status of laparoscopy for colon and rectal cance现状腹腔镜结肠癌和直肠癌课件

Current Status of Laparoscopy for Colon and Rectal Cancer Steven D Wexner, MD, FACS, FRCS, FRCS (Ed) Chairman, Department of Colorectal SurgeryChairman, Department of Colorectal Surgery 21st Century Oncology Chair in Colorectal Surgery21st Century Oncology Chair in Colorectal Surgery Chief of StaffChief of Staff Cleveland Clinic FloridaCleveland Clinic Florida Professor of Surgery, Ohio State UniversityProfessor of Surgery, Ohio State University Health Sciences Center at theHealth Sciences Center at the Cleveland Clinic FoundationCleveland Clinic Foundation Clinical Professor of Surgery,Clinical Professor of Surgery, University of South Florida College of MedicineUniversity of South Florida College of Medicine Clinical Professor of Biomedical ScienceClinical Professor of Biomedical Science Department of Biomedical ScienceDepartment of Biomedical Science Florida Atlantic University College of MedicineFlorida Atlantic University College of Medicine Dan Dan EngerEnger Ruiz, MD Ruiz, MD David Vivas, MDDavid Vivas, MD Clinical Research FellowsClinical Research Fellows Laparoscopy: Colorectal cancer Short term benefits Bowel function recovery Quality of life (including pain) Hospital stay Costs Long term benefits Recurrence Survival AuthorYearN of patientsBowel function (mean/median n of days) LapOpenLapOpen Milsom1998545334 Curet200018182.74.4 Lacy20021111081.52.3 Hasegawa2003293023.3 Kaiser2004292034 p ng/ml vs. 20 cases; Random audit of cases Weeks et al. JAMA 2002Weeks et al. JAMA 2002 Laparoscopic Colectomy : Cancer Outcomes: Survival: still pending QOL at 2days, 2 weeks and 2 months using: Symptom Distress Scale, Global QOL Scale, QOL index Results: Intention to Treat Analysis Shorter use of narcotics Shorter length of stay by 0.8 days (p0.05P0.05 CLASICC: Complications Intraoperative complications Laparoscopic (intention to treat) Open General54 (10%)27 (10%) (Colon) Haemorrhage Cardiac/Pulmonary Bowel Injury Ureteric Injury Other 2 (1%) 10 (4%) 6 ( 2%) 2 (1%) 2 (1%) 5 (4%) 4 (3%) - - 2 (1%) (Rectum) Haemorrhage Cardiac/Pulmonary Bowel Injury Ureteric Injury Other 17 (7%) 11 (4%) 3 ( 1%) - 9 (4%) 7 (5%) 4 (3%) 1 (1%) 4 (3%) 2 (2%) GuillouGuillou, Lancet 2005, Lancet 2005 P 0.05P 0.05 CLASICC: Complications 30 days post opLaparoscopicOpen Converted Total Complications133 (39%)115 (42%)99 (69%) (Colon) wound infection chest infection anastomotic dehiscence DVT Other 8 (4%) 10 (5%) 7 (4%) 5 (3%) 32 (17%) 7 (5%) 5 (3%) 5 (3%) - 31 (22%) 5 (8%) 6 (10%) 1 (2%) - 11 (18%) (Rectum) wound infection chest infection anastomotic dehiscence DVT Other 16 (10%) 12 (8%) 13 (8%) - 30 (19%) 16 (12%) 6 (5%) 10 (7%) 2 (2%) 33 (25%) 16 (20%) 12 (15%) 12 (15%) 1 (1%) 35 (43%) Death16 (1%)15 (5%)13 (9%) GuillouGuillou, Lancet 2005, Lancet 2005 P0.05P0.05 CLASICC: Conversions Conversion Rate (Colon) 61 (25%) -Tumor fixity -Uncertainty of tumor clearance -Obesity 37 (61%) 13 (21%) 5 (8%) Conversion Rate (Rectum) 82 (34%) -Tumor fixity/Uncertainty of tumor clearance -Obesity -Anatomical uncertainty -Inaccessibility of tumor 34 (41%) 21 (26%) 17 (21%) 16 (20%) GuillouGuillou, Lancet 2005, Lancet 2005 Laparoscopic Colectomy : Prospective, Randomized, Controlled Open N=20 Converted N=13 Laparoscopic N=15 Recurrence % 5230 Survival Status Alive without disease % 906293 Alive with disease % 5230 Died, Disease-related % 587 Died, non-disease related % 080 Outcome