Long-term results of laparoscopic colorectal cancer resection

 

Abstract

Background

Although minimally invasive surgery has been accepted for a variety of disorders, laparoscopic resection of colorectal cancer is performed by few. Concern about oncological radicality and long term outcome has limited the adoption of laparoscopic surgery for colorectal cancer.

Objectives

To determine long-term outcome after laparoscopically-assisted versus open surgery for non-metastasised colorectal cancer.

Search methods

The Cochrane library, EMBASE, Pub med and Cancer Lit were searched for published and unpublished randomised controlled trials.

Selection criteria

Randomised clinical trials comparing laparoscopically-assisted and open surgery for non-metastasised colorectal cancer were included. Studies that did not report any long-term outcomes were excluded.

Data collection and analysis

Two reviewers independently assessed the studies and extracted data. RevMan 4.2 was used for statistical analysis.

Main results

Thirty-three randomised clinical trials (RCT) comparing laparoscopically-assisted versus open surgery for colorectal cancer were identified. Twelve of these trials, involving 3346 patients, reported long-term outcome and were included in the current analysis. No significant differences in the occurrence of incisional hernia, reoperations for incisional hernia or reoperations for adhesions were found between laparoscopically assisted and open surgery (2 RCT, 474 pts, 7.9% vs 10.9%;P = 0.32 and 2 RCT, 474 pts, 4.0% vs 2.8%; P = 0.42 and 1 RCT, 391 pts, 1.1% vs 2.5%;P = 0.30, respectively). Rates of recurrence at the site of the primary tumor were similar (colon cancer: 4 RCT, 938 pts, 5.2% vs 5.6%; OR (fixed) 0.84 (95% CI 0.47 to 1.52)(P = 0.57); rectal cancer: 4 RCT, 714 pts, 7.2% vs 7.7%; OR (fixed) 0.81 (95% CI 0.45 to 1.43) (P = 0.46). No differences in the occurrence of port-site/wound recurrences were observed (P=0.16). Similar cancer-related mortality was found after laparoscopic surgery compared to open surgery ( colon cancer: 5 RCT, 1575 pts, 14.6% vs 16.4%; OR (fixed) 0.80 (95% CI 0.61 to 1.06) (P=0.15); rectal cancer: 3 RCT, 578 pts, 9.2% vs 10.0%; OR (fixed) 0.66 (95% CI 0.37 to 1.19) (P=0.16).
Four studies were included in the meta-analyses on hazard ratios for tumour recurrence in laparoscopic colorectal cancer surgery. No significant difference in recurrence rate was observed between laparoscopic and open surgery (hazard ratio for tumour recurrence in the laparoscopic group 0.92; 95% CI 0.76-1.13). No significant difference in tumour recurrence between laparoscopic and open surgery for colon cancer was observed (hazard ratio for tumour recurrence in the laparoscopic group 0.86; 95% CI 0.70-1.08).

Authors' conclusions

Laparoscopic resection of carcinoma of the colon is associated with a long term outcome no different from that of open colectomy. Further studies are required to determine whether the incidence of incisional hernias and adhesions is affected by method of approach. Laparoscopic surgery for cancer of the upper rectum is feasible, but more randomised trials need to be conducted to assess long term outcome.

 

Plain language summary

This systematic review focuses on long-term outcome of laparoscopic versus open surgery for colorectal cancer, including long-term complications and cancer outcome.

Laparoscopic resection of carcinoma of the colon is associated with a long term outcome no different from that of open colectomy. In the case of rectal cancer, data on long term outcome are scarce and the results of large randomised trails have to be awaited.
Laparoscopic approach offers short-term benefits to patients, such as less pain and quicker recovery. However, concern about port-site metastases (laparoscopic incision wound) and irradical laparoscopic resections withheld many surgeons from performing laparoscopic surgery for cancer. Minimally invasive surgery for colon and rectal cancer has mainly been performed within the framework of randomized clinical trials.

