extreme laparoscopy: expanding the surgical horizon ...galaxy care laparoscopy institute ,pune ,...
TRANSCRIPT
Sponsored by
AAGLAdvancing Minimally Invasive Gynecology Worldwide
Extreme Laparoscopy: Expanding the
Surgical Horizon (Didactic)
PROGRAM CHAIR
Arnaud Wattiez, MD
Christophe Pomel, MD Shailesh P. Puntambekar, MD David B. Redwine, MD
Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.
Table of Contents
Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 What Does Extreme Laparoscopy Mean? A. Wattiez ..................................................................................................................................................... 5 Extreme Attitude Toward Organs S.P. Puntambekar ......................................................................................................................................... 8 Extreme Dissection D.B. Redwine .............................................................................................................................................. 17 Extreme Situation in Oncology C. Pomel ..................................................................................................................................................... 20 “Extreme” as a Philosophy A. Wattiez ................................................................................................................................................... 29 What Is Behind My Extreme Attitude? S.P. Puntambekar ....................................................................................................................................... 34 What Is Behind My Extreme Attitude? D.B. Redwine .............................................................................................................................................. 39 What Is Behind My Extreme Attitude? C. Pomel ..................................................................................................................................................... 46 Cultural and Linguistics Competency ......................................................................................................... 50
PG 111 Extreme Laparoscopy: Expanding the Surgical Horizon (Didactic)
Arnaud Wattiez, Chair
Faculty: Christophe Pomel, Shailesh P. Puntambekar, David B. Redwine
Course Description
Surgery should never be unpredictable and surgeons are exposed to constraints that should be
respected, understood and overcome. There is no place for uncertainty and that is why every single
action that may reduce the amount of uncertainty is paramount in surgery. The surgical act is a
succession and/or a series of basic actions. These basic actions do not require particularly complex skills
but when put together they create sophisticated surgical actions. These surgical actions can be called
“emergent” because they overcome the complexity of the original entity. It is relatively easy to reach an
average level in any type of surgery, but if one wishes to expand his surgical horizon, he must
understand that only surgical emergence is an art form as it is closely linked to the surgeon’s capacity,
ability, intelligence, vision and willpower.
Laparoscopy has come to the point where anything seems possible in the hands of certain people.
However, surgery cannot be guided by the surgeon’s ego and that is why improving one’s surgical skills
is such an important issue. This course has been developed to demonstrate the knowledge required and
the path to follow to become an “extreme” surgeon.
Learning Objectives
At the conclusion of this course, the participant will be able to: 1) Use the learning process to understand the power of endoscopic surgery; 2) master the theory of laparoscopic surgical rules; 3) identify the key steps of laparoscopic surgery; 4) recognize extreme situations; 5) explain the surgical basics required to face extreme situation; and 6) review the special training required to broaden your skills.
Course Outline 1:30 Welcome, Introductions and Course Overview A. Wattiez 1:35 What Does Extreme Laparoscopy Mean? A. Wattiez 2:00 Extreme Attitude Toward Organs S.P. Puntambekar 2:25 Extreme Dissection D.B. Redwine 2:50 Extreme Situation in Oncology C. Pomel 3:15 Questions & Answers All Faculty
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3:25 Break 3:40 “Extreme” as a Philosophy A. Wattiez 4:05 What Is Behind My Extreme Attitude? S.P. Puntambekar 4:30 What Is Behind My Extreme Attitude? D.B. Redwine 4:55 What Is Behind My Extreme Attitude? C. Pomel 5:20 Questions & Answers All Faculty 5:30 Course Evaluation
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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer ‐ Olympus, Lecturer ‐ Karl Storz Endoscopy‐America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties ‐ CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium ‐ Ethicon Endo‐Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy‐America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor ‐ Intuitve Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Arnaud Wattiez Consultant: VECTEC, Karl Storz Germany Christophe Pomel* Shailesh P. Puntambekar* David B. Redwine* Stephanie N. Morris* Asterisk (*) denotes no financial relationships to disclose.
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EXTREME LAPAROSCOPY....what does it means?
A. WATTIEZ
Disclosure
Consultant Karl Storz Gmbh
Consultant Vectec
• Objective1. To present the philosophy of extreme laparoscopy from a
different point of view.
d ll l b i i i d 2. To draw a parallel between extreme situations in surgery and other real situations in life.
Video• Learning points of course & video:1. To properly understand the definition of extreme laparoscopy
2. To recognize the extreme situations and review their management
3. To understand the advantages & power of endoscopic surgery
4. To master the theory of laparoscopic strategy & surgical rules
5. To review the special training required to broaden your skills
Extreme laparoscopy
• Definition • Management• Training
Extreme laparoscopy
.......a misunderstanding?
definition
4
video
•Understand
Management
think!
Principles
•Strategy & Rules
•Excellence
•Training
• Are you aware of the power of the scope?
StrategyStrategy
“To apply certain sequences in a certain order with the goal to achieve a task”
training
5
Is that enough?Is that enough?
The Philosophy of Extreme The Philosophy of Extreme
•think different!
Conclusions• Extreme laparoscopy is a relative concept and its definition must not be
misunderstood
• No matter the difficulty of the situation, surgery should never be unpredictable
• Mastering the principles of surgery & proper training are fundamental when dealing with extreme situations
• Technology can not replace dissection as the pivot of surgery
• Training in laparoscopical surgery must be progressive & continuous
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EXTREME ATTITUDE TOWARD ORGANS
DR SHAILESH PUNTAMBEKARDR .SHAILESH PUNTAMBEKARMD
ASSOCIATE PROFESSORMEDICAL DIRECTOR
GALAXY CARE LAPAROSCOPY INSTITUTE ,PUNE , INDIA
Disclosures
No financial relationships to disclose
OBJECTIVES…
To evaluate the feasibility of various types of laparoscopic exenterative surgeries in oncology.
That laparoscopic exenterative surgeries canThat laparoscopic exenterative surgeries can be achieved safely with comparable oncological results.
Use of anatomical landmarks while performing these procedures.
INTRODUCTION...Exenteration is an established procedure for treatment of gynecological cancers.
Since June 2003 till September 2012‐ 92 patients underwent different types of pelvic exenterations at our institute‐
‐82 patients underwent laparoscopic procedure while 10 were done Robotically.
40
50
60
70
Ca Endometrium n‐2
Ca Vagina n‐1
DISTRIBUTION OF CANCER CASES
0
10
20
30
A E P E T P E
64
9 11
Ca Ovary n‐5
Ca Cervix n‐84
OUR STATISTICS…
OPERATION AE PE TPE TOTAL
Laparoscopic 60 11 11 82
Robotic 9 0 1 10
Total 69 11 12 92
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LAPAROSCOPIC ANTERIOR EXENTERATION
• 60 women who underwent LAE at our institute between June 2003 to
September 2012 were retrospectively analysed .
TOTAL CASES 60 Primary surgery(n‐25)
Secondary surgery post CT/RT(n‐35)
Cervix 15 30
Ovary 8 5
Vagina 1 ‐
Uterus 1 ‐
• Anterior Exenteration‐ resection of uterus with urinary bladder
LAPAROSCOPIC ANTERIOR EXENTERATION
PRESENT STUDY Lap. Anterior Exenteration(n‐60)
Median surgical duration 180 mins(160‐200)
Median blood loss 220 ml
Mean hospital stay 6 days
Intra op blood tranfusion 0
Median followup 30 months
Immediate mortality 0
LAPAROSCOPIC ANTERIOR EXENTERATION
• Type of urinary diversion important
• Earlier diversions ‐ureterosigmoidostomy ‐has high complication rate.
• Since last few years Ileal conduit and Indiana• Since last few years ‐Ileal conduit and Indiana pouch.
• 2 cases with Mainz II.
TYPES OF URINARY DIVERSIONS(LAPAROSCOPIC)
NO OF PATIENTS (n‐60)
Ureterosigmoidostomy 38
LAPAROSCOPIC ANTERIOR EXENTERATION-TYPES OF URINARY DIVERSIONS
Mainz II 2
Ileal conduit 15
Indiana pouch 5
Neo ‐bladder 0
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Recurrence rate in Lap. Anterior Exenteration
• In our series, 33 patients of recurrence in 3 years.
‐Out of these patients ,10 patients had primary surgery and 23 patients had surgery post CT/RT .
Variable Number of patients with recurrence (n‐33)
Primary surgery 10
Secondary surgery(post CT/RT) 23
Recurrence rate in Lap. Anterior Exenteration
• Earliest recurrence seen 6 months following surgery.
