Live surgerySeptember 7, 20235:29:3114 speakersAvailable in: EN / IT
Live Surgery #2 2023 – ICG-Guided Laparoscopic Subtotal Gastrectomy in a Complex Case
Live ICG-guided laparoscopic subtotal gastrectomy in a patient with gastric adenocarcinoma and metastatic melanoma, with lectures on staging, neoadjuvant therapy, FOTONOZ and RIDGETRIAL.
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Clinical case
Adenocarcinoma del corpo gastrico (versante grande curva) in paziente con melanoma metastatico BRAF mutato, tumore di Brenner ovarico e pregresso carcinoma papillare tiroideo
Patient framing as discussed at case introduction
SexF
Age70
StagecT2 N1-N2 M0 (gastrico); melanoma stadio IV con metastasi cerebellare radiotrattata
DiagnosisAdenocarcinoma del corpo gastrico (versante grande curva) in paziente con melanoma metastatico BRAF mutato, tumore di Brenner ovarico e pregresso carcinoma papillare tiroideo
Clinical historyTiroidectomia totale 20+ anni prima per ca. papillare con metastasi costale trattata con radioiodio; nel 2022 tre melanomi (spalla, dorso, inguine) con sentinella inguinale positiva; metastasi cerebellare singola trattata con Cyberknife 24 Gy; ovariectomia per tumore di Brenner. Performance status 100%.
NotesCaso complesso multidisciplinare: discussione approfondita su upfront surgery vs neoadiuvante; decisione di procedere a chirurgia gastrica upfront vista la prognosi condizionata dal melanoma e l'assenza di chemioterapia efficace su entrambe le neoplasie. Marcatura endoscopica ICG pre-operatoria.
Overview
Second episode of the Permanent School on ICG Surgery 2023, dedicated to a complex case of gastric adenocarcinoma in a 70-year-old patient with concomitant metastatic melanoma (BRAF-mutated, with a radiotherapy-treated cerebellar metastasis), previous thyroid carcinoma and ovarian Brenner tumor. The day opens with Umberto Bracale's lecture presenting the AGENAS-SICE data published in Updates in Surgery on gastric surgery in Italy 2015-2020: 11% 90-day mortality in real-world practice, low uptake of laparoscopy (26% in 2020) and a dramatic fragmentation of volumes (only ~40 Italian centers with >21 cases/year). A broad debate follows on centralization, multidisciplinarity and the role of neoadjuvant therapy.\n\nThe clinical case is staged with dedicated CT by Barbara Frittoli (GIRCG protocol with gaseous distension and 3D virtual gastroscopy) as T2 N1-N2 M0, with two equivocal perigastric nodes/lesions in subcardial and subpyloric locations. Oncologist Giulia Grizi highlights the importance of molecular profiling already on biopsy (MSI, PD-L1), presenting the DANTE trial (FLOT+atezolizumab) and Pietrantonio's INFINITY trial (neoadjuvant immunotherapy with pathological complete response rates up to 60% and the prospect of non-operative management). Preoperative endoscopic tattooing is performed by Biagio Elmo with diluted ICG delivered in glycerol into the submucosa.\n\nThe laparoscopic live surgery includes subtotal gastrectomy with ICG-guided D2 lymphadenectomy, discussed with Simone Giacopuzzi (rolling pancreas, KLASS-02), Lorenzo Cinelli, Monica Gualtierotti (AIGreenGo study) and Federico Marchesi, who presents the FOTONOZ study on lymphadenectomy quality assessed via fluorescence of the operative field. Reconstructive techniques (uncut Roux-en-Y, esophagojejunostomy reinforced with V-Loc), trocar placement, duodenal transection and 3D vision are discussed. Edoardo Rosso illustrates the Virtual Surgical Masterclass and the French centralization model. The day closes with Jacopo Weindelmayer's presentation of the multicenter RIDGETRIAL on drainage after gastrectomy, showing that drainage significantly reduces postoperative reinterventions and percutaneous drainages.
Topics
Real-world data on gastric surgery in Italy (AGENAS study)
Centralization and volumes in Italian centers
30- and 90-day mortality and the role of multidisciplinarity
Neoadjuvant therapy and immunotherapy (FLOT, DANTE, INFINITY)
Microsatellite instability and molecular profiling on biopsy
CT staging with gaseous distension and 3D virtual gastroscopy
Preoperative endoscopic ICG tattooing
ICG-guided D2 lymphadenectomy and quality of lymphadenectomy
