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161
12 Colon Cancer: Advantages of the Laparoscopic Approach
to the same as open surgery. A detailed discussion of the oncological safety of
laparoscopic versus open colorectal surgery would warrant its own textbook.
Some key details can be summarized.
12.1.5.1 Port Site Recurrence
Several groups have demonstrated that modern laparoscopic techniques such as
wound protectors, controlled per port desuffl ation, and local cytocidal agents have
controlled this problem. The Italian registry group 2002 reported an incidence of
0.9% in 1,753 cancers [
31 ] . Wexner in 2001 reported an incidence of 1% in 1,737
reported cases [ 32 ] . The CLASSICC trial reported a stable 2.4% port site recurrence
risk after 5 years follow-up [ 2 ] .
12.1.5.2 Local Recurrence
One of the great safety concerns of any form of cancer surgery is local recurrence
(LR). Reviewing the available meta-analysis data for local recurrence, 1,987 patients
were analyzable for LR, revealing an overall rate of 5.2% for the laparoscopic group
versus 5.3% in the open group [ 33 ] . A subgroup analysis examining colonic disease
(930 cases) showed the local recurrence rate was 5.2% laparoscopically versus 5.6%
open, and rectal subgroup analysis (714 patients) revealed a rate of 7.2% for laparos-
copy versus 7.7% open. The initial fears expressed by the fi rst reporting of the
CLASSICC of a trend toward higher local recurrence in upper rectal cancers have
not materialized in subsequent long-term follow-up of the CLASSICC trial patients.
12.1.5.3 General Oncological Outcomes
The wider oncological outcomes of laparoscopic colorectal surgery have been widely
studied. The transatlantic trials group, consisting of prominent members of the
CLASSICC, COLOR, and COST trials, analyzed their combined data in 2007 and
concluded that there were no oncological differences between the two groups [ 34 ] .
12.1.5.4 Mortality
Overall mortality for both laparoscopic and open groups as analyzed by the Cochrane
database is approximately 1% with no signifi cant difference between laparoscopic
and conventional groups. Again, this probably represents the bias of randomized
controlled trials as this is considerably better than the NBOCAP reported rate in the
United Kingdom.
We can therefore state that the morbidity advantage to laparoscopic surgery does
not, as yet, manifest itself as improved mortality.
162
H.J. Gallagher and S.E. Noblett
12.1.5.5 Conclusion
In conclusion, therefore, there is high-level evidence that laparoscopic surgery con-
fers superior overall morbidity, superior wound morbidity, and improved pain
control.
Laparoscopic surgery is equivalent to open surgery in overall mortality, local
recurrence, oncological outcomes, adhesions, and cardiorespiratory and thrombotic
complications. Early concerns over anastomotic leak rates are now allayed.
One of the most striking facts is the dramatic reduction in wound infections asso-
ciated with the laparoscopic approach. With the current targeting of wound infec-
tion risks, particularly MRSA infection by the Department of Health, this confers a
considerable benefi t to laparoscopic versus the open approach.
While the risk profi les are less well established in laparoscopic versus open rec-
tal surgery, there is no evidence of any increased safety risk to the patients by the
laparoscopic approach.
12.2 Enhanced Recovery After Surgery
12.2.1 Introduction
The stress response to trauma was fi rst described by Cuthbertson, who established
the link between trauma and altered tissue metabolism, describing a posttraumatic
catabolic state and rise in oxygen consumption [ 35 ] . Over the next decades, causal
factors were sought, and the neuroendocrine response to injury was identifi ed. The
discovery of increased glucocorticoid release following trauma implicated the major
role of the hypothalamo-pituitary axis in the response to stress. Subsequently, the
role of the sympathetic nervous system in the physiological response to surgical
trauma was established [ 36 ] .
Following major surgical procedures, there is a functional deterioration and
increased risk of morbidity due to several pathogenic factors. There are increased
cardiac demands and oxygen consumption often combined with impaired pulmo-
nary function, coagulation/fi brinolysis alterations, increased catabolism, sleep dis-
turbance, and ileus, which can all lead to considerable organ dysfunction. The use
of nasogastric tubes, drains, urinary catheters, and prolonged fasting may contribute
to immobility and morbidity.
Armed with this greater understanding of surgical physiology, over the past
decade regimens have been developed and introduced to improve postoperative
recovery. The principle behind these programs is to employ a multimodal approach
to perioperative care. This aims to modify the stress response to surgical trauma by
retaining the benefi cial effects (wound healing and resolution of infl ammation)
while attenuating the more undesirable effects. In addition to this, many traditional
163
12 Colon Cancer: Advantages of the Laparoscopic Approach
approaches to surgical care have been challenged. Numerous studies have been
carried out investigating these factors independently, and it is now increasingly rec-
ognized that employing a regimen to “optimize” these aspects of perioperative care
has a signifi cant and cumulative benefi t on patient outcome.
