Management of early gastric cancer
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Management of Early Gastric Cancer. Charing Chong Division of Upper GI Surgery Department of Surgery Prince of Wales Hospital The Chinese University of Hong Kong. Early Gastric Cancer. Definition – tumour confined to the gastric mucosa or submucosa Convention management – Gastrectomy.

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Management of Early Gastric Cancer

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Management of early gastric cancer

Management of Early Gastric Cancer

Charing Chong

Division of Upper GI Surgery

Department of Surgery

Prince of Wales Hospital

The Chinese University of Hong Kong


Early gastric cancer

Early Gastric Cancer

  • Definition – tumour confined to the gastric mucosa or submucosa

  • Convention management – Gastrectomy


Conventional open gastrectomy vs laparoscopic assisted gastrectomy

Conventional Open Gastrectomy vs Laparoscopic Assisted Gastrectomy


Pwh experience laparoscopic assisted gastrectomy

PWH experience - Laparoscopic assisted gastrectomy

  • 2003 - 2005

  • 25 patients

  • Laparoscopic D2 subtotal gastrectomy

  • Mean OT time: 330 mins

  • Hospital stay: 7 days

  • Complication

    • Minor anastomotic leak (1)

    • Anastomotic bleeding (1)

  • No conversion


Minimal invasive treatment options of egc

Minimal Invasive Treatment Options of EGC

Local - regional Treatment

Local Treatment

Endoscopic Resection

(EMR/ESD)

Laparoscopic AssistedGastrectomy

(LAG)


How to choose

How to choose

  • Major factors predicting the survival:

    • lymph node status

    • depth of wall invasion

  • Risk of LN metastasis in EGC is very low

    • Mucosa: 1 – 3%

    • Submucosal: 11 – 20%

  • Risk of gastrectomy and negative effect on patient’s quality of life


Management of early gastric cancer

Endoscopic Mucosal Resection (EMR)


Emr classification pulling or suction methods

EMR - Classification- Pulling or suction methods

Injection and Cut Technique

Injection, Lift and Cut Technique

Cap Technique

Ligation Technique

Soetikno;J Clin Oncol; 2005


Emr results

Survival:

99% 5-year and 10-year disease specific survival

Complications:

Perforation

0 - 1.5%

Bleeding

6 -15%

Local recurrence

EMR - Results

Tanabe et al; GIE; 2002

Hamanaka et al; Dig Endosc; 2005

Uedo et al; Gastric Cancer; 2006


Emr limitation local recurrence after conventional emr

EMR - Limitation- Local recurrence after conventional EMR

Author

Methods

Recurrence rate

Tanabe et al

Strip Biopsy, EAM

3.5% (15/423)

Kawaguchi et al

Strip Biopsy, EMR-C

35.3% (97/266)

Ida et al

EMR+Laser

6.7% (11/165)

Chonan et al

EMR

10.9% (21/193)

Hirao et al

ERHSE

2.3% (8/349)

Mitsunaga et al

Strip Biopsy

18.2% (54/296)

Strip Biopsy

8.5% (53/620)

NCCH (1988-1998)


Emr limitation en bloc resection

EMR – Limitation- en-bloc resection

Piecemeal resection

One piece resection


Emr limitation tumor size

EMR – Limitation- tumor size


Endoscopic resection changing criteria

Endoscopic Resection– changing criteria

Gotoda;

Gastric Cancer; 2000


Management strategy for early gastric cancer

Management Strategy for Early Gastric Cancer

Guidelines for the Treatment of Gastric Cancer; The Japanese Gastric Cancer Association; 2001


Endoscopic submucosal dissection esd

Endoscopic Submucosal Dissection (ESD)


Esd procedures

ESD - Procedures

  • Marking of the periphery of the lesion with needle knife

  • Injection of diluted epinephrine to raise the submucosal layer

  • Circumferential mucosal cutting

  • Subumucoal dissection

  • Specimen resected in one -piece


Esd results

ESD - Results


Pwh experience esd

PWH experience - ESD

  • 2004 to 2006

    • 25 ESD performed for early gastric cancer

    • Mean duration: 84.3 mins

    • Hospital stay: 3 days

    • Mean size of the specimen: 8.5 cm2

    • Perforation - 0 (0%);

      Bleeding - 1 (4%);

      Margins involved - 1 (4%);

    • Mean follow-up: 12 months

    • No local recurrence


Conclusion

Early Gastric Cancer

Mucosal Tumour

Submucosal Tumour

Intestinal Type

Diffuse Type

Intestinal Type

> 30mm

No Ulceration

Ulceration

Sm 1,

< 30 mm

< 30 mm

> 30 mm

Endoscopic Resection

Endoscopic Resection

Laparoscopic Surgery

Conclusion


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