Laparoscopic Colorectal Surgery May Improve Outcomes in Some Patients

Roxanne Nelson

June 28, 2007

June 28, 2007 — Laparoscopic colectomy has evolved as a technical option in the treatment of both benign and malignant colonic diseases. Although it is still not widely used and accounts for only a small percentage of colon cancer surgeries, a study presented at the annual meeting of the American Society of Colon and Rectal Surgeons (ASCRS), in St. Louis, Missouri, reported that patients undergoing a laparoscopic procedure had improved outcomes and similar costs compared with open resection.

Colon cancer continues to be a major health issue in the United States, explained Scott Steele, MD, a colorectal surgeon at Madigan Army Medical Center, in Fort Lewis, Washington. "Recently, laparoscopy has come to the forefront as an acceptable treatment for cancer.

"We wanted to see, outside of a clinical trial, what the average surgeon or colorectal surgeon is doing for colon cancer," said Dr. Steele, who is the senior author of the study.

Dr. Steele and colleagues used the Nationwide Inpatient Sample (NIS), which is the largest all-payer inpatient-care database in the United States, to identify patients with a primary diagnosis of colon cancer who underwent elective resection. "The NIS has a few inherent weaknesses associated with it," Dr. Steele pointed out, "But overall, it gives a general overview of what's happening in America."

The most recent NIS data available is for 2004, which was an interesting time period, according to Dr. Steele. "This was when the Clinical Outcomes of Surgical Therapy Study Group published its findings that compared laparoscopically assisted colectomy and open colectomy. That was like a benchmark that future studies can be earmarked against.

"We can then see how these numbers change, and I think in the future we are going to be seeing a larger number of laparoscopic procedures," he said.

Using data from the 2003 and 2004 NIS, the researchers compared outcome measures and identified independent predictors of a laparoscopic approach with multiple linear and logistic regression analyses. They identified a total of 98,923 hospital admissions of patients with colon cancer. Of this primarily white (81%) cohort, 63% had localized disease, 56% had private insurance, and nearly all patients (87%) had their surgery performed at a hospital located in an urban setting.

The majority of patients had an open colectomy performed. Laparoscopic resection was done in only 3296 cases, or 3.3% of the population. "In 2004, laparoscopic procedures still represented only a paucity of operations as compared with open resection, but I think we are going to see that number rise in newer editions of the NIS," he said. "We also looked only at elective cases, as many surgeons may still not have the comfort level or skill to perform laparoscopic procedures in emergency situations."

Laparoscopic surgery was associated with a lower rate of complications as compared with open resection (18% vs 22%), a shorter length of stay (6 vs 7.6 days), a reduced need for skilled care in the postoperative period (5% vs 11%), and a lower mortality rate (0.6% vs 1.4%). The mean hospital charges were similar for both groups ($34,685 vs $34,178).

"The only outcomes available from the NIS are complications and in-house mortality," said Dr. Steele. "This is an administrative database, so data on margins, lymph node involvement, and similar factors were not available to us.

"The trend toward these less invasive techniques continues to grow, and our goal was to identify any factors that inhibit surgeons or make them shy away from doing laparoscopy," Dr. Steele concluded. "We found that it does have improved perioperative outcomes at a similar cost to open surgery. As surgeons become more comfortable with this procedure, it will continue to show further benefits."

A second study presented at the ASCRS meeting found that the benefits of laparoscopic resection are more pronounced in elderly patients. Marco Braga, MD, from the department of surgery at San Raffaele University, in Milan, Italy, and colleagues, evaluated the impact of either laparoscopic or open colorectal resection on short-term morbidity in both elderly and younger patients.

A cohort of 535 patients with colorectal disease was randomly assigned to either laparoscopic or open colectomy. Elderly was defined as being over the age of 70 years, which was 37.6% of the study population. The researchers found that the incidence of colon cancer was higher among elderly patients as compared with younger ones. In patients who underwent the open procedure, the elderly had a higher rate of morbidity (37.5% vs 23.9%) and a longer length of hospital stay (13.0 vs 10.6 days) than the younger group. There was a higher rate of wound infections and cardiovascular complications among the older patients.

In the group who underwent laparoscopic resection, a significant difference was not seen in both the rate of morbidity (20.2% vs 15.1%) and length of hospital stay (9.5 vs 9.1 days) between elderly and younger patients. Laparoscopic resection among elderly patients appeared to decrease the morbidity rate (20.2% vs 37.5%) and length of stay (9.5 vs. 13.0 days) compared with open colectomy.

The benefits of laparoscopic resection were more pronounced in elderly patients, write the researchers. "In colorectal surgery, advanced age is still associated with a worse outcome when performed using an open approach, but not if performed laparoscopically."

Annual meeting of the American Society Colon and Rectal Surgeons: Abstracts S25, S27. Presented June 4, 2007.

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