[Show abstract][Hide abstract] ABSTRACT: In 1981, Dr. PH Sugarbaker, challenging oncological orthodoxy, considered carcinomatosis to be a locoregional stage of the disease that was still susceptible to treatment with curative intent. To this end he developed a new therapeutic alternative based on the combined treatment. The macroscopic disease treated by maximum radical oncological cytoreductive surgery (through the peritonectomies described by him), followed by treatment of the residual microscopic disease with the direct intra-abdominal application of intraoperative chemotherapy with locoregional intensification, modulated by hyperthermia and early normothermic postoperative intra-abdominal chemotherapy. Using this new therapeutic regimen, known as "Sugarbaker s Protocol", his group has reported 45% survival rates in carcinomatosis of colorectal origin at 5 years, and, in selected groups of patients, 50% survival rates at 5 years. The scientific community, however, has criticized these results considering that: it is a personal experience, with a not homogenous treatment protocol with developmental modifications over time, that it is a retrospective non-randomized study, and finally that the cytostatics used in his protocol are obsolete. Various European groups have replied to these main criticisms confirming the good results that this new therapeutic alternative offers for patients with carcinomatosis of colorectal origin. The purpose of this article is to present these contributions.
All the articles published in the English language by European groups in the world s medical literature have been reviewed using the Pubmed-MEDLINE database to identify the relevant articles related to the treatment of carcinomatosis of colorectal origin using cytoreduction and intraperitoneal chemotherapy from January 1980 to January 2008.
The European contribution during these 25 years in favour of the "Sugarbaker s Protocol" has consisted fundamentally in: a) one multicenter retrospective study; b) two randomized prospective phase III studies; and c) the use of oxaliplatin and irinotecan as new cytostatic agents in the protocols for intraperitoneal chemotherapy. At the same time, two new transcendental European contributions have been made in which the possibility has been considered of combined simultaneous treatment for patients with hepatic metastases and carcinomatosis, and the introduction, as a selection factor, of patients responsive to intravenous induction chemotherapy within the regimen of sandwich treatment (with systemic neoadjuvant and adjuvant chemotherapy) complementary to intraperitoneal chemotherapy.
The results obtained by European groups using "Sugarbaker s protocol" and "Elias protocol" with oxaliplatin compel us to request that these treatments be considered by all professionals involved in the treatment of patients with colorectal carcinomatosis as the best treatment currently available for this condition. Furthermore a randomized, prospective, multicenter study should be carried out to clarify its value and the degree of scientific evidence. A validation of this treatment will change, in the future, the dogmatic consideration of carcinomatosis as an incurable disease stage.
Preview · Article · Mar 2009 · Revista espanola de enfermedades digestivas: organo oficial de la Sociedad Espanola de Patologia Digestiva
[Show abstract][Hide abstract] ABSTRACT: The use of a new therapeutic alternative involving cytoreductive surgery with perioperative intraperitoneal chemotherapy in the treatment of patients suffering from peritoneal carcinomatosis represents a new challenge for the multidisciplinary teams caring for these patients. Their post-operative progress and care needs, apart from differing from those of conventional patients, have not yet been completely defined or protocolised. In this presentation we explain the special characteristics of these patients compared to the usual surgical patients, the possible physiopathological mechanisms which may give rise to the different types of complications, the circumstances when a temporary abdominal closure is necessary, the ideal conditions required for an optimal technique, and finally our experience with the open vacuum abdomen technique in the treatment of the complications that appear in patients treated by this new triple combined therapy.
Based on our personal experience in the treatment of 110 cytoreductions carried out between February 1997 and February 2007 on 71 patients suffering from peritoneal carcinomatosis of various origins. Of the 71 patients, 50 (70%) suffered some kind of complication during their postoperative evolution, 28 of them requiring re-operation for a Grade III-IV postoperative complication. The abdominal situation made a temporary closure desirable in 17 patients, having applied an open vacuum abdomen technique on every occasion. We study this group of patients according their original type of tumour and stage of the disease at the cytoreductive procedure, peritonectomies and visceral resections required, type of postoperative complications, treatment applied and evolution.
A total of 52 open vacuum abdomen procedures were required (median, 2.8 per patient; range, 1-10) before the abdominal complication could be completely kept under control in these 17 patients. Only 2 postoperative intestinal fistulas were directly related to this technique, and a primary closure of the whole abdominal wall was possible in 11 of these patients (66%). All but one of them left the hospital alive and well.
