Whipple's Procedure after chemoradiotherapy: Glimmer of hope for patients with large pancreatic tumors detected late

Whipple's procedure (pancreatoduodenectomy; PD) is currently the only curative option available for cancer limited to the head of the pancreas (CaHOP).

Many patients with CaHOP present with advanced tumors that involve major adjacent blood vessels and traditionally are/were not deemed candidates for Whipple's procedure. Many such patients undergo a non curative 'double bypass' surgery. As the name suggests this procedure provides only an alternative pathway for the flow of food and bile into the small intestine without the removal of tumor. Consequently the likely survival following 'double bypass' is around 10 months only.

Advancements in chemotherapy & radiotherapy that downstage the disease together with advancements in surgical techniques (vascular resection & reconstruction) mean that Whipple's procedure can now be successfully performed for patients deemed traditionally 'unresectable'. 

(https://gicancerindia.blogspot.com/2019/05/the-emerging-role-of-neoadjuvant.html)

In India this combined modality treatment is currently available at limited number of centers only. 

We report one such patient managed recently by our team.

A bright, young lady, Ms A from Baghdad, Iraq was diagnosed with cancer of pancreatic head ( YouTube ➤ https://youtu.be/gP4Ws5AcA_g). She underwent surgical exploration with intent of Whipple's procedure in her home country. At surgery, she was found to have advanced pancreatic head tumor that involved adjacent major blood vessels (SMV). Hence the tumor could not be removed and double bypass operation was performed.

Determined to fight her disease, in October 2018, Ms A attended Outpatients' Clinic of the Department of Surgical Gastroenterology at Max Hospital, Saket, New Delhi. She underwent a through re-evaluation by a multidisciplinary team. Her PET – CT scan revealed that the tumor was confined to the pancreas with no spread to other organs of the body. The pancreatic protocol CT scan showed the tumor involved major adjacent blood vessels (Figure 1).

Figure1. Pre CRT Pancreatic protocol CT scan 

Tumor infiltrating SMV (> 180 degrees) with contour abnormality 

A diagnosis of BRPC (borderline resectable pancreatic cancer) was thus made and she was advised chemoradiotherapy (CRT) to downstage the disease. Due to logistic reasons the patient and her family decided to undertake CRT in her home country.

In July 2019, almost 11 months after her initial double bypass surgery and having completed CRT, Ms A again reported to our clinic. She appeared in good health and was therefore re-evaluated. Her repeat pancreatic protocol CT scan and PET – CT scan showed that there was a remarkable reduction in the size of the tumor (Figure 2) and no spread to other organs of the body. 

Figure 2. Post CRT Pancreatic protocol CT scan. SMA & SMV free of tumor

Ms A subsequently underwent open Whipple's procedure (duct – mucosa PJA with internal stent). The surgery was challenging in view of dense adhesions due to previous double bypass and loss of tissue planes with major blood vessels (IVC, SMA & SMV) due to radiotherapy; however no vascular resection was required. The postoperative period was uneventful and she was discharged on seventh postoperative day.

The final biopsy confirmed complete removal of the tumor (R0 resection). The retroperitoneal margin (4 mm) was free of tumor. All examined lymph nodes were also free of tumor.

In high spirits, Ms A has gone back home to continue further treatment with her team of doctors. We wish her well and hope to see her in good health in 3 months time.

Comments: In summary this strategy of Whipple's procedure after chemoradiotherapy provides a glimmer of hope to patients with large pancreatic head tumors involving neighboring major blood vessels.

