Rome - 2013, October 18
The Current Management of Colorectal Cancer
Laparoscopic Surgery Massimo Carlini
S. Eugenio Hospital - Rome
Prof. Massimo Carlini Director of Department of Surgery Head of Division of General Surgery
A ogni passo della storia della chirurgia c’ è sempre stato qualcuno che ha affermato : “La chirurgia ha raggiunto una tale perfezione che è impossibile immaginare ulteriori miglioramenti”
Philippe Mouret
Carlini – Roma - 2013
fine ‘800 all’ospedale Maggiore di Milano pag. 89
“I progressi Listeriani trovavano nell’ Ospedale più scettici che credenti; e (non sembri strano a dirsi) gli scettici erano rappresentati soprattutto dai vecchi primarii di chirurgia generale, i quali, pur vantando un lodevole passato, erano ormai giunti a un’età nella quale è umano che si rifugga dal nuovo e si tenda più al dubbio che alla speranza.”
anno 1935 Carlini – Roma - 2013
pag. 174
“Oggi , potendo considerare la chirurgia addominale come qualcosa di fisso e definito, mi pare interessante darne un quadro completo.…”
tav. XXVII
anno 1939
Carlini – Roma - 2013
pag. 47
“Sorge la chirurgia mininvasiva, quella del massimo rispetto per il corpo. Tramonta l’ipotesi del “grande chirurgo, grande taglio”. Su questo scenario si chiude il meraviglioso XX secolo. La prospettiva è quella di un futuro ancora più straordinario.”
anno 2000
Carlini – Roma - 2013
Le pietre miliari della chirurgia del cancro del colon retto (1) William Ernest Miles 1906 Amputazione addominoperineale
Henri Albert Hartmann 1895-1899 Le anastomosi intestinali 1931 L’intervento di Hartmann
Carlini – Roma - 2013
Le pietre miliari della chirurgia del cancro del colon retto (2)
1920 Gli aghi atraumatici 1960 Le prime suturatrici meccaniche russe 1970 Le fibre di vetro e l’endoscopia 1987 La nascita della chirurgia laparoscopica
1990 Nuovi devices (ultrasuoni, radiofrequenze, ecc) Carlini – Roma - 2013
Le pietre miliari della chirurgia del cancro del colon retto (3) La prima resezione VLS del colon per cancro
M Jacobs Minimally invasive colon resection (laparoscopic colectomy)
Surg Laparosc Endosc. 1991 Sep;1(3):144-50. Carlini – Roma - 2013
Le pietre miliari della chirurgia del cancro del colon retto (4)
Anni 2000 La chirurgia robotica
Carlini – Roma - 2013
New ideas tend to come unforeseeable.
Kennedy
Carlini – Roma - 2013
Anche se chi ha bisogno di un’operazione si aspetta la guarigione senza considerare le dimensioni dell’incisione, i grandi tagli non sono più sinonimo di grandi chirurghi. Bertrand Millat Carlini – Roma - 2013
Passato Chirurgia Open prima tagliare e poi guardare
Carlini – Roma - 2013
Tagliare, tagliare……
Carlini – Roma - 2013
Presente Chirurgia Mininvasiva prima guardare e poi tagliare (poco)
Carlini – Roma - 2013
Il progresso tecnologico rende la chirurgia meno invasiva e più gentile INVASIVITA’
Laparotomia Fino al 1990
PROGRESSO TECNOLOGICO
Laparoscopia Dal 1990 ad oggi
Carlini – Roma - 2013
Chirurgia Mininvasiva del Colon-Retto VANTAGGI Minime incisioni Risultati estetici migliori Minori perdite ematiche Ridotto dolore post-operatorio Diminuzione delle complicanze settiche Diminuzione della degenza ospedaliera Ripresa più veloce dell’ attività lavorativa Carlini – Roma - 2013
Carlini – Roma - 2013
La chirurgia laparoscopica del cancro colo-rettale è una metodica (1991) che ha determinato una vera rivoluzione copernicana in una chirurgia consolidata da 100 anni di attività…
Carlini – Roma - 2013
