Welcome to the first issue of Physician Update, a newsletter for health-care professionals on topics in minimal access surgery.

This newsletter is designed to provide an ongoing exchange of information about our clinical and research experience in laparoscopic approaches to all areas of surgery, so that we may help you deliver the most effective care possible to your patients.

The surgeons at both Columbia Presbyterian and New York Weill Cornell are dedicated to bringing the latest surgical advances to patients as quickly as possible. To that end, New York-Presbyterian Hospital created the Minimal Access Surgery Center and has hired a director. The Center includes surgeons from most surgical subspecialties as well as educators and researchers at both Weill Medical College of Cornell University and Columbia University College of Physicians and Surgeons.

My goal as director of the Center is to work collaboratively with surgeons on both campuses in performing surgery, employing minimal access techniques and investigating new ideas for surgical approaches using laparoscopic technology. I would also like for the Center to become a regional resource for physicians whose patients may benefit from less invasive, more cost-effective surgical methods. Therefore, I welcome your questions and suggestions.

-Dennis L. Fowler, M.D.

Dennis L. Fowler, M.D. and Daniel J. Gagne, M.D.

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal problems in the United States. GERD is the term used to describe any symptomatic condition or tissue damage resulting from the movement of gastric contents into the esophagus. It has been reported that more than 40% of Americans experience symptoms of GERD at least once a month, and up to 10% of the population experience daily symptoms. (1-4)

Though exact figures are unknown, it is estimated that 17 - 40 million adults in the United States suffer from GERD. (5) The prevalence of GERD has increased dramatically this century, as esophagitis was at one time a very rare finding at autopsy. (6) The increasing prevalence of reflux is probably related to changes in diet and lifestyle.

The most common symptom of GERD is heartburn. Heartburn (pyrosis) is experienced as a retrosternal burning discomfort, commonly after meals and when supine. It is caused by acid stimulation of sensory nerve endings in the deeper layers of the esophageal epithelium.

The second most common symptom is regurgitation. Regurgitation is the effortless return of gastric or esophageal fluid into the pharynx without nausea, retching, or abdominal contractions. Regurgitation often occurs at night while the patient is sleeping. When this results in a sudden awakening with hot fluid in the throat, it is called water brash. It is often associated with coughing, choking, and shortness of breath due to aspiration of the regurgitated fluid. It can also occur after a large meal, when stooping over, or exercising.

A third symptom is dysphagia, and this occurs in about one third of people with GERD. It can be caused by a peptic stricture, a Schatzki ring, or peristaltic dysfunction.

Numerous other symptoms are labeled as atypical symptoms. These include chest pain, wheezing, hoarseness, chronic cough, choking, globus, and even dental caries. These symptoms are caused by injury of the esophagus, larynx, airways, pharynx, or teeth by refluxed fluid from the stomach. It has been estimated that 80% of patients with hoarseness and 70-80% of patients with asthma have GERD. Many of these patients with atypical symptoms do not have heartburn or regurgitation. Because of the atypical symptom of chest pain, 75,000-100,000 (normal) cardiac catheterizations are performed each year. (5)

The etiology of GERD is multifactorial. GERD can be caused by a failure of one or more of the intrinsic antireflux mechanisms: the lower esophageal segment (LES), the function of the esophageal body, and the function of the gastric reservoir. Though the esophagus must be able to clear acid normally, and the stomach must be able to empty normally, a weak or defective LES is the most important contributor to GERD.

To function appropriately, the LES must have a normal length, normal pressure, normal relaxation, and be located intra-abdominal below the diaphragmatic crura. There, the intra-abdominal pressure can assist the action of the LES. The LES pressure is usually low in patients with GERD but may be normal or even elevated. The most important factor causing GERD is transient relaxation of the LES, a sudden loss of tone not preceded by swallowing. Transient relaxation of the LES, not a low resting pressure, is the most important cause of reflux.

