The Value of Laparoscopic Ultrasound in Patients Undergoing Laparoscopic Resection for Cancer of the Colon or Rectum
The Value of Laparoscopic Ultrasound in Patients Undergoing Laparoscopic Resection for Cancer of the Colon or Rectum
The following project deals with a Danish multicenter trial that evaluates the value of
 Laparoscopic Ultrasound examination (LUS) in laparoscopic surgery for colon and rectum cancer
 (CRC).

 The project "The value of laparoscopic ultrasound in patients undergoing laparoscopic
 resection for colon and rectum cancer. - A prospective randomized trial" is part of a ph.d-
 study at the University of Southern Denmark in collaboration with several surgical
 departments at hospitals in Southern Denmark.

 The primary purpose is to investigate whether the use of laparoscopic ultrasound examination
 (LUS) will change the stage of the tumor, lymph node and metastasis (TNM stage) and the
 surgical approach in patients undergoing laparoscopic surgery for colorectal cancer (CRC).

 As a secondary objective; an evaluation of the use of LUS will change the treatment strategy
 for the individual patient with CRC.

 As an other objective we wants to investigate whether the use of contrast enhanced ultrasound
 examination in connection with LUS procedure increases the number of detected liver
 metastases.
Laparoscopic surgery for cancer in the colon or rectum seems to be equal standing to open
 surgery with regards to the morbidity, mortality and the oncologic results (radicality and
 re-lapse frequency and long-term survival). Laparoscopic surgery for colon and rectum cancer
 is now a well-understood and well-established surgical method, but there are only few
 randomized trials dealing with the long-term results. The latest inventory work calls for
 better documentation of long-term results and calls for further randomized studies. Despite
 this, the number of laparoscopic operations for colorectal cancer (CRC) in Denmark is
 increasing, and laparoscopic surgery has partially become established as standard treatment
 for CRC.

 Liver metastases are frequent in patients with CRC and about 15-20% of patients already have
 metastases at the diagnosis. Ultrasound examination during open surgery (IOUS) has shown to
 be an important diagnostic tool with high sensitivity (98%) and positive predictive value
 (86%) for detection liver metastases that are undiagnosed on preoperative computed tomography
 scan (CT) or Positron emission tomography-computed tomography scan (PET-CT). IOUS is
 considered as the gold standard for hepatic metastases within open surgery for CRC. In
 laparoscopic surgery this option disappears, but it is likely that Laparoscopic Ultrasound
 examination (LUS), may provide the same information as found by IOUS.

 While laparoscopy and laparoscopic ultrasound examination (LUS) is well established in the
 staging and treatment of upper gastrointestinal cancers, this method is only sparsely
 evaluated in the treatment of CRC. There are only very few and older data dealing with the
 use of LUS in the Tumor - lymph Node and Metastases (TNM) staging in patients with cancer in
 the colon and rectum. Several small studies have investigated the use of LUS to evaluate the
 M-stage in laparoscopic colorectal surgery and all studies show an increased detection of
 liver metastases. Overall, seems LUS to be better than the current pre-operative image
 modalities, and the LUS and the IOUS has also been found to be able to locate small tumors in
 the colon.

 Based on the above, a recent review concluded that the data about the routine use of
 laparoscopy and LUS in patients with CRC are not sufficient, but that LUS probably could be
 used for assessment of the liver, liver-metastases and non-regional lymph nodes. There are no
 randomized studies dealing with the use of LUS in laparoscopic surgery for CRC.

 It is not a standard routine to use LUS of the liver, tumor and retroperitoneum during
 laparoscopic surgery for CRC.

 In prospective and blinded studies a percutaneous contrast-enhanced ultrasound examination
 (CEUS) of the liver proved to be able to detect significantly more liver metastases from CRC
 than conventional percutaneous ultrasound.

 With the new second-generation contrast agents CEUS seems to be equivalent to the
 contrast-enhanced CT and Magnetic resonance imaging (MRI) for detection liver-metastases.

