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Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)


Medical editor Stein Gunnar Larsen MD
Gastroenterological Surgeon
Oslo University Hospital
Norway

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

 


Preparation

  • The patient is informed that a colostomy may be necessary. Its location is marked preoperatively on the skin.
  • Patients to have a resection with anastomosis in the rectum should have a thorough preoperative bowel preparation.
  • The patient is given a preoperative dose of low molecular weight heparin and support hose with inflatable cuffs for the lower extremities to reduce the risk of thrombosis.
  • Epidural catheter is placed for postoperative pain treatment.
  • A bladder catheter is inserted.
  • The patient lies supine with the legs in stirrups.
  • The operation is carried out under general anaesthesia.

Implementation

A few principles are demonstrated in the film.
  • The abdomen is opened with a long mid-line incision.
  • Extent of carcinomatosis is surveyed thoroughly.
  • It is assessed whether the cancer grows infiltratingly or only on the peritoneum. A frozen section may be helpful .

Maximal cytoreductive surgery (CRS) techniques

The procedure often starts with an omentectomi.Thereafter, a final surgery in the pelvis including a peritonectomy is often performed, along with a resection of rectum and genitalia interna if necessary. Any affected peritoneum in the flank is resected if necessary and the need for colon surgery is considered.The need for resection of the peritoneum at the diaphragm is then considered. On the right side it may be necessary to perform a cholecystectomy and resection of tissue on the surface of the liver and subhepatically. On the left side, the spleen sometimes must be removed and a gastrectomy may be necessary.

Hyperthermic intraperitoneal chemotherapy (HIPEC) techniques

  • A rubber drape is attached to the edges of the incision.
  • The heart-lung machine is assembled to administer the chemotherapy.
  • The rubber drape must be carefully attached to the skin around the entire circumference of the opening. Confirm there is no leakage of chemotherapy.
  • The lavage fluid is warmed until the abdominal fluid has a temperature > 40.0°C. When the system functions optimally, the gel port is fixed on the plastic surface and chemotherapy is added to the perfusion circuit.
  • The chemotherapy is administered for 90 minutes.
  • The abdominal cavity is then perfused with NaCl and the equipment is disassembled.
  • The abdomen is closed.

Follow-up

The average length of hospital stay after surgery is 11 days, but may be considerably longer for some patients.

Complications

  • Extensive operation with multiple resections as well as blood transfusion increase the danger for infections and anastomosis leakages. There is evidence that both intraperitoneal chemotherapy and hyperthermia may increase the risk for this. Reoperations may therefore be necessary in some cases.
  • In rare cases, HIPEC may cause neutropenia and thrombocytopenia.
  • Other complications can occur depending on which organs are removed.

Patients with widespread peritoneal surface malignancies or aggressive histology have a significant risk of recurrence. These patients are also at risk for distant metastases to the liver and lung.


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