E08 Masterclass with Sav Brar On Gastric Cancer

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast, with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  00:50

Today we have the opportunity of getting an absolute masterclass on gastric cancer from Dr. Sav Brar. Dr. Brar is a surgical oncologist at Mount Sinai Hospital in Toronto. We had an in-depth discussion on the workup of gastric cancer and Dr. Brar gave us some technical pearls on doing gastrectomy. He also talked about the unique relationship between the musician, Braun, and surgeon, Bill Roth. We hope you enjoy it. If you have more ideas on topics we should discuss, please email us at podcast.cjs@gmail.com. If you enjoy the podcast, please leave us a review on iTunes. You can also find the podcast on Spotify, Google Play, Stitcher, or wherever you get your podcasts. Now, on to the show. I wanted to start off with a scenario. So, 50-year-old Caucasian male presents with early satiety, 10 to 15 pound weight loss and melena stool. He’s had an EGD which shows a friable mass in the cardia of the stomach. This is biopsied and confirms invasive gastric adenocarcinoma. Can you walk us through how you would approach a patient like this? Both from particular things on history, physical, as well as other investigations that you might do.

Sav Brar  02:18

Yeah, I think one of the important things when discussing stomach cancer is getting an accurate sense of the endoscopy report. There were studies done, I think in Toronto, but I can’t remember exactly where, where they analyzed endoscopy reports at the diagnosis of stomach cancer. And they found that the endoscopy reports were often missing important information. Some of that important information was critical for planning of treatment, including surgery, but also classification. I think one of the critical things is, when you’re talking about gastric cancers, figuring out whether or not you would treat this as, truly, a gastric cancer or whether or not it’s a gastroesophageal cancer, that you would treat more like esophageal cancer. So the relationship between the extent of the tumor and the GE junction, and paying important attention to where the center of the tumor is. Which is in the new AJCC 8 staging the way that we classify esophageal versus gastric tumors. So, one thing you’d want to do is talk to the gastroenterologist and look at the report and see whether or not you had accurate information about the location of the tumor. Then after that, you want to see how many biopsies they took and if those biopsies came back with a diagnosis met adenocarcinoma. If there was any concerns and you’re someone who treated stomach cancer with the previous endoscopy, I don’t think there should be any hesitation to repeat endoscopy yourself to get a sense of the location of the tumor, and whether or not there’s any other issues that need to be done. Once you’ve done that, you obviously will have to see the patient and do a history of physical exam. Important things to note are, as you discussed before, satiety, is this patient obstructed or symptomatic in a way that require some interventions in the near term? Are they bleeding? You mentioned the melena stools? Are they anemic? Then obviously, an important issue is family history and trying to ascertain if this is a solitary stomach cancer, which the majority are. Or is this one of the cases, less than 10%, that is part of a familial syndrome. Once you have the information from the endoscopy and you’ve seen the patient, done your history and physical examination, really, the key is trying to figure out, is this an early stomach cancer, or an advanced stomach cancer, or a metastatic stomach cancer? That really is the next big step in trying to figure out what to do for this unfortunate 50-year-old gentleman.

Ameer Farooq  04:59

How often are you having to repeat the EGD yourself?

Sav Brar  05:05

I think it’s an important question. I think, as a surgeon, I really feel like if you’re going to do stomach cancer surgery, that you should repeat the EGD yourself. So, I, almost always, will repeat the EGD myself. And not because I take them lightly. But stomach cancer is exceedingly rare. It’s the 14th most common cancer in Canada. So very rare. There are only about 3000 cases in the country in a given year, many of which don’t go to surgery. So, the chance that the endoscopist, surgeon or gastroenterologist has a expertise in stomach cancer is unlikely. So, they may not know some of the pertinent information. And so, it’s important for you to repeat for yourself to get a sense of its location for operative planning. Whether or not you think it’s going to be obstructing in the near future. And also, if you need to do repeat biopsies to get an accurate diagnosis. I generally tend to repeat them often. I’ll do the repeat endoscopy at the same time as a diagnostic laparoscopy, if that’s part of the plan, and go from there.

Ameer Farooq  06:22

Where does EUS fit into your practice when working these up?

Sav Brar  06:26

Yeah. I think one thing that we have to recognize is that EUS is not easy to get in many Canadian centers. And so, that is a system issue that we have to be cognizant of. Though, I do think the rule is to confirm whether or not a cancer is early or advanced stomach cancer. So, let me tell you a scenario. So, most stomach cancers are advanced or metastatic. They have metastatic disease in some place outside of the stomach. Either non-regional lymphadenopathy, peritoneal carcinomatosis, liver metastases, or a combination thereof. And EUS, in those cases, is probably not useful. Unless it’s to maybe confirm with a biopsy that the presence of metastatic disease, but that’s unusual. I think where EUS fits in is, if you think someone may not actually have advanced gastric cancer. So that they may have a node negative gastric cancer or a T1 gastric cancer, where they may be amenable to going into surgery first without any other therapy. I think, if you think a patient might fit into that category, then EUS is helpful to confirm that. So cross-sectional imaging is limited in accuracy in both T and N categories. EUS is additive, but it’s also not perfect. So if you’re sure that a gastric cancer is node positive, or that you’re sure that their T3 or T4, based on cross-sectional imaging, then getting EUS doesn’t actually add very much. If you’re wondering whether or not a gastric cancer is actually T1, and that they may actually go straight to surgery without any perioperative therapy, then the EUS could be a confirmatory test for that. That’s my general approach. I think if you have access to EUS, you can do it for any patient that’s not metastatic, to confirm or help confirm the T category. But we do know from randomized control studies, where EUS and CT were done in all patients pre-op, that the accuracy of the T and N categories is not perfect.

