University of Groningen
Innovation in surgical oncology Vrielink, Otis
DOI:
10.33612/diss.173351128
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2021
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Vrielink, O. (2021). Innovation in surgical oncology. University of Groningen.
https://doi.org/10.33612/diss.173351128
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Chapter 1
General introduction and
outline of thesis
GENERAL INTRODUCTION 1
Health care innovation is a dynamic and continuous process involving the introduction of a new technique or technology aimed to initiate a change in practice and ultimately improve the outcome of patients.1 The introduction of minimally invasive surgery is an example of an important health care innovation. In the 1980s the laparoscopic cholecystectomy was successfully introduced, followed by the introduction of numerous minimally invasive surgical procedures in ensuing years.2,3 Several studies have shown multiple benefits of minimally invasive surgery to patients, including reductions in complication rates, postoperative pain and hospital stay, coupled with faster recovery times and improved cosmetic outcomes.3-6
Following the successful introduction of minimally invasive surgery for mainly benign diseases, the question arose as to whether minimally invasive surgery could also be introduced as part of cancer treatment in the field of surgical oncology. Initially, concerns were raised regarding the oncological outcome of the procedures, including the achievement of a radical oncological resection, extent of staging, dissemination of tumour cells and long-term outcomes, and initial studies seemed to show a higher incidence of port site metastases.5,7,8 However, these concerns were largely alleviated by the publication of a large randomized controlled trial demonstrating similar oncologic outcomes for open and laparoscopic colectomies in colon cancer in 2004.9 Following these results, many other studies comparing open and laparoscopic procedures were published showing similar recurrence and overall survival rates, and the use of minimally invasive surgery in cancer patients has been widely accepted ever since.10-18
Despite the benefits of minimally invasive surgery to patients, the implementation of a new minimally invasive surgical procedure into clinical practice can be difficult. The lack of sufficient evidence (especially long-term outcome), correct equipment, training possibilities, mentoring and a potential long learning curve are all barriers for successful implementation.7 Furthermore, structured guidelines for the implementation of new minimally invasive surgical procedures are still lacking.
Minimally invasive adrenalectomy
One of the minimally invasive surgical techniques that was successfully introduced in the early 1990s, is the laparoscopic adrenalectomy, which rapidly replaced the traditional open adrenalectomy due to its various advantages including decreased postoperative pain, blood loss and complications.6,19,20 Especially for benign and small- to medium- sized adrenal tumours, the laparoscopic adrenalectomy became the standard surgical procedure.21 After continuous developments and improvement of the technique, the
Chapter 1
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procedure also proved to be safe and feasible for larger (>6 cm) tumours.22,23 Currently, several minimally invasive approaches have been described for performing laparoscopic adrenalectomy, whereof the laparoscopic transperitoneal adrenalectomy (LTA) is most frequently performed.22 Due to the posterior location of the adrenal glands and in an attempt to further improve patient outcome, Walz et al.24 introduced the posterior retroperitoneoscopic adrenalectomy (PRA). In this approach, a more direct route to the adrenal glands is used, avoiding opening of the peritoneum and mobilizing various fragile intra-abdominal organs such as the spleen, pancreas and liver, thereby possibly decreasing the number of complications.22,24 Another potential advantage of the PRA is the use in patients with a medical history of abdominal surgery and possible peritoneal adhesions. In the retroperitoneum, often there are no adhesions. Furthermore, this approach can be used in patients with an indication for a bilateral adrenalectomy without the need to reposition the patient intraoperatively. Several studies have shown superior outcomes of the PRA compared to the LTA on selected patients with small- to medium- sized adrenal tumours. However, the outcome of the PRA compared to the LTA has never been well assessed for all adrenal tumour sizes. Moreover, the unfamiliar anatomic environment, smaller working space and potential long learning curve are important barriers for the implementation of the PRA into clinical practice. For the LTA, 20-40 procedures are required to fulfil the surgical learning curve.25-27 However, the learning curve for the PRA, a potential barrier for implementation, has not been fully assessed.
