The Role Of Cytoreductive Surgery
and HIPEC in Peritoneal surface
Malignancy With Ovarian origin
Dr. ABDULAZIZ ALZAHRANI
INTRODUCTION AND LITERATURE
2
- Cancers originating from organs in the peritoneal cavity
account for approximately 250,000...
INTRODUCTION AND LITERATURE
Ovarian cancer is the fifth leading
cause of cancer death in females.
Epithelial ovarian cance...
INTRODUCTION AND LITERATURE
The prevalence of advanced stage disease with
peritoneal and distant metastasis (FIGO stage
II...
INTRODUCTION AND LITERATURE
Although ovarian cancer is often responsive to
initial maximal cytoreductive surgery (CRS)
and...
INTRODUCTION AND LITERATURE
Intraperitoneal (IP) chemotherapy, given by infusion of
chemotherapeutic agents directly into ...
INTRODUCTION AND LITERATURE
Postoperative adjuvant IP chemotherapy:
-Evaluated in several RCTs and has
demonstrated an imp...
INTRODUCTION AND LITERATURE
Intraoperative intraperitoneal chemotherapy : :
- known as hyperthermic intraperitoneal chemot...
INTRODUCTION AND LITERATURE
Intraoperative intraperitoneal chemotherapy : :
- Recently, Spiliotis et al. in a phase III pr...
Peritoneal shedding of tumor cells
. Free intraperitoneal tumor emboli as a result of full thickness
invasion of the bowel...
• Passive Mode.
– Gravity
– Respiratory movements
– Peritoneal recesses
• Active movement
How do cancer cells move in the ...
Peritonectomy :
-An attempt to do complete
Cytoreduction of the malignant
peritoneal involvement by stripping
the involved...
Definitions :
cont.
:PCI
- Peritoneal Cancer Index
-A score used to assess the feasibility of
Cytoreductive Surgery .
- Sc...
Definitions
Peritoneal Surface Disease Severity Score
• PSDSS I < 4, PSDSS II = 4–7, PSDSS III = 8–10,
and PSDSS IV > 10
Definitions :
Rationale for Hyperthermic Intraperitoneal
Chemotherapy (HIPEC)
- In the treatment of peritoneal malignancies, it
is well ...
• IP Chemotherapy
– Pharmacokinetic argument:
- Peritoneal-plasma barrier makes higher
dose
. Of cytotoxic agents feasible...
• IP Chemotherapy
• Hyperthermia
– Pharmacodynamic argument;
- increased drug penetration
– Selective cytotoxicity of hype...
Rationale for Hyperthermic Intraperitoneal
Chemotherapy (HIPEC))
So , the advantages of HIPEC in the treatment of
peritone...
29
30
31
Gastrointestinal Cancers Symposium2012ASCO,
J Clin Oncol 30, 2012
Early and long-term outcome data on 2,298 patients with
...
Gastrointestinal Cancers Symposium2012ASCO,
J Clin Oncol 30, 2012
Early and long-term outcome data on 2,298 patients with ...
Gastrointestinal Cancers Symposium2012ASCO,
J Clin Oncol 30, 2012
Early and long-term outcome data on 2,298 patients with ...
• 301 Patients from 18 French-speaking
centres
• 109 females and 111 males
• Mean age 52
• PMP from appendix 91%, ovary 7%...
43
44
401 Patients
Median Follow-Up 33 months
(range 1 to 235 months)
Epithelioid - 318 (79%)
Mean PCI – 20
CC0/1 – 187 (46%)
HI...
Patients with epitheloid tumors with complete (CC0) cytoreduction
Median
Survival
87 months
•- 23 articles reporting M&M from various
peritonectomy units were reviewed.
•- Institutions categorised between high and
...
Mean ICU Stay = Range from 1 to 5
Mean Hospital Stay = Range 7 to 48
Overall Mortality = 0 to 17%
High Volume Centres
Mort...
• Between January 1997 and October 2008
• 243 consecutive patients undergoing CRS and
HIPEC for PMP
• Complications assign...
NCI - CTC
• Grade 0 – no complication
• Grade 1 – minor complication self remediating
• Grade 2 – complication requiring m...
French Multicentre Data
n = 1290
25 centres
Case volume Total Pts
Institution 1 403 403
3 100-300 450
3 50-100 225
4 20-50...