Ameer Farooq  08:37

Are you getting your gastroenterologist to biopsy suspicious looking nodes on EUS?

Sav Brar  08:44

Not regularly, no. I think if the T stage is early. So, if it’s a T1a, the likelihood of lymph node metastasis is quite low. And the accuracy of EUS-guided biopsy of lymph nodes is limited. So, it’s sort of a decision that you make with the radiologist and the gastroenterologist about the utility of that test. For me, the main crux of the test is trying to figure out what the T.

Ameer Farooq  09:19

Gotcha. Are you ever using PET-CT as part of your initial workup?

Sav Brar  09:25

It’s very good question. So there really isn’t any evidence for the benefit of PET-CT for stomach cancer. For T junction or esophageal cancer, it’s a bit of a different story. But for stomach cancer, for true stomach cancer, many stomach cancers aren’t positive on PET, even the primary, so it’s not felt to be useful for staging. So, my general staging would be a CT scan, chest, abdomen, pelvis and the chest part of that is somewhat controversial. And we use a gastric protocol here at Mount Sinai, where we give the patient some effervescent capsules that expand the stomach so that the resolution of the stomach wall is a little bit better. And we can see the lesion and its involvement of the serosa a little bit better. Depending on what you think the T and N categories are, we would either add EUS to confirm an early gastric cancer or a diagnostic laparoscopy to look for occult metastatic disease in advanced stomach cancers.

Ameer Farooq  10:37

Well, that’s a good segue, because I was going to ask you about diagnostic laparoscopy. Tell me a little bit about who is getting diagnostic laparoscopy for you.

Sav Brar  10:45

Yeah, so I think it’s easy, in stomach cancer, to get lost in some of the details because there’s, sometimes, some lack of clarity of who should get what test and people have different views. I think as of AJCC/UICC 7, peritoneal cytology was considered metastatic disease. So, I think any patient with an advanced gastric cancer should get a diagnostic laparoscopy with cytology, to rule out occult peritoneal carcinomatosis, which doesn’t show up on CT, as well as occult cytology-positives disease. The rate is between 25% and 30% of patients who had advanced cancer, who have a normal CT, will have occult metastatic disease, so a significant proportion of patients. I think if you look at the rates of cytology-positive and peritoneal carcinomatosis-positive disease, it’s mostly the T3 and T4 patients. Though it’s hard, I think, for most of us to distinguish between T2 and T3, even with CT scan and EUS. So, I like to keep things simple. So, for me, if someone has advanced stomach cancer, that means T2 or node positive disease, I treat them all the same. They get a CT, chest, abdomen, pelvis. And if they have T2 or N positive disease, they all get a diagnostic laparoscopy, Because I’m not sure that a T2 or T3 is accurately distinguishable on preoperative staging. It also lets things stay simple for me. I’m a simple person. I try to keep things in buckets. So, if you’re an early stomach cancer, you get a CT, chest, abdomen, pelvis. If it’s about to be T1 and 0, then you’d get an EUS to confirm, and you wouldn’t get a diagnostic laparoscopy.

Ameer Farooq  12:33

That makes a lot of sense. So, you’re treating the washings so that if they come back as malignant, you’re treating this as metastatic disease and you send them off for…

Sav Brar  12:42

Yean. I think there’s been a slow transition to this. I think there’s still some people out there who don’t do cytology-positive disease, or sometimes you’ll hear people say that they’ll only do diagnostic washings when they don’t want to operate, say a patient who has multiple comorbidities or advanced age. But I think the staging criteria is clear. It’s now in its second iteration, that cytology-positive disease is metastatic disease. You can do with that information what you want to do. But to me, it’s akin to not doing a CT test for a rectal cancer. You may still operate if they have small volume metastatic disease. That answer, I’m not 100% sure of, though I have my biases. But to not completely stage a patient, I think is, in 2020, suboptimal.

Ameer Farooq  13:35

Yeah. It’s interesting that in our local institution, the upper GI surgeons actually typically aren’t sending washings. And they point to some studies, I believe, out of England, where some people they were able to convert from positive washings to negative.

