Tryst with minimally invasive surgery for cancer: Better late than never

Gaurav Das

doi:10.4103/aort.aort_30_22

EDITORIAL

Year : 2022 | Volume : 2 | Issue : 2 | Page : 63-65

Tryst with minimally invasive surgery for cancer: Better late than never

Gaurav Das
Department of Surgical Oncology, Unit of Tata Memorial Centre, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India

Date of Submission	31-Oct-2022
Date of Acceptance	31-Oct-2022
Date of Web Publication	18-Nov-2022

Correspondence Address:
Dr. Gaurav Das
Room No. 30, Dr. B. Borooah Cancer Institute, Ak Azad Road, Gopinath Nagar, Guwahati - 781 016, Assam
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aort.aort_30_22

How to cite this article:
Das G. Tryst with minimally invasive surgery for cancer: Better late than never. Ann Oncol Res Ther 2022;2:63-5

How to cite this URL:
Das G. Tryst with minimally invasive surgery for cancer: Better late than never. Ann Oncol Res Ther [serial online] 2022 [cited 2023 Mar 29];2:63-5. Available from: http://www.aort.info/text.asp?2022/2/2/63/361497

Introduction

Minimally invasive surgery (MIS) for cancer has made great strides over the past three decades and has become an integral part of standard-of-care surgical approaches in several solid malignancies. In this brief review, I wish to highlight the key developments that have happened over time in special relation to colorectal cancer and esophageal cancer. This is in context to the progress which has been made in our own surgical unit over the past 4 years.

Historical Perspective

The evolution of MIS had its origins in the invention of the first endoscope in 1806 by Philipp Bozzini in Frankfurt.^[1] Over the course of time, such endoscopes and their upgrades were used for diagnostic thoracoscopy and laparoscopy. Swedish Hans Christian Jacobaeus used to do therapeutic pneumothorax thoracoscopically for adhesiolysis in tuberculosis. He was a pioneer on diagnostic laparoscopy.^[2] Around the same time, Bertram Bernheim (Baltimore, US) described the use of a sigmoidoscope.^[3] Georg Kelling (1866–1945, Germany) used to do laparoscopy, which he called “celioscopy,” for the diagnosis of various intra-abdominal lesions and tumors.^[4] Heinz Kalk (Berlin) and John Ruddock (Los Angeles) performed several hundred procedures of diagnostic laparoscopy and biopsies in the first half of the 20^th century.^[5]

Fiber optics and the Hopkins rod-lens system were key developments in the 1960s that propelled MIS by producing better and brighter images.^[6] Kurt Semm (Munich, Germany) was probably the first true exponent of operative laparoscopy. By the 1970s, he was developing instruments for cutting, suturing, and tying knots through “fixed” ports. He performed more than 3000 gynecological procedures by laparoscopy including myomectomies, ovariectomy, and ovarian cyst removal. He also did the first laparoscopic appendicectomy in 1980.^[7] Erich Muhe (Boblingen, Germany) performed the first laparoscopic cholecystectomy in 1985.^[8] Video-laparoscopy with the help of a chip camera mounted to the laparoscope was introduced in 1986. By the 1990s, the use of MIS percolated to almost all the specialties of surgery.

Minimally Invasive Surgery in Colorectal Cancer

The use of MIS in oncology was fostered by the publication of several randomized controlled trials in the early 2000s. The European multicentric COlon carcinoma Laparoscopic or Open Resection (COLOR), the UK MRC Conventional versus Laparoscopic-Assisted Surgery in Colorectal Cancer (CLASICC) trial, and the Clinical Outcome of Surgical Therapy Study group multicentric trial all established the oncological safety of laparoscopic colectomy in colon cancer and provided an alternative to open surgery.^{[9],[10],[11]} The studies showed that there were decreased duration of hospital stay, decreased blood loss, less analgesic requirement in laparoscopic surgery, and lower incidence of surgical site infections. There was no difference in the extent of lymphadenectomy, and survival outcomes were not different between the laparoscopic and open approaches. While there were some concerns about increased incidence of positive radial margin after laparoscopic low anterior resection for rectal cancer in the CLASICC trial, the subsequent COLOR II trial established the equivalence of both laparoscopic and open surgery as far as margin resection rates were concerned whereas postoperative recovery was improved after laparoscopic surgery.^[12]

