Multiorgan resections for cancer: advanced surgical techniques PDF
Preview Multiorgan resections for cancer: advanced surgical techniques
Multiorgan Resections for Cancer Advanced Surgical Techniques Marco P Merlini, MD, FACS, FRSM, FACA, FCCP Professorof Surgery Faculté de Biologie et Médecine Universityof Lausanne Head of the Department of Surgery GeneralHospital La Chaux-de-Fonds Switzerland Ronald F Martin, MD, FACS Staff Surgeon Departmentof Surgery Marshfield Clinic Marshfield,Wisconsin ClinicalAssociate Professorof Surgery Universityof Vermont Burlington, Vermont USA Lieutenant Colonel Medical Corps United StatesArmy Reserve With contributionsby M Dusmet,AE Castellanos,C Karakousis,RF Martin, MP Merlini,WC Meyers,M Oncel,IN Ponomarenko, RMQuiros,FHRemzi,HLRossi,TSaclarides,LJSkandalakis, JE Skandalakis, PH Sugarbaker, V Usatoff, HJ Wanebo, RCN Williamson,O Zoras 272 illustrations Thieme Stuttgart · New York IV LibraryofCongressCataloging-in-PublicationData Important note: Medicine is an ever-changing science under- Multiorganresectionsforcancer:advancedsurgicaltechniques/ going continual development. Research and clinical experience [editedby]M.P.Merlini,R.F.Martin. arecontinuallyexpandingourknowledge,inparticularourknowl- p.;cm. edgeofpropertreatmentanddrugtherapy.Insofarasthisbook ISBN3–13–135611–1(alk.paper)–ISBN1–58890–354–0 mentionsanydosageorapplication,readersmayrestassuredthat (alk.paper) the authors, editors, and publishers have made every effort to 1.Gastrointestinalsystem–Cancer–Surgery. I.Merlini,MarcoP.II. ensurethatsuchreferencesareinaccordancewiththestateof Martin,R.F. knowledgeatthetimeofproductionofthebook. [DNLM:1.DigestiveSystemNeoplasms–surgery. WI149 Nevertheless,thisdoesnotinvolve,imply,orexpressanyguar- M961.2006] anteeorresponsibilityonthepartofthepublishersinrespectto RD668.M85.2006 any dosage instructionsand forms of applicationsstated in the 616.99'433059–dc22 book.Everyuserisrequestedtoexaminecarefullythemanufac- 2006009251 turers’leafletsaccompanyingeachdrugandtocheck,ifnecessary inconsultationwithaphysicianorspecialist,whetherthedosage schedulesmentionedthereinorthecontraindicationsstatedbythe manufacturers differ from the statements made in the present book.Suchexaminationisparticularlyimportantwithdrugsthat areeitherrarelyusedorhavebeennewlyreleasedonthemarket. 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ISBN-13:978-3-13-135611-6(GTV) ISBN-10:1-58890-354-0(TNY) ISBN-13:978-1-58890-354-9(TNY) 123456 V Foreword Thisbookrepresentstheultimatechallengeofasurgi- applicableinmultiorganresectionforlocallyadvanced caloncologypractice,thatistoconsidergoingbeyond cancersinthepresumedabsenceofdistantmetastases. the ordinary surgical resection criteria to include re- Before undertaking a risky extended operation, every movaloforgansadjacenttotheprimarycancersitefor attempt should be made to characterize, within the thecompletionofan“en-bloc”resectionoflocallyad- knowable facts, the reasonable health of the patient vanced cancers. As a resultof their extensivetraining andtheabsenceofdistantmetastasestofitthesurgery and exposure to patients with advanced cancers, the totheexpectationofareasonableresult. authors are very experienced in the operations they Some procedures proposed by authors in this vol- describe.Nowherearethe benefitsof specializedsur- umeareyettobewidelyaccepted ordocumented by gicaloncologytrainingmoreapparentthaninthesub- long-termdata,suchasintraperitonealchemotherapy jectsaddressedinthisbook.Throughoutthebook,the after extensive peritoneum resection of widespread authorsemphasizetheneedforcarefuldetailedpreop- peritonealsurfacecancers.Theauthorspresentconsid- erativework-up andevaluation of thepatient,careful erable preliminary survival data that supports their case selection, and acknowledgment of confidence in explanationsofcomplexprocedures(i.e.,technology), the surgical skill and personal experience required to buttheirsuccessstillneedstoberelatedtothebiology undertakesuchadvancedprocedures. oftheparticularcancers.Somelow-gradelesionsmay Acommonthreaddiscussedwithinthechaptersof have extensive peritoneal spread and a large body of this book is that a significant proportion of patients literatureexiststodocumentthis. Substantialbibliog- withlocallyadvancedcancersneverthelesshavelymph raphies accompany the articlesand are importantfor nodes free of metastaticdisease, indicatinga reduced justification. This literature supports the concept of riskofdistantmetastasesdespitelargetumorsize.This resectingadjacentorgansinselectedpatientswithad- biological situation increases the