• Patients who developed recurrence in 3 years , 80% had distant metastasis and 20% had local & distant
disease. Variable No. of patients (n‐33)
Distant recurrence 26 (80%)
Local and distant recurrence 7 (20%)
Lymph node involvement 33 (100%)
Surgical margins 3 (9%)
Recurrence rate in Lap. Anterior Exenteration
All the patients with recurrence had nodal metastasis at the time of surgery
3 of the patients with recurrence had surgical margins positivemargins positive.
80% of patients were free of local symptoms post surgery.
Survival ratesurvival solely dependant on
‐ negative nodal status
‐ tumour free marginsPRESENTSTUDY(N‐60)
No. of patients Primarysurgery
Secondary surgery
Percentage
3 year survival rate
27 21 6 45%
5 year survival rate
15 9 6 25%
Survival rate of Lap. Anterior Exenteration
• 3‐year survival‐ 27 patients
• disease free‐21 patients
• Disease free survival after 3 years ‐ 35%.
Conclusion
All 6 patients with recurrent disease were having nodal involvement. Hence nodal status is important prognostic factor for survival.
Survival is much better when primary surgery.
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Conclusion
5‐year survival ‐25%
Results comparable to our open cases , other world series.
M j it h i t i th th l l Majority having systemic recurrence rather than lacal .
Quality of life post‐surgery directly related to surgical expertise.
Hurdles perceived in feasiblilty of laparoscopy
Multi organ involvement requiring extensive dissection
Technical feasibility of a urinary diversion
LAPAROSCOPIC POSTERIOR EXENTERATION
11 patients who underwent LPE for advanced gynecological malignant disease studied.
laparoscopic surgery beneficial in carefully selected patients following R 0 resectionselected patients following R‐0 resection.
Posterior exenteration
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LAPAROSCOPIC POSTERIOR EXENTERATION
OUR STUDY (2010)(N‐10)
No. of patients
Primary surgery 7
S d 3Secondary surgery 3
Temporary stoma 7
Permanent stoma 3
Reference - The J of minimal invasive gynecology ,2010
LAPAROSCOPIC POSTERIOR EXENTERATION
INCLUSION CRITERIA EXCLUSION CRITERIA
OVARIAN CANCER INVOLVING THE POUCH OF DOUGLAS
EXTRA PELVIC SPREAD
POST RADIATION CERVICAL CANCERRECURRENCE LOCALISED POSTERIORLY
DISTANT METASTASIS INCLUDING PARAAORTIC NODES
CA CERVIX WITH RVF INVOLVEMENT OF URINARY BLADDER
CA VAGINA WITH RECTAL INVOLEMENT INVOLVEMENT OF URETERS
LIMB OEDEMA AND SCIATIC PAIN
MEDICALLY UNFIT
Reference - The J of minimal invasive gynecology ,2010
LAPAROSCOPIC POSTERIOR EXENTERATION
Operative data (our data 2010)(n‐10)
Median
Age 54 yrs
Operative time 220min
Blood loss 360 ml360 ml
Length of hospital stay 9days
No of blood transfusion 1.3
Median follow‐up 26 months
Lymph node yield in cervical and vaginal cancers
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Reference - The J of minimal invasive gynecology ,2010
LAPAROSCOPIC POSTERIOR EXENTERATION
Variable Primary surgery Secondary surgery
No. of patients 3 2
Tumor size,mean ,cm 5.5 4
Pathologic characteristics of cervical carcinoma
No. of nodes harvested,mean
22 16
No.of positive nodes,mean 8 3
Margins positive 1 0
Recurrence 1 0
Reference - The J of minimal invasive gynecology
LAPAROSCOPIC POSTERIOR EXENTERATION
Major morbidity after LPE 30%
Complications (our data 2010)(n‐10)
No. of patients(%)
Delayed bladder recovery 4(40)Delayed bladder recovery 4(40)
Surgical site infection 1(10)
Anastomatic leak 1(10)
Pronged ileus 1(10)
Reference - The J of minimal invasive gynecology ,2010
LAPAROSCOPIC POSTERIOR EXENTERATION
• Morbidity in open series 40% to 60%
• In our series ‐surgical site infection ‐1
‐anastomatic leak ‐1‐managed conservatively.
• Successful colostomy reversal ‐in 6 patients.
• No 30‐day operative mortality
• No major intra‐op complications
• No conversions.
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CONCLUSION
disease free survival in LPE ‐ 80%.
‐after median follow‐up of 26 months –
‐9 out of 11 patients were alive
8 i f f di‐8 patients were free of disease
Survival is much better in cancer cervix than in cancer ovary
POSTERIOR EXENTERATION‐CONCLUSION
Restoration of complete anatomy is possible.
LPE has a good 5 year survival rate, but cases are few.
i i i i dDespite extensive experience in LRH and anterior and total pelvic exenteration, only 11 patients were eligible to undergo LPE during study.
TOTAL PELVIC EXENTERATION
• We have successfully performed laparoscopic TPE 11 cases
• in 1 patient ‐robotic TPE
i i d i• no patients required conversions to open surgery.
• relief from local symptoms was dramatic and was documented in all patients.
Lap. Total Pelvic Exenterations
Our series ‐ 11 patients• Median operative time 200 min.• Average blood loss 400 ml• postop. hospital stay 6 days
6 patients have completed one year follow –up and are disease free.
• Compared to a total of 600 cases of Lap radical hysterectomies, 10% were of LAE, 1.5 % were of LPE, and 1% were of TPE .
• This is because of stringent criteria in selection of cases for exenteration procedure.
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Complications of Laparoscopic Exenteration
Complications No. of patients(n‐81)
Bleeding 2
Ureteric injury 3j y
Intestinal leak 4
Wound infection 1
Prolonged ileus 8
Complications of Exenteration
Bleeding
ureteric injuryj y
intestinal leak
wound infection
ileus
no major complication
COMPARISON OF OUR OPERATIVE DATA
PRESENT STUDY(n‐81)
LAP. ANTERIOR EXENTERATION
(N‐60)
LAP. POSTERIOR EXENTERATION
(N‐11)
LAP. TOTAL EXENTERATION
(N‐11)
Median surgical duration
180 mins (160‐200) 220 mins (180‐430) 230+/‐15 mins
Median blood loss 220 200 250
Mean hospital stay 6 7 7
Intra op blood transfusion
0 1.3 5
Median follow up 30 26 24
Immediate mortality 0 0 0
Our 5 year Survival Rate of LPE ,LAE and TPE
60%
70%
80%
0%
10%
20%
30%
40%
50%
Anterior Exenteration (N‐69)Posterior Exenteration (N‐11)Total Exenteration (N‐12)
25%
80%
0%
SURVIVAL
• Survival rate in LPE is better as compared to LAE .
• Because of physiologically weaker cervicovescical fascia cancerous cells tends tocervicovescical fascia ,cancerous cells tends to invade bladder more frequently compared to rectum.
Comparison of 5 year Survival Rates Of pelvic exenteration
30%
40%
50%
60%
70%
60% 54%
0%
10%
20%
30% 54%41% 44% 45%
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Robotic Exenteration
• With the advent of da vinci robotic system, many surgeries that would have been done with an abdominal incision are now being performed with minimal invasive techniques using DRS.
• In our institute,since 2009 we performed 10 cases of pelvic exenteration with robotic approach.pp
• Recently we performed first robotic total pelvic exenteration, Our data shows..
• All patients who underwent robotic exenteration were underwent chemoradiations before surgery.
• We have only 3 year survival data of these patients, as we started using robot since 2009.