Drill Down PMP French Study
Centre 3Yr 5Yr
Best 87 77
Worst 47 45
Elias + Assoc F de Chir EJSO 2010
What is the learning curve about?
Selection
Decision Making
Technical Factors
Team (Nurse, Anaesthetist, ICU,
Oncologi...
PATIENT SELECTION
The outcome of CRS is affected variably by;
- Patient conditions.
Age,nutrition , performance , comorbid...
Selection Protocol
PMP DPAM - Any Vol
PMCA (Angio CT, PET) Signet
CRC PCI <20, +/- Liver <4, Diff, Signet
(Angio CT, PET, ...
MDT MEETING
Radiology
Surgery
Oncology
ICU
Records
Consent/Education
Information Book
Education
More than 1 person to consent
Other patients
CHEMOTHERAPY PROTOCOL
and sarcomamesotheliomaFor ovarian cancer,
1. Add cisplatin (50 mg/m²) ________ mg to 2 liters of 1....
CHEMOTHERAPY PROTOCOL
and sarcomamesotheliomaFor ovarian cancer,
)5-1(postoperative daysPaclitaxel
1. Paclitaxel _________...
Peritonectomy Techniques
Open vs closed
position:
Modified lithotomy position is achieved with the legs
extended in St. Ma...
Peritonectomy Techniques
Procedure :
-Long midline incision.
-After full exposure of intraperitoneal cavity, tumour burden...
Peritonectomy Techniques
Bookwalter or Thompson ,Argon beam, CUSA, Smoke
evacuator ,Ball-tip (3mm)
Total anterior parietal...
Peritonectomy Techniques
Total anterior parietal peritonectomy
Then > greater omentectomy, and splenectomy.
>Right upper q...
Peritonectomy Techniques
> Left upper quadrant peritonectomy
Left hemidiaphragm peritoneal striping
? Total or partial gas...
Peritonectomy Techniques
> Pelvis
Hysterectomy
transection of the
rectum beneath the
peritoneal reflection
> Small bowel a...
Peritonectomy Techniques
At the end of peritonectomy > secure hemostasis
wash thoroughly
Then > Chemo setting
Coliseum Tec...
76
The Peritonectomy Unit
At KAMC
The Story Of The Start
Establishment Stages
•With medical oncology:
•1- Convince them that we are able to operate(mortality
and morbidity issues)...
•OR stage:
•We need a special set up.
•-Hyperthermia perfusion pump + the disposabe circuits
for HIPEC (BELMONT)
•-Train p...
Anaesthesia special preparation:
•- Got the protocol for anaesthesia during
HIPEC.
•- Cooling measures to overcome HIPEC
h...
Getting Started
•The first case:
•-63 yrs female
•-PMP …..Very high volume diease and redo
surgery debulked three times in...
•Operation done……> HIPEC went smooth
•>21 hrs
•> 15 kg of tumor is out
•>8 units of PRBCS
•
•Did well except morphia adict...
2nd case :
42 yrs male
Healthy otherwise
Low volume peritoneal
carcinomatosis(appendex )
Tumor Board > for CRS &HIPEC
Oper...
3rd case
47 yrs male
PMP (high volume disease )
PCI> 30
PROCEDURE > peritonectomy omentectomy
distal gastrictomy distal pa...
4TH case
•49 yrs male
•Rectosigmoid ca with peritoneal mets
•Radiological PCI >10
•Operative PCI 17
•Neoadjuvent chemo.
•S...
5th and 6th cases are doing fine as well.
Cases # 12 and 13, done two weeks back;
One of them is 72 yrs old female with hi...
THANK YOU
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Gyne onco- conference-3

  1. 1. The Role Of Cytoreductive Surgery and HIPEC in Peritoneal surface Malignancy With Ovarian origin Dr. ABDULAZIZ ALZAHRANI
  2. 2. INTRODUCTION AND LITERATURE 2 - Cancers originating from organs in the peritoneal cavity account for approximately 250,000 new cancer cases annually in the USA. - The peritoneal cavity is a common site for metastases owing to locoregional spread. - Ovarian cancer with peritoneal involvement when treated with aggressive surgical debulking combined with intravenous chemotherapy is yielding ,unlike the nongynecological malignancies.
  3. 3. INTRODUCTION AND LITERATURE Ovarian cancer is the fifth leading cause of cancer death in females. Epithelial ovarian cancer accounts for the majority of ovarian cancers (>75%). The diagnosis is often delayed because of the nonspecific nature of its presenting symptoms.
