Influence of reduced-port laparoscopic surgery on perioperative indicators, postoperative recovery, and serum inflammation in patients with colorectal carcinoma

Abstract

BACKGROUND

Conventional five-port laparoscopic surgery, the current standard treatment for colorectal carcinoma (CRC), has many disadvantages.

AIM

To assess the influence of reduced-port laparoscopic surgery (RPLS) on perioperative indicators, postoperative recovery, and serum inflammation indexes in patients with CRC.

METHODS

The study included 115 patients with CRC admitted between December 2019 and May 2023, 52 of whom underwent conventional five-port laparoscopic surgery (control group) and 63 of whom underwent RPLS (research group). Comparative analyses were performed on the following dimensions: Perioperative indicators [operation time (OT), incision length, intraoperative blood loss (IBL), and rate of conversion to laparotomy], postoperative recovery (first postoperative exhaust, bowel movement and oral food intake, and bowel sound recovery time), serum inflammation indexes [high-sensitivity C-reactive protein (hs-CRP), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6)], postoperative complications (anastomotic leakage, incisional infection, bleeding, ileus), and therapeutic efficacy.

RESULTS

The two groups had comparable OTs and IBL volumes. However, the research group had a smaller incision length; lower rates of conversion to laparotomy and postoperative total complication; and shorter time of first postoperative exhaust, bowel movement, oral food intake, and bowel sound recovery; all of which were significant. Furthermore, hs-CRP, IL-6, and TNF-α levels in the research group were significantly lower than the baseline and those of the control group, and the total effective rate was higher.

CONCLUSION

RPLS exhibited significant therapeutic efficacy in CRC, resulting in a shorter incision length and a lower conversion rate to laparotomy, while also promoting postoperative recovery, effectively inhibiting the inflammatory response, and reducing the risk of postoperative complications.

Key Words: Reduced-port laparoscopic surgery, Colorectal carcinoma, Perioperative indicators, Postoperative recovery, Serum inflammation indexes

Core Tip: Colorectal carcinoma (CRC) is a fatal but preventable gastrointestinal malignancy, with surgical treatment being the standard of care. However, conventional laparoscopic surgery has obvious disadvantages. This study compared reduced-port laparoscopic surgery (RPLS) and conventional laparoscopic surgery and confirmed that the former had more advantages than the latter in CRC based on perioperative indicators, postoperative recovery, serum inflammatory responses, postoperative complications, and therapeutic efficacy. RPLS not only reduced the incision length and the rate of conversion to laparotomy but also promoted postoperative recovery, effectively inhibited the inflammatory response, and reduced the risk of postoperative complications.

INTRODUCTION

Colorectal carcinoma (CRC) is a fatal but preventable gastrointestinal malignancy and is the third most common cancer worldwide[1]. Smoking, high body fat, lack of exercise, and unhealthy eating habits, among others, may contribute to the occurrence of CRC[2]. Nearly 1.8 million new CRC cases and approximately 900000 associated deaths are reported every year, with a 5-year survival rate < 20% in patients with metastatic CRC[3,4]. Surgical treatment, the standard treatment for CRC, aims to resect the primary tumor and surrounding lymph nodes[5,6]. However, conventional laparoscopic surgery involves a five-port procedure, which not only affects the postoperative aesthetics of patients but also carries the risk of blood vessel and nerve damage in the abdominal wall and complication by trocar site hernia[7,8]. Therefore, optimizing surgical procedures based on conventional laparoscopic surgery could significantly improve the surgical outcomes and postoperative recovery of patients.

Reduced-port laparoscopic surgery (RPLS) implements an auxiliary incision combined with a single-port protocol. Port reduction (final two ports) is achieved by combining two auxiliary operation ports and one observation port in the auxiliary incision and then operating alongside the main operation port to achieve laparoscopic radical resection of CRC[9,10]. This surgical modality is minimally invasive and less labor-intensive[11]. Inaki[12] found that RPLS can be performed for bariatric surgery and sleeve gastrectomy for the resection of benign gastric submucosal tumors, providing better cosmetic effects and even achieving a permanent cure. Borodulin et al[13] demonstrated that the application of RPLS in bilateral salpingectomy provides good cosmetic outcomes while ensuring safety and feasibility. RPLS for patients with CRC has also been reported in previous studies as an alternative to conventional multi-port laparoscopic colectomy[14].

