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Laparoscopy for gastric cancer

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Laparoscopy for gastric cancer

  1. 1. Laparoscopy for Gastric Cancer Abeezar I. Sarela MBBS FRCS Consultant in Upper Gastrointestinal & Minimally Invasive Surgery The General Infirmary at Leeds, United Kingdom Massachusetts General Hospital, August 17, 2006
  2. 2. The General Infirmary at Leeds
  3. 3. Chairs of Surgery in Leeds Berkeley G.A. Moynihan FRCS <ul><li>Pioneer abdominal surgeon </li></ul><ul><li>Founder: Association of Surgeons of GB </li></ul><ul><li>Founder: The British Journal of Surgery </li></ul>
  4. 4. Chairs of Surgery in Leeds Phillip Allison FRCS
  5. 5. Chairs of Surgery in Leeds John C. Goligher FRCS <ul><li>Eminent colorectal surgeon </li></ul><ul><li>Peptic ulcer surgery </li></ul>
  6. 6. Chairs of Surgery in Leeds Contemporary <ul><li>David Johnson FRCS </li></ul><ul><li>Pioneer of HSV and bariatric surgery </li></ul><ul><li>Pierre J. Guillou FRCS </li></ul><ul><li>PI: MRC CLASICC Trial </li></ul><ul><li>Michael J. McMahon FRCS </li></ul><ul><li>President, Association of Laparoscopic Surgeons of GB </li></ul>
  7. 7. Upper GI & Laparoscopic Surgery Current Unit in Leeds <ul><li>Simon P. Dexter FRCS </li></ul><ul><li>Michael J. McMahon FRCS </li></ul><ul><li>Abeezar I. Sarela FRCS </li></ul><ul><li>Henry M. Sue-Ling FRCS </li></ul>
  8. 8. Gastric Cancer Role of Laparoscopy <ul><li>Staging </li></ul><ul><ul><li>for carcinoma </li></ul></ul><ul><li>Curative Resection </li></ul><ul><ul><li>for carcinoma and GIST </li></ul></ul><ul><li>Palliation </li></ul><ul><li>Treatment of sequels of open gastrectomy </li></ul><ul><ul><li>Incisional hernia </li></ul></ul><ul><ul><li>Intestinal obstruction </li></ul></ul>
  9. 9. Staging Philosophy <ul><li>CT staging: False-negative results </li></ul><ul><li>M1 is incurable disease </li></ul><ul><li>Treatment-intent </li></ul><ul><ul><li>Optimise quality of life </li></ul></ul><ul><ul><li>Prolong length of survival </li></ul></ul><ul><ul><li>Minimise treatment-related complications </li></ul></ul>
  10. 10. Laparoscopic Staging of Gastric Carcinoma Memorial Sloan Kettering Cancer Center Experience <ul><li>Period: 1993-2002 </li></ul><ul><li>Gastric or GOJ carcinoma 1748 patients </li></ul><ul><li>Selection criteria: </li></ul><ul><ul><li>Clinically & radiologically 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>Laparoscopic false-negative M0 9% </li></ul><ul><li>Sarela AI (Brennan MF) et al. Am J Surg. 2006;191:134-38 </li></ul>
  11. 11. Laparoscopic Staging <ul><li>For patients with laparoscopic M1 disease, is no resection of the primary tumour associated with: </li></ul><ul><li>High incidence of complications? </li></ul><ul><li>Shorter survival? </li></ul>
  12. 12. Laparoscopic M1Gastric Carcinoma, No Resection Memorial Sloan Kettering Cancer Center Experience Sarela AI (Brennan MF) et al. Ann Surg 2006;243:189-95
  13. 13. Laparoscopic M1, No resection 165 Patients Sarela AI (Brennan MF) et al. Ann Surg 2006;243:189-95 Primary Tumour Location
  14. 14. Laparoscopic M1, No Resection Peritoneal metastasis P1: adjacent to stomach P2: few distant lesions P3: disseminated 165 patients 9%
  15. 15. Laparoscopic M1, No Resection Sarela AI (Brennan MF) et al. Ann Surg 2006;243:189-95 Intervention
