WHICH LYMPH NODES SHOULD BE

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1 Y.K.: 82 Y.O. WOMAN WITH ANEMIA No GI symptoms. Chronic AF taking coumadin: INR=2.1. HCT=24. Anemia persists despite Rx. Colonoscopy: tumor in ascending colon. Bx: adenocarcinoma. Rx: Laparoscopic right hemicolectomy. Pathology: Tumor 3x3 cm, located 1.5 cm from ileocecal valve. Mod. diff. adenocarcinoma with metastatic CA in 1/12 LN (pt2n1). MODERN STANDARDS FOR OPERATIONS FOR COLON CANCER Madhulika G. Varma, MD Associate Professor Chief, Section of Colorectal Surgery University of California, San Francisco HOW MUCH COLON SHOULD BE RESECTED? Classic teaching 5 cm on either side of tumor Concern regarding microscopic intramural spread Shrinkage of s 45% Immediate contraction 29% Shrinkage in formalin 24% WHICH LYMPH NODES SHOULD BE REMOVED? Lymphatic drainage of colon follows mesenteric blood supply Drainage: epicolic, paracolic, intermediate, principal and retroperitoneal LN Drainage affected by location of tumor Between primary blood vessels Blockage of lymphatics Prognosis affected by resection of unaffected LN but not affected LN Sternberg A. J Surg Onc

2 LYMPH NODE METASTASES Park IJ et al Ann Surg Onc 2009 HOW MANY LYMPH NODES SHOULD BE REMOVED? #LN retrieved is considered a quality measure % hospitals compliant with 12 LN retrieval measure compliance only 38% Most compliant were NCI designated cancer centers(78%) compared to academic (52%),VA (53%) or community(33%) Many patient-level studies suggest that retrieval of 12 LN confers survival advantage However, use of national database for a hospital level study suggests that hospitals with higher LN retrieval rates after colectomy for colon cancer do not have better survival rates WHAT ABOUT RADIAL MARGINS? DOES LAPAROSCOPY AFFECT RESECTIONS? COST TRIAL 2004 Laparoscopic Open Bowel length (cm) Proximal (cm) Distal (cm) Mesenteric length (cm) 9 8 # of Lymph nodes West NP et al. Lancet Oncol

3 MW: 56 y.o. man: Epigastric pain for 3 months. No dysphagia or weight loss. Endoscopy: malignant ulcer. Bx: poorly diff. adenocarcinoma. EUS: primary tumor involves muscularis but not serosa. No signs of LN involvement. CT scan: No local or distant mets seen. Oncology consult: Adjuvant treatment depending on path findings. Op Findings: multiple large LN along LGA. 3 cm diameter malignant ulcer at lesser curve 5 cm from GEJ. Op: Total gast + D2 LN dissection. 3/20/2009 Gastric Cancer KNOWLEDGE OF QUALITY CRITERIA A SURVEY OF SURGEONS Gen Surgeons were questioned about current standards of practice Quality Criteria % Correct Size of prox 50% Frozen section prox Frozen section distal 52% 35% Lymphadenectomy 14% Postop adjuvant chemorx No. lymph nodes expected 70% 9% Helyer LK et al. Gastric Cancer 2007;10:205: KNOWLEDGE OF QUALITY CRITERIA A SURVEY OF SURGEONS Gen Surgeons were questioned about current standards of practice Quality Criteria % Correct Answer Size of prox 50% 6 cm Frozen section prox Frozen section distal 52% routine 35% routine Lymphadenectomy 14% D1 or D2 Postop adjuvant chemorx No. lymph nodes expected 70% yes 9% 15 EFFECT OF HOSPITAL TYPE AND VOLUME ON SPECIMEN LN EVALUATION Histologic determination of nodal involvement affects prognosis and adjuvant treatment decisions. AJCC and NCCN recommend that 15 or more LN be present and studied in each gastrectomy specimen. Hospital Type Median No. LN % Patients >15 LN NCCN-NCI 12 42% Other academic 8 25% Community 8 18% Hosp Vol. Quartiles Median No. LN % Patients >15 LN Highest 10 35% High 8 22% Moderate 6 18% Low 6 17% Bilimoria KY et al. Arch Surg 2008;143:671. Helyer LK et al. Gastric Cancer 2007;10:205 3

