ANZ Journal of Surgery

Long‐term survival following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in Waikato, Aotearoa New Zealand: a 12‐year experience

AbstractBackgroundsCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have improved survival for selected cases of peritoneal surface malignancy. In 2008, a CRS/HIPEC service was first established in Aotearoa New Zealand (AoNZ) at Waikato and Braemar Hospitals in the Waikato region.MethodsThis is a retrospective review of a prospectively maintained database of all patients undergoing CRS/HIPEC from 1 January 2008 to 1 November 2020 at Waikato and Braemar Hospitals. We analysed long‐term survival and predictors of survival for each tumour type.Results240 procedures were performed for 221 patients, including 22 re‐do procedures. Cases had a median peritoneal cancer index of 16. Complete cytoreduction (CC0‐1) was achieved in 196 cases (81.7%). All complete cytoreduction cases received HIPEC. There were 152 pseudomyxoma peritonei (PMP), 39 colorectal cancers (CRC), 29 appendiceal cancers, eight ovarian cancers, six peritoneal mesotheliomas, and six other cancers. The 5‐year overall survival (OS) for PMP with acellular mucin, low‐grade mucinous carcinoma peritonei, and high‐grade mucinous carcinoma peritonei with or without signet cells were 91.6%, 80.5%, and 72.2%, respectively. 2‐ and 5‐year OS in CRC were 56.7% and 40.4%. The achievement of complete cytoreduction improved the 5‐year OS to 87.9% across all PMP and 45.1% in colorectal cancer. Incomplete cytoreduction predicted worse survival in appendiceal PMP. In colorectal cancer, worse survival was predicted in those who had incomplete cytoreduction, liver metastasis, and presentation with obstruction and perforation.ConclusionFavourable long‐term outcomes following CRS/HIPEC for peritoneal surface malignancy have been achieved in AoNZ through the Waikato peritonectomy service.

Lytic effects of water on cancer cells: Implications for post‐operative irrigation

AbstractBackgroundIntraoperative tumour spillage can be concerning during cancer excisions, given it can lead to tumour‐cell re‐implantation and local recurrence. Examples include bladder tumour recurrences post‐transurethral resection, or peritoneal spillage during laparotomy/laparoscopy for bowel and ovarian cancers. One approach to reducing implantation is mechanical wash out of free‐floating tumour cells. Irrigation with water may have additional effectiveness compared to iso‐osmotic irrigants (e.g. saline) by causing osmotic cytolysis, but this is not well‐characterised. This in vitro study aimed to ascertain the time‐course of osmotic effects of water on various cancer cell lines to provide guidance for clinical usage.MethodsAssays were conducted on six cancer cell lines (bladder [HT1197, HT1376], colon [KM12, LIM2405], kidney [SKRC52], and ovarian [COV434]). Cells were exposed to water or 0.9% saline and cell counts were performed using a haemocytometer at 10, 20, 40, 60, 120 and 180 min. Cell viability was determined using Trypan Blue exclusion.ResultsIn all cell lines, exposure to water led to 100% cell lysis within a median time of 40 min (range 10–180 min), while exposure to saline led to a gradual decline in cell viability (median 50.2%, range 6.7%–100.0%) over 3 h, and did not result in complete cell lysis. An increase in osmotic gradient equivalent to a concentration of 5% NaCl was sufficient to impede the effects of water‐mediated cell lysis.ConclusionOur studies suggest that water has a rapid osmolytic effect on cancer cells. The required exposure time to reach 0% cell viability varied between individual cell lines.

Malignant sex cord tumour of the ovary in Peutz‐Jeghers syndrome

Rare case of cervical colorectal cancer metastasis

Posterior retroperitoneal adrenalectomy for metastatic disease: a multi‐site Australian series

