Cytoreductive Surgery For Peritoneal Malignancies Research Articles

The influence of postoperative morbidity on medium to long-term quality of life trajectories following cytoreductive surgery for peritoneal malignancy – A prospective cohort study

PurposeCytoreductive surgery (CRS) improves survival of selected patients with peritoneal malignancy. However, postoperative morbidity rates remain high. The aim of this study was to determine the impact of postoperative morbidity on the quality of life (QOL) trajectories of patients undergoing CRS. MethodsThis prospective cohort study included consecutive patients undergoing CRS for peritoneal malignancy between April 2017 and March 2023. QOL measures were collected at baseline, pre-discharge, 3, 6, 12, 18 and 24 months postoperatively using the short-form 36 (SF-36v2) survey. Postoperative in-hospital complications were defined according to the Clavien-Dindo Classification. Differences in QOL trajectories for patients with, and without, postoperative complications, length of stay (short versus long) were determined using mixed effects analyses. ResultsA total of 368 patients were included. Mean age was 55 years and 56.2% were female. The main indications for CRS were colorectal peritoneal metastases (46.9%) and appendix adenocarcinoma (23.9%). Overall, QOL decreased sharply from baseline to pre-hospital discharge, returning to baseline 6 to 12 months post-surgery. Severity of postoperative complication and longer length of stay were the main factors negatively impacting physical component trajectories. Postoperative complication, severity of complication and longer length of stay negatively influenced mental component scores, mostly at pre-discharge. ConclusionsQOL following CRS returns to baseline levels within 6 to 12 months. Postoperative morbidity was associated with poorer health related QOL trajectories. Interventions aimed at reducing postoperative morbidity and targeted support may enhance long-term QOL outcomes.

Negative-Pressure Wound Therapy for Open Abdomen in Surgical Reintervention after Curative Surgery of Peritoneal Malignancy Increases the Risk of Recurrence.

Negative-pressure wound therapy for open abdomen (NPWTOA) helps reduce the risk of abdominal compartment syndrome. However, the risk of recurrence of cancer is unclear when NPWTOA is applied after oncologic resection. The aim of this study was to evaluate the effects of NPWTOA used for major complications on patients treated with cytoreductive surgery for peritoneal malignancy (PM). All patients who underwent an NPWTOA after potentially curative surgery of PM in a single institution were included. These patients were pair matched 1:3 on the Peritoneal Cancer Index, completeness of cytoreduction using a scoring index, and PM origin with patients who underwent surgical reintervention without NPWTOA after curative surgery of PM. Survival among the two groups was compared using the Kaplan-Meier method. Between 2011 and 2017, among 719 curative surgeries for PM, 13 patients underwent an NPWTOA after surgical reintervention. Researchers paired 9 of these patients to 27 others without NPWTOA after surgical reintervention. Median overall survival was 4.8 and 35 months (P = .391), and median disease-free survival was 4.0 and 13.9 months (P = .022) for the NPWTOA and non-NPWTOA groups, respectively. The use of the NPWTOA during surgical reintervention after curative surgery for PM may increase the risk of early recurrence.

Parenteral nutrition after cytoreductive surgery for peritoneal malignancy: Should it be administered routinely?

