Gastric Carcinoma and Extended Surgery

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Slide 1 : Gastric Carcinoma and Extended Surgery - Dr Steven Dubenec (Mentor: Dr Bryan Yeo)
Slide 2 : Gastric Carcinoma Diffuse M:F 1:1 Onset Middle Age 5 yr surv overall <10% Aetiology Diet H. pylori Intestinal M:F 2:1 Onset Middle Age 5 yr surv overall 20% Aetiology Unknown Blood group A association H. pylori
Slide 3 : Gastric Carcinoma Japanese & Chinese mortality rates for Gastric Ca ~2x southern hemisphere Disease of lower socioeconomic groups
Slide 4 : Gastric Carcinoma Staging JRSGC – PHNS System P- Grade of peritoneal spread H- Presence of Hepatic Mets N- Extent of lymph node involvement S- Extent serosal invasion Internationally Unified TMN Staging
Slide 5 :
Slide 6 : Gastric Carcinoma Surgery Western societies when resecting stomach tend not to be as extensive as the Japanese The extent of resection is described as D1. Limited Lymphadenectomy. All N1 Nodes removed en bloc with the stomach D2. Systematic Lymphadenectomy. N1 & N2 nodes en bloc with stomach D3. Extended Lymphadenectomy. A more radical en bloc resection including N3 nodes
Slide 7 :
Slide 8 : Gastric Carcinoma Surgery The case for D2 systematic lymphadenectomy is controversial Japan practices this routinely Western medicine tends to take a more conservative approach
Slide 9 : Indications for Splenectomy If macroscopic disease can be resected & the operation is potentially curative then en bloc splenectomy or pancreaticosplenectomy is worthwhile. If it is more palliative then this benefit must be weighed against the potential complications of splenectomy and more extensive operation
Slide 10 : Distal Pancreatectomy Associated with marked increase in morbidity & mortality with or without splenectomy Indications for pancreatectomy: Direct invasion of the tail of the pancreas Likelihood of splenic artery nodal involvement
Slide 11 : “No survival benefit from combined pancreaticosplenectomy and total gastrectomy for gastric cancer” Kitamura K, et al., Br J Surg 86:119-122; 1999
Slide 12 : Introduction Gastric Carcinoma is a common fatal malignancy More common in Japan c/w rest of world Japan reports better survival rates Stage Migration Thinner Population Experience with Gastric Surgery
Slide 13 : Introduction Combined pancreaticosplenectomy does have increased morbidity & mortality† †Cuschieri A, Fayers P, Fielding, etal. Postoperative morbidity and mortality after D1 & D2 resections for gastric cancer: preliminary results of the MRC randomised controlled surgical trial. The Surgical Cooperative Group. Lancet 1996; 347: 995-9
Slide 14 : Question? Does Extended Surgery for Gastric Carcinoma offer any survival benefit?
Slide 15 : Methods Retrospective Study Data collected from 1969 – 1996 Total number of patients undergoing gastric surgery 1844 190 – Total Gastrectomy + Pancreaticosplenectomy 206 Total Gastrectomy + Splenectomy
Slide 16 : Methods Pathology based on Japanese Research Society for Gastric Surgery Patients with direct invasion of pancreas or suspected lymph nodes along splenic artery had TG+PS Patients with suspected splenic hilum nodes had TG+S
Slide 17 : Statistical Analysis c2 used to assess clinicopathological difference between groups Kaplan-Meier used for cumulative survival rates Wilcoxon test used for survival curves
Slide 18 : Results No differences in ages or sex between groups TG+S groups had smaller tumours and were more superficial (p<0.005) TG+PS groups had more frequent lymph node metastases & were more histologically advanced No difference in histological type
Slide 19 : Morbidity
Slide 20 : Post-Op Survival (9/190) 5% of TG+PS died within 30/7 of Post-Operatively (12/206) 6% of TG+S died within 30/7 of Post-Operatively
Slide 21 : Post-Op Survival Survival rates only for stage 3&4 disease looked at because of numbers
Slide 22 : Post-Op Survival No Statistical Significance Between Survival of Stage 3&4 Disease for TG+S & TG+PS 5 Year Survival
Slide 23 : Post-Op Survival
Slide 24 : Post-Op Survival
Slide 25 : Pancreaticosplenectomy 83 patients had TG+PS for direct invasion of pancreas 104 patients had TG+PS when lymph node metastasis was evident or suspected 46/83 had histological confirmation of direct invasion 22/104 had confirmation of lymph node metastasis at histology 6 of 46 lived for > 5 years 2 of 22 lived > 5 years
Slide 26 : Discussion Assumption that TG+PS has improved survival rate TG+PS routine in Japan >30 years No direct evidence
Slide 27 : Discussion Of the TG+PS 6 long term survivors with direct invasion of pancreas 2 patients with metastases along splenic artery survived > 5years after TG+PS 20 of 22 Patients with splenic hilar nodes died before 5 years after TG+S
Slide 28 : Discussion TG+S does not appear to be beneficial in patients with splenic hilar nodes Extended Surgery offers some advantages for patients with direct invasion of pancreas body or tail TG+PS has most morbidity
Slide 29 : Discussion TG+PS mortality in Japan is about 10% c/w 1996 MRC trail in UK 16% ? This due to More surgical experience with this disease Thinner patients Case mix differences Co-morbidities
Slide 30 : Conclusion Extended surgery for Gastric Ca not beneficial unless there is direct invasion of the pancreas body or tail TG+PS not routine TG+PS not useful for lymph node metastases along splenic artery
Slide 31 : Pros Purpose clearly stated Good comprehensive collation of results which were well presented Results collated support the conclusions derived This study offer clinical significance for surgical treatment of Gastric Ca
Slide 32 : Cons Retrospective study Surgical decision for TG+S or TG+PS was subjective ? Anatomical position of tumour. Is it important? ? Co-morbidities of the patients. Did they die of causes other than their Ca No mention of the specific post-op complications that led to patients death within the 30/7

 


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