Debulking (cytoreductive)

surgery

By Tsega T(BSc. MSc/IESO)

Menelik II Medical and health Science college
 Learning Objectives
• After completing the learning activity,
students should be able to:
• Understand the role of cytoreductive surger
• Formulate a strategic operative approach to
advanced-stage ovarian cancer and implement
appropriate patient selection criteria.
• Describe the critical steps in performing
advanced cytoreductive surgical procedures.
 Introduction
•  Debulking (cytoreductive) surgery is done to
remove some, but not all, of the cancer.
• It’s done when taking out all of the tumor would
cause too much damage to nearby organs or
tissues.
• In these cases, we take out as much of the tumor as
possible and then treat what’s left with radiation or
chemotherapy.
• Debulking surgery may be used for advanced cancer
of the ovary and some lymphomas.
 Prevalence-Ovarian cancer
• Ovarian cancers (of the several cell types) comprise 4%
of new cancers and 6% of cancer deaths in the female,
according to the American Cancer Society in 2004.
• Fourth most common cause of death in women
• 30% of genital malignancies in the developed countries
• Lifetime risk of having ovarian cancer 1.7%
• Majority (60-70%) of cases are diagnosed in advanced
stage .
 EPITHELIAL OVARIAN CANCER

• Most common ovarian cancer- 90% .

• 80% are primary in ovary
• 20% -metastatic from breast ,GIT , and colon
• Mean age at diagnosis - 60 years.
• Effect of menopausal status
– In menopausal women- 30% of ovarian neoplasm
are malignant
– In premenopausal women- 7% are malignant.
 ETIOLOGY

Various theories
Etiology not well known
Hereditary or familial ovarian cancer
1) BRCA 1&2 mutations
2) Ras oncogenes,
3) p53 mutations
 RISK Modifiers

Risk factors Protective factors

• Nulliparity • Oral contraceptive
• Infertility • Pregnancy
• Breast feeding
• Early menarche
• Tubal –ligation
• Late menopause • Hysterectomy
• Endometriosis • Prophylactic salpingo-
• Family history oophorectomy.
• Prolonged use of ovulation
inducing drugs
• HRT
 Ovarian Cancer
• No effective screening
• More than 60% stage III-IV
• Agressive cytoreduction
followed by platin - taxane
chemotherapy
• 70-80% clinical remission
• Most patients will relapse and cure rate is 20-
25%
• The aim is the prevention or delay of
progression, and recurrence after PDS
 Cont’d
• The effects of chemotherapy (with agents such as
cisplatin-cyclophosphamide, peclitaxel-cisplatin, etc.)
are variable, as these tumor cells develop resistance
or become relatively dormant and nonsusceptible to
the drugs.
• On that basis, it has been found that minimizing the
residual tumor tissue surgically, i.e., employing a
cytoreductive or a “debulking”procedure, can
prolong the patient’s survival and sometimes permit
chemotherapy to be more effective subsequently.
 Therapy depends on:
• Patients’ factor
– (Age, performance, fertility desire)
• Tumor factors
– (Histology, grade, molecular)
• Genetic alterations
• Surgeon factor
• Clinical factors
– (Accurate diagnosis, extend of tumor, experienced
team, high-volume hospital)
 Pre-operative work-up
• History-Examination
– (systemic, abdominal, pelvic)
• Lab studies
– (cyto, chemical marker… etc )
• Imaging
– ( USG, CT, if needed MRI, positron
emission tomography (PET))
• L/S (open) or Small Incision L/T
– ( Primary or metastatic possibility of
surgery – Fagotti’s, Bristow’s,
– Leuven-Essen criterias)
 Currently Standard Upfront
Therapy
• In advanced epithelial OC primary
debulking surgery aiming to remove
all visible tumor tissue followed by
adjuvant CT with Platinum/Taxane ±
Bevacizumab
 Cytoreductive surgery
• Cytoreductive surgery is done primarily after the diagnosis
and staging are determined or in response to a second-look
procedure after a course of chemotherapy.
• Unfortunately, ovarian cancer can spread directly in the
pelvis, including genitalia, bladder, and rectosigmoid colon,
and to pelvic and paraaortic lymph nodes (requiring
lymphadenectomy), greater omentum, small intestine
(especially terminal ileum), spleen, liver, diaphragm, and
peritoneal surfaces, etc.
• The goal of the surgery is to excise or ablate as much of the
gross metastatic tumor and involved organs as possible.
• The procedure can be formidable, and clinical judgment
must guide the extent of the procedure.
Rationale of Primary Debulking Surgery
• Nearly all rapid proliferation of tumor cells is in the
preclinical phase
• Bulky tumors respond poorly to chemotherapydue to
poor blood supply
• Removal of large bulky tumors improves the sensitivity
of residual masses to postoperative chemotherapy by
shifting to rapid growth phase of the cell cycle
• With less tumor volume, there is a greater likelihood
of tumor eradication before chemoresistance develops
• Tumor burden of 3x1012 is lethal
Primary Debulking Surgery
PDS IDS SDS
Middle & Lower Upper Abdominal
Abdominal
Hysterectomy Diaphragm
Oopherectomy Splenectomy
Bowel resection Distal Pancreatectomy
Appendectomy Liver resection
LND (Pelvic,aortic) Porta Hepatis resection
Others

