T4 Colon Cancer and Laparoscopic Approach Gustavo Plasencia MD FACS, FASCRS Clinical Professor of...

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T4 Colon Cancer and T4 Colon Cancer and Laparoscopic Approach Laparoscopic Approach Gustavo Plasencia MD FACS, Gustavo Plasencia MD FACS, FASCRS FASCRS Clinical Professor of Surgery Clinical Professor of Surgery Florida International Florida International University College of Medicine University College of Medicine MISS, Salt Lake City, 2011 MISS, Salt Lake City, 2011

Transcript of T4 Colon Cancer and Laparoscopic Approach Gustavo Plasencia MD FACS, FASCRS Clinical Professor of...

T4 Colon Cancer andT4 Colon Cancer and Laparoscopic Approach Laparoscopic Approach

Gustavo Plasencia MD FACS, Gustavo Plasencia MD FACS, FASCRS FASCRS Clinical Professor of SurgeryClinical Professor of Surgery

Florida International University Florida International University College of MedicineCollege of Medicine

MISS, Salt Lake City, 2011MISS, Salt Lake City, 2011

Guidelines for Laparoscopic Guidelines for Laparoscopic Resection of Curable Colon Resection of Curable Colon

and Rectal Cancerand Rectal Cancer Best available approachBest available approach Systematic review of available data Systematic review of available data

and expert opinionand expert opinion Not necessarily the best approachNot necessarily the best approach Complex health care environmentComplex health care environment FlexibleFlexible Periodically updated Periodically updated

Oncologic PrinciplesOncologic Principles

Proximal ligation of the primary arterial Proximal ligation of the primary arterial supplysupply

Adequate proximal and distal marginsAdequate proximal and distal margins Appropriate lymphadenectomy (level 1 Appropriate lymphadenectomy (level 1

evidence)evidence) Minimum of 12 lymph nodesMinimum of 12 lymph nodes Inability to follow the oncologic Inability to follow the oncologic

principles should lead to conversion to principles should lead to conversion to open surgeryopen surgery

Recent GuidelinesRecent Guidelines

The European Association of The European Association of Endoscopic Surgery (Veldkamp et al Endoscopic Surgery (Veldkamp et al 2004) and French Society of 2004) and French Society of Digestive Surgery (Peschaud et al Digestive Surgery (Peschaud et al 2006) both recommend open 2006) both recommend open resection for preoperatively resection for preoperatively suspected T4 colorectal cancers.suspected T4 colorectal cancers.

Laparoscopic en-bloc Laparoscopic en-bloc Resection for a T4 LesionResection for a T4 Lesion En bloc resection with negative margins En bloc resection with negative margins

is curativeis curative Depends on: Depends on:

structure tumor is adherentstructure tumor is adherent

surgeons skillsurgeons skill

surgeons experiencesurgeons experience

avoid perforation of the tumoravoid perforation of the tumor

conversion is an optionconversion is an option

T4 Colorectal Cancer: Is T4 Colorectal Cancer: Is Laparoscopic Resection Laparoscopic Resection

Contraindicated? Contraindicated? 39 patients with suspected T4 lesion39 patients with suspected T4 lesion Organ involved:Organ involved:

abdominal or pelvic side wall abdominal or pelvic side wall 2121

bladder 4bladder 4

small bowel colon 6small bowel colon 6

vagina and ovary 3vagina and ovary 3

prostate and seminal vesicles 3prostate and seminal vesicles 3

duodenum 2 duodenum 2

F Bretagnol etal 2010F Bretagnol etal 2010

T4 Colorectal Cancer: Is T4 Colorectal Cancer: Is Laparoscopic Resection Laparoscopic Resection

Contraindicated?Contraindicated? 39 patients, 20 men and 19 women39 patients, 20 men and 19 women Median age 73 years (49 – 90 years)Median age 73 years (49 – 90 years) Right colon 18Right colon 18 Left colon 9Left colon 9 Rectum 12Rectum 12 Diagnosis made by endorectal Diagnosis made by endorectal

ultrasound, abdominal CT scan and ultrasound, abdominal CT scan and pelvic MRI pelvic MRI

F Bretagnol etal 2010F Bretagnol etal 2010

Combined Resection of a Combined Resection of a Preoperatively Invaded Preoperatively Invaded

OrganOrgan Abdominal wall and pelvic lateral side wall 21Abdominal wall and pelvic lateral side wall 21 Partial cystectomy 4Partial cystectomy 4 Posterior vaginal wall 2Posterior vaginal wall 2 Small bowel resection 4, segmented colectomy Small bowel resection 4, segmented colectomy

22 Partial prostatectomy 1, seminal vesicles 3Partial prostatectomy 1, seminal vesicles 3 Partial duodenal resection 1Partial duodenal resection 1 Bilateral oophrectomy 1Bilateral oophrectomy 1

F Bretagnol etal 2010F Bretagnol etal 2010

Conversion Conversion Rate/Morbidity and Rate/Morbidity and

Mortality RateMortality Rate 7 out of 39 patients (18%)7 out of 39 patients (18%)

Tumor fixity 3Tumor fixity 3 Difficult in performing a bloc resection 3Difficult in performing a bloc resection 3 Intra-abdominal bleeding 1Intra-abdominal bleeding 1

Morbidity rate 33% Morbidity rate 33% Mortality rate 2.5% Mortality rate 2.5%

F Bretagnol F Bretagnol etal 2010 etal 2010

Histopathology/SurvivalHistopathology/Survival

T4 tumor in 30 of 39 patients (77%) T4 tumor in 30 of 39 patients (77%) Right colectomy 17 of 18 (94%)Right colectomy 17 of 18 (94%) Left colectomy 6 of 9 (67%)Left colectomy 6 of 9 (67%) Rectum 7 of 12 (58%)Rectum 7 of 12 (58%)

Overall R1 resection rate was 13%Overall R1 resection rate was 13% Survival at 19 months median f/u 94% Survival at 19 months median f/u 94%

(3 pt’s with metastatic disease no (3 pt’s with metastatic disease no local recurrence local recurrence

FBretagnol etal 2010FBretagnol etal 2010

Patient U.C.Patient U.C.

57 y/o male57 y/o male Colon tumor found in colonoscopyColon tumor found in colonoscopy CT scan 04/02/10 showed a sigmoid CT scan 04/02/10 showed a sigmoid

mass with involvement of the mass with involvement of the bladder, air in the bladder. bladder, air in the bladder.

Follow up 09/23/10, on chemo now.Follow up 09/23/10, on chemo now. PET CT planned for February 2011.PET CT planned for February 2011.

Patient U.C.Patient U.C.

Laparoscopic sigmoid colectomy Laparoscopic sigmoid colectomy with resection of colovesical fistula with resection of colovesical fistula performed on 05/13/10performed on 05/13/10

Clear MarginsClear Margins Pathology T4N0Pathology T4N0

VideosVideos

ConclusionConclusion

Not enough data today Not enough data today Never compromise oncological principleNever compromise oncological principle If specimen requires a long incision (>8 If specimen requires a long incision (>8

cm) procedure should be done opencm) procedure should be done open Common sense may be better than Common sense may be better than

medical evidence in some situationmedical evidence in some situation Be honest with our own skills and Be honest with our own skills and

experienceexperience