Robotic surgery and cancer gastrointestinal and thoracic

Robotic Surgery and Cancer: Gastrointestinal and Thoracic

Annual Advances in Oncology Symposium Mills-Peninsula Health Services

Burlingame, CA October 24, 2015

Kimberly Moore Dalal, MD, FACS Medical Director, Surgical Oncology

General Surgery Mills-Peninsula Hospital

Burlingame, CA

Da Vinci Robot

Robotic surgery and Cancer

Advantages to Using the Da Vinci Robot


3-D, high definition visualization with 10x magnification Wristed instrumentation ‘Intuitive’ movement

Precision and Accuracy

https://www.youtube.com/watch?v=Sz5m--Wz2EU


https://www.youtube.com/watch?v=Sz5m--Wz2EU

The Starting Point: da Vinci Prostatectomy

Prostatectomy 2014

The Next Frontier… General Surgery Colorectal Thoracic

2001


Robotic Procedures Performed at Mills-Peninsula 11/8/12-present, 648 cases

Pulmonary lobectomy Thymectomy Esophagectomy Gastrectomy Distal pancreatectomy Duodenal polypectomy Splenectomy Adrenalectomy Low anterior resection Abdominoperineal resection Colectomy (sigmoid, right, total)

Cholecystectomy Inguinal hernia repair Ventral hernia repair Paraesophageal hernia repair Nissen fundoplication Rectopexy Small bowel resection Prostatectomy Nephrectomy Hysterectomy


Robotic Procedures Performed at Mills-Peninsula 11/8/12-present, 648 cases

Pulmonary lobectomy Thymectomy Esophagectomy Gastrectomy Distal pancreatectomy Duodenal polypectomy Splenectomy Adrenalectomy Low anterior resection Abdominoperineal resection Colectomy (sigmoid, right, total)

Cholecystectomy Inguinal hernia repair Ventral hernia repair Paraesophageal hernia repair Nissen fundoplication Rectopexy Small bowel resection Prostatectomy Hysterectomy Nephrectomy


Epidemiology of Lung Cancer

Estimated U.S. incidence in 2015: 221,200 cases/year

158,040 deaths in men and women

Siegel R, et al., CA Cancer J Clin, 2015; 65:5-29.


Robotic Lobectomy Reduces Length of Stay, Morbidity, and Mortality

Study (n) Comparator LOS, days

(p value vs. robotic)

Chest tube duration, days


Overall Complications %


30 day Mortality % (p value vs.

robotic)

Kent 20131

Open (1,233) SID (national

database)

8.2 (<.0001) NA 54.1 (.003) 2.0 (.016)

VATS (1,233) 6.3 (NS) NA 45.3 (NS) 1.1 (NS)

Robotic (411) 5.9 NA 43.8 0.2

Farivar 20142

Open (4,612)

STS database

7.3 (<.0001) 4.8 (<.0001) NA 2.0 (<.0001)

VATS (5,913)

5.3 (<.0001)

3.7 (.0005) NA 0.9 (<.0001)

Robotic (181) 2 centers 3.2 2.9 NA 0

Cerfolio 20113

Open (318) Single center

4.0 (.02) 3.0 (<.001) 38.0 (.05) 3.0 (NS)

Robotic (106) 2.0 1.5 27.0 0

1Kent M, et al., Open, video-assisted thoracic surgery, and robotic lobectomy: review of a national database. Ann Thorac Surg. 2014 Jan;97(1):236-42. 2Farivar, AS, et al., Comparing robotic lung resection with thoracotomy and video-assisted thoracoscopic surgery cases entered into the Society of Thoracic Surgeons database. Innovations (Phila).2014 Jan-Feb;9(1):1-5. 3Cerfolio, RJ, et al. Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms. J Thorac Cardiovasc Surg.2011 (Oct);142(4):740-6.


