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

Bowel Tumours Laparoscopy

Objectives

• Role of laparoscopy

• Surgical technique

• Tumour-specific indications

– GIST

– Adenocarcinoma

– Lymphoma

– Metastasis

Bowel Tumours Laparoscopy

Role of Laparoscopic SurgeryExtending Paradigms for Colorectal & Upper GI Carcinoma

• Diagnosis

• Staging

• Palliation

• Curative Resection

• Post-operative mechanical problems

– Adhesive obstruction

– Incisional hernia

Bowel Tumours Laparoscopy

Location-Specific Resection

• Duodenum– Segmental resection

– Pancreaticoduodenectomy

• Jejunum

• Ileum– Segmental resection

– Ileocolic resection

Bowel Tumours Laparoscopy

Technical Issues

• Laparoscopically-assisted resection

• Totally laparoscopic resection

• Anastomosis

– Extra-corporeal

– Intra-corporeal

• Additional organ resection

• Lymphadenectomy

Bowel Tumours Laparoscopy

Techniques

1

2

3

4

Bowel Tumours Laparoscopy

Small Bowel GIST

Biological Implications for Laparoscopic

Resection

•Wide heterogeneity in size and consistency

•Lymphadenectomy not necessary

•Sarcomatosis is rare

Bowel Tumours Laparoscopy

Laparoscopic ResectionSmall Bowel GIST

• 2000-2005

• Mount Sinai Medical Centre, New York

• 15 patients

• Median size: 3.7cm (0.4-8.5)

• Conversion: 2 patients

• 1 major complication: anastomotic bleeding

Nguyen et al. Surg Endosc 2006;20:713-716

Bowel Tumours Laparoscopy

Duodenal AdenocarcinomaSurvival is distinct from Pancreatic Cancer

Yeo CJ et al (Johns Hopkins). Ann Surg 1998;227:821-31

Bowel Tumours Laparoscopy

Sarela AI et al (Memorial Sloan Kettering). Ann Surg Oncol 2004;11:380-386

Duodenal AdenocarcinomaSurvival is similar to Gastric Cancer

Bowel Tumours Laparoscopy

Duodenal Adenocarcinoma

• 137 patients• 1983-2001• Potentially curative resection: 53% • Pancreaticoduodenectomy: 78%• Isolated duodenal resection: 22%• Median diameter 4 cm (1.5-11)• pN1: 43% - significant prognostic factor• ≥15 lymph nodes: important for prognostic

discriminationSarela AI et al (Memorial Sloan Kettering). Ann Surg Oncol 2004;11:380-86

Bowel Tumours Laparoscopy

Laparoscopic Staging of Small Bowel CarcinomaUsing the Gastric Carcinoma Paradigm

• Period: 1993-2002• Total 1748 patients

• Selection criteria for laparoscopy:– Radiological M0– Acceptable risk for major operation– No obstruction or bleeding

• Laparoscopy 657 patients

• Laparoscopic M1 23%Sarela AI et al (Memorial Sloan Kettering). Ann Surg. 2006;243:189-95

Bowel Tumours Laparoscopy

Small Bowel Carcinoma

Anterior abdominal wall limits the extent of mesenteric retraction for radical lymphadenectomy

–Transverse colon tumours excluded from trials of laparoscopic colorectal resection.

Guillou P.J., PI, UK MRC CLASICC study

–Dissection of greater omentum and omental bursectomy are limiting steps of laparoscopic D2 gastrectomy

Bowel Tumours Laparoscopy

Primary Small-bowel LymphomaLaparoscopy for Diagnosis & Staging

Bowel Tumours Laparoscopy

Small Bowel Metastasis

• Palliation

• Laparoscopic resection

• Laparoscopic bypass

Bowel Tumours Laparoscopy

Summary

• Radiological suspicion of small bowel tumour Laparoscopy for diagnosis

• Reasonable to extend paradigms for gastric carcinoma

• Staging of carcinoma and lymphoma• GIST: Always consider laparoscopic

resection• Bowel resection-anastomosis techniques

are well-established & safe