Surg Endosc (2014) 28:1555–1562 DOI 10.1007/s00464-013-3351-3
and Other Interventional Techniques
Laparoscopic cytoreductive surgery and early postoperative intraperitoneal chemotherapy for patients with colorectal cancer peritoneal carcinomatosis: initial results from a single center Soo Yeun Park • Gyu-Seog Choi • Jun Seok Park Hye Jin Kim • Jong-Pil Ryuk • Sung-Hwan Yun • Jong Gwang Kim • Byung Woog Kang
•
Received: 31 March 2013 / Accepted: 20 November 2013 / Published online: 25 December 2013 Ó Springer Science+Business Media New York 2013
Abstract Background In recent decades, a combination of cytoreductive surgery and intraperitoneal chemotherapy has yielded improvements in the survival of patients with peritoneal carcinomatosis. Laparoscopic cytoreductive surgery and intraperitoneal chemotherapy comprise a challenging and rarely reported surgical procedure. Methods Between November 2004 and February 2010, 29 patients underwent cytoreductive surgery and early postoperative intraperitoneal chemotherapy for peritoneal carcinomatosis secondary to colorectal cancer. Of the 29 patients, 15 underwent laparoscopic surgery and 14 underwent open surgery. Results The patient characteristics did not differ significantly between the two groups. Synchronous peritoneal carcinomatosis with a primary tumor was more common in the laparoscopic group, and the Gilly stage of peritoneal carcinomatosis was found more frequently in the open group. Complication rate and hospital stay were less in the laparoscopic group. However, the outcomes for the patients undergoing the combined treatment were similar between the two groups with respect to completeness of cytoreduction, operation morbidity, and overall survival. The laparoscopic group had a cytoreduction completeness
S. Y. Park G.-S. Choi (&) J. S. Park H. J. Kim J.-P. Ryuk S.-H. Yun Colorectal Cancer Center, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, 807 Hogukro, Buk-gu, Daegu 702-210, Korea e-mail:
[email protected] J. G. Kim B. W. Kang Department of Hematology/Oncology, Kyungpook National University Medical Center, School of Medicine, Kyungpook National University, Daegu, Korea
of 86.7 % and an operative morbidity of 13.3 %. Operative mortality occurred for one patient after open surgery. Conclusions Laparoscopic cytoreductive surgery and early postoperative intraperitoneal chemotherapy can be performed safely for selected patients with peritoneal carcinomatosis from colorectal cancer to a limited extent. Further studies with longer follow-up periods and larger numbers of patients are warranted to confirm the study findings. Keywords Colorectal cancer Laparoscopy Peritoneal carcinomatosis Cytoreductive surgery
Multicenter randomized trials have shown that laparoscopic colon cancer surgery provides short-term recovery benefits without compromising oncologic safety [1]. Although evidence from randomized trials for laparoscopic rectal cancer surgery is not as strong as for laparoscopic colectomy, recent studies have demonstrated that laparoscopic surgery is associated with short-term benefits and oncologic outcomes similar to those for open surgery [2–4]. Based on these studies, laparoscopic colorectal surgeons have expanded the scope of laparoscopic surgery. Complex procedures, such as resection of ultralow rectal cancer, multivisceral resection for advanced colorectal cancer, and intracorporeal anastomosis after right colectomy have been performed successfully after careful patient selection [5–7]. Colorectal cancer with peritoneal metastasis (CPM) is one of the conditions that demand extended surgery for the radical resection of the colorectal cancer. At the time of the initial colorectal cancer diagnosis, CPM is detected in 5–15 % of patients [8]. It is a common event affecting up to 50 % of patients with recurrence after curative resection.
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Among these patients, 10–35 % have peritoneal carcinomatosis as the only form of tumor dissemination [9]. Cases of CPM are associated with a poor prognosis. When colorectal cancer is accompanied by peritoneal carcinomatosis, survival generally is 6–9 months in the absence of treatment. However, during the last two decades, cytoreductive surgery (CRS) combined with intraperitoneal chemotherapy (IPC) for CPM has been reported widely. This aggressive treatment has produced excellent results in terms of survival improvement. To maximize the effect of IPC, surgical resection should be maximally radical resection, which usually consists of visceral resection and peritonectomies in various combinations [10]. Because of the need for extended resection and procedural complexity, such operations have been performed mostly with extended abdominal incisions. We report our initial experience with laparoscopic CRS and early postoperative intraperitoneal chemotherapy (EPIC) in a series of 15 patients. We evaluated the technical feasibility and safety of these procedures by comparing the clinical outcomes with those of patients undergoing open surgery.
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nodules. Peritonectomy procedures were based on Sugarbaker’s description only for sites of tumor deposits [10]. The patient with a primary colorectal cancer underwent standard colectomy with a maintained safe margin, regional lymphadenectomy up to the feeding artery, and selective peritonectomy. The patient with recurrent CPM underwent surgical resection for visible peritoneal lesions. Before closure of the abdomen, three silicon catheters were placed in the cul-de-sac and in bilateral subphrenic spaces. The extent of peritoneal carcinomatosis was categorized according to Gilly staging: stage 1 (tumor nodules smaller than 5 mm in diameter and localized to one part of the abdomen), stage 2 (tumor nodules smaller than 5 mm in diameter but distributed throughout the abdomen), stage 3 (tumor nodules 5 mm to 2 cm in diameter), and stage 4 (tumor nodules larger than 2 cm in diameter) [11]. The completeness of cytoreduction (CCR) was assessed at the end of surgery and classified as CCR-0 (no macroscopic disease), CCR-1 (no residual nodules larger than 2.5 mm in diameter), and CCR-2 (residual nodules larger than 2.5 mm in diameter) [12]. Laparoscopic surgical technique
Methods Between January 2005 and February 2010, 29 patients underwent CRS with EPIC for CPM at Kyungpook National University Medical Center. The demographics, operative data, short-term postoperative outcomes, and the long-term recurrence and survival outcomes of these patients were reviewed. The exclusion criteria for CRS with EPIC, defined according to the institutional policy, specified patients 70 years of age or older, serious comorbidities (e.g., cardiorespiratory, neurologic, liver, or renal diseases), and perforated tumors with peritonitis. The surgical method (laparoscopic or open) was chosen first according to the preoperative imaging studies for all the patients and second according to the laparoscopic exploration. For the patients with peritoneal nodules in multiple quadrants shown on imaging studies, laparoscopic exploration was performed to confirm the possibility of performing a radical resection. Extensive explanation of the surgical procedures and EPIC was offered, and informed consent was obtained from all the patients at the preoperative meeting. This study was approved by the Institutional Review Board of Kyungpook National University Medical Center. Surgical procedures All the procedures were performed by a single surgeon (C, G-, S). The goal of surgery was to remove all visible
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Laparoscopic CRS was performed with four or five ports and a 0° endoscope. After diagnostic laparoscopy, we decided to complete CRS laparoscopically when curative resection could be achieved. Working ports were located in the right lower quadrant or in the left upper quadrant according to the sites of the lesions. Bowel anastomosis after resection of the left-sided colon or rectum was performed intracorporeally. Otherwise, it was performed extracorporeally after externalization of the bowel segment through a minilaparotomy. All specimens were delivered through a minilaparotomy. A port incision was used to introduce a drainage catheter when its location was appropriate for EPIC. EPIC and postoperative management On the day of surgery, the peritoneal cavity was irrigated with 1.5 % dextrose peritoneal dialysis solution until the fluid draining from the catheters became clear. Mitomycin C (10 mg/m2/day) was given on postoperative day 1, and 5-fluorouracil (700 mg/m2/day) was administered during the next 4 days. The drugs were diluted in 1 L of peritoneal dialysis fluid. Each day, chemotherapy agents were retained in place for 23 h, after which draining was performed for 1 h. The drainage catheters were removed sequentially after a reduced volume of drainage had been confirmed. Clear liquid intake was started on postoperative day 6. A soft diet was allowed on the next day if tolerated by the patient.
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Follow-up evaluation All patients were recommended to undergo systemic chemotherapy and were followed up for at least 5 years or until their death. Follow-up evaluation consisted of a physical examination and measurement of serum tumor markers every 3 months, with an abdominal computed tomography scan performed every 6 months. Other studies such as positron emission tomography scans also were recommended if needed. Statistical analysis Chi square analysis or Fisher’s exact test was used to compare categorical data, as appropriate. Continuous variables were compared using Student’s t test. Survival was estimated using Kaplan–Meier analysis and compared using the log-rank test. All statistical analyses were performed using the SPSS software package for Windows (SPSS 15.0; SPSS, Chicago, IL, USA). A p value lower than 0.05 was considered statistically significant.
