short term outcomes of laparoscopic ... - escrs-eg.org · amir fawzy abd el hamid lecturer of git...
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Short Term Outcomes of Laparoscopic Resection for Left Sided Colon and Rectal Cancer
By
Amir Fawzy Abd El Hamid lecturer of GIT Surgery
Faculty of Medicine Tanta University
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Introduction
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Colorectal cancer has gradually become one of the most significant
leading causes of death from malignancies worldwide, surgical
management is still the mainstay of the treatment .
Conventional open surgery is reported with significant morbidity and
a long recovery period .
The evolution of minimally invasive surgery allowed laparoscopic
colorectal resections, first described in 1991.
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LCS is technically challenging as it involves almost all
advanced laparoscopic techniques, such as mobilization,
intracorporeal division, dissection of major vessels, and
anastomosis.
a steep learning curve, but when it has been
conquered, the benefits of laparoscopic surgery with
respect to decreased morbidity, decreased pain, faster
recovery, shorter hospital stay and possibly reduced
immunosuppression, comparing with open surgery .
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Initial concerns on the radicality of the resection and the
oncologic outcomes as well as the early reports on the high
incidence of wound recurrence limited the wide application of
laparoscopic colectomy for malignancy .
Barcelona, COST, CLASICC and COLOR studies showed
that, in experienced hands, laparoscopy has a beneficial effect
on post-operative recovery, when compared to open surgery,
without compromising the oncological results in the long run .
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Aim of the work
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The aim of this work was to evaluatelaparoscopic resection for left sidedcolon and rectal cancer as regardfeasibility, safety and short termoutcomes.
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Patients and Methods
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Tanta University Hospitals and Ain ShamsUniversity Hospitals .
40 patients having left sided colon and rectal cancer.
29 patients with rectal cancer and 11 patients withleft sided colon cancer.
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Inclusion criteria:
Patients with resectable left sided colon or rectalcancer.
Exclusion criteria:
Irresectable or metastatic left sided colon or rectalcancer. .
emergency presentation (obstruction 0r perforation).
prior major abdominal surgery causing dense scartissue.
Coagulation disorders, hepatic dysfunction (Child-Pugh class C).
High risk patients for general anesthesia (ASA IV).
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Methodology Informed written consent
History Clinical examination Investigations
Laboratory: Routine pre-operative lab.
Tumor markers. Carcinoembryonic antigen (CEA).
Radiological
1) ultrasound to detect any hepatic focal lesions or ascites.
2) CT abdomen and pelvis for regional tumor extension, lymphatic and distantmetastasis and tumor related complications as perforation or fistula formation.
3) MRI for middle and lower rectal carcinoma for determining the depth ofinvasion, mesorectum and perirectal lymph node.
4) Barium enema helps in diagnosis, localization and exclusion of other colonic lesions.
5) Plain CXR and CT chest to exclude pulmonary metastasis.
Endoscopic examination
Colonoscopy and biopsy: complete colonoscopy was done in all patients.
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Operative technique
Positions of the equipment and the surgical team for the laparoscopic left side colectomy.
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Peritoneal Access
Position of the ports
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Division of gastrocolic omentum and opening of lesser sac
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Identification of IMV lateral to the fourth part of the duodenum then
dissection (medial to lateral approach)
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Division of inferior mesenteric artery (IMA)
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Mobilization of the Sigmoid and Descending Colon
Medial Mobilization of splenic flexure
Division of inferior mesenteric vein after proximal clipping
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Lateral mobilization of the colon
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Dissection of the Rectum (posterior-Rt lateral-lt lateral- Anterior)
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Distal bowel division
Division of distal rectum using articulated endo GIA
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Proximal Division extracted through a small pfannestiel incision. The proximal resection
is performed on the anterior abdominal wall using conventionaltechniques.
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The anastomosis is then done under laparoscopic guidance,
a standard double-stapled anastomosis.
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Assessment Short term outcomesOperative timeAmount of blood loss.Time of first bowel motion, time of first passing flatus.Postoperative analgesia requirements.Duration of hospital stay.Operative mortality:Operative morbidityPathological outcome: radial and distal resection
margins and number of lymph nodes harvested. Conversion Recurrence (local and systemic).
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Results
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Patients' characteristics
gender
40.00%
60.00%
Male Female
Age
ranged from 25 to 71 years with the mean age 51.22±11.96 years.
BMI
ranged from 22-35 kg/m2, with a mean of 28.02 ± 3.39 kg/m2.
