Systematic review of laparoscopic surgery for colorectal malignancy

Background: We set out to evaluate the current literature on the use of laparoscopic surgery for malignant colorectal disease and identify its place in current practice. Methods: We performed a systematic review of the literature that included papers published from January 1991 to March 1997. Inclusion criteria were used to select the most robust studies. The quality of each study was assessed against predefined criteria and weighted according to hierarchy of evidence and sample size. Results: The published literature was found to be low in the hierarchy of evidence. Of the 157 studies located, only 42 papers were found to be of sufficiently high quality to be included in the review. Only 13 of these 42 papers concentrated specifically on malignant colorectal disease. We noted the following findings: The average age of patients was 63.2 years. The most frequently reported contraindication to laparoscopic surgery was obesity. Conversion rate to open procedure varied between 1.5% and 48%. The most common postoperative complication was wound infection. Thirty-day mortality varied between 0 and 5.1%. Disease stage and pathology were poorly reported. Patient recovery benefits varied. It was not possible to identify the effectiveness, safety, survival outcome, or cost of laparoscopic surgery for colorectal malignancy in comparison to open surgery. Conclusions: Six years after the first report of laparoscopic surgery, studies low in the hierarchy of evidence continue to be reported. This reflects a lack of control following the introduction of this new technology. The majority of reports continue to be feasibility studies. The variable nature and content of the literature demonstrate the lack of standardization and the absence of an agreed core minimum data set. The benefit of laparoscopic surgery for malignant colorectal disease remains unclear. Until the mechanisms of port site recurrences are elucidated and long-term data on survival outcomes become available, laparoscopic surgery for malignant disease should be carried out only in the context of a large, multicenter randomized controlled trial.