Surgical Therapy for Colorectal

Adenocarcinoma
Neal Wilkinson, MD, Carol E.H. Scott-Conner, MD, PhD
*
Department of Surgery, University of Iowa Carver College of Medicine, 200 Hawkins Drive,
Iowa City, IA 52240, USA
C
olon and rectal adenocarcinoma was projected to afict 153,800 Amer-
icans in 2007 and was estimated to cause more than 52,000 deaths [1].
Colorectal cancer (CRC) remains the second leading cause of cancer
mortality among men, and the third leading cause among women. Worldwide,
CRC is the fourth most common cancer with approximately 1 million new
cases annually. North America, Europe, Australia, and New Zealand are
high-risk regions [2]. Unfortunately, advanced disease at diagnosis is still all
too common. Locally advanced rectal cancer, node-positive colon cancer,
and metastatic disease still compose a signicant proportion of colon and rectal
cancer [1]. Surgery is the mainstay of treatment, providing denitive manage-
ment and potential cure in early cases, and effective palliation in advanced
cases. Chemotherapy and, sometimes, radiotherapy are essential components
of effective treatment. This article briey reviews the general principles of
surgical management and describes recent developments.
GENERAL PRINCIPLES OF SURGICAL TREATMENT
CRC is generally diagnosed by colonoscopy or contrast radiography. An
increasing percentage of cases are rst detected by abdominal CT. Surgical
planning is inuenced by the cancer location, the clinical stage, and other
factors, such as comorbid conditions, patient frailty, and prior surgery. Preop-
erative colonoscopy provides a secure histologic diagnosis and determines
whether the remainder of the colon is clean of polyps or synchronous cancers.
A preoperative CT scan provides additional staging information and assesses
whether adjacent vital structures, such as the ureters (for low pelvic lesions)
or the duodenum (for right transverse colon lesions), are involved. The local
extent of rectal carcinoma is best assessed by endorectal ultrasound, as de-
scribed in an accompanying article by Bhutani, elsewhere in this issue. Neither
histologic grade nor molecular markers currently inuence the contemplated
surgery, but these factors may become important in subsequent therapy.
*Corresponding author. E-mail address: carol-scott-conner@uiowa.edu
(C.E.H. Scott-Conner).
0889-8553/08/$ see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.gtc.2007.12.012 gastro.theclinics.com
Gastroenterol Clin N Am 37 (2008) 253267
GASTROENTEROLOGY CLINICS
OF NORTH AMERICA
Similarly, serum carcinoembryonic antigen levels do not inuence preoperative
decision making, but may assist in postsurgical monitoring.
Resection is based on standard anatomic regions according to the regional
lymphatic drainage and blood supply (Figs. 1 and 2). An adequate lymphade-
nectomy should remove all draining lymphatics at risk for metastatic involve-
ment. Numerous large clinical trials have demonstrated that surgery alone
results in a 5- or 10-year survival of 50% to 60% for stage III cancer [3,4].
The Cancer Staging Handbook of the American Joint Committee on Cancer
recommends that at least 12 lymph nodes draining the primary cancer should
be excised and examined to ensure proper staging and provide adequate
surgical clearance [5]. For cancers above the peritoneal reection, the length
of colon resected is generally determined by the mesenteric vascular segmental
Fig. 1. Extent of resection (dashed line) for right hemicolectomy for carcinoma of the cecum.
(From Scott-Conner CEH, editor. Chassins operative strategy in colon and rectal surgery. New
York: Springer Verlag; 2006; with kind permission of Springer Science and Business Media.)
254 WILKINSON & SCOTT-CONNER
Fig. 2. Extent of resection (dashed line) for left hemicolectomy for carcinoma of the descend-
ing colon. (From Scott-Conner CEH, editor. Chassins operative strategy in colon and rectal sur-
gery. New York: Springer Verlag; 2006; with kind permission of Springer Science and
Business Media.)
255 SURGICAL THERAPY FOR COLORECTAL ADENOCARCINOMA
anatomy and the surgical margins are usually ample. Frozen sections are rarely
required.
Below the peritoneal reection, the desire for wide surgical margins must be
balanced against sphincter preservation. The most difcult margin to control
may, in fact, not be the longitudinal margin (ie, distance from the cancer to
the sphincters) but the radial margin using the total mesorectal excision
(TME) technique. This technique has been thoroughly analyzed, and is now
considered standard for rectal cancer. The role of staging and neoadjuvant
therapy for rectal cancer is discussed later.
