Transcript Operative Procedures

Surgical oncology ; introduction
• Surgery is the treatment of choice for most
localized, solid neoplasms.
• Surgery has recognized limits in its
application.
• Surgery is increasingly combined with other
treatment modalities.
Role of the Surgical Oncologist
• Consultant
Special training or skills
Tumor board
• Educator
Cancer conferences
Teaching programs
• Organizer and Leader
Cancer programs
Cancer committee
Tumor registry
Oncology section
• Researcher
Clinical protocols
Roles of Surgeon in Management of
Cancer Patients
• Prevention
• Diagnosis
• Definitive treatment
• Palliation
• Rehabilitation
Prevention
• Educating patients about carcinogenic
hazards
• Surgical intervention for the preventable
cancer
Sugery That can Prevent Cancer
• Underlying condition
cryptochidism
polyposis coli
familial colon cancer
ulcerative colitis
MEN type II, III
familial breast cancer
familial ovarian cancer
• Prophylactic surgery
Orchiopexy
Colectomy
Colectomy
Colectomy
Thyroidectomy
Mastectomy
Oophorectomy
Role of Surgeon in Management of
Cancer Patients
• Prevention
• Diagnosis
• Definitive treatment
• Palliation
• Rehabilitation
Diagnosis of Cancer
• Acquisition of tissue for histologic
diagnosis
• Staging of patients
Techniques for Obtaining Tissue
• Needle biopsy
• Incisional biopsy
• Excisional biopsy
Needle biopsy ; advantages
• Simplest method
• Inexpensive
• Causes minimal disturbance of the
surrounding tissue
Needle biopsy ; disadvantages
• Danger of implanting tumor cells in a
needle tract
• Not representative of the total tumor
• The needle misses the lesion
Needle biopsy ; types
• Fine needle aspiration biopsy
• Large bore needle biopsy ;
Vim Silverman needle
Tru cut needle
Principles of the performance of all
surgical biopsies
• Needle tract or scar should be removed as
part of subsquent definitive surgical
procedure
Principles of the performance of all
surgical biopsies
• Do not contaminate new tissue plane
during the biopsy
Principles of the performance of all
surgical biopsies
• Choice of biopsy technique should be
selected carefully in order to obtain
an adequate tissue sample for the
needs of the pathologist
Diagnosis of Cancer
• Acquisition of tissue for histologic
diagnosis
• Staging of patients
TNM Classification System
Describes the anatomic extent of disease
based on assessment of three components
T Primary tumor size and extent
N Regional lymph node involvement
M Distant metastasis absent or present
TNM Classification System
• Primary tumor (T)
TX
T0
Tis
T1,T2
T3,T4
Primary tumor cannot be assessed
No evidence of primary tumor
Carcinoma in situ
Increasing size or local extension
Increasing extent of primary tumor
TNM Classification System
• Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1,N2,N3 Increasing involvement of regional
lymph nodes
TNM Classification System
• Distant metastasis (M)
MX Presence of distant metastasis cannot be
assessed
M0 No distant metastasis
M1 Distant metastasis (may be further specified
according to size of occurrence)
Role of Surgeon in Management of
Cancer Patients
•
•
•
•
•
Prevention
Diagnosis
Treatment
Palliation
Rehabilitation
Considerations in choosing
therapy
• Disease and results obtained from each type
of therapy
• Patient’s general conditions and co-existing
disease
• Patient’s life situation and psychological
makeup
American Society of Anesthesiologists
Physical Status Classification
CLASS
DESCRIPTION
Ⅰ
Healthy patient
Ⅱ
Mild systemic disease, no functional limitation
Ⅲ
Severe systemic disease, definite functional
limitation
Ⅳ
Sever systemic disease that is a constant threat
to life
Ⅴ
Moribund patient unlikely to survive 24 hours
with or without operation
From Miller RD: Principles and Practice of Anesthesia,
2nd ed. New York, Churchill Livingstone, 1986, with
Permission.
