Laparoskopska resekcija širokega črevesa in danke zaradi raka: včeraj, danes, jutri Laparoscopic resection of colon and rectal cancer: past, present and future Tomaž Benedik Klinični center Ljubljana, Klinični oddelek za abdominalno kirurgijo, Bolnica dr. P. Držaja, Ljubljana, Slovenija Avtor za dopisovanje (correspondence to): asist. Tomaž Benedik, dr. med., Bolnica dr. P. Držaja, Klinični oddelek za abdominalno kirurgijo, Vodnikova 62, 1000 Ljubljana, Slovenija Prispelo/Received: 8.4.2006 Kmalu po uveljavitvi laparoskopske metode pri operativnem zdravljenju drugih bolezni v trebušni votlini, predvsem simptomatskih žolčnih kamnov, so se pojavili tudi poskusi uporabe te metode za resekcijo širokega črevesa. Od prve objave laparoskopske resekcije kolona v strokovni literaturi leta 1991 (Jacobs.et al) je tako minilo že četrt stoletja. Kot se v kirurgiji pogosto zgodi, se je začetno navdušenje zaradi številnih prednosti nove metode čez čas ohladilo zaradi poročil o pogostejših pooperativnih zapletih. Rezerviranost do nove metode je bila še zlasti izražena pri laparoskopski resekciji kolona zaradi raka. Rak širokega črevesa in danke je bolezen, ki je potencialno ozdravljiva le z radikalnim kirurškim posegom. Povsem jasno je, da uveljavljenih onkoloških načel operiranja ne moremo in ne smemo obiti in da na tem področju ne sme biti kompromisov. Tako so prva poročila o zasevkih na mestu vbodnih trokarskih ran in o nesprejemljivo visokih stopenj ponovitve bolezni (Nduka et al., 1994, Wexner et al., 1995) učinkovala na uveljavitev laparoskopskega operativnega zdravljenja raka širokega črevesa in danke zelo negativno. Predvsem v luči novo uveljavljene metode za operativno zdravljenje raka danke »Totalne Soon after laparoscopy had become a well- established technique for operative treatment of abdominal pathologies, especially symptomatic gallstones, first attempts were made to apply this procedure for resection of the colon. Nearly a quarter of a century has passed since the publication of the first report on laparoscopic colon resection in 1991 (Jacobs et al). As is often the case in the field of surgery, the initial enthusiasm was soon diminished by the reports on higher postoperative complication rates. Surgeons were particularly reluctant to adopt the new technique for colon resection for cancer. Colorectal cancer is a potentially curable disease on condition that the operating surgeon strictly adheres to the principles of oncologic radicality without making any compromises. The intial reports on unacceptably high rates of port- site metastases and disease recurrence (Nduka et al., 1994, Wexner et al., 1995) have strongly deterred surgeons from adopting the minimally invasive technique for operative treatment of colorectal carcinoma. After the introduction of total mesorectal excision (TME), a new surgical technique for treating rectal cancer (Heald, 1984), the question arose as to whether the new operative therapy Endoscopic Rev, Vol. 11, No. 25, April 2006 mezorektalne ekscizije« – TME (Heald, 1984) so se mnogi spraševali, ali z novo metodo sploh izpostavljamo pravi problem, ki je na prvem mestu radikalno operiranje po onkoloških načelih. Kot je v zgodovini v navadi, je čas zadnji sodnik. Po prvih nespodbudnih poročilih o pooperativnih zapletih po laparskopskih resekcijah širokega črevesa in danke so v sredini devetdesetih let prejšnjega stoletja pričeli multicentrične randomizirane študije, v katerih so primerjali odprto, klasično operativno metodo z laparoskopsko, da bi dobili odgovor o onkološko sprejemljivi varnosti laparoskopske metode. Rezultati metaanalize 12 randomiziranih kliničnih študij, v katere je bilo vključenih 2512 bolnikov z rakom širokega črevesa, je bilo pred kratkim objavljeno v BMJ (Abraham et al.2004). V tej študiji ni bilo statistično pomembnih razlik med obema operativnima metodama glede onkoloških parametrov in pooperativne smrtnosti, pač pa so bili rezultati glede zgodnjega pooperativnega poteka in hitrejšega okrevanja močno v prid laparoskopski metodi. Pomemben mejnik je bila tudi objava konference konsenza o laparoskopski resekciji širokega črevesa zaradi zdravljenja raka v organizaciji Evropskega združenja za endoskopsko kirurgijo EAES (Veldkamp et al., 2004). Na konferenci so sodelovali vidni strokovnjaki s področja kolorektalne in laparoskopske kirugije, med njimi tudi Bill Heald, napravljeni so bili obsežni sistematični pregledi strokovne literature v podatkovnih zbirkah in stališča