Total Parietal Peritonectomy Research Articles

Perioperative outcomes and platinum resistant recurrence in patients undergoing systematic, protocol-based, total parietal peritonectomy during interval cytoreductive surgery for advanced ovarian cancer: results of the TORPEDO study.

The TORPEDO (CTRI/2018/12/016789) is the single-arm, prospective, interventional study evaluating the role of a total parietal peritonectomy (TPP) in patients undergoing interval cytoreductive surgery (iCRS). In this manuscript, we report the perioperative outcomes and platinum resistant recurrence (PRR) in 218 patients enrolled in the study. A TPP was performed in all patients undergoing iCRS irrespective of the residual disease extent. hyperthermic intraperitoneal chemotherapy (HIPEC) was performed as per the clinician's discretion with 75 mg/m² of cisplatin. Maintenance therapy was also used at the discretion of the treating clinicians. From 9th December 2018 to 31st July 2022 (recruitment complete), 218 patients were enrolled at 4 medical centers in India. The median surgical peritoneal cancer index was 14 and a complete gross resection was achieved in 95.8%. HIPEC was performed in 130 (59.6%) patients. The 90-day major morbidity was 17.4% and 2.7% patients died within 90 days of surgery. Adjuvant chemotherapy was delayed beyond 6 weeks in 7.3%. At a median follow-up of 19 months (95% confidence interval [CI]=15.9-35 months), 101 (46.3%) recurrences and 19 (8.7%) deaths had occurred. The median progression-free survival was 22 months (95% CI=17-35 months) and the median overall survival (OS) not reached. Platinum resistant recurrence was observed in 6.4%. The projected 3-year OS was 81.5% and in 80 patients treated before may 2020, it was 77.5%. The morbidity and mortality of TPP with or without HIPEC performed during iCRS is acceptable. The incidence was of PRR is low. Early survival results are encouraging and warrant conduction of a randomized controlled trial comparing TPP with conventional surgery.

Short- and long-term morbidity of total parietal peritonectomy for advanced ovarian cancer

ObjectiveTotal parietal peritonectomy is gradually being recognized as a surgical option for advanced ovarian cancer; however, evidence regarding its efficacy and safety remains insufficient. Herein, we aimed to assess the...

Platinum resistant recurrence and early recurrence in a multi-centre cohort of patients undergoing interval cytoreductive surgery for advanced epithelial ovarian cancer.

BackgroundAggressive locoregional therapies like hyperthemic intraperitoneal chemotherapy(HIPEC) and total parietal peritonectomy(TPP) have been used to delay recurrence in patients with advanced ovarian cancer undergoing interval cytoreductive surgery(CRS). The aim of this retrospective study was to evaluate the incidence of platinum resistant recurrence (PRR) and early recurrence (ER)(recurrence within 6 months and 1 year of the last dose of platinum based therapy, respectively) in patients undergoing interval CRS. The secondary goal was to study impact of each of these therapies on PRR and ER.MethodsOne-hundred and fifty-three patients undergoing interval CRS from July 2018 to June 2020 were included. The surgical strategy was to perform a TPP in which the entire parietal peritoneum is resected irrespective of the disease extent or a selective parietal peritonectomy (SPP) in which only the peritoneum bearing visible residual disease is resected. The use of HIPEC was at the discretion of the treating oncologists.ResultsThe median surgical PCI was 15 [range, 0-37]. A CC-0 resection was obtained in 119 (77.7%) and CC-1 in 29 (18.9%) patients. Eighty-one (53%) patients had a TPP and 72 (47%) had SPP. HIPEC was performed in 98(64%) patients. Bevacizumab maintenance was administered to 31(19.6%) patients. No patients received PARP inhibitors during first-line therapy. PRR was observed in 8(5.2%) patients and ER in 30(19.6%). The respective incidences of PRR and ER were 4.9% and 16% in the TPP group, 4.1% and 23.6% in the SPP group, 9% and 20% in the no-HIPEC group and 3% and 19.3% in the HIPEC groups. On multivariate analysis, CC-0(p=0.014) resection and HIPEC(p=0.030) were independent predictors of a low ER. All patients with PR and 70% with ER had peritoneal recurrence with or without extra-peritoneal sites of recurrence.ConclusionsThe incidence of PRR and ER in this cohort was low as compared to historical data. This low incidence could be attributed to the use of aggressive locoregional therapies like TPP and HIPEC. In future, studies should be conducted to confirm these findings and evaluate the potential additive benefit of TPP and HIPEC coupled together as well as their combination with maintenance therapies.

