ATLAS OF PROCEDURES IN SURGICAL ONCOLOGY WITH CRITICAL,EVIDENCE-BASED COMMENTARY NOTES
ATLAS OF PROCEDURES IN SURGICAL ONCOLOGY WITH CRITICAL,EVIDENCE-BASED COMMENTARY NOTES
Editor
Riccardo A Audisio Whiston Hospital, University of Liverpool, UK
World Scientific NEW JERSEY
•
LONDON
•
SINGAPORE
•
BEIJING
•
SHANGHAI
•
HONG KONG
•
TA I P E I
•
CHENNAI
Published by World Scientific Publishing Co. Pte. Ltd. 5 Toh Tuck Link, Singapore 596224 USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601 UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE
Library of Congress Cataloging-in-Publication Data Atlas of procedures in surgical oncology with critical, evidence-based commentary notes (with DVD-ROM) / editor, Riccardo A. Audisio. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-981-283-293-1 (hardcover : alk. paper) ISBN-10: 981-283-293-9 (hardcover : alk. paper) 1. Cancer--Surgery--Atlases. I. Audisio, Riccardo A. [DNLM: 1. Neoplasms--surgery--Atlases. QZ 17 A88046 2009] RD651.A765 2009 616.99'4059--dc22 2009011129
British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library.
Copyright © 2010 by World Scientific Publishing Co. Pte. Ltd. All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system now known or to be invented, without written permission from the Publisher.
For photocopying of material in this volume, please pay a copying fee through the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission to photocopy is not required from the publisher.
Typeset by Stallion Press Email:
[email protected]
Printed in Singapore.
SC - Atlas of procedures.pmd
1
10/21/2009, 6:27 PM
June 27, 2009
12:6
B-601
fm
FA
Foreword
THE IMPORTANCE OF SURGICAL TECHNIQUE IN SURGICAL ONCOLOGY Quality surgery is crucial for the management of all solid malignant tumours. A multidisciplinary approach is accepted and therefore chemotherapy and radiotherapy will contribute enormously to a satisfactory outcome. However, very few studies have demonstrated that these or other modalities will correct for inadequate excisional surgery. Surgeons must have a leadership role in multidisciplinary care so that possibilities, but also limitations, of non surgical treatments will be evaluated before a major resection is undertaken. Surgeons have four major responsibilities in dealing with cancers. The cancer should be removed with a clear margin of excision to avoid local recurrence, which can be devastating. The surgeon must excise draining lymph nodes which will improve prognosis but also determine whether adjuvant therapy is required. Thirdly, it is essential to achieve these aims with a low morbidity and mortality. Accordingly, careful and fastidious technique in excision and reconstruction is paramount. Finally, the surgeon must be cognisant of the need for good cosmetic results to improve the quality of life. These procedures should be well documented so that the surgeon can review the results of short- and long-term outcomes.
v
June 27, 2009
vi
12:6
B-601
fm
FA
Foreword
In this book, Professor Audisio and colleagues have provided surgical oncologists with a practical, clinical and technical reference for dealing with malignant disease. All the common, as well as not so common, malignancies are included and in each case, the contributors are recognised experts in their field. The book provides essential basic information, but in addition, is full of good sense and tips for achieving optimal surgical results. It is highly unlikely that an individual surgeon will attempt all the different procedures described in this book but rather will concentrate on a single specialty field, e.g. a colorectal surgeon might delve into TME for rectal cancer, robotic assisted laparoscopic surgery, total proctocolectomy and ileoanal pouch, reconstruction of the perineum, how to make a good stoma, pelvic extenteration for rectal cancer, extended hepatectomy, and atypical liver resections for colorectal liver metastases. For those wishing to hone their plastic and reconstructive skills as part of a surgical oncological practice, there are important chapters on flap technology and reconstructive techniques, breast reconstructive techniques, skill/nipple sparing mastectomy and reconstruction of the perineum by a gluteal fold flap. There is also much to interest head and neck surgeons with total thyroidectomy, neck dissection for thyroid carcinoma, total laryngectomy, and total paroidectomy. These are merely examples of a comprehensive collection of important technical articles for both the surgeon-in-training and the experienced consultant. The European Society of Surgical Oncology supports training of its members through courses and lectures but also through important initiatives such as this book in the anticipation that outcomes for our patients will be improved.
June 27, 2009
12:6
B-601
fm
FA
Foreword
vii
The authors are to be congratulated for providing this valuable addition to the literature on crucially important technical aspects of surgical oncology.
Professor Irving Taylor Professor of Surgery Director of Medical Studies & Vice-Dean University College London, UK ESSO Past-President Professor Cornelis J.H. van de Velde Professor of Surgery Leiden University Medical Center Department of Surgery, The Netherlands ESSO President
June 27, 2009
12:6
B-601
fm
FA
Preface
Young surgeons and applicants to the EUMC examination have often been asking for a textbook on surgical oncology; a text they could consider as a standard in their education in cancer surgery. Textbooks on medical oncology were predominantly mentioned but a surgical counterpart could not be identified. This collection of surgical techniques represents our first step in this direction. Surgery, like sailing, is an art, and just as there is no “exact” way to set your sails, there is no exact way to tie your knots. However, in surgery, as in sailing, experience and evidence are pivotal in improving our skills. I am extremely grateful to all of the contributors who took the time to put a short text together, summarising their expert views on the surgical procedures that they have mastered. Importantly, the text is thoroughly referenced and supported by data from the literature, where available. I would like to congratulate the young colleagues who have assisted their mentors in setting this up; this project was always intended to be educational. The true target of a great surgeon is to set up a team around him. The privilege and pleasure of sharing knowledge is immense. In this way, key contributors have been working alongside their supportive teams to make this project possible. A wide range of oncological procedures are taken into account: from urology to breast, colorectal to hepato-biliary, gynaecology, thoracic, and so on. This is the completion of a goal that the European Society of Surgical Oncology (ESSO) had in mind. ESSO was founded ix
June 27, 2009
x
12:6
B-601
fm
FA
Preface
in 1981 to advance the art, science and practice of surgery for the treatment of cancer. I firmly believe that organ-based societies will not be able to represent the opinion of a surgical oncologist who is constantly engaged in a multidisciplinary approach to cancer patients. Scientific knowledge has no boundaries; although there are no geographical limitations to medical progress, this book attempts to collect examples of master knowledge from all around Europe. This knowledge was conceived within the Education & Training Committee at the European Society of Surgical Oncology. It is to this Society to which I am indebted for supporting me and providing a network of information, which has definitively been useful in assembling this collection of surgical procedures. The image on the book cover is an original illustration by Michael Howard, a brilliant visual artist who also contributed to some figures within the book. It is my sincere hope that through this book the readers will expand their knowledge and experience and that this will be reflected in improved care and treatment of patients.
Prof. Riccardo A. Audisio Consultant Surgical Oncologist University of Liverpool St Helens Hospital Marshalls Cross Road St Helens WA9 3DA - UK
June 27, 2009
12:6
B-601
fm
FA
Contents
Foreword
v
Preface
ix
List of Contributors
xvii
Chapter 1.
Axillary Lymph Node Dissection for Breast Cancer Elisabeth A. te Velde and Emiel J. Th. Rutgers
1
Chapter 2.
Breast Reconstructive Techniques Fabricio Brenelli, Umberto Napoli, Stefano Martella and Jean-Yves Petit
7
Chapter 3.
Skin/Nipple-Sparing Mastectomy Leif Perbeck
19
Chapter 4.
Radio-Guided Occult Lesion Localisation of Subclinical Breast Lesions Hodigere S. J. Ramesh, Matilde M. Audisio and Riccardo A. Audisio
25
xi
June 27, 2009
xii
12:6
B-601
fm
FA
Contents
Chapter 5.
Technical Note on Total Parotidectomy Eberhard Stennert and Orlando Guntinas-Lichius
33
Chapter 6.
Total Thyroidectomy Niall O’Higgins
41
Chapter 7.
Neck Dissection for Thyroid Cancer ˇ Jan Betka, Petr Lukeš, Zdenˇek Cada and Jaroslav Betka
45
Chapter 8.
Total Laryngectomy Mohssen Ansarin, Augusto Cattaneo and Fausto Chiesa
55
Chapter 9.
Transcervical Extended Mediastinal Lymphadenectomy Jarosław Ku˙zd˙zał, Marcin Zielinski ´ and Łukasz Hauer
63
Chapter 10. Minimally Invasive Techniques for Early Lung Cancer Contardo Vergani, Luca Despini and Giancarlo Roviaro
71
Chapter 11. Resection of Superior Sulcus Cancers: Anterior Approach Marco Alifano, Salvatore Strano and Olivier Schussler
79
Chapter 12. Surgical Staging for Lung and Mediastinal Cancers Ramón Rami-Porta, Sergi Call-Caja, Roser Saumench-Perramon and Mireia Serra-Mitjans
87
June 27, 2009
12:6
B-601
fm
FA
Contents
Chapter 13. Transthoracic Oesophagectomy and Lymphadenectomy Philippe Nafteux, Willy Coosemans, Herbert Decaluwé, Georges Decker, Paul De Leyn, Dirk Van Raemdonck and Toni Lerut
xiii
95
Chapter 14. Transhiatal Esophagectomy J. Jan. B. van Lanschot, Khe T. C. Tran, Bas P. L. Wijnhoven and Hugo W. Tilanus
103
Chapter 15. Gastrectomy for Adenocarcinoma Hartgrink H. Hartgrink and Cornelis J. H. van de Velde
109
Chapter 16. Stenting Gastro-Oesophageal Tumours Els M. L. Verschuur, Frank P. Vleggaar and Peter D. Siersema
117
Chapter 17. Total Pancreatectomy Jens Werner and Markus W. Büchler
125
Chapter 18. Radiofrequency Ablation in the Treatment of Liver Tumours Joris Joosten and Theo Ruers
133
Chapter 19. Atypical Liver Resections of Colorectal Metastases Bjarne Ardnor and Peter Naredi
141
Chapter 20. Extended Hepatectomy for Primary and Metastatic Liver Lesions René Adam, Emir Hoti, Dennis A. Wicherts and Robert J. de Haas
149
June 27, 2009
xiv
12:6
B-601
fm
FA
Contents
Chapter 21. Isolated Hepatic Perfusion: How It Should Be Done Alexander L. Vahrmeijer, Liselot B. J. van Iersel, Peter J. K. Kuppen and Cornelis J. H. van de Velde
157
Chapter 22. Robot-Assisted Laparoscopic Colorectal Surgery Omer Aziz and Ara W. Darzi
165
Chapter 23. How to Make a Good Stoma Robin Phillips and Simon Phillips
171
Chapter 24. Palliative Stenting for Colorectal Malignant Strictures Thomas M. Raymond, R. Bhardwaj and Mike C. Parker
179
Chapter 25. Technical Notes on TME for Rectal Cancer Bill J. Heald
187
Chapter 26. Total Proctocolectomy with Ileoanal Pouch Anastomosis Thomas Lehnert, Silke Schüle and Frank Starp
195
Chapter 27. Pouches and Coloanal Anastomosis Sylvain Kirzin, Guillaume Portier and Franck Lazorthes
203
Chapter 28. Pelvic Exenteration for Rectal Cancer Klaas Havenga and Theo Wiggers
209
Chapter 29. Reconstruction of the Perineum by Gluteal Fold Flap Niri S. Niranjan
215
June 27, 2009
12:6
B-601
fm
FA
Contents
xv
Chapter 30. Local Treatment for Primary Melanoma Omgo E. Nieweg
219
Chapter 31. Ilioinguinal Dissection for Melanoma Alessandro Testori and Mark Zonta
223
Chapter 32. Surgical Treatment of Peritoneal Carcinomatosis Marcello Deraco, Dario Baratti, Barbara Laterza, Domenico Sabia and Shigeki Kusamura
229
Chapter 33. Laparoscopic Management of Adnexal Tumours Liselotte Mettler, Ivo Meinhold-Heerlein and Andreas G. Schmutzler
237
Chapter 34. Excision of Intra-Abdominal Sarcomas: Technical Notes on Surgical Procedures Beate Rau and Peter M. Schlag
245
Chapter 35. Laparoscopic Adrenalectomy for Tumours in the Adrenal Glands Bergþór Björnsson, Guðjón Birgisson and Margrét Oddsdóttir
253
Chapter 36. Isolated Limb Perfusion Harald J. Hoekstra
259
Chapter 37. Cone and Wedge Resection in Renal Cell Carcinoma Frederik C. Roos and Joachim W. Thüroff
267
Chapter 38. Transperitoneal Laparoscopic Radical Nephrectomy Hugh F. O’Kane, Alex MacLeod, Christopher Hagan and Thiagarajan Nambirajan
275
June 27, 2009
xvi
12:6
B-601
fm
FA
Contents
Chapter 39. Radical Prostatectomy for Locally Advanced Prostate Cancer Marc Claessens, Steven Joniau and Hendrik Van Poppel
281
Chapter 40. Flap Technology and Reconstructive Techniques in Urology Milomir Ninkovic and Gustavo Sturtz
289
Index
301
June 27, 2009
12:6
B-601
fm
FA
List of Contributors
René Adam AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, F-94804 Villejuif, France Inserm, Unité 785, F-94804 Villejuif, France Université Paris-Sud, UMR-S 785, F-94804 Villejuif, France Marco Alifano Chirurgien des Hôpitaux, Unité de Chirurgie Thoracique, Hôtel-Dieu University Hospital, 1, Place du Parvis Notre-Dame, 75004 Paris, France Mohssen Ansarin Head and Neck Department, European Institute of Oncology, Via Ripamonti, 435 I-20141 Milan, Italy Bjarne Ardnor Department of Surgery, Umea University Hospital, S-90185 Umea, Sweden Matilde M. Audisio Carmel College, Prescot Road, St Helens, Merseyside WA10 3AG, UK Riccardo A. Audisio Department of Surgery, Whiston Hospital, Warrington Road, Prescot L35 5DR, UK
xvii
June 27, 2009
12:6
xviii
B-601
fm
FA
List of Contributors
Omer Aziz Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St Mary’s Hospital, London W2 1NY, UK Dario Baratti Department of Surgery, National Cancer Institute of Milan, 1, 20133 Milan, Italy Jan Betka Department of Otorhinolaryngology and Head and Neck Surgery, Faculty Hospital Motol, Charles University, 150 06 Prague 5, Czech Republic. Jaroslav Betka Department of Otorhinolaryngology and Head and Neck Surgery, Faculty Hospital Motol, Charles University, 150 06 Prague 5, Czech Republic. Rakesh Bhardwaj Department of Surgery, Darent Valley Hospital, Dartford, Kent DA2 8DA, UK Guðjón Birgisson Department of Medicine, University of Iceland Medical School and Landspitali-University Hospital, Reykjavik, Iceland Bergþór Björnsson Department of Medicine, University of Iceland Medical School and Landspitali-University Hospital, Reykjavik, Iceland Fabricio Brenelli Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Via Ripamonti, 435 20141-Milan-Italy
June 27, 2009
12:6
B-601
fm
FA
List of Contributors
xix
Markus W. Büchler Department of General, Visceral, and Transplant Surgery, University of Heidelberg, INF 110, 69120 Heidelberg, Germany ˇ Zdenˇek Cada Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Postgraduate Medical School, Charles University in Prague Sergi Call-Caja Thoracic Surgery Service, Hospital Mutua de Terrassa, Plaza Dr. Robert, 5, 08221 Terrassa, Barcelona, Spain Augusto Cattaneo Head and Neck Department, European Institute of Oncology, 435, I-20141 Milan, Italy Fausto Chiesa Head and Neck Department, European Institute of Oncology, 435, I-20141 Milan, Italy Marc Claessens Department of Urology, University Hospital Leuven, UZ 3000 Leuven, Belgium Willy Coosemans Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Ara W. Darzi Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St Mary’s Hospital, London W2 1NY, UK Herbert Decaluwé Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium
June 27, 2009
xx
12:6
B-601
fm
FA
List of Contributors
Georges Decker Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Robert J. de Haas Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands Marcello Deraco Department of Surgery, National Cancer Institute, Via Venezian 1, 20133 Milano, Itally Luca Despini Department of Surgical Sciences, State University of Milan and Department of General Surgery, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS, Milan, Via Francesco Sforza 35, 20122 Milano, Italy Orlando Guntinas-Lichius Department of Otorhinolaryngology, Friedrich-Schiller-University Jena, Lessingstrasse 2, D-07740 Jena, Germany Christopher Hagan Department of Urology, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, Northern Ireland Hartgrink H. Hartgrink Department of Surgery, Leiden University Medical Center, 2300 RC, Leiden, The Netherlands Łukasz Hauer Department of Thoracic Surgery, Pulmonary Hospital Zakopane, 34-500 Zakopane, Poland Klaas Havenga Department of Surgery, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
June 27, 2009
12:6
B-601
fm
FA
List of Contributors
xxi
Bill J. Heald Department of Colorectal Surgery, Pelican Cancer Foundation, North Hampshire Hospital, Basingstoke RG24 9NA, UK Harald J. Hoekstra Division of Surgical Oncology, Department of Surgery, Groningen University Hospital, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands Emir Hoti AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, F-94804 Villejuif, France Liver Transplant Unit, Saint Vincent’s University Hospital, Dublin 4, Ireland Steven Joniau Department of Urology, University Hospital Leuven, UZ 3000 Leuven, Belgium Joris Joosten Department of Surgery, CanisiusWilhelmina Hospital, 6500 HB, Nijmegen, The Netherlands Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands Sylvain Kirzin Service de chirurgie digestive CHU Purpan, Place du Dr Baylac, 31059 Toulouse, France Peter J. K. Kuppen Department of Surgery, Leiden University Medical Center, 2300 RC, Leiden, The Netherlands Shigeki Kusamura Department of Surgery, National Cancer Institute of Milan, 1, 20133 Milan, Italy
June 27, 2009
xxii
12:6
B-601
fm
FA
List of Contributors
Jarosław Ku˙zd˙zał Department of Thoracic Surgery, Pulmonary Hospital Zakopane, 34-500 Zakopane, Poland Barbara Laterza Department of Surgery, National Cancer Institute of Milan, 1, 20133 Milan, Italy Franck Lazorthes Service de chirurgie digestive CHU Purpan, Place du Dr Baylac, 31059 Toulouse, France Thomas Lehnert Departments of General, Visceral, Vascular and Oncology Surgery, Klinikum Bremen-Mitte, St Juergen Strasse, 1, DE 28205 Bremen, Germany Toni Lerut Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Paul De Leyn Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Petr Lukeš Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Postgraduate Medical School, Charles University, 150 06 Prague 5, Czech Republic Alexander MacLeod Department of Urology, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, Northern Ireland Stefano Martella Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Via Ripamonti, 435 20141-Milan-Italy
June 27, 2009
12:6
B-601
fm
FA
List of Contributors
xxiii
Ivo Meinhold-Heerlein Department of Obstetrics and Gynecology, Christian-AlbrechtsUniversity of Kiel, Klinikum Schleswig-Holstein, Campus Kiel, Michaelisstr. 16, 24105 Kiel, Germany Liselotte Mettler Department of Obstetrics and Gynecology, Christian-AlbrechtsUniversity of Kiel, Klinikum Schleswig-Holstein, Campus Kiel, Michaelisstr. 16, 24105 Kiel, Germany Philippe Nafteux Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Thiagarajan Nambirajan Department of Urology, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, Northern Ireland Umberto Napoli Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Via Ripamonti, 435 20141-Milan-Italy Peter Naredi Department of Surgery, Umea University Hospital, S-90185 Umea, Sweden Omgo E. Nieweg Department of Surgery, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
June 27, 2009
12:6
xxiv
B-601
fm
FA
List of Contributors
Milomir Ninkovic Department of Plastic, Reconstructive, Hand and Burns Surgery, Hospital Bogenhausen — Technical University Munich, Munich 81925, Germany Niri S. Niranjan Department of Plastic and Reconstructive Surgery, St. Andrews Centre for Plastic Surgery, Broomsfield Hospital, Broomsfield, Chelmsford CM1 7ET, Essex, UK Margrét Oddsdóttir Department of Surgery, Landspitali-University Hospital, 101 Reykjavik, Iceland Niall O’Higgins Department of Surgery, RCSI Medical University of Bahrain, Busaiteen 436, Kingdom of Bahrain Hugh F. O’Kane Department of Urology, Belfast City Hospital, Lisburn Road, Belfast, Northern Ireland Mike C. Parker Department of Surgery, Darent Valley Hospital, Dartford, Kent DA2 8DA, UK Leif Perbeck Department of Surgery, Karolinska University Hospital, SE-171 76 Stockholm, Sweden Jean-Yves Petit Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Via Ripamonti, 435 20141-Milan-Italy Robin Phillips Department of Surgery, Imperial College London, South Kensington Campus, London SW7 2AZ
June 27, 2009
12:6
B-601
fm
FA
List of Contributors
xxv
Simon Phillips Department of Surgery, Imperial College London, South Kensington Campus, London SW7 2AZ Hendrik Van Poppel Department of Urology, University Hospital Leuven, UZ 3000 Leuven, Belgium Guillaume Portier Service de chirurgie digestive CHU Purpan, Place du Dr. Baylac, 31059 Toulouse, France Dirk Van Raemdonck Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Hodigere S. J. Ramesh Department of Surgery, Whiston Hospital, Warrington Road, Prescot L35 5DR, UK Ramón Rami-Porta Thoracic Surgery Service, Hospital Mutua de Terrassa, Plaza Dr. Robert, 5, 08221 Terrassa, Barcelona, Spain Beate Rau Department of Surgery and Surgical Oncology, University of Berlin, Charité Campus Milte, Charite platz 1, 10 M7 Berlin, Germany Thomas M. Raymond Department of Surgery, Darent Valley Hospital, Dartford, Kent DA2 8DA, UK Frederik C. Roos Department of Urology, Johannes Gutenberg-University Mainz Medical School, 55101 Mainz, Germany
June 27, 2009
12:6
xxvi
B-601
fm
FA
List of Contributors
Giancarlo Roviaro Department of Surgical Sciences, State University of Milan and Department of General Surgery, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS, Milan, Via Francesco Sforza 35, 20122 Milano, Italy Theo Ruers Department of Surgical Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands Emiel J. Th. Rutgers Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital, PO Box 90203, 1006 BE Amsterdam, The Netherlands Domenico Sabia Department of Surgery, National Cancer Institute of Milan, Via Venezian 1, 20133 Milano, Italy Roser Saumench-Perramon Thoracic Surgery Service, Hospital Mutua de Terrassa, Plaza Dr. Robert, 5, 08221 Terrassa, Barcelona, Spain Peter M. Schlag Department of Surgery and Surgical Oncology, University of Berlin, Charité Campus Milte, Charite platz 1, 10 M7 Berlin, Germany Andreas G. Schmutzler Department of Obstetrics and Gynecology, Christian-AlbrechtsUniversity of Kiel, Klinikum Schleswig-Holstein, Campus Kiel, Michaelisstr. 16, 24105 Kiel, Germany Silke Schüle Departments of General, Visceral, Vascular and Oncology Surgery, Klinikum Bremen-Mitte, St. Juergen Strasse, 1, DE 28205 Bremen, Germany
June 27, 2009
12:6
B-601
fm
FA
List of Contributors
xxvii
Olivier Schussler Chirurgien des Hôpitaux, Unité de Chirurgie Thoracique, Hôtel-Dieu University Hospital, 1, Place du Parvis Notre-Dame, 75004 Paris, France Mireia Serra-Mitjans Thoracic Surgery Service, Hospital Mutua de Terrassa, Plaza Dr. Robert, 5, 08221 Terrassa, Barcelona, Spain Peter D. Siersema Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, The Netherlands Department of Gastroenterology and Hepatology, University Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands Frank Starp Departments of General, Visceral, Vascular and Oncology Surgery, Klinikum Bremen-Mitte, St. Juergen Strasse, 1, DE 28205 Bremen, Germany Eberhard Stennert Department of Otorhinolaryngology, Jean-Uhrmacher-Institute, University of Cologne, Geibelstrasse 29-31, Koeln, Germany Salvatore Strano Chirurgien des Hôpitaux, Unité de Chirurgie Thoracique, Hôtel-Dieu University Hospital, 1, Place du Parvis Notre-Dame, 75004 Paris, France Gustavo Sturtz Department of Plastic, Reconstructive, Hand and Burns Surgery, Hospital Bogenhausen – Technical University Munich, Munich, Germany
June 27, 2009
12:6
xxviii
B-601
fm
FA
List of Contributors
Alessandro Testori Division of Melanoma and Soft Tissue Sarcoma, European Institute of Oncology, Italy European Institute of Oncology, via Ripamonti 435, 20141 Milano, Italy Elisabeth A. te Velde Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital, 1006 BE Amsterdam, The Netherlands Joachim W. Thüroff Department of Urology, Johannes Gutenberg-University Mainz Medical School, 55101 Mainz, Germany Hugo W. Tilanus Department of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CA Rotterdam, the Netherlands Khe T. C. Tran Department of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CA Rotterdam, the Netherlands Alexander L. Vahrmeijer Department of Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands Cornelis J. H. van de Velde Department of Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands Liselot B. J. van Iersel Department of Clinical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands J. Jan. B. van Lanschot Department of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CA Rotterdam, the Netherlands
June 27, 2009
12:6
B-601
fm
FA
List of Contributors
xxix
Contardo Vergani Department of Surgical Sciences, State University of Milan and Department of General Surgery, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS, Milan, Via Francesco Sforza 35, 20122 Milano, Italy Els M. L. Verschuur Department of Gastroenterology and Hepatology, University Utrecht, 3508 GA Utrecht, The Netherlands Frank P. Vleggaar Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Heidelberglann 100, 3584 cx Utrecht, The Netherlands Jens Werner Department of General, Visceral, and Transplant Surgery, University of Heidelberg, INF 110, 69120 Heidelberg, Germany Dennis A. Wicherts AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, F-94804 Villejuif, France Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands Theo Wiggers Department of Surgery, University Medical Center Groningen, 9700 RB Groningen, The Netherlands Bas P. L. Wijnhoven Department of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CA Rotterdam, The Netherlands Marcin Zielinski ´ Department of Thoracic Surgery, Pulmonary Hospital Zakopane, 34-500 Zakopane, Poland
June 27, 2009
xxx
12:6
B-601
fm
FA
List of Contributors
Mark Zonta Division of Melanoma and Soft Tissue Sarcoma, European Institute of Oncology, Italy European Institute of Oncology, via Ripamonti 435, 20141 Milano, Italy
June 9, 2009
14:6
B-601
ch01
FA
chapter
1
Axillary Lymph Node Dissection for Breast Cancer Elisabeth A. te Velde and Emiel J. Th. Rutgers∗,†
INDICATIONS Nowadays, for diagnostic staging of the axilla, dissection of the sentinel lymph node is the advised procedure, preferably preceded by ultrasound of the axilla with fine needle aspiration (FNA) if suspicious lymph nodes are seen. Consequently, axillary lymph node dissection for breast cancer is indicated mainly for treatment of (early) lymph node metastases. An axillary dissection is performed if: • The sentinel node is considered positive, with a tumour load of more than 0.2 mm1 ; • FNA cytology or core biopsy confirms lymph node metastases; • The sentinel node cannot be found or is not performed.
∗ Corresponding
author. of Surgical Oncology, Antoni van Leeuwenhoek Hospital, PO Box 90203, 1006 BE Amsterdam, The Netherlands. E-mail:
[email protected] † Department
1
June 9, 2009
2
14:6
B-601
ch01
FA
E. A. te Velde and E. J. Th. Rutgers
TECHNIQUE We prefer the following technique for axillary lymph node dissection for breast cancer: • The patient is in a supine position, tilted away from the surgeon. The lateral chest wall of the patient is placed close to the side of the table. The ipsilateral arm is in maximal abduction on an arm board and can be draped separately. • Curvilinear incision is cranial along the lateral border of the pectoralis major muscle and distal towards the posterior axillary line. • Dissect the dorsal skin flap down to Scarpa’s fascia to reach the free anterior border of the latissimus dorsi (LD) muscle. • Free the LD muscle from the anterior by lifting the muscle upwards by traction to the skin with the free hand. This is the lateral border of the dissection. • Free the thoracodorsal bundle (nerve and vessels) and secure crossing vessels until the axillary vein. Usually, by retracting the axillary fat pad ventrally, the nerve is medial to the vessels at the cranial part (Fig. 1).
FIGURE 1 The thoracodorsal bundle (nerve and vessels) has been freed. The axillary fat pad is retracted ventrally.
June 9, 2009
14:6
B-601
ch01
FA
Axillary Lymph Node Dissection for Breast Cancer
3
• Intercostobrachial nerves are sensory nerves for the medial aspect of the upper arm, and the posterior aspect of the axilla and can be preserved.2,3 It is uncertain whether this will lead to less sensory disturbances. • From dorsolateral the fascia of the serratus anterior muscle can be cleared. • The long thoracic nerve can be identified at the level of the highest descending branch of the intercostobrachial vessels towards the thoracic wall. It should not be dissected from the thoracic wall. • The ventral skin flap is dissected to free the lateral border of the pectoralis major muscle and further dorsal to the pectoralis minor muscle. The crossing vessels can be spared, harvesting the interpectoral nodes (Rotter’s nodes). • Cranially, the axillary vein’s inferior margin is dissected and forms the cranial border of the dissection. The small motor nerves to the lateral part of the pectoralis minor muscle should be spared. The descending ventral branch(es) of the vein usually needs to be dissected. Care should be taken not to clear completely the perivascular fascia and the fatty tissue surrounding the vein. • The total content of the axilla dorsal from the pectoralis minor muscle is removed (level II). • The caudal border of the dissection is the axillary tail of the breast tissue. • Finally, the axillary specimen is cleared from the serratus anterior muscle fascia, the proximal part of the thoracodorsal nerve and of the anterior plane of the subscapular muscle (Fig. 2). • If level III needs to be dissected (in the case of palpable nodes), the complete proximal part of the minor pectoral muscle is lifted by a large Langenbeck’s retractor and the area boarded medially by the clavipectoral fascia, which can be palpated as a bridging fascia, cranially by the subclavian vein, and the medial border of the pectoralis minor muscle cleared and the fat pad removed. • Remove the specimen. It is advised to mark the medial apex (top) and the axillary tail of the breast specimen for orientation by the pathologist.
June 9, 2009
4
14:6
B-601
ch01
FA
E. A. te Velde and E. J. Th. Rutgers
FIGURE 2 The axillary dissection is completed and the apex is marked.
• Closure of Scarpa’s fascia by absorbable sutures. Obliteration of dead space of the axilla by tagging down the subcutis to the serratus anterior fascia is optional.4 • Skin closure by running subcuticular absorbable sutures (Fig. 3). • There is no need for external compression dressing.
FIGURE 3 Skin is closed by running sutures without a dressing. The axilla is drained for 24 hours.
June 9, 2009
14:6
B-601
ch01
FA
Axillary Lymph Node Dissection for Breast Cancer
5
• Different drain policies are advocated: — None5 ; — 24-hour suction drainage6 ; — 3–5 days. An alternative — more traditional — method is described by Ung et al.7 Our dorsal approach has the great advantage that the important motoric nerves are easily identified and spared, also in obese patients.
REFERENCES 1. Lyman GH, Giuliano AE, Somerfield MR, et al.; American Society of Clinical Oncology. (2005) American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 23(30): 7703–7720. 2. Muscolino G, Leo E, Sacchini V, et al. (1988) Resectable breast cancer: axillary dissection sparing pectoralis muscles and nerves. Eur J Surg Oncol 14(5): 429–433. 3. Salmon RJ, Ansquer Y, Asselain B. (1998) Preservation versus section of intercostal-brachial nerve (IBN) in axillary dissection for breast cancer — a prospective randomized trial. Eur J Surg Oncol 24(3): 158–161. 4. Chilson TR, Chan FD, Lonser RR, et al. Seroma prevention after modified radical mastectomy. Am Surg 58(12): 750–754. 5. Garbay JR, Picone O, Baron-Merle G, et al. (2004) Axillary lymphadenectomy with muscular padding, without drainage. Gynecol Obstet Fertil 32(12): 1039–1046. 6. Baas-Vrancken Peeters MJ, Kluit AB, Merkus JW, Breslau PJ. (2005) Short versus long-term postoperative drainage of the axilla after axillary lymph node dissection: a prospective randomized study. Breast Cancer Res Treat 93(3): 271–275. 7. Ung O, Tan M, Chua B, Barraclough B. (2006) Complete axillary dissection: a technique that still has relevance in contemporary management of breast cancer. ANZ J Surg 76(6): 518–521.
June 9, 2009
14:6
B-601
ch02
FA
chapter
2
Breast Reconstructive Techniques Fabricio Brenelli† , Umberto Napoli† , Stefano Martella† and Jean-Yves Petit∗,†
The reconstruction of the breast is a hallmark in the surgical management of breast cancer. It reduces the anxiety of the patient and thereby improves the quality of life. It can be done at the time of mastectomy (immediate reconstruction) or any time after (delayed reconstruction). It can be performed either using prosthesis or an autogenous tissue. If the preference is for a prosthesis, either a temporary implant (tissue expander) or a definitive implant (silicone or saline prosthesis or a definitive expander) can be used. If reconstruction with autogenous tissue is preferred, a latissimus dorsi (LD) or a transverse rectus abdominal muscle (TRAM) flap can be used. Pedicle free flaps are gaining space, mainly the free TRAM flap and the deep inferior epigastric (DIEP) flap, both of them require a microsurgery-trained team, this will be not discussed in this chapter.
RECONSTRUCTION WITH PROSTHESIS Breast Reconstruction with a Definitive Prosthesis Technique: Drawing of both inframammary fold and sternal line must be done preoperatively as an anatomical reference. Measurement of the breast’s base helps to program the width of the prosthesis to be placed (Fig. 1). ∗ Corresponding
author.
† Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Via
Ripamonti, 435 20141-Milan-Italy. E-mail:
[email protected] 7
June 9, 2009
8
14:6
B-601
ch02
FA
F. Brenelli et al.
FIGURE 1 Pre-operative drawing of the inframammary fold and sternal line.
The technique consists of a complete or partial muscular pocket. After mastectomy, smooth dissection of the space between the pectoralis major and minor muscle is performed. This is followed by a sharp dissection, undermining the subpectoral space, cutting the muscle’s insertion medially from the sternum up to 4–5 cm from the mammary fold. Inferiorly, dissection is completed achieving the inframammary fold after complete severance of the pectoralis fibbers. The lateral extent of the dissection continues beneath the serratus anterior muscle, and stops at the predetermined lateral border of the breast (Figs. 2 and 3). If the lateral skin of the mastectomy is thick and well irrigated, a complete muscular pocket can be avoided, in order to give more lateral projection to the breast. The implant is placed in the subpectoralis
June 9, 2009
14:6
B-601
ch02
FA
Breast Reconstructive Techniques
9
FIGURE 2 Mastectomy defect and exposure of the pectoralis major muscle.
FIGURE 3 Dissection of the sub-pectoralis space: Medially, severance of the pectoralis major fibers from the sternum; inferiorly: Severance of the pectoralis fibers achieving the inframmary fold; lateraly: Completion of the muscular pocket with dissection of the serratus anterior muscle.
June 9, 2009
10
14:6
B-601
ch02
FA
F. Brenelli et al.
FIGURE 4 Partial pocket; lateraly, the prosthesis is covered by the lateral skin flap of the mastectomy.
space as well, and just an inferior portion of the anterior serratus is dissected. Then the pocket is closed with the pectoralis major and the lateral part of the mastectomy (Fig. 4). Indications: Cases of small and medium breasts, where mastectomy does not require extent skin removal or partial removal of muscular tissue. Contraindications: When muscular invasion exists, or when a large amount of skin must be excised, making it impossible to build a muscular pocket or having an adequate skin envelope. Adjuvant radiotherapy is a relative contraindication.
Breast Reconstruction with Tissue Expander This technique consists of the placement of a temporary or definitive implant which is inflated with saline solution until the desired volume is reached, and is exactly the same technique as described above. After the expander is positioned inside the muscular pocket, the catheter and port are tunnelled and brought to a position under the skin in
June 9, 2009
14:6
B-601
ch02
FA
Breast Reconstructive Techniques
11
FIGURE 5 Temporary tissue expander. Expantion is performed with saline solution through the port.
the axilla. As an alternative, in some expanders the port is located on the surface of the implant itself. In such cases a magnetic device can help to localize the port and thereby guide the inflation. The expander is inflated by passing a needle through the port and injecting saline solution through it (Fig. 5). After suitable expansion, the expander is replaced by a permanent prosthesis.
RECONSTRUCTION WITH LATISSIMUS DORSI FLAP (L. D.) Technique: The donor site skin must correspond to the quantity of breast skin that will be removed. The drawing should be elliptical to provide adequate closure, minimising scar defect. It can be horizontal (better aesthetical result as the scar remains under the bra), or oblique (facilitates the closure) (Fig. 6). The patient’s position is very important. A lateral decubitus position provides the surgeon an easy access to the L.D. muscle and surrounding tissues. Its position is secured with a bean bag.
June 9, 2009
12
14:6
B-601
ch02
FA
F. Brenelli et al.
FIGURE 6 Different possibilities of skin pad donation in the L.D. flap. In the left, horizontal scar that can be hidden by the bra.
The flap comprises skin paddle, underlying fat and L.D. muscle. After skin incision, flap is taken down to the muscle, and the area of adjacent skin is undermined. The flap is mobilised by incising muscle along its anterior margin and continuing the dissection posteriorly, and the flap is thus liberated from the underlying rib cage. Peripheral attachments are severed by sharp dissection, beginning inferiorly and continuing superiorly. Along the superior aspect of the dissection, particular attention must be taken to identify and preserve the thoracodorsal pedicle which provides the flap’s blood supply (Fig. 7). Finally, a tunnel is created with blunt dissection between the axilla, from the donor site to the mastectomy defect, allowing the rotation of the flap. Suction drain is positioned and the back wound is closed in two layers. The patient is rotated to a supine position. The final step is shaping of the flap, fixing it to the muscular chest wall, creating a pocket. A prosthesis is placed in order to achieve a symmetric breast volume (Fig. 8).
June 9, 2009
14:6
B-601
ch02
FA
Breast Reconstructive Techniques
13
FIGURE 7 Irrigation of the L.D. muscle. The thoracodorsal pedicle and its amplification.
FIGURE 8 Placement of the L.D. muscle over the prosthesis, creating a new pocket.
A total breast reconstruction with L.D. flap is feasible in cases of small or medium breast, with an extended latissimus dorsi flap (ELD). The technique involved is the same as the one described above, but the undermining of the adjacent skin is performed on a subcutaneous
June 9, 2009
14
14:6
B-601
ch02
FA
F. Brenelli et al.
plane, and the muscle is removed together with the superficial fat lying above it, resulting in a more voluminous flap. Indications: Almost every case of mastectomy and breast reconstruction. Contraindications: Cases where a great amount of skin must be removed and the flap skin is not enough to cover it. Relative contraindication is the presence of homolateral arm lymphedema due to previous axillary dissection.
RECONSTRUCTION WITH TRAM FLAP Technique: The patient must be marked preoperatively with an indelible ink. The donor site is outlined superiorly just above the umbilicus, laterally to the iliac crest, and inferiorly, the position being dependent on the possibility of performing a good closure without much tension (Fig. 9).
FIGURE 9 Pre-operative drawing of the TRAM flap donor site: Superiorly, just above the umbilicus; Lateraly at the Iliac crest; Inferiorly, above the pubis, always when it allows a good closure.
June 9, 2009
14:6
B-601
ch02
FA
Breast Reconstructive Techniques
15
After incision, sharp dissection is performed just above the rectus abdominal fascia, undermining the subcutaneous space, from the superior incision up to the xiphoid, creating a tunnel. The lateral anatomical reference is the rib cage. The random part of the flap that will not be attached to the muscle is undermined until the rectus is reached, preserving as much perforator vessel as possible. At this point, the rectus fascia is opened on its longitudinal axis up to the xiphoid and the muscle is exposed. The rectus muscle is dissected free posteriorly and the lateral aspect of the rectus sheath is divided with a scalpel up to the superior border of the flap. The medial border of the rectus sheath is divided to the level of the umbilicus, which is then dissected free from the flap. The surgeon places two finger underneath the rectus and lifts it anteriorly with gentle tension, permitting the palpation and vision of the inferior pedicle, which is ligated while the muscle is being divided. The rectus muscle is completely mobilised by sharp and blunt dissection and the superior pedicle is identified. A tunnel is created through the inframammary fold, communicating with the mastectomy defect. The flap is then rotated into the wound (Fig. 10).
FIGURE 10 Positioning the contra-lateral TRAM flap: Attention to avoid tension or strugling of the pedicle. The lateral part of the flap (less irrigated) is placed in the lateral part of the defect, allowing an easier flap ressection in case of partial necrosis.
June 9, 2009
16
14:6
B-601
ch02
FA
F. Brenelli et al.
FIGURE 11 Positioning of the ipsi-lateral TRAM flap. Attention to avoid torsion of the pedicle, folding the rectus upon itself. The lateral part of the flap remains external to the mastectomy defect.
The pedicle can be ipsi or contralateral to mastectomy (Figs. 10 and 11). Great attention must be paid to its positioning, in order not to cause its distension or strangulation. At the end, shapening of the flap is performed by cutting off the excess tissue from zone 3 and 4 (the farthest zone from the pedicle). When the mastectomy defect is very large, and the flap must be used on its full dimension, it is necessary to perform a bipedicle TRAM flap, using both abdominal rectus (Fig. 12). The technique used is the same as described above, but implicates the use of the two rectus muscles. Abdominal closure is a very important step. The suture of the fascia should be done with the patient in the lying position, while the closure of the cutaneous flaps will be done at the end in a sitting position. The fascia can be closed directly with nonabsorbable stitches under moderate tension in cases of a mono pedicle. Otherwise, in cases of important tension and bipedicle TRAM, we recommend the use of a nonabsorbable mesh.
June 9, 2009
14:6
B-601
FA
ch02
Breast Reconstructive Techniques
17
FIGURE 12 Bipedicle TRAM flap. Both rectus are dissected, a small amount of midline Fascia being kept, preserving the umbilicus and its irrigation.
Close attention must be paid to the umbilicous repositioning, especially in cases of a mono pedicle TRAM. Centralisation can be obtained, thanks to a plicature of the fascia of the opposite muscle. It is also possible to create the future hole of the umbilicus on the median line and to use its length to centralizate. Indications: Almost every case of breast reconstruction. Contraindications: Relative, in cases of obesity, heavy smokers and previous abdominal surgery.
June 9, 2009
14:6
B-601
ch03
FA
chapter
3
Skin/Nipple-Sparing Mastectomy Leif Perbeck∗
INTRODUCTION Skin sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) followed by immediate breast reconstruction have gained popularity, since they result in a shape of a natural breast with an intact submammary fold and require only one operation, except for the nipple reconstruction in SSM. SSM has been described as an operation including resection of the nipple–areola complex and any existing biopsy scar, and removal of the entire breast parenchyma.1 SSM and NSM require technical expertise to avoid partial or full-thickness loss of skin flaps,2 which can lead to delay in starting chemotherapy or radiotherapy.3 There are concerns about the oncological safety. By preserving the skin there is a large area in which a local recurrence can occur, such as the nipple–areola complex. A local recurrence is a risk factor for systemic relapse and the patients have a survival curve corresponding to that in cases with one metastasis in the axilla at the primary operation.4 The local recurrence can be treated with local excision, followed by radiotherapy and further oncological treatment. However, it is a psychological burden for the patient. There is no
∗ Department
of Surgery, Karolinska University Hospital, SE-171 76 Stockholm, Sweden. E-mail:
[email protected]. 19
June 9, 2009
20
14:6
B-601
FA
ch03
L. Perbeck
consensus regarding the indications for SSM and NSM, but there are contraindications, such as excessive skin involvement in both cases and additionally for NSM the existence of a retro-nipple area cancer within 2.5 cm from the base of the nipple.5 There have been no randomised trials comparing SSM and NSM with mastectomy, but several articles have addressed the oncological safety.4 The introduction of anatomically shaped cohesive silicon gel has improved the cosmetic outcome for the patient.
TECHNIQUE The following description refers to NSM. There are roughly three types of breast shapes to consider, namely 0–2 cm ptosis, 2–4 cm ptosis and over-4-cm ptosis, demanding different kinds of skin incisions and different locations of the implant. In breasts with 0–2 or 2–4 cm ptosis, either a lazy-S incision from the upper border of the areola and laterally, or an incision 1.5 cm above and parallel to the submammary fold is used (see Table 1). The advantage of the lazy-S incision is that it permits good exposure of the whole breast (Fig. 1). The dissection is at the level of Scarpa’s fascia and the breast glandular tissue is first mobilised medially and laterally from the nipple–areola complex before a biopsy sample for frozen section is taken under the base of the nipple. If a frozen biopsy sample is negative for tumour cells, the Table 1
Incision and Implant Location in Relation to the Ptosis of the Breast
Breast Shape
0–2 cm Ptosis
2–4 cm Ptosis
>4 cm Ptosis
Incision
Lazy-S submammary fold
Lazy-S submammary fold
Subcutaneous reduction mammaplasty Cranial pedicle
Implant location
Submuscular
Cranially submuscular Caudally subcutaneous
Submuscular
June 9, 2009
14:6
B-601
FA
ch03
Skin/Nipple-Sparing Mastectomy
21
FIGURE 1 The lazy-S incision.
nipple–areola complex is preserved. The thickness of the breast glandular tissue that is left beneath the nipple is 3 mm and its diameter is 10 mm. After the breast glandular tissue has been mobilised from the subcutaneous tissue, it is removed from the pectoralis major muscle, leaving the fascia behind. Any tissue around the earlier resection cavity area is properly removed to avoid future local recurrence. The incision 1.5 cm above and parallel to the submammary fold has the advantage that the scar is hidden behind the ptotic breast, but the dissection of the breast glandular tissue is more difficult. With this incision the breast glandular tissue is first mobilised from the pectoralis major muscle, making the breast more mobile when the skin flaps are dissected in the subcutaneous layer. The dissection is performed under direct vision. A pocket for the implant is dissected between the pectoralis major and minor muscles, and in cases where the implant is placed submuscularly the pocket is dissected 1.5 cm below the submammary fold and laterally behind the serratus anterior muscle. In patients with ptosis of 2–4 cm the intention is to preserve the submammary fold and try to create a natural ptosis. The pectoralis major muscle is divided caudally as low as possible and the muscle is then sutured to the overlying subcutaneous tissue without skin tension. An anatomical cohesive gel implant is placed under the pectoralis major muscle cranially and subcutaneously caudally, thereby creating a natural ptosis. The use of a test implant, with the patient in a sitting position, facilitates an optimal choice of size of the permanent implant.
June 9, 2009
22
14:6
B-601
ch03
FA
L. Perbeck
In a patient with >4 cm ptosis a subcutaneous reduction mammaplasty (SRM) is needed. In SRM it is safer to use a cranial pedicle, because of its shorter distance to the nipple–areola complex, than a caudally located pedicle, in which the circulation has been shown to be only 13% of the normal circulation (Figs. 2 and 3).6 The implant
FIGURE 2 The construction of the vertical pedicle of the skin and fat.
FIGURE 3 The final result of subcutaneous reduction of mammaplasty.
June 9, 2009
14:6
B-601
ch03
FA
Skin/Nipple-Sparing Mastectomy
23
is placed submuscularly in SRM and usually a cohesive gel is used, but an expander implant can be considered if a volume of >225 cc is desired.
DISCUSSION The advantage of NSM is that the whole breast reconstruction is performed in one operation and results in the appearance of a natural breast with the patient’s own nipple–areola complex. It is possible to spare the submammary fold. Usually no contralateral operation is needed except for SRM. Historically, submuscular placement of the implant is preferred because of the high frequency of capsular contracture when a silicon implant is located subcutaneously. The use of a saline-filled implant located subcutaneously results in a capsular contracture frequency after 5 years of 14%, and if radiotherapy is given, of 41%, but after one re-operation with capsulotomy or capsulectomy of the ventral surface of the capsule, no further capsulectomy is required.7 With the introduction of an anatomically shaped cohesive gel breast implant and with the use of a test implant, an adequate permanent implant can be chosen which does not lose volume with time as do saline-filled implants. Future studies are needed to determine whether there are any differences between different implants in relation to their textured surfaces with different pore sizes.
REFERENCES 1. Carlson GW, Bostwick J III, Styblo TM, et al. (1997) Skin-sparing mastectomy: oncologic and reconstructive considerations. Ann Surg 223: 570–575. 2. Meretoja TJ, Rasia S, Von Smitten KAJ, et al. (2007) Late results of skinsparing mastectomy followed by immediate breast reconstruction. Br J Surg 94: 1220–1225. 3. Hultman CS, Daiza S. (2003) Skin-sparing mastectomy flap complications after breast reconstruction: review of incidence, management, and outcome. Ann Plast Surg 50: 249–255.
June 9, 2009
24
14:6
B-601
ch03
FA
L. Perbeck
4. Benediktsson KP, Perbeck L. (2007) Survival in breast cancer after nipple-sparing subcutaneous mastectomy and immediate reconstruction with implants: a prospective trial with 13 year median follow-up in 216 patients. Eur J Surg Oncol 1–6. E-pub. 5. Cense HA, Rutgers Th EJ, Lopes Cardozo M, Van Lanschot JJB. (2001) Nipple-sparing mastectomy in breast cancer: a viable option? Review article. Eur J Surg Oncol 27: 521–526. 6. Perbeck L, Proano E, Westerberg L. (1992) Circulation in the nipple– areola complex following subcutaneous mastectomy in breast cancer. Scand J Plastic Reconstr Hand Surg 26: 217–221. 7. Benediktsson K, Perbeck L. (2006) Capsular contracture around salinefilled and textured subcutaneously-placed implants in irradiated and non-irradiated breast cancer patients: five years of monitoring of a prospective trial. J Plast Reconst Aesthet Surg 59(1): 27–34.
