The 1 st Oesophago gastric Cancer Centers Meeting for The Anglia Cancer Network

Transcription

1 The 1 st Oesophago gastric Cancer Centers Meeting for The Anglia Cancer Network Date: Sept 28 th 2012 Venue: The Bedford Lodge Hotel Attendees: NORFOLK & NORWICH Mr Ed Cheong (UGI Cancer Lead) Dr Ben Simpson (UGI cancer radiology Lead) Mr M Lewis (UGI Cons surgeon) Mr Hugh Warren (UGI Cons surgeon) Mr Filip van Tornout (Thoracic surgeon) Dr Jenny Nobes (UGI Oncologist) Dr Manu Naik (Cons anaesthetist and intensivist) Dr Kamal Al-Naimi (Cons anaesthetist) Dr Andrew Hart (Cons Gastroenterologist) ADDENBROOKES Mr Richard Hardwick (UGI Lead Clinician) Mr Peter Safranek (UGI Surgeon) Mr Andy Hindmarsh (UGI Surgeon) Mr Vijay Sujendran (UGI Surgeon) Dr Famila Alagarsamy (UGI Consultant Anaesthetist) Dr Nick Carroll (Consultant Radiologist) Ben Smith (Lead Upper GI Cancer Nurse Specialist) Sister Nryarai Chinyama (Upper GI Nurse Practitioner) Sister Sarah Coles (Upper GI Support Cancer Nurse Specialist) Sam Grimes (Upper GI Lead Dietitian) Chairs: Mr. Richard Hardwick & Mr. Ed Cheong Topic: Management protocols for patients having surgery with radical intent at Cambridge University Foundation Trust (CUFT) and The Norfolk & Norwich Hospital (N&N) Introduction: At the previous Cancer Network Upper GI (UGI) site specific group (SSG) meeting it was agreed that the two cancer centers serving East Anglian patients with Oesophago-gastric (O-G) cancer should meet to discuss their respective management protocols to explore any differences and agree future audits. The group met on the 28 th Sept 2012; each team presented it s current protocol for staging, pre-operative assessment of fitness for surgery, the surgical approaches they use for different tumour types, their peri-operative protocols and how they follow-up patients in the clinic. Each topic was discussed in turn and is summarized below. Staging:

2 Both teams are using the same staging algorithm. The only slight difference was that N&N do not attempt an EUS for patients whose tumours were not traversable at endoscopy. But patients for the ST03 trial do get an EUS attempt to make them eligible for ST03. CUFT tend to book an EUS and PET scan together but N&N use the PET to exclude patients from EUS if it shows metastatic disease. These slightly different approaches both have merit (avoiding target breaches vs. reduced costs) but it was agreed that they are both valid. Fitness for Surgery: CUFT places considerable weight on the Consultant Surgeons opinion as to whether a patient is fit enough for surgery. They do pulmonary function tests on everyone and use echocardiography selectively. Their operative mortality is about 2%. N&N also have a very low post-operative mortality in the last 2 years but use a combination of consultant opinion and objective tests including walking the patient up two flights of stairs and cardio-pulmonary exercise tests (CPEX). In addition, a Consultant Anesthetist sees the patients pre-operatively. It was agreed that the extra objectively of tests designed to assess patients fitness for major surgery would help the CUFT team although CPEX testing is not available there and the interpretation of the results from this test is still controversial. Everyone agreed that CUFT and N&N should use the same written information for patients about the importance of stopping smoking and the need to take regular exercise prior to and after surgery (an exercise prescription and an exercise diary). Action: Both teams to share current advice given to patients at each hospital and create a unified protocol and documentation. Surgery: Overall agreement on surgical approaches for different tumour types was high. Both teams strive to obtain clear longitudinal and circumferential margins (an R0 resection) with radical lymphadenopathy (two field for oesophagectomy and D2 for gastrectomy). N&N were more likely than CUFT to do a 3-phase McKeown type oesophagectomy for middle third oesophageal tumours. Two of the four CUFT surgeons preferred to approach small Siewert type I tumours and all type II & III tumours via a left Thoraco-abdominal approach. Some Surgeons in both CUFT and N&N perform a pyloroplasty when doing an oesophagectomy and some do not. This has always been a contentious area of surgical practice. Conduit dysfunction (poor eating, nausea, regurgitation and reflux) is common after oesophagectomy and may be more so if the pyloric sphincter is left intact. However, troublesome bile reflux may be more common after a pyloroplasty.

