Peritoneal Surface Malignancies Research Articles

677P - Consecutive Complete Radical Surgery (Crs) Plus Hyperthermic Intraperitoneal Chemotherapy (Hipec) Procedures in Patients with Peritoneal Carcinomatosis (Pc). Clinical Results and Survival According to Malignancy Type (Spain)

ABSTRACT Aim: CRS + HIPEC offers clinical benefits 0ver conventional treatment in certain types of Peritoneal Surface Malignancies (PSM). This type of treatment is performed with curative intent, and considered standard therapy in pseudomyxoma peritonei, peritoneal mesothelioma and PC from colorectal and appendiceal tumors. It is recommended in primary as well as recurrent ovarian tumors. There is consensus in PC of gastric origin and other infrequent PSM. International Health Agencies recommend using this treatment modality at highly specialized centers, by an experience team able to ensure efficacy and safety results, under carefully controlled research programs, regularly evaluated. Methods: From September06 to April14, 466 pt swith PC from different PSM types have been treated with 513 CRS + HIPEC procedures. 200 pts had PC from colon tumors, 99 pseudomyxoma peritonei, 78 recurrent ovarian cancer, 26 gastric PC, 21 appendiceal tumors, 16 malignant peritoneal mesothelioma, 11 no-GIST peritoneal sarcomatosis, 8 rectum tumors, 5 urachus origin and 4 from small bowel tumors. 79.9% had chemotherapy prior to CRS + HIPEC, and 91.2% prior surgery. Mean PCI 13/39. CRS achieved in 95.4%. HIPEC adjusted the type of chemotherapy agent and exposure time to the PSM. Mean HIPEC temp: 42.5°C. Mean op time was 368 min. Mean ICU and hospital stays, 2d and 13.1 d, respectively. Results: A third party is currently auditing these preliminary results. Morbidity: 25.5%. Reoperations: 3.4%. Anastomotic dehiscence's: 0%. Hospital readmissions: 4.6%. 30-day mortality: 1 pt Mean follow up: 24.7m. 1y predicted survival: 90.3%. Mean sv: 46.2m. Colon PC: sv probability at 12m: 91.5%, 3y sv 48.3%, 5y sv: 32%. Mean sv 41.3m. Pseudomyxoma peritonei: 1y sv: 96.9%, 3y sv: 87.4%. Mean sv 67m. Recurrent ovarian cancer: 1y sv: 93.1%. Mean sv 41.6m and median sv 45.4m. Appendiceal PC: 1y sv: 84%. Mean sv 36.8 and median sv 35.2m. Gastric PC: 1y sv: 66.3%. Median sv 27.2m Malignant peritoneal mesothelioma: sv probability at 12m: 79.3%. Mean sv 35.4m and 5y predicted sv 41%. Conclusions: Our experience confirmed that CRS + HIPEC offers clinical benefits over conventional treatment in certain types of Peritoneal Surface Malignancies (PSM), as described in other series. Disclosure: All authors have declared no conflicts of interest.

675P - Peritoneal Carcinomatosis (Pc) from Gastric Origin. 26 Consecutive Patients Treated By Radical Surgery (Crs) Plus Hyperthermic Intraperitoneal Chemotherapy (Hipec). Results from the Catalonian Peritoneal Carcinomatosis Programme (Spain)

