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SOFT TISSUE AND SKIN 1. Amputations 3 2. Retroperitoneal sarcoma excisions 6 3. Extremity sarcoma excisions 4 4. Excision of skin cancers 3 5. Excision of pelvic tumour 1 Total 17 BREAST CANCER 1. Radical mastectomies 3 2. Modified radical mastectomies (MRM)17 3. Breast conservation surgery 1 4. Breast reconstructions 2 Total 23 RECONSTRUCTION 1. Deltopectoral flaps 2 2. Pectoralis major myocutaneous flaps 8 3. Lattissmus dorsi flaps 2 4. Local rotation flaps 11 5. Abee / Estlander flaps 2 6. Radial forearm flaps 2 Total 27 RESULTS Though majority of the tu-mors taken up for surgery (>75%) were in advanced stage but curative resec-tions were performed in almost 90% of patients and in only 11% palliative surgery could be possible. All these 21 patients (11%) in the palliative group belonged to G.I. cancer (G-B. and Pancreatic Cancers). All the procedures were performed by standard operative techniques. There were no intraoperative complication such as neurovascular injury or injury to vital structures etc, in any of the patients. The average infra operative blood requirement was 2 units. Our hospital does not have postoperative ward/surgical ICU so all the patients were managed in General Surgical Ward and only 2% of the patients needed respiratory intensive care. There were 9 perioperative deaths. Cause of deaths were pulmonary embolism, septicemia, metabolic acidosis and myocardial infarctions. None of the patients died due to haemorrhage. 17 (9%) patients had postoperative complications like haemo-rrhage (n=4), Anastomotic leak (n=6), orocutaneous fistula (n=2), flap necrosis (n=2) and wound sepsis (n=3), but all these patients were salvaged. DISCUSSION Medical Science is rapidly progressive with vast informations, therefore needs multiple divisions to understand and utilize it properly. Oncology itself is a vast subject and modern management of cancer is a multi-modality approach by surgical, medical and radiation oncologists. In development countries like USA outcome of cancer management is totally different as compared to our country. As per the American Cancer Society among all cancers overall 80% of the cancer patients survive for at least 5 years while 60% of the patients are cured of their disease in their country. Specialised services in cancer surgery is one of the factors behind such good results. Following points highlights the need for oncologic surgeon in cancer management. 1. Cancer is a disease which affects every organ of the body and to understand its pattern of occurrence, progress, behaviour and response to therapy needs devotions and dedication which Is only possible by an oncologist not by every speciality surgeon or general surgeon. 2. Majority of the cancers usually presents in the advanced stage and surgical management is not only difficult but also time consuming the results are poor as compared to surgery of the non-cancerous diseases. This leads to a gradual liking for non-cancerous surgery and aversion for malignancy among the individuals surgeons of different specialities. On the contrary cancer management needs devotion and more expertise by the surgeons for better results. 3. Existing speciality division of the surgery are anatomically based rather than disease based and there is a separate speciality surgeon for every anatomical division. This pattern is defective in the context of cancer management. 4. Major cancer surgery for many cancers involves resections of the different anatomical/speciality regions, and reconstructions- For example surgical management of hypopharyngeal cancers involves surgery of the neck, thorax and abdominal region, which is possible either by the involvement of three speciality surgeons or will not be done. Similarly complete cytoreduction for ovarian tumours involves upper abdominal and pelvic surgery in addition to the removal of uterus and ovary which is not possible by General Gynaecologist alone. Involvement and coordination of more than one surgeon is impractical and such surgeries either incompletely done or not at all done. 5. Anatomically intermediate and overlapping areas between two specialities of the surgery remain overlooked by both the specialists, for example cancers of the head and neck are neither covered properly by ENT surgeon, Dental surgeon or General Surgeon. Ultimately such approach leads to inadequate training for major oncologic resections and reconstruction in general surgery and different surgical specialities. 6. Most of the non-oncologic surgeons are interested in operative part of cancer management and has no concept of multimodality approach. The patients referred to the radiation or medical oncologist only if surgeon do not found themself comfortable with the operative management or after performing the surgery, without knowing the correct need of adjunct therapy. Also the follow-up policies are very poor, rather this important part of cancer management is left on the radiation oncologist. Non-oncologic surgeons do not have the concepts of salvage surgery for post radiotherapy or post surgery recurrence. In this bargain patients usually shunts between surgeon and radiotherapist or chemotherapist and lost the precious time ultimately resulting into poor outcome of cancer management. In the present analysis the surgical oncologist have been considered better at the following steps of cancer management. A. Diagnosis Surgical oncologist was helpful in solving diagnostic problems of unknown or occult primary and suspicious lesions and was able to make prompt clinical diagnosis with minimum investigations, On the other hand desired diagnostic/staging/ metastatic workup was properly done curtailing unnecessary investigations by the oncologist compared to other surgeons. B. Treatment Planning Proper multimodality approach including neoadjuvant/adjuvant therapy was planned at the beginning in all the cases and optimistic approach rather than passimistic/or gloomy view was adopted for advanced cancers. Assessment of tumour extent and technical operability was also better by the surgical oncologist and many patients who were referred surgery by other surgeon on technical grounds were operated successfully. More patients were considered for surgery where other surgeons do not found the indications. C. Surgical technique Surgical oncologist was more confident, successfully handled all the intraoperative problems and performed radical but precise surgery by standard surgical steps with minimum intrao-perative complications, Vessels, Nerves and other vital structures were dissected/demonstrated and saved whenever indicated which was not practiced by most of the general surgeons even in the commonly performed surgeries like MRM, parotidectomy and thyroidectomy. D. Range of surgery performed More than 50% of the surgeries performed by surgical oncologist were not being attempted by other surgeons which mainly include head and neck, thoracic, pelvic and major soft tissue resection. E. Follow-up This important aspect of cancer management is overlooked by the non oncologic surgeons. In the present study regular follow-up with appropriate clinical examination and workup was done in all the cases and salvage therapy was provided whenever required. In our operative series, 29 patients were post surgery or post radiotherapy recurrence who were satisfactorily operated. Conclusion Many general surgeons wish to be surgical oncologist but do not want to leave non cancer benign surgery which is improper. For best results the surgical oncologist should exclusively be doing the oncology work so that he shall be able to concentrate fully on cancer patients. On the other hand developing surgical oncology as a separate speciality does not mean that other surgeons should not do the oncology work rather the routine oncologic surgeries should continue to be done by general surgeons. Cancer is a rapidly progressive disease and therefore cancer patients should not compete with other non cancer patients for their turn in OPD, admission to hospital and operation theatre, this problem can be solved to some extent by creating separate speciality for their management. Therefore we conclude that at major treatment center surgical oncology should be developed as a separate speciality area which will be helpful in, 1. Providing expert consultation for unusual or difficult oncologic patient problems. 2. Providing unique surgical expertise in the area unfamiliar to general surgeons like major soft tissue resections, head and neck cancers, thoracic cancers and pelvic exentrations etc. 3. Organising clinical research protocols for surgical oncology patients. 4. Organising surgical oncology teaching programmes for staff, residents and students. |
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