laparoscopy for gastric cancer
TRANSCRIPT
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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
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Laparoscopy for Gastric Cancer
The General Infirmary at Leeds
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Laparoscopy for Gastric Cancer
Chairs of Surgery in LeedsBerkeley G.A. Moynihan FRCS
• Pioneer abdominal surgeon
• Founder: Association of Surgeons of GB
• Founder: The British Journal of Surgery
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Laparoscopy for Gastric Cancer
Chairs of Surgery in LeedsPhillip Allison FRCS
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Laparoscopy for Gastric Cancer
Chairs of Surgery in LeedsJohn C. Goligher FRCS
•Eminent colorectal surgeon•Peptic ulcer surgery
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Laparoscopy for Gastric Cancer
Chairs of Surgery in LeedsContemporary
• David Johnson FRCSPioneer of HSV and bariatric surgery
• Pierre J. Guillou FRCSPI: MRC CLASICC Trial
• Michael J. McMahon FRCSPresident, Association of
Laparoscopic Surgeons of GB
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Laparoscopy for Gastric Cancer
Upper GI & Laparoscopic SurgeryCurrent Unit in Leeds
• Simon P. Dexter FRCS
• Michael J. McMahon FRCS
• Abeezar I. Sarela FRCS
• Henry M. Sue-Ling FRCS
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Laparoscopy for Gastric Cancer
Gastric CancerRole of Laparoscopy
• Staging– for carcinoma
• Curative Resection– for carcinoma and GIST
• Palliation• Treatment of sequels of open gastrectomy
– Incisional hernia– Intestinal obstruction
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Laparoscopy for Gastric Cancer
Staging Philosophy
• CT staging: False-negative results
• M1 is incurable disease
• Treatment-intent
– Optimise quality of life
– Prolong length of survival
– Minimise treatment-related complications
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Laparoscopy for Gastric Cancer
Laparoscopic Staging of Gastric CarcinomaMemorial Sloan Kettering Cancer Center Experience
• Period: 1993-2002
• Gastric or GOJ carcinoma 1748 patients
• Selection criteria:– Clinically & radiologically M0– Acceptable risk for major operation– No obstruction or bleeding
• Laparoscopy 657 patients
• Laparoscopic M1 23%• Laparoscopic false-negative M0 9%
Sarela AI (Brennan MF) et al. Am J Surg. 2006;191:134-38
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Laparoscopy for Gastric Cancer
Laparoscopic Staging
For patients with laparoscopic M1 disease, is no resection of the primary
tumour associated with:
•High incidence of complications?
•Shorter survival?
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Laparoscopy for Gastric Cancer
C u ra t iv e -in te n tE x c lu d e d
L a p a ro s c o p yo n ly
N = 1 4 7
M 1
M 1N = 1 8
T 4 tu m o u rN o M 1
E x c lu d e d
L a p a ro to m yN o re s e c t io n
M 0
S ta g in g L a p a ro s c o p yN = 7 1 8
P ro s p e c t iv e ly m a in ta in e d d a ta b a s e1 9 9 2 -2 0 0 2
N = 1 7 4 8
Sarela AI (Brennan MF) et al. Ann Surg 2006;243:189-95
Laparoscopic M1Gastric Carcinoma, No ResectionMemorial Sloan Kettering Cancer Center Experience
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Laparoscopy for Gastric Cancer
Laparoscopic M1, No resection
18%
16%
27%
23%
16%
Entire
Proximal
GEJ
Body
Antrum
165Patients
Sarela AI (Brennan MF) et al. Ann Surg 2006;243:189-95
Primary Tumour Location
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Laparoscopy for Gastric Cancer
Laparoscopic M1, No Resection
30%
35%
8%16%
10%
P3
P2
P1Combined
Liver
Peritoneal metastasisP1: adjacent to stomachP2: few distant lesionsP3: disseminated
165 patients
9%
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Laparoscopy for Gastric Cancer