  4. 4. INTRODUCTION AND LITERATURE The prevalence of advanced stage disease with peritoneal and distant metastasis (FIGO stage III/IV) is high, with the chance of cure being low The overall 5-year survival rate of patients with ovarian cancer of all stages is 43%, and it decreases to <22 % in patients with advanced disease. Ovarian cancer spreads through exfoliation of malignant cells into peritoneal fluid, disseminating along the abdominal and pelvic peritoneum
  5. 5. INTRODUCTION AND LITERATURE Although ovarian cancer is often responsive to initial maximal cytoreductive surgery (CRS) and platinum-based chemotherapy, there remains a high rate of recurrence(up to 70%) and poor long-term survival. Maximal cytoreductive surgical efforts against recurrent ovarian cancer have been shown to be independently associated with improved overall survival. .
  6. 6. INTRODUCTION AND LITERATURE Intraperitoneal (IP) chemotherapy, given by infusion of chemotherapeutic agents directly into the peritoneum, has been investigated; - Demonstrated an improvement in overall and disease-free survival. Two forms of IP chemotherapy may be delivered: 1 -Postoperative adjuvant IP chemotherapy delivered as adjuvant treatment after recovery from CRS 2 -Intraperitoneal chemotherapy delivered as a heated chemoperfusate intraoperatively . .
  7. 7. INTRODUCTION AND LITERATURE Postoperative adjuvant IP chemotherapy: -Evaluated in several RCTs and has demonstrated an improvement in overall and disease-free survival. .
  8. 8. INTRODUCTION AND LITERATURE Intraoperative intraperitoneal chemotherapy : : - known as hyperthermic intraperitoneal chemotherapy (HIPEC). -A recent systematic review on the combination of CRS and HIPEC in ovarian cancer shows significant potential benefits in disease-free and overall survival rates -Showed acceptable rates of morbidity and mortality including platinum resistant cases. .
  9. 9. INTRODUCTION AND LITERATURE Intraoperative intraperitoneal chemotherapy : : - Recently, Spiliotis et al. in a phase III prospective trial evaluated the role of CRS and HIPEC plus systemic chemotherapy versus CRS plus systemic chemotherapy in women with recurrent EOC after initial debulking surgery and systemic chemotherapy. - The median survival rate was 19.5 months versus 11.2 months ( P < 0.05) - The three-year survival was 50% versus 18% in favor of the HIPEC group . .
  10. 10. Peritoneal shedding of tumor cells . Free intraperitoneal tumor emboli as a result of full thickness invasion of the bowel wall by cancer. . Leakage of malignant cells from transected lymphatic channels. . Dissemination of malignant cells from trauma as a result of dissection at a narrow margin. . Blood clots that remain in the abdomen or pelvis that contain viable cancer cells;. . Fibrin entrapment of intraabdominal tumor emboli on traumatized peritoneal surfaces. . Tumor promotion of these entrapped cells through growth factors involved in the wound healing process
  11. 11. • Passive Mode. – Gravity – Respiratory movements – Peritoneal recesses • Active movement How do cancer cells move in the peritoneal cavity?
  12. 12. Peritonectomy : -An attempt to do complete Cytoreduction of the malignant peritoneal involvement by stripping the involved parietal peritoneum and ablation or resection of the involved visceral peritoneum. Definitions :
  13. 13. Definitions : cont. :PCI - Peritoneal Cancer Index -A score used to assess the feasibility of Cytoreductive Surgery . - Scored from 0 to 39 . - Preoperative PCI (Radiological) . - Intraoperative PCI .
  14. 14. Definitions
  15. 15. Peritoneal Surface Disease Severity Score • PSDSS I < 4, PSDSS II = 4–7, PSDSS III = 8–10, and PSDSS IV > 10
  16. 16. Definitions :
  17. 17. Rationale for Hyperthermic Intraperitoneal Chemotherapy (HIPEC) - In the treatment of peritoneal malignancies, it is well known that there will be at least residual microscopic cancer cells remaining in the peritoneal cavity after the surgical procedure. -Residual disease < 2.5 mm is amenable to destruction by HIPEC and that counts for CC0 and CC1 .