As a consequence of this experience, in our opinion, the open vacuum abdomen is the ideal election technique to be employed in any temporary closure of the abdominal cavity for whatever reason it is required, including the worst possible surgical scenario, as we have demonstrated in the treatment of surgical complications after cytoreductive procedures and intraperitoneal chemohyperthermia.
No preview · Article · Nov 2008 · Cirugía Española
[Show abstract][Hide abstract] ABSTRACT: La utilización de una nueva alternativa terapéutica en pacientes afectos de carcinomatosis peritoneal mediante la aplicación de cirugía citorreductora radical oncológica, junto con la administración de quimioterapia intraperitoneal perioperatoria, supone un nuevo reto para los equipos multidisciplinarios que están al cuidado de estos pacientes, por cuanto su evolución postoperatoria y requerimientos de cuidados además de ser distintos de los de los pacientes convencionales, no están totalmente definidos ni protocolizados. El objetivo del presente trabajo es exponer nuestra experiencia con la aplicación del abdomen abierto en vacío, como técnica de cierre abdominal diferido, en el tratamiento de las complicaciones aparecidas en los pacientes sometidos a esta nueva triple terapia combinada.
No preview · Article · Oct 2008 · Cirugía Española
[Show abstract][Hide abstract] ABSTRACT: Malignant peritoneal mesothelioma is the most common primary neoplasm of the serous peritoneum. Most patients die of the complications of local disease confined to the peritoneal cavity, while nodal or distant dissemination is extremely rare. Prognosis with traditional therapeutic options is dismal, with a median survival of between 4 and 12 months from diagnosis. The application of a new combined therapy with cytoreductive surgery, intraperitoneal perioperative chemotherapy and heated intraperitoneal intraoperative chemotherapy, followed by early postoperative intraperitoneal chemotherapy is currently providing good results, in some instances even allowing curative intent. We present a series of patients treated with this triple combined therapy.
Between December 1998 and December 2005, 78 cytoreductive surgeries were performed in 50 patients in our peritoneal carcinomatosis program at the San Jose Policlinic in Vitoria (Spain), for distinct reasons. Among these patients, surgery was performed on 11 occasions in seven patients with a diffuse malignant peritoneal mesothelioma. The present study focuses on this latter group of seven patients.
Eleven cytoreductions were performed in seven patients with diffuse malignant peritoneal mesothelioma. There were four men and three women, with a mean age of 50 years (range 31-57 years). None of the patients had a history of occupational exposure to asbestos or contact with this substance. All the patients had received more than one surgical intervention before entering our program. Only two patients had also received systemic chemotherapy as adjuvant treatment after their initial diagnosis, as the only possible therapeutic alternative. Treatment with curative intent was provided, obtaining complete cytoreduction of macroscopic disease in all patients, followed by application of intraperitoneal perioperative chemotherapy for the treatment of any residual microscopic disease. Pathologic analysis showed biphasic sarcomatous mesothelioma in two patients and epithelial mesothelioma in the remaining five patients. Postoperative complications occurred in five patients, resulting in a mean length of postoperative hospital stay of 41.5 days (range 17-84 days). Three patients died from disease progression at 3, 9 and 11 months after the initial cytoreduction; of these, two patients had diffuse biphasic sarcomatous mesothelioma. The remaining four patients are still alive at 5, 9, 19 and 54 months after the initial cytoreduction without evidence of disease at the present time.
Radical oncologic cytoreductive surgery combined with intraperitoneal perioperative chemotherapy provides good results with prolonged survival in selected cases, although morbidity is high. Based in our experience, biphasic sarcomatous mesotheliomas should be excluded from this protocol because of their aggressiveness; these tumors should be included only in conventional therapeutic strategies with palliative intent.
No preview · Article · Mar 2007 · Cirugía Española
[Show abstract][Hide abstract] ABSTRACT: El mesotelioma peritoneal maligno es la neoplasia primaria más común de la serosa peritoneal. Presenta un alto grado de agresividad local y es rara su diseminación ganglionar y/o a distancia. Su pronóstico con el enfoque de tratamiento tradicional es nefasto, con medianas de supervivencia de 4 a 12 meses. La aplicación de una nueva terapia combinada de cirugía citorreductora junto con quimioterapia intraperitoneal perioperatoria, quimioterapia intraperitoneal intraoperatoria hipertérmica (QIIH), seguida de quimioterapia intraperitoneal postoperatoria precoz (QIPP), está posibilitando buenos resultados, incluso en ocasiones con intención curativa. Se presenta nuestra serie personal tratada con esta triple terapia combinada.
No preview · Article · Feb 2007 · Cirugía Española