Resection For Advanced Ovarian Cancer Research Articles

Extended-duration antibiotics are not associated with a reduction in surgical site infection in patients with ovarian cancer undergoing cytoreductive surgery with large bowel resection

Objective(s)To evaluate whether extended dosing of antibiotics (ABX) after cytoreductive surgery (CRS) with large bowel resection for advanced ovarian cancer is associated with reduced incidence of surgical site infection (SSI) compared to standard intra-operative dosing and evaluate predictors of SSI. MethodsA retrospective single-institution cohort study was performed in patients with stage III/IV ovarian cancer who underwent CRS from 2009 to 2017. Patients were divided into two cohorts: 1) standard intra-operative dosing ABX and 2) extended post-operative ABX. All ABX dosing was at the surgeon's discretion. The impact of antibiotic duration on SSI and other postoperative outcomes was assessed using univariate and multivariable Cox regression models. ResultsIn total, 277 patients underwent cytoreductive surgery (CRS) with large bowel resection between 2009 and 2017. Forty-nine percent (n = 137) received standard intra-operative ABX and 50.5% (n = 140) received extended post-operative ABX. Rectosigmoid resection was the most common large bowel resection in the standard ABX (89.9%, n = 124) and extended ABX groups (90.0%, n = 126), respectively. No significant differences existed between age, BMI, hereditary predisposition, or medical comorbidities (p > 0.05). No difference was appreciated in the development of superficial incisional SSI between the standard ABX and extended ABX cohorts (10.9% vs. 12.9%, p = 0.62). Of patients who underwent a transverse colectomy, a larger percentage of patients developed a superficial SSI versus no SSI (21% vs. 6%, p = 0.004). Conclusion(s)In this retrospective study of patients with advanced ovarian cancer undergoing CRS with LBR, extended post-operative ABX was not associated with reduced SSI, and prolonged administration of antibiotics should be avoided unless clinically indicated.

Cardiophrenic and costophrenic lymph node resection via subxiphoid approach only

When enlarged cardiophrenic lymph nodes (CPLN) are resected the impact on survival is still uncertain, but resection contributes to accurate staging and complete gross resection in advanced ovarian cancer. CPLN resection can be performed via video-assisted thoracic surgery or transabdominally through the subxiphoid or transdiaphragmatic routes. The subxiphoid approach is used to reach the prepericardiac nodes located in the anterior mediastinum. The transdiaphragmatic route is used to remove the costophrenic and supradiaphragmatic paracaval lymph nodes located in the middle and posterior mediastinum, respectively. However, the transdiaphragmatic approach necessitates diaphragm opening and, in most cases, liver mobilization. Costophrenic nodes can be resected through the subxiphoid route in appropriate patients without opening the diaphragm. Thus, the subxiphoid approach may be preferred to remove the costophrenic lymph nodes, in cases in whom diaphragm resection is not anticipated, and especially when the resection procedure is planned to include the prepericardiac nodes. In this video article, we present the method of resecting both prepericardiac and costophrenic lymph nodes using only the subxiphoid approach in a case of advanced ovarian cancer. The subxiphoid virtual space between the pericardium and diaphragm was developed. The observed and palpated CPLNs were dissected and excised from the prepericardiac and right latero-cardiac spaces. Thereafter, diaphragm peritoneum beneath the right costophrenic nodes was dissected. After identifying any enlarged costophrenic nodes by palpation, the sternal and costal diaphragmatic attachments were incised and the right latero-cardiac space was extended. When the single enlarged node was reached, it was grasped and pulled with curved-ring forceps and ultimately resected.

