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 guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.