Robotic Lobectomy Increases Nodal Upstaging

Study n Hilar upstaging %

(p value vs. VATS) Mediastinal upstaging %

(p value vs. VATS) Overall upstaging % (p value vs. VATS)

Boffa 20121

Open 7,137 9.3 (<.001) 5.0 (NS) 14.3 (<.001)

VATS 4,394 6.7 4.9 11.6

Licht 20132

Open 796 13.1 (<.001) 11.5 (<.001) 24.6 (<.001)

VATS 717 8.1 3.8 11.9

Merritt 20133

Open 69 17.4 (NS) 7.2 (NS) 24.6 (.05)

VATS 60 8.3 1.8 10

Park 20124

Robotic 325 NR NR 24.0 (N/A)


1Boffa, DJ, et al., Lymph node evaluation by open or video-assisted approached in 11,500 anatomic lung cancer resections, Ann Thorac Surg. 2012 AUg;94(2):347-353. 2Licht, PB, et al., A national study of nodal upstaging after thoracoscopic versus open lobectomy for clinical stage I lung cancer. Ann Thorac Surg. 2013 Sep;96(3):943-9. 3Merritt, RE, et al. Lymph node evaluation achieved by open lobectomy compared with thoracoscopic lobectomy for N0 lung cancer. Ann Thorac Surg.2013 Oct;96(4):1171-7. 4Park, BJ, et al., Robotic lobectomy for non-small cell lung cancer (NSCLC): long-term oncologic results. J Thorac Cardiovasc Surg.2012 Feb;143(2):383-9.

Robotic Right Upper Lobectomy


Port placement Transection of right superior pulmonary vein

Transection of minor fissure

Removal of hilar and interlobar lymph nodes (10R, 11R) and superior mediastinal lymph nodes

Cerfolio RJ, Bryant AS, Robotic-assisted pulmonary resection-Right upper lobectomy Ann Cardiothorac Surg 2012 May;1(1):59-60.

Epidemiology of Colorectal Cancer

Estimated U.S. incidence in 2015 132,700 cases/year

49,700 deaths in men and women

– Mortality has decreased 35% since 1990 Earlier diagnosis through screening Better treatment

Siegel R, et al., CA Cancer J Clin, 2015; 65:5-29.


Minimally Invasive Resections: Immediate Outcomes

Smaller incisions1 Less pain->Less medication2

– Briefer use of i.v. narcotics (3 days vs. 4 days, p<0.001)

– Shorter use of oral analgesics (1 day vs 2 days, p=0.02)

Home earlier->normal activities2

– Shorter hospital stay (5 days vs. 6 days, p<0.001)

Equal rates of complications (20%) and mortality (1%)2

Quicker initiation of adjuvant therapies

1http://www.columbiasurgery.org/pat/colorectal/procedures.html 2The Clinical Outcomes of Surgical Therapy Study Group, N Engl J Med, 2004; 350:2050-2059. 3http://www.urmc.rochester.edu/MediaLibraries/URMCMedia/hh/images/Surgery-robotic/Colon_-Incision_Comparison.jpg

Traditional open vs. minimally invasive incisions for colon resections


Gold Standard for Rectal Cancer Resection


http://complexsurgicaloncology.com/lectures/total-mesorectal-excision/ http://www.slideshare.net/ESOSLIDES/160211-1600-becker

Robotic Low Anterior Resection (LAR): Trend toward Improved Margins


Robotic LAR Reduces Complications, Improves TME Resections

Robotic LAR Lap LAR P

Number of Patients 56 57

Complication Rate (%) 5.4% 19.3% 0.025 - Anastomotic leakage (n) 1 4

Macroscopic Specimen Judgment - Complete [n (%)] 52 (92.9) 43 (75.4) 0.033 - Near Complete [n (%)] 4 (7.1) 12 (21.1) - Incomplete [n (%)] 0 (0.0) 2 (3.5)

Conversion Rate [n (%)] 0 (0.0) 6 (10.5) 0.013

Length of Stay [Mean ± SD] 5.7 ± 1.1 7.6 ± 3.0 0.001

Days to Soft Diet [Mean ± SD] 4.7 ± 1.1 5.5 ± 1.5 0.008

Operative Time 190.1 ± 45.0 191.1 ± 65.3

Baik, SH et al. Robotic versus laparoscopic low anterior resection of rectal cancer:

short-term outcome of a prospective comparative study. Ann Surg Oncol 2009 Jun; 16(6):1480-7/


Dr. Allen’s Robotic LAR


Enhanced Recovery After Surgery (ERAS)

Multimodal perioperative pathway Reexamines traditional practices and replaces them with evidence-based best practices

– NPO after MN vs. apple juice 2 hrs preop

Covers all areas of a patient’s journey through the surgical process

– IV pain medication – IV fluids – Bed rest

Reduced postoperative complications by up to 50%1 Decreased need for iv pain medication

– IV tylenol and motrin – Gabapentin

Quicker return of bowel function Start eating POD 0/1 Reduced length of stay (3 v 5 d)

1Varandhan KK, ERAS pathway for patients undergoing major elective open colorectal surgery. Clin Nutr 2010.


