Comprehensive treatment for the peritoneal metastasis from gastric cancer

Figure 1 Dissection of the lower parietal peritoneum.

Figure 2 Dissection of the upper right parietal peritoneum.

Figure 3 Mobilization of spleen and pancreas tail. The prerenal fascia is cut and the anterior surface of the left adrenal gland is visualized.

Figure 4 Detachment of lesser omentum from Arantius’ duct.

Figure 5 Detachment of greater omentum from transverse colon.

Figure 6 Dissection plane between posterior and anterior transverse mosocolon.

Figure 7 Stripping of the pelvic peritoneum. A: Stripping of the pelvic peritoneum from the urinary bladder and side walls of the pelvis in male; B: Stripping of the pelvic peritoneum with uterus and ovaries in female.

Figure 8 Rectum-preserving peritonectomy. A: The pelvic peritonectomy is started by stripping the peritoneum covering urinary bladder and recto-vesical pouch in male.and the dissection plane reaches the anterior wall of the rectum; B: Photograph after removal of pelvic peritoneum. Rectum is preserved completely.

Figure 9 Pelvic peritonectomy combined with the resection of rectum, uterus and vagina (A) and cut-section in a specimen of low anterior resection of rectum/hysterectomy/bilateral salphyngo-oophorectomy shows peritoneal metastasis on Douglas pouch (B).

Figure 10 Neoadjuvant intraperitoneal/systemic chemotherapy. Oral S-1 (Taiho Pharmaceutical Co., Ltd., Tokyo, Japan) is administered for 14 d at a dose of 60 mg/m², following 7 d rest. Docetaxel (30 mg/m²) and cisplatin (CDDP) (30 mg/m²) are administered by intraperitoneal infusion on day 1 and days 8. Therapy is repeated three times, and laparptomy is done 3 to 4 wk after the last cycle.

Figure 11 Bidirectional intraperitoneal and systemic induction chemotherapy. Oral S-1 is administered for 14 d at a dose of 60 mg/m², followed 7 d rest. Docetaxel (30 mg/m²) and cisplatin (CDDP) (30 mg/m²) are administered by intraperitoneal infusion on day 1, and the same dose of docetaxel and CDDP are systemically administered on days 8. Therapy is repeated three times, and laparotomy is done 3 to 4 wk after the last cycle.

Figure 12 Survival curves of patients treated with cytoreductive surgery and neoadjuvant intraperitoneal/systemic chemotherapy alone. CRS: Cytoreductive surgery; NIPS: Neoadjuvant intraperitoneal/systemic chemotherapy.

Figure 13 Survival of histological responders with negative cytology and peritoneal cancer index ≤ 6 after complete cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy.