1. { Upper Abdominal Debulking of Gynecologic Malignancies Shaun McKenzie, MD Assistant Professor of Surgery University of Kentucky

2.  To describe the rationale behind the inclusion of upper abdominal debulking procedures to achieve complete cytoreduction  To review the pertinent anatomy and techniques necessary for upper abdominal debulking  To describe the perioperative outcomes associated with an aggressive upper abdominal approach Objectives

3.  Extensive upper abdominal disease portends aggressive tumor biology precluding a benefit from surgery  The morbidity and mortality of upper abdominal debulking is prohibitive  Lack of comfort in performance of these procedures or lack of appreciation of the biology of these diseases and the importance of optimal cytoreduction Obstacles to an Aggressive Approach

4. Aggressive Surgical Effort and Improved Survival in Advanced Stage Ovarian Cancer  Retrospective analysis of 194 patients  Need for radical surgery did not adversely impact survival  In patients with carcinomatosis, performance of radical surgery was associated with improved survival (44% vs 17%,p<0.001)  The only independent predictor of survival was residual disease Aletti et al. Obstet Gynecol 2006; 107: 77-85

5. Aggressive Surgical Effort and Improved Survival in Advanced Stage Ovarian Cancer Aletti et al. Obstet Gynecol 2006; 107: 77-85

6.  Diaphragmatic procedures: stripping or resection, ABC  Splenectomy with or without distal pancreatectomy  Porta hepatis resection  Liver resection  Cholecystectomy  Gastric resection Upper Abdominal Debulking Procedures

7.  262 consecutive patients  Addition of upper abdominal resections increased OC from 53% to 82%  Required in 1/3 of patients  No difference between complication rate between groups  No survival difference between OC groups with or without upper abdominal debulking Eisenhauer et al. Gynecol Oncol 2006; 103

8. Chi et al. Gynecol Oncol 2009;114

10.  Wide Exposure and thorough organ mobilization  Critical Understanding of the Anatomy, particularly vascular anatomy  Understand the predictable sites of disease  Bring all your toys to the table Principles of Upper Abdominal Debulking

13. Diaphragmatic Procedures Fanfani et al. Gynecol Oncol 2009; 116

14. Is It Safe?  141 eligible patients with 229 EUAS procedures performed  90 % optimally reduced (30% R0)  Grade 3-5 morbidity in 22%  68% of complications managed by a percutaneous procedure  Mortality 1.4% Chi et al. Gynecol Oncol 2010; 119

15.  Optimal Cytoreduction should be the plan of attack for any woman undergoing debulking surgery  The addition of an aggressive approach to upper abdominal disease is associated with increased rates of optimal debulking without a negative impact in cancer outcome  EUAS can be performed safely in experienced centers with a multidisciplinary approach  Adherance to sound surgical principles optimizes outcome Conclusion