Life ScienceS | Medicine Single port laparoscopic colectomy for colonic cancer Trung Vy Pham, Nhu Hiep Pham*, Huu Thien Ho, Anh Vu Pham, Hai Thanh Phan, Thanh Xuan Nguyen, Nghiem Trung Tran, Xuan Dong Pham, Tien Nhan Van, Trung Hieu Mai Hue Central Hospital, Vietnam Received 10 July 2017; accepted 30 November 2017 Abstract: Objectives: The evaluation of feasibility, safety, and outcomes of single port laparoscopic colectomy (SPLC) for colonic cancer. Prospective study of 114 patients with colonic cancer (84 right side, 17 left side, and 13 sigmoid colon) who underwent SPLC between October 2010 and October 2016 in Hue Central Hospital. Results: Mean age of patients was 56.1±15.2 (25-87 years), male/female ratio was 70/44. Mean BMI was 23.5±2.2 kg/m2. Procedures included 84 right hemi-colectomies (73.7%), 17 left hemi-colectomies (14.9%), and 13 sigmoidectomies (11.4%). Six cases required additional ports, and 19 were converted to open surgery. Mean tumor size was 3.7±2.7 cm. Stage I: 6.1%; stage IIa: 43.9%; stage IIIa: 36.8%; and stage IIIc: 13.2%. Mean operation time was 160.5±75.5 min. There had been no deaths/intraoperative complications. Mean incisional length (including extraction) was 5.5±2.2 cm. Mean lymph nodes was 16.2±4.5. Mean hospital stay was 7.5±6.1 days. The surgical site infection rate was 3.5%, and 1 patient required reoperation (anastomotic leakage: 0.9%). After 32.2±7.5 (3-65 months) follow-up, there were no late surgical complication, incisional hernia, or incision metastasis. There were five local recurrences, and three patients developed liver metastasis in the open conversion group. The overall survival time after 2 years was 87.5%, and after 5 years, it was 59.4% (Kaplan-Meier). Conclusion: SPLC is feasible and safe procedure for the treatment of colon cancer. The cosmetic value is better (short incision confounded by umbilicus). Other outcomes were equivalent to conventional laparoscopy. Keywords: colon cancer, single port laparoscopic colectomy. Classification number: 3.2 Introduction Colonic cancer is among the most commonly occurring cancers (ranking 2nd in women and 3rd in men) in the world and the 4th cause of death after lung, stomach, and liver cancer [1]. In Vietnam, colorectal cancer is the 4th leading cause of death after gastric cancer, lung cancer, and liver cancer [2]. Since Jacobs successfully performed the first laparoscopic right hemi-colectomy for a cecal tumor in 1991, laparoscopy for colon cancer has been widely used, and it is as effective as open surgery in oncological terms [3]. In 2008, P. Bucher, et al. reported the first case right hemicolectomy by single port access laparoscopy and in 2009, single-port access laparoscopic radical left colectomy was successfully performed and reported [4]. SPLC allows intra-abdominal operation through a small umbilical incision [5]. With the development of techniques and instruments (Harmonic-Scapel, Ligasure, etc.), SPLC is being widely and successfully applied around the world [5, 6]. This study aimed to evaluate the feasibility, safety and early results of this technique. Materials and methods Materials: 114 colon cancer cases confirmed by preoperative colonoscopic biopsy. All tumors were ≤8 cm, stage III or under, non-invasive to adjacent organs, with no distant metastasis on CT-scan. Patients were ASA 1-3. Methods: Prospective study: general characteristics of patients, surgical procedures, conversion rate, complications during and after surgery, the results of surgery, and hospital stays were collected for analysis. *Corresponding author: Email: 42 Vietnam Journal of Science, Technology and Engineering December 2017 • Vol.59 Number 4 Life ScienceS | Medicine Equipment: Karl-Storz endoscopes 300 (5 mm diameter, 60 cm length), SP from COVIDIEN, long and conventional laparoscopic instruments, staplers, etc. placement of SP device; insufflation of CO2 into the peritoneal cavity (12 mmHg). Ligation of blood vessels close to Technique: The patient was their origins; mobilization of the colon; Fig. 1. Position of patient, surgeon, and assistant. (A) right colon, (B) left colon and sigmoid colon. underwent general anesthesia, supine for right colon cancer and in lithothomy position for left colon and sigmoid colonic cancer (Fig. 1). Insufflation; longitudinal incision through the umbilicus (2-2.5 cm); removal of the SP device; and expanding the incision, if necessary. Placement of the incision protective device; removal of the colon and tumor; and anastomosis performed by hand or stapler (Figs. 2-5). Fig. 2. SP right hemi-colectomy. Fig. 3. Specimen with ascending colonic cancer. Fig. 4. Post-op pathology with 19 lymph nodes examined. Fig. 5. Scar after 2 years. December 2017 • Vol.59 Number 4 Vietnam Journal of Science, Technology and Engineering 43 Life ScienceS | Medicine Results General characteristics of patients Staging Stage n This