Cardiophrenic and costophrenic lymph node resection via subxiphoid approach only

Even the resection's impact of enlarged cardiophrenic lymph nodes (CPLN) on survival still uncertain, it contributes to accurate staging and complete gross resection in advanced ovarian cancer. CPLN resection can be performed via video-assisted thoracic surgery or transabdominally through the subxiphoid or transdiaphragmatic routes. The subxiphoid approach is utilized to reach the prepericardiac nodes located in the anterior mediastinum. The transdiaphragmatic route is used to remove the costophrenic and supradiaphragmatic paracaval lymph nodes located in the middle and posterior mediastinum, respectively. Transdiaphragmatic approach necessitates diaphragm opening and, in most cases, liver mobilization. However, costophrenic nodes can be resected through the subxiphoid route in appropriate patients without opening the diaphragm. Thus, the subxiphoid approach can be firstly preferred to remove the costophrenic lymph nodes, in cases whose diaphragm resection is not anticipated, and especially when the resection procedure is planned to include the prepericardiac nodes. In this video article, we present the method of resecting both prepericardiac and costophrenic lymph nodes through the subxiphoid approach in an advanced ovarian cancer case. The subxiphoid virtual space between the pericardium and diaphragm was developed. The observed and palpated CPLNs were dissected and excised from the prepericardiac and right latero-cardiac spaces. Thereafter, diaphragm peritoneum beneath the right costophrenic nodes was dissected. After determining the enlarged costophrenic node by palpation, the sternal and costal diaphragmatic attachments were incised and the right latero-cardiac space was extended. When the node was reached, it was grasped and pulled with curved-ring forceps and ultimately resected.

Quality of life from cytoreductive surgery in advanced ovarian cancer: Investigating the association between disease burden and surgical complexity in the international, prospective, SOCQER-2 cohort study.

ObjectiveTo investigate quality of life (QoL) and association with surgical complexity and disease burden after surgical resection for advanced ovarian cancer in centres with variation in surgical approach.DesignProspective multicentre observational study.SettingGynaecological cancer surgery centres in the UK, Kolkata, India, and Melbourne, Australia.SamplePatients undergoing surgical resection (with low, intermediate or high surgical complexity score, SCS) for late‐stage ovarian cancer.Main Outcome MeasuresPrimary: change in global score on the European Organisation for Research and Treatment of Cancer (EORTC) core quality‐of‐life questionnaire (QLQ‐C30). Secondary: EORTC ovarian cancer module (OV28), progression‐free survival.ResultsPatients’ preoperative disease burden and SCS varied between centres, confirming differences in surgical ethos. QoL response rates were 90% up to 18 months. Mean change from the pre‐surgical baseline in the EORTC QLQ‐C30 was 3.4 (SD 1.8, n = 88) in the low, 4.0 (SD 2.1, n = 55) in the intermediate and 4.3 (SD 2.1, n = 52) in the high‐SCS group after 6 weeks (p = 0.048), and 4.3 (SD 2.1, n = 51), 5.1 (SD 2.2, n = 41) and 5.1 (SD 2.2, n = 35), respectively, after 12 months (p = 0.133). In a repeated‐measures model, there were no clinically or statistically meaningful differences in EORTC QLQ‐C30 global scores between the three SCS groups (p = 0.840), but there was a small statistically significant improvement in all groups over time (p < 0.001). The high‐SCS group experienced small to moderate decreases in physical (p = 0.004), role (p = 0.016) and emotional (p = 0.001) function at 6 weeks post‐surgery, which resolved by 6–12 months.ConclusionsThe global QoL of patients undergoing low‐, intermediate‐ and high‐SCS surgery improved at 12 months after surgery and was no worse in patients undergoing extensive surgery.Tweetable Compared with surgery of lower complexity, extensive surgery does not result in poorer quality of life in patients with advanced ovarian cancer.

Surgical Techniques and Outcomes of Colorectal Anastomosis after Left Hemicolectomy with Low Anterior Rectal Resection for Advanced Ovarian Cancer.

