Umeå University Medical Dissertations

Umeå University Medical Dissertations
Umeå University Medical Dissertations
New series No 889 – ISBN 91-7305-613-8 ISSN 0346-6612
From the Department of Surgical and Perioperative Sciences, Surgery,
Umeå University Hospital,
Umeå, Sweden
LAPAROSCOPY AND TUMOUR GROWTH
A clinical and experimental study
Owe Lundberg
Umeå 2004
Copyright © Owe Lundberg
ISBN 91-7305-613-8
Printed by Solfjädern Offset
Umeå, Sweden, 2004
To my late Grandfather Bertil who never had a
chance
CONTENTS
ABBREVIATIONS
6
ABSTRACT
7
POPULÄRVETENSKAPLIG SAMMANFATTNING
9
ORIGINAL PAPERS
11
INTRODUCTION
12
History of laparoscopic surgery
13
Carcinoma of the gallbladder
15
The concept and aetiology of port site metastases
20
AIMS
4
Definition
20
Clinical situation
21
Incidence
22
Aetiology
23
-Haematogenous spread
23
-Wound implantation
23
-Surgical technique
24
-Pneumoperitoneum
25
-Immune response
27
30
PATIENTS, MATERIALS AND METHODS
31
Clinical studies – paper I, II and III
31
Statistics and ethics
32
Experimental studies – paper IV, V and VI
33
Laser Doppler blood flow
36
Statistics and ethics
37
RESULTS
38
Clinical studies – paper I, II and III
38
Experimental studies – paper IV, V and VI
43
DISCUSSION
44
Clinical studies - paper I, II and III
44
Experimental studies - paper IV, V and VI
49
SUMMARY AND CONCLUSIONS
53
ACKNOWLEDGEMENTS
54
REFERENCES
55
PAPERS I-VI
72
5
ABBREVIATIONS
ACTH
ADH
CRP
DTH
EpC
GBC
GH
IFN-γ
IL-1,-2,-6
LC
LDF
NK-cells
OC
PSM
PU
SoS
Th-cells
TSH
TNF-α
6
Adrenocorticotropic stimulating hormone
Antidiuretic hormone
C-reactive protein
Delayed type hypersensitivity
Epidemiologiskt centrum
Gallbladder cancer
Growth hormone
Interferon gamma
Interleukin 1, 2 and 6
Laparoscopic cholecystectomy
Laser Doppler flowmetry
Natural Killer cells
Open cholecystectomy
Port site metastases
Perfusion units
Socialstyrelsen
T-helper cells
Thyroid stimulating hormone
Tumour necrosis factor alpha
ABSTRACT
Background and aims: Laparoscopic technique was quickly adopted in
general surgery because of less pain, quicker recovery and shorter hospital
stay. In the 1990´s several reports on port site metastases restrained the enthusiasm to use laparoscopic surgery in malignant diseases. The numerous
reports on port site metastases initiated a debate whether laparoscopic surgery would increase the risk of tumour spread and growth. Personal experience of two patients who developed port site metastases from an incidental
gallbladder cancer (GBC) after laparoscopic cholecystectomy (LC), encouraged us to study the incidence of wound metastases from gallbladder cancer
after laparoscopic and open cholecystectomy (OC). Experimentally we examined whether pneumoperitoneum would increase the risk of tumour development. Several studies had demonstrated that minimally invasive procedures exert a less negative influence on the immune system and may have
beneficial effects for cancer patients.We wanted to compare the long term
survival after OC and LC and if the occurrence of port site metastases had
any impact on survival.
Material and methods: A questionnaire was sent to all major hospitals in
Sweden requesting information about the number of port site metastases
encountered 1991-1994. Data on all patients with verified GBC were obtained from the Swedish Oncological Centres. Data on all patients with
gallbladder cancer registered with surgical codes for cholecystectomy were
collected from the National Board of Health and Welfare (EpC). The patient
files were scrutinised and long term survival data was achieved (EpC).
In the first experiment on Wistar Fu rats, adenocarcinoma cells were injected intraperitoneally in animals insufflated with air, CO2 and in not insufflated controls. In the following studies, rats were similarly insufflated with
air, CO2 and compared to not insufflated controls. Laser Doppler blood flow
in the abdominal wall was concomitantly measured. To study the effect of
reduced blood flow, one rectus muscle was clamped and the other not and
laser Doppler blood flow was measured in both rectus muscles. Adenocarcinoma cells were injected into the rectus muscles in all animals at the induction of pneumoperitoneum /clamping.
Results: 14 of 55 patients developed wound metastases from gallbladder
cancer after LC and 12 of 187 after OC. Gallbladder perforation was overrepresented in patients with wound metastases. Improved survival was noted
after LC in patients with T3 tumours. Experimentally, air and CO2 equally
increased intraperitoneal tumour development. Insufflation with air, CO2
and clamping decreased blood flow in the abdominal wall and increased
tumour growth at the same site.
7
Conclusion: Despite a high rate of wound metastases, LC does not seem to
worsen the prognosis of GBC and may even have a positive effect on survival. Perforation of the malignant gallbladder seems to be associated with
an increased risk of metastatic formation. In the experimental setting,
pneumoperitoneum seems to increase tumour development. Other features
of laparoscopic surgery such as decreased blood flow in the abdominal wall
may contribute to increased risk of tumour progress.
Key words: Laparoscopy, tumour growth, metastases, gallbladder cancer,
pneumoperitoneum, blood flow.
8
POPULÄRVETENSKAPLIG SAMMANFATTNING (SUMMARY IN
SWEDISH).
Den snabba utvecklingen och spridningen av den laparoskopiska kirurgin torde sakna motstycke i den moderna kirurgins historia. Fördelarna
med mindre smärta, snabbare återhämtning och kortare sjukhusvistelse utgjorde grunden till genombrottet för denna s.k. ”titthålskirurgi”. Tidigt utfördes även cancerkirurgi med laparoskopisk teknik men rapporter om dottersvulster i ärren efter titthålsinstrumenten, s.k. porthålsmetastaser, gjorde
att entusiasmen för laparoskopisk cancerkirurgi avtog. En intensiv debatt
vidtog huruvida laparoskopisk kirurgi ökade risken för tumörspridning. Ett
flertal studier visade samtidigt att laparoskopisk kirurgi var mindre påfrestande för patienterna och sannolikt ett bättre bevarat immunförsvar. Laparoskopisk teknik skulle därmed teoretiskt sett kunna innebära en minskad risk
för tumörspridning för cancerpatienter som opererades med denna teknik.
En patient av hundra som genomgår gallblåsekirurgi har gallblåsecancer. Inte sällan är detta ett överraskningsfynd då diagnosen oftast är okänd
före operationen. Efter att personligen ha opererat ett par patienter som senare utvecklade porthålsmetastaser från gallblåsecancer, väcktes intresset att
studera frekvensen av detta nya och okända fenomen.
En förfrågan om antalet porthålsmetastaser som påträffats 1991-1994,
skickades till alla större sjukhus i Sverige. Med hjälp av register för patienter med gallblåsecancer (Onkologiska Centra) och operationskoder för öppen och laparoskopisk galloperation (SoS; EpC) kunde vi beräkna antalet
patienter med gallblåsecancer som opererats med borttagande av gallblåsan.
Efter att ha läst igenom samtliga patientjournaler kunde andelen ärrmetastaser utvärderas. Utdrag ur dödsorsaksregistret gav oss senare tillgång till
långtidsuppföljning och möjlighet att i efterhand utvärdera om överlevnadstiden påverkades om patienter var opererade med öppen eller laparoskopisk
teknik.
Resultaten visade att patienter med gallblåsecancer opererade med
laparoskopisk teknik utvecklade ärrmetastaser i fler fall än de öppet opererade. Däremot verkade risken vara mindre att dö i sin gallblåsecancer för
patienter opererade med laparoskopisk jämfört med öppen teknik. Kirurgisk
teknik, avspeglat som instrumentorsakat hål i den canceromvandlade gallblåsan (gallblåseperforation) har ofta föregått uppkomsten av ärrmetastaser.
Metastaser från gallblåsecancer till operationsärret är oftast ett uttryck för
redan spridd sjukdom och har oftast i sig ingen avgörande inverkan på den
för gallblåsecancer redan dåliga prognosen. Dock finns enstaka fall av patienter med tidig gallblåsecancer där gallblåseperforation orsakad av kirurg/instrumenthantering kan ha haft betydelse för spridning av cancersjukdomen. Även om hål i gallblåsan är överrepresenterat vid laparoskopisk
9
kirurgi så finns det inga säkra belägg för att detta skulle innebära en ökad
risk för utveckling av metastaser i operationsärret. Kliniskt bör man dock
försöka att identifiera patienter med gallblåsecancer före operationen så att
den elakartade tumören kan hanteras på ett kirurgiskt adekvat sätt. I de enstaka fall med tidig och potentiellt botbar gallblåsecancer bör sannolikt öppen kirurgi väljas framför allt som den förmodligen är mindre behäftad med
risk för perforation av gallblåsan.
Djurexperimentellt har vi på råtta studerat hur den gasinblåsning (insufflation) som används vid laparoskopisk kirurgi påverkar tumörtillväxten i
bukhålan. Koldioxid (CO2) som är den gas som används vid laparoskopisk
kirurgi har använts och jämförts med inblåsning av vanlig rumsluft. Tumörceller injicerades i bukhålan och buken hölls uppblåst i 45 min till ett tryck
av 10 mmHg. Efter 12 dagar avlivades djuren och en ökad tumörutveckling
hos både luft och CO2 insufflerade råttor jämfört med icke insufflerade kontroller kunde noteras. Även den uppblåsta buken (pneumoperitoneum) och
dess påverkan på blodflödet i bukväggen och samtidig effekt på tumörtillväxt har studerats. Då inblåsning av gas (CO2 eller luft) påtagligt minskade
blodflödet i bukväggen på råttorna har även blodflödesminskning med mekanisk avstängning studerats. Efter injektion av tumörceller i bukväggen och
insufflation som tidigare beskrivits, noterades en ökad tumörtillväxt i bukväggen hos djur insufflerade med CO2 eller luft. Även blodflödesminskning
med mekanisk avstängning orsakade en viss ökning av tumörtillväxten. Detta skulle kunna tyda på att blodflödesminskning i bukväggen bidrar till ökad
tumörtillväxt.
