Minimally-invasive surgery needs more data on outcomes
23 March 2009
Minimally-invasive oncologic surgery procedures can be beneficial,
but physicians need to be prudent when recommending the option to their
patient according to Thomas A D'Amico, MD, of Duke Comprehensive Cancer
Center. Dr D'Amico detailed the benefits and controversies of minimally
invasive alternatives as well as emerging techniques including natural
orifice surgery at the US National Comprehensive Cancer Network (NCCN)
14th Annual Conference.
Dr D'Amico acknowledged the tremendous technological advances that
have resulted in minimally invasive offerings, but emphasized three
guidelines that physicians need to be aware of when presenting the
option to patients; the minimally invasive option must be oncologically
equivalent or superior to the open procedure, the procedure should offer
quality of life outcome advantages, and cost effectiveness needs to be
Five minimally invasive procedures for oncologic surgery including
robotic prostatectomy, laparoscopic colectomy, laparoscopic
adrenalectory, minimally invasive esophagectomy, and thoracoscopic
lobectomy were presented by Dr D'Amico.
In each procedure, he provided a comparison of the minimally invasive
option versus the traditional open approach to surgery, noting operating
time, cost, recovery rates, length of stay, and oncologic outcomes.
Overall, the benefits to the minimally invasive options were a
shorter hospital stay, faster recovery, and less pain. However, except
for the thoracoscopic lobectomy, there is no data from randomized
controlled clinical trials on minimally invasive options to provide any
insight into oncologic outcomes or survival rates.
"The lack of evidence-based data for the majority of minimally
invasive surgical options is one of the current shortcomings in the
field," stated Dr D'Amico.
Another cause of debate includes the training and credentialing of
physicians who perform minimally invasive procedures. Dr. D'Amico stated
that the learning curve for physicians being trained needs to be
addressed. Lastly, Dr D'Amico touched upon the controversy of using
minimally invasive surgery as a marketing tool particularly in the field
of robotics, which can lend itself to eye-catching publicity.
The future of minimally invasive surgery will likely see an expanded
use of robotics as well as an increased interest in a new technique
called natural orifice surgery. Dr D'Amico explained that natural
orifice surgery is when surgeons conduct surgery through the natural
orifices in the body such as the mouth, nose, or rectum. Since there are
no incisions made on the body, the benefits are a reduced risk of
infection and a quicker recovery, stated Dr D'Amico.
In conclusion, Dr D'Amico stressed again that improved outcomes
should drive the utilization of minimally invasive procedures and that
oncologic principles must be preserved.
"There is continued progress of minimally invasive oncology surgery,"
said Dr D'Amico, "but also the need for further evolution to optimize
morbidity and oncologic outcomes. The question we need to ask ourselves
is not 'what can be done', but 'what should be done'."
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