June 9, 2009
14:6
B-601
ch04
FA
chapter
4
Radio-Guided Occult Lesion Localisation of Subclinical Breast Lesions Hodigere S. J. Ramesh† , Matilde M. Audisio‡ and Riccardo A. Audisio∗,†
INTRODUCTION With the introduction of screening mammography, the incidence of sub-clinical lesions has doubled in the past decade. One out of three breast cancer operations are aimed at removing non-palpable lesions. These lesions need to be removed with precision, satisfying the oncological criteria (safe margin) as well as patient expectations (cosmesis). Several localisation techniques have been described. The most popular one is wire-guided lumpectomy (WGL), although this may be associated with several drawbacks, such as difficult placement of the wire in a dense breast, displacement, traumatic injury to patient and surgeon, long needle tract, interference in the processing of the specimen, and inflexibility in the approach to the lesion due to the entry point of the wire. New methods of localisation are now being developed; examples are ultrasound-guided skin ∗ Corresponding
author. Hospital, Warrington Road, Prescot L35 5DR, UK. E-mail: raudisio@ doctors.org.uk ‡ Carmel College, St Helens, UK. † Whiston
25
June 9, 2009
26
14:6
B-601
ch04
FA
H. S. J. Ramesh et al.
marking, intra-operative ultrasound-guided excision, carbon tracer, haematoma-directed ultrasound-guided excision and radio-guided occult lesion localisation (ROLL).
EVOLUTION OF ROLL The use of radio-pharmaceutical compounds to localise breast lesions was pioneered in the 1990s at the European Institute of Oncology, Milan.1–3 It immediately gained popularity because of its precision in localising non-palpable lesions while allowing the use of sentinel node biopsy. The technique described below is our modification of the original one to reduce radioactive dosage and an extra day of hospital stay,6–8 as well as to eliminate pre-operative scintigraphy.
GENERAL PRINCIPLES (t/2 = 6 hours) is suspended in a macro-aggregate of albumin (LyoMAA). It contains approximately 90,000 particles and has a particle size of 10–90 µm. The radioactivity administered is 1 MBq, equal to 0.02 msv (i.e. the same dosage as for a chest X-ray). This radio-pharmaceutical is delivered in a pre-loaded, sterile-packed syringe within a protective lead case. It is important to shake the syringe gently to mix the macro-aggregates before injection. Within the core of the lesion, 0.2 ml of LyoMAA is injected under ultrasound guidance 1–4 hours before surgery, as 75% of lesions are ultrasoundvisible. Alternatively, stereotactic localisation can be employed. ROLL localisation is used for diagnostic excision biopsy of suspicious lesions and therapeutic excision of a proven cancer. The aim is to localise precisely the target and to excise it within the smallest amount of glandular tissue in order to achieve excellent cosmetic results. The procedure is performed under general anaesthesia and as a day case. Initial diagnostic imaging (i.e. mammogram and/or US) should be available at the time of localisation, in order to plan the
99m Tc-labelled
June 9, 2009
14:6
B-601
ch04
FA
Radio-Guided Occult Lesion Localisation of Subclinical Breast Lesions
27
surgical approach and to compare the specimen X-ray for the presence of the lesion.
PRE-OPERATIVE CONSIDERATIONS Indications • • • • •
Micro-calcifications Parenchymal distortions, i.e. radial scars, atypical hyperplasia Suspicious soft tissue masses Impalpable cancers following neo-adjuvant chemotherapy Foreign bodies within soft tissue
Contraindication • Allergy to albumin
BEFORE ANAESTHESIA It is important to check for radioactive signals with the patient in a sitting and a supine position. This will not only ensure the functionality of equipment (gamma camera and radioisotope) but also provide a final opportunity to plan, discuss and mark the most appropriate approach to the lesion.
PATIENT POSITION The patient should rest in a supine position, with the arm well abducted to expose the outer quadrants and axilla. The extended elbow should rest on a well-padded arm board.
INCISIONS The skin incision should allow lesion removal in accordance with the oncological principles while giving the best cosmetic results. ROLL
June 9, 2009
28
14:6
B-601
ch04
FA
H. S. J. Ramesh et al.
offers flexibility in the approach to the lesion, bearing in mind that the incision line should fall within the boundaries of the subsequent mastectomy or lumpectomy. When possible we make an infra-mammary incision for lesions at the lower quadrants (Fig. 1), a peri-areolar incision for lesions at the central quadrant (Fig. 2), or an axillary incision for lesions at the upper-outer quadrant (Fig. 3), which offer excellent cosmetic results. Skin incisions paralleling Langer’s lines which result
FIGURE 1 Sub-mammary approach.
FIGURE 2 Peri-areolar approach.
June 9, 2009
14:6
B-601
ch04
FA
Radio-Guided Occult Lesion Localisation of Subclinical Breast Lesions
29
FIGURE 3 Preferred incisions: axillary approach, peri-areolar approach, submammary approach.
in thin, cosmetically acceptable scars may also be considered for all peripheral lesions when a direct approach is preferred.
HANDLING OF THE GAMMA CAMERA The gamma camera with a mounted collimator is wrapped in a sterile polythene cover. After the skin is incised, checks for gamma signals facilitate choosing the most direct approach to the lesion. A radioguided excision biopsy is carried out following audible signals and tissue palpation. We aim to achieve 1 cm of healthy margins encasing the neoplasm surgery. The complete excision of the target is confirmed by the presence of signals in the specimen and the absence of residual signals in the excision cavity. The specimen is marked with standard orientation stitches, as per agreed laboratory practice.
June 9, 2009
30
14:6
B-601
ch04
FA
H. S. J. Ramesh et al.
SPECIMEN X-RAY The specimen X-ray ensures the presence of the target within the excised tissue, although it must be appreciated that this does not measure the adequacy of the excision margin for neoplasm.
WOUND CLOSURE The best cosmetic result is obtained by approximating the breast plates of the excision cavity with an absorbable running suture. The skin edge is approximated with a continuous sub-cuticle absorbable 000 suture. The wound edges are reinforced with 1/4” steri-strips. The use of breathable dressing or pressure dressing is avoided and we do not routinely drain the surgical cavity.
POST-OPERATIVE CARE Resume normal activities on the evening of the surgery.
ADVANTAGES6–10 • • • • • • • •
Accurate localisation and surgical removal Improved margin clearance Reduced size of the excised specimen Better cosmetic results Reduced localisation time Cost-effectiveness Patient satisfaction (reduced pain) Reduced local recurrence rate
Finally, the simultaneous use of two radioisotopes to localise both primary cancer and the sentinel lymph node known as SNOLL is feasible.4,5,11
June 9, 2009
14:6
B-601
ch04
FA
Radio-Guided Occult Lesion Localisation of Subclinical Breast Lesions
31
RADIATION SAFETY The radiation dose absorbed by hospital personnel is low and requires neither radiation protection control nor separation of exposed workers into class A and class B. Special containers for radioactive waste are necessary in the administration room but not in the operating room, where possible contamination is negligible.12 In the case of a surgeon performing 100 procedures per annum, an FD dose of approximately 1 mSv is received, well within the annual dose limit of 150 mSv. The annual WBD (whole body dosage) to assisting staff may reach 0.04 mSv, compared to an annual limit of 6 mSv. These low doses and the lack of contamination of radioactive waste indicate that no additional radiation protection measures are required.11
REFERENCES 1. Luini A, Zurrida S, Galimberti V, Paganelli G. (1998) Radioguided surgery of occult breast lesions. Eur J Cancer 34(1): 204–205. 2. Gennari R, Galimberti V, De Cicco C, et al. (2000) Use of technetium-99mlabeled colloid albumin for preoperative and intraoperative localization of nonpalpable breast lesions. J Am Coll Surg 190(6): 692–698. 3. De Cicco C, Pizzamiglio M, Trifiro G, et al. (2002) Radioguided occult lesion localisation (ROLL) and surgical biopsy in breast cancer: technical aspects. Q J Nucl Med 46(2): 145–151. 4. Feggi L, Basaglia E, Corcione S, et al. (2001) An original approach in the diagnosis of early breast cancer: use of the same radiopharmaceutical for both non-palpable lesions and sentinel node localisation. Eur J Nucl Med 28(11): 1589–1596. 5. Ronka R, Krogerus L, Leppanen E, et al. (2004) Radio-guided occult lesion localization in patients undergoing breast-conserving surgery and sentinel node biopsy. Am J Surg 187(4): 491–196. 6. Audisio RA, Nadeem R, Harris O, et al. (2005) Radioguided occult lesion localisation (ROLL) is available in the UK for impalpable breast lesions. Ann Roy Coll Surg 87(2): 92–95. 7. Nadeem R, Chagla LS, Harris O, et al. (2005) Occult breast lesions: a comparison between radioguided occult lesion localisation (ROLL) vs. wire-guided lumpectomy (WGL). The Breast 14(4):283–289.
June 9, 2009
32
14:6
B-601
ch04
FA
H. S. J. Ramesh et al.
8. Thind CR, Desmond S, Harris O, et al. (2005) Radio-guided localization of clinically occult breast lesions (ROLL): a DGH experience. Clin Radiol 60(6): 681–686. 9. Ramesh HSJ, Anguille S, Chagla LS, et al. Recurrence after ROLL lumpectomy for invasive breast cancer. Submitted. 10. Rampaul RS, Dudley NJ, Thompson JZ, et al. (2003) Radioisotope for occult lesion localisation (ROLL) of the breast does not require extra radiation protection procedures. The Breast 12(2): 150–182. 11. Ramesh H, Chagla LS, Ray A, et al. (2007) SNOLL is up and running in UK — an early experience. EJSO 33: 1121. 12. Ferrari M, Cremonesi M, Sacco E, et al. (1998) Radiation protection in the use of tracers in radioguided breast surgery. Radiol Med (Torino) 96(6): 607–611.
June 9, 2009
14:6
B-601
ch05
FA
chapter
5
Technical Note on Total Parotidectomy Eberhard Stennert∗,† and Orlando Guntinas-Lichius‡
DEFINITION OF AND INDICATIONS FOR TOTAL PAROTIDECTOMY In the literature, the definition of total parotidectomy is inconsistent. Often, total parotidectomy is declared although only subtotal parotidectomy has been performed. Therefore, it is important to differentiate between the two techniques: subtotal parotidectomy includes a lateral parotidectomy, i.e. the resection of all parotid tissue lateral to the facial plexus, and partially medial to the facial plexus, but not necessarily including the deep portion, under preservation of the facial nerve. To fulfil the criteria for total parotidectomy, an additional complete resection of the deep portion is mandatory. Absolute indications for total parotidectomy are malignant parotid tumours independent of the subtype, metastasis to the parotid gland and chronic parotitis.
∗ Corresponding
author.
† Jean-Uhrmacher-Institute,
University of Cologne, Geibelstrasse 29-31, D-50931 Koeln, Germany. E-mail: eberhard.stennert@ uni-koeln.de ‡ Department of Otorhinolaryngology, Friedrich-Schiller-University Jena, Lessingstrasse 2, D-07740 Jena, Germany. E-mail:
[email protected] 33
June 9, 2009
34
14:6
B-601
ch05
FA
E. Stennert and O. Guntinas-Lichius
STEP 1: BEDDING OF THE PATIENT The patient is rested in a supine position in order to minimise intraoperative bleeding, with his hyperextended head rotated to the opposite side. The bed is tilted head up–feet down as far as is defensible.
STEP 2: FACIAL NERVE MONITORING In addition to standard surgical coverage, the ipsilateral face is covered with a transparent sheath to guarantee optical monitoring of the face by the assistant surgeon (Fig. 1). By this, even slight movements of the face become obvious when anaesthesia is performed without relaxation. In addition, electric monitoring can be performed optionally.
FIGURE 1 Tumour in the infra-auricular region of the left parotid gland. Ipsilateral face is covered with transparent sheath for optical facial nerve monitoring. Tumour localisation, incision line, angle of the mandibule and course of the zygomatic arch are plotted on the face.
June 9, 2009
14:6
B-601
FA
ch05
Technical Note on Total Parotidectomy
35
STEP 3: SKIN INCISION AND SKIN FLAP PREPARATION A preauricular and submandibular lazy S incision (modified Blairs incision) is performed (Fig. 1). It is oriented along the preauricular crease and inferior in the neck along natural skin lines. A distance of at least 2 cm from the mandibule is important, to avoid damage to the marginal mandibular branch of the facial nerve. If a neck dissection is planned, the submandibular incision can be modified easily. If the tumour is lying lateral to the main trunk of the facial nerve or if an exposure of its intramastoidal segment is necessary, the incision can also be extended retroauricularily. By blunt dissection, the parotid gland is separated from the ear cartilage in the preauricular region and from the sternocleidomastoid muscle until the exposure of the digastric muscle. It is often necessary to ligate the greater auricular nerve. Ligation is mandatory in order to prevent neuroma formation. However, preservation of its posterior branch should be intended. The preparation of the buccal skin flap is most important. The flap is lifted in the layer between the parotid pseudocapsule and the deep buccal fascia, combined with a short platysmal dissection in the neck. The fascia has to be protected as a barrier in order to decrease Frey’s syndrome.
STEP 4: ANATOMICAL LANDMARKS FOR IDENTIFICATION OF THE FACIAL NERVE The primary approach to identifying the facial nerve depends on the site and extension of the lesion. The preparation of the entire plexus, i.e. the nerve trunk and all peripheral branches, is performed under microscopic control to minimise their trauma. There are three surgical approaches: (1) Anterograde approach: identification of the facial nerve at its exit at the stylomastoid foramen. Then, the bifurcation and the different branches are prepared in the proximal-to-distal direction.
June 9, 2009
36
14:6
B-601
ch05
FA
E. Stennert and O. Guntinas-Lichius
Three landmarks help to identify the main trunk: (a) Conley’s pointer is a conchal cartilage extension of the ear canal at the medial end of its anterior–inferior edge; the nerve lies 5–6 mm inferior to this pointer (see Video-clip); (b) the tympanomastoid fissure is better palpable than visible; the facial nerve lies 6–8 mm medial to the anterior end of the fissure; (c) the lateral surface of the digastric muscle lies in the same plane as the facial nerve. (2) Retrograde approach: the best landmark to start with this preparation is the middle third of the zygomatic arch, where the frontal branch crosses its periosteum. A zygomatic branch is found about 1 cm inferior to the arch. Alternatively, identification of Stenson’s duct might be helpful, which is crossed by a buccal branch. (3) In many cases, a combination of the anterograde and the retrograde approach is necessary. Anyway, the parotid surgeon has to be trained in all these techniques.
STEP 5: LATERAL PAROTIDECTOMY The anterograde and the retrograde preparation, or a combination of the two procedures, lead step by step to exposure of the whole peripheral nerve plexus, including the trunk and bifurcation. Hereby, the parotid tissue lateral to these nerve structures is progressively dissected free and finally delivered. Touching of the tumour has to be avoided. If the tumour is lying in the lateral lobe, the lateral parotid is removed with the associated tumour en bloc (Fig. 2).
STEP 6: COMPLETION OF TOTAL PAROTIDECTOMY The main trunk and the facial nerve branches are dissected from the underlying tissue in an atraumatic fashion. Step by step, every branch is gently lifted by using rubber slings to dissect the underlying parotid tissue. Stretch and compression trauma to the nerve has to be avoided. Finally, the underlying masseter muscle is visible in the whole area. To clear the retromandibular space, it is mandatory
June 9, 2009
14:6
B-601
ch05
FA
Technical Note on Total Parotidectomy
37
FIGURE 2 Situs after lateral parotidectomy as the first step of total parotidectomy. The complete facial nerve fan is explored. Upper right inlay: Resected specimen corresponds to the lateral lobe of the parotid gland including the tumour.
to resect the retromandibular vein by ligation distally in the submandibular fossa and proximally next to the zygomatic arch. Finally, the parotid tissue of the deep lobe has to be resected completely along the skull base up to the stylomastoid process (Fig. 3).
STEP 7: DEFECT FILLING Its accomplishment depends on the underlying disease, the size of the defect and the patient’s will. There are two options: (1) Preparation of a muscle flap from the craniolateral aspect of the sternocleidomastoid muscle lateral to the spinal accessory nerve, which is rotated anteriorly into the defect. The mastoid attachment has to be preserved, to ensure occipital blood supply to the flap. (2) For large defects, primarily abdominal fat is used. The fat is harvested via a periumbilical incision. Meticulous bleeding control is necessary, to avoid abdominal haematoma formation. Some overcorrection is necessary because of postoperative shrinkage. The fat is fixed with several sutures, avoiding any contact with nerve branches.
June 9, 2009
38
14:6
B-601
ch05
FA
E. Stennert and O. Guntinas-Lichius
FIGURE 3 Final situs after total parotidectomy. For the resection of the medial “lobe” and the deep portion it is mandatory to mobilise the complete facial nerve plexus.
STEP 8: WOUND CLOSURE A Redon drainage is placed without contact with nerve structures. The wound is closed in two layers by subcutaneous and cutaneous sutures. A circular head–neck bandage is recommended. The drainage is removed within 24–72 h.
REFERENCES 1. Guntinas-Lichius O, Kick C, Klussmann JP, et al. (2004) Pleomorphic adenoma of the parotid gland: a 13-year experience of consequent management by lateral or total parotidectomy. Eur Arch Otorhinolaryngol 261(3): 143–146. 2. Guntinas-Lichius O, Klussmann JP, Wittekindt C, Stennert E. (2006) Parotidectomy for benign parotid disease at a university teaching hospital: outcome of 963 operations. Laryngoscope 116(4): 534–540. 3. O’Brien CJ. (2005) The parotid gland as a metastatic basin for cutaneous cancer. Arch Otolaryngol Head Neck Surg 131(7): 551–555. 4. Patel RS, Low TH, Gao K, O’Brien CJ. (2007) Clinical outcome after surgery for 75 patients with parotid sialadenitis. Laryngoscope 117(4): 644–647.
June 9, 2009
14:6
B-601
ch05
FA
Technical Note on Total Parotidectomy
39
5. Stennert E, Kisner D, Jungehuelsing M, et al. (2003) High incidence of lymph node metastasis in major salivary gland cancer. Arch Otolaryngol Head Neck Surg 129(7): 720–723. 6. Stennert E, Wittekindt C, Klussmann JP, et al. (2004) Recurrent pleomorphic adenoma of the parotid gland: a prospective histopathological and immunohistochemical study. Laryngoscope 114(1): 158–163. 7. Wittekindt C, Streubel K, Arnold G, et al. (2007) Recurrent pleomorphic adenoma of the parotid gland: analysis of 108 consecutive patients. Head Neck 29(9): 822–828.
June 9, 2009
14:6
B-601
ch06
FA
chapter
6
Total Thyroidectomy Niall O’Higgins∗
(1) The operation is usually carried out under general anaesthesia with the patient in the supine position with the neck slightly extended and the table top tilted so that the head is raised. (2) The incision is planned in a transverse skin crease approximately half way between the suprasternal notch and the thyroid cartilage. The incision line is mainly horizontal, with a slight upward concavity depending on skin creases. It is rarely necessary to extend the incision further than the anterior borders of the sternocleidomastoid muscle. For large multinodular goitres extending behind the sternum, the incision is placed somewhat higher in the neck to facilitate access to the upper pedicles of the thyroid, as these are likely to be situated higher in the neck than is the case with a normal thyroid. (3) The skin incision is deepened in the same line through the platysma. The flap of skin and platysma is dissected upwards as far as the thyroid cartilage and downwards to the suprasternal notch. This dissection is facilitated by staying close to the deep surface of the platysma rather than the superficial surface of the underlying deep fascia.
∗ Department
of Surgery, RCSI Medical University of Bahrain, Kingdom of Bahrain. E-mail:
[email protected] 41
June 9, 2009
14:6
42
B-601
ch06
FA
N. O’Higgins
(4) Once the flaps have been developed and retracted, the deep fascia is divided in the midline between the strenohyoid muscles and incised upwards and downwards to the extent of the elevated skin/muscle flaps. The midline is easy to identify lower in the neck where the space between the sternohyoid muscles is readily seen as they separate before insertion to the sternum. The underlying sternothyroid muscles are then identified and elevated with the sternohyoids on each side. If the thyroid is big, the sternothyroids may become attenuated and stretched and may lie lateral to the midline. Elevation of the sternohyoid and sternothyroid (strap) muscles exposes the plane of the thyroid. Retraction of these muscles provides good access to the thyroid and it is rarely necessary to divide them. (Clip 1: Exposure and retraction of the strap muscles.) (5) Retraction of the upper part of the strap muscles allows the superior pole of the thyroid to be displayed. A useful instrument here is the Dunhill double-angled retractor. The main lobe of the thyroid is retracted downwards medially, a manoeuvre sometimes facilitated by a transfixing suture into the belly of the lobe. The superior thyroid vessels can thereby be exposed. (Clip 2: Display of the superior thyroid vessels.) (6) The external branch of the superior laryngeal nerve, running downwards and medially along the cricothyroid muscle, can often be seen. (Clip 3: Demonstration of the external laryngeal nerve.) The superior thyroid are ligated or clipped and divided separately, care being taken to ensure that there is a substantial cuff of the artery and vein artery distal to the clip or ligature in order to minimise the risk of slippage. In a small percentage of cases, the superior laryngeal nerve runs between the superior artery and vein and could then be damaged if the vessels are not separately ligated. (7) Once the superior pedicle has been divided, the lobe of the thyroid is rolled medially and held in this position with the aid of a dry swab. Lateral retraction of the strap and sternocleidomastoid muscles together with the carotid sheath brings the middle
June 9, 2009
14:6
B-601
ch06
FA
Total Thyroidectomy
(8)
(9)
(10)
(11)
43
thyroid veins and the border of the gland into view. Once the middle thyroid vein or veins have been divided, the inferior thyroid artery, the parathyroids and the recurrent laryngeal nerve are sought. (Clip 4: Exposure of the superior and inferior parathyroid glands.) The nerve, usually behind but sometimes anterior to the artery, has a distinctive serpiginous blood vessel on its surface and should be traced throughout its cervical course to the point where it dips into the larynx. The small branches of the artery are followed to the surface of the gland, where they are divided. This capsular dissection technique has the advantages of (i) preserving the blood supply to the parathyroid glands, which receive the blood supply from the inferior thyroid artery before its branches enter the thyroid, and (ii) protecting the recurrent laryngeal nerve and the parathyroid glands from inadvertent damage. At this stage the full cervical extent of the recurrent laryngeal nerve can be traced. (Clip 5: The recurrent laryngeal nerve exposed throughout its cervical extent to its entry to the larynx.) The remaining attachment of the upper pole by the ligament of Berry can be safely divided with a pointed blade, the nerve being displaced laterally. Attention is then turned to the inferior thyroid veins as they run vertically from the lower part of the gland. (Clip 6: Demonstration of the inferior thyroid veins before they are divided). After these have been divided, the lobe is almost completely free. Steps 5–8 are repeated on the contralateral lobe. (Clip 7: Dissection of the contralateral recurrent laryngeal nerve from metastatic lymph nodes.) The entire gland, which is now fully mobilised, is dissected off the trachea from inferior to superior by sharp dissection. The gland is now attached only by the pyramidal lobe. (Clip 8: Display of the total thyroidectomy specimen attached only by the pyramidal lobe.) Holding the thyroid away from the trachea allows the pyramidal lobe to be traced upwards and removed completely and en bloc with the rest of the thyroid. Care is taken to ensure complete haemostasis. A small ooze of venous blood sometimes occurs near where the recurrent
June 9, 2009
44
14:6
B-601
ch06
FA
N. O’Higgins
laryngeal nerve enters the larynx. This can readily be stopped with a pledget of gauze. Use of diathermy near the nerve should be avoided. (12) Prospective studies have demonstrated that the use of vacuum drains following thyroidectomy is of no particular benefit, yet the practice remains common as a small amount of blood is almost always collected in vacuum drains during the first few hours after the operation. (13) The strap muscles are reunited with absorbable interrupted sutures, the platysma is similarly sutured and a subcuticular 4/0 or 5/0 suture is inserted. A loose dressing is applied.
REFERENCES 1. Harness JK, Fung L, Thompson NW, et al. (1986) Total thyroidectomy: complications and technique. World J Surg 10(5): 781–786. 2. Delbridge L, Reeve TS, Khadra M, Poole AG. (1992) Total thyroidectomy: the technique of capsular dissection. Aust N Z J Surg 62(2): 96–99. 3. Reeve TS, Thompson NW. (2000) Complications of thyroid surgery: how to avoid them, how to manage them, and observations on their possible effect on the whole patient. World J Surg 24(8): 971–975. 4. Wheeler MH. (1998) The technique of thyroidectomy. JR Soc Med 91(Suppl) 33: 12–16.
June 9, 2009
14:6
B-601
ch07
FA
chapter
7
Neck Dissection for Thyroid Cancer † and Jaroslav Betka† ˇ Jan Betka∗,† , Petr Lukeš† , Zdenˇek Cada
The importance of treating lymph node metastasis of thyroid papillary and follicular carcinoma is still controversial. The extent of treatment of lymph node metastasis of papillary and follicular carcinoma is still being discussed and many different points of view on this subject still exist. The first problem to discuss is: Is it beneficial to treat lymph-nodemetastatic involvement? There is not even a general consensus about the importance of lymph-node-metastasic involvement in the currently used classification and staging system for differentiated thyroid carcinoma. Lymph-node-metastatic involvement is not even included in some of the prognostic criteria. For example, the criteria being used at the Mayo Clinic, called MACIS, include as prognostic criteria distant metastasis, patient age, completion of resection, local invasion and tumour size. So lymph nodes are not included. Another prognostic schema, called GAMES, is used by the Memorial Sloan-Kettering Cancer Center. In their GAMES scoring system, G is for Grade, A for Age of the patient when the tumour is discovered, M for Metastase of the tumour (other than neck LN), E for Extent of the primary tumour ∗ Corresponding
author. of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Postgraduate Medical School, Charles University in Prague. E-mail:
[email protected]. † Department
45
June 9, 2009
46
14:6
B-601
ch07
FA
J. Betka et al.
and S for Size of the tumour. So, again, lymph node metastases are missing. In the sixth edition of the American Joint Committee on Cancer (AJCC), 2002, it is already seen that authors started to imagine the importance of metastasic spread into the regional lymph nodes for treatment of differentiated thyroid carcinoma. They divide the N status more accurately than for previous classifications: N No: metastatic nodes N1: regional lymph node metastasis N1a: metastases in ipsilateral cervical lymph node(s) N1b: metastases in bilateral, midline or contralateral cervical or mediastinal lymph node(s); unifocal T1 (≤ 1 cm) N0M0 and no extension beyond the thyroid capsule In accordance with this system, the panel on European consensus for the management of patients with differentiated thyroid carcinoma agreed to group patients into three risk categories at the time of initial treatment. The lymph nodes play an important role in this division. These groups are: Very low risk: unifocal T1 (−1 cm) N0M0 and no extension beyond the thyroid capsule or T2N0M0 or multifocal T1N0M0 Low risk: T1 (> 1 cm) N0M0 or T2N0M0 or multifocal T1N0M0 High risk: any T3 and T4 or any T, N1 or any M1 Not all authors believe that lymph node involvement in differentiated thyroid carcinoma has little or no importance for the final result on treatment of thyroid carcinoma. Massaferi.1,2 states that radical surgery can positively influence overall survival and that current tumour staging systems are too inaccurate to guide surgery. He believes, on the basis of his long-time observations and similar studies, that an aggressive approach to initial management and follow-up may render nearly 90% of the patients permanently tumour-free. Lin3 analysed patients with lymph node involvement and postulated, that it did not influence the survival rate, but that patients with poor prognostic factors needed more aggressive treatment to avoid progression
June 9, 2009
14:6
B-601
ch07
FA
Neck Dissection for Thyroid Cancer
47
of the cancer. Lymph node metastases can develop even in early stages of thyroid carcinoma.4 Patients with positive lymph nodes have a higher recurrence risk, but no significant increase in death. Surgical radicalness and technique can positively influence the survival of patients with papillary thyroid cancer.5 Even European consensus placed all patients with positive lymph nodes in the high risk group.8 In conclusion, we currently feel that radical surgery can positively influence recurrence risk and maybe even survival of patients. The next problem is: Who is indicated for lymph node surgery? Wada6 writes in his article that patients with differentiated carcinoma who had lymphonodopathy, which is palpable, should have therapeutic node dissection. Palpable disease in the lateral neck is widely accepted as an indication for neck treatment by many others. The problem starts when positive nodes are not palpable. Currently, ultrasonography is the most accurate imaging technique for the detection of suspicious cervical lymph nodes as small as a few millimetres in diameter. Ultrasonographic features suggestive of malignant lymph nodes depend on typical appearance, size, shape, hypervascularity and internal architecture. A rounded lymph node or one causing a mass effect is also at elevated risk of being malignant. Lymph nodes with short axis measuring more than 7 mm should be considered suspicious. Yasuhiro7 advocated that neck treatment is not indicated in a group of patients without lateral node metastasis detected by ultrasonography preoperatively. Many other papers support this experience and neck dissection is not indicated as elective surgery. Prophylactic node dissection is not beneficial to those without palpable or ultrasonographically suspicious neck lymphonodopathy. Ultrasonography is ideally connected with fine needle aspiration biopsy. This technique in the experienced hands of a trained cytologist can give an accuracy of about 95%. The next indication for neck intervention can be preoperatively proven and by frozen section verified positive metastatic lymph node. In conclusion, compartment-oriented dissection of lymph nodes should be performed in cases of preoperatively suspected and/or
June 9, 2009
48
14:6
B-601
ch07
FA
J. Betka et al.
intraoperatively proven lymph node metastases. The rationale for this surgical approach is based on evidence that radical primary surgery has a favourable impact on survival in high-risk patients, and on the recurrence rate in low-risk patients. On the other hand, there is little benefit from prophylactic (elective) surgical nodal treatment in the absence of pre or intraoperative evidence for nodal disease. There is no evidence that it improves recurrence or mortality rates, but it may be better and an accurate staging of the disease that may guide subsequent treatment and follow-up.
SURGICAL MANAGEMENT AND TECHNIQUE The standard procedure for treatment of lymph node metastases is posterolateral and central compartment neck dissection.9 Posterolateral neck dissection refers to the removal of lymph nodes at levels II–V — basically all nodal groups except levels IA and IB (Fig. 1). The standard procedure is selective modified posterolateral neck dissection with preservation of the non-lymphatic structures: the spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle.10 The procedure is carried out under general anaesthesia. The surgical field must not be sterilised with iodine solution, as this would compromise radioiodine uptake. The skin incision is a combination of classical horizontal (for thyroidectomy) continuing to mastoid on the operated side. It is possible to also make a single horizontal long incision. This incision is cosmetically more favourable, but there is difficulty in making it reach all parts of the surgical field. Next is elevation of the skin flaps together with platysma muscle, and the deep neck fascia is exposed. The fascia is separated from sternocleidomastoid muscle and included in the dissection. The dissection usually starts cranially. The great auricular nerve is identified and the spinal accessory nerve is separated, and both are saved. Compartments IIA and IIB are dissected, and the cervical/brachial plexus is exposed and the lateral cervical triangle cleared. The transverse cervical artery and
June 9, 2009
14:6
B-601
FA
ch07
Neck Dissection for Thyroid Cancer
49
FIGURE 1 Lateral view of neck compartments.
vein can usually be spared. The space above the clavicle is very important (compartment VB), as metastatic lymph nodes can be hidden in fatty tissue here. The anterocranial border of the dissection is the submandibular salivary gland and we identify the hypoglossal nerve and lymph nodes with fatty tissue from the carotid and jugular sheet. The vagus nerve comes into view and all structures are isolated gently and followed caudally (Fig. 2). If the en-bloc dissection is connected with thyroidectomy, it is the time to identify the superior thyroid vascular pedicle and ligate it, preferably just above the lateral lobe of the thyroid gland. This secures the superior laryngeal nerve. Dissecting the anterior border of compartments III and VI, we open up space around the laryngeal recurrent nerve, which must be identified and spared. Also, both parathyroid glands are visible and must be separated from the thyroid gland and neck dissection tissue from the anterior aspect, as both have blood supply from the inferior thyroid artery, which
June 9, 2009
50
14:6
B-601
ch07
FA
J. Betka et al.
FIGURE 2 Posterolateral neck dissection.
gives them a connection from the inferior aspect. In this area there is no strict anatomical borderline between compartment IV and compartment VI. Sternocleidomastoid muscle is elevated and tissue from the lateral triangle is removed together with the specimen, taking the subclavian vessels as the caudal border. If the surgery continues with thyroidectomy, the specimen can be left with a connection to the thyroid gland (Fig. 3). It is recommended that there be negative suction for two days after surgery. Central compartment neck dissection refers to the bilateral removal of lymph nodes surrounding the midline visceral structures of the anterior neck — level VI. The lymph nodes include the preand paratracheal, the precricoid (Delphian) and the perithyroidal. The superior limit of the dissection is the hyoid bone, the inferior limit is the suprasternal notch, and the lateral limits are the carotid artery sheets. This surgery is preferably performed together with thyroidectomy. If the primary thyroid tumour is having a rupture through
June 9, 2009
14:6
B-601
FA
ch07
Neck Dissection for Thyroid Cancer
51
FIGURE 3 Drain position.
the thyroid capsule, it is indicated to dissect prelaryngeal muscles as sternohyoid, sternothyroid and thyreoglossus. Dissection below the hyoid bone lateral borders are carotid arteries and compartment IV. We have to the pay meticulous attention to the recurrent laryngeal nerve and especially the inferior parathyroid gland, where blood supply can be in danger. The next important structure is the thoracic duct, and it is usually ligated to prevent postoperative lymphorrhoea. The dissection runs caudally, following as the lateral border both carotid arteries, and ends below the suprasternal notch following the tracheal rings (Fig. 4). In young patients we meet the apex of the thymus
June 9, 2009
52
14:6
B-601
ch07
FA
J. Betka et al.
FIGURE 4 Frontal view of central neck dissection.
gland, and it can be dissected. After finishing dissection we should ask the anaesthesiologist to perform positive thorax pressure to make sure that there is no bleeding from mediastinal vessels. Before suture, negative suction is inserted.
COMPLICATIONS Permanent hypocalcaemia can be seen in 3–5% of operative cases. It is more likely to develop after bilateral posterolateral and central neck dissection with total thyroidectomy. It can be due to revascularisation of parathyroid glands or their accidental removal. It is more likely to remove or injure the inferior parathyroid glands. If a parathyroid gland is removed, it must be implanted back into the muscle. Before implantation, the parathyroid gland is divided by a sharp instrument into small cubes not larger than 1 mm. The implanted parathyroid
June 9, 2009
14:6
B-601
ch07
FA
Neck Dissection for Thyroid Cancer
53
tissues are integrated and have blood supply from the surrounding muscle bed. The second-most-common complication is recurrent laryngeal nerve injury. It is reported to be about 1–2% and is more likely with more excessive surgery. To prevent nerve injury the recurrent nerves must be identified, and the vascular bed of the nerves must be respected. Routine use of a neurostimulator to identify the recurrent nerves is recommended. If bilateral vocal cord palsy occurs, it is an indication for immediate surgical revision under the guidance of a thyroid surgical expert. Future development will probably focus on minimising surgical complications. It can be predicted that there will be routine use of magnifying loops or microscopes for a better understanding of the operative field. The nerve neurostimulator will be a routine tool in every operating theatre. Endoscopically assisted surgery can avoid the necessity for large incisions, and a well-illuminated and magnified surgical field can be beneficial in avoiding surgical complications.
REFERENCES 1. Mazzaferri EL. (1999) An overview of the management of papillary and follicular thyroid carcinoma. Thyroid 9(5): 421–427. 2. Mazzaferri EL. (2007) Management of low-risk differentiated thyroid cancer. Endocr. Pract. 13(5): 498–512. 3. Lin JD, Liou MJ, Chao TC, et al. (1999) Prognostic variables of papillary and follicular thyroid carcinoma patients with lymph node metastases and without distant metastases. Endocr Relat Cancer 6(1): 109–115. 4. Reddy RM, Grigsby PM, Moley JF, Hall BL. (2006) Lymph node metastases in differentiated thyroid cancer under 2 cm. Surgery 140(6): 1050– 1054. 5. Roh J-L, Park J-Y, Park CI. (2007) Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients. Ann Surg 245(4): 604–610.
June 9, 2009
54
14:6
B-601
ch07
FA
J. Betka et al.
6. Wada N, Duh QY, Sugino K, et al. (2003) Lymph node metastasis from 259 papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection. Ann Surg 237(3): 399–407. 7. Yasuhiro I, Chisato T, Takashi U, et al. (2004) Preoperative ultrasonographic examination for lymph node metastasis: usefulness when designing lymph node dissection for papillary microcarcinoma of the thyroid. World J Surg 28(5): 498–501. 8. Pacini F, et al. (2006) European consensus for the management of patients with differentiated carcinoma of follicular epithelium. Eur J Endocrinol 154: 787–803. 9. Astl J. (2007) Surgical Treatment of Thyroid Gland Diseases, Maxdorf, Ed. Jessenius, Prague, p. 208 (in Czech). 10. Betka J, Mrzena L, Astl J, et al. (1997) Surgical treatment strategy for thyroid gland carcinoma nodal metastases. Eur Arch Otorhinolaryngol 254(Suppl 1): S169–S174.
June 9, 2009
14:6
B-601
ch08
FA
chapter
8
Total Laryngectomy Mohssen Ansarin† , Augusto Cattaneo† and Fausto Chiesa∗,†
INTRODUCTION The first total laryngectomy (TL) was performed by Billroth, in 1873,1 while Bottini2,3 was the first surgeon to carry out a laryngectomy for cancer, in 1875. The separation of the trachea from the larynx to create an end stoma and the primary closure of the pharynx was performed by Gluck in the early 1900.4 Between 1920 and 1950, radiotherapy was the treatment of choice.5 From 1950, TL was the gold standard for the treatment of advanced or recurrent laryngeal carcinomas.6 Between the end of the last century and the beginning of the third millennium TL played a restricted role in the management of untreated advanced laryngeal cancer owing to the progressive increase of non-surgical therapies, the so-called organ preservation schedules: neoadjuvant chemotherapy followed by radiotherapy or concomitant chemoradiation treatment.7 Hoffman in 2006 reported a decreasing survival rate among patients with laryngeal cancer during the last two decades in the US.8 In his opinion these poor results could be explained by the increasing use of conservative treatment modalities (i.e. selective neck dissection, conservative surgical techniques such as laser resection and organ preservation schedules). ∗ Corresponding
author. and Neck Department, European Institute of Oncology, Milan, Italy. E-mail:
[email protected] † Head
55
June 9, 2009
56
14:6
B-601
ch08
FA
M. Ansarin et al.
Today TL remains the gold standard therapy for laryngohypopharyngeal cancers in the following cases: (a) advanced squamous cell carcinoma (SCC) or other non-epithelial tumours of the larynx with massive invasion of the cartilage framework; (b) recurrences after chemo-radiotherapy; (c) recurrence after conservative laryngectomy; (d) as an emergency procedure in massive airway obstructive tumours or in rare complications of previous treatments such as chondro-radionecrosis. Before performing a TL, we must also consider the potential metastatic spread of laryngeal carcinoma to the cervical lymph nodes. The supraglottic area has a rich lymphatic network and about 50% of T1–T4 tumours of this area develop metastases into the cervical nodes. However, glottic carcinoma has a low rate (<10%) of nodal metastases in early stages (T1–T2), and about 30% in T3–T4 cancers.7 Primary subglottic carcinoma is unusual (<3% of laryngeal cancers) and tends to spread to the nodes of the central neck compartment (VI level). In laryngeal cancer, the cervical nodes at risk are levels II–III–IV and VI. We therefore suggest performing a selective neck dissection (II–V and VI) in cN0 T2–T4 laryngeal cancers, enlarged to hemi- or total thyroidectomy if the tumour invades the cartilage framework or the subglottic area.9
TECHNIQUE We may summarize the operation in five steps, starting from the incision in the neck and going through the mobilization of the larynx, resection of the trachea, removal of the larynx and, finally, closure with repair of the neo-pharynx. These surgical steps were carried out for a patient who had undergone previous tracheotomy for a severe dyspnoea due to bulky transglottic tumour of the left hemilarynx with fixation of the cricoarythenoid joint and significant submucosal extension to the left subglottic area. The surgical indication was TL with bilateral selective
June 9, 2009
14:6
B-601
ch08
FA
Total Laryngectomy
57
neck dissection (II–V levels) enlarged to hemi-thyroidectomy and left paratracheal lymph nodes (central compartment) dissection. The neck incision should provide a good exposure not only of the larynx but also of the laterocervical compartment if a neck dissection or an extended laryngectomy needs to be carried out. When planning the incision, surgeons should also consider providing for the necessity of enlarging the excision to other structures, such as base of tongue, hypo-pharynx or tracheal rings and the possible reconstructive procedures (e.g. the creation of a permanent end stoma), without causing tension and subsequent necrosis of flaps, mainly in patients previously treated with radiotherapy. The “apron flap” incision guarantees both good access and good cover for the pharyngeal suture line (Fig. 1). All structures involved or at risk of being involved by the tumour must be resected: laryngeal box, preepiglottic space,
FIGURE 1 Apron flap incision of the neck: (a) previous tracheotomy; (b) subplatismal flap; (c) anterior jugular vein; (d) external jugular vein; (e) superficial cervical fascia.
June 9, 2009
58
14:6
B-601
ch08
FA
M. Ansarin et al.
tracheostoma, strap muscles, and ipsilateral lobe of the thyroid gland and paratracheal lymph nodes. The larynx is mobilized by resecting the pharyngeal and prelaryngeal strap muscles, separating the thyroid gland and ligating its vascular pedicules. The strap muscles are cut at their insertion on the sternum and on the superior edge of the hyoid bone; ipsilateral thyroid artery and veins are ligated, the recurrent laryngeal nerve is cut in the tracheo-oesophageal groove and the pharyngeal muscles are excised along the posterior edge of the thyroid cartilage. The larynx is now freed on the opposite side, and mobile up to the level of the hyoid bone in order to better control the tumor (Figs. 2 and 3).
FIGURE 2 Mobilization of the larynx: (a) hyoid bone; (b) left submandibular gland; (c) internal jugular vein; (d) carotid artery; (e) strap muscles, sectioned.
June 9, 2009
14:6
B-601
ch08
FA
Total Laryngectomy
59
FIGURE 3 Mobilization of the larynx: (a) constrictor muscle; (b) carotid artery; (c) sternocleidomastoid muscle; (d) thyroid cartilage; (e) thyroid gland.
The trachea is divided at the second ring or below according to the extension of the tumour, the superior part of the remaining ring is sewn to the lower skin border and a cuffed tube is placed in the trachea. The entire larynx can now be removed from above downward paying attention to cuts in healthy tissue. The base of the tongue is divided and the pharynx opened. The tip of the epiglottis is grasped and pulled anteriorly and inferiorly and the pharyngeal mucosa together with the pharyngeal constrictor muscles is cut on each side of the epiglottis, and of the superior cornu of thyroid cartilage toward the posterior part of the arythenoid cartilage, below the crico-arytenoid joint (Fig. 4). The final step is the repair of the pharynx and the closure of the entire neck. The pharynx should be closed, with a line of interrupted sutures, in three layers: mucosal, facial and muscular (constrictor
June 9, 2009
60
14:6
B-601
ch08
FA
M. Ansarin et al.
FIGURE 4 Opening of the larynx: (a) epiglottis; (b) pyriform sinus; (c) superior cornu of the thyroid cartilage; (d) sternocleidomastoid muscle; (e) trachea; (f) tumor.
muscles) (Fig. 5). The skin is closed in two layers, and two suction drains are placed close to the suture and one or two more are placed in the laterocervical space (in the case of monolateral or bilateral neck dissection). The lower part of the apron flap is sutured to the membranous part of the trachea.
DISCUSSION Indications for the management of advanced laryngeal cancer can be found in the National Comprehensive Cancer Network (NCCN) practice guidelines.10 When post-operative histology shows involved margins or extracapsular extension of nodal metastases, a combined chemoradiation post-surgical approach is recommended.11 Clinical trials based on different treatment modalities in advanced laryngeal
June 9, 2009
14:6
B-601
ch08
FA
Total Laryngectomy
61
FIGURE 5 Closure of the neopharynx: (a) mucosa; (b) extra-mucosal suture; (c) carotid artery; (d) sternocleidomastoid muscle.
cancers should be planned considering the severe physical and psychological outcomes which arise as a result of the mutilation following TL, and the low cure rate of alternative treatment schedules.
REFERENCES 1. Billroth T, Gussenbauer C. (1874) Ulber die Erst durch T. Billroth am Menschen ausgefuhrte kehlkopf-Extirpation. Und die Auswendung eines Kunstichen Kehlkopfes. Arch Clin Chir 17: 343–356. 2. Alberti PW. (1975) Panel discussion: the historical development of laryngectomy. II. The evolution of laryngology and laryngectomy in the mid19th century. Laryngoscope 85: 288–298. 3. Thomson StC. (1939) The history of cancer of the larynx. J Laryngol Otol 54: 61–87.
June 9, 2009
62
14:6
B-601
ch08
FA
M. Ansarin et al.
4. Gluck T. (1912) Die chirurgische Terapie des Kehlkopfkarzinomas. Jahreskurse Artzt Forbild 2: 20–41. 5. Lederman M. (1975) Panel discussion: the historical development of laryngectomy. VI. History of radiotherapy in the treatment of cancer of the larynx, 1896–1939. Laryngoscope 85: 333–353. 6. Ogura JH, Bello JA. (1952) Laryngectomy and neck dissection for carcinoma of the larynx. Laryngoscope 62: 1–52. 7. Marioni G, Marchese-Ragona R, Cartei G, et al. (2006) Current opinion in diagnosis and treatment of laryngeal carcinoma. Cancer Treat Rev 32: 504–515. Epub 2006 Aug 22. Review. 8. Hoffman HT, Porter K, Karnell LH, et al. (2006) Laryngeal cancer in the United States: changes in demographics, patterns of care, and survival. Laryngoscope 116 (Suppl 111): 1–13. 9. Chiesa F, Tradati N, Calabrese L, et al. (2001) Surgical treatment of laryngeal carcinoma with subglottis involvement. Oncol Rep 8: 137–140. 10. National Comprehensive Cancer Network. (2007) Clinical practice guidelines in head and neck cancers. www.nccn/org 11. Bernier J, Cooper JS, Pajak TF, et al. (2005) Defining risk levels in locally advanced head and neck cancer: a comparative analysis of concurrrent post-operative radiation plus chemotherapy trials of EORTC (n. 22931) and RTOG (n. 9501). Head and Neck 27: 843–850.
June 9, 2009
14:6
B-601
ch09
FA
chapter
9
Transcervical Extended Mediastinal Lymphadenectomy ´ † and Łukasz Hauer† Jarosław Ku˙zd˙zał ∗,† , Marcin Zielinski
INTRODUCTION Despite the recent developments in the imaging of metastatic mediastinal lymph nodes, these techniques have not replaced the tissue diagnosis in the pre-treatment staging in non–small cell lung cancer (NSCLC) patients. The advances of the technique of endoscopic needle aspiration biopsy have made it a promising alternative for a considerable percentage of these patients, but the surgical biopsy is still necessary in many of them. For this purpose, cervical mediastinoscopy (CM) is regarded as the gold standard. Although the standard CM is simple and safe, it only enables access to 5 out of 12 mediastinal lymph node stations (2R, 2L, 4R, 4L and 7, according to the UICC classification1 ). Some other techniques have been developed to overcome this weakness of CM, but none of them enables removal of the whole content of all the 12 mediastinal nodal compartments (see Table 1). The technique called transcervical extended mediastinal lymphadenectomy (TEMLA), developed in 2004 by Marcin Zielinski, ´ makes it possible to remove the whole lymphatic content ∗ Corresponding
author. of Thoracic Surgery, Pulmonary Hospital Zakopane, Poland. E-mail:
[email protected] † Department
63
Disadvantages
Cervical Mediastinoscopy
2R, 2L, 4R, 4L, 7
Cervical incision (about 3 cm)
No
Simplicity, short operative time, safety
Limited number of accessible lymph node stations
Cervical Mediastinoscopy Plus Extended Cervical Mediastinoscopy
2R, 2L, 4R, 4L, 7, 5, 6
Cervical incision (about 3 cm)
No
Possibility of biopsy of station 5 and 6 nodes
Risk of serious complications; limited number of accessible lymph node stations
Anterior Mediastinotomy
5, 6
Parasternal incision
No
Possibility of biopsy of station 5 and 6 nodes
Additional skin incision; limited number of accessible lymph node stations
VTS
2R, 4R, 7, 8, 9∗ or 5, 6, 7, 8 9†
3 ports on each side
Yes
Possibility of biopsy of some stations inaccessible during mediastinoscopy
Considerable number of unsuccessful procedures (adhesions); selective ventilation necessary; post-operative chest tube
VAMLA
2R, 2L, 4R, 4L, 7
Cervical incision (about 3 cm)
No
Lymphadenectomy (rather than a biopsy) in the range accessible during the standard mediastinoscopy
Limited number of accessible lymph node stations
TEMLA
1, 2R, 2L, 3A, 4R, 4L, 5, 6, 7, 8
Cervical incision (5–6 cm)
No
Complete mediastinal lymphadenectomy (with the exception of station 9 nodes); no need for re-staging
Long operative time, learning curve
∗ For † For
right-sided VTS. left-sided VTS.
FA
Advantages
ch09
Chest Tube
B-601
Surgical Approach
14:6
Nodal Stations Accessible
J. Ku˙zd˙zał et al.
Technique
June 9, 2009
Comparison of Invasive Techniques for Mediastinal Staging of NSCLC
64
Table 1
June 9, 2009
14:6
B-601
ch09
FA
Transcervical Extended Mediastinal Lymphadenectomy
65
of the mediastinum, with the exception of the pulmonary ligament nodes (station 9) and the most distant 4L nodes.
TECHNIQUE The principle of the TEMLA technique is the use of the cervical incision to gain wide access to the mediastinum, enabling open-fashion dissection of the lymph nodes. It is possible due to two manouevres: (1) elevation of the sternum using a retractor connected to the tablemounted frame, and (2) dissection free of the trachea and the great vessels of the superior mediastinum and lower neck, enabling retraction of these structures to the left or right. The two manouevres used together create a fairly wide space for the dissection. After making a 6 cm collar incision in the lower neck, the skin flaps are developed in the subplatysmal plane: the upper one to the level of the thyroid cartilage, and the lower one to the level of the sternal notch. The strap muscles are divided in the midline and retracted aside. Next, both of the common carotid arteries are dissected — the lower thyroid
FIGURE 1 The right paratracheal space.
June 9, 2009
66
14:6
B-601
ch09
FA
J. Ku˙zd˙zał et al.
FIGURE 2 The subcarinal region.