Results Open surgery was chosen for 9 patients according to the preoperative imaging scan and for 5 of 20 patients immediately after explorative laparoscopy. The remaining 15 patients were treated with laparoscopic surgery. The characteristics of the laparoscopic and open surgery groups are detailed in Table 1. Both groups were similar in terms of age, gender ratio, body mass index, American Society of Anesthesiologists classification score, and primary tumor location. No patients received neoadjuvant chemotherapy for peritoneal carcinomatosis. Although the characteristics of the primary tumors were similar in terms of tumor depth, regional lymph node involvement, and histologic differentiation, synchronous peritoneal carcinomatosis with primary tumors was more common in the laparoscopic group. Synchronous metastases at other sites were found in two patients who had laparoscopic surgery and in three patients who had open surgery. One patient in the laparoscopic group was able to complete curative resection of the lesion. Intra- and postoperative outcomes In the laparoscopic group, nine patients (60 %) had Gilly stage 1 tumors, two patients (13.3 %) had Gilly stage 3 tumors, and four patients (26.7 %) had Gilly stage 4 tumors. In the open group, four patients (28.6 %) had Gilly stage 1 tumors, seven patients (50.0 %) had Gilly stage 3 tumors, and three patients (21.4 %) had Gilly stage 4 tumors. A higher proportion of patients with Gilly stage 3
1557 Table 1 Patient characteristics p valuea
Characteristics
Laparoscopic surgery (n = 15)
Open surgery (n = 14)
Median age, years (range)
52 (21–70)
53 (24–68)
Sex, n (%) Male Female Median BMI, kg/m2 (range)
6 (40.0) 9 (60.0) 22 (19–30)
2 (14.3) 12 (85.7) 22 (15–28)
ASA score, n (%) 9 (60.0)
10 (71.4)
2
6 (40.0)
4 (28.6)
Colon
11(73.3)
12 (85.7)
Rectum
4 (26.7)
2 (14.3)
Site of primary tumor, n (%)
0.651
pT stage of primary tumor, n (%)
0.096
T3
5 (33.3)
9 (64.3)
T4
10 (66.7)
5 (35.7)
pN stage of primary tumor, n (%)
0.554
N0
2 (13.3)
2 (14.3)
N1
6 (40.0)
3 (21.4)
N2
7 (46.7)
6 (64.3)
11 (73.3)
12 (85.7)
4 (26.7)
2 (26.7)
Tumor differentiation, n (%) Poor Time to PC, n (%)
0.067 0.700
1
Moderate
0.776 0.122
0.651
0.041
Synchronous
13 (86.7)
7 (50.0)
Metachronous
2 (13.3)
7 (50.0)
Distant metastasis to liver or lung, n (%)
0.564
Yes
2 (13.3)
3 (21.4)
No
13 (86.7)
11 (78.6)
a Chi square test for comparison of proportions and Student’s t test for continuous variables
BMI body mass index, ASA American Society of Anesthesiologists, PC peritoneal carcinomatosis
or 4 tumors was noted in the open surgery group (78.6 %) than in the laparoscopic group (40.0 %) (p = 0.089) (Table 2). A comparison of the two groups showed no differences in terms of other operative outcomes such as completeness of CRS, operation time, and blood loss. Colectomy was more commonly performed in the laparoscopic group. In 82.8 % of the patients, all visible tumor nodules within the peritoneal cavity were resected, and the completeness of CRS did not differ significantly between the two groups. Two patients in the laparoscopic group underwent CCR2 resection. They had aggressive carcinomatosis over an
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Table 2 Intraoperative outcomes Surgical results
a
Table 3 Postoperative outcomes after cytoreductive surgery (CRS) and early postoperative intraperitoneal chemotherapy (EPIC)
Laparoscopic surgery (n = 15)
Open surgery (n = 14)
p value
Median operation time, min (range)
180 (90–300)
195 (110–330)
0.471
Median hospital stay, days (range)
Median blood loss, ml (range)
63 (20–100)
216 (50–500)
0.102
Blood transfusion, n (%)
0 (0.0)
0 (0.0)
1.000
1.000
Postoperative mortality, n (%)
0 (0.0)
1 (7.1)
0.292
0.089
Postoperative complications, n (%)
2 (13.3)
8 (57.1)
0.021
Intraoperative transfusion, n (%)
0 (0.0)
0 (0.0)
9 (60.0)
4 (28.6)
6 (40.0)
10 (71.4)
Gilly stage, n (%) 1–2 3–4 Procedures performed, n (%)
Laparoscopic surgery (n = 15)
Open surgery (n = 14)
p value
13 (9–16)
15 (9–49)
0.048
Anastomotic leakage
0 (0.0)
0 (0.0)
1.000
Abscess
0 (0.0)
1 (7.1)
0.292
Pneumonia
0 (0.0)
1 (7.1)
0.292
Omentectomy
14 (93.3)
12 (85.7)
0.501
Neutropenia
1 (6.7)
3 (21.4)
0.249
Colectomy
13 (86.7)
7 (50.0)
0.033
Nausea, ileus
