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Peritonectomy and HIPEC procedure description.pptx
- 1. HIPEC and PIPACfor PERITONEAL MALIGNANCY
- 2. Appendiceal tumours Metastatic Colorectal Cancer Peritoneal metastatic disease from GI cancer Peritoneal Mesothelioma Primary Peritoneal Carcinoma Rare tumours
- 3. Mucocoele of the Appendix Non neoplastic Neoplastic Serrated polyps Mucinous appendiceal neoplasms Mucinous adenocarcinomas of the appendix
- 4. Mucinous appendiceal neoplasms Low GradeAppendiceal Mucinous Neoplasms (LAMNs) Dysplastic epithelium that produces abundant mucin and exhibits expansile growth with a pushing border. Epithelium does not invade but mucin often acellular dissects through the appendiceal wall
- 5. Mucinous appendiceal neoplasms High Grade Appendiceal Neoplasms(HAMNs) Have epithelial dysplasia that may be high grade but lack infiltrative invasion.
- 6. Adenocarcinoma of the appendix Characterised by infiltrative invasion. Well, Moderate, Poorly differentiated. Signet cells designate poor differentiation. Mucinous or non mucinous
- 8. Pseudomyxoma Peritonei Describes theclinical syndrome of mucinous appendiceal neoplasm with diffuse clinical spread that includes abundant mucin production
- 10. Pseudomyxoma Peritonei Rare Commonlyclinically present with signs and symptoms of abdominal distension without a history of RIF pain. Diagnosis is made by imaging or at operation (hernia repair). Often no symptoms for years.
- 11. Diagnosis Lab. CEA,Ca19.9, Ca 125.
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- 13. Colonoscopy Volcano sign 10 to 40% of patients with appendiceal neoplasms have synchronous colonic lesions.
- 14. STAGING LAMNs thatare confined to the appendiceal wall without invasion or loss of the muscularis propria are classified as Tis(LAMN). This is to reflect the excellent outcome for confined LAMNs. The T1 and T2 stages are not used for LAMNs. LAMNs that demonstrate involvement with either acellular mucin or mucinous epithelium of the subserosa or serosa are classified as T3 or T4a, respectively. Acellular mucin involving the appendiceal serosa or mesoappendix is classified as T4a, while mucin involvement of distant peritoneal sites is classified as M1. In order to address the improved outcome for cases in which peritoneal dissemination is limited to acellular mucin only, these cases are classified as M1a. Other metastatic categories are M1b, which refers to metastases confined to the peritoneum only, and M1c, which refers to metastases outside the peritoneum.
- 15. STAGING In contrastto LAMNs, high-grade appendiceal mucinous neoplasms (HAMNs) are staged not as in situ tumors but as invasive adenocarcinomas (T1 to T4), because of their higher risk of recurrence. However, this area is controversial, and the clinical significance of a diagnosis of HAMN, as opposed to LAMN, remains unclear.
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- 17. SURGICAL TREATMENT OF MUCOCOELEINTACT OR RUPTURED Appendicectomy with mesoappendix with or without caecectomy. Ileocolic resection ONLY if this will remove all disease. Thorough laparoscopy or laparotomy documenting and biopsing sites of disease within the peritoneal cavity. DO NOT ATTEMPT TO DEBULK THE PERITONEAL CAVITY. TUMOUR CELLS LOVE RAW SURFACES
- 18. NEXT STAGES Moststudies show that patients with just acellular mucin deposits on the visceral peritoneal surface of the appendix (T4a)have a recurrence rate of 3 to 7 percent while for those with cellular mucin(T4M1) outside of the appendix, the risk is higher and ranges from 33 to 78 percent. LAMN 7% lymph node metastases at Right Hemicolectomy and no difference in 5 year survival. Disseminated mucous or tumour deposits require complete debulking and Heated Intraperitoneal Chemotherapy (HIPEC)
- 19. Preoperative preparation. Discussionand consent with family Anaesthetic review Stomal therapy review Prehabilitation Vaccinations in case of splenectomy. Cessation of anticoagulants Bowel preparation preop Preop carbohydrate drinks.