Innovative technology of total parietal peritonectomy for peritoneal carcinomatosis

BACKGROUND: Peritonectomy is an integral part of cytoreductive surgery, accompanied by a fairly high incidence of postoperative complications and mortality. In this regard, the improvement and development of easy-to-perform, low-traumatic and safe methods of peritonectomy are topical in oncology.
 AIM: Based on experimental studies to develop a technology of pneumodissection of the peritoneum using carbon dioxide insufflation and evaluate its effectiveness.
 MATERIALS AND METHODS: The study was conducted on 10 non-embalmed corpses of deceased people whose cause of death is not related to tumors of the abdominal cavity and pelvic organs. The Karl STORZ Thermoflator 26432020-1 Insufflator (FSZ registration certificate 2011/09444, dated 12/21/2017), carbon dioxide cylinders with a volume of 20 liters, silicone lines 1.5 meters long, 1 cm in diameter; Seldinger puncture needle 18 G; flexible polypropylene bougie 16 G were used.
 RESULTS: The conducted experimental study made it possible to develop and test a method of total parietal peritonectomy based on the technology of peritoneal pneumodissection using carbon dioxide insufflation. The analysis of the obtained results made it possible to define the concept of a new technology as a method of tissue separation based on the insufflation of carbon dioxide into the connective tissue layers of the retroperitoneal space for the purpose of safe dissection of anatomical structures.
 CONCLUSIONS: Peritoneal pneumodissection using gas insufflation is a new and promising technology with a number of obvious advantages. First of all, they include ease of execution, low injury, high safety and, probably, ablasticity, which can potentially create conditions for the prevention of unintentional dissemination of tumor cells in the abdominal cavity. The data obtained as a result of the experimental study allow us to conclude that pneumodissection of the peritoneum using carbon dioxide insufflation is an effective method of performing total parietal peritonectomy and can be used in performing cytoreductive surgical interventions in patients with peritoneal carcinomatosis.

Retrospective Analysis of Total Parietal Peritonectomy Without Systematic Lymphadenectomy for Advanced Epithelial Ovarian Cancer.

Total parietal peritonectomy (TPP) is a surgical procedure used for complete resection of microscopic peritoneal dissemination. This study analyzed the perioperative complications that developed when omitting systematic lymphadenectomy from TPP. We retrospectively analyzed perioperative complications in epithelial ovarian cancer patients with stage IIIB-IVB who underwent TPP during primary and interval cytoreductive surgeries between April 2018 and October 2021. Thirty-three patients were enrolled in the study. The median patient age was 62 years. Of 31 patients (94%) with stage IIIC/IV disease, 24 (73%) had high-grade serous carcinoma. The median operative time and blood loss were 447 min and 2,831 ml, respectively. Complete tumor resection was performed in 30 patients (91%). Only five patients underwent partial lymphadenectomy for clinical metastatic lymph nodes. Further, grade 3 complications were observed in seven (21%) patients, and there were no fatal events in this study. Three patients (9%) had ureteric injuries, which was the most frequent complication in this study. Only one patient developed an intra-abdominal infection due to ascites. In this case, partial para-aortic and pelvic lymphadenectomies were performed. TPP without systematic lymphadenectomy reduces the frequency of perioperative complications associated with ascites.

