The purpose of this study was to demonstrate the feasibility and safety of laparoscopic-assisted anterior resection (LAAR) for colorectal cancer in a local Asian population.
This is a retrospective review of all patients with colorectal cancer operated from November 2017 to October 2018. Main variables of interest were demography, type and surgery, length of stay (LOS), and the involvement of proximal and distal doughnut. Postoperative complications were analysed using chi-square or Fisher exact and Mann-Whitney tests.
There were 23 patients with a mean age of 62.5 ± 12.2 years. The mean time from diagnosis to surgery was 97.1 ± 154.84 days. There were 12 patients in the LAAR group and 11 in the open anterior resection (OAR) group. Duration of surgery was shorter in OAR (129.58 ± 51.38 minutes) compared to LAAR (147.91 ± 39.37 minutes). Mean LOS was shorter in the LAAR group with 5±1.5 days compared to the OAR group of 7.42 ± 4.25 days. However, there was no significant P-value for both duration of surgery (P = 0.322) or LOS (P = 0.87). A total of 3 complications were recorded after OAR and 2 after LAAR. Both groups had clear proximal and distal margins with 16 (12–18.5) harvested lymph nodes in LAAR and 18 (16–22) in OAR, which were equal (P = 0.155).
This study reports a shorter LOS in the minimally invasive group of 2 days with similar oncologic resection outcomes. This shows that LAAR is feasible in Malaysia and has potential outcome benefits.
Since the advent of laparoscopic colonic resections 2 decades ago, advances in technology have allowed more complex colorectal surgeries to be performed laparoscopically [
This is a retrospective review of all patients who were diagnosed with sigmoid, rectosigmoid, upper rectal, or midrectal cancer undergoing elective LAAR or OAR at the Hospital Sultanah Aminah Colorectal Surgery Unit, Malaysia between October 2017 and November 2018.
All patients were examined with a colonoscopy, confirmed positive histology results of colorectal cancer, contrast computed tomography (CT) scan of thorax, abdomen, and pelvis for staging prior to surgery. After these examinations were performed, the results were evaluated by the colorectal consultant surgeon and the decision for upfront surgery or neo-adjuvant chemotherapy was made. Generally, preoperative chemotherapy was given to patients with fixed T4 disease. Laparoscopic resections were performed based on (1) the anticipated difficulty during laparoscopic surgery due to previous abdominal surgeries; (2) evidence of possible tumor infiltration to surrounding organs on the contrast CT scan and (3) the choice and preference of the patient. The surgical approach was decided by the surgeon and patient after understanding the risks and benefits of each procedure. The study was conducted in compliance with the ethical principles outlined in the Declaration of Helsinki and Malaysian Good Clinical Practice Guideline. Permission from the local Institutional Review Board, the hospital director and head of the Department of General Surgery was obtained prior to the collection of data. Ethical approval was granted by the Ministry of Health Malaysia Medical Research Ethics Committee (KKM/NIHSEC/P19-2163). As patient data were collected anonymously, informed consent was waived and not required. A flowchart showing inclusion and exclusion criteria is presented in
Surgical resections were classified as OAR or LAAR. The majority of the surgeries were performed by the sole consultant colorectal surgeon and the remainder of cases by the colorectal fellow in training under direct supervision. There have been numerous publications describing the operative technique for OAR and LAAR [
In our centre, there is a strict adherence to the enhance recovery after surgery protocol [
Parameters of interest were divided into patient demography, operative/postoperative details and histopathology variables. Patient demography included patients age, sex, race, source of referral, chief complaint, comorbidities, and any family history of colonic cancer. Operative/postoperative details were mean duration of surgery, length of stay, and postoperative complications. Histopathology variables of interest were type of cancer, tumor differentiation, lymphatic invasion, proximal, distal, and circumferential margin.
Data were analysed using SPSS ver. 16.0 (SPSS Inc, Chicago, IL, USA). All continuous variables were expressed as median with interquartile range and categorical variables were expressed as frequencies and percentages. Each variable was tested for differences between OAR and LAAR using univariate analysis. Categorical data were analysed with chi-square or Fisher exact tests when more than 20% of cells had expected frequencies <5 and continuous variables were analysed with the Mann-Whitney test. All P-values less than 0.05 were considered statistically significant.