 Liver metastases are frequent in patients with CRC and the use of intraoperative ultrasound
 (IOUS) during open surgery for CRC, has previously been regarded as the gold standard.
 Contrast-enhanced IOUS (CE-IOUS) during open surgery for CRC is only sparsely evaluated, but
 has been shown to increase sensitivity for detection liver-metastases. There is on the other
 hand, not found literature that has been describing the use of laparoscopic CE-IOUS during
 laparoscopic surgery for CRC.

 With this project we want to elucidate whether the use of LUS in laparoscopic surgery for CRC
 will alter the patient's TNM stage and surgical approach and whether potential changes have
 any clinical consequence for the individual patient. Furthermore, we wish to investigate
 whether contrast-enhanced LUS increases detection rate for liver metastases.

 Method The study is designed as a prospective, randomized multicenter study and include 280
 patients.

 At the Department of Surgery, Odense University Hospital, they annually conducted around 150
 laparoscopic resections for CRC, but the department has a selected patient material. To get a
 representative sample of patients with CRC, and to get included as many patients as possible
 within the given timeframe, the project will therefore be conducted as a multicenter study.

 The participating centers perform all laparoscopic CRC surgery at a high level, and both the
 technical equipment and the necessary scanning competencies are available on the departments
 involved.

 Prior to the start of the project, the surgeons of the included departments will be trained
 in the LUS method, so that assessment and description of the intra-abdominal findings are
 standardized.

 They included patients randomly assigned either to the department's standard laparoscopic
 surgery or standard laparoscopic surgery plus a LUS examination.

 In the standard arm the conditions at the abdomen is only assessed by laparoscopy immediately
 prior to the resection.

 In the second group the intra-abdominal conditions are also assessed by laparoscopy, but then
 supplemented with a LUS examination of the primary tumor, liver and retroperitoneum.

 Both laparoscopy and LUS will take place just prior in to the operation itself and will not
 require further intervention or additional portholes.

 If there at the LUS examination is found undiagnosed liver metastases or lymph nodes outside
 the planned operation field, then the patient is sent to the Department of Surgery A, Odense
 University Hospital, for a multidisciplinary tumor conference.

 In cases where the LUS examination suspects liver metastases and / or remove lymph node
 metastases in patients who are included in the project at the Department of Surgery A, Odense
 University Hospital, then a intraoperative LUS-guided fine-needle aspirations- biopsy (FNA)
 or tru-cut biopsy will be performed and marked with a little silver pin. The latter is used
 for follow-up after pretreatment and to locate potential rest tumor.

 All other patients follow the Departments usual routines for adjuvant therapy.

 Those patients who are selected for laparoscopic resection at the Department A, University
 Hospital also offers to participate in a contrast-enhanced laparoscopic Ultrasound
 examination during surgery. A specialist with skills in contrast-enhanced ultrasound will
 perform the examination.

 Before the contrast study is performed the surgeon notes the findings after conventional LUS,
 so that the patients examined at University Hospital also is part of the total material on an
 equal footing with those scanned in the other departments.

 All patients included in the project will undergo a three-phase control computed tomography
 (CT) scan 3 months after surgery. This is to evaluate whether there might be overlooked
 metastases in the laparoscopy and LUS evaluation.

 All the information about the patients are entered and recorded in a database. Information on
 death will be deducted from the Civil Registration and local administrative databases.

 After completion of the inclusion of patients, the two arms will be compared with account of
 changes in the TNM-stage and surgical approach in relation to the pre-operative assessment.

 The possible changes are evaluated from strict, predefined criteria and are assessed whatever
 they have clinical relevancy, and finally the potential effect of contrast-enhanced LUS
 compared to LUS alone is assessed.
Inclusion Criteria:

 -  Patients with colon and rectum cancer without known metastasis

 -  Patients who gives informed consent

 -  Patients who are referral to laparoscopic surgery

 Exclusion Criteria:

 -  Patients who are not able to give informed consent

 -  Patients who are under 18 of age Patients with known metastasis.

 -  Patients who are allergic to contrast agents

 -  Patients who are pregnant or lactating