A Cut Above Open Surgery

ALLISON ROSEN, colorectal cancer survivor PHOTO: ADOLFO CHAVEZ III / THE UNIVERSITY OF TEXAS MD ANDERSON CANCER CENTER

After living with Crohn’s disease for most of her life, Allison Rosen was no stranger to gastrointestinal issues. Patients with Crohn’s, a type of inflammatory bowel disease with no cure, suffer from abdominal pain, severe diarrhea, bloody stool and other debilitating symptoms. But at age 32, Rosen was proud to be in the best shape of her life, and her disease had gone into remission.

“I was working out all the time and eating healthy. Then one day, my stomach started to hurt more than usual, and there was definitely increased rectal bleeding, more severe than I had previously experienced,” says the Houston resident, now 37 years old. Rosen figured her Crohn’s was flaring up again, but as the days went by, she noticed signs of something more serious. She lost weight and became very anemic, and her bowel habits changed dramatically. After returning home from an out-of-town bachelorette party, she called her gastroenterologist to schedule a colonoscopy.

“Two days after my scope, my doctor called me on my cell phone and asked if I could come into her office to discuss the results,” she says. “As soon as that happened, I knew something was seriously wrong. In my gut, I feared it was cancer.”

In June 2012, Rosen received a diagnosis of stage 2 colorectal cancer — the disease had spread through the outer layer of the colon wall but not to nearby organs. The next several months would be a whirlwind of chemotherapy, radiation and surgery; over several years, she ended up having three open surgeries. Similarly, Stephen Estrada went through chemotherapy and two open surgeries after receiving a diagnosis of stage 4 colon cancer at just 28 years old. He had been experiencing major abdominal symptoms — bloody stool, terrible cramps — that were initially misdiagnosed as constipation.

STEPHEN ESTRADA, colorectal cancer survivor - PHOTO: SUNNI KIM COOK / CCALLIANCE

“I would be pacing around the neighborhood at 3 in the morning trying to get rid of the pain,” says Estrada, a 31-year-old Denver resident. “I went to the emergency room twice, and they treated me like I was looking for drugs, so my pain went unmanaged for several more weeks.”

Estrada demanded a CT scan, which confirmed his worst fears: a mass in his colon that had broken through the colon wall. Four days later, his doctors rushed him into an emergency open right hemicolectomy, a procedure that removes the right side of the colon and attaches the remaining portion to the small intestine.

Surgery is often the main treatment for colorectal cancer, although the type of procedure depends on the stage and location of the disease. The part of the colon or rectum containing the tumor is removed with either open or minimally invasive surgery. Open surgery involves the tried-and-true method of a single long cut in the abdomen, which gives the surgeon direct and unfettered access to the patient’s organs. Minimally invasive procedures include both laparoscopy-assisted surgery, an operation performed through small cuts in the abdomen with the aid of a camera, and robotic surgery, which is also laparoscopic but conducted by a surgeon who controls robot arms with instruments, theoretically allowing for more precise movements.

Although it wasn’t available as an option for Estrada or Rosen, minimally invasive surgery for colorectal cancer is gaining popularity with patients due to its shorter recovery time. However, is it as effective as traditional open surgery? How much more expensive is minimally invasive surgery?

A number of recent studies investigated the pros and cons of each method of surgery — open, laparoscopic and robotic — in terms of prevalence, efficacy, safety and cost. So far, the findings largely support laparoscopy as safer than open surgery and less costly than robotic.

“There are three ways to do colorectal surgery. One is the traditional open approach, and this is the way most surgeons have been trained for the past couple of decades,” says Martin Weiser, M.D., a surgical oncologist at Memorial Sloan Kettering Cancer Center in New York City. “Second is laparoscopic surgery, which is still relatively new and developed within the last 20 years, and many surgeons had to learn the technique after formal training. Robotic surgery is the newest. It also requires additional training and is a type of laparoscopic using a robot to assist.”

