Prehabilitation of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancy

Home-Based Trimodal Prehabilitation in Patients with Peritoneal Carcinomatosis Undergoing Cytoreductive Surgery: Effect on Functional Walking Capacity and Skeletal Muscle Mass

BACKGROUND

Patients with peritoneal carcinomatosis often suffer from loss of skeletal muscle mass and require extensive surgery. Multimodal prehabilitation may improve physical status but its benefits for these specific patients remain unknown. This study aimed to evaluate the effect of prehabilitation on functional walking capacity and skeletal muscle mass, as well as its association with postoperative complications.

PATIENTS AND METHODS

A prospective study of patients with peritoneal carcinomatosis following a home-based trimodal prehabilitation program was carried out. Functional walking capacity was assessed with the 6-min walk test (T6MWT), and by the appendicular skeletal muscle index (ASMI) estimated by bioelectrical impedance analysis. Data were collected at the first medical appointment and on the day before surgery. A 90-day postoperative morbidity was registered according to the Clavien-Dindo classification.

RESULTS

A total of 62 patients were included in the analysis. Women were more prevalent (77.4%) and peritoneal metastasis from ovarian origin accounted for 48.4%. Clavien II-V grades occurred in 30 (57.7%) patients. After prehabilitation, functional walking capacity improved by 42.2 m (39.62-44.72 m) compared with baseline data (p < 0.001), but no improvement was observed in the ASMI (p = 0.301). Patients able to walk at least 360 m after prehabilitation suffered fewer Clavien-Dindo II-V postoperative complications (p = 0.016). A T6MWT of less than 360 m was identified as an independent risk factor in the multivariable analysis (OR 3.99; 1.01-15.79 p = 0.048).

CONCLUSIONS

This home-based trimodal prehabilitation program improved functional walking capacity but not ASMI scores in patients with peritoneal metastasis before surgery. A T6MWT of less than 360 m was found to be a risk factor for postoperative complications.

A global analysis of nutrition support practices in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignancy

BACKGROUND

Perioperative nutritional care has been identified as an important factor in the management of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Nevertheless, there is no published consensus on best practice for nutritional management specific to this patient group. The purpose of this study was to identify the current nutrition care practices among international centres performing CRS and HIPEC for patients with peritoneal malignancy.

METHODS

An online survey was developed and sent to experienced CRS and HIPEC centres. The survey questions covered clinician and institution demographics, formal nutrition care pathways, pre-operative nutrition care, post-operative nutrition support and post-discharge nutritional follow-up.

RESULTS

Eighty-two centres were contacted, and 42 responses were received. Respondents were from 20 different countries and were mostly dietitians (71%). Nutrition assessments were frequently completed (52% pre-operatively and 86% post-operatively) and most centres used a validated nutrition screening or assessment tool (79%). Perioperative nutrition support with respect to the use of enteral nutrition, parenteral nutrition and enhanced recovery after surgery varied widely between centres. The use of routine parenteral and enteral nutrition was significantly higher in Europe compared with other locations (p = 0.028).

CONCLUSIONS

Nutrition care is pivotal and has been positively integrated into the complex management of patients undergoing CRS and HIPEC globally, however variation in practice is evident. The findings highlight a unique opportunity to collaboratively investigate the role nutrition plays in determining outcomes and to identify the most appropriate nutrition support methods to achieve improved clinical outcomes for these high-risk patients.

Extrapelvic Endometriosis Mimicking Peritoneal Surface Malignancy: Case Report and a Review of Literature

Extrapelvic endometriosis is a rare presentation of endometriosis with atypical clinical symptoms. It can mimic peritoneal surface malignancy, as well as some abdominal infectious diseases. A 29-year-old Moroccan woman presented with abdominal pain, progressive abdominal distention, and an intermittent inflammatory syndrome. Imaging revealed multiple, progressively growing abdominal cysts. She had elevated tumor markers CA125 and CA19.9. Despite thorough investigation, several differential diagnoses persisted for a long time. Definitive pathological diagnosis could only be established after debulking surgery. Literature review on malignant and benign conditions causing multicystic abdominal distention is provided. When definitive diagnosis is not established, but suspicion for peritoneal malignancy remains, a debulking procedure can be undertaken. Organ preservation can be pursued whenever benign disease is still considered. In case of malignancy, short-term (curative) debulking procedure with or without hyperthermic intraperitoneal chemotherapy (HIPEC) can be proposed.

