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Converting Laparoscopic Colon Cancer Surgery to Open Surgery Does Not Impair Survival

Key findings

  • Among 1,387 colon cancer surgery patients, the group that underwent laparoscopic surgery converted to open surgery had five-year survival rates similar to those of the group that had planned open surgery
  • However, patients who underwent either converted surgery or open surgery had significantly worse survival rates than those who had successful laparoscopic surgery
  • After propensity score matching that accounted for differences in baseline and pathologic features, survival rates were similar in the three groups; only length of stay and the need for blood transfusion were higher after converted surgery
  • These data support attempts to perform laparoscopic resection in patients with colon cancer, barring well-known contraindications such as prior abdominal surgery and large tumor size

The feasibility of laparoscopic surgery for colon cancer is now well established. However, the risk of recurrence and death are lower with open surgery, and morbidity rates are also lower.

In an estimated 9% to 17% of cases, conversion to open surgery is required. Some studies suggest that outcomes with conversion are comparable to those of completed laparoscopic resection, while others suggest a higher rate of postoperative morbidity.

A more relevant analysis is to compare converted surgery with planned open surgery, according to Lieve G.J. Leijssen, MD, researcher, Anne M. Dinaux, MD, researcher, Hiroko Kunitake, MD, colorectal surgeon in the Division of General and Gastrointestinal Surgery at Massachusetts General Hospital and surgeon at the Mass General Cancer Center, Liliana G. Bordeianou, MD, MPH, chief of the colorectal surgery program, and David L. Berger, MD, colorectal and gastrointestinal surgeon. In the Journal of Surgical Research, they report on a retrospective study in which survival rates were similar for converted, open and successfully completed laparoscopic surgery for colon cancer.

The Study Cohort

The researchers reviewed 1,347 patients who underwent elective surgery for colon cancer at Mass General between 2004 and 2014. All procedures were performed by high-volume gastrointestinal surgeons who were very experienced with minimally invasive surgery. The choice between an open or laparoscopic approach was purely the surgeon's preference.

The patients fell into three groups:

  1. Had laparoscopic surgery completed (n=505, 37.5%)
  2. Required conversion to open surgery (n=53, 3.9%)
  3. Underwent planned open surgery (n=789, 58.6%)

Thus, the conversion rate was 9.5% (53 of 558 patients who were intended to have laparoscopic surgery).

Outcomes Within 30 Days

Length of hospital stay, rates of in-hospital complications, readmission rates, need for blood transfusion and the number of patients with sepsis were all significantly higher after converted surgery than after completed laparoscopic surgery.

Outcomes in the converted surgery and open surgery groups were more comparable. Still, though, the conversion was associated with significantly worse outcomes in terms of intra-abdominal abscesses or leaks, transfer to the intensive care unit and surgical-site infections compared with either laparoscopic surgery or open surgery.

Rates of reoperation and mortality were comparable with converted surgery versus laparoscopic surgery and with converted surgery versus open surgery.

Longer-term Outcomes

The researchers then performed a long-term analysis of the 1,097 patients who had stage I to stage III disease. The median follow-up was 48 months.

Recurrence rates were significantly higher in the converted group (21%) and the open group (15%) than in the laparoscopic group (9.8%). The researchers mainly attribute these differences to a higher rate of distant metastasis in the converted group than in the laparoscopic group and to a significantly higher rate of local recurrence after open surgery than after laparoscopic surgery.

The converted group and the open group had similar five-year survival rates. However, patients who underwent either converted surgery or open surgery had significantly worse overall survival, disease-specific survival and disease-free survival than those who had successful laparoscopic surgery.

Propensity Score Matching

To account for the heterogeneity of the three treatment groups, the researchers created a propensity-matched cohort that had 48 patients in each group. The groups were matched on age, gender, American Society of Anesthesiologists score, body mass index, stage, tumor size and year of surgery.

Only the length of stay and need for blood transfusion remained significantly greater in the converted group than in the laparoscopic group. The most notable finding was that average five-year survival was statistically similar for all groups:

  • Overall survival: 86 months in the laparoscopic group, 86 months in the converted group and 100 months in the open group
  • Disease-specific survival: 97, 105 and 123 months
  • Disease-free survival: 88, 98 and 119 months

The researchers conclude that their data support surgeons' decisions to attempt laparoscopic surgery in patients with colon cancer, barring well-known contraindications such as prior abdominal surgery and large tumor size.

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