Authors:

Dr Nitin Vashistha, MS, FIAGES, FACS

Dr Dinesh Singhal, MS, FACS, DNB (Surg Gastro)

Department of Surgical Gastroenterology,
Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com

www.gicancerindia.com

Links:
1. http://www.drugtodayonline.com/medical-news/review/9699-max-docs-shrink-tumor-then-operate-to-save-iraqi-patient.html
2. https://www.onlymyhealth.com/whipple-procedure-for-pancreatic-cancer-a-new-ray-of-hope-for-treating-inoperable-pancreatic-cancers-1566810639
3. http://bwhealthcareworld.businessworld.in/article/Whipple-s-Procedure-After-Neo-adjuvant-Chemo-radiotherapy-New-Hope-for-Locally-Advanced-inoperable-Pancreatic-Cancers-Tumours/26-08-2019-175236/

Outcomes of Colorectal Surgery (CRS) at Department of Surgical Gastroenterology, Max Hospital (Saket): International quality at affordable Indian costs

Our team attended annual conference of the Society of American Gastrointestinal & Endoscopic Surgeons (SAGES) held at Baltimore, USA April 2019. We presented 3 studies including one entitled ‘Outcomes following colorectal surgery: A comparative study CR-POSSUM and ACS-NSQIP risk calculator^’.¹

In the following section we share some of the highlights of this study.

A recent study published in New England Journal of Medicine examined 30 -day readmission data of 479,471 patients from 3004 USA hospitals undergoing six major surgical procedures (colectomy and 5 other surgical procedures). The study concluded that following major surgical procedures, nearly one in seven patients are readmitted to the hospital within 30 days of discharge and readmission data is an indicator of quality of surgical care at any hospital.²

We therefore performed audit of colorectal surgery (CRS) outcomes at our department using American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) risk calculator - one of the most widely utilized and validated universal risk calculator for clinical audits.

The ACS NSQIP risk calculator was developed by utilizing data collected from 4.3 million operations performed across 780 hospitals participating in ACS NSQIP to predict outcomes for 1500 surgical procedures. The risk calculator estimates an individual’s risk of developing 18 different complications within 30 days after surgery.

The risk adjusted scoring systems such as ACS NSQIP risk calculator are important because in heterogeneous cohorts of surgery patients, crude postoperative morbidity and mortality as an outcome measure is misleading. Therefore, for meaningful conclusions from clinical audits and compare outcomes between different units or regions, risk adjusted patient outcomes are essential.

Our single centre observational study included 86 consecutive adult (≥ 18 years) patients who underwent elective or emergency, resective &/or reconstructive CRS from March 2013 to March 2018. Procedures such as appendicectomy, diverting colostomy, laparoscopic rectopexy were excluded from analysis. Data was accessed from institutional electronic health record system and pre-anaesthetic charts. ACS – NSQIP score for each patient was calculated. Actual outcomes were then compared with those predicted by risk calculators.

Of the 86 patients (60 Indians and 26 International) there were 56 males and 30 females with a mean age of 57 (range 18-93) years. Of these 59 (68.6%) underwent elective whereas 27(31.4%) had emergency CRS. We performed complete range of procedures for cancer as well as benign diseases. Sixty-two (72%) and 24 (38%) patients underwent open and minimally invasive procedures (laparoscopic -21 and robotic -3) respectively. The median length of stay was 08 (range 02-40) days. The mortality following elective and emergency operations was 1/59 (1.6%) and 8/27(29.6%) respectively. The readmission rate was 05 (5.8%)

Objective comparison between overall actual outcomes and those predicted by ACS – NSQIP risk calculator revealed no statistically significant difference in any of the parameters studied such as mortality, major complication, anastomotic leak, return to OT, surgical site infection length of stay, and readmission (Figure 1). 

Figure 1. Actual versus predicted outcomes by ACS-NSQIP risk calculator

Additionally there is significant cost advantage - all-inclusive costs of surgery (admission to discharge) were one fifth of the costs incurred for colectomy at comparable US NSQIP hospitals (Figure 2).

Figure 2. Comparison of costs for Colectomy at MSSH & US NSQIP hospitals

In conclusion at Department of Surgical Gastroenterology, Max Super Speciality Hospital, Saket outcomes of colorectal surgery are comparable to best of international centres - US NSQIP hospitals at affordable Indian costs.