ìTransient relaxation of the LES, not a low resting pressure, is the most important cause of refluxî

Hiatal hernia also contributes to GERD. A hiatal hernia is a common anomaly in which the esophagogastric junction and some part of the stomach lie above the diaphragm and in the thorax. It is estimated that hiatal hernia occurs in more than 15% of the general population, but most are asymptomatic. It should be noted that up to 85% of patients with symptomatic reflux have a hiatal hernia, and hiatal hernia is common in those with erosive esophagitis.

Though gastric acid reflux is an essential component of GERD, refluxate is a combination of gastric juice and duodenal juice in 60%. (7) Acid-only reflux occurs in only 40%. Gastric juice contains both HCl and the enzyme pepsin, while duodenal juice contains alkaline bile salts and pancreatic juice. Acid, pepsin, and bile salts interact together and contribute to erosive esophagitis. There is evidence that they act synergistically, causing more severe mucosal damage to the esophagus than acid alone.

Up to 20% of patients with GERD develop complications. (8) Complications of GERD include the local effects on the esophagus and the effects on the respiratory tract (aspiration pneumonia, asthma, pulmonary fibrosis). Esophageal complications include erosive esophagitis, esophageal ulcers, stricture, and Barrettís esophagus. Some patients with severe esophagitis, including peptic strictures and Barrettís esophagus, do not have heartburn. Ten percent of patients undergoing endoscopy have evidence of Barrettís esophagus.

Barrettís esophagus is the metaplastic change of normal squamous epithelium to not just columnar epithelium, but columnar epithelium containing intestinal metaplasia. It is a premalignant condition. There is significant evidence that Barrett¹s esophageal mucosa is prone to develop adenocarcinoma of the esophagus. Barrett¹s mucosa places the patient at increased risk (30 fold to 350 fold) for the subsequent development of esophageal adenocarcinoma. (9,10) In patients with Barrett¹s mucosa, the risk of developing carcinoma is about 1% per year.

Historically, adenocarcinoma of the esophagus accounted for fewer than 8% of all esophageal tumors, but it now accounts for at least 50% of esophageal cancers. It has been suggested that the rising incidence may be due to the increasing occurrence of Barrett¹s metaplasia. The increased prevalence of adenocarcinoma at the gastroesophageal junction is a matter of concern, and seems to be related to inadequate control of gastroesophageal reflux. (10,11)

Unfortunately, a significant number of patients with Barrettís esophagus have become asymptomatic due to chronic injury of the sensory mechanism of the esophagus. Additionally, control of symptoms (heartburn) is not an indicator of improvement of the metaplasia in these patients. Therefore, as many as 90% of patients with Barrettís esophagus may not seek medical attention for GERD, and early cancers may be missed.

When symptoms of heartburn and regurgitation are present together, the diagnosis of GERD can be established with more than 90% accuracy, and patients can be treated empirically without further diagnostic testing. (12) Further workup, usually with endoscopy, is undertaken on patients with symptoms of GERD that continue after one course of therapy or when proton pump inhibitor use is required for more than 6 weeks. (13)

Diagnostic evaluation of a patient with GERD is indicated when heartburn becomes chronic, is refractory to treatment, or is accompanied by dysphagia, odynophagia, or upper GI bleeding. Esophagogastroduodenoscopy (EGD) with biopsy should be used as the initial evaluation of suspected GERD because it provides the most diagnostic information in one test, and because it has the potential to manage complications such as stricture or bleeding. However, only 60% of patients with GERD symptoms have endoscopic abnormalities.

If the diagnosis of GERD is still suspected after a normal EGD, a 24 hr. pH study should be considered. It is the definitive test for acid reflux. To obtain a meaningful study, the patient must discontinue use of all acid reducing therapy for several days or weeks, and this often precipitates a major increase in symptoms. However, if the acid reducing therapy has been effective in eliminating ongoing injury of the esophagus or respiratory tract, there will not be apparent abnormalities at the time of EGD, and 24 hr. pH monitoring is the only other way to objectively prove the presence of reflux.

Lifestyle modifications and medications are the cornerstone of nonsurgical treatment. (12-14) Helpful lifestyle modifications include elevation of the head of the bed when supine and avoidance of eating for 2 to 3 hours before reclining. Avoidance of fatty or spicy food, cessation of smoking, elimination or reduction in the use of alcohol or caffeine, and even elimination of peppermint or spearmint use can also significantly improve symptoms. However, lifestyle and dietary changes are successful for the long term in only 20% of patients.