Approximately 5% of patients who undergo colon cancer surgery have
synchronous lesions. The management depends on the relative location of
the synchronous lesions, family history, patient age, and other factors. Most
surgeons prefer an extended resection encompassing both lesions with a single
anastomosis, rather than two discontinuous segmental resections with two
anastomoses. Subtotal colectomy may be required to accomplish this goal.
High-risk situations, such as chronic ulcerative colitis with severe dysplasia
or familial adenomatous polyposis, are best managed by prophylactic surgery
(restorative proctocolectomy) before carcinoma develops. When frank carci-
noma is encountered in these situations, treatment of the existing malignancy
takes precedence over prevention of a subsequent cancer, and a slightly
more conservative resection, such as a subtotal colectomy, rather than restor-
ative proctocolectomy or even proctocolectomy with ileostomy, may be elected
to minimize complications.
In preparation for elective colon resection, the patient undergoes careful
assessment of risk, including cardiac, pulmonary, and hematologic evaluation.
Mechanical bowel cleansing is obtained by a combination of cathartics and
enemas, or by antegrade lavage. If a CRC is nearly obstructing, the bowel
preparation may require modication. Mechanical bowel preparation is supple-
mented by preoperative administration of antibiotics. Surgery is usually
performed under general anesthesia. Epidural catheters are placed for postop-
erative pain control.
RIGHT AND LEFT HEMICOLECTOMY
As an example of open colon resection, consider elective right hemicolectomy,
performed for cancer of the cecum or ascending colon. The lateral peritoneal
attachment is incised, and the colon is mobilized medially, to expose the right
kidney, ureter, and duodenum. The peritoneum is incised over the base of the
mesenteric vesselsin this case, the ileocolic artery and vein. Typically the colon
is divided just proximal to the main trunk of the middle colic artery, to preserve
a robust blood supply to the transverse colon, and the entire cecum and a few
centimeters of terminal ileum are included in the resection. These points of
division are identied and windows are made in the mesenteric surface of the
bowel (Fig. 3). The bowel is divided with a stapling device. The mesentery is
divided between clamps and the resected specimen is removed. Gastrointestinal
256 WILKINSON & SCOTT-CONNER
continuity is established by a stapled (Fig. 4) or hand-sewn (Fig. 5) anastomosis.
The abdomen is closed without external drains.
When the lesion is in the left colon, particularly when below the peritoneal
reection, technical modications allow restoration of intestinal continuity in
Fig. 3. Division of mesentery (arrowhead) during right hemicolectomy. (From Scott-Conner
CEH, editor. Chassins operative strategy in colon and rectal surgery. New York: Springer Ver-
lag; 2006; with kind permission of Springer Science and Business Media.)
257 SURGICAL THERAPY FOR COLORECTAL ADENOCARCINOMA
the deep and narrow connes of the pelvis. The most common method is
transanal insertion of a circular stapling device (Fig. 6).
Unexpected ndings at surgery can require surgical modications. Despite
preoperative workup, peritoneal implants or small hepatic metastases may be
identied by careful palpation at surgery. Generally the surgeon proceeds
with resection of the primary cancer as planned, and performs a biopsy to
document the extent of metastatic disease. When a single isolated metastasis
is identied, it may be excised. Controversy surrounds the issue of whether
to resect a single hepatic metastasis. Surgeons often individualize this decision
based on the size and ease of removal of the lesion. Often, a staged curative
surgery is performed for isolated hepatic metastasis. Proper documentation
of the presence or absence of peritoneal disease strongly impacts on the surgical
decision. Standard therapeutic lymphadenectomy should be performed if
future surgical management of metastatic disease is to be entertained. Aggres-
sive debulking is generally not performed during the primary procedure. It
may be elected later as part of comprehensive multimodality therapy.
Fig. 4. Completion of stapled anastomosis for right hemicolectomy. (From Scott-Conner CEH,
editor. Chassins operative strategy in colon and rectal surgery. New York: Springer Verlag;
2006; with kind permission of Springer Science and Business Media.)