12.2.2 ERAS Components: Tradition Versus Evidence-Based
Medicine
There are many published ERAS programs, and most share the same principles of
care. Table 12.2 summarizes the ERAS protocol used by the colorectal surgery
departments within the Newcastle Upon Tyne NHS trust. Initially, acceptance of
many of these components was slow as evidence-based medicine challenged tradi-
tional surgical practice. The body of evidence is ever increasing; the main aspects of
the ERAS regimen together with evidence from randomized controlled trials and
meta-analyses have been summarized.
Table 12.2 Summary of the ERAS protocol used by the Colorectal Surgery Departments within
the Newcastle upon Tyne NHS Trust
Time Procedure
Pre-operative
Informed consent
Discuss programme and anticipated discharge
with patient and next of kin
Anaesthetic pre-assessment
Community stoma education (if necessary)
Day of surgery Day of surgery admission
Carbohydrate supplement
Enema (if left-sided/rectal resection)
Intraoperative Laparoscopic resection
Epidural analgesia
Active warming
Fluid optimisation
No NG tubes or abdominal drains
Postoperative Early mobilisation (out of bed for 8+ h from day 1
and short walks on ward)
No restriction to enteral intake
High protein supplement drinks
Switch to oral analgesia at 48 h
Urinary catheter removed at earliest point (patient
mobile/epidural disconnected)
Discharge Discharge criteria met
Information leafl et to patient
Follow-up plan
164
H.J. Gallagher and S.E. Noblett
12.2.2.1 Education
Many patients and their families will have preconceived expectations of their periop-
erative management, largely based on previous experience of family/friends and
media portrayal. It is important that both patients and their carers/next of kin are aware
of the aims of the enhanced recovery program, i.e., enhancing recovery not simply
freeing up beds! It is useful to give a brief summary of what the patient will experience
as part of the preoperative counseling, and written information should be provided,
explaining both the preoperative and in-hospital program and discharge advice.
12.2.2.2 Preassessment
It is well recognized that other comorbidities have a direct effect on the develop-
ment of complications, outcome, and hospital stay postsurgery [
37 ] . Patients should
have preoperative assessment and optimization of any coexisting illness prior to
admission for their surgical procedure.
12.2.2.3 Bowel Preparation
Traditionally, patients have received full colonic bowel preparation prior to elective
colon and rectal resection. A recent meta-analysis of almost 5,000 patients under-
going colonic resection showed there was no increase in anastomotic leak rate with
the omission of mechanical bowel preparation (MBP) [ 38 ] . The study did show
however an increase in deep abdominal abscesses with omitted MBP, the number
needed to harm was 333 patients, and thus this was not felt to be clinically signifi -
cant, particularly in the context of other harmful effects of MBP such as fl uid and
electrolyte disturbance [ 39 ] . A Cochrane review (4,821 patients) looking at MBP
versus no MBP in both colon and rectal surgery found no signifi cant difference in
anastomotic leak, mortality, peritonitis, need for reoperation, or wound infection
and concluded that there is no evidence that MBP improves the outcome for patients
[ 40 ] . The ACPGBI guidelines for the management of patients with colorectal can-
cer advise that bowel preparation should not be routinely used before colorectal
cancer resection [ 41 ] .
12.2.2.4 Carbohydrate Loading
The need for the strict “nil-by-mouth from midnight” rule has been revised, and
current recommendations are more liberal without putting the patient at increased
risk, and may also be of considerable benefi t.
Following surgical trauma, there is a reduction in the effects of insulin and a
compensatory rise in insulin release. Insulin resistance has been shown to be an
independent predictive factor for length of postoperative hospital stay [ 42 ] . The
165
12 Colon Cancer: Advantages of the Laparoscopic Approach
postoperative catabolic state is also associated with loss of body fat and protein
stores. The fasted state at the time of operation represents an additional metabolic
stress to the patient.
Studies altering the anabolic/catabolic milieu using preoperative intravenous
glucose have shown reduced nitrogen losses immediately following surgery [
43 ] ,
while the infusion of glucose, potassium, and insulin before cardiac surgery has been
reported to reduce morbidity and hospital stay [ 44 ] . A near-isotonic carbohydrate-
rich beverage (12.5% carbohydrate but only 285 mOsm) composed of maltodextrin
in water has been shown to be safe, reduce postoperative insulin resistance, and
enhance recovery after surgery [ 45, 46 ] .
12.2.2.5 Incision
Long abdominal incisions cause pain and can reduce ambulation and forced cough
with clearance of secretions and can lengthen recovery time following major
abdominal surgery and is one of the advantages of the laparoscopic approach. In
conventional open surgery, reducing incision morbidity can be achieved. The lim-
ited transverse skin crease incision for right hemicolectomy has been shown to
reduce recovery time and length of stay compared to midline vertical wounds [ 47 ] .
Similar results have been shown with a left minilaparotomy skin crease incision for
left-sided tumors [ 48 ] .
12.2.2.6 Fluids
General surgical fl uid management is discussed elsewhere in this book. In terms of
enhanced recovery, the aim of fl uid therapy is to avoid tissue hypoperfusion, activa-
tion of the SIRS response, and organ dysfunction and, at the same time, prevent
fl uid overload with its subsequent complications. A proactive approach with goal-
directed perioperative fl uid therapy based on fl ow parameters allows patients to
achieve their individual optimized hydration state. Goal-directed optimization regi-
mens have been shown to signifi cantly reduce morbidity and shorten hospital stay
following major surgery [ 49– 51 ] .