Eastern Cooperative Oncology Group
Performance Scale and Corresponding
ECOG-PS
GRADE
0
DESCRIPTION
1
Restricted in physically strenuous activity,
but ambulatory and able to carry out work
of a light or sedentary nature
80-90
2
Ambulatory and capable of all self-care, but
unable to carry out any work activities; up
and about more than 50% of waking hours
60-70
3
Capable of only limited self- care; confined
to bed of chair 50% or more of waking
hours
40-50
4
Completely disabled; cannot carry on any
self-totally confined to bed or chair
≤30
Fully active, able to carry on all predisease
activities without restriction
KARNOFSKY
RATING
100
Major Challenges Confronting the
Surgical Oncologist I
• Accurate identification of patients who can
be cured by local treatment alone
Major Challenges Confronting the
Surgical Oncologist II
• Development and selection of local
treatments that provide the best balance between
local cure and the impact of treatment morbidity
on the quality of life
Major Challenges Confronting the
Surgical Oncologist III
• Development and application of
adjuvant treatments that can improve
the control of local and distant
invasive and metastatic disease
Cancer surgery ; principles
• Enucleation or incomplete excision of
tumor mass is never indicated as a
therapeutic measure
• Prevention of tumor cell implantation during
surgery
• Prevention of vascular dissemination at surgery
Types of cancer operations
• Local resection
• Radical local resection
• Radical resection with en bloc excision of
lymphatics
• Extensive surgical procedures
Adequate margin of Resection
• A complete margin of normal tissue around the
primary lesion
• Frozen sections used to evaluate tissue margins in
instances of doubt
• Complete removal of involved regional lymph
nodes
• Resection of involved adjacent organ
• En bloc resection of biopsy tracts and tumor
sinuses
Roles of Surgery in the Treatment of
Cancer
• Definitive surgical treatment for primary cancer
• Surgery for reduce the bulk of residual disease
• Surgical resection of metastatic disease with curative
intention
• Surgery for treatment of oncologic emergencies
Surgery for residual disease
• In selected cancers, surgical resection
of bulk disease may lead to
improvement in the ability to control
residual gross disease that has not been resected
Surgery for metastatic disease
• Resection of pulmonary metastasis in
patients with soft tissue and bony sarcomas
• Resection of pulmonary metastasis in
patients with colon cancer
• Resection of hepatic metastasis in patients with
colorectal cancer
Surgery for oncologic emergencies
•
•
•
•
exsanguinating hemorrhage
perforation
drainage of abscess
impending destruction of vital organs
Role of Surgeon in Management of
Cancer Patients
• Prevention
• Diagnosis
• Definitive treatment
• Palliation
• Rehabilitation
Surgery for Palliation
• To improve the quality of life
• Examples ; relief of intestinal obstruction,
removal of mass causing pain
Role of Surgeon in Management of
Cancer Patients
• Prevention
• Diagnosis
• Definitive treatment
• Palliation
• Rehabilitation
THE CANCER SURGEON
• AS A CARE PROVIDER
Brings surgical skill and compassionate care to
patients
Leads screening, prevention, and risk assessment
programs
Facilitates molecular characterization of tumor and
surrogate tissues
Coordinates mu1tidisciplinary clinical care teams
THE CANCER SURGEON
• AS A RESEARCHER
Facilitates laboratory research
Coordinates epidemiologic studies
Conducts clinical trials research
Develops novel approaches to education
THE CANCER SURGEON
• AS A TEACHER
Ensures excellence in surgical care
Leads a multidisciplinary team to implement
integrate oncology training
Stomach and Duodenum
•
•
•
•
Anatomy
Physiology
Operative procedures
Gastric disorders
peptic ulcer diseases
tumors
structural disorders
inflammatory and infectious diseases
traumas
Tumors of the Stomach
•
•
•
•
•
•
•
Adenocarcinoma
Lymphoma
Stromal tumors
Gastric carcinoid
Metastasis to the stomach
Gastric polyps
Miscellaneous
Gross Classification of
Advanced Gastric Cancer
• Borrmann 1형 : 융기형(fungating, polypoid type)
• Borrmann 2형 : 궤양-융기형(ulcerofungating type)
• Borrmann 3형 : 궤양-침윤형(ulceroinfiltrative type)
• Borrmann 4형 : 미만형(diffuse infilrative, linitis plastica type)
• Borrmann 5형 : 분류 불능(unclassified type)
Gastric Cancer – As a Public Health
Problem
• Accounts for about 10% of cancers worldwide
• Is the 2nd leading cause of cancer death
worldwide(after lung cancer)
• Has a low 5-year case survival(approx.20%)
Gastric Cancer – Epidemiological Trends
• Regional variations:
- Low incidence in economically developed “western”
pop. (+ India)
- Risk reductions reported in migrants
moving to
low Regions
Gastric Cancer – Epidemiological Trends
• Incidence higher in:
- Males (male-to-female ratio approx. 2
- Older age groups (eg, 70+ yrs)
- Lower socio-economic groups
- Some races (eg, in the USA: Black and
Asian pop.)