Sammanfattningsvis finns det inga belägg för att laparoskopisk kirurgi
vid gallblåsecancer skulle innebära en försämrad prognos även om det finns
indikationer på en ökad frekvens ärrmetastaser. Det kan finnas företeelser i
den laparoskopiska kirurgin som påverkar tumörspridning och tumörtag/tumörtillväxt i både positiv och negativ riktning. Fortsatt forskning behövs för att vi ska kunna minimera laparoskopiteknikens eventuella negativa
effekter och samtidigt utnyttja dess positiva potential även vid kirurgi på
patienter med cancersjukdom.
10
ORIGINAL PAPERS
This thesis is based on the following papers, which will be referred to in the
text by their Roman numerals:
I.
Lundberg O, Kristoffersson A. Port Site Metastases from Gallbladder Cancer after Laparoscopic Cholecystectomy. Results of a Swedish Survey and Review of Published Reports. Eur J Surg 1999;
165:215-222.
II.
Lundberg O, Kristoffersson A. Wound recurrences from gallbladder
cancer after open cholecystectomy. Surgery 2000; 127:296-300.
III.
Lundberg O, Öberg Å, Kristoffersson A. Long term results after
open and laparoscopic surgery for gallbladder carcinoma (submitted).
IV.
Lundberg O, Kristofferson A. Effect of pneumoperitoneum induced
by carbon dioxide and air on tumor load in a rat model. World J Surg
1998; 22:470-472.
V.
Lundberg O, Kristoffersson A. Pneumoperitoneum impairs blood
flow and augments tumor growth in the abdominal wall – an experimental study in rats. Surg Endosc DOI: 10.1007/s00464-0039035-7 29 December 2003 (Epub ahead of print).
VI.
Lundberg O, Kristoffersson A. Reduction of abdominal wall blood
flow by clamping or CO2 insufflation increases tumour growth in the
abdominal wall – an experimental study in rats (submitted).
Reprints were made with permission of the publishers.
11
INTRODUCTION
Since Mouret performed the first laparoscopic cholecystectomy (LC)
in 1987, this technique has rapidly replaced conventional open cholecystectomy (OC) and become the standard treatment for surgical management of
gallstone disease.1 The widespread adoption of laparoscopic surgery in
general and laparoscopic cholecystectomy in particular, was done with the
assumption that this technique was beneficial for the patient especially in
aspects of less pain, quicker recovery, shorter hospital stay and reduced
costs.2 However, the early expansion of LC occurred without scientific evidence to support these assumptions.2 The laparoscopic technique was
quickly implemented to other surgical procedures including surgery for malignant disease. In the early nineties several case reports were published on
the occurrence of metastases from malignant tumours to the port sites after
laparoscopic surgery.3 This new phenomenon raised an intense debate
whether the laparoscopic technique was appropriate or not in oncologic surgery.4
In 1994 I personally operated on two patients with gallstone disease
who later developed port site metastases from gallbladder cancer (GBC)
after laparoscopic cholecystectomy. As in many patients with gallbladder
cancer the finding of a malignant specimen was unexpected and therefore
the patients were planned for laparoscopic cholecystectomy. In approximately 0.5-2.0 % of all cholecystectomy patients an incidental gallbladder
cancer is encountered and the surgeon and the patient are subjected to
laparoscopic handling of a possibly malignant disease as laparoscopic
cholecystectomy has become the standard treatment for gallstone disease5-7.
The clinical findings of port site metastases encouraged us to examine the
incidence of metastatic spread from gallbladder cancer to the wound sites
created by the laparoscopic working ports and subsequently to study the
incidence of wound metastases after open cholecystectomy. Concomitantly,
we experimentally wanted to investigate if there could be any features associated with the laparoscopic technique contributing to an increased growth
of malignant cells in laparoscopic surgery.
12
History of laparoscopic surgery
The first descriptions of endoscopic examinations emanates from the
Kos school led by Hippocrates (460-375 BC), who described a rectal speculum, remarkably similar to the ones used today.8,9 Similar speculums, furthermore used for the inspection of the vagina and the inside of nose and ear
were also discovered in the ruins of Pompeii.10 In 1585 Aranzi introduced
illumination into endoscopy by focusing sun light through a flask of water
and projected sun light into the nasal cavity.11 In 1805 Philip Bozzini, an
obstetrician from Frankfurt built an aluminium tube with mirrors to reflect
images illuminated by a wax candle – the “Lichtleiter”- which could be used
to look into various body cavities 12 (figure 1). Fifty years later the French
urologist Antoine Jean Desormeaux further developed the Lichtleiter and
replaced the candle by a brighter-burning mixture of alcohol and turpentine.
His improvements initiated a more common use of the rectoscope in clinical
practice 13 and his monograph from 1865, “De l`endoscopie” is said to have
stimulated American instrument makers to commence the production of
endocopes.14 He is therefore often considered as the “father of endoscopy”.
A shift of interest towards the upper gastrointestinal tract began in 1868
when Adolf Kussmaul did the first gastroscopy attempt by passing a rigid
metal tube down the oesophagus of a professional sword-swallower.13
Modern endoscopy was born in 1879 when the Dresden physician
Maximilian Nitze presented the “Blasenspiegel”, a cystoscope constructed
in cooperation with the Viennese instrument maker Josef Leiter.10,15 The
first experimental laparoscopy was performed 1901 in Berlin by the German
surgeon Georg Kelling who used a cystoscope to peer into the abdomen of a
dog after first insufflating with air, a technique he described as kolioskopie
when published in 1902.16 Soon after, the Swedish surgeon HC Jacobaeus
used this procedure in the thorax and abdomen on patients but without employing a pneumoperitoneum. He was the first to use the term “laparothorakoskopie” when publishing his 115 cases of laparoscopy (with only one
serious complication!) in 1911.17 In 1921, a pneumoperitoneum needle for
safer introduction into the peritoneal cavity 18 and the insufflator, was developed.19 A few years later, Zollikofer of Switzerland discovered the benefit of CO2 gas for insufflation rather than atmospheric air.20 The still commonly used Veress needle was developed in 1938 by the Hungarian Janos
Veress. Veress himself used this needle for the induction of pneumothorax
rather than for laparoscopy purposes.21 In 1963 the German gynaecologist
Kurt Semm developed the automatic insufflator, capable of monitoring both
gas flow and intraabdominal pressure.22 Although his ideas and visions were
controversial, the inventions of Semm allowed a safer laparoscopy and had
a great impact on the development of modern laparoscopy. His pioneer
13
work was probably also one of the reasons why gynaecologists in the 1970´s
thoroughly incorporated the technique into their practice while general surgeons remained confined to traditional open surgery.10 Kurt Semm also performed the first laparoscopic appendectomy in 1980, a procedure at the time
regarded as unethical by many prominent surgeons.23
The rod-lens system was invented already in 1953 by the British optical physicist Hopkins, improving image brightness and clarity.24 Together
with the development of fiberoptic light sources in the early 1960´s, they
revolutionized laparoscopic surgery. In the 70´s a blunt mini-laparotomy
technique was proposed by Hasson a method which permits direct visualisation of trocar entrance into the peritoneal cavity.25 The era of video-guided
surgery started in 1986 with the development of a computer chip TV camera
attached to the laparoscope. Video imaging facilitated the education of other
surgeons and house staff.
As previously mentioned the laparoscopic cholecystectomy performed
by Mouret in Lyon in 1987 started the rapid development of laparoscopic
technique in the field of general surgery. Although the credit is given to
Mouret, Erich Mühe of Boblingen, Germany performed the first documented laparoscopic cholecystectomy already in 1985.26 In Sweden as well
as all over Europe an astonishing development of laparoscopic surgery was
seen during the 1990´s. Laparoscopic appendectomy, herniorraphy, fundoplication, adrenalectomy, colorectal surgery and all kinds of procedures in
general surgery were done all over the world in a few years. After the initial
unrestrained and rapid spread of laparoscopic surgery the situation today
seems more controlled. The only laparoscopic procedure in Sweden that has
fully replaced the conventional open technique is still laparoscopic cholecystectomy.
Figure 1. The licht leiter endoscope developed by Philip Bozzini (1805).
Picture from “Highlights in the history of laparoscopy”
by G.Litynski at www.laparoscopy.com
With permission.
14
Carcinoma of the gallbladder
This neoplasm was first described in 1777 and still more than 200
years later constitutes a major diagnostic as well as therapeutic dilemma.27
Although not a common disorder it is nevertheless the fifth most common
cancer of the gastrointestinal tract.28 It is a fatal and often misunderstood
diagnosis. The patients usually present with diffuse symptoms and are often
beyond surgical cure by the time of discovery. In addition, many patients
are diagnosed after being subjected to a “simple” cholecystectomy.29 Patients with gallbladder cancer have a very bad prognosis and 90% of the
patients with tumours stage T2-4 have usually succumbed after a few
months.30 Aggressive surgical therapy and early diagnosis will hopefully
contribute to an improved prognosis for these patients.
Incidence
GBC is the 5th most common malignancy of the gastrointestinal tract
and reveals some interesting ethnical and geographical characteristics. It is a
very common malignant disorder in South-America, Poland, Japan and Israel. It affects women 2-3 times more often than men and is usually encountered in elderly patients. The incidence has been reported as high as 7/100
00 for men and 23/100 000 women in native American and South Americans.31 In Sweden, gallbladder carcinoma represents 1% of all malignancies
and the incidence is approximately 1.4/100 000 for men and 3.3/100 000 for
women.32
Pathogenesis
The majority of patients with GBC suffer from cholelithiasis. Although gallstones are present in 65-90% of patients with GBC, only 1% of
all patients with gallstones develop carcinoma of the gallbladder.33 Some
data indicate that female patients with stones larger than 3 cm are at special
risk of developing cancer of the gallbladder.34 The presence of calcifications
of the gallbladder in so called “porcelain gallbladder” and larger polyps are
possibly premalignant conditions as well as anatomical variations of the bile
duct and dearrangement of ratios between bile salts/lecithin and cholesterol.35-38 A range of carcinogenic substances have also been discussed in
association to the occurrence of gallbladder cancer. Other factors mentioned
are obesity, infectious diseases such as typhoid and chronic inflammation of
the gallbladder, colitis and multiple polyposis of the colon.34Patients with
gallbladder carcinoma often have a family history of malignancy and a second neoplastic disease is encountered in 15% of the patients.39
15
Clinical symptoms
Most patients present with diffuse symptoms although some also are
encountered as surgical emergencies with intestinal haemorrhage, obstruction or severe jaundice.34 Unfortunately, the presence of these symptoms is
usually linked to a noncurable disease in more than 50% of the patients.