This study hypothesized that RPLS has superior clinical advantages over conventional five-port laparoscopic surgery in the treatment of CRC, which is hereby verified and reported in detail.

MATERIALS AND METHODS

General information

One hundred and fifteen patients with CRC admitted to The First Affiliated Hospital of Ningbo University from December 2019 to May 2023 were selected as the study subjects. The control group (n = 52) underwent conventional five-port laparoscopic surgery, while the research group (n = 63) underwent RPLS. The two case groups were clinically comparable with no significant differences in baseline data (P > 0.05).

Criteria for patient enrollment and exclusion

Inclusion criteria: All patients included in this study were clinically diagnosed with CRC[15] and met the indications for surgical treatment; and had complete clinical data, normal cognitive and communication abilities, and no water–electrolyte disturbance or acid–base imbalance.

Exclusion criteria: Minors, elderly patients aged > 80 years, and pregnant or lactating women were ineligible for this study. Also excluded were patients who had recently received chemoradiotherapy; patients with heart/lung/kidney dysfunction, coagulation dysfunction, autoimmune system defects, or other malignant tumors; and those suffering from serious gastrointestinal dysfunction, disorders, or other diseases before surgery that might affect the evaluation of gastrointestinal function.

Treatment methods

The research group underwent RPLS. The protocol involved performing an auxiliary incision, and a single port was adopted. The conventional two 5-mm auxiliary operation ports and 10-mm observation port were combined in the auxiliary incision of about 5 cm in length and used together with a 12-mm main operation port for the procedure. After general anesthesia, the patient was placed in a lithotomy position with the head low and feet high. A longitudinal incision approximately 5 cm long was made under the umbilicus into the abdomen, and a disposable retractor was placed in it and secured. After cutting the fingertips of a surgical glove, a 5-mm trocar was inserted into the thumb and little finger as the operating ports, and a 10-mm trocar was inserted into the middle finger as the observation port. A CO₂ pneumoperitoneum with an abdominal pressure of 12 mmHg was established, and a 12-mm trocar was inserted as the main operating port and positioned at the location of the CRC. Finally, laparoscopic radical resection of CRC was performed by removing the cancerous bowel segment, anastomosing the intestinal end, and dissecting the regional lymph nodes.

The control group underwent routine five-port laparoscopic surgery. Anesthesia and posture were the same as those in the research group. A pneumoperitoneum was established, the cancerous intestinal segment was removed at the tumor site, the severed intestinal end was anastomosed, and the regional lymph nodes were removed. Finally, indwelling drainage and conventional suture were performed to complete the surgery.

Endpoints

Perioperative indicators: The operation time (OT), incision length, intraoperative blood loss (IBL), and rate of conversion to laparotomy were measured and recorded.

Postoperative recovery: The first postoperative exhaust, bowel movement, and oral food intake, as well as bowel sound recovery, were monitored and documented.

Serum inflammation indexes: Early in the morning, 3 mL of venous blood was collected from the patient with an empty stomach and stored in test tubes for several minutes. After centrifugation, the serum was separated, and the supernatant was collected into EP tubes and refrigerated at −20°C for testing. Enzyme-linked immunosorbent assay was performed to quantify high-sensitivity C-reactive protein (hs-CRP), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6).

Incidence of postoperative complications: Adverse events, such as anastomotic leakage (AL), incision infection, bleeding, and ileus, and their incidence rates were determined and recorded.

Efficacy: Assessment A marked response refers to the significant relief of gastrointestinal symptoms, such as diarrhea, constipation, and rectal bleeding, following treatment; complete removal of cancer lesions on imaging examination; and the absence of postoperative complications or adverse effects. A response is defined as the effective symptom control, complete resection of the cancer on imaging examination, and the presence of mild but controllable complications, such as infection and bleeding, after surgery. Non-response indicates no considerable improvement of symptoms, residual tumor resection by imaging examination, and serious postoperative complications and adverse events. The overall response rate (ORR) is the percentage of the sum of marked response and response cases to the total number of cases.

