Lessons learned from initial experience with peritonectomy and intra-peritoneal chemotherapy infusion

Patients diagnosed with peritoneal carcinomatous usually survive for less than 6 months. Cytoreductive surgery allows relief of the obstruction and improvement in functional status, while intraperitoneal chemotherapy infusion provides high local concentrations of chemotherapeutic agents. Our institutional experience is reviewed to assess the selection criteria, peri-operative complications, and outcomes.

We carried out a retrospective review of nine patients who had undergone aggressive cytoreductive surgery and hyperthermic intra- and early post-operative chemotherapy by a single surgeon between April 2000 and October 2004. The inclusion criteria were: (1) a demonstrated absence of extra-peritoneal and hepatic spread, (2) fitness of the patient and ability to tolerate cytoreductive surgery and intra-operative chemotherapy, and (3) the presence of a primary tumor originating form the gastro-intestinal tract (colonic, appendiceal, and gastric primaries).

Seven women and two men, with a median age of 55 years, were treated. The median duration of the operation was 12 hours and 55 minutes. Seven of the nine patients required the insertion of at least one chest tube. All patients were monitored in the surgical intensive care unit (SICU) for a median of 1 day, started on feeds after a median of 6 days, and were hospitalized for a median of 16 days (range:11-18 days). There was no peri-operative mortality and only one major peri-operative complication (11.1%). At the time of analysis, the median follow-up was 16 months (range: 2-40 months), and the median disease-free survival was 8 months, with four of the nine patients showing no evidence of recurrence. To date, all of the patients are still alive. A 1-year survival rate of 100% is also documented.

This article describes our initial experience with peritonectomy and intra-operative, intra-peritoneal chemotherapy infusion. Our initial problems included difficulty with leakage of the chemotherapeutic agents into the thoracic cavity that had to be overcome by the early insertion of chest-tubes. With appropriate patient selection, cytoreductive surgery with the infusion of intra-operative chemotherapy can be considered to be a therapeutic option for some patients with diffuse peritoneal metastases, and good disease-free and overall survival can be achieved with minimal morbidity.