James W. Fleshman M.D.

Conrad, C. and J. W. Fleshman, Jr. (2019). “Minimally Invasive Oncologic Surgery, Part II.” Surg Oncol Clin N Am 28(2): xv-xvii.

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Minimally invasive techniques for the management of intra-abdominal cancer have become an accepted option for almost all solid tumors. Some of these approaches have been vetted with prospective trials, some even randomized, but it is unusual to find a discussion that encompasses all in one publication. It was this reason that led to these two-part Surgical Oncology Clinics of North America issues that contain discussions of almost every solid intra-abdominal tumor. The experts who have participated are experienced with both open and minimally invasive approaches, and they understand the issues that arise when making recommendations for treatment of curable cancer with new techniques. Dr Conrad and I are indebted to them for their truly authoritative contributions. The discussion around limitations of a technique is almost more important than the assumed possibilities and the recovery outcomes beyond cancer cure. As the advanced techniques are applied in institutions beyond academic institutions where clinical trials are underway, the most important consideration becomes whether generalization of the technique is possible or even appropriate. As one reads this compilation of articles, it is hoped that a balanced message will be apparent, and that the thoughtful application of surgical judgment will be enhanced by the contents herein. Each year brings more applications for minimally invasive surgery regardless of the specific technique. The current level of application of minimally invasive techniques to cancer shows that we have the opportunity to expand their use for even the most basic and appropriate indications. Educators involved in the continued education of surgical trainees and practicing surgeons should be able to use the articles within this issue to engage trainees in a thoughtful approach to expand their use of minimally invasive surgery for resection of cancer. (Excerpt from commentary on a special issue of the journal, p. xvi.)

Fleshman, J., M. E. Branda, D. J. Sargent, A. M. Boller, V. V. George, M. A. Abbas, W. R. Peters, Jr., D. C. Maun, G. J. Chang, A. Herline, A. Fichera, M. G. Mutch, S. D. Wexner, M. H. Whiteford, J. Marks, E. Birnbaum, D. A. Margolin, D. W. Larson, P. W. Marcello, M. C. Posner, T. E. Read, J. R. T. Monson, S. M. Wren, P. W. T. Pisters and H. Nelson (2019). “Disease-free Survival and Local Recurrence for Laparoscopic Resection Compared With Open Resection of Stage II to III Rectal Cancer: Follow-up Results of the ACOSOG Z6051 Randomized Controlled Trial.” Ann Surg 269(4): 589-595.

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OBJECTIVE: To determine the disease-free survival (DFS) and recurrence after the treatment of patients with rectal cancer with open (OPEN) or laparoscopic (LAP) resection. BACKGROUND: This randomized clinical trial (ACOSOG [Alliance] Z6051), performed between 2008 and 2013, compared LAP and OPEN resection of stage II/III rectal cancer, within 12 cm of the anal verge (T1-3, N0-2, M0) in patients who received neoadjuvant chemoradiotherapy. The rectum and mesorectum were resected using open instruments for rectal dissection (included hybrid hand-assisted laparoscopic) or with laparoscopic instruments under pneumoperitoneum. The 2-year DFS and recurrence were secondary endpoints of Z6051. METHODS: The DFS and recurrence were not powered, and are being assessed for superiority. Recurrence was determined at 3, 6, 9, 12, and every 6 months thereafter, using carcinoembryonic antigen, physical examination, computed tomography, and colonoscopy. In all, 486 patients were randomized to LAP (243) or OPEN (243), with 462 eligible for analysis (LAP = 240 and OPEN = 222). Median follow-up is 47.9 months. RESULTS: The 2-year DFS was LAP 79.5% (95% confidence interval [CI] 74.4-84.9) and OPEN 83.2% (95% CI 78.3-88.3). Local and regional recurrence was 4.6% LAP and 4.5% OPEN. Distant recurrence was 14.6% LAP and 16.7% OPEN.Disease-free survival was impacted by unsuccessful resection (hazard ratio [HR] 1.87, 95% CI 1.21-2.91): composite of incomplete specimen (HR 1.65, 95% CI 0.85-3.18); positive circumferential resection margins (HR 2.31, 95% CI 1.40-3.79); positive distal margin (HR 2.53, 95% CI 1.30-3.77). CONCLUSION: Laparoscopic assisted resection of rectal cancer was not found to be significantly different to OPEN resection of rectal cancer based on the outcomes of DFS and recurrence.

Conrad, C. and J. W. Fleshman (2019). “Minimally Invasive Oncologic Surgery, Part I.” Surg Oncol Clin N Am 28(1): xv-xvii.

