Plenary lectures

Vol. 8, No.7S 2004

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PLENARY LECTURES PL-ISDS Lecture Surgical Education into the Millenium Ara Darzi Department of Surgical Oncology & Technology, Imperial College London, UK The aim of a surgical residency program is to produce competent professionals, displaying the skills required to meet the needs of society. However, many surgeons are concerned that this will not be possible with the limitations placed upon work hours, together with increased public and political pressures to achieve defined levels of competence prior to independent practice. Solutions to these issues require formalisation of residency programs, whereby training occurs within a pre-defined curriculum to teach the skills required. Each step of the curriculum begins in the skills laboratory, utilising tools such as synthetic models, animal tissue and virtual reality simulation. Associated with this is the objective assessment of technical competence using methods such as dexterity-based, eye-tracking and video analysis systems. The development of a simulated operating theatre environment, analogous to those used by the military for training in conflict situations, enables assessment of non-technical skills such as decision making and inter-personal communication. This stepwise, competence-based curriculum also enables trainees to leave the program at defined points and allows them to pursue a generalist surgical role as pure service providers. It refocuses the emphasis upon what is learnt as opposed to how many hours are spent in the hospital environment, and enables us to achieve our goal of educating the surgeons of the future.

PL-SSAT Lecture Novel Treatment of Pancreatic Cancer for the 21st Century Keith D. Lillemoe Department of Surgery, Indiana University School of Medicine, USA Pancreatic cancer accounts for over 28,000 deaths annually in the United States making it the 5th leading cause of cancer death in that country. Although progress has been in the last 20 years in the operative management of this disease, significant progress will be necessary to further improve survival. Improvement in survival for pancreatic cancer must focus upon early detection. The recognition of the familial pattern of pancreatic cancer may be a key to the identification for some patients. Detection of molecular abnormalities in either serum, stool, or pancreatic juice may allow the early diagnosis. A marked improvement in surgical results has occurred over the last two decades lowering the morbidity and mortality in many centers following pancreatic resection to less than 2%. Further improvements will need to focus on decreasing the incidence and severity of surgical complications. There seems to be no evidence that wider, more radical resection offers any advantage in the cure rates for pancreatic cancer based on prospective randomized trials. Perhaps the biggest area for potential improvement in the treatment of pancreatic cancer is in nonsurgical oncologic therapy. Trials of adjuvant and neoadjuvant therapy using aggressive chemo-radiation protocols have suggested improvement, but the

optimal regimen has yet to be defined. Immunotherapy or other novel therapies may also offer the potential for benefit based on preliminary results. Although significant improvement has been observed in the surgical treatment of pancreatic cancer, there is clearly room for the development of novel treatments for the treatment of this disease.

PL-19th WC-ISDS Lecture Extension of Surgical Indications in the Treatment of Liver Metastases from Colorectal Cancer Hiroshi Shimada Department of Gastroenterogical Surgery, Yokohama City University Graduate School of Medicine, Japan Aim: Whether late results justify extended resection using several major developments for multiple bilor liver metastasis from colorectal cancer(CLM). Patients and Methods: Out of 364 patients with CLM, 213 patients who underwent hepatic resection were classified into H1(unilateral, n=117), H2(bilateral, <4 nodules, n=46), and H3(bilateral, >5 nodules, n=50). Results: The resection rate of overall, H1, H2, and H3 were 58.5%, 86.7%, 69.7%, and 30.7%. Overall cumulative 5-year survival was 46.7% showing similar survival among H1, H2, and H3. However, disease-free survival at 5 years of H1 patients(31.1%) was significantly higher than that of H2(14.6%) and H3(9.2%). Adjuvant chemotherapy of circadian chronotherapy using FU+FOL+CDDP via HAI provided low toxicity and high response rate(72.7%). In H3 patients, hepatectomy involved straightforward hepatectomy in 20, portal embolization(PE) prior to hepatectomy in 10, two step hepatectomy in 5 and two step hepatectomy with PE in 15, accompanying zero of mortality and less than 20% of morbidity. The latter two approaches were employed in synchronous cases. The overall response rate of neoadjuvant chemotherapy(NAC) was 41.7%. 5-year survival was statistically similar between patients who did and those who did not receive NAC(38% vs 35%). Patients who responded to NAC showed significantly better survival benefit than non responder. Conclusion: Extended hepatectomy including PE and multi-step hepatectomy combined with perioperative chemotherapy for H3 patients can provide same survival benefit as in hepatectomy for H1 patients, especially for patients who responded to NAC. It is an urgent issue to determine what regimen provides best response for each patient resulting in establishment of down staging strategies.

