Synchronous Laparoscopic Resection of Colorectal and Renal/Adrenal Neoplasms
Simon S. M. Ng, FRCSEd (Gen), Janet F. Y. Lee, MD, FRCS (Edin), Raymond Y. C. Yiu, FRCS (Edin), Jimmy C. M. Li, FRACS, and Ka Lau Leung, MD, FRCS (Edin)
Abstract: Synchronous laparoscopic resections of coexisting abdominal diseases are shown to be feasible without additional postoperative morbidity. We report our experience with synchronous laparoscopic resection of colorectal carcinoma and renal/adrenal neoplasms with an emphasis on surgical and oncologic outcomes. Five patients diagnosed to have synchro- nous colorectal carcinoma and renal/adrenal neoplasms (renal cell carcinoma in 2 patients, adrenal cortical adenoma in 2 patients, and adrenal metastasis in 1 patient) underwent synchronous laparoscopic resection. The median operative time was 420 minutes and the median operative blood loss was 1000 mL. Three patients developed minor complications, including wound infection in 2 patients and retention of urine in 1 patient. There was no operative mortality. The median duration of hospital stay was 11 days. At a median follow-up of 17.6 months, no patient developed recurrence of disease. Synchronous laparoscopic resection of colorectal and renal/ adrenal neoplasms is technically feasible and safe.
Key Words: synchronous, laparoscopic resection, colorectal neoplasms, renal cell carcinoma, adrenal neoplasms
(Surg Laparosc Endosc Percutan Tech 2007;17:283-286)
B ecause of the widespread use of computed tomogra- phy (CT), magnetic resonance imaging, and positron emission tomography in preoperative staging work-up of colorectal carcinoma, surgeons are seeing more synchro- nous urologic neoplasms in the kidneys and the adrenal glands.1,2 Some of these lesions are potentially malignant and thus surgical resection, preferably synchronous resection of both colorectal carcinoma and urologic neoplasms, is recommended. With advancements in minimally invasive surgery, synchronous laparoscopic resection of coexisting abdominal diseases and neoplasms is shown to be feasible with no additional postoperative morbidity.3 We have previously reported a case of
synchronous hand-assisted laparoscopic right hemicolect- omy and right adrenalectomy for synchronous colonic and adrenal neoplasms in 2002.4 Recently, we have reported the technical aspects of another case of endolaparoscopic left hemicolectomy and synchronous laparoscopic left radical nephrectomy for obstructive carcinoma of the descending colon and renal cell carcinoma.5 Altogether we have performed 5 cases of synchronous laparoscopic resection of colorectal and renal/adrenal neoplasms in our institution. In this study, we present our surgical experience with these 5 patients with an emphasis on surgical and oncologic outcomes.
MATERIALS AND METHODS
Between July 2000 and July 2005, 5 patients with colorectal carcinoma were diagnosed to have synchro- nous renal/adrenal neoplasms on preoperative staging work-up with CT. Two patients were noted to have unilateral renal mass with contrast enhancement, which was highly suspicious of renal cell carcinoma (Fig. 1). Adrenal metastasis was suspected in 3 patients who had unilateral adrenal mass measuring 2 to 6cm in size (Fig. 2). Endocrine assessment including 24-hour urine for free cortisol and catecholamines was normal in these 3 patients. No other distant metastases were detected. All patients underwent synchronous laparoscopic resection of the colorectal and renal/adrenal neoplasms. The laparo- scopic colorectal procedures and adrenalectomies were performed by colorectal surgeons, whereas the nephrec- tomies were performed by urologists.
The patients were initially placed in the Lloyd- Davies position for performing the laparoscopic colorectal procedures. Our laparoscopic techniques for colorectal resection have been reported previously.6 In principle, we mobilized the relevant segments of the bowel and transected the lymphovascular pedicles with endo- scopic linear staplers intracorporeally. For left-sided colorectal resection, the distal bowel was also transected intracorporeally. The patient was then repositioned for performing the urologic procedures. Thereafter, a port wound was extended to deliver the specimen under the protection of a plastic bag. The division of the remaining mesentery, the marginal artery, and the bowel was done extracorporeally. For right-sided colonic resection, the ileocolic anastomosis was performed extracorporeally
Received for publication January 20, 2006; accepted March 12, 2007. From the Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China. Reprints: Simon S. M. Ng, FRCSEd (Gen), Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China (e-mail: simonng@surgery.cuhk.edu.hk). Copyright @ 2007 by Lippincott Williams & Wilkins
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The laparoscopic urologic procedures were per- formed using a transperitoneal approach. The patients were placed in the lateral decubitus position with the waist flexed. Appropriate working ports were inserted according to the site of the neoplasms. A hand-assisted approach was used in the first case of right adrenalect- omy,4 whereas a totally laparoscopic approach was used in the other cases, depending on the preference of the operating surgeons. The retroperitoneal urologic organs were better exposed after mobilization of the large bowel. For laparoscopic adrenalectomy, the adrenal gland was completely mobilized, and the adrenal vein was controlled before the artery. For laparoscopic radical nephrectomy, the renal artery and vein were freed and divided in sequence with endoscopic linear staplers. The ureter was divided distally to just beyond the iliac vessels. The kidney with the adrenal gland and perirenal fat tissue were dissected en bloc and placed inside an endoscopic bag, and retrieved via an extended port wound, the location of which was determined by the site of the colorectal carcinoma.