Most symptomatic patients treat themselves with over the counter medications, such as antacids or H2-receptor antagonists. Only a small percentage of people who actually experience GERD consult a physician. H2-receptor antagonist use in standard doses can achieve symptomatic relief in 25% to 60% of patients, and endoscopic resolution of esophagitis in 50%. Use of high dose H2-receptor antagonists can result in healing rates of 45-75%.

Proton pump inhibitors (PPI) are the most effective medical therapy to control symptoms and heal esophagitis. Treatment with standard doses of PPIís resolves symptoms in 80-90% of patients, and heals the esophagitis in up to 90%. Larger doses are usually required in patients with high-grade esophagitis. However, GERD is a chronic condition and patients tend to relapse if the drug dose is stopped, decreased, or sometimes even if a dose is skipped. Patients with esophagitis relapse up to 80% of the time within 200 days, both symptomatically and by endoscopy, if PPI therapy is stopped or the drug dose is decreased.

ìTreatment with standard doses of PPIís resolves symptoms in 80-90% of patients, and heals the esophagitis in up to 90%.î

There may also be diminished effectiveness over time, requiring the patient to take increasing doses. There is evidence that the use of lower doses of acid suppressing medical therapy may allow esophageal mucosal damage to occur while the patient is relatively asymptomatic. (15)

The cornerstone of medical treatment is acid reducing therapy, yet the primary abnormality in patients with GERD is a defective LES. That is why the medication is not always completely effective, particularly in patients with a severely weakened LES or in patients with a hiatal hernia. Additionally, the acid reducing therapy does nothing to prevent the effect of pepsin and duodenal contents on the esophageal mucosa. Surgery is the treatment currently available that can prevent esophageal exposure to both gastric and duodenal juices. Antireflux surgery also repairs the hiatal hernia, often a significant contributor to the reflux.

There is general agreement in both the medical and surgical literature on the indications for surgical therapy in the treatment of GERD, (12,13,16-19), as follows:

…        Failure of medical management occurs in about 10% of patients. These patients have persistent, symptomatic esophagitis that are resistant to PPIís, and require escalating doses to treat their symptoms.

…        Young patients may opt for surgery despite successful medical management. This may be due to lifestyle considerations including the desire to avoid life-long medical therapy, the need for continuous therapy, the desire to avoid symptoms if a single dose is missed, or due to the expense of the medication.

…        Most patients experience eradication of heartburn with medication, but many patients still have troublesome regurgitation that forces them to make significant lifestyle modifications. Many patients sleep with the head of the bed elevated or in chairs and avoid evening meals in an attempt to minimize regurgitation. GERD may limit a patientís ability to exercise or play sports, or become pregnant.

Complications of GERD occur in up to 20% of patients. These include continued esophagitis, grade 3 or 4 esophagitis, esophageal ulcers, esophageal stricture, and Barrettís esophagus.

…        Extraesophageal or atypical symptoms are common and are primarily pulmonary and laryngeal. These manifestations include asthma, chronic cough, hoarseness, laryngitis, chest pain, and recurrent aspiration. Although the outcome of surgery in patients with extraesophageal symptoms is, in general, less successful than in patients with typical symptoms, patients tend to require less corticosteroid treatment for asthma after surgery. The best surgical results are in those patients with a good response to PPIís.

…        Finally, patients with a symptomatic hiatal hernia or paraesophageal hernia deserve consideration for surgical repair to correct the hernia.

The indications for antireflux surgery have not really changed, but patient and physician acceptance of a minimal access surgical procedure has increased.

The major goal of the preoperative evaluation is to make a definitive diagnosis. EGD with biopsy and/or 24hr. pH studies are the only tests that can objectively prove reflux. Tests to assess the motor function of the esophagus, and perhaps the stomach, are also needed.

