Assessment of outcomes and morbidity following diaphragmatic peritonectomy for women with ovarian carcinoma

Abstract

Objective-To describe the technique of diaphragmatic peritonectomy (DP) for ovarian cancer cytoreduction and to assess associated morbidity.Methods-Retrospective review yielded 56 patients who underwent DP as part of a cytoreductive procedure for primary or recurrent ovarian cancer between 1988 and 2004. Patients who underwent diaphragmatic resection, removal of diaphragmatic implants with CUSA, cautery, curette, or finger fracture, and patients with pseudomyxoma were excluded from analysis.Results-DP was performed as a component of primary or secondary cytoreduction in 37 (66%) and 19 (34%) patients, respectively. Extended procedures including bowel resection, hepatic resection, splenectomy, or radical hysterectomy were performed with DP in 47 patients (82%). Resection of all disease > 1 cm was achieved in 95% (microscopic residuum in 43%). For those undergoing primary cytoreduction, median survival was 59 months and 5-year survival was 49% with median follow-up of 34 months. When performed for recurrent ovarian carcinoma, 5-year survival was 16% and median survival was 23 months. No intra-operative complications could be specifically attributed to DP. Post-operative complications included a 30% rate of pleural effusion which was associated with entry into the pleural space during DP (p<0.0001); thoracentesis was required in 12.5%.Conclusions-Diaphragmatic metastases are a common obstacle to optimal cytoreduction for patients with ovarian cancer. When necessary, utilizing DP in concert with other extended procedures to obtain maximal cytoreduction is associated with excellent survival. It should be recognized that DP is associated with an increased incidence of post-operative pleural effusion, particularly when the pleural space is entered.

Surgical Procedures and Morbidities of Diaphragmatic Surgery in Patients Undergoing Initial or Interval Debulking Surgery for Advanced-Stage Ovarian Cancer

“…With this extensive surgery, rates of complete cytoreduction reported in the literature ranged from 16% to 89%. [6][7][8][9][10][11][12][13][14] In this study, we achieved similar rates: 68% of intestinal resections, 33% of splenectomies, 76% of pelvic and para-aortic lymphadenectomies, and 95% of complete cytoreduction.…”

“…These results are in agreement with previous studies that reported a pneumothorax rate ranging from 0% to 33% and a rate of secondary chest-tube drainage ranging from 7% to 27%. [7][8][9][10][11][12][13][14] Our findings suggest 3 important points. First, when DS is feasible, we can obtain complete cytoreduction at the time of INS or IDS in the majority of cases (95%).…”

“…The right hemidiaphragm was more frequently involved in all studies. [7][8][9][10][11][12][13][14] However, a higher rate of bilateral DS was reported in the studies with a higher rate of complete cytoreduction. In our institution, we performed bilateral DS in 50% of the cases to obtain a 95% rate of complete cytoreduction.…”

“…In the literature, the rate of postoperative pleural effusion after cytoreductive surgery with DS ranged from 10% to 59%. 7-14 Dowdy and colleagues 11 reported a strong association between pleural opening and postoperative pleural effusion. In addition, data in the literature suggest that the rate of chest-tube placement during and after surgery was correlated with the rate of pleural opening (Table 5).…”

Complications of Cytoreductive Surgery and HIPEC in the Treatment of Peritoneal Metastases

“…Several studies have reported the incidence of grade 3/4 pulmonary complications to be in the range of 10-16 % [15,[22][23][24]. As expected, peritonectomy of abdominal diaphragmatic surfaces significantly increases post-operative pleural effusions, particularly in absence of systematic thoracic drainage [25,26]. However, this strategy can reduce but not abolish intrinsic risk of pleural effusion, which remains the second most common pulmonary complications [22].…”