General Surgery #7: Peritoneal Surgery

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Questions and Answers

Who was one of the first to consider HIPEC as a possible addition to peritoneal surgery?

Sugarbaker

What is peritoneal disease often associated with?

Lung cancer

Stomach cancer (correct)

Liver cancer

Breast cancer

Peritoneal metastases can occur from ovarian, gastric, colorectal, HPV, breast, and melanoma cancers.

True

What is considered the 'king of radiological exams' for diagnosing and staging peritoneal carcinomatosis?

CT scan Signup and view all the answers

What are some symptoms that may lead to the identification of peritoneal disease as an incidental finding?

Patients not digesting well, swollen abdomen, repetitive burping, build-up, ascites Signup and view all the answers

The peritoneum has a ________ plasma barrier that limits penetration of chemotherapeutics.

peritoneal Signup and view all the answers

MRI is not commonly used in the assessment and staging of peritoneal carcinomatosis.

False Signup and view all the answers

Match the following peritoneal tumors with their primary usage:

Benign mesothelial tumors = Hyperplasia, inclusion cyst, adenomatoid tumor Malignant mesothelioma = Poor prognosis and considered incurable Secondary cancers = Peritoneal metastases from appendiceal, gastric, colorectal, HPV, and ovarian cancers Signup and view all the answers

HIPEC usually lasts between 30-90 minutes, during which cytotoxic agents are administered into the peritoneal cavity at an elevated temperature of to degrees Celsius.

41, 43 Signup and view all the answers

Match the chemotherapy agent with its associated complication:

Mitomycin = Severe neutropenia Cisplatin = Acute kidney insufficiency Oxaliplatin = Postoperative bleeding risk Signup and view all the answers

What are the benefits of heat in HIPEC? Select all that apply.

Reduces or destroys chemoresistance mechanisms Signup and view all the answers

What does HIPEC stand for?

Hyperthermic Intraperitoneal Chemotherapy Signup and view all the answers

The Peritoneal Carcinomatosis Index (PCI) is a score used to assess the disease based on _____ regions.

12 Signup and view all the answers

Mitomycin has specific toxicity on the hematological system.

True Signup and view all the answers

What is described by patients as a very sharp feeling that is so peculiar that it sometimes lets you diagnose it immediately?

Perforation Signup and view all the answers

Which diagnostic tool is considered one of the most accurate and complete examinations?

CT scan Signup and view all the answers

Acute appendicitis is the most frequent organic cause of acute abdomen.

True Signup and view all the answers

The highest incidence of appendicitis is between ages 15 and 30, though it also occurs in ______ and the elderly.

children Signup and view all the answers

The results of studies on surgeons and personnel exposed to HIPEC showed significant risks.

False Signup and view all the answers

What may a gastric cancer surgeon specialize in?

Lymphadenectomy Signup and view all the answers

What is the particular treatment mentioned that may require a second specialized doctor's opinion?

NIPS Signup and view all the answers

Match the following diseases with their main diagnosis:

Acute appendicitis = 1 Acute cholecystitis = 2 Acute pancreatitis = 3 Signup and view all the answers

Which type of tumor is linked to the neuroendocrine system and has specific markers?

Goblet cell tumor Signup and view all the answers

Mesothelial tumors include well-differentiated papillary mesothelioma, multicystic mesothelioma (borderline condition), and ____________ mesothelioma.

malignant Signup and view all the answers

Study Notes

Introduction to Peritoneal Surgery

Peritoneal disease, which was once considered incurable, can now be treated with specific surgical techniques and a better understanding of the disease's physiopathology.
Peritoneal surgeons must be wise and consider the benefits and disadvantages of oncological treatment and overall patient survival.

History of Peritoneal Surgery

The concept of treating peritoneal disease began in the 1980s with Dr. Sugarbaker, who founded the International Society of Regional Cancer Therapy.
Dr. Sugarbaker considered HIPEC (Hyperthermic Intraperitoneal Chemotherapy) as a possible addition to peritoneal surgery.

Classification of Peritoneal Tumors

Peritoneal tumors can be classified into:
- Benign and malignant tumors of mesothelial derivation (primary tumors of the peritoneum)
- Lesions of the secondary Mullerian system (e.g., endometriosis)
- Secondary cancers (e.g., peritoneal metastases from other cancers)

Pathophysiology of Peritoneal Disease

The peritoneum has a plasma barrier that limits the penetration of chemotherapeutics.
Peritoneal fluid circulation follows gravity and a counterclockwise pattern, with preferred implantation sites in the pelvis, diaphragm, and latero-colic spaces.
The peritoneum and omentum have specific areas (milky spots) where the plasma barrier is less present, allowing for fluid reabsorption and carcinomatosis implantation.

