The surgical management of gastroesophageal cancer

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  • Figure 11-22. Level of lymph node dissection. Data from several series suggest that the level of lymph node dissection accompanying gastrectomy for gastric cancer can influence survival. The lymphadenectomies that have come into use are classified according to the specific echelon of nodes removed and may differ depending on tumor location. A , Tiers of nodes from perigastric (N1) to para-aortic (N4) are shown. B , Removal of the primary draining lymph nodes (N1) shown as closed circles in with greater and lesser omenta is an R1 dissection and constitutes the minimal acceptable operation for gastric cancer. R2 dissection requires secondary lymph node excision (N2) in the celiac and hepatic regions, as well as splenic hilar nodes when the tumor involves the adjacent stomach. Splenectomy is controversial as a means to remove the latter nodes. More extensive dissections (R3) of tertiary nodes and the lining of the lesser sac are rarely performed because of their greater morbidity and unclear benefits. ( A , From Jeyasingham []; with permission.) ( B , Adapted from Shui et al. []; with permission.)
  • Figure 11-19. Operations for gastric carcinoma. At the present time, surgical extirpation is the only method of cure for invasive gastric cancer. In the United States, however, 10% to 15% of patients with gastric carcinoma will prove to be resectable for possible cure (removal of all gross disease with microscopic margins free of tumor) at operation. Of these, only a subgroup of patients with early disease by careful staging have a good chance of 5-year survival. Although the operations offered to patients for gastric cancer vary in their technical aspects related to lymph node dissection, distal subtotal gastrectomy ( A ) and total gastrectomy ( B ) remain the operations of choice in treating resectable gastric cancers with the exception of those involving the gastric cardia. This latter group is managed by esophagogastrectomy. The distal stomach can be brought up to either the midesophagus in the right chest or to the cervical esophagus after transhiatal esophagectomy []. ( From Scott et al. []; with permission.)
  • Figure 12-29. A-B , Lymph node involvement. Identification of lymph node involvement is best characterized by mapping of the cervical, mediastinal, and subdiaphragmatic areas. This information is useful in predicting survival rates as well as in directing radiation therapy. ( Adapted from Casson [].)
  • The surgical management of gastroesophageal cancer

