Trial Information

Australasian Multicentered Prospective Randomised Clinical Study Comparing Laparoscopic and Conventional Open Surgical Treatments of Colon Cancer in Adults

AIMS

The primary aim of the study is to test the hypothesis that tumour related disease free
interval and overall survival are equivalent regardless whether patients receive
laparoscopic colon resection (LCR) or open colon resection (OCR) at three and five years
post operatively. The secondary aims of the study are to determine the safety of LCR
compared to OCR and 30 day mortality and compare post operative pain, paralytic ileus, early
and late morbidities (including wound site recurrence), recovery, transfusion requirements,
cost and quality of life scores.

BACKGROUND

The ALCCaS Trial is an Australasian, multicentred, prospective, randomised clinical study
comparing laparoscopic and conventional open surgical treatments of colon cancer in adults.
This trial has been recruiting patients since 1998.

Patients are randomised to receive either laparoscopic or conventional open resection for
colon cancer. A Randomisation Centre was established to provide a 24-hour randomisation
service and this centre is situated in Christchurch, New Zealand. The Health Research
Council of New Zealand Data Safety Committee, chaired by Professor Tom Fleming, access the
ALCCaS Trial annually to ensure that it meets strict ethical and research related criteria.

During the recruitment period (Jan 1998 to March 2005) 601 patients were recruited into the
ALCCaS Trial. There have been 37 surgeons involved in recruiting patients at 20 hospitals
within Australia and New Zealand. All surgeons participating in the ALCCaS trial are
accredited in laparoscopic surgical techniques. To gain accreditation, a surgeon must have
carried out no less than 20 supervised colon resections and must provide video evidence of
two laparoscopic colonic resections for review. Surgeons from throughout Australia and New
Zealand are participating in this study. The Research Ethics Committees at a variety of
hospitals throughout New South Wales, Queensland, South Australia, Victoria, Western
Australia and New Zealand have approved the study.

DATA COLLECTION

The type of colon resection performed by the individual surgeon will follow standard
oncologically safe principles. The following intra-operative details will be collected, the
patient epidemiology, ASA status, previous abdominal surgery, incision type, site of
carcinoma, modality of diagnosis, pre operative haemoglobin and lung function tests, pre
operative blood transfusion, planned operation, planned incision. Intra operatively the date
of the operation, whether DVT prophylaxis has been used, the type of bowel preparation, the
type of operation performed, if the laparoscopic procedure is performed whether it included
mobilisation of the bowel, ligation of main artery and vein, transection of the bowel,
resection of the bowel and anastomosis done as an intraperitoneal procedure are recorded.

The use of cytotoxic irrigation of the peritoneum, wound and colonic lumen is noted.
Estimated surgical blood loss and intra operative blood transfusion is recorded. The post
operative position of the tumour is noted. The type of incision and size of incision is
recorded. Any reason for change in planned incision is recorded and the theatre utilisation,
and total anaesthetic time and duration of the operative procedure are recorded. Intra
operative temperature record is kept. Reason for stoma formation, if applicable, is
recorded. The intra operative costs and disposable items are identified. Intra operative
complications are identified as well as adverse events involving surgical equipment.

In the post operative phase the total intravenous fluid requirement, blood transfusion, pain
scores, amount of Morphine used, whether the patient vomited and whether nasogastric tube is
required as well as lung function tests and any adverse events are noted at 30 minutes
following the procedure, 6 hours, 24 hours, 48 hours, 72 hours, 96 hours, 120 hours, 144
hours, 168 hours and continued daily until the patient is discharged if not already
discharged at that time. At discharge from hospital, total hospital days are identified as
well as time in high dependency unit or intensive care unit, reason for delay in discharge
is noted, post operative events including cardiac, respiratory, renal, ileus, wound
infection, anastomotic leakage and other events are identified.

Pathology includes the site of tumour, TNM staging, ACPS staging, length of resected colon,
proximal clearance, distal clearance, number of nodes obtained, tumour differentiation,
venous invasion, perineal invasion and histological type. Adjuvant chemotherapy if planned
is noted. Patients in the study may be entered into an adjuvant chemotherapy trial following
surgery provided the subsequent trial does not have radiation as a component of therapy and
that the chemotherapy trial allows entering of patients from both surgical arms of the
study. Follow up is quarterly for the first year, 6 monthly for year two and three and then
annually until year five. At follow up wounds are check for any evidence of recurrence. A
colonoscopy is performed 12 months following resection and then every three years following
that if negative. Chest xray, abdominal CT or liver ultrasound, a complete blood picture are
performed if clinically indicated, CEA’s performed six monthly.

FOLLOW-UP SCHEDULE

Patients are followed for tumour recurrence and survival. Patients are advised on, and
offered standard treatment with, adjuvant therapy. Follow-up is standardised to provide
accurate data on recurrence and survival and more frequent examinations and investigations
are performed if clinically indicated.

Frequency of Follow-up:

The minimum number of follow-up evaluations is as follows:

- every 3 months for the lst year.

- every 6 months for the 2nd and 3rd years.

- annually for the 4th and 5th years.

Test Schedule:

The minimal requirements for follow-up investigations are as follows:

- History and examination with a specific check for tumour wound recurrence.

- Colon evaluation including colonoscopy or sigmoidoscopy plus barium enema.

- Annual examination if positive for neoplasia (earlier if preoperative proximal
examination is incomplete for technical reasons); examination every 3 years if
negative.

- haemoglobin and white cell count

- creatinine, SGOT, alkaline phosphatase, total bilirubin, CEA

- Chest X-ray

- Abdominal CT scan or liver ultrasound annually for 5 years.

- Quality of Life and Complications documentation postoperatively at 2 days, 2 weeks, 2
months and 18 months.

SIGNIFICANCE AND OUTCOMES

The study will determine the efficacy and safety of laparoscopic assisted resection of
colonic adenocarcinoma. It will also answer questions of cost effectiveness and quality of
life improvement. It will determine if port site recurrence is a real issue in this type of
surgery.

The study will also give valuable data about the outcomes of patients undergoing laparotomy
in regard to current length of hospital stay, effectiveness of post-operative analgesia, in
hospital complications and transfusion requirements.