The amount of colon or rectum removed depends on the tumor’s location and how much the cancer has spread. For resectable, or operable, colon cancer, a colectomy removes all or part of the colon, as well as nearby lymph nodes. In a hemicolectomy, the surgeon takes out the part of the colon with cancer, plus a small segment of normal colon on either side. A total colectomy removes the entire colon.

Resectable rectal cancer can be removed with reconnection of the colon to re-establish continuity through an operation called low anterior resection. The surgeon resects the part, or nearly all, of the rectum containing the tumor, as well as a margin of normal tissue on either side and all nearby lymph nodes. If the tumor resides in the very low part of the rectum and involves the anal sphincters, the whole rectum and anus may require removal, known as an abdominalperineal resection, requiring a colostomy.

For rectal cancers, using preoperative chemotherapy and radiation sometimes allows for less aggressive surgery and can avoid the need for a colostomy.

CONSIDERING THE PROS AND CONS

“The primary treatment for colon or rectal cancer that has not spread is surgery to remove the part of the bowel with the tumor, a margin of normal bowel and all the associated lymph nodes,” says George J. Chang, M.D., a colorectal surgeon at the University of Texas MD Anderson Cancer Center, in Houston. “It’s important that we completely remove the tumor with clear margins, and the lymph nodes, whether we perform it in an open or minimally invasive way.”

With the development of new technology, the field has witnessed a widespread shift toward minimally invasive procedures like laparoscopic and robot-assisted surgery.

Several studies have shown that laparoscopic surgery remains oncologically comparable to open surgery but offers many advantages, such as fewer wound complications, quicker return of bowel function and normal diet, shorter postoperative hospitalization and faster recovery. The clinical benefits of robot-assisted surgery compared with the other methods have not been as well documented. A recent observational study aimed to answer this question by analyzing data from the National (Nationwide) Inpatient Sample, the largest all-payer inpatient database in the United States. The study, published last year in Scientific Reports, found that both laparoscopic and robotic surgeries were associated with lower in-hospital mortality, fewer complications and less time as an inpatient than open surgery.

However, the investigators did not find a clear clinical advantage of robotic over laparoscopic surgery. In terms of total cost, robotic surgery was the most expensive operation at $19,185, followed by open surgery at $16,486 and laparoscopic surgery at $13,844. Other studies confirm these results.

For instance, in a report looking strictly at rectal cancer, the mean cost of robotic surgery was $22,640 versus $18,330 for the laparoscopic approach.

Chien-Chang Lee, M.D., principal investigator of the Health Economic Outcomes and Research Group at National Taiwan University Hospital in Taipei, says that robotic and laparoscopic surgeries tend to retain their status as the most and least expensive methods, respectively, after insurance has been applied and patients are asked to pay their portion. “Our data suggest that both laparoscopic and robotic surgery are associated with better survival and lower complication rates as compared with conventional open surgery,” he says.

“Robotic surgery does not offer significant clinical benefit over laparoscopic surgery but is encumbered with a significant increase in cost.”

The analysis is based on data collected between 2008 and 2012, when robotic surgery was first introduced, Lee says. As the technology continues to advance and more surgeons train in the technique, the outcomes and cost of robot-assisted surgery could improve.

Minimally invasive surgery is not right for every patient, however. Open surgery may be more appropriate for those with advanced colorectal cancer or who require emergency surgery. Due to the nature of their disease, Estrada and Rosen were not candidates for minimally invasive surgery.

Estrada’s emergency open right hemicolectomy was followed by six weeks of chemotherapy to shrink the tumor in his mesentery, the tissue that attaches the intestines to the walls of the abdomen. He then went through an experimental NanoKnife procedure that used electrical currents to destroy cancer cells — again, an open surgery due to the location of his tumor. “I wasn't a candidate for laparoscopic surgery, and so for open surgery, the recovery time is much longer,” Estrada says. “I’m naturally a competitive person, and I thought I could get up and go to the gym after surgery, which wasn’t possible. You have to be easy on yourself when you’re healing like that.”

None of Rosen’s surgeries could be done laparoscopically. Her surgeon recommended a total colectomy with a diverting colostomy, which would connect the colon to an opening in the skin of the abdomen to allow stool out.