EGD is performed to look for esophagitis and complications of GERD such as stricture or Barrettís metaplasia. EGD also can usually detect hiatal hernia. 24 hr. pH monitoring is the most accurate test for the detection of GERD, but is only 85-90% accurate. It should be performed liberally, but is probably not needed in those patients with typical symptoms of GERD and evidence of esophagitis on endoscopy. It is a useful test in patients with atypical symptoms or extraesophageal manifestations of GERD, or in patients with typical symptoms of GERD but who have normal findings on endoscopy. Unfortunately, patients must stop taking PPIs for 10-14 days prior to testing.

Esophageal manometry is performed to evaluate the strength and adequacy of both the upper and lower esophageal segments, as well as the strength and coordination of peristalsis in the body of the esophagus. It is the definitive test for primary motor disorders of the esophagus, such as achalasia and nutcracker esophagus. In patients with GERD, esophageal manometry determines that 10-15% of patients have poor esophageal motility and may require a partial (Toupet) fundoplication. Patients with GERD tend to have low LES pressures, but they may also be normal or high.

A barium esophagram is the test of choice to evaluate dysphagia. In patients with GERD, it allows assessment of a hiatal hernia or paraesophageal hernia. Barium esophagram is also sensistive in the detection of esophageal strictures. It is not a good test for the detection of reflux. If symptoms of gastric stasis such as nausea and emesis of retained food - are prominent, or if the patient is a diabetic, then a gastric emptying study will rule in or out delayed gastric emptying. A pyloroplasty or pylormyotomy may be required at the time of surgery if there is poor gastric emptying.

Antireflux surgery involves reduction of a hiatal hernia combined with wrapping a portion of the stomach around the LES. This constructs a valve mechanism to re-establish gastroesophageal junction competence. Because this creates a barrier to the reflux of gastric contents, it provides relief of symptoms and prevents the complications associated with GERD.

Surgery for GERD was first performed in 1956, but because of the development of effective medical therapy, and the relatively smaller numbers of patients afflicted, surgical treatment was not widely performed between 1960 and 1990. In 1991, laparoscopic Nissen fundoplication was reported. (16) Since that time, more than 10,000 laparoscopic antireflux procedures have been reported, and many more have been performed. The advantages of laparoscopic antireflux surgery are similar to those reported after other laparoscopic procedures, such as cholecystectomy. These include a short (one night) hospital stay, a quicker return to work and normal activities (two weeks), and fewer complications such as atelectasis, pneumonia, splenic injury, and fewer incisional hernias.

Laparoscopic antireflux surgery is technically challenging and should be performed only by surgeons with training and experience in advanced laparoscopic surgical techniques. The two most commonly performed procedures are the Nissen fundoplication, which is a complete wrap, and a modification of the Toupet fundoplication, which is a partial wrap. The latter is utilized in the small percent of patients who have severe dysmotility of the esophageal body. The mortality of this procedure is essentially zero, and the morbidity is around 5%, which is less than after open surgery. The conversion rate to an open surgical technique is also less than 2%.

Most patients experience a mild degree of dysphagia postoperatively, but this resolves in more than 95% of patients within the first month. The long-term incidence of postoperative dysphagia is 2% or less. Other symptoms that the patient may experience early after the surgery include early satiety, hyperflatulence, bloating, and diarrhea. These symptoms also tend to be transient and resolve with time. The success of the operation in preventing reflux as determined by a 24 hr. pH study one year postoperatively is 93%. (18) Patients with Barrettís esophagus prior to surgery still need surveillance endoscopy after surgery to evaluate for the development of dysplasia.

GERD is an extremely common disease that afflicts millions of people. Most patients can control their symptoms of heartburn with lifestyle changes and medications. The major drawback to medical therapy is its inability to address the underlying problem of a structurally defective LES. At this time, only surgery can improve the function of the LES.

Laparoscopic fundoplication is an option that more patients and their physicians are accepting as an alternative to a lifetime of medication. It is effective therapy for patients with GERD, and for some patients, may be more effective than medical therapy at controlling their symptoms and allow them to resume a normal lifestyle. Laparoscopic antireflux surgery should be strongly considered in patients with poorly controlled reflux, young patients, those with complications from their reflux, and those with atypical reflux symptoms.