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Modern cancer surgery has the unique and unprecedented capacity to go beyond technical aspects of removing the tumor, focusing simultaneously on the cancer’s biology and its morbidity. For example, while Halsted’s radical mastectomy certainly helped many patients suffering from breast cancer, later attempts to reduce the morbidity in the context of progress in oncologic management led to a significant reduction of morbidity. Similarly, once surgeons such as Codivilla (1898), Kausch (1912), and Whipple (1935) pioneered the complex operation of a pancreaticoduodenectomy, attempts to perform the operation less invasively led to Gagner and Pomp reporting the first laparoscopic pancreaticoduodenectomy in 1994. In parallel, after the first successful liver resection by the German surgeon Langenbuch in 1888 (the specimen showed normal liver), the eagerness of performing liver surgery according to anatomic principles resulted in post-1950 reports of selective anatomic liver resection by Honjo (Japan), Lortat-Jacob (France), and Ton That Tung (Vietnam). Then, minimally invasive liver resection was introduced in the 1990s. Like many daring innovations, early attempts to develop minimally invasive surgery have not always drawn praise, or even approval. For example, after Semm performed the first laparoscopic appendectomy from the gynecological clinic of Kiel in 1981, the president of the German Surgical Society wrote to the Board of Directors of the German Gynecological Society requesting suspension of Semm from medical practice. Stories of such challenging environments are numerous and well known, and the ability of surgeons to push through those have paved the way for the exciting time in cancer surgery we live in today. This historic time includes standardizing minimally invasive operations and augmenting its potential by injecting high-tech applications, such as augmented reality or fluorescent-guided surgery. This issue of Surgical Oncology Clinics of North America on Minimally Invasive Cancer Management, written by experts from around the world, provides an up-to-date overview on the tremendous progress that has been made in this field. In my role as Editor, I was fortunate to learn about the frontiers of our field from the editorial process and from scientific exchange with the contributing authors. Reviewing the beautiful and concise articles summarizing the tremendous progress in the field of minimally invasive cancer surgery takes me back to early days in my career, at the threshold of committing to surgery as my specialty. Some of my professors discouraged me, envisioning that cancer surgery would have been completely replaced by the progress in systemic therapies by now. Reality has proven the opposite, where the efficacy of systemic therapies has allowed surgical interventions against cancer to become more aggressive and effective. I am humbled and honored to contribute to the community of minimally invasive surgeons who hope to help their patients’ battles by skillfully trading morbidity for radical oncologic surgery, maximizing the time and quality of a patient’s life with their loved ones. (Excerpt from the introduction to a special issue of Surgical Oncology Clinics of North America, 28:1.)

Wells, K. and J. Fleshman (2018). “Nonsurgical, Minimally Invasive, and Surgical Methods in Management of Acute Diverticulitis.” JAMA Surg Nov 21. [Epub ahead of print].

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The surgical approaches for complicated diverticulitis are shifting, with more stringent absolute indications for resection in practice today. Clinical trials have failed to demonstrate measurable benefit of LL over sigmoid resection, and LL is currently not supported as a standard of care. Resection is recommended in patients with stricturing or fistulizing disease and those with significant comorbidity, including immunocompromise, for whom repeated attacks would have severe consequences. These specific conditions aside, elective resection should be a consideration but not a mandate for patients whose disease resolves after acute presentation; however, surgeons lack specific predictors of failure of expectant management to fully inform this decision. Although the research is in its infancy, genetic predictors have come to light that may, in the future, establish criteria for elective resection. (Excerpt from text, p. e2; no abstract available.)

Conrad, C. and J. W. Fleshman, Jr. (2019). “Minimally Invasive Oncologic Surgery, Part I.” Surg Oncol Clin N Am 28(1): xv-xvii. Nov 12. [Epub ahead of print].

Full text of this article.

This issue of Surgical Oncology Clinics of North America on Minimally Invasive Cancer Management, written by experts from around the world, provides an up-to-date overview on the tremendous progress that has been made in this field. Modern cancer surgery has the unique and unprecedented capacity to go beyond technical aspects of removing the tumor, focusing simultaneously on the cancer’s biology and its morbidity. For example, while Halsted’s radical mastectomy certainly helped many patients suffering from breast cancer, later attempts to reduce the morbidity in the context of progress in oncologic management led to a significant reduction of morbidity. Similarly, once surgeons such as Codivilla (1898), Kausch (1912), and Whipple (1935) pioneered the complex operation of a pancreaticoduodenectomy, attempts to perform the operation less invasively led to Gagner and Pomp reporting the first laparoscopic pancreaticoduodenectomy in 1994. In parallel, after the first successful liver resection by the German surgeon Langenbuch in 1888 (the specimen showed normal liver), the eagerness of performing liver surgery according to anatomic principles resulted in post-1950 reports of selective anatomic liver resection by Honjo (Japan), Lortat-Jacob (France), and Ton That Tung (Vietnam). Then, minimally invasive liver resection was introduced in the 1990s. Like many daring innovations, early attempts to develop minimally invasive surgery have not always drawn praise, or even approval. For example, after Semm performed the first laparoscopic appendectomy from the gynecological clinic of Kiel in 1981, the president of the German Surgical Society wrote to the Board of Directors of the German Gynecological Society requesting suspension of Semm from medical practice. Stories of such challenging environments are numerous and well known, and the ability of surgeons to push through those have paved the way for the exciting time in cancer surgery we live in today. This historic time includes standardizing minimally invasive operations and augmenting its potential by injecting high-tech applications, such as augmented reality or fluorescent-guided surgery. (Except from text, p. xv-xvi.)