Oesophago-gastric resections in Hong Kong Visiting Professor Simon Law Queen Mary Hospital and Mr. David Leung United Christian Hospital

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1 AUGIS Trvel Fellowship Report Mohn Singh ST8 Oesophgo-gstric surgery, West Midlnds Oesophgo-gstric resections in Hong Kong Visiting Professor Simon Lw Queen Mry Hospitl nd Mr. Dvid Leung United Christin Hospitl In Mrch 2017 I hd the opportunity to visit Professor Simon Lw t Queen Mry Hospitl (QMH) nd Mr. Dvid Leung t United Christin Hospitl (UCH) in Hong Kong (HK). Being ttched to two hospitls gve me the opportunity to oserve four full-dy resectionl lists every week, longside endoscopy. Hong Kong hs high incidence of oesophgogstric (OG) cncers, nd Prof Lw s OG Unit is prgon with exemplry long-term survivl dt nd one of the lowest moridity nd mortlity rtes fter oesophgectomy in the world. In this summry I im to compre wht I hve oserved nd lernt out surgicl trining nd OG resections in HK to my experience in the UK. Surgicl trining in Hong Kong Surgicl trining in HK comprises one yer internship (FY1 level in the UK) then two yers BST (CT1-CT2), followed y four yers HST (ST3-ST6), culminting in 1-2 yers in post-frcs Fellowship. Trining in HK demnds degree of resilience fmilir to pre-ewtd Clmntrined surgeons in the UK. Interns, BSTs, HSTs nd Fellows work 2.5 weekends month, nd when on-cll they work continuously for 24 hours (or 48-hour weekends) nd stright into norml working dy the next dy. Due to the lrge numer of endoscopies, the entire tem is involved, such tht n FY2 equivlent hd performed in excess of 100 dignostic OGDs on her own, leit supported y Fellows nd Consultnts running djcent prllel sessions. BSTs re tught to perform edside ultrsound for gllstones nd free fluid when on-cll, whilst HSTs re tught therpeutic OGDs nd colonoscopies. With such sustntil experience (pproximtely 700 OGDs per month in Prof Lw s unit lone), ll OG Consultnt Surgeons in HK do EMR, ESD, EUS, RIG, RIJ, mnometry, stenting, dilttion nd POEMs (preferred choice of tretment for chlsi in HK) themselves. Minimlly invsive oesophgectomies (MIOs) The OG deprtment t QMH is sperheded y Professor Simon Lw, who is involved in ll oesophgectomies. As unit with 3 OG Consultnts, they perform round 50 oesophgectomies (80% of these s MIOs) plus 75 gstrectomies yer (80% lproscopiclly). These figures re different to our most recent UK OG udit where 41% of oesophgectomies nd 14% of gstrectomies were performed using minimlly invsive pproch 1. As the tumours in HK re minly squmous cell crcinoms (>90%) nd midoesophgel, 3-stge resection with cervicl nstomosis is routinely performed. The thetre is OR1 redy with lminr flow, complete with multiple pull-down screens nd HD stck systems. All OG resections commence with n OGD nd injection of fluorescent dye (indocynine green, ICG) peri-tumourlly (sumucoslly) for rightly fluorescent visulistion of the regionl lymph nodes (LNs) during thorcoscopic resection to ensure the completeness of lymphdenectomy (Fig. 1-). It is effortless to lternte etween stndrd Xenon white light nd fluorescence imging mode intropertively y pressing utton on the endoscope for stunning contrst imges which redily detect ny potentil LNs still lurking within the opertive field.

2 1() During white light thorcoscopy is this drining LN? Or just ft? 1() In fluorescence mode with ICG, it is confirmed s drining LN which thus needs excision Surgery commences with neck dissection to identify the recurrent lryngel nerve (RLN, Fig. 2) nd the implnttion of nerve stimultor for nerve mpping nd continuous RLN nerve monitoring during thorcoscopic upper oesophgel dissection (Fig. 2-c). This llows more ggressive nodl dissection. VATS is then crried out vi three ports plus mini-thorcotomy (Fig. 3-c). The verge lymph node yield from MIOs is 45. Thorcoscopic dissection is then followed y lproscopic gstric moilistion which is comined with mini-lprotomy for gstric tuulristion, culminting with retrosternl delivery of the gstric conduit for hndsewn (continuous, single lyered) O-G neck nstomosis. A structure RLN Proe Fig. 2 () Pre-opertive loclistion of RLN for nerve mpping nd continuous nerve monitoring, () during thorcoscopic dissection, proe is utilised to identify if structure encountered is ctully the RLN, question which is nswered (c) oth uditorily nd sinusoidlly y the mplitude of the voltge gined on contct c Mini-thorcotomy Endoscope Ports Lung-retrctor & sucker c Fig. 3 () Set-up for thorcoscopic dissection, 3 ports + mini-thorcotomy () for lung retrction nd suction, (c) ptient on the left lterl position with Prof Lw operting ehind the ptient Following lproscopic gstric moilistion (set-up s in Fig. 5), mini-lprotomy is performed in order to crry out their routinely-performed pyloroplsty nd gstric tuulristion. Intrvenous ICG is then dministered nd fluorescence imging vi SPY lser imging system (Novodq) visulises the viility of the conduit prior to oesophgogstric nstomosis (ICG ngiogrphy, Fig. 4). This enhnces the ility to ojectively ssess conduit perfusion intr-opertively in rel-time (Fig. 4). I found the enefits fforded y this cutting-edge fluorescence imging technology extremely useful ecuse it provides

