Gastric Cancer Surgery.pptx
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Surgery in Gastric Cancer
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Gastric Cancer Surgery.pptx
- 1. GASTRIC CANCER - SURGERY Prof. S. Subbiah et al
- 2. BLOOD SUPPLY, LIGAMENTS AND LYMPHATICS Prof. S. Subbiah et al
- 3. BLOOD SUPPLY, LIGAMENTS AND LYMPHATICS Prof. S. Subbiah et al
- 4. BLOOD SUPPLY, LIGAMENTS AND LYMPHATICS Prof. S. Subbiah et al
- 5. TREATMENT โข Surgery โข Systemic therapy โข Radiotherapy SURGERY SYSTEMIC THERAPY GASTRIC CANCER RADIO THERAPY Cornerstone - Surgery Prof. S. Subbiah et al
- 6. Guidelines and Evidences Western Japanese Prof. S. Subbiah et al
- 7. Guidelines Localized cancer (cTis or cT1a) Locoregional cancer (cT1bโcT4a) Metastatic cancer (cT4b, cM1) Prof. S. Subbiah et al
- 8. Western guidelines - Summary Prof. S. Subbiah et al
- 9. Guidelines Non Metastatic Metastatic Prof. S. Subbiah et al
- 10. Japanese Guidelines - Summary Prof. S. Subbiah et al
- 11. T1a Prof. S. Subbiah et al
- 12. Endoscopic Resection Prof. S. Subbiah et al
- 13. EMR & ESD Prof. S. Subbiah et al
- 14. Endoscopic Resection Vs Gastrectomy Wang et al- Meta analysis โข No difference in OS โข Shorter hospital stay and reduced perioperative morbidity with ER Prof. S. Subbiah et al
- 15. Endoscopic Resection Endoscopic Resection Evaluation of Curability Treatment & Surveillance Prof. S. Subbiah et al
- 16. Endoscopic Resection - Curability UL - Ulceration SM 1 - <500microns from m.mucosa VM - Vertical margin HM - Horizontal margin LyV - Lymphovascular invasion Prof. S. Subbiah et al
- 17. T1a - Surgery โข Tumors that do not meet the criteria for EMR/ESD โข Proximal or Pylorus preserving Gastrectomy โข D1 lymphadenectomy โข No role for nodal sampling or SLN Mapping Prof. S. Subbiah et al
- 18. T1a - Surgery Proximal Gastrectomy Pylorus preserving Gastrectomy Prof. S. Subbiah et al
- 19. T1a - Surgery Local Resection Segmental Gastrectomy Non Standard Treatment ( Investigational ) Prof. S. Subbiah et al
- 20. T1b Prof. S. Subbiah et al
- 21. T1b โข Gastrectomy โ depending upon the tumor site โข D1 Lymphadenectomy โ Differentiated type & 1.5 cm or smaller โข D1+ lymphadenectomy โ all other T1b tumors Prof. S. Subbiah et al
- 22. T1b Prof. S. Subbiah et al
- 23. Sentinel lymph node biopsy โข Inappropriate for clinical use in Early gastric cancer Prof. S. Subbiah et al
- 24. Locoregional cancer T2-4 Prof. S. Subbiah et al
- 25. T2-4 Prof. S. Subbiah et al
- 26. Criteria of Unresectability โข Locoregionally advanced o Disease infiltration of the root of the mesentery o Para-aortic lymph node highly suspicious on imaging or confirmed by biopsy o Invasion or encasement of major vascular structures (excluding the splenic vessels) โข Distant metastasis or peritoneal seeding (including positive peritoneal cytology) Prof. S. Subbiah et al
- 27. Locoregional cancer โ T2 and above, any N Medically fit and potentially resectable Loco regional โข Surgery or Periop Chemo or Preop ChemoRT Medically fit and unresectable Loco regional โข Chemoradiation or Systemic therapy Non surgical candidates Loco regional โข Palliative/Best supportive care Prof. S. Subbiah et al
- 28. Staging Laparoscopy and Peritoneal cytology โข Staging laparoscopy should be done before surgery, as CT cannot detect peritoneal metastasis with <5mm size. โข Unnecessary laparotomies can be avoided in 38% (Muntean et al) โข It allows assessment of peritoneal cytology and laparoscopic ultrasound โข NCCN recommends diagnostic laparoscopy for patients with resectable stage cT1b or higher locoregional disease Prof. S. Subbiah et al
- 29. Surgery for Locoregional Cancer โข Gastric Resection โข Lymphadenectomy โข Reconstruction Prof. S. Subbiah et al
- 30. Surgery for Locoregional Cancer Standard Gastrectomy Total Gastrectomy D2 lymphadenectomy Subtotal Gastrectomy D2 lymphadenectomy Non Standard Gastrectomy Multi organ resection Extended lymphadenectomy Prof. S. Subbiah et al
- 31. Standard Gastrectomy TOTAL GASTRECTOMY SUBTOTAL GASTRECTOMY Prof. S. Subbiah et al