  18. 18. • IP Chemotherapy – Pharmacokinetic argument: - Peritoneal-plasma barrier makes higher dose . Of cytotoxic agents feasible(MMC 40 times) – Maximal effect immediately after . cytoreduction – Limited systemic resorption / toxicity Rationale for Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
  19. 19. • IP Chemotherapy • Hyperthermia – Pharmacodynamic argument; - increased drug penetration – Selective cytotoxicity of hyperthermia – Synergism with chemotherapy Rationale for Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
  20. 20. Rationale for Hyperthermic Intraperitoneal Chemotherapy (HIPEC)) So , the advantages of HIPEC in the treatment of peritoneal malignancies are numerous; 1) The residual malignant cells are directly exposed to higher doses of chemotherapy than would be possible with systemic chemotherapy. 2) The addition of heat, which potentiates the chemotherapy, also increases its penetration into malignant cells. Heat itself is preferentially cytotoxic to malignant cells. 3) Toxicity of the chemotherapy agents is not an issue for the patient, as these are delivered while the patient is under general anesthesia.
  21. 21. 29
  22. 22. 30
  23. 23. 31
  24. 24. Gastrointestinal Cancers Symposium2012ASCO, J Clin Oncol 30, 2012 Early and long-term outcome data on 2,298 patients with pseudomyxoma peritonei treated by a strategy of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. 2298 patients from 16 specialized units underwent CRS &HIPEC for PMP. -Mortality was 2% -Major operative complication was 24% -The median survival was 196 months -The median progression-free survival was 98 months 5-,10- and 15-year survival rate of 78%, 63% and 59% respectively
  25. 25. Gastrointestinal Cancers Symposium2012ASCO, J Clin Oncol 30, 2012 Early and long-term outcome data on 2,298 patients with pseudomyxoma peritonei treated by a strategy of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Independent predictors for a poorer progression-free survival are; -PMCA histopathological subtype (P<0.001) -Major postoperative complication (P=0.008) -High PCI (P=0.013) -Debulking surgery (CCR2/3) (P<0.001)
  26. 26. Gastrointestinal Cancers Symposium2012ASCO, J Clin Oncol 30, 2012 Early and long-term outcome data on 2,298 patients with pseudomyxoma peritonei treated by a strategy of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Independent predictors of a poorer overall survival are; -Older age (P=0.006) -Major postoperative complication (P<0.001) -Debulking surgery (CCR2/3) (P<0.001) -Prior chemotherapy treatment (P=0.001) -PMCA histopathological subtype (P<0.001)
  27. 27. • 301 Patients from 18 French-speaking centres • 109 females and 111 males • Mean age 52 • PMP from appendix 91%, ovary 7% • Mean PCI 18.5
  28. 28. 43
  29. 29. 44
  30. 30. 401 Patients Median Follow-Up 33 months (range 1 to 235 months) Epithelioid - 318 (79%) Mean PCI – 20 CC0/1 – 187 (46%) HIPEC – 372 (92%)
  31. 31. Patients with epitheloid tumors with complete (CC0) cytoreduction Median Survival 87 months
  32. 32. •- 23 articles reporting M&M from various peritonectomy units were reviewed. •- Institutions categorised between high and •low volume
  33. 33. Mean ICU Stay = Range from 1 to 5 Mean Hospital Stay = Range 7 to 48 Overall Mortality = 0 to 17% High Volume Centres Mortality rates ranged 0.9% to 5.8%
  34. 34. • Between January 1997 and October 2008 • 243 consecutive patients undergoing CRS and HIPEC for PMP • Complications assigned based on NCI CTC
  35. 35. NCI - CTC • Grade 0 – no complication • Grade 1 – minor complication self remediating • Grade 2 – complication requiring medical therapy • Grade 3 – complication requiring invasive radiological intervention • Grade 4 – complication requiring re-operation
  36. 36. French Multicentre Data n = 1290 25 centres Case volume Total Pts Institution 1 403 403 3 100-300 450 3 50-100 225 4 20-50 100 5 10-20 75 6 <10 45
  37. 37. Drill Down PMP French Study Centre 3Yr 5Yr Best 87 77 Worst 47 45 Elias + Assoc F de Chir EJSO 2010
  38. 38. What is the learning curve about? Selection Decision Making Technical Factors Team (Nurse, Anaesthetist, ICU, Oncologist, Radiology) MDT
  39. 39. PATIENT SELECTION The outcome of CRS is affected variably by; - Patient conditions. Age,nutrition , performance , comorbidities - Disease volume. PCI - The biological behavior of the tumor . low grade VS high grade. . propensity to spread by direct peritoneal attachment and proliferation VS lymphatic and hematogenic.