Robotic Exenteration PRESENT STUDY
(N‐10)ROBOTIC ANTERIOR EXENTERATION
(n‐9)
ROBOTIC TOTAL EXENTERATION
(n‐1)
Median surgical duration 120 mins 150 mins
Median blood loss 100 ml 150 ml
Intra op blood transfusion 0 0
Mean hospital stay 5 5
Immediate post op mortality 0 0
Comparison of world Laparoscopic series
Author(year)
No ofpts
Surgical method
Mean time of procedure
Blood loss Hospital stay
Follow‐up 5 year Survival
Ferennscild(2009)
69 Open exenteration
448 mins 6300 ml 17 days 45%
Maggion(2005)
106 Open exenteration
490 mins 1240 ml 21 days 52%
PRESENTSTUDY
92 LAP.‐82ROBOTIC ‐ 10
180 MINS 200 ML 7 DAYS 26 (16 ‐54 )months 60%
Ferron et al (2006)
7 Laparoscopy‐assisted pelvicexenteration:
6.5 hours less than 500 ml 27 days 14 months2 pts free of disease1 pt local reccurenceexenteration:
2 pts total3 pts anterior2 pts posterior
1 pt local reccurence4 pts died (3 weremetastatic)
Uzan et al (2006)
5 LaparoscopicPelvicexenteration:2 pts total1 pts posterior2 pts anterior
4.5‐9 hours 370 ml 3 pts died (3 weremetastatic)4 pts alive for 11 and 15 months
Ferron et al (2006)
5 Laparoscopy‐assisted pelvicexenteration:1 pts total2 pts anterior
6 hours(range 4.5‐9 h)
less than 500 ml 27 days(13‐33 days)
3‐16 months3 pts free of disease2 pts growing metastatis1 pt died after 8 months
LAPAROSCOPIC ANTERIOR EXENTERATION(VIDEO)
LAPAROSCOPIC POSTERIOR EXENTERATION(VIDEO)( ) Laparoscopic Total Exenteration(VIDEO)
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Robotic Vault excision
Summary
• Exenteration is supposedly a very extensive procedure but it has a definite role in the treatment of cancer cervix
• It gives a distinct chance (20%) of cure to the• It gives a distinct chance (20%) of cure to the patient
• Its offers excellent palliation
References
• Netters Atlas of Anatomy
• J.Pelvic Surgery Sep2002
• Journal of Gynecologic Oncology. 102(2006)513‐516.
• Journalof Minimally Invasive Gynecology 14 682‐• Journalof Minimally Invasive Gynecology. 14, 682‐689 July 2006.
• Journal of Minimal Invasive Gynaecology
• J.of Biomedical Sci, March 2009
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Extreme dissectionExtreme dissectionWhat surgical horizons?What surgical horizons?
David B. Redwine, M.D.Bend, OregonDavid B. Redwine, M.D.Bend, Oregon
PG Course 11141st Global CongressLas Vegas, NVNovember 5, 2012
PG Course 11141st Global CongressLas Vegas, NVNovember 5, 2012
The painted hills, John Day, Oregon The painted hills, John Day, Oregon
DisclosureDisclosure
I have no financial relationships to discloseI have no financial relationships to disclosedisclose.disclose.
ObjectiveObjective
ObjectivesObjectives
Demonstrate unusual and difficult dissections in the surgical treatment of endometriosisDemonstrate unusual and difficult dissections in the surgical treatment of endometriosisin the surgical treatment of endometriosisin the surgical treatment of endometriosis
Describe the rationale behind such dissectionsDescribe the rationale behind such dissections
As a resultAs a result
Attendees may augment their surgical skill set for better surgical care of their patientsAttendees may augment their surgical skill set for better surgical care of their patients
Extreme dissection
Most often required in excision of endometriosisMost often required in excision of endometriosis
S i l t t t f d t i iS i l t t t f d t i iSurgical treatment of endometriosis demands complete freedom within the abdominal and thoracic cavities
Surgical treatment of endometriosis demands complete freedom within the abdominal and thoracic cavities
Surgical treatment of endometriosis is excellent training for everything elseSurgical treatment of endometriosis is excellent training for everything else
Extreme dissection
Surgical treatment of endometriosis is excellent training for everything else
angiolysis
Surgical treatment of endometriosis is excellent training for everything else
angiolysisangiolysis
neurolysis
intestinal resections
urological resections
diaphragmatic resections
angiolysis
neurolysis
intestinal resections
urological resections
diaphragmatic resections
Did I missany organsystems?
Did I missany organsystems?
Extreme dissection
If you can excise endometriosis anywhere laparoscopically, you can treat anything everywhere laparoscopically
If you can excise endometriosis anywhere laparoscopically, you can treat anything everywhere laparoscopicallyy p p yy p p y
If you can’t excise endometriosis laparoscopically, learn how to do it at laparotomy.
If you can’t excise endometriosis laparoscopically, learn how to do it at laparotomy.
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Extreme dissectionImportant principles of severe endometriosis:Important principles of severe endometriosis:
Ovarian endometriosis carries a higher risk of:Ovarian endometriosis carries a higher risk of:- more extensive pelvic involvement- intestinal involvement- more extensive pelvic involvement- intestinal involvementPositive scans of endometriomas are misleading – there is more disease!Positive scans of endometriomas are misleading – there is more disease!If you plan to treat only ovarian disease, you will leave a lot of disease behindIf you plan to treat only ovarian disease, you will leave a lot of disease behind
Extreme dissectionImportant principles of severe endometriosis:Important principles of severe endometriosis:
Obliteration of the cul de sac:Obliteration of the cul de sac:
M h th dh i blM h th dh i blMuch more than an adhesive problemMuch more than an adhesive problem
Signifies invasive disease of the uterosacral ligaments, cul-de-sac and anterior rectum
Signifies invasive disease of the uterosacral ligaments, cul-de-sac and anterior rectum
Some type of rectal surgery in >70%Some type of rectal surgery in >70%
Extreme dissection
Three examplesThree examples
Di h ti d t i iDi h ti d t i i
Umbilical endometriosisUmbilical endometriosis
Diaphragmatic endometriosisDiaphragmatic endometriosis
Intestinal endometriosisIntestinal endometriosis
Schematic of obliterated cul de sac dissection
Redwine DB, J ReprodMed, 1992
Extreme dissectionRectosigmoidresectionRectosigmoidresection
Ultimate nerve sparingUltimate nerve sparing
mesenterymesentery
Extreme dissectionDiaphragmatic resectionDiaphragmatic resection
headhead
Symptomatic disease is always on posterior diaphragm behind liverSymptomatic disease is always on posterior diaphragm behind liver
Umbilical portUmbilical port
Right costal marginRight costal margin
headhead
feetfeet
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Extreme dissectionDiaphragmatic resectionDiaphragmatic resection
Do pelvic, intestinal surgery first
Left lateral decubitus positionLeft lateral decubitus position
Allows liver to fall away from diaphragmAllows liver to fall away from diaphragm
Extreme dissectionDiaphragmatic resectionDiaphragmatic resection
full thickness resection requiredfull thickness resection required
~ 5 mm ~ 8 - 10 mm
END OF STORYEND OF STORYEND OF STORYEND OF STORY
ReferencesRedwine DB. Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertil Steril 1991; 56:628-34.
Redwine DB. Laparoscopic en bloc resection for treatment of the obliterated cul de sac in endometriosis. J Reprod Med 1992;37:695-8.
Redwine DB. Ovarian endometriosis: A marker for more severe pelvic and intestinal
Redwine DB. Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertil Steril 1991; 56:628-34.
Redwine DB. Laparoscopic en bloc resection for treatment of the obliterated cul de sac in endometriosis. J Reprod Med 1992;37:695-8.
Redwine DB. Ovarian endometriosis: A marker for more severe pelvic and intestinal pdisease. Fertil Steril 1999;73:310-5.
Redwine DB, Wright J. Laparoscopic treatment of obliteration of the cul de sac in endometriosis: Long term followup. Fertil Steril 2001;76:358-65.
Peireira R, Zanatta A, Redwine DB. The feasibility of laparoscopic bowel resection performed by a gynecologist to treat endometriosis. Curr Opin Obstet Gynecol 2010, 22:344 – 53.
pdisease. Fertil Steril 1999;73:310-5.
Redwine DB, Wright J. Laparoscopic treatment of obliteration of the cul de sac in endometriosis: Long term followup. Fertil Steril 2001;76:358-65.
Peireira R, Zanatta A, Redwine DB. The feasibility of laparoscopic bowel resection performed by a gynecologist to treat endometriosis. Curr Opin Obstet Gynecol 2010, 22:344 – 53.
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Extreme Situation in Oncology
Professor Christophe Pomel
Professor in Oncology and General SurgeryJean Perrin Cancer Centre, France
Faculty of MedicineAuvergne University , Clermont‐Ferrand, France
INSERM UNIT 990
I have no financial relationships to disclosedisclose
Laparotomy / laparoscopy and
extreme situation in surgical oncology
Gynaecologist oncologist surgeons have to deal with dramatic amount of variety
of disease And various anatomical areas
From the top of the diaphragm till the vulva
Size of the Mass/TumourAnd also nature of the tissue are extremely variable in the
field of GYNAECOLOGIC MALIGNANCIES.
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With One objectiveCLean the disease / O residual tumour Furthermore dissection after
‐chemo‐radiation
chemotherapy alone is sometime‐chemotherapy alone is sometime extremely difficut
Operation in early stages is very different than operating on pre-irradiated tissue.