ABSTRACT Aim: PC from gastric origin is a quite frequent manifestation. It is diagnosed at the time of initial surgical treatment in 15-50% of pt with gastric serosal involvement. Once it is present, it is associated with poor survival, with mean survival of 3-9 months, and 0% survival at 5y. PC is the most common cause of therapeutic failure during curative treatments of gastric cancer. Systemic chemotherapy offers little benefit in symptom control and survival. CRS + HIPEC has beneficial impact in selected patients with gastric carcinoma, with significant statistically benefit in mean survival (21months) and overall survival (29% 5y survival). We present the results of patients with PC from gastric origin treated with CRS + HIPEC, at a highly specialized PC programme. Methods: From September06 to April14: 466 patients with PC from different types of peritoneal surface malignancies have been treated by 513 CRS + HIPEC procedures. Of those, 26 pt had gastric PC. F:21, M:5. Mean age: 48.7 y. 20 pts had PC synchronous with gastric tumor, and in 6 pts PC presented as recurrent disease. 22 pt received prior systemic chemotherapy (up to 3 lines). 6 pt had prior surgery, with a PSS of 3/4. Mean PCI 8/39. CRS: CC0 in 19 pt and CC1 in 4. HIPEC: CDDP + doxorubicin, at 42.5°C, 60 min. Mean operative time 379 min (270 - 600). ICU and Hospital stay: 2 and 16.3 days. Results: A third part is currently auditing these preliminary results. Mean follow up: 20.2 months (2–51 months) Morbidity: 13.6%. No anastomotic dehiscence. Mortality: 0% Mean ICU and hospital stay of 2.0 and 16.5 days. One-year survival: 66.3%. Mean survival: 27.2 m. Conclusions: CRS + HIPEC it is highly recommended for PC from gastric carcinoma, in a very selected group of pt. Low PCI (≤10/39), favorable histological grade, complete cytoreduction surgery and good response to prior systemic therapies are prognostic factors used for pt selection at our Program. Although published survival results are poor compared with other PCs, they are far better when compared with systemic therapies. It is especially important to refer these pts early on to specialized centers. Disclosure: All authors have declared no conflicts of interest.

Recurrence and outcome after complete tumour removal and hyperthermic intraperitoneal chemotherapy in 512 patients with pseudomyxoma peritonei from perforated appendiceal mucinous tumours

BackgroundPseudomyxoma peritonei (PMP) usually originates from perforated mucinous appendiceal tumours and may present unexpectedly at surgery, or be suspected at cross sectional imaging. The optimal treatment involves macroscopic tumour removal by cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC). The 10-year Kaplan–Meier predicted disease-free survival is 61%. Some patients with recurrence are amenable to further CRS and HIPEC. AimTo evaluate the outcomes of re-do surgery in a large single centre series of reoperation for recurrence of peritoneal surface malignancy. MethodRetrospective analysis of prospective database of 752 patients undergoing CRS for perforated appendiceal tumours analysed. Routine follow up involved annual CT scans and serum tumour marker measurement. The survival and recurrence in the 512/752 (68.1%) who had complete cytoreduction between March 1994 and January 2012 was calculated by Kaplan–Meier univariate analysis. ResultsOverall 137/512 (26.4%) developed recurrence and of those 35/137 (25.5%) underwent repeat surgery. Complete tumour removal was again achieved in 20/35 (57.1%). There were no postoperative deaths and no significant difference in early postoperative complications and length of stay compared to primary CRS surgery. The 5-year survival in the 375 without recurrence, the 35 who had re-do surgery and the 102 who had recurrence with no surgery was 90.9%, 79.0% and 64.5% respectively. ConclusionApproximately one in four patients develops recurrence after complete CRS and HIPEC for PMP of appendiceal origin. Selected patients can undergo salvage surgery with good outcomes.

American Society of Peritoneal Surface Malignancies opinion statement on defining expectations from cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with colorectal cancer.

American Society of Peritoneal Surface Malignancies opinion statement on defining expectations from cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with colorectal cancer.

Care of the open abdomen after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies.

