A decade-long study comparing conventional colon cancer surgery with “keyhole” surgery found identical success rates, disproving fears that tumors would be more likely to return if surgeons did not open up the patient’s belly for a full view.
In conventional surgery, doctors remove a cancerous colon segment through an eight-inch cut down the abdomen. In keyhole, or laparascopic, surgery, they operate with a laparoscope, or tiny video camera, and miniaturized surgical instruments that are inserted through half-inch incisions. The diseased section of colon is removed through a two-inch cut.
The biggest comparison of the two procedures to date, involving 48 U.S. and Canadian hospitals, found the same rates of survival, tumor recurrence and surgical complications. In addition, patients who had laparascopic surgery had less pain and less time in the hospital.
Experts predicted the results will end the virtual moratorium on such surgery that began in 1994 because of spotty evidence that tumors returned in up to 21 percent of patients getting laparoscopic procedures — much more frequently than with open surgery.
The study was funded by the National Cancer Institute and published in Thursday’s New England Journal of Medicine.
“Now we can say it’s safe, it’s effective and it’s beneficial for patients with colon cancer,” said lead researcher Dr. Heidi Nelson, chairwoman of colon and rectal surgery at the Mayo Clinic in Rochester, Minn. “Patients recovered faster with fewer days in the hospital and fewer days on painkillers.”
She said the laparoscopic procedure and the much smaller scars it leaves are less intimidating to many patients.
About 100,000 colon cancer operations are performed in this country each year.
Popularity of 'keyhole' surgeries expected to grow
Nelson and other experts predict the laparoscopic surgery now will be performed more frequently.
However, surgeons trained more than a decade ago first must learn the more-difficult laparoscopic technique, which requires lots of practice.
“I don’t see an immediate boom,” said Dr. Philip B. Paty, a colorectal surgeon at Memorial Sloan-Kettering Cancer Center in New York.
In addition, the technique is appropriate only when the tumor is easily reached with laparoscopic instruments and has not spread widely to nearby organs and lymph nodes.
Still, Paty hailed the study, because it included 66 surgeons across North America, showing good results can be achieved in many hospitals.
In an accompanying editorial, Drs. Theodore Pappas and Danny Jacobs of Duke University said cancer surgeons now are deciding whether to endorse laparoscopic procedures for cancer of the liver, pancreas, stomach and esophagus.
The study involved 872 patients. Half were randomly chosen for the laparoscopic procedure, while the rest got open surgery, with strikingly similar results.
Complications, such as wound infections and bleeding, occurred in 21 percent getting laparoscopy and 20 percent getting open surgery, while 86 percent of patients getting the laparoscopic procedure and 85 percent getting open surgery were alive three years later. Cancer returned in 16 percent of patients getting laparoscopy, versus 18 percent getting open surgery.
Also, patients getting laparoscopic surgery needed intravenous narcotics and pain pills about two days less and went home a day earlier.
The patients all had potentially curable cancer. Forty-eight of the laparoscopic patients and 61 of the open surgery patients died of cancer within 4½ years.
Paty said the study’s only weakness was that 21 percent of patients slated for the laparoscopic surgery had to be switched to open surgery during the procedure because of problems such as the cancer having spread more than doctors thought.
Surgeons first tried laparoscopic surgery on colon cancer in 1990, after it became popular for removing the appendix and gallbladder. Most stopped voluntarily a few years later, at the urging of major medical organizations, because of some poor results.
In both types of colon cancer surgery, the diseased section and some adjacent lymph nodes are cut out, and the two ends are sewn together.
If a laboratory examination of the lymph nodes finds cancer, the patient is usually given chemotherapy.