258 WILKINSON & SCOTT-CONNER
Emergency surgery may be required for three cancer complications: colonic
obstruction, bleeding, or perforation. The surgeon should endeavor to remove
the cancer whenever possible, but the complication rate is higher and the qual-
ity of the resection is worse when this surgery is performed in an emergency
situation. Restoration of gastrointestinal continuity is generally not feasible
Fig. 5. Completion of suture anastomosis for right hemicolectomy. (From Scott-Conner CEH,
editor. Chassins operative strategy in colon and rectal surgery. New York: Springer Verlag;
2006; with kind permission of Springer Science and Business Media.)
Fig. 6. Completion of stapled anastomosis after left colon resection by transanal insertion of
a circular stapling device. (From Scott-Conner CEH, editor. Chassins operative strategy in
colon and rectal surgery. New York: Springer Verlag; 2006; with kind permission of Springer
Science and Business Media.)
259 SURGICAL THERAPY FOR COLORECTAL ADENOCARCINOMA
and the patient receives a colostomy. Preoperative marking of possible colos-
tomy sites ensures proper placement of the stoma. With improvements in
systemic therapy, many patients will survive for a signicant time, and a func-
tional stoma can positively impact on their quality of life.
Obstruction is the most common indication for emergency surgery. Surgery
may be limited to a decompressive colostomy or may include resection of the can-
cer with creation of an end colostomy and distal blind pouch (Hartmann proce-
dure). Primary anastomosis is ill advised because the proximal bowel is dilated
and lled with feces. Temporizing endoscopic maneuvers (dilatation and stent
placement) maypermit colonic decompressionwithout surgerythat provides a pe-
riod of time during which the medical condition can be optimized and the diagno-
sis conrmed. Elective resection may be performed thereafter under controlled
conditions. Perforation of CRC is uncommon. It generally requires resection of
the perforated colonic segment with creation of a proximal colostomy (Hartmann
procedure). Bleeding that is sufciently brisk to require surgery is rare.
The surgical treatment of an asymptomatic primary in the setting of
advanced incurable cancer is uncertain. Fear of subsequent complications
from the primary cancer needs to be balanced against delays in chemotherapy
resulting from the surgery. Retrospective reviews demonstrate an acceptable
complication rate, when the primary is left intact and untreated, of obstruction
in 10% to 20%, bleeding in 4%, stula formation in 4%, and perforation [68].
Bleeding, perforation and obstruction, though uncommon, can occur in up to
20% and 30% of patients who survive more than 2 years after such surgery
with an intact primary.
MANAGEMENT OF RECTAL CARCINOMA
Rectal adenocarcinoma was projected to afict 41,400 Americans in the year
2007 [1]. Surgical and adjuvant therapies have recently evolved considerably
to help preserve sphincter function and prevent pelvic recurrence. The tradi-
tional surgical treatment of rectal cancer of radical surgery had excessive local
failure rates. The classic Miles procedure, rst described in 1908, involved
surgical removal of the distal rectum and perineum, including all radial margins
out to the pelvic sidewall. This procedure, however, resulted in a permanent
colostomy and frequent perineal wound complications [9]. Low anterior resec-
tion has therefore grown in favor as an alternative surgical technique, but local
recurrence remains a problem. Improvements in surgical technique have not
been limited to sphincter preservation. TME involves complete sharp surgical
resection of all pelvic nodal tissue in conjunction with a rectal cancer. Using
this technique, Heald and colleagues [10] reported a 5.0% local recurrence
rate, which compared favorably to the best reported results of adjuvant studies
conducted by the North Central Cancer Treatment Group (NCCTG) during
the same period. The NCCTG reported a local recurrence rate of 25%
using conventional surgery plus radiation, and a local recurrence rate of
13.5% using conventional surgery plus chemotherapy and radiation [11].
Although direct comparison of these results is not scientically valid, the
260 WILKINSON & SCOTT-CONNER
importance of TME cannot be ignored as a surgical technique for rectal cancer
[12]. These surgical results, however, have not yet been duplicated. TME alone
therefore is currently not a standard therapy for stage T3 with N disease;
adjuvant therapy with uoropyrimidines and radiation is a category 1 National
Comprehensive Cancer Network recommendation [13].
Preoperative/neoadjuvant therapy for rectal cancer may provide potential
benets of downstaging of the lesion, increased margin clearance, possible
sphincter preservation, decreased tumor spillage intraoperatively, and im-
proved tissue oxygenation and hence radiation efcacy, aside from limiting
small bowel radiation that may occur postoperatively. Generally, the patho-
logic CR rates with neoadjuvant therapy are 10% to 20% and the incidence
of local recurrence is about 3% to 10%. This improvement is achieved at the
expense of 15% to 25% grade 3 toxicity.
