The Importance of the Multi-Disciplinary Team (MDT)

Speakers:
Vlad Teodor Berbecar , Kirill Kuzmichev,
Sarah Craig, Natalia Maciuszko
Scientific adviser:
Leidenius Marjut
Department Head, Senior Lecturer in Surgery
Breast Surgery Unit, Helsinki University Central Hospital
Poznań, the 19th of August 2011
Outline
• Chapter 1 - Why Surgery?
• Chapter 2 - Modern technologies in tumour
surgery
• Chapter 3 –MDT and Reconstructive surgery
• Chapter 4 - Palliative surgery
Speaker:
Vlad Teodor Berbecar
“Carol Davila” University of Medicine and Pharmacy
Scientific adviser:
Marjut Leidenius
Department Head, Senior Lecturer in Surgery
Breast Surgery Unit, Helsinki University Central Hospital
Poznań, the 19th of August 2011
HISTORY OF SURGERY
Greek
“xeir”=hand
“ergon”=work
1600 BC - First recorded description
of the surgical treatment of cancer (in
Egypt)
800 BC – Sushruta =“Father of
surgery”
-wrote a book containg over 300
surgical procedures and 120 surgical
instruments
400 BC – Hippocrates describes the stages
of cancer and advises against surgery for
terminal disease; he coins the terms
“carcinoma”(crab-leg tumor) and
“sarcoma”(fleshy tumor)
200 AD - Galen identifies cancer as a
systemic disease (primary and metastasis)
Celsus – description
of a barber surgeon:
“His
temperament
should
be
well
balanced. His hands
well formed with long
slender fingers and he
should be free from
bodily tremors”.
Relationship between
doctors and surgeons
Henri de Mondeville (12601320):
My good man it is well known
that surgeons are arrogant
and completely ignorant, and
that the little store of
knowledge they have was
obtained from us doctors”.
ANESTHESIA & ANTISEPSIS
John Collins Warren – 1st to remove tumour
under ether anesthesia
Ignaz Philipp Semmelweis (1818-1865)
“the incidence of puerperal fever could be
drastically cut by the use of hand disinfection
in obstetrical clinics.”
Louis Pasteur (1822-1895) – germ theory
Joseph Lister (1827-1912)
Before 1850 Early heroic attempts
to resect cancer
1850-1950 Development of
standard surgical
resection techniques
1950-1960 Development of
extended radical
surgical procedures
Year
1809
1846
1867
1860:1890
1878
1880s
1890
1896
1904
1906
1908
1912
1910:1930
1913
1927
1933
1935
1945
1958
Selected Historical Milestones in Surgical Oncology
Surgeon
Event
Ephraim McDowell
Elective abdominal surgery (excised ovarian tumor)
John Collins Warren
Use of ether anesthesia (excised submaxillary gland)
Joseph Lister
Introduction of antisepsis
Albert Theodore Billroth First gastrectomy, laryngectomy, and esophagectomy
Richard von Volkmann Excision of cancerous rectum
Theodore Kocher
Development of thyroid surgery
William Stewart Halsted Radical mastectomy
G. T. Beatson
Oophorectomy for breast cancer
Hugh H. Young
Radical prostatectomy
Ernest Wertheim
Radical hysterectomy
W. Ernest Miles
Abdominoperineal resection for rectal cancer
E. Martin
Cordotomy for the treatment of pain
Harvey Cushing
Development of surgery for brain tumors
Franz Torek
Successful resection of cancer of the thoracic esophagus
G. Divis
Successful resection of pulmonary metastases
Evarts Graham
Pneumonectomy
A. O. Whipple
Pancreaticoduodenectomy
Charles B. Huggins
Adrenalectomy for prostate cancer
Bernard Fisher
Organization of NSABP to conduct prospective randomized
trials
BIRTH OF SURGICAL ONCOLOGY
1912 – Memorial
Hospital NYC
Dr. James Ewing
4 MAIN ROLES
1. Diagnosis and staging
2. Curative
3. Palliative
4. Prophylactic
(1) definitive surgical treatment for primary
cancer
(2) surgery to reduce the bulk of disease
(3) surgical resection of metastatic disease
with curative intent
(4) surgery for the treatment of oncologic
emergencies
(5) surgery for palliation
(6) surgery for reconstruction and
rehabilitation
There must be a final limit to the development of
manipulative surgery, the knife cannot always
have fresh fields for conquest and although
methods of practice may be modified and varied
and even improved to some extent, it must be
within a certain limit. That this limit has nearly, if
not quite, been reached will appear evident if we
reflect on the great achievements of modern
operative surgery. Very little remains for the
boldest to devise or the most dextrous to perform.
