Laparoscopic colectomies associated with decreased retrieval of 12 or more lymph nodes compared to open in elective colon cancer surgery

Abstract

Background: Colorectal cancer is the third most commonly diagnosed cancer worldwide. Lymph node (LN) retrieval is a key factor for pathologic staging and prognosis of colorectal cancer. Increase in number of LNs removal suggests improvement in tumour clearance and decrease in metastatic spread. Studies have suggested that excising 12 or more LNs during colectomy in patients with colon cancer is associated with improved survival. To date, there have been no studies to determine whether minimally invasive surgery affects the ability to retrieve 12+ LNs in elective colon cancer surgery. Therefore, we elected to determine whether a difference exists on the ability to retrieve 12+ nodes in elective colon cancer colectomies performed open versus laparoscopic. Methods:The National Surgical Quality Improvement Program (NSQIP) Procedure Specific Colectomy database was analysed for the year 2014-2015. Inclusion criteria were colon cancer (ICD-9 Code 153.9), age greater than 18 years. Exclusion criteria were missing data. Data abstracted included patient demographics, type of operation performed and number of LNs retrieved. The patients were categorised based on their elective colon cancer colectomies such as laparoscopic or open. Binary logistic regression was used to identify confounding variables in the retrieval of 12+ LNs. Results:After accounting for missing cases, a total of 18,792 patients with a diagnosis of colon cancer were analysed. Twelve or more LNs were retrieved in 88% (16,538) of patients, Among them, 2,516 patients underwent laparoscopic colectomy and 5,284 patients underwent open colectomy. The difference was not statistically significant for the average number of LNs retrieved among both the groups. Open operative approach compared to the laparoscopic approach was associated with 15% greater odds of retrieval of >12 LNs (OR 1.148; 95% CI (1.035-1.272); p = 0.008). Conclusion:The majority of colectomies such as open or laparoscopic are able to retrieve 12 or more LNs. However, there are greater odds of retrieving more than 12 LNs with the open approach compared to the laparoscopic approach. By allowing for more LN retrieval, open colectomies suggest improvement in tumour clearance and decrease metastatic spread. Additional research is needed to further investigate the specific factors influencing the ability to retrieve an adequate number of LNs, such as viewing angles provided with an open approach versus laparoscopic approach.

Association between the number of retrieved lymph nodes and demographic/tumour-related characteristics in colorectal cancer: a systematic review and meta-analysis

“…In the meta-analysis, seven studies containing 23 297 patients with colorectal cancer revealed higher LN yield in the T3+T4 group than the T1+T2 group (OR=1.57, 95% CI (1.25 to 1.97), p<0.001, I 2 =70.46%) (figure 2 and online supplemental figure 11). 13 56–59 66 67 Likewise, four studies with 21 293 patients with colon cancer showed higher LN yield in the T3+T4 group than in the T1+T2 group (OR=1.41, 95% CI (1.09 to 1.82), p=0.008, I 2 =68.36%) (figure 3 and online supplemental figure 12). 56 57 59 66 Five studies containing 22 254 patients with colorectal cancer showed that more LNs were obtained from the T2 group than the T1 group (OR=1.88, 95% CI (1.26 to 2.79), p=0.002, I 2 =95.09%) (figure 2 and online supplemental figure 13).…”

“…13 56–59 66 67 Likewise, four studies with 21 293 patients with colon cancer showed higher LN yield in the T3+T4 group than in the T1+T2 group (OR=1.41, 95% CI (1.09 to 1.82), p=0.008, I 2 =68.36%) (figure 3 and online supplemental figure 12). 56 57 59 66 Five studies containing 22 254 patients with colorectal cancer showed that more LNs were obtained from the T2 group than the T1 group (OR=1.88, 95% CI (1.26 to 2.79), p=0.002, I 2 =95.09%) (figure 2 and online supplemental figure 13). 12 14 50 61 63 In addition, 4 studies containing 44 563 patients with colorectal cancer showed that more LNs were obtained from the T3 group than the T1 group (OR=2.96, 95% CI (1.50 to 5.85), p=0.002, I 2 =98.26%) (figure 2 and online supplemental figure 14),12 14 50 63 and 4 studies containing 10 211 patients with colorectal cancer showed that more LNs were obtained from the T4 group than the T1 group (OR=3.95, 95% CI (2.14 to 7.27), p=0.002, I 2 =92.50%) (figure 2 and online supplemental figure 15).…”

“…Finally, 54 studies were included, with 30 included in the systematic review,5 19–47 and 24 in the meta-analysis (figure 1). 12–14 48–68…”

“…In the systematic review of association between the N stage and LN yield in colorectal cancer, six studies mentioned that the N stage had no significant association with the LN yield,21 28 35 38 39 57 whereas the other six studies indicated that the N status played an essential role in the number of retrieved LNs (online supplemental table 6). 23 26 33 36 41 48 In the meta-analysis, 5 studies containing 21 508 patients showed that more LNs could be obtained from the N2 group than the N0 group (OR=1.32, 95% CI (1.15 to 1.51), p<0.001, I 2 =0.72%) (figure 2 and online supplemental figure 17).…”

Clinicopathological Factors Affecting Lymph Node Yield and Positivity in Left-Sided Colon and Rectal Cancers

“…No difference was found in LNY between LS and OS. However, Puckett et al [ 15 ] study showed that an open operative approach, when compared to the laparoscopic approach, was associated with 15% greater odds of retrieval of >12 LNs (OR 1.148; 95% CI (1.035-1.272); p = 0.008).…”