ìLaparoscopic fundoplication is an option that more patients and their physicians are accepting as an alternative to a lifetime of medicationî

1. Nebel OT, Fornes MF, Castell DO. Symptomatic gastroesophageal reflux: incidence and precipitating factors. Dig Dis Sci 1976; 21:953-6
   
2. Princeton. Gallup survey on heartburn across America. At: March 28, 1988. The Gallup Organization
   
3. Howard PJ, Heading RC. Epidemiology of gastro-esophageal reflux disease. World J Surg 1992; 16:288-293
   
4. Locke GR, Talley Nj, Fett SL, et al. Prevalence and clinical spectrum of gastroesophageal reflux: A population-based study in Olmstead County, Minnesota. Gastroenterology 1997; 112:1448-1456
   
5. AMA News. March 10, 1997; 7-8
   
6. Stewart MJ, Hartfall SJ. Chronic peptic ulcer of the esophagus. J Path 1929; 32:9-14
   
7. Kauer WH, Peters JH, DeMeester TR, et al. Mixed reflux of gastric and duodenal juices is more harmful to the esophagus than gastric juice alone. The need for surgical therapy is re-emphasized. Ann Surg 1995; 222:525-531
   
8. Tytgat GNJ. Long-term therapy for reflux esophagitis. NEJM 1995; 333:17:1148-1150
   
9. Bremner CG, Bremner RM. Barrettís esophagus. Surg Clin North Am 1997; 77:1115-1137
   
10. Tytgat GNJ, Hameeterman W. The neoplastic potential of columnar-lined (Barrettís) esophagus. World J Surg 1992; 16-308-312
    
11. Chow WH, Findle WD, McLaughlin JK, et al. The relation of gastroesophageal reflux disease and its treatment to adenocarcinoma of the esophagus and gastric cardia. JAMA 1995; 274:474-7
    
12. Katz PO. Treatment of gastroesophageal reflux disease: Use of algorithms to aid in management. Am J Gastroenterol 1999; 94-S3-S10
    
13. Castell Do, Brunton SA, Earest Dl, et al. GERD: management algorithms for primary care physician and the specialist. Pract Gastroenterol 1998; 22:18-46
    
14. Devault KR, Castell DO. Guidelines for the diagnosis and treatment of gastroesophageal reflux disease. In Guidelines 1994 Statement of ACG, AGA, ASGE
    
15. Brossard E, Ollyyo JB, Monnier PH, et al. Columnar-type epithelium (Barrettís epithelium) develops after healing in 18% of adults with erosive esophagitis or ulcerative reflux esophagitis. Gastroenterology 1991; 100(5):A36
    
16. Hinder RA, Smith SL, Klinger PJ, et al. Laparoscopic antireflux surgery: Itís a wrap! Dig Surg 1999; 16:7-11
    
17. Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen Fundoplication: Preliminary report Surg Laparosc Endosc 1991; 1:138-143
    
18. Hunter JG, Trus TL, Branum GD et al. A physiologic approach to laparoscopic fundoplication for gastroesophageal reflux disease. Ann Surg 1996; 226:673-687
    
19. Peters JH, DeMeester TR, Crookes P, et al. The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: Prospective evaluation of 100 patients with typical symptoms. Ann Surg 1998; 228:40-50

Richard L. Whelan, M.D.
Minimal Access Surgery Center
Site Director, Columbia-Presbyterian Medical Center

On the heels of the laparoscopic cholecystectomy ìrevolution,î laparoscopic techniques for more complicated and involved general surgery procedures were introduced. One of these so called ìadvancedî minimally invasive procedures was laparoscopic colectomy. The first such colectomies were carried out in the United States in late 1990.