Perioperative nutritional assessment and interventions in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC): A systematic review

BACKGROUND

Peritoneal carcinomatosis is a catabolic state and cytoreductive surgery (CRS) is a high morbidity operation. Optimising perioperative nutrition is crucial to improve outcomes. This systematic review sought to examine literature describing clinical outcomes related to preoperative nutrition status and nutrition interventions in patients undergoing CRS with hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

A systematic review was registered with PROSPERO (300326). A search of eight electronic databases was undertaken on 8th May 2022 and reported according to the PRISMA statement. Studies reporting nutrition status through use of screening and assessment tools, nutrition interventions or nutrition-related clinical outcomes for patients undergoing CRS with HIPEC were included.

RESULTS

Of 276 screened studies, 25 studies were included for review. Commonly used nutrition assessment tools for CRS-HIPEC patients included Subjective Global Assessment (SGA), sarcopenia assessment with computed tomography, preoperative albumin, and body mass index (BMI). Three retrospective studies compared SGA with postoperative outcomes. Malnourished patients were more likely to have postoperative infectious complications (p = 0.042 SGA-B, p = 0.025 SGA-C). Malnutrition was significantly associated with increased hospital length of stay (LOS) in two studies (p = 0.006, p = 0.02), and with overall survival in another study (p = 0.006). Eight studies analysing preoperative albumin levels reported conflicting associations with postoperative outcomes. BMI in five studies was not associated with morbidity. One study did not support routine nasogastric tube (NGT) feeding.

CONCLUSIONS

Preoperative nutritional assessment tools, including SGA and objective sarcopaenia measures, have a role in predicting nutritional status for CRS-HIPEC patients. Optimisation of nutrition is important for preventing complications.

Cytoreductive surgery and intraperitoneal chemotherapy for peritoneal metastasis of colorectal cancer: long-term follow-up results at a single institution in Korea

PURPOSE

This study aimed to examine the 7-year follow-up results of cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) for peritoneal metastasis (PM) of colorectal cancer.

METHODS

We performed 54 cases of CRS and IPC in 53 patients with PM of colorectal cancer from December 2011 to December 2013. We prospectively collected data and analyzed peritoneal carcinomatosis grade, completeness of cytoreduction, and long-term follow-up (median, 10 [range, 2-92] months) results.

RESULTS

The mean peritoneal cancer index was 15 (1 ~ 35), and complete cytoreduction was possible in 35 (64.8%) patients. Excluding the four patients who died, 11 (22.4%) out of the 49 patients were alive at the time of the last follow-up, and the overall median survival period was 10.3 months. The overall 2- and 5-year survival rates were 31% and 17%, respectively. Patients with complete cytoreduction had a median survival period of 22.6 months, which was significantly longer than that for patients without complete cytoreduction (3.5 months) (P < 0.001). The 5-year survival rate for patients with complete cytoreduction was 24%, and four patients were still alive without disease.

CONCLUSIONS

CRS and IPC show a 5-year survival rate of 17% in patients with PM of colorectal cancer. A possibility of long-term survival is observed in a selected group. Multidisciplinary team evaluation for careful patient selection and CRS training program to achieve complete cytoreduction are significantly important factors in improving survival rate.

Randomized Controlled Trial Investigating Perioperative Immunonutrition for Patients Undergoing Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

BACKGROUND

Immunonutrition has been shown to reduce hospital stay and postoperative morbidity in patients undergoing gastrointestinal, and head and neck surgery. However, its use has not been demonstrated in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). This study aims to determine the effectiveness of perioperative immunonutrition on patients undergoing CRS-HIPEC in reducing length of hospitalization and postoperative complications.

PATIENTS AND METHODS

From April 2017 to December 2018, patients undergoing CRS-HIPEC for peritoneal metastases in a single center were enrolled in a randomized controlled trial. Patients with evidence of intestinal obstruction or with diabetes mellitus were excluded. Patients were randomly assigned in a 1:1 fashion to receive perioperative oral immunonutrition or standard nutritional feeds. Length of hospital stay and rates of wound infection and complications were recorded and compared between the two groups in an intention-to-treat manner.

