Laparoscopic Versus Conventional Surgery in Colorectal Cancer

PICHON RIVIERE, A.; AUGUSTOVSKI, F.; GARCIA MARTI, S.; GLUJOVSKY, D.; ALCARAZ, A.; LOPEZ, A.; BARDACH, A.; CIAPPONI, A; CERNADAS, C; FERRANTE, D; REGUEIRO, A.; MORAES MORELLI, D

Laparoscopic Versus Conventional Surgery in Colorectal Cancer

IECS

Año: 2012 p. 1 - 30

1668-2793

Colorectal cancer (CRC) is one of the most common cancers in the world, mainly in developed countries. In Argentina, 11,043 new cases (2008) and 3,655 deaths (2011) were reported, ranking CRC as the second most lethal cancer after lung cancer and third in incidence. Its etiology is multifactorial; early diagnosis and tumor staging determine the most adequate treatment. In early stages of colon cancer, primary surgical treatment achieves 80% of cure potential, in late stages, surgery is usually palliative and both chemotherapy or biological therapy is recommended. For colorectal cancer, which generally has worse prognosis and higher risk of relapse, neoadjuvant therapy is currently recommended. The conventional technique for CRC resection is open surgery (OS). Laparoscopic resection is proposed as a less invasive alternative.TechnologyLaparoscopic surgery (LS) consists in removing the affected part of the colon or rectum by making tiny abdominal incisions through which specific tools are inserted; that will allow the surgeon to resect the tumor while watching the intra abdominal region in a monitor.PurposeTo assess the available evidence on the efficacy, safety and coverage related aspects regarding the use of laparoscopic surgery in patients with colorectal cancer.MethodsA bibliographic search was carried out on the main databases: DARE, NHS EED, on Internet general search engines, in health technology evaluation agencies and health sponsors. Priority was given to the inclusion of systematic reviews; controlled, randomized clinical trials (RCTs); health technology assessments and economic evaluations; clinical practice guidelines and coverage policies of other health systems.ResultsThree meta-analyses and two RCTs that were not included in the meta-analyses comparing LS with OS, two health technology assessments and eight clinical practice guidelines (CPG) were selected.Colorectal CancerIn 2010, one meta-analysis which included 15 RCTs (n=4,207), compared LS with OS, considering a 14 and 51 month follow up period; it did not find statistically significant differences when comparing long-term results for overall, local, in situ recurrence or distant metastasis in CRC. The LS group presented less general post-surgery complications, odd ratio (OR) of 0.71 (95% CI 0.58 to 0.87; p=0.001).Another 2012 meta-analysis which included 24 RCTs (n=6,264), did not find significant differences in the number of resected lymph nodes between LS and OS.Colon CancerOne 2012 meta-analysis, which included 12 RCTs (n=4,614) compared LS and OS for the treatment of colon cancer, with a 30 to 95 month follow up. Long term, no significant differences were observed in the general or cancer-related mortality results or in overall local recurrences or distant metastasis. Short-term, no significant differences were found between OS and LS in relation to time to oral diet, number of resected lymph nodes and peri-operative mortality. LS showed less peri-operative complications (OR=0.73; 95% IC 0.56 to 0.95; p=0.02), a lower rate of post-surgical ileum (OR=0.40; 95% CI 0.35 to 1.48; p=0.0003) and a shorter hospital stay (Mean difference of -2.28 days (95%CI -4.05 to -0.52; p=0.01).In 2011, one RCT (n=786) compared the incidence of post LS or OS intestinal obstruction for colon cancer, with a 5 year follow up period, reporting similar results in both groups.Rectal CancerThe abovementioned 2010 meta-analysis did not find statistically significant differences as to mortality between LS and OS groups after analyzing the five RCTs (n=991) just for rectal cancer.One RCT, published in 2010 (n=304) compared the short-term results of LS and OS for rectal cancer treatment and medium term for stage T3N0-2 with no distant metastasis after neoadjuant chemo-radiotherapy. No statistically significant differences were found between the groups in terms of resection circumferencial margin, macroscopic quality of the mesorectum total excision, morbidity, number of resected lymph nodes or complications. LS showed better results than OS in terms of bleeding (p=0.006), recovery of intestinal movement (p<0.0001) and morphine use (p<0.0001).The CPGs and the technology assessments consider the use of LS as an alternative to OS in the treatment of CRC provided that surgery is considered suitable for the tumor stage, trained surgeons perform it and the needs and preferences of the patients are taken into account.The cost of LS varies from AR$18,000 to AR$30,000 (Argentine pesos, August 2012), while OS varies from AR$24,000 to AR$26,500 (Argentine pesos, August 2012) both including the procedure and hospitalization time.ConclusionsThe evidence found is of good quality and comes from the meta-analysis and the RCTs. Results for mortality and short and long-term tumor recurrence suggest an oncological equivalence of LS and OS. LS was associated to less peri-operative complications, shorter hospital stay and recovery period. All the clinical practice guidelines and technology assessments analyzed consider the use of LS as an equivalent alternative to OS for the treatment of CRC. Its use will depend on the patient´s profile (cancer stage, comorbidities and preferences), availability of surgeons with experience in the technique and its cost.