Peritonectomy2 Asgo 2007
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Peritonectomy2 Asgo 2007

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Safety / feasability study of peritonectomy for advanced ovarian/peritoneal cancer

Safety / feasability study of peritonectomy for advanced ovarian/peritoneal cancer

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Peritonectomy2 Asgo 2007 Peritonectomy2 Asgo 2007 Presentation Transcript

  • Peritonectomy Is this a realistic, safe and viable option for improving ovarian cancer cytoreductive surgery? Alex J Crandon & Marcelo Carraro Nascimento Qld Centre for Gyn. Cancer
  • Advantages of Cytoreductive Surgery
    • Generally accepted as the corner stone for treating advanced ovarian cancer
    • Gives most accurate diagnosis & staging
    • Rapidly improves symptoms and QOL
    • Optimises response to chemotherapy
    • May improve host immune response
    • Improves survival
  • Residual Disease –v- Survival in Advanced EOC 16 (>2cm) 45 (<2cm) Delgado, G 1984 16 (>2cm) 45 (<2cm) Pohl, R 1984 14 (>2cm) 25+ (<2cm) Conte, P 1985 8 ( >1cm) 19 ( ≤1cm) Zang, RY 2000 18 (>2cm) 30+ (<2cm) Posada, JG 1985 15 ( ≥2cm) 24 (<2cm) Louie, KG 1986 21 (>3cm) 72 ( ≤3cm) Hainsworth, J 1988 21 (>1cm) 48 ( ≤1cm) Piver, MS 1988 23 ( ≥3cm) 45 (<3cm) Sutton, GP 1989 15 (>2cm) 25 ( ≤2cm) Munkarah 1997 10 ( >1cm) 38 ( ≤1cm) Bristow, RE 1999 Suboptimal debulking Survival (months) Optimal debulking Survival (months) Study View slide
  • Optimal Debulking
    • Variously defined in the literature from <0.5cm (Hacker, NF 1983) to ≤3cm (Hainsworth, 1988 & Sutton, 1989)
    • Consistently associated with better survival
    • Most studies are retrospective
    View slide
  • QCGC Database
    • New database commissioned in 1994
    • Prospectively accumulated data on 701 patients with stage 3C epithelial ovarian cancer
    • Stratified residual disease left at the end of surgery into 6 categories: nil residuum, <1cm, 1-2cm, >2cm but not gross residuum, gross residuum & unknown.
  • Stage 3C EOC Breakdown 100 701 Total 24.1 169 Unknown 9.3 65 Gross 6.4 45 >2cm 8.6 60 1-2cm 32.4 227 <1cm 19.3 135 Nil Percent Number Residual Disease
  • Stage IIIC EOC Residual Disease –v- Disease Specific Survival
  • Stage IIIC EOC Residual Disease and Relapse Free Survival
  • Conclusions
    • Nil residuum have a statistically significantly better overall and relapse free 5 year survival, p<0.001
    • Once the residuum gets to ≥1cm then it doesn’t matter how much residuum you leave behind
    • The proportion left with nil residuum needs to be increased
  • Management of Advanced Disease
    • Pelvic & omental disease well managed
    • Tendency to leave paracolic, abdominal wall, sub-diaphragmatic, retro-hepatic and para-splenic disease to be dealt with by chemotherapy
    • This last decision is obviously detrimental to patient survival
  • Peritonectomy Study
    • This is a prospective feasibility study into the techniques of peritonectomy to determine its transferability to surgery for ovarian and primary peritoneal carcinoma
    • During the course of the study patients with other peritoneal carcinomatoses have been referred for surgery
  • Peritonectomy Methodology
    • Very careful selection of patients for this procedure
      • Relatively fit and well
      • Three day pre-operative inpatient assessment by anaesthetist, intensivist, medical oncologist & surgeon
      • Reservations involving 2 or more and the patient doesn’t get done
  • Peritonectomy Workup
    • Full blood count
    • Blood group and antibody screen
    • Coagulation screen
    • Biochemistry and liver function tests
    • Echocardiogram
    • Full lung function tests
    • Nutritional assessment
    • Visit ICU and ward
    • Pathology liaises with Red Cross blood bank
    • Immunise for possible splenectomy (pneumococcus, haemophilus influenzae & meningococcal C)
  • One Patient Rejected
    • One woman aged 43 with peritoneal mesothelioma was rejected for surgery
    • Previous left pneumonectomy
    • On admission for work up was found to have a resting tachycardia ~100bpm
    • Echocardiogram showed pulmonary hypertension and tricuspid incompetence
    • Patients father took her to Boston where peritonectomy & HIPC performed
    • Returned to Brisbane 12 weeks later
    • Died of right heart failure 10 days after returning
  • Peritonectomy Admission
    • Admitted at least 1 day prior to surgery
    • High nitrogen low residue diet continued (started at home)
    • Full bowel prep with IV infusion running
    • Repeat FBC, Biochem & LFT’s, Magnesium
    • Possible stoma sites marked
  • Day of Surgery
