Transcript Upper Abdominal Debulking - University of Kentucky | Medical Center

Upper Abdominal Debulking
of Gynecologic Malignancies
{
Shaun McKenzie, MD
Assistant Professor of Surgery
University of Kentucky
Objectives
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To describe the rationale behind the inclusion
of upper abdominal debulking procedures to
achieve complete cytoreduction
To review the pertinent anatomy and
techniques necessary for upper abdominal
debulking
To describe the perioperative outcomes
associated with an aggressive upper abdominal
approach
Obstacles to an Aggressive
Approach
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Extensive upper abdominal disease portends
aggressive tumor biology precluding a benefit
from surgery
The morbidity and mortality of upper
abdominal debulking is prohibitive
Lack of comfort in performance of these
procedures or lack of appreciation of the
biology of these diseases and the importance of
optimal cytoreduction
Aggressive Surgical Effort and
Improved Survival in Advanced
Stage Ovarian Cancer
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Retrospective analysis of 194
patients
Need for radical surgery did
not adversely impact survival
In patients with
carcinomatosis, performance
of radical surgery was
associated with improved
survival (44% vs 17%,p<0.001)
The only independent
predictor of survival was
residual disease
Aletti et al. Obstet Gynecol 2006; 107: 77-85
Aggressive Surgical Effort and
Improved Survival in Advanced
Stage Ovarian Cancer
Aletti et al. Obstet Gynecol 2006; 107: 77-85
Upper Abdominal
Debulking Procedures
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Diaphragmatic procedures: stripping or
resection, ABC
Splenectomy with or without distal
pancreatectomy
Porta hepatis resection
Liver resection
Cholecystectomy
Gastric resection
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262 consecutive patients
Addition of upper
abdominal resections
increased OC from 53% to
82%
Required in 1/3 of patients
No difference between
complication rate between
groups
No survival difference
between OC groups with or
without upper abdominal
debulking
Eisenhauer et al. Gynecol Oncol 2006; 103
Chi et al. Gynecol Oncol 2009;114
Chi et al. Gynecol Oncol 2009;114
Principles of Upper
Abdominal Debulking
Wide Exposure and thorough
organ mobilization
 Critical Understanding of the
Anatomy, particularly vascular
anatomy
 Understand the predictable sites of
disease
 Bring all your toys to the table
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Diaphragmatic Procedures
Fanfani et al. Gynecol Oncol 2009; 116
Is It Safe?
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141 eligible patients with 229
EUAS procedures performed
90 % optimally reduced (30%
R0)
Grade 3-5 morbidity in 22%
68% of complications
managed by a percutaneous
procedure
Mortality 1.4%
Chi et al. Gynecol Oncol 2010; 119
Conclusion
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Optimal Cytoreduction should be the plan of
attack for any woman undergoing debulking
surgery
The addition of an aggressive approach to
upper abdominal disease is associated with
increased rates of optimal debulking without a
negative impact in cancer outcome
EUAS can be performed safely in experienced
centers with a multidisciplinary approach
Adherance to sound surgical principles
optimizes outcome