Upper GI Surgery

QiP – The Amsterdam experience
Surgeon‘s perspective
Suzanne S. Gisbertz, MD, PhD
Upper GI Surgeon
Academic Medical Center Amsterdam
Zurich, april 2015
No Disclosures
Upper GI Surgery Introduc1on Esophageal surgery Transthoracic esophagectomy Gastric surgery Total gastrectomy
•  Thoracolaparoscopic or open •  2 stage, intrathoracic anastomosis •  3 stage, cervical anastomosis •  Laparoscopic or open
•  Roux-Y
Transhiatal esophagectomy •  Laparoscopic or open •  Cervical anastomosis Subtotal gastrectomy
•  Laparoscopic or open
•  Roux-Y
Incidence of esophageal cancer Introduc1on AMC new pa1ents / admi?ance 1me 2009-­‐2013 Oesofagus en maagcarcinoom GIOCA 2009-­‐2013
8
7
250
Aantal Patienten
6
200
5
150
4
3
100
2
50
1
0
0
2009
2010
2011
Jaar
2012
2013
Mediane Verwijstijd in dagen
300
Medi a ne Verwi js tijd
Pa tiënten
Esophageal resections
AMC 2004-2014
120
96
100
90
78
80
89
81
78
77
76
73
67
60
83
64
59
56
47
40
31
20
Minimally invasive resections
8
Total number of resections
0
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
Gastrectomies
AMC 2011-2014
35
31
30
30
25
23
21
20
15
13
9
10
Minimally invasive resections
5
Total number of resections
0
0
2011
2012
2013
2014
Esophagectomy High-­‐complex procedure Procedure depends on tumor loca1on Proximal-­‐ mid-­‐thoracic Distal esophageal / Gastro esophageal Junc1on Lymph node dissec1on Thorax Thorax Thorax Thorax Thorax Thorax -­‐ thoracoscopy Thorax -­‐ thoracoscopy Thorax -­‐ thoracoscopy Abdomen Abdomen
Positioning and set-up
Abdomen Abdomen Gastric tube reconstruc1on Esophagectomy Major Procedure 2 or 3 phases a total of 6-­‐8 hrs of surgery •  Thoracic phase •  Prone pos?on •  Pneumothorax 6-­‐8 mmHg •  Lung collaps during 1-­‐2 hrs •  Abdominal phase •  An?-­‐Trendelenburg posi?on •  Pneumoperitoneum 12-­‐15 mm Hg •  (Cervical phase) •  Fragile reconstruc?on Pa1ent Selec1on Fit pa1ents? Comorbidity! Neoadjuvant CRT Case
Neoadjuvant CRT Neoadjuvant Chemoradiotherapy Chemoradiotherapy regimen:
Paclitaxel 50mg/m2 + Carboplatin AUC=2 on days 1, 8, 15,
22 and 29
Concurrent radiotherapy of 41.4 Gy in 23 fractions of 1.8 Gy
Surgery within 6 weeks after completion of chemoradiotherapy
Neoadjuvant CRT – CROSS study NEJM 2012 Neoadjuvant CRT In Summary: Upper GI Surgery (ánd Anaesthesiology) •  Major surgery under extreme condi?ons •  In unfit pa?ents with extensive comorbidity •  AOer neoadjuvant chemoradiotherapy Morbidity in Upper GI pa1ents Dutch Upper GI Cancer Audit Esophagus – postopera1ve complica1ons Percentage)pa+ënten)met)een)gecompliceerd)beloop))
)
100%#
90%#
80%#
70%#
60%#
Ziekenhuis#
50%#
Gemiddelde#
40%#
95%#BI##
30%#
20%#
10%#
0%#
0#
50#
100#
150#
200#
250#
300#
Aantal)pa+ënten)dat)een)opera+e)ondergaat)vanwege)een)slokdarmcarcinoom)per)ziekenhuis)
(2011?2013)))
Dutch Upper GI Cancer Audit Stomach – postopera1ve complica1ons Percentage)pa+ënten)met)een)gecompliceerd)beloop))
)
100%#
90%#
80%#
70%#
60%#
Ziekenhuis#
50%#
Gemiddelde#
40%#
95%#BI##
30%#
20%#
10%#
0%#
0#
10#
20#
30#
40#
50#
60#
70#
80#
Aantal)pa+ënten)dat)een)opera+e)ondergaat)vanwege)een)maagcarcinoom)per)ziekenhuis)(2011?2013)))
