Complications de la chirurgie radicale des cancers de l’ovaire de stade avancé

Feasibility of laparoscopic diaphragmatic peritonectomy during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer

OBJECTIVE

To describe the surgical technique and evaluate the safety, feasibility and efficacy of laparoscopic diaphragmatic peritonectomy during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer (OC).

METHODS

This report is part of a Service Evaluation Protocol (Trust number 3267) on laparoscopy in patients with OC following neo-adjuvant chemotherapy. Between April 2015 and November 2017, all patients underwent to exploratory laparoscopy and a selected court was offered laparoscopic VPD. Laparoscopic diaphragmatic surgery was considered if there was no full thickness involvement. Primary endpoints of this part of the study were the safety, feasibility and efficacy of laparoscopic diaphragmatic peritonectomy. We report the surgical technique and outcomes.

RESULTS

Ninety-six patients underwent diaphragmatic surgery during the study period. Fifty patients (52.1%) had intra-operative exclusion criteria and/or full thickness diaphragmatic resection, 46 (47.9%) had peritonectomy and were included in the study. Laparoscopic diaphragmatic peritonectomy was performed in 21 patients (45.4%, group 1), while in 25 patients (54.6%, group 2) laparotomy was necessary. Extent of disease and complexity of surgery were similar. Reasons for conversions were disease coalescing the liver to the diaphragm preventing safe mobilization (22 patients) and accidental pleural opening (3 patients). Overall, intra- and post-operative morbidity was lower in group 1 and pulmonary specific morbidity was very low.

CONCLUSION

Diaphragmatic peritonectomy can be safely accomplished by laparoscopy in almost half of the patients with OC whose disease is limited to the diaphragmatic peritoneum.

M-TRAP: Safety and performance of metastatic tumor cell trap device in advanced ovarian cancer patients

OBJECTIVE

Despite radical surgery and chemotherapy, most patients with ovarian cancer die due to disease progression. M-Trap is an implantable medical device designed to capture peritoneal disseminated tumor cells with the aim to focalize the disease. This trial analyzed the safety and performance of the device.

METHODS

This first-in-human prospective, multi-center, non-blinded, single-arm study enrolled 23 women with high-grade serous advanced ovarian cancer. After primary or interval debulking surgery, 3 M-Trap devices were placed in the peritoneum of the abdominal cavity. 18-months post-implantation or at disease progression, devices were initially removed by laparoscopy. The primary safety endpoint was freedom from device and procedure-related major adverse events (MAEs) through 6-months post-implantation compared to an historical control. The primary performance endpoint was histopathologic evidence of tumor cells capture.

RESULTS

Only one major adverse event was attributable to the device. 18 women were free of device and procedure related MAEs (78.3%). However, the primary safety endpoint was not achieved (p = 0.131), primarily attributable to the greater surgical complexity of the M-Trap patient population. 62% of recurrent patients demonstrated tumor cell capture in at least one device with a minimal tumor cell infiltration. No other long-term device-related adverse events were reported. The secondary performance endpoint demonstrated a lack of disease focalization.

CONCLUSIONS

The M-Trap technology failed to meet its primary safety objective, although when adjusted for surgical complexity, the study approved it. Likewise, the devices did not demonstrate the anticipated benefits in terms of tumor cell capture and disease focalization in recurrent ovarian cancer.

PROFAST: A randomised trial implementing enhanced recovery after surgery for highcomplexity advanced ovarian cancer surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) programs include multiple perioperative elements designed to achieve early recovery after surgery and a shorter length of stay (LOS) in hospital. The PROFAST trial aimed to expand the evidence base for implementing ERAS in advanced gynaecologic oncology surgery.

