The Surgical Management of Gastroesophageal Cancer

Abeezar I. Sarela MSc,MS,MD,FRCS

Consultant in Upper GI & Minimally Invasive Surgery

Hon. Senior Lecturer in Surgery

Agenda

• Laparoscopic staging of gastric adenocarcinoma

• Extent of lymphadenectomy for gastric adenocarcinoma

• Transhiatal vs. transthoracic resection of oesophageal carcinoma

• Laparoscopic resection: Quo vadis?

Staging Laparoscopy

New diagnosis of gastric adenocarcinomaN=211 patients

Radiological stagingN=208

No SurgeryN=87

LaparoscopyN=57

LaparotomyN=62

Radiological M1N=45

Radiological M0 Unfit/Unwilling for operation

N=30

Radiological M0 Locoregionally advanced

N=12

Laparoscopic M1N=16

Laparoscopic M0N=41

Radiological M1Palliative gastectomy

N=2

Radiological M0 but M1 at laparotomy

“Open-close”N=1

EMRN=2

False-negative M0(M1 at laparotomy)

N=3

GastrectomyN=2

“Open-close”N=1

Surgical Staging of Gastric Adenocarcinoma

Metastatic (M1) Gastric AdenocarcinomaInitial non-operative management

N=55 patients

Subsequent stomach-related interventionN=14 patients (25%)

NO subsequent stomach-related intervention

N=41 patients (75%)

ObstructionN=11 patients (20%)

15 procedures

BleedingN=4 patients (7%)

7 procedures

PerforationN=1 patient (2%)

1 procedure

Stenting5 procedures

Radiation5 procedures

Laparotomy3 procedures

Other3 procedures

Argon plasma coagulation4 procedures

Laparotomy1 procedure

Other1 procedure

Laparotomy1 procedure

Outcomes: M1 Gastric Adenocarcinoma, No Gastrectomy

Gastric AdenocarcinomaExtent of Lymphadenectomy

• D1 – limited or perigastric lymphadenectomy

• D2 – extended lymphadenectomy

Operation for Gastric Carcinoma

Lymphadenectomy: D1 or D2?Randomized Clinical Trials

• Significantly higher morbidity and mortality for D2

• No difference in long-term survival

– Bonenkamp et al. (Dutch)• NEJM 1999 25;340:908-14• J Clin Oncol 2004 1;22:2069-77

– Cuschieri et al. (MRC, UK)• Lancet. 1996 13;347:995-9

• Br J Cancer. 1999;79:1522-30

Laparoscopic Gastrectomy for Carcinoma

RCT: Laparoscopic vs. Open Subtotal Gastrectomy for

Adenocarcinoma• 59 patients

• Single centre

• Laparoscopic arm: significant benefit for pain, recovery, blood loss, hospital stay

• Similar lymph node retrieval

• No difference in survival

Huscher et al. Ann Surg 2005;241:232-237

Authors Study Period

Total no. of gastrectomies

Laparoscopic gastrectomy for adenocarcinoma

12 month volume

Advanced gastric cancer

Total gastrectomy

Lymph node retrieval2

Weber et al, USA

1997-2000

25 9 (36%) 3 67% 0 8 (4-14)

Carboni et al, Italy

2003-2004

66 20 (30%) 20 75% 40% 23-47

Dulucq et al, France

1995-2004

52 21 (46%) 2 48% 33% 24±12

Varela et al, USA

2001-2006

36 15 (42%) 3 46% 13% 15±9

Huscher et al, Italy

1992-2005

NS 100 8 75% 11% 35 (7-106)

Topal et al, Belgium

2003-2006

60 38 (63%) 10 55% 100% NS

Singh et al, UK

2001-2006

NS 20 4 50% 5% 15 (4-29)

Pugliese et al, Italy

2000-2005

147 48 (33%) 10 39% 8% 34 (28-40)

Sarela et al, Leeds

2005-2007

29 18 (62%) 9 67% 33% 23 (10-44)

Western Series of Laparoscopic Gastrectomy for Carcinoma

Oesophagectomy for CarcinomaExtent of Lymphadenectomy

Ivor Lewis Operation

Abdomen

Right Chest

Oesophagectomy for CancerTranshiatal or Transthoracic?

Randomized Clinical Trial

• Higher morbidity and mortality with trans-thoracic operation

• No difference in survival

Hulscher et al. NEJM 2002;347:1662-1669

Omloo et al. Ann Surg 2007;246:992-1000

Oesophagectomy: Peri-Operative Outcomes

Minimally Invasive Oesophagectomy

1. Totally laparoscopic trans-hiatal resection with cervical anastomosis.

2. Laparoscopic trans-hiatal dissection with mini-laparotomy with cervical anastomosis.

3. Right thoracotomy, laparoscopic gastric tubularization and cervical anastomosis.

4. Combined laparoscopic and thoracoscopic dissection.

5. Thoracoscopic excision of oesophageal leiomyomas and GISTs.

pT1 Oesophageal Adenocarcinoma

Jan 2000-Dec 2006Esophagectomies for

Adenocarcinoma172 patients

Pathological stage: T1No neo-adjuvant therapy

44 patients (26%)

Laparoscopic Transhiatal Esophagectomy

16 patients (36%)

Open Ivor Lewis Esophagectomy

24 patients (55%)

Open Transhiatal Esophagectomy

4 patients (9%)

Post-operative follow-up: median 44 months (range, 12-93)

Laparoscopic vs. Open Resection

Laparoscopic Transhiatal

16 patients

Open

Ivor Lewis

24 patients

Open Transhiatal

4 patients

Post-operative Mortality

0 2 0

Lymph node retrieval

15 (4-41) 19 (10-51) 16 (3-28)

Pathological CharacteristicsOesophagectomy for pT1 adenocarcinoma

Feature No. of patients (%)

Total: 44 patients

Submucosal invasion (pT1b) 11 (25%)

Poor differentiation 4 (9%)

Long segment Barrett’s (> 3cm) 31 (70%)

Tumor length > 1cm 14 (32%)

Impediments to

EMR

No. of patients (%)

Total : 44 patients

Lymph node metastasis 2 (5%)

Multifocal carcinoma or HGD 27 (61%)

Lymphovascular invasion 2 (5%)

Pathological Characteristics Esophagectomy for pT1 adenocarcinoma

Aggregate number of patients who may have been

inadequately treated by EMR: 29 (66%)

Oncological Outcome Oesophagectomy for pT1 Adenocarcinoma

Operation Tumor Depth

Differentiation Node status

Time to recurrence

Site of recurrence

Lap. Trans-Hiatal

T1b Poor N0 6 Nodes

Open Ivor Lewis

T1b Poor N1 8 Liver

Open Ivor Lewis

T1a Poor N0 22 Liver

PT1 Oesophageal Adenocarcinoma

• Similar lymph node retrieval with laparoscopic trans-hiatal esophagectomy or open esophagectomy

• Small but definite risk (7%) of recurrent disease after esophagectomy for T1 adenocarcinoma

• No evidence of oncological detriment by laparoscopic resection

PT1 Oesophageal Adenocarcinoma

• 66% of early esophageal adenocarcinoma

may have been inadequately treated by

EMR

• EMR should be reserved for highly

selected patients