2 (13.3)
5 (35.7)
0.159
Oophorectomy
0 (0.0)
8 (57.1)
0.001
Reoperations, n (%)
0 (0.0)
0 (0.0)
Hysterectomy
0 (0.0)
4 (28.6)
0.026
Smallbowel resection
1 (6.7)
3 (21.4)
0.249
Adjuvant chemotherapy, n (%)
Parietal peritonectomy
Yes 11 (73.3)
9 (64.3)
Visceral resection, n (%)
0.159
Yes
13 (86.7)
9 (64.3)
No
2 (13.3)
5 (35.7)
Fecal diversion, n (%)
0.941
Yes
2 (13.3)
2 (14.3)
No
13 (86.7)
14 (85.7)
Completeness of CRS, n (%)
0.564
CCR-0
13 (86.7)
11 (78.6)
CCR-1
0 (0.0)
0 (0.0)
CCR-2
0.599
2 (13.3)
3 (21.4)
a Chi square test for comparison of proportions and Student’s t test for continuous variables
CRS cytoreductive surgery, CCR completeness of cytoreduction
extensive peritoneal surface that could not be removed by open surgery, so they underwent palliative resection with omentectomy and EPIC. Three patients in the open group also had CPM too extensive for complete removal. The hospital stay was significantly shorter in the laparoscopic group (13 days) than in the open group (15 days) (p = 0.048) (Table 3). The overall morbidity rate for all the patients was 34.5 %. Although complications developed in both groups at similar rates, the overall morbidity rate was significantly higher in the open surgery group (p = 0.021). The patients experienced neither anastomotic leakage nor the need for reoperation. The open group had one death within 60 days of surgery, giving an overall
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No Adjuvant chemotherapy, n (%)
1.000 0.584
13 (86.7)
13 (92.9)
2 (13.3)
1 (7.1) 0.822
Fluorouracil-based
2 (15.4)
1 (7.7)
Oxaliplatin or irinotecan-based
8 (69.2)
9 (69.2)
Bevacizumab or cetuximab
3 (23.1)
3 (23.1)
3-Year OS (%)
43.5
50.8
0.640
3-Year OS (CCR-0) (%)
58.6
56.1
0.913
Overall disease progression (%)
60.0
64.3
0.812
3-Year PFS (%)
42.9
23.1
0.126
3-Year PFS (CCR-0) (%)
53.8
27.3
0.130
Location of disease progression, n (%)
0.356
Peritoneum only
4 (36.4)
5 (50.0)
Peritoneum and other
2 (18.2)
0 (0.0)
Other (liver, lung, lymph node, bone)
5 (45.5)
5 (50.0)
OS overall survival; CCR completeness of cytoreduction, PFS progression-free survival
mortality rate of 3.4 %. This was a result of uncontrollable sepsis arising from hospital-acquired pneumonia 49 days after the operation. Survival After CRS and EPIC, 26 patients received adjuvant systemic chemotherapy. The median follow-up period was
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Fig. 1 Survival curves after cytoreductive surgery (CRS) with early postoperative intraperitoneal chemotherapy (EPIC). A Overall survival after CRS with EPIC: CCR-0 vs CCR-2 (p \ 0.001). B Overall survival after CRS with EPIC: Gilly stages 1–2 vs Gilly stages 3–4
(p = 0.003). C Overall survival after CRS with EPIC among patients with CCR-0: laparoscopic surgery vs open surgery (p = 0.913). CCR, completeness of cytoreduction
31.0 months (range, 9.0–69.0 months) for the laparoscopic group and 20.5 months (range, 2.0–46.0 months) for the open group (p = 0.184). The median overall survival time was 33.0 months, with 1- and 3-year survival rates of 64.8 and 47.0 %, respectively. The median progression-free survival time was 12 months. The 3-year overall survival rate for the 24 patients with CCR-0 resection (57.1 %) was significantly higher than for the 5 patients with CCR-2 resection (0.0 %) (p \ 0.001; Fig. 1A). The 3-year overall survival rate for the 12 patients with Gilly stage 1 or 2 peritoneal carcinomatosis
(66.6 %) was higher than for the 17 patients with Gilly stage 3 or 4 peritoneal carcinomatosis (30.4 %) (p = 0.003; Fig. 1B). The 3-year overall survival rate was similar in the open and laparoscopic groups (50.8 vs 43.5 %; p = 0.640) (Table 3). For the patients who had CCR-0 resection, the 3-year overall survival rate did not differ between the two groups (laparoscopic group 58.6 % vs open group 56.1 %; p = 0.913; Fig. 1C). The 3-year progression-free survival rate did not differ between the open and laparoscopic groups, whether the survival was compared for all the patients (laparoscopic
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group 46.7 % vs open group 23.1 %; p = 0.126) or for the patients who had CCR-0 resection (laparoscopic group 53.8 % vs open group 27.3 %; p = 0.130).