Sav Brar  13:57

Yeah, so what I’d say to people is, if you have that information and you decide to operate, one thing that would be responsible is to let the patient know that they have a very high chance of relapse. If you operate on cytology-positive disease. The evidence is clear that patients with cytology-positive disease do slightly better than peritoneal carcinomatosis-positive disease, but much, much, much worse than patients who have cytology-negative and peritoneal carcinomatosis-negative disease. If you look at the available data, it’s quite clear that this is metastatic disease with early relapse. So, if you have a patient and you’re going to offer them a total gastrectomy, which is a highly morbid surgery, with significant adverse effects on quality of life, and not insignificant, perioperative mortality, that you should be doing it with the full information available. And to me, not doing the cytology-positive, so if you do a diagnostic laparoscopy and you’re looking for carcinomatosis, about 2/3 of patients with occult metastatic disease will have carcinomatosis-positive disease. Another 1/3 will have cytology-positive disease. So, it’s a significant portion of these people that we’re actively doing diagnostic laparoscopy for, that actually have occult cytology-positive disease, which is metastatic disease. If you look at the survival curves, they do a little bit better than carcinomatosis-positive disease, but not very much better. So yeah, it’s not as bad as carcinomatosis, probably, but it’s still metastatic disease. And if you want to treat them with perioperative chemotherapy and they convert, then that’s something that I think we should be doing in studies because we don’t know what the answer for that is. But if someone who has cytology-positive disease and continues to have cytology-positive disease after chemotherapy, we know that their outcomes are very poor. So, you might be subjecting them to a surgery that has a high morbidity and mortality. Somewhere around 4% to 6% perioperative mortality after a gastrectomy for cancer. And you may actually be making them so unwell that they can’t get the life-extending chemotherapy that they might need.

Ameer Farooq  16:10

That makes a lot of sense. I think with the advent of FLOT things are certainly changing for gastric cancer. Can you talk to us a little bit about who you’re sending for new Agilent therapy, and particularly how you think FLOT is going to change things? And where that’s gonna fit into your practice?

Sav Brar  16:32

So when I was a resident, and Dr. Ball can probably speak to this as well, when I was a resident, the MAGIC study had just been published. There was a lot of hesitation among surgeons, about sending patients to chemotherapy before surgery, they were worried that they were gonna get quite sick. I think the pendulum is swung. We know that patients with advanced cancer have poor outcomes. And we think with perioperative chemotherapy, we may improve those outcomes significantly. So, I think people have bought into the idea of perioperative chemotherapy as a treatment choice for patients with advanced stomach cancer, who don’t have significant complications that preclude them getting chemotherapy. Most obviously, significant bleeding or gastric outlet obstruction. So, a patient who’s well enough to get chemo without obstruction or bleeding, who has advanced stomach cancer, meaning T2 or greater N positive disease, who has negative-cytology, negative diagnostic laparoscopy, I would be sending for perioperative chemotherapy. Unless we had a study, and we do have other studies about perioperative chemo, plus/minus radiation. And I think the evidence is clear that FLOT does much better than epirubicin, cisplatin, 5-FU for these patients. So, the MAGIC regimen with a significantly improved overall survival compared to FLOT. So, I think any patient who fits that criteria, so advanced stomach cancer T2 or greater, node positive, who doesn’t have an obstruction or bleeding, is well enough to get chemo, and I would refer to medical oncologists. And I think our medical oncology colleagues hesitate, somewhat, to give the FLOT regimen to older patients, or patients 70 or older, due to the toxicity. But that’s a discussion that they can have about the actual regimen. But that would be my sort of outlook. If a patient is unwell, they’re obstructed, or they have significant bleeding requiring multiple transfusions, I would advocate for surgery first.

Ameer Farooq  18:51

I guess we should back up for our listeners. Can you talk a little bit about what FLOT is? And a little bit about the studies that have been done about this?

Sav Brar  19:04

So in the mid 2000s, the MAGIC study was published, that compared the standard of care at the time, which was surgery alone to pair up with chemotherapy, the ECF regimen, so epirubicin, cisplatin and 5-FU, patients got 3 cycles of chemotherapy before surgery and 3 cycles after. Many patients did not complete all 6 cycles. But despite that, on intention to treat analysis, there was a significant survival benefit. And FLOT was a study that compared that regimen of ECF, 3 cycles before surgery and 3 cycles after, with a regimen that changed some of the medications. So, fluorouracil leucovorin, that’s the F, the L. And then oxaliplatin and a taxane docetaxel. So slightly changed the regimen and added a taxane to then compare that to ECF or ECX and showed a significant survival benefit. So, the regimen is slightly different. You got 4 cycles before and 4 cycles afterwards, for 8 cycles in total, each cycle was 2 weeks. So, you got 8 weeks of chemo, and 8 weeks of chemo afterwards. And the survival difference, the median overall survival on ECF, on the study, was 35 months, and with FLOT, it was 50 months, which is a pretty big survival benefit for the FLOT. And the difference in the overall survival rate, I think it was like 48% versus 58% or 57% with FLOT. So significant improved overall survival and median survival with this regimen. And the big difference in the regimen is adding a taxane which isn’t a new thing for stomach cancer. People have been using taxanes for stomach cancer a long time but hadn’t been shown in the perioperative setting to be associated with improved survival. The worry, when the study was being conducted, was the toxicity of the study. This is a German study and they didn’t report any difference in toxicity between ECF and FLOT. But that was, sort of, the main concern of our medical oncologists here, that patients may have significant toxicity with the FLOT regimen.

