Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Mr Wild is an advanced pelvic malignancy and peritoneal tumor consultant at the Christie. He's also an honorary senior lecturer at Ed University uh and is um a member of the Faculty of Surgical Trainers of the War College of Surgeons of Edinburgh, for which he was the first to be awarded that membership. And he's going to talk to us about cytoreductive surgery and high pe. So, thank you very much. Thank you. Um Thanks to the gigs er club team for inviting me to speak today. Good afternoon everybody. I'm just talking to Professor Sear about the one type of surgery he didn't include in his uh list of uh of important areas of surgery to be in open surgeries, um is obviously peritoneal surgery as well. But um you, this, this talk will cover some of that. Ok. So, um yeah, I'm a member of the, er Christie core on the peritoneal Oncology um center, the, the team there where we um this talk is gonna focus on a highly specialized, er, commission service of the peritoneal service, but we're also the core of our work is also our Advanced Public Emergency Center beyond TME recurrent rectal cancers with the largest anal cancer MDT in the UK, maybe Europe, a European accredited center and we have a regional Sarcoma service as well. Um, in terms of 15 minutes, the title of Cyto Surgery and Hip is a challenge. But I thought I'd, I'd focus just on an overview and the indications and some overview outcomes of cy and surgery and hype from our center and then focus more on appendiceal tumors and er pseudomyxoma peritonei. Um And also thinking about more your practice and more relevant in terms of the management of incidental appendix um tumors that you may encounter. So in terms of the treatment of peritoneal malignancies, um it's multi modal, um clearly there's a, a strong role for systemic treatment. Um This talks focusing on, on those patients whose peritoneal service emergencies are amenable to surgical resection with side eruptive surgery with the additional additive of of HIPEC for additional benefit. There's also more experimental treatments like PEC, which is pressurized delivery of intraperitoneal chemotherapy or an early postoperative intraperitoneal chemotherapy and the adjuvant intra pre chemotherapy too. But again, the focus of this talk is on the sides surgery and hip. So what is side to surgery in high p for those of you who are with it? So the side of surgery is the most important element of, of this treatment. Um it's um that, that's where we aim to remove all of the visible disease. So that will involve removal of the uh abnormal, any abnormal viscera um including um multi visceral resections, er peritonectomy for um uh abnormal um peritoneum. And then we also resect uh all the structures that are at high risk of recurrence. So, the ovaries in females, um the greater and lesser omentum and we also routinely reset the falciform ligament. Um then once the sive surgery, part of the um the procedure is completed, we then may add, add in the hype. Um So that's heated intra chemotherapy hyperthermic where um it's heated to 40 °C, which increases the penetration of the chemotherapy agent into the, if there's any residual peritoneal disease. Um So, but the, the, the, the, the main, er, the only point I want you to take away is that it's not all about the hype ci get annoyed when people refer it as hype C surgery. It's the CT surgery, the high PC, er, er, may bring an added benefit in selected patients. And the two main agents we use are the Crisia Oxaliplatin and mitoMYcin. So, what's the current landscape in terms of the pathologies that we um treat with cy surgery and hypo? Well, in the, er, NHS um we, the NH NHS England um commissions um surge surgeon for a appendix tumors. So they're the low grade append of mucinous neoplasms that can lead to pseudomyxoma, peritonei, the appendix, adenocarcinomas and the goblet cell cancers of the appendix and then colorectal pa metastases in the UK and the NHS, we also give Cyto I for patients with, with peritoneal metastases from ovarian origin within, within trial, present with the OO two trial. And then mesothelioma, there is an indicator, again, highly selected patients with peritoneal mesothelioma. You're talking about a handful of patients each year and that's performed, it's not commissioned, but it is performed in the HS at Basingstoke through a National UK and Ireland MDT. But in the rest of the world there's a, there's some crazy stuff going on with, there's, there's a, there's some evidence supporting, um, very low volume peritoneal metas from gastric cancer. Um, giving, giving hype in, in, in that setting. But you, you may find that hype C is thrown into the, you know, into patients with small bowel adenocarcinomas with um metasis from er cio carcinoma sarcoma uterine malignancies. But there's, there's no evidence at all that support supporting that. That's not, that's not performed in, um, in, in the NHS. Um, so with, with regards to cyto surgery, our aim is what we call a complete cyto reduction. So that, that is acc zero when, when all the visible disease has been removed. Um ACC one is when the, there may be very low volume, er, peritoneal deposits, that can't be, um, recessive. For example, if they're involving a proximal small bowel or around the, er, around the porter, around, around the stomach. Um, if, if the disease is less than 0.25 centimeters in. Then, in combination with the hype C because high PC can penetrate peritoneal nodules that um a less than um than 40 millimeters. So um with, with the CC one, with the high pe then that what that's an adequate size reduction. But