Furthermore, literature concerning other aspects related to the transition from LTA to PRA and implementation of PRA is limited.
Minimally invasive treatment in melanoma patients
In melanoma patients with a clinically palpable lymph node in a regional basin, a therapeutic lymph node dissection is standard of care. However, the incidence of complications following a traditional open inguinal lymph node dissection can be as high as 70%.28-33 Chronic lymphedema can occur on the long-term, accompanied by complications such as swelling of extremities, mobility problems and an increased risk of recurring infections resulting in significant limitation of everyday activities.34,35 Several modifications to the conventional procedure including relocating skin incisions, thicker skin flaps, preservation of the saphenous vein and sartorius muscle transposition have not led to a substantial decrease in the number of complications.36-39 Following the results of the Multicenter Selective Lymphadenectomy Trial II, which showed no survival benefit for an immediate completion lymph node dissection in melanoma patients with a positive sentinel lymph node biopsy, the completion lymph node dissection has been abandoned.34 However, there remains an indication for a therapeutic lymph node dissection in melanoma patients with macroscopic disease. For these patients, the minimally invasive inguinal lymphadenectomy developed by Delman et al.40 in 2010,
might be an alternative approach. Some centres have already published their initial
1
experience with this procedure and reported promising results. However, these are just a few small series presenting their initial experience and there is still a lack of evidence on the short- and long-term outcomes of the videoscopic inguinal lymphadenectomy.
Further research is necessary to contribute to the existing limited literature.
Innovations in the field of surgical oncology are not only due to the development of surgical techniques. Novel systemic treatment options have been introduced, forcing surgeons to reconsider the necessity for surgical interventions and operative strategies.
The introduction of targeted therapies and immune checkpoint inhibitors led to a dramatic improvement of the long-term outcome of melanoma patients.41 With the introduction of these successful systemic treatment options, the role of surgical therapies in melanoma patients has changed, for example in the treatment of satellite and in-transit metastases. Satellite and in-transit metastases are locoregional metastases, thought to be caused by lymphatic dissemination.42,43 Due to ulceration, bleeding, infection and pain, satellite and in-transit metastases can have significant impact on a patients’ quality of life. Treatment of these metastases can be a challenge due to the great variation in clinical presentation and the unpredictable behaviour of the disease. Surgical resection is, if feasible, the preferred treatment.44-46 Alternative treatment options are topical and intralesional therapies, hyperthermic isolated limb perfusion, isolated limb infusion, radiotherapy and systemic therapy, although almost all of these treatment options are associated with considerable morbidity.47,48 CO2 laser evaporation is a simple and effective treatment performed under local or regional anaesthesia and can be repeated in case of recurrent disease.49-52 In patients with multiple comorbidities or in patients with satellite or in-transit metastases located at the head and neck region where surgery can be severely mutilating or even be impossible, CO2 laser evaporation might be an attractive alternative.
Furthermore, there might be an indication for CO2 laser evaporation in patients with stage IV disease were locoregional control cannot be achieved with systemic treatment. In addition, growing evidence suggests that concurrent systemic and locoregional therapy enhances efficacy and eventually improves long-term survival.53,54 However, the role of CO2 laser evaporation in the treatment of melanoma patients with satellite and in-transit metastases in an era of effective systemic therapy has never been well assessed.
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OUTLINE OF THESIS
This thesis aims to describe the implementation and outcome of minimally invasive treatment in oncologic patients. In Part 1 of this thesis, focus lays on the implementation process of minimally invasive surgical procedures itself. Chapter 2 aims to offer an overview of possible challenges encountered during the implementation process of new minimally invasive surgical procedures and to develop a structured guideline for successful implementation of these procedures.
In Part 2 of this thesis, the implementation and outcome of the minimally invasive adrenalectomy are described. In Chapter 3, the outcomes of the LTA and PRA are compared. The number of procedures required to fulfil the surgical learning curve of the PRA is assessed in Chapter 4. In Chapter 5 all aspects related to the transition from LTA to PRA and implementation of PRA are described.