4 IMPROVED RESULTS ACHIEVABLE WITH HIGH- VOLUME PRACTICE Data from US Natl Cancer Data Base, If outcomes at low-volume were as good as those at high-volume hospitals Gastric Cancer Potentially avoidable perioperative deaths Potentially avoidable longterm deaths 10,130 ops Total: 672 (6.6%) Technique for D2 Lymph Node Dissection 4. Common Hepatic Artery Dissection, Celiac Axis, Proximal 3. Porta Hepatis, Splenic Artery, and Left Suprapyloric Lymph, Gastric Artery and Hepatic Artery Dissection Node Dissection 1. Greater curvature nodal dissection Bilimoria KY et al. J Clin Oncol 2008;26: SMV and infrapyloric lymph node dissection R.O.: 78 Y.O. MAN A 2.5 cm cyst was found in the head of the pancreas 8 years ago and has been followed since. A recent CT scan showed it had grown to 3.2 cm (diameter). There were several other smaller cysts in the pancreatic head, suggesting IPMN. No symptoms. No diabetes mellitus. Heart: good function. Prostate cancer, E.P.: 64 Y.O. WOMAN Episodic abdominal and back pain for one year. No loss of weight. Several visits to ERs. CT and MR scans showed diffuse cystic disease throughout the pancreas. No region was spared. CA 19-9 was normal. A total pancreatectomy was performed. She recovered without complications, and now, 8 months later, she feels well. 4

5 IPMN RESECTION: FACTORS Signs / Symptoms Jaundice (elevated bilirubin) Weight loss abdominal pain, new onset diabetes, steatorrhea, nausea Imaging features Size > 3 cm Intra-cystic mural nodules Cyst-rim calcifications Main duct involvement or obstruction invasive carcinoma 50 92% main duct IPMN, 0 31% branch-duct IPMN EUS / FNA criteria Cellular atypia, dysplasia, malignancy extra cellular mucin & CEA > 200 ng / ml are markers for IPMN MANAGEMENT OF IPMN EUS / FNA: IS IT USEFUL? 50-60% of cyst aspirations are non-diagnostic or acellular In samples that contain mucin-secreting cells - definitive differentiation between GI contamination and pancreatic mucinous neoplasm is not possible CEA level cannot reliably determine whether malignancy is present Tanaka et al., International Consensus Guidelines IPMN, 2006; 6:

6 CONSIDERABLE OVERLAP IN FNA CEA LEVEL IN BENIGN AND MALIGNANT IPMN Kawai M et al, Arch Surg 2004; 139: Shami VM et al, Pancreas 2007; 34: Brugge WR et al, Cooperative Pancreatic Cyst Study, Gastro 2004: 126; LARGE SURGICAL SERIES IPMN Traverso Amer J Surg 2005 Lillimoe Ann Surg 2004 Farnell Arch Surg 2008 Warshaw Ann Surg 2004 N Benig n / CIS Invasive Main Duct Total Pancreatectom y % 25% % % 38% 28% 15% % 30% 37% 19% % 42% 100% 19% MANAGEMENT OF POSITIVE MARGINS IPMN Adenoma IPMN with Borderline Atypia IPMN with CIS or Invasive Carcinoma No further resection florid papilla formation may require further resection, if clinically indicated Should be completely resected whenever feasible Management based on the degree cytologic atypia - if frank CIS is noted, further resection may be attempted, if clinically indicated Tanaka et al., International Consensus Guidelines IPMN, 2006; 6: CONCLUSIONS Small (< 3 cm), branch-duct IPMNs with no factors suggestive of malignancy (Sx, mural nodules, rim calcifications, atypia on FNA) should be followed expectantly IPMN with main duct involvement, or factors suggestive of malignancy, should be resected Whipple or distal pancreatectomy (depending on IPMN location) is the default procedure Total pancreatectomy is reserved for cases that involve the entire gland (15% of cases) 6

