Diagnostic Laparoscopy as a Selection Tool for Patients with Colorectal Peritoneal Metastases to Prevent a Non-therapeutic Laparotomy During Cytoreductive Surgery

Abstract

Objective. The aim of this study was to evaluate the introduction of diagnostic laparoscopy (DLS) in patients with colorectal peritoneal metastases (PM) to prevent nontherapeutic laparotomies during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS ? HIPEC). Methods. Patients with histologically proven colorectal PM who underwent a laparotomy for potential CRS ? HIPEC from January 2006 to January 2019 were retrospectively identified from a prospectively maintained database. In 2012, DLS was introduced in the preoperative work-up for CRS ? HIPEC in our academic center. The rates of non-therapeutic laparotomies, major postoperative complications (Clavien-Dindo grade III or higher), and survival outcomes were investigated for patients who underwent a laparotomy before (cohort A) and after (cohort B) the introduction of DLS. In cohort B, the reasons to refrain from DLS were retrospectively explored from medical records. Results. Overall, 172 patients were included [cohort A: 48 patients (27.9%); cohort B: 124 patients (72.1%)]. A

Comment on “Diagnostic Laparoscopy as a Selection Tool for Patients with Colorectal Peritoneal Metastases to Prevent a Non-therapeutic Laparotomy During Cytoreductive Surgery”

“…In this study, the median survival of patients who had CRS/HIPEC was 36.4 months. 1 This prolonged survival is similar to the 41-month median survival of patients in the PRODIGE 7 trial reported at ASCO. 8 In both studies, patients are treated with a combination of systemic chemotherapy and CRS/HIPEC.…”

“…Concerns regarding the safety of DLS in this patient population, given the high rate of prior surgery and the potential risk of port-site metastases, have not been confirmed. Hentzen et al 1 as well as prior reports, 2,3,7 find no significant complications; therefore, avoiding the alternative of a non-therapeutic laparotomy is well worth the risk of a DLS.…”

“…The limits of cross-sectional imaging are well known to peritoneal surgeons, and better modalities are needed to diagnose and assess peritoneal disease for treatment planning, be it cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) or systemic chemotherapy. Hentzen et al 1 review their experience with diagnostic laparoscopy (DLS) as a selection tool for CRS during two periods in their practice. From 2006 to 2011 patients referred to their center for CRS had an exploratory laparotomy and hence constitute the historic control group (or cohort A).…”

“…The question of systemic therapy versus CRS/HIPEC does not align with current practice patterns and is unlikely to accrue patients. 11,12 Hentzen et al 1 describe several important trends in their study. The patients in cohort B were older and more often presented with metachronous disease, and only 18.6% of patients had a PCI [ 20, compared with 45.5% in cohort A.…”

Concomitant intraperitoneal and systemic chemotherapy for extensive peritoneal metastases of colorectal origin: protocol of the multicentre, open-label, phase I, dose-escalation INTERACT trial

“…Current radiological imaging techniques are valuable in the detection of distant metastasis but underestimate the extend of peritoneal disease 9–11. To prevent unnecessary open-close procedures/laparotomies in patients with a PCI >20, a diagnostic laparoscopy (DLS) is recommended during preoperative work-up for CRS-HIPEC 12 13. DLS can prevent up to 40% of open-close procedures 13.…”