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Joint Hospital Grand Round

Joint Hospital Grand Round. Surgical management of CA stomach Dr. K. W. Chan. Gastric cancer - incidence. Worldwide - 5 th most common cancer - 4 th most common cause of cancer death 5YS is still low despite recent advancement. Gastric cancer – Hong Kong.

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Joint Hospital Grand Round

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  1. Joint Hospital Grand Round Surgical management of CA stomach Dr. K. W. Chan

  2. Gastric cancer - incidence • Worldwide - 5th most common cancer - 4th most common cause of cancer death • 5YS is still low despite recent advancement

  3. Gastric cancer – Hong Kong

  4. SURGERY = primary treatment

  5. Gastric cancer surgery - controversies • Extent of lymph node dissection • Addition of pancreato-splenectomy • Total Vs subtotal gastrectomy • Reconstruction methods

  6. 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% Extent of Lymph node dissection – Japanese Vs Western

  7. Extent of lymph node dissection – Why Japanese results are superior? • Effects of massive screening • Early detection • Ethinic difference in body build • ? Effect of extensive surgery

  8. 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

  9. Extent of lymph node dissection –definition of radical 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

  10. Extent of lymph node dissection –RCT comparing D1 and D2 • South Africa Study (Dent 1988) • Dutch Gastric Cancer Trial (DGCT) – 1989 to 1993 • Medical Research Coucil in Britain (MRC) 1989 to 1995

  11. D1 dissection: 22 patents 14% morbidity 0% hospital mortality D2 dissection 21 patients 19% morbidity 0% hospital mortality Extent of lymph node dissection – South Africa Study

  12. Extent of lymph node dissection - DGCT Exclusion : Previous gastrectomy Previous or co-existing cancer 1,078 patients eligible Inclusion : Adenoca, no metas Age <85, in good health 82 patients failed Randomization because of no supervisor a/v 996 patients randomized 711 patients resectable (380 D1 + 331 D2) 285 patients unresectable (133 D1 + 152 D2)

  13. Extent of lymph node dissection - DGCT • Quality 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

  14. Extent of lymph node dissection – DGCT (results)

  15. Extent of lymph node dissection – DGCT (conclusion) • 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

  16. 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 – D2 dissection 200 patients - D1 dissection

  17. Extent of lymph node dissection – MRC trial (results)

  18. Extent of lymph node dissection – MRC trial (conclusion) • 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

  19. 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

  20. 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

  21. 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

  22. 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

  23. Subtotal Vs total gastrectomy • An Italian study (Bozzetti 1999): 622 patients (319 subtotal gastrectomy + 303 total gastrectomy)

  24. Subtotal Vs total gastrectomy – Italian study (results) • 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)

  25. 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

  26. Reconstruction methods • More patients will enjoy longer life expectancy after gastric cancer surgery • Traditional methods: • Billroth I • Billroth II • Roux-en-Y

  27. Reconstruction methods – disadvantages of traditional methods • Disadvantages: • Impaired nutrition • >10% weight loss • Indigestion and diarrhoea • Dumping syndrome • Reflux and anastomotic ulcer at B-I and B-II reconstruction

  28. Reconstruction methods – new technique • Pouch reconstruction • Hunt-Lawrence-Rodino pouch

  29. Reconstruction methods – new technique • Jejunal interposition with or without pouch

  30. Reconstruction methods – summary of current evidence • 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

  31. Reconstruction methods – summary of current evidence • 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

  32. Reconstruction methods - conclusion • There 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

  33. 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

  34. Thank you

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