  40. 40. Selection Protocol PMP DPAM - Any Vol PMCA (Angio CT, PET) Signet CRC PCI <20, +/- Liver <4, Diff, Signet (Angio CT, PET, ?Laparoscopy) Meso Epith ? No Sarcomatoid (Angio CT, PET) Ovarian Recurrent disease (Angio CT, PET) Gastric PCI <10 (Angio CT, PET, Laparoscopy) Redos PMP. Meso ?CRC
  41. 41. MDT MEETING Radiology Surgery Oncology ICU Records
  42. 42. Consent/Education Information Book Education More than 1 person to consent Other patients
  43. 43. CHEMOTHERAPY PROTOCOL and sarcomamesotheliomaFor ovarian cancer, 1. Add cisplatin (50 mg/m²) ________ mg to 2 liters of 1.5% dextrose peritoneal dialysis solution. Add doxorubicin (15 mg/m²) _______ mg to same 2 liters of 1.5% dextrose peritoneal dialysis solution. 2. Add ifosfamide (1300 mg/m²) ________ mg to 1 liter 0.9% sodium chloride. Begin continuous IV infusion over 90 minutes simultaneously with IP chemotherapy. 3. Add mesna disulfide (260 mg/m²)________ mg to100 ml 0.9% sodium chloride to be given IV as a bolus 15 minutes prior to ifosfamide infusion. 4. Add mesna disulfide (260 mg/m²)________ mg to 100 ml 0.9% sodium chloride to be given IV as a bolus 4 hours after ifosfamide infusion begins. 5. Add mesna disulfide (260 mg/m²)________ mg to 100 ml 0.9% sodium chloride to be given IV as a bolus 8 hours after ifosfamide infusion begins. 6. Send all the above to operating room #________ at ________ o’clock on ___________ (Date) for a 90-minute treatment.
  44. 44. CHEMOTHERAPY PROTOCOL and sarcomamesotheliomaFor ovarian cancer, )5-1(postoperative daysPaclitaxel 1. Paclitaxel __________ mg (20-40 mg/m2 x __________ m2) (maximum dose: 80 mg) in __________cc 6% Hetastarch (B. Braun, Irvine, CA) via IP catheter on _________________. Last dose _________. 2. Infuse as rapidly as possible via Tenckhoff catheter. Dwell for 23 hours. Drain from Tenckhoff x 15 minutes before draining all catheters for one hour prior to next instillation. 3. Use 1 liter 6% Hetastarch for body surface 1 - 2 m2, 1.5 liters for body surface > 2.0 m2. 4. Continue to drain abdominal cavity after last dose until Tenckhoff catheter is removed. 5. During initial 6 hours after chemotherapy infusion, patient's bed should be kept flat. The patient should be on the right side during infusion. Turn at ½-hour post infusion onto the left side and continue to change sides at ½-hour intervals for 6 hours. 6. Monitor with pulse oximeter during the first 6 hours of intraperitoneal chemotherapy
  45. 45. Peritonectomy Techniques Open vs closed position: Modified lithotomy position is achieved with the legs extended in St. Mark's leg holders. .
  46. 46. Peritonectomy Techniques Procedure : -Long midline incision. -After full exposure of intraperitoneal cavity, tumour burden is checked . -In PMP & Ovarian tumours , if > more than 1.5 m of small bwoel can be saved > Go ahead . -In other diseases > PCI then decide. Which is first ? -If liver and rt upper quadrant is extensively involved > start there. -If liver and rt upper quadrant involvement is not bad > start in the pelvis(almost always extensively involved)
  47. 47. Peritonectomy Techniques Bookwalter or Thompson ,Argon beam, CUSA, Smoke evacuator ,Ball-tip (3mm) Total anterior parietal peritonectomy .
  48. 48. Peritonectomy Techniques Total anterior parietal peritonectomy Then > greater omentectomy, and splenectomy. >Right upper quadrant peritonectomy right hemidiaphragm, right subhepatic space the surface of the liver Cholecystectomy stripping of the hepatoduodenal ligament resection of the falciform ligament
  49. 49. Peritonectomy Techniques > Left upper quadrant peritonectomy Left hemidiaphragm peritoneal striping ? Total or partial gastrectomy and reconstruction ?Resection of the tail of the pancreas .
