10.1586/ERA.13.2 395ISSN 1473-7140© 2013 Expert Reviews Ltdwww.expert-reviews.com

Meeting Report

The World Congress of the International Association of Surgeons, Gastroenterologists and Oncologists (IASGO) convenes annually to provide current information on the diagnosis and management of gastrointestinal (GI) diseases. Nicholas J Lygidakis (Athens Medical Centre, Athens, Greece) founded IASGO in 1988 with the objective of globalization of medical knowledge relating to the diagnosis and treat-ment of benign and malignant diseases of the alimentary tract. The 22nd World Congress of IASGO was held from 5–8 December 2012 at the Shangri-La Hotel, Bangkok, Thailand and was hosted by the Congress President, Nopadol Wora-Urai. Masatoshi Makuuchi (Japanese Red Cross Medical Center, Tokyo, Japan) opened the congress as President of IASGO by ringing a ceremonial gong. Themed ‘Challenges and

Controversies in the Management of Abdominal Diseases: Current Possibility and Future Expectation’, the congress featured ten main top-ics including: upper GI tract surgery; lower GI tract surgery; hepatic surgery; biliary tract sur-gery; pancreatic surgery; interventional chemo-immuno-radiotherapy; laparoscopic endoscopic surgery; multidisciplinary approaches; innova-tion and advanced technology and robotic sur-gery. Approximately 200 guest speakers were invited to share their experiences and expertise while 600 abstracts were submitted for oral and poster presentations. Live surgery was also included in this comprehensive program.

Esophageal cancerKen-Ichi Mafune from the Mitsui Memorial Hospital in Japan spoke about the treatment

Michael Bouvet* and Jason K SicklickThe Department of Surgery, University of California, San Diego, CA, USA*Author for correspondence: Tel.: +1 858 822 6191 Fax: +1 858 822 6192 mbouvet@ucsd.edu

The World Congress of the International Association of Surgeons, Gastroenterologists and OncologistsBangkok, Thailand, 5–8 December 2012

The 22nd World Congress of the International Association of Surgeons, Gastroenterologists and Oncologists was held from 5–8 December 2012 in Bangkok, Thailand. Themed ‘Challenges and Controversies in the Management of Abdominal Diseases: Current Possibility and Future Expectation’, the congress featured ten main topics including: upper GI tract surgery, lower GI tract surgery, hepatic surgery, biliary tract surgery, pancreatic surgery, interventional chemo-immuno-radiotherapy, laparoscopic endoscopic surgery, multidisciplinary approaches, innovation and advanced technology and robotic surgery. Approximately 200 guest speakers were invited to share their experiences and expertise, while 600 abstracts were submitted for oral and poster presentations. In this article, the authors highlight and summarize some of the presentations from this conference.

Management of abdominal malignancies: updates from the International Association of Surgeons, Gastroenterologists and OncologistsExpert Rev. Anticancer Ther. 13(4), 395–397 (2013)

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Meeting Report

for esophageal cancer over a 30-year period at his institution. Five-year overall survival rates after esophagectomy were 21.3% in 1976–1981, 32.4% in 1988–1990, 38.8% in 1991–1996, 60.8% in 1997–2004 and 58.8% in 2005–2012. The outcome after esophagectomy was remarkably improved after 1997. This improvement may be due to earlier detection of esophageal cancer and improvement in adjuvant (or neoadjuvant) chemotherapies. In addition, this one can hypothesize that better imaging modali-ties may have improved patient selection over time. Moreover, decreased incidences of the cervical and the upper mediastinal recurrences, as well as the efficacy indexes of lymphadenectomy suggest the importance of wide-range lymphadenectomy, defined as D3 according to the Japanese N-grouping system for thoracic esophageal cancer.

Jean-Marie Collard (Saint-Luc Academic Hospital, Brussels, Belgium) reported that over the last 30 years, the Japanese-like technique of esophageal resection has progressively been mas-tered with a continuous increase in life expectancy for esophageal cancer patients. The 5-year survival rate after esophagectomy for curative intent increased from 8 (1978) to 25% (1986) followed by 35 (1990), 42 (1994), 49 (2001) and 56% (2010) in each respective year. Meanwhile, several original surgical techniques have been invented at Collard’s institution including the semi-mechanical anastomosis technique in the neck, as well as three novel esophageal substitutes including the whole stomach trans-plant, the antrally-innervated stomach transplant and the distal ileum transplant.