METHODS

This prospective, interventional randomised clinical trial enrolled women undergoing surgery for either suspected or diagnosed advanced ovarian cancer, at a reference hospital in gynaecologic oncology in Barcelona (Spain) and who were treated after either an ERAS protocol or conventional management (CM) protocol. All enrolled women who underwent cytoreductive surgery were included in the primary analysis. The primary outcome was reduction in LOS, and secondary outcomes were incidence and type of intraoperative and postoperative complications, rate of readmission and mortality within a 30-d follow-up period. This trial is registered at ClinicalTrials.gov, number NCT02172638.

FINDINGS

From June 2014 to March 2018, 110 women were recruited, of which eleven were excluded. The ERAS group comprised 50 patients, and the CM group, 49 patients. Both groups were comparable with respect to baseline characteristics and complexity of the cytoreductive surgery, with an overall medium/high Aletti surgical complexity score of 7.4. Overall compliance to the ERAS protocol was 92%. As compared with the patients in the CM group, patients in the ERAS group had a decreased median of LOS of two days (7 versus 9 days; p = 0.0099) and a decreased rate of readmission (6% versus 20%, p = 0.0334). No further significant differences were detected with respect to incidence of intraoperative or postoperative complications, severe (Clavien-Dindo grade IIIB-IV) complications, Comprehensive Complication Index, reoperation during primary stay, or mortality.

INTERPRETATION

Patients with advanced ovarian cancer in the ERAS program had a decreased LOS and decreased rate of readmission as compared with those in CM, with no increased morbidity or mortality. This study provides important evidence for the benefits of ERAS management even for gynaecologic surgeries of medium/high complexity and suggests that ERAS should be a standard practice for cytoreductive surgeries for peritoneal carcinomatosis.

The place of secondary complete cytoreductive surgery in advanced ovarian cancer

Despite optimal treatment, three-quarters of the patients with advanced ovarian cancer, experiment relapse and its treatment has become a public health issue. Initially debated, surgery is gaining legitimacy in the treatment of late relapse patients, compared to chemotherapy alone. Secondary complete cytoreduction should be proposed only to a highly selected population. The type of surgery depends on the recurrence localization and the relapse extension in the pelvis and to other organs. Innovating techniques of surgery have become widespread including heated intra peritoneal chemotherapy (HIPEC), laparoscopy and robotic surgery. These specialized treatments should only be carried out in reference centers by oncological surgeons.

Association of Diaphragmatic Surgery as Part of Cytoreductive Effort in Advanced Stage Ovarian Cancer

BACKGROUND/AIM

Diaphragmatic surgery in advanced-stage ovarian cancer has been considered since long time to increase the rates of postoperative complications. However, improvement of surgical techniques and perioperative management of these patients has lead in the last decade to a safe association of such procedures as part of debulking process. The aim of the current paper was to report our experience regarding the role of diaphragmatic resections as part of debulking surgery for advanced stage ovarian cancer.

MATERIALS AND METHODS

Between 2014 and 2016 diaphragmatic surgery was performed in 22 cases with advanced stage ovarian cancer.

RESULTS

Diaphragmatic surgery consisted of diaphragmatic peritoneal resection in 10 cases, full thickness diaphragmatic resections in four cases and coagulation of peritoneal nodules in eight cases. In all but two cases debulking surgery to no residual disease was achieved. Other upper abdominal resections consisted of splenectomy - in four cases, liver resections - in three cases, glissonian capsule resections - in eight cases, distal pancreatectomy - in one case and partial gastrectomies in two cases. The postoperative outcomes were similar irrespective of type of diaphragmatic surgical procedure.

CONCLUSION

Diaphragmatic surgery is a crucial procedure which can be safely associated as part of debulking surgery for advanced stage ovarian cancer.

The outcomes of intestinal resection during debulking surgery for ovarian cancer

OBJECTIVE

To evaluate the clinical and surgical outcomes of intestinal resection during primary debulking surgery for ovarian cancer.

MATERIAL AND METHODS

This retrospective study was conducted at Zekai Tahir Burak Women's Health Training and Research Hospital between 2009 and 2013. The patients who underwent intestinal resection during debulking surgery for stage 3 ovarian cancer were included in the analysis. Data regarding patient age, body mass index, tumor histology, disease stage, the site of intestinal resection, all postoperative complications, duration of intensive care unit admission and hospital stay were collected and analyzed.

