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Diaphragmatic Peritoneal Stripping Versus Full-Thickness Resection in CRS/HIPEC: Is There a Difference?

  • Peritoneal Surface Malignancy
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Pleural recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is rare and poorly delineated. Specifically, data are limited on the effect that diaphragmatic peritoneal stripping versus full-thickness resection has on the nature of ipsilateral pleural recurrence and postoperative morbidity.

Methods

Patients with peritoneal carcinomatosis who underwent CRS/HIPEC were included from a prospectively maintained database. The patients were divided into three cohorts based on surgical management of the diaphragm as follows: diaphragm-stripping (DS) cohort, full-thickness resection (FTR) cohort, and no diaphragm manipulation (ND) cohort. Postoperative morbidity and incidence of ipsilateral pleural recurrence were evaluated. All diaphragmatic defects were closed before abdominal chemoperfusion.

Results

The inclusion criteria were met by 409 CRS/HIPEC procedures: 66 in DS, 122 in FTR, and 238 in ND. Ipsilateral pleural recurrence rates did not differ significantly between the three cohorts (DS 6%, FTR 3%, ND 3%; p = 0.470). Postoperative respiratory complications and overall morbidity were significantly greater for the patients who underwent diaphragmatic disruption (stripping and/or resection) than for the patients who did not (p ≤ 0.0001), but the two groups did not differ in terms of 30-day mortality. However, comparison of FTR with DS showed no impact on major morbidity or pleural recurrence.

Conclusion

Although patients undergoing surgical manipulation of the diaphragm during CRS/HIPEC experienced significantly greater morbidity, diaphragmatic stripping did not differ from full-thickness resection in terms of grades 3 and 4 complications or incidence of ipsilateral pleural recurrences. When deemed necessary to achieve complete cytoreduction, full-thickness diaphragmatic resection should be undertaken. In addition, the data support the observation that definitive repair of the diaphragmatic defect before abdominal chemoperfusion does not adversely influence ipsilateral pleural recurrence.

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References

  1. Kuncewitch M, Levine EA, Shen P, Votanopoulos KI. The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for appendiceal tumors and colorectal adenocarcinomas. Clin Colon Rectal Surg. 2018;31:288–94. https://doi.org/10.1055/s-0038-1642052.

    Article  Google Scholar 

  2. Sugarbaker PH. Peritoneal metastates: a fronteir for progress. Surg Oncol Clin North Am. 2018;27:413–24. https://doi.org/10.1016/j.soc.2018.02.001.

    Article  Google Scholar 

  3. Zivanovic O, Chi DS, Filippova O, Randall LM, Bristow RE, O’Cearbhaill RE. It’s time to warm up to hyperthermic intraperitoneal chemotherapy for patients with ovarian cancer. Gynecol Oncol. 2018;151:555–61. https://doi.org/10.1016/j.ygyno.2018.09.007.

    Article  Google Scholar 

  4. Franssen B, Tabrizian P, Weinberg A, Romanoff A, Tuvin D, Labow D, Sarpel U. Outcome of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy on patients with diaphragmatic involvement. Ann Surg Oncol. 2015;22:1639–44. https://doi.org/10.1245/s10434-014-4083-x.

    Article  Google Scholar 

  5. Shen P, Levine EA, Hall J, et al. Factors predicting survival after intraperitoneal hyperthermic chemotherapy with mitomycin C after cytoreductive surgery for patients with peritoneal carcinomatosis. Arch Surg. 2003;138:26–33.

    Article  CAS  Google Scholar 

  6. Van Sweringen HL, Hanseman DJ, Ahmad SA, Edwards MJ, Sussman JJ. Predictors of survival in patients with high-grade peritoneal metastases undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Surgery. 2011;152:617–24. https://doi.org/10.1016/j.surg.2012.07.027.

    Article  Google Scholar 

  7. Votanopoulos KI, Bartlett D, Moran B, et al. PCI is not predictive of survival after complete CRS/HIPEC in peritoneal dissemination from high-grade appendiceal primaries. Ann Surg Oncol. 2018;25:674–8. https://doi.org/10.1245/s10434-017-6315-3.

    Article  Google Scholar 

  8. Sugarbaker PH, Chang D, Stuart OA. Hyperthermic intraoperative thoracoabdominal chemotherapy. Gastroenterol Res Pract. 2012:1–7. https://doi.org/10.1155/2012/623417.

    Article  Google Scholar 

  9. Ahmed S, Levine EA, Randle RW, Swett KR, Shen P, Stwart JH, Votanopoulous KI. Significance of diaphragmatic resections and thoracic chemoperfusion on outcomes of peritoneal surface disease treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Ann Surg Oncol. 2014;21:4226–31. https://doi.org/10.1245/s10434-014-3891-3.

    Article  Google Scholar 

  10. Grotz TE, Mansfield PF, Royal RE, et al. Intrathoracic chemoperfusion decreases recurrences in patients with full-thickness diaphragm involvement with mucinous appendiceal adenocarcinoma. Ann Surg Oncol. 2016;23:2914–9. https://doi.org/10.1245/s10434-016-5209-0.

    Article  Google Scholar 

  11. Pestieau SR, Esquivel J, Sugarbaker PH. Pleural extension of mucinous tumor in patients with pseudomyxoma peritonei syndrome. Ann Surg Oncol. 2000;7:199–203.

    Article  CAS  Google Scholar 

  12. Beane JD, Wilson GC, Sutton JM, et al. Pleuropulmonary recurrence following cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for appendiceal pseudomyxoma peritonei. Ann Surg Oncol. 2019;1429–36. https://doi.org/10.1245/s10434-018-07091-z.

