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Laparoscopic surgery is safe and effective for rectal cancer: ongoing studies may confirm that the results of minimally invasive surgery are just as good as with open surgery.

Laparoscopic surgery--which is carried out through small incisions and guided by a viewing tube (laparoscope)--has been used to treat intestinal disorders for almost two decades. Its benefits are less postoperative pain, less scarring, and faster healing. A 2009 study has suggested that the minimally invasive approach can be as effective as traditional open surgery for treating rectal tumors, which occur in the last several inches of the colon.


LAPAROSCOPY UNDERUSED IN RECTAL CANCER. Laparoscopic rectal surgery also enables an earlier return to a normal oral diet, because normal colon function is re-established sooner than with open surgery, and hence a faster recovery with a shorter hospital stay.

In a study published in the July 2009 issue of Diseases of the Colon and Rectum, 95 percent of 103 rectal cancer patients whose tumors were removed via laparascope emerged with an intact and functioning rectum, and none had cancer-positive tumor margins (cancer cells at the edge of the tissue that has been removed). The patients received regular follow-up for five years, and overall survival remained high at 91 percent, with more than 73 percent of patients completely cancer-free.

Despite these promising findings, minimally invasive techniques haven't been considered the most ideal approach for dealing with rectal cancer, however. Rectal surgery, according to Jeffrey Milsom, MD, chief of colon and rectal surgery at NewYork-Presbyterian/Weill Cornell, and lead author of the study, is inherently more challenging than colon surgery. "The pelvic cavity, where the rectum lies, is a narrow space, making rectal tumors difficult to access," he explains. "Surgical success depends not only on the complete removal of the cancerous tumor and repair of the rectum, but also on restoring continence. For these reasons, rectal cancer has been a difficult arena in which to apply advances in minimally invasive surgery."

A NEW SURGICAL STANDARD. Initial reports of minimally invasive rectal cancer surgery also indicated a higher incidence of cancer-positive cells along the margins of tumors removed via laparascope, compared with open surgery. Early data suggested that as a result, more patients might experience a local recurrence of their rectal cancer after laparoscopic surgery. Dr. Milsom's study refutes this, but its small size, lack of randomization, and relatively short follow-up period all point to the need for large, randomized studies before its findings can be considered definitive.

Dr. Milsom's surgical team is now participating in two such studies, one in collaboration with the American College of Surgeons Oncology Group (ACSOG) and the other headed up by Sang Lee, MD, director of Weill Cornell's laparoscopic colon surgery course, and a key surgeon for Dr. Milsom's study. "In terms of cancer cure and recovery, these outcomes are at least as good as the best outcomes seen with open surgical techniques," says Dr. Lee. "When you add in all the advantages of laparoscopic surgery, it seems clear that this is an approach that could evolve to become the surgical standard."

JOHN MIGALY, MD, FACS, FASCRS, Assistant Professor of Surgery-Colon and Rectal Surgery, Division of General Surgery, Duke

A Challenging Surgery

"The benefits of laparoscopic colectomy for colon cancer have been demonstrated in multi-institutional randomized trials; however, outcomes and cancer-free survival for rectal cancer are closely related to surgeon experience and technique. Operating in the pelvis, which is a compact, narrow space, can be quite challenging, and applying a laparoscopic technique to the removal of these tumors is even more challenging. The evidence presented by Dr. Milsom's group is convincing, but it is limited by the fact that it is a single institution's experience. There is currently a multi-institutional, randomized trial examining the feasibility of laparoscopic rectal resections on a larger scale. Until further evidence is available, laparoscopic treatment of rectal cancer should be performed at high volume, specialized, tertiary or quaternary referral centers."

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Title Annotation:CANCER
Publication:Duke Medicine Health News
Date:Feb 1, 2010
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