to 1)
Gastric Cancer – Epidemiological Trends
• Secular reductions in:
- Incidence
- Mortality (more so)
- Case fatality(?)
• Diminished secular reductions in
incidence/mortality
Gastric Cancer incidence in KOREA
Seoul(1992-94)
Male Female
Crude rate 45.7 26.7
ASR
71.4 30.4
Kangwha(1986-92)
Male
Female
80.2
65.9
34.4
25.0
Cancer of the Gastric CardiaEpidemiological Trends
• Higher male-to-female ratio
- approx. 4 to 1 c/f 2 to 1 for other
gastric cancers
• Younger age distribution
• Regional variations:
- High incidence in economically developed “western” pop.(+
China)
- Preponderance in males higher in economically developed
“western” pop. (+ China)
• Secular increases in incidence
Risk Factors associated with gastric
cancer
• Nutritional factors
• Environmental factors
• Social factors
• Medical factors
Nutritional factors
• Low intake of fruit & vegetables
• High intake of salted food & smoked, cured &
picked foods
• (?) High intake of high-nitrate & high
Starch foods
• Low intake of allium products (eg,garlic and onions)
and green tea
Environmental factors
-Lack of refrigeration
-Ionizing radiation
-(?)Alcohol and tobacco
-Helicobacter pylori
Medical factors
•
•
•
•
•
•
•
previous gastric surgery
Helicobactor pylori infection
gastric polyp
achlorhydria and pernicious anemia
atrophic gastritis
intestinal metaplasia
giant hypertrophic gastritis
Patterns of Spread
• Local extension
• Lymphatic metastasis
• Peritoneal metastasis
• Hematogeneous dissemination
Staging
• Clinical staging - cTNM
• Pathologic staging - pTNM
병기분류의 목적
• 환자의 예후 판정
• 치료계획의 수립
• 치료방법에 따른 결과의 비교
Definition of TNM
Primary tumor (T)
•
•
•
•
•
•
•
TX
T0
Tis
T1
T2
T3
T4
primary tumor cannot be assessed
no evidence of primary tumor
carcinoma in situ
tumor invades lamina propria or submucosa
tumor invades muscularis propria
tumor invades adventitia
tumor invades adjacent structures
T1
T2
T3
T4
Regional lymph nodes (N)
•
•
•
•
•
Nx
N0
N1
N2
N3
regional lymph node scannot be assessed
no regional lymph node metastasis
metastasis in 1 - 6 regional lymph nodes
metastasis in 6 - 15 regional lymph nodes
metastasis in >15 regional lymph nodes
M: Distant Metastasis
• MX : 원격전이 유무를 알 수 없음
• M0 : 원격전이 없음
• M1 : 원격전이 있음
P: Peritoneal Metastasis
•
PX : 복막전이 유무를 알 수 없음
•
P0 : 복막전이 없음
•
P1 : 복막전이 있음
H: Hepatic Metastasis
•
HX : 간전이 유무를 알 수 없음
•
H0 : 간전이 없음
•
H1 : 간전이 있음
Stage IA
T1
N0 M0
Stage IB
T1
T2
N1M0
N0M0
Stage II
T1
T2
T3
N2M0
N1M0
N0M0
Stage IIIA T2
T3
T4
N2M0
N1M0
N0M0
Stage IIIB T3
N2M0
Stage IV
T4
N1, N2, N3 M0
T1, T2, T3 N3M0
Any T Any NM1
위암수술의 기본요건
• 근치성 (Complete resection with
no residual tumor)
• 안전성
• 기능보존성
• Quality of life의 유지 및 향상
Technique of Operation
• intraoperative staging
• determine the extent resection
Basic Information Required for Surgical
Decision Making
• Epidemiology
• Grading and tumor growth pattern
• Rules of tumor progression
• Location and Lymphatic drainage
Location
1995
1999
Lower third
44%
45%
Middle third
34%
32%
Upper third
10%
12%
2%
3%
Entire stomach
Local extension
• penetration into the gastric wall
• through the intramural lymphatics
Operative Procedures
• Gastric Resection
• Combined Resection
• Lymph node Dissection
Gastric Resections
• Total gastrectomy
• Distal gastrectomy
