Michael A. Choti, MD, FACS Department of Surgery Johns Hopkins Medicine, Baltimore, MD

Transcription

1 Michael A. Choti, MD, FACS Department of Surgery Johns Hopkins Medicine, Baltimore, MD

2 Surgical Therapy of Gastric Cancer CLINICAL QUESTIONS 1. How much of the stomach should be removed? 2. How many lymph nodes should be removed and why? 3. If inoperable for curative intent, how can symptoms of obstruction be treated non-surgically?

3 Surgical Therapy of Gastric Cancer CLINICAL QUESTIONS 1. How much of the stomach should be removed? 2. How many lymph nodes should be removed and why? 3. If inoperable for curative intent, how can symptoms of obstruction be treated non-surgically?

4 Extent of Gastrectomy TOTAL vs. SUBTOTAL

5 Subtotal Gastrectomy with Billroth II Gastrojejunostomy

6 Subtotal Gastrectomy with Roux-en-Y Gastrojejunostomy

7 Total Gastrectomy with Roux-en-Y Esophagojejunostomy

8 Extent of Gastrectomy TOTAL (TG) vs. SUBTOTAL (SG) Long-Term Function Quality of life and function in long-term survivors following gastrectomy, TG (n=105) vs. SG (n=90) RESULTS: Weight loss, number of daily meals, bowels/day, and overall physical function score was significantly better with SG vs TG. No difference in emotional status or social activities. Jentschura et al. Hepatogastroenterol, 1997

9 GE junction / Gastric Cardia Tumors Important to distinguish between lower esophageal CA and Barrett s Rarely associated with GERD Poorer prognosis Resection: transhiatal extended total gastrectomy Abdominal vs. thoracoabdominal approach

10 Endoscopic Mucosal Resection for Early Gastric Cancer

11 What is the Optimal Extent of Gastric Resection? Subtotal gastrectomy unless: proximal location necessary to achieve negative margins diffuse growth pattern early stage favorable cancer (T1a), then consider EMR

12 Surgical Therapy of Gastric Cancer 2. How many lymph nodes should be removed and why?

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14 Japanese Classification of Regional Gastric Lymph Nodes Perigastric Nodes Extraperigastric Nodes

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16 Extent of Lymphadenectomy DUTCH TRIAL 996 patients 80 Dutch hospitals Quality control with experienced Japanese surgeons Randomized to D1 vs. D2 lymphadenectomy Bonenkamp et al. NEJM 340:908 (1999)

17 Extent of Lymphadenectomy DUTCH TRIAL Bonenkamp et al. NEJM 340:908 (1999)

18 Impact of Node Number and Survival SURVIVAL IN STAGE III PATIENTS < 15 nodes (n= 124 ) > 15 nodes (n=23) Liu et al. Surgery 134:639 (2002)

19 What is the Optimal Extent of Lymphadenectomy? Gastrectomy with curative intent should include an adequate lymphadenectomy. > 15 nodes in the specimen is optimal. Formal D2 dissection is probably not necessary.

20 Surgical Therapy of Gastric Cancer 3. How can symptoms of obstruction be treated non-surgically?

21 Nausea Pain Obstruction Perforation Bleeding

22 Palliative resection Surgical bypass (gastrojejunostomy) Radiation therapy Endoscopic techniques Endoscopic stent placement

23 Stent Gastro-Jej Comparable technical success Comparable major complications Recurrent obstruction higher with stent Jeurnink, et al. BMC Gastroenterology 2007

24 Surgical Therapy of Stomach Cancer 1. Surgical resection remains the principle modality of curative therapy for gastric cancer. 2. Options for resection of gastric cancer includes subtotal or total gastrectomy, laparoscopic resection, and endoscopic mucosal removal. 3. Inclusion of an adequate lymphadenectomy is important in most cases. 4. Nonsurgical management of obstruction can be achieved through endoscopically placed stenting, although surgical bypass or palliative resection should be considered.

25 Surgical Therapy of Stomach Cancer 1. Increasing use of minimally invasive approaches for gastric resection. 2. Expanding use of local therapies for advanced gastric cancer (e.g. resection of hepatic metastases). 3. Optimizing the integration of adjuvant and neoadjuvant therapies in patients undergoing surgery. 4. Developing personalized strategies for multimodality therapy of stomach cancer through advances in molecular genetics.

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