Ameer Farooq  21:34

That’s a fantastic review of the workup and management of gastric cancer. But let’s get to the fun part. I wanted you to talk a little bit about some technical aspects of doing a subtotal gastrectomy. Can you walk us through, first, how do you choose an approach? Do you do it laparoscopically or open? And then, a little bit about how you think about the operation and what are your sequence of steps, and how do you approach this operation?

Sav Brar  22:05

One of the more formative experiences of my training was late in my fellowship, I went to Japan for 2 months and worked in Tokyo with a group of surgeons there, led by Dr. [inaudible]. They did a lot of gastrectomies, 15 or 20 gastrectomy a week, which is much higher than the volume that I saw in residency or fellowship. When I think about a total gastrectomy, I think about it the way they approach it. One thing that really changed my outlook was, thinking about the operation with a greater curvature up. So, the way I conduct this operation, both open and laparoscopically is, the first step would be to liberate the mentum of the transverse colon, and then retract the greater curvature up towards the interior abdominal wall. What that does is, give you a roadmap of the lymph node stations that you need to tackle when you’re doing D2 or D1 lymphadenectomy. It really is an elegant way to approach the operation. So, for listeners, if you look up the Japanese gastric cancer guidelines, they’ll have a diagram of the D1 and D2 lymphadenectomy stations. In their diagram, they have the stomach with a greater curvature up, which is different than our normal anatomic textbook diagrams. That’s how I try to set up the operation and that’s the way I think about the operation from the get go. So, from a conceptual standpoint, having a greater curvature up is, from an anatomical standpoint, the way I like to approach these things. You have [inaudible]. You know, I think there is ongoing studies in Asia, the first of which has been just recently published. Looking at the difference between open and laparoscopic surgery for gastric cancer. There’s the results of the class study, the Korean laparoscopic gastric cancer surgery study showed that, for early stomach cancer, that there was no difference in oncological outcome between the 2 approaches of laparoscopic versus open. And then now, a more recent study from China showed no difference between open and laparoscopic distal gastrectomy for advanced stomach cancer. So, there’s growing literature that shows that these are equivalent approaches from an oncologic standpoint. I think people should do what they’re most comfortable with. I offer patients both. Most patients will go for a laparoscopic approach. I do tell them that the data to support a laparoscopic gastrectomy for advanced stomach cancer is still maturing. And despite that, most patients will go for a laparoscopic approach. So, having said that, the approach in terms of steps is basically the same. So, step 1, you want to make sure your patients have appropriate antibiotics and VTE prophylaxis. For laparoscopic gastrectomy, I like to do a Hasson approach above the umbilicus and place two 10 mm ports, sort of a handbreadth lateral to the umbilicus on the right and left. and then towards the costal margin. I put two 5 mm ports, somewhat lateral to those, so it makes kind of a box with my ports. And then I also use a Nathanson liver retractor to get that left lateral segment out of the way of our lesser omentum during the dissection. After that, the first step is to divide the omentum off of the transverse colon. I think this is a trickier part. If you really understand the omentum’s anatomy and embryology, it gets more difficult, because you want to be accurate. And the importance of that is, you want to use the omentum to lead you to the first lymph node station, which is the left gastroepiploic vessels. And I think, the important thing is to follow the omentum down to the left gastroepiploic vein and artery, right where they are seen above the distal end of the pancreas. And once those are divided, turn my attention towards the right side of the patient. So follow the omentum down to the right to gastroepiploic vein. And I think, if you have seen Japanese or Korean surgeons do this part of the operation, it will demonstrate the concept of, you don’t know what you don’t know. So, I think, before I went to Japan, I just thought, okay, you find the gastroepiploic and you divide them, and that’s it. But if you actually look at the Koreans’ approach to D2, to an accurate right gastroepiploic division for the D2 lymphadenectomy, you have to see the confluence of this right gastroepiploic vein and the anterior superior pancreaticoduodenal vein. So, you’re getting right to the trunk of Henle, which is much deeper than most surgeons in North America are used to doing for gastric cancer operations. For pancreas operations, this is common territory. But you’re getting close to the trunk of Henle when you’re doing a true lymphadenectomy for gastric cancer. Before we get any further, the right gastroepiploic nodes are not even D2, they’re part of the D1 lymph node stations, station 6. So that’s part of your D1. And when you see them do it, you realize that even our D1, in North America, aren’t really up to the standards that they set. You divide the right gastroepiploic vein at the confluence and you then move up and, taking all of the lymphatic tissue around it, up to the right gastroepiploic artery. And if you’re low enough on the vein, there should be a significant amount of space between the vein and the artery. And what you want to do at this point is, take the artery at its branching point, off the gastroduodenal artery. Once you’ve done this, I always tell people this, even though it’s station 6, it’s supposed to be the start of the operation. To me, if you’ve done this part, you’ve done the hardest part of the operation because you found the right plane, which is a plane anterior to the gastroduodenal artery, which we’re going to follow behind the duodenum and the pylorus