Surgically directed chemotherapy: heated intraperitoneal lavage with a dynamic cytologic control in the complex treatment of pancreatic cancer
Authors: M. S. Zagriychuk  , I. I. Bulik  , Y. I. Masyuk  , K. P. Tumasova  , Y. V. Romaniv  , Yu. V. Nezhentseva  , O. O. Podoprigora  , D. M. Skrypka  , M. V. Riznyk  
Published: July 2019

The aim — to improve the long‑term treatment results of patients with pancreatic adenocarcinoma at different stages by introducing into the complex therapeutic algorithm of intraoperative and postoperative peritoneal lavage with hyperthermic solutions with chemotherapeutic agents and dynamic cytological control using peritoneal washings and imprints.Materials and methods. The study included 14 patients with moderately differentiated (G2) adenocarcinoma of the pancreas I and II stage treated from 2015 to 2018. The men were 9, women — 5. The average age of patients was 62 ± 2.4 years. In the main group, surgical treatment was supplemented with intraoperative peritoneal lavage with gemcitabine and saline warmed to 43 — 45 ° C for 40 min and gemcitabine as an adjuvant treatment by systemic administration. In the comparison group, radical surgery and adjuvant gemcitabine treatment was performed. The quality of peritoneal lavage was controlled by methods of peritoneal imprints and swabs with cytological control. 5 patients after pancreatic‑duodenal resection and 2 patients after distal subtotal resection of the pancreas with splenectomy were enrolled in each group. The average duration of the Whipple surgery was (348 ± 34) minutes, distal resection of the pancreas with splenectomy — 168 ± 21 minutes in the comparison group, the average duration of the Whipple was 408 ± 38 minutes, distal resection of the pancreas with splenectomy 228 ± 23 minutes in the main group. The reliability of the cytological evaluation, the value of the dissemination coefficient at the beginning and at the end of the operation, before and after the peritoneal lavage, the duration of the recurrent free period, the median survival time and the duration of the period from the moment of surgery to the death of the patient were analyzed.Results and discussion. Peritoneal dissemination studies were conducted in both groups at the beginning and at the end of the operation. Peritoneal imprints were taken from 5 zones of the abdominal cavity, according to the results of cytological analysis of the impressions; the coefficient of dissemination was calculated. Of the 7 patients in the main group, tumor cells or their complexes were detected in 4 cases (57.1 %) of these, in three cases, the coefficient is equal to 2 and in one case, and the coefficient was 3. In three other cases, free tumor cells were not verified, and therefore the coefficient of dissemination was equal to 1. Free tumor cells in the abdominal cavity were detected in 3 patients from 7 (42.9 %), but all three had coefficient 2 in the comparison group. The complications in the immediate postoperative period associated with intraoperative hyperthermia was not noticed. The frequency of other complictions was 15.4 and 16.2 % respectively. The mortality rate was 0. The average duration of the postoperative period was 12.4 and 11.8 days, respectively. The average duration of a non‑recurent period in 3 patients with a dissemination coefficient equal to 1 from the main group was 17.4 months, in 4 patients with a dissemination coefficient in the comparative group. The mean duration of the non‑recurrent period was 12.6 months. In 4 patients in the main group with a coefficient 2, the average duration of the non‑recurrent period was 9.2 months, while in the comparison group in 3 similar patients; this criterion did not exceed 7.4 months. One patient in the main group with a coefficient equal to 3, the duration of the non‑recurrent period was 6 months.4 patients in the main group and 5 patients from the comparison group at the time of writing the article are alive, and therefore, it is not possible to assess the median survival. During the period from 2015 to 2017, 3 patients in the main group were operated, one of whom lived for 36 months after the operation, and two died in 18 and 23 months respectively. In the comparison group, 2 patients operated during the analogical period died at 12 and 14 months respectively.Conclusions. Hypothermic peritoneal lavage with chemotherapeutic drugs, which is performed during surgery, improves the life expectancy and duration of the disease free period in patients with pancreatic cancer. Dynamic cytological monitoring of peritoneal imprints and washes is effective, convenient and practical. Further multicenter research is needed for a more detailed study of the proposed methodology effectiveness.