In Part 3 of this thesis, minimally invasive treatment options in melanoma patients are described. The outcome of the videoscopic inguinal lymphadenectomy, a minimally invasive alternative to the conventional open technique, is investigated in Chapter 6. In Chapter 7, focus lays on the treatment of satellite or in-transit metastases in melanoma patients and the role of minimally invasive treatment with CO2 laser evaporation of satellite or in-transit metastases is investigated in an era of novel successful systemic treatment options.
REFERENCES 1
1. Siddaiah-Subramanya M, Tiang KW, Nyandowe M. A new era of minimally invasive surgery:
Progress and development of major technical innovations in general surgery over the last decade. Surg J (N Y). 2017;3(4):e163-e166.
2. Hatlie MJ. Climbing ‘the learning curve’. new technologies, emerging obligations. JAMA.
1993;270(11):1364-1365.
3. Choh MS, Madura JA,2nd. The role of minimally invasive treatments in surgical oncology. Surg Clin North Am. 2009;89(1):53-77, viii.
4. Bosker R, Groen H, Hoff C, Totte E, Ploeg R, Pierie JP. Effect of proctoring on implementation and results of elective laparoscopic colon surgery. Int J Colorectal Dis. 2011;26(7):941-947.
5. Hamed OH, Gusani NJ, Kimchi ET, Kavic SM. Minimally invasive surgery in gastrointestinal cancer: Benefits, challenges, and solutions for underutilization. JSLS. 2014;18(4):10.4293/
JSLS.2014.00134.
6. Hallfeldt K K J KK. Laparoscopic lateral adrenalectomy versus open posterior adrenalectomy for the treatment of benign adrenal tumors. Surg Endosc. 2003-2;17(2):264-7.
7. Birch DW, Misra M, Farrokhyar F. The feasibility of introducing advanced minimally invasive surgery into surgical practice. Can J Surg. 2007;50(4):256-260.
8. Vukasin P, Ortega AE, Greene FL, et al. Wound recurrence following laparoscopic colon cancer resection. results of the american society of colon and rectal surgeons laparoscopic registry.
Dis Colon Rectum. 1996;39(10 Suppl):S20-3.
9. Clinical Outcomes of Surgical Therapy Study Group, Nelson H, Sargent DJ, et al. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med. 2004;350(20):2050- 2059.
10. Veldkamp R, Gholghesaei M, Bouvy ND, Kazemier G, Bonjer HJ. Laparoscopic resection of colonic cancer. Scand J Surg. 2003;92(1):97-103.
11. Zanghi A, Cavallaro A, Piccolo G, et al. Dissemination metastasis after laparoscopic colorectal surgery versus conventional open surgery for colorectal cancer: A metanalysis. Eur Rev Med Pharmacol Sci. 2013;17(9):1174-1184.
12. Fleshman J, Sargent DJ, Green E, et al. Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST study group trial. Ann Surg. 2007;246(4):655-62;
discussion 662-4.
13. Ben-David K, Rossidis G, Zlotecki RA, et al. Minimally invasive esophagectomy is safe and effective following neoadjuvant chemoradiation therapy. Ann Surg Oncol. 2011;18(12):3324-3329.
14. Mungo B, Lidor AO, Stem M, Molena D. Early experience and lessons learned in a new minimally invasive esophagectomy program. Surg Endosc. 2016;30(4):1692-1698.
15. Rossidis G, Kissane N, Hochwald SN, Zingarelli W, Sarosi G, Ben-David K. Overcoming challenges in implementing a minimally invasive esophagectomy program at a veterans administration medical center. Am J Surg. 2011;202(4):395-399.
16. Tegels JJ, Silvius CE, Spauwen FE, Hulsewe KW, Hoofwijk AG, Stoot JH. Introduction of laparoscopic gastrectomy for gastric cancer in a western tertiary referral centre: A prospective cost analysis during the learning curve. World J Gastrointest Oncol. 2017;9(5):228-234.
17. Komatsu S, Scatton O, Goumard C, et al. Development process and technical aspects of laparoscopic hepatectomy: Learning curve based on 15 years of experience. J Am Coll Surg.