The majority of laparoscopy procedures in oncology are for early stage disease
Patients benefits:Patients benefits:
--less blood loss.less blood loss.--less scar.less scar.less painless pain--less pain.less pain.
--Short hospital stay.Short hospital stay.--quick recovery.quick recovery.
« the laparoscopic approach to radical prostatectomy has become widespread
with several technical variations»
Trabulsi, GuillonneauLaparoscopic radical prostatectomy J Urol 2005Laparoscopic radical prostatectomy.J Urol. 2005 Apr;173(4):1072-9. Review. 1000 cases…
・Zheng SB, Liu CX, Xu YW.Laparoscopic radical cystectomy and sigmoid colon orthotopic neobladder reconstruction: report of 26 cases
20
Three randomized studies of colo-rectal cancer treated by laparoscopy without
compromising survival
Ka Lau Leung et al. Scopy VS Tomy
Lancet 2004; 363: 1187-91
(203 versus 200)
Lacy AM et alLacy AM et al.
Lancet 2002; 359: 2224-29 (111 versus 108)
Clinical Outcomes of Surgical Therapy Study Group.N Engl J Med. 2004 May 13;350(20):2050-9.
872 patientes de 48 institutions!!!
Because the laparoscopy was use in the anterior part of the pelvis by the urologist, the posterior part by the
l t l t t d tcolorectal surgeons, we started to perform laparoscopic pelvic
exenteration in 2002
We started doing pelvic exenterations in 2002.
All patients were operated after failure of chemo rad treatmentof chemo-rad treatment
- abdominal MRI- thoracic Scan- TEP Scan
The procedure
Confection of the ileal loop conduit
21
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•Pomel C and Castaigne D.•Laparoscopic hand assisted Miami Pouch following laparoscopic anterior pelvic exenteration.•Gynecol Oncol. 2004 May; 93 (2): 543-545 Posterior exenteration with illeal diversion.
C. Pomel, R. Rouzier, M. Pocard, A. Thoury, L. Sideris, P. Morice et al.Laparoscopic total pelvic exenteration for cervical cancer relapseGynecol Oncol, 91 (3) (2003), pp. 616–618
G. Ferron, D. Querleu, P. Martel, B. Letourneur, M. Soulié Laparoscopy-assisted vaginal pelvic exenterationGynecol Oncol, 100 (3) (2006), pp. 551–555
G. Ferron, T.Y. Lim, C. Pomel, M. Soulie, D. Querleu Creation of the miami pouch during laparoscopic-assisted pelvic exenteration: the initial experienceInt J Gynecol Cancer, 19 (3) (2009), pp. 466–470
E. Lambaudie, F. Narducci, E. Leblanc, M. Bannier, G. Houvenaeghel Robotically-assisted laparoscopic anterior pelvic exenteration for recurrent cervical cancer: report of three first casesGynecol Oncol, 116 (3) (2010), pp. 582–583
A. Martinez, T. Filleron, L. Vitse, D. Querleu, E. Mery, G. Balague et al.Laparoscopic pelvic exenteration for gynaecological malignancy: is there any advantage?Gynecol Oncol, 120 (3) (2011), pp. 374–379
Laparoscopic pelvic exenteration for advanced pelvic cancers: A review of 16 casesShailesh Puntambekar et al.Gynecol Oncol. 2006 Sep;102(3):513-6. Epub 2006 Feb 28
23
before…
after…
1 No technique limits with laparoscopy for cervical cancer treatment whatever the stage.
2 They are still ergonomic and volume limits.
Tumor of more than 10 cm
Laparosocpy and pelvic exenterations
Previous large abdominal surgery with strength adherences.
Obesity (BMI>31)
Vaginal reconstruction and the use of laparoscopy
???
LIMITATIONS OF LAPAROSCOPY
G Ferron et al, GOF January 2012, 43–47
The need of plastic surgery in exenteration ...
LIMITATIONS OF LAPAROSCOPY
Isolated pelvic perfusion S Bonvalot (Gustave Roussy Institute)
LIMITATIONS OF LAPAROSCOPY
Vascular resection for gynaecological malignancies
-Vena cava
LIMITATIONS OF LAPAROSCOPY
-Internal iliac vessels
-Common and/or Extenal iliac vessels
24
Vascular resection for cervical cancer relapse
Inferior cavectomy
Inferior C-+avectomy
Vascular resection for ovarian cancer relapse
Lateral extension of resection: Okabaiashy
Vascular resection for ovarian cancer relapse
Lateral extension of resection:
25
LEER
Resection of common and external iliac vessels
Ileo‐ureteric plasty
OVARIAN CANCER The need of upper abdomen expertise
26
HIPEC and ovarian cancer
?
Sugarbaker and colleagues7 cases of laparoscopic intra-peritoneal hyperhermic chemotherapy
EJSO: sept 2006
Gynaecologist oncologist surgeons are always touching the boundaries of other speciality…
They are in facts dealing with
…General surgery, urology, colorectal surgery, vascular
CONCLUSIONS
g y, gy, g y,surgery, plastic surgery and … medical oncologist…
It is still an utopia to consider that all Gyn Onc cancer can be treated by full laparoscopic approach
27
The Philosophy of Extreme
A. Wattiez, M. Puga, J. Albornoz, E. Faller A. Wattiez, M. Puga, J. Albornoz, E. Faller
Disclosure• Consultant: VECTEC, Karl Storz Germany
What is extreme?What is extreme?
definition
P ti i ti t di t ti i t i Participating or tending to participate in a very dangerous or difficult task
Video 1 Para ver esta película, debedisponer de QuickTime™ y de
un descompresor .
28
definition
Participating or tending to participate in a very dangerous or difficult sport
Being in or attaining the greatest or highest degree
definition
highest degree
• Understand
......to reach the limit
• Strategy & Rules
• Training
To Understand
think!
Laparoscopy is more than just another surgical route....
29
Vision is powerVision is power
ErgonomyErgon = Work Nomos = Law
Strategy & Rules Strategy
Why?• Keep your assitant
• Improve Vision
Para ver esta película, debedisponer de QuickTime™ y de
un descompresor H.264.
• Improve surgical performance
• Save Time
30
g
g
Train hard
Do not underestimate training!
definition
Extending far beyond the norm
.......To push the limits.......To push the limits
HOW?Fantasy
Courage
Innovation
Conviction
PerseverancePerseverance
Humility
......but
if you don’t try you’ll never know!
Surgery is 75% cerebral and 25% manualSurgery is 75% cerebral and 25% manual
31
Surgery cannot be unpredictable .....
Dissection is the Pivot step of surgery• Surgery is a succession and/or an addition of basicactions.
• These single actions are not very «smart», but they acttogether or interact to create sophisticated surgicalactions.
Para ver esta película, debedisponer de QuickTime™ y de
un descompresor .
Para ver esta película, debedisponer de QuickTime™ y de
un descompresor .
•These surgical actions can be named «emergent»because they transcend the complexity of their originalentity.
•Only«the surgical emergence» is an art, because itstightly depends on the surgeon’s capacity.
video
Thank you for your attention!Thank you for your attention!
A. WATTIEZ / A. VÁZQUEZ / S. MAIA / J. ALCOCER
32
What Is Behind My Extreme Attitude
DR SHAILESH PUNTAMBEKARDR .SHAILESH PUNTAMBEKARMD
ASSOCIATE PROFESSORMEDICAL DIRECTOR
GALAXY CARE LAPAROSCOPY INSTITUTE ,PUNE , INDIA
Disclosure
• I have no financial relationships to disclose.
Going back to roots
Basic training as surgeon.
Trained as a cancer surgeon at Tata Memorial i l b i f 989 993Hospital,Mumbai from 1989‐1993.
Mindset
• One sees what the mind wants to see
• The famous TMH philosophy‐
India
• Cancer Cervix is still the numero uno among female cancers
• Large number of cancer cervix patients
i i l• No screening system in place yet
• Radiation facilities available at few centers
• State of art facilities available in big cities
Indian scenario:• Ca cervix kills one Indian every 7 minutes.
• Three‐quarters of the world's burden of cervical cancer falls on developing countries such as India.
• Late presentation is predominantly due to both inadequate knowledge and lack of effectiveinadequate knowledge and lack of effective screening, especially in rural areas.
• In developing countries more than three‐fourths of these cancers are diagnosed in advanced stages with poor prospects for long‐term survival and cure.
