A tribute to Paul Sugarbaker: the father of cytoreductive surgery

Nearly thirty years ago Paul Sugarbaker first published the classification and description of the techniques of peritonectomy procedures and organ resections as part of cytoreductive surgery1. Since then, Paul Sugarbaker has published numerous manuscripts, books and book chapters and produced videos on peritonectomy procedures. Some of these have been improvisations of the previous descriptions while others have been descriptions of new peritonectomy procedures that he had devised2,3,4. The description of the hepatic bridge and the clearance of the peritoneum in the tunnel created by it, clearance of peritoneal disease in an inguinal hernia, clearance of the foramen of Winslow and peritonectomy of the sub-pyloric space are some of the techniques published subsequently5,6,7,8,9,10. The most recent addition to the list was peritonectomy of the colonic mesentery published in 202111.

Paul Sugarbaker started working on the treatment of peritoneal malignancies in the early eighties and coined the term cytoreductive surgery for a surgical procedure that involved resection of all macroscopic tumor, including electrosurgical removal of the peritoneal tumor deposits, combined with administration of intraperitoneal chemotherapy12,13. The body of publications by Sugarbaker on peritonectomy procedures is the most comprehensive resource on these procedures in the literature, both in terms of the included procedures and the technical descriptions of these procedures. In 2016, Grey’s anatomy, for the first time, included a chapter on the anatomy of the peritoneum by Paul Sugarbaker14. Paul Sugarbaker has set the bar for the quality of operative surgical images published in these manuscripts. Cytoreductive surgery addresses different regions of the peritoneal cavity, and organ systems, and can appear disjointed and unstructured, especially in the setting of extensive peritoneal disease. The intraoperative images in his manuscripts are pristine, demonstrating each anatomical structure with great clarity15. This attention to detail underlines the importance of meticulous surgical technique, and the pursuit of perfection, which to those who have trained and worked with him, are his well-known hallmarks.

Paul Sugarbaker has over the years laid great emphasis on minute technical aspects of cytoreductive surgery, such as the incision and exposure of the peritoneal cavity, meticulous excision of previous surgical scars, use of high voltage electrocautery and copious lavage of the peritoneal cavity16,17,17. One of his most famous aphorisms ‘It’s what the surgeon does not see that kills the patient’ is a manuscript focusing on meticulous surgical technique to reduce peritoneal dissemination from colorectal primary tumors19. In current times, this aphorism incorporates , and underlines, the importance of ‘complete’ cytoreductive surgery which requires meticulous exploration of the abdominal cavity and identification and resection of all sites of disease. However, the original aphorism refers to another important concept that he introduced whereby he described the technique of centripetal surgery which involved starting the dissection far away from the tumor, and employing local peritonectomy procedures to contain the colorectal primary tumor19. While most of his work was on peritoneal metastases of gastrointestinal origin, the principles and concepts introduced by him are applicable to all surgical approaches for peritoneal malignancies. Another very significant Sugarbaker concept is that the peritoneum helps prevent retroperitoneal dissemination of peritoneal malignancy and is thus “the first line of defense” again peritoneal metastases20.

We have, in this short manuscript, attempted the daunting, near impossible, task of summarizing his main work on the principles and techniques of cytoreductive surgery. While not aiming to summarize the survival benefit of cytoreductive surgery, we also draw reference to his work in other fields, especially in the management of parastomal hernias. Many patients who require CRS need an intestinal stoma and live for many years with an excellent quality of life, long enough to develop parastomal hernias, a credit to the efficacy of the procedure for a disease that was a near fatal condition before the era of Paul Sugarbaker21. Arguably, Paul Sugarbaker has also described the most effective method of treatment of parastomal hernias, “the Sugarbaker repair” which is still widely used22,23.

His work on defining crucial imaging features of disease unresectability and the preclinical and clinical work on intraperitoneal chemotherapy would require separate manuscripts to summarize24,25,26,27.

In this issue of the journal, we publish the results of a consensus that aimed to revise the classification of peritonectomy procedures and anatomically define the boundaries of each peritonectomy procedure28,29,30. We involved Paul Sugarbaker in coining, and defining the most appropriate term for each procedure and selecting the most appropriate way to classify these procedures. The manuscripts carry many important remarks and insights from ‘the father of peritonectomy procedures’ and ‘the father of cytoreductive surgery’. As the second, third and fourth generation of peritoneal malignancy surgeons who have worked closely with him for varying periods of time, we hereby ‘render unto Caeser what belongs to Caeser’.