References:

1. Vashistha N, Verma A and Singhal D. Outcomes following colorectal surgery: A comparative study CR-POSSUM and ACS-NSQIP risk calculator. Surg Endosc. 2019;33:S241

2. Tsai TC, Joynt KE, Orav EJ et al. Variation in surgical readmission rates and quality of hospital care. N Engl J Med 2013;369:1134-42

      

      Authors:

Dr Nitin Vashistha MS, FIAGES, FACS
Dr Dinesh Singhal MS, FACS, DNB (Surg Gastro)

Department of Surgical Gastroenterology,

Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com

www.gicancerindia.com

Tips & Tricks for Safe Anastomosis in Minimally Invasive Colorectal Surgery

Part B.   Intraoperative assessment of anastomotic integrity

This is second part in series of the blog 'Tips & tricks for safe anastomosis in minimally invasive colorectal surgery' (https://gicancerindia.blogspot.com/2019/07/tips-tricks-for-safe-anastomosis-in.html).

Anastomotic leak (AL) is the most feared complication of colorectal anastomosis (CRA) with a reported incidence of 8.1% after right hemicolectomy and 5.8% after high anterior resection and 10.8% after low anterior resection¹.

The attributes of 'Safe' intestinal anastomosis include tension free anastomosis between well vascularised bowel segments. In the era of open surgery, surgeons assessed the latter by a combination of observation (' healthy' color and pulastile bleeding at cut end of the bowel) and palpation (arterial pulsations in the mesocolon). In MIS, options available to the surgeons are more limited and viability of the colon following resection and subsequent anastomosis is determined largely by observing the color.

However the predictive accuracy of surgeons' clinical risk assessment for AL is reported to be low and is not influenced by training level (surgeon versus assistant surgeons)².

To make this assessment less observer dependent and to more objectively assess anastomotic integrity and tissue perfusion, several intraoperative tests have been introduced in clinical practice over last few years.

1.       Intraoperative air leak test (ALT): For left sided anastomosis, the test is simple and performed by insufflating the rectum with air while submerging the anastomosis³.

2.       Intraoperative flexible sigmoidoscopy for assessment of colorectal anastomosis (CRA): This is a safe and reliable method for direct assessment of anastomotic integrity as well as bleeding ⁴. More commonly performed in units where surgeons themselves are trained to perform colonoscopy.

3.       Intraoperative Indocyanine Green (ICG) fluorescence imaging: Intraoperative ICG imaging is a simple reproducible technique for real time assessment intestinal perfusion ¹. The data from non randomized studies on the subject suggests decreased anastomotic leak following ICGA^5,6. However results of a recent multicenter randomized controlled trial from Italy suggests that while ICGA can effectively assess vascularisation of the colic stump and anastomosis and led to further proximal resection in 11% of patients, there was no statistically significant reduction of anastomotic leak in the ICGA arm² . Further one multicenter phase II trial investigating the role of ICG imaging in elective CRS has reported that while the technique helped reduce AL rates in left sided resections  - particularly LAR, it did not add any value to outcomes following  ileocolic anastomoses ¹ .

Comments: We routinely do the intraoperative ALT for left sided anastomoses. For the right side, we perform extracorporeal anastomosis and have not introduced ICG fluorescence imaging. For elective CRS the overall AL in our unit is 5.08%

References:

1.       Ris E, Liot E, Buchs NC et al Multicenter phase II trial of near infrared imaging in elective colorectal surgery Br J Surg 2018;105:1359-1367

https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.10844

2.       Karliczek A, Harlaar NJ, Zeebregts CG et al. Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis 2009;24(5):569-76

https://link.springer.com/article/10.1007%2Fs00384-009-0658-6

3.       Monson JR, Weiser MR, Buie WD et al. Practice parameters for the management of rectal cancer (Revised) Dis Colon Rectum. 2013;56(5):535-50.