• Proximal gastrectomy
• Wedge resection
• Segmental gastrectomy
Function preserving procedures
•
•
•
•
•
•
Endoscopic mucosal resection
Laparoscopic wedge resection
Segmental resection
Pylorus preserving distal gastrectomy
Vagus nerve preserving gastrectomy
Proximal gastrectomy
Single Jejunum(21)
Pouch(13)
A limited fundectomy includes limited resection of the upper
stomach, limited dissection of lymph nodes along the resected
stomach (right cardia, lesser curvature, left cardia, and upper part
of greater curvature), and preservation of the vagal nerve. The
reconstruction was performed using the single jejunum in 21
patients and the jejunal pouch in 13 patients.
Segmental Resection
SR. The middle portion of the stomach, including the cancerous
lesion, is resected and the pylorus is preserved. Lymph node
dissection is limited to nodes near the resected portion of the stomach
(DO-1). The omentum is preserved. The hepatic and celiac branches
of the vagal nerve are completely preserved. Reconstruction is
performed as a gastro-gastrostomy.
Combined resections
•
•
•
•
•
•
•
Spleen
Liver
Pancreas
Transverse colon
Gall bladder
Adrenal gland
Ovary
Total gastrectomy with splenectomy and pancreaspreserving dissection of lymph nodes along splenic artery.
The splenic artery is cut at the distal site of branching of
the dorsal pancreatic artery.
Extended operation-left upper abdominal exenteration
plus Appleby’s method. The whole stomach, pancreas
body and tail, spleen, transverse colon, gallbladder, and
left adrenal are removed en bloc. The celiac artery is
resected at the root.
Lymph node dissection
• D0 ; no dissection or incomplete dissection
• D1 ; dissection of the N1 group ( MRD )
• D2 ; dissection of N1 and N2 group ( SRD )
• D3 ; dissection of N1, N2, and N3 group ( ERD )
• D4 ; dissection of N1, N2, N3, and N4 group ( SERD )
Controversies in lymph nodes dissection
•
•
•
•
•
•
Local or systemic disease
Difference of biological characteristics
Stage migration phenomenon
Patient’ factors
Surgeon
Randomized prospective study
Surgery for Palliation
• palliative resection
• intestinal bypass
• enterostomy
Aims of palliative surgery
• Relief of symptoms to improve quality of life
• prolongation of comfortable survival without
producing new symptoms or incurring excessive
mortality or morbidity
Palliative surgery ;
preoperative consideration
• Reasonable length of life
• cost-benefit equation
• balancing symptoms with operative
morbidity and postoperative symptoms
Survivals in Gastric Cancer
100
%
91.6
79.2
82.0
stage Ⅰ
66.9
stage Ⅱ
50
47.6
36.4
stage Ⅲ
21.9
14.7
0
5
years after
operation
stage Ⅳ
10 ys
CADO,1985
Gastric Cancer Surgery
Survival - US vs. Japanese vs. Korea
US
Stage
I
II
III
IV
(%)
(18.1)
(16.2)
(35.6)
(30.1)
Japan
5-yr sur
50
29
13
3
(%) 5-yr sur
(45.7) 91
(11.9) 72
(21.8) 44
(20.6)
9
Korea
(%) 5-yr sur
(28.9) 89
(15.0) 69
(43.3) 38
(13.2)
9
Maruyama et al., World J Surg 11:418-25, 1987
Recent advances in gastric cancer
Surgical Treatment for Gastric Cancer
size
Depth
M elevated
depressed
0.1-1.0
1.1-2.0
2.1-
EMR*
EMR*
Limited Surg*
EMR* EMR/Lim.Surg
Limited Surg*
SM
MP
subtotal/total Gx＋D2 dissection
SS
SE-SI
s/t Gx＋D2/Extended*
Adjuvant Chem.*
Scirrhous ca.