Some key concerns such as port site metastasis,^[13],[14] adequacy of surgical resection (margins as well as extent of lymphadenectomy), and the effect of pneumoperitoneum on tumor spread were dispelled over time.^[15] MIS caused less alterations of the immune system and lower wound infections and morbidity rates, partly attributable to the preserved immune function. Meta-analysis of trials comparing laparoscopic versus open colectomy demonstrated a reduction in the perioperative mortality associated with laparoscopy. The incidence of wound infections and complications such as incisional hernia were significantly decreased. This is over and above the advantage of better cosmesis of smaller scars.^{[16],[17],[18]}

Minimally Invasive Surgery in Esophageal Cancer

The initial attempts at minimally invasive esophagectomy (MIE) were hybrid operations which combined both open and minimally invasive approaches. It was in 1992 that Cuschieri (Dundee, UK) reported about the endoscopic esophagectomy through a right thoracoscopic approach in five patients.^[19] The same year, Dallemagne (Strasbourg, France) reported about subtotal esophagectomy performed by thoracoscopy and laparoscopy (for gastroplasty) in an 80-year-old man with cancer of the middle third of the esophagus.^[20] In 2002, the Medical Research Council Oesophageal Cancer Working Group (MRC OEO2) published the results of a randomized controlled trial on esophageal cancer with or without preoperative chemotherapy, wherein the esophagectomy was performed using thoracoscopy, laparoscopy, and a cervical anastomosis.^[21] Of the 222 patients, 93% of patients had MIE as planned. The reported operative mortality was only 1.4%, and the incidence of anastomotic leak was 11.7%. The median intensive care unit stay was 1 day, and the median hospital stay was 7 days. These outcomes were favorable compared to the reported series on open esophagectomies. There have been several other published series which have reported lesser early and late complication rates in the patients undergoing MIE compared to the open approach. Such variables include blood loss, hospital stay, decline in vital capacity, and other functional evaluations such as dyspnea-limiting exercise tolerance. At the same time, oncological parameters such as lymph nodal yield and survival rates have been comparable between MIE and open surgeries.^[22] The long-term follow-up results of the MIRO trial, which compared the hybrid approach (laparoscopy and thoracotomy) to the open approach, demonstrated a significantly lower rate of major complications with the former.^[23] The multicenter randomized TIME trial compared MIE (thoracoscopy, laparoscopy, and neck anastomosis) with the open approach and found that MIE was superior with respect to blood loss, length of hospital stay, postoperative pulmonary infections, postoperative pain scores, and quality of life.^[24] Several meta-analyses have shown that overall postoperative complications (and specifically pulmonary complications) were lower in the MIE compared to the open approach.^[25],[26]

Progress in Our Department

I serve at an institute which is a public tertiary cancer care center located in a Tier 2 city in North-East India, catering to more than 12,000 new patients with cancer annually. In the department of surgical oncology, about 1000–1200 major surgeries are performed per year. This is excluding two divisions, namely, head-and-neck oncology and gynecologic oncology. The foray into MIS for cancer truly began in 2018, although a few such surgeries were performed prior to that. The percentage of definitive surgeries for colorectal cancer increased from 10.6% in 2018 to 20.6% in the first three quarters of 2022, and the percentage of minimally invasive esophagectomies increased from a modest 8.7% to 78.4% over the same time period. The number of video-assisted thoracoscopic surgery for lung resections for primary and metastatic disease and that of laparoscopic radical gastrectomy remain confined to just over a dozen cases as of yet. The collective experience of the surgeons of the department in performing MIS for cancer is an area which will improve over a period of time, and a timely audit of the database will prove valuable in the evaluation of the progress made in the institutional MIS program.

A discussion about the robotic approach for cancer surgeries has been purposefully omitted as our department has not ventured into robotic surgeries at the time of writing this manuscript.

Conclusion

The practice of evidence-based medicine in surgical domain includes the adoption of surgical innovations to improve patient care. MIS offers a lot of advantages compared to the open approach, and the body of current evidences suggests its use in the treatment of several cancers, especially colorectal cancer and esophageal cancer, among others.

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