Transcript Joint Hospital Grand Round

Joint Hospital Grand Round
Surgical management of CA
stomach
Dr. K. W. Chan
Gastric cancer - incidence
 Worldwide
- 5th most common
cancer
- 4th most common cause of
cancer death
 5YS is still low despite recent
advancement
Gastric cancer – Hong Kong
Gastric cancer surgery controversies
1.
2.
3.
4.
Extent of lymph node dissection
Addition of pancreato-splenectomy
Total Vs subtotal gastrectomy
Reconstruction methods
–
Japanese Vs Western
Extent of Lymph node dissection
 In




Japan,
Belief in an orderly
spread along
lymphatic
Advocates D2
dissection
Resectability =
93%
5YS = 61%
 In
Western
countries




McNeer(1956) –
extended surgery =
high complication and
mortality
Advocates D1
resection
Resectability = 48%
5YS = 28%
–
Why Japanese results are
superior?
Extent of lymph node dissection
 Effects

of massive screening
Early detection
 Ethinic
difference in body build
 ? Effect of extensive surgery
Extent of lymph node dissection
-
guideline
 Japanese
Research Society for the Study
of Gastric Cancer (JRSGC) set the
guideline (Kajitani 1981)
•
•
•
•
•
16 stations of LN classified into 4 tier
Station 1,3,5, (lesser curve) = N1
Station 2,4,6, (greater curve) = N1
Station 7(left gastric), 8(common hepatic), 9
(coeliac), 10 and 11(splenic) = N2
Others = N3 and N4
–
definition of radical
dissection
Extent of lymph node dissection
 D1
dissection = removal of stomach +
greater and lesser omentum
 D2 dissection = omental bursa removed
with frontal layer of transverse
mesocolon + clearance of the involved
vascular pedicle*
*involving splenic vessels for proximal and middle tumour
–
RCT comparing D1 and D2
Extent of lymph node dissection
 South
Africa Study (Dent 1988)
 Dutch Gastric Cancer Trial (DGCT) –
1989 to 1993
 Medical Research Coucil in Britain
(MRC) 1989 to 1995
–
South Africa Study
Extent of lymph node dissection
 D1



dissection:
22 patents
14% morbidity
0% hospital
mortality
 D2



dissection
21 patients
19% morbidity
0% hospital
mortality
Extent of lymph node dissection
- DGCT
Exclusion :
Previous gastrectomy
Previous or co-existing cancer
Inclusion :
Adenoca, no metas
Age <85, in good health
82 patients failed
Randomization because
of no supervisor a/v
1,078 patients eligible
996 patients randomized
711 patients resectable
(380 D1 + 331 D2)
285 patients unresectable
(133 D1 + 152 D2)
Extent of lymph node dissection
 Quality
•
•
•
- DGCT
control
One Japanese gastric surgeon trained 11
local supervisors who attended all the other
D2 dissection
All the D1 dissection was attended by
another coordinator
The no. of stations of LN detected in the
specimen was assessed
Extent of lymph node dissection
– DGCT
(results)
D1 dissection
D2 dissection
Complication rate
25%
43%
Postop death
4%
10%
Median stay
14 days
(7-143 days)
45%
16 days
(7-277 days)
47%
43%
37%
5YS
5Y relapse rate
– DGCT
(conclusion)
Extent of lymph node dissection
 The
excess morbidity and mortality
together with lack of long term effect
did not justify standard use of D2
dissection in Western patients with
gastric cancer
Extent of lymph node dissection
– MRC
trial
Exclusion:
emergency surgery
Previous gastric surgery
Coexisting cancer
Age <20
Comorbid cardiorespiratory problem
Inclusion:
potentially curable
adenocarcinoma of
stoach
Eligible patients
Staging laparotomy
200 patients - D1 dissection
200 patients – D2 dissection
– MRC
trial (results)
Extent of lymph node dissection
D1 dissection
D2 dissection
complications
28%
46%
Hospital mortality
6.5%
13%
5YS
35%
33%
Multivariate analysis showed the difference in morbidity and mortality
became insignificant after allowance for pancreaticosplenectomy
– MRC
trial (conclusion)
Extent of lymph node dissection
 Although
D2 dissection offered no
survival advantage over D1, that
could not exclude the advantage of
D2 dissection in selected group,
especially if pancreas and spleen
are preserved
Addition of pancreato-splenectomy
 According
to the JRSGC,
For proximal ca and ca involving greater
curve, distal pancreatectomy and
splenectomy may be necessary for
adequate clearance of splenic LN
Addition of pancreato-splenectomy
 Disadvantage:






