Laparoscopy in the Management of Peritoneal Carcinomatosis

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Abstract

The use of videolaparoscopy in the assessment of peritoneal carcinomatosis extent is now universally accepted. This procedure allows us to define with certainty the origin of the neoplasm, the peritoneal cancer index (PCI), the involvement of the small bowel and its mesentery, the feasibility of surgery and the index of attainable cytoreduction, the evaluation of an eventual multiorgan resection, and finally results in no mortality and very low morbidity.

The indications for laparoscopy are as follows: staging of the carcinomatosis already diagnosed with imaging (CT scan and MRI), staging of carcinomatosis of dubious origin (biopsy), restaging after neoadjuvant chemotherapy, restaging during follow-up in the case of dubious imaging, and restaging after adjuvant chemotherapy.

Open (Hasson) technique has always been used in the introduction of the first trocar, and the changing position of the surgical bed allows for the evaluation of all the abdominal quadrants, limiting viscerolysis to the essential minimum to avoid iatrogenic lesions. Associating the intraoperative ultrasound has allowed us to reduce understaging of lesions at the depth of the diaphragm, of hepatic metastases and neoplastic masses at the pancreatic tail, and of the omental retrocavity.

In all the cases in which diagnostic laparoscopy was followed by peritonectomy, we found a good correlation between open surgery data and the laparoscopic PCI. We excluded patients from peritonectomy if the staging laparoscopy showed a significant involvement of the small bowel or mesentery.

We used videolaparoscopy to stage 197 cases of peritoneal carcinomatosis and achieved full laparoscopic PCI assessment in 196 of 197 (99.49%) cases, whereas only 4 of 197 (2.03%) cases were understaged before the routine use of laparoscopic ultrasound. Four complications were observed: 2 cases (1.02%) involved an infection of the trocar insertion site, which was treated with antibiotic therapy, and 2 cases (1.02%) involved diaphragm perforation and intraoperative bleeding, respectively, both resolved with videolaparoscopic technique. Two trocars were sufficient in 184 of 197 cases. There was no mortality and no port site metastasis.

More recently, we have used videolaparoscopic surgery in the treatment of neoplastic ascites that did not respond to chemotherapy for palliative purposes, which resulted in the total disappearance of the ascites. It is now possible, in light of acquired experience, to evaluate with precision the indications, the technique, and the limits of the method both in the assessment of the carcinomatosis extent and in its palliation. In 28 cases of neoplastic ascites nonrespondent to chemotherapy, we were able to implement fully laparoscopic hyperthermic chemotherapy for the palliative treatment of the ascites, with total disappearance of it in all cases. The l-hyperthermic intraperineal chemotherapy was carried out at 42°C for 90 minutes with 1.5% dextrose solution as a carrier. The chemotherapy solution was cisplatin and doxorubicin, or mitomycin, depending on the type of primary tumor. The drains were left in place and were removed when profuse drainage ceased.

Ascites were controlled in all treated cases. A computed tomography scan performed in follow-up showed a small, clinically undetectable, fluid accumulation in the pelvis of 1 patient. Neither mortality nor morbidity was observed in connection with the procedure.

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