33
Surgical Philosophy
• Screening and diagnostic facilities poor
• Less awareness for the disease
• Many patients presented in advanced stage of h dithe disease
Surgical Philosophy
• Chemotherapy and radiation therapy second options
• Anterior CT+RT was not available
di l h h h• Hence Radical surgery was the chosen path
Surgical practices
• Thus exenterative procedures were very common
• This was duly followed in my practice after passing outpassing out
• Thus in 12 years of open surgical practice‐more than 60 exenterations done
Evolution of laparoscopic radical hysterectomy
• The philosophy and the surgical skills were already developed before embarking on laparoscopy.
• In 2004 first laparoscopic radical• In 2004 ,first laparoscopic radical hysterectomy was done by us.
• Opposition to this procedure came from most established centers doing open radical hysterectomies
• Two things that my Guru taught me‐
‐”Surgery takes place in the mind and is just executed on the table!”
”S i b i i‐”Science progresses more by opposition than by appreciation!”
The urge to match the outcome to that of open surgery and make laparoscopic radical hysterectomy a duplicable procedure‐
BIRTH OF PUNE TECHNIQUE!BIRTH OF PUNE TECHNIQUE!
34
A new Era
• Gone are days of” big surgeons –big incisions”
• Current philosophy‐ “big surgeons‐small incisions”
i id h h ld f• Innovations ride on the shoulders of technology.
• Next three years‐
• Completed more than 250 lap radical hysterectomies
i f h b i h• Downstaging of the tumor by anterior chemo‐radiation‐more patients in operable stages
• Patients with central recurrences after completing chemo‐radiation were referred
Reaching a plateau
After doing a considerable no of lap radical hysterectomies‐
• The confidence levels increased
• An excellent trained team was in placeAn excellent trained team was in place
• Advanced optics and energy sources available
• Better understanding of lap anatomy‐ like the only structures to be preserved were the ureters and the external iliac vessles.
<Picture anatomy>
Indian Scenario
• Radical surgeries being done@ TMH
• Open surgical experience
• With large numbers‐ standardization of l i h i dlaparoscopic techniques and steps
• Natural progression to the next step‐exenterative procedures
• First laparoscopic exenteration‐an anterior exenteration
WORLD SCENARIO
• Involvement of contiguous organs‐a contraindication for laparoscopy.
• Serosal involvement‐ contraindication for laparoscopylaparoscopy.
• Postchemo/radiotherapy‐ patients presented with resectable diseases.
35
The world scene
• By 2005‐ only two case reports of laparoscopic exenteration available in literature‐
‐by Pommel et al
Pomel C, Rouzier R, PocardM, Thoury A, Sideris L, Morice P et al. Laparoscopic total pelvic exenteration for cervical cancer relapses. Gynecol Oncol 2003; 91: 616-618
World Scene
• Increased importance to quality of life
• Demanding patients
• Technological advances‐better i i b iinstrumentation, energy sources, better optics
The next summit
• High volumes and experience of open exenterative procedures‐
‐the idea of laparoscopic exenterations was bornborn.
• We started with anterior exenterations‐graduating to
‐ posterior exenterations
‐ Total pelvic exenterations
• After successfully completing a good number of laparoscopic exenterations, the robotic exenterations followed with equal success
The confidence and competence
• Surgical confidence is
‐directly proportional to surgical competence
‐inversely proportional to complications.inversely proportional to complications.
• As the competence grew
‐ the confidence grew
‐the complications reduced
• Alexander Brunschwig gave the the world message to do anterior exenterations
• Pune brought the laparoscopic exenteration to the world live telesurgery @ the AAGLthe world – live telesurgery @ the AAGL annual conference in 2010
36
Which is the next summit
• The ideal urinary diversion
• Natural orifice surgery
• ?single port surgery
The mission
• What America believes in‐
‐reproducibility
• Thus what starts as anecdotal grows into a i d d dseries and as more and more centers adapt
the procedure‐ will be an accepted procedure!
References
• Netters Atlas of Anatomy
• J.Pelvic Surgery Sep2002
• Journal of Gynecologic Oncology. 102(2006)513‐516.
• Journalof Minimally Invasive Gynecology 14 682‐• Journalof Minimally Invasive Gynecology. 14, 682‐689 July 2006.
• Journal of Minimal Invasive Gynaecology
• J.of Biomedical Sci, March 2009
37
What is behind my extreme attitude?
David B. Redwine, M.D.Bend, OregonDavid B. Redwine, M.D.Bend, Oregon
PG Course 11141st Global CongressLas Vegas, NVNovember 5, 2012
PG Course 11141st Global CongressLas Vegas, NVNovember 5, 2012
DisclosureDisclosure
I have no financial relationships to discloseI have no financial relationships to disclosedisclose.disclose.
ObejectiveObejective
ObjectivesObjectives
Describe the journey I’ve taken to become an über surgeonDescribe the journey I’ve taken to become an über surgeonüber surgeon über surgeon
Explain why I undertook this journeyExplain why I undertook this journey
As a resultAs a result
Attendees may decide whether to take such a journey for themselvesAttendees may decide whether to take such a journey for themselves
What is behind my extreme attitude?
Simplicity of treating endometriosisSimplicity of treating endometriosis
1. Woman has disease1. Woman has disease
2 Disease causes pain ? infertility2 Disease causes pain ? infertility2. Disease causes pain, ? infertility2. Disease causes pain, ? infertility
3. No medicine eradicates disease3. No medicine eradicates disease
4. Surgeon removes disease4. Surgeon removes disease
What could be more simple?What could be more simple?
What is behind my extreme attitude?
CorollariesCorollaries
Medicine treats only symptomsMedicine treats only symptoms
Surgery treats the diseaseSurgery treats the diseaseSurgery treats the diseaseSurgery treats the disease
Medical therapy is a cliché “Why don’t doctors treat the disease instead of just the symptoms?” The Public at Large
Medical therapy is a cliché “Why don’t doctors treat the disease instead of just the symptoms?” The Public at Large
What is behind my extreme attitude?
Lupron treatment of endometriosisLupron treatment of endometriosis
By one year after stopping treatment:By one year after stopping treatment:
62% have not returned to baseline E262% have not returned to baseline E2
50% have E2 < 10050% have E2 < 100
12.5% have E2 < 2012.5% have E2 < 20
Is long-term ‘improvement’ at expense of ovarian function?Is long-term ‘improvement’ at expense of ovarian function?
M84-042M84-042
38
What is behind my extreme attitude?
Lupron treatment of endometriosisLupron treatment of endometriosis
M92-878M92-878
12 months Rx
Norethindrone lessened but did not eliminate this racial differenceNorethindrone lessened but did not eliminate this racial difference
What is behind my extreme attitude?
Lupron-only x 6 months treatment of endometriosisLupron-only x 6 months treatment of endometriosisPlacebo rate with Lupron: 5% - 14%, depending on symptomPlacebo rate with Lupron: 5% - 14%, depending on symptom
M86-031M86-031
46% require narcotics during time of peak Lupron efficacy46% require narcotics during time of peak Lupron efficacy
100% of patients completing Rx require OTC or narcotic meds during treatment100% of patients completing Rx require OTC or narcotic meds during treatment
Dropout rate due to side effects: 9.4%Dropout rate due to side effects: 9.4%
What is behind my extreme attitude?
Lupron-only x 6 months treatment of endometriosisLupron-only x 6 months treatment of endometriosis
The symptom responding best is dysmenorrhea, a uterine symptomThe symptom responding best is dysmenorrhea, a uterine symptom
M86-031, M86-039M86-031, M86-039
Between 42% and 73% of patients still had pelvic pain or tenderness at final check during maximum Lupron effect M86-031, M86-039
Between 42% and 73% of patients still had pelvic pain or tenderness at final check during maximum Lupron effect M86-031, M86-039
What is behind my extreme attitude?
Lupron treatment of endometriosisLupron treatment of endometriosis
Many other major ‘data management problems’Many other major ‘data management problems’
M84-042M86-031M86-039M90-471M91-601M92-878M97-777M86-050
M84-042M86-031M86-039M90-471M91-601M92-878M97-777M86-050
Original proprietary studies which brought Lupron to market.Original proprietary studies which brought Lupron to market.
Now under federal court seal atrequest of Abbott Labs.Now under federal court seal atrequest of Abbott Labs.
WHY?WHY?
The “D” is silent
DISTRIBUTION RESTRICTEDDISTRIBUTION RESTRICTEDDISTRIBUTION RESTRICTEDDISTRIBUTION RESTRICTED
What is behind my extreme attitude?
“Ablation” of endometriosis“Ablation” of endometriosis
Vascular adhesions Carbon
Persistent endometriosis
39
What is behind my extreme attitude?
