Yonsei Med J.  2017 May;58(3):497-504. 10.3349/ymj.2017.58.3.497.

Port-Site Metastases and Chimney Effect of B-Ultrasound-Guided and Laparoscopically-Assisted Hyperthermic Intraperitoneal Perfusion Chemotherapy

• Ba MC
• Long H
• Zhang XL
• Gong YF
• Yan ZF
• Wang S
• Tang YQ
• Cui SZ

• KMID: 2419105
• DOI: http://doi.org/10.3349/ymj.2017.58.3.497

Abstract

PURPOSE
COâ‚‚ leakage along the trocar (chimney effect) has been proposed to be an important factor underlying port-site metastasis after laparoscopic surgery. This study aimed to test this hypothesis by comparing the incidence of port-site metastasis between B-ultrasound-guided and laparoscopically-assisted hyperthermic intraperitoneal perfusion chemotherapy (HIPPC).
MATERIALS AND METHODS
Sixty-two patients with malignant ascites induced by gastrointestinal or ovarian cancer were divided into two groups to receive either B-ultrasound-guided or laparoscopically-assisted HIPPC. Clinical efficacy was assessed from the objective remission rate (ORR), the Karnofsky Performance Status (KPS) score, and overall survival. The incidence of port-site metastasis was compared between the two groups.
RESULTS
Patients in the B-ultrasound (n=32) and laparoscopy (n=30) groups were comparable in terms of age, sex, primary disease type, volume of ascites, and free cancer cell (FCC)-positive ascites. After HIPPC, there were no significant differences between the B-ultrasound and laparoscopy groups in the KPS score change, ORR, and median survival time. The incidence of port-site metastasis after HIPPC was not significantly different between the B-ultrasound (3 of 32, 9.36%) and laparoscopy (3 of 30, 10%) groups, but significantly different among pancreatic, gastric, ovarian, and colorectal cancer (33.33, 15.79, 10.00, and 0.00%, p<0.001).
CONCLUSION
The chimney effect may not be the key reason for port-site metastasis after laparoscopy. Other factors may play a role, including the local microenvironment at the trocar site and the delivery of viable FCCs (from the tumor or malignant ascites) to the trauma site during laparoscopic surgery.

Keyword

Chimney effect; laparoscopy; B-ultrasound; HIPPC; port-site metastasis

MeSH Terms

Adenocarcinoma/etiology/*secondary
Adult
Aged
Antineoplastic Agents/*administration & dosage
Ascites/*drug therapy/etiology
Chemotherapy, Cancer, Regional Perfusion/*methods
Colorectal Neoplasms/drug therapy/pathology
Female
Humans
Hyperthermia, Induced/*methods
Incidence
Laparoscopy/adverse effects/*methods
Middle Aged
Neoplasm Metastasis
Ovarian Neoplasms/drug therapy/pathology
Peritoneal Cavity
Peritoneal Neoplasms/complications/*drug therapy
Prospective Studies
Remission Induction
Surgical Instruments
Ultrasonography, Interventional/*methods
Antineoplastic Agents

Figure

• 

  Fig. 1 Placement sites for the infusion and outflow catheters, for B-ultrasound-guided HIPPC (A) and laparoscopically-assisted HIPPC (B). a mark the two infusion catheters, b mark the two outflow catheters, and the white clips mark the loop circuit for HIPPC preparation. HIPPC, hyperthermic intraperitoneal perfusion chemotherapy.

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  Fig. 2 Abdominal CT scan (axial) showing a port-site metastasis (arrow) on the right abdominal wall.

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  Fig. 3 Abdominal CT scan (axial) in a patient with gastric cancer exhibiting port-site metastasis (arrow) and recurrence of ascites 3 months after B-ultrasound-guided hyperthermic intraperitoneal perfusion chemotherapy.

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  Fig. 4 Histopathological examination of a resected tumor (hematoxylin and eosin staining, ×400). The metastatic nodule resected from the abdominal wall was a well-differentiated adenocarcinoma; the pathological type and degree of differentiation were the same as those of the primary tumor.

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  Fig. 5 Immunohistochemical assessment of a metastatic nodule in the abdominal wall (hematoxylin and eosin staining, ×100). The carcinoembryonic antigen expression of the metastatic nodule was the same as that of the primary tumor.

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