Adjunct surgical techniques safe for complex ovarian cancer cytoreduction


Adjunct surgical techniques such as ultrasonic aspiration and argon-enhanced electrocautery may be safely incorporated during primary debulking surgery for patients with advanced epithelial ovarian, fallopian tube or primary peritoneal cancer with miliary disease, according to a retrospective study in the International Journal of Gynecologic Cancer.

However, these procedures did not improve the rate of complete or optimal cytoreduction.

“Patients with widely disseminated miliary disease have the poorest prognosis and lowest rates of complete resection because of the complexity associated with disease removal,” said first author Sue Li, MD, a resident physician in ob/gyn at Brigham and Women’s Hospital and Massachusetts General Hospital in Boston. “Adjunct surgical techniques are additional tools that may facilitate complete cytoreduction.”

The investigators wondered if these tools were safe and potentially associated with higher rates of complete surgical resection.

The medical records of 135 patients with miliary disease who underwent primary debulking surgery at the two hospitals between 2010 and 2014 were reviewed, of whom 30 (22.2%) patients had surgery using adjunct surgical techniques.

The two most common devices were ultrasonic surgical aspiration (40%) and argon-enhanced electrocautery (36.7%), followed by thermal plasma energy and traditional electrocautery ablation.

First author Sue Li, MD, a resident physician in ob/gyn at Brigham and Women’s Hospital and Massachusetts General Hospital in Boston.

First author Sue Li, MD, a resident physician in ob/gyn at Brigham and Women’s Hospital and Massachusetts General Hospital in Boston.

The four most frequent sites for adjunct techniques were the diaphragm (63.3%), pelvic peritoneum (30%), bowel mesentery (20%) and large bowel serosa (20%).

No differences were detected in age, stage, primary site, histology, operative time, surgical complexity or postoperative complications for patients operated on with or without these devices. “It was very reassuring that in these complex procedures, the use of adjunct surgical techniques was safe,” Dr. Li told Contemporary OB/GYN.

The study also found that the volume of residual disease between 0.1 cm and 1.0 cm was similar: 60.0% with adjunct techniques vs. 68.6% without. Complete surgical resection rates were comparable as well: 16.7% and 13.3%, respectively.

“We were surprised that rates of complete resection were similar, regardless of the use of adjunct surgical techniques,” Dr. Li said. “However, our rate of complete resection was higher compared to previous studies focusing on patients with a large volume of widely disseminated disease.”

For patients with ≤ 1-cm residual disease, the current study found median progression-free survival and median overall survival rates to be statistically nonsignificant: 15 months and 40 months for adjunct techniques vs. 15 months and 55 months without, respectively.

“Not all of our results may be generalizable to institutions that are less familiar with complex resections without the use of adjunct surgical techniques,” Dr. Li said.

“In settings where surgeons may be less equipped for complex resections than the two institutions in the current study, adjunct surgical techniques can safely be used and are better than abandoning resection in a particular anatomic area.”

A patient’s survival is significantly improved when a complete resection is achieved, according to Dr. Li. “The more tools you have in your ‘surgical toolbox,’ the better equipped you will be to safely achieve a complete resection,” she said.

The ongoing PlaComOv randomized controlled trial in The Netherlands is designed to evaluate the safety and efficacy of plasma thermal energy as an adjunct surgical technique.

“Beyond safety, that study is powered to evaluate equivalency in survival when using the technology to resect disease as opposed to simply using conventional surgical resection techniques,” Dr. Li said. “Our study was not powered to look at survival, so the Netherlands study should shed further light on the use of adjunct surgical techniques.”

Dr. Li reports no relevant financial disclosures.


  1. Li S, Manning-Geist B, Gockley A, Ramos A, et al. Use of ablation and ultrasonic aspiration at primary debulking surgery in advanced stage ovarian, fallopian tube, and primary peritoneal cancer. Int J Gynecol Cancer. Published online June 2, 2020. doi:10.1136/ijgc-2020-001466.
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