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

Laparoscopy for Gastric Cancer

The General Infirmary at Leeds

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

Laparoscopy for Gastric Cancer

Chairs of Surgery in LeedsPhillip Allison FRCS

Laparoscopy for Gastric Cancer

Chairs of Surgery in LeedsJohn C. Goligher FRCS

•Eminent colorectal surgeon•Peptic ulcer surgery

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

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

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

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

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

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?

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

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

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%

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

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

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

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

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?

Laparoscopy for Gastric Cancer

Laparoscopic Gastric Resection

GIST

Carcinoma

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

Laparoscopy for Gastric Cancer

Laparoscopic Gastric Resection for CarcinomaAims

• Entirely laparoscopic

• Specimen-retrieval via lower abdominal incision

• Negative primary tumor resection-margins

• D2 lymphadenectomy

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

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

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

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

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?