Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for perforated low-grade appendiceal mucinous neoplasms

• Published in: Surgical endoscopy Vol. 34; no. 12; pp. 5516 - 5521
• Main Authors: Abudeeb, Haytham, Selvasekar, Chelliah R., O’Dwyer, Sarah T., Chakrabarty, Bipasha, Malcolmson, Lee, Renehan, Andrew G., Wilson, Malcolm S., Aziz, Omer
• Format: Journal Article
• Language: English
• Published: New York Springer US 01.12.2020; Springer Nature B.V
• Subjects: Abdominal Surgery; Chemotherapy; Gastric cancer; Gastroenterology; Gynecology; Hepatology; Medicine; Medicine & Public Health; Proctology; Surgery; Tumors; Hyperthermic intraperitoneal chemotherapy; Low-grade appendiceal mucinous neoplasms; Laparoscopic; Cytoreductive surgery
• ISSN: 0930-2794; 1432-2218
• DOI: 10.1007/s00464-019-07349-x

Introduction Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an established treatment for pseudomyxoma peritonei (PMP) from perforated low-grade appendiceal mucinous neoplasms (LAMN II). In a selected group of LAMN II patients without established PMP, CRS/HIPEC can be performed laparoscopically (L-CRS/HIPEC); however the short-term benefits and safety of this approach have yet to be determined. This study aims to determine the short-term outcomes from a series of L-CRS/HIPEC LAMN II patients compared to those who have undergone a similar open operation (O-CRS/HIPEC) for low-volume PMP. Methods LAMN II patients undergoing L-CRS/HIPEC at a UK national peritoneal tumour centre were compared to O-CRS/HIPEC patients (peritoneal cancer index ≤ 7). Outcomes of interest included Clavien–Dindo complication grade, operative time, blood transfusions, high dependency unit (HDU) admission, length of hospital stay, and histopathological findings. Results 55 L-CRS/HIPEC were compared to 29 O-CRS/HIPEC patients (2003–2017). Groups were matched for age, sex, and procedures. Median operative time was 8.8 (IQR 8.1–9.5) h for L-CRS/HIPEC versus 7.3 (IQR 6.7–8) h for O-CRS/HIPEC (Mann–Whitney test p  < 0.001). Post-operative HDU admission was 56% versus 97% (OR 0.04 95% CI 0.01–0.34) and median length of stay = 6 (IQR 5–8) versus 10 (IQR 8–11) days ( p  < 0.001) for L- versus O-CRS/HIPEC. Despite a normal pre-operative CT scan, 13/55 (23.6%) L-CRS/HIPEC patients had acellular mucin and 2/55 (3.5%) had mucin with epithelium present in their specimens. Residual appendix tumour was identified in 2/55 patients (3.6%). Clavien–Dindo Grade 1–4 complications were similar in both groups with no mortality. Conclusion L-CRS/HIPEC for LAMN II takes longer; however patients have significantly reduced length of HDU and overall stay, without increased post-operative complications. A significant proportion of LAMN II patients undergoing L-CRS/HIPEC have extra-appendiceal acellular mucin with some cases demonstrating residual cellular epithelium from the LAMN II. The risk of these patients developing PMP without surgery is under current review.