Short-term benefits for laparoscopic colorectal resection

Colorectal cancer is one of the most common cancers in industrialised countries, in both female and male persons. Treatment involves surgical removal (resection) of the segment of the bowel containing the tumor and wide tumorfree margins. Lymph nodes in the area are also removed (lymphadendectomy). conventional surgery which is the mainstream treatment of colorectal cancer and has good survival rates for stage-1 tumors. Other diseases that can require removal of sections of the large bowel include inflammatory diseases such as diverticulitis, Crohn's disease, ulcerative colitis, familial adenomatous polyposis (FAP) and rectal prolapse.
The conventional approach to surgery involves making a cut through the abdominal wall. For many people it is now possible to use video-endoscopic surgery (laparoscopy), which may have short term advantages that include less pain, better pulmonary function, shorter time for return of bowel function (duration of postoperative ileus), less fatigue, better quality of life and improved convalescence. However, the procedure is complex and for colorectal cancer the oncological long-term results on survival not known.
The review authors identified 25 controlled trials in which 3526 men and women were randomized to one surgical technique or the other. Colorectal resection was most often required for colorectal carcinoma. Overall, laparoscopic colon resections showed advantages over conventional surgery. Blood loss was a little less (by 113 to 31 ml, mean 72 ml); pain, which was treated with epidural or patient-controlled on demand analgesia, was less intense; time to return of bowel function was less, by about one day; lung function was improved with reduced postoperative stay in hospital (by 1.4 days) and improved quality of life in the first 30 days. The operation time was longer with laparoscopic surgery than with conventional surgery (by 42 minutes, range 30 to 55 minutes). Re-operation was not more likely after laparoscopic surgery and general complications in the lungs, heart, urinary tract or deep vein thrombosis (DVT) were similar with the two surgery techniques. Wound infections were less in laparoscopic patients. Some patients are not suitable for laparoscopy.

Authors' conclusions: 

Under traditional perioperative treatment, lapararoscopic colonic resections show clinically relevant advantages in selected patients. If the long-term oncological results of laparoscopic and conventional resection of colonic carcinoma show equivalent results, the laparoscopic approach should be preferred in patients suitable for this approach to colectomy.

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Background: 

Colorectal resections are common surgical procedures all over the world. Laparoscopic colorectal surgery is technically feasible in a considerable amount of patients under elective conditions. Several short-term benefits of the laparoscopic approach to colorectal resection (less pain, less morbidity, improved reconvalescence and better quality of life) have been proposed.

Objectives: 

This review compares laparoscopic and conventional colorectal resection with regards to possible benefits of the laparoscopic method in the short-term postoperative period (up to 3 months post surgery).

Search strategy: 

We searched MEDLINE, EMBASE, CancerLit, and the Cochrane Central Register of Controlled Trials for the years 1991 to 2004.
We also handsearched the following journals from 1991 to 2004: British Journal of Surgery, Archives of Surgery, Annals of Surgery, Surgery, World Journal of Surgery, Disease of Colon and Rectum, Surgical Endoscopy, International Journal of Colorectal Disease, Langenbeck's Archives of Surgery, Der Chirurg, Zentralblatt für Chirurgie, Aktuelle Chirurgie/Viszeralchirurgie. Handsearch of abstracts from the following society meetings from 1991 to 2004: American College of Surgeons, American Society of Colorectal Surgeons, Royal Society of Surgeons, British Assocation of Coloproctology, Surgical Association of Endoscopic Surgeons, European Association of Endoscopic Surgeons, Asian Society of Endoscopic Surgeons.

Selection criteria: 

All randomised-controlled trial were included regardless of the language of publication. No- or pseudorandomised trials as well as studies that followed patient's preferences towards one of the two interventions were excluded, but listed separately. RCT presented as only an abstract were excluded.

Data collection and analysis: 

Results were extracted from papers by three observers independently on a predefined data sheet. Disagreements were solved by discussion. 'REVMAN 4.2' was used for statistical analysis. Mean differences (95% confidence intervals) were used for analysing continuous variables. If studies reported medians and ranges instead of means and standard deviations, we assumed the difference of medians to be equal to the difference of means. If no measure of dispersion was given, we tried to obtain these data from the authors or estimated SD as the mean or median. Data were pooled and rate differences as well as weighted mean differences with their 95% confidence intervals were calculated using random effects models.

Main results: 

25 RCT were included and analysed. Methodological quality of most of these trials was only moderate and perioperative treatment was very traditional in most studies. Operative time was longer in laparscopic surgery, but intraoperative blood was less than in conventional surgery. Intensity of postoperative pain and duration of postoperative ileus was shorter after laparoscopic colorectal resection and pulmonary function was improved after a laparoscopic approach. Total morbidity and local (surgical) morbidity was decreased in the laparoscopic groups. General morbidity and mortality was not different between both groups. Until the 30th postoperative day, quality of life was better in laparoscopic patients. Postoperative hospital stay was less in laparoscopic patients.

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