Department of general and abdominal surgery ARTMED MRC

Department of general and abdominal surgery “ARTMED” MRC

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Articles

Standard and multivisceral colectomy in locally advanced colon cancer

Artur M. Sahakyan, Andranik Aleksanyan, Hovhannes Batikyan, Hmayak Petrosyan, Mushegh А. Sahakyan
Department of Surgery ,N1, Yerevan State Medical University after M.Heratsi, Yerevan, Armenia
Department of General and Abdominal Surgery, ArtMed MRC, Yerevan, Armenia
Clinic of Surgery, Mickaelyan Institute of Surgery, Yerevan, Armenia
The Intervention Center, Oslo University Hospital Rikshospitalet, Oslo, Norway

Radiol Oncol 2020

Received 21 February 2020

Accepted 30 April 2020

Correspondence to: Mushegh A. Sahakyan, M.D., Ph.D., The Intervention Center, Oslo University Hospital Rikshospitalet, Sognsvannsveien 20, 0424 Oslo, Norway;

Background. Management of locally advanced colon cancer (LACC) is challenging. Surgery is the mainstay of the treatment, yet its outcomes remain unclear, especially in the setting of multivisceral resections. The aim of the study was to examine the outcomes of standard and multivisceral colectomy in patients with LACC. Patients and methods. Patients demographics, clinical and perioperative data of patients operated within study period 2004–2018 were collected. LACC was defined as stage T4 colon cancer including tumor invasion either through the visceral peritoneum or to the adjacent organs/structures. Accordingly, either standard or multivisceral colectomy (SC and MVC) was performed.

Results. Two hundred and three patients underwent colectomy for LACC. Of those, 112 had SC (55.2%) and 91 (44.8%) had MVC. Severe morbidity and mortality rates were 5.9% and 2.5%, respectively. MVC was associated with an increased blood loss (200 ml vs. 100 ml, p = 0.01), blood transfusion (22% vs. 8.9%, p = 0.01), longer operative time (180 minutes vs. 140 minutes, p < 0.01) and postoperative hospital stay (11 days vs. 10 days, p < 0.01) compared with SC.

The complication-associated parameters were similar. Male gender, presence of ≥ 3 comorbidities, tumor location in the left colon and perioperative blood transfusion were associated with complications in the univariable analysis. In the multivariable model, the presence of ≥ 3 comorbidities was the only independent predictor of complications. Conclusions. Colectomy with or without multivisceral resection is a safe procedure in LACC. In experienced hands, the postoperative outcomes are similar for SC and MVC. Given the complexity of the latter, these procedures should be reserved to qualified expert centers. Key words: colectomy; colon cancer; locally advanced; multivisceral; morbidity

Gastrectomy for Metastatic Gastric Cancer: a 15-year Experience from a Developing Country

Published: 29 May 2019

Mushegh А. Sahakyan, Artak Gabrielyan, Davit L. Aghayan, Shushan Yesayan, Hmayak Petrosyan, Аlina Chobanyan, Airazat M. Kazaryan & Artur M. Sahakyan 

Indian Journal of Surgical Oncology volume 10, pages527–534(2019)

Abstract

The role of surgery in the management of metastatic gastric cancer (MGC) remains unclear. The aim of this study was to investigate the surgical and oncologic outcomes of gastrectomy in patients with MGC. The study included prospectively collected data of patients with MGC operated at four medical centers in Yerevan, Armenia, between 2000 and 2014. Armenian National Center of Oncology Registry and hospital records were used to obtain survival data. Factors associated with performing gastrectomy in patients with MGC were analyzed by using the logistic regression model. The Kaplan-Meier method was applied for survival analysis, and the Cox regression model with backward selection was used for multivariate analysis. A total number of 733 patients were operated for gastric cancer including 112 (15.3%) with MGC. Of those, 70 underwent gastrectomy, while 42 had exploratory laparotomy or bypass. Morbidity and mortality were similar after gastrectomy and exploratory laparotomy/bypass (18.6 vs 21.4%, p = 0.71 and 2.9 vs 7.1% p = 0.36, respectively). Female gender, involvement of N1 and/or N2 lymph node stations, and differentiated adenocarcinoma were associated with opting for gastrectomy. Gastrectomy with synchronous resection of distant metastases resulted in postoperative outcomes similar to those following gastrectomy without synchronous organ resection. Median follow-up was 6 months. Eighteen (16.1%) patients received chemotherapy. Median survival following gastrectomy and exploratory laparotomy/bypass were 7 and 4 months (p = 0.015), respectively. The use of chemotherapy following gastrectomy significantly improved survival compared with gastrectomy only (14 vs 6 months, p = 0.01). In the multivariable analysis, chemotherapy and nodal stage correlated with survival after gastrectomy. Gastrectomy for MGC is associated with satisfactory surgical outcomes and can be combined with synchronous resection of distant metastases in selected patients. Gastrectomy results in longer survival compared with exploratory laparotomy/bypass, especially when followed by chemotherapy.

