SESSION 6. Progrès en chirurgie et endoscopie des cancers digestifs. Modérateur : Dr. François QUENET

SESSION 6 Progrès en chirurgie et endoscopie des cancers digestifs Modérateur : Dr. François QUENET

La chirurgie robotique Pr. Philippe ROUANET

La Chirurgie Robotique en cancérologie digestive Philippe Rouanet

Chirurgie Robotique Contrôle «Intuitif» des instruments Contrôle de la Camera Vision 3D HD Instrumentation «EndoWrist» Ergonomie pour le chirurgien

Depuis 1990.. Robotic Surgery 5999 Robotic oncologic surgery 446 Robotic digestive surgery 206

Robot assistance in liver surgery: a real advantage over a fully laparoscopic approach? Results of a comparative bi-institutional analysis. Troisi R & al. Int J Med Robot 2013 LAPR (Laparoscopic liver resection) vs ROBR (Robot assisted Liver Surgery) LAPR ROBR N 223 40 Hépatectomie majeure 17% 0 Chirurgie segmentaire 34% 55% Lésions réséquées 1,57 1,97 Conversion 7,6% 20% Saignement 174 ml 330 ml

Major early complications following open, laparoscopic and robotic gastrectomy Kim KM & al. BJS 2012 Open Laparoscopic Robotic p n 4542 861 436 LNH 40* 37 40* <0,001 T1/4 (%) 48 / 25 77 / 5 77 / 6 <0,001 R0 (%) 99,3 99,8 99,3 0,2 Hosp Stay 10,2 7,8* 7,5* <0,001 Temps Op 158 176 226 <0,001 Morbidity 10,7 9,4 10,1 0,494 Leak (%) 1,1 2,1 2,3 0,017 Abscess 3,3 2,0 1,4 0,013 Reoperation 1 1 1,6 0,483 Mortality 0,5 0,3 0,5 1

Cancer Control. 2013

Outcomes After Minimally Invasive Esophagectomy Review of Over 1000 Patients Luketich & al. Ann Surg 2012 MIE Neck McKeown MIE Chest Ivor-Lewis

The rise in minimally invasive esophagectomy publications in United States National Library of Medicine service, PubMed. Luketich & al. Ann Surg 2012

Notre démarche 2006 : Corum Montpellier Farid Gharagozloo, M.D. Washington Institute of Thoracic and Cardiovascular Surgery George Washington University 37 LS Robot avec anastomose intra thoracique 2012: University Medical Center Utrecht Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial) van der Sluis et al. Trials 2012, 13:230 http://www.trialsjournal.com/content/13/1/230

Technical aspects and early results of robotic esophagectomy with chest anastomosis. Cerfolio RJ & al. J Thorac Cardiovasc Surg 2013 22 patients R0 100% LNH 18 BL 40 ml Anastomoses IT - 6 mécaniques morbidité 80% - 16 manuelles morbidité 0%

Robot-assisted laparoscopic surgery of the colon and rectum. Antoniou sa & al. Surg Endosc 2012 39 nonrandomized studies : 1012 patients 13 ileocaecal resections 220 Right colectomies Right C Left C AR APR Total C 190 Left Colectomies 440 Anterior resection 149 APR 11 Total colectomies 60% RC

Randomized clinical trial of robot-assisted versus standard laparoscopic right colectomy. Park JS & al. Br J Surg. 2012 NCT01042743 70 patients : 35/35 Similar Hosp stay - Complications - post op pain blood loss - resection margin - LNH Conversion (0) Duration of surgery R > L (195/130 ; p:<0.0001) Hospital cost R > L (12.235$ / 10.320 $ ; p:0.013) CCl: Robotic-assisted laparoscopic right colectomy was feasible but provided no benefit to justify the greater cost

Robotic versus laparoscopic anterior resection of Sigmoid colon cancer: comparative study of long-term oncologic outcomes. Lim DR & al. Surg Endosc 2012 180 sigmoid colon K: 34 R 146 L Operative technique: Anterior resection Operative time 252 / 217 p: 0.016 Post op complications 10.3% / 5.9% p:0.28 OS3 92% / 93% p:0.723 CONCLUSION: In this study, R-AR showed safety and feasibility in terms of perioperative clinical and long-term oncologic outcomes. However, the advanced technologies of R-AR did not translate into better long-term oncologic outcomes compared with L-AR

