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

Abstract

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.

Enhanced recovery after surgery in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: national survey of peri-operative practice by Indian society of peritoneal surface malignancies

“…Evidence and ERAS guidelines have supported the avoidance of routine mechanical bowel preparation and use only for left sided colonic resections, particularly due to adverse outcomes such as hypovolemia and dehydration and the fact that it does not decrease post-operative morbidity [ 6 ]. But nearly 62 % of the surgeons in the survey still insist on it routinely, probably because in CRS most patients need multi visceral resections and there is no way to predict to whom we perform only left sided resections [ 20 ].…”

Distribution of residual disease in the peritoneum following neoadjuvant chemotherapy in advanced epithelial ovarian cancer and its potential therapeutic implications

“…There are some studies that have compared resection of only involved regions of the peritoneum (selective parietal peritonectomy) with resection of the entire parietal peritoneum (total parietal peritonectomy). [17,18] Each of these has several limitations due to which nothing definite can be inferred from them. However, the morbidity of a total parietal peritonectomy was acceptable.…”

Surgical Options for Peritoneal Surface Metastases from Digestive Malignancies—A Comprehensive Review

“…The completeness of the cytoreductive procedure has a direct impact on the survival of patients with PSM in most malignancies. Although the goal of CRS should be the achievement of a CC-0 score (no macroscopic residual tissue), at least in ovarian cancer, even a CC-1 score (persistent nodules less than 2.5 mm in largest diameter) seems to be associated with improved OS [ 9 ]. In order to achieve a CC-0/CC-1 score, a dedicated team involving surgeons, anesthesiologists, medical oncologists, and radiologists should evaluate the patient and subsequently perform the procedure, preferably in a high volume-center [ 10 ].…”