Common symptoms of gallbladder cancer
Symptoms
Abdominal pain
Weight loss
Anorexia
Nausea and vomiting
Palpable tumour
Jaundice
Abdominal distention
Pruritus
Frequency ( %)
82
72
74
68
65
44
30
20
From Misra, ref 34
Pathology
As seen in breast and pulmonary carcinoma, gallbladder carcinoma is
probably a progressive disease with a continuum from dysplasia, cancer in
situ to invasive carcinoma. The majority of cases are adenocarcinomas,
which represents about 85% of all gallbladder malignancies.40 The metastatic pattern includes direct, lymphatic, vascular, neural, intraperitoneal and
intraductal spread.41 Tumours are usually spread primarily among lymphatic
pathways and venous blood is drained into the 4th segment of the liver which
affects surgical strategy.
Different staging systems for GBC have been utilized, but today the
TNM staging system and stage grouping 41 are most commonly used and
have basically replaced the Nevin classification system.42 Descriptions of
the different staging systems are presented below and histology of the gallbladder is illustrated in fig 2.
16
Nevin classification
TNM staging – T stage
I – Intramucosal
II – Tumour extends
to the muscularis
IV – Transmural involvment and cystic
lymph node involvement
Tis – Carcinoma in situ
T1 – Tumour invades lamina propria or
muscle layer;
T1a – invades lamina propria
T1b – invades muscle layer
T2 – Tumour invades perimuscular connective
tissue; no extension beyond
serosa or into the liver
T3 – Tumour perforates serosa or directly
invades one adjacent organ,
or both (extension < 2 cm
into the liver)
V – Direct extension
into the liver and/or
distant metastasis
T4 – Tumour extends > 2 cm into the liver
and/or into two or more adjacent
organs
III – Tumour extends
through serosa
TNM staging – N and M stages
Regional lymph nodes (N):
NX – Regional lymph nodes can not be assessed
N0 – No regional lymph node metastasis
N1 – Metastases in lymph nodes close to the primary
tumour (cystic duct,pericholedochal etc)
N2 – Metastases in lymph nodes not in the immediate
proximity of the primary tumour (periduodenal,periportal etc)
Distant metastases (M):
MX – Distant metastasis can not be assessed
M0 – No distant metastasis
M1 - Distant metastasis present
17
TNM stage grouping system
Stage
0
I
II
III
IVA
IVB
T
Tis
T1
T2
T3
T1-3
T4
anyT
anyT
N
N0
N0
N0
N0
N1
N0-1
N2
anyN
M
M0
M0
M0
M0
M0
M0
M0
M1
Figure 2. Photomicrograph of gallbladder wall a. Mucosa - simple columnar epithelium b. Lamina propria - loose irregular connective tissue c. Muscularis d. Subserosal connective tissue (shared with liver in gallbladder bed) e. Serosa - absent in the
attachment between the gallbladder and liver
Diagnostic aspects
Ultrasound is usually the first investigation in the work-up of a suspected GBC. In most cases it is also the only necessary investigation.37
However, often a CT is added. The value of MRT and MRCP has still not
been fully evaluated.44 Diagnostic laparoscopy has become a common surgical procedure in order to evaluate resectability and peritoneal carcinomatosis.29 Biochemical markers that are specific for GBC are not available.45
18
Treatment
The only ultimate treatment for gallbladder carcinoma is surgery but
only 10-30% of patients with a known diagnosis are candidates for radical
surgery due to widespread disease at the time of diagnosis. Surgery implies
simple or extended cholecystectomy.40 In cases of incidentally discovered
GBC after laparoscopic cholecystectomy, the TNM classification of the tumour often has major impact on the decision of further surgical procedures.46 The value of intra- or postoperative radiation therapy has been discussed and the results are conflicting. 47 Various combinations of chemotherapy have been evaluated but no conclusive results have been reported so
far.48
Prognosis
As in most neoplastic disorders the prognosis and survival rate is dependent on the stage of disease at discovery. Reported 5-year survival rates
differ considerably: for stage I cancer 5-year survival rates range from 40100%, stage II 10-80%, stage III 5-60% and stage IV 1-25%.49 An early
diagnosis of gallbladder carcinoma may be even more important than radical surgical approaches, although some promising reports recently haven
been published from Japan.50 Patients suspected to have a gallbladder carcinoma or being diagnosed after cholecystectomy should be evaluated for a
second operation and may benefit from the referral to oncological and surgical centres with special interest in gallbladder cancer.
19
The concept and aetiology of port site metastases
Definition
Port site metastases has not been strictly defined but is regarded as a
tumor deposit in the scar after a laparoscopy port. It is located in the abdominal wall but without discrimination between subcutaneous or muscular
tissue. In the literature, there is often no distinction between port site metastases as an isolated phenomenon or in association with widespread metastases or carcinomatosis. It has been proposed that PSM per definition not
should be associated with peritoneal carcinomatosis.51 However, PSM have
to be present at the site of a port wound or scar but can be found concomitantly with tumor deposits at other locations intraabdominally, in the abdominal wall or elsewhere. PSM are reported as isolated recurrences after
curative surgery as well as together with other tumour manifestations indicating a more generalised disease.52 The growth of a primary tumour or local recurrence per continuitatum to the scar is not to be regarded as a port
site metastasis. The definition described above is equally applicable to
wound metastases after open surgery.
In 1978 Dobronte and coworkers were the first to report on a patient
with a metastasis in the laparoscopy wound.53 The metastasis occurred two
weeks after a diagnostic laparoscopy and was considered to be “extremely
rare”. During the rapid expansion of laparoscopic surgery in the 1990´s numerous case reports on port site metastases were presented.54 This started an
intense debate whether laparoscopic surgery implied an increased risk of
spreading malignant disease. The discussion resulted in a common scepticism among surgeons whether laparoscopic surgery was appropriate to use
in malignant diseases.55,56 Furthermore, a number of experimental studies
were performed to examine the aetiology of port site metastases and
whether tumour development was increased by the laparoscopic technique.57
20
Clinical situation
In the early 1990´s laparoscopic surgery for cancer was done outside
controlled studies. Without knowledge of long term results laparoscopic
surgery for colorectal cancer was then proven to be technically feasible.58,59
The occurrence of port site metastases reduced the initial enthusiasm for this
new technique.56 The debate on port site metastases has also mainly been
focused on laparoscopic colorectal cancer. The concern that laparoscopic
surgery may increase the risk of spreading tumour cells to the surgical
wound has urged the design of clinical trials. Several large prospective randomised studies are also in progress in Europe and overseas.60 These studies
will hopefully give us the true incidence of port site metastases as well as
long term results after laparoscopic versus open surgery for colonic cancer.
The situation on port site metastases and gallbladder cancer however,
is somewhat different. First, colorectal cancer is more than ten times as
common as gallbladder cancer.33 Secondly, as previously mentioned, gallbladder cancer is often found incidentally (i.e. not preoperatively known).
Furthermore gallbladder cancer has a very dismal prognosis with a short
median survival time.30 Altogether it would be difficult to conduct a prospective randomised trial to study any potential differences between laparoscopic and open cholecystectomy concerning the incidence of port site metastases, survival or any other endpoint. To my knowledge no such studies
are in progress or have ever been performed.
Most surgeons today agree that laparoscopic surgery for cancer should
not be performed outside randomised controlled studies. Although neither
the aetiology nor the incidence of port site metastases are known, survival
should be the preferable endpoint for such studies. Although PSM is an interesting and new phenomenon, numerous reports of this dismal complication must not evidently imply that the incidence of wound metastases from
GBC is higher after LC than after OC. Moreover, a high incidence of port
site metastases after LC does not rule out improvement of survival after
laparoscopic surgery. A comparable incidence of wound metastases after
open surgery is also hard to assess prospectively especially since open
cholecystectomy nowadays seldom is performed.
21
Incidence
Wound metastases are not unique to laparoscopic surgery. The studies
of Reilly and Hughes have reported an incidence of wound metastases following open surgery for colorectal cancer slightly below 1%.61,62 Hence,
their results have been commonly accepted and consequently an acceptable
PSM rate after laparoscopic surgery for colorectal cancer is regarded to be
below 1%.59 A post mortem study on colorectal cancer patients by Welch
and Donaldson reported 16% wound metastases, all associated with disseminated disease.63 Small prospective randomised studies from specialised
institutions have reported no differences in wound metastases between open
and laparoscopic surgery for colonic cancer. The rates of wound metastases
in both groups have been equal and well below the presumably acceptable
1% level.64,65 In addition, none of the ongoing large prospective randomized
trials (NCI in USA, Conventional Versus Laparoscopic-Assisted Surgery for
Colorectal Cancer Trial in U.K and the COLOR-study in Europe) had to be
stopped due to an unacceptable PSM rate.60 This would indicate that it is
possible to perform laparoscopic colonic surgery with an acceptable number
of PSM.
Only scattered reports exist attempting to determine the incidence of
PSM from GBC after LC and as mentioned above no prospective randomised trials have been conducted comparing open versus laparoscopic surgery
for GBC. Paolucci et al have, in a large series including 117 840 LCs out of
which 409 had GBC, reported an incidence of 17% PSM and 26 out of the
409 patients with GBC had an early cancer (Tis or T1).54 Z´graggen et al
reported 37 patients with GBC of 10 925 patients subjected to LC and found
that 14% developed PSM.66 More recently Paolucci and coworkers have
reported 142 cases of incidental GBC following LC, 79 following OC and
24 after a converted procedure.67 With a median follow up of 27 months
they reported similar wound recurrence rates, 7% after LC and 5.1% following OC as well as similar total recurrence rates.
22
Aetiology
Although numerous papers have been published proposing a number
of mechanisms the aetiology of port site metastases remains unknown. Despite several case reports, most research in the field of laparoscopic surgery
and tumour development has been experimental studies.57 In the clinical
situation, especially after studies on laparoscopic colonic cancer, the initial
fear of PSM has somewhat faded.68 However, there might still be features of
the laparoscopic technique that facilitates tumour spread and growth.69
Haematogenous spread
It has been shown that localized tissue trauma increases the ability of
implantation of tumour cells 70,71 and metastases predominantly develop in a
fresh wound.72,73 Even if only a small number of tumour cells are able to
produce a metastasis it is known that malignant cells have been detected in
the systemic circulation of patients with cancer.74 In the laparoscopic situation it has been proposed that the increased intraabdominal pressure would
facilitate the liberation of tumour cells into the circulation or the passage
from lymphatic to venous vessels.75,76 Nevertheless, haematogenous spread
has been regarded unlikely to play a central role in the development of PSM
and has been sparsely studied.
Wound implantation
In contrast to haematogenous spread, direct implantation of tumour
cells is considered to play a major role in the development of PSM.77 There
are several possible mechanisms for tumour cells to deposit in the port site.
1. Extraction of specimen
The extraction of a malignant specimen through a narrow access
wound represents an obvious risk of tumour cell contamination of the abdominal wall. In patients who developed PSM after LC for unknown GBC,
Paolucci and coworkers reported that the port used for retraction of the gallbladder was the most common site of recurrence but 42% of PSM did not
occur at the extraction port.52 Consequently this theory does not explain the
large number of recurrences seen in other port sites than the extraction
wound.
23
2. Instrument contamination
Grasping and manipulating a tumour with laparoscopic instruments
should clearly be a risk for contaminating the instruments and subsequently
port sites with cancer cells. Both clinical and experimental studies have
demonstrated tumour cell contamination of both laparoscopic instruments
and trocars.78,79 Experimental studies have also shown that increased instrument movement and manipulation of ports augments tumour cell implantation.80,81 Still, PSM have been reported from pancreatic cancer after
diagnostic laparoscopy without manipulation of the tumour.82 Free intraperitoneal tumour cells exist, especially but not exclusively in advanced malignancies and could theoretically have contaminated the laparoscopic instruments in such cases.83 Even so, reports of PSM after LC from previously
undiagnosed tumours of the colon and occult pancreas cancer indicate that
wound contamination may not be the single definitive cause of port site metastases.84,85,86
3. Chimney effect and aerosolization
The chimney effect refers to the potential translocation of tumour cells
to the port sites caused by leakage of gas along the trocars. This requires
free intraperitoneal tumour cells preferably in aerosol formation. Most studies have failed to demonstrate significant aerosolization of tumour cells both
in vivo and in vitro studies.81,87-89 Ikramuddin et al studied 37 patients who
underwent elective laparoscopy for malignancy and found that tumour cells
were aerosolized but only in the presence of carcinomatosis.90 The Dutch
group who coined the term “chimney effect” has later presented a study
were they conclude that this phenomenon is unlikely to explain the development of port site metastases.91
Surgical technique
As previously proposed in open cancer surgery 92, surgical technique
is suggested to be the most important factor influencing tumour cell spread
and recurrence in laparoscopic surgery.93 Laparoscopic surgery for large
bowel cancer is technically demanding and has a long learning curve. This
may explain the incidence of PSM as high as 21% reported in the early
years 56 compared to more recent studies where a 0.6 % PSM rate was reported from the Colon and Rectal Clinic of Orlando.94 Such a low incidence
may also reflect that the operations were conducted at a centre specialised in
colorectal cancer surgery and well experienced with the laparoscopic technique.
24
In a murine model with a subcapsular spleen tumour, Lee and coworkers demonstrated that the incidence of PSM after laparoscopically assisted resection of spleen decreased to a level comparable with that of an
open operation with increasing experience of the surgeon as the experiment
progressed.95 In another study with a similar animal model they also showed
that a meticulous resection technique decreased the incidence of PSM and
this was independent of whether pneumoperitoneum was used or not.96 In a
study in rats, Mutter et al noted an increase of intraabdominal tumour
growth and metastatic formation after tumour manipulation in open and
laparoscopic surgery but with further enhancement of tumour growth in the
open group.97
Another aspect of surgical technique is the high proportion of intraoperative gallbladder perforation among patients with PSM from GBC after
LC.66 Doudle et al showed that gallbladder mucosal cells were found on
instruments at the end of surgery in 6 of 15 patients undergoing LC.98 This
could indicate that “micro perforation” occurs, with a possibility of spreading even an early GBC without macroscopic perforation of the gallbladder.
Although surgical technique, skill and experience seem to be the most important factors for tumour spread and growth after laparoscopic surgery, it
can hardly explain the development of PSM after diagnostic laparoscopy
with no manipulation of the tumour at all.99,100
Pneumoperitoneum
The technique of laparoscopic surgery is basically the same as used in
conventional open surgery. Although smaller wounds, absence of hands and
longer instruments the major dissimilarity between open and laparoscopic
surgery is the establishment of pneumoperitoneum. Pneumoperitoneum has
in many ways been regarded as responsible for or at least contributing to an
increased risk of tumour spread and growth in laparoscopic surgery:
1. Carbondioxide
Previous used gases as room air, oxygen and nitrous oxide were all
abandoned mainly because of their explosive features and the former ones
also had the potential for venous embolism. Other gases as Argon, Xenon
and Helium have been used mainly in the research setting. Carbondioxide
(CO2) is relatively inexpensive, readily available, colourless, odourless,
non-flammable, non-explosive, highly soluble in plasma and therefore suitable to use in laparoscopic surgery. CO2 is also the most commonly used gas
for insufflation in laparoscopic surgery.1995, in a hamster model, Jones et al
were the first to report that CO2 pneumoperitoneum resulted in “increased
25
implantation of free intra-abdominal cancer cells at wound sites of the abdominal wall or in the abdominal cavity”.101 Soon after, Bouvy and coworkers showed that laparoscopy with CO2 pneumoperitoneum resulted in increased tumour growth and bigger port site metastases compared with gasless laparosocopy.102 Jacobi reported in 1997 that CO2 per se seemed to
stimulate the growth of malignant cells compared to helium and controls.103
Several animal studies have afterwards reported promoting effects of CO2
on intraperitoneal tumour development compared with gasless laparoscopy
104-106
or helium pneumoperitoneum.107,108 In contrast, other studies have
reported that tumour cell proliferation and growth are independent of the
insufflating gas used.109.110 CO2 pneumoperitoneum may decrease subcutaneous pH levels, and it has been debated whether direct exposure of the
peritoneum to CO2 or CO2 induced acidosis may promote tumour growth in
the abdominal wall.111
2. Intraabdominal pressure
It is known that intraabdominal pressure caused by pneumoperitoneum may influence hemodynamics and particularly the splanchnic circulation.112 The effects of intraabdominal pressure have gained new interest in
studies of the pathogeneses of port site metastases. Jacobi et al studied the
effect of different pressures on tumour growth and port site metastases in a
rat model both in vivo and in vitro.113 They found a decrease of in vitro intraperitoneal tumour growth after incubation of tumour cells with CO2 at 10
and 15 mmHg compared with pressures at 0 and 5 mmHg. In vivo, intraperitoneal tumour growth was increased after laparoscopy at 5 and 10 mmHg
but decreased at a pressure of 15 mmHg compared with the control group.
Subcutaneous tumour growth was increased at laparoscopy at 5, 10 and 15
mmHg compared with controls. Other studies have reported that highpressure CO2 stimulates intraabdominal tumor growth.114,115 Another effect
of pneumoperitoneal pressure was demonstrated by Moreira et al in a hamster model. They found that an increase of intraabdominal pressure did not
influence aerosolization but significantly increased the rates of both instrument contamination and tumour recurrence.116
The increased rate of wound metastases caused by inadequate surgical
technique seems to be aggravated by CO2 insufflation compared with gasless laparoscopy. This was demonstrated by Watson et al who showed that
laceration of tumours in the abdominal wall resulted in more wound metastases after laparoscopy with CO2 pneumoperitoneum then after gasless
laparoscopy.106 On the other hand a few studies have demonstrated that intraabdominal pressure (i.e. CO2 pnumoperitoneum) does not increase tumour spread or growth compared with gasless controls.117-119 As noted, most
of these studies have used CO2 pneumoperiotneum as an “elevator of intra26
abdominal pressure” making it hard to exclude a possible effect on tumour
growth by CO2 itself. The suggestion that high intraabdominal pressure
and/or CO2 may increase tumour development has promoted the concept of
gasless laparoscopy. One argument against this procedure is the number of
reported PSM cases after thoracoscopy performed with no insufflation at
all.120 An interesting effect of pneumoperitoneum, probably due to the elevated intabdominal pressure and distension, is the injury to the peritoneal
layer presumably making it susceptible for metastases formation.121
3. Blood flow
Pneumoperitoneum and its effects on blood flow have mainly been
studied with focus on general hemodynamic consequences and effects on
the splanchnic circulation.112 Especially high pressure pneumoperitoneum is
known to impair intraabdominal blood flow.122 The effects of pneumoperitoneum on abdominal wall blood flow, were port site metastases actually
occur, have been sparsely studied and conflicting results reported.123,124 The
lack of knowledge and the fact that ischemia may promote tumour development 125 encouraged us to further examine the effects of pneumoperitoneum on blood flow and tumour growth in the abdominal wall.
Immune response
Numerous clinical and experimental studies have addressed the hypothesis that laparoscopic surgery should be less traumatic and thereby less
immunosuppressive than open surgery.126 Accordingly, the potential preservation of immune response after laparoscopic surgery for the cure of malignancy has gained much attention. The concern of an increased risk of tumour development after laparoscopic surgery has subsisted in parallel.