RESULTS

A total of 62 patients were recruited and randomized into two groups. Compliance to nutritional feeds in the preoperative period was significantly higher in the standard nutrition group (95.2% versus 75.4%, p = 0.004). There was no difference in postoperative compliance rates. Length of hospital stay and rates of wound infection and postoperative complications were higher in the standard nutrition group when compared with patients on immunonutrition (15.5 versus 11.1 days, p = 0.186; 19% versus 9.7%, p = 0.473; 16% versus 9.7%, p = 0.653; respectively).

CONCLUSIONS

Patients undergoing CRS-HIPEC who received perioperative immunonutrition had shorter hospitalization and less wound infections and postoperative complications, although the differences with the standard nutrition group were not statistically significant. Potential benefits of perioperative immunonutrition need to be further evaluated in larger studies.

Functional Outcomes Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Prospective Cohort Study

BACKGROUND

Pre-operative physical status and its association with post-operative surgical outcomes is poorly understood in patients with peritoneal malignancy who undergo cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC). The aims of this study were to determine the pre-operative physical function in patients having CRS-HIPEC and investigate the association between physical function and post-operative outcomes.

PATIENTS AND METHODS

Patients undergoing CRS-HIPEC between 2017 and 2021 were recruited at a single quaternary referral hospital in Sydney, Australia. The primary physical function measures were the 6-min walk test (6MWT) and the five-times sit to stand test (5STS). Data were collected pre-operatively and at post-operative day 10, and were analysed according to pre-operative patient characteristics and post-operative outcomes such as length of hospital stay (LOS) and complications.

RESULTS

The cohort of patients that participated in functional assessments consisted of 234 patients, with a median age of 56 years. Patients having CRS-HIPEC performed worse on the 6MWT pre-operatively compared with the general Australian population (p < 0.001). Post-operatively, these patients experienced a further deterioration in 6MWT and 5STS performance and the degree of the post-operative decline in function was associated with post-operative morbidity. A higher level of pre-operative physical function was associated with shorter LOS and minor post-operative complications.

CONCLUSIONS

Patients who have undergone CRS-HIPEC were functionally impaired pre-operatively compared with the general population and experience a further deterioration of physical function post-operatively. A higher level of pre-operative physical function is associated with minor post-operative morbidity, which is highly relevant for pre-operative optimisation of patients with cancer.

Upper-Abdominal Cytoreduction for Advanced Ovarian Cancer—Therapeutic Rationale, Surgical Anatomy and Techniques of Cytoreduction

Cytoreductive surgery (CRS) is the cornerstone of treating advanced ovarian cancer. Approximately 60–70% of patients with advanced ovarian cancer will have involvement in the upper abdomen or the supracolic compartment of the abdominal cavity. Though the involvement of this region results in poorer survival compared, complete cytoreduction benefits overall survival, making upper-abdominal cytoreduction an essential component of CRS for advanced ovarian cancer. The upper abdomen constitutes several vital organs and large blood vessels draped with the parietal or visceral peritoneum, common sites of disease in ovarian cancer. A surgeon treating advanced ovarian cancer should be well versed in upper-abdominal cytoreduction techniques, including diaphragmatic peritonectomy and diaphragm resection, lesser omentectomy, splenectomy with or without distal pancreatectomy, liver resection, cholecystectomy, and suprarenal retroperitoneal lymphadenectomy. Other procedures such as clearance of the periportal region, Glisson’s capsulectomy, clearance of the superior recess of the lesser sac, and Morrison’s pouch are essential as these regions are often involved in ovarian cancer. This manuscript covers the surgical anatomy of the upper abdomen, the techniques and therapeutic rationale of upper-abdominal cytoreduction, and specific measures for perioperative management of these patients. The main focus is the description of various peritonectomies and regional lymphadenectomies.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases in an elderly population: outcomes from a single centre

BACKGROUND

The prevalence of elderly patients with resectable colorectal peritoneal metastases (CRPM) is increasing. This study aimed to compare short and long-term outcomes of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for CRPM in patients above and below 70 years of age.

METHODS

This was a retrospective, 10-year analysis of 90-day major morbidity and mortality, and long-term survival.

RESULTS

Thirty-two (21.3%) of 150 consecutive patients who underwent CRS and HIPEC during the study period were aged 70 and older. PCI (P = 0.04), perioperative chemotherapy use (P < 0.01) and organ resections (rectum P = 0.04, diaphragm P = 0.03) were less in the over 70 group. There was no significant differences in major morbidity (P = 0.19) and mortality (P = 0.32). There was also no difference in 5-year overall survival (OS) (≥70: 26% vs. <70: 39%; P = 0.68) and disease-free survival (DFS) (≥70: 25% vs. <70: 14%; P = 0.22). Age above 70 was not independently associated with worse OS (HR 1.55, P = 0.20) and DFS (HR 1.07, P = 0.81).