RESULTS

A total of 22 patients with a mean age of 53.4 years were included in the study. Optimal cytoreduction was achieved in 14 (63%) patients. Transverse colectomy was the most common type of intestinal resection (63%). The most common postoperative complication was transfusion of blood products (63%). No postoperative mortality was observed.

CONCLUSION

Intestinal resection is a crucial part of debulking surgery for advanced ovarian cancer, with acceptable complication rates. Despite the limited number of patients, the results obtained from the present study are comparable with previous reports.

Optimal cytoreduction with neutral argon plasma energy in selected patients with ovarian and primitive peritoneal cancer

INTRODUCTION

Epithelial ovarian cancer (EOC) is a deadly disease for which optimal cytoreduction to microscopic disease has shown the best correlation with survival. Electrically neutral argon plasma technology is a novel surgical tool to allow aggressive cytoreduction in selected patients with EOC, primary peritoneal cancer, and tubal cancer.

METHODS

We conducted a prospective feasibility study of the use of neutral argon plasma technology to complete cytoreductive surgery in order to assess its ability to obtain optimal cytoreduction.

RESULTS

Six patients had their surgery completed with the neutral argon plasma device. None of the patients would have had optimal surgery unless the device had been available. All patients had cytoreduction to less than 5 mm to 10 mm without additional morbidity. One patient had complete cytoreduction, and two had residual disease of less than 2 mm.

CONCLUSION

Electrically neutral plasma argon technology is a useful technology to maximize cytoreduction and to reduce tumour burden in selected cases of EOC.

Morbidity of Surgery After Neoadjuvant Chemotherapy Including Bevacizumab for Advanced Ovarian Cancer

Objective

Neoadjuvant chemotherapy followed by interval debulking surgery is an alternative for the management of advanced ovarian cancer (AOC). Owing to unresectable disease at initial evaluation, some patients received bevacizumab in addition to neoadjuvant chemotherapy. The aim of this study was to evaluate the safety and postoperative course of patients who had received bevacizumab before debulking surgery for AOC.

Methods

In 2012, we identified all patients with AOC who had received neoadjuvant bevacizumab before debulking surgery. We recorded patients’ characteristics, surgical course, and postoperative complications.

Results

Five patients were identified, of whom 80% were International Federation of Gynecology and Obstetrics stage 4 at diagnosis. All patients underwent surgery after 6 courses of neoadjuvant chemotherapy with carboplatin, paclitaxel, and bevacizumab. The median number of bevacizumab injections was 3 (3–4), and the median time between the last injection of bevacizumab and surgery was 54 days (34–110 days). One patient had a grade 3 complication (lymphocyst with puncture under computed tomographic scans).

Conclusion

In this preliminary study, debulking surgery after neoadjuvant chemotherapy that included bevacizumab did not increase the rate of postoperative complications when there was a reasonable interval between the last bevacizumab injection and surgery. Larger studies are warranted to assess surgical safety after antiangiogenic treatment in the neoadjuvant setting for advanced ovarian cancer.

Comparison of morbidity and survival between primary and interval cytoreductive surgery in patients after modified posterior pelvic exenteration for advanced ovarian cancer

OBJECTIVE

Surgical management of advanced ovarian cancer often requires low modified posterior pelvic exenteration (MPE) to achieved complete resection. The aim of this study was to evaluate the morbidity of MPE at the time of primary cytoreductive surgery (PCS) and interval cytoreductive surgery (ICS) after neoadjuvant chemotherapy.

MATERIALS AND METHODS

From 2001 to 2009, 63 patients underwent MPE for advanced ovarian cancer. We analyzed and compared surgical characteristics and postoperative courses between PCS and ICS.

