Long-term results of laparoscopic-assisted colectomy are comparable to results after open colectomy.

The laparoscopic approach for the surgical treatment of many benign conditions appears to offer many advantages, including reduced postoperative pain, improved cosmesis, possibly quicker return of bowel function, and decreased length of stay. However, in oncological surgery, while these outcomes are important, survival rates are of utmost importance. Thus, laparoscopic colectomy for colon cancer has been adopted cautiously, particularly following early reports of port site recurrences, a complication that was rarely seen after open surgery. The Barcelona Trial was particularly important because it was the first randomized controlled trial to report on oncological outcomes in patients having surgery for colon cancer who were randomized to laparoscopic-assisted colectomy (LAC) or open colectomy. Their results in 219 patients with cancers of the right or left colons were reported in 2002 and not only did they show that laparoscopic surgery could be performed without a negative impact on oncological outcomes, but that survival was actually significantly better in patients having stage III colon cancers. Subsequently, the results of 3 other multicenter trials have been published: the Clinical Outcome of Surgical Therapy (COST) Study Group trial included 872 patients from 48 centers in United States and Canada. Again, patients with transverse colon cancers were excluded. The Colon Cancer Laparoscopic or Open Resection (COLOR) trial included 1248 colon cancer patients with similar characteristics from 29 centers in Western Europe. Finally, the MRC Conventional vs Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC) trial included 794 patients, of whom 413 had colon cancers. With mean follow-ups of 3 to 5 years, these trials also confirmed that there was no significant difference in survival or risk of recurrence. Two recent smaller single institution studies also have shown no difference in survival with recurrence with short-term follow-up. This most recent report of Lacy and colleagues, thus, is again important because it now reports on the long-term outcomes in this cohort of patients. With a median follow-up of 95 months (range 77 to 133), the reported overall mortality was 36% in the LAC and 49% in the open colectomy group (P 0.06), and the cancer-related mortality was 16% in the LAC and 27% in the open colectomy group (P 0.07). Once again, the difference in survival was almost solely due to improved outcome in patients with stage III cancer. The authors hypothesize that the improved survival may be due to differences in the surgical stress response, cellular immunity, cytokine release, intraoperative tumor manipulation, complication rates, and blood transfusion factors. However, it is much more likely that it is a chance occurrence. It is hard to postulate that there is a biologic reason why survival should be improved in patients with stage III cancers and not in other less advanced tumors. Furthermore, this trend was not observed in any of the other 3 trials. Finally, in a recent meta-analysis combining individual data from 1536 patients from this and the other 3 large trials, the 3-year disease-free survival rates were 75.8% in the LAC and 75.3% in the open surgery groups (95% CI of the difference 5% to 4%) and the 3-year overall survival rates were 82.2% after LAC and 83.5% after open surgery (95% CI of the difference