Background: The peritoneum of the cul-de-sac is frequently affected in advanced ovarian cancer patients. Stripping of the pelvic peritoneum (SoP) combined with rectosigmoidectomy (RS) in patients with confluent tumor are safe techniques that can eradicate macroscopic disease. We evaluated the therapeutic value of this maximal surgical effort in advanced ovarian cancer. Study design: Data from all consecutive patients with stages IIIC and IV epithelial ovarian cancer, primarily operated on from 1994 through 1998, were collected and analyzed using the chi-square test, Cox regression analysis, and Kaplan-Meier curves including log-rank test. Results: Two hundred forty-four eligible patients were identified; 209 patients had tumor involving the peritoneum of the cul-de-sac. For this subgroup, those who were managed with stripping of the peritoneum (SoP, n = 77) or rectosigmoidectomy (RS, N = 57) had improved 5-year overall survivals relative to those who were not (n = 75). (SoP = 37% versus RS = 39% versus neither = 6%; p < 0.0001). In the subgroup of patients with cul-de-sac involvement optimally cytoreduced, we noted a survival benefit for those who were managed with a maximal pelvic surgical effort (5-year overall survival, 38% [SoP] versus 38% [RS] versus 15% [neither]; p = 0.02). When evaluating patients with no macroscopic residual disease, a survival advantage for patients managed with RS compared with SoP was observed (5-year overall survival, 89% (RS) versus 50% (RS); p = 0.04). Conclusions: Surgical resection of cul-de-sac disease by SoP and RS is associated with improved survival in ovarian cancer patients. Tumor resection with en bloc RS may be preferable to allowing microscopic or infiltrative residual tumor.
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