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- 23. Surgical Technique RightHemicolectomy with enbloc peritonectomy Ureteric exposure Pelvic clearance including stripping bladder and rectum of peritoneum Left paracolic gutter dissection or Left colectomy (Appendices Epiploica) Omentectomy Small bowel clearance R Diaphragm stripping, Liver capsule excision L Diaphragm stripping +/- splenectomy Lesser omentum and stomach
- 24. Exclusions to operation Extensive small bowel disease requiring resection to treat Disease requiring total gastrectomy Extensive non resectable porta hepatis disease
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- 30. PROCEDURE DETAILS Mean blood loss:1046 ml Chemotherapy: Mitocycin C: 71 Oxaliplatin: 14 Cisplatin: 5 Not given: 20 Complete reduction achieved: 79/105 (75%) Disease unresectable: 25 /105 Complete reduction not planned: 5 cases
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- 36. PRODIGE 7 –ACCORD 15 The trial criteria included a 6 month treatment course of perioperative systemic chemotherapy administered either before or after cytoreductive surgery (CRS). CRS was performed in experienced peritoneal malignancy units and patients were randomized to CRS alone with complete tumour removal or CRS and HIPEC while in the OR. HIPEC consisted of Oxaliplatin (460 mg/m2) heated to between 42 and 43 degrees for 30 minutes. 5FU & Folinic acid were given intravenously over 20mins in HIPEC cases.
- 37. The primaryendpoint was the overall survival (OS). (Wanted to increase from 30% to 48%) Secondary endpoints were relapse-free survival (RFS) and toxicity. 264 patients were required to show a gain in median OS from 30 to 48 months (HR = 0.625) with a two-sided α = 0,046 and 80% power.
- 38. 265 patientsfrom 17 centers were included between February 2008 and January 2014: 132 in Arm without HIPEC and 133 in Arm with HIPEC. The median age was 60 years (range: 30-74). Baseline characteristics were well balanced. The overall post-operative mortality rate was 1.5% and was not different between the two arms. (90% R0) The morbidity rates did not differ statistically at 30 days. At 60 days, the grade 3-5 morbidity rate was significantly higher with HIPEC (24.1% vs. 13.6%, p= 0.030).
- 39. After amedian follow up of 63.8 months (95% CI: 58.9-69.8), the median OS was 41.2 months (95% CI 35.1-49.7) in the non-HIPEC Arm and 41.7 months (95% CI: 36.2-52.8) in the HIPEC Arm, HR = 1.00 (95% CI: 0.73-1.37) p = 0.995. The median RFS was 11.1 months (95% CI: 9-12.7) in non-HIPEC Arm and 13.1 months (95% CI: 12.1-15.7) in HIPEC Arm, HR = 0.90 (95% CI: 0.69-1.90) (p = 0.486), whilst the 1-year RFS rates were 46.1% in non-HIPEC Arm and 59 % in the HIPEC Arm.
- 40. Conclusions: Thetherapeutic curative management of PC from colorectal cancer by CRS shows satisfactory survival results. While the addition of HIPEC with oxaliplatin does not influence the OS. Finding: Statistically improved survival in a subgroup PCI 11-15.