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Anatomical distribution of the tumors
The studied patients with left
sided colon or rectal cancer
(n=40)
Site of the tumor
%n
27.511Colon:
7.53-Descending colon
20.08-Sigmoid colon
72.529Rectum:
20.08-Upper rectum
20.08-Mid-rectum
32.513-Lower rectum
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Operative time and Intraoperative blood loss
The studied patients with left sided colon or rectal cancer
(n=40)Variables
Total
(n=40)
Rectum Colon
140-300
193.25±37.08
165-300
206.03±33.09
140-220
159.54±23.92
0.001*
Operative time in
minutes:
Range
Mean±SD
P value
Operative blood loss (cc):
25-250
86.87±51.8
30-200
91.90±46.80
25-250
73.64±63.90Range
Mean±SD
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Intraoperative Complications
The studied patients with leftsided colon or rectal cancer(n=40)
Intraoperative complications
%n
Intraoperative complications:
82.533No
17.57Yes:
7.53-Bleeding
2.51-Injury of colonic wall close to
tumor site
5.02-Injury of gonadal vessel
2.51-Ureteric injury
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The studied patients with left sided
colon or rectal cancer
Postoperative complications
30 75
No
10 25
Yes:
10.0 4-Wound Infection
2.51-Abdominal hemorrhage
2.51-Partial Intestinal obstruction
2.51-Ileus
2.51-Anastomotic leakage, BPR
abdominal hemorrhage
2.51-Pulmonary embolism
2.51-ureteric fistula
Postoperative complications
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The post operative recovery data
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
Analgesicsusage days
Peristalsisrecovery
days
Oral intakedays
Hospitalstay days
3.20 3.02 3.47
7.17M
ea
n v
alu
es
): Mean values of postoperative recovery data
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Pathological evaluationThe studied patients with left sided colon or rectal cancer(n=40)
Variables
•Tumor size (cm):
1-73.57±1.41
Range
Mean±SD
•Margins (cm):
colon:
-proximal
7-1510.54±2.84
Range
Mean±SD
-distal
6.5-10.78.32±2.3
Range
Mean±SD
Rectum:
-proximal
6.5-149.32±3.23
Range
Mean±SD
-distal
0.50-63.22±1.64
Range
Mean±SD
3.45 % -Circumferential
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22.5%
52.5%
10.0%15.0%
Well differentiated Moderate differentiatedPoor differentiated Mucinous
Histological differentiation of the tumors
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Tumor distribution according to AJCC staging system
17.5%
22.5%60.0%
Stage 1 Stage 2 Stage 3
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Number of lymph nodes retrieved and lymph node metastasis
The studied patients with
left sided colon or rectal
cancer
Variables
•Number of removed lymph
nodes:
2-27
11.25±4.91
Range
Mean±SD
•Number of cases with lymph
nodes metastasis:
16No
24Yes
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Conversion
There was (22.5%) rate of conversion (9 out of 40).
77.5%
22.5%
No Yes
Occurrence of conversion to open surgery among the studied patients
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conversion 9 cases, all of them were females.
The BMI in converted patients ranged from 22-35kg/m2 with mean 30.22±3.99 kg/m2, while in non converted patients BMI ranged from 23-35 with mean 27.39±2.97 kg/m2.
There were significant difference in the body mass index between the converted cases and the non converted cases (0.025*).
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Number of conversion Anatomical site
1 out of 3Descending colon
2 out of 8Sigmoid colon
1 out of 8Upper rectum
2 out of 8Middle rectum
3 out of 13Lower rectum
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0%
1%
2%
3%
4%
5%
6%
7%
8%
Extensiveadhesion tothe uterus
Bleedingfrom
posteriormesorectum
and IMA
Colostomywas obstacle
fordissection
Bladderinvasion
Bulky tumorand intimateadherence to
the ureter
Uretericinjury
7.5%
5.0%
2.5% 2.5% 2.5% 2.5%
% o
f co
nve
rsio
n c
au
ses
to o
pe
n s
urg
ery
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The mean operative time was longer in converted cases
with significant difference .
The mean hospital stay and the mean duration of
analgesia were longer in the converted cases than non
converted cases with significant difference;
The first time of bowel motion and first time of oral
intake were longer in the converted group than the
non converted patients with significant difference.
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As regard to recurrence there was no recurrence
during the period of the follow up neither local nor
systemic. The case of involved circumferential
resection margin received adjuvant treatment
chemotherapy and closely observed with no evidence
of recurrence till the end of follow up.
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Conclusion
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The results of this study showed that laparoscopic resection for left sided colon and rectal cancer is :
technically feasible,
oncologically safe and
benefits of the short term outcomes of laparoscopy
like less analgesia.
early return of bowel functions.
early resumption of oral intake.
short hospital stay.
Less blood loss
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Thank you