Study supports routine omentectomy in the absence of metastasis during CRS-HIPEC

Almost one-third of patients undergoing omentectomy for peritoneal metastases had occult omental metastases, supporting routine omentectomy before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), the retrospective review authors concluded.

Among 72 patients with a grossly normal omentum, 23 had occult metastases. More than half of the patients who did not undergo omentectomy had peritoneal recurrences, including omental recurrences in more than 20% of cases.

“Patients who underwent CRS-HIPEC with major omentectomy and had a grossly normal omentum had a high rate of occult histological omental metastases,” explained Drs Annals of Surgical Oncology. “Omentectomy was not associated with higher morbidity than in patients without omentectomy. In addition, one fifth of patients without omentectomy had recurrence of the omentum.

“A routine omentectomy in the absence of gross metastases is therefore recommended during CRS-HIPEC procedures.”

The study provides guidance on the potential value of routine omentectomy during CRS-HIPEC, said Daniel Joyce, MBBCh, of the Cleveland Clinic, who was not involved in the study.

“Personally, I always do a major omentectomy because the omentum can be a nuisance to the outflow catheters with the closed HIPEC technique,” Joyce said MedPage today by email. “This paper strengthens the oncology case for CRS-HIPEC. Interestingly, much has been written about the role of omentectomy in curative gastric cancer surgery and there may not be any significant benefit to this patient population. But of course this is a different disease and different disease stage compared to this patient population.”

CRS-HIPEC has received support for the treatment of peritoneal mesothelioma and isolated peritoneal metastases, which are associated with multiple types of cancer, including malignancies of the stomach, appendix, colon and ovaries. There is no standard CRS-HIPEC protocol for different malignancies, and approaches vary from center to center, Baumgartner’s group noted.

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Peritoneal recurrence rates also vary with histology and disease burden, but generally depend on the completeness of cytoreduction, they added.

A major omentectomy during CRS has also traditionally been performed without visible omental metastases. The rates of omental metastases without visible disease are generally unknown. Given the physiologically uncertain role of the omentum and the potential risks of omentectomy, some specialists have questioned the need for omentectomy with other surgical oncology procedures.

Baumgartner and colleagues performed a retrospective review of omentectomy cases to determine the rate of occult omental metastases in patients undergoing CRS-HIPEC for peritoneal malignancies. Data analyzes included 683 CRS-HIPEC procedures performed in 654 patients from August 2007 to August 2020. Major omentectomy was performed in 580 (84.9%) cases.

The most common types of cancer were appendicitis (61.6% of cases), colorectal cancer (20.8%) and mesothelioma (9.1%). Patients who underwent major omentectomy had higher rates of complete cytoreduction (97.3% vs 92.2%) and splenectomy (36.4% vs 10.7%, P<0.001) and longer hospital stay (9 vs. 7 days).

Time to return of bowel function, postoperative ileus rate, and 60-day overall complication index were similar in patients with and without omentectomy.

In the omentectomy group, 452 patients (77.9%) had gross signs of omental metastases intraoperatively and 72 (12.4%) had a grossly normal omentum. In the remaining 56 (9.7%) cases, gross omental appearance was not documented.

Pathology confirmed omental metastases in 421 of 452 (93.1%) patients with macroscopic intraoperative omental metastases. Of the 72 patients with a grossly normal omentum, pathologic evaluation revealed benign histology in 49 (68.1%) cases and occult omental metastasis in 31.9%. Patients with occult omental metastasis had a significantly higher peritoneal cancer index compared to patients without occult metastasis (9 vs. 6, P=0.013).

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The authors identified 43 cases without major omentectomy who had residual mesh described in the surgical notes. During a median follow-up of 25.9 months, 24 (55.8%) patients developed recurrence, which was omental in 9 (37.5%) and extra-omental in 15 (62.5%) cases.

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    Charles Bankhead is senior editor for oncology and also covers urology, dermatology and ophthalmology. He joined MedPage Today in 2007. consequences

disclosure

Baumgartner and co-authors and Joyce disclosed no industry affiliations.

Main source

Annals of Surgical Oncology

Credit: Khan S, et al. “Is Routine Omentectomy a Necessary Part of Cytoreductive Surgery and HIPEC?” Ann Surg Oncol 2023; DOI: 10.1245/s10434-022-12714-7.

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