In addition to the cosmetic benefits of having a smaller incision, patients who received the minimally invasive procedure, called laparoscopically assisted colectomy, also required one less day in the hospital, one less day on intravenous pain killers and one less day on oral pain killers.
The team cautions, though, that the procedure is only safe and effective if stringent surgical standards are followed.
"When we started this study we were concerned that the procedure itself could help the cancer spread, so we wanted to make sure it wasn't going to result in a bad outcome for our patients," says James W. Fleshman Jr., M.D., professor of surgery at the School of Medicine. "We found that, in the hands of an experienced surgeon, laparoscopically assisted colectomy is indeed an acceptable alternative for treating colon cancer. Now we have the task of defining who is an 'experienced surgeon.'"
Fleshman was a key contributor to the study, which was led by the Mayo Clinic. The results will be presented May 12 at the annual meeting of the American Society of Colon and Rectal Surgeons in Dallas and will be published in the May 13 issue of the New England Journal of Medicine.
About 100,000 Americans are diagnosed with colon cancer each year, and more than 90 percent of them require surgery. Typically, surgeons open the abdomen with a six-to-eight-inch incision and then cut away the portion of the colon containing cancer. During laparoscopically assisted colectomy, the same procedure is performed through three one-half-inch incisions and one two-inch incision.
The minimally invasive version has been performed since 1990, but some small studies suggested that patients who underwent laparoscopically assisted colectomy were more likely to have another bout of colon cancer or to develop cancer at or near the surgical incisions.
"Most patients ask for minimally invasive surgery because it's less painful and requires a smaller incision," Fleshman says. "But no one had rigorously evaluated the safety and effectiveness of the procedure."
So a group of American and Canadian colon surgeons did something rare in the medical field: They launched the first systematic study of the procedure and put a moratorium on laparoscopically assisted colectomy performed outside the scope of their study.
The team also enforced qualification requirements for the 66 surgeons who participated in the study, and established standardized operating procedures.
Patients in the study were randomly assigned to receive either standard or minimally invasive surgery and their progress was followed for eight years.
The team found that cancer returned to the colon or to the location of the surgical wound at almost the exact same rate in both groups of patients. The survival rate, overall survival and rates of complications also were nearly identical.
According to Fleshman, these positive results were due in large part to the study's stringent requirements. The research team has submitted a position statement for review by the American Society of Colon and Rectal Surgeons proposing that credentials for performing laparoscopically assisted colectomies should only be given to surgeons who meet specific qualifications and strictly adhere to standard operating procedures. At the moment, no such credentialing system exists.
All five Washington University colorectal surgeons already meet these criteria.
"Our plea is that the surgical community apply the same standard operating techniques known to safely remove cancer when they perform this less invasive procedure," Fleshman says.
Nelson H, Sargent DJ, Wieand S, Fleshman J, Anvari M, Stryker SJ, Beart RW, Hellinger M, Flanagan R, Peters W, Ota D. A comparison of laparoscopically assisted and open colectomy for colon cancer. New England Journal of Medicine, May 13, 2004.
Funding from the National Cancer Institute supported this research.
The full-time and volunteer faculty of Washington University School of Medicine are the physicians and surgeons of Barnes-Jewish and St. Louis Children's hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked second in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children's hospitals, the School of Medicine is linked to BJC HealthCare.
Journal
New England Journal of Medicine