Institutional members access full text with Ovid®

Share this article on:

Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery: A Randomized Clinical Trial (LAFA-study)

Vlug, Malaika S. MD, PhD*; Wind, Jan MD, PhD*; Hollmann, Markus W. MD, PhD, DEAA; Ubbink, Dirk T. MD, PhD; Cense, Huib A. MD, PhD§; Engel, Alexander F. MD, PhD; Gerhards, Michael F. MD, PhD**; van Wagensveld, Bart A. MD, PhD††; van der Zaag, Edwin S. MD‡‡; van Geloven, Anna A.W. MD, PhD§§; Sprangers, Mirjam A.G. PhD¶¶; Cuesta, Miguel A. MD, PhD***; Bemelman, Willem A. MD, PhD*LAFA study group

doi: 10.1097/SLA.0b013e31821fd1ce
Randomized Controlled Trials

Objective: To investigate which perioperative treatment, ie, laparoscopic or open surgery combined with fast track (FT) or standard care, is the optimal approach for patients undergoing segmental resection for colon cancer.

Summary Background Data: Important developments in elective colorectal surgery are the introduction of laparoscopy and implementation of FT care, both focusing on faster recovery.

Methods: In a 9-center trial, patients eligible for segmental colectomy were randomized to laparoscopic or open colectomy, and to FT or standard care, resulting in 4 treatment groups. Primary outcome was total postoperative hospital stay (THS). Secondary outcomes were postoperative hospital stay (PHS), morbidity, reoperation rate, readmission rate, in-hospital mortality, quality of life at 2 and 4 weeks, patient satisfaction and in-hospital costs. Four hundred patients were required to find a minimum difference of 1 day in hospital stay.

Results: Median THS in the laparoscopic/FT group was 5 (interquar-tile range: 4–8) days; open/FT 7 (5–11) days; laparoscopic/standard 6 (4.5–9.5) days, and open/standard 7 (6–13) days (P < 0.001). Median PHS in the laparoscopic/FT group was 5 (4–7) days; open/FT 6 (4.5–10) days; laparoscopic/standard 6 (4–8.5) days and open/standard 7 (6–10.5) days (P < 0.001). Secondary outcomes did not differ significantly among the groups. Regression analysis showed that laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity.

Conclusions: Optimal perioperative treatment for patients requiring segmental colectomy for colon cancer is laparoscopic resection embedded in a FT program. If open surgery is applied, it is preferentially done in FT care. This study was registered under NTR222 (www.trialregister.nl).

Important developments in elective colorectal surgery include the introduction of laparoscopy and implementation of a program for enhanced recovery after surgery. This trial investigated which perioperative treatment, ie, laparoscopic or open surgery combined with fast track or standard care, is the optimal approach for patients undergoing segmental resection for colon cancer.

*Department of Surgery

Department of Anesthesiology

Department of Quality Assurance and Process Innovation, Academic Medical Center, Amsterdam, the Netherlands

§Department of Surgery, Red Cross Hospital, Beverwijk, the Netherlands

Department of Surgery, Zaans Medical Center, Zaandam, the Netherlands

**Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands

††Department of Surgery, Sint Lucas Andreas Hospital, Amsterdam, the Netherlands

‡‡Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands

§§Department of Surgery, Tergooi Hospital, Hilversum, the Netherlands

¶¶Department of Medical Psychology, Academic Medical Center, Amsterdam, the Netherlands

***Department of Surgery, VU Medical Center, Amsterdam, the Netherlands

Reprints: Willem A. Bemelman, Department of Surgery, Academic Medical Center, P.O. Box 22660, 1100 DD Amsterdam, the Netherlands. E-mail address: w.a.bemelman@amc.uva.nl.

The study was supported by Johnson and Johnson International and Nutricia and funded by a governmental subvention (ZonMW).

Financial Disclosure and Commercial Sponsorship: The authors received a governmental subvention (ZonMW) and a financial support of Johnson and Johnson International and Nutricia. None of them had a role in study design, data collection, data analysis, data interpretation, or writing of the report.

All the authors have made substantial contributions to conception and design, and/or acquisition of data, and/or analysis and interpretation of data; all participated in drafting the article or revising it critically for important intellectual content; and all authors gave final approval of the version to be published.

Collaborative LAFA Study Group: Benedikt Preckel, MD, MA, DEAA; Patrick Bossuyt, PhD; Dirk Gouma, MD, PhD; Mark van Berge Henegouwen, MD, PhD; Jan Fuhring, BSc; Ineke Picard van Lenthe, BSc; Chris Bakker, BSc; Bellinda King-Kalimanis, MSc (Academic Medical Center, Amsterdam the Netherlands); Jan Hofland, MD, PhD (Erasmus Medical Center, Rotterdam, the Netherlands); Cornelis Dejong, MD, PhD; Ronald van Dam, MD, PhD (Academic Center Maastricht, Maastricht, the Netherlands); Donald van der Peet, MD, PhD; Edith van Zalingen, MD; Astrid Noordhuis, BSc; Dick de Jong, BSc (VU Medical Center, Amsterdam, The Netherlands); T. Hauwy Goei, MD; Erica de Stoppelaar, MD; Marjon van den Dongen, BSc (Zaans Medical Center, Zaandam, the Netherlands); Willem van Tets, MD, PhD; Maarten van den Elsen, MD; Annemiek Swart, BSc (Sint Lucas Andreas Hospital, Amsterdam, the Netherlands); Laurens de Wit, MD, PhD; Muriel Siepel, MD; Glaresa Molly, BSc (Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands); Jan Juttmann, MD, PhD; Wilfred Clevers, MD; Andrea Bieleman, BSc (Tergooi Hospitals, Hilversum, the Netherlands); Ludo Coenen, MD; Elly Bonekamp, BSc (Gelre Hospitals, Apeldoorn, the Netherlands); Jacobus van Abeelen, MD; Diana van Iterson – de Jong, MD; and Margriet Krombeen, BSc (Red Cross Hospital, Beverwijk, the Netherlands).

© 2011 Lippincott Williams & Wilkins, Inc.