The following parameters were recorded: demo- graphic and pathologic data, operative time, blood loss, time to first bowel motion, time to resuming full diet, time to full ambulation, hospital stay, morbidity, mortality, and oncologic outcomes.
RESULTS
The patients’ characteristics and the nature of the laparoscopic procedures are summarized in Table 1. There were 3 men and 2 women, with a median age of 73 (range, 45 to 82). All except 1 patient had comorbidities. One of the patients had undergone 3 synchronous laparoscopic resections: low anterior resection with total mesorectal excision for rectal carcinoma, right adrena- lectomy for adrenal metastasis, and cholecystectomy for gallstones. The median operative time was 420 minutes (range, 335 to 460 min). The median operative blood loss was 1000 mL (range, 200 to 1500 mL), and the median number of units of blood transfusion was 1.5 (range, 0 to 4).
The median times to first bowel motion, resuming full diet, and resuming full ambulation were 4 days (range, 2 to 7d), 5 days (range, 4 to 5d), and 5 days (range, 4 to 6d), respectively. The median duration of hospital stay was 11 days (range, 7 to 21 d). Three patients developed minor complications, including wound infec- tion in 2 patients and retention of urine in 1 patient. There was no operative mortality.
The pathologic data and oncologic outcomes are shown in Table 1. The median length of the colorectal carcinoma was 5cm (range, 5 to 9 cm) and the median number of lymph nodes removed was 21 (range, 11 to 25). The 2 patients with renal mass were pathologically confirmed to have pT1N0 renal cell carcinoma, whereas only 1 of the 3 patients with adrenal mass was confirmed to have metastasis; the other 2 patients had adrenal cortical adenoma. The median length of follow-up was 17.6 months (range, 2.5 to 50.8 mo). One patient died of
| TABLE 1. Patients' Characteristics and Outcomes | |||||
|---|---|---|---|---|---|
| Case 1 | Case 2 | Case 3 | Case 4 | Case 5 | |
| Sex/age (y) | F/82 | F/45 | M/73 | M/80 | M/68 |
| Comorbidities | DM, HT, old CVA | No | DM, HT, old MI | Previous cholecystectomy | HT |
| Colorectal neoplasms | Ascending colon carcinoma | Rectal carcinoma | Sigmoid carcinoma | Descending colon carcinoma | Rectal carcinoma |
| TNM staging of colorectal neoplasms | T3N0M0 | T3N2M0 | T3N0M0 | T3N1M0 | T3N1M1 |
| Urologic neoplasms | Right adrenal cortical adenoma | Left adrenal cortical adenoma | Right renal cell carcinoma | Left renal cell carcinoma | Right adrenal metastasis |
| Size of urologic neoplasms on CT scan (cm) | 6 cm | 2 cm | 5 cm | 4 cm | 4 cm |
| Laparoscopic colorectal procedure | Right hemicolectomy | Abdominoperineal resection | Sigmoid colectomy | Left hemicolectomy | Low anterior resection with total |
| Laparoscopic urologic procedure | Right adrenalectomy (hand-assisted) | Left adrenalectomy | Right radical nephrectomy | Left radical nephrectomy | mesorectal excision (cholecystectomy as well) Right adrenalectomy |
| Operative time (min) | 335 | 420 | 420 | 370 | 460 |
| Blood loss (mL) | 1000 | 700 | 200 | 1500 | 1000 |
| Hospital stay (d) | 11 | 21 | 7 | 9 | 18 |
| Morbidity | No | Perineal wound infection | No | Wound infection | Retention of urine |
| Outcomes | Died from primary lung carcinoma 4 y after the operation (no recurrence) | Died from cardiac event 3 mo after the operation (no recurrence) | Died from myocardial infarction 4 y after the operation (no recurrence) | Remained alive without disease 17 mo after the operation | Remained alive without disease 17 mo after the operation |
| DM indicates diabetes mellitus; HT, hypertension; old CVA, previous history of cerebrovascular accident; old MI, previous history of myocardial infarction. | |||||
sudden cardiac arrest about 3 months after the operation, whereas 2 patients died of primary lung carcinoma and myocardial infarction, respectively, 4 years after the operation (these 2 patients had no evidence of recurrence before they died). No evidence of port site metastasis or recurrence was detected in the remaining 2 patients.