VATS
 Preparation of the Patient
• Apply antiembolitic hose.
• Patient is in modified lithotomy position
with the buttocks positioned just over
the lower break in the table and the
arms extended on padded armboards.
• Padded shoulder braces are secured to
the table.
• The table may be placed in
Trendelenburg position.
• Pad all bony prominences and areas
vulnerable to skin and neurovascular
trauma or pressure.
• CVP and arterial lines may be required;
consult surgeon and anesthesia
provider.
• Apply electrosurgical dispersive pad.
Skin Preparation
• Both a vaginal and an abdominal prep
are required; two separate prep trays
are require used.
• The patient’s legs are placed in a
froglike position; prep as for D&C.
• Insert Foley catheter and connect it to
drainage unit.
• Return the patient’s legs to their
original position, place the drainage
tubing and unit below the level of the
table, and replace the safety belt.
• For the abdominal preparation, begin
at the midline, extending from nipples
to mid-thighs and down to the table at
the sides.
• Draping Folded towels and a transverse
or laparotomy sheet
Equipment
• Sequential compression device
with disposable leg wraps, if
requested
• Forced-air warming blanket, if
ordered
• Central venous pressure (CVP)
equipment, optional
• Padded shoulder braces
• Suctions (2)
• ESU Scales (2) for weighing
sponges
• Cavitational Ultra Sound
• Aspirator (CUSA) console, optional
• Argon beam coagulator console,
optional
Instrumentation
• Major procedures tray Long
instruments tray, available
• Vascular procedures tray,
available
• Gastrointestinal tray, available
• Gastrointestinal staplers (with
staples in unit), e.g., EEA,TA, GIA,
available
• Multifire Hemoclip applicators
with clips
• CUSA handpiece with tip
(aspiration, irrigation, ultrasound
vibration) and cord, optional
• Argon beam coagulator
handpiece and cord, optional
 Supplies

• Antiembolitic hose
• Blades, (3) #10
• Basin set
• Needle magnet or counter
• Suction tubing with in-line filter, e.g., Clear View
• Electrosurgical pencil and cord with holder and scraper
• Foley catheter with tubing and drainage unit
• Aspiration tubes for washings, several, as needed
• Labels for aspiration tubes
• Pleurevac™, if diaphragm is perforated, optional
• Chest tube, e.g., Argyle, optional
• Connector 5-in-1 (for chest tube)
• Colostomy pouch (Karaya Seal™), optional
• Sanitary napkin belt or T-binder
• Perineal pad
 Procedure

• The peritoneal cavity is entered by a lower

midline incision (that can be extended
cephalad, as necessary).
• The entire peritoneal cavity is explored, and
any ascitic fluid is sent for cytologic exam.
• In the absence of ascites, washings taken in the
pelvis, paracolic gutters, and subdiaphragmatic
spaces are sent for cytological examination.
• Tissue samples may also be sent.
 Cont’d

• If ovarian cancer is confirmed, hysterectomy and

bilateral salpingo-oophorectomy is performed.
• In special circumstances, oocytes may be harvested
for fertility considerations (in vitro fertilization with
surrogate implantation).
• If no gross metastases are found, multiple biopsies are
taken in the peritoneal cavity and retroperitoneally.
• If metastatic disease is present, the surgery may be
terminated and chemotherapy instituted with
subsequent cytoreductive surgery, or the procedure to
be performed initially is undertaken.
 Cont’d
• After incising the hepatic ligaments, the peritoneum
can be stripped from the diaphragm.
• If the diaphragm is perforated, these wounds are
repaired and a thoracostomy tube is placed.
• The rectosigmoid colon can be resected with primary
anastomosis or Hartmann procedure.
• If segments of the small bowel are involved, especially if
a pending obstructive situation can be determined,
local limited resection (or bypass) can be done.
• The abdomen is closed in layers.