The immune reaction or stress response triggered by surgery is a very
complex and incompletely understood phenomenon. Briefly, surgery produces a local reaction which initiates the coagulation cascade and the accumulation of leucocytes and platelets as well as activation of fibroblasts and
endothelial cells. Many of these cells produce cytokines such as IL-6, IL-1
and TNF-α which go on to mediate a variety of systemic effects. Interactions exist with the neural and endocrine response such as catecholamines,
aldosterone, ADH, ACTH, TSH, GH, insulin etc resulting in peripheral fat
and protein breakdown, insulin resistance, water retention and gluconeogenesis which is in proportion to the degree of surgical injury.127,128 Numerous studies have focused on rates, levels or products of one or more of the
parameters mentioned above as well as CRP which is a classic marker of the
acute-phase reaction known to be proportional to the extent of injury. Spe27
cific immunity as reflected by NK- and T-cells, as well as their function
often measured by DTH, has been commonly studied.129
Even though conflicting data exist in studies regarding some immune
parameters, it is clear that major surgery results in a period of cell-mediated
immunosuppresion.126 The fact that malignancies were encountered after
immunosuppression was noted already in immunosuppressed patients after
kidney transplantations.130 Immune function as reflected by studies on DTH
response has shown that open surgery is associated with a suppression of
cell-mediated immunity.131 Brune et al demonstrated that suppression of T
lymphocytes functions, as reflected by decreased production of IFN-γ,TNFα and IL-2, was noted after OC but not after LC. This effect was mediated
by downregulation of the specific Th1 cellmediated immune response.132
Clinical studies on immune response mainly derive from comparisons
between OC and LC. Most studies on serum levels of IL-6 and CRP demonstrates less increase after LC, indicating greater trauma after OC.129 McMahon et al, found no difference in these markers comparing LC with
minilaparotomy cholecystectomy.133 It has been suggested that studies of
immunologic functions are more relevant than to assess plasma levels of
immunologic parameters.134 In a prospective randomised trial by Ordemann
et al the monocyte production of cytokines after ex vivo endotoxin stimulation was increased after laparoscopic colorectal resection compared to open
surgery.135 Plasma cytokine levels (IL-6, TNF-α) were significantly higher
in patients after open surgery. In a review of laparoscopic surgery and the
systemic immune response Vittimberga et al it is suggested that the body´s
response to laparoscopy is one of lesser immune activation as opposed to
immunosuppression.136
The alterations in the immune system and tumour growth in laparoscopy is well summarized by Hartley and coworkers.129 According to their
review an increasing body of evidence from both animal and clinical studies
suggest that specific immunity function is better preserved after laparoscopic than after open surgery. Recent clinical studies from laparoscopic
colorectal cancer and immune response show more conflicting results.131,137,138 However no clinical trial has been able to demonstrate any
good correlation between the changes in immunologic parameters and relevant postoperative clinical endpoints such as significant postoperative complications.134
Recently the interest in immunologic changes has been focused on
changes in the local peritoneal immune system after laparoscopic surgery. In
a small prospective randomized study after laparoscopic or open colon resection, Wu et al noted much more pronounced elevation of postoperative
cytokine levels (Il-6) in peritoneal fluid than in serum, although significant
differences in Il-6 levels between the open and laparoscopic groups were
28
noted only in serum and not in peritoneal fluid.139 Several animal studies
have demonstrated an impairment of peritoneal macrophage function after
exposure to CO2-pneumoperitoneum but results are conflicting.126,140
Laparoscopic surgery seems to reduce the immunologic consequences
of the stress response after surgery compared to conventional open technique. Minimally invasive methods may be associated with oncologic advantages but the impact of better preserved immune response in laparoscopic surgery for malignant disease still remains unclear.
In conclusion, numerous experimental studies have been performed
concerning laparoscopy and tumour spread and growth. Substantial variations in material and methods may reflect the vide range of findings and
conflicting results reported. Nevertheless, it is still not clear whether laparoscopic surgery alters the metastatic pattern, increases the risk of tumour
spread and growth or if laparoscopic technique may have a beneficial effect
in cancer surgery compared with conventional open surgery.
29
AIMS
To study the incidence of wound metastases from gallbladder cancer after
laparoscopic and open cholecystectomy.
To study the long term results after open and laparoscopic surgery for gallbladder cancer.
To experimentally study the effects of air and CO2 pneumoperitoneum on
intraperitoneal tumour growth.
To experimentally study the effects of air and CO2 pneumoperitoneum on
blood flow and tumour growth in the abdominal wall.
To experimentally study whether a decrease of blood flow by clamping increases tumour growth in the abdominal wall.
30
PATIENTS, MATERIALS AND METHODS
Clinical studies – paper I, II and III
A written questionnaire was sent to all university (n=8) and central
(n=24) hospitals in Sweden requesting information about the number of LC,
the number of converted cases and the number of patients who developed
port site metastases from GBC after LC done during 1991-94. To assess the
incidence of PSM, patient data with histopathologically verified adenocarcinoma or carcinoma in situ of the gallbladder were obtained from the Swedish Oncological Centres. The registry of patients with GBC was matched
against the patients with surgical classification codes for cholecystectomy
(laparoscopic or open) as reported to The National Board of Health and
Welfare (EpC). To identify if patients with completed or converted LC incorrectly were registered as OC, we doublechecked all patients registered as
OC with the Swedish Registry of Laparoscopic Cholecystectomy which
covered the years 1991-93. The check up for 1994 was done by reviewing
the records of all patients with gallbladder cancer recorded as open cholecystectomies. Further information on patients with port site metastases was
achieved through a review of their records or information from the operating
surgeon.
To estimate the incidence of wound metastases from GBC after OC
we reviewed the files of all patients with GBC registered as OC. Patient
files were scrutinized with respect to surgical procedure, indications for surgery, preoperative suspicion of malignancy as well as the occurrence of
wound metastases. Pathological reports were reexamined and classified according to the TNM system.141 In our first study we classified tumours according to the Nevin system 41 but in our second study we used the more
commonly used TNM system – descriptions of the staging systems are
shown on page 17.
In study I no follow up was performed in LC patients where no PSM
were reported. In study III we requested and reviewed the files from all
GBC patients registered as LC. In addition the National Board of Health and
Welfare provided us with data on hospital stay, additional surgical procedures performed and time and causes of death on all patients with GBC operated with OC or LC. Survival data were achieved until 2001 to obtain long
term follow up on all patients with GBC operated with open or laparoscopic
cholecystectomy.
31
Statistics and ethics
Kaplan-Meier curves and log rank test were used to calculate survival.
Statistical analyses were performed using a statistical software package
(SPSS10.0, SPSS Inc. IL, USA). The study was approved by the Regional
Research Ethic Committee at Umeå University.
32
Experimental studies – paper IV,V and VI
In all experiments Wistar Fu rats were used. They were anesthetized
with a cocktail of midazolam, fentanyl citrate and fluanisone. The cell line
used in all experiments was syngenic colonic adenocarcinoma cells. The
tumour cells were primarily nitrosoguanidine-induced (NGW) and prepared
by homogenizing tumours resected from carrier rats. Pneumoperitoneum in
all experiments was maintained for 45 minutes at a pressure of 10 mmHg.
In the first experimental study (IV) a cell suspension of 1 ml (105)
adenocarcinoma cells was injected intraperitoneally into three groups of
rats. 13 rats were insufflated with room air, 13 with CO2 and 13 were not
insufflated. After 12 days the rats were killed and the intraperitoneal tumour
load was quantified using a modification of the peritoneal cancer index
(PCI) scoring system described by Eggermont 142 (table 1).
Table 1. Modification of the peritoneal cancer index (PCI) scoring system
described by Eggermont to assess the quantity of intraperitoneal tumour load.
Tumour load
PCI
No intraperitoneal tumour
0
< 4 tumour foci with a diameter < 1 mm
1
4-10 tumour foci
2
10-50 tumour foci
3
Moderate intraperitoneal tumour load (> 50 foci
but not replacing most of the peritoneal cavity)
4
Abundant intraperitoneal tumour replacing most
of the peritoneal cavity
5
33
In studies V and VI a 2x2 cm pouch was created in the upper midline
and abdominal wall blood flow was continuously measured by a 10 mm
preperforated laser Doppler probe holder sutured to the rectus muscle (fig
4). Blood flow was measured with laser Doppler probes with a fibre separation of 0.25 mm. Light was generated (780 nm wavelength) and flow measurement was monitored on a Periflux master (Perimed, Sweden) with a time
constant of 0.03 sec. Blood flow was registered and presented in arbitrary
perfusion units (PU). In study V and VI a tumour cell suspension of 0.1 ml
with 50 000 cells was used. After the experiment the probes were removed
and the skin was sutured.
In study V 40 rats had a laser Doppler probe placed on their left rectus
muscle and a tumour cell suspension injected into their right rectus muscle.
20 rats were insufflated with air and 20 were not insufflated and served as
controls. One pair of animals, one insufflated and one control, was always
studied simultaneously to ensure that tumour cells from the same solution
with equal viability were used (fig 4). Blood flow was continuously measured and registrations were made before, during and after insufflation.
In study VI 16 rats had a laser doppler probe placed on their right and
left rectus muscle. The left rectus muscle was clamped with two forceps,
one cranial and one caudal to the laser Doppler probe. The tumour cell suspension was injected into both rectus muscles respectively, but the right
rectus muscle was not clamped and served as control. Blood flow was
measured simultaneously on both rectus muscles as described above (figure
4). After 9 days the animals were sacrificed and the weight and volume of
the tumours were calculated according to the formula V = a x b / 2 as described by Carlsson et al.143 In the second part of the experiment (VI), 11
pairs of rats were studied. 11 animals were insufflated with CO2 and 11
were not insufflated. Tumour injection and blood flow measurements were
performed as in study IV.
34
Figure 3. Rat with left rectus muscle clamped with two forceps and right rectus muscle
not clamped (control). Probes sutured on each rectus muscle measuring laser Doppler
blood flow.
Figure 4. Experimental (insufflated ) and control (not insufflated) rats with laser
Doppler probes sutured to the rectus muscles.
35
Laser Doppler blood flow
The theory of laser Doppler flowmetry is that a beam of laser light,
carried by a fibre-optic probe, is scattered and partly absorbed by the tissue
being studied. Light hitting moving blood cells undergoes a change in wavelength (Doppler shift) while light hitting static objects is unchanged (figure
5). The magnitude and frequency distribution of these changes are directly
related to the number and velocity of blood cells but unrelated to their direction of movement. The information is picked up by a returning fibre, converted into an electronic signal and analyzed. Laser Doppler perfusion
represents the velocity and concentration of moving blood cells.179
Figure 5. Illustration of Laser Doppler
flowmetry - transmitted laser light is
absorbed and reflected by the studied
tissue and picked up by the receiving
fibre. Change in wavelength occurs
when the light hits moving blood cells
(Doppler shift).
