No Difference in Postsurgery Fatigue With Laparoscopic vs Open Surgery for Colorectal Cancer With Enhanced Recovery Program
In a UK trial (EnROL) reported in the Journal of Clinical Oncology, Kennedy et al compared outcomes with open vs laparoscopic resection of colorectal cancer within a multimodality enhanced recovery program. Such programs are intended to improve all aspects of perioperative care and have been shown to reduce postoperative complications. The trial showed no difference between the surgical approaches in the primary outcome measure of physical fatigue. Laparoscopy was associated with a shorter hospital stay.
Study Details
In the trial, 204 patients with resectable colorectal cancer of any stage from 12 UK centers were randomly assigned between July 2008 and April 2012 to undergo laparoscopic resection (n = 103) or open surgery (n = 101) in the setting of an enhanced recovery program. Randomization was stratified by center, cancer site (colon vs rectum), and age group (> 66 vs 66–75 vs > 75 years). Physical fatigue at 1 month postsurgery was assessed by the physical fatigue domain of the Multidimensional Fatigue Inventory 20 (MFI-20). Patients and investigators who assessed outcome were blinded until 7 days postsurgery or earlier discharge. Pathologic assessment of surgery quality was blinded.
The laparoscopy and open surgery groups were generally balanced for age (mean, 69 and 70 years; 29% and 27% < 66, 41% and 44% 66–75, and 30% in both > 75 years), cancer site (colon in 73% and 74%), sex (54% and 70% male), body mass index (eg, 39% and 44% overweight, 33% and 29% obese), American Society of Anesthesiologists grade (I in 12% in both, II in 59% and 65%, III in 28% and 23%), relevant previous abdominal surgery (29% and 23%), preoperative radiotherapy (14% and 10%), blood transfusion within 7 days before surgery (4% and 0%), metastatic disease (8% and 2%), and previous malignancy (4% and 0%).
Fatigue
On analysis of covariance adjusting for baseline physical fatigue, cancer site, age, stoma, and metastasis, there was no significant difference between the laparoscopy and open surgery groups in 1-month physical fatigue scores (mean, 12.28 vs 12.05, adjusted mean difference = −0.23, 95% confidence interval [CI] = −1.52 to 1.07). There were no differences according to disease in the colon (adjusted mean difference = −0.70, 95% CI = −2.28 to 0.88) or rectum (adjusted mean difference = 1.00, 95% CI = −1.42 to 3.42). There were no differences between groups in the MFI-20 general fatigue, activity, motivation, or mental fatigue subscales, Short Form 36 (SF-36) physical health or subscale scores, or SF-36 mental health or subscale scores. There were no differences in specimen quality on central pathologic review.
Hospital Stay and Complications
Primary hospital stay was significantly longer in the open surgery group (median, 5 vs 6 days, P = .011), including significantly prolonged stay in patients with rectal cancer (median, 5 vs 6 days, P = .024) but not in those with colon cancer (median, 5 vs 6 days, P = .08). Total hospital stay, including readmissions up to 30 days after surgery, was also significantly longer with open surgery (median, 5 vs 7 days, P = .033).
The numbers of surgical, cardiorespiratory, and infectious complications were similar in the two groups. Within 30 days postsurgery, there were no significant differences between the laparoscopy and open surgery groups in patients experiencing ≥ 1 complication (32% vs 36%, P = .55), readmissions (14% vs 10%, P = .38), or second surgeries (11% vs 6%, P = .21).
The investigators concluded, “In patients treated by experienced surgeons within an [enhanced recovery program], physical fatigue and other [patient-reported outcomes] were similar in both groups, but laparoscopic surgery significantly reduced length of hospital stay.”
Robin H. Kennedy, MS, of St. Mark’s Hospital, Harrow, is the corresponding author for the Journal of Clinical Oncology article.
The study was supported by the Bobby Moore Fund, Cancer Research United Kingdom, National Cancer Research Network, Ethicon Endo-Surgery Europe, Medical Research Council ConDuCT Hub, and Yorkshire Cancer Research. Dr. Kennedy receives research funding from Ethicon Endo-Surgery. Philip Quirke, PhD, MRCPath, receives research funding from Medical Research Council UK.
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