…ma le nuove metodiche in chirurgia devono essere valutate in termini di Fattibilità, Efficacia, Riproducibilità
• Personal Experience • Randomized Clinical Trials Carlini – Roma - 2013
Personal Experience
La chirurgia laparoscopica del cancro colorettale
Controindicazioni e Limiti Infiltrazione* di organi contigui (T4) Tumori molto voluminosi (20 cm Ø) Aderenze addominali massive Obesità grave (?) * Macro Carlini – Roma - 2013
Laparoscopic colorectal surgery
I.R.E. 1994-2003
Esperienza Personale 1994 – 2013 (Settembre)
O.S.E. 2004-2013
621 casi
202
419
Patologia maligna Patologia benigna
568 (91%) 53 (9%)
( Polipi, Diverticoli, Megacolon, Crohn, Colite ulcerosa, FAP )
Carlini – Roma - 2013
Laparoscopic colorectal surgery Esperienza Personale O.S.E. 2004 – 2013 (Settembre) Procedure
419 casi Sede Colon destro Trasverso Angolo sinistro Colon sinistro Sigma Retto Sedi multiple Intero colon
123 20 18 34 91 124 5 4
Emicolectomie dx Res. trasverso Res. angolo sinistro Resezioni segmentarie Emicolectomie sin Resezioni sigma Resezioni retto con TME Miles e Hartmann Res multiple Colectomie totali
123 20 18 18 22 87 64 47 12 4 4
Carlini – Roma - 2013
Laparoscopic colorectal surgery Esperienza Personale O.S.E. 2004 – 2013 (Settembre) Stadio *
419 casi Grading G1 G2 G3
130 202 87
0 16 I 75 IIA 178 IIB 12 IIC 8 IIIA 1 IIIB 91 IIIC 24 IV 14 * AJCC 2009 Carlini – Roma - 2013
Laparoscopic colorectal surgery Esperienza Personale O.S.E. 419 casi
Early results 1 Conversioni 21 sconfinamenti neoplasia 4 anastomosi incomplete 1 perforazione vescica 3 emorragie Durata interventi
Media 90’
N. medio di linfonodi asportati
29 (6,9%)
Range 60’ – 205’
13.2 (range 0-35) Carlini – Roma - 2013
Laparoscopic colorectal surgery Esperienza Personale O.S.E. 419 casi
Early results 2 Complicazioni
49 (11,7%)
Generali
18
(4,3%)
Locali
31
(7,4%)
(4 polmoniti, 9 insuff. cardiorespiratorie, 1 ascite, 4 insuff renali)
(6 emorragie, 6 occlusioni, 2 sepsi, 11 deiscenze anastomosi, 6 stenosi anastom.)
Reinterventi (4 emorragie, 2 occlusioni, 4 deisc. anastomosi) Decessi (2 insuff. cardioresp., 1 sepsi, 1 infarto intestinale)
15 (3,6%) 4 (0,9%)
Carlini – Roma - 2013
Laparoscopic colorectal surgery Esperienza Personale - 419 casi
Late results Sopravvivenza (%)
100
74,3
80 60
72,8
40
VLS OPEN
20 0 0
12
24
36
48
60
Mesi
Overall survival (%) Ogni Stadio Carlini – Roma - 2013
Randomized Clinical Trials
Laparoscopic surgery for colorectal cancer Trials were initiated with the aim to answer the following questions: 1.What are the quantifiable benefits of laparoscopic surgery for colorectal cancer that make it worth the added cost, extended operating times and increased difficulty? 2.More importantly, is laparoscopic surgery oncologically safe? Carlini – Roma - 2013
Laparoscopic surgery for colorectal cancer
Laparoscopic surgery for colorectal cancer is difficult and challenging because of the multiple steps required for oncological radicality
Carlini – Roma - 2013
Laparoscopic surgery for colorectal cancer
Adoption of the technique was slow due to: • Lack of expertise • Limited instrumentation
Carlini – Roma - 2013
Laparoscopic surgery for colorectal cancer
Early enthusiasm was dampened by reports of
• Increased complication rates (8-59%)
• Uncertain oncological outcomes (port-site recurrences)
Carlini – Roma - 2013
Laparoscopic surgery for colorectal cancer Port-Site and Scar Recurrence The etiology is now clear.
