Peritonectomy2 Asgo 2007


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

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Peritonectomy2 Asgo 2007

  1. 1. 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
  2. 2. Advantages of Cytoreductive Surgery <ul><li>Generally accepted as the corner stone for treating advanced ovarian cancer </li></ul><ul><li>Gives most accurate diagnosis & staging </li></ul><ul><li>Rapidly improves symptoms and QOL </li></ul><ul><li>Optimises response to chemotherapy </li></ul><ul><li>May improve host immune response </li></ul><ul><li>Improves survival </li></ul>
  3. 3. 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
  4. 4. Optimal Debulking <ul><li>Variously defined in the literature from <0.5cm (Hacker, NF 1983) to ≤3cm (Hainsworth, 1988 & Sutton, 1989) </li></ul><ul><li>Consistently associated with better survival </li></ul><ul><li>Most studies are retrospective </li></ul>
  5. 5. QCGC Database <ul><li>New database commissioned in 1994 </li></ul><ul><li>Prospectively accumulated data on 701 patients with stage 3C epithelial ovarian cancer </li></ul><ul><li>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. </li></ul>
  6. 6. 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
  7. 7. Stage IIIC EOC Residual Disease –v- Disease Specific Survival
  8. 8. Stage IIIC EOC Residual Disease and Relapse Free Survival
  9. 9. Conclusions <ul><li>Nil residuum have a statistically significantly better overall and relapse free 5 year survival, p<0.001 </li></ul><ul><li>Once the residuum gets to ≥1cm then it doesn’t matter how much residuum you leave behind </li></ul><ul><li>The proportion left with nil residuum needs to be increased </li></ul>
  10. 10. Management of Advanced Disease <ul><li>Pelvic & omental disease well managed </li></ul><ul><li>Tendency to leave paracolic, abdominal wall, sub-diaphragmatic, retro-hepatic and para-splenic disease to be dealt with by chemotherapy </li></ul><ul><li>This last decision is obviously detrimental to patient survival </li></ul>
  11. 11. Peritonectomy Study <ul><li>This is a prospective feasibility study into the techniques of peritonectomy to determine its transferability to surgery for ovarian and primary peritoneal carcinoma </li></ul><ul><li>During the course of the study patients with other peritoneal carcinomatoses have been referred for surgery </li></ul>
  12. 12. Peritonectomy Methodology <ul><li>Very careful selection of patients for this procedure </li></ul><ul><ul><li>Relatively fit and well </li></ul></ul><ul><ul><li>Three day pre-operative inpatient assessment by anaesthetist, intensivist, medical oncologist & surgeon </li></ul></ul><ul><ul><li>Reservations involving 2 or more and the patient doesn’t get done </li></ul></ul>
  13. 13. Peritonectomy Workup <ul><li>Full blood count </li></ul><ul><li>Blood group and antibody screen </li></ul><ul><li>Coagulation screen </li></ul><ul><li>Biochemistry and liver function tests </li></ul><ul><li>Echocardiogram </li></ul><ul><li>Full lung function tests </li></ul><ul><li>Nutritional assessment </li></ul><ul><li>Visit ICU and ward </li></ul><ul><li>Pathology liaises with Red Cross blood bank </li></ul><ul><li>Immunise for possible splenectomy (pneumococcus, haemophilus influenzae & meningococcal C) </li></ul>
  14. 14. One Patient Rejected <ul><li>One woman aged 43 with peritoneal mesothelioma was rejected for surgery </li></ul><ul><li>Previous left pneumonectomy </li></ul><ul><li>On admission for work up was found to have a resting tachycardia ~100bpm </li></ul><ul><li>Echocardiogram showed pulmonary hypertension and tricuspid incompetence </li></ul><ul><li>Patients father took her to Boston where peritonectomy & HIPC performed </li></ul><ul><li>Returned to Brisbane 12 weeks later </li></ul><ul><li>Died of right heart failure 10 days after returning </li></ul>
  15. 15. Peritonectomy Admission <ul><li>Admitted at least 1 day prior to surgery </li></ul><ul><li>High nitrogen low residue diet continued (started at home) </li></ul><ul><li>Full bowel prep with IV infusion running </li></ul><ul><li>Repeat FBC, Biochem & LFT’s, Magnesium </li></ul><ul><li>Possible stoma sites marked </li></ul>
