Total retroperitoneal en bloc resection of multivisceral-peritoneal packet (TROMP operation): a novel surgical technique for advanced ovarian cancer

Short- and long-term morbidity of total parietal peritonectomy for advanced ovarian cancer

OBJECTIVE

Total parietal peritonectomy is gradually being recognized as a surgical option for advanced ovarian cancer; however, evidence regarding its efficacy and safety remains insufficient. Herein, we aimed to assess the short- and long-term post-operative safety profiles of total parietal peritonectomy.

METHODS

We reviewed the medical records of post-operative morbidity and mortality of patients who underwent cytoreductive surgery with total parietal peritonectomy for stage III and IV ovarian cancer between April 2018 and January 2023.

RESULTS

Fifty patients were enrolled in the study: 31 who underwent primary cytoreductive surgery and 19 who underwent interval cytoreductive surgery. The median age of all patients was 57 (range, 23-74) years. The median follow-up period was 22 (range, 3-59) months. Of 44 patients (88%) with stage IIIC/IV, 38 patients (76%) had high-grade serous carcinoma. The complete resection rates were 94%, 91%, and 100% in all patients, the primary cytoreductive surgery group, and the interval cytoreductive surgery group, respectively. There were 63 post-operative complication events overall, including 17 (27%) major complication events in 15 patients within 1 year post-operatively. Ten major complications occurred within 30 days of surgery, mainly in the primary cytoreductive surgery group (9 cases). Regarding complication type, the most frequent major event was pleural effusion (3 cases, 7%). After 30 days, there were a total of 17 all-grade complication events, of which ileus and hydronephrosis were major complications in 3 cases each (18%). There were no mortalities related to cytoreductive surgery. The scheduled adjuvant chemotherapy could be completed in 96% of patients.

CONCLUSIONS

Total parietal peritonectomy is a feasible procedure for managing advanced ovarian cancer. Short- and long-term complications may include pleural effusion and ileus/hydronephrosis, respectively.

Cost analysis of the enhanced recovery after surgery protocol applied in advanced ovarian cancer: A secondary outcome of the PROFAST trial

INTRODUCTION

A randomised trial implementing Enhanced Recovery After Surgery (ERAS) for high complexity advanced ovarian cancer (AOC) surgery (PROFAST) demonstrated a reduction of median length of stay and hospital readmissions when compared to patients managed conventionally. One secondary objective was to determine if an ERAS pathway in the perioperative management of advanced ovarian cancer patients led to cost savings.

MATERIAL AND METHODS

Secondary objective of a prospective randomised trial of patients with suspected or diagnosed advanced ovarian cancer allocated to conventional or ERAS perioperative management, carried out at a referral centre from June 2014 to March 2018. Treatment was determined by a computer-generated random allocation system.

METHODS

Gross counting was employed to estimate the cost of hospitalisation in wards, intensive care unit (ICU) and surgical care, while micro-costing was used to obtain image and laboratory test costs. Mean costs between trial arms were considered. Sensitivity analyses were performed.

RESULTS

Ninety-nine patients (n = 50 ERAS group, n = 49 Conventional group) were included. Mean costs per patient were 10,719€ in the ERAS group and 11,028€ in the conventional group, leading to an average saving of 309€ per patient. These results were based on 96 patients, excluding 3 extreme outliers mainly related with very high ICU costs. Savings, which were significant for hospital ward costs (-33% total; 759€ per patient in first hospitalisation, and 914€ per partient/day of readmission) were found as robust in the sensitivity analysis.

CONCLUSIONS

Implementation of an ERAS pathway leads to cost savings when compared to conventional management after AOC surgery.

Ultra-radical (extensive) surgery versus standard surgery for the primary cytoreduction of advanced epithelial ovarian cancer

BACKGROUND

Ovarian cancer is the seventh most common cancer among women and the leading cause of death in women with gynaecological malignancies. Opinions differ regarding the role of ultra-radical (extensive) cytoreductive surgery in ovarian cancer treatment.

OBJECTIVES

To evaluate the effectiveness and morbidity associated with ultra-radical/extensive surgery in the management of advanced-stage epithelial ovarian cancer.

SEARCH METHODS

We searched CENTRAL (2021, Issue 11), MEDLINE Ovid and Embase Ovid up to November 2021. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or non-randomised studies (NRS), analysed using multivariate methods, that compared ultra-radical/extensive and standard surgery in women with advanced primary epithelial ovarian cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed whether potentially relevant studies met the inclusion criteria, abstracted data and assessed the risk of bias. We identified three NRS and conducted meta-analyses where possible.

