Laparoscopic colorectal surgery

Few, if any, major surgical trials have caused as much of a stir as the Clinical Outcomes of Surgical Therapy (COST) study. The release of the long-awaited results in May marked the beginning of a new, minimally invasive age in colon cancer treatment.

The study showed conclusively that, in experienced hands, laparoscopic colectomy offers the same oncologic outcomes as the open procedure – with shorter hospital stays and less postoperative pain. But the publication triggered as many questions as it answered about the future of colon cancer surgery.

Before the trial, the main issue was whether laparoscopic colectomy was a safe procedure; now, the question is how to ensure that it stays safe. Some surgeons worry about a repeat of the cholecystectomy debacle of the early 1990s, when mortality and morbidity rates shot up as laparoscopy was adopted. They fear wound metastases and complication rate from laparoscopic colectomy will rise if inexperienced surgeons push too far, too quickly. Surgical societies, hospitals, industry and surgeon face difficult decisions about how to educate and train physicians for the new procedure. In clinical trials and laboratories, too, the focus has changed. With the main study over, investigators are zeroing in on questions that until now were in the background of the laparoscopic colectomy debate.

Of these, none has garnered as much attention as research suggesting laparoscopic surgery offers better oncologic results than open surgery. Basic science research and animal studies indicate that minimally invasive surgery provides greater oncologic benefits because of a shorter period of cell-mediated immunosuppression following surgery. A highly controversial single-center, randomized study was published in 2002 in which they concluded this effect was evident in humans.

They reported that stage III cancer patients had the most dramatic benefit in oncologic outcomes when patients underwent laparoscopic, rather than open, surgery. Other single-center studies showed similar survival benefits for laparoscopic surgery.

Trials are ongoing to establish the best surgical techniques, patient selection criteria and co-effective of laparoscopic colectomy. In an effort to elucidate the implications of the COST study for the future of colon cancer.

A group of colorectal specialists was interviewed to share their thoughts on what is ahead for colon cancer treatment.

The panel includes the lead investigator in the COST trial; world-renowned laparoscopic specialist and instructors; a COST trial investigator who is spearheading one of the largest research projects in the immunologic consequences of minimally invasive surgery; a private-practice surgeon who completed a colorectal fellowship last year; and a well-known advocate for the open approach to colon cancer surgery.