    • Transfer to OT by 0700 hr
    • General anaesthetic
    • Arterial line
    • Central line
    • Oesophageal temperature probe
    • Indwelling urinary catheter
    • Patient positioned for surgery on warming air mattress
    • Intra-operative “echo”
  • Peritonectomy Positioning
  • Peritonectomy Methodology
    • Long midline incision – assess and decide if proceed to peritonectomy
    • Total omentectomy up to spleen and splenic flexure +/- splenectomy
    • Excise falciform ligament and ligamentum teres, mobilise liver and do right upper quadrant; left upper quadrant; abdominal wall and paracolic gutters; pelvis with retrograde hysterectomy, BSO, pelvic peritonectomy +/- low restorative rectal resection; finish mesentry & small bowel.
    • Insertion naso-jejunal feeding tube
    • All surgery performed by QCGC staff
  • Important Aspects
    • Harmonic shears for omentectomy and splenectomy saves time & bleeding
    • The whole surgical team needs to stop every 4 hours and take a break; rehydration and food is important
    • Peritoneal stripping should be done either with electrodiathermy using 3mm ball on pure cut or Argon plasma coagulator
  • Peritonectomy Patients Died of bowel obstruction FOD ?PD ?PD FOD FOD FOD DOD SD FOD Recurrence (L & H) FOD Status 2 7.5 3C R Ovary 77 PP 3 14 3C Peritoneum 53 SW 7 10.25 3C R Ovary 66 ES 4 17 D R Appendix 61 VM 8 13 3C R Ovary 57 SM 0 10.25 4 R Mesothelioma 40 KC 3 10 3C Ovary 60 SD 3 5.75 4 R Mesothelioma 59 ML 0 5 3C R Peritoneum 59 IK 3 8.5 3C Peritoneum 74 MT 0 5 3C Ovary 65 VW 0 5.5 3C R Ovary 54 SB Intra-op Transfusion (units) Operative Time (hrs) Stage Primary Disease Site Age Patient
  • Peritonectomy Extent of Surgery
    • 10 thoracotomies – 6 ICC’s
    • 8 significant diaphragmatic resections
    • 7 subsegmental liver resections
    • 3 cholecystectomies
    • 6 splenectomies, 2 distal pancreatectomies
    • 3 partial cystectomies, 1 ureteric implantation
    • 6 GIT resections; 4 small, 4 large & 1 partial antrectomy
    • 5 HIPC, 4 post operative IPC.
  • Post Operative Management
    • All patients admitted to ICU ventilated
    • Ventilatory support for 3 to 8 days
    • ICU stay for 5 to 10 days
    • Post-operative hospital stay 16 to 45 days
    • Naso-jejunal feeding started soon after admission to ICU
  • Total Peritonectomy Post-operative Complications
    • No returns to theatre & No operative related deaths (one death at day 34 post-op from unresolved functional bowel obstruction)
    • One post-op bleed not requiring surgical intervention
    • One left subphrenic haematoma found 4 weeks post peritonectomy
    • One wound breakdowns
  • Modified/Subtotal Peritonectomy
    • 7 done to date,
    • All admitted to ICU
    • Ventilation 1 to 3 days
    • 1 superficial wound breakdown
    • One left subphrenic abscess 3 months following surgery
    • One recto-vaginal fistula several months following surgery (2 months after closure of ileostomy)
  • Lessons Learnt
    • Requires a real team approach
    • Advantages in having an anaesthetist with cardiac/hepatobiliary experience
    • Extent of peritonectomy dependent on disease distribution & prior chemotherapy
    • Liver mobilisation often uncovers covert disease
    • Temperature control can be a problem – use an air mattress circulating warm air
  • Where could we be? 100 20.2 8.8 8.8 60.3 Modified Peritonectomy 100 886 Total 20.2 179 Unknown 8.8 78 Gross 8.8 78 >2cm 10.3 92 1-2cm 34.1 302 <1cm 17.8 158 Nil Percent Number Residual Disease
  • Imagine
    • If over half of our patients with Stage 3C EOC were being debulked to nil residuum with an overall 5-year survival of 47 per cent.
  • Conclusion 1 from Peritonectomies
    • Peritonectomy is a relatively safe procedure
  • Conclusion 2 from Peritonectomies
    • If disease can be debulked to 2cm then it can be debulked to nil residuum but however long it takes to get to 2cm it will take 1 to 2 times as long again to get to nil residuum.
  • Conclusion 3 from Peritonectomies
    • At laparotomy if initial assessment indicates that disease cannot be debulked to nil residuum then limited omentectomy only should be performed with a view to interval debulking if good response to Chemo
    • On present experience modified peritonectomy is a feasible and viable procedure for advanced EO & PP carcinoma and should become the standard of care
  • Conclusion 4 from Peritonectomies
    • Patient selection for modified peritonectomy remains the most difficult issue in planning operating lists with ovarian cancer cases
  • Conclusion 5 from Peritonectomies
    • How to train the next generation of Gynaecological Oncologists?