Simple SummaryWe tried to minimize the number anastomoses, restore intestinal continuity, and avoid stoma creation for 295 patients with stage III/IV ovarian cancer who underwent low anterior rectal resection (LAR) with or without colon resection during cytoreductive surgery. When remaining colon cannot reach the rectal stump after left hemicolectomy with LAR, we used the following three techniques for tension-free anastomosis: right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, or additional colic artery division. The rate of stoma creation and rectal anastomotic was 3% (9/295) and 6.6% (19/286), respectively. Among 21 patients in whom the remaining colon did not reach the rectal stump after left hemicolectomy with LAR, 20 underwent tension-free anastomosis, including eight, six, and six patients undergoing right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, and an additional colic artery division, respectively. Colorectal anastomosis is feasible in patients with extended colonic resection.Extended colon resection is often performed in advanced ovarian cancer. Restoring intestinal continuity and avoiding stoma creation improve patients’ quality of life postoperatively. We tried to minimize the number of anastomoses, restore intestinal continuity, and avoid stoma creation for 295 patients with stage III/IV ovarian cancer who underwent low anterior rectal resection (LAR) with or without colon resection during cytoreductive surgery. When the remaining colon could not reach the rectal stump after left hemicolectomy with LAR, we used the following techniques for tension-free anastomosis: right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, or an additional colic artery division. Rates of stoma creation and rectal anastomotic were 3% (9/295) and 6.6% (19/286), respectively. Among 21 patients in whom the remaining colon did not reach the rectal stump after left hemicolectomy with LAR, 20 underwent tension-free anastomosis, including eight, six, and six patients undergoing right colonic transposition, retro-ileal anastomosis through an ileal mesenteric defect, and an additional colic artery division, respectively. Colorectal anastomosis is feasible for patients with extended colonic resection. Low anastomotic leakage and stoma rates can be achieved with careful attention to colonic mobilization and tension-free anastomosis.

Thoracic anatomical landmarks and uniportal VATS cardiophrenic lymph node resection in advanced ovarian cancer

Thoracic anatomical landmarks and uniportal video-assisted thoracoscopic surgery (VATS) cardiophrenic lymph node resection in advanced ovarian cancer. VATS represents a useful approach in advanced ovarian cancer. Its main indications are...

Liver Resection as Part of Cytoreductive Surgery for Ovarian Cancer.

Objective: The aim of this study was to describe and evaluate the safety of hepatic resections for ovarian cancer liver metastases and the benefit in terms of survival as part of cytoreductive surgery among peritoneal seeding and parenchymal metastases.Materials and Methods: Data were reviewed retrospectively from patients who underwent liver resection as part of cytoreductive surgery for ovarian cancer at the Instituto Nacional de Enfermedades Neoplásicas, in Lima, Perú, from January 2009 to December 2017.Results: From January 2009 to December 2017, 1211 patients underwent surgical cytoreduction for ovarian cancer; 39 of these patients had liver resection as part of their surgical treatment, with 9, 17, and 13 patients receiving primary, secondary, and tertiary, resections, respectively. The mean age of the patients was 46, the majority (87%) had stage III/IV ovarian cancer. In addition, 21 patients had parenchymal metastasis resections, and 95% of the patients had Dindo–Clavien I and II grade complications. The 30-day mortality rate was 0.Conclusions: Liver resection for advanced ovarian cancer is a safe procedure for primary up to quaternary cytoreduction and may confer survival benefits to patients.

Surgery performed later in the week is associated with failure to achieve complete radical surgical resection in advanced ovarian cancer

Background: The surgical treatment of advanced ovarian cancer aims to resect all visible tumor to no gross residual, these procedures are often extensive with need of prolonged attention to detail. Our objective was to investigate the association between week-day of surgery, time of year (season) when surgery was performed and non-radical surgery (surgical failure) in advanced ovarian cancer.Material and methods: Women diagnosed with primary invasive epithelial ovarian cancer in the Stockholm/Gotland Region, Sweden were identified in the regional Swedish Quality Registry of Gynecologic Cancer (SQRGC). Data of all women with International Federation of Gynecology and Obstetrics (FIGO) stages III and IV were validated against the National Cancer Registry. Women subjected to surgery with curative intent were selected and included in the analysis. Uni- and multivariable regression analyses were performed.Results: Out of 538 women identified in the SQRGC-string ovary between 2014 and 2016, 240 were eligible for analysis. In 29% of women, complete radical resection was not achieved. There was a significant trend of increased non-radical resection when surgery was performed from Monday through Thursday (p = .03). The adjusted odds of non-radical surgery increased if surgery was performed on Thursday rather than Monday (Odds Ratio (OR) 3.04, 95% Confidence Interval (CI) 1.05–8.79, p = .04). Surgery performed during summer compared to the rest of the year, did not significantly increase the adjusted odds of non-radical surgery (OR 1.92, 95% CI 0.91–4.07, p = .09).Conclusion: Complete surgical resection of tumor is one of the strongest prognostic factors for survival in advanced epithelial ovarian cancer. For this reason, advanced ovarian cancer surgery should be scheduled early in the week.

