Abstract
Background: Routine resection of falciform ligament and ligamentum teres hepatis (FL-LTH) during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) has been advocated but may be associated with increased complications. We aimed to study the role of FL-LTH resection at the time of CRS+HIPEC. Methods: Retrospective review of patients who underwent CRS+HIPEC from January, 2010 to April, 2013 was conducted. Non-parametric methods were used for analyses. Results: CRS-HIPEC was performed in 71 patients (FL-LTH resection in 57, 80.2%). The sensitivity and specificity of visual examination were calculated as 97.4% and 75.0%, respectively. Visual examination falsely classified 1/33 cases as disease free (3.0% False-negative, pathology showed carcinomatosis) and 6/24 as diseased (25% False-positive, pathology showed fibroadipose tissue). False-positive resection was not associated with increased complications (0/6). The recurrence in porta-hepatis (of n=48 with CC0 cytoreduction) was lower in the resected group (3/41, 7.3%) vs. nonresected (2/7, 28.6%), and associated with a hazard-ratio of 0.17 (95% CI 0.02 – 1.20, p-value 0.07) at a median 11 (IQR 7.0 – 16.7) months follow-up. Conclusions: Visual examination during CRS+HIPEC may miss disease at the falciform ligament. A policy of routine resection is not associated with increased complications and should be considered.
Highlights
Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS+ HIPEC) is an evolving paradigm in the treatment of cancer disseminated into the peritoneum [1,2]
Even though routine resection of falciform ligament and ligamentum teres hepatis (FL-LTH) has been proposed to avoid the possibility of any missed disease, [8] in clinical practice, it is often performed based on the visual examination for disease that may not be reliable
The current study aimed to examine the correlation of visual findings of a surgeon with the pathological findings of resected specimens of FL-LTH, and to evaluate the impact of FL-LTH resection during CRSHIPEC on the oncological outcomes in terms of recurrence of disease at porta hepatis
Summary
Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS+ HIPEC) is an evolving paradigm in the treatment of cancer disseminated into the peritoneum [1,2]. A common site of disease recurrence resulting in treatment failure in these patients is the perihepatic region and porta hepatis [7,8]. This could potentially be attributed to the complex anatomy of the liver surface with its fissures and ligaments that may result in inadequate visualization of disease and incomplete cytoreduction [8]. Routine resection of falciform ligament and ligamentum teres hepatis (FL-LTH) during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) has been advocated but may be associated with increased complications. We aimed to study the role of FL-LTH resection at the time of CRS+HIPEC
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