result was similar to those of other % domestic or international studies [7, 8]. n=114 % Male/Female 70/44 1.6/1 Mean age 56.1±15.2 Min 25 Max 87 BMI (kg/m2) 23.5±2.2 Adenocarcinoma (colonoscopy + 114 100 biopsy) Tumor size/CT scan 3.7±2.7 (cm) Min 3 Max 8 CEA (ng/ml) < 5 52 45.6 ≥ 5 62 54.4 Surgical techniques Procedures performed N % Right hemi-colectomy 84 73.7 Left hemi-colectomy 17 14.9 Sigmoidectomy 13 11.4 Stage I 7 Stage IIa 50 Stage IIIa 42 Stage IIIc 15 Stage IV 0 Postoperative follow-up Mean time follow-up 32.2±7.5 (3-65) months Postoperative CEA≥ 5 ng/ml Liver metastasis 3 Local recurrence 5 Lung metastasis 0 Incisional hernia 0 Incisional metastasis 0 Overall survival time Meier) 6.1 43.9 36.8 13.2 0 % 21.9 2.6 4.4 0 0 0 (Kaplan- Regarding the sex, there were 70 males and 44 females in our study. This foctor was different from the results of several studies, including those of William Tzu-Liang Chen’s study [9] and B. Peter’s study [1]. However, this difference did not affect the outcomes of SPLC. The overweight patients are more difficult since mesenteric blood vessel cannot be seen easily [10]. It is well recognized that this is one of the factors that leads to the conversion from SP laparoscopy to conventional laparoscopy or laparotomy [9]. This influence is especially evident in SP laparoscopy. Indeed, I. Diego, et al. found the conversion rate was higher in the group with BMI over 25 kg/m2 compared to Conversion Open conversion n=19 16.7% Right colon 17 14.9 Left colon 2 1.8 Additional trocars n=6 5.3% Right colon 4 3.5 Left colon 2 1.8 the group with BMI less than 25 kg/m2 [11]. The average BMI in our study was 23.5±2.2 kg/m2. The conversion rates in other studies of SP laparoscopy had relatively low BMI, such as the meta-analysis study of T. Makino, et al. had BMI of 25.5 kg/m2 [3], the meta-analysis Causes for open conversion Causes n=19 16.7% Peritumoral inflammation 7 6.1 Tumoral invasion 12 10.5 Operative results After 2 years: 87.5% and after 5 years: 59.4%. Discussions study of A.K. Fung, et al. had 25.8 kg/m2 [7]. Even in the randomized comparative study of William Tzu-Liang Chen, et al., BMI was 23.3 kg/m2 [9]. Thus, we could consider the BMI in our study was similar to other studies. Operating time (minutes) Lymph nodes examined Incisional length (cm) Drain Postoperative pain (days) Bowel movement return (days) Hospital stay (days) Incisional infection Anastomotic leakage Min Max Mean 140 300 160.5±75.5 12 25 16.2±4.5 4 10 5.5±2.2 n=5 4.4% 2 6 4.1±2.5 2 5 3.5±1.2 6 16 7.5±6.1 n=4 3.5% n=1 0.9% Based on our experience, in 114 patients with colonic cancer undergoing SPLC, there were 19 conversions, six needed additional ports; there were no deaths, no intra-operative complications, and only one case of anastomotic leakage. Four patients had surgical site infections. This study showed that SPLC treatment of colon cancer is feasible and safe. Although the patients had been selected before the surgery, the general characteristics of the patients in our study were similar to other studies. The mean age of the study: 56.1±15.2 years. Our selection of patients with tumor size on CT scan averaged at 3.7±2.7 (2-8) cm. Randomized comparative study of H.T. Papaconstantinou, et al., in the SP laparoscopic group, the average tumor size was 4±2 (0.9-9.5 cm) [12]. Thus, the criteria for patient selection related to the size of our tumor was similar to other authors. Another factor related to SPLC in colon cancer is surgical procedure. Most published studies have evaluated the feasibility and safety of right SPLC [1, 6, 9, 11, 13]. Only a few studies 44 Vietnam Journal of Science, Technology and Engineering December 2017 • Vol.59 Number 4 Life ScienceS | Medicine studied left SPLC [14, 15]. Most operating time was shorter in the latter cases of abdominal incision infection authors agree that SP laparoscopy half of our series. [1]. A study of 22 cases of right SPLC of left colectomy or sigmoidectomy, which requires dissection in the pelvis and freeing the splenic flexure, is more difficult. According to F. Leblanc, et al. both medial to lateral and lateral to medial approaches were used to ligate the vessels for 11 right and 6 left colectomies [16]. The small rate of left hemicolectomy or sigmoidectomy in our study was not due to that reason. In our study, there were only 17 left colon cancers. Most of the patients with left colon cancers hospitalized in our department were in intestinal sub-occlusion or occlusion situation; thus, we couldn’t select them for our study. Operating time for SP laparoscopy was longer than conventional laparoscopy in the randomized comparative study of William Tzu-Liang Chen, et al. [9] with an average operating time of 175 minutes [9]. In the Papaconstantinou, et al. the study showed that operating time was equal between the two groups, where the average operating time was 