7 Lap Chole OP Notes: How do we describe identification of the cystic duct? We exposed the gallbladder with cephalad and lateral infundibular retraction. We then performed our standard triangle of Calot dissection. This allowed us to clearly dissect the cystic duct away from surrounding structures. We then performed an extended infundibular dissection taking two-thirds of the gallbladder out of the gallbladder fossa before transecting any other structures. We then used hook cautery to develop the medial border of the gallbladder to facilitate exposure of Calot's triangle. We identified the cystic duct and cystic artery which were circumferentially freed. We placed 2 clips on the inferior aspect and one on the superior aspect of the cystic artery and divided it. We then circumferentially freed the cystic duct and divided it. We exposed the gallbladder with cephalad and lateral infundibular retraction. We then performed our standard triangle of Calot dissection. This allowed us to clearly dissect the cystic duct away from surrounding structures. We then performed an extended infundibular dissection taking two-thirds of the gallbladder out of the gallbladder fossa before transecting any other structures. We then used hook cautery to develop the medial border of the gallbladder to facilitate exposure of Calot's triangle. We identified the cystic duct and cystic artery which were circumferentially freed. We placed 2 clips on the inferior aspect and one on the superior aspect of the cystic artery and divided it. We then circumferentially freed the cystic duct and divided it. The peritoneum was dissected off the cystic duct. This was identified, and a clip was placed close to the junction of the gallbladder and cystic duct. A small incision was then made in the cystic duct, and an attempt to perform an intraoperative cholangiogram was made. This was unsuccessful due to inability to pass the catheter due to spiral valves. The duct was then divided between clips. The cystic artery was then divided between clips. The gallbladder was taken out of the gallbladder fossa using electrocautery The peritoneum was dissected off the cystic duct. This was identified, and a clip was placed close to the junction of the gallbladder and cystic duct. A small incision was then made in the cystic duct, and an attempt to perform an intraoperative cholangiogram was made. This was unsuccessful due to inability to pass the catheter due to spiral valves. The duct was then divided between clips. The cystic artery was then divided between clips. The gallbladder was taken out of the gallbladder fossa using electrocautery Using blunt dissection, the omental adhesions were removed from the infundibulum of the gallbladder. The cystic artery was encountered, identified, double clipped, and sharply divided. The cystic duct was identified, cleared of its surrounding adhesions, and doubly clipped. It was found to be fairly thick after sharp division, so an Endoloop chromic suture was used to close the cystic duct stump. Using blunt dissection, the omental adhesions were removed from the infundibulum of the gallbladder. The cystic artery was encountered, identified, double clipped, and sharply divided. The cystic duct was identified, cleared of its surrounding adhesions, and doubly clipped. It was found to be fairly thick after sharp division, so an Endoloop chromic suture was used to close the cystic duct stump. I II COMMENTS: III Cystic duct cleared. Cystic duct and infundibulum cleared; Calot s triangle cleared. GB separated from liver for 1 cm. Strasberg calls this the clear view. IV Infundibular technique Cystic duct and infundibulum cleared to ensure they are in continuity. Cystic ductcommon duct junction cleared. The operative note should include a sentence describing how the cystic duct was identified. Mention the triangle of Calot. Ensure that the presumptive cystic duct continues uninterrupted into the infundibulum. Examples: infundibular and clear-view methods; both mimic top-down cholecystectomy. No proof that one is better than the other. Say this much: 1) triangle of Calot; 2) dissection to expose medial side of infundibulum; and 3) trace cystic duct continuously into the infundibulum. 7