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June 28, 2002
By LAWRENCE K. ALTMAN
A less invasive surgical technique for removing colon
cancers is superior to the standard operation because it
can reduce the risk of the cancer recurring and improve a
patient's chances for survival, according to a new study by
Spanish doctors.
The newer technique, known as laparoscopy, also shortened
the hospital stay and led to fewer post-operative
complications among patients whose cancer had not spread,
the doctors report in the June 29 issue of The Lancet.
In laparoscopy, surgeons see through a small camera and
work with instruments that are inserted through small holes
in the abdomen. Laparoscopy has been widely used to perform
gallbladder surgery in the United States and Europe over
the past decade, and it has been tried for other
conditions.
But in this country, laparoscopy has been used far less
often for colon cancer and has been controversial in part
because of the lack of rigorous studies showing its
benefits. Some earlier reports suggested shorter hospital
stays, but other studies found as many as 21 percent of the
colon cancers recurring in the scars from laparoscopy.
Also, laparoscopic surgery requires practice and skill that
only a small number of colon cancer surgeons have acquired.
Colon cancer will be diagnosed in an estimated 107,300
Americans this year, making it the third most common cancer
among men and women in the United States, the American
Cancer Society said.
Many polyps that are on the verge of becoming cancerous or
that have developed early cancer can be removed when
doctors insert a flexible tube through the anus into the
bowel in a nonsurgical procedure known as a colonoscopy.
But most advanced colon tumors are removed in an operation
that requires an incision 8 to 12 inches long.
The Spanish study is the first to directly compare cancer
recurrence and survival in laparoscopy and standard colon
cancer surgery in a randomized controlled trial. In it, the
participants agreed to leave the choice of operation to the
statistical equivalent of flipping a coin. The surgical
team, led by Dr. Antonio M. Lacy, was skilled in
laparoscopy and performed both types of operations at the
University of Barcelona.
The team compared the two procedures on 219 patients from
November 1993 to July 1998. Those who had laparoscopic
surgery stayed in the hospital for five days, three days
less than patients who had the standard operation. But
other surgeons noted that patients undergoing the standard
operation in American hospitals now tended to stay about
six days.
Of 111 patients who underwent laparoscopic colon surgery,
12 developed complications, compared with 31 in the group
of 108 who had the standard operation.
``If these results were confirmed by ongoing multicenter
randomized trials, laparoscopy would become the standard
surgical approach to patients with colon cancer,'' Dr. Lacy
said.
A number of studies involving thousands of patients in this
country and elsewhere are in progress.
Dr. Alfred M. Cohen, a colon cancer specialist who also
directs the Lucille P. Markey Cancer Center at the
University of Kentucky in Lexington, said in an interview
that the Spanish study was ``well done.''
Many doctors who do the procedure are enthusiastic about
it. ``This study will generate a flurry of activity because
even the evangelical groups in this country now are
downplaying the benefits of laparoscopic colon surgery,''
Dr. Cohen said.
About 50,000 Americans with colon cancer could benefit from
laparoscopy each year if other studies confirm the Spanish
trial, Dr. Cohen said.
Laparoscopic surgery leaves smaller incisions than standard
operations, leading to their description as pinhole and
keyhole surgery. But the laparoscopic incisions are larger
than pinholes: for a colon cancer operation, a surgeon
makes four or five incisions about one-quarter to one-half
inch in length through which the camera and instruments are
inserted into the abdomen.
An additional incision of two to three inches is made
through which the bowel is brought out from the abdomen to
remove the cancerous section and the two ends of the bowel
are sewn together
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