FIGURE 3 The region of aorto-pulmonary window.
veins are clipped and divided. Having dissected the carotid arteries free, the recurrent nerves are identified using a method described in detail elsewhere.2 The station 1 nodes, lying above the left innominate vein, are removed en bloc, together with the fatty tissue surrounding
June 9, 2009
14:6
B-601
ch09
FA
Transcervical Extended Mediastinal Lymphadenectomy
67
the lower thyroid veins (the veins are clipped and divided close to the innominate vein). Whilst dividing the tissue along the recurrent nerves, the cautery should not be used. Retracting the trachea and the innominate artery to the left side, the right paratracheal space is opened and its contents (stations 2R and 4R) are dissected using a peanut sponge to the level below the azygos vein. The borders of the dissection are the superior vena cava anteriorly, the ascending aorta, the trachea and the oesophagus on the left side, the mediastinal pleura on the right side and the spine posteriorly. The right main bronchus, the right pulmonary artery and its upper trunk are the lower margin of dissection. In some patients the retrotracheal nodes (station 3P) can be found and removed. Next, the trachea is retracted to the right side, the left common carotid artery and aortic arch to the left and anteriorly, and the left paratracheal nodes (stations 2L and 4L) are dissected to the level of the bifurcation of the left main bronchus, carefully preserving the left laryngeal recurrent nerve, which should be visualised in its whole course. In some patients the most distal station 4L nodes are dissected with the aid of a mediastinoscope after removal of the station 7 and 8 nodes. For the dissection of the subcarinal and paraoesophageal nodes (stations 7 and 8), the Wolf mediastinoscope (Richard Wolf GmbH, Knittlingen, Germany) is used. The right pulmonary artery is retracted upwards with the spreadable, upper blade of the mediastinoscope, and the subcarinal nodes are dissected. The length of the mediastinoscope (19 cm) enables dissection along the oesophagus to a level about 5 cm below the carina. The access to the region of the aortopulmonary window is gained in the plane between the left common carotid artery and the left innominate vein. The plane is developed by blunt dissection along the course of the vagus nerve, the artery and the aortic arch are pushed downwards and the aortopulmonary window (station 5) nodes are removed. The Botallo ligament is visualised, and the paraaortic (station 6) nodes located to the right of the ligament and in front of the aortic arch are removed. It should be noted that the left phrenic nerve courses close to the region of the station 6 nodes, and care must be taken to avoid injury to the nerve
June 9, 2009
68
14:6
B-601
ch09
FA
J. Ku˙zd˙zał et al.
during dissection of the nodes or when using cautery in this area. As the approach to the aortopulmonary window is relatively narrow, an additional source of light is useful (we use the rigid thoracoscope for this purpose). The last step is dissection of the anterior surface of the confluence of innominate veins and the superior vena cava, which are pushed downwards, and removal of the prevascular (station 3A) nodes. The whole dissection is performed in the open fashion, using standard instruments. The wound is closed by approximating the strap muscles and then placing the subcutaneous sutures and the skin sutures. No drain is left in the mediastinum. The technique of TEMLA is presented in detail in the Multimedia Manual of Cardiothoracic Surgery (http://mmcts.ctsnetjournals.org/cgi/content/full/2006/ 1009/mmcts.2005.001693). This manual also includes video presentations of the technique.
DISCUSSION Regarding the completeness of the mediastinal lymphadenectomy, TEMLA compares favourably with all other techniques of surgical staging (see Table 1). It is more complete even than the dissection at thoracotomy, as the latter enables removal of 6 stations (right thoracotomy) or 5 stations (left thoracotomy, unless the aortic arch is not mobilised to gain access to the left paratracheal nodes). In the recently published analysis of 256 procedures, the mean number of lymph nodes removed is 38.9. TEMLA was proved to be highly sensitive and accurate in detecting metastatic mediastinal lymph nodes, with the sensitivity 94.1%, accuracy 98% and NPV 97.2%. The mean operative time was 161 min (range: 80–330 min).3 This seems to be quite long, but taking into account the number of nodes removed, the time necessary for dissection of one node was only 4.1 min. Complications associated with the TEMLA procedure occurred in 11.3% of patients and most of them were mild, not requiring any treatment. Temporary laryngeal recurrent nerve palsy occurred in 6 of 256 patients (2.3%) and permanent nerve palsy in 2 of 256 patients (0.8%).3 These figures are much
June 9, 2009
14:6
B-601
ch09
FA
Transcervical Extended Mediastinal Lymphadenectomy
69
smaller than those reported for thyroid surgery, where permanent laryngeal recurrent nerve palsy occured in 1.7–3.8% of patients operated on for benign conditions and in 8% for thyroid cancer.4 It should be noted that during thyroid surgery the recurrent nerves are vulnerable only in a short part, whereas during TEMLA they are dissected free over almost all their length. The only other technique including a similar extent of dissection in the vicinity of the recurrent nerves is oesophagectomy with three-field lymphadenectomy. For this procedure the rate of the laryngeal recurrent nerve palsy was reported to be as high as 69% (42% temporary and 27% permanent).5 The TEMLA technique was compared with the standard cervical mediastinoscopy in a prospective, randomised trial, which has shown that TEMLA was significantly more effective in detecting mediastinal node metastases in NSCLC patients than cervical mediastinoscopy, while there was no significant difference in invasiveness between the two procedures, except for the post-operative pain.6 Also, it is not associated with a greater incidence of respiratory insufficiency and does not increase the number of patients unfit for subsequent pulmonary resection, compared to standard mediastinoscopy. Moreover, the TEMLA procedure does not produce greater alterations in lung ventilation or gas diffusion across the alveolar capillary membrane, compared to standard mediastinoscopy.7 Further, there is potential for therapeutic impact of bilateral lymphadenectomy in NSCLC patients. However, the follow-up is currently too short for a final conclusion in this regard, the preliminary results may suggest some therapeutic impact for patients who underwent TEMLA and subsequent R0 resection.3
REFERENCES 1. Mountain CF, Dresler CM. (1997) Regional lymph node classification for lung cancer staging. Chest 111(6): 1718–1723. 2. Zielinski M, Kuzdzal J, Szlubowski J, Soja J. (2005) Safe and reliable technique of visualization of the laryngeal recurrent nerves in the neck. Am J Surg 189: 200–202.
June 9, 2009
70
14:6
B-601
ch09
FA
J. Ku˙zd˙zał et al.
3. Zielinski M. (2007) Transcervical extended mediastinal lymphadenectomy: results of staging in two hundred fifty-six patients with non–small cell lung cancer. J Thorac Oncol 2(4): 370–372. 4. Wagner HE, Seiler C. (1994) Recurrent laryngeal nerve palsy after thyroid gland surgery. Br J Surg 81(2): 226–228. 5. Fujita H, Sueyoshi S, Tanaka T, et al. (2003) Optimal lymphadenectomy for squamous cell carcinoma in the thoracic esophagus: comparing the short- and long-term outcome among the four types of lymphadenectomy. World J Surg 27(5): 571–579. 6. Kuzdzal J, Zielinski M, Papla B, et al. (2007) The transcervical extended mediastinal lymphadenectomy versus cervical mediastinoscopy in non– small cell lung cancer staging. Eur J Cardiothorac Surg 31: 88–94. 7. Kuzdzal J, Zielinski M, Papla Narski M, et al. (2007) Effects of bilateral mediastinal lymphadenectomy on short-term pulmonary function. Eur J Cardiothorac Surg 31: 161–166.
June 9, 2009
14:6
B-601
ch10
FA
chapter
10
Minimally Invasive Techniques for Early Lung Cancer Contardo Vergani∗,† , Luca Despini† and Giancarlo Roviaro†
BASIC CONSIDERATIONS Although a number of authors1–5 advocate VATS for staging and treating stage I lung cancer, this approach is still widely debated. More than 16 years since the first videothoracoscopic lobectomy in 1991,6 thoracoscopic major resections still have to achieve diffusion, mainly owing to persistent concerns about their oncologic validity. Initial fear of intraoperative accidents has gradually faded and, at present, evidence shows that VATS lobectomies are safe, with mortality and morbidity comparable to conventional procedures. In our series of 230 VATS lobectomies for cancer, we recorded no intraoperative mortality, and a postoperative mortality rate of 0.87%.1 Similar results have been observed in other series.5,7,9 Altough videothoracoscopic dissection of the pulmonary vessels is a delicate procedure, the risk of intraoperative bleeding has proved small.1–5,7–9 ∗ Corresponding
author.
† Department of Surgical Sciences, State University of Milan and Department of Gen-
eral Surgery, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS, Milan, Via Francesco Sforza 35, 20122 Milano, Italy. E-mail: contardo.vergani@ unimi.it 71
June 9, 2009
72
14:6
B-601
ch10
FA
C. Vergani et al.
According to several randomised studies, postoperative pain is reduced in comparison with muscle-sparing thoracotomy,1,5,8–10 even though others could not find any difference.11 According to some non-randomised studies, pulmonary function seems better after VATS than after conventional lobectomy.9 Technical differences regard the site and size of the utility thoracotomy, the use of the rib spreader, and the site of insertion of the trocars. Most authors agree that thoracoscopic lobectomy should entail separate dissection and securing of the hilar elements. Simultaneous stapling mass ligation of the hilum12 is considered an unorthodox procedure by most. The oncologic validity of VATS lobectomies for cancer is still unproven, but evidence is mounting that they offer results similar to those of open lobectomy. Concern about increased recurrence rates or tumour seeding on the port sites seems inconsistent, provided that careful manipulation during dissection and wound protection during the extraction of the specimen is adopted. We have not experienced any recurrence, and in the other clinical series the recurrence rate has been low or null.1,7,8 Regarding long term results, in our experience VATS lobectomy for stage I lung cancer yelded a global survival rate of 77.7% at three years and 63.64% at five years. For patients younger than 70 years old the rate is significantly (p < 0.01) better (82.4% at three years and 72.3% at five years).7 Other large clinical series have confirmed results similar to those of open resection or even better.2,7–9 These good results have been attributed to a more favourable immunological response after VATS, better preservation of cell-mediated immunity, reduced release of stress hormones, and lower levels of C-reactive protein and IL-6.10,8 VATS resection should follow the same principles as oncologic surgery, and the desire to offer the patient the advantages of VATS resection should not authorise one to perform lesser resection in case of difficult lobectomy. Formal lobectomy is the standard; however, sublobar resections are acceptable in frail patients. Despite the initial
June 9, 2009
14:6
B-601
ch10
FA
Minimally Invasive Techniques for Early Lung Cancer
73
studies stressing the increased rate of local recurrences after segmentectomy or wedge resection, many authors now report very good results after sublobar resection. The problem is still open.
INDICATIONS Indications are not unanimously defined. We limit VATS lobectomy to peripheral T1N0 and T2N0 lung cancer with no infiltration of the lobar bronchus, no atelectasis, or infiltration of the parietal pleura, even though VATS lobectomy for cancer is technically feasible in many other conditions.
TECHNIQUE The patient is intubated with a double lumen Carlens tube for selective ventilation or collapse of the chosen lung, and in lateral decubitus as for postero-lateral thoracotomy. A pillow is placed under the chest, and the table is flexed in order to avoid any limitation on movements of the camera by the iliac crest. The surgical team is positioned according to Fig. 1. Positions will change depending on the different steps of the operation. The optics are inserted in the seventh or eighth intercostal space on the mid-axillary line. A second port is inserted in the fourth or fifth space posteriorly and a 3–4 cm incision is carried out along the inframammary sulcus in the third or fourth space, where the intercostal spaces are wider and no major muscles must be sectioned. This “utility thoracotomy” permits the introduction of non-endoscopic instruments, provides useful access in case of problems, and ensures the extraction of the specimen at the end of the resection. Rib spreaders are not used except for extracting the specimen, in order to prevent nerve damage and reduce postoperative pain. We always start the procedure with a thorough “surgical” exploration (which we have called videothoracoscopic operative staging, VOS) of the pleural cavity to rule out inoperability and to confirm the
June 9, 2009
74
14:6
B-601
ch10
FA
C. Vergani et al.
FIGURE 1 Positioning of the patient, the team and the equipment. Two monitors are placed at the head of the patient who is in lateral decubitus. The surgeons usually stands in front of the patient. Positions of the team can change rapidly.
videothoracoscopic feasibility of the lobectomy. This exploration can entail lysis of the adhesions and section of the pulmonary ligament, but also complex manoeuvres such as dividing the azygos vein, or opening the pericardium. Diffuse pleural adhesions can impair lung collapse, and can call for conversion.
MEDIASTINAL PHASE (FIGS. 2 AND 3) Isolation of mediastinal vessels can be achieved with sharp and blunt dissection, through gentle swabbing towards the lung (never in the
June 9, 2009
14:6
B-601
ch10
FA
Minimally Invasive Techniques for Early Lung Cancer
75
FIGURE 2 Right upper lobectomy: isolation of the right upper pulmonary vein.
FIGURE 3 Right upper lobectomy: isolation of the anterior trunk.
opposite direction), and must be more extensive than in open surgery, to allow positioning of the endostapler. Once isolated the vessel is encircled with a thread to facilitate the positioning of the stapler. Finding the correct angle of insertion of the stapler can be difficult and changing the site of insertion may be necessary. Any dangerous traction on the instruments must be avoided. As a rule the
June 9, 2009
76
14:6
B-601
ch10
FA
C. Vergani et al.
artery is divided before the vein and the bronchus is sectioned last, but sometimes it is more convenient to separate the vein before the artery.
FISSURAL PHASE (FIG. 4) Isolating the artery within the fissure is a crucial step. The lobar hilum is complex and sometimes lymphnode reaction or partially developed fissure makes the approach more difficult. Once the artery and its branches have been isolated, they can be stapled or clipped according to their size. Smaller vessels, such as veins and arteries for the middle lobe, the lingula, the left upper lobe or the posterior ascending artery, can usually be sectioned between clips. An incomplete fissure can be completed, but sometimes a thick parenchyma must be pressed with a clamp before stapling it. Sealed fissure or adherent lymphnodes can make the arterial isolation difficult or impossible and can require conversion.
FIGURE 4 Right lower lobectomy: intrafissural isolation and sectioning of the artery to the lower lobe.
June 9, 2009
14:6
B-601
ch10
FA
Minimally Invasive Techniques for Early Lung Cancer
77
BRONCHIAL PHASE The bronchus is usually the last element to be divided. Isolation can be accomplished with a mounted swab, endoscissors and judicious use of electrocoagulation. It must be sufficient to pass the endostapler, but vascularisation of the stump must be preserved. Lobar bronchi are usually secured with 3.5 mm staples, whereas the main stem bronchus or thickened lobar bronchi require 4.8 mm staples.
LYMPHADENECTOMY VATS lymphadenectomy is technically feasible to the same extent as open surgery and follows the same steps. All suspect lymphnodes are sent for frozen section examination and, when the response is positive, we convert the intervention to an open procedure, irrespective of whatever phase of the procedure has been reached. In skilled hands and with accurate selection of patients, VATS lobectomy for cancer is a safe and valid alternative to the conventional open procedure, with similar short- and long-term results. Notwithstanding, larger series are needed to confirm these attractive results.
REFERENCES 1. Roviaro GC, Varoli F, Vergani C, Maciocco M, Nucca O, Pagano C. (2004) Video-assisted thoracoscopic major pulmonary resections: technical aspects, personal series of 259 patients, and review of the literature. Surg Endosc 18: 1551–1558. 2. Naruke T. (2000) Thoracoscopic lobectomy with mediastinal lymph node dissection or sampling. In: Yim APC, Hazelrigg SR, Izzat MB et al., (eds.), Minimal Access Cardiothoracic Surgery. Philadelphia, PA, WB Saunders, pp. 116–126. 3. Kaseda S, Aoki T, Hangai N. (1998) Video-assisted thoracic surgery (VATS) lobectomy: the Japanese experience. Semin Thorac Cardiovasc Surg 10: 300–304.
June 9, 2009
78
14:6
B-601
ch10
FA
C. Vergani et al.
4. Yim APC. (2002) VATS major pulmonary resection revisited — controversies, techniques, and results. Ann Thorac Surg 74: 615–623. 5. McKenna RJ Jr et al. (1998) VATS lobectomy: the Los Angeles experience. Semin Thorac Cardiovasc Surg 10: 321. 6. Roviaro GC, Rebuffat C, Varoli F, et al. (1992) Videoendoscopic pulmonary lobectomy for cancer. Surg Laparosc Endosc 2: 244–247. 7. Roviaro GC, Varoli F, Vergani C, Nucca O, Maciocco M, Grignani F. (2004) Long-term survival after videothoracoscopic lobectomy for stage I lung cancer. Chest 126: 725–732. 8. Walker SW, Codispoti M, Soon SY, et al. (2003) Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothorac Surg 23: 397–402. 9. Sugiura H, Morikawa T, Kaji M, et al. (1999) Long-term benefits for the quality of life after video-assisted thoracoscopic lobectomy in patients with lung cancer. Surg Laparosc Endosc 9: 403–410. 10. Sugi K, Kaneda Y, Esato K. (2000) Video-assisted thoracoscopic lobectomy reduces cytokine production more than conventional open lobectomy. Jpn J Thorac Cardiovasc Surg 48: 161–165. 11. Kirby TJ, Mack MJ, Landreneau RJ, et al. (1993) Initial experience with video-assisted thoracoscopic lobectomy. Ann Thorac Surg 56: 1248–1253. 12. Lewis RJ, Caccavale RJ. (1998) VATS lobectomy. Semin Thorac Cardiovasc Surg 10: 332–339.
June 9, 2009
14:6
B-601
ch11
FA
chapter
11
Resection of Superior Sulcus Cancers: Anterior Approach Marco Alifano∗,† , Salvatore Strano† and Olivier Schussler†
Superior sulcus tumours are generally defined as primary lung cancers involving the apex of the chest wall and usually associated with pain in the shoulder and/or arm. Invasion of one or more of the following structures is frequent: lower roots of the brachial plexus, stellate ganglion and sympathetic trunk, upper thoracic ribs or vertebrae, subclavian vessels.1,2 A multimodality approach (including pre- and/or post-operative radiotherapy and chemotherapy) has been used for some decades in the treatment of this condition.1,3 Surgical access is classically achieved by the Paulson–Shaw posterior approach.1,4 This access is fully satisfactory when one is dealing with posteriorly located tumours, but may be inadequate in the presence of involvement of anterior structures. For this reason, several anterior approaches have been developed, including the cervicosternothoracotomy,5 the hemiclamshell,6 and the transcervical-transthoracic approach with resection of the clavicle.7
∗ Corresponding
author. des Hôpitaux, Unité de Chirurgie Thoracique, Hôtel-Dieu University Hospital, 1, Place du Parvis Notre-Dame, 75004 Paris, France. E-mail: marco.alifano@ htd.aphp.fr † Chirurgien
79
June 9, 2009
80
14:6
B-601
ch11
FA
M. Alifano et al.
More recently, the transmanubrial approach, which will be described in detail in this article, has been proposed and it represents our first-choice approach for anterior forms of the superior sulcus tumours.8 In our practice, indications for this anterior approach are as follows: (1) presence of a palpable supraclavicular mass, (2) clinical involvement of the C7 and/or C8 root, (3) Horner syndrome, and (4) proven or suspected vascular infiltration. The operation is carried out under general anaesthesia and double-lumen intubation to allow single-lung ventilation. The patient is positioned in the supine position, with the neck hyperextended and the head turned towards the side controlateral to the involved one. A vertical roll is placed under the spine to allow the shoulder of the operated side to gently fall. The operative field includes the whole homolateral neck and thorax, and skin preparation and draping is extended some centimetres away from the midline. The skin incision includes a vertical presternocleidomastoid incision which is prolonged over the upper sternal manubrium and then horizontally two transverse fingers below the clavicle up to the deltopectoral groove. The lower portion of the internal jugular vein is dissected, and the manubrium and upper portion of the second rib are exposed. The first intercostal space is opened, thus allowing finger exploration of the pleural cavity and anticipation of further technical aspects of the operation. Internal thoracic vessels are subsequently dissected and transected at the first intercostal space level. This allow exposition of the lateral aspect of the sternal manubrium, which can be now transected by an oscillating saw in an L-shaped fashion: midline vertical, and horizontal from the midline to the lateral aspect. This allows preservation of the sternoclavicular joint (Fig. 1). The sternoclavicular flap may be opened only after scissors section of the first rib cartilage at its sternal insertion and provided that no tumour invasion is present at this level. In parallel with flap elevation, section of the costoclavicular ligament is carried out, thus providing increasing amplitude to the operative field.
June 9, 2009
14:6
B-601
ch11
FA
Resection of Superior Sulcus Cancers
81
FIGURE 1 The manubrial sternum has been transacted and the first intercostal space opened. * = sternocleidomastoid muscle; ** = jugular vein; ↑ = cut sternal manubrium.
Exposure of the whole cervicothoracic junction is now achieved. Further dissection depends on the extent of tumours and infiltration of different structures (upper ribs, especially in their anterior portion, subclavian vessels, apical pleura, sympathetic chain and brachial plexus). Section of the internal jugular vein may seldom be necessary in order to allow better access to posterior plans. The subclavian vein is dissected and spared if free, or easily resected without subsequent revascularisation if invaded. Thus the main venous axis, the phrenic nerve and the anterior scalene muscle are exposed. Section of this muscle in a tumour free margin, after mobilisation of the phrenic nerve (if not infiltrated by the tumour), allows exposition of the subclavian artery. Sacrifice of its branches may be required; care should be taken to spare, if possible, the vertebral artery. If the tumour is adherent to the subclavian artery, dissection in the subadventitial plane is often sufficient to dissect the tumour with free margins (Fig. 2); if this kind of dissection seems not adequate, resection of the artery is necessary. End-to-end anastomosis may be sufficient to re-establish arterial flow
June 9, 2009
82
14:6
B-601
ch11
FA
M. Alifano et al.
FIGURE 2 Subclavian vessels are retracted laterally and upward (the artery has been dissected in the subadventitial plane and encircled), allowing exposition of the apical tumour.
if the extent of resection is limited, otherwise polytetrafluoroethylene graft interposition is necessary. Chest wall resection represents another fundamental step of the operation. In our opinion it should be carried out en bloc with the lobectomy. Anterior section of the first rib is carried out as a step of the anterior access, as previously described, and its posterior section may also be easily performed using the anterior approach. The number of ribs to be resected is variable. If the transmanubrial approach has been chosen, anterior rib involvement should be limited to the first (maximum the first two) ones; otherwise, alternative anterior approaches (such as the hemiclamshell incision) should have been adopted. On the other hand, if involvement concerns the ribs posteriorly, below the second or the third one, the transmanubrial approach is carried out as described, and posterior rib resection is performed
June 9, 2009
14:6
B-601
ch11
FA
Resection of Superior Sulcus Cancers
83
FIGURE 3 Closure of the approach: the metallic wires have been passed.
through an associated posterior approach which is also used to carry out lobectomy and nodal dissection. After dissection and/or resection of the chest wall and remaining structures of the cervicothoracic junction (apical pleura, sympathetic chain, brachial plexus), the osteomuscular flap is returned to its position, sternal manubrium is sutured with two metallic stitches and soft tissues are closed in the usual way. Motility of the shoulder is thus completely preserved (Fig. 3). The patient is then turned in the full lateral position for posterolateral thoracotomy to perform lobectomy and possibly complete chest wall resection. In a few cases (thin patients with limited tumours not involving hilar structures or the posterior chest wall), lobectomy may be carried out through the anterior approach. In our opinion, lobectomy should constitute the standard pulmonary resection and we perform sublobar resections only in the presence of severe respiratory impairment. Nodal dissection is routinely carried out.
June 9, 2009
14:6
84
B-601
ch11
FA
M. Alifano et al.
We have recently reviewed retrospectively the results of surgical treatment of superior sulcus tumours by our team.2 An isolated posterior approach was used in 49% of the cases, whereas all the remaining patients but one (who had an isolated anterior approach) had combined anterior and posterior approaches. In this study operative mortality was 8.9%, a percentage which is relatively high but is explained by the extent of resection in patients presenting frequently important comorbidities. Long-term results were relatively satisfactory, with figures of overall survival (including non-cancer-related deaths) of 54% and 36.2% at 2 and 5 years, respectively. Multivariate analysis showed that the completeness of resection (82% of the cases in our series), T status and the presence of associated comorbidities were independent prognostic factors. It is noteworthy that patients with T3N0 tumours experienced a 5-year survival of 47.7%.2 Our results are similar to those published in other, often smaller, retrospective series and compare very favourably with series of nonsurgical treatment. Thus, it is generally accepted that surgical treatment should be proposed in operable patients, although the level of evidence is relatively low.1−3,9 On the other hand, the kind and timing of association of neo-adjuvant or adjuvant treatments remains controversial. A phase II study including patients with disease initially considered resectable showed that induction chemo-radiotherapy has limited morbidity and mortality but results in post-induction surgery in only 80% of cases.10 This strategy is associated with a satisfactory percentage of complete resection (76%), and provides satisfactory results with regard to long-term outcome (5-year survival rates of 44%). It now warrants confirmation by further study, to increase the level of evidence.
REFERENCES 1. Wright CD, Moncure AC, Shepard JA, et al. (1987) Superior sulcus lung tumors: results of combined treatment (irradiation and radical resection). J Thorac Cardiovasc Surg 94: 69–74.
June 9, 2009
14:6
B-601
ch11
FA
Resection of Superior Sulcus Cancers
85
2. Alifano M, D’Aiuto M, Magdeleinat P, et al. (2003) Surgical treatment of superior sulcus tumors: results and prognostic factors. Chest 124: 996–1003. 3. Martinod E, D’Audiffret A, Thomas P, et al. (2002) Management of superior sulcus tumors: experience with 139 cases treated by surgical resection. Ann Thorac Surg 73: 1534–1539. 4. Shaw RR, Paulson DL, Lee JL. (1961) Treatment of superior sulcus tumor by irradiation followed by resection. Ann Surg 54: 29–40. 5. Masoaka A, Ito Y, Yasumitsu T. (1979) Anterior approach for tumors of the superior sulcus. J Thorac Cardiovasc Surg 78: 413–415. 6. Bains MS, Ginsberg RJ, Jones WG, et al. (1994) The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumors. Ann Thorac Surg 105: 1025–1034. 7. Dartevelle PG, Chapelier AR, MacChiarini P, et al. (1993) Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg 105: 1025–1034. 8. Grunenwald D, Spaggiari L. (1997) Transmanubrial osteomuscular sparing approach for apical chest tumor. Ann Thorac Surg 63: 563–566. 9. Rusch VW, Parekh KR, Leon L, et al. (2000) Factors determining outcome after surgical resection of T3 and T4 lung cancer of the superior sulcus. J Thorac Cardiovasc Surg 119: 1147–1153. 10. Rusch VW, Giroux DJ, Kraut MJ, et al. (2007) Induction chemoradiation and surgical resection for superior sulcus non-small-cell lung carcinomas: long-term results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160). J Clin Oncol 25: 313–318.
June 9, 2009
14:6
B-601
ch12
FA
chapter
12
Surgical Staging for Lung and Mediastinal Cancers Ramón Rami-Porta∗,† , Sergi Call-Caja† , Roser Saumench-Perramon† and Mireia Serra-Mitjans†
INTRODUCTION Surgical staging for lung and mediastinal cancers, as well as for those tumours that may extend into the mediastinum from neighbouring areas, such as pleural mesothelioma, is crucial for planning treatment and assessing prognosis. Staging evidence derived from surgical explorations has the highest certainty, compared with clinical evaluation, radiological explorations and endoscopies with or without fine needle aspiration or biopsy.1
MEDIASTINOSCOPY Mediastinoscopy is the gold standard for staging lymphatic spread and direct invasion of lung cancer into the mediastinum. Current European guidelines recommend mediastinoscopy if there are ∗ Corresponding
author. Surgery Service, Hospital Mutua de Terrassa, Plaza Dr. Robert, 5, 08221 Terrassa, Barcelona, Spain. E-mail: rramip@ terra.es † Thoracic
87
June 9, 2009
88
14:6
B-601
ch12
FA
R. Rami-Porta et al.
enlarged nodes on computed tomography (CT) or abnormal uptake on positron emission tomography (PET). If CT is normal, mediastinoscopy still is recommended except in cT1N0 squamous cell carcinomas. If PET does not show abnormal uptake in the mediastinum, surgical exploration is recommnended in central tumours, tumours with low uptake, nodes larger than 1.6 cm, and when there is evidence of N1 disease.2 Other indications include diagnosis and staging of mediastinal lymphoma, mesothelioma, mediastinal tumours, and diagnosis of granulomatosis and infections. A 3–5-cm-long collar incision above the upper limit of the manubrium, followed by deeper dissection and opening of the pretracheal fascia, allows the surgeon to insert the index finger and create a pretracheal space into which the mediastinoscope will be inserted. The range of exploration of mediastinoscopy includes all lymph nodes around the trachea and the main bronchi, and those in the subcarinal space. Mediastinoscopy allows the surgeon (i) to inspect — usually, normal mediastinal nodes are black and those involved with tumour, greyish; (ii) to palpate and feel the intimate relation of nodes or tumours with the trachea and to differentiate mere contact from tumour invasion; (iii) to puncture with the double purpose to determine if the structure that will be biopsied is a vessel or not, and to aspirate material for cytological examination from nodes and tumours adhered to vessels; and (iv) to biopsy lymph nodes, mediastinal fat and tumours. These manoeuvres are best performed if the surgeon sits at the head of the patient.3 Remediastinoscopy to stage recurrent or new primary tumours and to assess tumour response after induction therapy is technically feasible and useful for identifying patients who will benefit most from lung resection.4
PARASTERNAL MEDIASTINOTOMY For tumours or nodal stations beyond the range of mediastinoscopy, other procedures are required. Parasternal mediastinotomy allows one to explore and biopsy subaortic and anterior mediastinal nodes on the left side, and prevascular nodes on the right side, as well as
June 9, 2009
14:6
B-601
ch12
FA
Surgical Staging for Lung and Mediastinal Cancers
89
FIGURE 1 Bimanual palpation from the cervical incision of mediastinoscopy and from the incision of left parasternal mediastinotomy.
any anterior mediastinal tumour. Parasternal mediastinotomy is a required complement to mediastinoscopy for staging lung cancers of the left upper lobe and hilum, because these can spread to subaortic and anterior mediastinal nodes.5 Bimanual palpation of the aortic arch is indicated in tumours of the aortopulmonary window, which may be invading vascular structures and be deemed unresectable (Fig. 1). A 5–7 cm incision is performed on the second or third costal cartilage on the required side. The cartilage can be removed or not, depending on the operative field needed. The internal mammary vessels are identified, and individually ligated if needed. If direct inspection of the mediastinum is not adequate, the mediastinoscope can also be inserted through this incision. This versatile approach gives access to the pleural space and the lung, and the pericardial space by opening the mediastinal pleura and the pericardium, respectively.
EXTENDED CERVICAL MEDIASTINOSCOPY Extended cervical mediastinoscopy is an alternative to left parasternal mediastinotomy for staging cancers of the left lung.6 From the collar incision of mediastinoscopy, a passage is created by finger
June 9, 2009
90
14:6
B-601
ch12
FA
R. Rami-Porta et al.
dissection over the aortic arch between the innominate artery and the left carotid artery. The mediastinoscope is then inserted into the incision and obliquely advanced over the aortic arch along the dissected passage, leaving the left innominate vein either in front of or behind the mediastinoscope. Once the pulsating aortic arch is
FIGURE 2 Extended cervical mediastinoscopy: the mediastinoscope is advanced obliquely from the cervical incision over the aortic arch.
FIGURE 3 Extended cervical mediastinoscopy: the mediastinoscope is positioned between the innominate artery and the left carotid artery.
June 9, 2009
14:6
B-601
ch12
FA
Surgical Staging for Lung and Mediastinal Cancers
91
seen, the mediastinoscope is advanced further into the subaortic space and the anterior mediastinum (Figs. 2 and 3). Lymph nodes are then dissected from the fatty tissue that usually occupies this area and removed or biopsied (video-clip on CD). Published data are scarce but homogeneous, and sensitivity values ranging from 0.60 to 0.81, diagnostic accuracy of 0.91–0.95, and negative predictive values of 0.89–0.91 have been reported.6,7 Specificity and positive predictive values are 1.
THORACOSCOPY AND VIDEO-ASSISTED THORACOSCOPIC SURGERY Posterior mediastinal tumours, tumours at the cardiophrenic angles, and the inferior mediastinal nodes cannot be reached with the procedures described above. In these situations thoracoscopy with or without video assistance is most useful.8 Lung cancers with pleural effusion or additional ipsilateral or contralateral nodules, and mesothelioma also benefit from thoracoscopic staging. Video-assisted thoracoscopic surgery allows removal of peripheral pulmonary nodules, creation of pericardial windows, and biopsy or removal of mediastinal nodes and tumours.
TRANSCERVICAL MEDIASTINAL LYMPHADENECTOMY The most recent and relevant advance in surgical staging for lung cancer derives from two procedures with the objective of removing all upper mediastinal lymph nodes: video-assisted mediastinoscopic lymphadenectomy (VAMLA)9 and transcervical extended mediastinal lymphadenectomy (TEMLA).10 VAMLA is a completely endoscopic procedure performed with the two-valved Wolf videomediastinoscope. It consists of en bloc removal of the fatty tissue and nodes of the subcarinal space, the right paratracheal and pretracheal
June 9, 2009
14:6
92
B-601
ch12
FA
R. Rami-Porta et al.
areas, and the left paratracheal space. TEMLA is a combined open and endoscopic procedure facilitated by an enlarged cervical incision resulting from the pulling of the sternum with a hook. The removal of the upper mediastinal nodes is performed with standard instruments. Then a videothoracoscope is used as an aid to dissect and remove the subaortic and anterior mediastinal nodes, and a videomediastinoscope is used to complete dissection and removal of the subcarinal and paraoesophageal nodes. In both series, sensitivity, diagnostic accuracy and negative predictive value were close to 1. The practical advantage of VAMLA and TEMLA over other staging procedures is that, in patients with lung cancer who eventually undergo lung resection, mediastinal lymphadenectomy of the explored stations is unnecessary because remnant lymphatic tissue is negligible.
REFERENCES 1. Sobin LH, Wittekind Ch (eds.). (2002) International Union Against Cancer: TNM Classification of Malignant Tumours, 6th edn. (New York: Wiley-Liss), p. 15. 2. De Leyn P, Lardinois D, Van Schil PE, et al. (2007) ESTS guidelines for preoperative lymph node staging for non-small cell lung cancer. Eur J Cardiothorac Surg 32: 1–8. 3. Rami-Porta R, Mateu-Navarro M. (2002) Videomediastinoscopy. J Bronchol 9: 139–144. 4. Van Schil P, De Waele M, Hendriks J, Lauwers P. (2007) Remediastinoscopy. J Thorac Oncol 2: 365–366. 5. Jiao X, Magistrelli P, Goldstraw P. (1997) The value of cervical mediastinoscopy combined with anterior mediastinotomy in the perioperative evaluation of bronchogenic carcinoma of the left upper lobe. Eur J Cardiothorac Surg 11: 450–454. 6. Ginsberg RJ, Rice TW, Goldberg P. (1987) Extended cervical mediastinoscopy: a single staging procedure for bronchogenic carcinoma of the left upper lobe. J Thorac Cardiovasc Surg 94: 673–678. 7. Lopez L, Varela A, Freixinet J, et al. (1994) Extended cervical mediastinoscopy: prospective study of fifty cases. Ann Thorac Surg 57: 555–557.
June 9, 2009
14:6
B-601
ch12
FA
Surgical Staging for Lung and Mediastinal Cancers
93
8. Rendina EA, Venuta F, De Giacomo T, et al. (1994) Comparative merits of thoracoscopy, mediastinoscopy, and mediastinotomy for mediastinal biopsy. Ann Thorac Surg 57: 992–995. 9. Witte B, Hürtgen M. (2007) Video-assisted mediastinoscopic lymphadenectomy (VAMLA). J Thorac Oncol 2: 367–369. 10. Zielinski M. (2007) Transcervical extended mediastinal lymphadenectomy: results of staging in two hundred fifty-six patients with non-small cell lung cancer. J Thorac Oncol 2: 370–372.
June 17, 2009
14:52
B-601
ch13
FA
chapter
13
Transthoracic Oesophagectomy and Lymphadenectomy Philippe Nafteux∗,† , Willy Coosemans† , Herbert Decaluwé† , Georges Decker† , Paul De Leyn† , Dirk Van Raemdonck† and Toni Lerut†
INTRODUCTION In oesophageal cancer, several controversies have arisen over the surgical approach, as well as the need for and the extent of lymph node dissection. Hulscher et al. published in 2002 a randomised study showing a clear, beneficial trend in survival favouring the more radical transthoracic approach which comprises two-field lymphadenectomy over the transhiatal approach to resectable adenocarcinoma of the distal oesophagus and the gastro-oesophageal junction. In particular, in the subset of patients presenting with adenocarcinoma of the distal oesophagus, the same group reported a 17% survival benefit in favour of the transthoracic approach. For this reason, the transthoracic approach with radical lymph node dissection is now considered at most centres as the gold standard procedure for resecting oesophageal cancer in the majority of patients. ∗ Corresponding
author. of Thoracic Surgery, UZ Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium. E-mail:
[email protected] † Department
95
June 17, 2009
96
14:52
B-601
ch13
FA
P. Nafteux et al.
TECHNIQUES The transthoracic approach can be carried out either through a right or a left thoracotomy, depending on the location of the tumour within the oesophagus and the preference of the surgeon. Our centre advocates right-sided approach for tumours above the carina level and a leftsided approach for tumours below.
Right-sided Approach Classically, a three-hole approach (McKeown) is advocated, with the patient installed in a left lateral position for the thoracic part of the operation and in a supine position for the laparotomy and cervicotomy. Some centres prefer a two-hole approach (Ivor-Lewis) and make the anastomosis at the apex of the chest, thus omitting the cervicotomy. The thoracotomy is performed by entering the fifth intercostal space. The azygos vein is divided and ligated. The oesophagus is mobilised with all its surrounding soft tissue. This is performed as a so-called en bloc resection, taking together with the oesophagus all perioesophageal tissues, the azygos vein, the thoracic duct, and subcarinal and paraoesophageal lymph nodes as a single entity (Fig. 1a). All branches of the azygos vein and arterial branches for the oesophagus coming off the aorta have to be divided and ligated or clipped. Great care is taken not to damage the membranous part of the airways. The dissection of the oesophagus is performed down into the hiatus oesophagei and cranially up into the neck. After the completion of those manoeuvres, the paratracheal nodes are removed separately, starting by dissecting the right paratracheal region, and removing all fatty and lymphatic tissues. The dissection is continued alongside the right recurrent nerve up to the neck, where the lymph nodes at the level of the brachiocephalic trunk extending into the basis of the neck are removed (Fig. 1b). If these nodes prove to be malignant on frozen section, a three-field lymphadenectomy (i.e. adding the cervical field) will be performed. Equally, the lymph nodes in the aortopulmonary
June 17, 2009 14:52
FIGURE 1 Right-sided oesophagectomy. (a) View of the posterior mediastinum after mobilisation of the oesophagus through a right-sided thoracotomy. The azygos vein and thoracic duct are removed en bloc with the oesophagus. (b) Visualisation of both recurrent nerves after oesophageal mobilisation and lymph node dissection. The right vagus nerve and the origin of the right recurrent nerve as well as the left recurrent nerve are clearly seen. Great care has to be taken not to damage these structures during lymph node dissection. (c) The trachea and the left main stem bronchus are retracted ventrally. Note the left pulmonary artery and the aortic arch after oesophageal mobilisation and lymph node clearance of the aortopulmonary window.
ch13
(c)
B-601
(b)
FA
Transthoracic Oesophagectomy and Lymphadenectomy
(a)
97
June 17, 2009
98
14:52
B-601
ch13
FA
P. Nafteux et al.
window and alongside the left recurrent nerve are dissected away from these structures, taking care not to damage them (Fig. 1c). After closure of the chest and turning the patient to a supine position, a laparotomy is performed, using a midline or a bisubcostal incision, according to the surgeon’s preference. Mobilising the left hepatic lobe facilitates access to the hiatus in order to finalise the dissection of the oesophagus. As in general a gastric tube is used to restore continuity, it will be prepared accordingly. The greater curve is mobilised, preserving the right gastroepiploic vessels by dividing its branches for the greater omentum, as well as the short gastric vessels. The lesser omentum is opened and after dividing the hepatic branches of the vagal nerves the dissection is continued towards the hiatus oesophagei. The phreno-oesophageal ligament is incised, exposing the abdominal and distal oesophagus. If required for oncologic reasons a muscular rim of the hiatus oesophagei is resected as well. The right gastric artery is divided at a level close to the pylorus. The left gastric artery and vein are dissected and ligated with resection of all lymphatic and fatty tissues surrounding them. The gastric tube is fashioned using linear staplers (Fig. 2a). The lymph node dissection is continued by removing all nodes starting from the celiac axis, and extending further along the splenic artery into the splenic hilum. To the right all the lymph nodes and soft tissue along the common hepatic artery are cleared, the limit being the inferior vena cava and portal vein. This equals a DII lymphadenectomy. The gastric tube is then fixed to the partitioned lesser curvature with two stay sutures. A left cervical incision is performed, along the anterior border of the sternocleidomastoid muscle. The neurovascular structures are retracted laterally, and after dividing the inferior thyroid artery the prevertebral fascia is easily identified. Usually the cervical oesophagus and the attached gastric tube can be pulled into the operating field straightaway, since the mobilisation of the cervical oesophagus has already been carried out from the chest. An endto-side anastomosis is then performed, manually or using staplers (Fig. 2b).
June 17, 2009
14:52
B-601
FA
ch13
Transthoracic Oesophagectomy and Lymphadenectomy
(a)
99
(b)
FIGURE 2 (a) Gastric tube. Note the length that can be achieved. (b) Semi-mechanical anastomosis in the neck. The posterior aspect of the end-to-side oesophagogastrostomy has been performed using a stapler. Note the broad V-shaped widening that is achieved. This diminishes the incidence of anastomotic strictures requiring dilation.
Left-sided approach A thoracoabdominal approach (thoracophrenotomy) provides excellent exposure to both the upper abdomen and the mediastinum. It is used for tumours of the distal oesophagus and the gastro-oesophageal junction. The operation is performed with the patient placed in a right lateral position with the left hip rolled slightly towards the back to facilitate abdominal exposure. A posterolateral thoracotomy through the sixth intercostal space is extended across the costal margin slightly into the abdomen and is combined with a peripheral phrenotomy (leaving a diaphragmatic rim of 2 cm on the chest wall, which will permit closure of the diaphragm), thus preserving the phrenic innervation and related diaphragmatic function (Fig. 3a). The oesophagus is mobilised from its bed, taking it widely with all its surrounding soft tissues and paraoesophageal lymph nodes from the aortic arch flush along the descending aorta down to the hiatus. The pericardium can be resected en bloc if need be. The peritoneal fold behind the spleen is incised and the spleen together with the pancreas tail is mobilised. This exposes widely the left upper quadrant, facilitating not only lymphadenectomy but also the clearing-out of all surrounding fatty tissues and peritoneum, as well as creating better
June 17, 2009
100
14:52 B-601
P. Nafteux et al.
ch13
(a)
(b)
(c)
FA
FIGURE 3 Left-sided oesophagectomy. (a) Left-sided approach through a sixth interspace thoracophrenotomy. The costal arch is transected, followed by a limited extension of the incision into the abdominal wall. An incision of the diaphragm at its periphery conserving the phrenic nerve is then performed to complete the incision. (b) Upper abdominal compartment after lymph node dissection with visualisation of the arterial branches, portal vein and inferior vena cava (DII dissection). IVC — inferior vena cava; LGAS — left gastric artery stump; SA — splenic artery; CHA — common hepatic artery; PV — portal vein. (c) View of the posterior mediastinum after mobilisation of the oesophagus through the left-sided approach. Note the retracted oesophagus and aorta. Visualisation of both main bronchi and subcarinal region after lymph node dissection.
June 17, 2009
14:52
B-601
ch13
FA
Transthoracic Oesophagectomy and Lymphadenectomy
101
exposure to safely and completely resect bulky tumours. The greater curvature is mobilised fully, till the level of the pylorus is reached. The gastrohepatic ligament is divided, as well as the right gastric vessels. The left gastric vessels are divided as described above, and the gastric tube is fashioned. In the abdomen the lymph node dissection starts at the splenic hilum, going downwards alongside the splenic artery till the left gastric artery stump. To the right of the celiac trunk, the nodes and soft tissue surrounding the common hepatic artery are removed, the limit of the lymphadenectomy being the inferior vena cava and portal vein. Finally, the celiac axis nodes are removed, completing the DII lymphadenectomy (Fig. 3b). The thoracic oesophagus is freed behind the aortic arch using blunt dissection (décroisement aortique). The pleura is incised above the aortic arch and the blunt dissection of the oesophagus is continued upwards into the neck. Great care is taken not to damage the recurrent nerve or the membranous part of the trachea in this blunt dissection. Thoracic lymph node dissection is continued at the level of the subcarinal region and also includes the pulmonary hilar nodes and paratheaortic and aortopulmonary window nodes (Fig. 3c). Left paratracheal nodes are normally removed from behind and above the aortic arch. Enlarged brachiocephalic nodes can be palpated from the left and when judged appropriate can be removed by performing a three-field lymphadenectomy. The oesophagus is transected at the top of the chest and the gastric tube is placed in the bed of the oesophagus, brought up behind the aortic arch and fixed to the oesophageal stump using two stay sutures. Using the cervical procedure described above, the oesophagus and gastric tube can be pulled into the operating field and an anastomosis is performed.
June 17, 2009
102
14:52
B-601
ch13
FA
P. Nafteux et al.
REFERENCES 1. Hulscher JB, van Sandick JW, de Boer AG, et al. (2002) Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 347(21): 1662–1669. 2. Hulscher JB, van Lanschot JJ. (2005) Individualised surgical treatment of patients with an adenocarcinoma of the distal oesophagus or gastrooesophageal junction. Dig Surg 22(3): 130–134. 3. Ferguson MK. (2007) Ivor-Lewis esophagectomy. In: Ferguson MK (ed.), Thoracic Surgery Atlas. Philadelphia, Saunders, pp. 192–1195. 4. Launois B, Maddern G. (2006) Abdominal and right thoracic subtotal esophagectomy. In: Kaiser L, Jamieson G (eds.), Operative Thoracic Surgery, 5th ed. London, Hodder Arnold, pp. 367–377. 5. Ferguson MK. (2007) Esophagectomy via left thoracotomy. In: Ferguson MK (ed.), Thoracic Surgery Atlas. Philadelphia, Saunders, pp. 192–1195. 6. Liu JF. (2006) Left thoracic subtotal esophagectomy. In: Kaiser L, Jamieson G (eds.), Operative Thoracic Surgery, 5th ed. London, Hodder Arnold, pp. 379–395. 7. Hagen JA, DeMeester SR, Peters JH, et al. (2001) Curative resection for esophageal adenocarcinoma: analysis of 100 en bloc esophagectomies. Ann Surg 234(4): 520–530. 8. Lerut T, Coosemans W, Decker G, et al. (2005) Surgical techniques. J Surg Oncol 92: 218–229. 9. Lerut T, Nafteux P, Moons J, et al. (2004) Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma. Ann Surg 240: 962–972.
June 9, 2009
14:6
B-601
ch14
FA
chapter
14
Transhiatal Esophagectomy J. Jan. B. van Lanschot∗,† , Khe T. C. Tran† , Bas P. L. Wijnhoven† and Hugo W. Tilanus†
INTRODUCTION The best potentially curative treatment option for (advanced) esophageal carcinoma is surgical resection with or without neoadjuvant chemoradiation. For years the procedure of choice for esophageal resection has been the Ivor Lewis operation, in which the primary tumor and periesophageal tissue with adjacent lymph nodes are resected through a right-sided thoracotomy in combination with a laparotomy.1 In the last decades, two major surgical strategies to improve survival rates have emerged. To improve the cure rate, one strategy is to perform a more radical, en-bloc transthoracic resection with extended lymph node dissection. Alternatively, one could aim at a decrease in early postoperative morbidity and mortality by limiting the extent of operation. This might be achieved by a transhiatal resection, in which the esophagus is resected through a cervico-abdominal approach, thus avoiding a formal thoracotomy. Moreover, various minimally invasive ∗ Corresponding
author. of Surgery, Suite H-996, Erasmus Medical Center, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands. E-mail:
[email protected] † Department
103
June 9, 2009
14:6
104
B-601
ch14
FA
J. J. B. van Lanschot et al.
(thoracoscopically and/or laparoscopically assisted) techniques have recently been developed, but it remains to be determined whether these technically challenging approaches will lower morbidity or mortality and ultimately improve survival rates.2
TRANSHIATAL ESOPHAGECTOMY: TECHNICAL ASPECTS3 The transhiatal esophagectomy without thoracotomy has a number of practical advantages, such as short duration of operation, probably a lower incidence of pulmonary complications, and avoidance of postthoracotomy pain. This surgical approach is particularly appropriate for tumors originating from the cardia and gastroesophageal junction; via a surgically widened hiatus, the lower mediastinum can be approached. The organ for reconstruction is preferably the stomach, which is anastomosed to the remaining cervical esophagus. This can be achieved via the esophageal bed (the prevertebral route) or via the retrosternal route. The last option is preferable if a macroscopic locoregional residual tumor is left behind in the posterior mediastinum.
Operative Technique The operation is started with a median laparotomy; the incision extends from the xiphoid process to just below the umbilicus. The abdominal contents are inspected and palpated for metastases; if distant metastases are found, proceeding with a resection is contraindicated. After mobilizing the left lobe of the liver, the esophageal hiatus is visualized and inspected for tumor invasion. Subsequently, the stomach is mobilized. The esophagus is dissected in the hiatus, and, if necessary, a surrounding cuff of diaphram can be resected en-bloc with the specimen. Next, the central tendon of the right hemidiaphragm is incised, thus opening the lower mediastinum. The periesophageal fatty tissues of the left and right parietal pleura and pericardium are included in the surgical specimen (dotted line in
June 9, 2009
14:6
B-601
ch14
FA
Transhiatal Esophagectomy
105
FIGURE 1 Transhiatal esophagectomy: an early stage of the operation. After splitting the diaphragm, mobilisation of the distal esophagus, including periesophageal tissue (dotted line) is performed under direct vision. After fashioning of a gastric tube and transsecting of the esophagus in the neck, stripping of the esophagus is performed blindly using a “vein stripper”. The esophagus invaginates while the stripper is pulled distally. A string has been attached to the stripper.
