Gemma Gossedge

Treatment of peritoneal carcinomatosis with photodynamic therapy: Systematic review of current evidence

BACKGROUND Peritoneal carcinomatosis results when tumour cells implant and grow within the peritoneal cavity. Treatment and prognosis vary based on the primary cancer. Although therapy with intention-to-cure is offered to selective patients using cytoreductive surgery with chemotherapy, the prognosis remains poor for most of the patients. Photodynamic therapy (PDT) is a cancer-therapeutic modality where a photosensitiser is administered to patients and exerts a cytotoxic effect on cancer cells when excited by light of a specific wavelength. It has potential application in the treatment of peritoneal carcinomatosis. METHODS We systematically reviewed the evidence of using PDT to treat peritoneal carcinomatosis in both animals and humans (Medline/EMBASE searched in June 2017). RESULTS Three human and 25 animal studies were included. Phase I and II human trials using first-generation photosensitisers showed that applying PDT after surgical debulking in patients with peritoneal carcinomatosis is feasible with some clinical benefits. The low tumour-selectivity of the photosensitisers led to significant toxicities mainly capillary leak syndrome and bowel perforation. In animal studies, PDT improved survival by 15-300%, compared to control groups. PDT led to higher tumour necrosis values (categorical values 0-4 [4=highest]: PDT 3.4±1.0 vs. control 0.4±0.6, p<0.05) and reduced tumour size (residual tumour size is 10% of untreated controls, p<0.001). CONCLUSION PDT has potential in treating peritoneal carcinomatosis, but is limited by its narrow therapeutic window and possible serious side effects. Recent improvement in tumour-selectivity and light delivery systems is promising, but further development is needed before PDT can be routinely applied for peritoneal carcinomatosis.

Robotic Technique for Right Colectomy

only commercially available robotic system. It consists of three components: the operating console, the vision stack, and the robotic cart supporting the robotic arms. The operating console is remotely situated from the operating table and is where the surgeon sits to control the robotic arms and instruments. A pseudo-threedimensional (3-D) operative view is provided by a binocular imaging system. Movements of the robotic arms and instruments are controlled by the surgeon’s fi ngers in the master controls and through a series of foot pedals. The robotic cart supports a laparoscopic camera and two (da Vinci) or three (da Vinci-S, da Vinci-Si) robotic arms. This system is ideally suited to operating within the abdomen. Its advantages over conventional laparoscopy include a stable camera platform under direct surgeon control, a 3-D operative fi eld, intuitive instrument handling with 6-degrees of freedom and an ergonomic operating position for the surgeon. Since its introduction into clinical practice in 1999, this robotic system has been gaining increasing popularity, particularly in urology, gynecological oncology, and colorectal surgery. Initial reports have confi rmed the feasibility and safety of robotic colorectal surgery with a variety of totally robotic and hybrid robotic techniques being described for benign and malignant disease. However, just because a procedure can be performed robotically does not mean that it should be the default operative technique. The robotic approach needs to be justifi ed in terms of patient benefi t and cost-effectiveness. Efforts are being directed to determine the benefi t of the robotic approach in colorectal disease with multicenter, randomized clinical trials currently recruiting [ 1 ]. The purpose of this chapter is to discuss robotic right colectomy, providing a brief overview of the literature, describing the operative technique, and exploring potential advantages and disadvantages as compared to conventional laparoscopic approaches.