3 Minally invasive surgery is being used slightly differently in the two centres. Mr Cheong (N&N) is doing a minimally invasive two-phase Ivor-Lewis procedure and Mr Safranek (CUFT) offers appropriate patients a minimally invasive three-phase McKeown procedure. Both surgeons have introduced these techniques into routine practice in their Hospitals following the national guidelines for introducing new procedures with close auditing of the complications. Both teams routinely use surgical feeding jejunostomies for oesophagectomy patients but N&N also use them after total gastrectomy. This is not without risks. CUFT stopped using jejunostomies routinely for gastrectomy patients 5 years ago and have not seen any negative impact. For those patients that struggle to eat after gastrectomy, a naso-jejunal fine bore feeding tube can be placed. Actions: 1. Both teams to audit their longitudinal positivity rate in the last 100 consecutive resections. 2. Both teams to audit their incidence of conduit dysfunction in relation to whether a pyloroplasty was performed or not. 3. Minimally invasive oesophagectomy audits from both Hospitals to be circulated for comparison. 4. N&N to consider their current surgical jejunostomy practice and move to not using them routinely after total gastrectomy. Post operative recovery: Both teams stress the importance of early mobilization after surgery. N&N uses a marching on the spot regimen. Both teams try to remove chest drains and naso-gastric tubes as soon as possible. The only marked difference between CUFT and N&N was in the management of chyle leaks after oesophagectomy. CUFT would only take patients back to theatre if there was a high volume leak whereas one of the five surgeon at N&N would take all chyle leaks back regardless of the volume. It was agreed that a joint protocol on the management of chyle leaks would be helpful. Action: 1. CUFT to share current protocol of the management of chyle leaks post oesophagectomy with N&N. 2. Both teams to share with each other their current written recovery protocols to see whether one common document could be created and used in both hospitals. Follow up: CUFT currently request a base-line CT scan on all patients three months post surgery. This is not evidence based but has traditionally been done to provide a scan to compare against subsequently if the patient becomes unwell and there is concern about recurrent disease. N&N do not do this on all patients -

4 a CT scan is only performed after completion of the perioperative chemotherapy. It was agreed that CUFT would discuss this policy further internally with their Oncology colleagues with a view to stopping it. This would save approximately 100 CT scans per year. There is currently no uniform practice in either hospital regarding the use of feeding jejunostomies after discharge. It was agreed that this was an area of clinical practice that could be improved. N&N patients tend to have routine upper gastro-intestinal endoscopy as part of their follow-up. CUFT patients only have this investigation if they have symptoms such as dysphagia. It was agreed that routine endoscopy does not change patient management and should be abandoned. All patients at N&N complete a formal assessment of their quality of life. The results are collated by the specialist nurse and are used to identify patients who are struggling. CUFT agreed that it too would like to incorporate this into their routine follow-up. CUFT patients are now offered a telephone appointment by their specialist nurse after one year as an alternative to attending the clinic in person. It was agreed that this was good practice as it reduces costs and unnecessary journeys to the cancer centre. Actions: 1. CUFT to discuss internally the possibility of stopping doing base-line CT scans post surgery 2. Both teams to audit weight loss after surgery and see if there is any correlations with policy of using feeding jejunostomies post discharge or not. 3. N&N to stop routine endoscopies post surgery 4. CUFT to explore how to incorporate routine QOL assessment into its follow-up protocol. 5. N&N to explore the possibility of setting up a telephone follow-up clinic. Summary: The practice of both surgical teams is very similar and where differences exist there is general uncertainty about what constitutes best practice. Where agreement exists, the teams will endeavor to produce joint management guidelines and protocols. Where there are differences they will audit their current practice and compare the results with each other with a view to trying to unify practice in the future. The meeting was conducted in an atmosphere of co-operation and openness which bodes well for future collaboration and possible joint research projects between CUFT and N&N. Together, this group would be one of the highest volume surgical O-G centres in the UK. The next meeting will include the oncologists and endocopists together with surgeons, anaesthetists and specialist nurses to examine differences and similarities in oncological and endoscopic practice between the two centres.

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