LAPAROSCOPIC COLON RESECTION
There must be a nal limit to the development of manipulative surgery. The
knife cannot always have fresh elds for conquest. . ..Very little remains for
the boldest devise or the most dexterous to perform.
Sir John Erichsen, Introductory Address at University College, The
Lancet, 1873;2:489-90
This quotation from the nineteenth century demonstrates how we often fail to
anticipate what we cannot foresee. Minimally invasive surgery (MIS) is rapidly
evolving throughout surgery. The modern trained general surgeon, surgical
oncologist, and colorectal specialist are expanding the role of laparoscopy in
the treatment of colorectal cancer. New indications and contraindications are
emerging that may be modied with further experience. It is essential that
cancer treatment is enhanced and not compromised by this new technique.
Whether laparoscopy for colon cancer is ultimately embraced or rejected by
the medical community is currently unknown. All clinicians involved in the
diagnosis and treatment of colorectal cancer must understand how laparoscopy
impacts on cancer care.
MIS slowly entered into colorectal surgery, possibly because of the technical
complexity of colon surgery, which requires mobilization of large segments of
bowel, dividing large blood vessels in the mesentery, and anastomosis of the
enteric system, with inherent leak and infectious complications. Relative
contraindications include: inadequate surgeon experience, prior surgery pre-
cluding safe dissection, and bowel obstruction that limits bowel mobility and in-
traperitoneal visualization. Certain situations entail more complex and difcult
surgery. For example, obesity or rectal cancers seem to have the highest compli-
cation and conversion rates. There seem to be few absolute contraindications
for laparoscopic surgery for colorectal cancer. With early cancer, curative
MIS has been performed for all standard segmental colon resections with accept-
able results. With advanced cancer, MIS may provide alternatives not usually
considered, such as laparoscopic diversion of an obstructing rectal cancer,
261 SURGICAL THERAPY FOR COLORECTAL ADENOCARCINOMA
palliative resection, or bypass. When adequate cancer surgery cannot be per-
formed for any reason, early conversion to open technique must be performed.
LAPAROSCOPIC EQUIPMENT AND TECHNIQUES
Successful laparoscopy requires adequate surgical training and adequate techni-
cal equipment. The equipment includes excellent video equipment; straight or
zero-degree, angled or 30- or 45-degree laparoscopes of various diameters;
specialized staplers; and other instruments. With better capture technology
and brighter light sources, smaller-diameter laparoscopes can be used (from 10
mm down to 5 mm). Small (2 mm) scopes exist but these instruments may not
be appropriate for oncologic colon resection. The video camera typically captures
two-dimensional images that are directly in line with the lens using rigid instru-
ments. Recent, exciting technical innovations include exible laparoscopes and
three-dimensional systems. With these innovations, the principles of dissection
and anastomosis remain the same; most of these innovations have not signi-
cantly improved the basic technology for performing colon surgery.
Major improvements have been made in cutting and dissection instruments.
Initially, laparoscopic surgeons divided the mesentery with electrocautery, ties,
and metallic clip appliers. This technique was slow, and the clips had an unfor-
tunate tendency to be dislodged during the procedure resulting in intraopera-
tive hemorrhage. Recently developed instruments, such as ultrasonic shears
(Harmonic scalpel) and vessel-sealing cautery shears (Ligasure), permit rapid,
bloodless dissection. These instruments require little training and experience.
New devices promise further improvements. Recently developed laparoscopic
stapling devices that can be deployed through 12-mm ports come in a variety of
thicknesses and lengths. They can be used on bowel or major vessels. Straight
and circular staplers allow for many choices in anastomosis.
LAPAROSCOPIC RIGHT AND LEFT HEMICOLECTOMY
The preparation for laparoscopic colon resection is similar to that for conven-
tional surgery. Several differences should be emphasized. Because the surgeon
cannot palpate the colon, the cancer must be precisely localized preoperatively.