  16. 16. Day of Surgery <ul><li>Transfer to OT by 0700 hr </li></ul><ul><li>General anaesthetic </li></ul><ul><li>Arterial line </li></ul><ul><li>Central line </li></ul><ul><li>Oesophageal temperature probe </li></ul><ul><li>Indwelling urinary catheter </li></ul><ul><li>Patient positioned for surgery on warming air mattress </li></ul><ul><li>Intra-operative “echo” </li></ul>
  17. 17. Peritonectomy Positioning
  18. 18. Peritonectomy Methodology <ul><li>Long midline incision – assess and decide if proceed to peritonectomy </li></ul><ul><li>Total omentectomy up to spleen and splenic flexure +/- splenectomy </li></ul><ul><li>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. </li></ul><ul><li>Insertion naso-jejunal feeding tube </li></ul><ul><li>All surgery performed by QCGC staff </li></ul>
  19. 19. Important Aspects <ul><li>Harmonic shears for omentectomy and splenectomy saves time & bleeding </li></ul><ul><li>The whole surgical team needs to stop every 4 hours and take a break; rehydration and food is important </li></ul><ul><li>Peritoneal stripping should be done either with electrodiathermy using 3mm ball on pure cut or Argon plasma coagulator </li></ul>
  20. 20. 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
  21. 21. Peritonectomy Extent of Surgery <ul><li>10 thoracotomies – 6 ICC’s </li></ul><ul><li>8 significant diaphragmatic resections </li></ul><ul><li>7 subsegmental liver resections </li></ul><ul><li>3 cholecystectomies </li></ul><ul><li>6 splenectomies, 2 distal pancreatectomies </li></ul><ul><li>3 partial cystectomies, 1 ureteric implantation </li></ul><ul><li>6 GIT resections; 4 small, 4 large & 1 partial antrectomy </li></ul><ul><li>5 HIPC, 4 post operative IPC. </li></ul>
  22. 22. Post Operative Management <ul><li>All patients admitted to ICU ventilated </li></ul><ul><li>Ventilatory support for 3 to 8 days </li></ul><ul><li>ICU stay for 5 to 10 days </li></ul><ul><li>Post-operative hospital stay 16 to 45 days </li></ul><ul><li>Naso-jejunal feeding started soon after admission to ICU </li></ul>
  23. 23. Total Peritonectomy Post-operative Complications <ul><li>No returns to theatre & No operative related deaths (one death at day 34 post-op from unresolved functional bowel obstruction) </li></ul><ul><li>One post-op bleed not requiring surgical intervention </li></ul><ul><li>One left subphrenic haematoma found 4 weeks post peritonectomy </li></ul><ul><li>One wound breakdowns </li></ul>
  24. 24. Modified/Subtotal Peritonectomy <ul><li>7 done to date, </li></ul><ul><li>All admitted to ICU </li></ul><ul><li>Ventilation 1 to 3 days </li></ul><ul><li>1 superficial wound breakdown </li></ul><ul><li>One left subphrenic abscess 3 months following surgery </li></ul><ul><li>One recto-vaginal fistula several months following surgery (2 months after closure of ileostomy) </li></ul>
  25. 25. Lessons Learnt <ul><li>Requires a real team approach </li></ul><ul><li>Advantages in having an anaesthetist with cardiac/hepatobiliary experience </li></ul><ul><li>Extent of peritonectomy dependent on disease distribution & prior chemotherapy </li></ul><ul><li>Liver mobilisation often uncovers covert disease </li></ul><ul><li>Temperature control can be a problem – use an air mattress circulating warm air </li></ul>
  26. 26. 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
  27. 27. Imagine <ul><li>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. </li></ul>
  28. 28. Conclusion 1 from Peritonectomies <ul><li>Peritonectomy is a relatively safe procedure </li></ul>
  29. 29. Conclusion 2 from Peritonectomies <ul><li>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. </li></ul>
  30. 30. Conclusion 3 from Peritonectomies <ul><li>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 </li></ul><ul><li>On present experience modified peritonectomy is a feasible and viable procedure for advanced EO & PP carcinoma and should become the standard of care </li></ul>
  31. 31. Conclusion 4 from Peritonectomies <ul><li>Patient selection for modified peritonectomy remains the most difficult issue in planning operating lists with ovarian cancer cases </li></ul>
  32. 32. Conclusion 5 from Peritonectomies <ul><li>How to train the next generation of Gynaecological Oncologists? </li></ul>