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Radiology-guided percutaneous or endoscopic drainage: When a “mini-invasive” gesture can treat the complications of a “maxi-invasive” surgery
Journal of Visceral Surgery (2013) 150S, S1—S2
Available online at
www.sciencedirect.com
EDITORIAL
Radiology-guided percutaneous or endoscopic drainage: When a ‘‘mini-invasive’’ gesture can treat the complications of a ‘‘maxi-invasive’’ surgery
If you are planning to design a study to evaluate mortality after various types of surgery (for example, to decide whether extended lymphadenectomy after gastrectomy is dangerous or not), you should plan to randomize the study by surgical center. Yes, but why? Because mortality is not only surgeon-dependent but also center-dependent, i.e., dependent on the entire team who assists in the peri-operative and postoperative management of complicated cases — the anesthesiologists, intensivists, and especially the endoscopists and interventional radiologists at a particular center. Think back to the prospective study published in Lancet in 1995 evaluating D1 vs. D2 lymphadenectomy for gastric cancer that recommended against extended lymphadenectomy. Even though Dr Sasako, the Japanese surgeon, had trained the Dutch surgeons in that study and had actually participated in the surgical interventions, mortality was 10% for D2 vs. 4% for D1 procedures [1]. It was subsequently shown that specific centers were responsible for the excess mortality since they always re-operated for complications while at other centers (even in 1990), the radiologist was able to percutaneously drain pancreatic fistulas. This study is emblematic of the « center effect » on morbidity and mortality, since 10 years later in 2004, the same authors, analyzing their long-term follow-up results, recommended against systematic spleno-pancreatectomy and could not recommend whether a D1 or a D2 lymphadenectomy should be performed [2]. And finally, 5 years later in 2010, the same authors were finally able to demonstrate a survival benefit for D2 lymphadenectomy since time had finally overcome the effects of the initial excess mortality in the D2 group and to demonstrate excess late mortality in the D1 group due to tumor recurrence [3]. This is why in the last year, it has become clear that our management of gastric cancers has evolved [4]. Generally speaking, early results are dictated by the postoperative course, which also influences long-term survival: thus, it is very difficult to reach formal conclusions concerning the value of postoperative chemotherapy after excision of peritoneal metastases, since, outside of a randomized study based on intention to treat, most patients with a complicated postoperative course also do not receive chemotherapy [5]. Traditionally, postoperative management has been the responsibility of the surgeons and, generation after generation, we have learned the importance of prompt detection and treatment of complications. An old surgical adage states that « Two holes in the body are better than the body in a hole ». But a more modern modification of the adage would hold that « minimally invasive drainage is better than a surgical re-intervention ».
1878-7886/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.jviscsurg.2013.03.004
S2 In effect, there has been a radical change in the management of certain complications in recent years. The management of intra-thoracic leak from an esophago-gastric anastomosis is emblematic of this evolution. This complication used to carry such a grave prognosis that some surgeons chose to avoid performing intra-thoracic anastomosis altogether in favor of a cervical anastomosis. Even though cervical anastomoses were even more susceptible to leakage, they rarely resulted in patient death. But the introduction of endoscopic insertion of coated stents has changed the face of this complication; while anastomotic leak is still a grave complication, it now rarely results in mortality unless there is necrosis of the transplanted distal stomach. Similarly for subphrenic abscess, percutaneous radiology-guided drainage allows avoidance of re-operation for most supphrenic abscesses, where surgical re-intervention, particularly for late-developing abscesses, may be very destructive requiring takedown of the anastomosis and drainage of the collection; for that matter, drainage can also be performed by the endoscopist. And yet, much progress is still needed to define the indications for re-intervention and to develop more complex treatments that combine placement of an endoprosthesis with radiology-guided drainage. We must take care to avoid inflicting cumulative damage. But still we must not expect percutaneous drainage to solve all our problems, any more than we would hope to close a colovesical fistula in a setting of radiation enteritis by the application of an endoscopic clip the size of a wolf-trap. We must therefore refine our inter-disciplinary collaborations, our technologies, and our percutaneous interventions, thereby confirming the value of these prompt focused attacks and identifying the factors that allow us to maximize their chances of success. Further studies are needed and they will necessarily be multi-disciplinary. In this special issue of the Journal of Visceral Surgery, we have asked recognized specialists to synthesize the current state of the art for technical approaches that transform a complex post-surgical complication into a controlled
Editorial situation that offers hope of cure for our patients. You will read how surgeons — in collaboration with endoscopists and radiologists — can use mini-invasive approaches to help in the management of complications from maxi-invasive surgery.
Disclosure of interest The author declares that he has no conflicts of interest concerning this article.
References [1] Bonenkamp JJ, Songun I, Hermans J, et al. Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 1995;345:745—8. [2] Hartgrink HH, van de Velde CJ, Putter H, et al. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial. J Clin Oncol 2004;22:2069—77. [3] Songun I, Putter H, Kranenbarg EM, et al. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol 2010;11: 439—49. [4] Pocard M. Gastric cancer: so much has changed for surgeons! J Visc Surg 2011;148:1—2. [5] Passot G, Vaudoyer D, Cotte E, et al. Progression following neoadjuvant systemic chemotherapy may not be a contraindication to a curative approach for colorectal carcinomatosis. Ann Surg 2012;256:125—9.
