Looking Through the Keyhole
Colon cancer is the third most common cancer afflicting men and women alike. It's a challenging disease to live with and treat, but now its sufferers have a new alternative to standard open surgery. In a Mayo Clinic study reported in the New England Journal of Medicine last year, researchers demonstrated that "keyhole" laparoscopic surgery was as safe and effective as more invasive, or "open," operations for most people with colon cancer. The National Cancer Institute (NCI) funded this comparison study as a top priority clinical research project. Colon cancer surgery involves removing the diseased part of the colon and reattaching the healthy segments. With laparoscopic surgery, instead of doing this through a major incision, surgeons make several small "keyhole" incisions through which they insert a tiny camera and miniature surgical instruments, such as scissors and graspers. They manipulate the instruments based on images passed from the camera to a monitor in the operating room. According to Heidi Nelson, MD, a colorectal surgeon at the Mayo Clinic and chief author of the study, survival rates, tumor recurrence and complications are virtually identical with open and laparoscopic surgery. However, the laparoscopic procedure offers more quality-of-life advantages to patients. As with all laparoscopic procedures, for people with colon cancer, less invasive surgery translates to a less traumatic experience overall -- less postoperative pain, less pain medication, a faster recovery and the chance to go home a day or two earlier. After healing, instead of a six- to eight-inch vertical scar, a person is left with several smaller, less noticeable horizontal scars. Laparoscopic surgery for colon cancer was introduced in 1991, after being used in gallbladder and appendix operations in the 1980s. In 1994, performances of the procedure ground to a virtual halt due to widespread concerns: Surgeons could not remove all the cancer with this procedure... tumors cells would be disturbed... and there would be higher rates of recurrence. The seven-year international study put these concerns to rest, says Dr. Nelson. She and her colleagues at 48 hospitals in the US and Canada randomly assigned 872 people with colon cancer to undergo either standard or laparoscopic surgery. The study excluded patients with late-stage or metastatic cancer that had spread to other organs... extensive scarring from previous surgery... or rectal cancers or tumors in the mid-portion of the colon. Laparoscopic surgery is not for everyone. Very large tumors cannot be removed through a keyhole. Open procedures remain a better alternative when cancer spreads, to make sure the surgeon removes it all... and it is not possible to use laparoscopic surgery with hard-to-reach cancers. Dr. Nelson summarized the findings. Researchers found...
*A virtually identical survival rate -- 86% of laparoscopic patients were alive three years after surgery, as compared with 85% who underwent standard surgery.
*Almost exactly the same rate of colon cancer recurrence in both groups. Cancer recurred in 872 patients, 76 who underwent laparoscopic surgery and 84 who had the standard operation.
*Similar rates of complications during surgery and for 30 days afterward.
*A longer operation with the laparoscopic procedure (150 minutes compared with 95 minutes for the open operation), involving two or three quarter- to half-inch incisions and one two-inch incision, as opposed to one incision of six to eight inches or longer.
*A shorter hospital stay for laparoscopic patients (an average of four to five days instead of five to eight).
*Less pain following laparoscopic surgery, so less pain medication (three days versus four days of intravenous medication, and one day versus two of oral pain relievers).
*A quicker recovery overall with laparoscopic surgery -- one month rather than the usual six to eight weeks.
Laparoscopic surgery is more technically challenging than the standard open procedure, and it demands considerably more skill and experience. Dr. Nelson rates it as nine out of 10 on a scale of difficulty and complexity. Surgeons who participated in the study were required to have performed at least 20 laparoscopic colon surgeries. They also had to remain on their toes: In one out of five laparoscopic procedures, circumstances such as an unexpectedly large tumor compelled surgeons to change plans and perform open surgery. If you are considering this option, it is a good idea to interview potential surgeons first. Ask how familiar they are with the procedure, how many laparoscopic colon procedures they perform each year and where their training took place. If you are uncomfortable with any of the answers, move on to another surgeon. For more information, visit the Web site of the American Society of Colon and Rectal Surgeons at www.fascrs.org. Dr. Nelson anticipates that as a result of the national study, more surgeons will gain skill and experience in this procedure, and laparoscopic surgery for colon cancer will become more widely available. At present, laparoscopic procedures comprise only 10% of all colon cancer surgeries, but projections are that in time they will rise to 60%. At Mayo Clinic, the percentage already stands between 35% and 40%. This follows a trend that already has occurred with gallbladder operations, 90% of which are now performed laparoscopically. Minimally invasive surgical approaches are now a focus in medical schools -- and that is good news for all of us who might face surgery one day.