Combined Surgery and Extensive Intraoperative Peritoneal Lavage vs Surgery Alone for Treatment of Locally Advanced Gastric Cancer

Abstract

IMPORTANCE Peritoneal metastasis is the most frequent pattern of postoperative recurrence in patients with gastric cancer. Extensive intraoperative peritoneal lavage (EIPL) is a new prophylactic strategy for treatment of peritoneal metastasis of locally advanced gastric cancer; however, the safety and efficacy of EIPL is currently unknown.OBJECTIVE To evaluate short-term outcomes of patients with advanced gastric cancer who received combined surgery and EIPL or surgery alone. DESIGN, SETTING, AND PARTICIPANTS From March 2016 to November 2017, 662 patients with advanced gastric cancer receiving D2 gastrectomy were enrolled in a large, multicenter, randomized clinical trial from 11 centers across China. In total, 329 patients were randomly assigned to receive surgery alone, and 333 patients were randomly assigned to receive surgery plus EIPL. Clinical characteristics, operative findings, and postoperative short-term outcomes were compared between the 2 groups in the intent-to-treat population.MAIN OUTCOMES AND MEASURES Short-term postoperative complications and mortality. RESULTSThe present analysis included data from 550 patients, 390 men and 160 women, with a mean (SD) age of 60.8 (10.7) years in the surgery alone group and 60.6 (10.8) in the surgery plus EIPL group. Patients assigned to the surgery plus EIPL group exhibited reduced mortality (0 of 279 patients) compared with those assigned to surgery alone (5 of 271 patients [1.9%]) (difference, 1.9%; 95% CI, 0.3%-3.4%; P = .02). A significant difference in the overall postoperative complication rate was observed between patients receiving surgery alone (46 patients [17.0%]) and those receiving surgery plus EIPL (31 patients [11.1%]) (difference, 5.9%; 95% CI, 0.1%-11.6%; P = .04). Postoperative pain occurred more often following surgery alone (48 patients [17.7%]) than following surgery plus EIPL (30 patients [10.8%]) (difference, 7.0%; 95% CI, 0.8%-13.1%; P = .02).CONCLUSIONS AND RELEVANCE Inclusion of EIPL can increase the safety of D2 gastrectomy and decrease postoperative short-term complications and wound pain. As a new, safe, and simple procedure, EIPL therapy is easily performed anywhere and does not require any special devices or techniques. Our study suggests that patients with advanced gastric cancer appear to be candidates for the EIPL approach.

Predicting postoperative peritoneal metastasis in gastric cancer with serosal invasion using a collagen nomogram

“…Currently, there are two therapies for preventing peritoneal metastasis for GC patients with serosal invasion: extensive intraoperative peritoneal lavage (EIPL) and intraperitoneal chemotherapy (IPC) 7 . To date, the safety and efficacy of EIPL have been proven, but the long-term oncological outcomes are still unclear 8 . IPC was used to eliminate suspected malignant cells through locoregional chemotherapy.…”

Does hipec improve outcomes in gastric cancer patients treated with perioperative chemotherapy and radical surgery? A propensity‐score matched analysis

“…Among nonmetastatic patients, even after curative surgery, gastric cancer recurrence rates are still high, up to 50% in some series, with the peritoneum being the most common relapse site and the leading cause of death for patients . To improve these recurrence rates, since 1988 several local treatment modalities have been studied for better local control and improved survival, such as HIPEC and more recently the extensive intraoperative peritoneal lavage with physiological saline . Evidence from earlier and recent trials along with at least three metanalysis suggests a survival benefit of adding HIPEC to a curative surgical procedure.…”

“…16 To improve these recurrence rates, since 1988 several local treatment modalities have been studied for better local control and improved survival, such as HIPEC 17 and more recently the extensive intraoperative peritoneal lavage with physiological saline. 18 Evidence from earlier 3,19 and recent trials 20,21 along with at least three metanalysis 4,5,22 suggests a survival benefit of adding HIPEC to a curative surgical procedure.…”

Rapid Detection of Free Cancer Cells in Intraoperative Peritoneal Lavage Using One-Step Nucleic Acid Amplification (OSNA) in Gastric Cancer Patients

“…Even though the exact mechanism of peritoneal spread is still unclear, the presence of cancer cells during surgery may lead to a relapse in the peritoneum [ 2 ]. Recently, the use of Extensive Intraoperative Peritoneal Lavage method (EIPL) has been in a high demand as a new prophylactic strategy for treatment of peritoneal metastasis of locally advanced GC [ 25 ]. Currently, three multicenter randomized clinical trials are conducted to assess the safety and efficacy of EIPL.…”

“…The short-term outcomes of the SEIPLUS trial have been published. It has been proven that EIPL can increase the safety of D2 gastrectomy and decrease postoperative short-term complications and wound pain [ 25 ]. On the other hand, Misawa et al [ 26 ] in their open-label, multi-institutional, randomized, phase 3 trial (CCOG 1102 trial), reported that EIPL did not improve survival or peritoneal recurrence in patients who underwent gastrectomy for advanced GC.…”