Mid-Term Audit of a National Peritoneal Surface Malignancy Program Implementation in a Low Middle Income Country: The Moroccan Experience

Abstract

Implementing a multimodal management of peritoneal surface malignancies is a steep and complex process, especially as complete cytoreductive surgery (CRS) is the backbone and the major prognostic factor for hyperthermic intraperitoneal chemotherapy (HIPEC) procedures. The implementation of such a program is a challenging process, particularly in low-middle income (LMIC) countries where ressource restrictions may represent a major hurdle to HIPEC appliances acquisition. Herein is the first audit of the implementation of a national peritoneal malignancy program in a north African country. The audit process was performed according to the three implementation steps, namely initiation (“1”:2005–2008), transition (“2”:2009–2013) and consolidation (“3”:2014–2017). We included all consecutive CRS without HIPEC performed with curative intent for ovarian, gastric, colorectal and pseudomyxoma peritonei type of malignancies with an Eastern Cooperative Oncology Group (ECOG) performance Status ≤ 2. Target outcomes for incomplete cytoreduction (ICRS), serious complications ≥ 3b according to the Clavien-Dindo scoring, and early oncologic failure (EOF; disease progression within 2 years of treatment) were compared between the three phases. Independent risk factors correlated to these three outcomes were calculated using a logistic regression model.198 CRS procedures were completed with 49, 60 and 89 cases performed in the three phases, respectively. Overall, patients were comparable except for ECOG and ASA scores which were more severe in the third phase. The comparison of ICRS, serious complications and EOF rates showed a significant reduction between the three phases with (34%, 18% and 4% p = <0.001), (30.6%, 20% and 11.2%, p = 0.019) and (38.8%, 23.3% and 12.4% p = 0.002) respectively. Undergoing CRS in phase 3 on the other hand was a predictive factor of better short term surgical and oncological outcomes and completeness of cytoreduction, while ECOG performance status and spleno-pancreatectomy were also predictive factors of serious complications.

Current Opinion and Practice on Peritoneal Carcinomatosis Management: The North African Perspective

“…In resource restricted contexts such as in the North African region, the prioritization and indications for the curative treatment may also face the constraints of limited critical care and surgical resources management and expertise (22,(38)(39)(40)(41). In fact, while only 26.2% of our respondents reported having access to HIPEC, a similar study on practice patterns in PC from the USA identified 65.8% of its participants as having easy access to a HIPEC and CRS specialists, with 42.7% being in the same hospital (33).…”

“…As such, we choose to include the private sector in our analysis, which indeed demonstrated that the significantly higher availability in the private sector of some therapies such as pressurized intraperitoneal chemotherapy and low dose radiotherapy didn't necessarily yield a higher level of satisfaction in the available treatment modalities. Regardless of the activity sector, the level of expertise is considered a better reflection ( 22 ), especially as the PSM treatment learning curve can be steep and complex ( 43 ).…”

“…This region has particular characteristics when it comes to healthcare in general with the public and private sectors playing a complementary role ( 20 ) and where cancer incidence has a distincts pattern that completely differs from that of Central and Southern African countries as well as Europe ( 21 ). Nonetheless, there is no available data on the knowledge and practices in the management of PSM in this region, except for a few reports ( 22 ). The aim of this study was to assess and compare current practice and knowledge regarding PSM and examine satisfaction with available treatment options and need for alternative therapies in North Africa.…”

Hyperthermic Intraperitoneal Chemotherapy and Cytoreductive Surgery in Ovarian Cancer: An Umbrella Review of Meta-Analyses

“…This includes, hysterectomy, bilateral salpingo-oophorectomy, omentectomy as well as additional procedures such as peritonectomies ( 9 ), bowel resections, diaphragm peritonectomy with or without segmental full-thickness diaphragm resection, splenectomy with or without distal pancreatectomy, segmental liver resection, cholecystectomy, partial stomach resection, and partial bladder/ureteral resection ( 10 ). Postoperative residual disease was shown to be a major prognostic factor of overall survival ( 11 – 13 ), hence the necessity of surgery to be complete. In fact, surgery used to be qualified as “optimal” in reference to a residual tumour of less than 1 cm, but this is not the goal anymore.…”

CRS and HIPEC: Best model of antifragility in surgical oncology

“…In our experience, objectively and easily grading the extent of surgery through the BESt MAnagement Technique for HIpec score has allowed for better communication in the MDT, which has been reflected in clinical and postoperative results through better patient preparation and anticipation of the procedures. 5 The Besmathi score is a four scale tool that is categorized as follows:…”