3 cler demrction of non-vile res on the conduit which could otherwise e unintentionlly incorported into the O-G nstomosis s they my pper stisfctory to the nked eye. SPY hs een used for fluorescence imging t QMH for pst two yers nd hs revolutionised their prctice. Perfusion-deficient re Fig. 4 Assessing the viility of the gstric conduit. () Externl view of gstric conduit during lser fluorescence imging () Live imges from fluorescence imging of the gstric conduit with perfusion-deficient re A retrosternl conduit route is preferred, s Prof Lw hs noted reduced incidence of delyed gstric emptying in comprison to the orthotopic position. They do not use feeding jejunostomies, proly ecuse cervicl lek is rguly less morid nd esier to mnge thn n intrthorcic one. A single Blke sl sump drin on free dringe is used, which includes suction pump. Prof Lw does not feel it is necessry to insert prophylctic picl drin for potentil pneumothorces. This single Blke drin is very light nd flexile, with reduced clier, nd does not need n underwter sel. Consequently, ptients cn crry it round esily ecuse it is more comfortle nd less cumersome thn conventionl underwter-sel drins. Blke drins my e used just s effectively for oth ir nd fluid within the pleurl cvity. Ptients re usully dischrged on Dy 7-8. [Medin length of sty for MIOs is 11 dys, nd 13 dys for open/hyrid oesophgectomies in the UK 1 ]. Orl contrst swllow studies re not performed. Should there e clinicl suspicion (e.g. new AF, tchycrdi or pyrexi), n OGD is done preferentilly. Lproscopic gstrectomies The set-up used in HK is shown in Fig. 5. Agin, ICG is injected peri-tumourlly endoscopiclly just efore surgery for intropertive LN recognition. Peritonel cytology is performed immeditely prior to dissection. A Mrylnd ligsure is used for ll OG dissections. A ursectomy is not done s the results from the Jpnese JCOG1001 study 2 hve found tht lthough the opertive time incresed with ursectomy, this did nothing to improve LN yield, lter mortlity or ffect overll survivl even in ct3 or ct4 gstric denocrcinoms. Although distl gstrectomies re more common in HK, totl gstrectomy is discussed here s it is the more complicted procedure. Following D2 dissection (Fig. 5), the oesophgus is divided with n Endo-GIA, then n Orvil is pssed into the oesophgus while CEEA circulr stpler is inserted into the jejunum vi minilprotomy in the epigstrium. Where sutured nstomosis is performed (OJ or JJ nstomosis), ig ites of full thickness hve, in their experience, drmticlly reduced the incidence of leks. Interestingly, for Siewert II (junctionl) tumours, totl gstrectomy is performed in HK (nd in Jpn), insted of n oesophgectomy, which is more commonly

4 prcticed in the UK 1. Due to the incidence of sumucosl lymphtic spred it is thus mndtory for them to send the proximl resection mrgin for frozen section. Ptients re dischrged on Dy 3 (sutotl) or Dy 4 (totl gstrectomy) [Medin length of sty for lp. gstrectomies is 8.5 dys in the UK 1 ]. NG/NJ tues re not routinely used in gstrectomy ptients. Pre-op crohydrte loding drinks re used to enhnce recovery fter elective gstrectomy. Their post-opertive compliction rte is < 5%. Nthnson extended to minilprotomy Surgeon 10 mm Assistnt s Retrction 12 mm, Cmer Lproscope Holder (etween the legs) c Fig. 5 () Stndrd port plcements for lproscopic gstric moilistions/resections in HK () totl gstrectomy specimen, nd (c) circumferentil cncer occupying the entire stomch I m grteful to AUGIS for helping to mke this Fellowship possile, nd would recommend it to nyone with n interest in minimlly-invsive OG resections. References 1. The 2015 Annul Report of the Ntionl Oesophgo-Gstric Cncer Audit - An udit of the cre received y people with Oesophgo-Gstric Cncer in Englnd nd Wles 2015 Annul Report. ( _finl_interctive.pdf?relnme=q2mquw.pdf&v=0) 2. Primry results of phse III tril to evlute ursectomy for ptients with suserosl/serosl gstric cncer (JCOG1001). Tershim, M; Doki, Y; Kurokw, Y et l. nd Stomch Cncer Study Group, Jpn Clinicl Oncology Group. Journl of Clinicl Oncology :4_suppl, 5-5. (

5 Prof Simon Lw & tem Dvid Leung Simon Lw Simon Lw