Exposure inside the abdomen is obtained by pumping C02 into the abdomen through one of the 4 or 5 laparoscopic ports which are inserted through the abdominal wall. The ports are hollow cylinders with diameters ranging from 5 mm to 12 mm that have valves at the external end that prevent the escape of gas. A long telescope hooked up to a camera is inserted through one of the ports and provides the surgeon and his assistants with images of the abdominal organs that are projected on several television monitors in the operating room. The operation is then carried out with a variety of long and slender surgical instruments which are inserted through the ports. After the colon segment in question has been mobilized and resected, it is necessary to enlarge one of the port wounds to an overall length of 5 to 7 cm. in order to safely remove the specimen from the abdomen and to facilitate the re-anastomosis of the remaining bowel ends. Because of the need for this larger wound a more proper name for minimally invasive colectomy is ìlaparoscopic-assisted colectomy.î However, for brevityís sake, the name laparoscopic colectomy will be used in this article. For purposes of comparison, the length of a standard laparotomy incision for colectomy ranges from 15 to 28 cm.



ìEarly reports from ìcenters of excellenceî suggested that laparoscopic coletomy was associated with a number of benefitsî

It was quickly recognized that laparoscopic colectomy was a more difficult procedure than cholecystectomy since it involved more extensive dissection in several different quadrants of the abdomen, required division of the bowel and its blood supply, and also required an anastomosis. The complexity and rather lengthy learning curve of this procedure dissuaded many surgeons from performing these procedures. A persistent group of enthusiasts, however, continued to use the method.

Numerous early reports from ìcenters of excellence suggested that laparoscopic colectomy was associated with a number of short term outcome benefits. It has been well established in both randomized and non-randomized trials that laparoscopic patients havesignificantly less pain and require less pain medication than patients who undergo colectomy via laparotomy (open colectomy). (1) Laparoscopic patients, probably because they have less pain, ambulate earlier and more often than open patients. Similarly, most studies have reported a 1.2 to 3.0 day benefit for laparosocopic patients in regards to length of stay, time until first flatus or bowel movement, and tolerance of a diet. (2)

It has also been demonstrated in more recent randomized trials that pulmonary function is better preserved and more rapidly returns to baseline levels after laparoscopic colectomy than after open colectomy. (3,4) This may translate into a lower rate of pulmonary complications postoperatively. In theory, the number of abdominal wall adhesions to the bowel should be decreased by avoiding a lengthy skin incision, and it is hoped that the rate of late small bowel obstruction will be significantly lower after minimally invasive colectomy.

In the last decade, the instruments and the methods used to perform laparoscopic colectomy have been refined and improved. Many technical problems and challenges have been recognized and overcome.

Recent studies have confirmed the short term outcome benefits mentioned above. Laparoscopic methods have been shown to be effective and safe for the following benign colonic conditions:

…        diverticulitis and diverticular disease in general
…        inflammatory bowel disease
…        rectal prolapse
…        slow transit or dystonic colon
…       benign colonic neoplasms

Of note, recent reports have demonstrated that it is possible to safely perform laparoscopic-assisted near total proctocolectomy with formation of an ileoanal pouch for patients with ulcerative colitis or familial polyposis. This is a very challenging colorectal operation most often performed on young patients and usually requires a full length laparotomy incision. It is not always possible to complete a given case laparoscopically because of severe adhesions, unclear anatomy, or poor tolerance of the C02 pneumoperitoneum. In these cases, it is necessary to ìconvertî to a standard laparotomy incision. The conversion rate in most published series is between 8 and 15 percent. Fortunately, even when conversion is necessary, it is often possible to complete the operation through a smaller laparotomy incision than would otherwise be needed because of the work done laparoscopically prior to the conversion.

Soon after the method was introduced, numerous surgeons began performing laparoscopic colectomy for cancer. In 1993 and 1994, case reports began to surface regarding tumor recurrences that developed in one or more of the port wounds in patients that had undergone laparoscopic colectomy. (5) These ìport wound tumorsî cast doubt on the wisdom of using laparoscopic methods for patients with malignant tumors. Fears regarding these wound recurrences led most general and colon and rectal surgeons to abandon minimally invasive methods for patients with cancer. In order to determine how large a problem the port site tumor issue was and to establish the long term survival and recurrence rates, randomized and prospective trials comparing laparoscopic to open colectomy for patients with colon cancer were initiated. (6) The largest of these trials is the National Cancer Institute sponsored C.O.S.T. trial which, to date, has enrolled about 760 patients. Columbia Presbyterian Medical Center has been one of 48 centers involved in this trial, which will continue to enroll patients until June 2001. A similar European Trial has enrolled over 600 patients. Unfortunately, it will be several years before the five year survival and recurrence rates become available from these multi-center randomized trials.