Statistical analyses

In this study, both the measurement data (expressed as mean ± SE) and counting data (expressed as number of cases and percentage) were imported into SPSS22.0 software package for statistical analyses. The chi-square test (χ²) was used to compare counting data, and the independent sample t-test was used to compare measurement data between groups. In all tests, P < 0.05 indicated statistical significance.

RESULTS

Comparative analysis of baseline data

The comparison of baseline data revealed no significant inter-group differences in terms of sex, age, body mass index, surgical site, and tumor-nodes-metastasis staging (P > 0.05; Table 1).

Table 1 Comparative analysis of baseline data, n (%).

Factors	Control group (n = 52)	Research group (n = 63)	χ2/t	P value
Sex			0.151	0.697
Male	27 (51.92)	35 (55.56)
Female	25 (48.08)	28 (44.44)
Age (yr)	54.10 ± 9.56	55.02 ± 10.97	0.474	0.636
Body mass index (kg/m2)	23.73 ± 2.58	24.05 ± 3.04	0.601	0.549
Surgical site			1.901	0.387
Left colon	18 (34.62)	15 (23.81)
Right colon	20 (38.46)	31 (49.21)
Rectum	14 (26.92)	17 (26.98)
TNM stage			0.813	0.666
II	19 (36.54)	20 (31.75)
III	18 (34.62)	27 (42.86)
IV	15 (28.85)	16 (25.40)

TNM: Tumor-nodes-metastasis.

Comparative analysis of perioperative indicators

The perioperative indicators analyzed included OT, incision length, IBL, and rate of conversion to laparotomy. OT, IBL, and rate of conversion to laparotomy were comparable between the two groups (P > 0.05); however, the research group had a significantly shorter incision length (P < 0.05; Figure 1).

Figure 1 Comparative analysis of operation time, incision length, intraoperative blood loss, and rate of conversion to laparotomy. A: Operation time; B: Incision length; C: Intraoperative blood loss; D: Rate of conversion to laparotomy. ^aP < 0.01.

Comparative analysis of postoperative recovery indexes

The postoperative recovery of patients was determined mainly by postoperative anal exhaust, bowel movement, oral food intake, and bowel sound recovery. The times to the first postoperative exhaust, bowel movement, and oral intake were markedly shorter and time to bowel sound recovery was faster in the research group than in the control group (P < 0.05; Figure 2).

Figure 2 Comparative analysis of postoperative recovery indicators. A: First postoperative anal exhaust time; B: First postoperative bowel movement time; C: First postoperative meal time; D: First postoperative bowel sound recovery time. ^aP < 0.01.

Comparative analysis of serum inflammation indexes

Serum hs-CRP, TNF-α, and IL-6 levels were assessed pre- and postoperatively. No significant inter-group differences were observed in these indexes preoperatively (P > 0.05). However, all of them increased significantly in both groups postoperatively (P < 0.05). However, the levels in the research group were lower than those in the control group (P < 0.05; Figure 3).

Figure 3 Comparative analysis of serum inflammatory factors. A: High-sensitivity C-reactive protein; B: Tumor necrosis factor-α; C: Interleukin-6. ^aP < 0.05; ^bP < 0.01. hs-CRP: High-sensitivity C-reactive protein; TNF-α: Tumor necrosis factor-α; IL-6: Interleukin-6.

Comparative analysis of postoperative complications

In terms of complications, the occurrences of AL, incision infection, bleeding, and ileus were evaluated. The incidence of total postoperative complications was markedly lower in the research group than in the control group (P < 0.05; Table 2).

Table 2 Comparative analysis of postoperative complications, n (%).