Robotic Rectal Cancer

Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: a prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. P Quirke & al. Lancet 2009

RTME et Chirurgie conservatrice auteur type n durée Perte sang Spinoglio 2008 Choi 2009 Leong 07-10 Pigazzi 2010 Zimmern 2010 Koh 2010 Baek 2010 Conv % Morbidité % DMS Nbre N Full 19 338-4% 14% 7.7 22 - ½ Full* 1 dock Full ISR Full hybrid 50 305-0 18% 9.2 20 2% 29 325 50 0 31% 9 16 10% 112 297 283 4.9% 41% 8.3 14 0.7% hybrid 47 350 240 2% 22% 6.5 15 - full 19 316-0 23.8% 6.4 17.8 5.3% Hybrid 52 270 200 9.4% 31% 5 14.5 0 *: laparoscopic rectal section & anastomosis R1 %

KR: Robot vs Laparoscopie R L type Rob/ Lap durée Perte sang Conv % Morbidité % DMS Nbre N R1 % Bianchi 08-09 Full R 75% 25 25 237 240-0 1 16 24 6.5 6 18 17 0 4 Park 2010 Hyb 41 82 232 168 4.8% 7.3% 0 0 29 23 9.9 9.4 17 14 4.9 3.4 Baek 2011 Hyb 41 41 296 315 200 300 7 22 22 26.8 6.5 6.6 13 16 2.4 4.9 Patel 08-09 Hyb 30 30 237 181* 100 130 0 0 13 10 2.9 3.9* 17 20 0 0 Kwak 07-09 Full R 59 59 270 228* - 0 3.4 32 27-20 21 1.6 0

Meta-analysis of robotic and laparoscopic surgery for treatment of rectal cancer. Lin S & al. World J Gastroenterol. 2011 8 études : 268 RTME / 393 LTME DS: Taux de conversion NS: Temps op / Saignement / Reprise transit / Hospit Complications / Nbre GGl / DM / CRM

The impact of robotic surgery for mid and low rectal cancer: a case-matched analysis of a 3-arm comparison - open, laparoscopic, and robotic surgery. Kang J & al. Ann Surg 2013 OS LS RS p n 165 165 165 Op time 252 277 309 <0.001 CS 89% 95% NS 99% 0.01 Conv - 1.8% 0.6% 0.62 NOTES - 4% 22% <0.01 ileostomy 32% 27% 22% 0.40 EBL 275 140 133 <0.001 CRM+ 10.3% NS 6.7% 0.03 4.2% 0.09 LN harvested 17 16 15 0.07 Fist 3.4% 11% 7.3% 0.04 Hosp lenght 16 13.5 10.8 <0.001 NS

Cancer du rectum Notre pratique: 2010-2012 90 80 70 60 50 40 30 OS LS TEM Robotic 20 10 0 2010 2011 2012

Robotic and laparoscopic total mesorectal excision for conservative rectal surgery: a consecutive monocentric series of 120 patients. RTME n=60 LTME n= 60 p Age median (range) 62 (34 82) 60 (35 85) 0.375 BMI median 25.8 (17.5 41.6) 23.8 (17.3 38.6) 0.522 Gender M F 40 (66.7%) 20 (33.3%) 42 (70.0%) 18 (30.0%) 0.695 ASA score 1 2 3 4 20 (33.3%) 30 (50.0%) 9 (15.0%) 1 (1.7%) 18 (30.0%) 32 (53.3%) 10 (16.7%) 0 (0.0%) 0.748 Tumor location Upper 11 Mid 6-10 Lower 5 8 (13.3%) 26 (43.3%) 26 (43.3%) 13 (21.7%) 21 (35.0%) 26 (43.3%) 0.423 Pre op RCT 47 (78.3%) 39 (65.0%) 0.105

Robotic and laparoscopic total mesorectal excision for conservative rectal surgery: a consecutive monocentric series of 120 patients. RTME LTME p n=60 n= 60 Type of operation ULCRA PCAA DCAA LCAA 33(55.0%) 11 (18.3%) 8 (13.3%) 8 (13.3%) 30 (50.0%) 19 (31.7%) 11 (18.3%) 0 (0.0%) 0.013 ISR Complete Partial Mucosectomie None 1 (1.7%) 25 (41.7%) 1 (1.7) 33 (55.0%) 0 (0.0%) 29 (48,4%) 0 (0.0%) 31 (51.7%) 0.520 TAEP 1 (1.7%) 10 (16.7%) 0.004 Median operation time (range) 274 min (125 488) 228 min (127-431) 0.003 Diverting ileostomy 44 (73.3%) 35 (58.3%) 0.083 Median EBL (range) 200 ml (0 1100) 100 ml (0 1700) 0.174 Conversion 2 (3.2 %) 3 (4.8%) 0.661

