Laparoscopic Colorectal Surgery

The Lapco Manual

Mark Coleman, Tom Cecil, Mark Coleman, Tom Cecil

• Publisher: CRC Press
• Year: 2017
• Print ISBN: 9781138896994
• eBook ISBN: 9781498717182
• Topic: Medicine
• Subtopic: Gastroenterology & Hepatology

This unique reference in laparoscopic colorectal surgery starts by looking at the establishment of the Lapco training programme in the UK. It then goes on to provide a comprehensive technical manual of operative and patient care for laparoscopic colorectal surgery, offers insight into training and assessment methodology and finally looks to the future and where we may be going. It shares knowledge of a unique training programme which healthcare systems worldwide are trying to emulate, and provides an up-to-date manual of know-how from some of the world's most experienced laparoscopic colorectal trainers.

PART 1	SET

1 Evidence for laparoscopic surgery in the treatment of colorectal cancer

James Horwood and Jared Torkington

2 Design and development of a national training programme

Mark Coleman and Laura Langsford

3 Educational tools and assessment for laparoscopic colorectal surgery

Susannah M. Wyles and Danilo Miskovic

4 Outcomes of a national training programme

Hugh Mackenzie and George Hanna

5 Training the trainer in minimal access surgery

Nader Francis and John Griffith

1	Evidence for laparoscopic surgery in the treatment of colorectal cancer
	JAMES HORWOOD AND JARED TORKINGTON

Introduction

Short-term outcomes

Long-term outcomes and complications

Take-home message

References

LEARNING OBJECTIVES

■ Understand the evolution of laparoscopic colorectal surgery.

■ Review the major randomised trials upon which the National Institute for Health and Care Excellence (NICE) guidance regarding the introduction of laparoscopic colorectal surgery is based.

■ Review the evidence behind short- and long-term outcomes and morbidity from the laparoscopic approach to colorectal resections.

■ Provide an overview of ongoing clinical trials awaiting publication.

■ Discuss future development of minimally invasive techniques.

INTRODUCTION

The first description of laparoscopic surgery in the treatment of colon cancer is usually credited to Jacobs and colleagues in 1991 (1). The authors from Florida described a variety of procedures in 20 patients for various indications, 12 of whom had adenocarcinomas or large adenomas. They concluded that ‘although laparoscope-assisted colonic surgery may still be considered a procedure in evolution, we feel that in time it has the potential to be as popular as laparoscopic cholecystectomy’. Two decades later, laparoscopic colorectal surgery (LCS) has become the preferred surgical option for the treatment of colorectal cancer (CRC) when appropriate.

The subsequent uptake of LCS in the treatment of CRC was haphazard and generally slow. There were issues of standardising training and technique, rudimentary instrumentation, the difficulty of conceptualising anatomy in a different way, and significant concerns surrounding oncological safety. These fears of oncological compromise were fuelled by the emergence of cases of port site metastases (2), now clearly understood to be technique related but at the time multiple theories were proposed including the infamous ‘chimney effect’.

The most significant moment in the United Kingdom in the transition of LCS from a technique employed by enthusiasts (sometimes even viewed as mavericks) to mainstream surgery was the publication in August 2006 of Technology Appraisal 105 (TA105) (3) from the National Institute for Health and Care Excellence (NICE) entitled ‘Laparoscopic surgery for colorectal cancer’. These guidelines replaced those published in December 2000, TA17, which had called for laparoscopic surgery to only be carried out for colorectal cancer within the confines of a randomised controlled clinical trial. The new 2006 publication for NICE took advice from many surgeons and organisations and critically reviewed the results of those trials called for in the 2000 document to effectively open the door for LCS in the treatment of cancer. TA105 stated:

Laparoscopic surgery (including laparoscopically assisted surgery) is recommended as an alternative to open surgery for people with colorectal cancer if:

• Both laparoscopic and open surgery are suitable for the person and their condition.

• Their surgeon has been trained in laparoscopic surgery for colorectal cancer and performs the operation often enough to keep his or her skills up to date.

The decision about whether to use open or laparoscopic surgery should be made after informed discussion between the patient and the surgeon. In particular, they should talk about whether the patient’s condition is suitable for laparoscopic surgery, the risks and benefits of the two procedures, and the surgeon’s experience.

SHORT-TERM OUTCOMES

The critical trials in influencing this shift in policy were the Medical Research Council (MRC)-funded, UK-based Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC) trial (4); the North American Clinical Outcomes of Surgical Therapy (COST) trial (5); the European Colon Carcinoma Laparoscopic or Open Resection (COLOR) trial (6); and the trial from Lacy which has become known as the Barcelona trial (7). All four trials, published in high-impact journals, demonstrated the anticipated short-term advantages from LCS for colon cancer such as reduced post-operative pain, less blood loss, early return of bowel function, and faster discharge from hospital. Crucially, the studies also showed no evidence for any detrimental effect in terms of oncological safety. Although these trials are never likely to be repeated in terms of design and critics have pointed to various flaws in each, they remain perhaps the most important and influential clinical studies in colorectal cancer of that time.

It is important to emphasise that only the CLASICC trial included rectal cancer patients (with a 34% conversion rate), and the main conclusions of the body of work of these trials collectively apply to colon cancer resection only. Each of these four trials was also carried out in a pre-enhanced recovery era, and evidence suggests that when laparoscopy is integrated into such a programme then discharge is even quicker (8).

The Cochrane Library published a review of the short-term benefits of laparoscopic colorectal resection in 2005 including 25 randomised controlled trials (9). The authors concluded that ‘Under traditional perioperative treatment, laparoscopic 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’.

When looking for robust evidence for the use of LCS in rectal cancer specifically, we must turn to more recent studies. The first of these is the Comparison of Open versus Laparoscopic Surgery for Mid and Low Rectal Cancer after Neoadjuvant Chemoradiotherapy (COREAN) trial (10), which randomised 340 patients with rectal cancer to open or laparoscopic surgery and replicated the earlier findings of reduced blood loss, reduced analgesic requirement, earlier return of bowel function, and a non-statistically significant shorter hospital stay but also showed a longer operating time for the LCS group. A second multicentre study from Europe, the Laparoscopic versus Open Rectal Cancer Removal (COLOR II) trial (n = 739 vs. n = 364) confirmed these findings (11). Both studies showed no difference in morbidity or mortality and crucially once again, no oncological differences between groups in terms of quality of specimen, lymph node harvest, or circumferential resection margin involvement.

The final group to consider separately where possible are patients undergoing abdominoperineal resection of low rectal cancer (abdomin...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword
• Guest Editor
• Preface
• Acknowledgments
• Contributors
• Abbreviations
• PART 1 SET
• PART 2 DIALOGUE
• PART 3 CLOSURE
• Index