Reprint with permission of Perimed
A disadvantage of LDF is that measurements can only be expressed in arbitrary Perfusion units (PU) and not in absolute perfusion values (e.g.
ml/min/100mg tissue). Thus it is particularly important that the laser Doppler instrument is regularly calibrated, which in our studies was done with a
latex suspension motility standard (Perimed, Sweden). Another problem
with LDF is that movements of the probe affect the circulation measurements. In our studies the probe was sutured to the rectus fascia to ensure a
fixed position of the probe.
LDF is a well established method for assessing microcirculatory
changes that correlates well with the tissue oxygenation and total blood flow
of the tissue under study.180,181 In our setting with a fibre separation of 0.25
mm, a time constant of 0.03 sec and a laser diode with a wave length of 780
nm, the penetration depth is about 0.5-1 mm. The instrument used in our
studies (Periflux 4001 master, Perimed, Sweden) was provided with dual
channels making simultaneous blood flow measurements of one pair of rats
or both rectus muscles in one rat possible.
36
Statistics and ethics
Values were expressed as means ± s.e.m. Statistical analyses were
performed using a statistical software package (SPSS 10.0, SPSS Inc. IL,
USA). In paper IV, tumour weight was compared with the Mann-Whitney
U-test. In paper V, blood flow was analysed by means of ANOVA for repeated measurements using the Tukey post-hoc test. The distribution of tumour take between groups were analysed by the McNemar test and comparisons of tumour weight and volume by the Wilcoxon´s signed ranks test.
In paper VI blood flow was analysed by means of ANOVA for repeated
measurements using the Huynh-Feldt correction procedure. The distribution
of tumour take in the two groups was analysed by the McNemar test. Comparisons of tumour weight and volume were analysed by the Wilcoxon
signed rank test, using one-sided analysis since the hypothesis according to
our previous findings was an increase in tumour weight and volume. Studies
were approved by the Animals Ethics committee at the Umeå University
hospital, Umeå, Sweden.
37
RESULTS
Clinical studies – paper I, II and III
Replies were obtained from 30 of the 32 clinics (94%). 11 976 LC
were done during 1991-94 with a mean conversion rate of 9.4%. According
to the Oncologic Centres 447 patients with histologically verified adenocarcinoma or carcinoma in situ were registered. 270 of these patients had been
operated with OC and 55 with LC. In our questionnaire, nine patients were
reported to have developed port site metastases after LC from gallbladder
cancer (figure 6).
When reviewing the files of the 215 patients registered as OC, six
patients were excluded because of other malignant diagnoses than GBC.
Five patients had incorrect surgical codes and had in fact undergone LC (4
converted and 1 completed LC). Of the remaining 204 patients, clinical files
and follow up data were achieved in 186 patients (91%). 12 patients (6.5%)
developed wound metastases from GBC after OC (II).
Of 55 patients who had been subjected to LC, 3 files were not retrieved and 1 patient was excluded because of incorrect operation code (only
biopsy taken). One patient registered as LC had actually undergone open
cholecstectomy and was included in the open group (figure 6). When scrutinizing the 46 files of LC patients not previously reported with PSM, another
5 patients had tumour recurrences in the surgical wound. Three patients had
recurrences in the port sites (clinical examination) and two in the laparotomy wound after converted procedures. Totally 25% (14/55) of the laparoscopically operated GBC patients developed incisional metastases. Data on
patients with wound metastases are presented in table 2. Median interval to
the occurrence of wound metastases was 6 months for the open group and 8
months for the laparoscopic group.
38
447 patients with
gallbladder cancer
177 no cholecystectomy
270
cholecystectomy
Registry data
55 LC
3 files not
obtained
52 LC
1 excluded
51 LC
215 OC
Review of
files
Review of
files
5 LC
55 Laparoscopic
Cholecystectomy
46 LC
(19 converted)
Questionnaire
9 port site metastases
197 OC
18 files not
obtained
6 excluded
191 OC
1 OC
187 Open
Cholecystectomy
Review of files
Review of files
5 abdominal wall metastases
(3 port site + 2 wound after
converted procedures)
14 wound
metastases (25%)
12 wound metastases (6.5%)
Figure 6. Study setting, surgical procedures and wound metastases in 447 patients with
histopathologically verified adenocarcinoma or carcinoma in situ of the gallbladder.
39
TABLE 2. Tumour stage and intraoperative gallbladder perforation in patients with wound
recurrences from gallbladder cancer after laparoscopic and open cholecystectomy.
Laparoscopic cholecystectomy
(N=55)
Wound recurrences
Open cholecystectomy
(N=187)
14 (25%)
12 (6.5%)
2
1
2
7
0
2
0
1
2
8
1
0
9 (65%)
9 (75%)
Tumour stage
Tis
T1
T2
T3
T4
not stated
Gallbladder perforation
The long term follow up of 55 patients subjected to LC and 187 to OC
is schematically presented in figure 7 and 8. The median follow up time was
nine years and patients not registered as dead in 2001 at the National Board
of Health and Welfare are reported as alive.
55 LC
1 lost
12
alive
4 dead
other
disease
14 wound
metastases
25 dead GBC
(median 17
months)
1 alive
12 dead
(median 18
months )
Figure 7. Long term follow up after laparoscopic cholecystectomy (LC) in 55 patients with
gallbladder cancer.
40
187 OC
21
alive
12 wound
metastases
1? *
16
dead
other
disease
137 dead
GBC
(median 6
months)
12 dead
(median 11
months)
Figure 8. Long term follow up after open cholecystectomy (OC) in187 patients with gallbladder cancer.
(* Dead in disseminated malignancy of unknown origin.)
Crude 5-year survival in relation to T-stage for OC and LC group is
presented in table 3. Survival was significantly shorter in the OC group (figure 9). Patients with T3 tumours operated with LC showed significantly
better survival than patients operated with OC (figure 10). 5-year survival in
patients with T3 tumours was noted in only 2 patients of the LC and 1 patient of the OC group (table 3).
TABLE 3. Crude 5-year survival in relation to Tumour stage in patients with gallbladder
cancer operated with laparoscopic or open cholecystectomy.
Tumour stage
Tis
T1
T2
T3
T4
All Stages
Laparoscopic cholecystectomy
60 % (3/5)
83% (5/6)
37% (6/16)
8% (2/24)
0% (0/2)
30% (16/53*)
Open cholecystectomy
60% (3/5)
72% (13/18)
24% (12/50)
1% (1/80)
0% (0/30)
16% (29/183*)
*Tumour stage not stated in 2 patients from the laparoscopic group and 4 from the open group.
41
Figure 9. Kaplan Meier survival curves for all patients with gallbladder cancer and known
T stage operated with open (183 patients)) or laparoscopic cholecystectomy (53 patients).
P = 0.001.
Figure 10. Kaplan Meier curves for patients with T3 gallbladder tumours operated with
open (80 patients) or laparoscopic cholecystectomy (24 patients). P < 0.001.
42
Experimental studies – paper IV, V and VI
In the first experimental study (IV), both pneumoperitoneum with CO2
and air significantly increased intraperitoneal tumour load compared to controls. No difference in tumour growth was noted between the animals insufflated with air or carbondioxide. Animal weights were also significantly
increased in the control group but unchanged in the insufflated groups.
In study V insufflation with air caused an 82% reduction of blood
flow (p < 0.001), while no reduction was registered in the control group.
Tumours developed significantly more often in the insufflated group
(20/20) compared to the control group (14/20), p= 0.016. Tumour weight
(p = 0.003) and volume (p < 0.001) were significantly increased in the
insufflated group.
In study VI, insufflation of CO2 caused a 69% reduction of blood flow
( p < 0.001) while no reduction was registered in the not insufflated control
animals (figure 11). Tumour weight (p = 0.006) and volume ( p = 0.006) were
increased in the insufflated group. Clamping decreased blood flow in the rectus muscle with 69% (p < 0.001) while no decrease was registered in the
non-clamped rectus muscle. Tumour weight (p =0.028) and volume ( p =
0.030) were increased on the clamped side.
180
160
Blood flow (PU)
140
120
100
80
co ntro ls
CO2
60
40
20
0
Figure 11. Abdominal wall blood flow in controls (not insufflated) and insufflated animals
( P < 0.001).
43
DISCUSSION
Clinical studies paper I, II and III
The proportion of patients with GBC who were not subjected to surgery may seem high (177/447) but is in accordance with previous studies. In
a Swedish study on 63 consecutive GBC patients, 48% only had a biopsy
taken and 52% underwent cholecystectomy compared to 60% in our
study.144 The apparently low number of GBC patients who were subjected
to LC compared to OC has several explanations. During the study period
1991-1994 the majority of all cholecystectomies were performed with open
technique according to the National Board of Health and Welfare. In the
early 1990´s many hospitals in Sweden had just started to perform LC and
potentially more difficult cases were probably selected to open surgery. This
is reflected by the fact that patients who underwent OC had a suspicion of
malignancy, jaundice or acute cholecystitis preoperatively documented in
84% of the patients compared to 25% in the LC group.
The findings from our studies seem to indicate that the risk of incisional metastases is higher after LC compared to OC. Previous studies on
GBC have also demonstrated a high rate of PSM after LC.54,66 In a retrospective multicentre study by Paolucci and coworkers 117 840 LC were
examined and among those 409 patients had an unsuspected GBC. 70 of
these patients developed PSM.54 The common view that LC increases the
risk of wound recurrences from GBC has persisted despite the lack of comparative studies between open and laparoscopic cholecystectomy. Ricardo et
al reported from a tertiary referral centre on 79 patients with GBC. In their
study, 26 patients had an open, 21 a laparoscopic and 16 a converted procedure. Independent of the surgical procedure about 30% of the patients developed incisional metastases.145 89% of all patients in their study had an
advanced GBC (T3/T4) in contrast to 59% and 47.5% in our OC and LC
groups respectively. In a recent German study Paolucci and coworkers reported on 245 patients with postoperative incidental findings of GBC, 79
following OC and 142 following LC and 24 had a converted procedure.67
With a median follow up of 27 months they reported an incidence of wound
metastases of 5.1% after OC and 7% after LC. The total incidence of recurrences was similar in both groups and they concluded that the access technique, LC or OC, does not seem to influence the prognosis of GBC.
