What is Cytoreductive Surgery?
Cyto means cells and reduction means removal. Cytoreductive surgery or CRS refers to removal of all the tumor from the peritoneal cavity. The aim of the surgery is to remove all the tumors from different regions of the abdominal cavity.
The surgery comprises removal of the areas of peritoneum that are involved by the tumor as well as some organs that are involved by tumor as shown in the adjacent figure. The extent of surgery depends on the extent of cancer spread- if the cancer is confined to few areas, only those areas will be removed whereas when the cancer is widespread, more extensive surgery is required.
Before undertaking a patient for surgery, the surgeon studies the scans carefully to evaluate the extent of disease and determine if complete removal is possible. The goal of the surgery is also to enable the person to have a good quality of life and not longevity. The expertise of the surgeon lies in his/her ability to remove all the tumor deposits. The organs are removed in a way that is compatible with normal life after surgery.
Many times a key hole surgery or laparoscopy is performed to determine the exact location of the peritoneal tumor deposits. Peritoneal cancer consists of multiple small and large tumors scattered all over the peritoneum or the abdominal cavity. Many times, these tumors are less than a centimeter in size and cannot be detected on any scan. During laparoscopy, the surgeon can directly see the peritoneum, especially some key areas like the small intestine, to determine if complete removal is possible or not. When complete removal of the tumor seems unlikely, surgery is not undertaken.
The Procedure
The surgeon opens the abdomen with a long incision at the midline. A thorough examination of the peritoneal cavity is then performed to identify all the regions that contain tumor. The surgeon has already planned what areas could need removal based on the scans performed prior to surgery and a diagnostic laparoscopy if the same has been performed. However, some tiny nodules that are missed during these tests are identified during surgery and a final plan is made. Then the removal of the peritoneum and affected organs is carried out. As shown in the adjoining diagram, the entire peritoneum bearing small and large tumor nodules is removed during cytoreductive surgery. Once the tumor removal is complete, if required, HIPEC is performed.
Which Organs Are Removed During CRS?
During cytoreductive surgery the structures or organs that are removed are the:
Peritoneum that has tumor implants (commonly the peritoneum in the pelvis, on the undersurface of the diaphragms and the abdominal wall.)
Omentum which is an apron of blood vessels and fatty tissue which is attached to the stomach, covers the small bowel, and is often loaded with a tumor forming an ‘omental cake’. There is a high propensity of finding tumors in this structure and surgeons will remove it in the majority of the patients.
According to the situation of the individual patient, removal of the spleen, of the gallbladder, of the uterus and ovaries, of part of the diaphragm, of part of the small or the large bowel or of other organs may be required.
In most cases, removal of these structures does not have any long term impact on the patient’s quality of life and after complete recovery, most patients lead a normal life.
A specialist surgeon will be able to produce better results as compared to someone who is not specializing in performing these surgeries.
Patients Suitable For CRS
Patients with peritoneal cancer from certain primary tumors like colorectal cancer, ovarian cancer, appendix cancer, gastric cancer and primary peritoneal malignancies like peritoneal mesothelioma benefit the most from cytoreductive surgery and HIPEC and are commonly offered this treatment. In others like those with breast cancer, lung cancer, pancreatic cancer, peritoneal cancer is generally associated with cancer in other organs or parts of the body making them ineligible for such treatment.
There may be some exceptions where the disease is very limited or has been well controlled by chemotherapy and such treatment is offered. The surgeon and other specialists involved in the care of these patients will ensure that only patients who will benefit from the procedure and are in good health and can withstand it are offered this treatment. Many patients need supportive nutrition and physical exercises for several weeks before the procedure to be deemed ‘fit’ for it.
The two other concerns are the patient’s health condition and disease spread. For evaluating a patient’s general well being and the extent of disease spread, the surgeon performs a thorough evaluation. It is important for the patient to be in a good general condition. The blood tests and lung function should be normal. A CT scan/PET CT scan/MRI is done to evaluate the exact extent of disease in the peritoneal cavity and to rule out involvement of other organs.
Patients whose peritoneal cancer is very extensive or has spread to other organs as well may not be candidates for cytoreductive surgery and HIPEC. When the disease is very extensive and complete removal of all the disease is not possible, cytoreductive surgery is not performed.