“Ablation” of endometriosis“Ablation” of endometriosis
No follow-up in reoperated patientsNo follow-up in reoperated patients
No path reportNo path report
Illogical for treatment of deep endometriosisIllogical for treatment of deep endometriosis
Can’t always treat superficial endometriosisCan’t always treat superficial endometriosis
no evidence of efficacy in eradication or reduction of disease – symptoms only
no evidence of efficacy in eradication or reduction of disease – symptoms only
“Ablation” can’t treat deep or intestinal endometriosis safely
Superficial endometriosis
Obturator Obturator
Fibrosis around nerve
Fibrosis around nerve
nervenerve
Nodule ofendometriosisNodule ofendometriosis
? I thought you said it was superficial? I thought you said it was superficial
Ablation of endometriosis
Converts all disease into superficial disease in the
surgeon’s mind
Converts all disease into superficial disease in the
surgeon’s mindsurgeon s mindsurgeon s mind
Excision reveals the truthExcision reveals the truth
In the beginning . . .
Before danazolBefore danazol
Before GnRH agonistsBefore GnRH agonists
Before progestinsBefore progestins
Before birth control pills
Before aromatase inhibitorsBefore aromatase inhibitors
Before anti-angiogenicsBefore anti-angiogenics
Before laserBefore laser
Before electrocoagulationBefore electrocoagulation
There was excision. There was excision. And it was good.And it was good.
HOW GOOD?HOW GOOD?HOW GOOD?HOW GOOD?
40
Let’s talk about “CURE”
Cure (n): 1. a complete or permanent solution or Cure (n): 1. a complete or permanent solution or remedy2. a process or method of curing remedy2. a process or method of curing
How to prove cure of endometriosis?
Symptom relief? Symptom relief?
Pregnancy in infertile women? Pregnancy in infertile women?
NO Pain symptoms can be due to non-endometriotic syndromes.Absence of symptoms doesn’t prove absence of disease.
NO Pain symptoms can be due to non-endometriotic syndromes.Absence of symptoms doesn’t prove absence of disease.
Reoperation after medical/surgical treatment? Reoperation after medical/surgical treatment?
NO Infertility can be due to non-endometriotic issues.Successful pregnancy doesn’t prove absence of disease.
NO Infertility can be due to non-endometriotic issues.Successful pregnancy doesn’t prove absence of disease.
YESReoperation is the only way to judge if disease is present or absent YESReoperation is the only way to judge if disease is present or absent
CURE = absence of disease at reoperationCURE = absence of disease at reoperation
Absence of endometriosisat reoperation:
If not CURE, then what should we call it? If not CURE, then what should we call it?
Remission? Remission? NO - endometriosis is supposed to recur with the next menses NO - endometriosis is supposed to recur with the next menses pppp
Occult endometriosis? Occult endometriosis? NO - you can’t diagnose endometriosis by its absenceNO - you can’t diagnose endometriosis by its absence
Occult advanced cancer? Occult advanced cancer? NO - this makes as much sense as diagnosing endometriosis by its absenceNO - this makes as much sense as diagnosing endometriosis by its absence
Recurrence after LAPEX
11 359359 00 00 359.0 359.0 1010 0.028 0.028 33 0.008 0.008 0.028 0.028 0.008 0.008 1.67 1.67 1.331.3322 349349 1717 00 340.5 340.5 1111 0.0320.032 55 0.015 0.015 0.059 0.059 0.023 0.023 1.40 1.40 2.202.2033 321321 00 1515 313.5 313.5 99 0.0290.029 55 0.016 0.016 0.086 0.086 0.038 0.038 2.80 2.80 2.402.4044 297297 11 3030 281.5 281.5 1111 0.039 0.039 44 0.014 0.014 0.122 0.122 0.052 0.052 1.75 1.75 2.502.5055 255255 00 2727 241.5 241.5 33 0.0120.012 22 0.008 0.008 0.133 0.133 0.060 0.060 2.50 2.50 3.003.0066 225225 00 2222 214.0214.0 77 0.0330.033 11 0.005 0.005 0.161 0.161 0.064 0.064 2.00 2.00 4.004.0077 196196 00 1111 190.5190.5 44 0.0210.021 33 0.016 0.016 0.179 0.179 0.079 0.079 2.67 2.67 3.003.0088 181181 11 1818 171.5171.5 88 0.0470.047 44 0.023 0.023 0.217 0.217 0.101 0.101 2.00 2.00 2.502.5099 154154 00 2222 143.0143.0 55 0.0350.035 22 0.014 0.014 0.2450.245 0.113 0.113 1.001.00 1.001.00
1010 127127 11 1616 118.5118.5 33 0.025 0.025 22 0.0170.017 0.2640.264 0.1280.128 1.50 1.50 2.002.001111 107107 00 1818 98.098.0 55 0.051 0.051 22 0.0200.020 0.3000.300 0.146 0.146 1.00 1.00 1.001.001212 8484 11 1616 75.575.5 11 0.013 0.013 11 0.0130.013 0.3100.310 0.157 0.157 3.00 3.00 1.001.001313 6666 00 2424 54 054 0 00 0 0000 000 00 0 0000 000 0 3100 310 0 1570 157 0 000 00 0 000 00
Column 11: Cumulative persistence/recurrence rateColumn 11: Cumulative persistence/recurrence rate
0.60.6
0.50.5
Redwine, DB. Fertil Steril 1991;56:628-34.
Wheeler, MalinakWheeler, Malinak1313 6666 00 2424 54.054.0 00 0.000 0.000 00 0.000 0.000 0.310 0.310 0.157 0.157 0.000.00 0.000.001414 4242 11 99 37.037.0 00 0.000 0.000 00 0.000 0.000 0.310 0.310 0.157 0.157 0.00 0.00 0.000.001515 3232 00 44 30.030.0 00 0.000 0.000 00 0.000 0.000 0.310 0.310 0.157 0.157 0.000.00 0.000.001616 2828 00 22 27.027.0 11 0.037 0.037 00 0.000 0.000 0.336 0.336 0.157 0.157 0.00 0.00 0.000.001717 2525 00 55 22.522.5 11 0.044 0.044 11 0.044 0.044 0.366 0.366 0.194 0.194 1.00 1.00 1.001.001818 1919 00 44 17.017.0 00 0.000 0.000 00 0.000 0.000 0.3660.366 0.194 0.194 0.000.00 0.000.001919 1515 00 11 14.514.5 00 0.000 0.000 00 0.000 0.000 0.366 0.366 0.194 0.194 0.00 0.00 0.000.002020 1414 11 11 13.013.0 00 0.000 0.000 00 0.000 0.000 0.3660.366 0.194 0.194 0.00 0.00 0.000.002121 1212 00 33 10.510.5 00 0.000 0.000 00 0.000 0.000 0.366 0.366 0.194 0.194 0.000.00 0.000.002222 99 00 11 8.58.5 00 0.000 0.000 00 0.000 0.000 0.37 0.37 0.19 0.19 0.00 0.00 0.000.002323 88 00 00 8.08.0 00 0.0000.000 00 0.000 0.000 0.37 0.37 0.19 0.19 0.00 0.00 0.000.0024 24 88 00 11 7.57.5 00 0.0000.000 00 0.000 0.000 0.37 0.37 0.19 0.19 0.00 0.00 0.000.002525 77 00 00 7.0 7.0 00 0.000 0.000 00 0.000 0.000 0.37 0.37 0.19 0.19 0.000.00 0.000.002626 77 00 00 7.07.0 22 0.286 0.286 00 0.000 0.000 0.55 0.55 0.19 0.19 0.00 0.00 0.000.00
2727++ 55 00 00 5.05.0 00 0.000 0.000 00 0.000 0.000 0.55 0.55 0.190.19 0.000.00 0.00 0.00
23 23 8181 3535
1 2 3 4 5 6 7 8 9 10 11 12 16 17 21 22 26+1 2 3 4 5 6 7 8 9 10 11 12 16 17 21 22 26+Quarters post op
0.40.4
0.30.3
0.20.2
0.10.1
0.00.0 *
*
* ** ******
* RedwineRedwine**
*
***
* * *
Endometriosis: conservative excision at laparotomy
““ . . . recurrence is not . . . recurrence is not frequent, and frequent, and curecure . . . . . . by conservative surgery by conservative surgery
““ . . . recurrence is not . . . recurrence is not frequent, and frequent, and curecure . . . . . . by conservative surgery by conservative surgery y g yy g yis usual.is usual.””
y g yy g yis usual.is usual.””
