Comparison of laparoscopic and classical methods in patients operated on for colorectal cancer

Introduction

The constant increase in the diagnosis of colorectal cancer is the reason for great interest of scientists in the researched issue. The low percentage of permanently cured patients is also disturbing. Colorectal cancer is the most frequently diagnosed malignancy located in the gastrointestinal tract [1]. According to European data, it is the most common cancer. However, in Poland it is in third place [2].
The basis and standard of treatment for patients with colorectal cancer is removal of the cancerous lesion. Its extent depends on the location and stage of the cancer. Medical progress allows for expanding the possibilities of surgical resection of cancer. For the safety of the patient, the principle of maximum radicality of the procedure is introduced, with the lowest possible risk of serious postoperative complications and trying to maintain the continuity of the digestive tract [3–5].
Thanks to the great interest, development and creation of modern technologies and the availability of laparoscopic materials, operations performed in a minimally invasive manner are becoming safe and possible to perform even in the case of tumors located low in the rectum, creating undoubtedly unfavorable anatomical conditions. The quality of the procedures performed, even in anatomically difficult cases, is comparable to operations performed using the open method [6]. The great advantages of minimally invasive surgery also include: much less trauma to the operated area, shortened hospital stay, faster return of intestinal peristalsis, much less pain for the patient and much more favorable cosmetic results [7]. However, there are known contraindications to the use of the laparoscopic method of the large intestine. One of the main ones is the patient’s significant obesity or the presence of postoperative adhesions that hinder safe access to the cancerous lesion. The size of the tumor also presents a dilemma [1, 7]
Surgical treatment is complemented by additional therapeutic methods. Chemotherapy and radiotherapy aim to improve the results of surgical treatment. The decision on such a treatment model should be made on the basis of a multidisciplinary consultation involving many specialists. The entire treatment process and the prognosis for achieving complete remission of the disease depend on it [8, 9].
The aim of the study was to compare the results of surgical removal of colorectal cancer using laparoscopic and conventional methods.

Material and methods

A retrospective study was conducted on 269 consecutive patients who were diagnosed with colorectal cancer and underwent surgery to remove the cancerous lesion. Of the respondents, 126 people underwent laparoscopic removal of the large intestine. The rest were operated on using the classic method. The subjects were men and women aged 30–78.
The criteria for including patients in the study were the diagnosis of colorectal cancer and the eligibility of patients for surgical treatment. The exclusion criteria were: disseminated cancer, presence of distant metastases, patients hospitalized postoperatively in the department of anesthesiology and intensive care and lack of informed consent for surgical treatment.
The study was retrospective in nature. The diagnostic survey method was used. The data were based on information included in available documentation of inpatient and outpatient treatment.
Statistical analysis was used to analyze the results. The level of significance was assumed to be p = 0.05. Statistically significant results for the levels p = 0.01 and p = 0.001 are also indicated.
All calculations were performed using the R statistical package, version 4.1.3.

Results

The study included 269 patients. The mean age of the participants was 60.1 (±7.32) years. The youngest patient was 30 years old and the oldest was 78 years old. Men constituted 70.3% (n = 189) of all patients, while women constituted 29.6% (n = 80). More than half of the respondents (57.6%; n = 155) were city residents. In terms of education, people with secondary education represented the largest percentage (48%; n = 129). The majority of respondents described their marital status as married (56.5%; n = 152) (Table 1).
The most frequently performed type of surgery was left hemicolectomy (55%; n = 148). The procedures were performed using two methods, with the laparoscopic method used in 46.8% of cases and the classic method in 53.2%.