- 32. Margin ๏ง PROXIMAL MARGIN โข T1 tumours - 2cm โข T2 or deeper - 3cm for expansive growth pattern (type 1 & 2) 5cm for infiltrative growth pattern (type 3 & 4) ๏ง DISTAL MARGIN Distal to pylorus Subtotal Gastrectomy is done when a satisfactory proximal resection margin can be obtained Prof. S. Subbiah et al
- 33. Total Vs Subtotal Gastrectomy Angelov et al โ Comparable oncological outcome Prof. S. Subbiah et al
- 34. Lymphadenectomy Japanese Vs Western D2 or 16 nodes ? Prof. S. Subbiah et al
- 35. Lymphadenectomy - East โข D2 for cN+ or โฅ cT2 โข D2 lymphadenectomy should be performed whenever the possibility of nodal involvement cannot be dismissed. Prof. S. Subbiah et al
- 36. Lymphadenectomy - East Prof. S. Subbiah et al
- 37. D2+ Lymphadenectomy โข Dissection of No. 10 with or without splenectomy โข Dissection of No. 13 for cancer invading the duodenum Prof. S. Subbiah et al
- 38. Para aortic node dissection (PAND) โข Bulky D1 or D2 nodes โข Para aortic node + disease without other unresectable factors โ Neoadjuvant therapy followed by D2 lymphadenectomy and PAND โข Routine PAND ? No survival advantage Prof. S. Subbiah et al
- 39. Lymphadenectomy - West โข Gastrectomy with a D1 or a modified D2 lymph node dissection, with a goal of examining 16 or more lymph nodes โข D2 lymph node dissections should be performed by experienced surgeons in high-volume centers โข Trials ๏ง Dutch Gastric cancer group trial ๏ง Medical Research council (MRC) Trial -UK ๏ง Italian Gastric cancer study group Prof. S. Subbiah et al
- 40. Prof. S. Subbiah et al
- 41. Bursectomy โข No survival benefit Prof. S. Subbiah et al
- 42. Splenectomy Routine splenectomy is not indicated unless the spleen is involved or extensive hilar adenopathy is noted Prof. S. Subbiah et al
- 43. West meets East โ D2 lymphadenectomy Prof. S. Subbiah et al
- 44. Minimally Invasive surgery โข Non inferiority in terms of oncological outcomes โข Early Gastric Cancer vs Locally advanced GC โข KLASS-01 trial and JCOG 0703 โข KLASS-02 trial Prof. S. Subbiah et al
- 45. Minimally Invasive surgery Trials revealed similar overall and cancer-specific survival rates between patients receiving laparoscopic and open distal gastrectomy in EGC Prof. S. Subbiah et al
- 46. Minimally Invasive Surgery โข Locally advanced cancer โ Non inferiority trial โข 3 Year DFS โ Comparable โข Could be a potential standard treatment option for LAGC Prof. S. Subbiah et al
- 47. Multi-organ Resection Can be performed for R0 Resection in T4b tumours Prof. S. Subbiah et al
- 48. Reconstruction after Total Gastrectomy Prof. S. Subbiah et al
- 49. Reconstruction after Total Gastrectomy Prof. S. Subbiah et al
- 50. Palliative Surgery Modified Devines Prof. S. Subbiah et al
- 51. Endoscopy in palliation Prof. S. Subbiah et al
- 52. SEMS VS GJ โข Patients with acceptable PS should be primarily considered for a palliative GJ rather than stenting โข Life expectancy > 2 months โ GJ preferable Prof. S. Subbiah et al
- 53. Take home message โข Endoscopic resection vs Surgery โข Total Vs subtotal Gastrectomy โข Lymphadenectomy D2 vs D1 โข SLNB โข Bursectomy โข Splenectomy โข Multiorgan resection โข PAND โข Lap Vs open Surgery โข Reconstruction - Pouch โข Palliative surgery โ GJ vs SEMS Prof. S. Subbiah et al
- 54. THANK YOU Prof. S. Subbiah et al
Editor's Notes
- These are the derivatives of ventral and dorsal mesogastrium and carry the principal blood vessels of the stomach. Knowledge of these ligaments is necessary for us to identify and ligate these vessels at their origin
- From there we have moved on to the concept of lymph nodal stations. Where the west were recommending to go by the number of nodes, the eastern concept was centered around the location of metastasis.
- The japanese research society classified the nodes around the stomach as regional nodes or N1 nodes, other regional or N2 nodes, distant or N3 nodes. These distant nodes were still not considered to be metastatic ones
- Ct cannot identify low volume peritoneal microscopic metastasis that are <5mm in size