{{

Upper Abdominal Upper Abdominal Debulking of Gynecologic Debulking of Gynecologic

MalignanciesMalignancies

Shaun McKenzie, MDShaun McKenzie, MD

Assistant Professor of SurgeryAssistant Professor of Surgery

University of KentuckyUniversity of Kentucky

To describe the rationale behind the To describe the rationale behind the inclusion of upper abdominal debulking inclusion of upper abdominal debulking procedures to achieve complete procedures to achieve complete cytoreductioncytoreduction

To review the pertinent anatomy and To review the pertinent anatomy and techniques necessary for upper techniques necessary for upper abdominal debulkingabdominal debulking

To describe the perioperative outcomes To describe the perioperative outcomes associated with an aggressive upper associated with an aggressive upper abdominal approachabdominal approach

ObjectivesObjectives

Extensive upper abdominal disease Extensive upper abdominal disease portends aggressive tumor biology portends aggressive tumor biology precluding a benefit from surgeryprecluding a benefit from surgery

The morbidity and mortality of upper The morbidity and mortality of upper abdominal debulking is prohibitiveabdominal debulking is prohibitive

Lack of comfort in performance of these Lack of comfort in performance of these procedures or lack of appreciation of the procedures or lack of appreciation of the biology of these diseases and the biology of these diseases and the importance of optimal cytoreductionimportance of optimal cytoreduction

Obstacles to an Obstacles to an Aggressive ApproachAggressive Approach

Aggressive Surgical Effort and Aggressive Surgical Effort and Improved Survival in Advanced Improved Survival in Advanced

Stage Ovarian CancerStage Ovarian Cancer Retrospective analysis of Retrospective analysis of

194 patients194 patients Need for radical surgery Need for radical surgery

did not adversely impact did not adversely impact survivalsurvival

In patients with In patients with carcinomatosis, carcinomatosis, performance of radical performance of radical surgery was associated surgery was associated with improved survival with improved survival (44% vs 17%,p<0.001)(44% vs 17%,p<0.001)

The only independent The only independent predictor of survival was predictor of survival was residual diseaseresidual disease

Aletti et al. Obstet Gynecol 2006; 107: 77-85

Aggressive Surgical Effort Aggressive Surgical Effort and Improved Survival in and Improved Survival in Advanced Stage Ovarian Advanced Stage Ovarian

CancerCancer

Aletti et al. Obstet Gynecol 2006; 107: 77-85

Diaphragmatic procedures: stripping or Diaphragmatic procedures: stripping or resection, ABCresection, ABC

Splenectomy with or without distal Splenectomy with or without distal pancreatectomypancreatectomy

Porta hepatis resectionPorta hepatis resection Liver resectionLiver resection CholecystectomyCholecystectomy Gastric resectionGastric resection

Upper Abdominal Upper Abdominal Debulking ProceduresDebulking Procedures

262 consecutive patients262 consecutive patients Addition of upper Addition of upper

abdominal resections abdominal resections increased OC from 53% increased OC from 53% to 82%to 82%

Required in 1/3 of Required in 1/3 of patientspatients

No difference between No difference between complication rate complication rate between groupsbetween groups

No survival difference No survival difference between OC groups with between OC groups with or without upper or without upper abdominal debulkingabdominal debulking

Eisenhauer et al. Gynecol Oncol 2006; 103

Chi et al. Gynecol Oncol 2009;114

Chi et al. Gynecol Oncol 2009;114

Wide Exposure and thorough Wide Exposure and thorough organ mobilizationorgan mobilization

Critical Understanding of the Critical Understanding of the Anatomy, particularly vascular Anatomy, particularly vascular anatomyanatomy

Understand the predictable Understand the predictable sites of diseasesites of disease

Bring all your toys to the tableBring all your toys to the table

Principles of Upper Principles of Upper Abdominal DebulkingAbdominal Debulking

Diaphragmatic ProceduresDiaphragmatic Procedures

Fanfani et al. Gynecol Oncol 2009; 116

Is It Safe?Is It Safe?

141 eligible patients with 141 eligible patients with 229 EUAS procedures 229 EUAS procedures performedperformed

90 % optimally reduced 90 % optimally reduced (30% R0)(30% R0)

Grade 3-5 morbidity in 22%Grade 3-5 morbidity in 22% 68% of complications 68% of complications

managed by a percutaneous managed by a percutaneous procedureprocedure

Mortality 1.4%Mortality 1.4%

Chi et al. Gynecol Oncol 2010; 119

Optimal Cytoreduction should be the plan of Optimal Cytoreduction should be the plan of attack for any woman undergoing debulking attack for any woman undergoing debulking surgerysurgery

The addition of an aggressive approach to The addition of an aggressive approach to upper abdominal disease is associated with upper abdominal disease is associated with increased rates of optimal debulking without increased rates of optimal debulking without a negative impact in cancer outcomea negative impact in cancer outcome

EUAS can be performed safely in EUAS can be performed safely in experienced centers with a multidisciplinary experienced centers with a multidisciplinary approachapproach

Adherance to sound surgical principles Adherance to sound surgical principles optimizes outcomeoptimizes outcome

ConclusionConclusion