Second-look Surgery for Appendiceal High Grade and Colorectal Cancers Following Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Abstract

Background/Aim: Up to a third of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC) of appendiceal or colorectal origin receive a stoma during primary surgery. Stoma reversal provides an opportunity for second-look surgery. Patients and Methods: We performed a retrospective analysis of prospectively collected data of patients with colorectal cancer (CRC) or high-grade appendiceal cancer (AC) from 2006 to 2021 from our database. A total of 34 consecutive stoma closure patients with no evidence of preoperative disease recurrence (tumor markers and CT scans) were compared with 141 consecutive re-do CRS/HIPEC patients with known recurrence. Results: Eleven patients (32.4%) were identified to have peritoneal recurrence at stoma closure. Time between first and second CRS was 12 months (4 to 64.2) in the stoma closure group vs. 24.6 months (5.8 to 119.8) in the re-do group, while median peritoneal cancer index (PCI) was 4 (3 to 6) vs. 8 (1 to 39), respectively (p=0.0143). Conclusion: Second-look laparotomy during stoma closure identified unexpected PC in 32.4% of our patients with significantly lower PCI than planned re-do operations.In recent decades, cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for select patients with peritoneal carcinomatosis (PC) has shown improved survival rates compared to systemic chemotherapy with or without palliative surgery (1-5). One meta-analysis has shown that CRS with HIPEC offers a median survival of 29 months in patients with PC, which is significantly longer than the median survival of 17.9 months for standard chemotherapy alone (6).Despite advancements in CRS and HIPEC, peritoneal disease recurrence rates in colorectal cancer (CRC) or highgrade appendiceal cancer (AC) can be as high as 80% and 40%, respectively, within two years of surgery (7, 8). Currently, postoperative monitoring consists primarily of routine cross-sectional imaging by way of computed tomography (CT) scan, combined with serum biochemical markers to diagnose recurrence of disease (9). Patients with recurrent disease may then undergo a second CRS (hereafter, re-do CRS). However, recurrence is often difficult to detect by imaging and biochemistry alone as patients are often asymptomatic in the early stages of recurrence, and the sensitivity of CT scanning in detecting peritoneal recurrence approaches 60%, while also being influenced by factors such as size and extent of disease, location of spread, and radiologist expertise (10, 11). It has been established in the literature that the extent of peritoneal disease, as measured by the peritoneal cancer index (PCI), has a significant impact on the patient's prognosis, with a lower burden of peritoneal disease being associated with better CRS outcomes and improvements in morbidity (12). As earlier detection of disease is associated with a lower burden of peritoneal disease, better techniques should be devised to enable earlier 2350

Increased Incidence of Liver Metastases in ColorectalVersusAppendiceal Adenocarcinoma Peritonectomy Patients Despite Equivocal Survival

“…Thus, the higher PCIs of AAdenoCa patients and thus longer operation times explain their comparatively increased length of hospital and ICU stay. There is a linear correlation between elevated PCI and elevated CC-score (31). Thus, due to the higher and lower PCI cut-offs used in our study for AAdenoCa and CRAdenoCa peritonectomy patients, respectively, the association between AAdenoCa and CC-1 and CRAdenoCa and CC-0 is not surprising.…”