Purpose/backgroundCytoreductive surgery (CRS) is complex abdominal surgery that is used to treat peritoneal malignancy. CRS is associated with major morbidity and efforts to address this include optimisation of perioperative care. There is variation in international protocols on the nutritional management after CRS, in particular whether parenteral nutrition (PN) should be routinely or selectively administered. Hypothesis/aimThis study assessed parenteral nutrition use, factors associated with PN requirement and nutritional outcomes in a centre that selectively uses PN after CRS. Methods/interventionsA retrospective analysis was undertaken on patients who underwent cytoreductive surgery ± hyperthermic intraperitoneal chemotherapy (HIPEC) at Peter MacCallum Cancer Centre between 1st January 2015 and 31st December 2020 using data entered into a prospectively maintained database. Patient characteristics, nutritional status, oncological parameters, operative details and postoperative outcome data were retrieved. Categorical variables were compared using the chi-squared test and continuous data was compared using a non-parametric Mann–Whitney U-test. A p-value <0.05 was considered statistically significant. Cox regression analysis was performed to identify independent predictors of requiring PN and postoperative weight change over admission. ResultsA total of 222 patients who had CRS between were included (mean age 56 years; female 61.3%). Preoperative nutritional characteristics of participants included a mean body mass index (BMI) of 27.6 kg/m2 and the majority (77.9%) were not at nutritional risk pre-operatively with a Patient Generated Subjective Global Assessment (PG-SGA) score of category A. A high proportion of patients had surgery for colonic adenocarcinoma (58.1%), received HIPEC (87.4%) and achieved complete cytoreduction (82%). Postoperative parenteral nutrition was required for 65 patients (29.3%). The most frequent indication for PN was postoperative ileus (63.1%) with the mean (SD) time to commencing PN being postoperative day 5. Factors associated with the requirement for postoperative PN included preoperative albumin (OR 0.89; p = 0.015), weight loss >5% of body weight in the 6 months prior to admission (OR 2.2; p = 0.05), higher PCI score (OR 1.048; p = 0.005), number of anastomoses completed (OR 1.766; p = 0.017) and development of any postoperative complication (OR 2.71; p = 0.009). PN use was not associated with postoperative weight change. ConclusionMost patients undergoing CRS did not require post-operative PN. Nutritional and operative factors may identify patients who are likely to need PN after surgery. Selective use of PN did not impact on postoperative weight change.

Patients undergoing cytoreductive surgery for peritoneal malignancy of appendiceal origin should be consented for umbilical excision as 30% have umbilical infiltration

Cytoreductive surgery (CRS) for peritoneal malignancy has traditionally included umbilical excision with no published evidence on the incidence of umbilical involvement. The primary aim of this work was to determine the incidence of umbilical involvement in patients undergoing CRS for peritoneal malignancy of appendiceal origin. The secondary aim was to investigate the relationship of umbilical involvement with prior surgery affecting the umbilicus, such as diagnostic laparoscopy and midline laparotomy. This study is from a national referral centre in the United Kingdom for appendiceal tumours and peritoneal malignancy. It is a retrospective analysis from a dedicated prospective database. We evaluated the most recent 200 consecutive patients who underwent CRS for peritoneal malignancy of appendiceal origin where all pathology specimens were reported by a recognized expert pathologist in appendiceal tumours and peritoneal malignancy. From June 2016 to September 2019, 200 consecutive patients had CRS and 178 had umbilical excision. Of these 54/178 (30.3%) had disease involving the umbilicus. The pathological findings in the 178 patients were low-grade mucinous carcinoma peritonei in 90/178 (50.6%), high-grade mucinous carcinoma peritonei in 31/178 (17.4%), metastatic appendiceal adenocarcinoma in 29/178 (16.4%) and diffuse acellular mucin in 28/178 (15.7%). Umbilical involvement was found in 25/90 (27.8%) with low-grade, 11/31 (35.5%) with high-grade, 8/29 (27.6%) with adenocarcinoma and 10/28 (35.7%) of patients with acellular mucin. In the 54 patients with umbilical disease, 30/54 (55.6%) had previous diagnostic surgery affecting the umbilicus. In the 124 patients without umbilical disease, 76/124 (61.2%) had prior surgery involving the umbilicus. The difference between the groups was not significant (p=0.24). In patients with peritoneal malignancy of appendiceal origin, approximately 30% have umbilical involvement, irrespective of the primary appendiceal pathology. Umbilical involvement was not associated with prior surgery involving the umbilicus. This is the first report to document the incidence of umbilical pathology and supports consideration of routine umbilical excision in CRS for peritoneal malignancy.

ASO Author Reflections: Impact of Operative Technique on Anastomotic Failure During Cytoreductive Surgery for Peritoneal Malignancies-Surgeon Preference is Fine.

ASO Author Reflections: Impact of Operative Technique on Anastomotic Failure During Cytoreductive Surgery for Peritoneal Malignancies-Surgeon Preference is Fine.

