LAPAROSCOPIC SURGERY
| CURRENT STATUS OF LAPAROSCOPIC SURGERY FOR COLORECTAL CARCINOMA —Steven D. Wexner, MD,
Chair, Department of Colorectal Surgery, Cleveland Clinic Florida, and Chief of Staff, Cleveland Clinic Hospital, Weston,
FL
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| Laparoscopy for colon cancer: randomized trials—laparoscopic colectomy associated with more rapid return of bowel
function than laparotomy; data show less pain with laparoscopy; quality of life (QOL) harder to measure; Clinical Outcomes
of Surgical Therapy (COST) trial—first iteration with 449 patients (228 underwent laparoscopy, 221 underwent
open procedure); study looked at pain, hospital stay, and QOL at 3 intervals; good distribution between 2 groups for age,
sex, tumor stage, and American Society of Anesthesiologists (ASA) classification; early phase showed less pain and
shorter hospital stay with laparoscopy; no difference in other QOL parameters; cost of colorectal surgery—data based
on Colon Cancer Laparoscopic or Open Resection (COLOR) trial (Swedish) and looked at direct medical cost (hospital
and outpatient) and indirect costs; harder to analyze in United States because of payor system and insurance; COLOR
study showed laparoscopic surgery took longer than open resection, with no difference in length of stay between 2 groups;
cost of first admission higher for laparoscopic group; higher cost of care after discharge found in laparoscopic group, with
loss of productivity not factored in (balanced out when factored in); higher rate of complications and reoperations in laparoscopic
group; study found total cost to society similar between groups, with significantly higher cost to health care system
for laparoscopic group (higher operative costs, complication rate, and reoperation rate, with no reduction in length of
stay); faster recovery and return to work helped offset health care cost; with reduction in hospital stay and lower complication
rates (found in many other studies), data would favor laparoscopy
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| Recurrence rates and survival: study (median follow-up 4 yr) comparing laparotomy to laparoscopy showed that with
laparotomy, trend in tumor recurrence higher than, time to recurrence similar to, and local regional relapse double that for
laparoscopy; higher overall mortality in laparotomy group (higher cancer-related mortality statistically significant);
probability of being free of recurrence—predictive factors include lymph node metastases, serum carcinoembryonic
antigen (CEA), open (vs laparoscopic) procedure (predictive in overall and cancer-related survival); Lacy 2002—study
showed no significant difference in probability of survival between laparoscopic colectomy and open colectomy, no real
difference in cancer-related survival, and no real difference in stage I or II, but difference in stage III (all data from single
surgeon, which speaks to consistency of technique); systematic review—(published just before Lacy data) reported
nothing significantly advantageous about laparoscopic procedure; COST data—similar time period; execution of study
differed from design; at time of initial publication, with pending data, showed modest benefits in short-term QOL; American
Society of Colon and Rectal Surgeons (ASCRS) meeting (2004)—data with follow-up for 4.4 yr showed no increase
in recurrence in laparoscopic group (vs open surgery) and no change in 3-yr survival; no divergence in patients
with stage III disease; data extracted from 10 cases per surgeon over 7 yr (important that surgeon performd procedure;
data similar to reality); United Kingdom (UK) trial—similar to United States (US) trial; similar conversion rate (US at
21%; UK at 29%); rectal cancer included (unlike COST study); conversion group assessed separately; no significant differences
among groups; 82% of conversions due to tumor-related variables (fixed tumor [most common reason] and uncertainty
of tumor clearance); outcomes (ie, recurrence and survival) equivalent at 3 yr; meta-analysis (2004)—
included data from Lacy and COST and COLOR trials; significant improvement in morbidity in laparoscopic group; potentially
superior to open colectomy in short-term benefits; COLOR (2005)—conducted in 6-yr span (29 hospitals; 7
European countries); same criteria as used in COST trial; no significant difference between 2 groups; reasonable body
mass index (BMI); duration of surgery longer in laparoscopic group; less blood loss in laparoscopic group; conversion
rate similar (majority for preemptive reasons); more rapid fluid intake and first bowel movement, shorter hospital stay,
and less pain medication with laparoscopic colectomy; complications, reoperation, and mortality similar between groups;
5-yr survival and recurrence (COST data)—no differences in recurrence, overall survival, or disease-free survival between
laparoscopic and open colectomy groups; with laparoscopic colectomy, strong evidence of less pain, shorter hospital
stay, more cosmetic appeal, better QOL for first 12 mo, and no worse oncologic outcome
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| Rectal cancer: difficulties with laparoscopy in rectal surgery include working under prostate and seminal vesicles, or
uterus and vagina, absence of tactile sensation, and margins potentially difficult; outcome—prospective review (58 mo)
of open rectal resection vs laparoscopic resection; of 42 patients in laparoscopic group, only half actually had laparoscopic