Fig. 1). This procedure can be extended as far as the inferior pulmonary veins. The more proximal and, so far, unmobilized, part of the (normal) esophagus is bluntly mobilized or stripped, using a vein-stripper from the neck (Fig. 1). After completion of the intraabdominal dissection, a neoesophagus is created, preferably fashioning a 3 cm-wide tube from the stomach (Fig. 2). During this procedure, lymph nodes along the right and left gastric artery are removed. The gastric tube is pulled/pushed, via the prevertebral route, to the neck where an esophago-gastrostomy is created. When the retrosternal route is chosen, a tunnel is created by blunt retrosternal dissection
June 9, 2009
14:6
106
B-601
ch14
FA
J. J. B. van Lanschot et al.
FIGURE 2 After resecting of the lesser curvature, a gastric tube is fashioned. This tube receives its vascularization from the right gastro-epiploic artery and vein. The string, which has been pulled through the posterior mediastinum, is fixed to the top of the tube, after which the gastric tube is pulled up into the neck.
from the xiphoid process to the jugular notch. This retrosternal tunnel must be sufficiently spacious to avoid compromising the perfusion of the interposed conduit because of undue compression. This requirement sometimes necessitates resection of the sternoclavicular joint.
EVIDENCE IN FAVOR OF TRANSHIATAL OR TRANSTHORACIC APPROACH In 2001, a systematic review was published on the differences between transhiatal and transthoracic resections with respect to perioperative morbidity, early mortality and long-term survival.4 For this purpose,
June 9, 2009
14:6
B-601
ch14
FA
Transhiatal Esophagectomy
107
50 studies which were published in the English literature between 1990 and 1999 and which met the predefined quality criteria were analyzed. It was concluded that a transthoracic resection seemed to have a higher incidence of early postoperative complications and a higher hospital mortality, while there was no clear survival benefit of one approach over the other. However, this systematic review has several important limitations. First, many of the analyzed studies did not supply sufficient technical operative details. For that reason, this review compared surgical approaches rather than the extent of resection. Second, only three of the analyzed publications had a randomized study design and had included in total only 138 patients. Therefore, a large randomized trial was undertaken comparing a limited transhiatal resection and extended transthoracic resection with a two-field lymph node dissection. The limited transhiatal resection showed a lower morbidity than the extended transthoracic resected.5 After medium term follow-up, survival was not significantly different between the two groups, although there was a trend towards an improved survival in favor of the extended approach. In the final analysis of this trial after a minimum potential follow-up of five years, this trend persisted.6 In a subgroup analysis, patients with a true esophageal cancer (Siewert type-1) had an absolute 14% overall five-year survival benefit if operated via the chest. For patients with a gastroesophageal junction tumor (Siewert type-2), no survival benefit was seen for either approach. In a second subgroup analysis, especially patients with a limited number (1–8) of positive nodes in the resection specimen took advantage of an extended resection, while in patients without positive nodes and in patients with more than eight positive nodes, there was no survival difference. Based on this best available evidence, we now favor an extended transthoracic resection in patients with a type-1 tumor, unless the patient is unfit to undergo a thoracotomy. This is especially so, if there is a limited number of suspicious nodes at the preoperative staging procedures. On the other hand, we advocate a transhiatal approach in patients with a type-2 tumor at the gastroesophageal junction, unless
June 9, 2009
14:6
108
B-601
ch14
FA
J. J. B. van Lanschot et al.
there are suspicious nodes at the (supra-) carinal level, which can obviously not be removed without a thoracotomy.
REFERENCES 1. Lewis I. (1946) The surgical treatment of carcinoma of the oesophagus with special reference to a new operation for growths of the middle third. Br J Surg 34: 18–31. 2. Smithers BM, Gotley DC, Martin I, Thomas JM. (2007) Comparison of the outcomes between open and minimally invasive esophagectomy. Ann Surg 245: 232–240. 3. Lerut T, Van Lanschot JJB. (2004) Cancer of the esophagus and gastroesophageal junction; surgical aspects. In: Van Lanschot JJB et al. (eds), Integrated Medical and Surgical Gastroenterology, pp. 54–63. Thieme Verlag, Stutgartt. 4. Hulscher JBF, Tijssen JGP, Obertop H, Van Lanschot JJB. (2001) Transthoracic versus transhiatal resection for carcinoma of the esophagus: a metaanalysis. Ann Thorac Surg 72: 306–313. 5. Hulscher JBF, Van Sandick JW, De Boer AG et al. (2002) Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 347: 1662–1669. 6. Omloo JMT, Lagarde SM, Hulscher JBF, et al. (2007) Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the middle/distal esophagus: five year survival of a randomized clinical trial. Ann Surg: 246: 992–1001.
June 9, 2009
14:6
B-601
ch15
FA
chapter
15
Gastrectomy for Adenocarcinoma Hartgrink H. Hartgrink∗ and Cornelis J. H. van de Velde†
The only curative treatment for gastric adenocarcinoma is a radical resection. However, more extended treatment may lead to an increased operative morbidity and mortality. This chapter attempts to give evidence-based guidelines for the technique and extent of gastric resections. Lymph node dissections are defined according to the guidelines of the Japanese Research Society for the Study of Gastric Cancer. These guidelines are also recommended by the American Joint Committee on Cancer, and by the International Union Against Cancer. In these guidelines, 16 different lymph node compartments (stations) are identified as surrounding the stomach (Fig. 1). In general, the perigastric lymph node stations along the lesser (stations 1, 3, and 5) and greater (stations 2, 4, and 6) curvature are grouped as N1, while the nodes along the left gastric (station 7), common hepatic (station 8), celiac (station 9), and splenic (stations 10 and 11) arteries are grouped as N2. D1 dissection entails removal of the involved part of the stomach (distal or total), and the N1 lymph nodes including the greater and lesser omentum. For D2 dissection the N2 lymph nodes are also removed.
∗ Corresponding
author. of Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands. E-mail:
[email protected] † Department
109
June 9, 2009
14:6
110
B-601
ch15
FA
H. H. Hartgrink and C. J. H. van de Velde
FIGURE 1 Lymph node stations surrounding the stomach. 1 = right cardial nodes; 2 = left cardial nodes; 3 = nodes along the lesser curvature; 4 = nodes along the greater curvature; 5 = suprapyloric nodes; 6 = infrapyloric nodes; 7 = nodes along the left gastric artery; 8 = nodes along the common hepatic artery; 9 = nodes around the celiac axis; 10 = nodes at the splenic hilus; 11 = nodes along the splenic artery; 12 = nodes in the hepatoduodenal ligament; 13 = nodes at the posterior aspect of the pancreas head; 14 = nodes at the root of the mesenterium; 15 = nodes in the mesocolon of the transverse colon; 16 = para-aortic nodes.
In order to perform adequate surgery for gastric cancer, a wide operative field should be achieved. Although several abdominal incision lines can be used, we prefer the vertical incision. With strong retractors the costal arches are pulled upwards. First, the greater
June 9, 2009
14:6
B-601
ch15
FA
Gastrectomy for Adenocarcinoma
111
FIGURE 2 When the left gastric artery is divided at its origin, nodes at the celiac and splenic artery can be dissected (stations 9 and 10).
omentum is divided from the transverse colon. It will be removed en bloc with the stomach. The right gastroepiploic artery is divided at its origin. The lesser omentum is divided as close to the liver as possible and the right gastric artery ligated. The duodenum is mobilised from the gastroduodenal artery and divided with a stapling device distally to the pylorus. Now the lymph nodes along the hepatic artery can be dissected (stations 8 and 12). Following the hepatic artery will lead one to the left gastric artery, which is divided at its origin. Now lymph nodes along the celiac axis and the splenic artery can now be removed (stations 9 and 11) (Fig. 2). In a partial gastrectomy, all branches of the left gastric artery towards the stomach from the peritoneal plica over the oesophagus until as far as the resection line are ligated and divided (Fig. 3).
June 9, 2009
14:6
112
B-601
ch15
FA
H. H. Hartgrink and C. J. H. van de Velde
FIGURE 3 Branches of the left gastric artery are ligated and divided.
Total gastrectomy has a higher morbidity and hospital mortality rate than partial gastrectomy. A randomised trial in Italy showed that there is no survival benefit from total gastrectomy if resection margins are free of tumour.1 Total gastrectomy should be performed only if the site of the cancer does not allow a partial gastrectomy to be performed. Frozen sections of the resection margins are recommended.2 For many years it has been debated whether an extended lymph node dissection (D2) for gastric cancer is beneficial. Theoretically, removal of a wider range of lymph nodes by extended lymph node dissection increases the chance of a cure. Such resection, however, may be irrelevant if there are no lymph nodes affected or if the cancer has developed into a systemic disease, or if it increases morbidity and mortality substantially. Of five randomised studies,3–7 only the most recent one shows a significant overall survival benefit for extended lymphadenectomy.7 In the Dutch D1–D2 trial it has been shown that for patients with N2 disease, there is a significant benefit from a D2 dissection.6 The main problem, however is to identify these
June 9, 2009
14:6
B-601
ch15
FA
Gastrectomy for Adenocarcinoma
113
patients preoperatively. Furthermore, the cancer-related death rate in the Dutch study is higher in the D1 dissection group than in the D2 dissection group. The removal of too little lymph nodes may, however, an insufficient, diminish survival.8 It is recommended that at least 15 lymph nodes should be removed, preferably more. Splenectomy and pancreatectomy are important risk factors for morbidity and hospital mortality after D2 dissection. Randomised trials in Chili, Korea, found no survival benefit from a splenectomy in patients with total gastrectomy whereas morbidity was significantly increased.9,10 One Japanese trial is ongoing,11 two previous Japanese studies showed no beneficial effect on survival if pancreatosplenectomy was combined with total gastrectomy, whereas morbidity was increased in these patients.12,13 In the Dutch study, patients who did not require additional pancreatectomy and/or splenectomy still had increased morbidity and hospital mortality after D2 dissection, but there also was a significant survival advantage for the D2 dissection group. There seems to be a survival benefit from an extended lymph node dissection if morbidity- and mortalityincreasing procedures like pancreatectomy and splenectomy can be avoided. The main reason for performing a pancreatectomy and splenectomy with a D2 dissection is to allow an adequate dissection of stations 10 and 11. However, metastasis in these lymph nodes, means a poor prognosis. In the Dutch study, patients with metastasis at stations 10 and 11 had a survival rate at 11 years of 8% and 11% respectively, whereas patients without metastass had a survival rate of 27% and 35% respectively.6 So the relevance of the dissection of these nodes has to be questioned as the survival benefit is small and morbidity and hospital mortality are significantly increased. Adjuvant chemotherapy for gastric cancer was analysed in metaanalysis showing a significant but very small advantage. However, perioperative chemotherapy as tested in the MAGIC study has shown a significant advantage in overall survival of 13%.14 At this moment the ECX and EOX seem to be the most effective treatment regimens.15
June 9, 2009
14:6
114
B-601
ch15
FA
H. H. Hartgrink and C. J. H. van de Velde
The use of adjuvant radiochemotherapy was shown to be beneficial in the study16 and is now the standard treatment in the US. This study was criticised for the poor surgery performed (54% D0 resections). In the Netherlands, the CRITICS randomised trial is now underway to evaluate the use of adjuvant radiochemotherapy after adequate surgery and neoadjuvant chemotherapy. Sweden is also participating in this study, and probably other countries will join in soon. In conclusion, partial gastrectomy is sufficient treatment if the resection margins are free of tumour. At least 15 lymph nodes should be removed. Extended lymph node dissection is probably beneficial if morbidity- and mortality-increasing procedures like pancreatectomy and splenectomy can be avoided. The pancreas and spleen should be removed only if they are invaded by tumour. Perioperative chemotherapy is recommended. The benefit of adjuvant radiochemotherpy is under further investigation.
REFERENCES 1. Bozzetti F, Marubini E, Bonfanti G, et al. (1999) Subtotal versus total gastrectomy for gastric cancer: five-year survival rates in a multicenter randomised Italian trial. Ann Surg 230: 170–178. 2. Songun I, Bonenkamp JJ, Hermans J, van Krieken JHJM, van de Velde CJH, and the Cooperative Investigators of the Dutch Gastric Cancer Trial. (1996) Prognostic value of resection-line involvement in patients undergoing curative resections for gastric cancer. Eur J Cancer 32A: 433–437. 3. Dent DM, Madden MV, Price SK. (1988) Randomized comparison of R1 and R2 gastrectomy for gastric carcinoma. Br J Surg 75: 110–112. 4. Robertson CS, Chung SCS, Woods SDS, et al. (1994) A prospective randomized trial comparing R1 subtotal gastrectomy with R3 total gastrectomy for antral cancer. Ann Surg 220: 176–182. 5. Cuschieri A, Weeden S, Fielding J, et al. (1999) Patient survival after D1 and D2 resections for gastric cancer: long-term results of the MRC randomized surgical trial. Br J Cancer 79: 1522–1530.
June 9, 2009
14:6
B-601
ch15
FA
Gastrectomy for Adenocarcinoma
115
6. Hartgrink HH, van de Velde CJH, Putter H, et al. (2004) Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomised Dutch Gastric Cancer Group trial. J Clin Oncol 22: 2069–2077. 7. Wu CW, Hsiung CA, Lo SS, et al. (2006) Nodal dissection for patients with gastric cancer: a randomized controlled trial. Lancet Oncol 7: 309–315. 8. Huhndahl SA, Peeters KC, Kranenbarg EK, et al. (2007) Improved regional control and survival with “low Maruyama Index” surgery in gastric cancer: autopsy findings from the Dutch D1–D2 trial. Gastric Cancer 10: 84–86. 9. Csendes A, Burdiles P, Rojas J, et al. (2002) A prospective randomized study comparing D2 total gastrectomy versus D2 total gastrectomy plus splenectomy in 187 patients with gastric carcinoma. Surgery 131: 401–407. 10. Yu W, Choi GS, Chung HY. (2006) Randomized clinical trial of splenectomy versus splenic preservation in patients with proximal gastric cancer. Br J Surg 93: 559–563. 11. Sano T, Yamamoto S, Sasako M, for the Japan clinical oncology group. (2002) Randomised controlled trial to evaluate splenectomy in total gastrectomy for proximal gastric carcinoma. Jpn J Clin Oncol 32: 363–364. 12. Kodera Y, Yamamura Y, Shimizu Y, et al. (1997) Lack of benefit of combined pancreaticosplenectomy in D2 resection for proximal-third gastric carcinoma. World J Surg 21: 622–628. 13. Kitamura K, Nishida S, Ichikawa D, et al. (1999) No survival benefit from combined pancreaticosplenectomy and total gastrectomy for gastric cancer. Br J Surg 86: 119–122. 14. Cunningham D, Allum WH, Stenning SP, et al. (2006) Perioperative chemotherapy versus surgery alone for resectable gastroesophageal cancer. N Engl J Med 6: 11–20. 15. Cunningham D, Starling N, Rao S, et al. (2008) Capecetabine and oxaliplatin for advanced esophagogastric cancer. N Engl J Med 358: 36–46. 16. Macdonald JS, Smalley SR, Benedetti J, et al. (2001) Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J Med 345: 725–730.
June 9, 2009
14:6
B-601
ch16
FA
chapter
16
Stenting Gastro-Oesophageal Tumours Els M. L. Verschuur† , Frank P. Vleggaar ∗ and Peter D. Siersema∗,†
INTRODUCTION Despite recent advances in the curative treatment of oesophageal and gastric cardia cancer,1 more than 50% of patients have inoperable disease at presentation. For these patients, palliative treatment to relieve progressive dysphagia is usually the only treatment option. Selfexpanding stents are commonly used for the palliation of dysphagia due to irresectable primary carcinoma of the mid and distal oesophagus and gastric cardia.2 Stents are also effective in patients with complicated (oesophagorespiratory fistulas, or malignant tumours near the upper oesophageal sphincter) and recurrent oesophagogastric cancer after surgery.3,4 The aim of stent placement is to improve food intake, which, as a consequence, is associated with a positive effect on the experienced quality of life of patients.5 It has been demonstrated that stent placement should primarily be reserved for patients with dysphagia and a short life expectancy ∗ Corresponding
author. Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, The Netherlands. † Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands. E-mail: p.d.siersema@ umcutrecht.nl 117
June 9, 2009
14:6
118
B-601
ch16
FA
Els M. L. Verschuur et al.
(≤3 months), needing rapid relief, but also for patients with persistent or recurrent tumour after a single dose intraluminal radiotherapy (brachytherapy).6,7
TECHNIQUE Stents Covered stents are now the most frequently used in patients with oesophageal and gastric cardia cancer. The ideal stent would have the following characteristics: • It would have a large internal diameter to ensure the passage of a normal diet; • It would be flexible and non-traumatic while still achieving full expansion; • It would not migrate, yet could be repositioned or removed if necessary. Although this ideal stent does not exist, all available covered stents do meet some of these criteria (Table 1).
Stent placement procedure (video) Stent placement is usually done with the patient under conscious sedation with midazolam. The first step is to identify the upper and lower ends of the tumour (Fig. 1). If tumour obstruction does not allow passage of a standard diameter (8–10 mm) endoscope, either the tumour should be dilated to a maximum of 10–12 mm or, preferably, the standard endoscope should be changed for a small diameter (4.9–5.9 mm) endoscope to measure stricture length and to place a guidewire for stent placement. Dilation may increase the risk of perforation; however, there is no consensus on whether stepwise dilation in more than one session will lower the perforation risk.
Ultraflex
Cover Partial
Length (cm)
Characteristics of Currently Used Covered Self-expanding Stents
Diameter (mm)
Radial Force
Degree of Flexibility Material Stent and Shortening Cover
10, 15
prox.: 28/mid:20 High
20–30%
Medium
Flamingo Wallstent
Partial
12 14
prox.: 23/dist.:16 High prox.: 30/dist.:20
20–30%
Medium
Z stent
Complete 6, 8, 10, 12, 14
prox.: 25/mid:18 Medium No prox.: 25/mid:23
Low
Choo stent
Complete 8, 11, 14
prox.: 22/mid: 18 Medium No
Low
Polyflex
Complete 9, 12, 15
Low
Alimaxx-E
Complete 7, 10, 12
prox.: 20/mid: 16 High 20–30% prox.: 23/mid: 18 prox.: 25/mid: 21 prox.: 24/mid: 22 Medium 10–20% prox. 20/mid: 18
SX-Ella
Complete 8.5, 13.5
Niti-S
Complete 9, 12, 15
11,
High
prox.: 25/mid: 20 High
5–10%
Medium
prox.: 26/mid: 18 High
10–20%
Medium
Boston Scientific, Natick, USA
Nitinol with polyurethane cover Nitinol with polyethylene cover Nitinol with polyurethane cover
Alveolus, Charlotte, USA
Boston Scientific, Natick, USA Bosten Scientific, Natick, USA Wilson Cook, Winston-Salem, USA M.I. Tech, Seoul, South Korea Boston Scientific, Natick, USA
119
Ella-CS, Hradec Kralove, Czech Republic Taewong Medical, Seoul, South Korea
FA
Wallstent II Partial
Nitinol with polyurethane cover Stainless steel with silicone cover Elgiloy with polyethylene cover Stainless steel with polyethylene cover Stainless steel with polyurethane cover Polyester + silicone
ch16
High
B-601
prox.: 28/mid:23 Medium 30–40% prox.: 23/mid:18
Company
Stenting Gastro-Oesophageal Tumours
10, 12, 15
14:6
Stent Type
June 9, 2009
Table 1
June 9, 2009
14:6
120
B-601
ch16
FA
Els M. L. Verschuur et al.
FIGURE 1 The first step of oesophageal stent placement is to identify the upper and lower ends of the tumour. In this figure, a patient with a gastric cardia tumour is shown in retroversion.
When fluoroscopy is used, the proximal and distal margins of the stricture are demarcated by placing skin markers or intraoesophageal clips, or by the intramucosal injection of a radiopaque contrast agent. Injection of the lipid-soluble contrast agent lipiodol results in a persistent mark (Fig. 2). The next step is to place a stiff guidewire, such as a 0.038-inch Savary guidewire or 0.035-inch Amplatz guidewire, across the stricture into the stomach or, preferably, the duodenum and withdraw the endoscope. The stent is then carefully advanced over the guidewire. Most stents shorten during expansion (Table 1), which must be taken into consideration when positioning the introduction system. In order to prevent stent migration upon release from the introduction system, the system should not be advanced too distally. A stent no longer than 2–4 cm of the stricture length should be used, to allow for a 1–2 cm extension above and below the proximal and distal tumour margins. For stents placed across the gastro-oesophageal (GE) junction, stent length is guided by the rule that the proximal part of the stent should
June 9, 2009
14:6
B-601
ch16
FA
Stenting Gastro-Oesophageal Tumours
121
FIGURE 2 The proximal and/or distal margins of the tumour can be demarcated by the intramucosal injection of the lipid-soluble contrast agent lipiodol. In this figure, the upper end of a gastric cardia tumour (at the gastro-oesophageal junction) is demarcated.
lie at least 2–3 cm above the tumour margin, whereas the distal part should not overlap the tumour margin by more than 1 cm, to prevent ulceration of the posterior wall of the stomach by the distal end of the stent and avoid kinking of the stent, which could hinder food passage. Stents can be placed under fluoroscopic control and/or endoscopic control, or using the markers on the stent introduction system, as is the case with Ultraflex stents (Boston Scientific, Natick, USA) and SX Ella stents (Ella-CS, Hradec Kralove, Czech Republic). There is no objection to confirming endoscopically that the upper stent end is placed proximal enough and distal enough from the upper tumour margin; however, one should avoid passing the endoscope through the stent, as stent dislodgement caused by friction between the insufficiently deployed stent and the endoscope can be a consequence. Stent expansion can be confirmed endoscopically under direct vision (Fig. 3), by fluoroscopy, or, afterwards, with a barium swallow. Stent placement is an outpatient procedure which takes about 15–20 minutes. We prefer to prescribe high-dose proton pomp
June 9, 2009
14:6
122
B-601
ch16
FA
Els M. L. Verschuur et al.
FIGURE 3 Stent expansion can be confirmed endoscopically under direct vision.
inhibitors to patients for whom the distal end of the stent is positioned across the GE junction to prevent GE reflux after the procedure. Alternatively, a stent with an anti-reflux mechanism, such as a Z stent with a Dua valve (Wilson Cook, Winston-Salem, USA) or a Do stent (M.I. Tech, Pyongtack, Korea), can be used. In addition, all patients should be provided with eating instructions, such as thorough chewing of food and taking effervescent drinks between bites and after meals, to flush the stent. There is not a single stent that fits all patients with malignant dysphagia. The choice of stent type depends on the location (proximal vs. more distal), length and characteristics (extrinsic vs. exophytic; benign vs. malignant) of the tumour. In the case where a stent has migrated into the stomach, the first step is to re-position the stent, but if this is not successful, another stent design should be inserted or an alternative treatment should be used to adequately treat the symptoms. Additional stent placement is also the treatment of choice in patients with tumoural or nontumoural in- or overgrowth, whereas endoscopic cleansing of the stent is preferred if food obstruction occurs.2−4,8,9
June 9, 2009
14:6
B-601
ch16
FA
Stenting Gastro-Oesophageal Tumours
123
DISCUSSION Stent placement is a relatively easy procedure in patients with obstructing oesophageal or gastric cardia cancer. The technical success rate for metal stent placement is, in general, close to 100%. Causes of technical failure include severe pain during placement, extensive tumour growth in the stomach, failure of the stent to release from the introduction system and immediate stent migration due to tumour characteristics or resulting from placement of the stent too distally. Almost all patients experience improvement of dysphagia and this will remain stable until a specific complication (such as perforation, haemorrhage and fistula formation) or recurrent dysphagia (such as stent migration, tumoural or nontumoural in- or overgrowth, and food obstruction) occurs. The dysphagia score usually improves from a median of 3 (liquids only) to 1 (some difficulties with solids). Over the last few years, no differences have been reported in complication rates regardless the stent type, whereas some stent types effectively reduce recurrent dysphagia.4,8−10 In conclusion, stent placement is a safe and effective procedure in patients with dysphagia from inoperable oesophageal or gastric cardia cancer.
REFERENCES 1. Stein HJ, Siewert JR. (2004) Improved prognosis of resected esophageal cancer. World J Surg 28: 520–525. 2. Siersema PD, Marcon N, Vakil N. (2003) Metal stents for tumors of the distal esophagus and gastric cardia. Endoscopy 35: 79–85. 3. Siersema PD, Schrauwen SL, van Blankenstein M, et al. (2001) Selfexpanding metal stents for complicated and recurrent esophagogastric cancer. Gastrointest Endosc 54: 579–586. 4. Verschuur EML, Kuipers EJ, Siersema PD. (2007) Esophageal stents for malignant strictures close to the upper esophageal sphincter. Gastoinstest Endosc 66: 1082–1090. 5. Homs MY, Essink-Bot ML, Borsboom GJJM, et al. (2004) Quality of life after palliative treatment for esophageal carcinoma: a prospective
June 9, 2009
14:6
124
6.
7.
8.
9.
10.
B-601
ch16
FA
Els M. L. Verschuur et al.
comparison between stent placement and single dose brachytherapy. Eur J Cancer 40: 1862–1871. Homs MY, Steyerberg EW, Eijkenboom WM, et al. (2004) Single-dose brachytherapy versus metal stent placement for the palliation of dysphagia from oesophageal cancer: multicentre randomised trial. Lancet 364: 1497–1504. Steyerberg EW, Homs MY, Stokvis A, et al. (2005) Stent placement or brachytherapy for palliation of dysphagia from esophageal cancer: a prognostic model to guide treatment selection. Gastrointest Endosc 62: 333–340. Verschuur EML, Repici A, Kuipers EJ. (2008) New esophageal stents for the palliation of dysphagia from esophageal or gastric cardia cancer: a randomized trial. Am J Gastroenterol 103: 304–312. Verschuur EML, Steyerberg EW, Kuipers EJ, Siersema PD. (2007) Effect of stent size on complications and recurrent dysphagia in patients with esophageal or gastric cardia cancer. Gastoinstest Endosc 65: 592–601. Verschuur EM, Homs MY, Steyerberg EW, et al. (2006) A new esophageal stent design (Niti-S stent) for the prevention of migration: a prospective study in 42 patients. Gastrointest Endosc 63: 134–140.
June 9, 2009
14:6
B-601
ch17
FA
chapter
17
Total Pancreatectomy Jens Werner∗,† and Markus W. Büchler†
INTRODUCTION In the 1960s and 1970s, dissatisfaction with the early results of pancreatoduodenectomy for cancer of the head of the pancreas led surgeons to look for an alternative operation. Total pancreatectomy (TP) was proposed by some as a rational choice for some reasons. It can eliminate multifocal disease and achieve wider resection margins. It can also achieve a more extensive lymphadenectomy. And, finally, it allows one to avoid complications from the pancreatic remnant. However, in practice, the use of TP to reduce hospital mortality and improve prognosis proved disappointing.1 Therefore, TP was abandoned by many surgeons as a standard operation for pancreatic disease. The fear of performing TP was especially increased by reports of patients with brittle diabetes mellitus, and severe malabsorption secondary to the loss of exocrine pancreatic tissue. However, advances in peri- and postoperative management as well as surgical techniques in recent years have allowed one to ∗ Correspondind
author.
† Department of General, Visceral, and Transplant Surgery, University of Heidelberg,
INF 110, 69120 Heidelberg, Germany. E-mail:
[email protected].
125
June 9, 2009
14:6
126
B-601
ch17
FA
J. Werner and M. W. Büchler
perform TP with a morbidity and mortality comparable to that of other pancreatic resection procedures.2,3 The limitations caused by the ensuing insulin-dependent diabetes mellitus do not justify avoiding TP in selected patients. The indications for TP today include: • Oncological. To achieve an R0 resection in extended or multifocal adenocarcinoma of the pancreas.4 Similarly, longitudinal involvement of the pancreatic duct in some cases of intraductal papillary mucinous neoplasia (IPMN).3,4 • Chronic pancreatitis. In some patients with chronic pancreatitis, TP without or after previous partial pancreatic resection is indicated for recurrent complications of the disease.3,6,7 • Technical. TP might be indicated in the presence of an atrophic, soft and friable pancreatic remnant which does not hold sutures.8 Similarly, completion pancreatectomy might be necessary in cases of postoperative anastomotic complications.3 • Prophylactical. Patients with hereditary pancreatic cancer, hereditary chromic pancreatitis, or other known premalignant lesions in the pancreas and a considerable risk of developing pancreatic cancer.3,9
TECHNIQUE Initially, a wide Kocher manoeuvre is performed to assess the retroperitoneum, as well as to appraise the tumour and its relations to the SMA. We proceed with the resection only if we find no evidence that will preclude an R0 resection. The first steps are identical to the technique used for a pancreatic head resection. Access into the lesser sac is achieved by division of the gastrocolic ligament. On the left side, we divide the gastrocolic ligament only as far as the most medial branch of the short gastric vessels. This is to ensure an alternative venous drainage for the splenic blood flow in the event of any venous resection of the SMV-PV trunk. The gastrocolic venous trunk of Henle will be encountered here and, by
June 9, 2009
14:6
B-601
ch17
FA
Total Pancreatectomy
127
tracing it down, it will lead to the SMV. The gastroepiploic vein is then divided where it empties into the gastrocolic trunk. The SMV is then traced to the inferior margin of the pancreas. Cholecystectomy is performed, and the common bile duct transected just cephalic to the cystic duct. The proper hepatic artery is then identified and looped. The gastroduodenal artery can be isolated and dissected. Nodal tissues surrounding the proper hepatic artery and the common hepatic artery are excised. If preservation of the pylorus is planned, the right gastric and right gastroepiploic arteries are divided, and the duodenum is skeletonised beyond the pylorus and divided using a linear stapler. A tunnel is cautiously created between the SMV-PV trunk posteriorly and the pancreatic neck anteriorly. A silicon drain is then insinuated into this tunnel to loop up the neck. TP is performed en bloc in those cases where the tumour involves the whole pancreas (e.g. some cases of IPMN; Fig. 1) or in the cases described above. In patients with adenocarcinoma of the head of the pancreas, the pancreas is normally divided on the left margin of the portal vein for a Whipple procedure, and pancreatectomy completed in those cases with a positive resection margin. If venous resection is required, it is reserved as the last step in the extirpative phase and the resection is performed en bloc. To gain the best vascular control,
FIGURE 1 Pancreatectomy specimen: IPMN which involves the whole pancreas.
June 9, 2009
14:6
128
B-601
ch17
FA
J. Werner and M. W. Büchler
mobilisation of the left pancreas is performed in those cases to control the superior mesenteric, portal, and splenic vein before resection. If a TP is necessary because of cancer involvement of the distal stump, we resect the pancreas together with the spleen in order to ensure radicality. The short gastric vessels are divided. The splenic artery is divided at its origin, while the splenic vein is divided at its confluence with the SMV-PV trunk using a vascular stapler or just with suture closure. The distal pancreatic stump, together with the underlying splenic vein, is then retracted to the left, and the specimen dissected off the retroperitoneum towards the spleen. The IMV is ligated and divided. The last step is the division of the lienorenal ligament. We preserve the spleen in all cases where there is no oncological need for splenectomy, because of the potential deterioration of the immunological and haematological functions as well as the risk of portal thrombosis. In our series this has been the case in 33%. All the short gastric vessels are preserved, in case the splenic vessels need to be divided. This is followed by the tedious process of ligating or clipping, and cutting the multiple branches that connect the splenic vein and the splenic artery to the pancreas in the attempt to preserve both the splenic artery and the splenic vein. The pylorus is preserved in the same manner as we would in pylorus-preserving pancreatoduodenectomy. A distal gastrectomy is performed only if necessary secondary to oncological reasons or if the perfusion is compromised. Portal vein or superior mesenteric vein resection should be performed whenever necessary to achieve an R0 resection in pancreatic cancer. Vein resections can be performed with low morbidity and the reconstruction is performed either by direct end-to-end anstomosis or by vascular reconstruction with a Gore-tex graft. Secondary to the risk of graft thrombosis, grafts should only be used in cases where direct anstomosis is technically not possible. Since TP for adenocarcinoma is mainly indicated in more advanced cancers, venous resection has been performed in 26% of our patients.
June 9, 2009
14:6
B-601
ch17
FA
Total Pancreatectomy
129
FIGURE 2 Reconstruction after total pancreatectomy: biliodigestive (hepaticojejunal) anastomosis with a retrocolic jejunal limb. An antecolic end-to-side duodenojejunostomy is performed about 50–60 cm downstream from the bilioenteric anastomosis.
Reconstruction after TP consists of an interrupted end-to-side single-layer hepaticojejunal anastomosis with a retrocolic jejunal limb. An antecolic end-to-side duodenojejunostomy is then constructed about 50 cm downstream from the bilioenteric anastomosis (Fig. 2).
DISCUSSION Safety As there is no survival advantage for TP, most surgeons practise partial pancreatic resection for right-sided lesions, reserving TP for lesions extensively involving the gland or the rare situation in which the pancreas remnant is too inflamed, friable or soft for one to safely perform a pancreaticojejunostomy. However, today, an elective TP can be
June 9, 2009
14:6
130
B-601
ch17
FA
J. Werner and M. W. Büchler
performed with a perioperative morbidity and mortality comparable to that of other pancreatic resections.3
Oncological Advantage A curative resection (R0) is the single most important factor determining the outcome in patients with pancreatic adenocarcinoma.4 Hence, positive resection margins on frozen-section surgical margin analysis remains one of the few indications for us to proceed with a TP. Similarly, longitudinal involvement of the pancreatic duct in cases of IPMN is another reason for us to cut back until lesion-free margins are obtained, and on some occasions TP becomes necessary. Nevertheless, recent evidence has shown that the presence of atypia or carcinomain-situ at the ductal resection margin was not associated with a poor outcome,5 suggesting the abandonment of this practice with clear margins in cases of IPMN. However, most centres, including ours, believe that surgical resection should be tailored to the longitudinal spreading into the pancreatic duct, as established by routine frozensection of the surgical margins.
Functional Consequences Avoidance of TP prevents the inevitable total loss of exocrine and endocrine function and allows preservation of the spleen. Besides rendering a patient diabetic, TP takes a nutritional toll as a consequence of the loss of exocrine function, leading to persistent diarrhoea and steatorrhoea. If TP is accompanied by gastric resection vis-à-vis a standard Whipple, there will be further nutritional compromise due to decreased dietary intake as a result of the loss of gastric reservoir function. However, recent series have demonstrated that despite limitations caused by the ensuing insulin-dependent diabetes mellitus, the overall quality of life is acceptable.3,6 In fact, some centres advocate the combination of TP with islet autotransplantation for chronic pancreatitis.7
June 9, 2009
14:6
B-601
ch17
FA
Total Pancreatectomy
131
CONCLUSION In conclusion, the limitations do not justify avoiding total pancreatectomy in patients in whom the complete removal of the pancreas is required for oncological, technical, prophylactical or complicationsrelated reasons. Total pancreatectomy is a viable option in selected patients.
REFERENCES 1. Grace PA, Pitt HA, Tompkins RK, et al. (1986) Decreased morbidity and mortality after pancreatoduodenectomy. Am J Surg 151: 141–149. 2. Billings BJ, Christein JD, Harmsen WS, et al. (2005) Quality of life after total pancreatectomy: is it really that bad on long-term follow-up? J Gastrointest Surg 9: 1059–1066. 3. Müller MW, Friess H, Kleeff J, et al. (2007) Is there still a role for total pancreatectomy? Ann Surg 246: 966–975. 4. Wagner M, Redaelli C, Lietz M, et al. (2004) Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma. Br J Surg 91: 586–594. 5. D’Angelica M, Brennan, MF, Suriawinata AA, et al. (2004) Intraductal papillary mucinous neoplasms of the pancreas: an analysis of clinicopathologic features and outcome. Ann Surg 239: 400–408. 6. Behrmann SW, Mulloy M. (2006) Total pancreatectomy for the treatment of chronic pancreatitis: indications, outcomes, and recommendations. Am Surg 72: 297–302. 7. Blondet JJ, Carlson AM, Kobayashi T, et al. (2007) The role of total pancreatectomy and islet autotransplantation for chronic pancreatitis. Surg Clinics North Am 87: 1477–1502. 8. Büchler MW, Wagner M, Schmied BM, et al. (2003) Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 138: 1310–1314. 9. Brentnall TA. (2005) Management strategies for patients with hereditary pancreatic cancer. Curr Treat Options Oncol 6: 437–445.
June 9, 2009
14:6
B-601
ch18
FA
chapter
18
Radiofrequency Ablation in the Treatment of Liver Tumours Joris Joosten∗,† and Theo Ruers†
INTRODUCTION Surgical resection is still considered the gold standard for the treatment of malignant liver tumours. However, only a selected group of patients is amenable to resection. Several local tumour ablative techniques may offer an alternative therapeutic option in the case of non-resectable liver tumour. These techniques can be used either alone or in combination with resection. Among all local ablative techniques, radiofrequency ablation (RFA) is the most widely used. This technique is easy to perform and morbidity is low. Less commonly used techniques, with variable results in different series, are percutaneous ethanol injection (PEI), transarterial chemoembolisation (TACE), cryosurgery and laser-induced thermotherapy (LITT). Liver tumours of all origins can be treated by RFA. Where the technique has shown to be effective in hepatocellular carcinoma and ∗ Corresponding author. Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands. E-mail:
[email protected] † Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands. E-mail:
[email protected]
133
June 9, 2009
14:6
134
B-601
ch18
FA
J. Joosten and T. Ruers
neuroendocrine tumours, its efficacy in patients with colorectal liver metastases is still debatable.
TECHNIQUE AND RESULTS Radiofrequency current in tumour treatment was first described around 1910, when Beer and Clark treated bladder, breast and skin cancers. The basic idea behind local tumour ablation in liver tumours is to selectively destroy tumour tissue (including a rim of normal tissue around the tumour) without significant damage to vascular structures in the remaining liver and hence consequent loss of large areas of normal liver tissue. During RFA a small electrode is placed within the tumour, enabling the delivery of radiofrequency energy directly to the tissue. Radiofrequency current generates ionic agitation, which is converted into frictional heat. Tissue damage already occurs at temperatures above 42◦ C. Above 60◦ C denaturation of cellular proteins starts and cell damage is irreversible. At the moment there is a great variety in RFA electrodes and electrode systems. In general plain, cooled, expandable, wet and bipolar electrodes can be recognised. Also, there are electrode designs using double combinations like cooled–wet or expandable–wet electrodes. Even triple combination electrodes are on the market. Electrode systems can be used with one or multiple electrodes, and also the electric mode in which they are used is variable. In the monopolar mode all electrodes have the same polarity and current flows in the same direction to the grounding pad. Using bipolar electrode systems, the current flows between two or more parallel-inserted electrodes. A major problem when one is comparing different reports on RFA is the lack of uniformity and incomplicity in which the used RFA techniques are described. Evidently there was a strong need for standardisation of terminology and reporting criteria, as were recently provided by the International Working Party on Imageguided Tumour Ablation.1
June 9, 2009
14:6
B-601
ch18
FA
Radiofrequency Ablation in the Treatment of Liver Tumours
135
It has to be stated that with the (ongoing) developments in radiofrequency equipment, data from the early days of RFA are less convincing then recent results, which show much better total tumour ablation, less local recurrence and greater ablation zones even at difficult anatomic sites. RFA can be performed in several ways: percutaneously, laparoscopically and by laparotomy.2–4 The open and laparoscopic approach may have several advantages. First, during the open approach, RFA of non-resectable lesions can be performed in combination with resection of lesions that cannot be treated effectively by RFA because of their large size. Second, laparotomy or laparoscopy allows thorough evaluation of the extent of liver involvement by inspection and intraoperative ultrasound. Third, during open and laparoscopic RFA adjacent organs can easily be protected from burn injuries. The advantages of percutaneous techniques are obvious: less surgical trauma, shorter hospital stay and lower costs. It is also easier to repeat percutaneous treatment in the case of residual tumour or recurrence. The main disadvantage of such treatment seems to be that it is less reliable, especially for larger lesions and superficial lesions. For all approaches, correct positioning of the RFA probe is crucial, which requires honed skills. Poon et al. have described a clear learning curve for RFA percutaneously as well as surgically.5 In their first 50 patients complete tumour ablation was achieved in 85% (most incomplete ablations in percutaneously treated patients), while in the next 50 patients 100% tumour ablation was accomplished.
Postoperative Follow-up Imaging After local ablative treatment, a contrast-enhanced CT scan is generally used for follow-up. More recently, the FDG-PET scan has been used to follow up local ablative treatment. After successful treatment metastatic lesions become photopenic. Persistent activity after local tumour treatment is highly suspicious, suggesting inadequate treatment. Moreover, the reappearance of activity in photopenic areas is strongly indicative of tumour recurrence.6
June 9, 2009
14:6
136
B-601
ch18
FA
J. Joosten and T. Ruers
Complications Mulier et al. have reported in an extensive review on the complication rates in 3670 patients, treated for a variety of liver tumours by RFA either percutaneously, laparoscopically or during laparotomy.7 The complication rates were 7.2%, 9.5% and 9.9% respectively. The mortality rate during percutaneous RFA was 0.5% and zero for both of the other approaches. The most-encountered complications were intra-abdominal bleeding (1.6%), abdominal infection (1.1%) and biliary tract damage (1.0%). Other complications, which occurred less frequently, were pulmonary-related complications, dispersive pad skin burns, liver failure, visceral damage and hepatic vascular damage. When RFA was combined with resection, mortality and morbidity rates were comparable to those for patients treated by resection alone — 4.5% and 31.8%, respectively. The authors conclude that although the complication rate after RFA is low, it is higher than assumed and many complications can be prevented.
Local Recurrence A meta-analysis of the local recurrence rate after hepatic RFA was recently published by Mulier et al.8 Amongst others, this series comprised hepatocellular carcinoma (2369 lesions), unspecified lesions (1046) and colon cancer metastases (763 lesions). In a multivariate analysis, significantly less local recurrences were observed for small size lesions (P < 0.001) and for lesions treated using a surgical (versus percutaneous) approach (P < 0.001). Moreover, lesions close to vascular structures or located subcapsularly showed a higher tendency for recurrence. Except for neuroendocrine tumours that showed a more favourable local recurrence rate, histology of the lesions was of less importance. In an earlier analysis the same authors described 806 patients with colorectal liver metastases treated by RFA.9 For tumours <3 cm, the
June 9, 2009
14:6
B-601
ch18
FA
Radiofrequency Ablation in the Treatment of Liver Tumours
137
FIGURE 1 Introduction of radiofrequency probe into metastases.
local recurrence rate after the open or laparoscopic approach was zero versus 19% for the percutaneous approach. For lesions > 3 cm, the local recurrence rate after the open or laparoscopic approach was 20% versus 51% for the percutaneous approach. However, most percutaneous RFA procedures were performed under ultrasound guidance; series that report MRI-guided or CT-guided RFAprocedures generally report better local control rates.
Overall Survival A five-year survival of 18.4% is described in the largest and longest follow-up study of RFA in colorectal metastases.10 Strong predictors of survival are the number and dominant size of the metastases and the preoperative CEA level. In general, one-year overall survival after radiofrequency of non-resectable colorectal liver metastases varies between 80% and 93%, two-year overall survival is reported as between 50% and 75%, and three-year overall survival varies between 21% and 53%.11,12
June 9, 2009
14:6
138
B-601
ch18
FA
J. Joosten and T. Ruers
FIGURE 2 Ultrasound monitoring of treatment effect. Note air bubbles in treatment zone.
FIGURE 3 FDG-PET scan after RFAtreatment. Note dark photopenic areas, indicating successful treatment.
Survival rates for hepatocellular carcinoma are even more encouraging. A five-year overall survival of 55% is described by Raut et al.13 These figures strongly point to a difference in treatment success between different tumour origins.
June 9, 2009
14:6
B-601
ch18
FA
Radiofrequency Ablation in the Treatment of Liver Tumours
139
CONCLUSION Recent literature shows that RFA for liver tumours is feasible and safe. Although RFA has proved to be effective for local tumour control, at present there is no direct evidence that RFA is equal to resection. Until such a proof is obtained, resection of liver tumours should still be considered the gold standard.
REFERENCES 1. Goldberg SN, Grassi CJ, Cardella JF, et al. (Society of Interventional Radiology Technology Assessment Committee). (2005) Image-guided tumor ablation: standardization of terminology and reporting criteria. J Vasc Interv Radiol 16(6): 765–778. 2. Tateishi R, Shiina S, Teratani T, et al. (2005) Percutaneous radiofrequency ablation for hepatocellular carcinoma: an analysis of 1000 cases. Cancer 103(6): 1201–1209. 3. Berber E, Siperstein AE. (2007) Perioperative outcome after laparoscopic radiofrequency ablation of liver tumors: an analysis of 521 cases. Surg Endosc 21(4): 613–618. 4. Amersi FF, McElrath-Garza A, Ahmad A, et al. (2006) Long-term survival after radiofrequency ablation of complex unresectable liver tumors. Arch Surg 141(6): 581–587. 5. Poon RT, Ng KK, Lam CM, et al. (2004) Learning curve for radiofrequency ablation of liver tumors: prospective analysis of initial 100 patients in a tertiary institution. Ann Surg 239(4): 441–449. 6. Langenhoff BS, Oyen WJ, Jager GJ, et al. (2002) Efficacy of fluorine-18deoxyglucose positron emission tomography in detecting tumor recurrence after local ablative therapy for liver metastases: a prospective study. J Clin Oncol 20(22): 4453–4458. 7. Mulier S, Mulier P, Ni Y, et al. (2002) Complications of radiofrequency coagulation of liver tumours. Br J Surg 89(10): 1206–1222. 8. Mulier S, Ni Y, Jamart J, et al. (2005) Local recurrence after hepatic radiofrequency coagulation: multivariate meta-analysis and review of contributing factors. Ann Surg 242(2): 158–171. 9. Mulier S, Jamart J, Michel L. (2004) Hepatic radiofrequency coagulation: less local recurrences after surgical approach. Eur J Surg Oncol 30: 193–194.
June 9, 2009
14:6
140
B-601
ch18
FA
J. Joosten and T. Ruers
10. Siperstein AE, Berber E, Ballem N, Parikh RT. (2007) Survival after radiofrequency ablation of colorectal liver metastases: 10-year experience. Ann Surg 246(4): 559–567. 11. Joosten J, Ruers T. (2007) Local radiofrequency ablation techniques for liver metastases of colorectal cancer. Crit Rev Oncol Hematol 62(2): 153– 163. 12. Ruers TJ, Joosten JJ, Wiering B, et al. (2007) Comparison between local ablative therapy and chemotherapy for non-resectable colorectal liver metastases: a prospective study. Ann Surg Oncol 14(3): 1161–1169. 13. Raut CP, Izzo F, Marra P, et al. (2005) Significant long-term survival after radiofrequency ablation of unresectable hepatocellular carcinoma in patients with cirrhosis. Ann Surg Oncol 12(8): 616–628.
June 9, 2009
14:6
B-601
ch19
FA
chapter
19
Atypical Liver Resections of Colorectal Metastases Bjarne Ardnor† and Peter Naredi∗,†
INTRODUCTION Indications Radical resection of colorectal metastases to the liver is associated with a 30%–60% five-year survival rate, while the natural course or non-radical treatment options rarely give a survival rate past three years. The survival outcome is acceptable also after resection of bilobar lesions and when more than four metastases are present. Re-resections result in a survival rate similar to that after a primary liver resection. As a consequence, more patients undergo liver resections and instead of lobe resections multiple small resections are often preferred to preserve liver parenchyma.
Resection Margin A resection margin of at least 1 cm has been considered important to avoid recurrence in the resection area and it also correlates with better survival.1 Most cancer cells in the parenchyma can be found ∗ Corresponding
author.
† Department of Surgery, Umea University Hospital, S-90185 Umea, Sweden. E-mail:
[email protected] 141
June 9, 2009
14:6
142
B-601
ch19
FA
B. Ardnor and P. Naredi
within 2 mm from the colorectal liver metastases. Anarrower resection margin is therefore considered adequate if necessary. A surgical margin of 2 mm is an acceptable minimum requirement, with a 6% risk of margin-related recurrence. A margin of less than 2 mm increases the risk of relapse but is still better than refraining from resection.2 In fact, the size of the surgical margin did not influence the recurrence rate after curative liver resection.3 From a surgical oncology perspective there is another reason to avoid a narrow margin: when the resection is to close to the tumour, there is an increased risk of rupture of the surrounding soft liver parenchyma during resection of firm colorectal liver metastases. A rupture increases the risk of cancer cell seeding and tumour recurrence.
Surgical Techniques The parenchyma can be transected by several methods, and the choice of technique can be decided by the surgeon as no method has proved to be superior or inferior. The clamp crushing technique (Kelly clamp) with Pringle’s manoeuvre was found in a randomised trial to be faster and less costly than ultrasonic surgical aspiration, hydrojet or dissecting sealer.4 A drawback in that study was that Pringle’s manoeuvre was performed only with the clamp crushing technique. Other techniques are the finger fracture technique, diathermy, ultrasonic coagulating shears and staples. We prefer to use ultrasonic surgical aspiration with a nose cone for electrocoagulation.
TECHNIQUE An atypical liver resection is not primarily performed with anatomical borders, but with the location of the tumour being decisive as to how the resection should be performed. While segmental or lobe resections are mostly performed by central ligature of the vessels before parenchymal transection, the atypical resection is done with
June 9, 2009
14:6
B-601
ch19
FA
Atypical Liver Resections of Colorectal Metastases
143
a different technique. The vessels are occluded during the parenchymal transection. The tumour location determines whether the atypical resection is a wedge resection or has the form of a crater. Tumours close to the left or caudal border of segments I–VI are suitable for wedge resections (Fig. 1). Tumours more centrally located or at the dome of segment V, VII or VIII are resected leaving a crater (Fig. 2). The liver is exposed through a right subcostal incision which is sometimes extended to the left side. Ligamentum teres and the falciform ligament are always divided and we prefer to mobilise the left or right triangular ligament, depending on the tumour location. Except for tumours deeply central in the right lobe, any tumour can be taken out with an atypical resection. After mobilisation we perform an ultrasound to visualise blood vessels and bile ducts around the tumour. The liver capsule is marked 2 mm deep, with diathermy
FIGURE 1 Surgical anatomy with vessels and bile ducts to each liver segment.