MAIN RESULTS

We identified three retrospective observational studies for inclusion in the review. Two studies included women exclusively undergoing upfront primary debulking surgery (PDS) and the other study including both PDS and interval debulking surgical (IDS) procedures. All studies were at critical risk of bias due to retrospective and non-randomised study designs. Meta-analysis of two studies, assessing 397 participants, found that women who underwent radical procedures, as part of PDS, may have a lower risk of mortality compared to women who underwent standard surgery (adjusted HR 0.60, 95% CI 0.43 to 0.82; I2 = 0%; very low-certainty evidence), but the evidence is very uncertain. The results were robust to a sensitivity analysis including women with more-extensive disease (carcinomatosis) (adjusted HR 0.61, 95% CI 0.44 to 0.85; I2 = 0%; n = 283, very low-certainty evidence), but the evidence is very uncertain. One study reported a comparison of radical versus standard surgical procedures associated with both PDS and IDS procedures, but a multivariate analysis was only undertaken for disease-free survival (DFS) and therefore the certainty of the evidence was not assessable for overall survival (OS) and remains very low. The lack of reporting of OS meant the study was at high risk of bias for selective reporting of outcomes. One study, 203 participants, found that women who underwent radical procedures as part of PDS may have a lower risk of disease progression or death compared to women who underwent standard surgery (adjusted HR 0.62, 95% CI 0.42 to 0.92; very low-certainty evidence), but the evidence is very uncertain. The results were robust to a sensitivity analysis in one study including women with carcinomatosis (adjusted HR 0.52, 95% CI 0.33 to 0.82; n = 139; very low-certainty evidence), but the evidence is very uncertain. A combined analysis in one study found that women who underwent radical procedures (using both PDS and IDS) may have an increased chance of disease progression or death than those who received standard surgery (adjusted HR 1.60, 95% CI 1.11 to 2.31; I2 = 0%; n = 527; very low-certainty evidence), but the evidence is very uncertain. In absolute and unadjusted terms, the DFS was 19.3 months in the standard surgery group, 15.8 in the PDS group and 15.9 months in the IDS group. All studies were at critical risk of bias and we only identified very low-certainty evidence for all outcomes reported in the review. Perioperative mortality, adverse events and quality of life (QoL) outcomes were either not reported or inadequately reported in the included studies. Two studies reported perioperative mortality (death within 30 days of surgery), but they did not use any statistical adjustment. In total, there were only four deaths within 30 days of surgery in both studies. All were observed in the standard surgery group, but we did not report a risk ratio (RR) to avoid potentially misleading results with so few deaths and very low-certainty evidence. Similarly, one study reported postoperative morbidity, but the authors did not use any statistical adjustment. Postoperative morbidity occurred more commonly in women who received ultra-radical surgery compared to standard surgery, but the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

We found only very low-certainty evidence comparing ultra-radical surgery and standard surgery in women with advanced ovarian cancer. The evidence was limited to retrospective, NRSs and so is at critical risk of bias. The results may suggest that ultra-radical surgery could result in improved OS, but results are based on very few women who were chosen to undergo each intervention, rather than a randomised study and intention-to-treat analysis, and so the evidence is very uncertain. Results for progression/DFS were inconsistent and evidence was sparse. QoL and morbidity was incompletely or not reported in the three included studies. A separate prognostic review assessing residual disease as a prognostic factor in this area has been addressed elsewhere, which demonstrates the prognostic effect of macroscopic debulking to no macroscopic residual disease. In order to aid existing guidelines, the role of ultra-radical surgery in the management of advanced-stage ovarian cancer could be addressed through the conduct of a sufficiently powered, RCT comparing ultra-radical and standard surgery, or well-designed NRSs, if this is not possible.

Retrospective Analysis of Total Parietal Peritonectomy Without Systematic Lymphadenectomy for Advanced Epithelial Ovarian Cancer

BACKGROUND/AIM

Total parietal peritonectomy (TPP) is a surgical procedure used for complete resection of microscopic peritoneal dissemination. This study analyzed the perioperative complications that developed when omitting systematic lymphadenectomy from TPP.

PATIENTS AND METHODS

We retrospectively analyzed perioperative complications in epithelial ovarian cancer patients with stage IIIB-IVB who underwent TPP during primary and interval cytoreductive surgeries between April 2018 and October 2021.

RESULTS

Thirty-three patients were enrolled in the study. The median patient age was 62 years. Of 31 patients (94%) with stage IIIC/IV disease, 24 (73%) had high-grade serous carcinoma. The median operative time and blood loss were 447 min and 2,831 ml, respectively. Complete tumor resection was performed in 30 patients (91%). Only five patients underwent partial lymphadenectomy for clinical metastatic lymph nodes. Further, grade 3 complications were observed in seven (21%) patients, and there were no fatal events in this study. Three patients (9%) had ureteric injuries, which was the most frequent complication in this study. Only one patient developed an intra-abdominal infection due to ascites. In this case, partial para-aortic and pelvic lymphadenectomies were performed.