An update of peritonectomy procedures used in cytoreductive surgery for peritoneal malignancy

Background: Complete cytoreduction is acknowledged to be an effective way to achieve macroscopic tumor clearance for a variety of tumors confined to the peritoneal cavity. Recent trials have shown that surgery respecting anatomical planes results in excellent outcomes and even the chance of cure for some from what was once thought to be life-limiting disease.Objective: To describe peritonectomy procedures in the current era.Method: A thorough and systematic method for cytoreductive surgery aimed at complete surgical resection of peritoneal metastases (PMs) was described.Results: The general principles of cytoreductive surgery were set out including preoperative preparation, patient positioning and incision. Strategies for assessing disease extent and planning surgical steps were outlined and established peritonectomy procedures such as Glisson’s capsulectomy, omentectomy, left and right diaphragmatic peritonectomy, lesser omentectomy, stripping of the omental bursa, and pelvic peritonectomy were described. Novel techniques such as anterior pancreatic peritonectomy, small bowel mesenteric peritonectomy and cardiophrenic lymph node dissection were explained, and illustrated with accompanying video.Conclusion: Peritoneal metastases present a challenge to the surgeon which calls for a unique skill set if optimal outcomes are to be achieved. Attempts to standardize the surgical techniques described will allow further refinement as new technological advances occur.

Biological mesh is a safe and effective method of abdominal wall reconstruction in cytoreductive surgery for peritoneal malignancy.

BackgroundPatients with peritoneal malignancy often have multiple laparotomies before referral for cytoreductive surgery (CRS). Some have substantial abdominal wall herniation and tumour infiltration of abdominal incisions. CRS involves complete macroscopic tumour removal and hyperthermic intraperitoneal chemotherapy (HIPEC). Abdominal wall reconstruction is problematic in these patients. The aim of this study was to establish immediate and long‐term outcomes of abdominal wall reconstruction with biological mesh in a single centre.MethodsA dedicated peritoneal malignancy database was searched for all patients who had biological mesh abdominal wall reconstruction between 2004 and 2015. Short‐ and long‐term outcomes were reviewed. All patients had annual abdominal CT as routine peritoneal malignancy follow‐up.ResultsSome 33 patients (22 women) with a mean age of 53·4 (range 19–82) years underwent abdominal wall reconstruction with biological mesh. The majority (23) had CRS for pseudomyxoma (19 low grade), six for colorectal peritoneal metastasis and four for appendiceal adenocarcinoma; 18 had undergone CRS and HIPEC previously. Twenty‐five of the 33 patients had abdominal wall tumour involvement and eight had concurrent hernias. The mean duration of surgery was 486 (range 120–795) min and the mean mesh size used was 345 (50–654) cm2. Ten patients developed wound infections and four had a seroma. Two developed early enterocutaneous fistulas. Mean follow‐up was 48 months. Five patients developed an incisional hernia. Four died from progressive malignancy. A further 15 patients had disease recurrence, but only one had isolated abdominal wall recurrence.ConclusionBiological mesh was safe and effective for abdominal wall reconstruction in peritoneal malignancy. Postoperative wound infections were frequent but nevertheless incisional hernia rates were low with no instances of mesh‐related bowel erosion or fistulation.

Procalcitonin levels predict infectious complications and response to treatment in patients undergoing cytoreductive surgery for peritoneal malignancy

BackgroundCytoreductive-surgery for peritoneal-malignancy (PM) involves extensive intra-abdominal surgery and a massive post-operative systemic–inflammatory-response (SIRS). It is often challenging to differentiate SIRS that are solely surgery-associated from those of post-operative infections. White-Cell-Counts (WCC) and C-Reactive-Protein (CRP) are routinely used as markers for infection, but are non-specific and their elevation is often delayed in PM cases. Other markers need to be evaluated to assist early identification/prediction of post-operative infections. MethodologyProspective evaluation of serum procalcitonin (PCT), CRP and WCC in 50 patients pre-operatively (Day0), and on post-operative days (POD) 1, 3 & 6, following cytoreductive-surgery with or without splenectomy. ResultsDay0 PCT, CRP and WCC values were within normal limits, but increasing physiologically in post-operative period without infection, with noticeable higher PCT in splenectomized patients. In our cohort post-operative infections were diagnosed in 14 patients, often within 48 h. There was a trend for faster rise in serum PCT on POD1 compared to CRP and WCC, and faster PCT decline following appropriate therapy on POD3 and POD6 when infected cases were clinically resolving while WCC and CRP continued to rise, particularly in non-spelenectomised patients. The AUC on POD1 was significantly higher for PCT (0.689) vs. WCC (0.476) and CRP (0.477) (p = 0.04). Sensitivity, specificity, positive-predictive-value and negative-predictive-values for PCT ranged between (57%–100%), (22%–74%), (33%–47%) & (81%–100%), for CRP (28%–78%), (5.5%–86%), (18%–44.4%) & (40%–75.5%) and for WCC (14%–26.5%), (65.5–80.5%), (22%–25%), (67%–70%) respectively. ConclusionPCT, like WCC and CRP, needs to be interpreted with extreme cautions in the context of infections post-cytoreductive-surgery and should only be used in association with other clinical and investigational findings.