Total parietal peritonectomy for 61 patients: a retrospective study

Objective: To evaluate the morbidity of total parietal peritonectomy (TPP) during cytoreduction surgery, and its impact on the site of recurrence of different peritoneal surface malignancies (PSM). Methods: We led a retrospective study in a French tertiary cancer institution (Centre Oscar Lambret - Lille) experienced in treating PSM over a 6-year period from 2012 to 2018. All patients underwent a total parietal peritonectomy during a debulking surgery for PSM including ovarian cancer, appendiceal pseudomyxoma peritonei or peritoneal mesothelioma. Results: Among the 61 patients included in this study, 49 patients(80.3%) had an ovarian cancer. The rate of complete tumor resection reached 86.9% with almost 69% of surgeries being highly complex. 73.8% were transfused during the surgical procedure. The median length of hospital stay was 10 days including 7 days in Intensive Care Unit. Overall, 19 patients (31.1%) had an early postoperative complication, including 3 with a grade IIIB complication of Clavien Dindo classification. With a median follow-up of 30 months, the estimated disease-free survival in the ovarian cancer subgroup who had an initial peritonectomy (n = 42) was 84.7% at 1 year and 12.0% at 3 year. The main site of first and second recurrence was peritoneal (42% and 14%). Conclusion: TPP is a safe surgical procedure to treat peritoneal surface malignancies and their recurrences with a low rate of grade IIIB morbidity and no treatment-related death and allow optimal surgery. In this study there is no atypical recurrence site, such as abdominal muscle involvement.

Surgical and systemic therapies for addressing occult disease in advanced epithelial ovarian cancer

The incidence of peritoneal recurrence in advanced epithelial ovarian cancer (EOC) is high and could be attributed to the high prevalence of occult disease the persists despite complete cytoreductive surgery (CRS) and systemic chemotherapy. Several therapeutic approaches have been used to address such occult disease. Hyperthermic intraperitoneal chemotherapy (HIPEC) acts on microscopic disease as well as free intraperitoneal cancer cells shed during surgery, thus, reducing the risk of recurrence. Maintenance therapies like Poly ADP-Ribosyl Polymerase (PARP) inhibitors and the anti-angiogenic agent bevacizumab are used as maintenance therapies to delay recurrence. The most definitive way to eradicate such occult disease completely is resection of the peritoneum. The high preponderance of occult disease in the parietal peritoneum and some regions of the visceral peritoneum has led some surgeons to investigate the role of a total parietal peritonectomy (TPP) performed along with wide resection of the visceral peritoneum as a strategy for addressing occult disease. The mechanism of action differs from that of HIPEC and systemic therapies. It is possible that the benefit of each of these therapies is additive. EOC is a heterogeneous disease with a number of clinicopathological and molecular factors influencing the prognosis. There are likely to be different subgroups of patients that benefit from each of these 4 therapies or a combination of these. In this manuscript, we review the rationale and current evidence for the use of each of these therapies and discuss the potential role of a TPP in light of other therapies.

Visceral segmental serosectomy during debulking surgery for advanced ovarian and fallopian tubal cancer