12.2.2.7 Heat Loss
Intraoperative heat loss may be a stimulating factor in the surgical stress response,
as in an attempt to maintain body temperature there is an increase in oxygen con-
sumption and catabolic hormone release [ 52 ] . Therefore, efforts to prevent hypo-
thermia should always be made. It has been shown in patients undergoing colonic
surgery that preventing intraoperative hypothermia leads to a reduction in the inci-
dence of wound infection [ 53 ] .
166
H.J. Gallagher and S.E. Noblett
12.2.2.8 Drains and Tubes
Routine use of nasogastric tubes is not necessary following abdominal surgery and
may delay oral intake, prolong ileus, and be a risk factor for postoperative pneumo-
nia [
54 ] . Routine placement of abdominal drains following elective colorectal resec-
tion is not recommended based on evidence from randomized controlled trials and
subsequent meta-analysis showing no benefi t from drainage [
55, 56 ] . Rectal resec-
tions are associated with transient lower urinary tract dysfunction which may require
catheter drainage, use of suprapubic catheter for temporary drainage may be indi-
cated after pelvic dissections as they are safe and effective and allow assessment of
residual urine volumes prior to removal, and patients may be discharged from hos-
pital with the catheter in situ.
12.2.2.9 Feeding
Early enteral nutrition is important to help combat loss of muscle strength and
weight, which contributes to postoperative fatigue. Early nutrition has been shown
to be well tolerated and contribute to minimal postoperative insulin resistance and
nitrogen losses [ 57, 58 ] .
12.2.2.10 Pharmacotherapy
Postoperative ileus and gastrointestinal dysfunction represents one of the greatest
delaying factors in surgical recovery. Many of the components of the ERAS pro-
grams have a signifi cant positive effect on GI function. A novel breakthrough in the
treatment of postoperative ileus is an orally administered selective peripherally act-
ing m -opioid antagonist, Alvimopan. Trials have shown enhanced recovery of bowel
function following open abdominal surgery [ 59 ] . The cumulative benefi t however,
when combined with laparoscopic surgery and ERAS programs, is yet to be
established.
12.2.3 ERAS in Practice
Many units worldwide have now reported their experiences with enhanced recovery
or fast-track programs in a variety of surgical specialties. While colorectal surgery
remains one of the largest specialties to employ such regimens, patient benefi ts have
also been reported in aortic aneurysm surgery, prostate surgery, pancreaticoduo-
denectomy, and liver resection [ 60– 62 ] .
Established fast-track units have achieved median postoperative hospital stays
of 2 days following colonic resection [ 63 ] ; indeed, the combination of laparoscopic
167
12 Colon Cancer: Advantages of the Laparoscopic Approach
resection and an enhanced recovery protocol has resulted in a series of 23-h stay
colectomies being reported [ 64 ] . Meta-analysis of randomized controlled trial com-
paring enhanced recovery protocols with standard perioperative care has shown
reduced morbidity and hospital stay with the ERAS program without any increase
in readmission rates [
65 ] . A tendency exists to select patients for the ERAS pro-
gram, focusing particularly on the younger patient cohort. The elderly and frail
however often have less reserve to cope with surgical stress and morbidity, and
thus, they may benefi t more from the ERAS program; certainly, feasibility and
positive outcome has been confi rmed in patients of increasing age/signifi cant
comorbidity [
66 ] .
Despite increasing evidence highlighting the effi cacy and safety of ERAS pro-
grams, uptake has been slow. The relative contribution of each single element of the
program is uncertain, and the largest benefi ts are seen when the programs are com-
prehensive, incorporating all elements. A team approach is required for a successful
program, with a dedicated and motivated anesthetist, surgeon, dietician, physio-
therapist, and nursing staff. Comprehensive discharge planning is also an essential
requirement, particularly with regard to involvement of social services for antici-
pated convalescence placement or timely reestablishment of care packages. Simply
having a protocol in place is insuffi cient to ensure a successful program; without
motivated staff working toward complete protocol compliance, optimum results are
not achieved [ 67 ] . With a well-designed protocol and a multidisciplinary team
approach, ERAS programs can be successfully introduced, leading to signifi cant
reductions in morbidity, gastrointestinal dysfunction, faster patient recovery, and a
shorter hospital stay.
Key Points
Laparoscopic Versus Open Surgery
High-level evidence that laparoscopic surgery confers:•
Superior overall morbidity –
Superior wound morbidity –
Improved pain control –
Laparoscopic surgery is equivalent to open surgery in:•
Overall mortality –
Local recurrence –
Oncological outcomes –
Adhesions –
Cardiorespiratory complications –
Thrombotic complications –
Early concerns over anastomotic leak rates are now allayed. •
ERAS
See Table • 12.2
168
H.J. Gallagher and S.E. Noblett
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