June 9, 2009
14:6
144
B-601
ch19
FA
B. Ardnor and P. Naredi
FIGURE 2 Atypical liver resections in segments VI and VII (wedge resection) and segment V (crater-formed resection).
at the site of transection. If possible, this is at least 1 cm outside the outer border of the tumour. The intended line of transection is confirmed by ultrasound as the capsule mark is seen as a shadow and the margin between the tumour and the shadow can be estimated. Next, we adapt a cotton ribbon around the hepatoduodenal ligament and are prepared to strangle the inflow (Pringle’s manoeuvre) if necessary. The parenchymal transection is then performed by ultrasonic dissection (Integra CUSA EXcel™ Ultrasonic 36 kHz handpiece with a CEM™ nose cone, providing simultaneous or independent activation of ultrasonic and electrosurgical functions) and electrocoagulation of vessels with a diameter of less than 3 mm. Argon beam coagulation is effective if vessels are still bleeding. Vessels and bile ducts larger than 3 mm are ligated with 3-0 or 4-0 nonabsorbable coated braided polyester sutures or sutured with 3-0 or 4-0 nonabsorbable monofil polypropylene sutures (Fig. 3). We prefer to use half-circle-shaped
June 9, 2009
14:6
B-601
ch19
FA
Atypical Liver Resections of Colorectal Metastases
145
FIGURE 3 The liver parenchyma is dissected with ultrasonic apiration, leaving vessels and bile ducts as bridges. These are ligated and divided.
needles with a length of 26 or 36 mm, in order to avoid unneseccary traction in the parenchyma. A wedge resection is straightforward, paying attention to the 1 cm transection margin without the need to occlude any main branches to a liver segment. In a crater-formed resection the cylindric transection is continued past the depth of the tumour before the line of transection is directed 1 cm underneath the tumour. Centrally located tumours are often close to vital structures. We dissect the tumour free from the left and the right portal branch, the left or the right hepatic bile duct and the left or the right hepatic artery. At least one of the liver veins is saved. It is rare that resections of tumours with a diameter of 1 cm or less and located close to the surface have to involve large vessels. When the tumour is deep in the parenchyma or larger (> 2 cm), the transection will be at least 3 cm deep. As a consequence, segmental vessels or larger liver veins are often part of the margin.
June 9, 2009
14:6
146
B-601
ch19
FA
B. Ardnor and P. Naredi
Avoidance of bleeding is pivotal. This is simplified by decreasing the venous backflow and by inflow control. The venous backflow from hepatic veins is controlled by low central venous pressure (0– 5 cm H2 O).5 and by hand pressure on the parenchyma by the assistant. Inflow control by Pringle’s manoeuvre makes the resection easy and with minimal bleeding. The duration of the inflow control can safely be 60 minutes, and in most cases up to 90 minutes if the patient has normal liver function. There was less hepatic ischaemia with preconditioning and reperfusion in younger patients or patients with steatosis.6 Most patients with liver metastases have normal liver function, while liver cirrhosis and liver insufficiency are more common in patients with hepatocellular carcinomas. Inflow control rarely needs to be maintained for more than 20 minutes during an atypical resection and therefore Pringle’s manoeuvre can be used for 3–5 atypical resections during the same operation.
DISCUSSION Several factors influence whether an atypical or a segmental resection should be made. The size and location of the tumour and the number of metastases are most important. The residual volume and quality of the liver parenchyma are considered. Lobe or segment resections are often technically easier, but not necessary to perform or they would leave insufficient functional liver volume. An atypical resection should not be mistaken as a tumour excision or biopsy. Up to 25% of wedge resections were reported to be non-radical and therefore segment resections have been recommended as the preferred method.7 In our opinion the 1 cm margin can normally be achieved in well-planned atypical resections. Our position of favouring atypical resections is also based on our and others’3 experience that margin recurrences are rare and that atypical resections have not been associated with a worse survival outcome.8
June 9, 2009
14:6
B-601
ch19
FA
Atypical Liver Resections of Colorectal Metastases
147
REFERENCES 1. Elias D, Cavalcanti A, Sabourin JC, et al. (1998) Results of 136 curative hepatectomies with a safety margin of less than 10 mm for colorectal metastases. J Surg Oncol 69(2): 88–93. 2. Kokudo N, Miki Y, Sugai S, et al. (2002) Genetic and histological assessment of surgical margins in resected liver metastases from colorectal carcinoma: minimum surgical margins for successful resection. Arch Surg 137(7): 833–840. 3. Bodingbauer M, Tamandl D, Schmid K, et al. (2007) Size of surgical margin does not influence recurrence rates after curative liver resection for colorectal cancer liver metastases. Br J Surg 94(9): 1133–1138. 4. Lesurtel M, Selzner M, Petrowsky H, et al. (2005) How should transection of the liver be performed? A prospective randomized study in 100 consecutive patients: comparing four different transection strategies. Ann Surg 242(6): 814–822, discussion 822–823. 5. Jones RM, Moulton CE, Hardy KJ. (1998) Central venous pressure and its effect on blood loss during liver resection. Br J Surg 85(8): 1058–1060. 6. Clavien PA, Selzner M, Rudiger HA, et al. (2003) A prospective randomized study in 100 consecutive patients undergoing major liver resection with versus without ischemic preconditioning. Ann Surg 238(6): 843–850, discussion 851–852. 7. DeMatteo RP, Palese C, Jarnagin WR, et al. (2000) Anatomic segmental hepatic resection is superior to wedge resection as an oncologic operation for colorectal liver metastases. J Gastrointest Surg 4(2): 178–184. 8. Zorzi D, Mullen JT, Abdalla EK, et al. (2006) Comparison between hepatic wedge resection and anatomic resection for colorectal liver metastases. J Gastrointest Surg 10(1): 86–94.
June 9, 2009
14:6
B-601
ch20
FA
chapter
20
Extended Hepatectomy for Primary and Metastatic Liver Lesions René Adam∗,†,§, , Emir Hoti†,¶ , Dennis A. Wicherts†,‡ and Robert J. de Haas†,‡
INTRODUCTION Surgical resection is the only potentially curative treatment for the majority of primary and metastatic liver lesions. For example, curative resection of colorectal liver metastases may achieve five-year survival rates of >50% in selected patients.1 Due to significant improvements in liver surgery techniques, the possibility of curative hepatectomy is determined only by the extent of the resection in relation to the remnant liver volume. Resection of up to 75% of normal parenchyma can be performed without the risk of postoperative liver failure.2 Clearly, the most important indication for extended hepatectomy is the presence of extensive intrahepatic tumour, caused by either multinodular bilobar disease or large tumour size. Additionally, lesions
∗ Corresponding
author. Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, F-94804 Villejuif, France. E-mail:
[email protected] ‡ Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. § Inserm, Unité 785, F-94804 Villejuif, France. Université Paris-Sud, UMR-S 785, F-94804 Villejuif, France. ¶ Liver Transplant Unit, Saint Vincent’s University Hospital, Dublin 4, Ireland. †AP-HP
149
June 9, 2009
14:6
150
B-601
ch20
FA
R. Adam et al.
closely related to vascular or biliary structures may require larger resections. Extended hepatectomies can currently be performed with low mortality and acceptable morbidity, not so different from those reported overall for liver resections.3 The classification of extended hepatectomies is based on the segmental liver anatomy described by Couinaud.4 Extended hepatic resections are defined as resections exceeding the boundaries of a normal right (segments V–VIII) or left (segments II–IV) hepatectomy and are divided into six different types. Right hepatectomies can be extended to segment IV, segment I, or both [Figs. 1A–1C]. Similarly, extended left hepatectomies may include segment I, segments V and VIII, or segments I,V and VIII [Figs. 2A–2C].
FIGURE 1(A)–1(C) Right hepatectomy extended to segment IV (A), segment I (B), and segments I and IV (C).
FIGURE 2(A)–2(C) Left hepatectomy extended to segment I (A), segments V and VIII (B), and segments I, V and VIII (C).
June 9, 2009
14:6
B-601
ch20
FA
Extended Hepatectomy
151
TECHNIQUE Preoperative Evaluation and Patient Selection Computed tomography and magnetic resonance imaging of the liver are the preferred investigative modalities. Determining the intrahepatic extent of the disease and its relation to important vascular and biliary structures is essential for planning the extensiveness of the resection. The functional capacity of the liver is measured by the indocyanine green (ICG) test, to determine the necessary volume of the remaining liver after hepatectomy. Portal vein embolisation (PVE) may be considered when the remnant liver is too small in relation to the planned resection and the functional capacity. By compensatory hypertrophy of the nonembolised lobe, the future liver remnant may increase to a sufficient volume enabling resection.5 In general, to perform a safe resection, the remnant liver should have >30% of functional parenchyma in the absence of prolonged chemotherapy and normal ICG clearance. On the other hand, for patients who have had prolonged chemotherapy or abnormal ICG clearance, the functional parenchyma volume should be >40%.
Surgical Procedure A bilateral subcostal incision with a vertical extension is widely employed for extended liver resections. Once the abdomen is entered, thorough exploration is performed to identify all hepatic and extrahepatic disease, and if there are no contraindications to resection, liver mobilisation should start. At this point, it is important to use intraoperative ultrasound to define the resection plane correctly, which is a crucial step of the procedure.
Extended Right Hepatectomy The initial steps of this procedure are identical to those of a right hepatectomy. In addition, supplying vessels to segment IV should be
June 9, 2009
14:6
152
B-601
ch20
FA
R. Adam et al.
divided. This is done by transecting the parenchymal bridge between segments III and IV, followed by dissection on the right side of the ligamentum teres, identifying and suture-ligating all the portal branches with the accompanying arteries and ducts. In resections where segment I has to be included, its mobilisation is achieved by rotating the right lobe medially. The exposed hepatic veins can be divided and ligated from below upwards. The dissection is then continued on the lateral side of the inferior vena cava (IVC) dividing the draining veins of segment I under direct vision. This manoeuvre leaves the liver attached only on the main hepatic veins. The operation continues with the hilar dissection in order to divide the feeding vessels to segment I which arise from the left hepatic artery and vein.6 Another described approach involves anterolateral dissection; however, this is technically more difficult and surgeons often adopt a combination of approaches.7 The parenchyma is divided progressing posteriorly towards the junction of the right hepatic vein with the IVC. Transection is usually done by using an ultrasonic dissector. Hemostasis of the cut liver surface is secured by suture-ligation combined with a bipolar or argon beam. During this stage, using a tape along the retrohepatic surface can be useful in controlling the direction of the transection.
Extended Left Hepatectomy The initial steps are the same as for a left hepatectomy. Before defining the plane of parenchymal transection, it is important to complete two manoeuvres involving the portal triad and the common trunk of the middle and left hepatic vein. The structures of the portal triad are dissected above the origin of the feeding vessels to segment I, to secure and preserve them intact. However, if segment I has to be included in the resection, both bile duct and portal vein are ligated and divided close to the hilum. Further dissection continues to control the right anterior and posterior sectorial pedicle. Once this step is completed, the hepatic veins are dealt with. Their control, which is usually done
June 9, 2009
14:6
B-601
ch20
FA
Extended Hepatectomy
153
in their extrahepatic portion, is very important as it facilitates the later parenchymal transection and reduces blood loss. After a complete left lobe mobilisation and medial retraction, further dissection between the left hepatic vein (top of the caudate lobe) and the IVC opens a window which allows complete control of the middle and left hepatic vein. The parenchymal resection is done in an upward direction. Defining the resection plane is important, as it allows the preservation of the posterior sectorial pedicle which supplies segments VI and VII. Usually, this plane runs anterior to the right hepatic vein extending horizontally to the right of the gallbladder fossa. Early clamping of the anterior sectorial pedicle can be useful, as it better defines the line of resection by producing a clear parenchyma demarcation.
Haemorrhage Control Despite technical refinements, operative bleeding still remains a concern, clearly being an independent risk factor in the postoperative outcome.8 Inflow clamping is the most used technique to reduce blood loss. Vascular pedicles can be divided either during the preliminary portal dissection or during the division of the parenchyma. For complex hepatic resections where bleeding is anticipated, total vascular exclusion with or without IVC clamping and venovenous bypass can be useful.9,10 This approach has the advantage of eliminating bleeding as well as enabling vascular reconstruction. Obviously, vascular exclusion without clamping the IVC is the preferred approach as it avoids the negative consequences of IVC clamping [Fig. 3A]. When such a step is not feasible, for example in case of proximity of the tumour to the hepatic vein confluence, a true lobe ischaemia with IVC clamping should be performed [Fig. 3B]. A test clamp lasting 5 minutes should be done to see if the haemodynamic changes are tolerated by the patient. If IVC clamping is not tolerated, venovenous bypass remains the only available option through which resection can be done [Fig. 3C].
June 9, 2009
14:6
154
B-601
ch20
FA
R. Adam et al.
FIGURE 3(A)–3(C) Selective total vascular exclusion of the liver (A). Total vascular exclusion with clamping of interior vene cava (B). Total vascular exclusion combined with venous bypass (C).
DISCUSSION Resection of primary and metastatic liver lesions depends solely on the technical ability to resect the total number of lesions, while leaving a sufficient volume of remnant parenchyma. Accordingly, preoperative PVE can be used to facilitate such resections. For extended right and left hepatectomies, the control of supplying vessels to segments I and/or IV, and segments I and/or V and VIII, respectively, is a very important step to consider. Measures aimed at reducing blood loss, such as intermittent selective portal clamping and total vascular exclusion with or without bypass, should always be considered when performing extended hepatectomies.
REFERENCES 1. Simmonds PC, Primrose JN, Colquitt JL, et al. (2006) Surgical resection of hepatic metastases from colorectal cancer: a systematic review of published studies. Br J Cancer 94: 982–999.
June 9, 2009
14:6
B-601
ch20
FA
Extended Hepatectomy
155
2. Vauthey JN, Chaoui A, Do KA, et al. (2000) Standardized measurement of the future liver remnant prior to extended liver resection: methodology and clinical associations. Surgery 127: 512–519. 3. Vauthey JN, Pawlik TM, Abdalla EK, et al. (2004) Is extended hepatectomy for hepatobiliary malignancy justified? Ann Surg 239: 722–732. 4. Couinaud C. (1957) Le foie: études anatomiques et chirurgicales. Masson et Cie, Paris. 5. Azoulay D, Castaing D, Smail A, et al. (2000) Resection of nonresectable liver metastases from colorectal cancer after percutaneous portal vein embolization. Ann Surg 231: 480–486. 6. Yamamoto J, Takayama T, Kosuge T, et al. (1992) An isolated caudate lobectomy by the transhepatic approach for hepatocellular carcinoma in cirrhotic liver. Surgery 111: 699–702. 7. Elias D, Lasser PH, Desruennes E, et al. (1992) Surgical approach to segment I for malignant tumors of the liver. Surg Gynecol Obstet 175: 17–24. 8. Jarnagin WR, Gonen M, Fong Y, et al. (2002) Improvement in perioperative outcome after hepatic resection: analysis of 1803 consecutive cases over the past decade. Ann Surg 236: 397–407. 9. Cherqui D, Malassagne B, Colau PI, et al. (1999) Hepatic vascular exclusion with preservation of the caval flow for liver resections. Ann Surg 230: 24–30. 10. Shaw Jr BW, Martin DJ, Marquez JM, et al. (1984) Venous bypass in clinical liver transplantation. Ann Surg 200: 524–534.
June 9, 2009
14:6
B-601
ch21
FA
chapter
21
Isolated Hepatic Perfusion: How It Should Be Done Alexander L. Vahrmeijer† , Liselot B. J. van Iersel‡ , Peter J. K. Kuppen† and Cornelis J. H. van de Velde∗,†
INTRODUCTION Isolated hepatic perfusion (IHP) is based on the expectation that tumour cells confined to the liver can be killed by drug doses that would kill a patient if delivered systemically but will not cause fatal hepatotoxicity. Based on pre-operative CT scans, and when necessary MRI or PET scans in difficult cases, patients with irresectable metastases confined to the liver are considered for IHP treatment. Most experience is obtained in patients with irresectable colorectal cancer hepatic metastases.1–5 An obvious limitation of IHP is that its effect totally depends on a high peak concentration during a relatively short exposure time: the duration of IHP is usually limited to one hour. Alkylating compounds like the most frequently used drug, Melphalan ∗ Corresponding
author. of Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands. E-mail:
[email protected] ‡ Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands. † Department
157
June 9, 2009
14:6
158
B-601
ch21
FA
A. L. Vahrmeijer et al.
(L-PAM), are effective after a relatively short exposure time and show a steep dose–response relationship, and are therefore a logical choice for testing in an IHP setting. Throughout the perfusion period, systemic leakage should be avoided and an accurate leakage detection system is absolutely necessary.
TECHNIQUE OF IHP The liver is mobilised from the diaphragm through a hockey-stickshaped abdominal incision. Ultrasonography should be performed in order to prove irresectable disease and to exclude extrahepatic pathology. Moreover, one should estimate the amount of normal liver tissue, which should be at least 40% to prevent post-operative liver failure. Adequate mobilisation of the liver is mandatory. The round ligament is divided and the falciform ligament is dissected over its full length, just anterior to the inferior vena cava (IVC). The superior ligamentous attachments and the triangular ligaments are divided. The right adrenal gland should be separated from the liver and the adrenal veins are ligated. Mobilisation of the liver continues until the IVC is fully exposed (Fig. 1). Lumbar veins are ligated
FIGURE 1 Dissected inferior vena cava prior to cannulation.
June 9, 2009
14:6
B-601
ch21
FA
Isolated Hepatic Perfusion: How It Should Be Done
159
FIGURE 2 Dissected hepatoduodenal ligament prior to cannulation.
to prevent systemic leakage of perfusate. The gastrohepatic ligament should be dissected and inspected for a replaced left hepatic artery. The latter is extremely important, because in eight patients treated via the portal vein only at our institution, no tumour response was observed. Therefore, infusion of chemotherapy via the hepatic artery is absolutely necessary. At present, aberrant arterial anatomy is a contraindication for IHP. The common bile duct, the portal vein and the common hepatic artery are dissected over an adequate length in the hepatoduodenal ligament (Fig. 2). After heparinisation, the common hepatic artery is cannulated via the gastroduodenal artery (8-Fr 77008 one-piece pediatric arterial cannula; Medtronic, Minneapolis, Minnesota, USA). Subsequently, the portal vein is cannulated (12Fr perfex perfusion catheter). Both inflow limbs are connected to a heart–lung machine which consists of two independent roller pumps (model 10-30-00; Cobe/Stöckert, Munich, Germany). The inflow in the hepatic artery and portal vein is usually about 360 and 330 ml/min respectively.1 The IVC is cross-clamped above the hepatic veins, just
June 9, 2009
14:6
160
B-601
ch21
FA
A. L. Vahrmeijer et al.
below the diaphragm, and cannulated proximal of the renal veins (Polystan 36-Fr, straight, A/S; Värlöse, Denmark) to allow undisturbed blood flow from the hepatic veins through the IVC towards the heart–lung machine. The perfusion medium consists of intrahepatically trapped blood and 1250 mL Gelofusine (Vifor Medical, Sempach, Switzerland) plus 2500 units heparin (Leo Pharma, Breda, The Netherlands) to yield a final volume of approximately 2 litres. Throughout the 1 h perfusion period, the perfusate is kept at a temperature of 39.5◦ C by a heat exchanger and oxygenated using an oxygenator (Cobe VPCML; Cobe Cardiovascular, Arvada, Colorado, USA, or Dideco D901; SORIN group Italia, Mirandola, Italy). To isolate the hepatic circuit, tourniquets are secured around the hepatic artery, portal vein and IVC above the right renal vein. Blood from the IVC below the tourniquet and from the mesentery is shunted by applying a venovenous bypass. For the extracorporeal venovenous bypass, the right femoral vein (22-Fr cannula DIITF022L; Edwards Lifesciences, Irvine, California, USA) and the portal vein (17-Fr perfex perfusion catheter CH17; B. Braun) (proximal to the tourniquet) are cannulated and connected to the right axillary vein (18-Fr 7326 perfusion cannula; Lifestream International, The Woodlands, Texas, USA). The venovenous bypass is supported by a centrifugal pump (Medtronic BIO-Medicus, Eden Prairie, Minnesota, USA) and primed with 700 mL 0.9% saline.
SAFETY Leakage of perfusate into the systemic circulation is monitored using a 99m Technetium-pertechnetate (99m Tc)-based method that is adapted from a method described by Runia et al.6 Before isolation of the liver, tin pyrophosphate (1 mg in 2 ml of PBS) (Technescan Pyp, Mallinckrodt Medical) is intravenously injected. This will bind 99m Tc to red blood cells: detection of leakage is based on measurement of leakage
June 9, 2009
14:6
B-601
ch21
FA
Isolated Hepatic Perfusion: How It Should Be Done
FIGURE 3 bypass.
161
Isolated hepatic perfusion circuit with extracorporeal veno-venous
of erythrocytes from the isolated circuit to the systemic circulation. After 15–30 min, the liver is isolated from the systemic circulation as described above. Next, 10 MBq 99m Tc is added to the isolated circuit. The level of radioactivity is measured continuously by two detectors (NaI scintillation counters, model 51S51, efficiency 15.5%; Canberra, Cedex, France) — one placed above the tube of the venovenous bypass and the other above the tubing that directs blood flow from the liver (vena cava) to the heart–lung machine (Fig. 3). The detectors are shielded from the background using a cover of lead 1 cm thick. Tubing under the detector is winded to increase the detection volume in order to increase sensitivity. The volume under the systemic detector is 10.4 ml and under the isolated circuit detector 5.5 ml. Special
June 9, 2009
14:6
162
B-601
ch21
FA
A. L. Vahrmeijer et al.
software, based on the algorithms described by Runia et al.6 has been developed (Canberra Eurisys Benelux, Zellik, Belgium) for real time monitoring of leakage with a sensitivity of <1%. In case of leakage, the surgeons try to detect and solve the problem. Usually, clamping of the caval vein is not complete or lumbal veins at the back of the liver are not sufficiently ligated. Melphalan (200 mg total dose in our series) is administered if no leakage is detected and re-circulated during 1 h. During perfusion with melphalan, leakage is continuously monitored and in case of any leakage that cannot be stopped by the surgeons, the procedure is aborted and the liver flushed before a level of 10% leakage is reached. After perfusion, the liver is flushed for approximately 10 min with 3 litres Gelofusine . Next, all cannulas and clamps are removed, and the normal circulation is restored. To prevent possible post-operative chemotherapy-induced cholecystitis, a cholecystectomy is performed.
DISCUSSION Recently, phase II studies involving IHP in colorectal cancer patients have shown hepatic response rates of up to 76%, with a median time to hepatic progression of up to 14.5 months, a median overall survival of 27 months and 5-year survival of 9%, establishing its value in the treatment of colorectal liver metastases.1–5 Hepatic metastases derive most of their blood supply from the hepatic artery and, therefore, in an attempt to increase local drug concentrations, L-PAM was continuously infused at reduced flow (±100 ml/min) into the hepatic artery in a subset of patients.5 However, slow (20 min) infusion of L-PAM selectively in the hepatic artery did indeed increase the L-PAM concentration in the inflow catheter, but the tumour response rate was reduced.5 Most likely the decreased arterial flow resulted in a decreased arterial pressure, which probably caused insufficient tumour perfusion and decreased drug uptake. Therefore, it is recommended to perform an
June 9, 2009
14:6
B-601
ch21
FA
Isolated Hepatic Perfusion: How It Should Be Done
163
IHP procedure at high arterial flow. At present, percutaneously performed IHP procedures suffer from high levels of systemic leakage of perfusate7 and can therefore not replace the open technique, where leakage seldom occurs. In order to increase the tumour response rate, we recently started a study combining L-PAM and Oxaliplatin delivered via IHP at high arterial flow. At present, results from systemic chemotherapy trials are improving and therefore the timing of IHP before or after systemic chemotherapy is unclear. Further studies are needed to solve this problem and to determine whether IHP deserves a place in the treatment of patients with colorectal cancer hepatic metastases.
REFERENCES 1. Rothbarth J, Pijl ME, Vahrmeijer AL, et al. (2003) Isolated hepatic perfusion with high-dose melphalan for the treatment of colorectal metastasis confined to the liver. Br J Surg 90(11): 1391–1397. 2. Alexander HR, Jr., Bartlett DL, Libutti SK, et al. (1998) Isolated hepatic perfusion with tumor necrosis factor and melphalan for unresectable cancers confined to the liver. J Clin Oncol 16(4): 1479–1489. 3. Bartlett DL, Libutti SK, Figg WD, et al. (2001) Isolated hepatic perfusion for unresectable hepatic metastases from colorectal cancer. Surgery 129(2): 176–187. 4. Vahrmeijer AL, van Dierendonck JH, Keizer HJ, et al. (2000) Increased local cytostatic drug exposure by isolated hepatic perfusion: a Phase I clinical and pharmacological evaluation of treatment with high dose melphalan in patients with colorectal cancer confined to the liver. Br J Cancer 82: 1539–1546. 5. van Iersel LB, Verlaan MR, Vahrmeijer AL, et al. (2007) Hepatic artery infusion of high-dose melphalan at reduced flow during isolated hepatic perfusion for the treatment of colorectal metastases confined to the liver: a clinical and pharmacologic evaluation. Eur J Surg Oncol 33(7): 874–881. 6. Runia RD, de Brauw LM, Kothuis BJL, et al. (1987) Continuous measurement of leakage during isolated liver perfusion with a radiotracer. Nucl Med Biol 14: 113–118.
June 9, 2009
14:6
164
B-601
ch21
FA
A. L. Vahrmeijer et al.
7. van Etten B, Brunstein F, van Ijken MG, et al. (2004) Isolated hypoxic hepatic perfusion with orthograde or retrograde flow in patients with irresectable liver metastases using percutaneous balloon catheter techniques: a phase I and II study. Ann Surg Oncol 11(6): 598–605.
June 9, 2009
14:6
B-601
ch22
FA
chapter
22
Robot-Assisted Laparoscopic Colorectal Surgery Omer Aziz∗,† and Ara W. Darzi ‡
INTRODUCTION The advantages of laparoscopic colorectal surgery are well described in the literature and include reduced postoperative morbidity, small wound size, reduced postoperative pain, improved cosmesis, and reduced length of hospital stay.1 There are, however, important limitations on laparoscopic equipment that include loss of visual depth perception (through monoscopic vision), loss of the eye–hand–target axis, unnatural hand–eye co-ordination, and inability by the surgeon to control the view himself.2 The long instruments used in laparoscopic resections have limited degrees of freedom of movement, fixed entry points with a fulcrum effect, and a static position with non-ideal ergonomic characteristics.
∗ Corresponding
author. of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St Mary’s Hospital, London W2 1NY, UK. E-mail:
[email protected] ‡ Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St Mary’s Hospital, London W2 1NY, UK. E-mail:
[email protected] † Department
165
June 9, 2009
14:6
166
B-601
ch22
FA
O. Aziz and A. W. Darzi
The da Vinci surgical system (Intuitive Surgical, Sunnyvale, California), is a four-armed robot that tries to address these limitations in the following ways: A stereoscopic 3D vision system improves the surgeon’s view of the operative field as well as his depth perception, whilst a navigator system allows him to control the camera himself. The instruments all have a “wrist”, giving the operator seven degrees of freedom of movement. The eye–hand–target axis is restored, making movement intuitive and improving the ergonomics. Finally, tremor is removed, as is trocar resistance, and movement scaled.3 Other robotic systems include the single-armed robot AESOP and the three-armed robotic system Zeus.4,5 Despite this the da Vinci system, like laparoscopy, does not account for a loss of tactile feedback, which is something that can be addressed in the future by incorporation of emerging haptic technologies. Other limitations include a long set-up time, the large size of the robot, a limited variety of instruments compared to laparoscopy, and the need for a tableside surgeon and nurse to set up the system, place the trocars, and introduce the robotic instruments. Finally, the costs of both the robot and consumables are still significant, and a large number of procedures are required to make it cost-effective.
ROBOT-ASSISTED LAPAROSCOPIC SURGERY The procedures described in this article include anterior resection, abdominoperineal resection, and sutured rectopexy. (1) Preoperative preparation. It is important to note that patients should have full bowel preparation prior to the procedure, and be on deep venous thrombosis prophylaxis through the administration of pneumatic compression stocking and prophylactic dose low molecular weight heparin after the procedure. (2) Set-up. A nasogastric tube and a urinary catheter should be inserted and the patient placed in the modified Lloyd–Davis position. Pneumoperitoneum is established and a 12 mm port is
June 9, 2009
14:6
B-601
ch22
FA
Robot-Assisted Laparoscopic Colorectal Surgery
167
FIGURE 1 Port placement (left) and system layout (right).
placed at the umbilicus. The patient is positioned with a steep head-down tilt, and the da Vinci surgical cart is then positioned. The robotic arms are then placed over the patient and the 8 mm robotic ports are placed. The system layout and port placement are shown in Fig. 1. A camera port is inserted through the umbilical port and attached to the robotic camera arm. The primary surgeon is placed at the console, where he is remote from the patient and has a magnified 3D view of the operating site and control of both the camera and two wristed robotic instruments with seven degrees of freedom. (3) Mobilisation of the rectum. Anatomical landmarks that need to be identified are the sacral promontory, the right ureter, and the iliac artery. The peritoneum over the sacral promontory is placed under tension and incised using diathermy, allowing the entry of carbon dioxide into the mesorectal plane. Most of the posterior dissection is undertaken from the right side, taking care to identify the left ureter and pelvic nerves. The dissection is continued posteriorly and laterally down to the level of the pelvic floor and is assisted by retraction of the sigmoid colon by the use of an atraumatic grasper placed through the assistant port. The anterior dissection is completed and the rectum fully mobilised. These steps are shown in Fig. 2.
June 9, 2009
14:6
168
B-601
ch22
FA
O. Aziz and A. W. Darzi
FIGURE 2 Steps taken during mobilization of the rectum. The sacral promontory, iliac artery, and right ureter landmarks can be seen (far left). The peritoneum above the sacral promontary is shown being raised (middle), as is the completed mesorectal mobilization (far right).
(4) Anterior resection. The left ureter is identified, and the inferior mesenteric vessels are isolated and divided using a vascular laparoscopic stapler. The proximal resection site is identified and divided at this level using a laparoscopic gastrointestinal stapler, and the mesorectum is excised and divided 5 cm below the level of the tumour. The distal bowel is then stapled and divided, and the specimen removed through a small incision in the left iliac fossa. The anastomosis is performed intercorporeally, using a circular stapler device, and the integrity of the anastomosis is tested using air insufflation underwater. The key steps of the procedure are shown in Fig. 3. (5) Abdominoperineal resection. Following full rectal mobilisation (as above) and division on both the inferior mesenteric vessels and stapled resection of the proximal bowel resection site, the
FIGURE 3 Key steps taken during anterior resection of the rectum. The left ureter is identified (far left), and the inferior mesenteric vessels dissected and ligated (middle). Following proximal, and distal resection, the intracorporeal anastomosis is performed using a circular stapled anastomosis (far right).
June 9, 2009
14:6
B-601
ch22
FA
Robot-Assisted Laparoscopic Colorectal Surgery
169
FIGURE 4 Key steps taken during a sutured rectopexy.
perineum is incised and perineal dissection performed. The specimen is removed through the perineal wound and a left iliac fossa colostomy performed. (6) Sutured rectopexy. Once fully mobilised, the mesorectum is sutured to the presacral fascia in order to perform a rectopexy, as shown in Fig. 4.
CONCLUSION Robot-assisted laparoscopic colorectal procedures are feasible and safe. The advantages of the da Vinci robotic system are clear and include superior visualisation and enhanced dexterity when compared to conventional laparoscopy. This may be particularly important in total mesorectal excision (TME) for rectal cancer, where careful dissection of an avascular plane between the presacral fascia and the fascia propria of the rectum is required, without injuring the proper fascia of the rectum.6 Training on the da Vinci surgical robot is an important consideration and has led to the development of a total mesorectal excision simulator.7 Finally, cost and set-up time remain challenges that need to be met if robotic colorectal surgery is to become mainstream.
REFERENCES 1. Aziz O, Constantinides V, Tekkis PP, et al. (2006) Laparoscopic versus open surgery for rectal cancer: a meta-analysis. Ann Surg Oncol 13(3): 413–424.
June 9, 2009
14:6
170
B-601
ch22
FA
O. Aziz and A. W. Darzi
2. Marecik SJ, Chaudhry V, Jan A, et al. (2007) A comparison of robotic, laparoscopic, and hand-sewn intestinal sutured anastomoses performed by residents. Am J Surg 193(3): 349–355; discussion 355. 3. Baik SH, Lee WJ, Rha KH, et al. (2008) Robotic total mesorectal excision for rectal cancer using four robotic arms. Surg Endosc 22(3): 792–797. 4. Satava RM. (2006) Robotics in colorectal surgery: telemonitoring and telerobotics. Surg Clin North Am 86(4): 927–936. 5. Anvari M, Birch DW, Bamehriz F, et al. (2004) Robot-assisted laparoscopic colorectal surgery. Surg Laparosc Endosc Percutan Tech 14(6): 311–315. 6. Enker WE, Thaler HT, Cranor ML, Polyak T. (1995) Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 181(4): 335–346. 7. Marecik SJ, Prasad LM, Park JJ, et al. (2007) A lifelike patient simulator for teaching robotic colorectal surgery: how to acquire skills for robotic rectal dissection. Surg Endosc.
June 9, 2009
14:6
B-601
ch23
FA
chapter
23
How to Make a Good Stoma Robin Phillips∗ and Simon Phillips
INTRODUCTION Few other surgical procedures adversely affect a patient’s quality of life as much as a poorly functioning stoma.1,2 An ideal stoma meets two criteria: (1) The site is optimally matched to a patient’s variability in body form, physical ability and activities. (2) The construction minimises complications that relate to the use of stomal appliances and minimises technical failings such as parastomal hernia or prolapse. This chapter will address technical aspects of construction for (loop and end) ileostomies and colostomies.
TECHNIQUE A step-by-step description for each stage of stoma formation is given, then specific tips and adaptations for stomal types. ∗ Corresponding
author. of Surgery, Imperial College London, South Kensington Campus, London SW7 2AZ. E-mail:
[email protected]
† Department
171
June 9, 2009
14:6
172
B-601
ch23
FA
R. Phillips and S. Phillips
The Skin and Subcutaneous Incision A circular stomal opening is generally preferred, though for temporary stomata a linear incision minimises skin loss and may improve cosmesis after closure. We favour making a cruciate incision with cutting electrocautery, each quadrant being excised in a curved fashion with electrocautery or curved (Mayo) scissors to prevent charring. For trephine stomata without laparotomy, both limbs of the cruciate incision should equal the intended final diameter of the stoma. During laparoscopically assisted stomal formation, distension occurs due to the pneumo-peritoneum and the skin incision should take account of the retraction after release of the intra-abdominal pressure. Similarly, following laparotomy, the lateral diameter of the incision lengthens on closure of the abdominal wall and should be made shorter than the vertical incision so that a more geometric circle results.
Muscle Fascia A cruciate incision of the muscle fascia is generally used, mirroring that for the skin incision but without excision. It is common practice during laparotomy to align the muscle fasciotomy and skin incision by medial retraction of the rectus sheath using tissue-grasping forceps (e.g. Lanes’). This may reduce angulation of the bowel through the abdominal wall, though is unlikely to affect the duration of paralytic ileus in the post-operative phase and has little effect on eventual function. Other adaptations have minimal effect. Suturing of the anterior muscle fascia to Scarpa’s fascia does not alter peri-stomal bulging, nor is there any evidence to support suture of the anterior and posterior muscle fascia, though some believe that it reduces para-stomal hernia formation. Similarly, fixation of the mesentery does not affect the para-stomal hernia rate; nor does closure of the lateral space affect the incidence of intestinal obstruction.3,4 Recently, prosthetic mesh has been advocated for reducing the incidence of para-stomal hernia formation,5 though it is unnecessary with temporary stoma formation
June 9, 2009
14:6
B-601
ch23
FA
How to Make a Good Stoma
173
and ill-advised in the emergency situation where bowel perforation has occurred.
Muscle A muscle-splitting incision through rectus abdominis is advocated, though this may simply be a necessary anatomical consequence reflecting the preference for an anterior stoma distant from the umbilicus, iliac crest and midline wounds. Stomal formation lateral to rectus abdominis does not actually seem to increase the risk of para-stomal hernia formation.3 This is unsurprising, since muscle division and correct closure at apppendicectomy rarely leads to hernia formation. The diameter chosen for the muscle and fascial aperture remains a matter of intra-operative judgment with adjustment to account for bowel diameter, abdominal wall tissues and pathology. Narrow incisions may be widened more easily than those that are oversized, and para-stomal hernia is seen more commonly than stenosis at the abdominal fascia, suggesting that laxity, not tightness, is a greater problem.
Choice of Bowel for the Construction of a Stoma The principles of good anastamotic healing apply equally to stomal construction. Attention to tissue handling, vascularity and lack of tension encourage primary healing at the muco-cutaneous junction. Poor technique risks separation of the muco-cutaneous junction and prolonged healing by granulation, leading to stenosis. Tension may worsen stomal or spout retraction and can lead to difficulties in attaching stomal appliances to a concave stoma, particularly if a tight limb of the stoma gives a skin fold crease. Similarly, impaired vascularity can turn stomata a worrying colour, particularly if inotropes are required for a critically ill patient, and although frank necrosis is rare, stenosis may result in the longer term.
June 9, 2009
14:6
174
B-601
ch23
FA
R. Phillips and S. Phillips
End Ileostomy (See Slide Sequence) This is easiest to achieve with the terminal ileum due to the long terminal vascular arcade. For a more proximal end stoma, assessment of the vascular pedicle is important in order to maximise length. If it proves difficult to isolate enough length for spout eversion (e.g. due to Crohn’s disease, in obese patients, or in emergencies with peritonitis), an “end-loop” ileostomy may be constructed with the over-sewn end left in the abdominal subcutaneous tissue and the small bowel opened as for a loop ileostomy. The looser effluent and potential metabolic consequences of a proximal stoma should be borne in mind.6 For formation of an everted (“Brooke”) ileostomy, the mesentery should emerge cranially such that mucosal eversion naturally pushes the spout caudally. We recommend a “554 technique” (Fig. 1)7 with
FIGURE 1 Head end to right of picture. At 2 and 10 o’clock on either side of the mesentery, there is a 5 cm length from the sutured spout to a serosal stitch, but at 6 o’clock, this is 4 cm: 554 ileostomy — on tying the sutures, there is a 2.5 cm superior spout but only a 2 cm inferior spout.
June 9, 2009
14:6
B-601
ch23
FA
How to Make a Good Stoma
175
interrupted sero-muscular to full thickness dermal everting sutures and prefer a dissolvable, un-dyed, non-braided suture. Great care must be taken to judge the sero-muscular bite, particularly in Crohn’s disease or debilitated patients. An inadvertent full thickness bite or enterotomy at this site may lead to a peri-stomal fistula with resulting leakage and appliance slippage, irritation and pain, and often requires stomal revision.
Loop Ileostomy It is of primary importance that the ileal loop should reach the abdominal wall comfortably, without tension. If constructed with the intention of subsequent closure, the commonest error is selection of an ileal loop too close to the caecum, since ileostomy closure may be considerably more difficult, particularly if the patient has gained weight after an illness which required formation of the stoma. After restorative ileoanal pouch procedures, we routinely use a stomal bridge because of the inevitable tension caused by reorientation of the superior mesenteric artery (SMA) arcade and ileal vessels. We rarely use a bridge for any loop stomata in other circumstances unless there is excessive tension, since this increases stomal complications.8 For formation, operative aspects mirror those of end-ileostomy formation. We site the efferent limb superiorly (after ileoanal pouch formation this is inevitable), though some argue that an appliance can be applied more closely to an inferior spout, particularly in patients with impaired manual dexterity. A generous transverse enterotomy should be made to facilitate spout eversion.
End Colostomy A correctly sited end colostomy presents the fewest difficulties for patients. Attention should be paid to tissue vascularity and tension, as for all stomata. Some surgeons create a small (3–4 mm) spout to match the flange thickness of the stomal appliance,9 which
June 9, 2009
14:6
176
B-601
ch23
FA
R. Phillips and S. Phillips
can best be achieved by the sutures being placed leaving the knots buried.
Loop Colostomy There are several indications for loop colostomy formation. When constructed electively before (radiotherapy) treatment for rectal or anal cancer, or for diversion for intractable incontinence, few specific problems arise. Technical formation is similar to that of loop ileostomy (though no spout is formed). For patients who have had previous abdominal surgery or colonic resection, laparoscopic assistance can greatly ease formation and is a technique we recommend since a trephine colostomy may present a considerable technical challenge, even in thin patients. Correct orientation is essential, particularly if colon division is intended (with or without mucous fistula formation). Several techniques are described to aid orientation but being mistaken about the correct end is an error surprisingly easy to make. Care must be taken not to damage the (marginal) blood vessel arcade, since distal colonic ischaemia may result, particularly after colonic resection with distal anastomosis. This is a particular limitation on the use of a de-functioning loop colostomy after anterior resection of the rectum, and ischaemia may result from traction of the bowel through the abdominal wall even if the vessel is not otherwise compromised.
DISCUSSION Stomal construction is a technique that is often delegated to junior staff at the end of procedures that may have been long and/or physically tiring. Despite this, it has an enormous impact not just on patients’ quality of life but also on health care resources. Complications are common in all types of stomata, and are more frequent when formed during emergency surgery. Any technical modification or improvement in training to reduce this can be expected to have a large impact.
June 9, 2009
14:6
B-601
ch23
FA
How to Make a Good Stoma
177
Patients often judge a surgeon’s technical ability by the external appearance of scars, and may also judge a surgeon’s care and precision by the appearance and function of an abdominal stoma.
REFERENCES 1. Shellito PC. (1998) Complications of abdominal stoma surgery. Dis Colon Rectum 41: 1562–1572. 2. Gooszen AW, Geelkerken RH, Hermans J, et al. (2000) Quality of life with a temporary stoma: ileostomy vs colostomy. Dis Colon Rectum 43: 650–655. 3. Leong AP, Londono-Schimmer EE, Phillips RK. (1994) Life-table analysis of stomal complications following ileostomy. Br J Surg 81: 727–729. 4. Londono-Schimmer EE, Leong AP, Phillips RK. (1994) Life table analysis of stomal complications following colostomy. Dis Colon Rectum 37: 916–920. 5. Janes A, Cengiz Y, Israelsson LA. (2004) Randomized clinical trial of the use of a prosthetic mesh to prevent parastomal hernia. Br J Surg 91: 280–282. 6. Kaidar-Person O, Person B, Wexner SD. (2005) Complications of construction and closure of temporary loop ileostomy. J Am Coll Surg 201: 759–773. 7. Hall C, Myers C, Phillips RK. (1995) The 554 ileostomy. Br J Surg 82: 1385. 8. Speirs M, Leung E, Hughes D, et al. (2006) Ileostomy rod — is it a bridge too far? Colorectal Dis 8: 484–487. 9. Stephenson BM, Myers C, Phillips RK. (1995) Minimally raised end colostomy. Int J Colorectal Dis 10: 232–233.
June 9, 2009
14:6
B-601
ch24
FA
chapter
24
Palliative Stenting for Colorectal Malignant Strictures Thomas M. Raymond∗,† , R. Bhardwaj† and Mike C. Parker†
INTRODUCTION Self-expanding metal stents (SEMSs) are used to treat malignant luminal obstruction of the gastrointestinal tract. Initially they were used to relieve obstruction of biliary, hepatic and upper gastrointestinal lesions, but with advancing technology and the introduction of flexible stents with a larger lumen they are now used in the treatment of colonic obstruction, as first described by Dohmoto in 1991.1 Between 10 and 30% of patients with primary colonic cancer present with obstruction2 for which they are treated conventionally by surgical intervention. Obstructing cancers (either primary colorectal or extrinsic compression due to pelvic malignancy) are often advanced at the time of presentation and therefore any treatment is palliative. Furthermore emergency surgery is associated with a high morbidity and mortality and in the palliative setting the creation of a stoma is almost inevitable. Stoma formation has serious implications for quality of life and may also be a burden to caregivers during the final months of life. Various non-surgical treatments have been tried, including balloon dilatation, laser photo-ablation ∗ Corresponding † Darent
author. Valley Hospital, Dartford, Kent DA2 8DA, UK. E-mail: goozla@doctors.
org.uk 179
June 9, 2009
14:6
180
B-601
ch24
FA
T. M. Raymond et al.
and electro-coagulation, but their effectiveness is limited by complications, the need for repeated treatments and cost.3 Colorectal stents are an addition to the armamentarium in the palliative treatment of colorectal obstruction. They allow rapid and effective decompression, thus avoiding surgery and the creation of a stoma.4–6 They may be used as palliation alone or as a bridge to surgery. They are contraindicated in very low rectal strictures, ischaemia, perforation or when there are multiple levels of obstruction.
FIGURE 1 Intra-luminal view of in situ stent.
SEMSS — TYPES SEMSs are expandable metal tubes, usually of mesh design made from steel or nitinol (a nickel-and-titanium alloy with shape memory). They are advanced to the site of obstruction in the collapsed state, where following deployment they expand radially to their maximum diameter under their own force, thereby achieving patency. They differ in luminal diameter, length and radial expansile force,
June 9, 2009
14:6
B-601
ch24
FA
Palliative Stenting for Colorectal Malignant Strictures
181
which allows selection of the most suitable stent for the procedure. The stent becomes incorporated into the tumour and surrounding tissue, which provides anchorage for the stent, preventing migration.
PLACEMENT A retrograde radiographic contrast study or contrast CT should be obtained before stent placement to assess the anatomy, length of stricture and degree of obstruction and to exclude other levels of obstruction that would negate the effect of stenting a single site. Preparation with one to two cleansing enemas prior to the procedure should be considered so as to ensure that the distal colon is clear. The patient is placed initially in the lateral decubitus position, and standard intravenous conscious sedation is usually administered but is not absolutely necessary.
FIGURE 2 Radiographic view of stent following deployment.
June 9, 2009
14:6
182
B-601
ch24
FA
T. M. Raymond et al.
The stent is either placed under fluoroscopic guidance (shorter delivery system but large diameter stent) or passed through an endoscope (longer delivery system and smaller diameter stent).
Radiological Placement The lesion is located fluoroscopically, using a water-soluble contrast medium. The stricture is passed using a guide wire over which the stent is inserted into the obstructing lesion prior to release. Rarely, this may require balloon dilatation to aid expansion.
Endoscopic/Fluoroscopic Placement The distal end of the obstructing lesion is visualised endoscopically, at which point a biopsy may be taken. The length and configuration of the stenosis is demonstrated fluoroscopically, by injection of watersoluble contrast media. The guide wire is then passed through the stenosis and the stent delivery system inserted through the scope. The stent is positioned at the level of the stenosis and released under both endoscopic and radiological vision.
EFFICACY Stenting is technically and clinically successful in over 90% of cases (46–100%), with little difference between palliative and potentially curative patients.7,8 Failure is usually due to inability to pass the guide wire, particularly when negotiating a tortuous colon. For palliative patients the median duration of patency is over 100 days (68–288 days). For studies reporting patency rates the median at the end of follow-up (or time of death) is 100% (53–100%).7 Reintervention is required following 20% of palliative stent placements (0–100%) and includes unplanned surgery, placement of second or
June 9, 2009
14:6
B-601
ch24
FA
Palliative Stenting for Colorectal Malignant Strictures
183
subsequent stents or interventions to maintain patency (laser ablation, colonic irrigation). Patients undergoing palliative stenting have fewer admissions to the intensive care unit, fewer stomas and a reduction in the median hospital stay when compared with patients undergoing palliative surgery.7,9 When comparing the median survival there is no significant difference.1,8
SAFETY For all colorectal stents the median rate of migration is 11% (0–50%), with similar rates when used for palliation.7 If migration occurs no intervention is required in over 50% of patients. The remainder may require stent removal with no further intervention, stent re-insertion or surgery. Perforation caused by either the guide wire or the stent occurs in 4.5% (0–83%) of cases irrespective of the indication and may be increased by balloon dilatation of the stricture prior to stent insertion.8 Re-obstruction occurs in 12% (1–92%) of patients due to tumour overgrowth or ingrowth, migration and faecal impaction, and occurs from 48 hours to 480 days post-procedure. Modes of treatment include laser photo-ablation, re-stenting or colonic irrigation. Other reported complications include stent fracture, rectal bleeding, anal/abdominal pain, incontinence and tenesmus, particularly in patients with distally placed stents. These are relatively rare and are usually well tolerated by patients.
COVERED VS UNCOVERED STENTS Covered stents appear to resist tumour ingrowth, as reflected in lower re-obstruction rates, although they may be more prone to migration.
June 9, 2009
14:6
184
B-601
ch24
FA
T. M. Raymond et al.
COST CONSIDERATIONS The cost of palliative stenting may be half that of a surgically decompressed patient.10 This saving is due mainly to a shorter hospital stay, but also to fewer surgical procedures, less operating room time and reduced time in intensive care.
DISCUSSION SEMSs provide a quick and effective tool in the palliative treatment of obstructing colorectal lesions. They compare favourably with surgical intervention and help to avoid formation of stomas in selected cases.
REFERENCES 1. Dohmoto M. (1991) New method — endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endoscopia Digestiva 3: 1507–1512. 2. Deans GT, Krukowski ZH, Irwin ST. (1994) Malignant obstruction of the left colon. Br J Surg 81(9): 1270–1276. 3. Zollikofer CL, Jost R, Schoch E, Decurtins M. (2000) Gastrointestinal stenting. Eur Radiol 10(2): 329–341. 4. Law WL, Chu KW, Ho JW, et al. (2000) Self-expanding metallic stent in the treatment of colonic obstruction caused by advanced malignancies. Dis Colon Rectum 43(11): 1522–1527. 5. Liberman H, Adams DR, Blatchford GJ, et al. (2000) Clinical use of the self-expanding metallic stent in the management of colorectal cancer. Am J Surg 180(6): 407–411. 6. Turegano-Fuentes F, Echenagusia-Belda A, Simo-Muerza G, et al. (1998) Transanal self-expanding metal stents as an alternative to palliative colostomy in selected patients with malignant obstruction of the left colon. Br J Surg 85(2): 232–235. 7. Watt AM, Faragher IG, Griffin TT, et al. (2007) Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review. Ann Surg 246(1): 24–30. 8. Khot UP, Lang AW, Murali K, Parker MC. (2002) Systematic review of the efficacy and safety of colorectal stents. Br J Surg 89: 1096–1102.
