One of the surgical advances that has been accepted most quickly over recent years is the use of laparoscopic surgical techniques.
Hospital Clínic has been a pioneer in the use of laparoscopic surgery for the treatment of colorectal cancer and one study conducted by the Gastrointestinal Surgery Department was the first publication of a study with a high level of scientific evidence to show the advantages of laparoscopic surgery over conventional surgery for the treatment of colon cancer.
This has resulted in the department being considered a referral center both nationally and internationally for the use of laparoscopic techniques, both for treating colorectal cancer and carrying out training courses for surgeons from all over the world.
This technique has brought about a radical change in how surgery is performed as the publication of numerous papers in medical literature comparing laparoscopic surgery with the so-called open or conventional surgery show a series of advantages in the post-operative period of patients undergoing laparoscopic surgical techniques, such as:
- Disappearance of post-operative ileus.
- Less pain and therefore decreased need for analgesia.
- Fewer post-operative complications.
- Less impairment of respiratory function.
These benefits result in a shorter patient recovery time, shorter hospital stay and shorter convalescence.
Although laparoscopic techniques were initially accepted as the treatment of choice for gallstones, their use has gradually grown to treating most diseases affecting the abdominal cavity. Technological advances have allowed laparoscopic surgery to be used for treating more complex conditions, such as benign and malignant colon and rectal diseases.
Laparoscopic colorectal surgery should respect the basic principles of surgery in this area. Firstly, a series of considerations should be taken into account according to the type of condition for which the technique is to be used. Therefore, in patients with benign diseases, only technical issues should be considered regarding correct exposure of the area to be operated on in order to adhere to infection control principles. However, when treating cancer, it is vital to carefully follow oncological resection guidelines in addition to the aforementioned technical issues.
Numerous papers analyzing the results of prospective series comparing laparoscopic and conventional surgery in the treatment of colorectal cancer have shown that laparoscopic resection in the treatment of neoplastic diseases can be performed just as safely as open surgery, guaranteeing oncological resection of the segment of colon to be removed including resection of the blood vessels and excision of the corresponding lymph nodes.
The advantages offered by laparoscopic surgery, which have been published in numerous papers, seem to be a result of the reduced intensity of aggression inflicted by this type of surgery, such as preventing large incisions into the abdominal wall by making a minimum incision into the skin and being able to maintain the humidity and temperature conditions inside the abdominal cavity, when compared to open surgery.
Studies published to date enable us to answer three questions about the application of laparoscopy in the treatment of colorectal cancer in favor of laparoscopic surgery:
- Are the short-term post-operative outcomes more favorable in patients undergoing operations for colon neoplasia using laparoscopic surgery techniques?
- Can laparoscopic surgery guarantee the same oncological resection and tumor staging as conventional surgery in patients with colon neoplasia?
- Does laparoscopic surgery affect the long-term survival of patients?
Colon and rectal cancer
Colorectal cancer is one of the most common neoplasms in Western countries with an incidence of 20-34 cases per 100,000 inhabitants in our area. In Spain, as is generally the case in all industrialized countries, the incidence of colorectal cancer has tended to increase over recent years. Furthermore, despite advances in its treatment, colorectal cancer represents 41% of all deaths due to digestive system cancers in the world. It is the second leading cause of cancer death in Spain, exceeded by lung cancer in men and breast cancer in women, with an overall mortality of 40-50%.
The exact origin of colorectal cancer is still unknown, but there are multiple factors influencing this neoplastic process. These include:
- Genetic Factors: the appearance of colorectal cancer is possibly the result of a series of events starting with a chromosomal mutation or a similar process followed by progression phenomena in which both genetic and environmental factors may be involved.
- Inflammatory bowel disease: There is an increased risk of colon cancer (30 times higher) in patients with inflammatory bowel disease. However, of all the patients diagnosed with colorectal cancer, only 1% have a history of inflammatory bowel disease.
- Dietetic factors have also been linked to the etiology of colorectal cancer. Although studies conducted are not conclusive regarding the exact role of dietetic factors, it seems that diets high in fat and low in fiber play an important role in the development of colorectal cancer. The importance of high fiber diets lies in the fiber's capacity to bind bile acids and various carcinogens in the intestinal lumen and its fecal flora-modifying and intestinal transit-accelerating effects, which reduces the intraluminal concentration of carcinogenic or co-carcinogenic substances and reduces contact time between carcinogenic or co-carcinogenic substances and the colonic mucosa.
