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Page 8 of 16 Sugarbaker. J Cancer Metastasis Treat 2018;4:7 I http://dx.doi.org/10.20517/2394-4722.2017.67

Survival (%)
100

80

60

40

20

0 2 4 6 8 10
Time

Figure 5. Overall survival in gastric cancer patients with peritoneal carcinomatosis. (From Canbay et al. [58] with permission)

SURGERY FOR GASTRIC CANCER WITH PERITONEAL METASTASES AFTER NIPS
Gastrectomy and peritonectomy were performed if peritoneal wash cytology became negative or there was
a partial response to neoadjuvant chemotherapy. If peritoneal metastases on small bowel surfaces were
eliminated by NIPS, there was a possibility that gastrectomy and parietal peritonectomy could achieve a
complete cytoreduction. Patients with progressive disease or who continue to have positive cytology despite
4 to 6 cycles of NIPS were not candidates for surgery.

[56]
[57]
Sugarbaker and Yonemura et al. reported the use of peritonectomy for peritoneal metastases to
cytoreduce the peritoneal surface and facilitate total resection of all disease associated with the primary
[7]
gastric cancer. Peritonectomies required for gastric cancer have been described . The epigastric
peritonectomy includes any prior midline abdominal scar with the preperitoneal epigastric fat pad, xiphoid
process, round and falciform ligaments. The anterolateral peritonectomy removes the greater omentum with
the anterior layer of peritoneum from the transverse mesocolon, peritoneum of the right paracolic gutter
along the appendix, and the peritoneum in the right subhepatic space. Sometimes the peritoneum of the
right and left paracolic gutter must also be removed [Figure 6]. The subphrenic peritonectomy takes the
peritoneal surfaces from the medial half of the right and left hemidiaphragm as well as the left triangular
ligament [Figure 7]. The omental bursa peritonectomy starts with cholecystectomy and then removes the
peritoneal covering of the porta hepatis, hepatoduodenal ligament, and floor of the omental bursa including
the peritoneum overlying the pancreas [Figure 8]. If tumor was within the cul-de-sac, a pelvic peritonectomy
was also performed and electroevaporative surgery strips the peritoneum from the pouch of Douglas.
Sometimes, the pelvic peritonectomy will necessitate removal of the rectosigmoid colon [Figure 9]. Some
or all of these visceral resections and parietal peritonectomies were performed to completely remove visible
disease.

RESULTS AFTER NIPS
[58]
Canbay et al. analyzed 194 patients treated by NIPS. Average age was 51.5 ± 12.6 years. One hundred and
four patients had primary gastric cancer and 90 patients had recurrent PM. Peritoneal fluid cytology was