Which Surgery is Best Cure for Colorectal Cancer?

English: Persian Gulf (Jan. 18, 2007) - Fleet ...

Laparoscopic surgery (Photo credit: Wikipedia)

English: Colorectal cancer, gross appearance o...

English: Colorectal cancer, gross appearance of an opened colectomy specimen. (Photo credit: Wikipedia)

Advances in diagnosis and staging of colorectal cancer (CRC) plus improvements in adjuvant chemo has improved outcomes. Surgery remains the mainstay if cure is to be achieved, but should it be open or minimally invasive.

With the planned introduction of a national CRC population screening programme in Ireland next year, the ability to catch the cancer early will undoubtedly improve patient prognosis and survivals.

The critical determinants of survival in CRC are the tumour biology and potential for surgical resection.

Cure can only be achieved through surgery, but for it to be successful using the most appropriate surgical techniques are imperative. The most important tenets of using surgery in CRC patients are safety, achieving a cure, avoiding the need for a stoma and optimising functional outcome.

Colorectal Cancer – a Disease of the Elderly

In the future, the incidence of CRC is likely to increase as it is a disease of the aged.

The chance of developing it when you are aged 80 is five times that when you are aged 60. With this, are factors that are likely to make surgery more complicated, such as the presence of multiple co-morbidities, which are, of course, more common the older you get.

The overall risk of dying from CRC surgery is low. It is now estimated as being between 5 and 7%, and it has diminished by up to 40% in the last decade. The factors that have reduced mortality include the increased collaboration between the surgeon and his team, audit, good staging and imaging, and the surgeon being technically adept at the procedures used.

Laparoscopic Surgery for Colorectal Cancer

Minimally invasive options include the keyhole or laparoscopic options. There are advantages to the laparoscopic approach, and it is well established and oncologically safe in the right hands.

There are some data to show the patient recovers more quickly from the surgery because there is no big wound and fewer wound complications. Also it has the advantage that it is cosmetically more appealing.

Comparison with Open Surgery

Despite this, there is only limited evidence that the laparoscopic approach is actually superior in removing all of the cancers when compared with open surgery. There is also the fact that with laparoscopic surgery, there is a considerable learning curve and it takes longer to become adept at doing it. There is the cost of setting up a laparoscopic theatre. To an extent the costs of the procedure are offset by the reduced patient stay in hospital, but in terms of overall costs it is not that much less.

Figures for Ireland

Fewer than 10% of patients in Ireland have a laparoscopic colectomy, with the vast majority of patients getting conventional surgery. However, some patients will obviously benefit from the minimally invasive approach when it is conducted by skilled surgeons in experienced centres with higher caseloads.

The major problem of a local resection in CRC is the high recurrence rates even after complete removal of the rectum and anal canal. The problem is the failure to remove enough tissue at the tumour resection margin. If the circumferential margin is positive, then there is a very high probability of local recurrence and poor outcome. If there is complete excision with a negative circumferential margin then recurrence rates are low and survival high.

In patients with rectal cancer, total mesorectal excision improves survival and reduces local recurrence. This approach is now being applied to radical mesocolic resection for colon cancer.

Prospective results of using radical surgery in patients with stage I-III disease has shown that they have as low as 3.6% recurrence and up to 89% five-year survivals. Surgical resection based on anatomical planes appears to significantly improve outcomes.

Tumour Biology and Adjuvant Therapy

Tumour biology is hugely important because through understanding the biology the correct adjuvant therapies can be used most appropriately. Adjuvant therapy should be used with surgery and not in compensation for it. It is about increasing the success rate with surgical resection.


Future challenges for surgeons include keeping abreast with the improvements to surgical techniques and new imaging modalities and to tailor the appropriate surgical treatment to the individual patient.


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