In a 1-year period, we identified 23 patients which were included in this study and were predominantly male (69.6%) with a mean age of 62.5 ± 12.2 years. Open surgery was performed in 12 patients (52.2%) and 11 patients (47.8%) underwent LAAR. Comparisons of demographic and preoperative details between open and laparoscopic anterior resection are presented in
Comparison of surgery details revealed no statistical significance in the parameters of interest as seen in
Histologic details also revealed no statistical significance in a comparison of major parameters (
Colorectal cancer is the third leading cause of death in Malaysia and is the commonest cancer in both females and males in the developed nations of Europe, America, Asia, and Australia [
From our audit, we found that there were equivalent oncologic outcomes in both the laparoscopic and OAR group. From the histopathological results, tumor margin length (proximal and distal) and circumferential radial margin were almost identical in both the laparoscopic and open groups. All patients had a complete histopathological report. This result is similar to multiple studies and laparoscopic surgery is feasible with good surgical training in colorectal subspecialty [
As of 2013, the incidence and mortality rates of colorectal cancer in Malaysia were 21.3 and 9.79 cases per 100,000 residents [
This is a retrospective audit which is liable to have missing data and bias as patient selection were not standardized. Our hospital still relies heavily on handwritten clinical notes; therefore, another reason for missing data or misinterpretation was due to poor handwriting. To overcome this, the sample population from the colorectal surgery database was only from 1 year (October 2017 to November 2018). The colorectal consultant and operating surgeon responsible for the majority of these cases prior to data entry was consulted if any clinical data were in doubt. Other notable limitations were the exclusion of patients who were converted to open surgery. These data were not captured as the main objective in this study was to compare the outcomes of open and laparoscopic anterior resection.
In conclusion, this retrospective audit suggests laparoscopic anterior resection is feasible in a local Malaysian colorectal surgery unit. The observed benefits were a shorter length of stay with equivalent oncologic results. This result is similar to those of other international studies. The results are valuable data and laparoscopic anterior resection should be offered to patients who fit the eligibility criteria in a well-trained colorectal surgery centre. In light of this data, we hope that this paper may create more awareness of laparoscopic colorectal surgery in Malaysia.
No potential conflict of interest relevant to this article was reported.
Full acknowledgments are given to the colorectal coordinating nurse, Hidaryati Md Bamuchi, for dedicated data collection.
Flow chart showing the inclusion and exclusion criteria for patient selection. HPE, histopathology examination.
Comparison of demographic and preoperative details of open and laparoscopic surgery
Variable | Total (n = 23) | OAR (n = 12) | LAAR (n = 11) | P-value |
---|---|---|---|---|
Age (yr) | 62.5 ± 12.2 | 60.92 ± 10.98 | 64.27 ± 13.71 | 0.504 |
Sex | 0.554 | |||
Male | 16 (69.6) | 9 (75) | 7 (63.3) | |
Female | 7 (30.4) | 3 (25) | 4 (36.4) | |
Race | 0.555 | |||
Malay | 11 (47.8) | 7 (58.3) | 4 (36.4) | |
Chinese | 10 (43.5) | 4 (33.3) | 6 (54.5) | |
Indian | 2 (8.7) | 1 (8.3) | 1 (9.1) | |
Source of referral | 0.792 | |||
Primary health clinic | 10 (43.5) | 6 (50) | 4 (36.4) | |
District hospital | 2 (8.7) | 1 (8.3) | 1 (9.1) | |
Tertiary hospital | 4 (17.4) | 2 (16.7) | 2 (18.2) | |
Private hospital | 3 (13) | 2 (16.7) | 1 (9.1) | |
Intradepartment | 4 (17.4) | 1 (8.3) | 3 (27.3) | |
Symptoms | ||||
Rectal bleed | 18 (78.3) | 9 (75) | 9 (81.8) | 0.692 |
Abdominal pain | 5 (21.7) | 2 (16.7) | 3 (27.3) | 0.538 |
Diarrhoea | 4 (17.4) | 3 (25) | 1 (9.1) | 0.315 |
Constipation | 9 (39.1) | 4 (33.3) | 5 (45.5) | 0.552 |
Loss of weight | 14 (60.9) | 9 (75) | 5 (45.5) | 0.147 |
Loss of appetite | 14 (60.9) | 9 (75) | 5 (45.5) | 0.147 |
Abdominal distension | 1 (4.3) | 1 (8.3) | 0 (0) | 0.328 |
Abdominal mass | 1 (4.3) | 1 (8.3) | 0 (0) | 0.286 |
Tenesmus | 1 (4.3) | 0 (0) | 1 (9.1) | 0.286 |
CEA (ng/mL) | 7.9 ± 12.4 | 7.78 ± 10.45 | 8.03 ± 14.85 | 0.991 |
Comorbidities | ||||
Diabetes | 7 (30.4) | 3 (25) | 4 (36.4) | 0.554 |
Hypertension | 11 (47.8) | 5 (47.7) | 6 (54.5) | 0.537 |
Cardiovascular disease | 2 (8.7) | 1 (8.3) | 1 (9.1) | 0.949 |
Respiratory disease | 3 (13) | 1 (8.3) | 2 (18.2) | 0.484 |
Others | 5 (21.7) | 3 (25) | 2 (18.2) | 0.692 |
Smoking | 5 (21.7) | 4 (33.3) | 1 (9.1) | 0.159 |
Family history of colonic cancer | 5 (21.7) | 2 (16.7) | 3 (27.3) | 0.538 |
Values are presented as mean ± standard deviation or number (%).
