Peritonectomy

Abstract: Intraperitoneal chemotherapy and cytoreductive surgery have been combined to reach treatment objectives in patients with peritoneal carcinomatosis or sarcomatosis that neither modality by itself can achieve. These treatments must be combined with the proper selection of patients in order to observe "high value" results from therapy. There are three principles of management to support treatments for peritoneal carcinomatosis and sarcomatosis. First, the clinician must select patients who have isolated disease distributed on the surfaces of abdominal and pelvic structures. Patients treated for peritoneal implants who have persistent disease at other sites will profit little or not at all. Second, this disease must be reduced to its lowest possible mass by peritonectomy procedures and resections of viscera. Third, maximal intraperitoneal and systemic chemotherapy are utilized to eradicate the disease on peritoneal surfaces as well as control the primary or recurrent tumor. These principles of management and a presentation of the results achieved to date are reviewed.

Abstract: Although cancer surgery has been of great benefit to patients with large bowel cancer, a flaw that has caused the death of countless patients has gone unrecognized. Although surgeons have dealt successfully with the primary tumor, they have neglected to treat microscopic residual disease. Persistent cancer cells within the abdomen and pelvis are responsible for the death of 30-50% of the patients who die with this disease and for quality of life consequences that result from intestinal obstruction caused by cancer recurrence at the resected site and on peritoneal surfaces. New surgical techniques for large bowel cancer resection minimize the surgery-induced microscopic residual disease that may result from surgical trauma. New developments in exposure, hemostasis, adequate lymphadenectomy, and qualitatively superior margins of excision have occurred. Clinical data show that a 40% improvement in survival with an optimization of surgical technique is possible. Not only should the surgical event for primary colon and rectal cancer be optimized, but also the successful treatment of peritoneal carcinomatosis should be pursued. Resected site disease and peritoneal carcinomatosis can be prevented through the use of perioperative intraperitoneal chemotherapy in patients at high risk of persistent microscopic residual disease. These are patients with perforated cancer, positive peritoneal cytology, ovarian involvement, tumor spill during surgery, and adjacent organ involvement. Patients with established peritoneal carcinomatosis can be salvaged with an approximate 50% long-term survival rate if the timely use of peritonectomy procedures, intraperitoneal chemotherapy, and knowledgeable patient selection are utilized. Peritonectomy procedures allow the removal of all visible peritoneal carcinomatosis with acceptable surgical morbidity (25%) and mortality (1.5%) rates. Heated intraoperative intraperitoneal chemotherapy using mitomycin C, in addition to early postoperative intraperitoneal 5-fluorouracil, can eradicate microscopic residual disease in the majority of patients. The peritoneal cancer index, which quantitates colon cancer peritoneal carcinomatosis by distribution and by lesion size, must be used in the selection of patients who may benefit from these advanced oncologic surgical treatment strategies. The completeness of the cytoreduction score is the most powerful prognostic indicator in this group of patients. The surgeon must be aware that there are no long-term survivors unless complete cytoreduction occurs. With a combination of proper techniques for the resection of primary disease, peritonectomy procedures for the removal of all visible peritoneal implants, intraoperative and early postoperative chemotherapy for the eradication of microscopic residual disease, and quantitative tools for proper patient selection, one can optimize the surgical treatment of patients with large bowel cancer.

Abstract: Peritoneal carcinomatosis from gastrointestinal cancer has new treatment options for surgical management. The approach uses cytoreductive surgery which combines peritonectomy and visceral resection in an effort to remove all visible cancer within the abdomen and pelvis. Then the peritoneal cavity is flooded with chemotherapy solution in an attempt to eradicate residual disease. In order to select patients for this approach the quantitative prognostic indicators for carcinomatosis were reviewed, compared and contrasted. Prognostic indicators to be used to select patients for this aggressive approach at the initiation of surgery and after completion of cytoreduction were studied. Four quantitative assessments to be used at the time of abdominal exploration were the Gilly staging, Japanese gastric cancer P score, peritoneal cancer index (PCI), and the simplified peritoneal cancer index (SPCI). All have value with the PCI being the most validated and most precise. Preoperative assessments include the tumor histopathology and the prior surgical score. The completeness of cytoreduction score is an assessment of residual disease after a maximal surgical effort. An opportunity for long-term survival following treatment for carcinomatosis requires a complete cytoreduction in all reports for gastrointestinal cancer. Quantitative prognostic indicators need to be knowledgeably employed when patients with carcinomatosis are being treated. Improved patient selection with greater benefit and reduced morbidity and mortality should result.

Abstract: Background: Peritoneal surface malignancy can result from seeding of gastrointestinal cancer or abdominopelvic sarcoma; it can also occur as a primary disease, for example, peritoneal mesothelioma. In the past, this clinical situation was treated only with palliative intent. Methods: An aggressive approach to peritoneal surface malignancy involves peritonectomy procedures, perioperative intraperitoneal chemotherapy and knowledgeable patient selection. The clinical assessments necessary for valid clinical judgements include the cancer histopathology (invasive vs expansive progression), the preoperative abdominal and pelvic computed tomogram, the peritoneal cancer index and the completeness of cytoreduction score. Proper patient selection is mandatory for optimizing the results of treatment. Results: In a series of phase-II studies, appendiceal tumors with peritoneal seeding was the paradigm for success with a 75% long-term survival in properly selected patients. Carcinomatosis from colon cancer had an overall 5-year survival of 20% but with selected patients this reached 50%. Also, sarcomatosis patients overall had only a 10% 5-year survival but selected patients had a 75% survival. In all malignancies, early aggressive treatment of minimal peritoneal surface dissemination showed the greatest benefit. Conclusions: The surgeon must accept responsibility for knowledgeable management of peritoneal surface dissemination of cancer. A curative approach has been demonstrated in large phase-II studies. Adjuvant studies with perioperative intraperitoneal chemotherapy in diseases where peritoneal surface spread occurs are indicated.