It was due to uncorrect manipulation of the tumor with the laparoscopic instruments. This complication was described in the very early experiences but it was no longer detected in the most recent series. Carlini – Roma - 2013
Laparoscopic surgery for colorectal cancer
Port-site and wound recurrences In recent randomized trials were 0,1%, comparable to that of open surgery The early reports were technical inexperience
related
to
Kim SH: Dis Col Rectum 1998 Lacy AM: Surg Endosc 1998 Kaiser AM: J Laparoendosc Adv Surg Tech 2004
Carlini – Roma - 2013
Laparoscopic surgery for colorectal cancer
High-quality evidence in the past decade has confirmed the significant benefits of laparoscopic surgery over open laparotomy for colorectal cancer.
Carlini – Roma - 2013
Laparoscopic Surgery of Colon Cancer
Laparoscopic surgery for colon cancer Characteristics of RCTs comparing laparoscopic versus open resection for colon cancer RCT (years)
Institutions (numbers, location)
Trials LP
Pts OP
Type of patients included in trial
Braga 2002
Single center (IT)
136
133
Benign disease - colorectal
Lacy 2002
Single center (SP)
111
108
Non M+ colon cancers
Leung 2004
Single center (HK)
203
200
Only rectosigmoid cancers
COST 2004
Multicentre (48, N. Am)
435
428
Non M+ colon cancers
CLASICC 2005
Multicentre (27, UK)
526
268
Colon and rectal cancers
COLOR 2005
Multicentre (29,EU)
536
546
Non M+ colon cancers
Liang 2007
Single center (TW)
135
134
Only left-sided cancers
ALCCaS 2008
Multicentre (31,AU-NZ)
294
298
Non M+ colon cancers
Braga 2010
Single center (IT)
134
134
Only left-sided cancers
Carlini – Roma - 2013
Laparoscopic surgery for colon cancer Conversion rates RCT (years)
Conversion rate (%)
Braga
2002
5
Lacy Leung
2002 2004
11 15
COST
2004
21
CLASICC COLOR Liang
2005 2005 2007
25 17 3
ALCCaS Braga
2008 2010
15 5 Carlini – Roma - 2013
Laparoscopic surgery for colon cancer Conversion from laparoscopic to open Definitions Incision greater extraction
than
required
Premature abdominal incision dissection or vascular control
for for
specimen colorectal
Change in the intention from laparoscopic to open surgery. Carlini – Roma - 2013
Laparoscopic surgery for colon cancer Conversion from laparoscopic to open Reasons Tumour fixation or invasion Extensive adhesions Difficult visualization of important structures Surgeon lack of skill
Inability to complete surgery safely or oncologically Carlini – Roma - 2013
Laparoscopic surgery for colon cancer
Effect of the learning curve on conversion from laparoscopic to open approach Conversion rates decreased with operative experience: 38% conversion rate in the first year fell to 16% by year 6.
Carlini – Roma - 2013
Laparoscopic surgery for colon cancer Conversion from laparoscopic to open approach Conversion seems to have a negative impact on both short-term and long-term outcomes of laparoscopic colectomy patients. Converted patients suffered from increased intraoperative and postoperative complications, and prolonged hospital stay compared with laparoscopically completed patients
Survival was recurrence
worse
with
an
increased
local
Carlini – Roma - 2013
Laparoscopic surgery for colon cancer Conversion from laparoscopic to open Short-term outcomes of RCTs comparing laparoscopic versus open resection for colon cancer At the moment it seems that laparoscopic surgery, done at high volume centres may benefit from their lower conversion rates and expertise. Carlini – Roma - 2013
Laparoscopic versus open resection for colon cancer Short-term outcomes of RCTs
Intraoperative blood loss Better visualization in laparoscopy may be translated to decreased blood loss, significantly less by an average volume of 103.9 ml (P=0.008).