    1. 1. The Surgical Management of Gastroesophageal Cancer Abeezar I. Sarela MSc,MS,MD,FRCS Consultant in Upper GI & Minimally Invasive Surgery Hon. Senior Lecturer in Surgery
    2. 2. Agenda <ul><li>Laparoscopic staging of gastric adenocarcinoma </li></ul><ul><li>Extent of lymphadenectomy for gastric adenocarcinoma </li></ul><ul><li>Transhiatal vs. transthoracic resection of oesophageal carcinoma </li></ul><ul><li>Laparoscopic resection: Quo vadis? </li></ul>
    3. 3. Staging Laparoscopy
    4. 5. Surgical Staging of Gastric Adenocarcinoma New diagnosis of gastric adenocarcinoma N=211 patients Radiological staging N=208 No Surgery N=87 Laparoscopy N=57 Laparotomy N=62 Radiological M1 N=45 Radiological M0 Unfit/Unwilling for operation N=30 Radiological M0 Locoregionally advanced N=12 Laparoscopic M1 N=16 Laparoscopic M0 N=41 Radiological M1 Palliative gastectomy N=2 Radiological M0 but M1 at laparotomy “ Open-close” N=1 EMR N=2 False-negative M0 (M1 at laparotomy) N=3 Gastrectomy N=2 “ Open-close” N=1
    5. 6. Outcomes: M1 Gastric Adenocarcinoma, No Gastrectomy Metastatic (M1) Gastric Adenocarcinoma Initial non-operative management N=55 patients Subsequent stomach-related intervention N=14 patients (25%) NO subsequent stomach-related intervention N=41 patients (75%) Obstruction N=11 patients (20%) 15 procedures Bleeding N=4 patients (7%) 7 procedures Perforation N=1 patient (2%) 1 procedure Stenting 5 procedures Radiation 5 procedures Laparotomy 3 procedures Other 3 procedures Argon plasma coagulation 4 procedures Laparotomy 1 procedure Other 1 procedure Laparotomy 1 procedure
    6. 7. Gastric Adenocarcinoma Extent of Lymphadenectomy <ul><li>D1 – limited or perigastric lymphadenectomy </li></ul><ul><li>D2 – extended lymphadenectomy </li></ul>
    7. 8. Operation for Gastric Carcinoma
    8. 9. Lymphadenectomy: D1 or D2? Randomized Clinical Trials <ul><li>Significantly higher morbidity and mortality for D2 </li></ul><ul><li>No difference in long-term survival </li></ul><ul><ul><li>Bonenkamp et al. (Dutch) </li></ul></ul><ul><ul><ul><li>NEJM 1999 25;340:908-14 </li></ul></ul></ul><ul><ul><ul><li>J Clin Oncol 2004 1;22:2069-77 </li></ul></ul></ul><ul><ul><li>Cuschieri et al. (MRC, UK) </li></ul></ul><ul><ul><ul><li>Lancet. 1996 13;347:995-9 </li></ul></ul></ul><ul><ul><ul><li>Br J Cancer. 1999;79:1522-30 </li></ul></ul></ul>
    9. 10. Laparoscopic Gastrectomy for Carcinoma
    10. 11. RCT: Laparoscopic vs. Open Subtotal Gastrectomy for Adenocarcinoma <ul><li>59 patients </li></ul><ul><li>Single centre </li></ul><ul><li>Laparoscopic arm: significant benefit for pain, recovery, blood loss, hospital stay </li></ul><ul><li>Similar lymph node retrieval </li></ul><ul><li>No difference in survival </li></ul><ul><li>Huscher et al. Ann Surg 2005;241:232-237 </li></ul>
    11. 12. Western Series of Laparoscopic Gastrectomy for Carcinoma 23 (10-44) 33% 67% 9 18 (62%) 29 2005-2007 Sarela et al, Leeds 34 (28-40) 8% 39% 10 48 (33%) 147 2000-2005 Pugliese et al, Italy 15 (4-29) 5% 50% 4 20 NS 2001-2006 Singh et al, UK NS 100% 55% 10 38 (63%) 60 2003-2006 Topal et al, Belgium 35 (7-106) 11% 75% 8 100 NS 1992-2005 Huscher et al, Italy 15±9 13% 46% 3 15 (42%) 36 2001-2006 Varela et al, USA 24±12 33% 48% 2 21 (46%) 52 1995-2004 Dulucq et al, France 23-47 40% 75% 20 20 (30%) 66 2003-2004 Carboni et al, Italy 8 (4-14) 0 67% 3 9 (36%) 25 1997-2000 Weber et al, USA Lymph node retrieval 2 Total gastrectomy Advanced gastric cancer 12 month volume Laparoscopic gastrectomy for adenocarcinoma Total no. of gastrectomies Study Period Authors
    12. 13. Oesophagectomy for Carcinoma Extent of Lymphadenectomy
    13. 14. Ivor Lewis Operation Abdomen Right Chest
    14. 15. Oesophagectomy for Cancer Transhiatal or Transthoracic? Randomized Clinical Trial <ul><li>Higher morbidity and mortality with trans-thoracic operation </li></ul><ul><li>No difference in survival </li></ul><ul><li>Hulscher et al. NEJM 2002;347:1662-1669 </li></ul><ul><li>Omloo et al. Ann Surg 2007;246:992-1000 </li></ul>
    15. 17. Oesophagectomy: Peri-Operative Outcomes
    16. 18. Minimally Invasive Oesophagectomy <ul><li>Totally laparoscopic trans-hiatal resection with cervical anastomosis. </li></ul><ul><li>Laparoscopic trans-hiatal dissection with mini-laparotomy with cervical anastomosis. </li></ul><ul><li>Right thoracotomy, laparoscopic gastric tubularization and cervical anastomosis. </li></ul><ul><li>Combined laparoscopic and thoracoscopic dissection. </li></ul><ul><li>Thoracoscopic excision of oesophageal leiomyomas and GISTs. </li></ul>
    17. 19. pT1 Oesophageal Adenocarcinoma Post-operative follow-up: median 44 months (range, 12-93) Jan 2000-Dec 2006 Esophagectomies for Adenocarcinoma 172 patients Pathological stage: T1 No neo-adjuvant therapy 44 patients (26%) Laparoscopic Transhiatal Esophagectomy 16 patients (36%) Open Ivor Lewis Esophagectomy 24 patients (55%) Open Transhiatal Esophagectomy 4 patients (9%)
    18. 20. Laparoscopic vs. Open Resection 16 (3-28) 19 (10-51) 15 (4-41) Lymph node retrieval 0 2 0 Post-operative Mortality Open Transhiatal 4 patients Open Ivor Lewis 24 patients Laparoscopic Transhiatal 16 patients
    19. 21. Pathological Characteristics Oesophagectomy for pT1 adenocarcinoma 14 (32%) Tumor length > 1cm 31 (70%) Long segment Barrett’s (> 3cm) 4 (9%) Poor differentiation 11 (25%) Submucosal invasion (pT1b) No. of patients (%) Total: 44 patients Feature
    20. 22. Pathological Characteristics Esophagectomy for pT1 adenocarcinoma Aggregate number of patients who may have been inadequately treated by EMR: 29 (66%) 2 (5%) Lymphovascular invasion 27 (61%) Multifocal carcinoma or HGD 2 (5%) Lymph node metastasis No. of patients (%) Total : 44 patients Impediments to EMR
    21. 23. Oncological Outcome Oesophagectomy for pT1 Adenocarcinoma Liver 22 N0 Poor T1a Open Ivor Lewis Liver 8 N1 Poor T1b Open Ivor Lewis Nodes 6 N0 Poor T1b Lap. Trans-Hiatal Site of recurrence Time to recurrence Node status Differentiation Tumor Depth Operation
    22. 24. PT1 Oesophageal Adenocarcinoma <ul><li>Similar lymph node retrieval with laparoscopic trans-hiatal esophagectomy or open esophagectomy </li></ul><ul><li>Small but definite risk (7%) of recurrent disease after esophagectomy for T1 adenocarcinoma </li></ul><ul><li>No evidence of oncological detriment by laparoscopic resection </li></ul>
    23. 25. PT1 Oesophageal Adenocarcinoma <ul><li>66% of early esophageal adenocarcinoma may have been inadequately treated by EMR </li></ul><ul><li>EMR should be reserved for highly selected patients </li></ul>

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