Abstract 4877: Liver resection as part of cytoreductive surgery for ovarian cancer liver metastases in a national cancer hospital

Abstract Introduction The current standard of treatment for newly diagnosed ovarian cancer (OC) includes definitive staging or cytoreduction followed by platinum-based chemotherapy. Therefore, studies have explored the implementation of liver resection to achieve complete macroscopic cytoreduction. Objectives The aim of this study was to describe and evaluate the security of liver resections for OC liver metastases and the benefit in terms of survival as part of cytoreductive surgery. Methods Data from patients submitted to surgical cytoreduction for OC that included liver resection at Instituto Nacional de Enfermedades Neoplásicas from January 2009 to December 2017 was retrospectively reviewed. The collected information included the patient's age at initial diagnosis, the FIGO staging system, tumor histology and grade, neoadjuvant chemotherapy, associated organ resections, number, dimensions, type and the margin status. Postoperative complications were measured according to Dindo-Clavien score, the length of hospitalization, 30-day mortality, disease-free survival, and overall survival was estimated from the moment surgery. The statistical analysis was made with non-parametric tests; Kaplan-Meyer survival curves were used. Results 1211 patients were submitted surgical cytoreduction for OC surgery of whom 39 patients had liver resection as part of the surgical treatment of whom 21 had parenchymal metastasis. The mean age of patients was 46 years old, the 87% of patients had stage III/IV OC. 9, 17 and 13 patients had liver resection as part of cytoreductive surgery on primary, secondary and tertiary respectively. 58% of patients had epithelial type ovarian carcinoma, followed by 30% of stromal tumors. 35 patients had single liver metastasis, the mean diameter was 4.38 cm for parenchymal metastasis and 4.55 cm for peritoneal seeding, R0 resection was accomplished in 61% of patients. 33, 3 and 2 patients underwent minor hepatactomy, segmentectomy and major hepatectomy respectively. The margin status was not reported in 76 % of pathology reports. The most frequent associated organ resection was the spleen, omentum and peritoneum. The length of hospital stay was 5 days. 26 and 13 patients had Dindo-Clavien score I and II respectively, the 30-day mortality rate following surgery was 0. The disease free survival was better in patients with peritoneal seeding metastasis, however it was non-significant p:0.127. The overall survival analysis showed no difference p:0.752 between patients who were submitted to parenchymal or peritoneal seeding liver resection. Conclusions Liver resection for advanced OC is a safe procedure from primary to quaternary cytoreduction and may bring survival benefit. There is a difference in prognosis following surgery between patients with parenchymal or peritoneal seeding liver resection, however further research is needed Note: This abstract was not presented at the meeting. Citation Format: Jorge Luna Abanto, Luis Garcia Ruiz, Jheff Laura Martinez, Vladimir Villoslada Terrones. Liver resection as part of cytoreductive surgery for ovarian cancer liver metastases in a national cancer hospital [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4877.

Cardiophrenic lymph node resection in advanced ovarian cancer: surgical outcomes, pre- and postoperative imaging

Objective: To evaluate the accuracy of preoperative imaging in the diagnosis of cardiophrenic lymph node (CPLN) metastases and to report perioperative outcomes after resection of CPLN at the time of cytoreductive surgery for advanced epithelial ovarian cancer (EOC). Furthermore, to assess clearance of CPLN by postoperative imaging.Methods: All women with stage IIIC/IV EOC subjected to surgery at our institution from January 2014 to October 2016 were retrospectively identified from a database. Among these, women subjected to CPLN resection during surgery were identified. Pre- and postoperative computed tomography (CT) scans, pathology reports, surgical approach and outcomes were reviewed.Results: One hundred and eighty women with stage IIIC/IV EOC subjected to surgery with curative intent were identified. Twenty-four (13%) of these women underwent CPLN resection. All had CT imaging suggestive of CPLN metastases. 20/24 (83%) had confirmed metastases upon final pathology. CPLN resection was associated with longer operation time, more often advanced upper abdominal surgery and more postoperative complications but there was no difference in days from surgery to initiation of chemotherapy. Postoperative CT was still indicative of CPLN metastases in 13/22 (59%) women despite resection with confirmative pathology.Conclusions: Resection of CPLN metastases is highly feasible without considerable added morbidity. Concern regarding surgical clearance is raised since postoperative imaging was indicative of metastases in the majority of women. The prognostic significance of stage IV disease based exclusively on CPLN metastases is unclear and any survival benefit from the procedure is yet to be determined.