  16. 16. Laparoscopic M1, No Resection <ul><li>Intervention 42% </li></ul><ul><li>Laparotomy 8% </li></ul><ul><li>Mortality 1% </li></ul>Sarela AI (Brennan MF) et al. Ann Surg 2006;243:189-95
  17. 17. Laparoscopic M1, No Resection Survival Median survival: 10 months One year survival: 39% 156 patients
  18. 18. M1 Gastric Cancer Leeds Experience <ul><li>Total : 211 patients (2001-2004) </li></ul><ul><li>M1 disease: 67 patients </li></ul><ul><li>Intervention </li></ul><ul><ul><li>Obstruction: 20% </li></ul></ul><ul><ul><li>Bleeding : 7% </li></ul></ul><ul><ul><li>Perforation: 1% </li></ul></ul><ul><li>Laparotomy: 9% </li></ul><ul><li>Median Survival: 7 months </li></ul>Sarela A et al. Arch Surg. In press
  19. 19. Laparoscopic M1 Gastric Carcinoma <ul><li>Unique group </li></ul><ul><ul><li>Minimally symptomatic disease </li></ul></ul><ul><ul><li>Satisfactory functional performance status </li></ul></ul><ul><li>No-resection is safe and does not appear to shorten survival </li></ul><ul><ul><li>Quality of life? </li></ul></ul><ul><li>Role for resection of M1 disease? </li></ul>
  20. 20. Laparoscopic Gastric Resection <ul><li>GIST </li></ul><ul><li>Carcinoma </li></ul>
  21. 21. Laparoscopic Gastric Resection GIST <ul><li>Extra-luminal or Exophytic tumors </li></ul><ul><ul><li>“ Closed” wedge-excision </li></ul></ul><ul><li>Intra-luminal or Endophytic tumors </li></ul><ul><ul><li>“ Open” wedge-excision </li></ul></ul><ul><li>Segmental gastrectomy and anastomosis </li></ul>
  22. 22. Laparoscopic Gastric Resection for Carcinoma Aims <ul><li>Entirely laparoscopic </li></ul><ul><li>Specimen-retrieval via lower abdominal incision </li></ul><ul><li>Negative primary tumor resection-margins </li></ul><ul><li>D2 lymphadenectomy </li></ul>
  23. 23. Laparoscopic Gastric Resection for Carcinoma Outcome Measures <ul><li>Feasibility </li></ul><ul><li>Safety </li></ul><ul><li>Peri-operative benefits </li></ul><ul><li>Longer-term “mechanical” benefits </li></ul><ul><ul><li>Incisional hernia </li></ul></ul><ul><ul><li>Intestinal obstruction </li></ul></ul><ul><li>Recurrence </li></ul><ul><li>Survival </li></ul>
  24. 24. Laparoscopic Gastrectomy for Carcinoma 2005-2006 <ul><li>Selected group: 11 patients </li></ul><ul><li>8 men, 3 women </li></ul><ul><li>Pre-operative stage </li></ul><ul><ul><li>Early gastric cancer: 6 patients </li></ul></ul><ul><ul><li>Advanced gastric cancer: 5 patients </li></ul></ul><ul><li>Selection bias for advanced cancer patients </li></ul><ul><ul><li>Pulmonary disease </li></ul></ul>
  25. 25. <ul><li>Subtotal: 7 patients, Total: 4 patients </li></ul><ul><li>Conversion: 2 patients </li></ul><ul><li>Major post-op complication: 3 patients </li></ul><ul><li>Hospital stay: median 15 days (7-48) </li></ul><ul><li>Lymph node retrieval: median 22 (10-40) </li></ul><ul><li>Positive resection margins: 3 patients </li></ul>Laparoscopic Gastrectomy 2005-2006
  26. 26. Laparoscopic Gastrectomy Complications CT-drain Abscess 3. Lap Subtotal G (C) Re-laparoscopy Chest drain Bleeding O-J leak 2. Lap. Total G Re-laparoscopy Embolisation Duodenal leak Bleeding 1. Lap. Total G Treatment Complications Operation
  27. 27. Laparoscopic Gastrectomy for Carcinoma <ul><li>Entirely laparoscopic approach is feasible </li></ul><ul><li>Steep learning curve </li></ul><ul><li>Safe (?) </li></ul><ul><li>Tactile loss for primary tumour extent </li></ul><ul><li>Lymph node yield > minimum of 15 (AJCC) </li></ul><ul><li>Patient-selection? </li></ul>

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