In our studies the rate of port site metastases may be overestimated
and the true incidence of PSM after LC from GBC is hard to assess. A possible bias could be that at the time of our questionnaire the awareness was
high for the risk of PSM and therefore more likely to be found and reported.
Two patients reported with PSM were also poorly documented but as they
44
were reported in our questionnaire, they have not been excluded. On the
other hand, when reviewing the files of the LC group another 5 incisional
metastases after LC were found. Hence, the incidence of PSM after GBC in
all major hospitals in Sweden 1991-1994 seems to be approximately 25%.
The incidence of wound recurrences from GBC after OC in our second study may on the other hand be underestimated as many of the open
cases may not have lived long enough to develop any obvious recurrent disease. This is reflected by the fact that the median survival of the entire OC
group (6 months) was equal to the median interval time for wound recurrences (6 months) for patients subjected to open cholecystectomy. This is in
contrast to the LC group with a median survival of 17 months and a median
time to port site recurrence of 8 months. Careful clinical follow up of patients with GBC following OC have not been performed and the patients
may have developed incisional recurrences that were never detected. Furthermore, as noted by Reilly et al most wound metastases after open surgery
on large bowel cancer were incidentally identified at reoperation.61 This
may also be the case in GBC after OC. Still, Fahim et al already in 1962
examined 151 patients with GBC who all had surgery and found only 6 patients with abdominal wall metastases, all at the site of a previous cholecystostomy.146
The true incidence of wound metastases from GBC after OC is not
known since prospective randomised trials are difficult to design, especially
as GBC is quite uncommon and often accidentally encountered. This is in
contrast to laparoscopic colorectal cancer were ongoing large prospective
randomised trials hopefully will give the answer whether wound metastases
after laparoscopic surgery are more common than after open surgery. Even
more important is whether survival is affected by the used technique, laparoscopic or open. Although somewhat controversial, but in a prospective
randomised study, Lacy et al have reported survival benefits in patients with
laparoscopically operated T3 colonic tumours.65
The debate on laparoscopic surgery and tumour growth have also concerned whether the introduction of LC has worsened the prognosis of GBC.
Donohue et al compared registry data on 5000 GBC patients operated before
(1989-90) and during (1994-95) the LC era and could not find any adverse
effects on the general outcome for patients with GBC after the introduction
of LC in the United States.49 A similarly designed American study was performed by Whalen et al and they also concluded that LC did not deteriorate
the survival of GBC patients.147 They also reviewed the files of half of the
patient material (237 patients with GBC) and found that 36% of the patients
from the laparoscopic era actually had undergone OC. They also registered
the incidence of abdominal wall recurrence in serendipitously treated GBC
and found 11% in the laparoscopic group and 3% in the open group. In Ja45
pan, Suzuki and coworkers examined 5027 LC and found 41 GBC and 4
patients developed PSM.148 They compared survival data with previous
Japanese studies on OC and found similar 5-year survival rates as in patients
operated with LC (92% in Tis/T1, 59% in T2/T3). A similar Japanese survey of 498 patients with laparoscopically removed GBC reported high 5year survival rates (95% in T1, 70% in T2 and 20% in T3 tumours).149 They
also concluded that LC was not likely to worsen the prognosis of GBC. In a
review on early GBC patients subjected to LC, Weiland et al reported 3-year
survival rates (47% in T1, 40% in T2) which they concluded as worse than
previous reports for OC.150 In Donohue and coworkers review of 5000 GBC
patients in USA, 5-year survival rates of 39% for T1 and 15% for T2 tumours were reported.49
In our studies the overall crude 5-year survival rates were 16% for the
OC group and 30% for the LC group (table 3). The median survival was 6
months for the OC group and 17 months for the LC group. These differences may reflect the higher proportion of advanced tumours in the OC
group than in the LC group. However, median survival in T3 tumours was
16 months in the LC group and 5 months in the OC group. In the study of
Whalen et al they reported a similar proportion in T stage distribution of 154
GBC patients who underwent surgical procedures as in our study.148 Accordingly, most of their patients had a T3 tumour but median survival was
similar during the open (6 months) as well as during the LC period (8
months). In our study patients with T3 tumours had a median survival of 5
months in the open group but 16 months in the LC group. Whalen et al
could not find any differences, comparing Kaplan Meier survival in patients
subjected to OC and LC.148
In our study we found beneficial survival effects for patients operated
with LC compared with OC. This is illustrated by the Kaplan Meier curves
for patients with T3 tumours in figure 10. Patients with T3 tumours were
also most common in both OC (43%) and LC (44%) groups. Although improved survival was noted for patients with T3 tumours subjected to LC
only 2 of the patients were alive after 5 years. In our study converted cases
were analysed together with patients who underwent complete LC according
to the intention to treat principle. Not surprisingly, when comparing Kaplan
Meier survival for patients who underwent converted procedures with the
OC group, no difference was noted.
Despite an apparent higher rate of wound metastases LC does not
seem to have a negative impact on the survival in GBC patients. In contrast
to other studies, our material on GBC patients subjected to open and laparoscopic cholecystectomy comprises patients from the same hospitals operated
during the same period of time.
46
We could only identify 15 patients in the OC group (8%) and 6 patients (11%) in the LC group that had extended resections, in contrast to the
Japanese studies mentioned above where Ouchi et al reported additional
resection in 48% of the cases.149 This could also to some extent explain the
high survival rate in their study, as they also report a better survival after
additional excision in patients with T2 and T3 tumours compared with LC
only. The reason for improved survival in laparoscopically operated GBC
patients with T3 tumours in our study is not because of a higher number of
extended resections in the LC group as only one T3 patient in the LC group
had extended resection compared to 7 patients in the open group.
Intraoperative gallbladder perforation is regarded as a risk factor for
spreading malignant cells and concomitantly the development of PSM.66 In
our material on GBC patients with PSM, 65% had gallbladder perforation
compared to 38% in the whole LC group. In the OC group 75% of the patients with wound metastases and 23% in whole OC group were reported by
the surgeon to have had intraoperative gallbladder perforation. In the study
of Ouchi et al patients with gallbladder perforation were even shown to have
a significantly lower survival rate than those without perforated gallbladders,150 which has been confirmed in other studies.151-153 Some authors advocate that LC, with its potential for bile spillage, should be avoided as a
initial procedure in suspected GBC patients, especially as this may convert a
potentially curable early GBC to a incurable disease.151
In discussing whether LC increases the risk of tumour spread, the risk
of intraabdominal tumour dissemination in general should be distinguished
from the risk of metastases to the port site. In a recent French review by
Fondrinier et al they concluded that laparoscopy had no influence on tumour
growth but may affect peritoneal dissemination.154 This also reveals the controversy whether port site metastases are to be regarded as an isolated phenomenon or as a manifestation of disseminated disease.
In our study, 75% of the patients with wound recurrences in the LC
group and 91% of the patients in the OC group had T2, T3 or T4 tumours.
Our review of port site metastases confirms that the overwhelming majority
of patients had advanced tumours. Consequently all patients with incisional
metastases in our study except one have died from GBC. This would indicate that port site metastases predominantly are associated with advanced
disease and poor prognosis. Nevertheless, in our study on PSM after LC, 2
patients developed PSM after a Tis and one after a T1 tumour of the gallbladder. All 3 had intraoperative gallbladder perforation, and all subsequently died from disseminated disease with a mean survival of 51 months.
Only scattered reports exist of long time survivors after excision of
PSM.65,154 The only patient with PSM reported alive in our study has re-
47
cently (February, 2004), 11 years after the initial LC, been subjected to a
third reoperation for wound metastases from gallbladder cancer.
Our studies seem to indicate that wound recurrences from GBC may
be more common after LC than after OC, but do not seem to have any negative influence on survival. The median survival in the LC group is also similar to the median survival of the patients with PSM. Documented intraoperative gallbladder perforation is overrepresented in patients with wound metastases in both LC and OC groups. Gallbladder perforations are also more
frequently reported in the LC group than in the OC group which may contribute to an increased risk of PSM. Furthermore our studies indicate that the
risk of dissemination of GBC is not generally increased by LC as this most
likely should have had a negative influence on survival. Nevertheless, there
may be features in laparoscopic surgery that increase the risk of abdominal
wall metastases. This increased risk however, does not seem to influence
survival possibly because the majority of patients with wound metastases
already have an advanced disease and a short expected survival. However, it
can not be ruled out that a negative survival effect of PSM may to some
extent be compensated by less trauma and better preservation of the immune
response seen after laparoscopic cholecystectomy.
48
Experimental studies – paper IV, V and VI
Although instrumental manipulation and tumour cell spillage seem to
play a major role in PSM after laparoscopic cancer surgery, several experimental studies indicate that other features of minimal invasive surgery may
be involved in this phenomenon.57 Several studies have demonstrated a
promotive effect on intraperitoneal tumour development after CO2 pneumoperitoneum compared with gasless laparoscopy 104-106 or helium pneumoperitoneum.107,156 This encouraged us to perform the first experimental
study (IV) where air and CO2 pneumoperitoneum equally increased intraabdominal tumour growth compared to not insufflated controls. The enhancement of intraperitoneal tumour growth after insufflation being independent
of the used gas has been confirmed by others,110 indicating that other aspects
than the used gas is involved in the enhancement of tumour load in laparoscopic surgery.
Tumour cell suspension models have been criticized because of differences in tumour cell viability and for the large number of injected cells.93
In our experiments we studied experimental and control groups simultaneously with the same cell suspension to avoid variations in viability. The
number of injected tumour cells was studied by Wu et al who showed that
with a decreasing amount of tumor cells injected intraabdominally the tumour promoting effect of CO2 pneumoperitoneum was diminished.157 They
noted no enhancement in tumour growth after pneumoperitoneum when 1.6
x 105 human colon cancer cells were injected intraperitoneally in hamsters.
Although we used 105 adenocarcinoma cells in study IV, a comparison is
difficult because of differences in both metastatic and growth potential of
the tumour cells as well as animal features. This difficulty probably also
reflects the variety of findings and conclusions presented in animal studies
on laparoscopy and tumour growth. In addition, it illustrates the problem to
evaluate animal studies in relation to the clinical situation in general.
