Multiorgan resection for advanced abdominal malignancies--is it feasible?

In everyday clinical practice many unfortunate patients present with advanced abdominal malignancies and are referred to a medical oncologist for palliative chemoradiotherapy and very few of them are offered surgical treatment. Many such patients, detected either preoperatively or on exploration, are considered to be inoperable and left to live a short and morbid life. The aim of this study was to assess the feasibility and effect of aggressive surgical management with adjuvant chemotherapy in advanced abdominal malignancies requiring resection of one or more organs along with the primary organ of the disease. We retrospectively analyzed our experience of treating such patients.

A total of 62 patients were included in this study attending the clinic between January 2001 and January 2006. These patients were diagnosed to have advanced abdominal malignancies because of spread of the disease from the organ of origin to either contiguous or noncontiguous abdominal organ(s). The patients with ovarian and uterine (n=18) malignancy underwent resection of colon (5), omentum (18), distal pancreatectomy and splenectomy (2), cystectomy (4), parietal peritoneal excision (9), small bowel excision in various combinations along with radical hysterectomy. Twelve patients with advanced colorectal carcinoma (n=12) along with abdominoperineal excision, anterior resection or colonic resection underwent cystectomy (3), hysterectomy (4), small bowel resection (4), hepatic resection (7) or parietal peritoneal excision (4) in various combinations. A total of 14 patients with gastric and gastroesophageal junction malignancy (n=14) underwent gastrectomy or gastroesophagectomy with omentectomy (14), distal pancreatico-splenectomy (5), hepatic resection (9), transverse colectomy (2) and parietal peritoneal excision (2) due to advanced disease. Patients with pancreatic carcinoma (n=12) underwent Whipple's pancreaticoduodenectomy or distal pancreatectomy with hepatic resection (6), transverse colectomy (1), splenectomy (3), left nephrectomy and adrenalectomy (3), small bowel excision (1) and parietal peritoneal excision (3). Along with excision of nonsolid organ retroperitoneal tumors (n=6) the organs resected were left kidney with adrenal (2), spleen (2) right kidney and adrenal (2), segmental inferior vena cava (1) and colon (2). All patients (except those who died in the early postoperative period) received adjuvant chemotherapy (43) or chemobiologic therapy (12) or radiotherapy.

Out of the total 62 patients who underwent multiorgan resection 7 patients died in the immediate postoperative period due to massive pulmonary embolism (2), cardiorespiratory insufficiency (2) or sepsis (3). Important morbidities seen in the early postoperative period were anastomotic leak (3), hemorrhage (2), pulmonary infection (5), pancreatitis (1), wound infection (4) and urinary tract infection (2). There was 100% postoperative follow-up of the patients. The survival rate was 77% in the first, 56.45% in the second, 47% in the third, 32% in the fourth and 22% at the end of the five-year follow-up.

Aggressive surgical intervention by multiorgan resection and adjuvant chemo or chemobiological therapy is a feasible option in patients with advanced abdominal malignancies with statistically improved survival rate. Furthermore, it helps in getting better response to therapeutic manipulations and improved quality of life of the patients.