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Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

General

In principle all of the parietal peritoneum with visible tumor is resected. On the bowel, small tumor foci are carefully cauterized or excised. With more advanced involvement, the bowel segment is removed. Tumor tissue on the surface of the liver can be burned away or removed by capsulectomy.  A splenectomy is performed if there are tumors on the spleen. Peritoneum on the bladder can also be removed. The surgeon operates in one region at a time and removes all involved tissue. Normal peritoneum is usually not removed. Anastomosis is usually not carried out on the rectum due to the risk of leakage. A permanent or temporary colostomy may be necessary. After resection, HIPEC is performed and the abdomen is closed.

Resection of the peritoneum is often extensive surgery. The multimodality treatment is time consuming and duration of general anaesthesisa for 6-12 hours is customary, median time of surgery is 8 hours. With such comprehensive surgery, reoperations may be necessary due to complications such as infection, ileus or anastomotic leak. Approximately 10% are being reoperated after primary surgery.

Indication

Pseudomyxoma peritonei orginating from lesions in appendix

  • For possible treatment, normal intestinal sections must be present peroperatively.
  • Good general condition (ECOG 0-1). Patients with significant comorbidity and high age (> 75 year) are poor candidates.
  • The patient must be considered able to tolerate extensive surgery and subsequent chemotherapy with the drug applicable at the time.
  • There is not an upper limit of tumor extent for performing the surgery.

CRS-HIPEC for carcinomatosis from colorectal cancer

  • Confined stage IV colon/rectal cancer without Central lymph node metastases or systemic metastases.
  • Confined tumor spreading in an organ is acceptable in special situations.

The indications are the same as for pseudomyxoma from the appendix, with addition of:

  • The patient may have received first line chemotherapy at an earlier stage, but without any disease progression during ongoing chemotherapy.
  • The extent should be confined (PCI ≤ 20-25) with limited involvement of small intestine.
  • Histologically low-differentiated tumors or signet ring cell tumors have a very poor prognosis and are accepted only in exceptional cases.
  • It may be recommendable to perform second-look surgery 12 months after primary surgery in patients operated for localized carcinomatosis without HIPEC, or who had ovarian metastases at that time. Such patients are given 6 months of chemotherapy before 6 months of observation. Surgery may be appropriate if the extent of the disease is limited. Sometimes laparoscopy is performed to estimate the extent of the disease.  

CRS-HIPEC for carcinomatosis from abdominal mesotheliom

Indications are the same as for colon and rectal cancer. In addition must be excluded

  • whether the patient has mesothelioma in pleura with invasion to the abdominal cavity.
  • whether there is metastases to lymph nodes in the cardiophrenic angle of the thorax.

Goal

  • Curative treatment

 

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