so bila nato vrednotena po načelih »na dejstvih temelječe medicine« (evidencebased medicine). Rezultate lahko strnemo v ugotovitev, da je laparoskopska resekcija širokega črevesa za zdravljenje raka varna in primerna metoda, ki izboljša kratkoročni pooperativni potek bolezni. Bolniki z rakom širokega črevesa so imeli manj bolečin in znatno hitrejše okrevanje, preživetje pa se je izkazalo za vsaj tako dobro kot pri bolnikih, ki so bili operirani po odprti metodi. V lanskem letu sta Ameriško združenje kolorektalnih kirurgov -ASCRS in Združenje ameriških endoskopskih kirurgov – SAGES objavila uradno stališče o laparoskopski kolektomiji za operativno zdravljenje potencialno kirurško ozdravljivega raka širokega črevesa, ki predstavlja uradno zeleno luč za tovrstne posege v Združenih državah in postavlja tudi standarde in načela zdravljenja. maintains the established oncologic principles. As history shows only time can tell who is right. After the initial discouraging reports on postoperative complications associated with laparoscopic colorectal resection, multicentre randomized trials were initiated in the mid-1990s to compare laparoscopic and conventional open surgery, and to determine whether the former was acceptable from the oncological radicality point of view. The results of meta-analysis of 12 randomized clinical trials, including 2,512 patients with colon and rectal cancer, were recently published in the British Medical Journal (Abraham et al.2004). The study revealed no statistically significant differences between the two operative techniques concerning their oncologic parameters and postoperative mortality rates. Patients operated on by the minimally invasive technique, however, had a much smoother early postoperative course and faster recovery than those undergoing conventional resection. An important milestone was reached by the publiccation of the EAES Consensus Conference on Laparoscopic Resection of Colon Cancer (Veldkamp et al., 2004). The conference brought together prominent experts in the field of colorectal and laparoscopic surgery, among them Professor Bill Heald. Extensive and systematic reviews of the available literature databases were conducted, and the results were evaluated using the evidence-based medicine principles. The laparoscopic resection of colon and rectal carcinoma was shown to be a safe and appropri-ate surgical technique that improved postoperative short-term results. Patients treated laparosco-pically had less postoperative pain and faster recovery than those undergoing conventional surgery. Their survival was at least as good as that in patients operated on conventionally. Last year, the American Society of Colorectal Surgeons (ASCRS) and the Society of American Endoscopic Surgeons (SAGES) jointly endorsed an approval statement on laparoscopic colectomy for curable colon cancer. Thereby they gave the green light to this treatment modality in the States, and established standards for therapy Leading experts in the field stated that in the hands of a skilled and competent surgeon who strictly adheres to the agreed oncologic principles of surgery, laparoscopic colectomy is a safe and Endoscopic Rev, Vol. 11, No. 25, April 2006 Tako je stališče vrha stroke na tem področju v Združenih državah, da je ob pravilni laparoskopski operativni tehniki, upoštevanju onkoloških načel operiranja in z izkušenim laparoskopskim kirurgom laparoskopska resekcija kolona za zdravljenje potencialno kirurško ozdravljivega raka širokega črevesa varna in primerna metoda ter je enakovredna odprti metodi glede radikalnosti. Stališče postavlja tudi standard minimalne operativne izkušenosti kirurga, preden se loti omenjenih posegov. Tako naj bi kirurg opravil vsaj 20 laparoskopskih resekcij širokega črevesa z anastomozo zaradi benignih bolezni ali pri napredovalem raku z zasevki, preden lahko prične z laparoskopsko kolektomijo za operativno zdravljenje potencialno kirurško ozdravljivega raka širokega črevesa. Naj na tem mestu omenim še izkušnjo enega od pomembnejših svetovnih centrov s področja kolorektalne kirugije, St Mark's Hospital and Academic Institute, London. Ko sem obiskal kongres v njihovi organizaciji decembra leta 2004, so vsi njihovi vodilni kolorektalni kirurgi, kot sta J. Nichols in J. Northover, soglašali, da je laparoskopska resekcija kolona zaradi raka prva metoda izbire. Vpraševali so se le o vzrokih za močno zaostajanje britanske kirurgije na tem področju. Demonstrativno operacijo: laparoskopsko levo hemikolektomijo je namreč operiral vabljeni Leroy iz Strassbourga. Ugotovili so, da so jih Evropejci prehiteli zaradi drugačne organizacije specializacij. Evropski abdominalni kirurg je namreč zaradi rutinskih laparoskopskih holecistektomij vešč laparoskopskega pristopa in kolorektalne kirurgije, britanski kolorektalni kirurg pa le slednje. V najkrajšem času so potem v letu 2005 pri britanskih zdravstvenih oblasteh pričeli projekt za edukacijo kolorektalnih kirurgov s področja laparoskopske operativne tehnike, v St Mark's Hospital and Academic Institute pa sta zaposlila tudi nekaj vodilnih, laparoskopskih operacij veščih kirurgov iz drugih centrov. Zeleno luč torej imamo. Laparoskopska resekcija širokega črevesa in danke zaradi raka je varna in primerna metoda s številnimi prednostmi za bolnika in hitrejšim pooperativnim okrevanjem. V rokah izkušenega laparoskopskega kirurga in ob upoštevanju onkoloških načel je glede dolgoletnega preživetja vsaj tako učinkovita kot odprta metoda. Seveda pa so tovstne laparoskopske resekcije zahtevni posegi, ki zahtevajo precej obvladanja effective therapy for a curable colorectal cancer, equal to open surgery as concerns its oncologic radicality. The ASCRS/SAGES Statement sets minimum standards of experience for surgeons embarking on this type of surgery. To be able to carry out laparoscopic colectomy for a curable cancer of the colon, a surgeon must have accomplished at least 20 laparoscopic resections of the colon with anastomosis for benign tumors or advanced metastazing carcinomas. I would also like to mention the experience of one of the leading world centres of colorectal surgery, St Mark's Hospital and Academic Institute, London. At the congress organized by this institution in 2004, all leading colorectal surgeons unanimously recommended laparoscopic colon resection as the first-choice method for treating carcinoma. The question was raised, however, why British surgery was lagging behind in this area. The demonstration of laparoscopic left hemicolectomy was namely done by the invited surgeon Leroy from Strassbourg. British surgeons believed that their European colleagues were ahead of them because of different structure of their specialty training programme: abdominal surgeons in Europe gain skills in minimally invasive surgery by performing routine laparoscopic cholecytectomies and colorectal operations, while the training programme in Great Britain includes only the latter. The British health authorities responded quickly, and in 2005, a training programme in laparoscopic surgery for colorectal surgeons was initiated. St. Mark's Hospital and Academic Institute employed several prominent surgeons skilled in laparoscopic operations, from other centres. The discipline has thereby been given new impetus. Laparoscopic resection for colorectal carcinoma has proved to be a safe and appropriate treatment modality with many benefits for the patient, including faster postoperative recovery. In the hands of a skilled laparoscopic surgeon committed to follow closely oncologic principles, the laparoscopic technique is equal to open surgery regarding long-term survival. It goes without saying that laparoscopic resections are technically demanding and therefore require mastery of advanced endoscopic skills and experience in colorectal surgery. The only limitation seems to be that these procedures should preferably be performed in specialized surgery Endoscopic Rev, Vol. 11, No. 25, April 2006 veščin endoskopskega operiranja in določeno število izkušenj s področja kolorektalne kirurgije. Tu pa vidim tudi edino omejitev glede mesta, kjer naj bi tovrstne posege opravljali – v bolnišnicah z zadostnim številom kolorektalnih in laparoskopskih operacij, ker vaja dela mojstra. Če si dovolim pogled naprej, upam, da bomo lahko našim bolnikom z rakom širokega črevesa in danke v bližnji prihodnosti v centrih, ki se ukvarjajo s kolorektalno kirurgijo, ponudili to operativno metodo kot prvo metodo izbire in zlati standard za operativno zdravljenje te bolezni. centres that do a high volume of colorectal operations and laparoscopic procedures and have adequate experience with this kind of surgery. In the future, hopefully new national centres specialized in colorectal surgery will offer patients with colorectal cancer minimally invasive technique as the first-choice treatment modality and gold standard for treating this disease. Endoscopic Rev, Vol. 11, No. 25, April 2006