- 41. PRODIGE 7 Excellentoutcomes in patients with CPM treated by CRS (cytoreductive surgery) and intravenous chemotherapy in specialized peritoneal malignancy units. The results demonstrate unheralded control of peritoneal metastatic disease with a median survival of 40 months in both arms attributable to meticulous surgical technique in combination with systemic chemotherapy. Disease free survival 13 & 11 months
- 42. PRIMACY OF OPTIMALSURGERY Despite all advances in chemotherapy, optimal surgery is key to cancer control and cure for most cases. Patients with CPM deserve to be assessed, selected and managed by experienced peritoneal malignancy units where safe judicious use of CRS and HIPEC can optimize outcomes and minimize complications
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- 47. PIPAC A Minimally InvasiveApproach to Peritoneal Carcinomatosis. TQEH
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- 49. Low Volume –Best Outcome Not all patients are suitable for HIPEC
- 50. PIPAC: Pressurised Intraperitoneal Aerosol Chemotherapy Notall patients suitable for HIPEC Minimally invasive drug delivery system For Palliative management of Peritoneal Cancer due to: Colorectal Appendiceal Gastric Ovarian cancer
- 51. PIPAC vs. HIPEC Colorectal Cancer Appendiceal Cancer Gastric Cancer PIPACHIPEC PIPAC HIPEC PIPAC HIPEC Suitable for HIPEC No PCI<15 No Yes No PCI <6 Unsuitable for HIPEC Yes PCI>15 Yes No Yes PCI >6 Diffuse Small Bowel Involvement Yes No Yes No Yes No Infiltration Portal Structures Yes No Yes No Yes No Extraabdominal Metastases Yes Relative Yes Relative Yes Relative Unfavorable Histology (Signet Ring Cells) Yes No Yes No Yes No Refractory Ascites Yes No Yes No Yes No Systemic Chemo Intolerance Yes No Yes No Yes No Palliative Situation Yes No Yes No Yes No Small Bowel Obstruction No No No No No No
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- 53. CapnoPen® High-pressure mechanical injector Deliver aerosolized chemotherapy Avoid many problems associated with intravenous delivery
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- 56. Why Aerosol Delivery? Liquids: Occupythe lower part of a space corresponding to its own volume Do not expand Flow along a path of least resistance An aerosol is a suspension of liquid droplets within a gas A gas expands evenly within a closed space
- 57. PIPAC: Increased Tissue Penetration Omentum of a 64 y.o. colorectal cancer patient after repeated PIPAC with oxaliplatin Fibrotic capsule 2-3 mm thick (arrows) had developed at the outer edge of tumor Patient went on to have secondary cytoreductive surgery (CC-0) and HIPEC
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- 59. 1st Containment Level: ‘Air’Tight Abdomen Theabdomen contains all the toxic aerosol and is airtight Carbon dioxide flow < 0.2 ml/min
- 60. Second line containment.Plastic tent
- 61. 3rd Containment Level: RemoteControl Nobody is in the operating room during nebulization
- 62. Closed Aerosol Wasting System (CAWS) At the end of the procedure, the surgeon enters alone the OR Release over a closed aerosol waste system (CAWS) from abdomen CAWS consists of a line, two sequential microparticle filters and two valves.
- 64. PIPAC: Complex Effects Mechanisms ofaction of PIPAC over time: Red curve: aspecific chemical peritonitis with systemic inflammation Blue curve: specific cytotoxic effect on tumor cells, culminating at postoperative weeks 2 and 3; Green curve: tumor fibrosis (nodular sclerosis) with progressive tumor scarring and devascularisation.
- 65. PIPAC IN AUSTRALIA Theaim of this study is to assess feasibility, tumour response, occurrence and severity of adverse events, and quality of life scores, in determining the effective palliative nature of PIPAC therapy in Australian patients with peritoneal metastases from gastric, pancreatic, appendiceal and colorectal primary tumours.
- 67. PIPAC PIPAC (inc trial):32 patients; 65 procedures
- 68. PIPAC IN AUSTRALIA Resultsare promising with a statistically significant overall survival from time of first PIPAC in patients undergoing 3 or more PIPAC procedures. Although not statistically significant, results for PCI scores, ascites and quality of life show trends suggestive that PIPAC is beneficial. The absence of any severe complications (CTCAE Grade 4 or 5) in this study further supports that PIPAC is a safe and feasible treatment option.
Editor's Notes
- #25 Or can be closed approach.