Carlini – Roma - 2013
Carlini – Roma - 2013
Laparoscopic versus open resection for colon cancer Short-term outcomes of RCTs RCT (year) Braga 2002 Lacy 2002 Leung 2004 COST 2004 CLASICC 2005 COLOR 2005 Liang 2007 ALCCaS 2008 Braga 2010
Surgery
Pain
Days to first bowel movement
Hospital stay (days)
Days to activity
LAP
NA
4.2
8
32.1
OP
NA
5.7
10
65.3
LAP
NA
2.3
5.2
NA
OP
NA
3.5
7.9
NA
LAP
4
4.0
8.2
30.5
OP
6
4.6
8.7
45.0
LAP
3
NA
5
NA
OP
4
NA
6
NA
LAP
NA
5
9
NA
OP
NA
6
9
NA
LAP
2
3.6
8.2
NA
OP
4
4.5
9.3
NA
LAP
3
2
9
28
OP
5
4
14
56
LAP
NA
4.4
7
NA
OP
NA
4.9
8
NA
LAP
NA
NA
7
NA
OP
NA
NA
8
NA
Laparoscopic versus open resection for colon cancer Short-term outcomes of RCTs The obvious benefit of laparoscopic surgery is the smaller incision The mean incision length ranged from 4.5 to 10.6 cm for laparoscopic versus laparotomy incisions of 17.4–22 cm, with the maximum differences in length of up to 17.5 cm.
Carlini – Roma - 2013
Laparoscopic versus open resection for colon cancer Short-term outcomes of RCTs Small incision = less pain and analgesia requirements Analgesic consumption was shown to be significantly reduced in the laparoscopic groups, by as much as 30% Less pain permits a faster return to normal lung function and reduce pulmonary complications
Carlini – Roma - 2013
Laparoscopic versus open resection for colon cancer Short-term outcomes of RCTs
Minimal exposure of visceral contents, less retraction and handling of bowel occur in laparoscopic surgery This decrease in operative trauma leads to rapid restoration of gastrointestinal motility
Carlini – Roma - 2013
Laparoscopic versus open resection for colon cancer Short-term outcomes of RCTs
Laparoscopy shortened the interval
to first peristalsis by 12 h to first passage of flatus by 28 h to first bowel movement by 30 h
Carlini – Roma - 2013
Laparoscopic versus open resection for colon cancer Short-term outcomes of RCTs
Time to oral intake from 0.7 to 2.7 days faster than open (P0.0001)
Carlini – Roma - 2013
Laparoscopic versus open resection for rectal cancer Short-term outcomes of RCTs
Intraoperative blood loss Better visualization in laparoscopy may be translated to decreased blood loss, significantly less by an average volume of 123.7 ml (P=0.0001)
Carlini – Roma - 2013
Laparoscopic versus open resection for rectal cancer Short-term outcomes of RCTs RCT (years) COREAN 2010 Ng 2009 Lujan 2009 Braga 2007 CLASICC 2005 Baik 2011 Park 2009 Laurent 2009 Strohlein 2008
Conversion rate % 12.0 30.3 7.9 9.8 7.2 34.0 11.1 15.1 21.9 Carlini – Roma - 2013
Laparoscopic versus open resection for rectal cancer Short-term outcomes of RCTs
There is fairly good evidence that the laparoscopic technique confers short-term benefits over open surgery
Faster post-operative recovery Significantly smaller incisions Less pain Earlier ambulation
Carlini – Roma - 2013
RCT (years) COREAN 2010 NG 2009 Lujan 2009 Braga 2007 CLASICC 2005 Baik 2011 Park 2009 Laurent 2009 Strohlein 2008
Surgery
Time to first bowel movement (days)
Hosp.stay (days)
LAP
4.0
8.0
OP
5.2
9.09
LAP
4.1
8.4
OP
4.7
10.3
LAP
NA
8.2
OP
NA
9.9
LAP
4.3
10.8
OP
6.3
11.5
LAP
NA
9.0
OP
NA
11.0
LAP
1.5
8.0
OP
2.7
13.3
LAP
3.0
6.0
OP
4.0
7.0
LA
NA
NA
OP
NA
NA
LAP
NA
9.0
OP
NA
16.0
Carlini – Roma - 2013
Laparoscopic versus open resection for rectal cancer Short-term outcomes of RCTs
Laparoscopic versus open resection for rectal cancer Short-term outcomes of RCTs
Shorter time to Stoma function (WMD 1.52 days) First bowel movement (WMD 0.72 days) Feeding solids (WMD 0.92 days) were significantly surgery
compared
with
open
Carlini – Roma - 2013
Laparoscopic versus open resection for rectal cancer Short-term outcomes of RCTs
Time to oral intake from 2.25 to 3.5 days faster than open (P
