Cytoreduction of the small bowel surfaces

Incomplete Cytoreduction of Colorectal Cancer Peritoneal Metastases: Survival Outcomes by a Cytoreduction Score

Background

The surgical management of peritoneal metastases from colorectal cancer has been a topic of controversial discussion for many decades. Peritonectomy and perioperative intraperitoneal chemotherapy added options for surgical treatment of this condition beyond palliative surgery. The most favorable outcomes are recorded when peritoneal metastases from colorectal cancer can be resected to no visible evidence of disease.

Methods

To determine if any benefit from surgical treatment of patients with colorectal peritoneal metastases can occur from incomplete resection of peritoneal metastases, we studied patients by the completeness of cytoreduction (CC) score. The CC-3 indicated a palliative resection, CC-2 gross residual disease, and CC-1 almost complete cytoreduction but visible residual disease. The impact of clinical-, pathologic-, and treatment-related variables on the survival of the three groups was compared.

Results

Eighty-five patients with long-term follow-up were available for study. The median age was 53 years (range 18-82). There were 60 males (70.6%). Symptomatic patients, those with bowel obstruction, and patients with positive retroperitoneal lymph nodes had significantly reduced survival. The median survival of the CC-3, CC-2, and CC-1 groups were significantly different (p = 0.0027). The 2-year or greater survivals of the three groups were 4.8%, 15.1%, and 38.7%, respectively.

Conclusions

If a near complete cytoreduction combined with hyperthermic intraperitoneal chemotherapy can be performed, short-term survival benefit could be observed.

Interval cytoredutive surgery and HIPEC in advanced ovarian cancer with small-bowel disease: results and reflections

INTRODUCTION

Small-bowel involvement in patients with ovarian cancer has been strongly correlated with the possibility of cytoreduction and thus with survival. The main objective of this study was to evaluate the prognostic significance of small-bowel involvement in patients undergoing optimal-complete interval cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

METHODS

We included a series of patients diagnosed with stage IIIC-IVA (pleural effusion) high-grade serous epithelial ovarian cancer and in whom CRS + HIPEC was indicated after neoadjuvant systemic chemotherapy (NACT). The study period extended from January 2008 to January 2020, with a minimum follow-up of 12 months from the inclusion of the last patient. A multivariate analysis using Cox regression allowed us to identify the variables that were independently related to disease-free survival.

RESULTS

A total of 144 patients were selected, 13 (9%) of whom were excluded from the analysis, because their disease was considered unresectable. The study included a series of 131 patients with a median age of 62 years (34-79 years) and a median Peritoneal Cancer Index (PCI) calculated during surgery of 9 (1-35). The median PCI of bowel areas 9-12 (SB-PCI) was 3 (1-10). Performance of a CC-1 cytoreduction (HR: 1.93, 95% CI: 1.02-3.64, p = 0.042) and SB-PCI greater than 3 (HR: 2.25, 95%CI: 1.13-4.48, p = 0.21) were independent factors associated with shorter disease-free survival.

CONCLUSION

Small-bowel involvement, even in patients with a macroscopically complete resection, showed a correlation with worse prognostic outcomes and could be considered as a variable in the postoperative management of these patients.

Peritonectomy of the colonic mesentery. Case report of a new surgical technology

Introduction and importance

Malignant peritoneal mesothelioma is a local-regional disease process that requires a comprehensive treatment plan including complete cytoreductive surgery and regional chemotherapy.

Case presentation

Treatments used in our patient began with a complete cytoreductive surgery. This required visceral resections, parietal peritonectomy, peritonectomy of the small bowel and its mesentery, and a peritoneal resection of the colonic mesentery with sparing of the major vasculature of the large bowel.

Clinical discussion

Peritoneal resection of the colonic mesentery and other treatments were performed in the absence of major complications. A 20-day hospitalization was required. The patient shows no internal hernias and no evidence of disease by CT follow-up at 4 years postoperatively. Her quality of life is excellent.

Conclusions

Malignant peritoneal mesothelioma was in the past a disease of limited survival without effective treatment options. Peritoneal resection of the colonic mesentery may be required for complete cytoreduction. A sequence of cytoreductive surgical procedures and regional chemotherapy treatments has made long-term survival possible.