Laparoscopic M1, No Resection
O b s tru c t io n3 2 p a t ie n ts
B le e d in g 8 p a t ie n ts
P e r fo ra t io n 1 p a t ie n t
In te rv e n t io n o n p r im a ry tu m o r4 1 (4 2 % ) p a t ie n ts
G a s tr ic A d e n o c a rc in o m aL a p a ro s c o p ic s ta g e M 1
N o g a s t r e c to m y9 7 p a t ie n ts
Sarela AI (Brennan MF) et al. Ann Surg 2006;243:189-95
Intervention
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Laparoscopy for Gastric Cancer
Laparoscopic M1, No Resection
• Intervention 42%
• Laparotomy 8%
• Mortality 1%
Sarela AI (Brennan MF) et al. Ann Surg 2006;243:189-95
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Laparoscopy for Gastric Cancer
Laparoscopic M1, No ResectionSurvival
Months
42363024181260
Survival
1.0
.8
.6
.4
.2
0.0
Median survival: 10 monthsOne year survival: 39%
156 patients
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Laparoscopy for Gastric Cancer
M1 Gastric CancerLeeds Experience
• Total : 211 patients (2001-2004)• M1 disease: 67 patients• Intervention
– Obstruction: 20%– Bleeding : 7%– Perforation: 1%
• Laparotomy: 9%• Median Survival: 7 months
Sarela A et al. Arch Surg. In press
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Laparoscopy for Gastric Cancer
Laparoscopic M1 Gastric Carcinoma
• Unique group– Minimally symptomatic disease– Satisfactory functional performance status
• No-resection is safe and does not appear to shorten survival– Quality of life?
• Role for resection of M1 disease?
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Laparoscopy for Gastric Cancer
Laparoscopic Gastric Resection
GIST
Carcinoma
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Laparoscopy for Gastric Cancer
Laparoscopic Gastric ResectionGIST
• Extra-luminal or Exophytic tumors– “Closed” wedge-excision
• Intra-luminal or Endophytic tumors– “Open” wedge-excision
• Segmental gastrectomy and anastomosis
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Laparoscopy for Gastric Cancer
Laparoscopic Gastric Resection for CarcinomaAims
• Entirely laparoscopic
• Specimen-retrieval via lower abdominal incision
• Negative primary tumor resection-margins
• D2 lymphadenectomy
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Laparoscopy for Gastric Cancer
Laparoscopic Gastric Resection for CarcinomaOutcome Measures
• Feasibility• Safety• Peri-operative benefits• Longer-term “mechanical” benefits
– Incisional hernia– Intestinal obstruction
• Recurrence • Survival
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Laparoscopy for Gastric Cancer
Laparoscopic Gastrectomy for Carcinoma2005-2006
• Selected group: 11 patients
• 8 men, 3 women
• Pre-operative stage– Early gastric cancer: 6 patients– Advanced gastric cancer: 5 patients
• Selection bias for advanced cancer patients– Pulmonary disease
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Laparoscopy for Gastric Cancer
• Subtotal: 7 patients, Total: 4 patients
• Conversion: 2 patients
• Major post-op complication: 3 patients
• Hospital stay: median 15 days (7-48)
• Lymph node retrieval: median 22 (10-40)
• Positive resection margins: 3 patients
Laparoscopic Gastrectomy2005-2006
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Laparoscopy for Gastric Cancer
Laparoscopic GastrectomyComplications
Operation Complications Treatment
1. Lap. Total G Duodenal leak
Bleeding
Re-laparoscopy
Embolisation
2. Lap. Total G Bleeding
O-J leak
Re-laparoscopy
Chest drain
3. Lap Subtotal G (C)
Abscess CT-drain
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Laparoscopy for Gastric Cancer
Laparoscopic Gastrectomy for Carcinoma
• Entirely laparoscopic approach is feasible
• Steep learning curve
• Safe (?)
• Tactile loss for primary tumour extent
• Lymph node yield > minimum of 15 (AJCC)
• Patient-selection?