Objectives: To evaluate the effect and safety of conservatively ablative operation as an alternative to low anterior resection (LAR) on postoperative outcomes and survival in patients with advanced ovarian cancer. Methods: We collected data of patients with stage IIB to IVB ovarian cancer who underwent conservatively ablative operation or LAR from January 2013 to May 2020. Visceral segmental serosectomy (VSS) was conducted as conservatively ablative operation when tumors were not involved in the descending colon over the rectosigmoid colon and did not invade the mucosal layer of the rectosigmoid colon. The extent of surgery and all procedures were performed by a single gynecologic oncologist for minimizing the selection bias, based on total parietal peritonectomy and ultra-radical surgery. Especially, VSS was preferred when tumors involved the rectosigmoid colon within 18 cm because it was considered safe without tension increasing postoperative leakage. Results: A total of 83 patients were divided into the following three groups: VSS (n=44); LAR1 including patients with the rectosigmoid colon involved by tumors within 18 cm (n=18); LAR2 including patients with the rectosigmoid colon involved by tumors over 18 cm (n=21), which showed no difference in clinico-pathologic characteristics. Left diaphragm peritonectomy, right paracolic peritonectomy, and left paracolic peritonectomy were more frequently performed in VSS, LAR2 than in LAR1 (45.5% and 61.9% vs 22.2%; 68.2% and 66.7% vs 27.8%; 25% and 42.9% vs 22.2%; p<0.05). Splenectomy, cholecystectomy, portal triad stripping were more frequently performed in LAR2 and VSS than in LAR1 (81% and 61.4% vs 38.9%; 47.6% and 31.8% vs 11.1%; 42.9% and 25% vs 5.6%; p<0.05), whereas small bowel resection and anastomosis was more common tendency in LAR1 and LAR2 than in VSS (22.2% and 33.3% vs 9.1%; 11.1; p=0.052). Moreover, LAR2 showed longer operation time (median, 440 vs 300 and 343 mins; p=0.008), and more estimated blood loss (median, 2800 vs 1450 and 1615 mL; p=0.007) than VSS and LAR. VSS was a favorable prognostic factor affecting overall survival (adjusted HR 0.157; 95% confidence interval 0.035-0.696; p=0.015). Conclusions: Conservatively ablative operations such as VSS can be performed safely in AOC patients with tumors involving the rectosigmoid colon within 18 cm. Moreover, extensive involvement of the rectosigmoid colon over 18 cm may represent tumor biology affecting poor prognosis. To evaluate the effect and safety of conservatively ablative operation as an alternative to low anterior resection (LAR) on postoperative outcomes and survival in patients with advanced ovarian cancer. We collected data of patients with stage IIB to IVB ovarian cancer who underwent conservatively ablative operation or LAR from January 2013 to May 2020. Visceral segmental serosectomy (VSS) was conducted as conservatively ablative operation when tumors were not involved in the descending colon over the rectosigmoid colon and did not invade the mucosal layer of the rectosigmoid colon. The extent of surgery and all procedures were performed by a single gynecologic oncologist for minimizing the selection bias, based on total parietal peritonectomy and ultra-radical surgery. Especially, VSS was preferred when tumors involved the rectosigmoid colon within 18 cm because it was considered safe without tension increasing postoperative leakage. A total of 83 patients were divided into the following three groups: VSS (n=44); LAR1 including patients with the rectosigmoid colon involved by tumors within 18 cm (n=18); LAR2 including patients with the rectosigmoid colon involved by tumors over 18 cm (n=21), which showed no difference in clinico-pathologic characteristics. Left diaphragm peritonectomy, right paracolic peritonectomy, and left paracolic peritonectomy were more frequently performed in VSS, LAR2 than in LAR1 (45.5% and 61.9% vs 22.2%; 68.2% and 66.7% vs 27.8%; 25% and 42.9% vs 22.2%; p<0.05). Splenectomy, cholecystectomy, portal triad stripping were more frequently performed in LAR2 and VSS than in LAR1 (81% and 61.4% vs 38.9%; 47.6% and 31.8% vs 11.1%; 42.9% and 25% vs 5.6%; p<0.05), whereas small bowel resection and anastomosis was more common tendency in LAR1 and LAR2 than in VSS (22.2% and 33.3% vs 9.1%; 11.1; p=0.052). Moreover, LAR2 showed longer operation time (median, 440 vs 300 and 343 mins; p=0.008), and more estimated blood loss (median, 2800 vs 1450 and 1615 mL; p=0.007) than VSS and LAR. VSS was a favorable prognostic factor affecting overall survival (adjusted HR 0.157; 95% confidence interval 0.035-0.696; p=0.015). Conservatively ablative operations such as VSS can be performed safely in AOC patients with tumors involving the rectosigmoid colon within 18 cm. Moreover, extensive involvement of the rectosigmoid colon over 18 cm may represent tumor biology affecting poor prognosis.

Total parietal peritonectomy performed during interval cytoreductive surgery for advanced epithelial serous ovarian cancer results in a low incidence of platinum resistant recurrence— results of a prospective multi-centre study

BackgroundThe reported incidence of platinum resistant recurrence (PRR) (recurrence within 6 months of the last dose of platinum therapy) after interval debulking/cytoreductive surgery (CRS) is high compared to that after primary CRS. The goal was to study PRR following a total parietal peritonectomy (TPP), that addresses occult disease more completely. MethodsThis is a prospective multi-center study (CTRI/2018/08/015350). A TPP was performed during interval CRS following a fixed surgical protocol. Patients with a follow-up of 6 months(M) or more were included in this analysis. The incidence and patterns of PRR and factors affecting recurrence were analyzed. ResultsFrom July 2018 to October 2019, 70 patients with serous carcinoma were included. The median surgical PCI was 15 [range 5–37]. A CC-0 resection was obtained in 55 (78.5%); CC-1 in 10 (14.2%). Occult residual disease was seen in 40%. At a median follow-up of 13 months, 17 (24.2%) had developed recurrence/progression. PRR was seen in 5 (7.1%) patients. The sites of progression (>1 in 2 patients) were pleura (n = 1), visceral peritoneum (n = 2), retroperitoneal nodes (n = 2), mediastinal nodes (n = 1) and small bowel mesentery (n = 2). Overall, though the most common site of recurrence was the visceral peritoneum (N = 9), seven (>40%) patients did not develop recurrence in the visceral peritoneum. Patients with high PCI and grade 3–4 complications had a higher probability of developing recurrence. ConclusionsTPP performed during interval CRS resulted in a very low incidence of PRR. These findings need confirmation in a larger series. The benefit of TPP over conventional surgery should be evaluated in a randomized trial.

