Laparoscopic procedures have become standard surgical techniques for several benign abdominal diseases. Laparoscopic cholecystectomy, appendectomy, Nissen fundoplication, splenectomy, adrenalectomy, and palliative intestinal bypass procedures are widely accepted as standards of care. It was believed that the success of these laparoscopic procedures would soon transform colorectal surgery for neoplastic diseases. This enthusiasm is evident in many early publications cited in the article by Drs. Wexner and Hwang. The article offers a balanced and thorough review of laparoscopy in the management of colorectal neoplasms and emphasizes the significant controversy surrounding this topic.
Prospective Randomized NCI-Sponsored Trial
The initial enthusiasm for laparoscopic colorectal resection of potentially curable malignant disease prompted the development of a protocol and National Cancer Institute (NCI) funding of a prospective randomized trial. This trial is randomizing patients with resectable colon cancer to either laparotomy, colectomy, or laparoscopic colectomy. I emphasize this trial because only through a prospective comparison will surgeons be able to detect a difference in outcome and quality of life.
The authors point out that laparoscopic colorectal resections for malignant disease are feasible, and, in fact, many textbooks describe the technique in step-by-step detail. Despite this feasibility, laparoscopic procedures have not gained acceptance by the majority of surgeons because there are no prospective data demonstrating that laparoscopic colorectal resection is superior to open laparotomy and resection. Questions of disease control, difficulty in performing the procedure, and patient recovery time have dampened the initial enthusiasm, with only 14% of surveyed surgeons saying they would perform laparoscopic resections for potentially curable disease.
Ongoing Worldwide Trials
Several ongoing worldwide prospective randomized trials are comparing open vs laparoscopic colectomy. However, it will be a few years before data are sufficiently mature to determine whether disease control is altered by the laparoscopic procedure. Other important end points are quality of life and the economic benefit of the laparoscopic procedure.
Quality-of-life investigations require a smaller sample size, and the current NCI-sponsored trial has accrued a sufficient number of patients to allow a quality-of-life analysis in the near future. The data collection will also permit an economic analysis, despite the fact that this is a multi-institutional study. Once these data become available, surgeons will be able to judge the value of the procedure.
Other Laparoscopic Procedures
Drs. Wexner and Hwang maintain that laparoscopic resections are appropriate for benign polyps and symptomatic primary tumors of stage IV disease. While the smaller incisions may benefit the patient, there are no published randomized data to show that these patients recover faster and have a better quality of life after the laparoscopic procedure.
The authors also maintain that, in light of the technical difficulties involved in low anterior laparoscopic resection and coloanal anastomosis, laparoscopic abdominoperineal resection is a viable alternative. However, while laparoscopic abdominoperineal resection is feasible, it should not be considered if an open laparotomy and deep pelvic dissection can result in a sphincter-sparing coloanal anastomosis. Because rectal adenocarcinoma is responsive to preoperative therapy, many patients with distal rectal cancer are eligible for sphincter-preserving surgery.
All laparoscopic bowel surgery for colorectal cancer should be performed within the context of a prospective trial. The risks and benefits of this procedure remain controversial and should be explained to the patient.
The current randomized trials can determine the value and the appropriateness of this procedure. Those interested in participating in the NCI trial can obtain more information at the following website: http://ncctg.mayo.edu/lapcolon. Target patient accrual for this trial should be reached by the end of 2001.