Extended（LUAE）*
Adjuvant Chem.*
P1H1CY1M1
Chemotherapy*
Adjuvant Surg.*
* Study
Gx：Gastrectomy
SCH
Limited Surgery for Early Gastric
Cancer
Early gastric cancer is really cancer which has a
potential to grow to advanced cancer.
（1）Natural History
（2）Treatment
1） EMR
2） Limited Surgery
Fundectomy for cancer in the upper stomach
Segmental Resection for ca. in the middle
SCH
Interval from early cancer to advanced
cancer
100%
50
Median：37
months
0
0
10
20
30
40
50
60
70
Interval from the time of endoscopic diagnosis of early gastric
cancer(months)
80
Survival Curve of Early Cancer
100%
5-year survival rate：64.5%
50
Median：77 months
0
0
10 20 30 40 50 60 70 80 90 100
months
Proximal Resection
Eligibility：
Early Cancer（M）
Upper stomach
Less than 5 cm longitudinally
Out of criteria of EMR
Surgical Methods：
Proximal Gastrectomy（-1/2）
D0-1 lymph node dissection
Reconstruction using pouch jejunum
Single Jejunum(21)
Pouch(13)
A limited fundectomy includes limited resection of the upper
stomach, limited dissection of lymph nodes along the resected
stomach (right cardia, lesser curvature, left cardia, and upper part
of greater curvature), and preservation of the vagal nerve. The
reconstruction was performed using the single jejunum in 21
patients and the jejunal pouch in 13 patients.
Results
（Proximal Resection）
Surgical Risk
blood Loss（cc）
Postoperative Complication
anastmosis
failure
pancreas
fistula
stenosis
infection
gallstone
Prox. Gx
Total Gx
p
300±193
555±316
< 0.05
1 (2.9)
0
0
0
0
2 (5.0)
6 (15.0)
3 (7.5)
4 (10.0)
3 (7.5)
< 0.05
Segmental Resection
Eligibility：
Early Cancer（M）
Middle stomach
Less than 5 cm longitudinally
Out of criteria of EMR
Surgical Methods：
Segmental Gastrectomy（-1/2）
D0-1 lymph node dissection
Gastro-gastro-anastomosis
Segmental Resection
SR. The middle portion of the stomach, including the cancerous
lesion, is resected and the pylorus is preserved. Lymph node
dissection is limited to nodes near the resected portion of the stomach
(DO-1). The omentum is preserved. The hepatic and celiac branches
of the vagal nerve are completely preserved. Reconstruction is
performed as a gastro-gastrostomy.
Results
（Segmental Resection）
Segm. Gx
50
Distal Gx
50
239
342
< 0.05
1
7
< 0.05
1
8
< 0.05
p
Surgical Risk
mean blood loss（cc）
Postoperative
Complication
Gallstone
Subtotal/total Gx＋D2 dissection
（1）Common surgery in Japan safer D2
dissection lower incidence of
postoperative complication
（2）Survival rate in common operation（D2） is
better than that in Western countries
（3）Guideline of JGCA has no plan to compare
D2 surgery and D1.
Pancreas Preserving D2 Dissection
（Phase Ⅲ）
Eligibility：
MP-SE advanced cancer in the upper/middle of
the stomach
curative operation
Surgical Methods：
Total Gx＋Pancreatosplenectomy（Group A） vs
Total Gx＋Splenectomy（Group B）
Endpoint：
5 year survival rate, Surgical risk
Total gastrectomy with splenectomy and pancreaspreserving dissection of lymph nodes along splenic artery.
The splenic artery is cut at the distal site of branching of
the dorsal pancreatic artery.