Perioperative outcomes in patients treated with total parietal peritonectomy and multi-visceral resections with or without HIPEC at different time points in the history of advanced ovarian cancer

Perioperative outcomes in patients treated with total parietal peritonectomy and multi-visceral resections with or without HIPEC at different time points in the history of advanced ovarian cancer

Total Parietal Peritonectomy Can Be Performed with Acceptable Morbidity for Patients with Advanced Ovarian Cancer After Neoadjuvant Chemotherapy: Results From a Prospective Multi-centric Study.

Total parietal peritonectomy (TPP) removes areas of "normal-appearing" parietal peritoneum bearing microscopic residual disease and has the potential to improve survival of patients undergoing interval cytoreductive surgery (CRS) for advanced serous epithelial ovarian cancer. This report presents the morbidity outcomes for the first 50 patients enrolled in TORPEDO (CTRI/2018/12/016789), a prospective study. All the patients underwent a TPP during interval CRS. A surgicalprotocol that includes a description ofthe boundaries for each of the five peritonectomies was followed. The common toxicology criteria for adverse events (CTCAE) classification was used to record 90-day morbidity and mortality. The median Peritoneal Cancer Index (PCI) for 50 patients was 15 (range, 5-37). A complete cytoreduction (CC-0 resection) was obtained in 80%, a CC-1 resection in 16%. Abowel resection was performedin 70% of the patients. Grade 3 or 4 complications were seen in 11 patients (22%), and one patient died within 90days after surgery due to intraperitoneal hemorrhage. The most common complications were postoperative fluid collection requiring aspiration (n = 5), intraperitoneal hemorrhage (n = 2), abdominal wound dehiscence (n = 2), pseudo-obstruction (n = 1), urinary sepsis (n = 2), and ileostomy-related complications (n = 2). No bowel fistulas or anastomotic leaks occurred. Microscopic disease in 'normal appearing'peritoneum adjacent to tumor nodules was observed in 46% of the patients, and in regions given a lesion score of 0 in 34%. The parietal peritoneal regions (0-8) had a higher incidence of residual disease (p < 0.001) and occult disease (p < 0.001). During interval CRS, TPP can be performed with acceptable morbidity and mortality. The pathologic findings further support this therapeutic rationale. Survival outcomes should determine the future role of such a procedure in routine clinical practice.

ASO Author Reflections: Total Parietal Peritonectomy During Interval Cytoreductive Surgery for Advanced Ovarian Cancer-Proof-of-Principle and Analysis of Morbidity.

ASO Author Reflections: Total Parietal Peritonectomy During Interval Cytoreductive Surgery for Advanced Ovarian Cancer-Proof-of-Principle and Analysis of Morbidity.

Prospective Comparative Analysis of Total Versus Involved Field Parietal Peritonectomy During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC) for Peritoneal Surface Malignancies from Colorectal Cancer

Peritonectomy is the important component in management of peritoneal surface malignancies (PSM). The aim of this study was to assess the morbidity, recurrence pattern and oncological outcomes of extent of parietal peritonectomy done during CRS and HIPEC for colorectal carcinoma (CRC). Patients with PSM from CRC underwent total parietal peritonectomy (TPP) or IFP with CRS-HIPEC. Pre- and intra-operative data were analysed with main focus on postoperative morbidity, recurrence pattern and oncological outcomes. Of 40 patients in the study, 19 and 21 patients underwent TPP and IFP respectively. TPP group had longer duration of surgery (11 vs 9), more blood loss (1300 vs 835 ml), increased diaphragmatic resections (47.3% vs 9.5%) and multivisceral resection (47.3% vs 28.5%). Overall, G3–G5 morbidity TPP versus IFP was 47.3% versus 33.3% and surgical morbidity was 30.7% versus 23.8%. With a median follow-up of 30 months, DFS was significantly higher in the TPP group (12 months vs 8 months, p < 0.01) and a median overall survival was 21 months in the IFP group (yet to be achieved in the TPP group). The TPP group had most of the recurrences in visceral liver and lung (50.0%) followed by peritoneal (37.5%) and nodal (12.5%), whereas in IFP, it was peritoneum (42.8%), visceral (38.4%) and nodal (15.3%). The TPP group had significantly higher DFS and trend towards improved OS. This indicates aggressive surgical resection has benefit with manageable postoperative morbidity. However, longer follow-up and a prospective multi-institutional randomised study need to be designed for more evidence of the same.