A patient with a mucinous appendiceal cancer presents to the surgeon complaining of abdominal discomfort and nausea. Having undergone a prior right hemicolectomy, the patient has been disease free and on surveillance with clinical and carcinogenic antigen (CEA) monitoring. The CEA was noted to be elevated and a computed tomography scan revealed peritoneal nodules throughout the abdomen with a presumptive diagnosis of pseudomyxoma peritonei (progressive peritoneal implants from a mucinous primary). Several therapeutic options were offered and the patient selected to undergo cytoreductive surgery (CRS) with the potential to receive hyperthermic interoperative chemotherapy (HIPEC). Extensive resection was performed, including removal of the entire greater omentum, partial gastrectomy, and total pelvic exenteration with end colostomy and ileal conduit. Reassessment of the peritoneal cavity after the resections revealed almost complete cytoreduction. HIPEC was performed with mitomycin C and, after drainage and abdominal washing, the intestinal segments were anastomosed and the abdominal wall closed. Seven days postoperatively, an acute abdomen with septic shock developed as a result of a leak from the ileocolonic anastomosis. The patient returned to the operating room and an exploratory laparotomy, a small bowel resection, a resection of the ileocolonic anastomosis, and an abdominal washout were performed. Edema of the bowel caused by peritonitis resulting from the anastomotic leak necessitated delayed closure of the abdominal wall. A temporary abdominal closure using the ABThera™ Open Abdomen Negative Pressure Therapy system was applied and the abdomen was eventually closed.

P-0261 - The Management of Peritoneal Surface Malignancies at the American University of Beirut Medical Center: Initial Experience

P-0261 - The Management of Peritoneal Surface Malignancies at the American University of Beirut Medical Center: Initial Experience

The management of peritoneal surface malignancies: Single-center initial experience

The management of peritoneal surface malignancies: Single-center initial experience

Impact of introduction of laparoscopic surgery on management of unresolved intra-abdominal malignancies in a West African hospital.

Intra-abdominal malignancies often pose diagnostic problems to surgeons in resource-challenged centers such as ours due to limitations in modern imaging and other facilities. This prompted the adoption of laparoscopy in our hospital as an adjunctive tool in diagnosing these conditions. Pre- and per-operative data of consecutive cases of clinically unresolved advanced intra-abdominal tumors subjected to laparoscopy from January 2009 through June 2013 were reviewed. Anatomic diagnosis and tissue biopsies were carried out during the procedures. Of the 152 patients seen with intra-abdominal tumors, 74 (48.7 %) had advanced conditions that could not be resolved clinically. Of these, 33 (44.6 %) were able to afford and had computed tomography (CT), scan while the remaining (N = 41; 55.4 %) less endowed only had an ultrasound scan. This cohort underwent laparoscopic evaluation, and biopsies confirmed the following: 27 (36.5 %) metastatic adenocarcinomas, 12 (16.2 %) primary hepatic malignancies, 11 (14.9 %) cases each of lymphomas and colonic adenocarcinomas, 4 (5.4 %) gastrointestinal stromal tumors, 3 (4.1 %) pancreatic carcinomas, 2 (2.7 %) cases each of carcinoid tumors and abdominal tuberculosis, and one case each of schistosomiasis and HIV-related Kaposi's sarcoma. Additionally, 26 (35.1 %) had ascites, while 29 (39.1 %) had peritoneal surface malignancies. With local adaptations and improvisations, laparoscopy was cheaper than an abdominal CT scan in our setting, with the additional benefit of obtaining tissue diagnosis to institute treatment. Although laparoscopy is commonly used for staging intra-abdominal tumors, we found it useful in complementing clinical diagnosis and attaining histopathological confirmation in a setting where access to and funding of modern imaging is limited.

Quality of life in patients with peritoneal surface malignancies after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BackgroundAn increasing number of patients are presenting with peritoneal carcinomatosis and more centers are performing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). While morbidity and mortality are shown to be acceptable, quality of life after surgery should be assessed. Methods63 patients who had CRS and HIPEC from 2001 to 2012 and who were still alive and on follow up were included. The EORTC-QLQ-C30 was administered to the patients. ResultsMedian age was 53 years (14–71). 44% had ovarian primaries, 21% had appendicael primaries and 19% had colorectal primaries. Median follow-up was 1.08 years (0.06–9.8). The median time from surgery to the questionnaire was 1.3 years (0.24–10.18). There was no statistical difference in scores when comparing by age, gender, recurrence, gender, PCI score, presence of a complication and type of primary cancer. Scores were highest less than 6 months after surgery, dropped subsequently but rose again after 2 years. Our patients had better scores compared to a control group of outpatient cancer patients at our institution as well as the reference EORTC group. ConclusionsIn keeping with previous quality of life studies done for CRS and HIPEC patients, we have shown that our patients can achieve a good quality of life after CRS and HIPEC even with recurrent disease.