OAR, open anterior resection; LAAR, laparoscopic-assisted anterior resection; CEA, carcinoembryonic antigen.
Comparison of surgery details of laparoscopic-assisted and open anterior resection
Variable | Total (n = 23) | OAR (n = 12) | LAAR (n = 11) | P-value |
---|---|---|---|---|
Time from first visit to surgery (day) | 97.09 ± 154.84 | 77.83 ± 90.34 | 118.1 ± 205.98 | 0.195 |
Time of surgery (min) | 138.35 ± 45.96 | 129.58 ± 51.38 | 147.91 ± 39.37 | 0.322 |
Primary surgeon | ||||
Colorectal surgeon | 20 (87) | 11 (91.7) | 9 (81.8) | |
Colorectal trainee | 3 (13) | 1 (8.3) | 2 (18.2) | |
No. of intraoperative assistants | 2.2 ± 0.6 | 2.1 ± 0.6 | 2.2 ± 0.6 | |
Level of assistants | ||||
Surgeon | 13 (56.5) | 6 (50) | 7 (63.6) | |
Surgeon in gazettement | 9 (39.1) | 3 (25) | 6 (54.5) | |
Registrar | 13 (56.5) | 6 (50) | 7 (63.6) | |
Medical officer | 14 (60.9) | 8 (66.7) | 6 (54.5) | |
House officer | 4 (17.4) | 2 (16.7) | 2 (18.2) |
Values are presented as mean ± standard deviation or number (%).
OAR, open anterior resection; LAAR, laparoscopic-assisted anterior resection.
Postoperative outcomes
Variable | Total (n = 23) | OAR (n = 12) | LAAR (n = 11) | P-value |
---|---|---|---|---|
Length of stay (day) | 6.26 ± 3.41 | 7.42 ± 4.25 | 5.00 ± 1.55 | 0.87 |
Postoperative readmission | 4 (17.4) | 2 (16.7) | 2 (18.2) | |
Days to readmission | 27 ± 14.5 | 12 ± 7.07 | 17 ± 14.14 | 0.924 |
Complications | 5 (51.7) | 3 (25) | 2 (18.2) | |
Anastomotic leak | 2 (8.7) | 2 (16.7) | 0 (0) | |
Superficial surgical site infection | 1 (4.3) | 0 (0) | 1 (9.1) | |
Deep surgical site infection | 1 (4.3) | 1 (8.3) | 0 (0) | |
Enterocutaneous Fistula | 1 (4.3) | 0 (0) | 1 (9.1) |
Values are presented as mean ± standard deviation or number (%).
OAR, open anterior resection; LAAR, laparoscopic-assisted anterior resection.
