The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Cytoreduction surgery followed by hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis.
It replaces the previous guidance on Cytoreduction surgery followed by hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis (NICE interventional procedures guidance 116, November 2004).
Peritoneal metastases commonly result from the regional spread of gastrointestinal, gynaecological and other malignancies. Peritoneal carcinomatosis is an advanced form of cancer associated with short survival and poor quality of life, which may lead to bowel obstruction, ascites and pain.
This procedure was developed by Paul Sugarbaker at the Washington Cancer Institute. A laparotomy is performed under general anaesthesia and all gross tumour is removed along with the involved organs, peritoneum and tissue. The surgery includes:
- removal of the right hemicolon, spleen, gall bladder, parts of the stomach, greater omentum and lesser omentum
- stripping of the peritoneum from the pelvis and diaphragm
- stripping of tumour from the surface of the liver
- removal of the uterus and ovaries in women
- removal of the rectum in some cases.
The aim of the surgery is to remove all macroscopic tumour, although residual tumour is sometimes left behind.
In the second stage of the procedure , the abdomen is perfused with fluid containing a chemotherapy agent, heated to between 40 and 48°C. The fluid is perfused for 60 to 120 minutes and then drained from the abdomen, before the laparotomy is closed. A further course of systemic or intraperitoneal chemotherapy may be administered after the surgery.
Intraoperative intraperitoneal administration of chemotherapy allows the drug to be distributed uniformly to all surfaces of the abdomen and pelvis. Potential advantages of heating the perfusion fluid are that it increases drug penetration and the cytotoxic effect of drugs such as mitomycin C and cisplatin.
This procedure cannot be expressed in the OPCS-4 classification by a single code. The current guidance would be to code each organ removed as per normal coding rules, and to combine this with the ICD-10 diagnosis code C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum. The appropriate code for the primary malignant neoplasm is also recorded, if this is not stated or unspecified then a code from category C80.- Malignant neoplasm, without specification of site is recorded.
Heated chemotherapy cannot currently be specifically captured using OPCS-4. At present this is captured using the following codes:
T48.2 Introduction of cytotoxic substance into peritoneal cavity plus a code from categories X70-X71 Procurement of drugs for chemotherapy for neoplasm in Bands 1-10 dependent on the regimen prescribed.