Duration

The existence of differences between patient characteristics and the method of colon removal was examined. The analysis did not reveal statistically significant differences (Table 2). The comparison below contains variables related to factors occurring during the procedure and the method of colon removal. Statistically significant differences between the laparoscopic and classic methods were observed in the following variables:
• tumor size (cm) (Mann-Whitney U test, p < 0.01),
• treatment duration (minutes) (Mann-Whitney U test, p < 0.001),
• transfusion of blood and blood products (c² test, p < 0.01),
• type of surgery performed (Fisher’s test, p < 0.05),
• ength of surgical incision (cm) (Mann-Whitney U test, p < 0.001).
The laparoscopic method of removal of the large intestine was used in patients with significantly larger tumors than in the case of the classical method. Tumors removed using the minimally invasive method were on average 22.06 (±6.49) cm, while in the case of the classic method they were on average 19.95 (±9.57) cm (Fig. 1).
The duration of the surgical procedure was also analyzed. It showed that the time was significantly longer for the laparoscopic method (laparoscopic = 170.09 (±45.09) min; open approach = 145.38 (±64.03) min).
The laparoscopic method was used more often in the case of left hemicolectomy (63.5%; n = 80). The length of the surgical incision (cm) was compared, and was found to be significantly longer in the classical method than in the laparoscopic method. The average length of the surgical incision in the case of the laparoscopic method, calculated with a mini-laparotomy performed to remove the specimen, was 20.87 (±1.92) cm. In the case of the classic method, the length of the surgical incision was significantly longer, at 32.29 (±3.02) cm) (Fig. 2).
The percentage of respondents who required transfusion of blood or blood products was significantly lower in the laparoscopic method than in the classical method. The average number of respondents requiring blood transfusion was 11.9% in the laparoscopic method (n = 15), while in the classical method it was 27, 3% (n = 39). A smaller amount of blood loss was found in patients operated on using a minimally invasive method. Table 3 below presents precise data regarding the comparison of factors occurring during the procedure and the method of removing the large intestine.
Comparisons were also made for variables that were post-treatment factors. Statistically significant differences according to the method of colon removal were observed for the following variables:
• hospitalization time (days) (Mann-Whitney U test, p < 0.001),
• course of postoperative wound healing (Fisher’s test, p < 0.001),
• assessment of the risk related to the nutritional status (Nutritional Risk Score – NRS 2002) (c² test, p < 0.01),
• time the patient was upright (Mann-Whitney U test, p < 0.001),
• time of vertical positioning of the patient – categories (Fisher’s test, p < 0.05),
• volume of the drained substance (Mann-Whitney U test, p < 0.001),
• day of removal of the abdominal drain (Mann-Whitney U test, p < 0.001),
• day of removal of the abdominal drain – categories (Fisher’s test, p < 0.001). The hospitalization time after the laparoscopic method was significantly shorter than in the classical method. In the case of laparoscopic surgery, the average hospital stay was 10.13 (±1.77) days, while in the case of conventional surgery, the hospitalization time was 11.64 (±2.87) days (Fig. 3).
Moreover, after using the laparoscopic method in a short period of time, the percentage of people classified in care categories I and II was higher (85.7%, n = 108), which means greater independence of patients. Wound healing using the minimally invasive method was more successful than in patients operated on using the classic method.
Analyzing the study results, it was found that in patients operated on using the classical method, normal intestinal peristalsis returned significantly later. It was necessary to implement parenteral nutrition more often. In terms of the average time it took to position the patient, it was achieved faster in patients operated on laparoscopically.
In patients operated on laparoscopically, a significantly smaller volume of drained substance was found. Small drainage facilitated faster removal of the abdominal drain.