RESULTS

Modified posterior pelvic exenteration was performed during PCS for 50 patients (79%) and during ICS for 13 patients (21%). Complete cytoreduction was achieved in 80% of patients (84% in the PCS group and 69% in the ICS group; ns). There was no significant difference between the PCS and ICS groups in the type and the rate of standards or radical surgical procedures. Patients with ICS had a shorter length of stay in the intensive care unit (0.9 vs 2.7 days; P = 0.009), but there was no difference in the total length of hospitalization (P = 0.94). The global rate of postoperative complications was 76%. No differences were found between the 2 groups in digestive or extradigestive complications, iterative surgery, or interventional radiology procedures. The median overall survival was 49.4 months in the PCS group and 27.1 months in the ICS group (P = 0.27), and the median progression-free survival time in both groups was 20 months.

CONCLUSIONS

There was no difference in the occurrence of postoperative complications between PCS and ICS, especially in morbidity related to MPE. The specific morbidity of this surgical procedure remained low compared with the overall morbidity in cases of extensive surgery.

Lymphocele and ovarian cancer: risk factors and impact on survival

INTRODUCTION

We describe the incidence, impact on survival, and the risk factors for symptomatic lymphoceles in patients with ovarian cancer.

METHODS

This retrospective study includes patients with ovarian cancer who had complete cytoreductive surgery and para-aortic and pelvic lymphadenectomy performed in our institute from 2005 to 2011. Patients were classified into two groups: patients with symptomatic lymphoceles and a control group.

RESULTS

During the study period, 194 patients with epithelial ovarian cancer underwent cytoreductive surgery and a lymphadenectomy without macroscopic residual disease. Fifty-four patients had symptomatic lymphoceles (28%). In the multivariate analysis, only supraradical surgery was significantly and independently associated with the risk of symptomatic lymphoceles occurring postoperatively. Median follow-up was 24.8 months (range, 1-74 months). Survival rates were not significantly different between the symptomatic lymphocele group and the control group. Two-year disease-free survival rates were 54% for the lymphocele group and 48% for the control group. Two-year overall survival rates were 90% for the lymphocele group and 88% for the control group.

CONCLUSIONS

Symptomatic lymphoceles occur frequently after cytoreductive surgery in ovarian cancer. Supraradical surgery is an independent risk factor. The occurrence of symptomatic lymphoceles does not decrease survival. Nevertheless, further studies are needed to reduce the risk of lymphoceles in such patients.

Diaphragmatic Surgery During Primary Cytoreduction for Advanced Ovarian Cancer: Peritoneal Stripping Versus Diaphragmatic Resection

Background

Standard approach for medically stable advanced ovarian cancer patients should be primary cytoreduction following platinum-based chemotherapy. The aim of surgical effort should be the complete removal of all visible disease. Our objective was to compare perioperative features, postoperative complications, and secondarily oncological outcomes of patients who underwent diaphragmatic stripping with those who underwent diaphragmatic resection for advanced ovarian cancer.

Methods

One hundred twelve cases were identified, among them 79 underwent diaphragmatic stripping and 33 underwent diaphragmatic full-thickness resection. Data collected included patients’ age, all perioperative details and pathological findings, International Federation of Gynecology and Obstetrics stage, adjuvant therapy, and follow-up data.

Results

Larger residual tumors (mean, 5.1 vs 1.6 mm, respectively;P< 0.01) but shorter operating time (25 minutes shorter operative time,P= 0.07) were observed in the stripping group. Higher postoperative pleural effusions rates (63.6% vs 37.9%,P= 0.01), but no differences in the remaining complications, were observed in the resection group. After a mean of 31 months of follow-up, disease-free survival rates were 27.8% in the stripping group and 39.4% in the resection group (P= 0.04). No significant differences were observed for overall survival.

Conclusions

Diaphragmatic surgery at the time of primary cytoreductive surgery for advanced ovarian cancer may contribute to the achievement of complete cytoreduction with low perioperative complication rate; full-thickness resection is preferable if peritoneum stripping will not achieve a complete removal of the disease.