CONCLUSION

The surgical management of CRPM appears safe and feasible in this elderly population. Appropriate selection of elderly patients for such radical intervention is reinforced by the comparable survival with those under 70.

Prehabilitation – current role in surgery

Introduction Prehabilitation concerns preoperative activities aimed in proper preparation to undergo a surgery and improve postoperative recovery. It includes the interdisciplinary approach by presurgical improvement of physical fitness and nourishment status, mental training and quitting addictions. The aim of the study was to investigate the recent publications in the field of prehabilitation. Methods We performed a systematic review in the PubMed database using the formula ‘preopreative OR before surgery, postoperative OR after surgery, prehabilitation’. The inclusion criteria were studies with a minimum population of 50 patients, including preoperative interventions, defined with a term prehabilitation, and their impact on a postoperative course of the patient. Three hundred seventy records were revealed and 13 studies were finally included in the analysis. Results According to qualified studies, prehabilitation improves significantly postoperative complications rate, length of hospital stay, postoperative physical activity, treatment costs, perioperative transfusions rate, antibiotic administration, and following the postoperative recommendations by patients. On the other hand, there is a lack of statistically significant impact of prehabilitation on quality of life, psychological condition, readmissions, and reoperations. Discussion Prehabilitation promotes development of multimodal care putting the patient’s well-being in the centre. Numerous studies indicate positive results of prehabilitation programs. The final results depend on the protocol of prehabilitation, selected group of patients and standard of care of the center. Conclusion Prehabilitation is necessary for providing the highest quality of care for a surgical patient. Interdisciplinary approach benefit a patient during the operation as well as in the postoperative period. Every surgical clinic should be aware of the idea of prehabilitation and possibly create their own programs.

Primary and metastatic peritoneal surface malignancies

Peritoneal surface malignancies comprise a heterogeneous group of primary tumours, including peritoneal mesothelioma, and peritoneal metastases of other tumours, including ovarian, gastric, colorectal, appendicular or pancreatic cancers. The pathophysiology of peritoneal malignancy is complex and not fully understood. The two main hypotheses are the transformation of mesothelial cells (peritoneal primary tumour) and shedding of cells from a primary tumour with implantation of cells in the peritoneal cavity (peritoneal metastasis). Diagnosis is challenging and often requires modern imaging and interventional techniques, including surgical exploration. In the past decade, new treatments and multimodal strategies helped to improve patient survival and quality of life and the premise that peritoneal malignancies are fatal diseases has been dismissed as management strategies, including complete cytoreductive surgery embedded in perioperative systemic chemotherapy, can provide cure in selected patients. Furthermore, intraperitoneal chemotherapy has become an important part of combination treatments. Improving locoregional treatment delivery to enhance penetration to tumour nodules and reduce systemic uptake is one of the most active research areas. The current main challenges involve not only offering the best treatment option and developing intraperitoneal therapies that are equivalent to current systemic therapies but also defining the optimal treatment sequence according to primary tumour, disease extent and patient preferences. New imaging modalities, less invasive surgery, nanomedicines and targeted therapies are the basis for a new era of intraperitoneal therapy and are beginning to show encouraging outcomes.

The prognostic value of skeletal muscle index on clinical and survival outcomes after cytoreduction and HIPEC for peritoneal metastases from colorectal cancer: A systematic review and meta-analysis

BACKGROUND

Cytoreductive surgery (CRS) and hypertermic intraperitoneal chemotherapy (HIPEC) represent the most effective strategy to manage peritoneal metastases (PM). This systematic review and meta-analysis aimed to assess the impact of body composition on clinical outcomes in patients with PM.

METHODS

A systematic literature search was performed using Medline, Web of Science and EMBASE databases from inception to the 20^st August 2020. Data were independently extracted by 3 authors. Newcastle-Ottawa Scale was used to assess quality and risk of bias of studies. Pooled analyses were performed using Mantel-Haenszel method to estimate overall effect size with mean differences or odd ratios (ORs) and 95% confidence interval (CI). The primary outcome was postoperative complication (POC) rate, while secondary outcomes were severe POC and postoperative mortality.

