Introduction

Article Outline

• Copyright

As surgeons, we spend much of our professional lives in the operating room removing cancers, diseased bowel, and solid organs as well as repairing and fixing problems of one sort or another. If we were to count up the number of hours spent while scrubbed, it would surely add up to the thousands. During this time, how often do we consider how the surgical methods we use disturb the patient’s physiologic and immunologic milieu or that the surgery-induced changes may place the patient at risk for complications or tumor recurrences? I am not referring to the trauma patient or the setting of sepsis; we are all aware of the dangers of surgery in these urgent or emergent situations. As a group, we are also aware of surgery-related fluid shifts and of the cardiac, pulmonary, and renal alterations and risks associated with open and closed surgery. However, I believe it is rare for surgeons to spend much time thinking about how elective surgery affects the physiologic homeostasis of our patients. How does surgery change the makeup of the blood, how long do these alterations last, and should we care about any of these protein changes? Does surgical trauma affect immune function to an important extent? To what extent are the circulating immune cells (monocytes, granulocytes, neutrophils, and lymphocytes) “stunned” after surgery? What are the relative contributions of the abdominal incision and the intraabdominal parts of an operation to the overall trauma and stress that is induced? What are the systemic manifestations of wound healing? Are the chances of survival and implantation of circulating tumor cells different after surgery?

Up until 1991 these were not pressing questions since there was no alternative to the traditional “open” surgical methods. The advent of minimally invasive methods changed the situation. First, surgeons wanted to know why laparoscopic patients had a more rapid recovery clinically than their open counterparts. Second, it became easier to assess the impact of the laparotomy incision because there was an alternative abdominal access method to compare it to. Third, and most important, there was great concern about the safety of laparoscopy in the setting of cancer. Case reports regarding port-site tumors heightened the fears of the vast majority of surgeons. The result was a flurry of small animal and human studies that pitted open and laparoscopic access methods; pneumoperitoneum and laparotomy were closely scrutinized. These studies initially assessed stress markers, white blood cell counts, and immune function as well as tumor recurrences in the abdomen and wound. Later, the focus turned to surgery-induced protein compositional changes in the blood. On the clinical front, the most important development was the organization of numerous multicenter randomized colon cancer trials that compared open and closed methods. Because most surgeons were reluctant to perform minimally invasive cancer resections, there was a unique opportunity to properly study the new method before adoption by the mainstream of the surgery world.

A decade and a half later quite a bit has been learned about both open and minimally invasive surgery. The port-site tumor issue, the burning question of the 1990s, has been settled such that this topic is rarely mentioned or discussed in 2007. There is now intermediate-term cancer and survival data. Other unexpected things have been discovered; for example, it looks like one of surgery’s most enduring effects regards angiogenesis. This issue of Seminars in Colon and Rectal Surgery, which is as much about open surgery as it is laparoscopic methods, will attempt to review and summarize the results of both the clinical and the experimental studies that have been performed. Each article deals with a different topic; however, there is much overlap in places. The last article will attempt to make sense of it all and provide a view of the future. The guest editor of this issue would like to thank the editor of the series and the Seminars journal for the opportunity to gather and present this data. Further, I would like to thank the authors of the individual articles for their time and efforts.

This issue starts off with two thorough reviews of the clinical results, the first by Mark Whiteford and the second by Peter Marcello and company. Whiteford’s article covers pulmonary function, pain, and short-term results, in general, whereas Marcello’s piece provides an evidence-based review of the cancer literature that covers both the intermediate-term cancer results as well as the short-term clinical results. There is a fair amount of overlap in these two articles; however, this affords the reader with two perspectives on the parameters that have driven the growth of minimally invasive colorectal surgery. In the third article, Drs. Yoo and Lee review the immunologic manifestations of open and laparoscopic surgery and also provide an objective assessment the potential importance of the modest differences in immune function that have been noted between the two methods. The fourth piece, by Dr. Patricia Sylla, introduces a novel means of studying systemic immune function, namely RNA microarray analysis of circulating immune cells; the realization that microarray methods could be used in this manner is an unanticipated benefit of the decade-long debate regarding open and laparoscopic methods.

The fifth article, by Dr. Daniel Feingold, reviews the surgery-related protein compositional changes, not directly related to immune function, that might impact the growth of residual tumor cells early after surgery. The sixth piece, by Dr. Belizon and I, discusses surgery’s effect on several plasma proteins that play critical roles in angiogenesis; it also reviews the overall impact of surgery on the blood’s ability to support new blood vessel formation. Understanding that one of surgery’s more durable effects concerns angiogenesis is a “windfall” of the research stimulated by the introduction of advanced laparoscopic methods. The seventh contribution, by Dr. John Allendorf, reviews the literature regarding surgery’s effects on postoperative tumor growth. Although most of the literature concerns experimental small animal models, some human studies have also been done and are discussed. The eighth brief article reviews the literature in regards to port wound tumor recurrences. Although not presently a point of controversy, this topic was at the center of the maelstrom during the mid and late 1990s and, as such, needs to be included in this type of overall review.

In the last article I attempt to make some sense of it all and also discuss what I view as one of the main benefits of the debate regarding traditional and minimally invasive methods, namely, the realization that the postoperative period is a dangerous time for cancer patients. The fledgling efforts made thus far to find safe and effective anticancer drugs that can be used perioperatively are reviewed as well. From the outset I want to thank the editor of this series for the opportunity to collect and present the fruits of the basic science and clinical research that have been performed by a myriad of dedicated researchers over the past 15 years. It is rare to have such an opportunity and I doubt it will come my way again. Finally, it is hoped that the readership of Seminars will be able to plow through this issue and come away with some useful information and a better perspective of both open and closed surgical methods.