- Pelvic radiotherapy has been associated with the development of colon neoplasia with a mean interval to onset of 15.2 years.
Other more controversial factors include a sedentary lifestyle, the use of oral contraceptives, giving birth, morbid obesity and a high concentration of iron in feces.
Colorectal cancer is not just an isolated disease. It can also occur in the context of clinical syndromes such as adenomatous polyposis syndromes and hereditary non-polyposis colon cancer.
Intestinal polyposis syndromes
- Adenomatous polyps.
- Familial polyposis of the colon or familial adenomatous polyposis.
- Gardner syndrome.
- Turcot syndrome.
- Hamartomatous polyps.
- Juvenile polyposis syndrome.
- Peutz-Jeghers syndrome.
- Neurofibromatous polyposis.
- Cowden syndrome.
- Ruvalcaba-Myhre-Smith syndrome.
- Devon polyposis syndrome.
- Cronkhite-Canada syndrome.
- Hyperplastic polyposis.
- Inflammatory polyposis.
- Lymphoid nodular hyperplasia.
- Lymphomatous polyposis
The most common is familial adenomatous polyposis. This is an autosomal dominant inherited disease characterized by the presence of numerous adenomatous polyps (more than 100) in the large intestine. It tends to be diagnosed between the second and fourth decades of life. There are three varieties of adenoma in the intestine (tubular, tubulovillous and villous) that are generally small in size (less than 5 mm) and cover a large area of the mucosa.
Familial polyposis of the colon is a disease with high malignancy potential so if surgical treatment is not provided, progression to colorectal carcinoma occurs in 100% of cases before the age of 50. Treatment is always surgical and must be given without delay in patients over the age of 25. If there are only a few polyps in the rectum, subtotal colectomy with ileoproctostomy and periodical endoscopic examinations and fulguration of new polyps appearing in the rectum may be required. If there is a large number of rectal polyps, total colectomy with ileoanal reservoir is preferred.
- The treatment of colon cancer is always surgical and the surgery performed must comply with a series of principles to guarantee curative resection, known as adequate oncological resection.
- The principles of curative resection for colorectal cancer include excision of the primary tumor with adequate proximal, distal and lateral margins for local and regional tumor control, ensuring a secure, well-vascularized and tension-free anastomosis. The extent of the resection is determined by the site of the tumor, its vascularization, its lymphatic drainage and the presence or absence of direct extension into adjacent organs, ensuring en bloc resection of the entire area infiltrated by neoplasia.
- For tumors found in the cecum and ascending colon, the required surgery is a right hemicolectomy. The vascular section should include the ileal marginal arterial arcade, the ileocolic artery, the right colic artery and the right branch of the middle colic artery. The lymphatic territory should include the lymph nodes in the mesocolon and the lymph node chains from the ileocolic and right colic arteries to the edge of the superior mesenteric artery.
- For tumors of the hepatic flexure and the proximal half of the transverse colon, an extended right hemicolectomy will be performed in which the middle colic artery should be ligated at its origin at the level of the tail of the pancreas.
- For tumors of the splenic flexure, distal half of the transverse colon and descending colon, the surgery of choice is a left hemicolectomy with proximal ligation of the inferior mesenteric vessels and excision of the lymph nodes of the corresponding mesocolon and the main lymph node chains of the inferior mesenteric artery.
- For tumors in the sigmoid colon, the standard surgery is a sigmoidectomy with ligation of the inferior mesenteric artery at its origin. The extent of the resection will depend on the segment of sigmoid colon affected. Lesions of the proximal sigmoid colon will require an anastomosis between the descending colon and the distal sigmoid colon, lesions of the distal sigmoid will require an anastomosis between the proximal sigmoid and the upper rectum and lesions of the middle sigmoid, depending on the redundancy of the sigmoid colon, will require an anastomosis between the sigmoid-descending colon and the rectosigmoid junction.
- A subtotal colectomy is indicated in patients with synchronous carcinomas in different parts of the colon. Other indications for subtotal colectomy include: presence of multiple polyps not resected by endoscopy and young patients with a family history.