Joe Vincent Meigs (1892 Joe Vincent Meigs (1892 -- 1963)1963)Joe Vincent Meigs (1892 Joe Vincent Meigs (1892 -- 1963)1963)
J. V. MeigsJ. V. MeigsObstet Gynecol 2:46,1953Obstet Gynecol 2:46,1953J. V. MeigsJ. V. MeigsObstet Gynecol 2:46,1953Obstet Gynecol 2:46,1953
Published CURE rates following excisionPublished CURE rates following excision
As judged among reoperated patients:As judged among reoperated patients:As judged among reoperated patients:As judged among reoperated patients:
66%66% cured by laparotomy excisioncured by laparotomy excision
Wheeler, Malinak. Contr Obstet Gynecol 1987;16:13Wheeler, Malinak. Contr Obstet Gynecol 1987;16:13--2121
66%66% cured by laparotomy excisioncured by laparotomy excision
Wheeler, Malinak. Contr Obstet Gynecol 1987;16:13Wheeler, Malinak. Contr Obstet Gynecol 1987;16:13--2121
57%57% cured by laparoscopy excision*cured by laparoscopy excision*
Redwine DB. Fertil Steril 1991; 56:628Redwine DB. Fertil Steril 1991; 56:628--3434
57%57% cured by laparoscopy excision*cured by laparoscopy excision*
Redwine DB. Fertil Steril 1991; 56:628Redwine DB. Fertil Steril 1991; 56:628--343457%57% cured by laparoscopy excisioncured by laparoscopy excision57%57% cured by laparoscopy excisioncured by laparoscopy excision
(No post op medical therapy routinely in any series)(No post op medical therapy routinely in any series)(No post op medical therapy routinely in any series)(No post op medical therapy routinely in any series)
56% cured by laparoscopy excision
Abbott et al. Fertil Steril 2004;82:878 - 84
56% cured by laparoscopy excision
Abbott et al. Fertil Steril 2004;82:878 - 84
* DISEASE REDUCTION IN MOST OF THE OTHERS* DISEASE REDUCTION IN MOST OF THE OTHERS
57%57% cured by laparoscopy excisioncured by laparoscopy excision
Varol et al. JAAGL 2003:10;182Varol et al. JAAGL 2003:10;182--99
57%57% cured by laparoscopy excisioncured by laparoscopy excision
Varol et al. JAAGL 2003:10;182Varol et al. JAAGL 2003:10;182--99
60% cured by laparoscopy excision
Roman JD, JMIG 2010;17:42 - 6.
60% cured by laparoscopy excision
Roman JD, JMIG 2010;17:42 - 6.
41
Evidence-based medicine:
1. Bad1. Bad
2. Not good
3. Good
4. Pretty darn good
5. Darn good
Excision of endometriosis is 5. Darn good!
Excision of endometriosis is 5. Darn good!
EXCISION IS THE ONLY THERAPY
EXCISION IS THE ONLY THERAPY
PROVEN TO CURE ENDOMETRIOSIS
PROVEN TO CURE ENDOMETRIOSIS. .
Excision of endometriosis -the gold standard Endometriosis surgeon
Has to be able to treat disease anywhere
PelvisBowelPelvisBowelBowelBladderUreterDiaphragmThoraxUmbilicusSkinProstate
BowelBladderUreterDiaphragmThoraxUmbilicusSkinProstate
Endometriosis surgery
individual über-surgeon
vs
individual über-surgeon
vs
multi-disciplinary teammulti-disciplinary team
What is best for the patient?What is best for the patient?
Endometriosis surgery
Individual surgeon – surgical privileges required
Bowel
Urological
Individual surgeon – surgical privileges required
Bowel
UrologicalUrological
Gyn
Diaphragmatic
Urological
Gyn
Diaphragmatic
42
Endometriosis surgery
Individual surgeon – advantagesIndividual surgeon – advantages
M i i i l t thM i i i l t th
Focused, highly specialized skill set is developedFocused, highly specialized skill set is developed
Less need for preop scansLess need for preop scans
Less need for coordination of officesLess need for coordination of offices
Maximum experience is always at the operating tableMaximum experience is always at the operating table
Endometriosis surgery
Individual surgeon – disadvantages
Surgery can be exhausting
Sense of isolation
ff
Individual surgeon – disadvantages
Surgery can be exhausting
Sense of isolation
ffDifficult to gain credentials
Politically incorrect
Difficult to gain credentials
Politically incorrect
Endometriosis surgery
Multi-disciplinary team – advantages
General non-gyn skill set is available
Generic experience in non-gyncases
Multi-disciplinary team – advantages
General non-gyn skill set is available
Generic experience in non-gyncasescases
Other specialties usually available for pre- or intra-operative consult
Politically correct thing to do
Safe for the surgeons
cases
Other specialties usually available for pre- or intra-operative consult
Politically correct thing to do
Safe for the surgeonsIs it best for the patient?Is it best for the patient?
Endometriosis surgeryAd-hoc multi-disciplinary team – disadvantagesAd-hoc multi-disciplinary team – disadvantages
A general surgeon may want to do an intestinal diversion for seromuscular lacerationA general surgeon may want to do an intestinal diversion for seromuscular laceration
When simple suture repair is bestWhen simple suture repair is best
The care you planned for your patient can be hijackedThe care you planned for your patient can be hijacked
Others may want to remove the pelvic organs and leave the endometriosis inOthers may want to remove the pelvic organs and leave the endometriosis in
A urologist may just want to do a psoas hitchA urologist may just want to do a psoas hitchWhen segmental resection/anastomosis is bestWhen segmental resection/anastomosis is best
When removal of all endometriosis is bestWhen removal of all endometriosis is best
Endometriosis surgery
Best for the patient:
Excision of all disease by a dedicated multi-disciplinary team
or
Best for the patient:
Excision of all disease by a dedicated multi-disciplinary team
oror
by an Über-surgeon
or
by an Über-surgeon
If not by laparoscopy, then by laparotomyIf not by laparoscopy, then by laparotomy
Endometriosis surgery
Phrases to avoid:Phrases to avoid:
“Let’s not do such aggressive surgery, it will cause adhesions which might cause infertility.”“Let’s not do such aggressive surgery, it will cause adhesions which might cause infertility.”
Initial laparoscopic view
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Endometriosis surgeryPhrases to avoid:Phrases to avoid:“Let’s not do such aggressive surgery, it may cause injury. After all – PRIMUM NON NOCERE (Hippocrates)”
“Let’s not do such aggressive surgery, it may cause injury. After all – PRIMUM NON NOCERE (Hippocrates)”
What I actually said was:“The physician must . . . have What I actually said was:“The physician must . . . have
Hippocrates 460 BC – 370 BCHippocrates 460 BC – 370 BC
p ytwo special objects in view with regard to diseases, namely, to do good or to do no harm.”
p ytwo special objects in view with regard to diseases, namely, to do good or to do no harm.”
Redwine, GooglingEndometriosis: The lost centuries 2012
Redwine, GooglingEndometriosis: The lost centuries 2012
Endometriosis surgery
Phrases to avoid:Phrases to avoid:“It’s not really necessary to do all that aggressive surgery when good medical treatment is available.”“It’s not really necessary to do all that aggressive surgery when good medical treatment is available.”
“We’ll clean up any residual disease with Lupron ”“We’ll clean up any residual disease with Lupron ”
Medicine treats only symptoms, not the diseaseMedicine treats only symptoms, not the disease
We ll clean up any residual disease with Lupron.We ll clean up any residual disease with Lupron.
“There are dense adhesions in the cul-de-sac. This patient must have had an STD.”“There are dense adhesions in the cul-de-sac. This patient must have had an STD.”
“If you would just get pregnant, it would help your disease a lot. Most women are cured by pregnancy.”“If you would just get pregnant, it would help your disease a lot. Most women are cured by pregnancy.”
Lupron no better than bcps - Vercellini et al, 1993; Guzick et al 2011Lupron no better than bcps - Vercellini et al, 1993; Guzick et al 2011
This is complete obliteration of CDS with invasive endometriosis!!This is complete obliteration of CDS with invasive endometriosis!!
Pregnancy does not eradicate endometriosisPregnancy does not eradicate endometriosis
Endometriosis surgery
Phrases to avoid:Phrases to avoid:“I’m sorry I can’t talk with you anymore now, I have to run and deliver a baby, and you know how babies are –they won’t wait. My nurse will explain what’s next.”
“I’m sorry I can’t talk with you anymore now, I have to run and deliver a baby, and you know how babies are –they won’t wait. My nurse will explain what’s next.”