Colonoscopic tattooing is recommended for small lesions because colonoscopic
localization and colonic measurements are notoriously inaccurate when
approached transperitoneally. External clues often sufce to localize large
apple-core or serosally involved cancers. The operating surgeon should encir-
cle the cancer from afar rather than palpate and manipulate the cancer. In
selected cases, a radiographic contrast study, such as a contrast enema or
CT scan, provides a roadmap. Intraoperative colonoscopy to localize a cancer
is time consuming, lls the limited space within the peritoneal cavity with intra-
luminal gas, and renders it more difcult to manipulate the bowel and perform
an anastomosis. The requirements for bowel cleansing and for general anesthe-
sia are the same for laparoscopy as with open surgery. Epidural catheters are
seldom required for postoperative pain management.
262 WILKINSON & SCOTT-CONNER
Laparoscopic right hemicolectomy is the simplest and easiest colonic MIS.
The patient is positioned supine with the left arm tucked to increase the space
for the surgeon and surgical assistant. In select cases lithotomy positioning may
be used, but the perineum need not be prepped. Ports are placed and the colon
is mobilized by gentle medial retraction of the lateral and inferior attachments.
The transverse and ascending colon should become freely mobile to the
midline. A 6-cm long incision is then made for specimen retrieval. Mesentery
and bowel division can be performed extracorporeally with hand-sewn or
stapled ileotransverse anastomosis. The mesenteric defect should be closed
and the bowel returned to the abdominal cavity.
Laparoscopic left colon resection is somewhat different. The patient is
positioned with the legs spread apart to allow access to the anus (Fig. 7). Ports
are placed and the colon mobilized as described before (Fig. 8). The mesentery
and distal colon are often divided with a linear stapler. A small incision is
performed to remove the specimen. Intestinal continuity is restored by transa-
nal insertion of a circular stapling device. The patient is left with several small
incisions. Postoperative recovery is usually rapid.
Fig. 7. Patient position andlocation of surgical teamfor laparoscopic left colon resection. (From
Scott-Conner CEH, editor. Chassins operative strategy in colon and rectal surgery. New York:
Springer Verlag; 2006; with kind permission of Springer Science and Business Media.)
263 SURGICAL THERAPY FOR COLORECTAL ADENOCARCINOMA
TRAINING OF LAPAROSCOPIC SURGEONS
Laparoscopically assisted colectomy has evolved from a clinical experiment into
an accepted procedure in selected surgical communities. Early reports demon-
strated a long learning curve, associated with a technically demanding procedure.
Fowler and colleagues [14] reported a 40% complication rate for the rst 10 cases
and a 0% complication rate for the next 30 cases. Bennett and colleagues [15] re-
ported a less dramatic learning curve, but noted a complication rate of more than
10% until more than 39 cases have been performed. Generally, 30 cases are
needed to become procient in this technique. Conversion rates parallel the
learning curve. They range from 0% to 42% (average 14%). MIS is converted
to open surgery for multiple reasons. The conversion usually reects sound sur-
gical judgment. The benets of MIS cannot come at the expense of adequate can-
cer surgery. Proper oncologic technique takes precedence over laparoscopic
Fig. 8. Laparoscopic mobilization of splenic exure during left colon resection. (From Scott-
Conner CEH, editor. Chassins operative strategy in colon and rectal surgery. New York:
Springer Verlag; 2006; with kind permission of Springer Science and Business Media.)
264 WILKINSON & SCOTT-CONNER
maneuvers. The well-trained surgeon should be able to convert to an open pro-
cedure when adequate laparoscopic resection cannot be achieved.
PORT SITE RECURRENCE
A working denition of port site recurrence is early cancer recurrence at a local
incision after laparoscopy or thoracoscopy. This phenomenon is described
in the literature using various terms, including metastasis, recurrence, and im-
plant. Port site metastasis implies hematogenous or lymphatic spread and this
term is often avoided for this reason. Implant and recurrence are equally
good terms that are often used interchangeably. Soon after laparoscopic chole-
cystectomy became commonplace, cutaneous seeding of a port site was reported
after laparoscopic resection of an unapparent gallbladder cancer [16]. Interest-
ingly, this phenomenon is not specic to cancer. Endometrial implants have
been reported following diagnostic laparoscopy for endometriosis [17]. Recur-
rence at the port site in benign and malignant diseases implies that the phenom-
enon is a local wound problem rather than a metastatic phenomenon.