June 9, 2009
14:6
B-601
ch24
FA
Palliative Stenting for Colorectal Malignant Strictures
185
9. Law WL, Choi HK, Chu KW. (2003) Comparison of stenting with emergency surgery as palliative treatment for obstructing primary left-sided colorectal cancer. Br J Surg 90: 1429–1433. 10. Osman HS, Rashid HI, Sathananthan N, Parker MC. (2000) The costeffectiveness of self-expanding metal stents in the management of malignant left-sided large bowel obstruction. Colorectal Dis 2: 233–237.
June 9, 2009
14:6
B-601
ch25
FA
chapter
25
Technical Notes on TME for Rectal Cancer Bill J. Heald∗
All good rectal cancer surgery involves “TME principles”. For all cancers, either there must be 5 cm of mesorectum distal to the cancer or the whole mesorectum must be excised intact. The muscle tube may be divided 1–2 cm beyond a cancer but mesorectal clearance must be generous.
PRE-OPERATIVE STAGING Decisions regarding radiotherapy and chemotherapy now need to be made before surgery. • Clinical — especially digital rectal examination, and never omit the vaginal exam • Colonoscopy • CT chest, Abdo and Pelvis for metastatic spread • Specialised, fine slice pelvic MRI — this delineates the mesorectal fascial “holy plane”; cancer within 1 mm is the principal indication for pre-op CRT
∗ Pelican
Cancer Foundation, North Hampshire Hospital, Basingstoke RG24 9NA, UK. E-mail:
[email protected] 187
June 9, 2009
14:6
188
B-601
ch25
FA
B. J. Heald
SURGERY The rectum and the mesorectum constitute the embryological midline hindgut, surrounded by: • The autonomic nerves and hypogastric plexuses • The nonvisceral presacral fat pad (when present) • The parietal sidewall septum separating it from the internal iliac vessels • The seminal vesicles • The prostate in the male • The vagina in the female All of these should be painstakingly preserved, to avoid autonomic dysfunction or bleeding. The TME dissection plus pouch to anus reconstruction takes 3–5 hours; a conventional APE was often completed in an hour.
OPERATIVE TECHNIQUE Four great principles apply throughout: • Precise dissection under direct vision — never “blind” • Three-directional traction and countertraction to open up the “holy plane” • Sharp scissors or monopolar diathermy dissection of areolar tissue “on stretch” • Circumferential dissection — first here, then there, and never for too long on one area • Gentle surface protection with gauze swabs to avoid tearing Throughout the operation the ultimate quality of the TME specimen — intact and untorn — should be paramount: “specimenoriented surgery”.
June 9, 2009
14:6
B-601
FA
ch25
Technical Notes on TME for Rectal Cancer
189
THE INCISION — OPEN OR LAPAROSCOPIC? A long midline incision is made from the symphysis pubis almost to the xiphisternum. Young women may prefer a suprapubic incision with a vertical midline between the rectus muscles. Laparoscopic surgery is now a real alternative — especially for abdominoperineal excision (APE), avoiding an abdominal incision. The elevation of an intact mesorectal package, safely encompassing a large cancer, needs substantial upward traction, which is not easy laparoscopically without the risk of tearing. Great caution is advised with sphincterpreserving laparoscopy for tumours greater than 7 cm in size, which are probably best dealt with open. In open surgery, for careful packing and retraction clear access to the pelvis and long-lipped St. Marks retractors are essential.
STARTING RIGHT: THE “PEDICLE PACKAGE” — THE CLUE TO THE TOP OF THE “HOLY PLANE” Starting correctly involves identification of the plane between the back of the “pedicle package” and the gonadal vessels, ureter, and preaortic sympathetic nerves. Key is the shiny fascial covering of the tapering embryological midline “sausage” with inferior mesenteric vessels within. This is gently lifted forward to open the plane. Start on either the left or the right of the sigmoid mesocolon, and the superior hypogastric plexus is carefully preserved.
HIGH LIGATION OF THE INFERIOR MESENTERIC VESSELS With the pedicle package lifted gently forward, the dissection behind it can be extended up to its origin. Separate high ligations of the inferior mesenteric artery and vein can be performed with the artery
June 9, 2009
14:6
190
B-601
ch25
FA
B. J. Heald
controlled by the left index finger and thumb between it and the vein. The artery is divided 1–2 cm anterior to the aorta, so as to spare the sympathetic nerve plexuses; the vein several cm to the left of the artery above its last tributary and close to the pancreas. Otherwise avascular planes around this hindgut are developed for full mobilisation of the splenic flexure. Occasionally a long and healthy sigmoid may be used as an alternative. Pulsatile blood supply is essential.
“DIVISION OF CONVENIENCE” OF THE SIGMOID COLON The sigmoid mesentery and the sigmoid colon are divided well above the cancer. This facilitates gentle opening of perimesorectal planes by circumferential traction and countertraction.
PELVIC DISSECTION Start posteriorly lifting the rectosigmoid forward and follow the “holy plane” at various points on the mesorectal circumference in a stepwise manner. If bleeding in one area is troublesome tackle the opposite circumference to apply pressure while progress continues.
HIGH POSTERIOR DISSECTION The posterior embryological plane, i.e. the shiny posterior surface of the mesorectum within the bifurcation of the superior hypogastric plexus, is extended downward to beyond the tip of the coccyx, step by step as other sectors of the circumference are developed. The fascial condensation “rectosacral ligament” may require positive division with scissors or diathermy. Blunt manual extraction, haste or roughness may tear into the mesorectum or presacral veins. A presacral fat pad should be left alone.
June 9, 2009
14:6
B-601
FA
ch25
Technical Notes on TME for Rectal Cancer
191
PELVIC SIDEWALL DISSECTION The plane is extended around the sides, gently liberating the adherent hypogastric nerves laterally off the mesorectal surface under direct vision. The tangentially running hypogastric nerves are often first identified, the superior hypogastric plexus only later becoming apparent.
“LATERAL LIGAMENT” AREA As the “holy plane” is followed downward toward the vesicles, the expanding plexiform band of the inferior hypogastric plexus becomes increasingly adherent. There is no actual ligament — only adherence between mesorectum and plexus: small branches of nerves and vessels penetrate through and usually no major “middle rectals” pedicle. Sympathetic hypogastric nerves curve distally from the superior plexuses and “erigent pillars” (parasympathetic nerves) come forward from the roots of the sacral plexus. These erigent pillars pierce the sidewall septum to join the plexus and contribute nerve branches to the mesorectum and rectum. These “neural T junctions” are the nearest to “lateral ligaments” that careful surgeons will find if they
FIGURE 1 The autonomic nerves on the right pelvic sidewall.
June 9, 2009
14:6
192
B-601
ch25
FA
B. J. Heald
FIGURE 2 Denonvillier’s septum: the anterior surface of a good TME.
dissect perfectly between the mesorectum and the inferior hypogastric plexus.
ANTERIOR DISSECTION — DENONVILLIERS SEPTUM Following the correct plane forward will encompass the peritoneal reflection which remains on the specimen, allowing positive identification of seminal vesicles. Forceful forward retraction with a St. Mark’s retractor facilitates development of the areolar space between them and the smooth Denonvilliers rectogenital septum. This is divided transversely distally to the cancer as it becomes adherent to the posterior capsule of the prostate — carefully avoiding damage to the converging neurovascular bundles which form the neurovascular bundles of Walsh. These taper toward the urethra at the apex of the prostate, where they become the erectile nerves of the corpora cavernosa.
MANAGEMENT OF THE ANORECTUM DISTAL TO THE CANCER — STAPLING TECHNIQUES In more than 90% of rectal cancers it is technically feasible, though not necessarily optimal in terms of future function, to extend the
June 9, 2009
14:6
B-601
FA
ch25
Technical Notes on TME for Rectal Cancer
193
FIGURE 3 The inferior hypogastric plexus and right “erigent pillar.”
dissection down to a clean muscle tube where a cross clamp may be applied with “finger and thumb” clearance below the cancer. This is a challenging moment requiring skill and experience. We use a linear stapler as a right-angled clamp (the Moran triple stapling technique). The first TA-45 or TA-30 (Covidien Healthcare) staple line seals the muscle tube so that the anorectal lumen beyond can be washed out with water or a tumoricidal solution. A check with a proctoscope at this point may be desirable. Incorporation of exfoliated intraluminal cells in the second staple line is thus eliminated. A second TA-45 or TA-30 is fired through the washed bowel with powerful upward traction on the first (specimen-sealing) stapler. Only the washed staple line remains within the patient. The first is clear of the palpable distal edge of the cancer, which is almost always the microscopic limit since spread along the muscle tube is rarely important.
THE COLON POUCH, COLOPLASTY OR SIDE-TO-END? Several variations of reconstruction are available — typically a GIA60 is inserted 5 cm from the end of the fully mobilised colon to
June 9, 2009
14:6
194
B-601
ch25
FA
B. J. Heald
create a J pouch. The circular stapler, usually CEEA-31, is inserted transanally. It is essential with ultra-low anastomoses that only the internal sphincter is incorporated, i.e. only one thickness of muscle around the periphery of the cartridge. An adequate length of the colon is essential for the pouch to lie without tension in the sacral hollow, and demonstrably pulsatile blood supply is crucial. Two low-suction Abdovac drains are used for 48 hours.
Suggested Reading 1. MERCURY Study Group. (2006) Diagnostic accuracy of preoperative magnetic resonance imaging in predicting curative resection of rectal cancer: prospective observational study. Br Med J 333: 779; doi: 10.1136/bmj.38937.646400.55. 2. Holm T, Ljung A, Häggmark T, et al. (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94(2): 232–238. 3. Quirke P. (2003) Training and quality assurance for rectal cancer: 20 years of data is enough. The Lancet Oncology 4(11): 695–702.
June 9, 2009
14:6
B-601
ch26
FA
chapter
26
Total Proctocolectomy with Ileoanal Pouch Anastomosis Thomas Lehnert∗,† , Silke Schüle† and Frank Starp†
Total proctocolectomy with ileoanal pouch anastomosis is used to treat familial adenomatous polyposis and a few rare hereditary colorectal cancer syndromes, as well as ulcerative colitis.
BOWEL PREPARATION We do not use any form of bowel preparation preoperatively apart from a microenema on the morning of the operation. Prophylactic antibiotics (second generation cephalosporine plus metronidazole) are given with induction of anaesthesia, repeated once after six hours and then discontinued. Before transanal transection of the rectal mucosa, a clamp is placed on the mobilised rectum in the abdomen, and the rectum is washed out with povidone and then stuffed with two or three swabs to avoid soiling with rectal contents. ∗ Corresponding
author. of General, Visceral, Vascular and Oncology Surgery, Klinikum Bremen-Mitte, St Juergen Strasse, 1, DE 28205 Bremen, Germany. E-mail: thomas.
[email protected] † Departments
195
June 9, 2009
14:6
196
B-601
ch26
FA
T. Lehnert et al.
If a hand-sutured ileoanal anastomosis is performed, there is always some soiling from the pouch. Even if soiling was severe, local rinsing with copious saline and intraoperative rinsing of the pelvis through drains placed behind the pouch has in our experience reliably prevented septic complications in the pelvis.
ACCESS Proctocolectomy can be accomplished by minimal access techniques, and this route may be preferred for cosmetic reasons by young patients in which a prophylactic operation is planned.1 There are, however, drawbacks to this approach. The operation is much more timeconsuming, lymphadenectomy may be compromised (see below) and lengthening of the mesentery is limited.
LYMPHADENECTOMY In both conditions a decision has to be made regarding the extent of lymphadenectomy, depending on whether or not malignancy has been demonstrated preoperatively. In patients with classical (100– 1000 polyps) or severe (more than 1000 polyps) familial polyposis, we prefer a radical lymphadenectomy including total mesorectal excision even if malignancy has not been proven preoperatively. There are several reasons for this approach: if an extensive number of polyps are present there is a risk of malignancy going undetected preoperatively; there is no point in retaining the draining lymph nodes if the corresponding large bowel is removed; and, most importantly, the operation is much cleaner if blood vessels are divided at their origin and dissection observes avascular tissue planes throughout. In ulcerative colitis the same applies: the preoperative detection of malignancy in a severely inflamed large bowel can be challenging, because carcinoma in ulcerative colitis tends to grow primarily infiltrating the bowel wall and only rarely appears to develop
June 9, 2009
14:6
B-601
ch26
FA
Total Proctocolectomy with Ileoanal Pouch Anastomosis
197
via polyps protruding into the bowel lumen. We, therefore, perform a radical lymphadenectomy in almost all patients undergoing total proctocolectomy for ulcerative colitis and particularly if some degree of dysplasia has been detected preoperatively. In patients in whom we plan radical lymphadenectomy, we strongly prefer open access over laparoscopically assisted proctocolectomy, because we believe that lymphadenectomy will be more complete. A meta-analysis of 14 randomised trials confirms that significantly more lymph nodes were examined in colorectal cancer patients undergoing the open procedure as compared to the minimal access technique (p < 0.004).2 In patients in whom large bowel cancer is diagnosed preoperatively, lymphadenectomy follows the principles of oncologic surgery, even if this will mean that a pouch cannot be constructed, because the ileocolic vessels have to be resected. On the other hand, even if the ileocolic vessels have to be sacrificed, pouch formation is still possible in many patients. If this is not possible, then ileorectal anastomosis may be an option for some patients with familial polyposis. We would recommend this only in patients with limited polyposis of the rectum, as in attenuated forms of familial polyposis.
LENGTHENING OF THE MESENTERY Tension-free anastomosis is crucial to the success of this operation. In many instances no particular measures are necessary and the pouch can be advanced to the dentate line without tension. If this is not possible, then intermediate blood vessels are divided under diaphany to lengthen the mesentery. We prefer to use vascular clamps for preliminary interruption of perfusion before we actually ligate and divide vessels. Mistakes at this point inevitably result in the loss of small bowel and jeopardise preservation of continence. It is noted that diaphany and selection of proper vessels for division is more difficult if the abdomen is accessed via a transverse incision in the lower abdomen (Caesarean).
June 9, 2009
14:6
198
B-601
ch26
FA
T. Lehnert et al.
To achieve optimum length it is important to rotate the pouch so that the mesentery runs anteriorly, because the distance between the mesenteric root and the anterior circumference of the anal sphincter is the shortest. The antimesenteric bowel then nicely aligns with the hollow of the sacrum. If this does not result in sufficient length, then the next step is to incise the visceral peritoneum. Incisions are made at 1–2 cm intervals at a 90◦ angle to the mesenteric vessels starting proximal to the most peripheral arcades and progressing centrally towards the mesenteric root. They are made on both sides of the mesentery and care is taken not to injure any blood vessels, especially veins. This usually affords at least another centimetre of mesenteric length. If there is still too much distance for a tension-free anastomosis, then the mesenteric root is dissected free up to the pancreas, where care is taken to avoid injury to the uncinate process. This may add another centimetre of length to the mesentery, but obviously this is not easily achieved, if the dissection of the mesenteric root is to be accomplished through a transverse incision in the lower abdomen as in laparoscopically assisted proctocolectomy. Especially in tall patients it has been difficult to achieve sufficient lengthening of the mesentery to allow tension-free ileoanal anastomosis even after all three measures have been applied. In such cases we have resorted to supporting the patient’s legs for a few days in order to elevate the pelvis and thus reduce the distance between dentate line and mesenteric root. With these measures we have been lucky to avoid anastomotic complications in the past 50 patients.
RECTAL MUCOSECTOMY AND ILEOANAL ANASTOMOSIS Any retained rectal mucosa is likely to increase the risk of an anastomotic leak or formation of a pelvic fistula. In the long term there is also the risk of malignancy in both ulcerative colitis and familial polyposis. We, therefore, take great care to excise the mucosa completely, preferably together with 1 or 2 mm of anal epithelium. To accomplish this
June 9, 2009
14:6
B-601
ch26
FA
Total Proctocolectomy with Ileoanal Pouch Anastomosis
199
we choose a transanal route. Injection of the mucosa with adrenalinecontaining saline results in elevation of the mucosa from the anal sphincter. With the patient in the Lloyd-Davies position, the mucosal dissection is always started posteriorly and advanced on both sides to the anterior rectal circumference. As there is inevitable bleeding from the dissected mucosa, this approach allows better exposure. If the mucosal dissection is started anteriorly, then blood collection at the posterior aspect of the rectum will make identification of the optimal line of incision more difficult. The mucosa is gradually dissected off the muscular layer in a proximal direction, and the muscular cuff of the rectum is then transected approximately 2–3 cm above the dentate line to preserve as much of the anal sphincter as possible (Fig. 1). Transection of the anterior aspect of the rectal wall is usually performed from the abdomen. We never use double stapling for this procedure, because this technique results in unnecessary loss of sphincter muscle if the line of transection is low enough to include all rectal mucosa (Fig. 2). Alternatively, if the rectum is transected more proximally, then some rectal
FIGURE 1 Staged transsection preserving the sphincter and completely removing the rectal mucosa.
June 9, 2009
14:6
200
B-601
ch26
FA
T. Lehnert et al.
FIGURE 2 Low transsection including portions of the anal sphincter.
FIGURE 3 High transsection retaining the rectal mucosa.
June 9, 2009
14:6
B-601
ch26
FA
Total Proctocolectomy with Ileoanal Pouch Anastomosis
201
mucosa is retained, which is not desirable, as explained above (Fig. 3). Also, in our experience, we have related double stapling of coloanal pouches to severe scarring resulting in anastomotic stenosis requiring prolonged dilatation and severely compromised anorectal function.
POUCH FORMATION While we aim for a large pouch with a length of more than 15 cm, for practical reasons the pouch length is determined to a great extent by the mesenteric vasculature and optimal lengthening of the mesentery to achieve a tension-free anastomosis. The latter is the superior goal and we would rather allow for a smaller pouch than take any risk of anastomotic dehiscence and pelvic sepsis. Alternatively, an excessively long pouch may result. This is easily reduced by resection of a few centimetres of the distal ileum. For pouch formation we use linear staplers. Before they are inserted both limbs of the terminal ileum are aligned strictly antimesenterically with three to four 4–0 sutures to ensure that the transection does not compromise blood supply. Linear staplers need to be inserted at least twice to achieve sufficient pouch length. For insertion we always open the pouch at its apex, which is to become the site of the pouchanal anastomosis, and introduce the staplers always through this opening. In the past we have introduced the second stapler through the ileal end and a proximal incision of the afferent limb. This has sometimes resulted in incomplete transection of the bowel wall and retention of a tissue bridge in the middle of the pouch, compromising its volume. Careful selection of the type of linear cutters appears warranted, as some do not ideally control bleeding from the suture line. Obviously, arterial bleeding into the lumen of the just-created pouch is very undesirable. While we do use linear staplers to create the ileal pouch, we never use staplers to create the pouchanal anstomoses, for fear of
June 9, 2009
14:6
202
B-601
ch26
FA
T. Lehnert et al.
postoperative scarring, or insufficient mucosal or excessive muscular resection (Figs. 2 and 3). All ileoanal pouch anastomoses are handsutured transanally, using absorbable 3–0 braided sutures. Twelve or fourteen (never thirteen) interrupted sutures usually suffice. Several techniques have been proposed for exposure. We prefer to use a speculum, which is removed and re-inserted after each step to minimise injury to the anal sphincter.
PROTECTIVE ILEOSTOMY We believe in the benefit of ileostomy. A randomised study and a subsequent meta-analysis3,4 have shown that a diverting ileostomy reduces the frequency of clinical leaks in low anterior anastomosis, and the same benefit is assumed for ileoanal pouch anastomosis. A septic pelvis jeopardises the pouch, and even if the pouch can be saved, pouch function may be seriously compromised after an episode of severe pelvic sepsis.
REFERENCES 1. Polle SW, Dunker MS, Slors JF, et al. (2007). Body image, cosmesis, quality of life, and functional outcome of hand-assisted laparoscopic versus open restorative proctocolectomy: long-term results of a randomized trial. Surg Endosc 21(8): 1301–1307. 2. Lehnert T, Starp F, Hauschildt J, Schüle S. Personal Communication. 3. Matthiessen P, Hallböök O, Rutegård J, et al. (2007). Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg 246: 207–214. 4. Hüser N, Michalski CW, Erkan M, et al. (2008). Systematic review and meta-analysis of the role of defunctioning stoma in low rectal cancer surgery. Ann Surg 248: 52–60.
June 9, 2009
14:6
B-601
ch27
FA
chapter
27
Pouches and Coloanal Anastomosis Sylvain Kirzin† , Guillaume Portier† and Franck Lazorthes∗,†
INTRODUCTION Total mesorectal resection has led to reduced local recurrence and improved survival in patients with rectal cancer. Straight coloanal anastomosis after total protectomy can lead to functional disorders, including increased bowel movements, clusterings and fecal incontinence. This evacuation dysfunction has been described as the “anterior resection syndrome”. Therefore, alternative strategies for restoration, such as the colonic J pouch, side-to-end anastomosis and transverse coloplasty, have been developed in order to improve bowel function.
Is a Pouch Necessary? The first alternative process to be described was the colonic J pouch.1,2 Therefore, most of the studies compared this reconstruction to straight coloanal anastomosis. Many randomised, controlled trials have been performed, providing a high level of evidence to answer the question ∗ Corresponding
author. de chirurgie digestive CHU Purpan, Place du Dr Baylac, 31059 Toulouse, France. E-mail:
[email protected] † Service
203
June 9, 2009
14:6
204
B-601
ch27
FA
S. Kirzin, G. Portier and F. Lazorthes
whether a pouch is necessary. In particular, Heriot et al.3 conducted a meta-analysis of all published randomised, controlled trials in 2006. They identified 35 studies, which included 2240 patients. They concluded that there was significant reduction in the frequency of defecation per day and that the faecal urgency was less prevalent in patients with a J pouch than in those with straight coloanal anastomosis, stressing the functional benefits of the colonic J pouch. In 2007 Koh et al.4 compiled 10 randomised, controlled trials conducted with high quality methodology. They concluded that the colonic J pouch appeared more favourable in terms of stool frequency and continence, with a slighty lower risk of anastomotic dehiscence compared to straight coloanal anastomosis. In 2008, the Cochrane Library published a meta-analysis.5 Sixteen randomised, controlled trials were selected from 2609 published studies. Brown et al. stated that up to 18 months postoperatively the colonic J pouch was superior to straight anastomosis in bowel frequency, urgency, faecal incontinence and use of antidiarrhoeal medication. Thus, the multiplicity of studies and their systematic conclusion in favour of the colonic J pouch, as well as the results of the meta-analysis, leave no doubt about its superiority. Nevertheless, there remain concerns regarding long-term maintenance of the functionnal benefits of the colonic J pouch. Indeed, the systematic review by the Cochrane Library and the meta-analysis by Heriot et al. stated that there were functional benefits from the colonic J pouch for 18 and 24 postoperative months, respectively. Over that time period, the superiority of the colonic J pouch remains to be established. The work of the J pouch remains unclear: increased capacity or presence of a bowel segment with no functional peristalsis.
What Kind of Pouch? Colonic J pouches have been used for more than 20 years. The coloplasty pouch has been advocated more recently as an alternative to the
June 9, 2009
14:6
B-601
ch27
FA
Pouches and Coloanal Anastomosis
205
J pouch, particularly when the mesocolon is fat and bulky or in the case of insufficient colonic length.6 In 2006, Heriot et al.3 concluded that the J pouch was functionally superior to straight anastomosis, but also that more trials were needed to make a conclusive statement about the coloplasty. More recently, a randomised controlled trial has been published by Fazio et al.7 including 354 patients, of which 96 could not have a colonic J pouch for different reasons — narrow pelvis, bulky mesentery, insufficient colonic length — and were excluded from the analysis. A total of 268 patients were randomised: 137 in the J pouch (JP) group and 131 in the coloplasty (CP) group. The JP group had a smaller total number of daily bowel movements than the CP group at 4, 12 and 24 postoperative months. There were also differences in favour of the J pouch concerning night bowel movements. The faecal incontinence score (FISI) was significantly lower in the JP group, indicating higher continence, than in the CP group. Other randomised, controlled studies have been performed with smaller consequent numbers, showing more-confusing results. Therefore the colonic J pouch remains obviously the gold standard. Until further evidence is available, other procedures such as coloplasty and side-to-end anastomosis should remain alternative technical solutions in case of difficulties in making a J pouch. Moreover, in the study conducted by Fazio et al.,7 the 96 patients excluded from the trial for technical reasons were further randomised to receive a straight coloanal anastomosis (n = 49) or a coloplasty (n = 47). The results of the analysis showed no benefits from the coloplasty compared to straight anastomosis, suggesting that the best solution could be side-to-end anastomosis, a simple and fast solution, in case of technical difficulties in making a J pouch.
TECHNIQUE Historically, the J pouch was shown to have evacuatory problems related to the loss of rectal sensibility, requiring enema or laxatives. These problems were resolved with a smaller pouch. A 5-cm-long
June 9, 2009
14:6
206
B-601
ch27
FA
S. Kirzin, G. Portier and F. Lazorthes
pouch is enough, while 8–10 cm might be too long.8 There are few, if any, evacuatory problems with a 5-cm-long J pouch. As for any low anastomosis, the vascularisation of the colon has to be good, particularly at the distal extremity. The anastomosis should be performed tension-free. The pouch has to fill the pelvic cavity. Contrary to the custom, it seems to us that the colon should be folded to the left side of the patient. Indeed, the medial side of the colon (the right side of the patient) is more richly vascular than the lateral side. The GIA stapler can be introduced at the apex or the base of the pouch. Introduction at the apex was the originally described technique (Fig. 1). It suits mechanical coloanal anastomosis. A short, longitudinal colotomy is performed on the site of the future anastomosis. It should be slightly smaller than the diameter of the stapler and stand
FIGURE 1 Colon folded on the left side of the patient, introduction of the stapler at the apex of the pouch for mechanical anastomosis.
June 9, 2009
14:6
B-601
ch27
FA
Pouches and Coloanal Anastomosis
207
FIGURE 2 Indroduction of the stapler at the base of the pouch for manual coloanal anastomosis; colon folded to the right side of the patients (usual fashion).
at an equal distance from the meso and the antimesenteric border of the colon. The colotomy is sewn around the head of the stapler. This technique avoids septic handling. In the second style (Fig. 2), the colon is incised on the base of the J pouch, opposite to the site of the future coloanal anastomosis on both descenders of the J. This procedure is similar to the J pouch used during restorative coloproctectomy. After application of the GIA stapler there remains a link between the two descenders. Its section will expose to the risk of stains. This technique is suitable for manual endoanal anastomosis, particularly after intersphincteric resection when the pouch has to be pulled through the sphincter. Even if carefully sewn, an incision at the apex of the pouch would expose to leaks and stains during handling.
June 9, 2009
14:6
208
B-601
ch27
FA
S. Kirzin, G. Portier and F. Lazorthes
In both styles, the distal extremity of the colon should be carefully checked and readily cut again with a TA or TX stapler. As a conclusion, few subjects have previously been studied, and particularly with such a high quality of methodology in the field of surgery, to provide answers with a high level of evidence.
REFERENCES 1. Lazorthes F, Fages P, Chiotasso P, et al. (1986) Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum. Br J Surg 73 (2): 136–138. 2. Parc R, Tiret E, Frileux P, et al. (1986) Resection and colo-anal anastomosis with colonic reservoir for rectal carcinoma. Br J Surg 73(2): 139–141. 3. Heriot AG, Tekkis PP, Constantinides V, et al. (2006) Meta-analysis of colonic reservoirs versus straight coloanal anastomosis after anterior resection. Br J Surg 93(1): 19–32. 4. Koh PK, Tang CL, Eu KW, et al. (2007) A systematic review of the function and complications of colonic pouches. Int J Colorectal Dis 22(5): 543–548. 5. Brown CJ, Fenech DS, McLeod RS. (2008) Reconstructive techniques after rectal resection for rectal cancer. Cochrane Database Syst Rev 2: CD006040. 6. Z’Graggen K, Maurer CA, Buchler MW. (1999) Transverse coloplasty pouch: a novel neorectal reservoir. Dig Surg 16(5): 363–366. 7. Fazio VW, Zutshi M, Remzi FH, et al. (2007) A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers. Ann Surg 246(3): 481–488; discussion 488–490. 8. Lazorthes F, Gamagami R, Chiotasso P, et al. (1997) Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis. Dis Colon Rectum 40(12): 1409–1413.
June 9, 2009
14:7
B-601
ch28
FA
chapter
28
Pelvic Exenteration for Rectal Cancer Klaas Havenga∗,† and Theo Wiggers†
INTRODUCTION The basis for successful treatment of rectal cancer is a radical resection of the tumour. In the majority of cases, rectal cancer is confined to the mesorectal package. Total mesorectal excision with long course or short course preoperative (chemo-)radiotherapy, depending on the margin to the circumferential margin based on staging, is effective in these cases. In some cases rectal cancer extends to the anterior compartment of the pelvis. In male patients the tumour may grow into the prostate, seminal vesicles or the bladder. In female patients the tumour may grow into the posterior vaginal wall, the uterus or the bladder. Radical resection of these tumors requires resection of the affected organs. This may result in partial bladder resection, resection of the seminal vesicles, or resection of the uterus or posterior vaginal wall en bloc with total mesorectal excision. If radical resection makes it necessary to resect the prostate or the bladder, total pelvic exenteration — the resection of all pelvic viscera — is indicated. In this technical note we will discuss the relevant surgical anatomy and surgical technique for total pelvic exenteration. ∗ Corresponding
author. Medical Center Groningen, Department of Surgery, PO Box 30.001, 9700 RB Groningen, The Netherlands. † E-mail:
[email protected]; t.wiggers@ chir.umcg.nl † University
209
June 9, 2009
14:7
210
B-601
ch28
FA
K. Havenga and T. Wiggers
SURGICAL ANATOMY The pelvis consists of two compartments: a parietal outer compartment and a visceral inner compartment. The parietal compartment is built around the skeletal part of the pelvis (sacrum, pubic, iliac and ischiac bone). Muscles on the inside of the pelvis are the piriformis muscle, coccygeal muscle, levator ani muscle and obturator muscle. The common, internal and external iliac arteries and veins belong to the parietal compartment as well as the lumbosacral nerve plexus. Organs of the internal compartment are the rectum and bladder and the genitourinary organs: in females the uterus, the round ligament of the uterus, tubae and ovaries, and the vagina, in males the seminal vesicles, ductus deferens and prostate. The visceral compartment is loosely connected to the parietal compartment except for a zone on the lateral side and on the inferior side, where the anus and vagina or urethra come through the pelvic floor. On the anterior side of the visceral compartment, the bladder is connected to the pubic bone by a layer of loose areolar tissue. Dividing this layer opens up the space of Retzius. On the posterior side of the visceral compartment, the mesorectum is connected to the sacrum by another layer of loose areolar tissue (although not as loose as in Retzius’ space). Dividing this posterior layer open up the presacral space (Fig. 1). If both the presacral space and Retzius’ space are opened up, the visceral compartment is fixed to the pelvic side walls on the lateral side, in a line parallel to the internal iliac artery. The ureter enters the visceral compartment close to the bifurcation of the internal and external iliac arteries (Fig. 2).
SURGICAL TECHNIQUE FOR TOTAL PELVIC EXENTERATION Pelvic exenteration is in many ways similar to standard low anterior resection or abdominoperineal resection. The patient’s position in stirrups, the midline incision from the pubic bone to just above
June 9, 2009
14:7
B-601
ch28
FA
Pelvic Exenteration for Rectal Cancer
211
FIGURE 1 MRI reconstruction of the pelvic visceral compartment, showing a combined frontal/transversal reconstruction in 3 angles between the green lines, according to the pink line at the saggital reconstruction.
the umbilicus, the careful inspection of the abdomen and liver for metastatic disease and the exposition of the pelvis by installing a selfretaining retractor to keep the small bowel and omentum away are all the same. After mobilising and dividing the sigmoid, the superior rectal artery is divided close to the inferior mesenteric artery.
June 9, 2009
14:7
212
B-601
ch28
FA
K. Havenga and T. Wiggers
FIGURE 2 Pelvic view, showing the location of the ureter and gonadal vessels.2
The presacral plane is developed. It is helpful to identify the hypogastric nerves at this stage and find the plane posterior to these nerves, contrary to regular rectal resection. This outward plane follows the outer layer of the visceral pelvic compartment. It is filled with loose areolar tissue; some small vessels cross the layer. Often, this plane is oedematous by the neoadjuvant radiation therapy. The ureter is encountered at its crossing of the iliac artery. We divide the ureter at this point, putting a temporarily small (char. 8) silicone catheter in it to allow observation of diuresis. Dividing the ureter at this point allows an anastomosis to the Bricker loop at the promontory. A longer ureter could allow a Bricker anastomosis deeper
June 9, 2009
14:7
B-601
ch28
FA
Pelvic Exenteration for Rectal Cancer
213
FIGURE 3 Puboprostatic ligament and dorsal venous complex.2
in the pelvis, at risk for leakage in the pelvis as it is not covered with tissue and for obstruction in the case of recurrent disease. On the ventral side, the loose areolar tissue of Retzius’ space is divided. The remaining bridge to the pelvic side wall is now divided. This dissection is carried out close to the internal iliac artery and vein and their subsequent branches, and just outside the pelvic autonomic nerve plexus we try to preserve in regular rectal resections. We use a bipolar vessel-sealing device in this part of the operation.
June 9, 2009
14:7
214
B-601
ch28
FA
K. Havenga and T. Wiggers
At the caudal edge of the pubic bone, firm attachments of the prostate to the bone are found: the puboprostatic ligament (Fig. 3). Under this ligament and lateral to this, an extensive venous plexus may cause extensive bleeding if the dissection is carried forward into this plexus. It is better to identify and tie branches of the vesicoprostatic plexus cranially and/or to extent the dissection within the prostatic capsula towards the pelvic floor. The urethra is then encountered and divided. The final part of the resection has two options. In the case of a distal tumour, a perineal resection is mandatory. We advocate resecting the levator ani muscles en bloc with the specimen to increase the resection margin in distal tumours.1 In the case of a more proximal tumour, sphincter preservation or leaving the pelvic floor intact, preventing herniation, may be considered.
CONCLUSION Total pelvic exenteration is very similar to total mesorectal excision. The difference lies in the extension of the resection line to include the complete pelvic visceral envelope. Technically it is important to divide the ureter at the spot where it enters the visceral fascia (i.e. just medial to the iliac vessels). Secondly, it is important to incise the endopelvic fascia over the prostate anteriorly and to carefully ligate the dorsal venous complex.
REFERENCES 1. Havenga K, Grossmann I, DeRuiter M, Wiggers T. (2007) Definition of total mesorectal excision, including the perineal phase: technical considerations. Dig Dis 25(1): 44–50. 2. Waldeyer W. (1899) Das Becken. Bonn, Cohen.
June 9, 2009
14:7
B-601
ch29
FA
chapter
29
Reconstruction of the Perineum by Gluteal Fold Flap Niri S. Niranjan∗
INTRODUCTION The perineal region has two components: excretory and sexual. Hence, the aim of reconstruction should be to restore the function and the appearance. Here the video presentation is mainly reconstruction by gluteal fold flap of the vulval area. The perineum has a rich blood supply, provided by the femoral and iliac arteries. The branches of these arteries are medial-circumferential, superficial and deep external pudendal vessels, and the obturator artery and internal pudendal artery. From branches of these vessels arcades form around the urogenital and anal orifices, and there are numerous perforators from these vessels. The skin of the gluteal fold area is supplied by the lateral branch of the internal pudendal artery. This is located just medial to the ischial tuberosity, and the lateral branch runs away laterally in the gluteal fold area.
∗ St.
Andrews Centre for Plastic Surgery, Broomsfield Hospital, Broomsfield, Chelmsford, Essex. 215
June 9, 2009
14:7
216
B-601
ch29
FA
N.S. Niranjan
GLUTEAL FOLD FLAP A large ellipse of skin within the gluteal fold can be harvested, measuring 15 cm by 8 cm. This island of skin can be transposed for vulval defects and also perianal defects. The gluteal fold flap is ideal for perineal reconstruction, even for cancer patients as the donor site scar is well concealed and the lymphatic drainage is away from the donor area. It also gives a large amount of skin for larger defects up to 10 cm by 18 cm. Being local, it is very reliable and gives excellent cosmetic results. The disadvantage of the flap is loss of hair and sensation.
OPERATIVE TECHNIQUE Prior to the surgery a gluteal fold is marked when the patient is in a standing position so that the resulting scar will be well hidden in the fold. The patient should be informed about the nature of the surgery, possible complications and the post-operative regime. The surgery is performed under either general or regional anaesthesia. The patient is placed in the Lloyd–Davies position and can be manoeuvred further to suit while the resection and reconstructions are performed. An indwelling catheter is inserted. The defect is created following excision of a tumour or infected tissue. Once the dimension of the defect is mapped out, the required flap is planned over the donor area in a reverse manner, by using a sterile swab or a sterile tape measure. The flap harvesting should be carried out by using Loupe magnification. Initially an exploring incision is made at one edge of the flap down to the muscle. The flap is elevated, including the deep fascia. Usually there are three perforating vessels noted from the gluteus muscle and they can be ligated once the medial-most perforator is identified and also the lateral branch can be visualised just medial to the ischial tuberosity. The dissection of this area should be performed by using a pair of scissors, gently separating the tissue. Once the main perforating branch to the flap is identified, the flap can be islanded
June 9, 2009
14:7
B-601
ch29
FA
Reconstruction of the Perineum by Gluteal Fold Flap
217
completely on the medial-most perforator if not the lateral branch of the internal pudendal vessel. Some amount of subcutaneous tissue is left around this pedicle and this means less of a problem of venous drainage. The flap is now ready to be rotated or transposed towards the defect. The suturing of the flap is by absorbable sutures and the donor site can always be closed directly. A suction drain is inserted to prevent any haematoma. I usually use bulky dressings to keep the flap warm, and the patient is kept in a slightly abducted position and a pillow is placed under the knees so that they are slightly flexed. Postoperatively the flap monitor should be functioning almost every hour for the first 24 hours and infrequently for the next 24 hours. Patients who have had gluteal fold flaps usually feel uncomfortable sitting for a few weeks and they should be advised to use soft cushions. The indwelling catheter is removed after about three to five days and the patient is usually discharged after a week to ten days, depending on the extent of the reconstruction. Post-operative complications like
Michael Salmon (1936) Arteres de la peau
FIGURE 1 X-ray plate reproduced from Salmon’s book on arteries of the skin, showing the fine anastomotic network that links the arteries of the skin of the pubic, vulval and posterior perineal region in a woman aged 22 years. (Reproduced with permission from Elsevier Ltd., Oxford, UK)
June 9, 2009
14:7
218
B-601
ch29
FA
N.S. Niranjan
venous congestion can be corrected by using leeches or removing the stitches at the pedicle area, and one should anticipate some of these complications in patients who are obese or are smokers or diabetics. If there is only a small loss of flap, then this is generally allowed to heal be secondary intention following debridement.
REFERENCES 1. Cormack CG, Lambarty BG (1994). The Arterial Anatomy of Skin Flaps, 2nd ed. Edinburgh, Churchill Livingstone. 2. Blondell PN, Morris SF, Hallock GG, Neligan PC (eds.) (2006). Perforator Flaps: Anatomy, Technique and Clinical Applications. St Louis, Missouri, Quality Medical Publishing.
June 9, 2009
14:7
B-601
ch30
FA
chapter
30
Local Treatment for Primary Melanoma Omgo E. Nieweg ∗
A thorough physical examination must be performed when a patient presents with a lesion suspicious for melanoma. The skin and subcutaneous tissue around the primary lesion and between it and the regional nodal basin should be examined for satellite and intransit metastases. The regional nodal basin must be evaluated. The skin of the entire body must be examined for concurrent primary melanomas, as these occur in 1% of cases. Radiographic or laboratory studies are not needed. Initial wide excision for simultaneous diagnosis and definitive treatment is discouraged for two reasons. Clinical assessment carries a false positive rate of 30%. Furthermore, the margin of therapeutic excision is determined by the Breslow thickness of the lesion. Measurement of the Breslow thickness is unreliable with frozen section microscopy. A diagnostic excision with regional anaesthesia (field block) is advised as a separate procedure prior to treatment. The orientation of the biopsy wound is planned with the definitive excision in mind. The direction of the scar is usually longitudinal on an extremity and transverse on the trunk. The excisional biopsy is carried out with a small ∗ Corresponding author. Department of Surgery, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands. E-mail:
[email protected].
219
June 9, 2009
14:7
220
B-601
ch30
FA
O. E. Nieweg
margin of surrounding skin (2 mm), and into the subcutaneous tissue. The diagnostic procedure should not be mutilating in a functional or cosmetic sense. A length three times as long as the width allows the wound to be closed easily with a nice cosmetic result. Punch biopsy, incisional or shave biopsy and excochleation, whether or not followed by electrocoagulation or cryotherapy, are discouraged. An incisional biopsy is acceptable when the primary lesion is large or situated in a delicate location, such as the face or the acra. An incisional biopsy does not increase the risk of recurrent disease or tumour-related demise.1 Fine needle aspiration for a cytological diagnosis is unreliable. Definitive treatment is exclusively surgical as a rule and entails wide local re-excision of the biopsy wound with surrounding skin. The recommended margin of normal-appearing skin that needs to be taken is a 1 cm margin for melanomas up to and including 2 mm, according to Breslow. The optimal excision margin for thicker melanomas has been assessed in a British randomised study.2 It was found that survival after a 1 cm excision and after a 3 cm excision were similar, but local-regional recurrences were more often seen in the narrow excision group. Retrospective studies suggest that a 2 cm margin is adequate for such lesions.3,4 A Scandinavian study is currently addressing this same subject. A 2 cm margin appears acceptable for these thick melanomas because the risk of (fatal) systemic metastases exceeds the risk of local recurrence by far. These recommended margins are smaller than former directives advocate. Five randomised, prospective studies and two metaanalyses indicate that such a reduction is safe.5–7 Even narrower margins are justified when the melanoma is situated on the face or acra; the perhaps somewhat improved cure rate after wide excision does not always outweigh the drawback of the additional mutilation. The definitive excision can often be done with regional anaesthesia too. An easy way to do the procedure is to carry the incision into the superficial subcutaneous tissue around the entire area of skin that is to be removed. Then, carry the incision down to the underlying fascia at one end of the wound. Blood will not hamper the field of view
June 9, 2009
14:7
B-601
ch30
FA
Local Treatment for Primary Melanoma
221
if one starts at the end of the wound that is furthest from the table. Work steadily towards the opposite end. The fascia is usually left intact but can be excised when it has been exposed during the initial diagnostic procedure or in the case of a thin layer of subcutaneous tissue. Pulling firmly on the tissue that is being excised conveniently demonstrates the plane that is to be followed. The wound is usually closed primarily to provide the best possible long-term cosmetic and functional result. Undermining the skin edges can facilitate primary closure. The stitches are removed after three weeks. Earlier removal may cause dehiscence, because the wound is closed with considerable tension. A split-thickness skin graft is applied if primary closure is not possible. The donor site is chosen outside the tumour region. Radiotherapy is virtually never used to treat localised lesions, with the exception of lentigo maligna melanoma. The radiosensitivity of this particular melanoma type seems better than that of other types of melanoma, and radiotherapy may occasionally be used as an alternative to limit disfigurement.8
REFERENCES 1. Bong JL, Herd RM, Hunter JA. (2002) Incisional biopsy and melanoma prognosis. J Am Acad Dermatol 46: 690–694. 2. Thomas JM, Newton-Bishop JA, A’Hern RP, et al. (2004) Excision margins in high-risk malignant melanoma. N Engl J Med 350: 757–766. 3. Heaton KM, Sussman JJ, Gershenwald JE, et al. (1998) Surgical margins and prognostic factors in patients with thick (>4 mm) primary melanoma. Ann Surg Oncol 5: 322–328. 4. Ng AKT, Jones WO, Shaw JHF. (2001) Analysis of local recurrence and optimizing excision margins for cutaneous melanoma. Br J Surg 88: 137–142. 5. Lens MB, Dawes M, Goodacre T, et al. (2002) Excision margins in the treatment of primary cutaneous melanoma: a systematic review of randomized controlled trials comparing narrow vs wide excision. Arch Surg 137: 1101–1105. 6. Haigh PI, DiFronzo LA, McCready DR. (2003) Optimal excision margins for primary cutaneous melanoma: a systematic review and meta-analysis. Can J Surg 46: 419–426.
June 9, 2009
14:7
222
B-601
ch30
FA
O. E. Nieweg
7. Tsao H, Atkins MB, Sober AJ. (2004) Management of cutaneous melanoma. N Engl J Med 351: 998–1012. 8. Farshad A, Burg G, Panizzon R, et al. (2002) A retrospective study of 150 patients with lentigo maligna and lentigo maligna melanoma and the efficacy of radiotherapy using Grenz or soft X-rays. Br J Dermatol 146: 1042–1046.
June 9, 2009
14:7
B-601
ch31
FA
chapter
31
Ilioinguinal Dissection for Melanoma Alessandro Testori∗,† and Mark Zonta†
INTRODUCTION Ilioinguinal dissection for melanoma is indicated for positive sentinel nodes following selective lymphadenectomy or for palpable, histologically positive groin nodes. The procedure provides important staging information, helps with decision-making regarding adjuvant treatment, affords regional disease control and may be curative in patients without distant metastases. Several retrospective studies have demonstrated the importance of deep inguinal and pelvic lymphadenectomy in patients with superficial nodal involvement only.1–5
TECHNIQUE Under general anaesthesia and antibiotic prophylaxis, a urinary catheter is inserted and the patient is positioned supine, with the ipsilateral lower limb slightly abducted to flex the knee. ∗ Corresponding † Division
author. of Melanoma and Soft Tissue Sarcoma, European Institute of Oncology,
Italy. † European Institute of Oncology, via Ripamonti 435, 20141 Milano, Italy. E-mail:
[email protected] 223
June 9, 2009
14:7
224
B-601
ch31
FA
A. Testori and M. Zonta
The operative field is prepared with a small drape to exclude the genitals from the sterile field and to shift the genitals (male) contralaterally. The remaining drapes are positioned to expose an area from just superior of the iliac crest to just inferior of the apex of the femoral triangle. Various skin incisions have been described. We employ either a curvilinear elliptical incision from just medial of the iliac crest to the apex of the femoral triangle, or separate incisions including a curvilinear elliptical infrainguinal incision and an oblique iliac fossa incision (Fig. 1). The incisions incorporate the previous biopsy site and skin overlying palpable nodes. A lateral subcutaneous flap is mobilised until the medial border of the sartorius is exposed after incising the overlying fascia and sparing the lateral femoral cutaneous nerve. This flap is at least 0.5–1 cm thick, to avoid rendering it ischaemic. The superficial epigastric and superficial circumflex iliac vessels, the anterior saphenous vein and
FIGURE 1 Preoperative photo showing an iliac fossa incision to approach the deep pelvic nodes and an elliptical infrainguinal incision incorporating the previous sentinel node biopsy site.
June 9, 2009
14:7
B-601
ch31
FA
Ilioinguinal Dissection for Melanoma
225
the intermediate femoral cutaneous nerve are encountered as this flap is mobilised along its full length. A medial flap of similar thickness is mobilised to the medial border of the adductor longus. In males it is necessary to identify and retract the spermatic cord medial to the dissection. Below the pubic tubercle, the fascia over the medial border of the adductor longus is incised and dissected off this muscle and the pectineus after securing the external pudendal vessels, the accessory saphenous vein and the long saphenous vein. The suprainguinal lymph nodes are then dissected from the underlying external oblique to the level of the inguinal ligament. The femoral sheath is incised below the ligament and the femoral vein is identified just deep to the lateral border of the adductor longus. The vein is skeletonised of its adventitia and nodal tissue and the saphenofemoral junction is suture-ligated and divided. Unless there is gross disease involving the long saphenous vein, some surgeons preserve it to facilitate subsequent drainage of the limb. The femoral artery is identified immediately lateral to the femoral vein and is similarly skeletonised. The leash of motor branches of the femoral nerve are in a deeper plane and not usually exposed. The specimen is divided at the femoral canal, as there is no proven benefit in maintaining its continuity with the deep pelvic nodes. Various approaches to these nodes have been proposed. We employ a pararectus approach without dividing the inguinal ligament. The inguinal ligament is retracted to allow dissection between it and the femoral vessels, and to secure the inferior epigastric vessels. This will facilitate blunt separation of the peritoneum from the abdominal wall and external iliac nodes once the ligament is suspended and the abdominal wall divided along the lateral border of the rectus abdominis muscle. The retroperitoneal iliac fossa is exposed until the bifurcation of the common iliac artery and the ureter are identified. Retractors are positioned into the pelvic wound to maintain adequate exposure.
June 9, 2009
14:7
226
B-601
ch31
FA
A. Testori and M. Zonta
The nodal dissection then continues from the common femoral vessels to the bifurcation of the common iliac artery. This involves incising the adventitia of the anterior surface of the external iliac artery and vein, and dissecting the nodal tissue from them and towards the obturator fossa until both vessels have been circumferentially skeletonised. Proceeding cephalad, the vessels encountered during this phase of the dissection include the deep circumflex iliac vessels coursing laterally, the inferior epigastric vessels medially, and a variable communicating vein between the external iliac and obturator veins. Only the deep circumflex vessels can be preserved, as they do not impede the dissection. Care is needed in identifying and dividing the communicating vein, because its inadvertent laceration can cause troublesome bleeding. Once the common iliac bifurcation has been reached, an orientation suture is secured to the most proximal lymph nodes. The cephalad retroperitoneal lymphatics are ligated to reduce postoperative lymphorrhoea. Dissection of the obturator nodes is then initially performed to safely identify and preserve the obturator nerve posteriorly, and to dissect the lymphatic structures immediately cephalad to the pelvic wall. The bladder is dissected off the medial aspect of the obturator nodes and sponge-holding forceps are used to remove the remaining nodal tissue from deep within the pelvis whilst always visualising the nerve (Fig. 2). The obturator dissection is considered adequate when the branches of the internal iliac artery have been exposed. Following haemostasis a retroperitoneal pelvic drain is positioned via the groin. The peritoneal sac is re-positioned and the abdominal wall is closed in two layers including the transversalis fascia and external oblique aponeurosis. To prevent a femoral hernia, non-absorbable monofilament interrupted sutures are placed between Cooper’s ligament and the inguinal ligament. Some surgeons, including ourselves, recommend dividing the sartorius at its origin and rotating the muscle to cover the femoral vessels (Fig. 3), as this wound may be complicated
June 9, 2009
14:7
B-601
ch31
FA
Ilioinguinal Dissection for Melanoma
227
FIGURE 2 Operative photo after deep pelvic lymphadenectomy with the external iliac artery (broad arrow) and vein (narrow white arrow) and obturator nerve (black arrow) exposed.