Results
（Total Gx ＋ pancreas preserving dissection）
Surgical Risk
blood Loss（cc）
amylase（drain）
Group A
Group B
994.0±473.7
904.2±428.
6
16/55(29%)
（≧10,000u/L）
Postoperative Complication
pancreas fistula
8 (14.5)
anastmosis failure
2 (3.6)
liver dysfunction
2 (3.6)
bleeding
1 (1.8)
Dissected Nodes
dissected nodes
4.6±2.9
nodes with metastasis 4/55(7.3%)
6/55(11%)
5
(9.1)
2
(3.6)
1
(1.8)
4.1±2.6
0 (0)
3/55(5.5%)
p
< 0.05
Thoracotomy vs Conventional mediastinal
node dissection（JCOG）
Eligibility：
cardia cancer invading to esophagus（< 3cm）
curative operation
Surgical Methods：
Thoracotomy vs Laparotomy
Endpoint：
5 year survival rate
Under registration of patients
Extended Surgery
（1）A phase Ⅲ study：Para-aortic nodes dissection
（JCOG, ongoing）
（2）A phase Ⅲ study： Extended surgery （Left Upper
Abdominal Exenteration：LUAE） for scirrhous
gastric cancer vs Common surgery for SGC（JCOG,
plan）
Para-aortic Lymph Node Dissection
（JCOG）（phase Ⅲ）
Eligibility：
SS-SI
curative operation
Surgical Methods：
D2 node dissection vs D2＋para-aortic node
dissection
Endpoint：
5 year survival rate
- Under follow-up after registration -
Extended Operation for Scirrhous Gastric
Cancer（LUAE）（phase Ⅱ）
Eligibility：
Scirrhous gastric cancer（Type 4 cancer）
curative operation
Surgical Methods：
Total Gx＋pancreatosplenectomy vs
Left Upper Abdominal Exenteration：LUAE）
Endpoint：
feasibility, 5 year survival rate
Extended operation-left upper abdominal exenteration
plus Appleby’s method. The whole stomach, pancreas
body and tail, spleen, transverse colon, gallbladder, and
left adrenal are removed en bloc. The celiac artery is
resected at the root.
Mortality and Morbidity
Complication
LUAE（+Apl）
Control
（％）（Death）
（％）
Pancreatic fistula
(16)
22(33) (1)
5
Liver dysfunction
(16)
9(14) (1)
5
Anastomosis failure
(19)
2 (3)
6
Infection
1 (2)
－
Others
2 (3)
1 (3)
Survival Rates of Patients with
Scirrhous Gastric Cancer（stageⅢ）
100
％
Groups
1988-92
1983-87
1973-77
50
1978-82
0
1
2
3
4
5
6
7
8
9 10
SCH
Gastric Cancer Surgery
Survival - US vs. Japanese vs. Korea
US
Stage
I
II
III
IV
(%)
(18.1)
(16.2)
(35.6)
(30.1)
Japan
5-yr sur
50
29
13
3
(%) 5-yr sur
(45.7) 91
(11.9) 72
(21.8) 44
(20.6)
9
Korea
(%) 5-yr sur
(28.9) 89
(15.0) 69
(43.3) 38
(13.2)
9
Maruyama et al., World J Surg 11:418-25, 1987
Gastric Cancer
Surgical Techniques
4 Randomized D1 vs. D2 Studies
Hong Kong
N.S.
South Africa
N.S.
U.K.
N.S.
Holland
N.S.
Gastric Cancer
Adjuvant Chemotherapy
Individual Studies
and
Meta-analyses
No significant
benefit
Gastric Cancer
Sites of Failure
Local Regional (Total) 87%
Distant (Only)
25%
Local/Regional (Only) 53%
Adapted from Gunderson et al.
Subtotal/total Gx＋D2 dissection
Studies
（1）A phase Ⅲ study：Total Gastrectomy ＋
pancreato-splenectomy vs Total gastrectomy ＋
splenectomy（Furukawa, published）
（2）A phase Ⅲ study：Total gastrectomy ＋
splenectomy vs spleen preserving total gastrectomy
（JCOG plan）
（3）A phase Ⅲ study：Thoracotomy vs conventional
mediastinal dissection（JCOG ongoing）