Two main theories explain port site recurrence. First, indirect contamina-
tion, commonly called the chimney effect, can occur when a pressure
gradient between the pneumoperitoneum and ambient air drives cancer-con-
taminated uid or air into subcutaneous tissue at the port site. Port site
recurrences have occurred in gasless laparoscopy and thoracoscopy, however,
where pressure gradients are unlikely. Second, direct contamination can occur
when viable cancer cells are conveyed into the subcutaneous tissue by way of
surgical instruments or during cancer extraction. Recurrences have been
reported at ports sites that were not used for cancer manipulation or cancer
extraction, however. Presently, neither theory can completely explain all port
site recurrences, but neither theory can be completely discounted.
Because trocar recurrence is rare, most clinical data on this subject come
from case reports or retrospective series. In large MIS colon cancer series,
the risk for local and trocar recurrence parallels the risk in open surgical series.
The currently reported port site recurrence rate is 0.0% to 0.5% (see trials
discussed later). This rate compares favorably with incisional recurrence rates
in open colon cancer surgery.
LAPAROSCOPY AND IMMUNOSUPPRESSION
Surgical trauma causes temporary cell-mediated immunosuppression, which
can be measured as a decline in lymphocyte and neutrophil chemotaxis and
as impaired antigen presentation. Does the compromised immunity from an
open laparotomy have a detrimental oncologic effect? Can MIS decrease the
immunosuppression and improve cancer outcome? Several studies have
compared the systemic stress response from MIS versus open surgery. Cyto-
kine release (including interleukin 6 and 10, C-reactive protein, and granulo-
cyte elastase) seems to be less pronounced in the MIS group [18].
Theoretically, decreasing surgical trauma by MIS may better preserve immune
function and benet the cancer patient.
265 SURGICAL THERAPY FOR COLORECTAL ADENOCARCINOMA
LAPAROSCOPIC CLINICAL TRIALS
Laparoscopic resection of colon cancer remains investigational in many regions
of the United States. Clinical experience ranges from case series to retrospective
reviews, with randomized controlled trials only recently reported. After com-
pleting the learning curve, the laparoscopic approach seems to have benets
over the standard open technique in less frequent hernia formation or small
bowel obstruction, but does not seem to lower the rates of anastomotic leaks
and wound infections or reduce the amount of blood loss. Numerous clinical
trials have shown equivalent surgical margins and lymph node retrieval rates.
Laparoscopic surgery causes less postoperative pain and earlier return of bowel
function. With experienced surgeons and excellent technical hospital support,
MIS seems to have the same complication rate as conventional surgery. Unfor-
tunately, during the learning curve dramatic and otherwise highly unusual
complications have been reported, such as major vascular injuries, uncon-
trolled bowel perforations with gross contamination, and missed lesions.
With growing experience in early enteral feeding of MIS patients, surgeons
have explored a more aggressive feeding strategy after conventional open
surgery. Many surgical patients can tolerate feeding much earlier than appreci-
ated. Early feeding following surgery may be possible for MIS and conven-
tional surgery, thus negating this benet of MIS.
Numerous large clinical series examine the long-term surgical safety of
colorectal MIS. Two large retrospective case series have demonstrated equiva-
lent survival with MIS compared with national surgical standards, including
comparisons to the National Cancer Database and Surveillance, Epidemiology
and End Results. Two recent, large, well-designed, multi-institutional, random-
ized clinical trials compared the disease-free interval and overall survival for
MIS versus open surgery (872 patients in Clinical Outcomes of Surgical Ther-
apy (COST) and 794 patients in Conventional verses Laparoscopic-Assisted
Surgery In patients with Colorectal Cancer (CLASICC) trial) [19,20]. Both tri-
als concluded that MIS oncologic surgery could be performed in experienced
hands (Table 1) [21,22].
In conclusion, with improving surgical instruments and technology and
further surgical experience, laparoscopy should become an increasingly viable
surgical option for patients who have colon cancer.
Table 1
Surgical outcomes comparing MIS and open techniques
Trial Technique Disease-free survival Overall survival Port site recurrence
COST [21] MIS 84% 86% <1%
Open 82% (P NS) 85% (P NS) <1% (P NS)
CLASICC [22] MIS 66% 68% 2.5%
Open 68% (P NS) 67% (P NS) 0.6% (P NS)
Abbreviations: COST, clinical outcomes of surgical therapy; CLASSICC, Conventional verses laparoscopic-
assisted surgery in patients with colorectal cancer.
266 WILKINSON & SCOTT-CONNER
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