Factors	Control group (n = 52)	Research group (n = 63)	χ2	P value
Anastomotic leakage	3 (5.77)	0 (0.00)
Incision infection	10 (19.23)	3 (4.76)
Bleeding	1 (1.92)	2 (3.17)
Ileus	2 (3.85)	4 (6.35)
Total	16 (30.77)	9 (14.29)	4.549	0.033

Comparative analysis of efficacy

The ORR in the research group was 90.48%, which was significantly higher than the 75.00% of the control group (P < 0.05; Table 3).

Table 3 Comparative analysis of efficacy, n (%).

Factors	Control group (n = 52)	Research group (n = 63)	χ2	P value
Marked response	18 (34.62)	35 (55.56)
Response	21 (40.38)	22 (34.92)
Non-response	13 (25.00)	6 (9.52)
Overall response rate	39 (75.00)	57 (90.48)	4.947	0.026

DISCUSSION

Although surgery is the major treatment option for CRC, the procedure can lead to prolonged hospitalization, surgical infection, and postoperative ileus. The popularization of laparoscopic surgery has uncovered a more effective way of addressing these problems[16,17]. This study hypothesized that, compared with conventional five-port laparoscopic surgery, RPLS has a more prominent clinical effect in CRC treatment, which is hereby verified and reported.

In patients with CRC, RPLS has the same effects as five-port laparoscopic surgery in shortening OT, reducing intraoperative bleeding, and lowering the rate of conversion to laparotomy. However, RPLS more effective in shortening the incision length, as demonstrated by the evaluation of perioperative indicators. In terms of postoperative recovery, the research group exhibited significant advantages over the control group with a shorter time to first exhaust, bowel movement, oral food intake, and bowel sound recovery after surgery, indicating that RPLS can accelerate postoperative recovery. This could be attributed to the shorter incision length and less damage to gastrointestinal function in RPLS, ensuring the effective recovery of gastrointestinal function postoperatively[18,19]. Similarly, a meta-analysis indicated a shorter hospital stay in patients with gastric cancer who underwent RPLS compared with those who underwent conventional laparoscopic surgery, further demonstrating that RPLS accelerates patient recovery[20]. Similar to our results, Wu et al[21] found that RPLS has significant advantages over multi-port laparoscopic surgery in reducing surgical incision length, alleviating postoperative pain, shortening the time to first postoperative anal exhaust, and promoting early ambulation in elderly patients with upper rectal cancer.

hs-CRP, TNF-α, and IL-6 are closely correlated with physical trauma-induced inflammatory responses in patients following RPLS[22]. In the present study, postoperative hs-CRP, TNF-α, and IL-6 Levels in the research group increased significantly but were still significantly lower than those in the control group, indicating that RPLS can significantly inhibit surgery-related inflammatory reactions in patients with CRC. In addition, the research group had a lower in-cidence of total postoperative complications, such as AL, incision infection, bleeding, and ileus, than the control group (14.29% vs 30.77%, respectively). Thus, RPLS has a lower risk of postoperative adverse events. The higher safety rate of RPLS may also be attributed to the shorter incision length, indicating relatively less damage to the patient’s body structure and function, thereby ensuring fewer postoperative complications[23,24]. Finally, the research group showed a significantly higher ORR than the control group (90.48% vs 75.00%, respectively), indicating greater therapeutic efficacy obtained with RPLS. Kim et al[25] reported that RPLS for gastric cancer is not only safe and feasible but also has a shorter learning curve, similar to our findings. This is partly because RPLS has no effect on the surgical field, surgical area judgment, and tumor resection, thereby confirming the safety and clinical efficacy of the procedure[26].

The current study has several limitations. First, the sample size was small, and the effect of potentially confounding factors could not be ruled out, which would limit the generalizability of the research results. Second quality of life and stress indicators were not analyzed, which would have further verified the clinical advantages of RPLS. Finally, prognostic outcomes were not assessed, which would have offered insights into the long-term impact of RPLS.

CONCLUSION

In summary, RPLS offers more advantages in the treatment of CRC than five-port laparoscopic surgery, as reflected by a shorter incision length, faster recovery, regulation of the inflammatory response, and higher rates of postoperative safety and efficacy.