https://journals.lww.com/dcrjournal/fulltext/2013/05000/Practice_Parameters_for_the_Management_of_Rectal.2.aspx

4.       Kamal T, Pai A, Velchuru VR et al. Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection? Colorectal Dis 2015;17(2):160-4

https://onlinelibrary.wiley.com/doi/abs/10.1111/codi.12809

5.       Shen R, Zhang Y, Wang T Indocyanine Green Fluorescence Angiography and the incidence of anastomotic leak after colorectal resection for colorectal cancer: A Meta Analysis. Dis Colon Rectum 2018;61(10):1228-1234

https://journals.lww.com/dcrjournal/fulltext/2018/10000/Indocyanine_Green_Fluorescence_Angiography_and_the.17.aspx

6.       Blanco-Colino R, Espin –Basany E. Intraoperative use of ICG fluorescence imaging to reduce the risk of anastomotic leakage in colorectal surgery: a systematic review and meta- analysis. Tech Coloproctol 2018;22(1):15-23

https://link.springer.com/article/10.1007%2Fs10151-017-1731-8

7.       Nardi De, Elmore U, Maggi G et al. Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial. Surg Endosc 2019;doi:10.1007/s00464-019-06730-0

https://link.springer.com/article/10.1007%2Fs00464-019-06730-0

Authors:

Dr Nitin Vashistha MS, FIAGES, FACS
Dr Dinesh Singhal MS, FACS, DNB (Surg Gastro)

Department of Surgical Gastroenterology,

Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com

www.gicancerindia.com

Tips & Tricks for Safe Anastomosis in Minimally Invasive Colorectal Surgery

Part A. Techniques of Colorectal Anastomoses

We attended the recently held annual conference of the Society of American Gastrointestinal & Endoscopic Surgeons (SAGES) in the lovely city of Baltimore, USA April 2019. This was a well organised scientific meeting that fully lived up to the high standards expected of all SAGES meetings. Our team also presented 3 papers including one on outcomes of colorectal surgery in our department (Outcomes following colorectal surgery: A comparative study CR-POSSUM and ACS-NSQIP risk calculator. Abstract published in Surg Endosc. 2019;33:S241)

One of the key areas of focus for SAGES has been minimally invasive colorectal surgery (MI-CRS). Through interactive sessions and hands on courses, acknowledged leaders in the field discussed current best practices on wide range of subjects including techniques of safe anastomosis and early identification and appropriate management of anastomotic leaks.

Through a series of blogs, we will present salient features and provide a brief literature review pertaining to safe colorectal anastomosis:

A.      Techniques of colorectal anastomosis

B.      Intraoperative assessment of anastomotic integrity

C.      Management of anastomotic leak
First blog of the series covers part A and remaining parts B & C shall be covered in subsequent blogs. 

A.      Techniques of colorectal anastomosis

1.       Ileocolic anastomosis following MI right colectomy: Extracorporeal or Intracorporeal?

In view of its technical simplicity, extracorporeal anastomosis (ECA) is currently the preferred method for reconstruction following MI right colectomy. For ECA, the specimen is delivered through the midline extraction site and anastomosis is performed outside the abdomen.¹ When ECA is planned, bowel resection should preferably be done extracorporeal as this obviates of risk of anastomosis between twisted bowel ends - particularly ileum.