M. Pocard ∗ Service de Chirurgie digestive et carcinologique, Hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France ∗ Tel.:
+1 49 95 82 58; fax: +1 42 11 52 13. E-mail address: [email protected]
Available online at
www.sciencedirect.com
EDITORIAL
Radiology-guided percutaneous or endoscopic drainage: When a ‘‘mini-invasive’’ gesture can treat the complications of a ‘‘maxi-invasive’’ surgery
If you are planning to design a study to evaluate mortality after various types of surgery (for example, to decide whether extended lymphadenectomy after gastrectomy is dangerous or not), you should plan to randomize the study by surgical center. Yes, but why? Because mortality is not only surgeon-dependent but also center-dependent, i.e., dependent on the entire team who assists in the peri-operative and postoperative management of complicated cases — the anesthesiologists, intensivists, and especially the endoscopists and interventional radiologists at a particular center. Think back to the prospective study published in Lancet in 1995 evaluating D1 vs. D2 lymphadenectomy for gastric cancer that recommended against extended lymphadenectomy. Even though Dr Sasako, the Japanese surgeon, had trained the Dutch surgeons in that study and had actually participated in the surgical interventions, mortality was 10% for D2 vs. 4% for D1 procedures [1]. It was subsequently shown that specific centers were responsible for the excess mortality since they always re-operated for complications while at other centers (even in 1990), the radiologist was able to percutaneously drain pancreatic fistulas. This study is emblematic of the « center effect » on morbidity and mortality, since 10 years later in 2004, the same authors, analyzing their long-term follow-up results, recommended against systematic spleno-pancreatectomy and could not recommend whether a D1 or a D2 lymphadenectomy should be performed [2]. And finally, 5 years later in 2010, the same authors were finally able to demonstrate a survival benefit for D2 lymphadenectomy since time had finally overcome the effects of the initial excess mortality in the D2 group and to demonstrate excess late mortality in the D1 group due to tumor recurrence [3]. This is why in the last year, it has become clear that our management of gastric cancers has evolved [4]. Generally speaking, early results are dictated by the postoperative course, which also influences long-term survival: thus, it is very difficult to reach formal conclusions concerning the value of postoperative chemotherapy after excision of peritoneal metastases, since, outside of a randomized study based on intention to treat, most patients with a complicated postoperative course also do not receive chemotherapy [5]. Traditionally, postoperative management has been the responsibility of the surgeons and, generation after generation, we have learned the importance of prompt detection and treatment of complications. An old surgical adage states that « Two holes in the body are better than the body in a hole ». But a more modern modification of the adage would hold that « minimally invasive drainage is better than a surgical re-intervention ».
1878-7886/$ — see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.jviscsurg.2013.03.004
S2 In effect, there has been a radical change in the management of certain complications in recent years. The management of intra-thoracic leak from an esophago-gastric anastomosis is emblematic of this evolution. This complication used to carry such a grave prognosis that some surgeons chose to avoid performing intra-thoracic anastomosis altogether in favor of a cervical anastomosis. Even though cervical anastomoses were even more susceptible to leakage, they rarely resulted in patient death. But the introduction of endoscopic insertion of coated stents has changed the face of this complication; while anastomotic leak is still a grave complication, it now rarely results in mortality unless there is necrosis of the transplanted distal stomach. Similarly for subphrenic abscess, percutaneous radiology-guided drainage allows avoidance of re-operation for most supphrenic abscesses, where surgical re-intervention, particularly for late-developing abscesses, may be very destructive requiring takedown of the anastomosis and drainage of the collection; for that matter, drainage can also be performed by the endoscopist. And yet, much progress is still needed to define the indications for re-intervention and to develop more complex treatments that combine placement of an endoprosthesis with radiology-guided drainage. We must take care to avoid inflicting cumulative damage. But still we must not expect percutaneous drainage to solve all our problems, any more than we would hope to close a colovesical fistula in a setting of radiation enteritis by the application of an endoscopic clip the size of a wolf-trap. We must therefore refine our inter-disciplinary collaborations, our technologies, and our percutaneous interventions, thereby confirming the value of these prompt focused attacks and identifying the factors that allow us to maximize their chances of success. Further studies are needed and they will necessarily be multi-disciplinary. In this special issue of the Journal of Visceral Surgery, we have asked recognized specialists to synthesize the current state of the art for technical approaches that transform a complex post-surgical complication into a controlled
Editorial situation that offers hope of cure for our patients. You will read how surgeons — in collaboration with endoscopists and radiologists — can use mini-invasive approaches to help in the management of complications from maxi-invasive surgery.
Disclosure of interest The author declares that he has no conflicts of interest concerning this article.
References [1] Bonenkamp JJ, Songun I, Hermans J, et al. Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 1995;345:745—8. [2] Hartgrink HH, van de Velde CJ, Putter H, et al. Extended lymph node dissection for gastric cancer: who may benefit? Final results of the randomized Dutch gastric cancer group trial. J Clin Oncol 2004;22:2069—77. [3] Songun I, Putter H, Kranenbarg EM, et al. Surgical treatment of gastric cancer: 15-year follow-up results of the randomised nationwide Dutch D1D2 trial. Lancet Oncol 2010;11: 439—49. [4] Pocard M. Gastric cancer: so much has changed for surgeons! J Visc Surg 2011;148:1—2. [5] Passot G, Vaudoyer D, Cotte E, et al. Progression following neoadjuvant systemic chemotherapy may not be a contraindication to a curative approach for colorectal carcinomatosis. Ann Surg 2012;256:125—9.
M. Pocard ∗ Service de Chirurgie digestive et carcinologique, Hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France ∗ Tel.:
+1 49 95 82 58; fax: +1 42 11 52 13. E-mail address: [email protected]