Although the long term outcome data is not available yet, it has been established that there is no difference in the size of the specimens, the distal and proximal margins, or in the number of lymph nodes recovered when the open and laparoscopic specimens are compared. (2,6) Middle range follow-up data from one single center randomized and numerous non-randomized prospective trials of cancer patients suggest that the chances of a wound tumor forming in a laparoscopic port wound or a traditional laparotomy incision are similar (0.8 to 1%). Therefore, earlier fears that the incidence of port tumors would be considerably higher than the rate of open incisional recurrences appear to have been ill-founded. Most authorities think that poor surgical technique (e.g.: inadvertent grasping or traumatization of the tumor bearing segment) is the most important single factor leading to the formation of these tumors. However, the stage of the primary and the ìbiologyî of the tumor are other pertinent variables. The port site tumor issue has made it clear that surgeons should not perform laparoscopic colectomy for cancer until they have gained considerable laparoscopic experience with colectomy carried out for benign disease. The available middle range survival and recurrence rates from one single center randomized and several non-randomized prospective trials demonstrate no differences when traditional and laparoscopic patients are compared. (6-8) In summary, although five year results are lacking, it appears likely that minimally invasive colectomy for cancer will be shown to be a reasonable option.

The introduction of laparoscopic methods motivated numerous investigators to determine the physiologic impact of laparotomy and minimally invasive techniques. It has been shown in both human and animal studies that laparoscopic procedures, in general, were associated with better preservation of post-operative immune function than the equivalent procedures carried out via laparotomy. (9) Better preserved cell-mediated immune function as judged by delayed-type hypersensitivity testing has been documented after laparoscopic versus open colectomy in a study carried out at Presbyterian Hospital. (10) Other immune parameters such as lymphocyte proliferation, HLA-DR receptor expression, and the ability of monocytes to phagocytise Candida albicans have also been shown to be better preserved after minimally invasive procedures than following laparotomy. Although as of yet unproven, these results raise the possibility that laparoscopic methods may be associated with lower rates of post-operative infection than open techniques. The impact of abdominal surgery on peri-operative tumor growth has also been studied.

It has now been well established, in animal studies, that a full length laparotomy is associated with a period of increased tumor cell proliferation, decreased apoptosis, and increased rates of metastasis and tumor establishment. (11) The laparotomy-associated increased tumor growth is thought to be related to post operative immunosuppression and/or an incision-related serum factor(s). (12) Laparoscopy also stimulates tumor growth but to a significantly smaller degree than laparotomy. Thus far, there is no human data to support the conclusions of the animal studies just mentioned. Nonetheless, there exists the possibility that avoidance of a lengthy laparotomy incision may be associated with oncologic benefits.

In final summary, laparoscopic colectomy is an advanced minimally invasive procedure that has evolved over the last 9 to 10 years. It has been demonstrated that, in experienced hands, it is possible to carry out colonic resections comparable to those obtained with traditional methods. It can safely be said that laparoscopic colectomy for most benign colonic disorders is clearly a reasonable option and has shown to be associated with an improved short term outcome. Curative laparoscopic colectomy for cancer was avoided by most surgeons due to concerns regarding early tumor recurrences in the port wounds as well as a lack of 5 year oncologic results. However, recent middle range results from a number of different trials, both randomized and non-randomized, suggest that the recurrence and survival rates are similar regardless of the technique employed. In regards to port wound tumors, the most recent human data suggests that there is no significant difference in the rate of port and large incision tumor recurrences.