Following resection, depending on surgeon's preference, a side to side, isoperistaltic ileocolic ECA can then be completed in classical hand sewn or stapled manner. 
An Intracorporeal anastomosis (ICA) is performed within the peritoneal cavity after the specimen is completely detached from surrounding structures. The specimen is 'bagged' and subsequently removed thorough Pfannenstiel incision.
ICA is a stapled, side to side ileocolic anastomosis. Special focus is needed towards a safe laparoscopic closure of enterotomy (for stapler access) in view of its propensity to leak. When doing a sutured closure, the standard two layer technique using running barbed suture in the first layer is reported to be associated with lesser incidence of leak and bleeding.² The same study also reported totally stapled closure and robotic assisted are reported as non-inferior alternatives.²
A further valuable tip was provided by the expert panel during deliberations at the SAGES meeting - while doing a laparoscopic enterotomy closure with running barbed wire suture (V – Lock), absorbable clip should be applied after first stitch to keep this stitch snug.
ICA has several advantages including short term morbidity and shorter hospital stay³:
-          Particularly suitable for obese patients and those with shortened mesentery
-          No  risk of 'twisted' anastomosis
-          Less postoperative pain
-          Better cosmetic outcomes
-          Less prone to incisional hernia
-          Lower complication rate
-          Earlier discharge from the hospital 
The disadvantages of ICA include:

-          Needs high laparoscopic suturing skills

-          Needs more time

2.       Ileocolic anastomosis following MI right colectomy : Hand sewn or stapled

Recent European studies (population based Swedish study, nationwide retrospective Danish cohort study and a prospective multicenter study) have reported that the anastomotic leak rate following ileocolic anastomosis in patients with right colon cancer ranges between 3.2-8.4%^4,5. Further these studies report an increase (Odds ratio 2.04 -2.91) risk anastomotic leak following stapled anastomosis as compared to hand sewn anastomosis^4,5,6. Besides lower leak rate, the latter has advantage of lower material costs also⁶.

3.       Left sided ICA without using staplers

Invited experts through operative videos demonstrated robot assisted sigmoid colectomy for diverticular disease. The resected colon was delivered through the anal orifice thus obviating any incision to extract the specimen. The colorectal anastomosis was then fashioned with interrupted sutures in single layer similar to open surgery without using stapler.

Our technique:

We currently perform minimally invasive right colectomy with modified complete mesocolic excision (mCME ; Figure 1) with central vascular ligation (CVL; Figure 2) for patients of right colon cancer. All patients have had extracorporeal side to side, isoperistaltic, double layered, hand sewn ileo-colic anastomosis. We initiated minimally invasive right colectomy 5 years ago and with this technique  we have had no anastomotic leaks and all patients had uneventful recovery. 

 Figure 1: Robotic right hemicolectomy for cancer colon - mCME

Figure 2: Robotic right hemicolectomy for cancer colon - CVL

References

1.       Cleary R K, Kassir A, Johnson C S et al. Intracorporeal versus extracorporeal anastomosis for minimally invasive right colectomy: A multicenter propensity score matched comparative study.

Plos One doi.org/10.1371/journal.pone.0206277

2.       Milone M, Elmore U, Allaix ME et al.  Fashioning enterotomy closure after totally laparoscopic ileocolic anastomosis for right colon cancer: a multicenter experience

Surg Endosc 2019 doi 10.1007/s00464-019-06796-w

3.       Van Oostendorp S, Elfrink A, Borstlap W et al. Intracorporeal versus extracorporeal anastomosis in right hemicolectomy: a systematic review and meta analysis

Surg Endosc 2017;31(1): 64-77

4.       Nordholm – Carstensen A, Schnack Rasmussen M, Krarup PM. Increased leak rate following stapled versus handsewn ileocolic anastomosis in patients with right colon cancer: A nationwide cohort study

Dis Colon Rectum 2019;62:542-548

5.       Frasson M, Granero – Castro P, Ramos RJL et al. Risk factors for anastomotic leak and postoperative morbidity and mortality after elective right colectomy for cancer: results from a prospective multicentric study of 1102 patients.

Int J Colorectal Dis 2016;31:105-14

6.       Gustaffson P, Jestin P, Gunnarson U et al. Higher frequency of anastomotic leakage with stapled compared to hand sewn ileocolic anastomosis in a large population based study. World J Surg;39:1834-9

Authors:

Dr Nitin Vashistha MS, FIAGES, FACS

Dr Dinesh Singhal MS, FACS, DNB (Surg Gastro)
Department of Surgical Gastroenterology,
Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com