Impact of extent of parietal peritonectomy on oncological outcome after cytoreductive surgery and HIPEC.

BackgroundIn peritoneal surface malignancy (PSM), in spite of optimal cytoreductive surgery (CRS), majority of recurrences that occur are intraperitoneal. In patients with PSM, studies employing fluorescent imaging and microscopic examination have shown normal looking peritoneum may harbor active disease. This study was done to assess the recurrence pattern, oncological outcomes, and morbidity and mortality of the extent of peritonectomy in patients who underwent total parietal peritonectomy (TPP) or involved field peritonectomy (IFP) as a part of the procedure during CRS and hyperthermic intraperitoneal chemotherapy (HIPEC).MethodsThis was a retrospective analysis of prospectively collected data, from February 2013 to December 2017. A total of 163 patients with PSM underwent TPP or IFP with CRS plus HIPEC. Their oncological outcomes, recurrence pattern, postoperative morbidity and mortality were analyzed.ResultsOf the 163 cases, the primary organs of origin were ovary, colorectal, appendicular pseudomyxoma, stomach, mesothelioma and others (67.4%, 16.5%, 6.1%, 4.9%, 2% and 2%), respectively. TPP was performed in 70 patients and IFP in 93 patients. TPP group had higher mean PCI (16 vs. 14), longer duration of surgery (11 vs. 9 h), and more blood loss (1,243 vs. 675 mL). Overall G3–G4 morbidity was comparable in both groups (42.8% vs. 33.3%) as was mortality (5.7% vs. 4.4%). Kaplan–Meier analysis showed that with a median follow-up of 45 months, TPP group had a recurrence-free survival (RFS) of 26 months and overall survival (OS) was yet to be achieved, whereas the IFP group had a RFS and OS of 21 and 43 months, respectively.ConclusionsPerforming TPP reduces the chance of missing the microscopic disease, therefore can minimize local recurrence, and better oncological outcomes. TPP can be performed with acceptable morbidity and mortality, at the cost of increased duration of surgery and higher blood loss.

Clinico-pathological outcomes after total parietal peritonectomy, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in advanced serous papillary peritoneal carcinoma submitted to neoadjuvant systemic chemotherapy- largest single institute experience

IntroductionSerous papillary peritoneal carcinoma (SPPC) is a rare clinical entity. Based on the understanding of the pattern of spread, its multifocality, polyclonality and the high frequency of diffuse, widespread peritoneal metastasis, a robust rationale for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for SPPC exists. Herein we report the clinical outcomes of SPPC patients treated with neoadjuvant systemic chemotherapy (NACT) followed by CRS including total parietal peritonectomy and HIPEC. MethodsClinico-pathological data of 22 patients of serous papillary peritoneal carcinoma (SPPC) was retrospectively analyzed from a prospectively maintained database from June 2000 to July 2017. Patients were treated with CRS, total parietal peritonectomy and HIPEC with cisplatin (42 mg/L of perfusate) and doxorubicin (15 mg/L of perfusate) after NACT. Survival curves were calculated from the date of surgery. Results22 patients underwent CRS, total parietal peritonectomy and HIPEC. The median age was 62 years (Range 47–72). On histological evaluation, 18/30 (60%) parietal peritonectomy specimens showed microscopic disease, when no disease was evident macroscopically at surgical exploration. Grade III-IV surgical complications were recorded in 4/22 (18%) patients. There was no postoperative mortality. At a median follow up of 12 months, the five-year overall survival (OS) was 64.9%. The median OS was not reached. Median progression-free survival was 32.9 months and progression-free survival at 5 years was 33.2%. ConclusionCRS with total peritonectomy + HIPEC after NACT, presents as a promising treatment modality for SPPC, and could be associated with good survival results in patients with SPPC.