resection (remainder preemptively converted totally or partially to open procedure); slightly better longitudinal
margin in laparoscopic group than in open group; radial margin, lymph node yield, and specimen length similar between
groups; operating time longer in laparoscopic group; ileus shorter and hospital stay shorter in laparoscopic group; anastomotic
leakage higher (not statistically significant) in laparoscopic group; no difference in local recurrence rate or mortality
at median follow-up of 3 yr; procedure feasible in only half of patients; case-control study—showed short-term
advantages in hospital stay, fluid intake, diet, and amount of blood loss in laparoscopy group; study of laparoscopic total
mesorectal excision (TME) with colonic J-pouch reconstruction—local recurrence rate, 9%; 5-yr cancer-specific
survival, 81%; study (Italy)—open vs laparoscopic resection; patients ambulatory quicker, more rapid return of bowel
function, and shorter hospital stay in laparoscopic group; no difference in morbidity between groups, but significant improvement
in local recurrence rate in laparoscopic group; conclusion based on literature review—laparoscopic treatment
of curable colon and rectal cancer safe when correct oncologic technique used, but procedure not simple and
requires proper training and experience (extensive) in complex minimally invasive surgery
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| LAPAROSCOPIC SURGERY FOR GERD—Robert J Fitzgibbons Jr, MD, Professor of Surgery and Chief of Division of
General Surgery, Creighton University Medical Center, Omaha, NE
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| Gastroesophageal reflux disease (GERD): improper relaxation of lower esophageal sphincter (LES; from defective
LES, gastric emptying disorders, or esophageal motility disorder); contributing factors include environmental triggers
(alcohol, chocolate, peppermint, and smoking), anatomy (obesity, hiatal hernia, and diaphragm abnormalities), drugs (nitrates
and calcium channel blockers), and genetic predisposition; Helicobacter pylori—concern that eradication of H
pylori predisposed patients to Barrett’s esophagus and eventual gastroesophageal (GE) junction adenocarcinoma; not
proving true
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| Types of GERD: nonerosive (NERD); erosive; neoplastic (Barrett’s esophagus and adenocarcinoma); NERD—natural
history different from that of GERD; occurs in 50% of GERD population; less responsive to medical management; rarely
progresses to erosive disease; confusing relationship to visceral hyperalgesia (esophagus unusually sensitive to any type
of stimuli); erosive—seen in 47% of GERD population; danger of complications (eg, strictures); no predictive factors
(prolonged exposure not proven factor); severity of symptoms correlates weakly with development of strictures; recent
studies suggest higher incidence in white men; history of nonsteroidal anti-inflammatory drug (NSAID) use important;
complications—stricture; carcinoma; pulmonary problems (underreported)
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| Barrett’s esophagus: normal squamous epithelium of distal esophagus replaced by intestinal type (characterized by goblet
cells); biopsy necessary to distinguish from gastric form; 2 types, long segment and short segment (debate whether
difference exists between 2 types and their progression to malignancy); Barrett’s esophagus strongly associated with cancer;
screening patients difficult because most patients asymptomatic; screening everyone with GERD not sensible (many
people screened needlessly) and not without risk for complications; research to find biochemical screening method; current
recommendation of American College of Gastroenterology—endoscopy every 3 yr after 2 consecutive biopsies
showing no dysplasia; if dysplasia present, get second opinion; if confirmed, yearly endoscopy for low-grade dysplasia;
if high-grade dysplasia, repeat in 3 mo; consider endoscopic therapy if persistent; most surgeons consider esophagectomy
best for patient
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| Hiatal hernia: present in 50% of patients with GERD; only patients with large hiatal hernias consistently have GERD;
classifications—sliding (GE junction moves above diaphragm; accounts for 85% of hernias); paraesophageal (GE junction
in normal location and part of stomach passes into chest beside esophagus; mixed (combination of 2 types; 11% of
hernias); viscera in hernia other than stomach (colon, spleen, or other organs)
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| Diagnosis of GERD: signs and symptoms—heartburn; regurgitation; dysphagia; anemia (especially with erosive disease);
also common to have no symptoms; extraesophageal (supraesophageal or laryngoesophageal) signs and
symptoms—asthma; hoarseness; pharyngitis; chronic cough; nocturnal coughing; recurrent pneumonia; chest pain; acid
taste; halitosis; dental problems; barium esophagography—helpful in detection of mild strictures and esophageal motor
abnormalities; not reliable in determining esophagitis (except when severe); upper gastrointestinal (GI)
endoscopy—best for evaluation of esophagitis and to rule out neoplasia; poor sensitivity (50% of patients with GERD
do not have esophagitis); standard grading scales developed (eg, Los Angeles scale; 4 levels of esophagitis defined by
size of ulcer and whether >1 mucosal fold involved); 24-hr pH testing and manometry—24-hr pH gold standard for
making diagnosis; manometry useful for function, not for diagnosis; patients do not like probes; high resolution systems