Feasibility, safety and clinical outcomes of cardiophrenic lymph node resection in advanced ovarian cancer.

Surgical resection of enlarged cardiophrenic lymph nodes (CPLNs) in primary treatment of advanced ovarian cancer has not been widely studied. We report on a cohort of patients undergoing CPLN resection during primary cytoreductive surgery (CRS), examining its feasibility, safety, and potential impact on clinical outcomes. We identified all patients undergoing primary CRS/CPLN resection for Stages IIIB-IV high-grade epithelial ovarian cancer at our institution from 1/2001-12/2013. Clinical and pathological data were collected. Statistical tests were performed. 54 patients underwent CPLN resection. All had enlarged CPLNs on preoperative imaging. Median diameter of an enlarged CPLN: 1.3cm (range 0.6-2.9). Median patient age: 59y (range 41-74). 48 (88.9%) underwent transdiaphragmatic resection; 6 (11.1%) underwent video-assisted thoracic surgery. A median of 3 nodes (range 1-23) were resected. A median of 2 nodes (range 0-22) were positive for metastasis. 51/54 (94.4%) had positive nodes. 51 (94.4%) had chest tube placement; median time to removal: 4d (range 2-12). 44 (81.4%) had peritoneal carcinomatosis. 19 (35%) experienced major postoperative complications; 4 of these (7%) were surgery-related. Median time to adjuvant chemotherapy: 40d (range 19-205). All patients were optimally cytoreduced, 30 (55.6%) without visible residual disease. Median progression-free survival: 17.2mos (95% CI 12.6-21.8); median overall survival: 70.1mos (95% CI 51.2-89.0). Enlarged CPLNs can be identified on preoperative imaging and may indicate metastases. Resection can identify extra-abdominal disease, confirm Stage IV disease, obtain optimal cytoreduction. In the proper setting it is feasible, safe, and does not delay chemotherapy. In select patients, it may improve survival.

Feasibility, safety and clinical outcomes of cardiophrenic lymph node resection in advanced ovarian cancer

Feasibility, safety and clinical outcomes of cardiophrenic lymph node resection in advanced ovarian cancer

Total parietal peritonectomy with en bloc pelvic resection for advanced ovarian cancer with peritoneal carcinomatosis

ObjectiveThe majority of advanced ovarian cancer patients have peritoneal carcinomatosis involving from the pelvis to upper abdomen, which is a major obstacle to optimal cytoreduction. Since total parietal peritonectomy was introduced for treating peritoneal carcinomatosis from colorectal cancer [3], similar surgical techniques including pelvic peritonectomy have been applied in advanced ovarian cancer with peritoneal carcinomatosis [1], and these can increase the rate of complete cytoreduction up to 60% [2]. However, there are few reports on total parietal peritonectomy for ovarian cancer patients. In this surgical film, we showed total parietal peritonectomy with en bloc pelvic resection for treating advanced ovarian cancer with peritoneal carcinomatosis. MethodsA 43years-old woman was diagnosed with high-grade serous carcinoma of the ovary after right adnexectomy. Computed tomography demonstrated subdiaphragmatic involvements, omental cake, lymph node metastases and huge pelvic mass infiltrating the uterus, cul-de-sac, and pelvic peritoneum. Primary debulking surgery was considered because of a high likelihood for complete cytoreduction. ResultsFirst, the whole abdomen and pelvis were adequately exposed and the visceral organs thoroughly mobilized. Then, the parietal peritoneum was dissected from the subdiaphragmatic, paracolic and pelvic areas. Tumor-infiltrated visceral organs such as the uterus, adnexae, rectosigmoid colon and cul-de-sac were resected en bloc with the parietal peritoneum (Fig. 1). ConclusionsTotal parietal peritonecotmy with en bloc pelvic resection is a feasible procedure for removing peritoneal metastasis in advanced ovarian cancer patients, which contributes to optimal cytoreduction improving prognosis.

