Purpose: To identify differences in clinical features between laparoscopy and open resection for primary tumor in patients with stage IV colorectal cancer. We also evaluated short-term and oncologic outcomes after laparoscopy and open surgery.
Methods: A total of 100 consecutive stage IV patients undergoing open (n=61) or laparoscopic (n=39) major resection were analyzed. There were four cases (10%) of conversion to laparotomy in the laparoscopy group.
Results: Pathological T4 tumors (56% vs 26%), primary colon cancers (74% vs 51%), and larger tumor diameter (6 vs 5 cm) were more commonly managed with open surgery. Right colectomy was more common in the open surgery group (39%) and low anterior resection was more common in the laparoscopy group (39%, P=0.002). Hepatic metastases in segments II, III, IVb, V, and VI were more frequently resected with laparoscopy (100%) than with open surgery (56%), although the difference was not statistically significant. In colon and rectal cancers, mean operative time and 30-day complication rates of laparoscopy and open surgery did not differ. In both cancers, mean time to soft diet and length of hospital stay were shorter in the laparoscopy group. Mean time from surgery to chemotherapy commencement was significantly shorter with laparoscopy than with open surgery. In colon and rectal cancers, 2-year cancer-specific and progression-free survival rates were similar between the laparoscopy and open surgery groups.
Conclusion: Based on our findings, laparoscopy can be selected as an initial approach in patients with a primary tumor without adjacent organ invasion and patients without primary tumor-related symptoms. In selected stage IV patients, tumor factors such as primary rectal tumor, peritoneal carcinomatosis, or liver metastasis may not be absolute contraindications for a laparoscopic approach.
Keywords: colorectal neoplasms, laparoscopy, neoplasm metastasis
Laparoscopy for colorectal cancer has numerous short-term benefits such as less postoperative pain, shorter hospital stay, and an earlier return to work.1–3 In addition, laparoscopy is as effective as open surgery in terms of oncologic outcomes.4,5 However, information regarding optimal indications for laparoscopy is not readily available in patients with stage IV colorectal cancer, because a metastatic disease is frequently excluded from clinical trials.
Approximately 20%–25% of patients have synchronous metastasis at the initial diagnosis of colorectal cancer.6,7 There are various clinical scenarios regarding optimal first-line treatment in patients with stage IV disease.8,9 Removal of the primary tumor only, synchronous resection of metastatic tumor, or first-line chemotherapy can be considered. The primary tumor should be resected in symptomatic patients, but this method is still controversial in patients without primary tumor-related symptoms.10 Surgeons should determine which is the most appropriate treatment strategy. If a first-line surgery is chosen for primary tumor resection, either laparoscopy or open surgery must be selected.
Several studies have compared outcomes between laparoscopy and open surgery in patients with stage IV disease, and all reported favorable short-term11–18 and comparable oncologic outcomes11–16,18 between the two approaches. However, the clinical features associated with selecting surgical approaches such as laparoscopy or open resection for stage IV disease have not been investigated extensively. We postulated that certain patient or tumor factors are related to selecting surgical approaches and that identifying these factors could offer surgeons objective evidence and allow more patients with stage IV disease to be managed with a laparoscopic approach. This study aimed to identify differences in clinical features between laparoscopy and open resection for primary tumor in patients with stage IV colorectal cancer. We also evaluated short-term and oncologic outcomes after laparoscopy and open surgery.