INTRODUCTION: 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. PATIENTS AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
Abdomen/surgery , Antineoplastic Agents/administration & dosage , Carcinoma/drug therapy , Carcinoma/surgery , Peritoneal Neoplasms/drug therapy , Peritoneal Neoplasms/surgery , Peritoneum/surgery , Postoperative Complications , Carcinoma/pathology , Combined Modality Therapy , Female , Humans , Hyperthermia, Induced , Male , Negative-Pressure Wound Therapy , Neoplasm Staging , Perioperative Care , Peritoneal Neoplasms/pathology , Peritoneum/pathology , Reoperation , Treatment Outcome
Introducción. 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. Material y método. Nos hemos basado en nuestra experiencia personal en el tratamiento de 110 citorreducciones realizadas entre febrero de 1997 y febrero de 2007 en 71 pacientes afectos de carcinomatosis peritoneal difusa de diferente origen. De los 71 pacientes, 50 (70%) sufrieron algún tipo de complicación durante su evolución postoperatoria, 28 de estos pacientes precisaron alguna reintervención por complicaciones de grado III-IV. La situación abdominal hizo aconsejable un cierre abdominal diferido en 17 pacientes, en todas las ocasiones se practicó la técnica de abdomen abierto en vacío. Se estudia esta serie de pacientes en cuanto al tipo de tumor original y grado de enfermedad en el momento de la citorreducción, peritonectomías parietales y resecciones viscerales necesarias, tipo y momento de aparición de complicación, tratamiento aplicado y evolución. Resultados. Fue necesario un total de 52 abdómenes en vacío (mediana, 2,8 por paciente; intervalo, 1-10) antes de que la complicación abdominal estuviera completamente bajo control en estos 17 pacientes. Hemos observado solamente 2 fístulas intestinales relacionadas directamente con esta técnica, y en 11 (66%) de estos pacientes fue posible un cierre primario de toda la pared abdominal. Todos los pacientes, salvo uno, abandonaron el hospital vivos y con buen estado general. Conclusiones. Como consecuencia de esta experiencia, en nuestra opinión, el abdomen abierto en vacío es la técnica de elección para cualquier cierre temporal de la cavidad abdominal independientemente de la razón por la que se precise, incluso en el peor de los escenarios posibles, como hemos demostrado en el tratamiento de las complicaciones quirúrgicas tras citorreducciones y quimiohipertermia intraperitoneal (AU)
Introduction. 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. Patients and methods. 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. Results. 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. Conclusions. 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 (AU)
Humans , Male , Female , Postoperative Complications/diagnosis , Postoperative Complications/therapy , Fever/complications , Fever/diagnosis , Carcinoma/complications , Carcinoma/diagnosis , Sepsis/complications , Sepsis/diagnosis , Abdominal Wall/surgery , Disseminated Intravascular Coagulation/therapy
El cáncer de origen colorrectal es el tumor digestivo más frecuente. La alta incidencia de su diseminación abdominal, el mal pronóstico de estos pacientes, con una media de supervivencia de 5-9 meses demostrada en todos los estudios sobre la historia natural de la carcinomatosis colorrectal, y el fracaso del tratamiento adyuvante sistémico, con supervivencias máximas de 18 meses, han obligado al estudio y desarrollo de otras estrategias de tratamiento. Se presenta una revisión de los principios que fundamentan el Protocolo de Tratamiento de Sugarbaker, que comprende la máxima cirugía (..) (AU)
Colorectal cancer is the most frequent digestive tumor. The incidence of abdominal dissemination is high and all studies of the natural history of colorectal carcinomatosis demonstrate that prognosis in these patients is poor, with a mean survival of between 5 and 9 months. Furthermore, the results of systemic adjuvant treatment are disappointing, with a maximum (..) (AU)
Male , Female , Adult , Middle Aged , Humans , Carcinoma/diagnosis , Carcinoma/therapy , Clinical Protocols , Hepatectomy/methods , Colorectal Neoplasms/diagnosis , Colorectal Neoplasms/therapy , Injections, Intraperitoneal , Carcinoma/drug therapy , Antineoplastic Combined Chemotherapy Protocols , Colorectal Neoplasms/history
Colorectal cancer is the most frequent digestive tumor. The incidence of abdominal dissemination is high and all studies of the natural history of colorectal carcinomatosis demonstrate that prognosis in these patients is poor, with a mean survival of between 5 and 9 months. Furthermore, the results of systemic adjuvant treatment are disappointing, with a maximum survival of 18 months. Consequently, other treatment strategies need to be studied and developed. We present a review of the principles that underlie Sugarbakers treatment protocol, which includes maximal cytoreductive surgery for the treatment of macroscopic disease through peritonectomy together with perioperative intraperitoneal intensification chemotherapy for residual microscopic disease. We present all the phase II studies with more than 10 treated patients published in the medical literature by the main groups working in this line of treatment, together with the only phase III study published to date. With this new therapeutic alternative, the mean overall survival at 2 and 5 years is 40% and 20% respectively. Based on these results, this new therapeutic approach is recommended as the treatment of choice in these unfortunate patients. The limits of the treatment of advanced colorectal cancer are also discussed.
Carcinoma/secondary , Carcinoma/therapy , Colorectal Neoplasms/pathology , Peritoneal Neoplasms/secondary , Peritoneal Neoplasms/therapy , Clinical Trials as Topic , Combined Modality Therapy , Humans