Several studies have examined both abdominal wall and intraperitoneal tumour growth in relation to CO2 pneumoperitoneum and predominantly a promoting effect of CO2 has been noted.101-103,158,159 Some studies
have examined tumour growth outside the abdominal cavity and have been
unable to demonstrate any promotive effect of CO2 pneumoperitoneum.160162
This may support that the effects of pneumoperitoneum is a local event
mainly caused by the intraabdominal distention rather than the gas being
used. On the other hand, Jacobi et al found an increase of subcutaneous tumour growth in the back of rats after CO2 pneumoperitoneum independently
of intraperitoneal pressure.113 In the same study intraabdominal tumour
growth was increased after 5 mmHg and 10 mmHg CO2 pneumoperitoneum
but suppressed at 15 mmHg. In another study in rats, Wittich et al found an
49
increase in intraabdominal tumour growth after CO2 insufflation at 16 mm
Hg.163 Gutt and coworkers demonstrated that different tumour cell lines reacted disparately to in vitro exposure of CO2 at different pressures but concluded that the insufflation pressure may have additional effects in promoting tumour growth.114
Factors such as lipopolysaccharide in room air have also been proposed to increase peritoneal macrophage cytokine release (TNF-alfa) and
thereby enhance the immune response.164 Pidgeon et al further reported increased VEGF levels and metastatic tumour growth in mice exposed to air
(lipopolysaccharide) during laparoscopic or open surgery.165 Another negative effect of air is that peritoneal surfaces may dry out causing cell damage.
This is even proposed to explain the increased surgical trauma in laparotomy rather than the larger incisions compared to minimal invasive surgery.93 It has also been demonstrated in a rat model that laparotomy in a
warm humid environment caused less postoperative intraperitoneal tumour
growth than laparotomy in room air.93 Nduka et al reported less intraperitoneal tumour growth and spread with warmed compared to cold CO2.166
Many possible explanations are available for our findings that air and
CO2 pneumoperitoneum equally enhances intraperitoneal tumour growth.
Nevertheless, a possible enhancement of intraabdominal tumour development after laparoscopy compared to controls does not address whether the
risk of abdominal wall metastases is increased after laparoscopic surgery.
In our following experimental studies (V, VI) we wanted to investigate whether pneumoperitoneum influenced blood flow and tumour growth
in the abdominal wall where port site metastases actually originate. We
found a major decrease in abdominal wall blood flow during air as well as
during CO2 pneumoperitoneum. Insufflation with air caused a 82% reduction of blood and CO2 decreased the blood flow with 69% as measured with
laser Doppler technique. Tumour growth was enhanced in insufflated animals compared to controls but air insufflation also caused an increase in
tumour take (i.e. tumours developed more often) which was not seen in the
CO2 group. A possible explanation could be that there are different mechanisms involved in tumour growth compared to tumour take. To our knowledge this theory has never been studied or even discussed in the field of
laparoscopy and tumour growth.
Only a few studies have been published concerning changes in abdominal wall blood flow during pneumoperitoneum and conflicting results
are reported. Schilling et al studied laser Doppler blood flow in patients subjected to laparoscopic surgery and found the most pronounced decreases in
blood flow in the parietal peritoneum. Yavuz et al, in a study on pigs, registered an increase in the blood flow of the parietal peritoneum but no changes
in the rectus muscle during CO2 pneumoperitoneum.167 In another study on
50
CO2 pneumoperitoneum in pigs, Brundell and coworkers noted an increase
of peritoneal blood flow and suggested that CO2 induced vasodilatation was
responsible.123
In contrast to abdominal wall blood flow, several studies have examined the effect of pneumoperitoneum on intraabdominal circulation. Schaefer et al noted a reduction in hepatic blood flow and assumed that both increased intraabdominal pressure and hypercapnia were the main underlying
factors.169 Ishida et al injected tumour cells intraportally in mice and found
that the development of liver metastases was enhanced by increased CO2
insufflation pressure.170 In a similar study, Gutt and coworkers compared
the oncologic and immunologic effects on the liver of CO2 and helium
pneumoperitoneum.171 They found no differences between the two gases
and concluded that elevated intraabdominal pressure was responsible for
hepatic disadvantages during pneumoperitoneum and not carbon dioxide
itself.
We demonstrated that insufflation with CO2 and air equally decreased
abdominal wall blood flow and increased tumour growth. A similar decrease
in blood flow achieved by clamping also increased tumour growth in the
abdominal wall but not as significant as after insufflation. Tumour growth in
clamped and non-clamped (control) rectus muscle was studied simultaneously in the same animal. Thus, it is possible that systemic effects caused by
clamping of one rectus muscle affected tumour growth on the non-clamped
side. This design was chosen in order to have similar initial laser Doppler
blood flow levels in experimental and control muscle as laser Doppler
measurements may show interindividual variations. In contrast, the insufflated animals had another not insufflated animal serving as a control.
Robinson and Hoppe already in 1962 reported that ischemia enhances
the ability of tumour cells to produce metastases.125 Even though our studies
indicate that ischemia itself increases tumour growth, it can not be postulated that the reduction of blood flow is principally responsible. The more
pronounced increase in tumour development after insufflation than after
clamping may reflect that other factors related to pneumoperitoneum may
be involved in the development of abdominal wall metastases.
Pneumoperitoneum is also known to cause an increase in the activity
of proteolytic enzymes such as matrix metalloproteinases 172,173 with the
capability of degrading extracellular matrix allowing invasion of cancer
cells.174 Pneumoperitoneum is also known to cause hypoxia 175 which is
proposed to cause upregulaion of matrix metalloproteinase activity.176 In
our studies blood flow was significantly reduced after insufflation but oxygen tissue partial pressure was not analyzed. This parameter was assessed
by Wildbrett et al who found a decrease in partial pressure of oxygen in the
abdominal wall after insufflation with both helium and CO2.175
51
Previous to the debate on port site metastases, local trauma was reported to enhance the ability of tumour implantation.72,73 Not only the trocars but pneumoperitoneum itself is known to cause traumatic changes in
peritoneum.121 Ziprin et al also demonstrated that the adhesion of tumour
cells to the peritoneum in vitro was increased after the mesothelial cell
monolayer was exposed to pneumoperitoneum.177 The increase was independent of used gas (CO2, Helium or air) and associated with increased expression of mesothelial intercellular adhesion molecule-1 (ICAM-1). Ziprin
et al further suggested that the enhanced adhesion is related to the hypoxic
environment generated by pneumoperitoneum and further pronounced by
traumatic cytokine release.178
It is possible that a favourable tumour soil produced by ischemia is
augmented by local trauma and increased proteolytic activity created by the
hypoxic pneumoperitoneum. Enhanced adhesion of tumour cells during
pneumoperitoneum may also reflect an increased susceptibility for tumour
take rather than tumour growth.
52
SUMMARY AND CONCLUSIONS
In our clinical studies we have demonstrated that wound metastases
from GBC are a common phenomenon after open and laparoscopic cholecystectomy. Incisional metastases may be more common after LC but no
negative effect on survival can be demonstrated. There are indications that
surgical technique as reflected by intraoperative gallbladder perforation,
may contribute to an increased rate of tumour implants in the surgical scar.
This may be particularly important in early gallbladder carcinomas, where
perforation could convert a curable disease into a disseminated malignancy.
A secondary finding was that malignancy of the gallbladder is probably suspected more often than previously assumed. An increased awareness
preoperatively may help the surgeon to select a proper surgical approach.
This is most likely more important than a dogmatic regimen advocating one
surgical procedure before the other. Nevertheless, it may be recommendable
at least in cases with a suspected early GBC to perform conventional open
surgery to avoid a possible increased risk of gallbladder perforation in LC.
Lack of knowledge and experience of handling a malignant gallbladder
laparoscopically may also favour a recommendation of open surgery in
cases of GBC. The potential benefits of laparoscopic surgery for cancer
might well be recognized after further preferably prospective clinical studies.
Experimentally we have shown that pneumoperitoneum with air and
CO2 increases intraabdominal tumour growth. Pneumoperitoneum also reduces blood flow in the abdominal wall and enhances tumour growth at the
same site. Tumour growth was also enhanced by mechanical reduction of
blood flow by clamping indicating that impaired blood flow may promote
tumour development. Albeit strict clinical conclusions cannot be drawn, our
findings indicate that features of pneumoperitoneum may have negative
implications in oncologic surgery. Our studies may further help us to identify these potentially negative features so that they can be minimized in the
clinical situation. This is important particularly as laparoscopic surgery has
potential advantages in surgery for malignant disease as indicated in our
clinical studies.
More research could further clarify the effects of laparoscopy on tumour growth and hopefully reveal advantages that go way beyond quicker
recovery and shorter hospital stay. Our studies have demonstrated interactions between the laparoscopic procedure and tumour development in particular that subsequently may help us to understand aspects of tumour take
and growth in general.
53
ACKNOWLEDGEMENTS
I wish to express my sincere gratitude to:
Anders Kristoffersson my tutor and friend for his encouragement, fruitful
and enjoyable discussions and particularly for after long nights with scientific discussions providing me the “doctorial room” in his house.
Lars-Olof Hafström and Peter Naredi my former and present professor, for
scientific support and help in the start and engaged assistance in the finishing part respectively.
Karl-Axel Ängquist, former head of Department of Surgery for his support
and friendship.
Åke Öberg my colleague, travel partner and friend for his unique way and
arrangements to manage without me.
Anita Westman for skilful assistance and loyal company in the laboratory.
My friends, colleagues and staff at the Department of Surgery, especially
Örjan Norrgård and Maarku Haapamäki in the Colorectal team for doing the
hard work during my absence. Special thanks to my friend Birger Sandzen
who confirmed my belief in the importance of surgical technique and also
enlightened me in the TME concept and almost never sings out of tune.
Gunilla Östberg for help with all kinds of problems.
Göran Johansson and Håkan Jonsson for explaining statistics to a surgeon
far beyond two standard deviations.
All my friends and colleagues at Torsby hospital; the operation staff, Odd
Kleppenes who almost forced me into orthopaedics and especially Leif
Hoffman who taught me the basics of surgery and gave me unforgettable
help and friendship during my first years as a surgeon.
My wife Lena for accepting (?) computer work in the bedroom at night. My
outstanding children Ida, Anna, Eric and Karin for their mere existence.
This work was supported by the Lions Cancer Research Foundation, University of Umeå, Umeå Sweden.
54
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