to the hepatic artery. I think, once you’ve done this, this is the most stressful part of the operation for me, other than the anastomosis. So, once you’ve done this, you’re going to go behind the pylorus, liberating the tissue off the GA to its root. You’re going to divide the tissues around the duodenum and 2 cm distal to the pylorus, you’re going to divide the pylorus. I think, at this point, it’s important to recognize that if you have an OG tube or temperature probe in, that you ask the anesthesiologist to remove them completely, because you don’t want to come across them with a stapler. So, that’s an important consideration. I think, once the duodenal stuff is divided, you take a mental break and reassess, and go with the next part of the operation. Which is the trickier part of the lymphadenectomy. Which is, following along the hepatic artery. exposing the portal vein on the medial part of the hepatic artery up to the liver edge and then dividing pars flaccida up to the right crus of the diaphragm. Once you’ve done this, you’ve liberated the right sided attachments of your on-block lymphadenectomy. You’ve divided the right gastroepiploic vein and artery, you’ve divided the duodenum, the tissues over the gastroduodenal artery, you’ve divided the right gastric artery at this point, and mobilized the tissues over the left or medial side of the hepatic artery. And you’re now bringing all that stuff, medial towards the left gastric. And at this point, I think it’s important to think of bringing all the lymphatic tissue on block towards the left gastric artery, which is the last vessel that we would take. At this point, there’s a change of direction. So, we moved from the medial part of the hepatic artery and divided the lesser omentum. Up to the right gastroesophageal, the right hepatic crus. At this point, we’re going to turn directions and follow the hepatc artery down to the celiac and the proximal part of the splenic artery. And again, at this point, it’s important to recognize that you can do this the way that many North American surgeons do, which is just divide the left gastric artery where you see it. Or if you’ve seen a Japanese or Korean surgeon do it, you realize that there is a whole significant amount of lymphatic tissues, sort of behind the pancreas. So, what they do is they divide the peritoneum overlying the pancreas at its superior edge, exposing the splenic artery and seeing the splenic vein, and they take all that stuff up. So, you’re going way, way back posteriorly to Gerota’s and you’re lifting that up towards the left gastric artery. And now, for most stomach cancers, going up to the halfway part of the splenic artery with a lymphadenectomy is all that you need to do. If you’re having a go towards the distal splenic artery, or splenic hilar, you reserve that for mostly patients who have stomach cancers and the greater curvature of the stomach. Especially in the proximal half or even the upper third of the stomach, as those are the ones that are most likely to have positive nodes in those stations, the splenic hilar stations and the distal splenic artery stations. Once you’ve done that splenic hilars, splenic arterial dissection, then you’re going to bring that packet of your lymphadenectomy towards the left gastric as well, you will then encounter the left gastric vein, which you will divide. And then you’ll come up to the left gastric artery which, the old D1 wasn’t part of the lymphadenectomy, but for both the D1 and the D2 and the most recent gastric cancer guidelines from Japan, you do divide right at its origin. And having done this, you then proceed to mobilize the tissues in front of the aorta to the diaphragmatic crus and liberate station 1 and station 2 lymph nodes from around the diaphragmatic hiatus and mobilize the intra-abdominal esophagus. Laparoscopically, this is the difficult part of the operation. You want to have the distal stomach retracted into the lower abdomen, if possible, to get to intra-abdominal esophagus on stretch. At this point you divide, depending on your proximal margin, the esophagus just above the GE junction. For reconstruction, I think there’s many options, most people elect to do a circular stapler either in the open scenario, by putting a purse string in the anvil into the distal esophagus and using circular EEA stapler through the duodenum to perform your anastomosis. I don’t like the circular stapler on the esophagus, so I’ve now converted to doing a linear esophagojejunostomy for my reconstructions. I bring the duodenal limb up and using a purpura firing of the Tri-Stapler. I’m not sure if I’m supposed to be plugging instruments in here. But using a linear stapler, I do an anastomosis, a side-to-side anastomosis, bringing the duodenum up, posteriorly and to the left of the esophagus. And if I’m doing this laparoscopically, I close the common channel with a running suture, 3-0 polysorb suture. Then do a duodenostomy to perform the Roux-en-Y anastomosis about 45 cm distal to that anastomosis. One technique I’ve begun to use more recently is a duodenal pouch. So, a duodenal pouch has been shown in some smaller studies to be associated with better quality of life and less weight loss for patients. There was a meta-analysis that came out in January 2019, in the Annals of Surgery. And since then, I’ve been using it for patients who are doing a prophylactic gastrectomy because the outcomes tend to be robust over a longer period of time. And so, I will do a 15 cm duodenal pouch and anatomose that to the esophagus, if a patient is either a very early stomach cancer, or I’m doing prophylactic gastrectomy. For laparoscopic gastrectomies, I remove the specimen through a Pfannenstiel incision using Alexis Wound retractor, wound protector, it’s about a 5.5 cm to 6 cm Pfannenstiel incision on lower abdomen. I usually do this after the esophagus is divided but before the anastomosis is done. It gives you a chance to get most of the omentum out of the abdominal cavity. It gives you a moment to take a breather before you do the tricky part of the procedure, which is the anastomosis.