DISCUSSION
Because of the frequent use of imaging modalities like CT, magnetic resonance imaging, and positron emission tomography, an increasing number of asympto- matic synchronous urologic neoplasms is diagnosed incidentally during preoperative staging work-up for colorectal carcinoma.1,2 Synchronous renal cell carcino- ma may be found in up to 4.85% of colorectal carcinoma.1 They can be easily differentiated from other benign renal neoplasms by the characteristic CT features of significant contrast enhancement and central necrotic areas.7 If possible, synchronous resection of both color- ectal and renal carcinomas should be performed for cure.8
Incidental adrenal tumors or adrenal incidentalo- mas are commonly discovered by imaging modalities for reasons unrelated to adrenal diseases, with a prevalence of 1% to 4% by CT.2 Most of these lesions are benign, nonfunctioning cortical adenomas. However, in patients with malignancy who present with adrenal incidentalo- mas, up to 70% of these lesions are found to be adrenal metastasis, especially when the lesions are larger than 2 cm in size.2,9 Moreover, currently there is no imaging modality available that allows the distinction between adrenal adenoma and adrenal metastasis with 100% diagnostic accuracy.10 Therefore, in the absence of other metastasis, a patient with synchronous colorectal carci- noma and suspicious adrenal tumor should have both lesions resected to achieve a cure.
Synchronous resection of both colorectal and renal/ adrenal neoplasms with the conventional open approach, although is technically feasible and can save the patient a second operation, has been deterred by factors such as inconvenient wound to suit both operative fields and additional postoperative morbidity. These problems can be circumvented by the laparoscopic approach. With laparoscopy, different quadrants of the peritoneal cavity can be reached by insertion of extraworking ports. In addition, the laparoscopic approach can offer magnified visualization, early control of the organ’s pedicles, and the ability to effectively screen for conditions that preclude resection (ie, disseminated disease).11 Compar- ing with conventional open colorectal or urologic surgery, the laparoscopic approach is associated with faster postoperative recovery and lower morbidity.11-13 In fact, with advancements in minimally invasive surgery, syn- chronous laparoscopic resection of coexisting colorectal and renal/adrenal neoplasms is shown to be feasible and safe.14,15 The advantages of rapid postoperative recovery and minimal morbidity associated with this synchronous laparoscopic approach are also clearly demonstrated in our study.
There are several issues that must be addressed before performing synchronous laparoscopic resection for coexisting abdominal neoplasms, including planning of port placement, resection of 2 lesions that may contain malignancy in an oncologically safe manner, and se- quence of resection. Preferably, the benign lesion should be resected before the malignant lesion to reduce the chance of spreading malignant cells to the operating area for the benign lesion. In our study, all the colorectal procedures were performed before resection of the renal/ adrenal neoplasms, as these urologic neoplasms were also suspected to be malignant preoperatively. We believe that the retroperitoneal urologic organs will be better exposed after mobilization of the large bowel, especially when both pathologies are located on the same side of the abdomen. If the urologic procedures have been performed first, the bowel will become distended inevitably after 2 to 3 hours of manipulation, and the subsequent colorectal dissection and resection may become technically more difficult.
In our first case of right adrenalectomy for a 6-cm adrenal tumor, a hand-assisted approach was used at the discretion of the operating surgeon.4 Hand-assisted laparoscopy provides a good alternative to the open approach for large adrenal tumors and obese patients.16 The hand-port device allows the surgeon to use his hand to palpate, dissect, retract, and remove large adrenal tumor, but does not require as extensive an incision as open adrenalectomy. The hand-assisted approach can also facilitate dissection and specimen retrieval during synchronous resection of colorectal carcinoma. In a study comparing hand-assisted and standard laparoscopic nephrectomy, the hand-assisted approach was associated with decreased operative time, reduced blood loss, and fewer postoperative complications.17 Thus, the use of the hand during advanced laparoscopic procedures can provide tactile benefits of open surgery with the post- operative advantages of laparoscopy. However, there are surgeons who still prefer to use totally laparoscopic rather than hand-assisted approach in urologic surgery, as they feel that the hand in the operative field takes up too much working space, making visualization and exposure difficult.18
Oncologic outcome is often the most important concern in laparoscopic surgery for malignancy. Ample evidences from the literature have proven that laparo- scopic resection of colorectal carcinoma is oncologically as safe as the open counterpart.13 Recently, studies with intermediate and long-term data have also shown that laparoscopic radical nephrectomy and laparoscopic radi- cal adrenalectomy for localized renal/adrenal malignancy have similar survival rates comparing with open sur- gery.19,20 Synchronous laparoscopic resection is often reckoned to be associated with inferior oncologic out- come because it entails more extensive dissection and manipulation of 2 tumors for a prolonged operative time. Nevertheless, as long as the oncologic principles of open surgery including radical en bloc resection with adequate margins are strictly adhered to, the patients’ oncologic
results will not be jeopardized after synchronous laparo- scopic resection. This is illustrated by the fact that no patients in our study had developed port site metastasis or recurrence during the follow-up period.
In conclusion, our study has shown that synchro- nous laparoscopic resection of colorectal and renal/adre- nal neoplasms is technically feasible and safe, with good short-term clinical outcomes and favorable oncologic outcomes.
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