Tag Archives: Peritoneal Neoplasms

Emory Historical Article: Management of peritoneal carcinomatosis

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“Gastrointestinal malignancies frequently recur with metastatic disease limited to the abdominal cavity. Due to full thickness penetration of tumor through bowel wall and spillage of tumor from lymphatic channels by surgical trauma, tumor cells are disseminated throughout the peritoneal surfaces either prior to at the time of surgical removal of the primary tumor. Diagnosis of recurrent cancer is difficult because no sensitive diagnostic test is available by which to image a small tumor volume present on peritoneal surfaces. Computerized tomography can not demonstrate small to moderate nodules. Intraperitoneal instillation of 131-1 labeled monoclonal antibody has allowed visualization of mucinous tumor on peritoneal surfaces not seen by any other radiologic test. Intraperitoneal chemotherapy has been shown to provide palliation in patients with small volume disease confined to peritoneal surfaces. Because of limited penetration of chemotherapy into large tumor nodules this treatment strategy has not been effective for bulky intraabdominal recurrent cancer. Cytoreductive surgery can make patients relatively disease free. New surgical technologies combined with postoperative intraperitoneal chemotherapy have been shown to be curative for selected patients with recurrent cystadenocarcinoma. The wider application of immediate postoperative intraperitoneal chemotherapy treatments for gastrointestinal patients in an adjuvant setting may be of value in preventing the occurrence of peritoneal carcinomatosis and in improving survival.”

Sugarbaker, P H. “Management of peritoneal carcinomatosis.” Acta medica Austriaca vol. 16,3-4 (1989): 57-60. Request via ILLiad Interlibrary Loan

Extended-duration thromboprophylaxis after CRS/HIPEC

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Khan S, et al. Incidence, Risk Factors, and Prevention Strategies for Venous Thromboembolism after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol. 2019 Jul;26(7):2276-2284.

Full-text for Emory users.

“A policy change was made in February 2010 to discharge all patients post-CRS/HIPEC with 14 days of additional pharmacothromboprophylaxis, which consisted of low-molecular-weight heparin in 327 of 447 (73%) cases (Supplemental Figure). The 60-day VTE rate decreased from 10.2 to 4.9% after this policy was instituted (p = 0.10, Fig. 2).”

“This policy is in accordance with established guidelines indicating the need for a total of 4 weeks of pharmacothromboprophylaxis in high-risk patients after abdominal or pelvic surgery for cancer. [2,21] Given that patients have an average length of stay of nearly 2 weeks, discharging them on 14 days of pharmacothromboprophylaxis fulfills this duration.”

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Sclerosing encapsulating peritonitis

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One discussion this week involved small bowel obstruction and sclerosing encapsulating peritonitis (SEP).

Reference: Liberale G, Sugarbaker PH. Sclerosing encapsulating peritonitis as a potential complication of cytoreductive surgery and HIPEC: clinical features and results of treatment in 4 patients. Surgical Oncology. 2018 Dec;27(4):657-662.

Summary: Liberale and Sugarbaker (2018) define SEP as “a rare entity characterized by encapsulation of the small bowel and/or the colon by fibrous tissue forming a shell” (p.657). It is iatrogenic, idiopathic, or secondardy, and its pathophysiology is uncertain. The most common symptoms are abdominal pain, discomfort, and partial or complete obstruction.

In this article, the authors present 4 cases of SEP, all of which required additional surgery to alleviate recurrent episodes of small bowel obstruction.

In discussion, they provide some advice (p.661):

  • An adverse event to avoid is small bowel fistula following surgery.
  • The prevention of fistulization which results in enteric contamination of the peritoneal space is of utmost importance in reoperative surgery.
  • Careful marking of seromuscular tears and their repair prior to closing the abdomen is important.
  • A major problem that may occur in follow-up is the difficulty of distinguishing recurrence of peritoneal metastases from benign causes of bowel obstruction.

There are two types of SEP (p.661):

  • Type I: a fibrous membrane sheathing the bowel loops together without a clearly separated dissection plane. Surgery is challenging and the surgeon needs to open the plane between bowel loops while avoiding causing serosal tears.
  • Type II: a fibrous membrane forming an enterocele or ‘pseudocyst-like’ structure. These are easier to manage as, once the pouch is open, the small bowel can be dissected and separated easily from the surrounding sheath.