Ameer Farooq  36:53

Beautiful description of the operation. A few minor questions. Do you use any energy devices?

Chad Ball  37:04

Yeah, so I tend to use a harmonic. And really, the reason why that is, when I went to Japan, they use the harmonic for the laparoscopic cases. I think it is a bit of more flexibility with a harmonic and you just have to be careful if you haven’t used it a lot, because it’s slightly different than the ligature, which I think many Canadian surgeons are more comfortable with. Especially given that part of the instrument remains quite hot during its use. So, you just have to be very, very careful. I think it’s a bit more elegant in some of the more tricky parts of the lymphadenectomy. That being said, I had more recently used Maryland tip ligasure as well, with some success, just to give it a try. But my preferences is the harmonic.

Ameer Farooq  37:57

And how about drains? Do you leave drains?

Sav Brar  38:00

No, I don’t leave drains. Unless, sorry that’s wrong. I don’t leave drains unless I’ve really beaten up the pancreas during the lymphadenectomy. Usually, if I don’t see any saponification, I think I’ve done okay. If I see significant saponification, I get a bit worried. Even then, I often don’t leave a drain. But it’s very rarely that I leave a drain.

Ameer Farooq  38:24

What do you what do you do with the NG? Or I don’t know if you use it or not. If you do, when do you take it out?

Chad Ball  38:32

Yeah, so I don’t use an NG, even for my totals. I don’t leave any drains and I don’t use an NG. I also don’t oversell the duodenal stump. My post-op, I usually give them sips of clear fluid and then do a contrast study. On post-op day 2, if a contrast study is negative, I give them a clear fluid diet and transition them to a post gastrectomy diet on post-op day 3. If they tolerate that, then they go home on post-op day 4.

Ameer Farooq  39:09

That’s fantastic. That was, really, the bulk of what I wanted to talk about. I had a few quick hitter questions. Let’s say you have a patient who has gastric cancer and clearly has carcinomatosis, but you’re worried either they have gastric obstruction or you think they’re going to need one in the new future. What’s your palliative option of choice? Are you stenting them or are you doing a palliative GJ? What’s your approach?

Chad Ball  39:44

Yeah, that’s a very, very good question. I think one that you have to take out a case-by-case basis. We’re lucky in our group, we have a esophagus and gastric cancer tumor board so you often bring these patients up in that arena, to discuss options. I think there’s a rule of thumb out there that’s not based on randomized control trial data. But I think, in principle, is a good general framework. Which is, if you think the patient’s estimated survival is short, 3 months or less. Then I think a stent is probably the best course of action. I think, if you think that there’s a significant amount of stomach wall involved with cancer, be it either linitis plastica picture, or just a significant involvement of the distal stomach, then doing a bypass can be quite difficult. That being said, in those patients, doing a stent can be quite difficult. So you’re often stuck with a scenario where there isn’t great palliation for these patients. So, with significant carcinomatosis, I would worry about being able to do, safely, a bypass. But if I thought we could do it, that there was a good landing for the gastrointestinal anastomosis on the greater curvature of the stomach, that there wasn’t linitis plastica, that they had a good chance of robust survival. And especially if this was what’s going to keep them from getting chemotherapy, then I have no hesitation in doing a laparoscopic gastric duodenal bypass.

Ameer Farooq  41:32

Gotcha. And my last question is a perennial one. How do we interpret the different outcomes between the Japanese, Korean surgeons in terms of their D3, lymphadenectomy versus the western studies that don’t seem to support a more extensive lymphadenectomy? Is it just that they’re better at it?