PL-ISS Lecture Multimodal Treatment in Upper GI-Tract Tumors - Consequences for Surgery Ruediger Siewert Dept. of Surgery, Klinikum rechts der Isar, Technische Universität Münich, Germany Multimodal treatment in the western hemisphere means, neoadjuvant treatment. Reasons in favour of this preoperative treatment: · This type of treatment has been proven as being effective in a prospective controlled trial (MRC-Trial)

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Abstract of 19th WC-ISDS

· There are plenty of theoretical arguments in favour of the preoperative treatment (intact blood supply of the tumor,untouched good condition of the patient, immediate beginning of the treatment. · The effect of postoperative adjuvant or additive treatment is so far unproven. What are the consequences of this development for surgery? 1. The patient must be seen just after the diagnosis by a tumor board including surgeons as well as oncologists, radio-therapists, gastroenterologists etc. for adequate decision-making. In our own experience of 820 patients with esophageal cancer (out of 4200 GItumor patients) the indication for preoperative neoadjuvant treatment was seen in 51% of all patients. Only 25% of the patients were sent to primary surgery. In gastric cancer, 20%of our patients were sent to neoadjuvant treatment protocols (EORTC-trial). 2. Under neoadjuvant treatment early response evaluation with the PET-technique is possible. 3. We have to distinguish between responders and non-responders regarding the indication for surgery. Responders will benefit from surgery, non-responders have a higher risk, a higher mortality rate and bad survival. 4. We have learned from our own experience that the neoadjuvant treatment has a so called central petal effect, i.e. the effectiveness of the treatment is much better in the tumor center than in the periphery and in the lymph nodes. Conclusion: The extent of the resection is orientated on the initial tumor manifestation before neoadjuvant treatment. 5. Neoadjuvant chemo-therapy has no consequences for surgical techniques. There is no increased risk or mortality in this group of patients. On the other hand, following a combined radiochemotherapy, a long lasting sometimes severe immunosuppression is possible. A so called “safety surgery” is recommended.

PL-ISDE Lecture Quality in the Surgical Treatment of Cancer of the Esophagus and Gastroesophageal Junction Toni Lerut, Ph. Nafteux, J. Moons, W. Coosemans, G. Decker, P. De Leyn, D. Van Raemdonck Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium Surgical treatment of cancer of the esophagus and gastroesophageal junction (GEJ) remains a complex and challenging task. In recent literature a number of authors have advocated to concentrate these patients in high volume centres in order to decrease postoperative mortality. However it appears that hospital mortality is a poor tool to measure the quality. More likely specialisation as well as appropriate hospital environment supporting a dedicated multidisciplinary team are key elements in improving both the short term and long term results. The dedicated specialist surgeon has a key role in improving these results through surgical quality. The most important goal in the surgical treatment of these cancers is to perform a complete resection (R0). Data from literature seem to indicate that R0 resection combined with extensive lymphadenectomy are resulting in improved disease free survival and possibly in improved 5 year survival, often reported to exceed 35% after such interventions.Obviously these results suggest that there is a great need for standardisation of surgery. Such a standardisation and the resulting improved quality most likely will result in a significant improvement of outcome of esophagectomy for cancer of the esophagus and GEJ. These improvements in outcome should become the gold standard to which all other therapeutic

Journal of Gastrointestinal Surgery

regimens should be compared and under no circumstances poor surgical results by themselves should be a justification for multimodality regimen.