2017;224(5):841-850.
Chapter 1
18
18. van der Poel MJ, Besselink MG, Cipriani F, et al. Outcome and learning curve in 159 consecutive patients undergoing total laparoscopic hemihepatectomy. JAMA Surg. 2016;151(10):923-928.
19. Thompson G B GB. Laparoscopic versus open posterior adrenalectomy: A case-control study of 100 patients. Surgery. 1997-12;122(6):1132-6.
20. Brunt L M LM. Laparoscopic adrenalectomy compared to open adrenalectomy for benign adrenal neoplasms. J Am Coll Surg. 1996-7;183(1):1-10.
21. Smith C D CD. Laparoscopic adrenalectomy: New gold standard. World J Surg. 1999-4;23(4):389- 96.
22. Lombardi Celestino Pio CP. Endoscopic adrenalectomy: Is there an optimal operative approach?
results of a single-center case-control study. Surgery. 2008-12;144(6):1008-14.
23. Wang B, Ma X, Li H, et al. Anatomic retroperitoneoscopic adrenalectomy for selected adrenal tumors >5 cm: Our technique and experience. Urology. 2011;78(2):348-352.
24. Walz M K MK. [Dorsal retroperitoneoscopic adrenalectomy--a new surgical technique].
Zentralblatt für Chirurgie. 1995;120(1):53-8.
25. Goitein D, Mintz Y, Gross D, Reissman P. Laparoscopic adrenalectomy: Ascending the learning curve. Surg Endosc. 2004;18(5):771-773.
26. Sommerey S, Foroghi Y, Chiapponi C, et al. Laparoscopic adrenalectomy--10-year experience at a teaching hospital. Langenbecks Arch Surg. 2015;400(3):341-347.
27. Stefanidis D, Fanelli RD, Price R, Richardson W, SAGES Guidelines Committee. SAGES guidelines for the introduction of new technology and techniques. Surg Endosc. 2014;28(8):2257-2271.
28. Guggenheim MM, Hug U, Jung FJ, et al. Morbidity and recurrence after completion lymph node dissection following sentinel lymph node biopsy in cutaneous malignant melanoma. Ann Surg.
2008;247(4):687-693.
29. Baas PC, Schraffordt Koops H, Hoekstra HJ, van Bruggen JJ, van der Weele LT, Oldhoff J. Groin dissection in the treatment of lower-extremity melanoma. short-term and long-term morbidity.
Arch Surg. 1992;127(3):281-286.
30. Poos HP, Kruijff S, Bastiaannet E, van Ginkel RJ, Hoekstra HJ. Therapeutic groin dissection for melanoma: Risk factors for short term morbidity. Eur J Surg Oncol. 2009;35(8):877-883.
31. de Vries M, Vonkeman WG, van Ginkel RJ, Hoekstra HJ. Morbidity after inguinal sentinel lymph node biopsy and completion lymph node dissection in patients with cutaneous melanoma. Eur J Surg Oncol. 2006;32(7):785-789.
32. de Vries M, Hoekstra HJ, Hoekstra-Weebers JE. Quality of life after axillary or groin sentinel lymph node biopsy, with or without completion lymph node dissection, in patients with cutaneous melanoma. Ann Surg Oncol. 2009;16(10):2840-2847.
33. Faut M, Heidema RM, Hoekstra HJ, et al. Morbidity after inguinal lymph node dissections: It is time for a change. Ann Surg Oncol. 2017;24(2):330-339.
34. Faries MB, Thompson JF, Cochran AJ, et al. Completion dissection or observation for sentinel- node metastasis in melanoma. N Engl J Med. 2017;376(23):2211-2222.
35. Chang SK, Lee KY. Therapeutic advances: Single incision laparoscopic hepatopancreatobiliary surgery. World J Gastroenterol. 2014;20(39):14329-14337.
36. Sarnaik AA, Puleo CA, Zager JS, Sondak VK. Limiting the morbidity of inguinal lymphadenectomy for metastatic melanoma. Cancer Control. 2009;16(3):240-247.