FIGURE 3 The sartorius is mobilised on its preserved blood supply to be rotated over the femoral vessels.
June 9, 2009
14:7
228
B-601
ch31
FA
A. Testori and M. Zonta
by flap necrosis. The viability of each flap is assessed before closing the subcutaneous tissue with a continuous absorbable suture and the skin with interrupted sutures.
DISCUSSION The difference in morbidity by the addition of a pelvic dissection to an inguinal dissection is slight.6 In patients with microscopically positive superficial sentinel nodes, the incidence of deep nodal involvement may be substantial,7 and the incidence is even higher in the presence of palpable inguinal nodal metastases.8 Therefore, ilioinguinal dissection is justified for these patients and is vitally important for those with positive deep nodes and no distant metastases.
REFERENCES 1. Mack LA, McKinnon JG. (2004) Controversies in the management of metastatic melanoma to regional lymphatic basins. J Surg Oncol 86: 189–199. 2. Tonouchi H, Ohmori Y, Kobayashi M, et al. (2004) Operative morbidity associated with groin dissections. Surg Today 34: 413–418. 3. Mann GB, Coit DG. (1999) Does the extent of operation influence the prognosis in patients with melanoma metastatic to inguinal nodes? Ann Surg Oncol 6: 263–271. 4. Hughes TM, Thomas JM. (1999) Combined inguinal and pelvic lymph node dissection for stage III melanoma. Br J Surg 86: 1493–1498. 5. Strobbe LJ, Jonk A, Hart AA, et al. (2001) The value of Cloquet’s node in predicting melanoma nodal metastases in the pelvic lymph node basin. Ann Surg Oncol 8: 209–214. 6. Karakousis CP, Thompson JF. (2004) Groin and pelvic dissection for melanoma. In: JF Thompson, DL Morton and BB Kroon (eds.), Textbook of Melanoma, pp. 285–295. London, Martin Dunitz. 7. Karakousis CP, Emrich LJ, Driscoll DL, et al. (1991) Survival after groin dissection for malignant melanoma. Surgery 109: 119–126. 8. Karakousis CP, Emrich LJ, Rao U. (1986) Groin dissection in malignant melanoma. Am J Surg 152: 491–495.
June 9, 2009
14:7
B-601
ch32
FA
chapter
32
Surgical Treatment of Peritoneal Carcinomatosis Marcello Deraco∗,† , Dario Baratti‡ , Barbara Laterza,‡ Domenico Sabia‡ and Shigeki Kusamura‡
INTRODUCTION About three decades have passed since hyperthermic intraperitoneal chemotherapy (HIPEC) was first conducted by Dr. Spratt.1 In this period the treatment of peritoneal surface malignancy (PSM) with cytoreductive surgery (CRS) and HIPEC has gained enormous popularity, changing positively the expectations for a clinical condition that in former times was considered incurable. Results of phase II studies testing the efficacy of the combination in the treatment of pseudomyxoma peritonei, peritoneal mesothelioma and ovarian cancer have been somewhat encouraging.2−4 Results of a phase III trial have confirmed the superiority of CRS + HIPEC in the treatment of patients with carcinomatosis from colon cancer over other standard surgical and/or systemic chemotherapy modalities.5 The purpose of this article is to provide a short technical description of the local regional therapy of PSM. ∗ Corresponding
author.
† Istituto Nazionale Tumori Milano, Via Venezian 1, 20133 Milano, Itally. E-mail: mar-
[email protected] of Surgery, National Cancer Institute of Milan, Italy.
‡ Department
229
June 9, 2009
14:7
230
B-601
ch32
FA
M. Deraco et al.
TECHNIQUE The eligibility requirements for treatment are as follows: histologically confirmed diagnosis of peritoneal carcinomatosis or sarcomatosis; age < 75 years; no distant metastasis; adequate renal, haematopoietic and liver functions; and performance status (ECOG) 0, 1 or 2. The CRS is performed according to the Sugarbaker technique.6 Patients are put in the supine position with gluteal folds advanced to the break in the operating table. The surgical procedure starts with a xyphopubic, midline incision, and the successive layers of the abdominal wall are dissected until the parietal peritoneum is visualised. The dissection of the parietal peritoneum from the abdominal wall is begun without opening the peritoneal cavity and is continuous until the identification of the vena cava, aorta, iliac vessels and ureters. Then, the parietal peritoneum is incised and full access to the abdominal cavity is achieved. Peritoneal carcinomatosis is quantified according to the Peritoneal Cancer Index.7 The surgical procedure is carried out with one or more of the following steps, depending on disease extension, in order to achieve a residual disease of less than 2.5 mm: (1) greater omentectomy, right parietal peritonectomy ± right colon resection; (2) pelvic peritonectomy ± sigmoid colon resection ± hysteroadnexectomy; (3) lesser omentectomy and dissection of the duodenal–hepatic ligament ± antrectomy ± cholecystectomy; (4) right upper quadrant peritonectomy ± Glisson’s capsule; (5) left upper quadrant peritonectomy ± splenectomy; (6) other intestinal resection and/or abdominal mass resection. The stripping of the right upper quadrant continues until the bare area of the liver. At this point, tumour on the superior surface of the liver is electroevaporated until the liver surface is cleared. In the case of massive tumour implantation on the liver (Fig. 1), the Glisson capsule from the superior surface of the liver can be removed. Dissection continues down to the right subhepatic space. The right
June 9, 2009
14:7
B-601
ch32
FA
Surgical Treatment of Peritoneal Carcinomatosis
231
FIGURE 1 Intraoperative view of extensive peritoneal neoplastic dissemination in the upper abdomen of a pseudomyxoma peritonei patient.
diaphragmatic peritoneum is resected together with the peritoneum layering Morrison’s pouch. The gall bladder is removed from its fundus toward the cystic artery and cystic duct. The triangular ligament of the left lobe of the liver is resected in performing the left subphrenic peritonectomy. This completed, the left lateral segment of the liver is retracted left to right to expose the hepatogastric ligament. A circumferential release of this ligament from the fissure between liver segments 2, 3 and 1, and from the arcade of the right gastric artery to the left gastric artery along the lesser curvature of the stomach, is required. To resect the peritoneum from the anterior aspect of the hepatoduodenal ligament, its reflection to the liver surface is released and the peritoneum peeled away from the common bile duct and hepatic artery. Resection of the lesser omentum is always indicated, even in the absence of metastatic disease in this structure.
June 9, 2009
14:7
232
B-601
ch32
FA
M. Deraco et al.
After stripping the left upper quadrant peritoneum from the diaphragmatic muscle, we begin the greater omentectomy ± splenectomy. The greater omentum is elevated, and separated from the transverse colon. This dissection continues beneath the peritoneum that covers the transverse mesocolon, so as to expose the pancreas. The gastroepiploic and the short gastric vessels on the greater curvature of the stomach are clamped, ligated and divided. The peritoneum anterior to the pancreas is stripped. The splenic vessels at the tail of the pancreas are ligated in continuity and proximally suture-ligated. When the upper quadrant peritonectomy is completed, the stomach is reflected medially. Branches of the gastroepiploic arteries are ligated. The left adrenal gland, the pancreas, the left perirenal fatty tissue and the anterior peritoneal surface of the transverse mesocolon are totally exposed. A distal pancreatectomy is performed when required and the transection done using a GIA stapler with reinforcing handsewn separate Vycril 2-0 stitches. Whether a partial or total gastrectomy is performed, a Roux-en-Y reconstruction is indicated. Small bowel and colic anastomoses are hand-sewn in an end-to-end fashion using single-layer extramucosal continuous Maxon 4-0 or 3-0 stitches (Fig. 2). Most of the time the cul-de-sac area is filled with coalescing tumour implants that also include much of the sigmoid colon. A complete pelvic peritonectomy with a low anterior resection is frequently needed to completely remove these tumour implants. The low colorectal anastomosis is performed with an intraluminal stapler of 29–33 mm diameter.
HIPEC Generally speaking, there are two types of HIPEC modalities: the closed and open abdomen techniques. At the National Cancer Institute of Milan the closed technique is used. After cytoreduction, four silicone catheters are placed in the abdominal cavity: one in the right subphrenic cavity: one in the deep pelvis, one in the left
June 9, 2009
14:7
B-601
ch32
FA
Surgical Treatment of Peritoneal Carcinomatosis
233
FIGURE 2 Aspect of the upper abdomen after a radical cytoreduction with partial gastrectomy.
subphrenic cavity and one in the superficial pelvic site cavity. Two thermocouples are placed in the abdominal cavity. Using the closed abdomen technique, the skin is closed with a running suture. The catheters are then connected to the extracorporeal circuit Performer LRT®, RAND, Medolla (MO), Italy. The intraperitoneal chemotherapy regimens used are as follows: Cisplatin (CDDP-25 mg/m2 /L) and Mitomycin C (MMC-3.3 mg/m2 /L), or cisplatin (CDDP-43 mg/L of perfusate) and doxorubicin (Dx-15.25 mg/L of perfusate). A heat exchanger keeps the intracavitary perfusate temperature at 42◦ C to 43◦ C. The HIPEC lasts 60 to 90 minutes, depending on the drug schedule (Fig. 3).
DISCUSSION The local–regional therapy (CRS + HIPEC) has already been standardised and described in detail by its introducer.6 However, the increasing number of surgeons and centres interested in setting up a local–regional therapy unit in the world renders the procedure subject to several modifications.
June 9, 2009
14:7
234
B-601
ch32
FA
M. Deraco et al.
FIGURE 3 Extracorporeal circuit in hyperthermic intraperitoneal chemotherapy. This schema represents the extracorporeal circuit in the closed abdomen technique.The perfusate containing the drugs is mobilised by the pump and prepared by the heater up to the temperature of 42.5◦ C. Then, it is infused in the abdominal cavity through two inflow catheters of Tenkhoff (5 and 6). After the circulation inside the abdominal cavity, the perfusate is recovered by the outflow catheters (7 and 8), to be instilled again in the abdomen. The thermostat controls the temperature through four probes located respectively in the upper abdomen (1), lower abdomen (2), outflow (3) and inflow (4) of the circuit.
In December 2006 the National Cancer Institute of Milan organised a consensus statement on the management of PSM. This conference brought together experts in the field of local–regional therapy to discuss current approaches to PSM. The consensus was achieved with several conflicting points regarding the technical variations of CRS.8 The main conflicting points discussed were the radicalness of the peritonectomy procedure, the cytoreduction of neoplastic nodules < 2.5 mm, and indications of protective ostomies.
June 9, 2009
14:7
B-601
ch32
FA
Surgical Treatment of Peritoneal Carcinomatosis
235
A partial parietal peritonectomy restricted to the macroscopically involved regions could be indicated in all listed clinical conditions with the exception of peritoneal mesothelioma. According to the experts, a radical parietal peritonectomy is not advisable irrespective of the disease being treated. The electrovaporisation of small non-infiltrating metastatic nodules (< 2.5 mm) in the mesentery, after the completion of CRS, would be indicated, even if theoretically HIPEC could exert a microscopic cytoreductive effect. Regarding the policy for protective stomas, it could be flexible and the procedure could be done at the surgeon’s discretion. As to the modalities of HIPEC (open vs closed), it was concluded that the evidence in the literature is not sufficient to confirm the superiority of one modality over the others in terms of outcome, morbidity, and safety of the personnel in the operating theatre. Each option has its own experimental evidence and operational advantages and disadvantages.9 The continuous application of the local–regional treatment in different diseases and new clinical circumstances will require the adaptation of the original technique with further modifications. The validation of the current and future variations of the technique requires prospective randomised studies to be conducted.
REFERENCES 1. Spratt JS, Adcock RA, Muskovin M, et al. (1980) Clinical delivery system for intraperitoneal hyperthermic chemotherapy. Cancer Res 40(2): 256–260. 2. Baratti D, Kusamura S, Nonaka D, et al. (2008) Pseudomyxoma peritonei: clinical pathological and biological prognostic factors in patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Ann Surg Oncol 15(2): 526–534. Epub 2007 Nov 28. 3. Deraco M, Nonaka D, Baratti D, et al. (2006) Prognostic analysis of clinicopathologic factors in 49 patients with diffuse malignant peritoneal mesothelioma treated with cytoreductive surgery and intraperitoneal hyperthermic perfusion. Ann Surg Oncol 13(2): 229–237. Epub 2006 Jan 18.
June 9, 2009
14:7
236
B-601
ch32
FA
M. Deraco et al.
4. Ryu KS, Kim JH, Ko HS, et al. (2004) Effects of intraperitoneal hyperthermic chemotherapy in ovarian cancer. Gynecol Oncol 94: 325–332. 5. Verwaal VJ, van Ruth S, de Bree E, et al. (2003) Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol 21: 3737–3743. 6. Sugarbaker PH. (1995) Peritonectomy procedures. Ann Surg 221: 29–42. 7. Jacquet P, Sugarbaker PH. (1996) Current methodologies for clinical assessment of patients with peritoneal carcinomatosis. J Exp Clin Cancer Res 15: 49–58. 8. Kusamura S, O’Dwyer S, Baratti D, et al. (2008) Technical aspects of the cytoreductive surgery: results of consensus statement. J Surg Oncol, special issue, in press. 9. Kusamura S, Dominique E, Baratti D, et al. (2008) Drugs, carrier solutions and temperature in hyperthermic intraperitoneal chemotherapy. J Surg Oncol, special issue, in press.
June 9, 2009
14:7
B-601
ch33
FA
chapter
33
Laparoscopic Management of Adnexal Tumours Liselotte Mettler∗,† , Ivo Meinhold-Heerlein† and Andreas G. Schmutzler†
The adnexa provide a direct connection from the intraabdominal cavity to the outside through the Fallopian tubes across the uterus, cervix and vagina (Fig. 1). Bacteria can migrate to the genital tract and kidney region ascending across the cervix, the uterus and the tubes. On the other hand, a descending infection from the kidney region and the tubes can reach the ureters and the bladder or the uterus and the cervix. In the lower pelvis of a female the bladder is connected to the outside through the urethra and the uterus through the cervix so that the tubes have a natural predilection for infections and consecutive tubal occlusions. Till now no ovarian or tubal transplants have been available, so the organs should be carefully diagnosed and treated. A resection seems generally only indicated in the case of a malignant disease or in old age. In addition, removal of a damaged Fallopian tube may increase the success rate of in vitro fertilisation and embryo transfer. Even ovaries beyond the reproductive age carry a certain function and should only be removed if indicated. Nearly all adnexal tumours ∗ Corresponding
author. of Obstetrics and Gynecology, Christian-Albrechts-University of Kiel, Klinikum Schleswig-Holstein, Campus Kiel, Michaelisstr. 16, 24105 Kiel, Germany. E-mail:
[email protected] † Department
237
June 9, 2009
14:7
238
B-601
ch33
FA
L. Mettler et al.
FIGURE 1 Anatomy of the right half of the uterus and the right adnexa.
can be managed laparoscopically. Procedures include excision of ovarian or paraovarian cysts, partial oophorectomy, total (salpingo-) oophorectomy, enucleation of ovarian cysts with borderline malignancy and the treatment of tubal pregnancy. Tubectomy, fimbroplasty, salpingostomy, end-to-end anastomosis and adnexectomy are possible. In the case of ovarian cancer with an indication for radical surgery, the resection of the uterus, tubes and ovaries, as well as an extensive pelvic and parotic lymphadenectomy together with omentum resection, is generally possible. However, the surgical treatment of ovarian cancer by laparoscopy is still not widely accepted and the key general surgical options remain to be performed via laparotomy.6 The most common surgical procedures in the management of benign adnexal tumours are still the enucleation of ovarian cysts and adnexectomies. These two surgical procedures are performed as follows: (1) Ovarian cyst enucleation An endoscopic ovarian cyst enucleation must be carried out in toto in the correct anatomical plane. Any remnant, as sometimes in
June 9, 2009
14:7
B-601
ch33
FA
Laparoscopic Management of Adnexal Tumours
239
cases of endometriosis, is destroyed by electrocoagulation or other energy sources. As an example, six steps of enucleation of a 5cm-in-diameter ovarian cyst in a 23-year-old with a hyperechoic zone in ultrasonography with suspicion of borderline lesion are demonstrated in Fig. 2. Step 5 is controversial, as most surgeons prefer not to suture. (2) Adnexectomy Ovarectomy, tubectomy or adnexectomy is an easy laparoscopic procedure if the adnexa are not pathologically attached to the pelvic sidewall. Figure 3 details schematically a right adnexectomy using a stapler in six individual steps. Under traction the adnexa are pulled away from the ovarian and infundibulopelvic ligament, and separated from the uterus and infundibulopelvic ligament using a stapling gun. Other energy sources to be used are ultrasound, bipolar coagulation and thermofusion. Adnexa can only be reached intraperitoneally. Alternatively, sutures and the two- or three-loop ligation technique can be applied.6 Laparoscopic adnexal surgery has widely replaced laparotomy Every ovarian cyst without any suspicion of malignancy in the reproductive age range should be enucleated laparoscopically conserving the organ. Any functional cyst in this age range, however, should first be treated by estrogen suppressants and excised only if it persists. Each adnexal tumour with an ovarian cyst should be carefully evaluated preoperatively, by imaging techniques, tumour marker measurement and palpation. During endoscopic surgery the most modern oncological criteria must be observed. At most gynaecological–oncological surgical centres, in suspected ovarian cancer a primary laparotomy with the aim of an RO resection with hysterectomy, adnexectomy, lymph node resection and omentectomy is carried out. Only a few laparoscopic oncological centres have the know-how and the infrastructure to laparoscopically treat ovarian cancer. If
June 9, 2009
14:7
240
B-601
ch33
FA
L. Mettler et al.
FIGURE 2 Ovarian cyst enucleation (with suspicion of borderline lesion) (A) Ultrasound of the hyperechoic zone in a double-chambered ovarian cyst, tumour marker negative; (B) ovarian cyst, double the size of the normal ovary, between the ovary and the uterus, near the normal-looking ovary; (C) dissection of a cyst capsule; (D) coagulation of the cyst pedicle; the cyst is enucleated out of its bed; (E) putting the ovarian cyst in an endobag; (F) extraction of the cyst, tapping and adaption of wound edges with endosuture, and extracorporeal knotting.
malignancy is diagnosed during laparoscopy, the patient must be either treated adequately laparoscopically or subjected to laparotomy in the same session or within the next 5–8 days.3,8 In the case of borderline ovarian tumours, laparoscopic restaging should be regularly performed.1 After incomplete initial ovarian cancer
June 9, 2009
14:7
B-601
ch33
FA
Laparoscopic Management of Adnexal Tumours
241
FIGURE 3 Right adnexectomy using a stapling device and abdominal extraction in an endobag (A) Resection of the stretched adnexa from the uterus; (B) resection of adnexa from the pelvic sidewall above the infundibulopelvic ligament; (C) putting the adnexa in an endobag; (D) closing the endobag; (E) pulling the endobag in a 10 to 15 mm trocar; (F) widening the abdomen with two retractors and extraction of the endobag out of the abdomen.
surgery, laparoscopic restaging with pelvic and parotic lymphadenectomy, LAVH and/or salpingo-oophorectomy was found to essentially improve the prognosis of such patients.4 Every effort is made to avoid intraoperative capsule rupture during primary surgery. If this does happen, irrigation is carried out
June 9, 2009
14:7
242
B-601
ch33
FA
L. Mettler et al.
carefully with copious normal saline even though it has not been proved that rupture worsens the prognosis of ovarian carcinoma. In five-year survival studies of stage I (FIGO) ovarian carcinoma, capsule rupture and “spilling” has appeared to play no role. The grade of histological differentiation and ascitis seem to play a greater role in the case of stage I cancers.2,7 Vergote et al.9 proved in a multi-variate analysis of surgery on 1545 patients with ovarian cancer that the degree of differentiation is the most powerful prognostic indicator of diseasefree survival — followed, however, by rupture before surgery, rupture during surgery, and age. The specimen obtained by laparoscopy should be removed from the abdominal cavity in an endobag, so as to avoid port site metastases. An aggressive operative regimen in the field of endoscopic surgery for genital carcinomas can be discussed on a broad basis only if randomised double blind studies show better success with endoscopic surgery as compared to conventional surgery. In advanced ovarian carcinoma, we employ endoscopic methods merely for obtaining specimens, to avoid exploratory laparotomy. In benign ovarian and adnexal tumours, endoscopic surgery has already replaced conventional laparotomy.
REFERENCES 1. Darai E, Tulpin L, Prugnolle H, et al. (2007) Laparoscopic restaging of borderline ovarian tumors. Surg Endoscopy 21(11): 2039–2043. 2. Dembo AJ, Davy M, Stenwick, AE. (1990) Prognostic factors in patients with stage I epithelial ovarian cancer. Obstet Gynecol 74: 263–273. 3. Kindermann G, Jung EM, Maassen V, Bise K. (1996) Incidence of primary malignant lesions in clinically benign teratoma: on the problem of adequate surgical procedure. Geburtshilfe und Frauenheilkunde 56: 438–440. 4. Leblanc E, Querleu D, Narducci F, et al. (2005) Laparoscopic restaging of early-stage adnexal tumors: a 10-year experience. Obstet Gynecol Survey 60(1): 31–32. 5. Medeiros LR, Stein AT, Fachel J, et al. (2007) Laparoscopy versus laparotomy for benign ovarian tumor: a systematic review and
June 9, 2009
14:7
B-601
ch33
FA
Laparoscopic Management of Adnexal Tumours
6. 7. 8.
9.
243
meta-analysis. Int J Gynecol Cancer, Online-Article, publ. 10 Aug. 2007 (http://www.blackwell-synergy.com). Mettler L, Semm K, Gebhardt JH, et al. (2006) Manual for Laparoscopic and Hysteroscopic Gynecological Surgery. Jaypee Brothers, New Delhi. Sevelda P, Varra N, Schemper M, Salzer H. (1990) Prognostic factors for survival in stage I epithelial ovarian cancer. Cancer 65: 10. Salfelder A, Nugent A, Lueken RP, et al. (2002) Laparoscopic treatment of malignant ovarian tumors — late results. Geburtshilfe und Frauenheilkunde 62: 452–457. Vergote I, de Brabanter J, Fyles A, et al. (2001) Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma. Lancet 357(9251): 176–182.
June 9, 2009
14:7
B-601
ch34
FA
chapter
34
Excision of Intra-Abdominal Sarcomas: Technical Notes on Surgical Procedures Beate Rau∗ and Peter M. Schlag
INTRODUCTION Nonepithelial cancers derive from the various connective tissues and a variety of mesenchymal cell types (fibroblasts, adipocytes, osteoblasts and myocytes) throughout the body. These tumours, the sarcomas, constitute nearly 1% of the malignancies. Soft tissue sarcomas are slightly increased in patients with a variety of genetically transmitted diseases, and patients with soft tissue sarcoma very often have a recent history of a trauma or previous exposure to radiation. Approximately 60% of sarcomas occur in the extremities, 9% in the head and neck regions and 31% in the intra-abdominal cavity. Intra-abdominal soft tissue sarcomas (IASTS) are usually located in the retroperitoneal space in 40%. The remaining tumours are located in the abdominal or chest wall, the mediastinum and the breast. Most retroperitoneal soft tissue sarcomas are liposarcomas, leiomyosarcomas or malignant fibrous histiocytomas.1 ∗ Corresponding
author. Department of Surgery and Surgical Oncology, University of Berlin, Charité Campus Milte, Charite platz 1, 10 M7 Berlin, Germany. E-mail:
[email protected] 245
June 9, 2009
14:7
246
B-601
ch34
FA
B. Rau and P. M. Schlag
The tendency of soft tissue sarcomas to metastasise depends on the grade of the tumour. Low grade sarcomas are characterised mainly by local invasive growth, but do not tend to metastasise. High grade tumours are more likely to disseminate. Therefore in these tumours surgery is usually covered by a pre- and/or post-operative treatment strategy. However, complete resection and the grade of the tumour are the most important prognostic factors. Surgery plays an important role in the treatment of soft tissue sarcomas and is a challenging procedure especially in retroperitoneal tumours, because these are usually very large when detected. However, the anatomical location of most retroperitoneal sarcomas precludes complete surgical excision with tumour-free circumferential margin. Surgical excision should be aimed at removing all gross tumours with as much marginal tissue in the expected areas of local spread as is compatible with reasonable morbidity. Usually the retroperitoneal tumours are adjacent to, covered by or close to the big vessels of the aorta and cava vein, kidney, adrenal gland, diaphragm, pancreatic head, corpus or tail, spleen, liver, colon, rectum, stomach, etc. In the case of marginal excision of the tumour, additional radiotherapy should be considered, especially in high grade sarcomas, and the surgeon should outline the margins of resection with clips. However, any potential enhancement of local control by radiotherapy must be weighed against functional deficits and impairments in quality of life induced by radiotherapy.
OPERATIVE TECHNIQUE In retroperitoneal sarcomas, it is of major importance to resect the tumour within gross tumour-free circumferential margins. The average mean diameter of retroperitoneal tumours is often very impressive, so median laparotomy extends from the xiphoid process to pubic symphysis. Sometimes even lateral extension of the scar is
June 9, 2009
14:7
B-601
ch34
FA
Excision of Intra-Abdominal Sarcomas
247
necessary (be aware of the right angle of the incisions to each other, to avoid necrosis of the abdominal wall). Retroperitoneal sarcomas are covered ventrally by the bowel (see Fig. 1) and the peritoneum, and dorsally by the retroperitoneal plane adjacent to the autochthonous muscles and the vertebra as well as the lateral abdominal wall. Usually, to achieve complete resection, multivisceral en bloc resection has to be planned. Therefore the first step of the procedure should be dissection of the big vessels and a truncular cut through the mesenteric inferior and renal artery, if the kidney is involved. The same procedure has to be performed with the vein. The second step is dissection of the tumour within the retroperitoneal fascia and the ventral part of the adjacent autochthonous muscles of the back. Sometimes the complete muscles have to be resected including the femoral nerve. Preparation of the retroperitoneal space dorsal of the tumour could be very difficult, because of the bad view. To reduce the blood loss during the operation, especially in this part, sealing equipment could help. If nephrectomy is necessary for achieving complete resection, retransplantation of the kidney could be an option for organ-saving surgery. Then the cortex of the kidney has to be dissected outside the body and retransplantation of the kidney can be performed easily.
DISCUSSION The incidence of retroperitoneal sarcoma (RPS), a rare disease, appears stable. Most patients who undergo surgery do not receive any adjuvant radiotherapy, and very few receive preoperative radiotherapy. The Swedish Council of Technology Assessment in Health Care analysed the literature on radiation therapy for soft tissue sarcomas (STS).2 The review was based on data from 5 randomised trials, 6 prospective studies, 25 retrospective studies and 3 other articles involving 4579 patients. Again, prognostic factors for tumour-related death from STS re-confirmed the histological grade, tumour size and age. There
June 9, 2009
14:7
248
B-601
ch34
FA
B. Rau and P. M. Schlag
FIGURE 1 (a) A 54-year-old man was detected to have an incidental Grade 1 liposarcoma at the abdominal US. There was no evidence of metastatic spread. Radical surgical excision was undertaken. (b) Specimen of en bloc excision of the large liposarcoma with the left colon.
June 9, 2009
14:7
B-601
ch34
FA
Excision of Intra-Abdominal Sarcomas
249
is strong evidence that adjuvant radiotherapy improves the local control rate in combination with conservative surgery in the treatment of STS of extremities and the trunk in patients with negative, marginal or minimal microscopic positive surgical margins.2 For RPS no convincing studies exist which demonstrate the beneficial influence of adjuvant or neoadjuvant radiotherapy in these patients, mostly due to the radio-therapeutically induced toxicity. On the other hand, this leads to more sophisticated delivery methods that deliver high dose rates while sparing surrounding normal tissues. Preoperative radiotherapy for RPS demonstrated less local recurrence and a low rate of induced toxicity. However, even for large retroperitoneal tumours the data are still discussed to establish preoperative radiotherapy for RPS.2 There is no randomised study comparing external beam radiotherapy and brachytherapy. The data suggest that external beam radiotherapy and low-dose-rate brachytherapy result in comparable local control for high-grade tumours. Some patients with low-grade soft tissue sarcomas benefit from external beam radiotherapy in terms of local control. The available data are inconclusive concerning the effect of intraoperative high-dose-rate radiotherapy for RPS. Differences in adjuvant radiotherapy that are related to demographic and geographic factors suggest that at least some treatment variations reflect differences in individual and institutional practice patterns.2 However, there remains no definitive prospective, randomised trial that establishes the role of adjuvant or neoadjuvant radiation versus no radiation. Owing to significant radiation morbidity with adjacent organs, especially the small bowel, there exists no consensus on radiation timing, delivery method or dosing.3,4 The weighting of surgery in the multimodal treatment setting is widely accepted: complete resection of the sarcoma is the number one prognostic factor. But complete resection of RPS is difficult and is possible only in 50% of cases.1,5 Usually, incomplete resections over no resection have not shown a survival benefit. However, in selected patients with unresectable retroperitoneal liposarcoma, incomplete
June 9, 2009
14:7
250
B-601
ch34
FA
B. Rau and P. M. Schlag
surgical resection can provide prolongation of survival and successful symptom palliation. Most likely to benefit are those patients presenting with primary tumours, which suggests that surgical resection should be attempted in the majority of patients.6 The use of intraoperative radiation therapy has also been examined as a means of improving local recurrence rates, but may be associated with more radiation-related morbidity.7 To summarise the treatment strategies in RPS: surgery with complete resection is the most important factor for long term survival and recurrence rate. However, every effort should be made to minimise local recurrence, but recurrence alone does not define the long term outcome. The biology of the tumour seems to be the most important prognostic factor; therefore our challenge remains to find effective multimodal treatment strategies for ameliorating the result. Further studies are needed.
REFERENCES 1. Weiss SW, Goldblum J. (2001) Sarcomas in the retroperitoneum. In: Enzinger F, Weiss SW, editors, Soft Tissue Tumours, 4th ed. St. Louis, Mosby, pp. 37–44. 2. Strander H, Turesson I, Cavallin-Stahl E. (2003) A systematic overview of radiation therapy effects in soft tissue sarcomas. Acta Oncol 42(5–6): 516–531. 3. Tzeng CW, Fiveash JB, Heslin MJ. (2006) Radiation therapy for retroperitoneal sarcoma. Expert Rev Anticancer Ther 6(8): 1251–1260. 4. Tzeng CW, Fiveash JB, Popple RA, et al. (2006) Preoperative radiation therapy with selective dose escalation to the margin at risk for retroperitoneal sarcoma. Chirurg 107(2): 371–379. 5. Erzen D, Novak J, Spiler M, Sencar M. (2007) Aggressive surgical treatment of retroperitoneal sarcoma: long-term experience of a single institution. Surg Technol Int 16: 97–106. 6. Glass A, Wieand HS, Fisher B, et al. (1981) Acute toxicity during adjuvant chemotherapy for breast cancer: the National Surgical Adjuvant
June 9, 2009
14:7
B-601
ch34
FA
Excision of Intra-Abdominal Sarcomas
251
Breast and Bowel Project (NSABP) experience from 1717 patients receiving single and multiple agents [prior annotation incorrect]. Cancer Treat Rep 65: 363–376. 7. Pawlik TM, Ahuja N, Herman JM. (2007) The role of radiation in retroperitoneal sarcomas: a surgical perspective. Curr Opin Oncol 19(4): 359–366.
June 9, 2009
14:7
B-601
ch35
FA
chapter
35
Laparoscopic Adrenalectomy for Tumours in the Adrenal Glands Bergþór Björnsson∗,† , Guðjón Birgisson† and Margrét Oddsdóttir††
INTRODUCTION Laparoscopic adrenalectomy became the method of choice in the early 1990s for the removal of adrenal glands with presumed benign tumours.1 The laparoscopic approach, with its magnification and delicate instruments, was found to be ideal for the removal of these small organs deep in the retroperitoneum and in close proximity with the caval vein, the renal vessels as well as the spleen. Several studies have shown excellent outcomes with short hospital stays and low morbidity in comparison with the conventional open method.1 Malignant lesions of the adrenals are relatively rare. The laparoscopic approach is not feasible for invasive adrenal malignancy. However, for suspected malignancy without apparent local invasion, laparoscopic adrenalectomy is considered appropriate.2,3
∗ Corresponding
author. of Iceland Medical School and Landspitali-University Hospital, Reykjavik, Iceland. †† Landspitali-University Hospital, Reykjavik, Iceland. † University
253
June 9, 2009
14:7
254
B-601
ch35
FA
B. Björnsson et al.
TECHNIQUE The adrenal glands can be removed using the laparoscope by either the transperitoneal or the retroperitoneal approach. We prefer the transperitoneal route, and it is the technique more commonly used. The patient is placed in a lateral decubitus position. The braking point of the table should be at or just above the pelvic rim of the patient. The table is flexed to provide as much space as possible between the costal margin and the iliac crest (Fig. 1). The whole table is then adjusted so that the upper part is almost horizontal, but with the lower part sloping downwards. The legs are slightly bent, with a pillow between them. A small roll is placed in the axilla facing the table and the contralateral arm secured on an arm table. The patient is secured in this position with tape or stabilisers. It is convenient to mark the anterior and mid-axillary line while the patient is supine. The first trocar is placed at the anterior axillary line, 2–5 cm below the costal margin. We usually place the first trocar by the open technique and use a 30◦ laparoscope. This incision can later be enlarged if necessary to deliver the specimen out of the abdomen. Once the intra-abdominal pressure is 15 mmHg, a 5 mm trocar is placed below the costal margin
FIGURE 1 Patient position for laparoscopic left adrenalectomy.
June 9, 2009
14:7
B-601
ch35
FA
Laparoscopic Adrenalectomy
255
at the mid-clavicular line. Another 5 mm trocar is then placed just below the costal margin, just lateral to the mid-axillary line. On the right, the third 5 mm trocar is placed in the epigastrium for the liver retractor. Sometimes, the third 5 mm trocar is needed on the left side for additional retraction. On the left side, it may be necessary to take down the lateral attachments of the left colon flexure to accommodate this trocar. On the right, an additional trocar (5 mm) is placed in the epigastrium for a liver retractor. Sometimes, yet another 5 mm trocar is needed on the left side for retraction. The placement may either be in the epigastrium or posterolateral to the lateral 5 mm trocar, depending on the operative field. In general, we use a combination of electrocautery and ultrasonic scissors for dissection. The adrenal veins are controlled with titanium clips, but if they are large we prefer vascular staplers. It is important to handle the adrenal glands with care, so as to keep their fragile capsule intact.
Left Adrenalectomy The lienocolic ligament is divided and the left colon flexure is mobilised away from the spleen. The proximal part of the left colon may need to be mobilised from the lateral abdominal wall to give a good view of the area behind the spleen. The lateral attachments of the spleen are divided, starting below the inferior pole and continuing up to the diaphragm, where the attachments of the superior pole are divided. If the tip of the pancreas is noted, the dissection is continued dorsal to it. When fully mobilised the spleen falls medially without retraction and the area behind it is now visualised as “an open book”. The dissection is adequate when the medial edge of the adrenal gland is exposed. The inferior and medial border of the gland is mobilised, and as one dissects the medial-dorso-inferior part of the gland, the left adrenal vein comes into view (Fig. 2). Once around the vein it is secured with clips and divided. As one carries out the dissection superiorly, an additional branch may be found that needs attention.
June 9, 2009
14:7
256
B-601
ch35
FA
B. Björnsson et al.
FIGURE 2 Exposure of the right adrenal gland and the right adrenal vein.
The gland is now mobilised by freeing all its edges and then from the underlying retroperitoneum.
Right Adrenalectomy The lateral liver attachments and the triangular ligament are divided. With a retractor the liver is retracted. The dorsal peritoneal attachments to the liver are divided until the upper edge of the adrenal gland comes into view. The lateral edge of the caval vein and the medial side of the adrenal gland are carefully separated. Once the right adrenal vein is seen and isolated with a right angle dissector, it is secured with clips and divided (Fig. 3). The gland is fully mobilised by freeing its edges circumferentially and dividing the retroperitoneal attachments.
June 9, 2009
14:7
B-601
ch35
FA
Laparoscopic Adrenalectomy
257
FIGURE 3 Exposure of the left adrenal gland and the left adreanal vein.
An impermeable plastic bag is used for retrieval of the gland. It is taken out through the initial incision, which may need to be enlarged to deliver the specimen intact.
DISCUSSION Laparoscopic adrenalectomy is the standard of care for the removal of adrenal tumours confined to the adrenal gland.4,5 For a suspected malignant lesion of the adrenal gland, it is generally considered safe to use the laparoscopic approach.6,7 However, very large tumours and obvious signs of invasive tumour growth are indications for open surgery.
June 9, 2009
14:7
258
B-601
ch35
FA
B. Björnsson et al.
REFERENCES 1. Lee J, El-Tamer M, Schiffner T, et al. (2008) Open and laparoscopic adrenalectomy: analysis of the National Surgical Quality Improvement Program. J Am Coll Surg 206: 953–959. 2. Cobb WS, Kercher KW, Sing RF, Heniford BT. (2005) Laparoscopic adrenalectomy for malignancy. Am J Surg 189: 405–411. 3. Sturgeon C, Kebebew E. (2004) Laparoscopic adrenalectomy for malignancy. Surg Clin North Am 84: 755–774. 4. Bjornsson B, Birgisson G, Oddsdottir M. (2008) Laparoscopic adrenalectomies: a nationwide single-surgeon experience. Surg Endosc 22: 622–626. 5. Parnaby CN, Chong PS, Chisholm L, et al. (2008) The role of laparoscopic adrenalectomy for adrenal tumours of 6 cm or greater. Surg Endosc 22: 617–621. 6. McCauley LR, Nguygen MM. (2008) Laparoscopic radical adrenalectomy for cancer: long-term outcomes. Curr Opin Urol 18: 134–138. 7. Adler JT, Mack E, Chen H. (2007) Equal oncologic results for laparoscopic and open resection of adrenal metastases. J Surg Res 140: 159–164.
June 9, 2009
14:7
B-601
ch36
FA
chapter
36
Isolated Limb Perfusion Harald J. Hoekstra∗
INTRODUCTION Isolated limb perfusion (ILP) is performed in the limb salvage treatment of locally advanced melanoma or sarcoma.1,2 The theory behind regional chemotherapy is that a high drug uptake may be achieved without systemic toxicity. The delivery of chemotherapy within the ILP setting has three major advantages: the “first pass” effect, which results in an increased drug uptake; hyperthermia, which facilitates drug uptake through increased blood flow and permeability of the cell membrane; and the use of cytostatic agents, which cannot be used outside the ILP setting due to the high systemic toxicity.3
PERFUSION LEVEL Upper limb perfusions may be performed at two levels — axillary or brachial — and lower limb perfusions at three levels — iliac, femoral or popliteal (Fig. 1). The level of perfusion is determined by the involved ∗ Division
of Surgical Oncology, Department of Surgery, Groningen University Hospital, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands. E-mail:
[email protected]
259
June 9, 2009
14:7
260
B-601
ch36
FA
H. J. Hoekstra
FIGURE 1 Five different perfusion levels for regional perfusion of the extremities.
part of the limb and the kind of disease, e.g. skin malignancies versus sarcomas. For skin malignancies the most proximal site of cannulation is the best choice, since the whole limb is at risk. In sarcomas the level of perfusion is determined by the distinct part of the limb containing the tumour.
PERFUSION TECHNIQUE After dissection of the appropriate artery and vein and ligation of the collateral vessels, to control collateral flow and prevent leakage, the patient is heparinised systemically (heparin 3.3 mg/kg BW). The limb is isolated from the systemic circulation by an esmarch bandage twisted around the root of the limb and fixed around a pin inserted into the head of the humerus (axillary perfusion) or iliac crest (iliac perfusion). An inflating tourniquet (300–400 mm Hg) is used for brachial or popliteal perfusions. The artery and vein are exposed, cannulated with 14–16 F catheters and connected to an extracorporeal circulation system. Thermister probes are placed in the subcutaneous tissue and muscle for continuous temperature monitoring. The limb is wrapped in a thermal blanket (Fig. 2).
June 9, 2009
14:7
B-601
ch36
FA
Isolated Limb Perfusion
261
FIGURE 2 Schematic drawing of a regional perfusion circuit for an iliac perfusion of the lower extremity: an esmarch bandage around the hip with a Steinman pin inserted in the iliac crest, arterial and venous perfusion catheters connected to the arterial and venous line, membrane oxygenator, heat exchanger, roller pomp, continuous leakage monitoring with a scintillation detector placed over the heart, a warm water mattress and thermoprobes for skin and muscle temperature.
The extracorporeal circulation perfusion system consists of a roller pump, a membrane oxygenator, a heat exchanger and systems for continuous data monitoring of the temperature of the perfusate, the mean arterial and venous pressure in the perfusion canules, the mean arterial pressure in the system, and the venous saturation and electronic balance of the perfusion volume. The perfusate consists of 250 ml of Isodex in 0.9% saline, 250 ml of white-cell-reduced (filtered) packed red cells and 30 ml of 8.4% NaHCO3 ; 0.5 ml of 5000 IU/ml heparin is oxygenated by a membrane oxygenator (DIDECO, Mirandola, Italy) with a gas mixture of air and oxygen. Leakage into the systemic circulation is continuously monitored with radioactive tracers. A small calibration dose of radioactive iodine-131-labeled human serum albumin (RISA 0.5 MBq) and a dose of radioactive technetium-99m-labeled human serum albumin (RtcSA 10 MBq) are administered into the systemic circulation after the isolation of the limb is accomplished. The day before surgery the
June 9, 2009
14:7
262
B-601
ch36
FA
H. J. Hoekstra
thyroid is saturated through the oral administration of iodine. A tentimes-higher dose of RISA (5 MBq) is injected in the perfusion circuit. The 364 keV gamma rays emerging from the RISA and the 140 keV gamma rays from the RtcSA are measured with a NaI detector over the precordium. The risk of leakage is less than 3% (Fig. 2).4,5 Cytostatic agents are added into the arterial line to the limb when there is no leakage, and a limb temperature of 38◦ C is reached. Perfusions are flow- and pressure-regulated to achieve adequate tissue perfusion. Adjustments of the flow rate and pressure in the perfusion circuit by the perfusionist, as well as the blood pressure of the patient by the anaesthesiologist, together with an optimal isolation of the limb by the surgeon, ensure a stable and optimal perfusion. When there is an increase leakage to the systemic circulation (losing), the flow rate should be reduced and the systemic blood pressure increased, and eventually the tourniquet tightened, while with a loss of the systemic circulation into the perfusion circuit (gaining) the tourniquet should be tightened, the flow rate increased and the outflow “occluded.” In case of too much leakage, losing or gaining, the perfusion should be terminated for technical reasons to prevent loco-regional or systemic complications. After the perfusion the limb is washed out with 4–6 l of saline and filled with 250 ml of white-cell-reduced (filtered) packed red cells. The vessels are restored, heparin is antagonised with prothrombin, and a fasciotomy is performed. Patients perfused with TNFα are monitored during a period of 24 h in the intensive care unit, while patients perfused with melphalan are observed on the ward. No prophylactic antibiotics are prescribed. Patients receive subcutaneous low-dose molecular heparin till a full mobilisation is achieved.
CYTOSTATIC AGENTS Cytostatic agents used in ILP must have appropriate pharmacokinetic profiles, and steep dose-response curves without requiring metabolic activation (Fig. 3). A variety of cytostatic agents besides melphalan have been used: darcarbazide (DTIC), actinomycin-D,
June 9, 2009
14:7
B-601
ch36
FA
Isolated Limb Perfusion
263
FIGURE 3 Appropriate pharmacokinetic profiles for cytostatic agents used in ILP.
thiotepa, mitomycine-C, doxorubicin, cisplatin and carboplatin. The majority of these agents were ineffective, the duration of response was quite limited, or local toxicity hampered further application. Melphalan (Alkeran , GlaxoSmithKline Pharmaceuticals, Research Triangle Park NC) is the most effective drug in ILP for melanoma. The dose calculation of melphalan was in the past performed on body weight (lower limb 1.0–1.5 mg/kg BW and upper limb 0.5–0.7 mg/kg BW). Today the dosage is based on the perfused limb volume (lower limb 10 mg/L, upper limb 13 mg/L). Doses greater than 150 mg per limb result in regional toxicity. Tumour necrosis factor–alpha (TNFα; Boerhinger-Ingelheim GmbH, Vienna, Austria) is used together with melphalan in the treatment of locally advanced melanoma and sarcoma of the limb.1,2 TNFα attacks the neovascular endothelial cells, in particular the tumour vasculature, causing increased vessel permeability and facilitating melphalan uptake in the tumour cells.6 The dosage of TNFα for the upper limb and popliteal perfusion is 3 mg; for the lower limb, 4 mg. “TNF priming time” of 15–30 minutes prior to the intra-arterial delivery of melphalan seems appropriate. The clinically used perfusion time for
June 9, 2009
14:7
264
B-601
ch36
FA
H. J. Hoekstra Table 1
Grade I Grade II Grade III Grade IV
Grade V
Wieberdink’s Acute Regional Toxicity Grading System.
No reaction Slight erythema and/or oedema Considerable erythema and/or oedema with some blistering; slightly disturbed motility permissible Extensive epidermolysis and/or obvious damage to the deep tissues, causing definite functional disturbances; threatening or manifest compartmental syndrome Reaction which may necessitate amputation
melphalan alone is 45–60 minutes; for the combined TNF–melphalan perfusion, 60–90 minutes.7
TREATMENT TOXICITY The effects of the perfusate on normal tissues are recorded according to Wieberdink’s criteria and vary widely between individuals (Table 1).8 Melphalan may cause skin toxicity, erythema and blistering. This resolves in general within a month with regard to the accompanying procedures, e.g. tumour resection or radiation. A small proportion of patients undergoing ILP for melanoma will have long-term limb symptoms (5–8%), without severe impairment.9 After ILP for sarcoma impairment of limb function is not related to the ILP, but to the extent of surgery with or without adjuvant irradiation.10 Another risk factor in ILP is the vascular status of the (elderly) patient. Manipulation, cannulation and tight occlusion of sclerotic vessels might cause embolic events, arterial stricture after vessel repair, or arterial thrombosis, requiring reoperation or even amputation of the perfused limb. Deep venous thrombosis is sometimes encountered due to cannulation of the vein or the thrombogenic side effect of melphalan.
SUMMARY ILP is a technically demanding procedure that delivers safe and effective high doses of cytostatic agents in the limb-saving treatment of locally advanced melanoma or sarcoma.
June 9, 2009
14:7
B-601
ch36
FA
Isolated Limb Perfusion
265
REFERENCES 1. Hoekstra HJ. (2008) The European approach to in-transit melanoma lesions. Int J Hyperthermia 24: 227–237. 2. van Ginkel RJ, Thijssens KM, Pras E, et al. (2007) Isolated limb perfusion with tumor necrosis factor alpha and melphalan for locally advanced soft tissue sarcoma: three time periods at risk for amputation. Ann Surg Oncol 14: 1499–1506. 3. Guchelaar HJ, Hoekstra HJ, de Vries EG, et al. (1992) Cisplatin and platinum pharmacokinetics during hyperthermic isolated limb perfusion for human tumours of the extremities. Br J Cancer 65: 898–902. 4. Daryanani D, Komdeur R, Ter Veen J, et al. (2001) Continuous leakage measurement during hyperthermic isolated limb perfusion. Ann Surg Oncol 8: 566–572. 5. Van Ginkel RJ, Limburg PC, Piers DA, et al. (2002) Value of continuous leakage monitoring with radioactive iodine-131-labeled human serum albumin during hyperthermic isolated limb perfusion with tumor necrosis factor–alpha and melphalan. Ann Surg Oncol 9: 355–363. 6. Nooijen PT, Manusama ER, Eggermont AM, et al. (1996) Synergistic effects of TNF-alpha and melphalan in an isolated limb perfusion model of rat sarcoma: a histopathological, immunohistochemical and electron microscopical study. Br J Cancer 74: 1908–1915. 7. de Wilt JH, Manusama ER, van Tiel ST, et al. (1999) Prerequisites for effective isolated limb perfusion using tumour necrosis factor alpha and melphalan in rats. Br J Cancer 80: 161–166. 8. Wieberdink J, Benckhuysen C, Braat RP, et al. (1982) Dosimetry in isolated perfusion of the limb by assessment of perfused tissue volume and grading of toxic tissue reactions. Eur J Cancer Clin Oncol 18: 905–910. 9. Olieman AF, Schraffordt Koops H, Geertzen JH, et al. (1994) Functional morbidity of hyperthermic isolated regional perfusion of the extremities. Ann Surg Oncol 1: 382–388. 10. Hoven-Gondrie ML, Thijssens KM, Geertzen JH, et al. (2008) Isolated limb perfusion and external beam radiotherapy for soft tissue sarcomas of the extremity: long-term effects on normal tissue according to the LENT-SOMA scoring system. Ann Surg Oncol 15: 1502–1510.