in patients where there's a larger volume disease left behind unresectable disease, CC two CC three, then we really call that a major debulk and I wouldn't give HIPEC in that situation. It, it is, it will give no benefit. So you can see from the survival curves that I say the aim is for a complete size reduction. They're the three main disease groups. There's those are the colorectal peritoneum asses, um Appendix, adenocarcinomas and then the um pseudomyxoma peritonei group. Um And you see that the blue curve is the, is those that where we achieve a complete size reduction versus the wreck curve where we were unable to remove all macroscopic disease. And you can see a massive survival benefit. And those with in colorectal peritoneal metastases that you know in previous years will be given six month survival with a complete C reduction with HIPEC there. The median overall survival at five years is he's over four years survival. So the median survival is over four years. Now we get to 48 months, median over survival. And then with the appendix adenocarcinoma, 70% survival at five years. And with the Pseudomyxoma group who get a complete size reduction, then over 90% of patients are alive at 10 years. Uh, but as you, I'm sure you are, you, you know, it is whether surgery is the right thing, you know, you may feel the disease is resectable but, um, you know, it comes with the compromise of, er, er, inflicted a major complex surgery on a patient that, with, with associated risks and that over the years that's given cyto of, um, surgery with the hype a, a bad name going back sort of 1015 years ago where um the you can see in the, in these, in these groups, in these centers, some of this is more historic data, but then you've got low volume centers, they may be early in the learning curve but with major complication rates of, you know, over 40% you know, mortality rate ranging from three, up to 1890 day mortality of up to 18%. Um There's more recent data with um in the um soy register of obviously 2000 patients, but you're still looking at AAA major complication rate of, of, of 30% and mortality of 4%. But look at our Christie data since our first case of the Christie in 2011/2000 patients. This data we have to collect as part of being a highly specialized service. It's all prospective clean data and our major complication rate is lower at 12.5% with a 90 day mortality rate. Of less than 1%. Why do we get these results? It's all about a specialist MDT. Um, you can see from our referral practice over over the last 15 years. While the number of referrals are going up, we're through experience of the MDT being able to, to, you know, select the patients that are really going to benefit from surgery. And hip and data from the basing group really demonstrated that the learning curve for an individual surgeon is looking at 140 cases of side surgery with hip to become competent. So, in terms of the, the, the, the rest of the talk, I'm gonna focus on saturative surgery in hip for the appendix tumors. So the appendix tumors are rare. Um I'm, you know, Y CCT requirements is about 80 app appendicectomy. Um You probably encounter you may do, you should be doing about twice that number probably when you get, get CCT. So you may encounter, you know, a handful of appendix tumors in, in through your training. Um But they're rare, less than 1% less than one per 100,000 population account for less than 1% of internal intestinal neoplasms. And um, and they found in roughly 1% of appendicectomy specimens. How, how may uh the app in theal appendiceal tumor present? Well, you may find it when you've done your uh uh lap of appendicectomy for appendicitis on the pathology report it. Um, it report the pathologist report is an incidental appendage tumor. They may be found incidentally on scanning for other reasons. You may find a uh what's uh often known as a, a mucocele of the appendix. Um And then you may encounter a, an obviously a enlarged abnormal um appendix um at the time of a um a laparoscopy or a a laparotomy for presumed um acute appendicitis, acute appendicitis, appendix tumor may present in acute appendicitis with an inflammatory mass that you aim to treat conservatively initially. Um And you may, you may encounter an appendix tumor incidentally. Um A colonoscopy with mucin appearing from the appendix orifice. So, in terms of uh the different um er types of appendix tumors, um the, the most, you know, a common type of appendix tumor is a benign attention. C So this is chronic appendicitis. This is a, you know, what's known as a mucocele um the, the main cancer. So this, this there's no uh malignancy. This is AAA treatment with a an appendicectomy to get, get the patho pathological confirmation is all that's required. All the types of uh of benign appendix tumors include small incidental polyps that you may find in your appendix specimen and they may, they will require one of colonoscopy because there's an association with appendix polyps and chronic adenomas. But other than that, they uh they don't need any further follow up or treatment. Um The most common type of appendix tumors that you encounter incidentally on your path report is a um, appendiceal ne endocrine tumor. And um that's another talk separately, but the cytoid surgeon hype is indicated for that group. Um We'll focus on the, the bottom two pathologies. That's the appendiceal mucinous neoplasms, low grade and high grade or lambs or lambs or hams. Um And they're the type of tumor that can perforate leading to disseminated tumor cells and mucin in the peritoneal cavity leading to pseudomyxoma peritonei. Then you've got the