Complete peritonectomy versus selective peritonectomy in peritoneal carcinomatosis secondary to colorectal cancer: a prospective comparative analysis of outcomes

Abstract

Introduction: Cytoreductive surgery (CRS) with the intention to achieve complete cytoreduction is by far the most important factor deciding the outcome of peritoneal surface malignancy (PSM). There are a lot of grey areas with respect to the surgical technique in the management of PSM. In spite of doing selective disease-directed peritonectomy, fluoroscopic imaging and microscopy of remaining peritoneum have shown the presence of disease that is not visible to the naked eye. The aim of this study was to assess the morbidity and mortality, recurrence pattern, and oncological outcomes of the extent of parietal peritonectomy with CRS and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal carcinoma. Methods: Patients diagnosed with peritoneal surface malignancy from various diseases underwent complete parietal Peritonectomy (CPP) or selective parietal peritonectomy (SPP) with cytoreduction to achieve complete cytoreduction (CC score 0) followed by HIPEC done with the Performer HT (RanD) system. All data prospectively entered in the HIPEC registry were analyzed with main focuses on morbidity, mortality and oncological outcomes (DFS, OS, and recurrence pattern). Results: Of the 163 cases with peritoneal carcinomatosis secondary to colorectal cancer that were analyzed, 128 were females and 35 males. ECOG was 0 in 145 and 1 in 11 patients. Prior surgical scores of 0, 1, 2, and 3 occurred in 101, 18, 38, and 6 patients respectively. Cases were 20 upfront, 94 interval, and 49 recurrent. Of the patients, 70 and 93 patients CPP and SPP respectively. CPP group had higher PCI (18.5 vs 8), longer duration of surgery (11 vs 9), more blood loss (1050 vs 600 ml) and increased hospital stay (14 vs 11) when compared with the SPP group. The number of diaphragmatic resections, bowel resections, anastomosis, and stoma were the same among both groups but the CPP group had more splenectomies and multivisceral resections. The CPP group required more prolonged ventilation. Overall morbidity was increased in the CPP group (61.4% vs 32.3%), with pulmonary and intra-abdominal collections being important. With a median follow up of 45 months, the CPP group had a DFS and OS of 26 and 47 months, respectively, whereas the SPP group had 21 and 44 months, respectively. Most of the recurrences in the CPP group were in lymph nodes (55%), liver (18%), and extra-abdominal (27%), whereas in SPP the most common sites of recurrence were peritoneal (45%), nodal (30%) and extra-abdominal (25%). Conclusion: CPP can be done with acceptable morbidity. Complete parietal peritonectomy lead to a change in the pattern of recurrence moving from peritoneal to systemic recurrence and has shown better outcomes. One has to be watchful about fluid collections post surgery. Although the CPP group had better DFS, there was no significant difference in OS.