Laparoscopy for gastric cancer

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


The General Infirmary at Leeds


Chairs of Surgery in LeedsBerkeley G.A. Moynihan FRCS

• Pioneer abdominal surgeon

• Founder: Association of Surgeons of GB

• Founder: The British Journal of Surgery


Chairs of Surgery in LeedsPhillip Allison FRCS


Chairs of Surgery in LeedsJohn C. Goligher FRCS

•Eminent colorectal surgeon•Peptic ulcer surgery


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


Upper GI & Laparoscopic SurgeryCurrent Unit in Leeds

• Simon P. Dexter FRCS

• Michael J. McMahon FRCS

• Abeezar I. Sarela FRCS

• Henry M. Sue-Ling FRCS


Gastric CancerRole of Laparoscopy

• Staging– for carcinoma

• Curative Resection– for carcinoma and GIST

• Palliation• Treatment of sequels of open gastrectomy

– Incisional hernia– Intestinal obstruction


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


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


Laparoscopic Staging

For patients with laparoscopic M1 disease, is no resection of the primary

tumour associated with:

•High incidence of complications?

•Shorter survival?


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


Laparoscopic M1, No resection

18%

16%

27%

23%

16%

Entire

Proximal

GEJ

Body

Antrum

165Patients


Primary Tumour Location


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%



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


Intervention



• Intervention 42%

• Laparotomy 8%

• Mortality 1%



Laparoscopic M1, No ResectionSurvival

Months

42363024181260

Survival

1.0

.8

.6

.4

.2

0.0

Median survival: 10 monthsOne year survival: 39%

156 patients


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


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?


Laparoscopic Gastric Resection

GIST

Carcinoma


Laparoscopic Gastric ResectionGIST

• Extra-luminal or Exophytic tumors– “Closed” wedge-excision

• Intra-luminal or Endophytic tumors– “Open” wedge-excision

• Segmental gastrectomy and anastomosis


Laparoscopic Gastric Resection for CarcinomaAims

• Entirely laparoscopic

• Specimen-retrieval via lower abdominal incision

• Negative primary tumor resection-margins

• D2 lymphadenectomy


Laparoscopic Gastric Resection for CarcinomaOutcome Measures

• Feasibility• Safety• Peri-operative benefits• Longer-term “mechanical” benefits

– Incisional hernia– Intestinal obstruction

• Recurrence • Survival


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


• 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


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


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?

Laparoscopy for gastric cancer

Health & Medicine

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