Robotic and laparoscopic total mesorectal excision for conservative rectal surgery: a consecutive monocentric series of 120 patients. RTME (n=60) LTME (n=60) p Median DRM mm (range) 15.0 (2.0 73.0) 10.0 (0.0 80.0) 0.664 Positive CRM 1 3 (6.4%) 4 (9.3%) 0.605 Median HLN (range) 15 (1 71) 19 (3 68) 0.013 Median POS (range) 12 (6 27) 11 (6 60) 0.246 Severe Morbidity Fistula Colic necroses Occlusion Anastomotic abscess Other 17 (28.3%) 3 (5%) 4 (6%) 7 (11%) 1 (1.6%) 2 (3.2%) 12 (20.0%) 4 (6%) 0 (0%) 6 (10%) 2 (3.2%) 0 (0%) 0.286 Early postop surgery 2 (3.3%) 4 (6.7%) 0.402 Mortality 3 (5.0 %) 4 (6.8 %) 0.208 (Log-rank test) Median follow-up 8 [6.3 9.2] 19.9 [17.9 22.3] Months (95% IC)

Robotic and laparoscopic total mesorectal excision for conservative rectal surgery: a consecutive monocentric series of 120 patients. Minutes 450 400 Learning Curve 350 300 First 30 patients 250 200 150 1 4 6 8 10 12 15 17 19 21 23 25 27 29 31 500 400 60 patients Minutes 300 200 100 0 0 5 10 15 20 25 30 35 40 45 50 55 60

Randomized Trial on Robotic Assisted Resection for Rectal Cancer: ROLARR Robotic versus Laparoscopic Resection for Rectal cancer International, Multicentre, Prospective, Randomised controlled trial Total or hybrid procedure 400 patients / end date? Primary outcome: rate of conversion

Robot et chirurgie du KR? Dans la «course» entre Laparoscopie et Robotique, il n y a pas de vainqueur pour les cas «faciles» Aujourd hui, le Robot apporte un plus pour les cas difficiles: Homme gros à bassin étroit porteur de tumeur moyenne et basse, surtout antérieure. Mais demain,.?

Impact of Robotic Surgery on Sexual and Urinary Functions After Fully Robotic Nerve-Sparing Total Mesorectal Excision for Rectal Cancer. Luca F & al. Ann Surg 2013 4/08 4/10 ; 74 RTME ; Prospective evaluation Urinary functions Sexual functions Results Urinary: Incontinence, at 1year, unchanged for both sexes Sexual function and General sexual satisfaction decreased 1 month after the surgery comparable at 1 year to those measured before surgery CONCLUSIONS: RTME allows for preservation of urinary and sexual functions. This is probably due to the superior movements of the wristed instruments that facilitate fine dissection, coupled with a stable and magnified view that helps in recognizing the inferior hypogastric plexus.

Robotic cancer surgery M. H. Sodergren and A. Darzi Institute of Global Health Innovation, Imperial College London. BJS 2013 Robotics is unlikely to displace the human element in the art of surgery, but, with adequate funding, resource allocation and market competition, robotic assistance will likely complement human surgical skills and significantly improve cancer surgery outcomes in the future.

Cœlio-chirurgie des cancers œsogastriques Pr. Christophe MARIETTE

Service de chirurgie digestive CHRU - Lille

Open resections involve significant risk of morbidity and death Purported advantages of MIO Reduced blood loss Reduced morbidity Reduced respiratory complications Less pain Shorter hospital stay Earlier functionnal recovery

Minimally invasive oesophagectomy techniques for oesophageal cancer WITH Thoracoscopic Approach Thoracoscopic AND Laparoscopic oesophagectomy with Cervical Anastomosis Thoracoscopic AND Laparoscopic oesophagectomy with Intra- Thoracic Anastomosis Thoracic oesophageal mobilisation with Open Laparotomy and Cervical Anastomosis MIO MIO Hybrid WITHOUT Thoracoscopic Approach Laparoscopic Gastric Mobilisation with Open Thoracotomy and Intra-Thoracic Anastomosis Total Laparoscopic Transhiatal Oesophagectomy Hybrid MIO

