Surgical Results of Patients with Peritoneal Carcinomatosis Treated with Cytoreductive Surgery Using a New Technique Named Aqua Dissection

Hindawi Publishing Corporation Gastroenterology Research and Practice Volume 2012, Article ID 521487, 10 pages doi:10.1155/2012/521487 Clinical Study Surgical Results of Patients with Peritoneal Carcinomatosis Treated with Cytoreductive Surgery Using a New Technique Named Aqua Dissection Y. Yonemura,1, 2, 3 A. Elnemr,1 Y. Endou,4 H. Ishibashi,1, 3 A. Mizumoto,2 M. Miura,5 and Yan Li6 1 NPO Organization to Support Peritoneal Surface Malignancy Treatment, 1-26, Haruki-Moto-Machi, Kishiwada, Osaka, Japan of Surgery, Kusatsu General Hospital, Shiga, Japan 3 Department of Surgery, Peritoneal Surface Malignancy Center, Kishiwada Tokushukai Hospital, Kishiwada, Japan 4 Department of Experimental Therapeutics, Cancer Research Institute, Kanazawa University, Kanazawa, Japan 5 Department of Anatomy, School of Medicine, Oita University, Oita, Japan 6 Department of Oncology, Zhongnam Hospital and Cancer Center, Wuhan University, Wuhan, China 2 Department Correspondence should be addressed to Y. Yonemura, Received 14 January 2012; Accepted 11 March 2012 Academic Editor: Pompiliu Piso Copyright © 2012 Y. Yonemura et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. During 2004 to 2011, 81, 420, and 166 patients with colorectal cancer (CRC), epithelial appendiceal neoplasm (APN), and gastric cancer (GC) with PC were treated with cytoreductive surgery (CRS) plus perioperative chemotherapy. CRS was performed by peritonectomy techniques using an aqua dissection. Results. Complete cytoreduction was done in 62/81 (76.5%), 228/420 (54.3%), and 101/166 (60.8%) of patients with CRC, APN, and GC. The main reasons of incomplete resections were involvement of all peritoneal regions and diffuse involvement of small bowel. The incidence (64%, 302/470) of CC-0 resection after introduction of an aqua dissection was significantly higher than before (42%, 82/197). A total of 41 (6.1%) patients died postoperatively. Major complication (grade 3-4 complications) occurred in 126 patients (18.9%). A reoperation was necessary in 36 patients (5.4%). By the multivariate analysis, PCI scores capable of serving as thresholds for favorable versus poor prognosis in each group and CC scores demonstrated as the independent prognostic factors. Conclusions. Peritonectomy using an aqua dissection improves the incidence of complete cytoreduction, and improves the survival of patients with PC. Patients with PCI larger than the threshold values should be treated with chemotherapy to improve the incidences of complete cytoreduction. 1. Introduction The current state-of-the-art treatment for the peritoneal carcinomatosis (PC) from colorectal, appendiceal, and gastric cancers consists of a comprehensive management strategy using cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) [1–5]. Patients with a low tumor volume, well/moderately differentiated tumors, and complete cytoreduction may potentially benefit from combined treatment. No survival benefit has been reported by cytoreduction alone [3]. In contrast, CRS plus hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) confers a prolonged survival period [2, 3]. Among several prognostic factors, complete cytoreduction is the most important prognostic factor for a good outcome [1–3]. However, complete cytoreduction is sometimes difficult in patients with deep invasion into the liver hilum, lesser omentum, pelvic structures, liver parenchyma, or diffuse involvement of the mesentery and serosa of small bowel. Even by the most experienced surgeons in the world, the incidences of complete cytoreduction are reported 77% (617/802) [4]. However, the complete cytoreduction rate depends on the selection criteria for the CRS and the ability and experiences of the surgeons. In the present paper, our 2 surgical techniques for the complete yet safe cytoreduction and the results after CRS will be reported; 81 (42.9%), 420 (72.7%) and 166 (51.5%). 2. Patients and Methods 2.1. Patients. Between June, 2004, and January, 2011, a total of 667 patients underwent CRS combined with PIC for peritoneal carcinomatosis from colorectal origin (N = 81), epithelial appendiceal neoplasm (N = 420), and gastric cancer (N = 166), led by a single surgeon (Y. Yonemura) at Kishiwada Tokushukai and Kusatsu General Hospital, Japan. The included patients were >19 and, <87 years old, with good performance status (World Health Organization Performance Status ≤2). All patients underwent extensive preoperative investigations, which included physical examination and abdominal, pelvic, and chest computed tomography (CT) scans to assess the extent of the disease involved. CT scans were performed following the administration of oral and intravenous contrast media. Signed informed consent was obtained from all patients. 2.2. Quantitative Evaluation of the Volume of PC and Assessment Completeness of Cytoreduction. Preoperatively, the tumor volume was quantified according to computed tomography (CT) scans using the Peritoneal Cancer Index (PCI, Washington Cancer Institute) [6, 7]. The abdomen and pelvis were divided into nine regions and the small bowel into four: each assigned a lesion size (LS) score of 0–3, representative of the largest implant visualized. LS-0 denotes the absence of implants, LS-1 indicates implants <0.25 cm, LS-2 implants between 0.25 and 5 cm, and LS-3 implants >5 cm or a confluence of disease. These figures amount to a final numerical score of 0–39. 2.3. Selection Criteria for CRS. CRS consists of numerous surgical procedures depending on the extent of peritoneal tumor manifestation. Surgery may include parietal and visceral peritonectomy, greater and lesser omentectomy, splenectomy, cholecystectomy, resection of the liver capsule, small bowel resections, colonic and rectal resections, gastrectomy, pancreatic resection, hysterectomy, ovariectomy, and urine bladder resection [8]. Patients who had the following criteria are excluded as candidates for peritonectomy: (1) evidence of lymph node involvement and distant hematogenous metastasis confirmed by computed tomography (CT), magnetic resonance imaging (MRI), or 18 Fluorodeoxyglucose positron emission tomography (PET/CT), (2) progressive disease after preoperative chemotherapy, and (3) severe comorbidities or poor general condition. 2.4. Methods of CRS Using Peritonectomy Techniques 2.4.1. Dissection Techniques of CRS. Under general anesthesia, midline incision was made from the xiphoid to the pubis, and PCI score was calculated in each case [8, 9]. Gastroenterology Research and Practice For the tissue dissection, electrosurgical techniques are used. In electrosurgery, a generator delivers high frequency current greater than 200 kHz under high power electricity (100 Watt), and the tissue impedance converts electric current into thermal (...truncated)