Mohamed ElMakki Ahmed (Department of Surgery, Faculty of Medicine, University of Khartoum, Khartoum, Sudan) spoke about the current status and management of esophageal can-cer on the African continent. The disease is more common in sub-Saharan Africa, east and South Africa. Tobacco and alcohol consumption are documented as major etiological factors, while dietary intake of maize is a causative agent in South Africa. In Sudan, this disease accounts for 60% of GI cancers. Surgical treatment is confronted with logistic issues, limited experience, and unfit, debilitated patients. In turn, they have high mortal-ity rates ranging between 10 and 20%. Confounding this issue, chemoradiotherapy, a rather expensive treatment, is not available in most African countries, while palliative esophageal stenting is unaffordable. As a result, feeding jejunostomy has become the most common major palliative procedure [1].

Several authors gave perspectives on the use of robotics for esophagectomy including robotic-assisted transhiatal esophagec-tomy being preformed by surgeons from the USA [2], and robotic-assisted surgery for thoracic esophageal cancer currently being carried out in Japan [3]. Such techniques may allow for better visualization of critical structures during surgery and a quicker recovery time for patients.

Pancreatic cancerChristian Partensky of the International Agency for Research on Cancer in Lyon, France, offered perspectives on biologic contro-versies in the long-term survival (LTS) of patients following resec-tion of pancreatic ductal adenocarcinoma carcinoma (PDAC) [4].

The traditional explanation for improving LTS associated with PDAC is that surgery is the optimal approach for removing all cancerous cells located within the primary tumor and satellite lymph nodes, while putative undetectable extrapancreatic can-cerous cells are absent or killed by neoadjuvant and/or adjuvant chemotherapy. An alternative model envisions metastases as an inherent feature of PDAC that occurs early in its natural history. Arguments for this model are that cancerous cells can be isolated in the bloodstream prior to the formation of any identifiable pri-mary tumor; very small pancreatic tumors may have undergone microscopic metastasis prior to surgical removal and cancerous cells undergo epithelial-to-mesenchymal transition in which they lose their epithelial characteristics and acquire invasive properties with stem cell-like features. This new insight into the biology of PDAC highlights the fact that tumor biology is a robust determi-nant of LTS but it also provides important new insights into the mechanisms for developing newer, and potentially more optimal, therapeutic strategies.

Akimasa Nakao from the Department of Surgery at Nagoya Central Hospital in Japan shared his technique of the mesen-teric approach in isolated pancreaticoduodenectomy (PD) with a superb video presentation [5]. Before manipulation of the pancre-atic head, all arteries that supply the pancreatic head region are ligated and divided. This includes the inferior pancreatoduodenal artery (IPDA) arising from the superior mesenteric artery (SMA) and the gastroduodenal artery arising from the common hepatic artery. All veins draining the pancreatic head are also ligated and divided. A Kocher’s maneuver is not performed. To achieve this, the mesentery of the ligament of the Treitz is incised hori-zontally to the lower border of the second portion of the duode-num. All tissues other than the mesenteric veins and arteries are excised towards the mesenteric root. The mesenteric root lymph nodes and the right semicircular nerve plexus around the SMA are included in the resection. Histological diagnosis of cancer invasion to the connective tissue around the SMA is determined by frozen section. The jejunal artery and IPDA are exposed, and the IPDA is ligated and divided. After the mesenteric approach is completed, lymph node dissection is undertaken from the hepatic hilar region to the proper hepatic artery and common hepatic artery. The gastroduodenal artery is ligated and divided. If the superior mesenteric vein or portal vein is invaded by can-cer, venous resection is undertaken with catheter bypass of the portal vein. Isolated PD can thus be completed. The mesenteric approach allows resection from the non-cancerous side and facili-tates cancer-free surgical margins. These mesenteric approach procedures are the most important part of isolated PD.

Hepatobiliary surgeryHenri Bismuth, Director of the Hepatobiliary Institute (Villejuif, France), spoke about the practice of hepato-pancreatic-biliary (HPB) surgery and the formation of the HPB Surgeons. He retold the evolution of our understanding of liver anatomy since Glisson’s description in 1634 to the earliest descriptions of sectors by Couinaud in 1954 [6]. In 1957, Goldsmith and Woodburne linked liver anatomy with liver resection for first time [7]. Bismuth

Bouvet & Sicklick

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went on to help popularize the Couinaud anatomy [8]. Thus, the first pillar of liver surgery he emphasized was the impor-tance of achieving a perfect knowledge of liver anatomy. With this in mind, the second pillar of liver surgery is intraopera-tive ultrasound which allows the surgeon to not only to local-ize the tumor(s), but to also visualize the vessels because the relationship(s) between the tumor(s) and the vessels dictate how to achieve anatomical resections and to spare liver. Similarly, in his presidential address, Makuuchi extolled the importance of technical excellence in liver surgery. Without strong knowledge of anatomy and the inability to perform and interpret intra-operative liver ultrasound, such operations are not possible. With this working knowledge in place, patient selection is achieved according to many factors including: age of the patient, status of the liver parenchyma (normal, steatotic, fibrotic or cirrhotic), the biology of the disease, as well as the number, location and size of the tumor(s) relative to the vascular inflow and outflow of the liver segments. The technology of liver resection has widely expanded to include ultrasonography, ultrasonic dissectors, argon beam coagulation, radiofrequency devices and bipolar sealing devices, as well as even Cell Saver® (Haemonetics Corporation, MA, USA) and extracorporal circulation [9].