Treatment of Microscopic Disease with Hyperthermic Intraoperative Intraperitoneal Chemotherapy After Complete Cytoreduction Improves Disease-Free Survival in Patients with Stage IIIC/IV Ovarian Cancer

We analyze the efficacy of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) for microscopic residual disease in patients with stage IIIC/IV ovarian cancer after a complete cytoreduction of their disease. We analyzed the data of 87 consecutive patients diagnosed with stage IIIC/IV ovarian cancer operated between December 1998 and July 2011. In every patient it was possible to achieve a complete cytoreduction of their disease. (Since January 2008, our center has incorporated the use of HIPEC in patients with peritoneal surface malignancies, including patients with peritoneal dissemination of primary ovarian cancer.) Of 87 patients, 52 were treated with HIPEC (paclitaxel 60 mg/m(2), 60 min, 42 °C). After a univariate analysis, factors associated with lower disease-free interval were: performing a gastrointestinal anastomosis, operative time greater than 270 min, poorly differentiated histology, and not being treated with HIPEC. After multivariate analysis, independent prognostic factors included not being treated with HIPEC [hazard ratio (HR) 8.77, 95 % CI 2.76-14.42, p < 0.01] and the presence of poorly differentiated tumors (HR 1.98, 95 % CI 1.45-8.56, p < 0.05). Disease-free survival at 1 and 3 years was 66 and 18 %, respectively, in patients without HIPEC and 81 and 63 %, respectively, in patients treated with HIPEC (p < 0.01). HIPEC administration did not alter the results obtained for disease-free survival in patients with undifferentiated tumors. The treatment of the microscopic disease following complete cytoreduction with HIPEC in patients with advanced ovarian cancer is effective and can prolong disease-free survival. This survival benefit was not seen in undifferentiated tumors.

Bromelain and N-acetylcysteine inhibit proliferation and survival of gastrointestinal cancer cells in vitro : significance of combination therapy

BackgroundBromelain and N-acetylcysteine are two natural, sulfhydryl-containing compounds with good safety profiles which have been investigated for their benefits and application in health and disease for more than fifty years. As such, the potential values of these agents in cancer therapy have been variably reported in the literature. In the present study, the efficacy of bromelain and N-acetylcysteine in single agent and combination treatment of human gastrointestinal carcinoma cells was evaluated in vitro and the underlying mechanisms of effect were explored.MethodsThe growth-inhibitory effects of bromelain and N-acetylcysteine, on their own and in combination, on a panel of human gastrointestinal carcinoma cell lines, including MKN45, KATO-III, HT29-5F12, HT29-5M21 and LS174T, were assessed by sulforhodamine B assay. Moreover, the influence of the treatment on the expression of a range of proteins involved in the regulation of cell cycle and survival was investigated by Western blot. The presence of apoptosis was also examined by TUNEL assay.ResultsBromelain and N-acetylcysteine significantly inhibited cell proliferation, more potently in combination therapy. Drug-drug interaction in combination therapy was found to be predominantly synergistic or additive. Mechanistically, apoptotic bodies were detected in treated cells by TUNEL assay. Furthermore, Western blot analysis revealed diminution of cyclins A, B and D, the emergence of immunoreactive subunits of caspase-3, caspase-7, caspase-8 and cleaved PARP, withering or cleavage of procaspase-9, overexpression of cytochrome c, reduced expression of anti-apoptotic Bcl-2 and pro-survival phospho-Akt, the emergence of the autophagosomal marker LC3-II and deregulation of other autophagy-related proteins, including Atg3, Atg5, Atg7, Atg12 and Beclin 1. These results were more prominent in combination therapy.ConclusionWe report for the first time to our knowledge the growth-inhibitory and cytotoxic effects of bromelain and N-acetylcysteine, in particular in combination, on a panel of gastrointestinal cancer cell lines with different phenotypes and characteristics. These effects apparently resulted from cell cycle arrest, apoptosis and autophagy. Towards the development of novel strategies for the enhancement of microscopic cytoreduction, our results lay the basis for further evaluation of this formulation in locoregional approaches to peritoneal surface malignancies and carcinomatosis.