Y ’t d it llY ’t d it ll
“We are going to do definitive surgery for your endometriosis. We’re going to remove your uterus, tubes and ovaries. The endometriosis will just shrivel up and go away.”
“We are going to do definitive surgery for your endometriosis. We’re going to remove your uterus, tubes and ovaries. The endometriosis will just shrivel up and go away.”
You can’t do it allYou can’t do it all
The uterus, tubes and ovaries are uncommonly involved by endometriosis. Most disease will be left behind. Sampson 1940, Redwine,
1987 Aromatase problem
The uterus, tubes and ovaries are uncommonly involved by endometriosis. Most disease will be left behind. Sampson 1940, Redwine,
1987 Aromatase problem
Endometriosis surgery
Endometriosis is the only benign disease which is Endometriosis is the only benign disease which is gtreated surgically by removal of something else.
gtreated surgically by removal of something else.
Redwine, 1994Redwine, 1994
ReferencesSampson JA.The development of the implantation theory for the origin of peritoneal endometriosis. Am J Obstet Gynecol 1940;40:549 – 57.
Redwine DB. The distribution of endometriosis in the pelvis by age groups and fertility. FertilSteril 1987;47:173-5.
Redwine DB. Endometriosis persisting after castration: Clinical characteristics and results of surgical management. Obstet Gynecol 1994;83:405-13.
Vercellini P et al. A GnRH agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis Fertil Steril 1993;60:75 9
Sampson JA.The development of the implantation theory for the origin of peritoneal endometriosis. Am J Obstet Gynecol 1940;40:549 – 57.
Redwine DB. The distribution of endometriosis in the pelvis by age groups and fertility. FertilSteril 1987;47:173-5.
Redwine DB. Endometriosis persisting after castration: Clinical characteristics and results of surgical management. Obstet Gynecol 1994;83:405-13.
Vercellini P et al. A GnRH agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis Fertil Steril 1993;60:75 9associated with endometriosis. Fertil Steril 1993;60:75-9.
Guzick DS et al. Randomized trial of leuprolide versus continuous oral contraceptives in the treatment of endometriosis-associated pelvic pain. Fertil Steril 2011;5:1568 – 73.
Redwine DB. Googling Endometriosis: The lost centuries. 2012 https://www.createspace.com/3949764
TAP/Abbott Laboratories. M84-042, M86-031, M86-039, M90-471, M91-601, M92-878, M97-777, M86-050 Under federal court seal
Redwine DB. Leuprolide: The “d” is silent. 2011 Restricted distribution.
associated with endometriosis. Fertil Steril 1993;60:75-9.
Guzick DS et al. Randomized trial of leuprolide versus continuous oral contraceptives in the treatment of endometriosis-associated pelvic pain. Fertil Steril 2011;5:1568 – 73.
Redwine DB. Googling Endometriosis: The lost centuries. 2012 https://www.createspace.com/3949764
TAP/Abbott Laboratories. M84-042, M86-031, M86-039, M90-471, M91-601, M92-878, M97-777, M86-050 Under federal court seal
Redwine DB. Leuprolide: The “d” is silent. 2011 Restricted distribution.
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WHAT IS BEHIND MY EXTREME ATITUDE
Professor Christophe Pomel
Professor in Oncology and General SurgeryJean Perrin Cancer Centre, France
Faculty of MedicineAuvergne University , Clermont‐Ferrand, France
INSERM UNIT 990
I have no financial relationships to disclose.disclose.
Extreme attitude need the addition of
‐Multidisciplinary approach++
‐Quality control
Example of ovarian cancer
Only patient with complete resection can expect an acceptable 5 year overal survival rate.
Vergote I, Tropé CG, Amant F, Kristensen GB, Ehlen T, Johnson
N, et al. Neoadjuvant chemotherapy or primary surgery in stage
IIIC or IV ovarian cancer. N Engl J Med 2010;363:943—53.
Chi DS, Musa F, Dao F, Zivanovic O, Sonoda Y, Leitao MM, et al. An analysis of patients with bulky advanced stage ovarian, tubal, and peritoneal carcinoma treated with primary debulking sur‐ gery (PDS) during an identical time period as the randomized EORTC‐NCIC trial of PDS vs neoadjuvant chemotherapy (NACT).
Gynecol Oncol 2011
Complete surgery is the goalThe so called « optimal surgery » should be avoid.
This is also true for sarcoma, colorectal, etc…
Pomel C, Barton DP, McNeish I, Shepherd J. A statement for extensive primary cytoreductive surgery in advanced ovarian cancer. BJOG 2008;115:808—10.
Zapardiel I, Morrow CP. New terminology for cytoreduction in advanced ovarian cancer.Lancet Oncol 2011;12:214.
To reach that objective a various important technical surgical action are to be considered.
« agressivness and complexity of surgery must stay in keeping with both morbidity and quality of life issues»
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Lymphadectomy / no lymphadenectomy (benedetti et al.) Complete / uncomplete
Quality of peritonectomies in all areas…Quality of posterior pelvic exenteration : « one block resection»
46
Quality control
Whatever extent of the disease and surgeon’s expertise, complete resection is not always possible
Preoperative assessment ++p
MRI, CT, PET, … laparoscopy ?
Quality Control
Patient’s status? Evaluation of resectabilityOncogeritry, anesthetic, nutrition…
Will both patient and family accept the surgery and consequences? Per and postoperative morbidity, lost of function and autonomy, nutrition…
Need for multidisciplinary approach with high level of expertise +++Radiologist, radiotherapist, medical oncologists, gyn onc…
Appropriate hospitalPer operative team, ITU…
‐ CA 125 = WHAT IS THE CUT OFF VALUE = 500 iu/ml 1000 iu/ml ?
‐ IN THE NEAR FUTURE : GENOMIC ANALYSIS BY DNA CHIPS ?
( Berchuck 2004)
Role of biology in the future ?Role of biology in the future ?Role of biology in the future ?Role of biology in the future ?
SUBOPTIMAL DEBULKING
NON RESECTABLE ?
Role of C.T. SCAN (ovarian cancer)Role of C.T. SCAN (ovarian cancer)Role of C.T. SCAN (ovarian cancer)Role of C.T. SCAN (ovarian cancer)
J Clin Oncol. 2007 Feb 1;25(4):384-9. Multi-institutional reciprocal validation study of computed tomography predictors of suboptimal primary cytoreduction in patients with advanced ovarian cancer.Axtell AE, Lee MH, Bristow RE, Dowdy SC, Cliby WA, Raman S, Weaver JP, Gabbay M, Ngo M, Lentz S, Cass I, Li AJ, Karlan BY, Holschneider CH.
CT ?CT ?CT ?CT ?
Résécable Non résécable
ROLE +++ of laparoscopy for preoperative assessment of peritoneal resectability
As HIPEC procedure…
Laterza et al. In Vivo. 2009 Jan-Feb;23(1):187-90.
47
Avantage of laparoscopy
1 Simple procedure
2 biopsies
PCI scopy = PCI tomy
-Small bowel-omentum-pelvis -Anterior part of the diaphragm-Parieto-colic gutters
Pitfalls of laparoscopy
PCI scopy < PCI tomy
-Fixed omentum-Infiltration of posterior aspect of the diaphragm-Suprahepatic vessels -POsterior aspect of the porta-Lesser sac-Coeliac trunck
PCI index (Sugarbaker)/
Photos-videos
Behind my extreme attitude CONCLUSION
Contract of good practice:
Appropiate Human ressources and hospital :
-Hospital (ITU / 24H imaging availability …)
-Doctors :
Radiologist, Pathologist, Surgeons with vascular, urologic, colorectal expertises., medical / Gyn-onc
« Surgery for advanced gynaecological cancer
is not a limites to gynaecological surgery »
Appropriate management and MDT (including medical alternatives)
Balance the decision
« quality of life / quantity of life »
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CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as
the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians
(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which
recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).
California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws
identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org
Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from
discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national
origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the
program, the importance of the services, and the resources available to the recipient, including the mix of oral
and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.
Executive Order 13166,”Improving Access to Services for Persons with Limited English
Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,
including those which provide federal financial assistance, to examine the services they provide, identify any
need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.
Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every
California state agency which either provides information to, or has contact with, the public to provide bilingual
interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.
~
If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.
A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.
US Population
Language Spoken at Home
English
Spanish
AsianOther
Indo-Euro
California
Language Spoken at Home
Spanish
English
OtherAsianIndo-Euro
19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%
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