
  • Oncological results
  • Mean follow-up(mo)
  • Local recurrence (%)
  • Metachronous metastasis (%)
  • Cumulative survival probability(%)
  • LRH(n=57)
  •  
  •  
  • 20.60±6.97
  • 17.0±11.8
  •  
  •  
  • 19(8-53)
  • 1(1.8%)
  • 5(8.8%)
  • 78.9
  • ORH(n=65)
  •  
  •  
  • 23.15±6.86
  • 15.0±5.2
  •  
  •  
  • 20(9-59)
  • 1(1.5%)
  • 9(13.8%)
  • 74.5
  • P
  •  
  •  
  • 0.157
  • 0.543
  •  
  •  
  • 0.301
  • 0.928

 

 

Figure 1 Cumulative survival probability of LRH group and ORH group.

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