in development (allow for more accurate readings; easier to place); radio capsule (brandname Bravo) placed in esophagus
to avoid tubes (has battery power for 48 hr); mechanical impedance testing—technique for measuring nonacid reflux
(most notably, alkaline reflux); avoids need for Bilitech probe; measures electroresistance between several different electrodes
and indicates when reflux occurs (useful when 24-hr pH negative but typical symptoms present); proton pump inhibition
test—place patient on proton pump inhibitor (PPI) and observe reaction
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| Medical treatment: begin with lifestyle changes (sleep with head elevated; sleep on left side; avoid large late meals; saliva-stimulating
agents; loose fitting clothing; no smoking, alcohol, coffee, or chocolate); histamine-2 (H2 ) receptor
blockers bid for 8 to 12 wk, then stop medication; if patient asymptomatic, no more treatment needed; early
recurrence—endoscopy (rule out complication); PPI once daily or bid for 3 mo (15㪶 min before meal); if asymptomatic,
no need to treat further; early recurrence after PPI—consider work-up for surgical solution; medical treatment
failure—acid-suppressing drugs considered safe for long-term use, but medical therapy not always successful; acid suppression
does not affect alkaline reflux; body motility not improved; large hiatal hernia not affected; little effect on gastroparesis;
because GERD mechanical disorder, acid suppression treats cause but does not alleviate symptoms;
predictors of medical management failure—incompetent LES (monometry not always reproducible); severe esophagitis;
patients with reflux in supine position; patients with bilious reflux; patients who develop strictures despite medical
management
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| Laparoscopic surgery: reason for increase in surgery—lifelong medication eliminated; medical management does not
affect true natural history of disease; reflux surgery successful (90% at 10 yr), with decreased morbidity with laparoscopic
surgery; link between GERD and cancer has made patients look for more radical therapy; little pain with surgery
and short hospitalization; benefits—restores competence to LES; prevents mixed reflux (not addressed by medication);
improves body motility; corrects hiatal hernia; improves gastric emptying; controversy exists over using surgery instead
of medical management; indications—poor response to symptom management; complications; patient preference
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| Nonsurgical endoscopic treatments: radiofrequency energy (selective indications); injection techniques (polymer injected
into muscle layer of LES; removed from market); endoscopic suturing (technically difficult)
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| Considerations: whether propulsive force of esophagus adequate (possibility of dysphagia after surgery); shortened
esophagus (lengthening procedure necessary); associated peptic ulcer disease; adequate gastric emptying
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| Contraindications to surgery: severe motility disorder (scleroderma or achalasia); atypical symptoms; no response to
PPI; motility disorder
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| Procedures: Nissen-Rossetti fundoplication (complete wrap); Toupet fundoplication (partial wrap)
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| Technical considerations: positioning of patients—supine vs stirrups; good view of upper abdomen with stirrups (concern
of deep venous thrombosis and thromboembolic problems); supine with trocars along rib cage (optics positioned to
do left-sided dissection first); dissection—most surgeons dissect right side of esophagus first (take down gastrohepatic
ligament and expose right crus of diaphragm); speaker recommends right side for superficial exposure of right crus of diaphragm,
then shift to left side to take down short gastric vessels (less likely to injure stomach); short gastric vessels—
almost always divide; unable to divide in patients with previous gastric surgery (results in ischemic stomach); short
esophagus and lengthening techniques—speaker believes significant number of patients have short esophagus and
lengthening procedure necessary; Collis-Nissen (stapler used to create neoesophagus; cumbersome; requires large access
to get stapler in); transthoracic approach (involves incision in axilla and probe passed to diaphragm to hiatus; replace
with stapler and do lengthening procedure); perform gastric resection then create neoesophagus; fundoplication—
measure 3 cm below GE junction and on posterior stomach (other side of short vessels); measure 1.5 cm and put stitch to
mark; loose Nissen important for majority of patients (dysphagia most significant complication); use of bougie debatable
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Suggested Reading
Bjoholt I et al: Principles for the design of the economic evaluation of COLOR II: an international clinical trial in surgery
comparing laparoscopic and open surgery in rectal cancer. Int J Technol Assess Health Care 22:130, 2006; Bochkarev V
et al: One hundred consecutive laparoscopic Nissen’s without the use of a bougie. Am J Surg 194:866, 2007; Breukink S
et al: Laparoscopic versus open total mesorectal excision for rectal cancer. Cochrane Database Syst Rev 18:CD005200,
2006; Chen LQ et al: Antireflux surgery for Barrett’s esophagus: comparative results of the Nissen and Collis-Nissen operations.