Mostly single institution case series Few studies report on comparisons with historical/concurrent/matched controls Various surgical techniques used Differences between Eastern and Western countries Differences according to the study period (Learning Curve)

Prospective Database 2005 2009 Open surgery 64 Hybrid MIO 44 (Thoracoscopy / Laparotomy) Totally MIO 30 Survival curve comparing open (mean survival 37.93 months ) and MIO (hybrid plus total MIO) (mean survival 41.85 months) (p=0.501, n=137) World Journal of Surgery (2011) 35:790 797

Oncological results... Decreased LOS Postoperative complications reduced significantly World Journal of Surgery (2011) 35:790 797

University Hospital Vienna Case controlled pair matched study 31 consecutive patients undergoing MIO (laparoscopy and thoracoscopy) 31 consecutive open oesophagectomies

Retrospective Study Evaluation of outcomes in 1011 consecutive elective MIO Comparison of modified McKeown MIO to modified Ivor Lewis MIO Study period from 1996-2011 with progression to Ivor Lewis MIO and intrathoracic stapled anastomosis in 2005

Less respiratory morbidity Review 31 Articles All of Level III evidence Single centre cohort and comparative studies Shorter Hospital Stay Lower 30 Day Mortality

TOTALLY MIO vs. Open Oesophagectomy

HYBRID MIO vs. Open Oesophagectomy

Comparison open vs. MIO Multi-centre RCT MIO 56 patients Open Resection 59pts Oesophageal Tumours including Siewert type I MIO Performed By - Thoracoscopy / Laparoscopy and cervical incision Open Resection - Right thoracotomy and intrathoracic anastomosis Primary Endpoints - Respiratory complications in first 2 weeks Secondary Endpoints - Operative / Postoperative / Oncological Data

Pulmonary infection defined clinical manifestation with confirmation on CXR or CT scan and positive culture

Positive results appear to validate MIO by thoracoscopy and laparoscopy... However... Many non-studies variables strongly affect the primary endpoint of TIME trial (malnutrition, smoking habits, pulmonary co-morbidity, performance status)... and small sample? non-equivalent repartition of these variables One lung ventilation only applicable to one group A longitudinal assessment of QoL No multivariate analysis to test independent effect of MIO on post-op course Pneumonia rate in open surgery group is high (34%) may be related to a high vocal cord paralysis rate (14%) in open group (2% in MIO group) Mariette C Lancet 2012

372 Ivor-Lewis procedures for cancer 140 consecutive laparoscopy HMIO Randomly matched for: 140 open resections Open group ASA score, age, gender, denutrition, tumoural location and stage, histological subtype, neoadjuvant CRT, epidural analgesia

Briez N, Mariette C et al BJS in press

HMIO Independent protective factor against major pulmonary complications

HMIO -> independent protective factor against major pulmonary complications Laparoscopic gastric mobilisation in OC could be a promising approach Easy, little learning curve Reproducible Do not compromise carcinologic resection significantly pulmonary complications = main source of morbidity after oesophagectomy Briez et al BJS 2012

Comparison open vs. MIO Multi-centre RCT Oesophageal Tumours Including Siewert I Surgical Procedure - Thoracotomy plus Laparoscopy Primary Endpoints - Major 30 day morbidity Secondary Endpoints - 30 day morbidity, mortality, pulmonary morbidity - DFS, OS, QOL, Medico-economic

Formidable technical challenge Increased complexity brings a higher potential for error Is it sufficiently safe to be offered selectively to patients with early disease? Concerns regarding gastric conduit vascularity and oncological resection Is the middle ground a hybrid procedure? Mariette C Recent Results Cancer Res 2012

Morbidité significative donc licite d évaluer place MIG Nombreuses publications qualité hétérogène Méta-analyse ayant inclus essais randomisés et études comparatives de qualité Vinuela F Ann Surg 2012

Vinuela F Ann Surg 2012

Vinuela F Ann Surg 2012

Vinuela F Ann Surg 2012

Vinuela F Ann Surg 2012

Vinuela F Ann Surg 2012

Vinuela F Ann Surg 2012

Laparoscopie pour cancer gastrique distal tx complications globales et médicales, durée d hospi, pertes sanguines Pas sur mortalité et complications majeures Moins de gg analysés Peu de données de survie Questions en suspend Sécurité oncologique? Learning curve En Occident? Faisabilité pour gastrectomie totale?