37. Spillane AJ, Tucker M, Pasquali S. A pilot study reporting outcomes for melanoma patients of a minimal access ilio-inguinal dissection technique based on two incisions. Ann Surg Oncol.
2011;18(4):970-976.
1
38. Bartlett EK, Meise C, Bansal N, et al. Sartorius transposition during inguinal lymphadenectomy for melanoma. J Surg Res. 2013;184(1):209-215.
39. Dardarian TS, Gray HJ, Morgan MA, Rubin SC, Randall TC. Saphenous vein sparing during inguinal lymphadenectomy to reduce morbidity in patients with vulvar carcinoma. Gynecol Oncol. 2006;101(1):140-142.
40. Delman KA, Kooby DA, Ogan K, Hsiao W, Master V. Feasibility of a novel approach to inguinal lymphadenectomy: Minimally invasive groin dissection for melanoma. Ann Surg Oncol.
2010;17(3):731-737.
41. Puzanov I, Amaravadi RK, McArthur GA, et al. Long-term outcome in BRAF(V600E) melanoma patients treated with vemurafenib: Patterns of disease progression and clinical management of limited progression. Eur J Cancer. 2015;51(11):1435-1443.
42. Read RL, Haydu L, Saw RP, et al. In-transit melanoma metastases: Incidence, prognosis, and the role of lymphadenectomy. Ann Surg Oncol. 2015;22(2):475-481
43. Stucky CC, Gray RJ, Dueck AC, et al. Risk factors associated with local and in-transit recurrence of cutaneous melanoma. Am J Surg. 2010;200(6):770-4; discussion 774-5.
44. Testori A, Ribero S, Bataille V. Diagnosis and treatment of in-transit melanoma metastases. Eur J Surg Oncol. 2016.
45. Hoekstra HJ. The european approach to in-transit melanoma lesions. Int J Hyperthermia.
2008;24(3):227-237.
46. Bagge AS, Ben-Shabat I, Belgrano V, Olofsson Bagge R. Health-related quality of life for patients who have in-transit melanoma metastases treated with isolated limb perfusion. Ann Surg Oncol.
2016;23(6):2062-2069.
47. Dossett LA, Ben-Shabat I, Olofsson Bagge R, Zager JS. Clinical response and regional toxicity following isolated limb infusion compared with isolated limb perfusion for in-transit melanoma.
Ann Surg Oncol. 2016;23(7):2330-2335.
48. Hoekstra HJ, Veerman K, van Ginkel RJ. Isolated limb perfusion for in-transit melanoma metastases: Melphalan or TNF-melphalan perfusion? J Surg Oncol. 2014;109(4):338-347.
49. Waters RA, Clement RM, Thomas JM. Carbon dioxide laser ablation of cutaneous metastases from malignant melanoma. Br J Surg. 1991;78(4):493-494.
50. Hill S, Thomas JM. Treatment of cutaneous metastases from malignant melanoma using the carbon-dioxide laser. Eur J Surg Oncol. 1993;19(2):173-177.
51. Lingam MK, McKay AJ. Carbon dioxide laser ablation as an alternative treatment for cutaneous metastases from malignant melanoma. Br J Surg. 1995;82(10):1346-1348.
52. van Jarwaarde JA, Wessels R, Nieweg OE, Wouters MW, van der Hage JA. CO2 laser treatment for regional cutaneous malignant melanoma metastases. Dermatol Surg. 2015;41(1):78-82.
53. Heppt MV, Eigentler TK, Kahler KC, et al. Immune checkpoint blockade with concurrent electrochemotherapy in advanced melanoma: A retrospective multicenter analysis. Cancer Immunol Immunother. 2016;65(8):951-959.
54. Theurich S, Rothschild SI, Hoffmann M, et al. Local tumor treatment in combination with systemic ipilimumab immunotherapy prolongs overall survival in patients with advanced malignant melanoma. Cancer Immunol Res. 2016;4(9):744-754.
