Peritonectomy / Cytoreductive Surgery
Page Medically Reviewed and Edited by Paul Sugarbaker, M.D.This page has been fact checked by a Medical Doctor who specializes in mesothelioma. Sources of information are listed at the bottom of the article.
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Peritoneal mesothelioma is the second most common type of this rare form of cancer. Pleural mesothelioma is the most common, affecting the mesothelium of the chest cavity. Peritoneal mesothelioma, however, is the cancer of the tissue lining the abdominal cavity. As with its more common counterpart, this type of mesothelioma is difficult to treat. Patients who receive this diagnosis rarely have a good prognosis.
The surgical treatment option that provides the best opportunity to increase survival time is cytoreductive surgery with peritonectomy. This is a surgical procedure that removes all or some of the peritoneum, the lining of the abdominal cavity. Survival rates can be improved when surgeons administer heated chemotherapy directly into the abdominal cavity, called hyperthermic intraperitoneal chemotherapy, or HIPEC. When used together, these strategies reduce symptoms, extend life expectancy, and increase the duration before the cancer returns. Cure is an option.
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Peritoneal Mesothelioma
The peritoneum is the part of the mesothelium that lines the abdominal cavity and the organs inside. Mesothelioma is most strongly associated with inhaling tiny asbestos fibers, which is why the pleural form of the cancer is most common; however, those fibers may also be swallowed in the sputum. They may also migrate from the chest cavity to the abdominal cavity, causing tissue damage that leads to peritoneal mesothelioma.
Survival rates for peritoneal mesothelioma tend to be poor. About one quarter of people diagnosed will live for three or more years. Treatment can extend life expectancy. If the cancer is diagnosed early, there is a small chance of a cure or remission. The best way to achieve remission is by surgically removing cancerous tissues.
What Is a Peritonectomy?
Peritonectomy is a form of cytoreductive surgery. Cytoreductive surgery is any surgical procedure that removes cancerous tissue. The term peritonectomy refers specifically to removal of the peritoneum.[1] The surgery may also remove parts of organs with cancerous tissue. Organs that may be affected are the small intestines, large intestine, gallbladder, liver, stomach, pancreas, and spleen.
The surgery is mostly intended to relieve symptoms.[1] It may also slow progression and achieve remission, although the latter is not always possible. To improve the odds of remission and reduce the chance of a recurrence after surgery, the procedure is often combined with chemotherapy. This combination can eliminate cancer cells the surgeon was not able to safely remove or were too small to visualize during surgery.
Hyperthermic Intraperitoneal Chemotherapy
For peritoneal mesothelioma, HIPEC is often used after surgery. HIPEC is an innovative chemotherapy method that injects heated chemotherapy drugs directly into the abdominal cavity. This differs from traditional chemotherapy which administers drugs intravenously, allowing the drugs to circulate through the entire body.[2]
HIPEC is proven more effective for treating peritoneal mesothelioma than the standard chemotherapy. Some studies found that treatment with HIPEC gives patients significant extended survival times.[3] This is a major achievement for treating a disease that was previously so difficult to manage. The increased survival time after HIPEC is associated with the epithelial subtype of mesothelioma.
Benefits of Peritonectomy
There are several goals of peritonectomy followed by HIPEC. These procedures tend to be palliative, meaning they aim to reduce symptoms, extend survival times, and achieve the best chance at long-term remission. Curing peritoneal mesothelioma is a realistic goal; those persons with a lesser amount of mesothelioma have a better chance for this treatment combination resulting in long-term remission.
For most mesothelioma patients, this surgery is used to extend life. For those with advanced cancer, a benefit of peritonectomy is relief from symptoms. The removal or reduction of tumors in the abdomen can reduce pain and swelling, allowing the patient to feel more comfortable.
Risks and Complications
Peritonectomy followed by HIPEC is major surgery. While it may be less risky than radical surgeries used to treat pleural mesothelioma, it can still have major complications. Older patients or those with complex medical conditions are more likely to have postoperative complications from the surgery, yet anyone is susceptible.
Possible postoperative complications include fistulas from the bowels, leakage from sites where the bowel was sutured together, excessive bleeding, and intra-abdominal infection.[4] Other complications are the same as those seen with any major surgery, including blood clots and infections. unfortunately it is possible a patient will struggle to recover from this surgery only to have the cancer recur soon after.
Organ Damage and the Need for an Ostomy
Anytime there is an operation in the abdominal cavity, there is a small risk of injury to the bowel or urinary tract. If there is injury or obvious tumor involvement prohibiting the surgical repair, an ostomy may be necessary. An ostomy is a surgical procedure that diverts the digestive or urinary tract to the outside of the body. The procedure creates an opening, called a stoma, that links the small intestine, large intestine (colon), or ureter to the outside of the body, bypassing the normal routes through which waste is expelled from the body.[4]
Ostomies are typically done when the bladder or bowels cannot function normally due to disease. In rare cases, organ damage may occur as a complication of surgery. It is not a common complication, but any abdominal surgery, including a cytoreductive surgery, may result in damage that requires an ostomy. The ostomy may be permanent or may only be temporary to allow affected tissue to heal.
Living with an ostomy presents many challenges. Patients need an ostomy bag to collect feces or urine. The stoma does not have a valve to shut off flow, the patient is unable to control when waste passes from the body. Specialty ostomy nurses are an invaluable resource to provide a plan for management including problem solving for any issues that arise. It can be emotionally difficult to deal with complex body image changes. These can either be temporary or permanent. If a reversal is possible, it will require another surgery.
Recovery
Recovery from cytoreductive surgery plus HIPEC varies by patient. Younger, healthier patients, as well as those in earlier cancer stages typically recover more quickly and with fewer complications. If there is a complication, patients must remain in the hospital after surgery and HIPEC chemotherapy. Patients may receive intravenous medications and fluids after surgery. Initially, there is often a tube to drain the stomach until normal bowel function returns. The goal is to return to a modified diet as soon as possible. Having a nutritionist can be very helpful to provide new dietary recommendations. Once patients go home they will be on modified activity until fully recovered.
Peritoneal mesothelioma is a serious and aggressive cancer. Prognosis for this illness is generally poor; however, innovative treatment options have increased survival times. Cytoreductive surgery including peritonectomy followed by HIPEC is an effective way to help patients live longer. For some, this procedure may even provide a cure. If you are facing treatment for peritoneal mesothelioma, know your options. Your medical team can help you understand the risks and benefits of these aggressive treatments for peritoneal mesothelioma.
Page Medically Reviewed and Edited by Paul Sugarbaker, M.D.
Dr. Paul Sugarbaker is a leading expert in surgical oncology. He specializes in the surgical treatment of gastrointestinal cancers, peritoneal mesothelioma, and peritoneal metastases. He developed and advanced an important treatment procedure for peritoneal cancers and metastases known as HIPEC. The innovative strategy uses surgery followed by the circulation of heated chemotherapy drugs in the abdomen. Dr. Sugarbaker currently heads up the Peritoneal Surface Malignancy Program and the Center for Gastrointestinal Malignancies at Washington Hospital Center. He also works out of a private practice, Sugarbaker Oncology Associates.