appendix, adenocarcinoma groups which are subdivided into mucinous chronic type signet ring cells and goblet cell cancers of the appendix and their, they, their dissemination in the peritoneum leads to er per peritoneal carcinomatosis where you get more harder firm nodules that are more invasive rather than rather than the surface disease that you get in pseudomyxoma peritonei. So what his PMP is again is a rare disease, as I say, results from the dissemination of these mucin containing tumor cells that have risen from a app penicin mucinous neoplasm. And if left untreated, it can result like this gentleman. The photograph where he progressive abdominal distension leads to build up of mucin that can then solidify, causing intestinal obstruction, malnutrition, cachexia, and ultimately death. Um And the laparotomy, the the typical features of, of PNP can be seen in this video. We've got this extensive mucinous ascites, big, big um ovarian mass in the surgeon's handler. Um GM ca and the mucinous er disease along the the peritoneal surfaces. So a learning point is that app er P MP starts in the appendix. Cos you see this er CT scan from 2011 where a patient has got a, you know, a mucous has got abnormal um AAA appendix there. Now, this could um it, it's not the same patient but um a laparoscopic image could be like that. Um where this is what we call a lam one. So this is an underlying low grade append. Mucin is neoplasm, but the the tumor and the mucin is within the appendix, there's no extra appendiceal disease. So a an a an appendicectomy with a clear resection margin is all that's required to treat this patient or it could be a lam too where um the disease is localized in the right leg fossa, but there's extra appendiceal disease. So effectively, this is very early P MP. Well, unfortunately, that patient didn't um didn't have any treatment for whatever reason. And then um represented with abdominal distension. Only two years later, you could see extensive adnexal masses, extensive m asci with um scalloping of uh of the liver. So in terms of just so videos of surgery in the context of PMP, you can see here, this is in the right of a quadrant. So this is where similar to that image you saw with scalloping of the liver. There's immobilizing the diaphragmatic peritoneum off the surface of the liver. So the mobile, the liver's full immobilized here, leave it, you can, you can see, then they start the, the stripping of the, um, the diaphragmatic peritoneum off. You see the, the diaphragmatic muscles there. Um, I sometimes wonder why as a colorectal surgeon from a few years ago, Steve Brown was teaching me how to do vascular procedures under local aesthetic. And I wonder how I really ended up operating behind the liver and the um, uh hepatic veins and IVC often. But, um so that's the sort of a taste of what the saturative surgery component is. And then in terms of then the, the HIPEC, um this is an open approach. Essentially, there's two, there's a pair of drains that go in inflow and outflow where the, the high agent is circulated, heated, there's temperature probes there maintaining at 42 degrees hyperthermia and it circulates for, for 90 minutes of mitoMYcin. We, we've moved to AAA closed approach for, for different reasons. Um Most centers use a closed approach now, um uh where we close the abdomen temporarily and then we go back in after the hype and do any anastomoses at that point. Um And we are so majority of the time of surgery is performed with an open approach, but um selected patients do benefit from a minimally invasive approach. Um Christie, we published the largest series of, of laparoscopic surgery with high um where it's demonstrated it's safe with um with short term stay in hospital against selected patients with, with low volume disease. Um, and er, we compared um, matched groups in 22 of our cohorts, laparoscopic versus open, you clear, clear the benefit with these patients don't go to the critical care unit. They stay in for a medium of, of, er, 5.5 days, um, with, um, very low morbidity and very low morbidity and zero mortality. Uh, we've done our 1st, 1st 2, robotic, er, sur hip um, in the last three months. Again, it selected patients in terms of overall, you know, manage how we manage the low grade appendices, neoplasms, appendix cancer as well. There's no randomized controlled trials. The management is really guided by retrospective data and expert consensus guidelines. But the, the main headline for you is that side surgery hyper, is indicated for all appendix tumors who who obviously have um synchronous peritoneal disease at the time of diagnosis. But those that may have an appendicectomy where there's no appendix tumors. Certainly those that are perforated or T three T fours who are at higher risk of developing peritoneal necessities. They, they need referring to the um the specialty centers. Um, the, the, the two special centers being the Christie and Manchester where I, where I work and uh uh and the um President MS Institute of Basingstoke. So an example of why patients should need to be referred. This, this, there's a patient of mine who's 36 year old male had a, a laparoscopic appendicectomy in 2011. Um, and er, his, his, uh uh this isn't the same patient but when I review the operation, no, it's um, yeah, it would be a similar finding to this where there was some mucin on the surface of the appendix. Um, the pathologist in a local hospital diagnosed a perforated, low grade dependency, mucous neoplasm. But look, the patient did about it at any follow up that, that path report wasn't acted on. Um And the patient wasn't referred to a one of the two specialists, but