 

摘要

背景

進行腹腔鏡大腸癌切除治療的長期性影響

雖然微小切口手術已經被接受用來進行多種疾病的治療，但是腹腔鏡切除手術較少被應用在大腸癌的切除治療上，因為使用腹腔鏡切除手術來治療大腸癌係受到癌細胞的本質和長期治療成果影響

目標

本研究的主要目的在於評估利用腹腔鏡輔助治療和開放性手術進行非轉移性大腸癌治療的長期成效

搜尋策略

本研究係利用Cochrane library、EMBASE、Pub med和Cancer Lit來檢索已公開和未公開的隨機性對照試驗資料

選擇標準

針對使用輔助性腹腔鏡和開放性手術治療非轉移性大腸癌治療的隨機性對照試驗都會被納入本研究中，試驗中如果沒有提及有關於治療後的長期成果則將該試驗排除於研究之外

資料收集與分析

有2位審閱者獨立針對試驗進行評估，並將試驗中的數據取出，利用RevMan4.2軟體進行統計分析

主要結論

有33個RCT試驗係比較輔助性腹腔鏡手術和開放性手術進行大腸癌治療的功效，其中有12個試驗透過3346名受試者研究長期性的治療成果，並且被納入現行的分析中，在切口疝氣、因為切口疝氣再一次手術或因為沾黏再一次手術等項目中，使用輔助性腹腔鏡手術和開放性手術並沒有顯著差異(三個項目的數據分別為：2個RCT試驗，474位受試者，7.9％和10.9％，p = 0.32；2個RCT試驗，474位受試者，4.0％和2.8％，p = 0.42；1個RCT試驗，391位受試者，1.1％和2.5％，p = 0.30)，兩種治療方法對原位癌復發的機率也十分相似(大腸癌，4個RCT試驗，938位受試者，5.2％和5.6％，OR值(固定)為0.84，95％的信心區間介於0.47至1.52之間，p = 0.57；直腸癌，4個RCT試驗，714位受試者，7.2％和7.7％，OR值(固定)為0.81，95％的信心區間介於0.45至1.43之間，p = 0.46)，兩種治療方法在插管處/傷口處在復發上也沒有明顯差異(p = 0.16)，接受腹腔鏡手術和開放性手術後因為癌症而引發的死亡率也十分相似(大腸癌，5個RCT試驗，1575位受試者，14.6％和16.4％，OR值(固定)為0.80，95％的信心區間介於0.61至1.06之間，p = 0.15；直腸癌，3個RCT試驗，578位受試者，9.2％和10.0％，OR值(固定)為0.66，95％的信心區間介於0.37至1.19之間，p = 0.16)，有4個試驗的成果被納入後設分析中以評估利用腹腔鏡手術進行大腸直腸癌治療後，癌症復發的風險率，進行腹腔鏡手術或是開放性手術對於癌症的復發率並沒有顯著差異(進行腹腔鏡手術的癌症復發風險率為0.92，95％的信心區間介於0.76至1.13之間)，此外，兩種治療方法進行大腸癌治療對於癌症復發率也十分相似(進行腹腔鏡手術的癌症復發風險率為0.86，95％的信心區間介於0.70至1.08之間)

作者結論

利用腹腔鏡切除大腸癌和使用開放性結腸切除手術所引發的長期性治療成果十分相似，需要進行更多的研究來證明切口疝氣和沾黏情況的發生是受到手術方法影響所致，利用腹腔鏡手術來治療上直腸癌是可行的方法，但是仍需要更多的隨機性試驗來評估長期治療成果

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

本研究有系統性的針對使用腹腔鏡手術和開放性手術進行大腸直腸癌治療的長期性成果進行檢視，這些成果包括了長期性的併發症和其他癌症相關成果，使用腹腔鏡切除手術大腸癌和使用開放性手術切除在長期結果上並無不同，但是對於直腸癌來說，仍缺乏長期成果試驗的相關數據，而且也正在等待大型隨機性試驗結果的的揭露，腹腔鏡手術對於患者來說提供了短期性的功效，例如較少感到疼痛和較快達到復原的效果，但是若是考量到插孔位置的癌轉移(腹腔鏡切除傷口)和非輻射狀腹腔鏡切除，有許多醫師會考慮使用腹腔鏡手術來治療癌症，針對大腸和直腸癌患者施行微小切口手術主要只有在隨機性臨床試驗的架構下才能顯現其成效