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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 24-15 A-D. Image showing after mobilization, how the last adherent and
challenging attachment between the flexure and the spleen can be taken under vision
and with confidence, while keeping the pancreas, spleen, and colonic conduit safe.
TIPS
Care must be exercised here to:
Avoid breaching Gerota’s fascia. Occasionally, the left gonadal
vein is well developed, and its presence may cause confusion,
resulting in deviating from the correct plan (Fig. 24-7).
Avoid thermal injury while underneath the proximal descending
colon as this is the future conduit for reconstruction and restoring
gastrointestinal continuity.
Suggested Readings
Chand M, Miskovic D, Parvaiz AC. Is splenic flexure mobilization necessary in laparoscopic anterior
resection? Dis Colon Rec-tum. 2012;55(11):1195-1197.
Ludwig KA, Kosinski L. Is splenic flexure mobilization necessary in laparoscopic anterior resection?
Another view. Dis Colon Rectum. 2012;55(11):1198-1200.
Chapter 25
Cytoreductive Surgery and
Hyperthermic Intraperitoneal
Chemotherapy
ANTHONY COSTALES
ROBERT DEBERNARDO
Preoperative Considerations
The use of hyperthermic intraperitoneal chemotherapy (HIPEC) has been
evaluated in a number of malignancies, and although each of these differs
in fundamental ways, there is one overarching similarity—the benefit of
HIPEC is only realized following an optimal cytoreductive surgery (CRS),
preferably with no gross residual disease.
Low-grade appendiceal
Pseudomyxoma
Mesothelioma
Ovarian cancer
Primary, following neoadjuvant chemotherapy
Recurrent
Certain recurrent gastrointestinal cancers
Recognizing this, successful surgical cytoreduction often involves
multivisceral resection prior to instilling HIPEC (Fig. 25-1).
Pelvic exenteration
FIGURE 25-1 Multivisceral resection from peritoneal carcinomatosis.
Multiple bowel resections
Peritonectomy
Splenectomy +/− distal pancreatectomy
Partial liver resection
Diaphragm stripping or resection
Preoperative planning and assessment of the tumor distribution are
essential to determine how extensive the disease may be and what surgical
procedures would be necessary to render an R0 (complete) resection.
Calculating a peritoneal carcinomatosis/cancer index (PCI) will have a
predictive capability preoperatively to determine who is an appropriate
candidate (Fig. 25-2).
FIGURE 25-2 Peritoneal carcinomatosis/cancer index.
Careful preoperative assessment will often identify the need for a
multidisciplinary team of surgical specialists, such as surgical oncology,
gynecologic oncology, urology, plastics, hepatobiliary, or vascular
surgery.
TIPS
CRS should not be undertaken with curative intent in patients with PCI
≥20, as the results of CRS + HIPEC are no different than with
systemic therapy alone.
Intraoperative Assessment
Prior to committing to a radical surgery, determine whether the disease
can be completely resected.
Careful exploration: complete and thorough assessment of the abdomen
and pelvis (Fig. 25-3).
FIGURE 25-3 Carcinomatosis in the abdominal cavity.
Our preference is for laparotomy to ascertain the extent of disease.
Hand-assisted laparoscopy is preferred, especially if there are concerns
for unresectable carcinomatosis.
Complete lysis of adhesions and mobilization of the colon are
generally preformed.
Identification of major vessels and tagging ureters to facilitate
radical resection.
Ureteral stents are an alternative commonly used.
It is useful to have a complete understanding of the disease burden early in
the case to coordinate the efforts of your surgical team.
Using a completeness of cytoreduction score will help determine
prognosis and ability to undergo HIPEC (need to have CC 0/1; Table
25-1).
TABLE 25-1 CC score: completeness of cytoreduction score
CC0No residual tumor (= R0 resection)
(en bloc resection)
CC1<0.25 cm residual tumor tissue
(complete cytoreduction)
CC20.25-2.5 cm residual tumor tissue
(incomplete cytoreduction with moderate residual tumor
proportion)
CC3>2.5 cm residual tumor tissue
(incomplete cytoreduction with high residual tumor proportion)
Generally, we proceed quadrant by quadrant until the disease is
completely removed. Care is taken to evaluate the retroperitoneum and
identify urinary and vascular structures (Figs. 25-4 to 25-7).
FIGURE 25-4 View of the retroperitoneum.
FIGURE 25-5 View of the right pelvis with the iliac artery.
FIGURE 25-6 Gonadal vessels and ureter dissected free.
FIGURE 25-7 Closer view of the ureter and exposed retroperitoneum.
Once complete cytoreduction is accomplished, and prior to any bowel
anastomotic procedures, HIPEC tubing is placed, the abdomen is
closed, and the chemotherapy infusion is performed.
Program Requirements
Infusing chemotherapy in the operating room (OR), at first glance, appears
to be a simple process. What many fail to realize is that in order to
successfully infuse chemotherapy in an OR, numerous obstacles need to
be addressed well ahead of time.
Recommend identifying a team of health care professionals who are
committed to safely and efficiently administering HIPEC (Fig. 25-8).
Motivated surgeons
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