RESULTS

A total of 4 studies were included in the systematic review and meta-analysis, including 582 patients. A significant association between low skeletal muscle mass and POC was found (OR 1.45, 95% CI 1.04 to 2.03; p = 0.03), while no differences were found in terms operative time, estimated blood loss, length of hospital stay, and postoperative mortality (p > 0.05).

CONCLUSIONS

Low skeletal muscle mass at diagnosis is a valid prognostic factor for POC development in colorectal and PM patients undergoing CRS. Prospective and larger studies are needed to better investigate the role of CT scan derived body composition and to understand how to implement this tool in clinical practice.

Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): a cross-sectional survey

OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols have been questioned in patients undergoing cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies. This survey was performed to study clinicians' practice about ERAS in patients undergoing CRS-HIPEC.

METHODS

An online survey, comprising 76 questions on elements of prehabilitation (n=11), preoperative (n=8), intraoperative (n=16) and postoperative (n=32) management, was conducted. The respondents included surgeons, anesthesiologists, and critical care specialists.

RESULTS

The response rate was 66% (136/206 clinicians contacted). Ninety-one percent of respondents reported implementing ERAS practices. There was encouraging adherence to implement the prehabilitation (76-95%), preoperative (50-94%), and intraoperative (55-90%) ERAS practices. Mechanical bowel preparation was being used by 84.5%. Intra-abdominal drains usage was 94.7%, intercostal drains by 77.9% respondents. Nasogastric drainage was used by 84% of practitioners. The average hospital stay was 10 days as reported by 50% of respondents. A working protocol and ERAS checklist have been designed, based on the results of our study, following recent ERAS-CRS-HIPEC guidelines. This protocol will be prospectively validated.

CONCLUSIONS

Most respondents were implementing ERAS practices for patients undergoing CRS-HIPEC, though as an extrapolation of colorectal and gynecological guidelines. The adoption of postoperative practices was relatively low compared to other perioperative practices.

Effect of Preoperative Immunonutrition on Postoperative Major Morbidity after Cytoreductive Surgery and HIPEC in Patients with Peritoneal Metastasis

The effect of preoperative immunonutrition intake on postoperative major complications in patients following cytoreductive surgery (CRS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC) was assessed. The accuracy of C-Reactive Protein (CRP) for detecting postoperative complications was also analyzed. Patients treated within a peritoneal carcinomatosis program in which a complete or optimal cytoreduction was achieved were retrospectively analyzed. They were divided into two groups based on whether preoperative immunonutrition (IMN) or not (non-IMN) were administered. Clinical and surgical variables and postoperative complications were gathered. Predictive values of major morbidity of CRP during the first 3 postoperative days (POD) were also evaluated. A total of 107 patients were included, 48 belonging to the IMN group and 59 to the non-IMN group. In multivariate analysis immunonutrition (OR 0.247; 95%CI 0.071-0.859; p = 0.028), and the number of visceral resections (OR 1.947; 95%CI 1.086-3.488; p = 0.025) emerged as independent factors associated with postoperative major morbidity. CRP values above 103 mg/L yielded a negative predictive value of 84%. Preoperative intake of immunonutrition was associated with a decrease of postoperative major morbidity and might be recommended to patients with peritoneal carcinomatosis following CRS. Measuring CRP levels during the 3 first postoperative days is useful to rule out major morbidity.

Guide to Enhanced Recovery for Cancer Patients Undergoing Surgery: ERAS for Patients Undergoing Cytoreductive Surgery with or Without HIPEC

ERAS protocols may reduce length of stay and return to full functional recovery after cytoreductive surgery and HIPEC. Prehabilitation programs and post-operative goal directed pathways, along with other essential components of ERAS are discussed with supporting evidence.

Physical, psychological and nutritional outcomes in a cohort of Irish patients with metastatic peritoneal malignancy scheduled for cytoreductive surgery (CRS) and heated intrapertioneal chemotherapy (HIPEC): An exploratory pilot study

Background

Treatment for peritoneal malignancy (PM) can include cytoreductive surgery (CRS) and heated intrapertioneal chemotherapy (HIPEC) and is associated with morbidity and mortality. Physical, psychological and nutritional outcomes are important pre-operatively. The aim of this pilot study was to investigate these outcomes in patients with PM before and after CRS-HIPEC.

