Goal: The goal is to remove all the tumor. Before undertaking a patient for surgery, the surgeon studies the scans carefully to evaluate the extent of disease. When complete removal of the tumor seems unlikely, surgery is not undertaken.
Exploration: The surgeon opens the abdomen with a long incision at the midline. After liberatingadhesions, he/she will carefully evaluate the peritoneal cancer. There are 3 points ofconcern
What is the extension of the peritoneal cancer?
The surgeon measures the amount of cancer in 13 different regions of the abdomen and gives each region a score from 1 to 3. These scores are added to a global score (Sugarbaker Peritoneal Cancer Index). This scoring has a double aim.
In case of peritoneal cancer by a bowel tumor, it allows to avoid a meaningless operation: when the score is high, the chances of improving survival by performing a HIPEC are very small and the intervention is stopped. In addition, the score allows an estimation of the prognosis. The lower the score, the better the prospects.
Can all tumor implants be removed?
Especially in case of peritoneal cancer by a bowel tumor, it is very important to remove all visible tumor implants before rinsing the abdomen with the heated chemotherapy. When not all visible tumors can be removed, the chances of improving survival by performing a HIPEC are very small and the intervention is stopped. This can be the case when a too large part of the small bowel is covered with tumor: to allow normal food absorption, at least 1.5 m (of about 3 m) small bowelmust remain after resection. Secondly, the vessels to the liver can be encased bytumor at the site where they enter the liver, rendering impossible a complete tumorclearance.
Are there seedings in the liver?
In case of liver seedings, the chances of improving survival by performing a HIPEC are very small and the intervention is stopped. However in some selected cases with only two or three deposits in the liver which can be easily removed, this procedure may be carried out.
When the peritoneal cancer is not too extensive, appears to be completely resectable, and is not accompanied by liver metastases, the surgeon proceeds with thedebulking. If not, a HIPEC is not carried out and the risk of obstruction is evaluated. In case of imminent obstruction, a bypass between the bowel segment before and the segment behind the obstruction is realised.
Debulking (Cytoreductive Surgery)
Debulking or cytoreduction means surgical removal of all visible tumor implants.
- The peritoneum at the sites of the tumor implants.
- The omentum; an apron of blood vessels and fatty tissue which is attached to the stomach, covers the small bowel, and is often loaded with tumor forming an ‘omental cake’.
- According to the situation of the individual patient, removal of the spleen, of the gallbladder, of the uterus and ovaries, of part of the diaphragm, of part of the small or the large bowel or of other organs may be required. It is mainly this part of the intervention which can last many hours.
The expertise of the surgeon lies in the ability to remove all the tumor deposits. A specialist surgeon will be able to produce better results as compared to someone who is not specializing in performing these surgeries