Does laparoscopic vs. conventional surgery increase exfoliated cancer cells in the peritoneal cavity during resection of colorectal cancer?
OBJECTIVE
Traumatic manipulation of cancer specimens during laparoscopic colectomy may increase exfoliation of malignant cells into the peritoneal cavity, causing an early occurrence of peritoneal carcinomatosis or port-sites recurrence. Because of this concern, the routine use of intraperitoneal chemotherapy after laparoscopic colectomy for cancer was suggested recently. We assessed if laparoscopic vs. conventional surgery increases exfoliated malignant cells in the peritoneal cavity during resection of colorectal cancer.


METHODS
In a prospective, randomized fashion, 38 colorectal cancer patients undergoing an elective, curative operation were assigned to either a conventional or laparoscopic procedure between June 1996 and May 1997. In either group (n = 19), after the abdominal cavity was entered, saline was instilled into the peritoneal cavity, and the fluid was collected (Specimen 1). During surgery, all irrigating fluids were collected (Specimen 2). Both specimens were assessed for malignancy using four techniques: filtration process (ThinPrep), smear, cell block, and immunochemistry using Ber-EP4. The change in the amount of tumor cells in both specimens was compared between surgical groups. A pilot study was performed to validate the proposed cytologic method.


RESULTS
In the pilot study of 20 consecutive patients with colorectal cancer, postresectional peritoneal cytology was positive in six patients, including two Stage II (T3, N0, M0) patients. The pilot study also validated that our semiquantitative scoring system can be reliably used to assess the amount of free peritoneal cancer cells. In the main study, 16 right colectomies, 3 extended right colectomies, 17 proctosigmoidectomies, and 1 left colectomy were performed. The T and N stages were T1 (n = 13, T2 (n = 5), T3 (n = 8), T4 (n = 11); N0 (n =22), N1 (n = 8), N2 (n = 7). Malignant cells were not detected in any Specimens 1 or, more importantly, in Specimens 2 in either surgical group.


CONCLUSIONS
When performed according to strict oncologic surgical principles, laparoscopic techniques in curative colorectal cancer surgery did not have an increased risk of intraperitoneal cancer cell spillage, compared with conventional techniques. We hope that these results can decrease some of the concerns about tumor cell spillage and seeding during laparoscopy.
Department of Colorectal Surgery, Cleveland Clinic Foundation, Ohio, USA.
S H
SH
Kim
J W
JW
Milsom
T L
TL
Gramlich
S M
SM
Toddy
G I
GI
Shore
J
J
Okuda
V W
VW
Fazio
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001202:Ascitic Fluid / Q000166:cytology*; D003082:Colectomy / Q000379:methods*; D015179:Colorectal Neoplasms / Q000601:surgery*; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009366:Neoplasm Seeding; D010865:Pilot Projects; D011446:Prospective Studies; D007507:Therapeutic Irrigation