Discussion Peritoneal carcinomatosis is a cause of colorectal cancer dissemination, resulting in early cancer-related death when it is not treated. Traditional systemic chemotherapy and new chemotherapeutic agents including irinotecan, oxaliplatin, and targeted agents have been administered to treat this disease [13]. However, long-term survival has not been achieved because intravenous drugs have limited penetration through the peritoneum. During the last two decades, the survival benefits of CRS in combination with perioperative IPC have been largely defined for peritoneal surface malignances in many prospective and retrospective studies. The CRS removes visible seeded nodules, and the subsequent IPC treats invisible cancer cells. The suggested prognostic factors for survival after this aggressive treatment are the extent of carcinomatosis, the presence of positive lymph nodes, the delivery of adjuvant chemotherapy, and the completeness of CRS [14, 15]. To achieve complete cytoreduction, peritonectomies and visceral resection are required in various combinations. Therefore, a large laparotomic incision is usually required. Laparoscopic surgery for patients with colorectal cancers has been popularized with acceptable oncologic outcomes. To date, the common types of laparoscopic surgery used to treat peritoneal carcinomatosis include staging laparoscopy, neoadjuvant or adjuvant staged laparoscopic IPC, and palliative laparoscopic resection [16–18]. These types of laparoscopic surgery appear to be safe and feasible. However, laparoscopic CRS has been reported in a limited number of studies. Laparoscopic cytoreduction was successfully performed for a series of 23 patients with primary advanced ovarian cancers [19]. Recently, two articles from the same institution reported laparoscopic CRS with hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with peritoneal carcinomatosis from appendiceal tumors or mesotheliomas [20, 21]. One of the two studies included a case of CPM with extensive peritoneal carcinomatosis and open CRS. Our preliminary study included only a limited number of patients. However, to the best of our knowledge, this is the first study to compare open and laparoscopic CRS with IPC for patients with CPM. At our institution, a laparoscopic approach was applied in the following situations: for curative resection when preoperative and initial laparoscopy findings both showed limited peritoneal dissemination, for decision making when
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these were equivocal findings on preoperative imaging studies, for palliation when the disease was too extensive to be cured by either laparoscopic or open surgery. When these institutional indications were applied, laparoscopic CRS offered clinical outcomes similar to those for open surgery. After the exclusion of 2 patients who had surgically incurable carcinomatosis, 13 patients underwent gross radical resection by laparoscopic surgery. The overall complication rate for the laparoscopic group was 13 %. The patients did not experience anastomotic leakage or postoperative bleeding. Operative mortality occurred for one patient after open surgery. The rates of morbidity (22–57 %) and mortality (0–20 %) after CRS and IPC vary widely [8, 22–26]. The principal causes of death after CRS and IPC are sepsis and multiorgan failure resulting from surgical or chemotherapy-related complications. However, our cohort had no severe surgical complications, and the overall morbidity rate was within an acceptable range. Safe and effective laparoscopic CRS and IPC depend on two important factors: discreet patient selection and the skill of the laparoscopic surgeon. Several studies have suggested that a peritoneal cancer index exceeding 20 should be considered a relative contraindication for CRS and IPC [25]. Esquivel et al. [19] used laparoscopic surgery when patients had a risk of peritoneal relapse but negative imaging scans. They permitted laparoscopic CRS and HIPEC when laparoscopic exploration showed that the peritoneal cancer index was less than 10. We selected patients according to preoperative evaluations and diagnostic laparoscopic findings. Of 20 patients, 5 (25 %) were judged to require open surgery for complete cytoreduction after laparoscopic exploration. Of 15 patients, 2 patients (10 %) were indicated for palliative surgery, and 13 (65 %) underwent laparoscopic CRS and EPIC successfully with grossly complete removal of tumors. Using current surgical techniques, laparoscopic CRS can remove low-volume peritoneal carcinomatosis, so 60 % of the patients in the laparoscopic group were classified as Gilly stage 1. A certain learning curve is associated with the performance of technically and oncologically safe laparoscopic cancer surgery [27]. For CRS and IPC, highly skilled oncologic surgeons are required. A multicenter analysis found that the two primary factors affecting morbidity and mortality were the degree of carcinomatosis and the center at which the treatment was performed [26]. In a single-center study of this learning curve, the morbidity rate was found to be associated with the individual surgeon’s experience. Therefore, for oncologic safety, laparoscopic CRS and IPC should be performed by a highly skilled laparoscopic and
