Value of laparoscopy before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis

Our plain-English summary of Value of laparoscopy before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis, by L.H. Iversen, P.C. Rasmussen, S. Laurberg (The British Journal of Surgery, 2013).

The study

• Authors: L.H. Iversen, P.C. Rasmussen, S. Laurberg
• Journal: The British Journal of Surgery
• Published: 2013;100(2):285-92
• Cited by: 111 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: The outcome of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) depends on the extent of peritoneal carcinomatosis. The role of laparoscopy in the preoperative assessment of extent of peritoneal carcinomatosis in potential candidates for cytoreductive surgery and HIPEC was evaluated in a consecutive series.

Methods: Patients with peritoneal carcinomatosis from colorectal cancer or appendiceal cancer, pseudomyxoma peritonei or peritoneal mesothelioma referred to a single, national HIPEC centre were included prospectively between June 2006 and January 2012. From September 2010, preoperative evaluation also included a laparoscopy in patients deemed amenable to cytoreductive surgery and HIPEC after radiological evaluation, apart from those with pseudomyxoma peritonei with massive amounts of mucin.

Results: In the period before laparoscopic evaluation, 70 patients underwent laparotomy of whom 39 (56 per cent) completed cytoreductive surgery and HIPEC. After the introduction of laparoscopic assessment, diagnostic laparoscopy was planned in 45 patients and successful in 43. The laparoscopic evaluation excluded 18 patients from surgery because of extensive disease, among other reasons. Laparoscopy was uneventful and associated with no deaths. Twenty-seven patients were considered amenable to cytoreductive surgery and HIPEC based on laparoscopic findings, of whom 17 completed this treatment; the disease was unresectable in the remaining ten patients. Of 13 patients who were not eligible for laparoscopic evaluation and were subjected to cytoreductive surgery plus HIPEC, 11 completed the procedure. The overall completion rate of cytoreductive surgery and HIPEC increased to 70 per cent (28 of 40) after the introduction of laparoscopic evaluation.

Conclusion: Diagnostic laparoscopy was valuable in preoperative evaluation of the extent of peritoneal carcinomatosis, and improved patient selection for cytoreductive surgery and HIPEC.

Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

In plain English

This Danish study looked at whether adding a diagnostic laparoscopy (a keyhole look inside the abdomen) helped surgeons choose patients for cytoreductive surgery combined with heated chemotherapy inside the abdomen (HIPEC). Patients had peritoneal carcinomatosis from colorectal or appendiceal cancer, pseudomyxoma peritonei, or malignant mesothelioma. Asbestos exposure was not studied. From June 2006 to August 2010, before routine laparoscopy, 39 of 70 patients judged suitable completed the treatment (56 per cent). From September 2010 to January 2012, 45 patients were planned for laparoscopy. It succeeded in 43, and 18 were spared an open operation. Of 27 judged suitable at laparoscopy, 17 completed treatment. Of three patients with malignant mesothelioma who went on to open surgery after an attempted laparoscopy, two could not complete treatment; in one of them the laparoscopy had failed because of massive peritoneal thickness. The overall completion rate rose to 70 per cent (28 of 40), a difference that was not statistically significant. The authors concluded that laparoscopy seemed a valuable tool. They noted that patients ruled out at laparoscopy were never checked by open surgery, and that growing team experience may also explain the improvement.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Single-centre study of prospectively registered consecutive patients, comparing a period before and a period after routine diagnostic laparoscopy was introduced
• Who was studied: Patients with peritoneal carcinomatosis referred to a single national centre in Denmark. Period 1 (June 2006 to August 2010): 156 referred, 70 deemed amenable to surgery. Period 2 (September 2010 to January 2012): 116 referred, 45 planned for laparoscopy, 13 operated on without laparoscopy. The 45 laparoscopy patients included 4 with malignant mesothelioma.
• Exposure: No asbestos or fiber exposure was studied. What was compared was the addition of diagnostic laparoscopy to the preoperative evaluation, except in patients with pseudomyxoma peritonei whose CT showed massive amounts of mucin.
• Main results:
  • Period 1 (before laparoscopy): 56 per cent (39 of 70) of patients deemed amenable completed cytoreductive surgery and HIPEC.
  • Period 2 (after laparoscopy was introduced): the completion rate was 70 per cent (28 of 40). The increase was not statistically significant (P = 0.141).
  • Laparoscopy was performed successfully in 43 of 45 patients. In one of the two failures, a patient with malignant mesothelioma, the abdomen could not be accessed because of massive peritoneal thickness.
  • 18 of 45 laparoscopy patients were spared an exploratory laparotomy.
  • Of 27 of 45 patients judged amenable at laparoscopy, 17 completed treatment. All 17 had complete macroscopic cytoreduction (CCR-0 or CCR-1).
  • Ten patients went on to open surgery after an attempted laparoscopy but could not complete treatment. The two patients whose laparoscopy was unsuccessful were among these ten.
  • Identification of candidates failed in five of seven patients with recurrent colorectal cancer.
  • Identification of candidates also failed in two of three patients with malignant mesothelioma. One of these two was the mesothelioma patient whose abdomen was inaccessible at laparoscopy.
  • Among patients with colorectal and appendiceal cancer only, the completion rate was 52 per cent (22 of 42) in period 1 and 63 per cent (12 of 19) in period 2.
  • Laparoscopy understaged the number of involved regions in 14 of 25 patients and overstaged it in two.
  • Laparoscopy was not associated with any postoperative deaths. One patient on blood-thinning treatment had bleeding inside the abdomen, which was managed with transfusions.
• The authors' conclusion: The authors concluded that laparoscopic evaluation seemed to be a valuable tool in predicting whether complete cytoreduction could be achieved. Its main purpose, in their view, was to spare patients with massive disease an exploratory laparotomy.
• Limitations the authors state:
  • Patients judged not resectable at laparoscopy did not have an exploratory laparotomy, so some whose disease was overstaged might have been denied treatment. The authors believed this risk to be minimal.
  • The improved completion rate may also reflect increased experience in reading CT images and increased surgical experience.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Colon cancer.

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Colorectal Cancer, Peritoneal Mesothelioma, Laparotomy, Diagnostic Laparoscopy, Unresectable.

Related studies

• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in Asian patients: 100 consecutive patients in a single institution — M.C. Teo, G.H. Tan, et al. (2013)
• The results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1200 patients with peritoneal malignancy — B. Moran, T. Cecil, et al. (2015)
• Postoperative outcomes of laparoscopic vs open cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for treatment of peritoneal surface malignancies — G. Passot, N. Bakrin, et al. (2014)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)
• Long-term survival outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy: Single-institutional experience with 1225 cases — L.S. Kyang, N.A. Alzahrani, et al. (2019)
• Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion in Adolescent and Young Adults with Peritoneal Metastases — M. Dhir, L. Ramalingam, et al. (2017)

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