Peritoneal Surface Disease Severity Score as a predictor of resectability in the treatment of peritoneal surface malignancies

BackgroundWe evaluated the clinical utility of the Peritoneal Surface Disease Severity Score (PSDSS) as a preoperative predictor of resectability in the treatment of peritoneal surface malignancies. MethodsForty-nine patients were selected for cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) and were stratified according to the PSDSS retrospectively. ResultsOf 52 cytoreductive surgeries performed in 49 patients, HIPEC was performed in 33 cases (63%). We analyzed 31 cases of appendiceal and colorectal cancer patients who underwent CRS and HIPEC and 12 who underwent CRS only. 68% of the patients in whom CRS and HIPEC was performed were classified as PSDSS stage I or II. Contrastingly, all patients in whom CRS and HIPEC was unachievable were scored as PSDSS stage III or IV. ConclusionsThe outcomes of this study suggest that the PSDSS can be used as a preoperative assessment tool to predict disease resectability in the treatment of peritoneal surface malignancies.

Impact of hyperthermia on pharmacokinetics of intraperitoneal mitomycin C in rats investigated by microdialysis

Patients with peritoneal surface malignancies are treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, commonly using mitomycin C (MMC). The purpose of this study was to investigate impact of hyperthermia on pharmacokinetics of intraperitoneal MMC. In 14 athymic nude male rats, microdialysis (MD) probes were implanted in jugular vein (V), hind leg muscle (M) and extraperitoneal space (XP). Probes were calibrated by retrodialysis. Intraperitonal chemotherapy perfusion (IPEC) was administered over 90 min with MMC 5 mg/kg and saline 0.9% 500 ml/kg at 35 and 41°C, defining the normothermic (NG) and hyperthermic groups (HG), respectively. MD and peritoneal perfusion fluid (PPF) samples were collected at 10 min intervals to determine MMC concentration. Time-concentration curves were virtually parallel between temperature groups, with equal peak concentrations (µM) of 0.3 (V), 0.7 (XP) and 0.3 (M). The following area under time-concentration curve (AUC) ratios were calculated: AUC PPF/AUC V were 69 in NG and 79 in HG (P = 0.54); AUC XP/AUC V were 2.7 in NG and 2.6 in HG (P = 0.90). IPEC provides high intraperitoneal MMC concentration and increased bioavailability in extraperitoneal tissue, combined with low systemic absorption. Hyperthermia at 41°C did not modify MMC pharmacokinetics.

Intraperitoneal vascular endothelial growth factor burden in peritoneal surface malignancies treated with curative intent: The first step before intraperitoneal anti-vascular endothelial growth factor treatment?

IntroductionVascular endothelial growth factor (VEGF) is one of the most important angiogenic factors in solid tumours and plays an important role in ascites development in peritoneal surface malignancies (PSM). The main goal of this study was to determine the evolution and factors influencing intraperitoneal (IP) VEGF burden during cytoreductive surgery (CRS) with curative intent. Patients and methodsNinety-seven consecutive patients with PSM were treated with CRS at a single centre with curative intent. Patient data were collected prospectively between February 2012 and October 2012. An enzyme-linked immunosorbent assay technique was used to assess VEGF levels in intravenous (IV) systemic blood samples before incision and after abdominal closure, and in IP samples during abdominal cavity exploration, after completion of CRS, after hyperthermic IP chemotherapy, and at 1 and 24h after abdominal closure. ResultsThe IP VEGF burden increased significantly after CRS, and then decreased progressively (p<0.005). In multivariate analysis, neoadjuvant IV bevacizumab significantly decreased the preoperative IP VEGF burden, tumour load according to Peritoneal Cancer Index value increased significantly the preoperative IP VEGF burden and a low preoperative IP VEGF burden was associated with significantly increased postoperative complications. Neoadjuvant IV bevacizumab is the only factor that influences the preoperative IV VEGF concentration. ConclusionFor patients with PSM who were treated with curative intent, the IP VEGF burden increased after CRS, and was reduced prior to surgery by the administration of neoadjuvant IV bevacizumab.