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CRS surgeon for appropriately selected patients. Defining the clear indications and the learning curve of the combined laparoscopic treatment currently is not possible but has value for future studies. In the current study, the overall survival outcomes after CRS and EPIC for the patients with carcinomatosis were similar to those reported in previous studies, in which the median survival time was 13–62 months [28, 29]. In a randomized trial completed by the Netherlands Cancer Institute, the procedures resulted in significantly improved survival time compared with that for systemic chemotherapy alone [24]. After an 8-year follow-up period, the disease-specific survival time was 22.2 months, and the median survival time was 48 months when complete cytoreduction could be achieved [25]. The largest multicenter study to date reported a median survival time of 30.1 months and a 5-year survival rate of 27 % [26]. Considering that the status of CCR is an important prognostic factor, we compared the survival rates for the patients with CCR-0 resection and for all the patients. The laparoscopic and open groups showed comparable overall and progression-free survival rates. These similar rates can be attributed to diagnostic exploration performed laparoscopically for careful selection of patients with limited carcinomatosis. To date, our institutional treatment strategy for CPM is a combination of CRS and EPIC. In two multicenter studies, the survival rates did not differ between the HIPEC and EPIC arms [8, 26]. Although some studies have reported the efficacy of HIPEC over EPIC, no randomized controlled trial has compared these treatments [22]. According to the current evidence, EPIC is an appropriate option, especially when HIPEC is not available or when the patient is not indicated clinically for hyperthermic therapy. Randomized trials investigating the efficacy of optimal IPC methods should be undertaken. With current treatment methods, acceptable long-term patient survival is expected when CPM is treated at an early stage. However, imaging studies such as computed tomography and positron emission tomography have a low accuracy for detecting peritoneal cancer nodules, and peritoneal carcinomatosis is commonly detected only at later stages [30]. Peritoneal carcinomatosis after radical resection is associated with several cancer-related factors (perforation, advanced node metastasis, and ovarian metastases) [31]. Staged laparoscopic exploration can be practical as a diagnostic option to detect peritoneal recurrence in an early stage for high-risk patients. Laparoscopic exploration before CRS can identify occult peritoneal lesions that are not defined in preoperative imaging investigations. Of 17 patients in our cohort, 4 patients (23.5 %) initially planned for laparoscopic CRS had a change in the planned
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procedure. After further studies have clearly defined the groups at high risk for peritoneal relapse and the diagnostic advantage of laparoscopic exploration, laparoscopic surgery will have a greater role in the treatment of peritoneal carcinomatosis.
Conclusions Our initial experience showed that laparoscopic CRS with EPIC is safe and feasible for carefully selected patients with synchronous or metachronous CPM. Laparoscopic CRS with EPIC offers another treatment option for patients with limited CPM that does not lead to oncologic deterioration. This method represents a new frontier in the surgical treatment of CPM. Future studies involving larger numbers of patients and longer follow-up periods are required to validate our experience. Acknowledgments This study was supported by a grant from the Korea Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (A111345). Disclosures Soo Yeun Park, Gyu-Seog Choi, Jun Seok Park, Hye Jin Kim, Jong-Pil Ryuk, Sung-Hwan Yun, Jong Gwang Kim, and Byung Woog Kang have no conflicts of interest or financial ties to disclose.
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