Laparoscopic surgery for colorectal cancer: advantages and challenges

Excerpt

Over 30 years ago, the successes of the laparoscopic surgery used for gallbladder disease led to the spread of this surgical technique in a variety of conditions. Among the most frequent, the application of laparoscopy approach in the treatment of colorectal cancer produced the best results when considering safety, length of hospital stay, and post-operative recovery [1]. Overall, the laparoscopic surgery for colon and rectal cancers has been demonstrated to improve survival of cancer patients providing lower rates in all-cause and cancer-specific mortality [2]. Despite the wide spread of this technique as a valuable option in the management of such type of tumor, some issues should be considered before proceeding with the referral of the patients for this treatment. Elderly patients are the older proportion of patients that has grown following the increase in life expectancy and today represents a significant part of the subjects referred for the operation. This group of patients has demonstrated to undergo better recovery but no significant improvements in survival irrespectively of the treatment [3]. The main reason for the contrasting findings of minimally invasive surgery on such specific population rely on the possibility that these patients present higher rate of comorbidities that may affect their postoperative course. Indeed, indication for surgery in elderly individuals is not depending on patients’ age but must depend on the assessment of preoperative conditions known to be associated with worsening the outcome of the surgery and higher rate of complications or mortality [4]. Given the growing proportion of older patients affected by colorectal cancer and the higher prevalence of comorbidities compared with the younger, the use of grading systems to predict outcomes after surgery according number and type of comorbid conditions is necessary. Comorbid diseases impact colorectal patients’ survival more than single comorbid conditions and should be assessed in cancer management. Comorbid assessment tools provide valuable information on the influence of comorbidities at the initial diagnosis and prospective outcome of colorectal cancer patients due to their prognostic capacity on survival. A modified version of the Charlson comorbidity index (CCI) specifically developed for colorectal cancer patients showed that besides the conventional comorbidities considered in the original version of the score, some specific conditions should be evaluated to better predict survival of the patients (Table 1). In particular, the inclusion of 6-month weight loss ≥20 %, smoking >20 cigarettes/day, underweight condition, and cardiac arrhythmias to the other comorbid conditions tested in the CCI have demonstrated a better predictive value compared with the original CCI and other comorbidity indices, such as the Elixhauser method, the National Institute on Aging (NIA) and National Cancer Institute (NCI) comorbidity index, and the Adult Comorbidity Evaluation-27 (ACE- 27) [5]. Laparoscopic approach for colon cancer demonstrates better short-term outcome, oncologic safety, and equivalent long-term outcomes than open surgery. Despite laparoscopic surgery of rectal cancers may be more complex due to the tumor location, improvements in health outcomes have been reported also for rectal location of cancers, with comparable results to open surgery when the experience of the surgeon is well established. In any case, comorbid assessment has been demonstrated to affect patients’ survival, and should be taken into account particularly in elderly patients. When properly managed, the advantages of minimally invasive surgery may translate into better care quality for oncological patients and lead to improvements in recovery length and overall surgery outcome. …