AbstractBackgroundPosterior retroperitoneoscopic adrenalectomy (PRA) for isolated adrenal metastasis is minimally invasive, may prolong survival and improve quality of life. The current evidence base is scant.MethodsA multi‐site retrospective analysis of all cases of PRA for adrenal metastasis between 2011 and 2023, by four high‐volume adrenal surgeons was performed. Perioperative morbidity, disease‐free and survival outcomes were reported.ResultsOf 51 patients, 34(67%) male, mean age 63 ± 12 years, mean BMI 28; 49 PRAs for adrenal metastatectomy were completed (one abandoned due to tumour unresectability, one conversion to anterior laparoscopic approach) across 11 hospitals (49% public). Primary tumours included: 11 colorectal, 11 renal, 8 lung, 6 hepatocellular, 4 sarcoma, 3 breast, 2 melanoma, 2 ovarian and 1 each of pancreatic, oesophageal, testicular and prostate cancer. There were 12 synchronous (<6 months) and 39 metachronous (>6 months after primary diagnosis) tumours; 21 (42%) left sided, none bilateral. Mean operative time was 95 ± 34 minutes, mean maximal tumour diameter was 34 mm ± 13 mm and median length of hospitalization 1 ± 1 days. There were 8 (16%) complications; 1 ICU admission, 1 re‐admission for pneumonia and 6 Clavien‐Dindo grade I complications. There were 10 (20%) mortalities and a median overall survival of 29 months (range 7–123, n = 41). Disease recurred in 15 (40%) patients (n = 37), with a median disease‐free interval of 18 months (range 1–68). Port site recurrence occurred in 2 patients, both simultaneously with disseminated metastases.ConclusionIn carefully selected patients with adrenal metastases, PRA by high‐volume adrenal surgeons has minimal morbidity and short hospitalization. Surgery should be considered prior to local ablation.

A systematic review of minimally invasive cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with peritoneal malignancy

AbstractBackgroundCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is traditionally a maximally invasive operation with a large abdominal incision and multi‐visceral resections. However, to minimize abdominal wall morbidity and improve functional recovery, some centres have adopted a minimally invasive (MI) approach in select cases. The primary aim of this systematic review and meta‐analysis was to assess the evidence for safety and patient selection for minimally invasive approaches to CRS and HIPEC with curative intent.MethodsA PRISMA‐compliant systematic review was performed using three electronic databases: Ovid MEDLINE, EMBASE and Web of Science. Data regarding postoperative morbidity was meta‐analysed.ResultsThirteen studies met the inclusion criteria (N = 462 MI patients), all of which were retrospective in design. Six studies included an open comparison group. Pseudomyxoma peritonei, mesothelioma and ovarian carcinoma made up the majority of cases (>90%), with a PCI < 10 listed as a prerequisite to selection across all studies. On pooled analysis there was no difference in major morbidity between MI and open groups (OR 0.52 95% CI 0.18–1.46, P = 0.33). There was one perioperative death reported in the MI group. Length of stay appeared shorter in the MI group (median range MI: 4–11 v Open: 7–13 days). Short‐term recurrence and overall survival between both groups also appeared no different.ConclusionMinimally invasive CRS and HIPEC appears feasible and safe in appropriately selected patients. Clear histological stratification and longer term follow up is required to determine oncological safety, particularly in more aggressive tumours such as colorectal peritoneal metastases.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in New Zealand: peri‐operative outcomes and service development over a decade

AbstractBackgroundCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the standard of care for selected cases of peritoneal surface malignancy. However, due to its morbidity and learning curve, it is only delivered in six centres in Australia and Aotearoa New Zealand (AoNZ). In this study, we report peri‐operative morbidity and mortality following CRS/HIPEC at Waikato and Braemar Hospitals, which have treated patients from all regions of AoNZ since 2008.MethodsWe retrospectively reviewed a database of all patients undergoing CRS and HIPEC from 01/01/2008 to 01/11/2020 at Waikato and Braemar Hospitals.ResultsTwo‐hundred and forty procedures were performed for 221 patients with a mean age of 55, including 22 (9.2%) re‐do procedures. One hundred and eighty‐six cases were European, 32 were Māori, and 16 were Pasifika. There were 152 pseudomyxoma peritonei, 39 colorectal adenocarcinomas, 29 appendiceal cancers, 8 ovarian cancers, 6 peritoneal mesothelioma, and 6 other tumour types. The median PCI was 16. HIPEC was administered to 196 out of 196 CC0/1 cases (100%) and 3 out of 44 CC2/3 cases (6.8%). Fifty‐six cases (23.3%) had at least one major complication. There were two mortalities (0.8%) within 30 days. The median length of stay was 11 days. Operative duration was identified as an independent risk factor for major complications. There was considerable variation in the number of referrals from different regions of AoNZ. Over time, a decline in major complication rate is seen with increased case volume.ConclusionThe Waikato region has achieved favourable short‐term outcomes following CRS/HIPEC.

Blunt abdominal trauma resulting in ovarian mucinous cystadenoma rupture