Faisabilité technique démontrée Centres entraînés Bénéfices à ce jour non majeurs Peu de données oncologiques à long terme Reproductibilité??? Résultats d essais randomisés à venir Certainement l avenir pour certains patients

Endoscopie interventionnelle Dr. Marc GIOVANNINI

CFOD, 5-7 SEPTEMBRE 2013

DEVELOPPEMENTS RECENTS DISSECTION SOUS-MUQUEUSE RADIOFREQUENCE OESOPHAGIENNE ECHO-ENDOSCOPIE THERAPEUTIQUE DRAINAGE BILIAIRE GUIDE PAR EE ABLATION TUMORALE GUIDEE PAR EE

?

90-95% SM + 80-85% IE

HD ENDOSCOPY

ESD Mark the lesion Local Injection Marginal Incision SM Dissection Dyeing Sprayer Marking Local Injection Injection Needle Marginal Incision Electro Surgical Knife Submucosal Dissection Hemostasis Marginal Incision, SM Dissection Post ESD for prevention of complication Hemostasis Device

ESD> EMR pour les cancers superficiels de l estomac (Gotoda, 2007) ESD>EMR pour les cancers superficiels de l oesophage ( Ishihara et al : GIE,2008) Taux de résection curative: 97% vs 71% Pas de différence en terme de complication EMR= lesion <15 mm, ESD=lesion>15 mm ESD>EMR pour les cancers superficiels du colon et rectum (Saito et al, Surg Endosc 2010) 145 CRT traités par ESD vs 228 traités par EMR Taux de récidive de 2% pour l ESD vs 14% pour l EMR (p<0.001) Taux de Perforation =6.2% pour ESD vs 1% pour EMR

ENDOSCOPIE TRADITIONNELLE A ECHOUE OU EST IMPOSSIBLE COLLECTIONS PANCREATIQUES ABCES PELVIENS DRAINAGE BILIAIRE DRAINAGE DU WIRSUNG ANASTOMOSE CHOLECYSTO- DUODENALE CHIRURGIE

10 F 8 F 6 F 19 G

QUELLE ALTERNATIVE SI ECHEC DE LA CPRE OU EN CAS DE MODIFICATION ANATOMIQUE? GASTRECTOMIE DPC RESECTION DE LA VBP ET ANASTOMOSE HEPATICO-JEJUNALE CHIRURGIE OU DRAINAGE PERCUTANE RADIOLOGIQUE

COMPLICATION RATE : 31% 4 DEATHS ( 1 Bile leakage, 1 perforation, 2 bleedings) Extra-Hepatic Intra-Hepatic p value Success 75/89 (84.3%) 132/146 (90.4%) 0.15 Complications 29/89 (32.6%) 52/146 (35.6%) 0.64 Perforation 1/89 (1.1%) 11/146 (7.5%) 0.03 Bile leakage 13/89 (14.6%) 14/146 (9.6%) 0.24 Cholangitis 4/89 (4.5%) 7/146 (4.8%) 0.92 Bleeding 8/89 (9.0%) 18/146 (12.3%) 0.42 Pain 1/89 (1.1%) 4/146 (2.7%) 0.41 Stent Obstruction 2/89 (2.3%) 0/146 (0%) 0.07

AETIOLOGIES 14 10 K PANCREAS CCK META HILAIRE 8 NO FAILURE OF STENT INSERTION 5 4 3 2 1 0 1 0 5 4

YOUNG FEMALE OF 38 YEARS OLD WITH A LIVER MET OF OVARIAN CANCER STILL ALIVE AFTER 4 YEARS WITH 2 HEPATICO- GASTROSTOMIE AND 3 OTHER METALLIC STENTS IN THE RIGHT LOBE THIS KIND OF DRAINAGE WAS IMPOSSIBLE 10 YEAR AGO!!!!!

ENDOSCOPIE THERAPEUTIQUE OFFRE AUJOURD HUI UNE ALTERNATIVE A LA CHIRURGIE MAIS NECESSITE UNE SELECTION TRES PRECISE DES PATIENTS T SUPERFICIELLE DU TUBE DIGESTIF m3 ŒSOPHAGE-ESTOMAC Sm1 COLON-RECTUM ECHOENDOSCOPIE INTERVENTIONNELLE PERMET DES DRAINAGES BILIAIRES COMPLEXES