Dis Esophagus 18:320, 2005; Clinical Outcomes of Surgical Therapy (COST) study group: A comparison
of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 350:2050, 2004; Colon Cancer Laparoscopic
of Open Resection (COLOR) study group: Laparoscopic surgery versus open surgery for colon cancer: short-
term outcomes of randomized trial. Lancet Oncol 6:477, 2005; Fingerhut A et al: Laparoscopic approach to colonic cancer:
critical appraisal of the literature. Dig Dis 25:33, 2007; Fleshman J et al: Laparoscopic colectomy for cancer is not
inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 246:655, 2007; Kelly JJ et al:
Laparoscopic Nissen fundoplication: clinical outcomes at 10 years. J Am Coll Surg 205:570, 2007; McClusky DA 3rd et
al: Radiofrequency energy delivery to the lower esophageal sphincter (Stretta procedure) in patents with recurrent reflux
after antireflux surgery: can surgery be avoided? Surg Endosc 21:1207, 2007; Turner BG et al: Endoscopic pH monitoring
for patients with suspected or refractory gastroesophageal reflux disease. Can J Gastroenterol 21:737, 2007; Wehrli
NE et al: Secondary achalasia and other esophageal motility disorders after laparoscopic Nissen fundoplication for gastroesophageal
reflux disease. AJR Am Roentgenol 189:1464, 2007.
Educational Objectives
| The goal of this program is to improve management of colorectal cancer, gastroesophageal reflux disease (GERD), and
paraesophageal hernias through greater knowledege about laparoscopic surgery. After hearing and assimilating this program,
the clinician will be better able to:
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 | 1. Discuss data on laparoscopic colectomy.
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| 2. Evaluate data on laparoscopic rectal resection.
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| 3. Describe the types of GERD.
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| 4. Consider treatment options for GERD and the role of laparoscopic surgery.
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| 5. Enumerate the considerations and contraindications for laparoscopic surgery in the treatment of GERD.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee
members to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of
interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and
not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Wexner is a member
of the advisory committee for CB Fleet and has received financial support from Incontinence Devices, Power Medical
Interventions, Intuitive Surgical, MedSurge Medical, EZ Surgical, Covidien, Torax Medical, Baxter AG, Ventrus Biosciences,
Salix Pharmaceuticals, Unique Surgical Innovations, Advanced Surgical Innovations, Karl Storz Endoscopy
America, 21st Century Oncology, Olympus, Medtronic, SurgRx, and Gensyme. Dr. Fitzgibbons has been a consultant for
LifeCell Corporation and TyRx Pharma. The planning committee reported nothing to disclose.
Acknowledgements
Dr. Wexner was recorded at 70th Colon and Rectal Surgery: Current Principles and Practice 2007, held October 24-
27, 2007, in Minneapolis, MN, and sponsored by the Division of Colon and Rectal Surgery at the University of Minnesota
Medical School, Colon and Rectal Surgery Associates, Ltd, and the Minnesota Colon and Rectal Foundation.
Dr. Fitzgibbons was recorded at the 35th Annual Phoenix Surgical Symposium, held February 14-17, 2007, in Phoenix,
AZ, and sponsored by Banner Health and The Phoenix Surgical Society. The Audio-Digest Foundation thanks
the speakers and the sponsors for their cooperation in the production of this program.
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