Sir John Erichsen
Lancet, 1873
Speaker:
Kuzmichev Kirill
Moscow State University of Medicine and Dentistry
Scientific adviser:
Marjut Leidenius
Department Head, Senior Lecturer in Surgery
Breast Surgery Unit, Helsinki University Central Hospital
Poznań, the 19th of August 2011
Outline
• Minimally invasive surgery in oncology
• Da Vinci system (robotics surgery)
• Natural orifice transluminal endoscopic
surgery (N.O.T.E.S)
• Radio Guided Surgery
• Experimental methods
Chirurgus mente prius
et oculis agat, quam
armata manu.
A surgeon should use his eyes and mind before his
hand armed with the scalpel.
Aulus Cornelius Celsus
- “De Medicina”
Well-known advantages of
minimally invasive surgery
•Less pain
•Less risk of hernia development
•Less loss of blood
•Better visualization, easier access
• High-precision surgery
Better quality of life for the patient
Problems of minimally invasive
surgery
•Learning curve
•Centralization of surgery
•Cost of surgery (team, equipment, service)
•Oncological propriety and outcomes must be
maintained
•Extended length of surgery
•Risk of severe intra-operative hemorrhage
The main conclusion in most of the papers:
The surgery X is feasible, safe, and
effective. Outcomes appear comparable with
those via the open approach.
However, controlled trials are needed.
Do you think there will
be a time when robots
will replace surgeons?
Robotic surgery
Surgical robots - expensive toys or the
future of surgery?
Robotic surgery
http://www.davincisurgery.com/
Robotic surgery
In fact, DaVinci is not a robot.
It is a Surgical Telepresence Device as it
requires the presence of a human operator to
complete the surgery.
This is a surgical robot
(droid)
Natural orifice transluminal
endoscopic surgery - N.O.T.E.S.
NOTES in oncology and other areas is associated
with numerous technical and ethical questions.
Transanal Endoscopic
Microsurgery (TEM)
TEM has been proposed as a technology to be
used for NOTES.
TEM can be clearly considered a direct ancestor
in the lineage to NOTES in the field of general surgery,
it continues to contribute with its clinical application
in oncology surgery, to a real minimally invasive
technique for early rectal cancers.
Transanal Endoscopic
Microsurgery (TEM)
Radioguided surgery
Two main application domains:
•Sentinel lymph node biopsy (after administration
of a lymphotrophic radiopharmaсeutical)
•Radioguided occult lesion localization (ROLL)
(after intra-tumoral or systemical injection of tumorseeking radiofarmaсeuticals)
Radioguided occult lesion
localization (ROLL)
ROLL technique is as effective as wireguided localization for the excision of nonpalpable breast lesions.
In addition, ROLL improved the outcomes
by reducing localization and operation time,
preventing healthy tissue excision and achieving
clearer margins.
Ocal K, Dag A. Et al
Radioguided occult lesion localization versus wire-guided localization for non-palpable
breast lesions: randomized controlled trial. Clinics. 2011;66(6):1003-1007.
Optical Image-guided Surgery—
Where Do We Stand?
•PET-imaging
•Autofluorescence
•Optical Imaging with Conventional Fluorescence
•Non-targeted Activatable Organic Fluorophores
•Nanoparticles
All of them are not directly suitable for intra-operative use.
At least, now.