increased incidence of atelectasis
Increased subphrenic collection
Decreased immunity against infection
Decreased ability of tumour surveillance
Increased pancreatic fistula
Devascularization of the gastric stump
Addition of pancreato-splenectomy
 In
DGCT, splenectomy is one of the
risk factor for complication
RR = 2.16
 In MRC trial, pancreato-splenectomy
is associated with increased
mortality and morbidity
RR = 1.53
Addition of pancreato-splenectomy
–
conclusion
 Addition
of pancreato-splenectomy
is associated with increased
mortality and morbidity and should
not be performed unless it is really
necessary
Subtotal Vs total gastrectomy
 An
Italian study (Bozzetti 1999):
622 patients (319 subtotal
gastrectomy + 303 total
gastrectomy)
–
Italian study (results)
Subtotal Vs total gastrectomy
5YS : 65.3% for the SG, 62.4% for the TG
 Hazard ratio for mortality after SG Vs TG
1.01 (95% CI, 0.76 –1.33)


TG is associated with more splenectomy (p
=0.001)
Subtotal Vs total gastrectomy
-
conclusion
 For
distal lesions, if 5cm resection
margin is possible, subtotal
gastrectomy is as good as total
gastectomy in terms of oncological
clearance
Reconstruction methods
 More
patients will enjoy longer life
expectancy after gastric cancer
surgery
 Traditional methods:



Billroth I
Billroth II
Roux-en-Y
–
disadvantages of traditional
methods
Reconstruction methods
 Disadvantages:
 Impaired
nutrition
 >10% weight loss
 Indigestion and diarrhoea
 Dumping syndrome
 Reflux and anastomotic ulcer at B-I
and B-II reconstruction
–
new technique
Reconstruction methods
 Pouch
reconstruction
•
Hunt-LawrenceRodino pouch
–
new technique
Reconstruction methods
 Jejunal
interposition with
or without pouch
– summary of
current evidence
Reconstruction methods
 Schwarz

(1998):
Effect of pouch reconstruction




Less fullness
Slower food passage (t50 25 Vs 12min)
Fewer postprandial symptoms (4-10% Vs 20-60%)
Less weight loss (7 Vs 14kg)
Criticism: results incoherent, sample size small, lack of long
term follow up
– summary of
current evidence
Reconstruction methods

Effect of intestinal interposition




Less glucose disturbance (stimulated glucose level 22%
lower)
Less iron deficiency (Hb 13.9 Vs 12.5g/dL; iron 18.4 Vs
10.2 mol/l)
Less weight loss (8% higher)
Better quality of life (life quality score: 84 Vs 76 points)
Criticism: no. of randomised studies for the effect of intestinal
interposition is small, sample size small, lack of long term
follow up and suitable instruments to measure quality of life
Reconstruction methods
 There
- conclusion
may be a small benefit in term
of quality of life which need further
studies to be proven
 To perform such complex operation
outside clinical trial is still not
justified
What sorts of surgery should be performed in our
gastric cancer patients?
 Extended
lymph node dissection
should not be rountinely performed
except in selected cases
 No pancreato-splenectomy
 Subtotal gastrectomy if adequate
resection margin
 No fancy reconstruction methods