    Article  PubMed  Google Scholar 

  13. Tabrizian P, Shrager B, Jibara G, et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis: outcomes from a singe tertiary institution. J Gastrointest Surg. 2014;18:1024–31. https://doi.org/10.1007/s11605-014-2477-5.

    Article  Google Scholar 

  14. Jacquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis. In Sugarbaker PH (ed) Peritoneal carcinomatosis: principles of management. Boston: Kluwer Academic Publishers; 1996, pp 359–374.

    Chapter  Google Scholar 

  15. Sugarbaker PH. Cytoreductive surgery and perioperative intraperitoneal chemotherapy as a curative approach to pseudomyxoma peritonei syndrome. Eur J Surg Oncol. 2001;27:239–43.

    Article  CAS  Google Scholar 

  16. Levine EA, Steward JH IV, Shen P, Russell GB, Loggie BL, Votanopoulos KI. Intraperitoneal chemotherapy for peritoneal surface malignancy: experience with 1000 patients. J Am Coll Surg. 2014;218:573–85. https://doi.org/10.1016/j.jamcollsurg.2013.12.013.

    Article  Google Scholar 

  17. Downs-Canner S, Ding Y, Magge DR, et al. A comparative analysis of postoperative pancreatic fistulas after surgery with and without hyperthermic intraperitoneal chemoperfusion. Ann Surg Oncol. 2015;22:1651–7. https://doi.org/10.1245/s10434-014-4186-4.

    Article  Google Scholar 

  18. Glehen O, Gilly FN, Boutitie F, et al. Toward curative treatment of peritoneal carcinomatosis from nonovarian origin by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy: a multi-institutional study of 1290 patients. Cancer. 2010;116:5608–18. https://doi.org/10.1002/cncr.25356.

    Article  Google Scholar 

  19. Glehen O, Kwiatkowski F, Sugarbaker PH, et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study. J Clin Oncol. 2004;15:3284–92.

    Article  Google Scholar 

  20. Verwaal VJ, van Ruth S, de Bree E, van Sloothen GW, van Tinteren H, Boot H, Zoetmulder FA. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol. 2003;21:3737–43.

    Article  Google Scholar 

  21. Verwaal VJ, Bruin S, Boot H, van Slooten G, van Tinteren H. 8-Year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with peritoneal carcinomatosis of colorectal cancer. Ann Surg Oncol. 2008;15:2426–32. https://doi.org/10.1245/s10434-008-9966-2.

    Article  Google Scholar 

  22. van Driel WJ, Koole SN, Sonke GS. Hyperthermic intraperitoneal chemotherapy in ovarian cancer. N Engl J Med. 2018;378:1363–4. https://doi.org/10.1056/nejmc1802033.

    Article  PubMed  Google Scholar 

  23. Yan TD, Deraco M, Baratti D, et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for malignant peritoneal mesothelioma: multi-institutional experience. J Clin Oncol. 2009;27:6237–42. https://doi.org/10.1200/jco.2009.23.9640.

    Article  Google Scholar 

  24. Youssef H, Newman C, Chandrakumaran K, Mohamed F, Cecil TD, Moran BJ. Operative findings, early complications, and long-term survival in 456 patients with pseudomyxoma peritonei syndrome of appendiceal origin. Dis Colon Rectum. 2011;54:293–9. https://doi.org/10.1007/dcr.0b013e318202f026.

    Article  PubMed  Google Scholar 

  25. Singh B, Singh G, Alzhrani N, Arrowaili A, Morris D. Long-term survival and perioperative propensity score matched outcomes in diaphragmatic interventions in cytoreductive surgery and intra-peritoneal chemotherapy. Eur J Surg Oncol. 2019;45:620–4. https://doi.org/10.1016/j.ejso.018.2.021.

    Article  Google Scholar 

  26. Chen WJ, Yuan SF, Yan QY, et al. Intrapleural chemo- and hyperthermotherapies for malignant pleural effusion: a randomized prospective study. Cancer Invest. 2012;30:126–130. https://doi.org/10.3109/07357907.2011.633292.

    Article  CAS  PubMed  Google Scholar 

  27. Mujoomdar AA, Sugarbaker DJ. Hyperthermic chemoperfusion for the treatment of malignant pleural mesothelioma. Semin Thorac Cardiovasc Surg. 2008;20:298–304. https://doi.org/10.1053/j.semtcvs.2008.11.002.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Surgical Oncology, Mount Sinai St. Luke’s Roosevelt, New York, NY, USA

    Brianne J. Sullivan MD, Eliahu Y. Bekhor MD, Matthew Carpiniello MD, Natasha L. Leigh MD, Eric R. Pletcher MD, Daniel Solomon MD, Deepa R. Magge MD, Umut Sarpel MD, Daniel M. Labow MD & Benjamin J. Golas MD

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  1. Brianne J. Sullivan MD
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  2. Eliahu Y. Bekhor MD
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  3. Matthew Carpiniello MD
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  4. Natasha L. Leigh MD
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  5. Eric R. Pletcher MD
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Correspondence to Brianne J. Sullivan MD.

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Sullivan, B.J., Bekhor, E.Y., Carpiniello, M. et al. Diaphragmatic Peritoneal Stripping Versus Full-Thickness Resection in CRS/HIPEC: Is There a Difference?. Ann Surg Oncol 27, 250–258 (2020). https://doi.org/10.1245/s10434-019-07797-8

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  • DOI: https://doi.org/10.1245/s10434-019-07797-8

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