Resources for Peritoneal Surgery

The PSOGI (Peritoneal Surface Oncology Group International) is a society dedicated to peritoneal surface oncology.
The Chicago Consensus Guidelines (2018) provide a summary of treatments for peritoneal diseases.

Assessing Peritoneal Disease

To assess peritoneal disease, consider:
- Presence of a primary tumor
- Type of peritoneal disease (synchronous or metachronous)
- Burden of peritoneal disease (can be determined radiologically or with diagnostic laparoscopy)
- Peritoneal cancer index (PCI)

Diagnosis and Staging

Peritoneal disease can be diagnosed incidentally, during initial symptoms, or during the workup of a primary disease.
Diagnostic and staging exams include:
- CT scan
- MRI
- PET/CT scan
- Exploratory laparoscopy

Peritoneal Carcinomatosis Index (PCI)

The PCI is a score used to assess the burden of peritoneal disease.
The PCI is calculated by evaluating 12 regions of the abdomen and assigning a score based on the dimension of the carcinomatosis.

Multidisciplinary Tumor Board (MDT)

The MDT is essential for deciding on the best course of treatment for patients with peritoneal disease.
The MDT reviews images and decides on the best approach, considering the expertise of various specialists.

Surgery

Principles of surgery and therapy for peritoneal disease include:
- Completeness of cytoreduction score
- Indications for surgery (e.g., PCI score, disease location)### Peritoneal Surgery
Cytoreductive surgery (CRS) is the primary surgery for peritoneal disease, not a curative aimed resection.
CRS is classified into 4 categories based on the completeness of cytoreduction score (CC-0, CC-1, CC-2, CC-3).

Surgical Candidate

Patients must be able to tolerate long surgeries and potential multi-visceral resection.
The extent of carcinomatosis may not be fully predictable, and surgeries can be extremely long.

Techniques

Multi-visceral resection and peritonectomy are used to remove the peritoneum involved by the disease.
Sugarbaker's technique: complete peritonectomy + HIPEC (hyperthermic intraperitoneal chemotherapy).
Partial peritonectomy can be used for smaller nodules.

HIPEC

Hyperthermic intraperitoneal chemotherapy (HIPEC) involves administering cytotoxic agents into the peritoneal cavity at an elevated temperature (41-43°C).
Benefits of HIPEC include:
- Damaging locally the cells, addressing minimal residual disease.
- Allowing for better penetration of chemotherapeutic drugs into the tumor.
- Longer direct contact between tumor cells and the chemo reduces or destroys chemoresistance mechanisms.
HIPEC usually lasts between 30-90 minutes.

Disadvantages of HIPEC

Risks associated with heat:
- Hyperthermia of the patient.
- Worsening the risk profile associated with cytoreductive surgery.
Risks associated with chemotherapeutics:
- Mitomycin: toxicity on the hematological system, severe neutropenia.
- Cisplatin: acute kidney insufficiency, requires high-volume IV fluids.
- Oxaliplatin: postoperative bleeding risk, thrombocytopenia.

Choice of Chemotherapy Agent

Criteria for selecting a chemotherapy agent for HIPEC:
- Hydrosoluble.
- Active at HIPEC temperatures.
- High molecular weight.
- High systemic clearance.
- High capacity of intratumor diffusion.
- Not cell cycle specific.

HIPEC Techniques

Open technique: uses retractors to keep the abdomen open, and a surgeon with gloved hands to wash out the abdomen.
Closed technique: closes the abdomen, leaving the fascia exposed to chemotherapy, and uses a machine to heat and circulate the chemotherapy.

Patient Selection for HIPEC

Exclusion criteria:
- Advanced age (>75).
- Comorbidities (renal disease, etc.).
- Peritonitis or sepsis.
- Malnutrition.
- Extra-abdominal metastasis.
- Massive involvement of retroperitoneum.
- Inability to achieve complete or almost complete cytoreduction (CC-0, CC-1).

Alternatives to HIPEC

NIPEC (normothermic intraperitoneal chemotherapy): for drugs inactivated by heat.
EPIC (early postoperative intraperitoneal chemotherapy): uses peritoneal portal system.
PIPAC (pressurized intraperitoneal aerosol chemotherapy): for palliative reasons, uses pressurization to increase chemotherapy penetration.
NIPS (neoadjuvant intraperitoneal-systemic chemotherapy protocol): a bimodal therapy using IV and intraperitoneal chemotherapy.