Preliminary ERAS Results- Colorectal 5/7-9/30/15

Change in practice: – 66% of colorectal patients post-ERAS drank clear liquids 3 hrs before surgery,

versus no patients pre-ERAS – 95% of patients drank clear liquids the evening after surgery vs. 55% pre-ERAS – 85% of patients walked within the first 24 hrs at least once vs. 57% pre-ERAS – 92% of patients had their foley removed within 48 hrs vs. 76% pre-ERAS

Improved patient outcomes:

– 39% of patients’ bowel function returned by Post-Op Day 1 vs. 19.5% pre-ERAS – 73% of patients went home in 4 days or less vs. 52% of patients pre-ERAS – 44% of ASA 3 and 4 patients vs. 31% pre-ERAS


Length of Stay Pre-ERAS Post-ERAS 2 days or less 7% 17% 3 days or less 36% 51% 4 days or less 52% 73% 5 days or less 74% 78%

Our GI Surgical Oncology Team A *team of two board-certified surgeons* is used for every oncologic operation

Aziz Ahmad, M.D. Surgical Oncologist Board-Certified by the American Board of

Surgery Fellowship-Trained in Surgical Oncology Randolph Wong, M.D., F.A.C.S. General Surgeon Chairman, Department of Surgery Board-Certified by the American Board of

Surgery Vino Verghese, M.D. Chief, Interventional Gastroenterology Board-Certified by the American Board of

Medicine

Kimberly Moore Dalal, M.D., F.A.C.S Medical Director, Surgical Oncology Board-Certified by the American Board of

Surgery Fellowship-Trained in Surgical Oncology Bruce Allen, M.D., F.A.C.S. General Surgeon Physician champion for American College of

Surgeons National Surgical Quality Improvement Program (NSQIP)

Board-Certified by the American Board of Surgery

Lowell Albert Wetter, M.D., F.A.C.S General and Advanced Laparoscopic

Surgeon Board-Certified by the American Board of

Surgery


Mills-Peninsula Multidisciplinary Gastrointestinal Tumor Board 2nd and 4th Tuesdays, 12:30-1:30

Tailored approach to the treatment plan for each patient Team:

– Surgical oncologists – Medical oncologists – Radiation oncologists – Gastroenterologists – Interventional radiologists – GI pathologist – GI nurse navigator – Clinical trials nurse

Multidisciplinary clinic follows – Patient and family meet with

surgical oncologist, medical oncologist, radiation oncologist, and GI nurse navigator at one visit

Clinical trials Prospective database

– Short-term outcomes – Long-term outcomes


Mills-Peninsula Recognized for Meritorious Surgical Outcomes in 2014

For the 3rd consecutive year, Mills-Peninsula was 1 of 44 hospitals (top 1%) in the U.S. by NSQIP Best Hospital by U.S. News and World Report for Gastroenterology/ GI Surgery


GI Surgical Oncology At Mills-Peninsula

Mills-Peninsula has the highest caliber surgical team and technology to treat patients with gastrointestinal cancer.

Our collaborative, collegial, and customized multidisciplinary approach provides tailored treatment. Our morbidity and mortality are on par or lower than the NSQIP comparison benchmarks. We strive to expand our research efforts, including clinical trials and outcomes research, to improve our patient care.


Summary

Robotic lobectomies result in decreased length of stay, fewer complications, and increased nodal upstaging. Robotic low anterior resections reduce complications and improve total mesorectal excisions. ERAS pathway improves patient outcomes. Minimally invasive resections are safe and oncologically sound in selected patients in the hands of surgeons with laparoscopic/robotic skills.


Conclusion

We appreciate the desire of well-informed patients to stay within their community and to receive timely, cutting-edge, state-of-the-art care, and we believe our team can provide that service to our patients and their families.


Health & Medicine

Robotic surgery and cancer gastrointestinal and thoracic