CONCLUSION

TPP without systematic lymphadenectomy reduces the frequency of perioperative complications associated with ascites.

A Promising Approach for Primary Cytoreductive Surgery for Advanced Ovarian Cancer: Survival Outcomes and Step-by-Step Description of Total Retroperitoneal en-Bloc Resection of Multivisceral-Peritoneal Packet (TROMP)

(1) Background: A complete tumor resection during primary cytoreductive surgery has been reported to be the most important and perhaps the only independent prognostic factor in advanced ovarian cancers. The goal of complete cytoreduction needs to be weighed against the potential morbidities and long-term survival outcomes. (2) Methods: in this retrospective analysis of a prospectively obtained database, 208 consecutive patients with advanced ovarian cancer who underwent a conventional primary cytoreductive surgery (150 patients) or TROMP technique (58 patients) were included. Progression-free and overall survival rates were calculated using Kaplan–Meier analysis as well as the 95% confidence interval of the hazard ratio between treatment groups. (3) Results: After a median follow-up phase of more than 3 years (range 1–72 months), there are no statistically significant differences between both groups in progression-free and overall survival rates. Albeit, the TROMP group included statistically significant more advanced-stage cases compared to the conventional surgery group. (4) Conclusions: the TROMP technique is a promising tool for successful primary cytoreductive surgery in a selected group of patients with high tumor burdens in order to achieve optimal surgical results and survival outcomes without introducing any additional risks or complications.

Nerve-Sparing Systematic Lymph Node Dissection in Gynaecological Oncology: An Innovative Neuro-Anatomical and Surgical Protocol for Enhanced Functional Outcomes

Whilst systematic lymph node dissection has been less prevalent in gynaecological cancer cases in the last few years, there is still a good number of cases that mandate a systematic lymph node dissection for diagnostic and therapeutic purposes. In all of these cases, it is crucial to perform the procedure as a nerve-sparing technique with utmost exactitude, which can be achieved optimally only by isolating and sparing all components of the aortic plexus and superior hypogastric plexus. To meet this purpose, it is essential to provide a comprehensive characterization of the specific anatomy of the human female aortic plexus and its variations. The anatomic dissections of two fresh and 17 formalin-fixed female cadavers were utilized to study, understand, and decipher the hitherto ambiguously annotated anatomy of the autonomic nervous system in the retroperitoneal para-aortic region. This study describes the precise anatomy of aortic and superior hypogastric plexus and provides the surgical maneuvers to dissect, highlight, and spare them during systematic lymph node dissection for gynaecological malignancies. The study also confirms the utility and feasibility of this surgery in gynaecological oncology.

Feasibility and rationale of a novel approach in advanced ovarian cancer surgery: Bat- shaped en-bloc total peritonectomy and total hysterectomy salpingo-oophorectomy with or without rectosigmoid resection (Sarta-Bat approach)

OBJECTIVE

To evaluate the feasibility of bat-shaped en-bloc total peritonectomy and total hysterectomy-salpingo-oophorectomy with or without rectosigmoid resection as a novel approach in advanced ovarian cancer surgery.

METHODS

Advanced ovarian cancer patients with widespread peritoneal implants requiring total peritonectomy were the subject of the study. Thirteen cases were operated with Sarta-Bat approach between February 2019 and July 2020. Patients' clinical and surgical data were collected and statistically analyzed.

RESULTS

Median age of the patients was 52 (40-65). Histopathology of the tumors were high-grade serous carcinoma in 12 (92.3%) and carcinosarcoma in one (7.7%) cases and all of them originated from the ovary. Eight (61.5%), two (15.4%) and three (23.1%) patients were stage 3c, 4a, and 4b, respectively. Upper abdomen was involved in all cases. Nine cases underwent primary cytoreductive and four cases interval cytoreductive surgery. Sarta-Bat approach was performed as en-bloc total peritonectomy, total hysterectomy bilateral salpingo-oophorectomy with rectosigmoid resection in three and without rectosigmoid resection in 10 cases. Final surgery resulted in complete cytoreduction (no macroscopic residual) in all cases, with acceptable grade 2-3 morbidity rates.

CONCLUSION

Sarta-Bat approach is a feasible and convenient technique for cytoreductive surgery of advanced ovarian cancer with disseminated peritoneal metastases.