Laparoscopic surgery for small bowel tumours

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  • Figure 8-17. Primary small-bowel lymphoma: clinical staging. Primary small-bowel lymphoma is staged by the extent of disease, analogous to other extranodal lymphomas. Stage I 1E is confined to the small bowel, stage II IE involves adjacent nodes, and stage II 2E involves nonadjacent regional nodes. Stage III is more extensive and involves nodes on both sides of the diaphragm, with localized extralymphatic or spleen involvement. Stage IV is metastatic disease with involvement of extralymphatic sites.
  • Laparoscopic surgery for small bowel tumours

    1. 1. Laparoscopic Surgery for Small Bowel Tumours Symposium on Diseases of the Small Intestine, Jaslok Hospital, Dec. 9-10, 2006 Abeezar I. Sarela MSc MS FRCS The General Infirmary at Leeds University of Leeds School of Medicine
    2. 2. Objectives <ul><li>Role of laparoscopy </li></ul><ul><li>Surgical technique </li></ul><ul><li>Tumour-specific indications </li></ul><ul><ul><li>GIST </li></ul></ul><ul><ul><li>Adenocarcinoma </li></ul></ul><ul><ul><li>Lymphoma </li></ul></ul><ul><ul><li>Metastasis </li></ul></ul>
    3. 3. Role of Laparoscopic Surgery Extending Paradigms for Colorectal & Upper GI Carcinoma <ul><li>Diagnosis </li></ul><ul><li>Staging </li></ul><ul><li>Palliation </li></ul><ul><li>Curative Resection </li></ul><ul><li>Post-operative mechanical problems </li></ul><ul><ul><li>Adhesive obstruction </li></ul></ul><ul><ul><li>Incisional hernia </li></ul></ul>
    4. 4. Location-Specific Resection <ul><li>Duodenum </li></ul><ul><ul><li>Segmental resection </li></ul></ul><ul><ul><li>Pancreaticoduodenectomy </li></ul></ul><ul><li>Jejunum </li></ul><ul><li>Ileum </li></ul><ul><ul><li>Segmental resection </li></ul></ul><ul><ul><li>Ileocolic resection </li></ul></ul>
    5. 5. Technical Issues <ul><li>Laparoscopically-assisted resection </li></ul><ul><li>Totally laparoscopic resection </li></ul><ul><li>Anastomosis </li></ul><ul><ul><li>Extra-corporeal </li></ul></ul><ul><ul><li>Intra-corporeal </li></ul></ul><ul><li>Additional organ resection </li></ul><ul><li>Lymphadenectomy </li></ul>
    6. 6. Techniques 1 2 3 4
    7. 7. Small Bowel GIST <ul><li>Biological Implications for Laparoscopic Resection </li></ul><ul><li>Wide heterogeneity in size and consistency </li></ul><ul><li>Lymphadenectomy not necessary </li></ul><ul><li>Sarcomatosis is rare </li></ul>
    8. 8. Laparoscopic Resection Small Bowel GIST <ul><li>2000-2005 </li></ul><ul><li>Mount Sinai Medical Centre, New York </li></ul><ul><li>15 patients </li></ul><ul><li>Median size: 3.7cm (0.4-8.5) </li></ul><ul><li>Conversion: 2 patients </li></ul><ul><li>1 major complication: anastomotic bleeding </li></ul><ul><li>Nguyen et al. Surg Endosc 2006;20:713-716 </li></ul>
    9. 9. Duodenal Adenocarcinoma Survival is distinct from Pancreatic Cancer Yeo CJ et al (Johns Hopkins). Ann Surg 1998;227:821-31
    10. 10. Duodenal Adenocarcinoma Survival is similar to Gastric Cancer Sarela AI et al (Memorial Sloan Kettering). Ann Surg Oncol 2004;11:380-386
    11. 11. Duodenal Adenocarcinoma <ul><li>137 patients </li></ul><ul><li>1983-2001 </li></ul><ul><li>Potentially curative resection: 53% </li></ul><ul><li>Pancreaticoduodenectomy: 78% </li></ul><ul><li>Isolated duodenal resection: 22% </li></ul><ul><li>Median diameter 4 cm (1.5-11) </li></ul><ul><li>pN1: 43% - significant prognostic factor </li></ul><ul><li>≥ 15 lymph nodes: important for prognostic discrimination </li></ul><ul><li>Sarela AI et al (Memorial Sloan Kettering). Ann Surg Oncol 2004;11:380-86 </li></ul>
    12. 12. Laparoscopic Staging of Small Bowel Carcinoma Using the Gastric Carcinoma Paradigm <ul><li>Period: 1993-2002 </li></ul><ul><li>Total 1748 patients </li></ul><ul><li>Selection criteria for laparoscopy: </li></ul><ul><ul><li>Radiological M0 </li></ul></ul><ul><ul><li>Acceptable risk for major operation </li></ul></ul><ul><ul><li>No obstruction or bleeding </li></ul></ul><ul><li>Laparoscopy 657 patients </li></ul><ul><li>Laparoscopic M1 23% </li></ul><ul><li>Sarela AI et al (Memorial Sloan Kettering). Ann Surg. 2006;243:189-95 </li></ul>
    13. 13. Small Bowel Carcinoma <ul><li>Anterior abdominal wall limits the extent of mesenteric retraction for radical lymphadenectomy </li></ul><ul><ul><li>Transverse colon tumours excluded from trials of laparoscopic colorectal resection. </li></ul></ul><ul><ul><li>Guillou P.J., PI, UK MRC CLASICC study </li></ul></ul><ul><ul><li>Dissection of greater omentum and omental bursectomy are limiting steps of laparoscopic D2 gastrectomy </li></ul></ul>
    14. 14. Primary Small-bowel Lymphoma Laparoscopy for Diagnosis & Staging
    15. 15. Small Bowel Metastasis <ul><li>Palliation </li></ul><ul><li>Laparoscopic resection </li></ul><ul><li>Laparoscopic bypass </li></ul>
    16. 16. Summary <ul><li>Radiological suspicion of small bowel tumour Laparoscopy for diagnosis </li></ul><ul><li>Reasonable to extend paradigms for gastric carcinoma </li></ul><ul><li>Staging of carcinoma and lymphoma </li></ul><ul><li>GIST: Always consider laparoscopic resection </li></ul><ul><li>Bowel resection-anastomosis techniques are well-established & safe </li></ul>

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