Stijn Keereweer, Jeroen D. F. Kerrebijn et al –
Mol Imaging Biol (2011) 13:199Y207
Near-infrared (NIR) fluorescence
imaging
Near-infrared (NIR) fluorescence
imaging is an experimental technique that
can be used to visualize cancer cells during
surgery.
In current surgical practice, surgeons
can only rely on palpation and visual
inspection.
Near-infrared intra-operative
imaging systems
a - FLARE™ camera system
b - Artist impression of Fluobeam™
Near-infrared intra-operative
imaging systems
C - Artemis™ camera system
D - The Photodynamic Eye (Hamamatsu Photonics, Hamamatsu
City, Japan).
Swine Skin and Colon
SLN Mapping HSA800
Ohnishi S, Lomnes SJ, Laurence RG, Gogbashian A, Mariani G, Frangioni JV. Organic
alternatives to quantum dots for intraoperative near-infrared fluorescent sentinel lymph
node mapping. Mol Imaging. 2005;4:172-81.
NIR fluorescence imaging during
sentinel lymph node mapping in breast cancer patients
Merlijn Hutteman • J. Sven D. Mieog et al
Breast Cancer Res Treat (2011) 127:163–170
DOI 10.1007/s10549-011-1419-0
Who knows, what we will be able to
see in the operative field within the
next 20 years?
Summary of the chapter
Though nowadays we can use
numerous modern technologies in our
attempts to treat patients, we should
not forget that the main thing is
what do patients want…
and that we all work in one team.
Speaker:
Sarah Craig
Department of cardiovascular surgery
Scientific adviser:
Marjut Leidenius
Department Head, Senior Lecturer in Surgery
Breast Surgery Unit, Helsinki University Central Hospital
Poznań, the 19th of August 2011
What is an MDT?
The MDT
• No clinician has all the skills needed to treat all types of
cancers.
• The teams roles:
Planning
MDT
Preparing the
patient
Providing
information
Rehabilitation
Primary treatment
Teaching and
Learning
Palliative care
• MDT= survival advantages plus functional,
psychological, cosmetic and quality of life benefits.
The oncology team
•
•
•
•
•
•
•
Oncologist
Surgeon
Specialist Nurses
Radiologist and staff
Histopathologist
Councellor
Physiotherapist
• Occupational
Therapist
• Pain Team
• Palliative care
• Social Workers
The Oncology Team
• The Patient!
MDT = Greater survival
• Colorectal Cancer:
-5 year survival improved from 69.75% to 77.23% when MDT
took charge of patient care.
Du CZ et. al. World Journal of Gastroenterology 2011
• Oesophageal Cancer:
-5 year survival 52% in MDT group compared to 10% in non-MDT.
Operative mortality 5.7% vs. 26%
Stevens MR et. al. Diseases of the Esophagus 2006
• Head and Neck Cancer:
-1.45 times less likely to die if in the MDT than in the control group
Friedland PL et. al. British Journal of Cancer 2011
The importance of each team
member
• Specialist surgeons
reduce local
colorectal cancer
recurrence :
Specialist colorectal
surgeon achieved a local
recurrence rate of 3.7%
vs. 19% when performed
by general surgeons.
•
Ameer NA et. al. Proceedings of the Second Joint
Meeting European Council of Coloproctology: First
National Congress Italian Society of Colorectal
Surgery. 2005.
The importance of each team
member
• Breast Cancer care nurses:
Reduce psychological morbidity after
breast cancer diagnosis more so than
any other care worker in the fields of
•
•
•
•
•
anxiety,
severe depression,
insomnia,
somatic symptoms
social dysfunction.
JMC Mc. Ardle et. al. British Medical Journal. 1996
The importance of each team
member
• The nutritionist in
Head and Neck cancer
therapy:
Nutritional support 7-10
days preoperatively reduces
post-op complications by
10%.
Bertrand PC et. al. Current opinion in clinical nutrition and
metabolic care. 2002.
Reconstructive Surgery
Aims:
Return patients to an adequate and
reasonable quality of life after cancer
surgery.
Case 1: Basal Cell Carcinoma
• 62 ♀ presented with
a L. Colles fracture to
ED in Australia.
