Cytoreduction including total gastrectomy for pseudomyxoma peritonei

Background: Cytoreductive surgery supplemented by perioperative intraperitoneal chemotherapy is a therapeutic option for selected patients with pseudomyxoma peritonei syndrome. In some patients, the stomach and/or its vascular supply are so covered by mucinous tumour that total gastrectomy is required for complete resection. Methods: Forty-five patients underwent total gastrectomy with a temporary diverting jejunostomy as part of the surgical treatment of pseudomyxoma peritonei syndrome of appendiceal origin. Heated intraoperative intraperitoneal chemotherapy, with mitomycin was used in all patients, and 36 had early postoperative intraperitoneal 5-fluorouracil. To date, 39 patients have had second-look surgery and stoma closure; 37 had additional perioperative intraperitoneal chemotherapy. A prospective database was maintained on all patients. Results: The median age was 47 (range 33-66) years. Median interval from diagnosis of pseudomyxoma peritonei to definitive cytoreductive surgery was 23 (range 0-140) months. Six patients presented with intestinal obstruction. The need for gastrectomy was predicted before operation by abdominal computed tomography. Mean operative time was 13 (range 9-17) h. Mean intraoperative requirement for packed red blood cells was 3.0 units, and that for fresh frozen plasma was 9.9 units. Six peritonectomy procedures, including total gastrectomy, were required for complete cytoreduction. All except seven patients were maintained on parenteral nutrition before second-look surgery for jejunostomy closure. All but two patients have resumed oral nutrition with discontinuation of parenteral feeding. There was one postoperative death and one late death. Thirty-seven patients are alive and disease-free, 0-56 months after initiation of treatment. Conclusion: Total gastrectomy with a temporary, diverting jejunostomy may be used to facilitate complete cytoreduction in patients with advanced pseudomyxoma peritonei syndrome.