probability of long- vancedlocalcancerstoachieveagoodoutcomeatan termdisease-freesurvival.Thehighproportionofpa- acceptablecost. tientswithnegativelymphnodesindicatesthatmany Theauthorsemphasizethe“en-bloc”concept,which of these advanced cancers have a unique biological isofcourseessentialforagoodoutcome.Whilemanyof behaviorwhich,whilepermittingmoreadvancedlocal the apparent attachments to adjacent organs by pri- growth even into one or more adjacent organs, may mary cancers may actually be inflammatory connec- result in significant benefit from an extended opera- tions,thesurgeonshouldusuallyassumethattheyare tion.Onejustificationforsuchextendedsurgeryisthat cancerous. Such adherence should almost always be substantial long-term disease-free survival can be usedasanindicationfortheresectionoftheadjacent achievedwiththepatientexposedtoareasonablelevel possibly involved structure, since blundering into an ofriskofpostoperativemorbidityandevenmortality. assumedinflammatoryplanewithattachmentmaybe Manyyearsago,duringapresidentialaddressrelat- disastrous for the patient—because of violated can- ingtothebasicprinciplesinvolvedinsurgicaloncology, cer—iftheassumptioniswrong. Idescribedsurgicaloncologyusingthefollowingmeta- I commend this book to the surgical community, phor:“biologyistheking,caseselectionisthequeen, particularlythesurgicaloncologycommunity,asitrep- andthetechnicalmaneuversundertakenaretheprin- resentstheexperience, skills,andattitudesneeded to cesandprincessesoftherealm.”Sometimestheelab- carryouttheseextensive,potentiallymorbidandeven oratetechnicalfeaturesandequipmentavailabletoday potentially lethal surgical resections. Such extensive encouragesurgeons to get carried away into thinking resections provide the optimum chance for cure in a they can ignore the basic biology of the disease and selectgroupofpatientsthatfrequentlyhaveabiolog- careful patient selection for appropriate procedures. icalbehaviorthatlendsitselftolonger-termsurvival. Howeverthismayleadtoasituationwhere“theprinces orprincessesattempttorevoltandoverthrow there- BlakeCady gime”;byfocussingonthetechnologytheyarealmost always“defeatedbythepowerfulforcesofthekingand queen, which represent basic oncologic biology and careful case selection.” This metaphor is particularly VII Preface Multiorgan resections for cancer represent a special direct care of the principal surgeon, who is the team category of abdominal surgery. These complex proce- leaderandwhoisultimatelyresponsibleforthetactical durestend topushtheboundariesofoperability(i.e., decision-making and for the patient. The anesthetist the true indication for surgery) and resectability (i.e., and intensive care specialistare also key members of thefeasibilityofachievingacompleteresection).Tobe theteamthroughoutthesesamethreephases.Ifspecial justifiabletheymustofferthepatientareasonableand blood requirements are anticipated the blood bank meaningful chance of cure with acceptable morbidity needs to be advised. Finally, these can be very long andmortality.Thus,evenmorethaninanyotherfield operationsandspecialprovisionsmayberequiredfor of surgery, patient selection is of paramount impor- the operating room staff. This all means that these tanceand these operationsmustnever be considered operationsrequireverymeticulousplanningandcan- or undertaken lightly. The operationmustbenefit the notbeimprovisedatthelastminute.Thepostoperative patientandnotthesurgeon’sego.Precise,carefulpre- caremustbeequallyattentiveandrigorousandthese operativeevaluationisnowmorereadilyavailablewith arenotgoodoperationstodoonaFriday. modern 16- or 32-slice CT scanners using a properly Fromatechnicalperspectivetheseareverycomplex administered contrast medium, different imaging operations. There are three distinct areas within the planes,and3Dreconstructiontechnology.Thesemust abdomen from top to bottom. Above the mesocolon befullyexploitedtoprovidemaximalbenefit.Thepa- theorgansaredisposedinaveryasymmetricalmanner, tientmustbecarefullystagedtoruleoutdistantdisease sosurgeryontherightortheleftisquitedifferent.The usingthebesttechniquesavailable,suchasMRItorule structuresthatwillberesectedtendtobeclosetothe outbrainmetastasesandPETscanswhenappropriate. retroperitoneumandthecriticalabdominalbloodves- Laparoscopy can allow occult peritoneal spread to be sels. Below the mesocolon there is a much greater determined prior to submitting the patient to a full degree of symmetry within the peritoneal cavityand laparotomy. Lastly, the initial part of the operation theretroperitoneumisalsomoresymmetrical.Symme- should be considered a fact-finding