Discussion

The basic treatment procedure is the introduction of multidisciplinary therapy including surgery, radiotherapy and radio-chemotherapy used alone or in combination. In each case, an absolutely necessary stage of therapy is surgery to remove colorectal cancer. Progress in medicine has enabled the development of new surgical techniques, resulting in enormous progress in minimally invasive surgery. As a result, patients have access to various therapeutic options, differing in invasiveness, recovery process and risk of complications. The appropriate and accurate choice of therapy is a dilemma for the entire interdisciplinary team.
Until recently, most procedures in the large intestine were performed using the classic method. An analysis of data collected from 500 hospitals located in the United States in 2008 presented by Delaney et al. showed that the method of laparoscopic removal of the large intestine was used in 33.7% [10]. Currently, there is an increasing trend in the use of minimally invasive me­thods. According to Taylor et al., it is recommended to use laparoscopic intestinal resections wherever possible [11].
The available literature repeatedly emphasizes significantly lower pain sensations in patients operated on laparoscopically. The pain is much less severe than in the case of surgery performed using the classic method [12]. The conducted research showed significantly less pain in patients undergoing laparoscopic surgery already on the seventh day after the procedure. The demand for painkillers in patients undergoing classical surgery was much higher. However, in the case of both methods, pain tended to decrease already on the second postoperative day and decreased over time. The pain factor is an important element influencing the level of quality of life. The conducted research showed that patients operated on laparoscopically have greater comfort and a substantially higher quality of life.
Despite the many benefits of minimally invasive procedures, they have a significantly longer duration. According to the results of Masaaki et al., the average laparoscopic operation time is 208 minutes. Operations performed using the classical method are significantly shorter and take approximately 180 minutes [13]. Other studies show similar results. Matsuda et al. conducted research on nearly 70,000 thousand patients. The average duration of laparoscopic surgery was 216 minutes, while conventional surgery took an average of 160 minutes [14]. Our own research confirmed a significantly longer duration of surgery using the laparoscopic method (170.09 minutes) compared to the classical method (145.38 minutes). A longer duration of the procedure carries the risk of perioperative complications.
When evaluating the amount of blood loss, Masaaki et al. observed that it was significantly lower in patients operated on using a minimally invasive method. The amount of extravasated blood in patients operated on with this method was on average 25 ml, while in the case of open surgery, the amount of blood lost was on average 140 ml [13]. Similar results were obtained in the study by Matsuda et al., where intraoperative blood loss during laparoscopic surgery was 30 ml and during the classical method 100 ml [14]. Our own research confirms the above-mentioned analyses. The average blood loss in the case of minimally invasive surgery was 95.71 ml, while using the classic method the loss was significantly higher, at 136.78 ml.
The use of laparoscopic surgery significantly reduces the risk of developing wound infection. In the study by Masaaki et al., only 4 patients experienced complications related to impaired postoperative wound healing. Using the classical method, the wound became infected in 14 subjects [13]. The research conducted in this study confirms the results of Masaaki et al.: dete­rioration of postoperative wound healing was identified in only 4 patients. When using the classical me­thod, wound inflammation developed in 27 patients. The parameter significantly reduces the patient’s qua­lity of life [13].
Randomized studies comparing the classical me­thod to the laparoscopic method of resection of the large intestine have shown that laparoscopy gives better results for the patient on many levels. It is associated with shorter recovery time and less need for painkillers [15]. Other studies confirm that patients undergoing laparoscopic surgery are less burdened by treatment. The research was confirmed by the opinion of patients who considered the lack of surgical complications and the absence of cancer to be important factors in the postoperative period [16]. Niu et al. showed that patients operated on laparoscopically had a shorter recovery time and less severe undesirable symptoms [17]. The results of Zawisza et al. were similar. The researchers found that the average length of stay in hospital after laparoscopic surgery was 6.93 days, while in those operated on using the classical method it was 11 days [18, 19]. A slightly longer hospital stay was observed by Masaaki et al., who noted that the length of hospitalization was 12 days in the case of laparoscopic surgery and 15 days in the case of the classic method [13]. The conducted research confirmed the above results. Patients after laparoscopic procedures had a shorter hospital stay. The average hospital stay in patients operated on with this method was 10.13 (±1.77) days, while in the case of the classic method, the hospitalization time was 11.64 (±2.87) days. Moreover, it was observed that after using the laparoscopic method, the percentage of people classified in care categories I and II was higher and recovered from the procedure faster. It was 85.7% (n = 108), which means greater patient independence and better quality of life.

Conclusions

The study results support the beneficial effect of the laparoscopic method in the treatment of colorectal cancer. Many factors were significantly correlated with the surgical method. The selection of the surgical method affects the operation time, length of the surgical incision, hospitalization time, time of standing and mobilizing the patient, and the degree of blood loss. Moreover, the method performed influenced the wound healing process and the risk of infection caused by the length of the abdominal drains.
Significantly better results were obtained after using the laparoscopic method. A significantly shorter surgical incision length, shorter patient hospitalization time, faster patient verticalization and mobilization, and lower blood loss were achieved. Moreover, in patients operated on laparoscopically, the postoperative wound healing process was more efficient and with a lower degree of infection. Attention was also drawn to the results regarding the maintenance of abdominal drains, which in the case of patients operated on laparoscopically were maintained for a significantly shorter time and the volume of the drained substance was significantly lower.
The operation time was significantly shorter when the classical method was chosen. However, it was related to the type of surgery performed. The laparoscopic method was more often performed in the case of sigmoidectomy or left hemicolectomy, which, due to the extensiveness of the operation, extends the procedure time, regardless of the choice of surgical method.
It is worth noting, however, that despite the beneficial effect of the laparoscopic method on the convalescence process, there are contraindications to its use in general patients with colorectal cancer.

Disclosure

Institutional review board statement: Not applicable.
Assistance with the article: None.
Financial support and sponsorship: None.
Conflicts of interest: None.

References