Melphalan: A Promising Agent in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has become an option for peritoneal carcinomatosis (PC). Frequently, these patients have failed systemic chemotherapies and surgeries, including CRS/HIPEC with traditional regimens (mitomycin-C or platinum based). An alternative agent for failed or repeated CRS/HIPEC is unknown. We hypothesize that melphalan is an alternative agent in patients with PC from aggressive primaries, including recurrences following failed regional therapies. A retrospective review of a prospective database of 247 patients revealed 25 patients (9 male and 16 female) who received intraperitoneal melphalan (50 mg/m(2)) in 31 CRS/HIPEC procedures, of which 19 were repeated. Primary malignancies included 17 appendiceal, one colorectal, two ovarian, two uterine sarcomas, two primary peritoneal and one mesentery sarcoma. PC index (PCI) was ≥20 in 76 % of patients (19/25). 88 % of patients (22/25) had complete cytoreduction. Seventeen patients were alive, with mean survival of 63.6 months, and eight patients are deceased. Overall survival (OS) for the entire group since diagnosis was 95.8, 84.5, 50.9, and 38.2 % at 1, 3, 5, and 10 years, respectively; OS since melphalan HIPEC was 89.4, 45, and 30 % at 1, 3, and 5 years, respectively; and OS in patients with appendiceal malignancies was 91.7, 48.1 and 32.1 % at 1, 3 and 5 years, respectively. There was no postoperative mortality. Grade III-IV morbidity was 23 % (7/31). Nine patents had neutropenia, controlled with filgrastim. Melphalan is an efficacious alternative agent in patients undergoing CRS/HIPEC for aggressive and recurrent peritoneal surface malignancies. Its postoperative significant myelosuppression effect should be addressed.

Surgical treatment of peritoneal carcinomatosis: current treatment modalities

Selected patients with peritoneal surface malignancies (PSM) have been treated effectively by the combination of cytoreduction surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The purpose of this study is to summarize the treatment outcomes and general considerations regarding definitions and staging systems of current CRS and HIPEC modalities in malignant peritoneal mesothelioma and in secondary peritoneal malignancies such as peritoneal metastasis from appendiceal, colorectal, gastric, and epithelial ovarian cancers. Disease progression within the peritoneal cavity has in the past been regarded as a terminal event. Accumulating evidence underlines the therapeutic potential and the acceptable morbidity and mortality rates of CRS and HIPEC in selected patients.

Intraperitoneal chemotherapy: Rationale, applications, and limitations

Intraperitoneal chemotherapy, involving the administration of certain chemotherapeutic agents directly to the intraperitoneal cavity, was developed as a novel therapeutic strategy early in the 1950s. Intraperitoneal administration of chemotherapy results in higher intraperitoneal concentration of the cytotoxic medications and minimal systemic exposure than observed with intravenous administration, which in turn may increase the efficacy of these agents with substantial reduction in systemic toxicity. Intraperitoneal chemotherapy was used successfully in peritoneal surface malignancies, including malignant peritoneal mesothelioma, pseudomyxoma peritonei, malignant ascites, sarcomatosis, and peritoneal carcinomatosis from gastrointestinal and ovarian cancers. Pharmacists may play a major role in optimizing intraperitoneal chemotherapy through verification of chemotherapy order for proper doses, dilution, preparation, and administration. Moreover, pharmacists are medication experts who can provide other health care professionals with the necessary drug information. Despite the local application of chemotherapy, intraperitoneal chemotherapy is not free of systemic side effects and can be associated with serious complications. The benefits of intraperitoneal chemotherapy should be weighed against its potential harm to maximize efficacy and to minimize morbidity and mortality as much as possible. The aim of this article is to review the current available literature regarding the safety and efficacy of intraperitoneal chemotherapy in cancer treatment.