• O.E 15x15cm lesion
on the back. Grown
slowly from a nodule
over 5 years.
• No medical help
previously sought.
• None diabetic.
• ? BCC
• After Abx
(cephazolin =
metronidazole)
• Tumour was
resected with 1 cm
margin leaving a
defect with diameter
20cm.
• Pair helix flaps were
marked, cut and
sutured in place.
• End result:
Case 2: Total ear reconstruction after resection
of malignant melanoma.
Gault David. JPRAS. 2008
To conclude my chapter:
Every player in the MDT has a crucial
role and the management of patients in
this way increases survival from a wide
range of cancers.
To conclude my chapter:
A reconstructive surgeon is an important
member of this team.
In cancer surgery with curative intent, it is
important to consider the patients long term
needs and always offer reconstruction where
possible.
Speaker:
Natalia Maciuszko
University of Medical Sciences Poznań
Scientific adviser:
Marjut Leidenius
Department Head, Senior Lecturer in Surgery
Breast Surgery Unit, Helsinki University Central Hospital
Poznań, the 19th of August 2011
„The established goal in palliative
treatment is improvement in quality of
life and not survival” .
Palliative surgery for cancer pain
Laurence McCahill and Betty Ferrell
Palliative surgery
Symptoms that can be helped by palliative
surgery include:
• Pain
• Respiratory distress
• The inability to move or to function as usual
• An obstruction in digestive tract
Pain
Pain is commonly associated with cancer,
occurring in:
- about one quarter of patients with newly
diagnosed cancer
- and in nearly three quarters of cancer patients
with advanced disease.
Indications for surgical intervention for
pain relief in advanced malignant lesions:
• other less invasive means have failed
• selected therapy results in intolerable side
effects
From ArticlesBase „Palliative surgery”
Mesothelioma
Palliative surgery is focused on symptoms,
especially on the physical pain associated with this illness.
Surgical forms of treatment in
mesothelioma
1) Thoracentesis: drains excess fluid from
the space between the lung and the pleura.
2) Pleurodesis: is used to reduce the build-up
of fluid between the lung and the pleura.
3) Pleurectomy
4) Pneumonectomy
Bones metastases
• Bone metastases are frequently one of the first signs of
disseminated disease in cancer patients (breast,
prostate, lung)
• Generally prognosis is poor
• The intention of palliative surgery is to relieve pain,
prevent and treat fractures,
maintain activity
Forms of treatment in case of
bone metastases
• Prophylactic fixation
• Internal fixation
Forms of treatment in case of bone
metastases
• Arthroplasty
• Endoprosthetic replacement
A bowel obstruction
• It can present with abdominal pain and distention,
vomiting, fecal vomiting, constipation.
• May be complicated by electrolyte abnormalities,
ischaemia, perforation.
Colorectal Cancer
A tumour that is large enough to fill the entire
lumen of the bowel may cause bowel
obstruction.
Palliative surgery in case of
Colorectal cancer
• Resection of the primary tumour is offered
to reduce further morbidity.
• Fecal diversion
• Ileotransverse bypass
• Stent placement
• Laser coagulation
Esophageal cancer
• Dysphagia and odynophagia (painful
swallowing) are the most common symptoms.
• Most patients are not candidates for resection,
the main focus of treatment is palliation of
malignant dysphagia
Forms of treatment in esophageal
cancer
• Endoscopic-placed stent is used to provide palliation of
dysphagia, to decrease esophageal reflux and aspiration.
• Esophageal balloon dilation.
-Other goalspalliation of tumour fungation
Local resection, even if it is not complete
may be of value for a locally advanced
tumour mass that is necrotic and breaking
down.
Breast cancer
Toilet mastectomy for a progressive breast cancer
Melanoma
Ethical problems
„Palliative surgery(…) demands more
than individual surgical skills.
It urges moral education and ethical
reflection by all who provide treatment, as
well as sensibility to the patient's physical,
emotional and existential condition”.
British Journal of Surgery Society Ltd. Published by John Wiley & Sons
Thank you for
your attention!