Division of Surgical Oncology, Mount Sinai St. Luke's Roosevelt, New York, NY, USA.
Ann Surg Oncol. 2020 Jan;27(1):250-258. doi: 10.1245/s10434-019-07797-8. Epub 2019 Sep 9.
Pleural recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is rare and poorly delineated. Specifically, data are limited on the effect that diaphragmatic peritoneal stripping versus full-thickness resection has on the nature of ipsilateral pleural recurrence and postoperative morbidity.
Patients with peritoneal carcinomatosis who underwent CRS/HIPEC were included from a prospectively maintained database. The patients were divided into three cohorts based on surgical management of the diaphragm as follows: diaphragm-stripping (DS) cohort, full-thickness resection (FTR) cohort, and no diaphragm manipulation (ND) cohort. Postoperative morbidity and incidence of ipsilateral pleural recurrence were evaluated. All diaphragmatic defects were closed before abdominal chemoperfusion.
The inclusion criteria were met by 409 CRS/HIPEC procedures: 66 in DS, 122 in FTR, and 238 in ND. Ipsilateral pleural recurrence rates did not differ significantly between the three cohorts (DS 6%, FTR 3%, ND 3%; p = 0.470). Postoperative respiratory complications and overall morbidity were significantly greater for the patients who underwent diaphragmatic disruption (stripping and/or resection) than for the patients who did not (p ≤ 0.0001), but the two groups did not differ in terms of 30-day mortality. However, comparison of FTR with DS showed no impact on major morbidity or pleural recurrence.
Although patients undergoing surgical manipulation of the diaphragm during CRS/HIPEC experienced significantly greater morbidity, diaphragmatic stripping did not differ from full-thickness resection in terms of grades 3 and 4 complications or incidence of ipsilateral pleural recurrences. When deemed necessary to achieve complete cytoreduction, full-thickness diaphragmatic resection should be undertaken. In addition, the data support the observation that definitive repair of the diaphragmatic defect before abdominal chemoperfusion does not adversely influence ipsilateral pleural recurrence.
细胞减灭术（CRS）和腹腔内热灌注化疗（HIPEC）后的胸膜复发罕见且难以确定。具体来说，关于膈膜腹膜剥离与全层切除对同侧胸膜复发和术后发病率的影响的数据有限。
从一个前瞻性维护的数据库中纳入接受 CRS/HIPEC 的腹膜癌患者。根据膈膜的手术处理方式，将患者分为三组：膈膜剥离（DS）组、全层切除（FTR）组和无膈膜操作（ND）组。评估术后发病率和同侧胸膜复发的发生率。所有膈膜缺损在腹部化学灌注前关闭。
409 例 CRS/HIPEC 手术符合纳入标准：DS 组 66 例，FTR 组 122 例，ND 组 238 例。三组间同侧胸膜复发率无显著差异（DS 组 6%，FTR 组 3%，ND 组 3%；p=0.470）。与未行膈膜破坏（剥离和/或切除）的患者相比，行膈膜破坏的患者术后呼吸系统并发症和总发病率显著更高（p≤0.0001），但两组在 30 天死亡率方面无差异。然而，FTR 与 DS 比较并未显示在主要发病率或同侧胸膜复发方面有影响。
尽管在 CRS/HIPEC 期间行膈膜手术操作的患者发病率显著更高，但膈膜剥离在 3 级和 4 级并发症或同侧胸膜复发的发生率方面与全层切除无差异。在认为有必要实现完全减瘤时，应进行全层膈膜切除。此外，数据支持这样的观察结果，即在进行腹部化学灌注前明确修复膈膜缺损不会对同侧胸膜复发产生不利影响。