It is the authorís opinion that the long term results from the randomized trials will justify the performance of minimally invasive colectomy in the setting of malignancy. It is clear that cancers should not be attempted until adequate experience has been gained with colectomy for benign disease. Basic science data suggest that laparoscopic methods may be associated with immunologic and oncologic benefits. NewYork-Presbyterian Hospital has experienced surgeons on staff who carry out laparoscopic colectomy on a weekly basis. Several randomized trials regarding patients with colon and rectal cancer are either underway or about to start accruing patients. For more information regarding minimally invasive colectomy, please call (212) 305-6136.

1. Schwenk W, Bohm B, Muller JM. Postoperative pain and fatigue after laparoscopic or conventional colorectal resections. A prospective randomized trial. Surg Endosc 1998; 12:1131-6.
2. Lacy AM, García-Valdecasas JC, Pique JM, et al. Short-term outcome analysis of a randomized study comparing laparoscopic vs open colectomy for colon cancer. Surg Endosc 1995; 9:1101-1105.
3. Milsom JW, Bartholomäus B, Hammerhofer KA, Fazio V, Steiger E, Elson P. A prospective randomized trial comparing laparoscopic versus conventional techniques in colorectal cancer surgery: a preliminary report. J Am Coll Surg 1998; 187:46-57.
4. Schwenk W, Bohm B, Witt C, et al. Pulmonary function following laparoscopic or conventional colorectal resection: A randomized controlled evaluation. Arch Surg 1999; 134:6-13.
5. Wexner SD, Cohen SM. Port site mestastases after laparoscopic colorectal surgery for cure of malignancy. Br J Surg 1995; 82:295-298.
6. Franklin ME, Rosenthal D, Abrego-Medina D, Dorman JP, Glass JL, Norem R, Diaz A. Prospective comparison of open vs. laparoscopic colon surgery for carcinoma: five year results. 1996; 39:s35-s46.
7. Santoro E, Carlini M, Carboni F, et al. Colorectal carcinoma: Laparoscopic versus traditional open surgery. A clinical trial. Hepato-Gastroenterolgy 1999; 46:900-904.
8. Lacy AM, Delgado S, Garcia-Valdecasas JC, et al. Port site metastases and recurrence after laparoscopic colectomy. A randomized trial. Surg Endosc 1998; 12(8):1039-42.
9. Allendorf JD, Bessler M, Whelan RL, et al. Better preservation of immune function after laparoscopic-assisted vs. open bowel resection in a murine model. Dis Colon Rectum 1996; 10 supplement: s67-72.
10. Whelan RL, Franklin M, Donahue J, et al. Postoperative cell mediated immune response is better preserved after laparoscopic versus open colectomy in humans: A preliminary study. Surg Endosc 1998; 12(4)(abstract).
11. Allendorf JDF, Bessler M, Kayton ML, Oesterling SD, Treat MR, Nowygrod R, Whelan RL.. Increased tumor establishment and growth after laparotomy vs. laparoscopy in a murine model. Arch Surg 1995; 130:649-653.
12. Lee SW, Gleason NR, Southall JC, Allendorf JD, Blanco I, Huang EH, Bessler M, Whelan RL. A serum soluble factor(s) stimulates tumor growth following laparotomy in a murine model. Surgical Endoscopy, On line publication 3/24/2000 DOI:10.1007/s004640020061
    
    

The new Minimal Access Surgery Center at New York-Presbyterian Hospital offers the latest advances in minimally invasive surgical and diagnostic techniques for a wide range of conditions, including gallstones, GERD, hernia, and obesity. Minimally invasive surgical services are particularly applicable in the fields of gastroenterology, gynecology, urology, and cardiothoracic surgery and continue to be expanded to other areas. The Center is directed by Dennis L. Fowler, M.D., formerly director of the Allegheny Center for Laparoscopic and Minimally Invasive Surgery in Pittsburgh, Pennsylvania. Dr. Fowler completed his surgical residency at St. Lukeís Hospital in Kansas City, Missouri, and a surgical endoscopy fellowship at Massachusetts General Hospital in Boston. Known worldwide for his expertise in laparoscopic methods for gastroesophageal reflux disease, hernia repair, gallbladder removal and colon surgery, Dr. Fowler pursues research to develop new minimally invasive surgery techniques with a goal toward improving patient outcomes.