Preoperative prediction of suboptimal resection in advanced ovarian cancer based on clinical and CT parameters.

Background Cytoreduction is important as a survival predictor in advanced ovarian cancer. Purpose To determine the prediction of suboptimal resection (SOR) in advanced ovarian cancer based on clinical and computed tomography (CT) parameters. Material and Methods Between 2007 and 2015, 327 consecutive patients with FIGO stage III-IV ovarian cancer and preoperative CT were included. During 2007-2012, patients were assigned to a derivation dataset ( n = 220) and the others were assigned to a validation dataset ( n = 107). Clinical parameters were reviewed and two radiologists assessed the presence or absence of tabulated parameters on CT images. Logistic regression analyses based on area under the receiver-operating characteristic curve (AUROC) were performed to identify variables predicting SOR, and generated simple score using Cox proportional hazards model. Results There was no statistical difference in patients' characteristics in both datasets, except for residual disease ( P = 0.001). Optimal resection improved from 45.0% (99/220) in the derivation dataset to 64.4% (69/107) in the validation dataset. Logistic regression identified that Eastern Cooperative Oncology Group-performance status (ECOG-PS 2), involvements of peritoneum, diaphragm, bowel mesentery and suprarenal lymph nodes, and pleural effusion were independent variables of SOR. Overall AUROC for score predicting SOR was 0.761 with sensitivity, specificity, and positive and negative predictive values of 70.6%, 73.2%, 68.7%, and 91.9%, respectively. In the derivation dataset, AUROC was 0.792, with sensitivity of 71.4% and specificity of 74.3%, and AUROC of 0.758 with sensitivity of 69.2% and specificity of 72.8% in the validation dataset. Conclusion CT may be a useful preoperative predictor of SOR in advanced ovarian cancer.

En bloc pelvic resection for advanced ovarian cancer preceded by central ligation of vessels supplying the tumor bed: a description of surgical technique and a feasibility study

BackgroundThe resection of all visible malignancies increases the likelihood for long-term survival in epithelial ovarian cancer. The complete extinguishment of pelvic disease is possible using en bloc pelvic resection. The no-touch isolation technique aims to reduce cancer cells flowing from the primary tumor site to the liver and other organs by ligating blood and lymphatic vessels first. objectives are to present the operative details and to establish the feasibility of the modified technique of en bloc pelvic resection, which begins with the central ligation of vessels supplying the tumor bed.MethodsTwenty patients with pelvic tumor extensively infiltrating into adjacent pelvic organs were uniformly operated on. The surgical plan commenced with incisions along the lateral peritoneal reflections immediately medial to the white line of Toldt followed by a retroperitoneal central ligation of ovarian and mesenteric vessels and the ovarian lymphovascular flow. Then, the routine steps of en bloc pelvic resection were performed. Data on treatment were assessed.ResultsIn all cases, no gross residual disease was achieved. The median durations of the surgical procedure and the hospital stay were 320 min (range: 205–430 min) and 12 days (range: 7–44 days), respectively. The complications were as follows: wound infection (n = 1), anastomosis dehiscence (n = 1), total parenteral nutrition (n = 4), and death (n = 1, PE). The median follow-up time period was 19 months (range: 8–31 months). No patient experienced a recurrence of pelvic disease.ConclusionsPerforming a central ligation of vessels supplying the tumor bed prior to an en bloc pelvic resection is feasible with acceptable morbidity and mortality rates.

The sandwich technique of diaphragmatic stripping or full-thickness resection for advanced ovarian cancer: how to keep it short and simple.