Extended Gastrectomy for T4b Gastric Adenocarcinoma: Single-Surgeon Experience

Published: 21 March 2019

Mushegh А. Sahakyan, Artak Gabrielyan, Hmayak Petrosyan, Shushan Yesayan, Sevak S. Shahbazyan & Arthur M. Sahakyan 

Journal of Gastrointestinal Cancer volume 51, pages135–143(2020)

Abstract

Purpose
This study reports single-surgeon experience with extended gastrectomy including en-bloc resection of adjacent organs/structures for T4b stage gastric adenocarcinoma. Time-related changes in patient selection criteria and outcomes were also analyzed.

Methods
All consecutive gastrectomies for adenocarcinoma performed between May 2004 and December 2017 were extracted from prospectively collected database to study surgical and oncologic results. Time-related changes in outcomes were examined according to three time periods.

Results
Five hundred eighty-seven gastrectomies were performed throughout the study period including 87 (14.8%) extended resections. The latter most often included pancreatosplenectomy, colon, and liver resections (21, 16, and 11 patients, respectively) resulting in similar postoperative outcomes and survival. Extended gastrectomy was associated with larger tumor size (8.4 vs 5.6 cm), performing total gastrectomy (55.2 vs 35.2%, p < 0.01) and increased blood loss (375 vs 150 ml, p < 0.01) compared with standard gastrectomy. Larger experience in extended gastrectomy allowed for expanding patient selection criteria, considering complex resections and extensive lymphadenectomy. Median and 3-year survival following extended gastrectomy for T4b adenocarcinoma were 14 months and 18%, respectively, which was comparable to standard gastrectomy for T4a adenocarcinoma (p = 0.48). Obesity, nodal stage and type of gastrectomy were associated with survival in T4b adenocarcinoma in the univariable analysis. Obesity and N3a and N3b stages were independent predictors in the multivariable model.

Conclusions
Extended gastrectomy for T4b gastric adenocarcinoma provides satisfactory surgical outcomes even with expanded patient selection criteria and regardless of the organ involved. Given its poor prognosis, neoadjuvant therapy should be considered to improve the long-term oncologic results.

Gastrectomy for Gastric Cancer in Patients With BMI ≥ 30 Kg/M²

Mushegh A Sahakyan 1, Sevak S Shahbazyan 2, Aram Martirosyan 1, Artak Gabrielyan 3, Hmayak Petrosyan 3, Artur M Sahakyan 1

American surgeon  volume.86, No2, pages159–163(2020)

Abstract

Obesity is a major health issue in the modern world population and a risk factor for surgical procedures. This study examined perioperative and oncologic results of gastrectomy in obese patients diagnosed with gastric cancer. BMI ≥30 kg/m² was used to designate obesity. Five hundred and one patients were operated throughout the study period (2009-2018). The outcomes in obese patients (n = 205) were compared with those with normal weight (n = 171) and overweight (n = 125). The mean BMI was significantly different between the groups: 21.9 versus 26.7 versus 33.3 kg/m² (P < 0.01), respectively. Obesity was associated with higher incidence of comorbidities, longer operative time, and increased blood loss. Postoperative and short-term oncologic outcomes were similar. Median follow-up was 24 months with similar recurrence rates in the three groups. Median survival was comparable between the normal weight, overweight, and obese patients-36 (27-45) versus 42 (30-53) versus 32 (17-47) months, respectively (P = 0.63). Obesity itself does not deteriorate the surgical outcomes of gastrectomy in patients with gastric cancer. Although technically demanding in obese patients, adequate lymph node yield and satisfactory long-term oncologic outcomes can be achieved in this group.

Summary of referat PhD “The improvement of pre- and intraoperative management in patients with periampullary neoplasms undergoing pancreatoduodenectomy”

M. A. Sahakyan

In generally, the management of periampullary neoplasms requires a complex approach, including surgery and chemo-radiotherapy. However, pancreatoduodenectomy remains the only curative option leading to the relatively satisfactory outcomes. At the same time, the review of the relevant literature revealed a presence of significant controversy concerning such perioperative issues, as preoperative management of patients with jaundice, extent of surgery and technical approaches towards the reconstruction phase. Given these challenges, the improvement of the surgical outcomes problematical to date.

Yerevan, 2016

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Technical aspects of pancreatoduodenectomy for periampullery lesions

Sahakyan M.A., Stepanyan S.A., Gabrielyan A.M., Petrosyan H.P., Akunts A.R., Sahakyan A.M.