Mesothelial Tumors

Well-differentiated papillary mesothelioma: tends to be benign.
Multicystic mesothelioma: borderline condition.
Malignant mesothelioma: has a terrible prognosis if untreated.

Appendiceal Tumors

Secondary tumors that spread to the peritoneum.
Peritoneal metastasis varies depending on the type of tumor.
Perforation of the appendix increases the risk of peritoneal metastasis.
Pseudomixoma peritonei: a peculiar peritoneal tumor with a characteristic presentation, characterized by an abundant quantity of mucin.### Peritoneal Surgery
Types of appendiceal carcinoma:
- Low-grade tumor with disseminated mucin
- High-grade tumor with mucin
- High-grade tumor with signet ring cells
- Goblet cell tumor (specific entity of the appendix, interacts with the enterochromaffin system, has neuroendocrine markers)

Pseudomixoma Peritonei

Clinical presentation: clear diagnosis, symptoms like perforated appendix and other formations
Macroscopic and clinical appearance: "jelly belly" appearance

Principles of Systemic Chemotherapy and Surgery

Chemotherapy: depends on the type of cancer
Surgery: may require multiple visceral resections (up to 7-9 times), tolerable, but dependent on patient's condition (age, general health)
HIPEC: performed with specific dosages, may be considered for high-risk patients, extensive lymph node involvement, and specific histotypes related to metastasis

Secondary Carcinomatosis

Depend on the type of cancer:
- Colorectal carcinomatosis: responsive to drugs and surgery, high heterogeneity
- Pancreaticobiliary carcinomatosis: incurable, no survival improvement with cytoreduction or HIPEC

Colorectal Carcinomatosis

After response to generalized chemotherapy, HIPEC and surgery may be considered
PCI (Peritoneal Cancer Index) higher than 10: may be considered for HIPEC and surgery
Metachronous and synchronous metastasis may arise

Gastric Carcinomatosis

Recurrence of disease after surgery: common (up to 50% of patients)
Survival after peritoneal failure: 3-8 months
Adjuvant therapy may extend survival time
NOMOgrams: useful tools to understand and predict the risk of metachronous peritoneal carcinomatosis

Acute Abdomen

Definition: sudden onset of pain, requiring prompt decision on intervention
Causes:
- Distension or spasm of a hollow viscus
- Distension of the capsule of parenchymatous organs
- Traction on the mesentery, ligaments, or peritoneum (especially parietal peritoneum)
- Infiltration or compression of sensitive nerves
- Irritating substances (e.g., bile) in the peritoneum

Diagnostic Tools

Objective exam: Blumberg sign
US: first choice, non-invasive, useful for detecting air, perforation, or obstruction
CT scan: accurate and complete examination
Fecal exam: useful in patients with communication problems (psychiatric, neurologic, geriatric)

Disease Approach

Primite etiology: essential to avoid progression to peritonitis
Main causes of acute abdomen:
- Acute appendicitis
- Acute cholecistitis
- Acute pancreatitis

Appendicitis

Definition: obstruction of the appendix lumen, leading to bacterial overgrowth, stasis, and increased pressure
Causes:
- Fecaliths
- Foreign bodies
- Tumors
- Lymphoid hyperplasia
Stages:
- Minor inflammation
- Phlegmonous appendicitis
- Necrosis
- Gangrene
Complications:
- Localized or diffuse peritonitis
- Abscesses
- Rarely, portal vein thrombosis
Diagnosis:
- Clinical evaluation
- Laboratory tests
- Imaging (US, CT scans)
- Alvarado score
Treatment:
- Surgical (laparoscopic or open)
- Conservative (antibiotics)
Postoperative considerations:
- Complications (superficial and deep surgical site infections, bowel obstruction, secondary infertility)
- Chronic appendicitis: a controversial condition, may require elective appendectomy

Cholecystitis

Pathophysiology: similar to appendicitis
Risk factors:
- Conditions causing bile stasis
- Advanced age
- Hormonal factors
- Drug use
Diagnosis:
- Ultrasound
- CT scan with contrast (in severe cases)
Treatment:
- Surgery (cholecystectomy)
- Conservative management with antibiotics (in cases where surgery is delayed)
Complex cases:
- Alternative treatments (percutaneous cholecystostomy)
- Delayed, elective cholecystectomy

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Description

This quiz covers the introduction to peritoneal surgery, a relevant topic in the field of general surgery. It discusses key concepts and principles related to peritoneal surgery.