CRS with HIPEC is now a procedure with the potential to cure selected patients suffering from PC[13-17
]. PC can be considered a disease limited to the abdominal compartment, and based on this rationale maximal cytoreduction may be justified for various histological entities such as pseudomyxoma, ovarian cancer and colorectal cancer, etc
., thus improving overall and recurrence-free survival[13-21
Patient selection is certainly, as already mentioned, the “achilles heel” when including patients in this multimodal therapy. Radiological imaging estimates intraoperative tumor load, but reliable tumor identification in the critical regions such as the small bowel or ligamentum hepatoduodenale is still poor. Especially small lesions of about 1 cm or less are difficult to detect, even by PET-CT scan[22
In this article we describe our first experiences with CRS and HIPEC. Since this procedure entails a certain morbidity, also due to long operating time, intraoperative chemotherapy and multivisceral resection, we attempted to detect risk factors for patient selection with a view to perioperative morbidity. The literature currently available gives no conclusive data on age or BMI of patients for the purpose of patient selection for this multimodal therapy.
Since it is generally known that numeric age does not correlate with biological age, it is not acceptable to generally exclude older patients who are in good condition. Moreover, patients with a high BMI are often viewed negatively, because they are more challenging to operate and have a greater risk for perioperative complications.
Additionally, one of the main prognostic factors is PCI and when it exceeds 20 in colorectal cancers no survival benefit is achieved. However, for other entities it is still unclear and in pseudomyxoma the completeness of cytoreduction is the only prognostic factor, not tumor load.
From our results we concluded that tumor load, age and BMI had no significant impact on the perioperative complication rate according to the DINDO classification. Therefore, if desired, a biologically young patient should be included in this therapy if CC0/CC1 resection appears possible. We therefore hypothesize that the probability to achieve a CC0/CC1 resection should be the determining criterion for selection, and not PCI. Patients with a BMI over 25 had complication rates similar to those of patients with a BMI under 25. At any rate, we recommend that caution be exercised with superobese patients, because they were not represented in this study.
In obese patients with a low PCI, a laparoscopic approach with HIPEC might be an option and should be discussed[23
For patients with a high PCI this also seems valuable. The results of this study show that from the standpoint of postoperative morbidity more patients could be included in this therapy. Resectability should remain the main criteria for performing CRS and HIPEC.
In the beginning we generously applied a ureteral splint during peritonectomy for better orientation in patients with pelvic recurrence. Because of extensive pre- and postoperative pain and the questionable necessity of the splint during the operation we abandoned ureteral splinting completely in patients without hydronephrosis. In one case we had to perform a ureteral resection and end-to-end anastomosis because of tumor infiltration.
Our anastomotic leakage rate of 5.8% is acceptable and comparable with that of the current literature[10
]. However, we tended to avoid anastomoses or stomas in favor of meticulous cleaning of the small bowel and large bowel of tumor seedings whenever possible, especially in the most recent patients. Only four patients received a loop ileostomy after anterior rectal resection, two received a terminal ileostomy after colectomy and four patients a terminal colostomy. In our opinion resection of the colon should not be performed according to oncologic criteria with removal of a maximum of lymph nodes, except when there is a synchronous PC of colorectal cancer. More importantly, all macroscopically visible tumor seedings must be removed and the organs should be preserved whenever possible.
Most recurrences occurred in the right upper quadrant or in the retroperitoneum (data not shown). This might have been induced by the large wound surfaces and the increasing risk for tumor adherence[24
]. This observation has been known for a long time[25-27
]. In this regard, CRS should be performed only in the tumor-affected peritoneum and never in healthy tissue. Nonetheless, it is sometimes easier to begin with the parietal peritonectomy in the healthy region, for example by removing the peritoneum of the whole pelvis and not only the affected region in the Douglas space.
In the summary of the decision to include or not include a patient in this multimodal therapy is based on a variety of factors and should be done only at centers offering interdisciplinary evaluation by internal medicine specialists, surgical oncologists, anesthetists and radiologists. Lastly, the decision should be taken individually for each patient and high PCI, BMI or age should not be an exclusion criterion per se with regard to perioperative morbidity.