“Should we be generous in peritonectomy?”: First prospective comparative analysis of total versus involved field parietal peritonectomy in CRS-HIPEC for peritoneal surface malignancies from COLO-rectal cancer—ISPSM collaboration study.

633 Background: Peritonectomy is the important components in management of peritoneal surface malignancies (PSM). Immunofluoresecne study done after involved field peritonectomy (IFP) has showed diease in areas not suspected on gross examination stressing the need for total parietal peritonectomy (TPP) for complete cytoreduction. The aim of this study was to assess the morbidity &amp; mortality, recurrence pattern &amp; oncological outcomes of extent of parietal peritonectomy with CRS &amp; HIPEC for colorectal carcinoma. Methods: Patients with PSM from CRC underwent TPP or IFP with CRS- HIPEC. Pre &amp; intraoperative data were analyzed with main focus on postoperative morbidity, mortality, recurrence pattern and oncological outcomes. Results: 40 cases of CRC of which four upfront, 17 interval and 19 recurrent cases. 19 &amp; 21 patients underwent TPP &amp; IFP respectively. Base line characteristics were comparable except median PCI (17 versus 12). TPP group had longer duration of surgery (11 vs 9), more blood loss (1300 vs 700 ml) increased diaphragmatic resections ( 46.2% vs 14.2%), multivisceral resection ( 46.2% vs 28.5%). Number of bowel resections, anastomosis and stoma were comparable. Overall TPP group had more G3-G5 morbidity (46.1% vs 35.7%) &amp; surgical morbidity (30.7% vs 21.5%) . TPP group had increased pleural &amp; intra-abdominal collections which needed intervention. With a median follow up of 30 months, DFS was significantly higher in TPP group (12months vs 8months, p &lt; 0.01) and median overall survival was 21 months in IFP group (yet to be achieved in TPP group). TPP group had most of the recurrences in visceral liver &amp; lung (50.0%) followed by peritoneal (37.5%) &amp; nodal (12.5%) whereas in IFP it was peritoneum (42.8%), visceral ( 38.4%) &amp; nodal (15.3%). Conclusions: It is the first prospective comparative study done on total parietal peritonectomy in PSM of colorectal cancer origin. TPP group had significantly higher DFS, with comparable postoperative morbidity. However, longer follow up and a prospective multi-institutional randomized study needs to be designed for more evidence of the same.

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.

Extent of parietal peritonectomy does not change intraperitoneal chemotherapy pharmacokinetics.

To measure the clearance intraperitoneal mitomycin C and doxorubicin in patients having peritonectomy and analyze the impact of the extent of peritoneal resection on pharmacokinetics. A group of 15 patients with peritoneal carcinomatosis were submitted to cytoreductive surgery and heated intraperitoneal chemotherapy. Ten patients received mitomycin C and five, doxorubicin. Six patients underwent total parietal peritonectomy and nine had less-extensive peritonectomy. Pharmacokinetics were determined by sampling peritoneal fluid and blood. Drug concentrations over time, area under the curve ratios and the amount of drug recovered from the peritoneal cavity were calculated and compared between the groups. The concentrations of mitomycin C over time in the peritoneal fluid and plasma were similar in five patients with total parietal peritonectomy as compared to five patients with less-extensive peritonectomy ( P=0.5350 and 0.6991; Mann-Whitney test). Mitomycin C area under the curve ratio in total peritonectomy patients was 20.5 and 25.7 in patients with less-extensive peritonectomy. The difference in total amount of drug recovered from the peritoneal cavity was not significant (30.6+/-6.188% versus 22.6+/-3.84%, P=0.095). In the studies with doxorubicin, one patient underwent total parietal peritonectomy with similar pharmacokinetics to four patients submitted to partial peritonectomy. The extent of parietal peritoneal resection did not affect the pharmacokinetics of intraoperative intraperitoneal chemotherapy. The pharmacological barrier between the abdominopelvic cavity and plasma is not directly related to an intact peritoneum.