144 minutes [12]. In our study, the average operating time was 160.5±75.5 (140-300) minutes, which was longer than Papaconstantinou, et al. since there were 17 left hemi-colectomies (14.9%), 13 sigmoidectomies (11.4%), and 19 converted cases in our study, where the operating time was long. In contrast, there was no left hemi-colectomy in the study of Papaconstantinou, et al. [12]. The average operating time in SP laparoscopic group of C.G. Huscher [8] was 147±61 minutes, which may be related to the high rate of cancer stage 1 and 2 (12/16), accounting for the shorter operating time compared to our study. According to T. William, et al. [9], SP laparoscopy should be performed by experienced surgeons in laparoscopic surgery, and when this There were 19 conversions (16.7%) to open surgery in our study. The conversion rate in our study was higher than several other studies. The comparative study of William Tzu-Liang Chen, et al. [9] had three cases of conversion (3/18), where one case was of open surgery, and 2 cases were of traditional laparoscopy. In the study by Papaconstantinou, et al., 26 patients in SP laparoscopic group had 3 conversions, where two cases were converted to traditional laparoscopy and one to open surgery [12]. This even suggests that the selection of patients with low BMI and small tumor size is very important for SP laparoscopy. The reasons for conversion in our study were tumor invasion to adjacent organs (12/19 cases) and peri-tumor inflammation (7/19). In cases of peri-tumor inflammation, we added first additional port in RLQ or LLQ. If no progress was apparent, we converted to open surgery. We have been successful in 5 cases. In tumor invasion situations, we decided to convert to open surgery immediately without adding more ports. In the studies of A. Keshava, et al. [6] and William Tzu-Liang Chen, et al. [9], the average incision length was of 4 cm (3-6). In our study, the average incision length was 5.5±2.2 cm (4-10). We discerned, our incision was longer because several tumors in our study were of a bigger size, and so, we had to extend the incision to extract these tumors. In the studies of William Tzu-Liang Chen, et al. [9], the average tumor size was 2 cm (0.5-6), but for our study, it was 3.7±2.7 cm (3-8). Only 2 cases in SP laparoscopic group of William Tzu-Liang Chen, et al.’study [9] had complications related to surgery, and no cases needed re- by A. Keshava, et al. (BMI 27) had 2 cases of re-intervention [6]. Our study had five cases of complications, including 4 cases of wound infection and one case of anastomotic leakage that required re-intervention. Thus, our rate of complications was similar to studies by other authors and not a risk factor for SP laparoscopy. In our study, other results such as postoperative pain, bowel movement return, length of hospital stay were similar to the results of conventional laparoscopy [2]. Until recently, all four studies comparing SP laparoscopy with conventional laparoscopy showed that SP laparoscopy was feasible and safe, in both technical terms as well as oncological terms. However, these studies are yet to see any other outstanding advantages of SP laparoscopy as compared to conventional laparoscopy, except aesthetically [8, 9, 12, 17]. Only a comparative study by J.T. Poon, et al. on 50 patients recorded that SP laparoscopy had lesser postoperative pain and shorter hospital stay; however, the authors did not affirm the conclusions since the number of patients was small [17]. The results of postoperative follow-up had an average of 32.2±7,5 (3-65) months recorded. There was no incision hernia or metastasis. CEA ratio above 5 ng/ml was 21.9%, which is similar to the recognition of H.T. Papaconstantinou, et al. [12]. In our study, 5 patients had local recurrences and 3 liver metastases. All patients in the group of open conversion were in stage IIIC. Thus, we concluded that the recurrence rate in our study was not related directly to SP laparoscopy. Conclusions technique becomes routine, the time intervention. Research by B. Peter, et SPLC in the treatment of colon factor is no longer different between the two techniques. We also found that our al. on 50 cases of SP laparoscopy had one case of anastomotic leakage and 4 cancer is feasible, and safe. The cosmetic value is better (shorter incision, hidden December 2017 • Vol.59 Number 4 Vietnam Journal of Science, Technology and Engineering 45 Life ScienceS | Medicine by umbilicus). Other results are similar to conventional laparoscopy. However, a large number of patients are required accurate assessment of the long-term results, particularly in terms of oncology. REFERENCES [1] b. Peter, b. Van den, S. colin (2011), “Single-incision laparoscopic colorectal surgery, experience with 50 consecutive cases”, J. Gastrointest. Surg., 15, pp.1989-1994. 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