mission to deter- tryisrestoredinthepelvisandtheretroperitoneumis minesurgicallytheprecisestage,extent,andultimately muchlessofaproblemintermsofdeterminingresect- the true resectability of the tumor. Under no circum- ability.Surgicaltechniqueandtacticsarebasedonthis stancesmustanyirreversiblestepbetakenbeforethis and on the relative mobility of the more superficial operativeassessmentiscomplete. organs, whereas the deeper seated organs tend to be The patient must be fit for surgery. Co-morbidities completelyimmobile.Thesurgeonneedstoexploitthis must be carefully evaluated and the patient’s general mobilityandfreeupthemoresuperficialorgansbefore andnutritionalconditionshouldbeoptimizedpriorto tacklingthedeeperones. surgery, otherwise morbidity and mortality rates will Theseoperationsfollowaverylogicalstepwisepro- beprohibitive. gression.The basicoperativestrategy is based on the These operations often require close cooperation organwherethetumororiginatesandtheclassicsteps betweenseveralsurgeons.Whenplanningoneofthese ofitsresectionforcancer.Theoperationwillprogress proceduresitisimportanttorecognizeone’sstrengths downthispathuntilthesecondaryorganbecomesan and limitations so that the appropriate expertise is obstacle.Thesecondaryorganisonewhichhasbecome available at the time of surgery. These are complex, involvedbydirectextensionofthetumorintoit.Atthis stressful procedures and it is important to remain pointtheresectionoftheprimaryorganstopsandthe within one’s technical comfort zone. This ensures secondaryorganisresected.Thisresectionisthemin- smoothsurgeryandminimizestheriskofintraopera- imal resection required to achieve complete tumor tive complications as well as shortening the actual clearanceand does not necessarily necessitate all the length of the procedure. Thus, the team must be stepsthatwouldberequired ifthisweretheprimary plannedinadvance.Furthermore,acohesiveteamap- organ (e.g., if the secondary organ is the colon, wide proachisrequiredbefore,during,andaftersurgeryto resection of the mesentery to achieve lymph node obtainthebestresults.Thepatientshouldbeunderthe clearanceisnotperformed).Oncethesecondaryorgan VIII Preface has been completely mobilized the resection of the thisbook.Wehaveendeavoredtopresentasystematic primaryorgan resumes untilitscompletion. Thenthe approachtothesechallenging resectionsorganby or- reconstruction required by both resections can be ganandtodescribethedetailedandpracticalapproach undertaken.Afurtheraspectofthesemultiorganresec- tothesecomplexproblems.Wehopethatwewillhave tionscanbetherequirementforvascularresectionand described many littleor unknownaspectsof thissur- reconstruction to achieve the twin goals of complete gery to our readers and that we have been as all-in- tumorclearanceandsafeguardingthebloodsupplyto clusiveaspossible. the remaining vital structures in the abdomen or be- yond. Thisforewordismeanttogivethereaderagraspof MarcoPMerlini thebasicphilosophyofboththistypeofsurgeryandof RonaldFMartin IX Contributors MichaelDusmet,FRCS MustafaOncel,MD,FASC,FASCRS ConsultantinThoracicSurgery ResearchFellow TheRoyalBromptonHospital DepartmentofColorectalSurgery London ClevelandClinicFoundation UK Cleveland,Ohio USA AndresECastellanos,MD AssistantProfessor IhorNPonomarenko,MD DepartmentofSurgery GriffinHospital DrexelUniversityCollegeofMedicine Derby,Connecticut Philadelphia,PA USA USA RoderickMQuiros,MD ConstantineKarakousis,MD,PhD,FACS DepartmentofGeneralSurgery ProfessorofSurgery RushUniversityMedicalCenter StateUniversityofNewYorkatBuffalo Chicago,Illinois KaleidaHealth USA MillardFillmoreHospital Buffalo,NY FezaHRemzi,MD USA StaffSurgeon DepartmentofColorectalSurgery RonaldFMartin,MD,FACS ClevelandClinicFoundation StaffSurgeon Cleveland,Ohio DepartmentofSurgery USA MarshfieldClinic Marshfield,Wisconsin HeatherLRossi,MD ClinicalAssociateProfessorofSurgery AdjunctInstructorofSurgery UniversityofVermont UniversityofMinnesota Burlington,Vermont Minneapolis,Minnesota USA USA MarcoPMerlini,MD,FACS,FRSM,FACA,FCCP TheodoreSaclarides,MD ProfessorofSurgery DepartmentofSurgery FacultédeBiologieetMédecine Rush-Presbyterian-St.Luke’sMedicalCenter UniversityofLausanne Chicago,IL HeadoftheDepartmentofSurgery USA GeneralHospital LaChaux-de-Fonds LeeJSkandalakis,MD,FACS Switzerland ClinicalAssociateProfessorofSurgicalAnatomy andTechnique WilliamCMeyers,MD CentersforSurgicalAnatomyandTechnique AlmaDeaMoraniProfessor EmoryUniversitySchoolofMedicine Chairman,DepartmentofSurgery Atlanta,GA DrexelUniversityCollegeofMedicine USA PhiladelphiaPA USA
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