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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
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