Morbidität und Letalität der hyperthermen intraperitonealen Chemoperfusion

Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) is a treatment option for peritoneal surface malignancy. Despite the survival benefits, this treatment was previously associated with a high morbidity and mortality rates, and the perception of the poor perioperative outcomes associated with this regimen remains. Careful patient selection with an optimal level of postoperative care must be advocated to avoid undesirable complications of this treatment.However, for this treatment to be accepted as standard of care, teams undertaking this treatment strategy must aim to minimize morbidity and mortality by learning from the experience of established centers and using the "global learning curve". The HIPEC Registry and accreditation of centers will improve the quality of the treatment.

Postoperative outcomes of laparoscopic vs open cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for treatment of peritoneal surface malignancies

BackgroundCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are considered the only curative treatment for many peritoneal surface malignancies. The purpose of this study was to evaluate feasibility and safety of CRS combined with HIPEC by laparoscopy for patients with limited peritoneal disease and to compare postoperative outcomes with those for an open procedure. MethodsBetween January 2011 and November 2012, all patients with low-grade pseudomyxoma peritonei (PMP) or multicystic mesothelioma (MM) and limited peritoneal disease (Peritoneal Cancer Index [PCI] less than 10) underwent CRS and HIPEC by a laparoscopic approach. The study cohort was matched with a historical cohort of patients with the same characteristics (completeness of cytoreduction, HIPEC agent, PCI ± 11 and age ± 20 years) treated with CRS and HIPEC by laparotomy. ResultsEight patients (five low-grade PMP and three MM) treated by a laparoscopic approach were compared to eight patients treated by laparotomy. All patients underwent complete cytoreductive surgery with HIPEC, and no conversion to laparotomy was needed. The median surgical length was 210 min (150–300) vs 240 (210–360), with a median hospital stay of 12 days (9–18) vs 19 (13–33). One patient had a postoperative complication (intraperitoneal haematoma treated by radiological drainage) vs four in the laparotomy group. ConclusionLaparoscopic CRS combined with HIPEC is feasible and safe for curative treatment of strictly selected patients with peritoneal surface malignancy and might reduce postoperative complications and length of hospital stay.

The perioperative course and anesthetic challenge for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

BackgroundCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) by the closed technique provide a promising therapeutic option for highly selected patients with peritoneal carcinomatosis. CRS with HIPEC is a long and complex procedure with significant blood and fluid loss, hemodynamic, hematological, and metabolic alterations in the perioperative period, with resultant morbidity and mortality. This work was done to evaluate our early experience in anesthesia and early postoperative care for these cases.Patients and methodsThis retrospective study was done on 13 patients for CRS and HIPEC, with intraoperative and early postoperative recording and evaluation of the fluid and blood losses and replacement, changes in hemodynamic, metabolic, and respiratory parameters and any complications happened.ResultsOur data demonstrated high fluid and blood losses during CRS. During HIPEC, raised body temperature, increased central venous pressure and airway pressure, increased arterial partial carbon dioxide tension (PaCO2), decreased ratio of arterial oxygen partial pressure/fractional inspired oxygen (PaO2/FiO2), and increased serum lactate were recorded. These were associated with hemodynamic, metabolic, and respiratory acidosis. The patients were continuing resuscitation and correction of any derangements in intensive care unit.ConclusionCRS and HIPEC have become standard treatment for certain peritoneal surface malignancies. This extended surgery is considered a challenge for the anesthetist. It is associated with relevant fluid, blood, and protein losses, together with hemodynamic, respiratory, and metabolic derangements. However, these derangements are short lived and could be controlled by continuous monitoring and rapid intervention.