June 9, 2009
14:7
B-601
ch37
FA
chapter
37
Cone and Wedge Resection in Renal Cell Carcinoma Frederik C. Roos∗,† and Joachim W. Thüroff†
INTRODUCTION Nephron sparing surgery (NSS) is the treatment of choice for patients with localised renal cell carcinoma (RCC) when preservation of renal parenchyma is mandatory, such as in bilateral RCCs, RCC in a solitary kidney and in chronic renal failure (imperative indication).1 Elective NSS is defined as treatment of a single, safely resectable RCC in a patient with a normal contralateral kidney. Several reports have shown that NSS provides equivalent oncological2 and better renal functional results than radical nephrectomy (RN) for these patients.3 Long-term renal functional outcomes are better in patients undergoing NSS than RN; Lau et al.3 reported that progression to chronic renal failure (defined as a serum creatinine level of > 2.0 mg/dL) at 10 years occurred in 22.4% of patients after RN, versus 11.6% after NSS. Recent data suggest that NSS is safe for tumours up to 7 cm, and elective NSS is a reasonable option for all patients with a clinical T1 renal tumour.4,5 ∗ Corresponding
author. of Urology, Johannes Gutenberg-University Mainz Medical School, Germany. E-mail:
[email protected] † Department
267
June 9, 2009
14:7
268
B-601
ch37
FA
F. C. Roos and J. W. Thüroff
INTRAOPERATIVE PROCEDURE We generally prefer the extraperitoneal flank incision through the 10th or 11th intercostal space. After opening Gerota’s fascia, the kidney is completely mobilised, leaving the perirenal fat only attached at the site of the tumour. The renal vessels are exposed and secured by vessel loops. Clamping of the artery may not be necessary for excising small peripheral tumours. When cold renal ischaemia is required, the kidney is placed into a bowel bag, which is loosely tied around the renal hilus and has its bottom excised to be filled with slush ice. Ten minutes before clamping the renal artery, 1.2 mg of enalapril and mannitol 20% 1 ml/kg bw are administered intravenously. The fibrous renal capsule is incised at a 2–4 mm distance from the tumour in either a circle (cone resection) or an ellipse (wedge resection), depending on the size and location of the tumour and its intraparenchymal or exophytic extension (Fig. 1). A minimum of about 2 mm of normal renal parenchyma should be removed around the tumour. The cone
FIGURE 1 Illustration of cone (white scattered) and wedge resection (black scattered line).
June 9, 2009
14:7
B-601
ch37
FA
Cone and Wedge Resection in Renal Cell Carcinoma
269
resection (black dotted line) allows maximal preservation of renal parenchyma while the wedge resection (grey plotted line) allows easier re-approximation of the renal parenchyma after tumour resection, especially in the mid-portion of the kidney. Using brain spatulae, the renal parenchyma is sharply and bluntly separated in the renal cortex and only bluntly in the medulla along the parallel structures of the tubules and collecting ducts of the renal papillae (Fig. 2). Small vessels are coagulated and large vessels are oversewn with 4/0 polyglycolic acid, which does not melt during a following coagulation. Major vessels at the base of the resection are clamped and ligated. The excised tumour is sent for frozen sections for diagnosis and checking of margins of resection. If the tumour extends into the renal hilum, additional biopsies should be taken from tissue at the ground of resection to ensure complete resection. Intraoperative 7.5–12 MHz ultrasound is especially useful for identifying intraparenchymally embedded tumours and to outline central tumour extension. While obtaining negative surgical margins is imperative, the width of excised normal parenchyma around the tumour margin does not affect the likelihood of recurrence.7
FIGURE 2 Resection of the tumour by clamping the vessels at the tumour ground.
June 9, 2009
14:7
270
B-601
ch37
FA
F. C. Roos and J. W. Thüroff
If there is a positive margin, nephrectomy may not necessarily be required in all patients with a normal contralateral kidney.8 In patients with imperative indications (solitary kidney, chronic renal failure, bilateral RCCs), immediate extension of the resection or radical nephrectomy followed by dialysis may be elected. If renal calyces and/or renal pelvis had been opened, reconstruction is performed with 6/0 polyglycolic acid sutures. When drainage of the collecting system is required, an 8–12 F nephrostomy catheter is inserted and fixed by a 5/0 polyglytone purse-string suture.6 An argon-beam laser or an infrared sapphire coagulator may be used for coagulation. Both instruments provide the required haemostasis for parenchymal bleeding. The non-contact argon laser does so by superficial tissue carbonisation, while the infrared contact coagulator provides heat necrosis of 1–3 mm of tissue, depending on the selected exposure time (1–5 s), with little carbonisation and tissue adherence. Hence, infrared coagulation may be used not only for
FIGURE 3 Use of an argon-beam laser and/or an infrared sapphire coagulator in the coagulation of the tumour bed.
June 9, 2009
14:7
B-601
ch37
FA
Cone and Wedge Resection in Renal Cell Carcinoma
271
haemostasis but also for non-surgical extension of the safety margin of resection (Fig. 3). With application of either instrument, most monofilament sutures may melt, so that braided sutures should preferably be used for ligation or oversewing. The renal fibrous capsule is closed with a running monofilament mattress suture using 5/0 poly p-dioxanone; this is an important step in providing haemostasis by compression (Fig. 4). Cone resection of small tumours may be performed with or without renal clamping. In small exophytic renal tumours, the ground of resection usually does not reach the renal sinus and collecting system, rendering a superficial shallow defect of the parenchyma. When a shallow defect cannot be closed by adaptation of the renal capsule, a free patch of adjacent peritoneum or dexon cluster may be used to cover the defect.9
FIGURE 4 Suture of the renal capsular before releasing the arterial closure in order to maintain haemostasis.
June 9, 2009
14:7
272
B-601
ch37
FA
F. C. Roos and J. W. Thüroff
COMPLICATION MANAGEMENT In case of haemodynamically relevant postoperative bleeding, diagnostic angiography with an option of superselective embolisation of an arterial bleeding is required. If there is no arterial bleeding, conservative management is preferable to surgical revision. A urinary fistula or a urinoma is verified by examining the creatinine concentration in the fluid from the perirenal drain. Useful imaging modalities of a leakage are nephrotogram (if a nephrostomy catheter is available), IVP, CT or retrograde pyelography, which may be combined with insertion of a ureteric catheter or double-J (JJ) stent for drainage of the collecting system. When a JJ stent is placed, a continuous bladder catheter is required to prevent reflux. Large urinomas must be drained percutaneously by ultrasonographically guided placement of a drain. In all cases of urinary extravasation, antibiotic treatment is mandatory. Acute renal failure secondary to renal tubular ischemia requires temporary haemodialysis in cases of solitary kidneys or when chronic renal failure is pre-existent. Obstruction of the upper urinary tract may be caused by blood clots in the urine. If the patient is symptomatic (fever, pain), drainage by means of a ureteric catheter or a JJ/single-J stent and antibiotic treatment are required.
REFERENCES 1. Fergany AF, Saad IR, Woo L, Novick AC. (2006) Open partial nephrectomy for tumor in a solitary kidney: experience with 400 cases. J Urol 175: 1630–1633. 2. Lerner SE, Hawkins CA, Blute ML, et al. (1996) Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery. J Urol 155: 1868–1873. 3. Lau WK, Blute ML, Weaver AL, et al. (2000) Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc 75: 1236– 1242.
June 9, 2009
14:7
B-601
ch37
FA
Cone and Wedge Resection in Renal Cell Carcinoma
273
4. Becker F, Siemer S, Hack M, et al. (2006) Excellent long term cancer control with elective nephron-sparing surgery for selected renal cell carcinomas measuring more than 4 cm. Eur Urol 49: 1058–1064. 5. Pahernik S, Roos F, Röhrig B, et al. (2008) Elective nephron sparing surgery for renal cell carcinoma of larger than 4 cm. J Urol 179: 71–74. 6. Pahernik S, Gillitzer R, Thüroff JW. (2004) Surgical atlas: cone/wedge resection of renal cell carcinoma. BJU 93: 639–654. 7. Castilla EA, Liou LS, Abrahams NA, et al. ( 2002) Prognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma. Urology 60: 993–997. 8. Permpongkosol S, Colombo JR, Gill IS, et al. (2006) Positive surgical parenchyma margin after laparoscopic partial nephrectomy for renal cell carcinoma: oncological outcomes. J Urol 176: 2401–2404. 9. Lane BR, Novick AC. (2007) Nephron-sparing surgery. BJU 99: 1245–1250.
June 9, 2009
14:7
B-601
ch38
FA
chapter
38
Transperitoneal Laparoscopic Radical Nephrectomy Hugh F. O’Kane† , Alex MacLeod† , Christopher Hagan† and Thiagarajan Nambirajan∗,†
INTRODUCTION Since the first report in 1991,1 laparoscopic radical nephrectomy has become the mainstay of surgical treatment in the majority of patients requiring nephrectomy for malignant disease.2 Traditionally, open surgical removal of the kidney has been carried out through a midline, flank or lumbar approach. These large surgical incisions often result in significant post-operative wound pain leading to a prolonged recovery time. The majority of published series demonstrate clear advantages of laparoscopic nephrectomy over open surgery with regard to decreased post-operative pain, analgesic requirements, shorter hospital stay and reduced time to full recovery.3,4 Other advantages include fewer wound complications, improved cosmesis and reduced intraoperative blood loss. The laparoscopic approach was initially used for small T1–2 renal tumours, and as experience has grown, the indication for it has been extended to include more challenging, larger tumours. ∗ Corresponding
author. of Urology, Belfast City Hospital, Lisburn Road, Belfast, Northern Ireland. E-mail:
[email protected] † Department
275
June 9, 2009
14:7
276
B-601
ch38
FA
H. F. O’Kane et al.
With the introduction of any new technique, initial capital costs and a longer operating time as a result of the learning curve are cited as disadvantages. However, these issues have largely been resolved with time. In order for laparoscopic nephrectomy to be accepted as a treatment comparable to open surgery, the sound oncological principles of removal of the intact kidney and surrounding Gerota’s fascia need to be maintained. The two standard laparoscopic approaches, namely transperitoneal and retroperitoneal, when carried out correctly, adhere to these principles.
TECHNIQUE Pre-Operative Workup Pre-operative staging of renal tumours is performed with computerised tomography (CT) of the chest, abdomen and pelvis. The patients are cross-matched for two units of blood and have the side of the tumour marked on the skin prior to leaving for theatre. Patients are consented for the very small risk of conversion to open surgery (∼1%) in addition to specific laparoscopic complications, including bowel injury and post-operative shoulder tip pain related to CO2 insufflation. The correct tumour side is reaffirmed in theatre with CT films and with a urethral catheter inserted.
Transperitoneal Approach The patient is positioned in the lateral decubitus position at an angle of 40◦ –50◦ , with slight elevation of the kidney bridge. Careful positioning and pressure point padding prevents neuromuscular injury. The patient is strapped to the table to allow rotation if necessary to achieve an ergonomically comfortable position for the operating surgeon. Peritoneal access allowing establishment of the pneumoperitoneum is under direct vision via the Hassan approach, which is safer than the blind or “closed” Veress needle method.5
June 9, 2009
14:7
B-601
ch38
FA
Transperitoneal Laparoscopic Radical Nephrectomy
277
The primary laparoscope trocar is a 12 mm port inserted adjacent to the umbilicus. Two further 5–10 mm trocars are inserted under direct vision in the subcostal and iliac fossa positions. Port site placement follows the principle of triangulation to allow maximal access to the renal hilum, where the majority of the dissection takes place, but will also allow ureteric dissection. An additional 5 mm port may be required, particularly for right-sided nephrectomies which may need liver retraction (Fig. 1). A variety of laparoscopic instruments are available for tissue dissection and coagulation, including monopolar electric cautery, bipolar vessel electro-thermal sealers and ultrasonic shears (Harmonic scalpel, Ethicon endo-surgery). Dissection begins with an incision along the line of Toldt, allowing medial retraction of the colon. The ureter is identified and mobilised to help with retraction of the kidney and to guide the dissection cephalad towards the renal hilum. Careful dissection of the hilar vessels is achieved with the combination of a right angle dissector, suction and the harmonic scalpel. The renal artery which is usually found
FIGURE 1 Port placement for right transperitoneal laparoscopic radical nephrectomy. Note the preoperative arrow marking operative side and 4th 5 mm port to allow liver edge retraction.
June 9, 2009
14:7
278
B-601
ch38
FA
H. F. O’Kane et al.
posterior to the vein is ligated first, followed by the vein with particular care to avoid any unseen lumbar veins entering the renal vein posteriorly (Fig. 2). The two most commonly used methods for securing the renal vessels are endovascular linear staplers and non-polymer ligating clips (Hem-O-Lok, Weck closure system, Telelflex medical). Both methods are widely used (see video). Occasionally a large renal vein may require the placement of a loop around the vessel to “shrink” the vein so as to facilitate placement of the Hem-O-Lok clip.6 This manoeuvre is infrequently required, after the introduction of extra-large clips (Hem-O-Lok XL). Although surgeons’ preference, experience and training strongly influence the choice of the haemostatic method, all currently available techniques risk mechanical malfunction and user misuse. Once the hilar vessels have been ligated, the kidney is dissected free of its remaining attachments. For left-sided nephrectomy, attention is paid to avoiding splenic and pancreatic injuries. On the right side, particular care is given to the short adrenal vein.
FIGURE 2 An excellent view of the hilar vessels during transperitoneal laparoscopic radical nephrectomy. The renal artery is about to be clipped with a Hem-O-Lok clip.
June 9, 2009
14:7
B-601
ch38
FA
Transperitoneal Laparoscopic Radical Nephrectomy
279
FIGURE 3 Wounds following retrieval of the specimen.
After the ureter has been clipped and divided, the specimen is placed in a retrieval bag prior to removal via a muscle-splitting incision created by extending the iliac fossa trocar site (Fig. 3). The practice of specimen morcellation to allow extraction through a smaller incision is not popular, as this prevents optimal histopathological assessment and carries a small risk of tumour seeding.
DISCUSSION There is overwhelming evidence to support the use of laparoscopic nephrectomy over the open approach due to reduced post-operative analgesic requirements, a shortened hospital stay, improved cosmesis and an earlier return to normal activities. The majority of this evidence has been obtained from cohort studies, although one small, randomised study has been reported.7 Long term oncological data have also confirmed an outcome comparable to that of open radical nephrectomy.8 Laparoscopic radical nephrectomy is a standard treatment modality for T1–3a renal cell carcinoma patients. It is also
June 9, 2009
14:7
280
B-601
ch38
FA
H. F. O’Kane et al.
technically feasible for treating patients with T3b disease (tumour within renal vein) or N1–2 disease, and as a cytoreductive treatment for patients with metastatic disease.9 There have been very few randomised studies comparing the transperitoneal and retroperitoneal approaches to laparoscopic nephrectomy. One prospective randomised study failed to demonstrate any difference between the transperitoneal and retroperitoneoscopic approaches in terms of operative difficulty, complications or post-operative recovery time.10
REFERENCES 1. Clayman RV, Kavoussi LR, Soper NJ, et al. (2002) Laparoscopic nephrectomy. J Urol 167(2, Pt 2): 862. 2. Fenn NJ, Gill IS. (2004) The expanding indications for laparoscopic radical nephrectomy. BJU Int 94(6): 761–765. 3. Gill IS, Meraney AM, Schweizer DK, et al. (2001) Laparoscopic radical nephrectomy in 100 patients: a single center experience from the United States. Cancer 92 (7): 1843–1855. 4. Dunn MD, Portis AJ, Shalhav AL, et al. (2000) Laparoscopic versus open radical nephrectomy: a 9-year experience. J Urol 164(4): 1153–1159. 5. Bonjer HJ, Hazebroek EJ, Kazemier G, et al. (1997) Open versus closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg 84(5): 599–602. 6. Li SK, Hou SM, Fung B, et al. (2004) Safe control of the renal vein during laparoscopic nephrectomy using the “loop around the vein” technique. BJU Int 93(3): 420–421. 7. Burgess NA, Koo BC, Calvert RC, et al. (2007) Randomized trial of laparoscopic v open nephrectomy. J Endourol 21(6): 610–613. 8. Portis AJ, Yan Y, Landman J, et al. (2002) Long-term followup after laparoscopic radical nephrectomy. J Urol 167(3): 1257–1262. 9. Ono Y, Hattori R, Gotoh M, et al. (2005) Laparoscopic radical nephrectomy for renal cell carcinoma: the standard of care already? Curr Opin Urol 15(2): 75–8 (review). 10. Nambirajan T, Jeschke S, Al Zahrani H, et al. (2004) Prospective, randomized controlled study: transperitoneal laparoscopic versus retroperitoneoscopic radical nephrectomy. Urology 64(5): 919–924.
June 9, 2009
14:7
B-601
ch39
FA
chapter
39
Radical Prostatectomy for Locally Advanced Prostate Cancer Marc Claessens∗,† , Steven Joniau† and Hendrik Van Poppel†
INTRODUCTION Locally advanced prostate cancer (T3) is defined as cancer that has extended beyond the prostatic capsule with invasion of the pericapsular tissue or seminal vesicles, but without lymph node involvement or distant metastases.1 According to the 2002 TNM classification, T3a is an extracapsular extension either unilaterally or bilaterally and T3b involves invasion of seminal vesicles.2 According to the guidelines of the European Association of Urology, radical prostatectomy can be performed in patients with locally advanced CaP, PSA serum levels <20 ng/mL, ≤cT3a, biopsy Gleason score ≤8 and a life expectancy more than 10 years.3 MRI can be used to improve the detection of seminal vesicle or sphincter involvement, which excludes patients from surgery. Although still controversial, it is increasingly evident that surgery has a place in treating locally advanced disease with excellent 5-, 10- and 15-year CSS rates of 95–99%, 90–92% and 79%, respectively.4,5 ∗ Corresponding
author. Hospital Leuven, Department of Urology, Leuven, Belgium. E-mail:
[email protected] † University
281
June 9, 2009
14:7
282
B-601
ch39
FA
M. Claessens et al.
TECHNIQUE General Preparation and Positioning of the Patient General or locoregional anesthesia can be used. The authors prefer a spinal anesthesia, combined with an epidural catheter for postoperative pain control. The patient is placed in a supine position, with a slightly overstretched abdomen and pelvis. A 20F Foley catheter is placed after the patient is draped.
Incision and Exposure of the Pelvis A midline lower abdominal incision is performed. The peritoneum is mobilized from the Retzius space up to the iliac bifurcation. To attempt an extended lymph node dissection, it may be necessary to divide the vas deferens bilaterally, which allows further retraction of the peritoneum up to the aortic bifurcation, resulting in a better vascular exposure.
Pelvic Lymph Node Dissection (Fig. 1) Heidenreich et al. advocated extended resection of the iliac lymph nodes in prostate cancer patients who are at high risk for lymph
FIGURE 1 Extended lymph node dissection. (1) External iliac artery; (2) external iliac vein; (3) internal iliac artery; (4) obturator nerve.
June 9, 2009
14:7
B-601
ch39
FA
Radical Prostatectomy for Locally Advanced Prostate Cancer
283
node involvement.6 The boundaries for an extended lymphadenectomy are: laterally, the upper limit of the external iliac vein; caudally, the femoral canal; cranially, the bifurcation of the common iliac artery; medially, the lateral wall of the bladder; and inferiorly, the floor of the obturator fossa and internal iliac vessels.7
Incision of the Endopelvic Fascia and Lateral Dissection All fatty tissue covering the endopelvic fascia should be cleared. The endopelvic fascia is incised and the incision is extended posteriorly using curved scissors. The levator muscle is then gently dissected off the lateral prostate with the aid of a peanut dissector. The endopelvic fascia is further incised anteriorly until the apex of the prostate can be visualised and the apicourethral angle can be clearly recognised.
Division of the Puboprostatic Ligaments The puboprostatic ligaments are isolated using a right-angled clamp before being sectioned with electrocoagulation.
Control of the Dorsal Vein Complex The dorsal vein complex is ligated by passing a blunt right-angled clamp underneath, just anterior to the urethra. This manoeuvre is performed under digital control by the thumb and middle finger of the left hand. The right-angled grasps a 1-0 ligature that is tied, while the assistant is pushing the prostate posteriorly, enabling the knot to be tied as far caudally as possible. A 2-0 stitch is placed through the anterior commissure of the prostate to prevent extensive backbleeding. Transection of the dorsal vein complex is then done using electrocautery. Finally, the dorsal vein complex stump is oversewn using a 2-0 running-suture.
June 9, 2009
14:7
284
B-601
ch39
FA
M. Claessens et al.
Dissection of the Apex and Neurovascular Bundles and Division of the Urethra Under identical digital control, a right-angled clamp is passed underneath the urethra just anterior to the rectum. A vessel loop is placed behind the urethra, enabling a correct dissection of the prostatic apex before transection of the urethra. The tissue lateral to the urethra (consisting of the remnants of the endopelvic fascia covering the dorsal vein complex and the external urethral sphincter fascia) is dissected off the urethra using the dissection scissors inserted close to the urethra at the prostatourethral angle. After these paraurethral structures are clipped and divided bilaterally, the prostatic apex is completely freed and well visualised. The urethra can now be transected with the 20 F Foley catheter in place (Fig. 2).
Posterior Release The recto-urethral muscle is transected horizontally. Then the plane between the prostate and rectum is developed bluntly with the index finger up to the base of the seminal vesicles. In patients with a welldeveloped rectourethralis muscle however, it can be hard to distinguish it from the rectal muscular layer and an initial sharp dissection may be necessary.
FIGURE 2 Transection of urethra. (1) Prostate; (2) urethra; (3) pubic bone.
June 9, 2009
14:7
B-601
ch39
FA
Radical Prostatectomy for Locally Advanced Prostate Cancer
285
Resection of the Neurovascular Bundles and Division of the Pedicles The resection of the neurovascular bundles can be done using curved scissors after a 135◦ angle clamp is passed behind them and clipping of the tissue is done using large clips with the same-angled clipping forceps. The neurovascular bundle at the tumor bearing side cannot be spared. In selected patients with smaller unilateral and nonapical T3a prostate cancer, a contralateral nerve-sparing RP can be attempted, using small clips for the perforating vessels and nerve fibers. Sokoloff and Brendler suggested that absolute contraindications of nerve-sparing are T3b tumors and palpable lesion at the apex.8 The dissection is continued up to the lateral aspect of the seminal vesicles. To divide the pedicles gradually, a 135◦ clamp is passed through them, and the pedicles are clipped with large clips.
Resection of the Seminal Vesicles The Denonvilliers fascia is divided sharply between both the vasa deferentia reaching the posterior bladder wall. The ejaculatory complex is encircled by using curved dissection forceps, and the index finger is placed behind it. The top of the seminal vesicles is reached via peanut dissection and the vessels at their apex are clipped and divided. Both vasa deferentia are clipped with large clips. The prostate and seminal vesicles are now completely mobilised posteriorly as well as laterally up to the bladder neck.
Bladder Neck Dissection For extracapsular cancers, it is better to resect the bladder neck starting anteriorly9,10 (Fig. 3). The bladder is opened and the Foley catheter is grasped and pulled out of the bladder, in order to enable traction on the prostatovesicular block. The posterior bladder neck is sectioned, care being taken not to harm the ureteral orifices. A racket closure of the bladder neck with eversion of the mucosa is performed. For apical
June 9, 2009
14:7
286
B-601
ch39
FA
M. Claessens et al.
FIGURE 3 Resection of bladder neck. (1) Prostate; (2) 20 F Foley catheter; (3) bladder neck; (4) bladder.
T3 tumours, the intraprostatic bladder neck can usually be preserved, enabling a more anatomic reconstruction of the bladder neck.
Anastomosis Haemostasis is performed by using clips and/or a haemostatic sealant (e.g. FloSeal® or Tachosil® ) prior to finalising the anastomosis between the bladder and urethra. The quality of the vesicourethral anastomosis will directly influence urinary leakage, stricture formation and preservation of continence. The principle of the anastomosis is to obtain a perfect adaptation of the urethra with the reconstructed bladder neck, without compromising the integrity of the external sphincter.11 A 16 F Foley (silicone) catheter is inserted and proceeded into the reconstructed bladder neck. The balloon is not inflated in order to avoid inadvertent damage during anastomosis. A swab-on-a-stick is placed just posteriorly to the urethra, pushing the rectum downwards. Four stitches are sufficient for a good anastomosis. The first suture is placed at the 7 o’clock position, outside-in at the urethra and inside-out at the bladder neck. The second suture is started outside-in at the bladder neck at the 5 o’clock position and inside-out at the urethra. The third and the fourth sutures are placed at the 2 and 11 o’clock position in the
June 9, 2009
14:7
B-601
ch39
FA
Radical Prostatectomy for Locally Advanced Prostate Cancer
287
same way as the second. Then the balloon is inflated. Gentle traction on the catheter brings the bladder neck down to the urethral stump. The four sutures are tied and the bladder can be rinsed. Two suction drains are inserted to keep the Retzius space dry. The patient can be discharged at postoperative day 4. The Foley catheter is left for 10 days. Pelvic floor physiotherapy is started immediately after withdrawal of the Foley catheter.
DISCUSSION The goals of surgery for locally advanced prostate cancer are a more radical tumor extirpation including: — An extensive lymph node dissection. This might necessitate division of the vas deferens bilaterally, resulting in a better vascular exposure up to the aortic bifurcation — Good visualisation and complete resection of the apex. — Broad neurovascular bundle resection at least at the tumor bearing side. — Complete resection of the seminal vesicles. — Resection of the bladder neck in most cases, instead of a bladder neck sparing approach.
REFERENCES 1. Boccon-Gibod L, Bertaccini A, Bono A, et al. (2003) Management of locally advanced prostate cancer: a European consensus. Int J Clin Pract 57(3): 187–194. 2. Sobin LH, Wittekind C. (2002) TNM Classification of Prostate Cancer, 6th ed. New York, Wiley-Liss. 3. Heidenreich A, Aus G, Abbou CC, et al. (2007) Guidelines on Prostate Cancer. http://www.uroweb.org/fileadmin/user_upload/ Guidelines/break 07_Prostate_Cancer_2007.pdf 4. Ward JF, Slezak JM, Blute ML, et al. (2005) Radical prostatectomy for clinically advanced (cT3) prostate cancer since the advent of prostatespecific antigen testing: 15-year outcome. BJU Int 95: 751–756.
June 9, 2009
14:7
288
B-601
ch39
FA
M. Claessens et al.
5. Hsu CY, Joniau S, Oyen R, et al. (2006) Outcome for clinical unilateral T3a prostate cancer: a single-institution experience. Eur Urol Suppl 5(2): 213. 6. Heidenreich A, Varga Z, Von Knobloch R. (2002) Extended pelvic lymphadenectomy in patients undergoing radical prostatectomy: high incidence of lymph node metastasis. J Urol 167: 1681–1686. 7. Bader P, Burkhard FC, Markwalder R, Studer UE. (2002) Is a limited lymph node dissection an adequate staging procedure for prostate cancer? J Urol 168: 514–518. 8. Sokoloff M, Brendler C. (2001) Indication and contraindication for nervesparing radical prostatectomy. Urol Clin North Am 28(3): 535–543. 9. Van Poppel H. (2005) Surgery for clinical T3 prostate cancer. Eur Urol Suppl 4: 12–14. 10. Hsu CY, Joniau S, Van Poppel H. (2005) Radical prostatectomy for locally advanced prostate cancer: technical aspects of radical prostatectomy. EAU Update Ser 3: 90–97. 11. Gillitzer R, Thuroff JW. (2003) Technical advances in radical retropubic prostatectomy techniques for avoiding complication. Part II: vesicourethral anastomosis and nerve-sparing prostatectomy. BJU Int 92: 178–184.
June 9, 2009
14:7
B-601
FA
ch40
chapter
40
Flap Technology and Reconstructive Techniques in Urology Milomir Ninkovic† and Gustavo Sturtz∗,†
Failure in healing of perineal or pelvic wounds is common in the presence of infection, dead spaces, fistulas, chemotherapy or irradiation. Large soft tissue defects resulting from trauma or ablative operations continue to be a challenging problem, particularly when complicated by radiation. Previously radiated skin does not mobilise easily and does not tolerate tension. Ideally, the coverage of such defects should include the use of flaps of relatively uninvolved tissue with reliable blood supply. Such patients are usually ill and debilitated, so a singlestage reconstruction with a minimal donor defect is optimal. Reconstruction following resection of malignant tumours or treatment of congenital anomalies often requires a multidisciplinary approach, comprising specialists in urology, gynaecology, plastic surgery and oncology. The surgical treatment can involve repair, reconstruction or compensation of dysfunctional tissue. Skin grafts provide ideal coverage for shallow wounds in which no major structures, such as arteries, veins, nerves or tendons, are exposed. Split-thickness skin grafts can be applied directly onto abdominal viscera, but they lack the resistance to provide adequate
∗ Corresponding
author. of Plastic, Reconstructive, Hand and Burns Surgery, Hospital Bogenhausen – Technical University Munich, Munich, Germany. E-mail: medsturtz@ hotmail.com;
[email protected] † Department
289
June 9, 2009
14:7
290
B-601
ch40
FA
M. Ninkovic and G. Sturtz
protection to the viscera and are frequently unstable. The skin, in addition, adheres firmly to the surface of the gastrointestinal tract, making a subsequent operation difficult and treacherous. A defect with missing muscle and skin may benefit from a muscle or musculocutaneous flap to improve contour as well coverage. If the available local tissue is inadequate, regional flaps, such as a rectus abdominis flap or free tissue transfer, may provide additional tissue for reconstruction. All pedicled local or regional flaps have their limitations in terms of the arc of rotation, size, tissue volume and mobility restriction with functional and aesthetic disadvantages for the donor site. Another difficulty is that the well-perfused proximal part of the flap does not reach the defect, so that the defect is covered by poorly perfused parts of the flap or the flap cannot reach the defect at all. When the local flaps are unavailable or insufficient, free microvascular tissue transfer is the procedure of choice for complex anatomical and/or functional requirements. The transfer of a free flap is a well-established method and provides tissue with a rich blood supply. Good perfused tissue improves wound healing and allows early rehabilitation.
PELVIC FLOOR RECONSTRUCTION The pelvic floor consists of a number of individual anatomical structures (the pelvic diaphragm, the lower urinary tract, the reproductive organs, the colorectal system and the anal sphincter) with specific functions. Surgical treatment for pelvic floor disorders can involve repair, reconstruction, or compensation for replacement of the dysfunctional tissue, and these procedures can involve a vaginal, suprapubic, laparoscopic or mixed approach. The goal of reconstruction is to restore structural integrity by providing well-vascularised softtissue coverage and active support, protection and retention of the internal organs. The reconstructive surgeon must use tissue that has enough strength and stability to prevent hernia formation and that also has sufficient volume to fill or eliminate dead space. The proper
June 9, 2009
14:7
B-601
ch40
FA
Flap Technology and Reconstructive Techniques in Urology
291
selection of flaps is based on the requirements of each patient, considering the age; the cause, size, shape and depth of the defect; the donor site morbidity; the patient’s general condition; and the condition of the vascular supply of adjacent regions. The problem of small-bowel placement in the pelvic cavity denuded of peritoneum is still one of the most taxing and potentially troublesome problems in radical pelvic surgery. In addition, intestinal fistulas and small-bowel adhesive obstructions are not very rare as postoperative complications or as an effect of radiotherapy. Synthetic absorbable mesh or autologous materials such as omentum or peritoneal flaps have been used as substitutes for pelvic reconstruction. Well-vascularised tissue could lead to primary healing and very good protection from secondary complications (postradiation fistula, small-bowel obstruction, pelvic sidewall adherence). The suggested technique of using a rectus abdominis muscle flap after radical pelvic surgery is a very simple and efficient method of making a wellvascularised barrier and support for the small intestine. The transposed rectus abdominis muscle acts as a bed for the abdominal cavity and the small bowel is held out of the pelvic basin. The rectus muscles are carefully retracted downwards and the edges are sutured posteriorly to the promontorium and laterally around the linea terminalis. To avoid abdominal wall weakness, a precise abdominal closure using a synthetic mesh has to be performed. The reconstruction of full-thickness pelvic floor defects can be done with variably designed local flaps such as thigh or gluteal flaps. If the available local tissue is inadequate, regional flaps, such as the rectus abdominis, may provide additional tissue. However, if these flap tissues are unavailable or insufficient, free tissue transfer may be necessary. The available tissue from an amputated limb can be used as a pedicled-in-continuity fillet flap or a free microvascular fillet lower leg flap. This technique can be used to repair defects of the lower trunk without the need for vascular anastomosis and without incurring donor site morbidity. The oncological safety of using ipsilateral lower
June 9, 2009
14:7
292
B-601
ch40
FA
M. Ninkovic and G. Sturtz
extremity tissue must be considered in each case. Free microvascular tissue transfer from the lower leg, filleted from the tibia and fibula and supplied by the popliteal vessels, is a second option for obtaining a large amount of soft tissue for complex pelvic reconstruction.
VAGINAL RECONSTRUCTION Many techniques have been described for vaginal reconstruction in patients with congenital vaginal agenesis or in those undergoing anterior exenteration for malignant disease. They include Frank’s technique (non-surgical autodilatation), the McIndoe procedure, the rectus abdominis flap method the gracilis flap technique, the pudendal thigh flap method and the free jejunal flap technique. An immediate partial or total vaginal reconstruction is frequently proposed in cases of exenterative or extended radical pelvic surgery for cancer treatment. Probably the most common method for constructing a vagina in patients with Mayer–Rokitansky–Kuster–Hauser syndrome is the technique popularised by McIndoe and Banister in 1938 using split-thickness skin grafts. The undesirable complication is the late contraction of the neovagina. The vulvoperineal fasciocutaneous flap (Malaga flap) is safe and reliable for complete neovaginal plastic reconstructions in patients with Mayer–Rokitansky–Kuster–Hauser syndrome. Vaginal reconstruction can be performed as an elective surgical procedure when adequate lining of the whole rectovesical cavity or partial reconstruction of the vaginal wall is needed. A method of vaginoplasty using de-epithelialised vulvar transposition flaps has been used to enlarge the width of narrow vaginas.
VESICOVAGINAL FISTULA REPAIR Surgeons will often be required to adapt their approach and technique to the individual patient. When tissue interposition is desired, as in the case of failed previous repairs, the traditional Martius flap method
June 9, 2009
14:7
B-601
ch40
FA
Flap Technology and Reconstructive Techniques in Urology
293
is not ideal for proximal fistulas. In these cases, peritoneum is readily available for tissue interposition and it provides a well-vascularised layer without the need for other incisions or extensive dissection. Consequently, a peritoneal flap is used for proximal fistulas and a Martius flap is used for distal fistulas. A full-thickness labial flap is reserved for cases of insufficient vaginal epithelium. Chronic postoperative pouch-vaginal and vesicovaginal fistulas after hysterectomy and irradiation do not respond to conventional treatment. A synchronous vaginoabdominal approach using a vertical myocutaneous distally based rectus abdominis myocutaneous flap can be used successfully to close a pouch-vaginal fistula and simultaneously reconstruct the posterior vaginal wall. The endorectal advancement flap is a surgical procedure used in the treatment of anorectal and rectovaginal fistulas. It has been used to treat fistulas of various causes, including cryptoglandular disease, obstetric injury, trauma and inflammatory bowel disease. It has been used sucessfully in the treatment of both anorectal and rectovaginal fistulas. This flap consists of mucosa, submucosa and variable amounts of circular muscle. The distal portion of the flap is excised, the fistular tract curetted and the internal opening closed by apposition of the surrounding smooth muscle with absorbable sutures. The flap is then lowered to cover the internal opening and is sewn into place, without tension, using absorbable sutures.
RECTOURETHRAL FISTULA REPAIR Fistulas between the lower rectum and the urethra may be congenital, with a constellation of pelvic floor malformations, or acquired after inflammation, infection, neoplasia or trauma. Iatrogenic rectourethral fistulas may follow the treatment of prostatic cancer. Gracilis muscle transposition is an effective surgical treatment (Figs. 1 to 3). After muscle harvesting the patient is turned to the prone jackknife position. A horizontal incision is made between the anus and the scrotum, and is deepened in the space between the urethra and the rectum. The rectal
June 9, 2009
14:7
294
B-601
ch40
FA
M. Ninkovic and G. Sturtz
FIGURE 1 Defect on the pelvic floor after anorectal resection.
FIGURE 2 Intraoperative view of the gracilis flap with a distal skin island. The muscle is turned at its pivot point to fill the pelvic floor defect.
defect is then closed primarily or with an advancement flap and the urethral defect may be closed with interrupted absorbable sutures over the indwelling catheter. The subcutaneous tunnel between the perineum and the thigh is then approached through the perineal side,
June 9, 2009
14:7
B-601
ch40
FA
Flap Technology and Reconstructive Techniques in Urology
295
FIGURE 3 Postoperative view 10 days after the surgery.
and the gracilis is rotated and placed in the space between the rectum and the urethra. A scrotal dartos flap is well vascularised and easy to mobilise. After the bulbospongiosum has been detached from the perineal body, the impulse of the 8 F catheter in the fistula is carefully palpated. The fistula is dissected circumferentially and then excised completely. The rectum and the urethra are closed separately. The tip of the Vshaped perineal skin flap is incised to produce an island flap and then carefully de-epithelialised. The de-epithelialised dartos flap is taken to the undersurface of the urethra to cover the urethral closure. The perineal skin is reapproximated using a Y–V recession technique. Successful repair can be achieved in the majority of patients, with minimal morbidity, a short length of stay and a good post-operative quality of life.
PENILE AND URETHRAL RECONSTRUCTION Single-stage penile reconstruction is performed routinely. Advances in microsurgical flap transfer techniques permit harvesting of thin and pliable flaps, which are large enough to create a penis with
June 9, 2009
14:7
296
B-601
ch40
FA
M. Ninkovic and G. Sturtz
normal dimensions and an acceptable appearance. The anastomosis of sensory nerves can provide protective and erogenous sensation, enabling an erectile prosthesis to be implanted one year after completion of the phalloplasty. Many of these ideal requirements are met by using the radial forearm flap. The major disadvantage of this flap is the donor site morbidity. In patients who refuse a radial forearm flap, a pedicle anterolateral flap is the authors’ procedure of choice. The urethra is folded with full-thickness skin graft and adhered to the flap with fibrin glue. It is beyond the scope of this chapter to give a complete overview of all the possible flaps that can be used in penile and urethral reconstruction.
FUNCTIONAL BLADDER AND ABDOMINAL WALL RECONSTRUCTION The abdominal wall protects and surrounds the contents of the abdominal cavity and participates in a great variety of functions, such as posture, standing, walking and bending. The abdominal wall musculature aids in lifting and straining during urination, defecation, childbirth, vomiting and coughing. Bladder acontractility or permanent detrusor dysfunction is a debilitating disorder affecting a large number of relatively young people. The underlying abnormality may be due to damage to the detrusor muscle itself, its autonomic nerve supply, the spinal micturition centre or the upper motor neurone system. Latissimus dorsi muscle has a reliable and suitable anatomy (adequate size, volume and length of the neurovascular pedicle) and an appropriate muscle configuration to meet the functional needs of the abdominal wall reconstruction or functioning detrusor myoplasty. The latissimus dorsi muscle transferred to the abdominal wall or wrapped around the acontractile bladder is innervated by coaptation of the thoracodorsal nerve to the lowest intercostal motor nerves supplying the rectus abdominis muscle. This leads to abdominal wall stability, voluntary contraction and bladder emptying. Following reinnervation and adequate muscle training, the transplanted
June 9, 2009
14:7
B-601
ch40
FA
Flap Technology and Reconstructive Techniques in Urology
297
latissimus dorsi muscle provides sufficient capacity and strength to replace the missing urinary detrusor muscle. In the authors’ experience, functioning free muscle transplantation was able to restore voluntary voiding in 35 of 39 patients who had previously depended on long-term catheterisation. The latissimus dorsi detrusor myoplasty technique in combination with tissue engineering could be the keystone for complete autologous bladder reconstruction.
CONCLUSION Functional repair, patient satisfaction, early rehabilitation and quality of life are the goals for the reconstruction of urogenital organs. The keystone for complete bladder reconstruction could be the latissimus dorsi detrusor myoplasty technique in combination with the new technology of tissue engineering. In contrast to the traditional approach to pelvic surgery, managed by different surgical specialities, there is increasing recognition that optimal functional and anatomical reconstruction can be obtained through the interdisciplinary approach.
REFERENCES 1. Ninkovic M, Kronberger P, Harpf C, et al. (1998) Free innervated latissimus dorsi muscle flap for reconstruction of full thickness abdominal wall defects. Plast Reconstr Surg 101: 971–978. 2. Horch RE, Gitsch G, Schultze-Seemann W. (2002) Bilateral pedicled myocutaneous vertical rectus abdominis muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds. Urology 60: 502–507. 3. Ninkovic M, Stenzl A, Schwabegger A, et al. (2003) Free neurovascular transfer of latissimus dorsi for the treatment of bladder acontractility. II: Clinical results. J Urol 169: 1379–1383. 4. Ninkovic M, Strasser H, Schwabegger A, et al. (2000) The concept of functioning free skeletal muscle transfer in combination with tissue engineering for bladder substitution. World J Urol 18: 359–363. 5. Birch C, Frynes MM. (2002) The role of synthetic and biological prostheses in reconstructive surgery. Curr Opin Obstet Gynecol 14: 527–535.
June 9, 2009
14:7
298
B-601
ch40
FA
M. Ninkovic and G. Sturtz
6. Codeiro PG, Pusic AL, Disa JJ. (2002) A classification system and reconstructive algorithm for acquired vaginal defects. Plast Reconstr Surg 110: 1058–1065. 7. Seccia A, Salgarello M, Sturla M, et al. (2002) Neovaginal reconstruction with the modified McIndoe technique: a review of 32 cases. Ann Plast Surg 49: 379–384. 8. Huang WC, Zinmann LN, Bihrle W. (2002) Surgical repair of vesicovaginal fistulas. Urol Clin North Am 29: 709–723. 9. Sonoda T, Hull T, Piedmonte MR, Fazio VM. (2002) Outcomes of primary repair of anorectal and rectovaginal fistulas using the endorectal advancement flap. Dis Colon Rectum 45: 1622–1628. 10. Ninkovic M, Daberning W. (2003) Flap technology for reconstruction of urogenital organs. Curr Opin Urol 13: 483–488. 11. Hoefter E, Holm C, Dornseifer U, et al. (2005) Der freie und gestielte Muskeltransfer als Therapieotion in der urologischen Chirurgie. Urologe [A] 44: 743–750. 12. Monstrey S, Ceulemans P. (2006) Perineogenital reconstruction. In Perforator Flaps Anatomy, Technique and Clinical Applications (Quality Medical Publishing), pp. 903–915. 13. Ninkovic M, Sturtz G, Stenzl A. Analysis of the free neurovascular transfer of latissimus dorsi muscle for treatment of bladder acontractility. In Proc. ASPS/PSEF/ASMS Annual Scientific Meeting (Oct. 2006, San Francisco). 14. Stenzl A, Ninkovic M, Kölle D, et al. (1998) Restoration of voluntary emptying of the bladder by transplantation of innervated free skeletal muscle. Lancet 351(9114): 1483–1485.
Regional and Free Flaps Urological Reconstructions Regional Flaps: Lower Abdominal Wall
Rectus Abdominis Thoracoepigastric External Oblique Muscle or Myocutaneous Tensor Fascia Lata Groin Flap
June 9, 2009
14:7
B-601
ch40
FA
Flap Technology and Reconstructive Techniques in Urology
Sacral Area
Gluteus Maximus Muscle Superior Gluteal Artery Perforator Lumbar Artery Perforator Parassacral Artery Perforator Lateral Intercostal Artery Perforator
Ischial Area
Deep Femoral (posterior thigh) Artery Perforator Flap Posterior Gluteal Thigh Inferior Gluteal Artery Perforator (IGAP)
Trochanteric Area
Lateral Circumflex Femoris Artery Perforator Superior Gluteal Artery Perforator (SGAP) Deep Femoral (posterior thigh) Artery Perforator Flap
Perineogenital Area
Transverse/Vertical Rectus Abdominis Myocutaneous Pudendal Artery Thigh Internal Pudendal Artery Omentum Gracilis Muscle Anterolateral Thigh (free or pedicled) Gluteal Fold Rectal Advancement Flap Dartos Flap vulvoperineal fasciocutaneous flap (Malaga flap) Martius flap
299
June 9, 2009
14:7
300
B-601
ch40
FA
M. Ninkovic and G. Sturtz
Penile Reconstruction
Forearm Flap Deep Inferior Epigastric Perforator (DIEP) Anterolateral Thigh Flap Lateral Arm Flap
Distant/Free Flaps: Deep Inferior Epigastric Perforator (DIEP) Transverse/Vertical Rectus Abdominis Myocutaneous Thoracodorsal Artery Perforator (TAP) Latissimus Dorsi (defect coverage and functional transfer) Jejunal/Gastric Flap Anterolateral Thigh Forearm Flap (penis reconstruction) Tensor Fascis Lata Recipient Vessels for Free Flaps: Superior Gluteal vessels Inferior Gluteal Vessels Superficial Femoral Vessels (or side branches) Inferior Epigastric Vessels Recipient Nerves: Ilioinguinal Nerve (sensitive) Dorsal Clitoral or Penile (sensitive) Lower Intercostals (motor for Bladder and Abdominal Wall)
June 17, 2009
14:52
B-601
FA
index
Index
ablation, 133–135 adrenal tumour, 257 anastomosis, 195–198, 201, 202 anatomy, 209, 210 anterior approach, 79, 80, 82–84 anterior resection syndrome, 203 anterograde and retrograde nerve preparation, 36 atypical resection, 142, 143, 146 bladder reconstruction, 296, 297 breast cancer, 1, 2, 25 breast reconstruction, 7, 10, 13, 14, 17 Breslow thickness, 219 capsular dissection technique, 43 cardia, 117, 118, 120, 121, 123 central neck dissection, 48, 50, 52 chemotherapy, 113, 114 coloanal anastomosis, 203–207 colonic J pouch, 203–205 coloplasty, 203–205 colorectal, 179, 180, 183, 184 colorectal cancer, 157, 162, 163 colorectal liver metastases, 142 colostomy construction, 171 complication, 272 cytoreductive surgery, 229 cytostatic agents, 259, 262–264 deep lobe resection, 37 defect filling, 37 dose calculation, 263
en bloc resection, 247 esophageal carcinoma, 103 esophagogastrostomy, 105 excision, 219, 220 excision margin, 220 extended cervical mediastinoscopy, 89, 90 extended liver resection, 151 familial adenomatous polyposis, 195 flaps, 289–296 gastric cancer, 109, 110, 112, 113 gastroesophageal junction, 104, 107 gluteal fold flap, 215–217 groin, 223, 226 HIPEC, 229, 232, 233, 235 identification of the facial nerve, 35 ileoanal pouch, 195, 202 ileostomy construction, 171 ilioinguinal, 223, 228 immediate breast reconstruction, 19 inflow control, 146 intraperitoneal chemotherapy, 229, 233, 234 IPMN, 126, 127, 130 isolated limb perfusion, 259 isolated perfusion, 157, 161 Ivor Lewis operation, 103 J pouch, 203–207 301
June 17, 2009
302
14:52
B-601
index
FA
Index
laparoscopic, 275–277, 279, 280 radical transperitoneal nephrectomy, 275 laparoscopic adrenalectomy, 253, 257 laparoscopy, 238, 240, 242 laryngeal cancer, 55, 56, 60, 61 laryngectomy, 55–57 latissimus dorsi flap, 11, 13 left-sided oesophagectomy, 100 liver metastases, 162 liver resection, 141, 142, 144 liver surgery, 149 lobectomy, 71–73, 75–77 locally advanced, 281, 287 lumpectomy, 25, 28 lung cancer, 63, 71–73 lymph node, 45–50, 109–114 lymphadenectomy, 63, 64, 68, 69, 95, 96, 98, 99, 101, 223, 227 mastectomy, 7–10, 12, 14–16 mediastinoscopy, 87–90 mediastinum, 65, 68 melanoma, 223 mesorectum, 187, 188, 190–192 metastases, 134, 136, 137 microsurgery, 295 monitoring, 34 multivisceral resection, 247 nephron sparing surgery, 267 non-palpable, 25, 26 oesophageal cancer, 95, 117, 118, 123 palliative, 179, 180, 182–184 pancreas, 110, 114 pancreatic cancer, 126 pancreatic resection, 126, 129, 130 parasternal mediastinotomy, 88, 89 parathyroid gland, 49, 51, 52 perfusate, 261, 264 perfusion level, 259, 260 perfusion technique, 260 perineal reconstruction, 216 peritoneal carcinomatosis, 229, 230
peritoneal mesothelioma, 229, 235 peritonectomy, 230–232, 234, 235 posterolateral neck dissection, 48, 52 prevertebral route, 104, 105 primary melanoma, 219 proctocolectomy, 195–198 prostate cancer, 281, 282, 285, 287 pseudomyxoma peritonei, 229, 231 pulmonary, 71, 72, 74, 75 radical nephrectomy, 275, 279, 280 laparoscopic transperitoneal, 276 radical prostatectomy, 281 radiochemotherapy, 114 radiofrequency, 133–135, 137 radiotherapy, 221 rectal cancer, 187, 192, 203 rectum, 195, 197, 199 recurrent laryngeal nerve, 49, 51, 53 renal cell carcinoma, 267, 279 radical laparoscopic nephrectomy, 275, 279 resection margin, 141, 142 retroperitoneal sarcoma, 246, 247 retrosternal route, 104, 105 right-sided oesophagectomy, 97 robotic colorectal surgery, 169 ROLL, 26, 27 sentinel node, 1 skin incision, 35 skin/nipple sparing mastectomy, 19 small renal tumours, 271 spinal accessory nerve, 48 spleen, 114 stapling, 193 stent, 117–123 stent placement, 117, 118, 120–123 stenting, 179, 181–184 subclinical, 25 superior laryngeal nerve, 49 superior sulcus tumours, 79, 80, 84 surgery, 84, 110, 114, 246, 247, 249, 250 surgical procedure, 245 surgical techniques, 55, 142
June 17, 2009
14:52
B-601
FA
index
Index technique, 118 thoracodorsal bundle, 2 thoracoscopic lobectomy, 71, 72 thyroid carcinoma, 45–47 thyroidectomy, 41, 43, 44 tissue expander, 7, 10, 11 TME, 187, 188, 192 total exenteration, 209, 210, 214 total pancreatectomy, 125, 129, 131 total protectomy, 203 toxicity, 259, 263, 264 TRAM flap, 7, 14–17 transcervical extended mediastinal lymphadenectomy (TEMLA), 91 transhiatal esophagectomy, 103–105 transthoracic oesophagectomy, 95 tumour, 133–136, 138, 139
303
tumour necrosis factor alpha, 263 two-field lymph node dissection, 107 ulcerative colitis, 195–198 utility thoracotomy, 72, 73 video-assisted lobectomy basic considerations, 71 for lung cancer staging, 71–73 indications, 73 lymphadenectomy, 77 technique, 73 video-assisted mediastinoscopic lymphadenectomy (VAMLA), 91 video-assisted thoracoscopic surgery, 91 videothoracoscopic lobectomy, 71