Methods

Between June 2018 and November 2019, participants were recruited to a single-centre study. Primary outcome was cardiopulmonary exercise testing (CPET) variables oxygen uptake (VO₂) at anaerobic threshold (AT) and at peak. Secondary outcome measures were upper and lower body strength, health related quality of life (HRQoL) and the surgical fear questionnaire. Exploratory outcomes included body mass index, nutrient intake and post-operative outcome. All participants were asked to undertake assessments pre CRS-HIPEC and 12 weeks following the procedure.

Results

Thirty-nine patients were screened, 38 were eligible and 16 were recruited. Ten female and 6 male, median (IQR) age 53 (42–63) years. Of the 16 patients recruited, 14 proceeded with CRS-HIPEC and 10 competed the follow up assessment at week 12. Pre-operative VO₂ at AT and peak was 16.8 (13.7–18) ml.kg^-1.min^-1 and 22.2 (19.3–25.3) ml.kg^-1.min^-1, upper body strength was 25.9 (20.3–41.5) kg, lower body strength was 14 (10.4–20.3) sec, HRQoL (overall health status) was 72.5 (46.3–80) % whilst overall surgical fear was 39 (30.5–51). The VO₂ at AT decreased significantly (p = 0.05) and HRQoL improved (p = 0.04) between pre and post- CRS-HIPEC. There were no significant differences for any of the other outcome measures.

Conclusion

This pilot study showed a significant decrease in VO₂ at AT and an improvement in overall HRQoL at the 12 week follow up. The findings will inform a larger study design to investigate a prehabilitation and rehabilitation cancer survivorship programme.

[Treatment of primary and metastatic peritoneal tumors in the Covid-19 pandemic. Proposals for prioritization from the RENAPE and BIG-RENAPE groups]

La pandémie de COVID-19 modifie profondément l’organisation et l’accès aux soins, en particulier pour les pathologies néoplasiques péritonéales, dont la prise en charge curative mobilise des moyens importants en personnel, bloc opératoire et réanimation. Les groupes BIG-RENAPE et RENAPE proposent des pistes de réflexion et de priorisation pour leur prise en charge. Un renforcement des critères habituels de sélection est nécessaire pour une prise en charge à visée curative : patients jeunes, avec peu de co-morbidités et une extension péritonéale limitée. Il est souhaitable de prioriser les pathologies pour lesquelles la chirurgie de cytoréduction associée ou non à une chimiohyperthermie intrapéritonéale (CHIP) est le traitement de référence et celles pour lesquelles la chimiothérapie systémique ne peut être une alternative temporaire ou prolongée : pseudomyxomes péritonéaux ; mésothéliomes péritonéaux malins résécables ; métastases péritonéales d’origine colorectale si résécables, non répondeuses à la chimiothérapie systémique et/ou après 12 cures, carcinoses ovariennes en 1^re intention si résécables et limitées ou en situation intervallaire après un maximum de 6 cycles de chimiothérapie systémique. L’adjonction d’une CHIP devra être discutée au cas par cas, en centre expert. La priorisation des indications devra prendre en considération les conditions locales et la phase de la période épidémique pour permettre une prise en charge péri-opératoire optimale.

Treatment of primary and metastatic peritoneal tumors in the Covid-19 pandemic. Proposals for prioritization from the RENAPE and BIG-RENAPE groups

The Covid-19 pandemic is profoundly changing the organization of healthcare access. This is particularly so for peritoneal neoplastic diseases, for which curative treatment mobilizes substantial personnel, operating room and intensive care resources. The BIG-RENAPE and RENAPE groups have made tentative proposals for prioritizing care provision. A tightening of the usual selection criteria is needed for curative care: young patients with few or no comorbidities and limited peritoneal extension. It is desirable to prioritize disease conditions for which cytoreduction surgery with or without associated hyperthermic intraoperative peritoneal chemotherapy (HIPEC) is the gold-standard treatment, and for which systemic chemotherapy cannot be a temporary or long-term alternative: pseudomyxoma peritonei, resectable malignant peritoneal mesotheliomas, peritoneal metastases of colorectal origin if they are resectable and unresponsive to systemic chemotherapy after up to 12 courses, first-line ovarian carcinomatosis if resectable or in interval surgery after at most six courses of systemic chemotherapy. Addition of HIPEC must be discussed case by case in an expert center. The prioritization of indications must consider local conditions and the phase of the epidemic to allow optimal peri-operative care.