Preven1ng complica1ons in upper GI surgery Where to start? Clinical pathways Preopera?ve phase •  Pa?ent selec?on & pa?ent op?miza?on Peropera?ve phase •  Minimally invasive surgery •  Goal directed therapy Postopera?ve phase •  Enhanced recovery program Preopera1ve phase MDT Pa?ent selec?on – Mul? Disciplinary Team •  Selec?on of pa?ents for mul?modal therapy or surgery only •  Preopera?ve op?miza?on •  Physiotherapist •  Die?cian •  Life style changes (smoking / alcohol drinking cessa?on) Preopera1ve phase MDT Pa?ent selec?on – Who? MDT set up @ AMC • 
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Pathologist expert GI Gastro-­‐enterologist expert (interven?onal) Medical Oncologist GI only Radiotherapist GI only Surgeon upper-­‐GI Radiologist Nuclear medicine specialist Preopera1ve phase MDT Missing….. •  ICU specialist •  Anaesthesist Especially in ASA > 3 Peropera1ve phase Minimally invasive surgery TIME trial – Lancet 2012* RCT comparing Open versus minimally invasive esophagectomy * Biere et al. Lancet 2012
TIME trial
Conclusions
•  Minimally invasive esophagectomy results in a
significantly
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Lower incidence of pulmonary infections
Shorter hospital stay
Better short-term quality of life
Same completeness of resection
Biere et al. Lancet 2012
Peropera1ve phase Goal directed therapy Results presented by Dr. Veelo In conclusion: •  Significant reduc?on in pulmonary complica?ons •  Significant reduc?on in gastric tube necrosis •  Significant reduc?on in the amount of fluid administra?on Postopera1ve phase ERAS •  Enhanced recovery aOer surgery •  Introduc?on in 2009 •  Based on ERAS protocol for colorectal surgery •  LAFA trial; Vlug et al, Annals of Surgery 2011 •  Evalua?on aOer 19 months •  Blom et al, World Journal of Surgery 2013 ERAS Day – 1 – 0 •  Lab •  No seda?ves •  Carbohydrate loaded drinks un?l 2 hours prior to surgery ERAS Day 0 •  High thoracic epidural •  Th 5/6 or 6/7 •  Compression stockings un?l 24 hours aOer surgery •  Goal directed therapy •  Minimally invasive surgery •  Early extuba?on •  High Care (ASA I/II), ICU (ASA ≥ III) ERAS Day 1 Discharge criteria HC / ICU •  Extubated •  Awake, oriented •  Absence of significant blood loss [<50 ml/h] •  Absence of hypovolemia •  Sufficient respira?on [SaO2>90 %] •  Stable hemodynamics •  No use of vasoac?ve drugs ERAS Day 1 – 7 ERAS From day 7 Discharge criteria home •  Adequate pain control with oral analgesics •  Absence of nausea •  Adequate intake (orally and via jejunostomy catheter) •  Passage of flatus and/or stool •  Mobiliza?on •  Self-­‐support •  Pa?ent’s consent ERAS
Results
Blom et al, World J Surg 2013
ERAS
Results
ERAS
Results
Conclusion on protocolized clinical pathways •  Protocolized clinical pathways result in structured and bever care for pa?ents with esophageal cancer •  A shorter hospital stay and a lower pulmonary morbidity •  A clear plan for the pa?ent •  Some goals however are difficult to achieve Dedicated team Dedicated team Opera1on theatre • 
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Anaesthesiologist Anaesthesia nurse Scrub nurse Upper-­‐GI surgeon efficiency Team Work in Complex Surgery Future perspec1ves Do bever in preopera?ve selec?on •  Involve anaesthesist / ICU specialist Do bever in periopera?ve monitoring & surgical technique •  Op?mize goal directed therapy protocol •  Adjustments in surgical technique Do bever in postopera?ve care •  Extending goal directed therapy to HC / ICU