Cytoreductive surgery, also known as debulking, is a surgical option for peritoneal mesothelioma patients. The procedure aims to remove visible peritoneal tumors from within the abdominal cavity. Cytoreduction is a long procedure, averaging anywhere from 10-12 hours. The duration and complexity of cytoreduction performed correlates with the amount of peritoneal mesothelioma encountered in the abdominal cavity. Depending on the amount of visible tumors, cytoreduction may include the removal of: the omentum in front of the stomach, the greater omentum and spleen, tumors on the liver, part of the large intestine and uterus or ovaries in female patients, and part of the gall bladder and peritoneum between the stomach and liver.
Cytoreductive Surgery Procedure
After the initiation of general anesthesia, the patient is positioned lying on their back. The surgeon makes a large midline incision from the bottom of the sternum to the top of the pubic bone. The surgeon then examines the abdominal cavity and organs for visible tumors.
Cytoreduction is performed with a ball-tip electrosurgical hand piece which separates cancerous tissue from healthy peritoneal tissue. Electricity creates heat at the tip of the hand piece cauterizing as it cuts, minimizing blood loss. Heat also kills cancer cells as cancerous tissue is separated from healthy tissue. The goal of cytoreduction is to remove as much visible tumor as possible.
Cytoreduction with HIPEC
The surgery is often combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC), which helps kill any remaining cancer cells in the abdomen. HIPEC is when a heated chemotherapeutic agent is circulated throughout the abdominal cavity with occasional abdominal massage ensuring thorough distribution of chemotherapy throughout the abdominal cavity.
After cytoreduction is performed, the surgeon inserts two catheters, or tubes, into the abdominal cavity, closes the midline incision, and initiates HIPEC. The infused agent is heated to approximately 104-107 degrees and circulated throughout the abdominal cavity for 60-100 minutes. Accessing all areas in the abdomen during cytoreduction is difficult, thus, HIPEC it utilized to kill missed cells preventing them from growing into new tumors.
HIPEC is beneficial because it allows for a larger, more focused dose of chemotherapy to be administered. Heated chemotherapy enhances peritoneal tissue penetration and increases the efficacy of the chemotherapeutic agent. HIPEC does not have the systemic effects commonly associated with chemotherapy such as nausea, vomiting, and hair loss. The goal of HIPEC is to kill all intraperitoneal cancer cells, but successfully doing so cannot be guaranteed. After HIPEC is completed, the surgeon removes the catheters and closes the abdominal incision.
Patients spend up to two days in the ICU or Stepdown unit followed by eight to ten more days in the surgical unit. Surgical pain is controlled with a PCA (patient controlled analgesia) pump or IV pain medications. Patients also receive any food and fluids through an IV. They are connected to a nasogastric tube which drains stomach contents until normal bowel and digestive function resumes. Recovery focuses heavily on digestive function, where most of the complications occur.
Patients are usually encouraged to mobilize often by sitting in a chair and/or walking. Patients are also routinely use an incentive spirometer to maintain proper lung ventilation and function. Once discharged from the hospital, normal activity generally resumes within four to six weeks with lifting restrictions.
Risks and Benefits
As with all surgical procedures, there are inherent risks. These risks include reactions to anesthesia, damage to internal organs, blood loss, formation of blood clots, infection, and chemotherapeutic side effects. A majority of complications following cytoreduction deal with the digestive system.
Patients undergoing cytoreduction with HIPEC have experienced median survival rates up to 5 years. However, survival rates are dependent on several factors including the extent of intraperitoneal tumors encountered and success of the procedure itself. The Completeness of Cytoreduction Score, which ranges from 0 to 4, evaluates the amount of cancerous tissue that may remain. Patients with a score of 0 or 1 generally survive for 35 months.
Cytoreductive surgery can also be used to treat other more common cancers, including ovarian and stomach cancer. In other words, while mesothelioma is a rare cancer, the procedure has been used often and perfected over time, leading to high survival rates after surgery.
In general, combining cytoreductive surgery with chemotherapy has been reported to improve prognosis, with patients living between 3 to 7 years.
To find out which treatment option is best for you, talk with your doctor.