at 3 yearsOutcome at 3 years Kaiser, J Lap and Advanced Kaiser, J Lap and Advanced SurgSurg Tech 2004 Tech 2004 Equivalent in terms of recurrence and survivalEquivalent in terms of recurrence and survival Laparoscopy vs. Open: Colon Cancer Meta-analysis of 12 randomized controlled trials (2512 patients) Abraham, BJS 2004Abraham, BJS 2004 YearPatients Lacy 2002219 COST2002428 COLOR2002 Neudecker200230 Braga2002269 Singapore2001236 Schwenk200060 Leung200034 Curet200073 Hewitt199825 Milsom1998113 Stage199729 Laparoscopy vs Open: Colon Cancer Meta-analysis of 12 randomized controlled trials (2512 patients) Abraham, BJS 2004Abraham, BJS 2004 Odds RatioP value Mortality 0.85NS Morbidity 0.621000 ml FLUID INTAKE360.002 SOLID DIET (days)470.046 HOSPITALIZATION (days)12190.007 MORBIDITY37%51%N/A ANASTOMOTIC LEAK (n)22N/A MORTALITY(n)01N/A NConversion OR Time (mins) Anastomotic Technique Goh, 97OLAR LLAR 20 20 - 0% 73 90 Partial TME with double staple Leung, 97OLAR LLAR 50 50 - 16% 150 196 Partial TME with double staple Schwander, 99OLA/pr LLA/pr 32 32 - NS 209 281 LAR 19 Lap 19 Open, APR 13 Lap 13 Open Hartley, 01OLA/pr LLA/pr 22 42 - 50% 125 180 LAR, APR, Hartmann Anthuber, 03OLA/pr LLA/pr 334 101 - 11% 219 218 TME with colonic J if 2cm from dentate) Ultralow anterior (2cm from dentate) Coloanal (at or below dentate) 35 27 27 30 27 25 Diverting ileostomy00 Zhou, Zhou, SurgSurg EndoscEndosc 2004 2004 Laparoscopy: Rectal Cancer OpenLaparoscopicP value Operative time (min)106120NS Blood loss (ml)92200.02 Parenteral analgesics (days)4.13.9NS Solid intake (days)4.54.3NS Hospitalization (days)13.38.10.001 Morbidity Anastomotic leak 12.4% 3 6.1% 1 0.016 Mortality00NS Follow-up 1-16 months Port site metsNA2 Pelvic recurrence30 Zhou, Zhou, SurgSurg EndoscEndosc 2004 2004 105 patients Mean follow up time 26.9 (1.3-65.6) months Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstruction Tsang WWC, Ann Tsang WWC, Ann SurgSurg 2006 2006 Mean operative time 170.4 min Mean anastomotic distance from anal verge 3.9 cm Mean circumferential margin 17.1 mm Mean distal margin 3.4 cm Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstruction Tsang WWC, Ann Tsang WWC, Ann SurgSurg 2006 2006 5-year cancer-specific survival rate 81.3% Local recurrence rate 8.9% Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstruction Tsang WWC, Ann Tsang WWC, Ann SurgSurg 2006 2006 Laparoscopic Sphincter-Preserving TME with Colonic J-Pouch Reconstruction ConclusionConclusion Lap TME with colonic J-pouch is a safe procedure with Lap TME with colonic J-pouch is a safe procedure with reasonable operating time and does not appear to pose reasonable operating time and does not appear to pose any threat to the any threat to the oncologiconcologic and functional outcomes and functional outcomes Tsang WWC, Ann Tsang WWC, Ann SurgSurg 2006 2006 Laparoscopic vs. Open Surgery for Extraperitoneal Rectal Cancer 191 consecutive patients 98 patients underwent lap resection 93 patients underwent open resection MorinoMorino M, M, SurgSurg EndoscEndosc 2005 2005 Laparoscopic n = 98 Open n = 93 P Mean follow up (months)46.3 49.7NS Conversion rate (%)18.4 Mobilization (days)1.73.3 0.001 Flatus (days)2.63.9 0.001 Stool (days)3.84.7 0.01 Oral intake (days)3.44.8 0.001 Hospital stay (days)11.413.0NS MorinoMorino M, M, SurgSurg EndoscEndosc 2005 2005 Laparoscopic vs. Open Surgery for Extraperitoneal Rectal Cancer Laparoscopic n = 98 Open n = 93 P Morbidity (%)24