Professional risks when carrying out cytoreductive surgery for peritoneal malignancy with hyperthermic intraperitoneal chemotherapy (HIPEC): A French multicentric survey

BackgroundOver the last two decades, many surgical teams have developed programs to treat peritoneal carcinomatosis with extensive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Currently, there are no specific recommendations for HIPEC procedures concerning environmental contamination risk management, personal protective equipment (PPE), or occupational health supervision. MethodsA survey of the institutional practices among all French teams currently performing HIPEC procedures was carried out via the French network for the treatment of rare peritoneal malignancies (RENAPE). ResultsThirty three surgical teams responded, 14 (42.4%) which reported more than 10 years of HIPEC experience. Some practices were widespread, such as using HIPEC machine approved by the European Community (100%), individualized or centralized smoke evacuation (81.8%), “open” abdominal coverage during perfusion (75.8%), and maintaining the same surgeon throughout the procedure (69.7%). Others were more heterogeneous, including laminar flow air circulation (54.5%) and the provision of safety protocols in the event of perfusate spills (51.5%). The use of specialized personal protective equipment is ubiquitous (93.9%) but widely variable between programs. ConclusionProtocols regarding cytoreductive surgery/HIPEC and the associated professional risks in France lack standardization and should be established.

Division of the pont hepatique of the liver in cytoreductive surgery for peritoneal malignancy

The pont hepatique (also called the pons hepatis and hepatic bridge) connects segments 3 and 4B of the liver and forms a tunnel (Fig 1) in which occult metastatic tumor can occur in peritoneal malignancies including ovarian cancer. A thorough knowledge of the anatomy of this area andprocedure for dividing the pont, exposing the tunnel and ⁎ Corresponding author. Fax: +1 314 646 8627. E-mail address: chelm4@slu.edu (C.W. Helm). Fig. 1. The ligamentum teres is retracted anteriorly to allow the infero-posterior surface of the liver to be inspected. The inferior edge of the liver now lies at the top. The pont hepatique connects hepatic segments 3 and 4B. The ligamentum teres enters the inferior end of the tunnel and the left hepatic artery and left portal vein pass to the liver in close proximity to the superior end. 0090-8258/$ – see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ygyno.2012.09.018 resecting and ablating tumors within, can contribute to complete cytoreductive surgery. A 36 yr old lady underwent laparotomy for a mucinous carcinoma of the ovary of low malignant potential with pseudomyxoma peritonei. As part of her intra-operative assessment the pont hepatique was divided using a tissue sealing energy device to expose the underlying tunnel. Care was taken to avoid damaging the left hepatic artery which passes close to the superior end of the pont. Mucinous depositswere noted on the peritoneumof thefloor of the tunnel and on the terminal portion of the ligamentum teres. The ligamentum teres was isolated, ligated and divided close to its termination taking care not to damage branches of the left portal vein and left hepatic artery supplying segments 3 and 4B of the liver which run close to the base. Bleeding from hepatic parenchyma which formed the pont was controlled and residual mucinous deposits were ablated with the argon beam coagulator. The patient was then treated with hyperthermic intraperitoneal chemotherapy with mitomycin for 90 min. The postoperative course was uncomplicated. Conflict of interest statement Dr Helm has previously received grant support from ThermaSolutions, Inc. (White Bear Lake, Minn) for the HYPER-O registry and from Sanofi-Aventis (Bridgewater, NJ) for a clinical research study investigating hyperthermic intraperitoneal chemotherapy. Dr Jula Veerapong and Dr Harvey Solomon have no financial or other conflicts of interest. Appendix A. Supplementary data Supplementary data to this article can be found online at http:// dx.doi.org/10.1016/j.ygyno.2012.09.018. Reference [1] Sugarbaker PH. Pont hepatique (hepatic bridge), an important anatomic structure in cytoreductive surgery. J Surg Oncol 2010;101:251-2.