  50. 50. Peritonectomy Techniques > Pelvis Hysterectomy transection of the rectum beneath the peritoneal reflection > Small bowel and mesentry Marking stitches
  51. 51. Peritonectomy Techniques At the end of peritonectomy > secure hemostasis wash thoroughly Then > Chemo setting Coliseum Technique; .
  52. 52. 76
  53. 53. The Peritonectomy Unit At KAMC The Story Of The Start
  54. 54. Establishment Stages •With medical oncology: •1- Convince them that we are able to operate(mortality and morbidity issues) • •2-Bring our evidence on: •Patient &personnel safety •Survival benefits •No more high morbidity and mortality procedure. 3- Get them to write the IP Chemo protocool. Success and then discussed cases in tumor board and peritonectomythen we have patients listed for
  55. 55. •OR stage: •We need a special set up. •-Hyperthermia perfusion pump + the disposabe circuits for HIPEC (BELMONT) •-Train perfusionest •-Make sure that Chemo is prepared in large bag of 3 liters of Dianel 1.5(we are the only center to have it in the KSA) •Special retracor system( Bookwalter and Thompson with long side vertical bars)……..not optimal…..we modified our tecneque.(good) •Special sterile plastic drapes for isolation……….Available •Jet smoke evacuator with ball diathermy to coagulate at 100-120 •-Argon beam ,CUSA for liver resections and ablations. •…………………………………………………………Every thing is available
  56. 56. Anaesthesia special preparation: •- Got the protocol for anaesthesia during HIPEC. •- Cooling measures to overcome HIPEC hyperthermia(42-44 c) otherwise ,patient brain will be cooked easily. •cooling mattress •Ice bags around neck,axilla , groin, etc. •-Continuous monitor of core temp
  57. 57. Getting Started •The first case: •-63 yrs female •-PMP …..Very high volume diease and redo surgery debulked three times in other hospitals. •-PCI of 39 , badly symptomatic with respiratory compromise due the tense abdominal distension . •Option for her is either surgery or DNR.
  58. 58. •Operation done……> HIPEC went smooth •>21 hrs •> 15 kg of tumor is out •>8 units of PRBCS • •Did well except morphia adiction issues and rising bilirubin level ,liver biopsy > CASH. •2 months later > CVA ,aspiration pneumonia and DIC. > Death
  59. 59. 2nd case : 42 yrs male Healthy otherwise Low volume peritoneal carcinomatosis(appendex ) Tumor Board > for CRS &HIPEC Operation…..(peritonectomy ,omentectomy, Rt diaphragm and pelvic stripping +HIPEC withmitomycin c for 90 minutes. -7 hrs --No blood transfusion -- No EPIC - Sort hospital stay -- 6 months later . No recurrence.
  60. 60. 3rd case 47 yrs male PMP (high volume disease ) PCI> 30 PROCEDURE > peritonectomy omentectomy distal gastrictomy distal pancreatetomy splenectomy hepatic metastatectomy sig 1,2,6 porta hepatis and caudate lobe dissection resection of falciform lig. Cholecystectomy subtotal colectomy bilateral diaphragmatic and pelvic peritoneal stripping multiple segmental small bowel resections. Then HIPIC wit Mitomycin c. -19 hrs 6 units of PRBCS Post Op did well Now , he is disease-free with good quality of life.> 13 months
  61. 61. 4TH case •49 yrs male •Rectosigmoid ca with peritoneal mets •Radiological PCI >10 •Operative PCI 17 •Neoadjuvent chemo. •Surgery: •Anterior resection of rctosigmoid+primary anastomosis,Peritonectomy,Multiple liver resections, clearance of porta hepatus and caudate lobe, bilat. Diaghramatic and pelvic stripping. •EPIC with 5fu •Smooth Post-OP course
  62. 62. 5th and 6th cases are doing fine as well. Cases # 12 and 13, done two weeks back; One of them is 72 yrs old female with high volume disease(Ovarian) -Cisplatinum HIPEC used. No complication related to the HIPEC except ileus for 7days. Now ,in the ward , ready to be discharged. 2nd patient is peritoneal mesothelioma PCI >15 -Cisplatinum & Mitomycin C HIPEC used
  63. 63. THANK YOU

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