MAKING A DECISION

But as a young, single woman who wanted to date, she did not want an external colostomy bag and instead requested a colonic J-pouch — a small pouch made by doubling back a short segment of the colon to serve as a storage space for fecal matter. “It was the first major surgery I ever had, so I didn’t realize the extent of effort required for recovery. It was one of the hardest things I ever had to go through. I literally had to learn how to walk again while constantly fighting through abdominal pain,” Rosen says.

According to American Society of Colon and Rectal Surgeons’ clinical practice guidelines for treating colon cancer, surgeons should take a minimally invasive approach to colectomy when possible. However, guidelines regarding rectal cancer take a less definitive stance in supporting minimally invasive surgery. The authors say that, when performed by surgeons experienced in the procedure, laparoscopic surgery can be executed with oncological outcomes equivalent to those of open surgery.

They define oncological outcomes to include overall and cancer-related mortality, overall recurrence, local recurrence, distant metastasis and wound-site recurrence.

“Laparoscopic surgery for rectal cancer can be much more difficult than for colon cancer, and it’s not as broadly performed,” Chang says. “There are many surgeons who might perform colon surgery who do not perform rectal surgery, and it also can take longer to do laparoscopic surgery than open surgery for rectal cancer.”

Chang and other experts emphasize the importance of the surgeon’s experience and expertise in determining outcomes. Patients must consider the surgeon’s comfort with the approach, whether open or minimally invasive. They shouldn’t be afraid to interview surgeons, asking, for example, how frequently they perform surgery for colorectal cancer and what proportion is open versus minimally invasive.

“There are definitely patients that have a particular interest in having a procedure done a certain way, and if that’s the case, I think they should find a person that can do the surgery in that manner,” Weiser says. “There’s a learning curve for these procedures, and so patients should ask how many procedures the surgeon has done. No one is ever offended by that, and if you have a surgeon who is offended, you probably don’t want that person operating on you, because it’s a fair question.”

Both Rosen and Estrada did extensive research after their diagnoses and recommend that every patient do the same. For instance, they both referred to resources from the Colorectal Cancer Alliance (ccalliance.org), which offers a patient and family support navigator program, as well as a private Facebook group called Blue Hope Nation (ccalliance.org/get-support/online-communities), where patients can post questions and get immediate answers.

Although Rosen got the colonic J-pouch, her body kept rejecting it. She developed inflammation of the surgically created pouch and it ended up getting punctured during a routine colonoscopy. That led to an abscess in Rosen’s abdomen, which almost killed her. She had to have another surgery to reverse and reconnect the bowel with a temporary ileostomy in the hopes that the J-pouch would heal in time.

When her surgeon told her the J-pouch couldn’t be recovered, and fearing a cancer recurrence, Rosen chose quality of life over body image and had yet another major operation to remove the pouch completely. She now has an external ileostomy bag, but fully accepts it as part of her body. “After everything I’ve been through, I’m happier and healthier than I was before,” says Rosen, who has been cancer-free since September 2012. “Being alive is more important than being worried about having a scar or an ileostomy bag.”

Like Rosen, Estrada suffered a string of complications after surgery. He started hemorrhaging and having seizures nine days after the NanoKnife procedure. An emergency CT scan revealed that the procedure did not work, and the tumor was growing instead of dying.

Fortunately, Estrada enrolled into an immunotherapy trial in June 2014. His cancer is characterized by a condition known as microsatellite instability-high, which means its cells have trouble repairing their own DNA when damaged. This makes the cells vulnerable to treatments such as those Estrada got in the phase 1 trial: the immunotherapy Tecentriq (atezolizumab), which is already approved to treat urothelial and non-small cell lung cancers, along with Avastin (bevacizumab), which stops the growth of blood vessels that feed tumors.

Cancer-free for one year, Estrada now works as a certified patient and family support navigator and senior coordinator of community engagement for the Colorectal Cancer Alliance. “In the beginning, everything moves quickly, and it’s easy to get caught up in the rush. But I’m all about patients being informed and not making quick decisions,” he says. “Every cancer patient deserves the best, but they have to research and be their own advocates.”