Pancreatoduodenectomy (PD) is associated with considerable morbid, ranging from 35 to 40%. Thereby, endeavors to improve surgical technique remain highly relevant. The objective of the study was to analyze different technical approaches to crucial steps of PD, such as an extent of surgery, pancreatic anastomosis and external drainage of pancreatic duct (EDPD).

Medicine Science and Educations. Scientific and informational Journal, Yerevan, 2016, January, N20, p. 51-59.

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Pancreatoduodenectomy: our experience in treatment of patients with periampullary lesions

Sahakyan M.A., Stepanyan S.A., Gabrielyan A.M., Petrosyan H.P., Akunts A.R., Sahakyan A.M.

Surgery by means of pancreatoduodenectomy (PD) is the only curative option for patients with periampullary tumors. However PD is associated with high rates of postoperative morbidity. In this study we report on 79 patients, who underwent PD for periampullary lesions. Postoperative mortality and morbidity were observed in 4 (5,1%) and 31 (39,2%) cases, respectively. The latter included 21 (26,6%) patients with pancreatic fistula, defined according to ISGPF. Median postoperative hospital stay was 12 (7-59) days. Given the results of the report, we assume that PD applicable with satisfactory outcomes also in medium volume centers.

Journal Issues in Theoretical and Clinical Medicine, 2015, v.18, N4 (100), p. 3-7.

Risk factors of the pancreatic fistula following pancreatoduodenectomy

Sahakyan M.A., Stepanyan S.A., Gabrielyan A.M., Petrosyan H.P., Akunts A.R., Sahakyan A.M.

Pancreatjduodebectomy is the mine curative option for patients with periampullary malignancies. Pancreatic fistula is the most common complication after pancreatoduodenectomy, leading to an increase in severe postoperative morbidity, mortality and prolonged length of hospital stay. Besides that, pancreatic fistula results in an increase in hospital costs. The prevent study aimed to analyze the perioperative outcomes in patients undergoing pancreatoduodenectomy in order to identify the specific risk factors for pancreatic fistula after surgery.

The New Armenian Medical Journal Vol.9 (2015), No 4, p. 95-101

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Panreatoduodenectomy in treatment of periampullary tumors

M. A. Sahakyan

This review demonstrates modern approaches to the surgical treatment of preampullary tumors, as well as the pathways in decreasing postoperative morbidity. On the whole, pancreaticoduodenectomy remains the only curative option for this group of patients. Although resent studies have shown advances in treatment strategies, the rate of postoperative complications is still high (30-40%). There is yet much controversy concerning different aspects of treatment, particularly pre-, intra- and postoperative periods. All in all, further research is required to improve the postoperative results after pancreatоduodenectomy.

Medicinski Vestnik Erebouni, 2014; N2(58), p. 25-32

Obstructive jaundice in oncology: surgical correction in elderly patients

Prof. Sahakyan A. M., Gabrielyan A. M., Petrosyan H. P., Berberyan N. G.

We report about the role of surgical correction, such as biliary stenting or biliary drainage in case of mechanical jaundice in elderly patients with periampullary tumors. Our study compared the results of outcomes with or without pre-operative procedures for biliary decompression. Summarizing the results, we’ve concluded that when the level of preoperative bilirubin is not higher than 400mkmol/l, the main surgical procedure can be undertaken without prior biliary decompression. Moreover, biliary stenting or biliary drainage may lead to some complications, affecting on early postoperative results of treatment.

Materials of International Congress Herontosurgery, pg 224-225; 2013

Multivisceral resections in elderly patients with locally advanced gastric cancer

Prof. Sahakyan A. M., Petrosyan H. P., Gabrielyan A. M., Sahakyan M. A.

We evaluated the data of 119 patients with gastric cancer, that have undergone multivisceral resections, particularly the group of elderly patients . The most common locations of tumor invasion were pancreas and transverse colon. The evaluation of postoperative outcomes revealed, that patients will benefit from curative multivisceral resections. Non-curative resections should be indicated only in urgent cases. The advance of surgical technique can improve the early postoperative results of treatment.

Materials of International Congress Herontosurgery, pg 222-224; 2013

Surgical strategies in treatment of elderly patients with gastric cancer

Prof. Sahakyan A. M., Petrosyan H. P.

In this study we have analyzed the data of 691 patients with gastric cancer. The group of elderly patients included 156 cases. Even though in this group the oncological process had much more locoregional and distal spread, the growing volume and frequency of surgical procedures did not increase postoperative morbidity and mortality. We conclude, that age of patient should not be valued as a contraindication for curative resection for patients with gastric cancer.