Chad Ball  41:52

I think one thing that we should recognize is that there isn’t any equipoise in Japan and South Korea about doing anything less than a D2 lymphadenectomy. So, our ability to get robust clinical trial data to show benefit is probably not going to happen in East Asia. If you look at the western data, there is 3 major studies that people quote. One study was done in England, and one study was done in the Netherlands in the 90s. And one more recently done in Italy. I think, I can get into the details of these studies but, there were a lot of problems that people had with the Dutch and the English studies from the 90s that the surgeons were low volume, and not maybe not well trained, and that they were doing significant amount of distal pancreatectomies and splenectomies, for their D2 lymphadenectomy. And the feeling was that this surgery was not up to the standard of what Asian D2 lymphadenectomy would be. The Italian study that was published more recently, there was a lot of excitement about, they did their initial papers showing that perioperative outcomes are quite good, that there was not a significant morbidity or mortality from doing D2 lymphadenectomy. And so, the thought was that there would be a more truer picture of a benefit for the D2 lymphadenectomy. And what we can say is, that there wasn’t a strong signal that direction. What my take-homes from that study were, so there was a lot of crossover in the study. So, a lot of patients who were assigned to D1, got more than a D1 lymphadenectomy, maybe not quite a D2, but got more than a D1 lymphadenectomy. And a lot of patients in the D2 arm got slightly less than the D2 lymphadenectomy. So, it’s sort of grey’d the difference between the 2 arms in the study. The other important thing, and I think this is important for your exam, is that for patients with early stomach cancer, there was probably some harm from getting a D2 lymphadenectomy. So for early stomach cancer, or patients that you think might have early stomach cancer, in the absence of good, level 1 evidence of benefit for D2, that we shouldn’t be doing a D2 lymphadenectomy for those patients. If you don’t do a lot, there’s probably no reason to do a D2 lymphadenectomy. But there has been some analysis that show with increasing T or node-positive disease, that there might be a benefit of doing D2 lymphadenectomy. That’s the strongest signal on the increasing T stage. And so, if you have accurate preoperative staging, and you think that there’s cirrhosis involvement, that maybe D2 lymphadenectomy would be of benefit.

Ameer Farooq  44:42

Well, that was a fantastic overview of gastric cancer. And I’m sure there’s a few of us out there with a little quiz at the end of the year, will appreciate that. So, thank you for going through that.

Sav Brar  44:55

And obviously if you guys have more questions, happy to answer them. I think, a lot of confusion around these studies and I’m happy to clarify them if I can.

Chad Ball  45:08

Thank you so much, you’ve displayed why you’re the national leader in gastric cancer, quite frankly, but your depth of knowledge. And again, how you simplify complex topics, so thank you for that, I think we’ll all benefit from it. I want to shift gears a little bit and take 5 minutes or so and ask you some more personal questions so that our listeners can get to know you. Maybe like some of us know you. Just give us a sense of the pathway you, kind of, ended up at Mount Sinai in Toronto, with regard to training.

Sav Brar  45:42

Yeah, so I never thought I was going to be a surgeon. I went to med school at Western thinking maybe I was gonna do medicine, but I really wanted to be a pediatrician. In fact, there was a moment in second year where I had this real clarity and thought I knew for sure that I was gonna become a pediatric oncologist. I started doing observerships in pediatric oncology. I did a summer project at Sickkids and pediatrics thinking that was where I was going to go. What happened to me, actually, was I started losing interest in medical school and sort of dragged my feet getting 2 observerships and started mailing it in when it came to classes in my second year and my research in my second year, summer. And I really thought that was more having to do with my own work ethic and I thought I was just a bad fit in medicine, for whatever reason. At Western, December, I was assigned, during my core clerkship rotation to work with Dr. Girvin and Dr. Daryl Gray at Western, and it was a transformative experience. To be honest, the hints that I had an interest in surgery were already there, but I just had a lot of misconceptions, like many people, do about surgery. In our dissection lab in first year anatomy, I loved it. I had so much fun doing the dissections and I loved anatomy and I loved embryology. I think our core parts of a surgeon’s knowledge base. But when it came to thinking about doing surgery, I just assumed that I didn’t want to do a specialty where there was no patient interaction. I really wanted to be at that sharp end of patient care, no pun involved, no pun intended. But I really wanted to be at the bedside during hard decisions around cancer care. That’s where I thought I wanted to be a pediatric oncologist, I thought that, to me, was the ultimate version of that. Children with cancer and their families dealing with these difficult decisions about treatment, and outcomes, and relapse, and palliation or no palliation. And what I realized is that, you can get that in surgery. You can get that in surgery but also do surgery, which is so much fun and so rewarding. So, when I did my general surgery rotation as a clerk, it opened my eyes. I had to switch all my electives. And Daryl Gray was, kind enough to talk to me afterwards. And I said, “Dr. Gray, I’m really interested surgeon, I never thought I was going to, but I have no idea where to do electives.” And he goes, “Well Sav, what are you interested in?” And I said, “I really like the idea of doing cancer care.” And so he said, “Well, if you’re interested in that, you should go to Calgary and work with Walley Temple.” So that was the first elective I set up. I came to Calgary for an elective in September of my fourth year, which is a long time ago, now, in 2003. I worked with Walley Temple and Greg MacKinnon. Lloyd Mac was the fellow at the time and was obviously a well-established surgical oncologist in Calgary. And I really loved my time in Calgary. I had a great time with the residents and the staff, and I really liked how well people got along there. So, I came there for my residency. So, I came for residency in 2004. As you guys know, resident there for 5 years. Throughout the whole time, I was open to doing other things, but really, it came back to wanting to do surgical oncology. And the program that is the most well-known for fellowship is in Toronto. So, I did electives with Dr. Carol Swallow and Dr. Andy Smith in Toronto, in the surgical oncology program and was lucky enough to end up here for fellowship. Between my residency and my fellowship, I did a master’s degree in health economics, health policy at the London School of Economics, due to some interest I had in those topics. And it really was a great way for me to open up doors with people in Toronto that thought outside the box. Certainly, there were people in Calgary like that, too. Like Elijah Dixon who was one of my mentors in Calgary. But, for many American programs, it was sort of like, why would you want to do that? Why don’t you want to work in a lab and try to cure cancer by pipetting and doing micro RNA? So, I actually found it very difficult to get any doors open in the U.S. But I ended up coming to Toronto and doing my fellowship here. They, I think, saw something that they liked and asked me to stay and join a surgical oncology group at Mount Sinai Hospital, with my interest in stomach cancer that I pursued through my rotation in Japan. And then also I joined this sarcoma group, which has been an unexpected blessing. What I tell people all the time is, if you ask me, is this my dream job? I would say that this is actually better than my dream job. I never would have dreamt that I’d be in the position that I am now, working in a very high-volume surgical oncology center doing gastric cancer sarcoma, and being the program director at the University of Toronto Residency Program. I don’t think I would have expected that to be my outcome. I think it speaks to being in the right place at the right time, but also great mentorship from my mentors, like the people in Calgary and the people in Toronto that I’ve met along the way.