then presented nine years later with advanced PMP, it was inoperable and um I attempted a debor managed to get some oum out, but that was it. Um And the only treatment option for this patient was palliative chemotherapy. So, um you, you know, again, more relevant to your practice, you may find this at the time of a um a laparoscopy for presumed appendicitis where um you encounter a abnormal, clearly, there's a, there's an appendix tumor here. Um It could be any of those appendix tumors in my previous slide. Um The, the, the, the best way forward in this patient is that you, you need to perform a thorough laparoscopy. Um Try and identify, is there any evidence of any peritoneal disease? If there is um make an attempt at documenting, there is a peritoneal carcinoma, um index PCI where it gives a score out of 39 you may, you may be able to look that up, but don't worry too much about that. Just the extent and distribution, especially the, whether the small bowels are, um, affected, uh, whether there's disease, um, in all four quadrants, whether the stomach stomach's involved, they're, they're important things cause small nodules, tiny little nodules, less than five centimeters can often can't be seen on a CT scan. So, laparoscopic findings are important, um, take a biopsy of peritoneal lesion if present. Um, and, and um if it can be safely, don't perform an appendicectomy, er try and remove the me me all the emesi appendix on on block. Don't, don't just um skeletalis, the appendix like you may, you may do in a straightforward a appendicectomy and then like a endo gia a across the um across the base, taking a cuff of cecum. So you're doing AAA partial caecectomy or a cecal pole excision with appendicectomy. Um and then a uh avoid rupture, use a Burt bag and don't, don't be, don't be stingy on your extraction, incision, make a a generous incision at the like to, to the specimen in this situation. A right hemolectin is rarely required if your boss comes in and says, oh, I think these are right hemi, you know, say that it's not, you know, the, the a right hemi and even an appendix, adenocarcinoma actually doesn't have any survival benefit is an area of contention. But if this patient then goes on to have side and surgery, side surgery and I, then we can do the right hemy at that time. Um So, um, but sometimes the appendix tumor may be a maybe adhered to the, the ascending coon. See, I mean, you may need to do the right hemi just to get the specimen out. But, but right hem is rarely required. Um And of course, referred to, um to Basie Stowe called the Christie and then just my final couple of slides um in the other, the other way, an a, an a appendiceal tumor may present is uh with a inflammatory mass that you'll treat conservatively. Um But what is the risk of a, er, an underlying appendix neoplasm in, in patients with complicated appendicitis? There is evidence out there, there's a systematic review from North America in 2017, in about 1400 patients were in patients treated with complicated appendicitis. Actually, the rate of underlying neoplasm is in the region of 10 to almost 30%. So it's high and there was a randomized controlled trial from Finland, um where patients were randomized to two groups, one where the, the patient was in all patients were initially treated conservatively. Um then um group patients were randomized to either have an interval, appendicectomy or, or follow up, Mr, but the trial was terminated due to the high rate of neoplasms on interim analysis where in the overall, there was 20% risk of underlying appendix tumor with increasing to 30% in the over forties group. So patients who have initial conservative management of congregated appendicitis need follow up. They need ct to reassess if they're over 40 consider a colonoscopy, they need their appendix taken out. And if there's any concern on follow up imaging or the pathologist tells you that there's an underlying appendix tumor, they need to refer to a peritoneal tumor service MDT. And this is an example of why. So another patient who was referred to me, um 61 year old male had a appendix, abscess, managed conservatively had a percutane and his drain didn't have any follow up. And then presented three years later with a mass involving the bladder. His term sigmoid. He had, I performed cyto who did surgery with hype where I did right? Hemi sigmoid resection, partial cystectomy, a defunctioning iost that was subsequently reversed. The underlying pathology confirmed a metastatic appendiceal adenocarcinoma. He required adjuvant chemotherapy. He's done well since. But if, if he was referred back in 2018, he, he may have needed a, he would have had a, he would have had an interval, appendicectomy or he may, may then have needed a cyto surgeon HIPEC if he had a perforated tumor at that time in terms of risk reducing um er treatment, but that could have been done laparoscopic. He may have just needed a cecal pole excision and an omentectomy. Er, but obviously he, he, he, he needed more than that three years later. So um you can have a look at our website, there's some resources there and information on the diseases we treat the um the, the Christie. Um We have lots of fellowship opportunities, both research and clinical fellowships. Um We, we have our Royal College of Surgeons and ACP credited um fellowship post as well as the, the eo um creative Post. Um Our, our, our next vacancy though is is August 2025 2026. So um get in touch with the plan ahead. There's my email address. Is there any questions? Are we gonna save the questions uh if they could come find you? No problem. Thank you so much. Thank you very much.