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Malignant peritoneal mesothelioma has treatment options that combined surgery and regional chemotherapy.

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A major surgical challenge is complete mesenteric peritonectomy.

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Complete cytoreduction of the large bowel mesentery requires its resection with sparing major vasculature.

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Long-term survival is possible with low perioperative morbidity and mortality.

Readmissions after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy-a national population-based study

Background

Comprehensive readmission morbidity studies after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are scarce. This study aimed to investigate readmissions and in-hospital morbidity after CRS and HIPEC.

Methods

The national in-hospital patient register was used to identify patients via the HIPEC ICD code JAQ10 2004–2014. Data were retrieved from the index CRS/HIPEC treatment and from all HIPEC-related readmissions within 6 months. Univariate/multivariate logistical analyses were performed to identify risk factors for reinterventions and readmissions.

Results

A total of 519 patients (mean age 56 years) had a mean hospital stay of 27 days. Within 6 months, 150 readmissions for adverse events were observed in 129 patients (25%) with 67 patients requiring an intervention (13%). Totally 179 patients (34%) required a reintervention during the first 6 months with 85 (16%) requiring a reoperation. Of these 179 patients, 83 patients (46%) did not undergo the intervention at the HIPEC centre. Gastric resection was the only independent risk factor for in-hospital intervention, and advanced age for readmission.

Conclusion

Morbidity causing HIPEC-related readmission was higher than expected with almost half of the interventions occurring outside the HIPEC centre. Gastric resection and high age are independent predictors of morbidity and readmission.

Management of Peritoneal Malignancies

Peritoneal malignancies may result in a widespread disease process, peritoneal carcinomatosis (PC), which has significant morbidity and mortality for patients afflicted by this disease. Dissemination into the peritoneum and throughout the abdomen can be due to a primary peritoneal cancer or other primary malignancies that have metastasized, including (but not limited to) colorectal cancer, gastric cancer, pancreatic cancer, appendiceal cancer, ovarian cancer, and mesothelioma. Patients with gastrointestinal (GI) or gynecologic malignancies with peritoneal carcinomatosis may have dismal survival due to a high disease burden within the abdominal cavity. Some studies suggest the average survival for patients with peritoneal carcinomatosis of colorectal origin is 18–48 months, for high-grade appendiceal adenocarcinoma 12–36 months, and for low-grade appendiceal neoplasms >60 months. As the understanding of peritoneal malignancies and peritoneal carcinomatosis evolved, it may now be acceptable to treat this as locoregional disease.

Cytoreductive Surgery and Peritonectomy Procedures

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has become widely accepted as an effective method of treating peritoneal metastases (PM) from various cancers. CRS performed with the goal of removing all the macroscopic disease and comprises of peritonectomy procedures and visceral resections. CRS is a technically challenging surgery that requires a considerable amount of skill and appropriate patient selection. This article is a review of the techniques and current recommendations for performing CRS.

[Cytoreductive surgery for malignant peritoneal tumors]

Cytoreductive surgery is an essential part of a multimodality treatment concept for peritoneal metastases. Indications are primary peritoneal tumors like peritoneal mesothelioma or secondaries from colorectal cancer or pseudomyxoma peritonei. Patients with gastric or ovarian carcinoma or abdominal sarcoma with peritoneal seedings can be treated within studies. Tumor entity, tumor load, and tumor distribution are the most critical issues for patient selection. Complete macroscopic cytoreduction is the strongest prognostic factor and can be achieved by parietal and visceral peritonectomy. The operation should be performed in a standardized manner. Due to possible tumor manifestation in all four quadrants of the abdomen and extensive extraperitoneal dissection, extensive surgical and oncological expertise is prerequisite. Treatment in specialized surgical oncology centers is recommended to minimize morbidity and mortality. The German Society for General and Visceral Surgery is certifying centers of competence for surgical treatment of peritoneal malignancies. Data of all patients are documented in the HIPEC register. The inclusion of patients in studies is recommended.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei and Appendix Tumours