Residual tumor is an important prognostic factor in advanced ovarian cancer patients. A recent analysis from a large Gynecologic Oncology Group trial identified the diaphragm as the most common localization for residual tumor after surgery in advanced ovarian cancer. This stresses the need for more knowledge and training in diaphragmatic surgery in patients with advanced ovarian cancer. We aimed to describe a safe structured technique to perform transection of the peritoneal diaphragm or full-thickness resection of the diaphragm. The structured technique consists of 5 steps as follows: (1) knowledge of anatomical landmarks, (2) adequate exposure of the surgical field, (3) mobilization of the liver, (4) demarcation of the resection lines of the peritoneum, and (5) mobilization of the diaphragmatic peritoneum by using the sandwich technique or performance of a full-thickness resection with subsequent suture. Diaphragmatic surgery is an important part of upper abdominal surgery in advanced ovarian cancer patients. It is a safe structured procedure, which should be routinely performed to achieve optimal surgical results for these patients.

The “Sandwich-Technique” of diaphragmatic stripping or full-thickness resection for advanced ovarian cancer: how to keep it fast and simple

Objective: Residual tumor is the most important prognostic factor in advanced ovarian cancer patients. A recent analysis from a large GOG trial identified the diaphragm as the most common localization for residual tumor after surgery in advanced ovarian cancer. This stresses the need for more knowledge and training in diaphragmatic surgery in patients with advanced ovarian cancer.

Douglas peritonectomy compared to recto-sigmoid resection in optimally cytoreduced advanced ovarian cancer patients: Analysis of morbidity and oncological outcome

BackgroundRectosigmoidectomy (RR) with primary anastomosis or pelvic peritonectomy (PP) are often part of an optimal en bloc tumor resection in advanced ovarian cancer (AOC) patients with contiguous extension to or encasement of the reproductive organs, peritoneum of the cul-de-sac and sigmoid colon. We report our experience with two different surgical approaches in optimally cytoreduced AOC patients evaluating oncologic outcome and surgically associated morbidities MethodsData from all consecutive AOC patients undergoing PP or RR as part of the surgical procedure during primary cytoreduction from 2004 through 2009 were extrapolated and analyzed using the chi-squared test, Cox proportional hazard model and Kaplan-Meier method including log-rank test. ResultsDuring the study period, we identified 187 AOC patients, fitting the inclusion criteria: 71 (38%) were submitted to RR and 116 (62%) were managed with PP. The estimated mean disease-free survival (DFS) was 30.7 months (95% CI 24.6–36.8) in the RR arm vs. 25.9 months in the PP arm (95% CI 21.9–29.9) (p 0.299); similarly, the estimated mean overall survival (OS) was 38.8 months (95% CI 33.4–44.2) in the RR arm and 48.2 months in the PP arm (95% CI 43.1–53.3) (p = 0.122). No statistically significant differences were found in terms of DFS and OS according to the mesocolic lymphnode status (p = 0.65 and p = 0.81, respectively). ConclusionsIn conclusion, the current study clearly supports evidence that survival rates are similar for patients who achieved optimal residual tumor (RT), independent to whether they had RR or PP.

Significance of cytoreductive surgery including bowel resection for patients with advanced ovarian cancer.

The aim of this study was to determine the significance of bowel resection in advanced ovarian cancer. A total of 64 women with stage IIIc or IV epithelial ovarian cancer, who consecutively received primary treatment between 1991 and 1995, were entered in this prospective study. The outcome of the patients undergoing bowel resection was evaluated. Thirty-nine patients underwent cytoreductive surgery at initial surgery. Of them, 16 patients could undergo optimal operation without bowel resection. Twenty-three patients received bowel resection at initial surgery. Of these 23 patients, 16 underwent optimal operation and 7 did not. Among 25 patients judged as inoperable cases at initial surgery, 21 responded to chemotherapy and underwent second surgery. Of 21 patients receiving second surgery, 15 underwent optimal operation (7 without bowel resection and 8 with bowel resection). The 3-year survival rate for 24 patients undergoing optimal operation with bowel resection (46.8%) was not significantly different from that for 23 patients without bowel resection (59.1%). Postoperative complications were seen in 8 patients (21.6%) of the patients receiving bowel resection and 3 (13.0%) of those without bowel resection. Cytoreductive surgery including bowel resection is effective for an improvement of the survival in patients with advanced ovarian cancer, if an optimal operation can be performed.