Materials of International Congress Herontosurgery, pg 198-200; 2013

Resectability of gastric cancer with pancreatic invasion

Prof. Sahakyan A. M., Akunts A. R., Sahakyan M. A.

In this article we evaluate the indicataions of multivisceral resections for patients, who had gastric cancer with pancreatic invasion. It has been reported, that the abandonment of surgery in such cases was mostly connected with the lack of clear intraoperative strategy. Many authors emphasize, that the contraindication for such operations should commonly be the involvement of major vessels.We have proposed the strategy, that will let to evaluate the condition of major vessels und decrease the unnecessary abandonments of surgical procedure.

Materials of International Congress Herontosurgery, pg 220-222; 2013

Combined resections of stomach cancer

A.M. Sahakayan, Avetyan Mamikon

In the review indications to the combined resections for patients with a stomach cancer certain data are presented depending on localization and features of distribution of process, indicators of survival rate and the factors influencing on the prognoses. Indicators in some works, postoperative complications of 31.2 %, a lethality - 13.6 % and 5-year-old survival rate at T4 - 25 %, specify in efficiency en bloc the combined resections. The review testifies to ambiguity of the relation of experts to the combined resections in this connection, workings out in this direction are represented actually for improvement of results of treatment locally invasive of a stomach cancer.

Comparative evaluation of stomach cancer surgical treatment in 71-year-old and older patients

A.M. Sahakayan, H.P. Petrossyan. A.R. Akunc, A.M. Gabrielyan

In the surgical treatment of stomach cancer in elderly and seniie patients, a lot of items are still debatable. The statistics of more than 99 patients hospitalized between the years 1993-2007, aged over 71, regarding their clinical and therapeutical characteristics, are shown in this report. The investigation was done in two groups, those who were hospitalized before 2003 (including 47 observations) and those after 2003 (52 observations).

We find that the distention of surgical indications according to comcomitant diseases, as well as the application of spacious surgical interference in patients with relatively unfavo-urable clinical findings, give us the opportunity to improve the results of surgery and tumor resectability without increasing the rate of postoperative complications and mortality.

Prevention of the arm edema after radical mastectomy

A.M. Sahakyan, A.R. Akunts, G.S. Asilbeky

The possibility of prevention of the arm edema after the surgical treatment of breast cancer with dissection of axillary lymph nodes has been studied Its frequency is 43%. The conducing factors are body weight of patients more than 61 kg, size of the tumour being 3 cm and more, prolonged lymphorrhagia, 3 and more courses of adjuvant chemotherapy, paracentetic method of lymph evacuation from axillary space. The use of Detralex in the dose of 500 mg during 4 months, beginning from the 3rd or 4th day after surgery, made it possible to decrease the frequency of thoracic limb edema up to 18,2%, which is considered to be a great achievement in improving patient's life quality.

Surgery of gastric cancer among elderly population

A. P. Petrosyan

Despite total reduction of incidence of gastric cancer recently, the gastric cancer morbidity is increasing among aging patients who underwent surgery and makes over 20%. The review enlights the current state of gastric cancer in the elderly group Controversy remains in concern of patients' selection for surgery, gastric resection levels, necessity and expandance of regional lymph nodes dissection. Evidently, further recommendations for improvement of surgery outcomes should be worked out for treatment of elderly patients with gastric cancer.

The problem of resectability of advanced distal gastric cancer

A.M. Sahakyan, A. V. Barseghyan, A.R. Akunts

The surgery of advanced gastric cancer remains a serious problem with high level of complications and poor outcome results. A comparative analysis was performed on the base of data of 420 patients with the advanced distal cancer of stomach. Wide application of palliative (both Rl and R2) and combined gastric resections together with extensive lymph dissections D2 lead to significant impro-vement of the indices of resectability up to 75,0%. However, a moderate increase of both the frequency of surgical complications and the mortality rate without reliable statistic difference (12,1% and 18,9%, P>0,05; 7,0% and 12,2%. P>0,05 respectively) have been recorded.

The prophylaxis of thrombotic complications for oncologic patients

Sahakyan A.M., Akunts A.R., Gabrielyan A.M., Asilbekyan G.S.

During the work the contributing factors of thromboembolic disorders and the potentials of preparation "fraxiparin" are studied in their prophylaxis. The elderly age, the row of transferring and concomitant diseases, the level of creatinine 116 mcmol/L and more, palliative or extensive interventions, the duration of the operation more than 3 hours, regional or distant metastasis are risk factors in the development of thromboembolic disorders. The use of fraxiparin allows to lower the frequency of these complications to 1,9+1,3%, compared to 5,7+1,0% , which is significantly low (P<0,05). The preparation is an effective agent in the prophylaxis of postoperative complications for oncologic patients.

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