Histopathological details
Variable | Total (n = 23) | OAR (n = 12) | LAAR (n = 11) | P-value |
---|---|---|---|---|
Tumor location | ||||
Sigmoid colon | 8 (34.8) | 4 (33.3) | 4 (36.4) | |
Rectosigmoid junction | 2 (8.7) | 1 (8.3) | 1 (9.1) | |
Upper rectum | 11 (47.8) | 5 (41.7) | 6 (54.5) | 0.399 |
Mid rectum | 1 (4.3) | 1 (8.3) | 0 (0) | |
Lower rectum | 1 (4.3) | 1 (8.3) | 0 (0) | |
Adenocarcinoma | 23 (100) | 12 (100) | 11 (100) | |
Tumor differentiation | 0.283 | |||
Well | 6 (26.1) | 2 (16.7) | 4 (36.4) | |
Moderate | 17 (73.1) | 10 (83.3) | 7 (63.6) | |
Poor | 0 (0) | 0 (0) | 0 (0) | |
Lymphatic invasion | 0.469 | |||
Yes | 8 (34.8) | 5 (41.7) | 3 (27.3) | |
No | 15 (65.2) | 7 (58.3) | 8 (727) | |
Peritumoral lymphoid reaction | 0.836 | |||
No | 10 (43.5) | 4 (33.3) | 6 (54.5) | |
Mild | 10 (43.5) | 8 (66.7) | 2 (18.2) | |
Marked | 3 (13) | 0 (0) | 3 (27.3) | |
Perineural Invasion | 0.949 | |||
Yes | 2 (8.7) | 1 (8.3) | 1 (9.1) | |
No | 21 (91.3) | 11 (91.7) | 10 (90.9) | |
Harvested lymph nodes* | 17 (14–19.5) | 18 (16–22) | 16 (12–18.5) | 0.155 |
Positive lymph nodes* | 0 (0–2) | 0 (0–1.5) | 0 (1–2) | 0.971 |
Pathological staging | ||||
Primary tumor (T) | 0.461 | |||
T1 | 2 (8.7) | 0 (0) | 2 (18.2) | |
T2 | 3 (13) | 2 (16.7) | 1 (9.1) | |
T3 | 14 (60.9) | 8 (66.7) | 6 (54.5) | |
T4a | 3 (13) | 2 (16.7) | 1 (9.1) | |
T4b | 1 (4.3) | 0 (0) | 1 (9.1) | |
Regional lymph nodes (N) | 0.757 | |||
N0 | 15 (65.2) | 8 (66.7) | 7 (63.6) | |
N1a | 2 (8.7) | 1 (8.3) | 1 (9.1) | |
N1b | 3 (13) | 1 (8.3) | 2 (18.2) | |
N1c | 0 (0) | 0 (0) | 0 (0) | |
N2a | 1 (4.3) | 1 (8.3) | 0 (0) | |
N2b | 2 (8.7) | 1 (8.3) | 1 (9.1) | |
Distant metastasis (M) | 0.478 | |||
M0 | 22 (95.7) | 12 (100) | 10 (90.9) | |
M1a | 1 (4.3) | 0 (0) | 1 (9.1) | |
M1b | 0 (0) | 0 (0) | 0 (0) | |
Proximal margin (cm)* | 6 (4.7–8.75) | 6.3 (5.4–8.4) | 5 (3.5–9.5) | 0.949 |
Distal margin (cm)* | 2 (3–4) | 3.3 (3–4.2) | 3 (1.6–3.7) | 0.357 |
CRM (mm)* | 2 (1–2.9) | 1.6 (1–3) | 2 (1.9–2.9) | 0.170 |
Proximal margin clear | 23 (100) | 12 (100) | 11 (100) | |
Distal margin clear | 23 (100) | 12 (100) | 11 (100) | |
Duke's staging | 0.697 | |||
A | 5 (21.7) | 2 (16.7) | 3 (27.3) | |
B1 | 6 (26.1) | 4 (33.3) | 3 (27.3) | |
B2 | 4 (17.4) | 3 (25) | 1 (9.1) | |
C1 | 5 (21.7) | 3 (25) | 2 (18.2) | |
C2 | 3 (13) | 0 (0) | 2 (18.2) | |
D | 0 (0) | 0 (0) | 0 90) | |
Distant metastasis | 5 (21.7) | 3 (13) | 2 (18.2) | 0.925 |
Neoadjuvant chemotherapy | 5 (21.7) | 2 (16.7) | 3 (27.3) | 0.816 |
Neoadjuvant radiotherapy | 2 (8.7) | 1 (8.3) | 1 (9.1) | 0.943 |
Values are presented as mean ± standard deviation or median (interquartile range).
OAR, open anterior resection; LAAR, laparoscopic-assisted anterior resection; CRM, circumferential resection margin.