The European contribution to "Sugarbaker's protocol" for the treatment of colorectal peritoneal carcinomatosis.

INTRODUCTION: 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. MATERIAL AND METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Hemodynamic monitoring in a model of shock induced by intestinal reperfusion in the rat.

OBJECTIVE: An experimental model to monitor hemodynamics during intestinal reperfusion syndrome is presented. EXPERIMENTAL DESIGN: A) Three groups of rats were monitored during four hours: 1) CONTROL: sham operated, 2) Ischemic: clamping the superior mesenteric artery for 60' and 3) Saline: adding 2 ml of saline during the last 15' minutes of ischemia. Blood mean pressure, heart rate, breath rate and diuresis are monitored, while mortality is assessed 48 hours later, B) Blood gases, haematimetry and electrolytes were assessed both in control animals and in rats subjected to intestinal ischemia and reperfusion (at the beginning and concluding the ischemic period, and 5', 60' and 180' following reperfusion). RESULTS: Mortality rate was 0% for control animals, while 83% for both ischemic-reperfused groups (p < 0.01). Hemodynamic parameters remained stable during intestinal ischemia. Starting reperfusion, blood pressure and diuresis dropped sharply, while heart and breath rates showed a steady increase. The other parameters assessed also remained constant during ischemia. However, during reperfusion acidosis progressed (pH = 7.15, p < 0.01; HCO3 = 8, p < 0.01), hyperkalaemia appeared (6 mEq/l, p < 0.01), and haematocrit rose (56%, p < 0.01). CONCLUSION: This experimental model is easy to establish, allows an appropriate hemodynamic monitoring of shock during intestinal reperfusion syndrome, and seems appropriate for considering the impact of drug intervention.