With the evolution of technology, several surgeons advanced the field by presenting their experiences such as Rawisak Chanwat (Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand) who presented ‘Total Laparoscopic Right Hepatectomy for Large Hepatoma using the Glissonian Pedicle Control with Anterior Approach’, and Junichi Shindoh (Department of Surgery Graduate School of Medicine, University of Tokyo, Tokyo, Japan) who presented ‘Image-Guided HPB Surgery: A Next Step from 3D Simulation to Real-Time Navigation’. The new liver surgeon must be a specialist in liver anatomy, ultra-sonography, vascular surgery, microsurgery, laparoscopic surgery and of course, knowledgeable of hepatology and oncology.

Several novel techniques for improving outcomes after liver surgery were presented. Norihiro Kokudo (Department of Surgery, University of Tokyo, Japan) spoke about advanced liver resection using indocyanine green (ICG) fluorescence [10].

Classically, the ICG clearance test has been used to estimate liver functional reserve before hepatectomy. Recently, the ICG technique has been applied to hepatobiliary surgery, not only for visualization of the bile ducts (fluorescent cholangiography), and for intraoperative identification of liver cancers and liver segments to be removed. ICG-fluorescent imaging is expected to serve as a navigation tool, which can provide a road map of the extrahepatic bile ducts, liver cancer and liver segments during liver resection.

SummaryWe have briefly highlighted several of the advances presented at 22nd World Congress of the IASGO. We are clearly seeing improvements in the diagnosis and treatment of alimentary tract diseases, as we learn more about surgical anatomy, gain insight into tumor biology and see technological advances in surgical equipment and techniques. We are now at a precipice where perhaps our technique may portend the biology, rather than vice versa.

In summary, 20 years after its inception, the IASGO is a vibrant, strong and influential body of surgeons, gastro-enterologists, hepatologists, oncologists, endoscopists, lapa-roscopists, pathologists and radiologists, from over 90 different countries worldwide and with over 1700 members. The annual IASGO congresses, continuing medical education postgradu-ate training courses, the journal Hepato-Gastroenterology and the IASGO website contribute to the worldwide provision of the latest medical knowledge and expertise. The 23rd World Congress of the IASGO will be held in Bucharest, Romania, on 18–21 September 2013.

Financial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

References1 Abdelgadir MA, Mahadi SE, Nasr AO,

Ahmed ME. Role of jejunostomy feeding catheter as a model for nutritional support. Int. J. Surg. 8(6), 439–443 (2010).

2 Galvani CA, Gorodner MV, Moser F et al. Robotically assisted laparoscopic tran-shiatal esophagectomy. Surg. Endosc. 22(1), 188–195 (2008).

3 Seto Y, Mori K, Yamagata Y. I. Esophagus 2. Thoracoscopic oesophagectomy and robot-assisted surgery of esophageal cancer. Gan To Kagaku Ryoho. 39(9), 1341–1344 (2012).

4 Partensky C. Pancreatic surgery in France. Surg. Today 40(10), 895–901 (2010).

5 Nakao A, Kanzaki A, Fujii T et al. Correlation between radiographic classification and pathological grade of portal vein wall invasion in pancreatic head cancer. Ann. Surg. 255(1), 103–108 (2012).

6 Couinaud C. Lobes et segments hepatiques. Presse Med. 62, 709–712 (1954).

7 Goldsmith NA, Woodburne RT. Surgical anatomy pertaining to liver resection. Surg. Gynecol. Obstet. 195, 310–318 (1957).

8 Bismuth H. Revisiting liver anatomy and terminology of hepatectomies. Ann. Surg. 257(6), 383–386 (2013).

9 Mattos RO, Linhares MM, Matos D et al. Liver re-transplantation: internal validation of a predictive mathematical model of survival. Hepatogastroenterology 59(116), 1230–1233 (2012).

10 Satou S, Ishizawa T, Masuda K et al. Indocyanine green fluorescent imaging for detecting extrahepatic metastasis of hepatocellular carcinoma. J. Gastroenterol. (2012).

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