Pseudomyxoma peritonei (PMP) is the intra-peritoneal accumulation of mucus due to mucinous neoplasia, most often from a ruptured mucinous appendiceal neoplasm. A similar syndrome is caused by appendix cancer and other gastrointestinal malignancies. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) provides long-term survival in selected patients with these conditions. The management of the appendiceal neoplasm prior to development of peritoneal involvement is initially discussed. This is followed by an overview of the management of peritoneal disease caused by appendiceal neoplasms. The principles and basic techniques of CRS and intraperitoneal chemotherapy (both intraoperative and post operative) are then discussed. Survival outcomes from several large studies are summarised. Prognostic factors are also discussed. We report our basic outcome data for the 345 patients with PMP or appendix cancer treated at our institution. Finally, the promising upcoming treatment of mucolytic therapy is discussed. We conclude that appendiceal neoplasms, although rare can cause significant morbidity and mortality. With optimal management long-term survival is possible in the majority of patients. The key to treatment is complete cytoreduction and use of hyperthermic intraperitoneal chemotherapy.

Depth of colorectal-wall invasion and lymph-node involvement as major outcome factors influencing surgical strategy in patients with advanced and recurrent ovarian cancer with diffuse peritoneal metastases

Background

More information is needed on the anatomopathological outcome variables indicating the appropriate surgical strategy for the colorectal resections often needed during cytoreduction for ovarian cancer.

Methods

From a phase-II study cohort including 70 patients with primary advanced or recurrent ovarian cancer with diffuse peritoneal metastases treated from November 2000 to April 2009, we selected for this study the 52 consecutive patients who needed colorectal resection. Data collected included type of colorectal resection, peritoneal cancer index (PCI), histopathology (depth of bowel-wall invasion and lymph-node spread), cytoreduction rate and outcome. Correlations were tested between possible prognostic factors and Kaplan-Meier five-year overall and disease-free survival. A Cox multivariate regression model was used to identify independent variables associated with outcome.

Results

In the 52 patients, the optimal cytoreduction rate was 86.5% (CC0/1). In all patients, implants infiltrated deeply into the bowel wall, in 75% of the cases up to the muscular and mucosal layer. Lymph-node metastases were detected in 50% of the cases; mesenteric nodes were involved in 42.3%. Most patients (52%) had an uneventful postoperative course. Operative mortality was 3.8%. The five-year survival rate was 49.9% and five-year disease-free survival was 36.7%. Cox regression analysis identified as the main prognostic factors completeness of cytoreduction and depth of bowel wall invasion.

Conclusions

Our findings suggest that the major independent prognostic factors in patients with advanced ovarian cancer needing colorectal resections are completeness of cytoreduction and depth of bowel wall invasion. Surgical management and pathological assessment should be aware of and deal with dual locoregional and mesenteric lymphatic spread.

Morbidity and mortality outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy at a single tertiary institution: towards a new perspective of this treatment

INTRODUCTION

Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) is a treatment option for peritoneal surface malignancy. Despite the survival benefits, this treatment was previously associated with a high morbidity and mortality rates and the perception of the poor perioperative outcomes associated with this regimen remains. The aim of this study was to report the perioperative outcomes of CRS and PIC from a single institution to review factors that are associated with a poor perioperative outcome.

METHODS

The clinical- and treatment-related data of 243 consecutive procedures performed were prospectively collected and retrospectively reviewed. Adverse events were rated according to the National Cancer Institute's Common Toxicity Criteria (grade I-V). Univariate and multivariate analyses were performed to identify significant clinical and treatment-related factors for a poor perioperative outcome (grades III/IV/V morbidity).

RESULTS

The perioperative mortality rate was 3%. The rate of severe morbidity was 43%. Multivariate analysis demonstrated that left upper quadrant peritonectomy (P < 0.001) and small bowel resection (P < 0.01) were factors that predicted for a poor perioperative outcome.

CONCLUSIONS

The morbidity and mortality rates of CRS and PIC are within an acceptable range for a major gastrointestinal surgery which is performed with a curative intent. Patient selection is important in ensuring that suitable patients receive this treatment. A new perspective of this treatment needs to be sought.