Multiorgan resections for cancer: advanced surgical techniques

211 Pages·2006·18.78 MB·English

by  Merlini

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
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Multiorganresectionsforcancer:advancedsurgicaltechniques/ going continual development. Research and clinical experience
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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