Chad Ball  51:23

I think, as usual, you’re understated and humble, I think we all would have expected that level of performance and altitude from you, quite honestly.

Sav Brar  51:31

Thanks.

Chad Ball  51:32

Yeah, it’s very true. One of the things I think you share with one of our colleagues, Dr. Gomorrah is, you’re a very innovative thinker. And I don’t particularly love that out of the box terminology, but it might actually apply to you. I think a couple of the places that we’ve seen that, are in some of the stuff you published in Morad Hameed’s surgical magazine for CAGS called ROSCOE. The one in particular, I wanted you to talk about a little bit was your article on the connection between Billroth, of course, the father of modern surgery for all of us, and Brahms from the musical world.  Yeah, I mean, Billroth is fascinating, fascinating figure in the history of surgery. You know, revolutionized surgery, in many ways, as the chairman of the surgery department in Vienna, at the turn of the century, is sort of the quintessential answer to that quiz question. And it’s interesting because his influence on stomach surgery and stomach cancer surgeries is obviously there with his eponyms in the reconstructions Billroth I and Billroth II. But we think we know a lot about excellence and the whole idea of a 10,000 hours of practice and that we all have to be super specialized experts. And Billroth is an example of someone who said that he was married to medicine, but music was his mistress. This is a guy who, his whole life, would rather have studied and made and discussed music, but was led to medicine because of his family and the need for a more stable future. And at every stage of his career, he was seeking out opportunities to be involved in music, outside of medicine. So, he wrote about music when he was in Zurich. He was a guest conductor of the Zurich orchestra. When he moved to Vienna for the job that he became most famous for, he sought out people in music to discuss music and to hold concerts in his house, and to attend concerts. The connection he’s most famous for, though he’s not actually really famous for it, is with the conductor Brahms, who he had such a strong friendship with, that many of Brahms’s manuscripts would be sent to Billroth for editing and for input. Brahms actually dedicated a Piano Concerto in Billroth’s name, which you should find on whatever music streaming device you have. It’s a very nice Piano Concerto. And he wrote about music, he wrote about music and on the side of doing really, really, really revolutionary stuff in surgery. This is a time when the best surgeons in the world would come to his clinic to learn how he performed his operations. They would learn how he trained surgeons, because the surgeons he trained went on to be giants in, surgery wherever they went. And more than that, he actually was quite a scientific surgeon in that, before he tried these first, revolutionary stomach cancer operations, they planned them, they did anatomical studies, they practiced in animal models. It wasn’t just, sort of, cowboy stuff of them doing these big operations for the first time on the fly. They’re quite deliberative. So what is amazing about this story is that we often are told to be serious and be focused and do one thing well, and not to be a jack of all trades. But here is, probably, the most influential surgeon of all time, who, throughout his life, from teenager to his death, would probably have rather been a musician or writing music and being quite successful at both. And I think it’s a great lesson for all of us. That if you have interests outside of medicine, you shouldn’t be shy about pursuing them. I mean, not that everyone needs to be creative to be a great surgeon, I actually disagree with that conclusion, sometimes, that people make from his example. There are many surgeons who just did surgery but did it amazing. I just don’t think that you need to leave your life outside of medicine at home when you embark on this journey of becoming a surgeon.  I couldn’t agree more. Sometimes when one of those aspects of your life is a little slow, the other picks it up and keeps you moving.

Sav Brar  56:35

Yeah, I think I think that’s a great, great point. And I don’t know what the evidence for that is. I think, definitely, if you have a hobby or an interest outside of medicine. Not even a hobby, like another side gig or side hustle, sometimes when that’s going well, it helps your day job or your dream job.

Chad Ball  56:54

Well, Sav, thank you very much for doing this.

Ameer Farooq  57:08

You you’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So, feel free to email us at podcast.cjs@gmail.com, or connect with us on Twitter @CanJSurg. Thanks again.