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Nogueiro J, Fathi NQ, Guaglio M, Baratti D, Kusamura S, Deraco M. Risk factors for gastrointestinal perforation and anastomotic leak in patients submitted to cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:107020. [PMID: 37597284 DOI: 10.1016/j.ejso.2023.107020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/22/2023] [Accepted: 08/11/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Gastrointestinal leak is one of the most feared complications after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) and harbors significant postoperative morbidity and mortality. We aim to identify risk-factors for anastomotic leak (AL) and gastrointestinal perforation (GP) to optimize postoperative outcomes of this population. METHODS We performed a retrospective analysis of 1043 consecutive patients submitted to CRS in a single institution. Potential risk factors for AL and GP, both related to patient overall condition, disease status and surgical technique were reviewed. RESULTS Anastomotic leaks were identified in 5.2% of patients, and GPs in 7.0%. The independent risk-factors for AL were age at surgery (OR1.40; CI95% 1.10-1.79); peritoneal cancer index (PCI) (OR1.04, CI95% 1.01-1.07); Cisplatin dose >240 mg during HIPEC (OR3.53; CI95% 1.47-8.56) and the presence of colorectal (CR) or colo-colic (CC) anastomosis (OR5.09; CI95% 2.71-9.53, and 4.58; CI95% 1.22-17.24 respectively). Male gender and intraoperative red blood cell transfusions were the only independent risk factors for GP identified (OR1.70; CI95% 1.04-2.78 and 1.06; CI95% 1.01-1.12, respectively). Regarding 30-day and 90-day postoperative mortality, independent risk-factors were mainly related to patient's overall condition. CONCLUSION Gastrointestinal leaks are a frequent source of postoperative morbidity, mainly at the expense of GP. A careful and systematic intraoperative revision of all potential gastrointestinal injuries is equally critical to perfecting anastomotic fashioning techniques to decrease gastrointestinal complication rates. We identified multiple risk-factors for AL and GP related to disease status and patient condition. Our study suggests that patient-related conditions are of paramount relevance, highlighting the importance of patient selection and preoperative patient optimization.
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Affiliation(s)
- Jorge Nogueiro
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Fellow from Department of General Surgery, São João University Hospital Center, Porto, Portugal; Medical Faculty, University of Porto, Porto, Portugal
| | - Nik Qisti Fathi
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Fellow from University Putra Malaysia, Malaysia
| | - Marcello Guaglio
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Dario Baratti
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Shigeki Kusamura
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marcello Deraco
- Peritoneal Surface Malignancies Unit Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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Strowitzki MJ, Kimmer G, Wehrmann J, Ritter AS, Radhakrishnan P, Opitz VM, Tuffs C, Biller M, Kugler J, Keppler U, Harnoss JM, Klose J, Schmidt T, Blanco A, Taylor CT, Schneider M. Inhibition of HIF-prolyl hydroxylases improves healing of intestinal anastomoses. JCI Insight 2021; 6:139191. [PMID: 33784253 PMCID: PMC8119215 DOI: 10.1172/jci.insight.139191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 03/24/2021] [Indexed: 12/15/2022] Open
Abstract
Anastomotic leakage (AL) accounts for a major part of in-house mortality in patients undergoing colorectal surgery. Local ischemia and abdominal sepsis are common risk factors contributing to AL and are characterized by upregulation of the hypoxia-inducible factor (HIF) pathway. The HIF pathway is critically regulated by HIF-prolyl hydroxylases (PHDs). Here, we investigated the significance of PHDs and the effects of pharmacologic PHD inhibition (PHI) during anastomotic healing. Ischemic or septic colonic anastomoses were created in mice by ligation of mesenteric vessels or lipopolysaccharide-induced abdominal sepsis, respectively. Genetic PHD deficiency (Phd1-/-, Phd2+/-, and Phd3-/-) or PHI were applied to manipulate PHD activity. Pharmacologic PHI and genetic PHD2 haplodeficiency (Phd2+/-) significantly improved healing of ischemic or septic colonic anastomoses, as indicated by increased bursting pressure and reduced AL rates. Only Phd2+/- (but not PHI or Phd1-/-) protected from sepsis-related mortality. Mechanistically, PHI and Phd2+/- induced immunomodulatory (M2) polarization of macrophages, resulting in increased collagen content and attenuated inflammation-driven immune cell recruitment. We conclude that PHI improves healing of colonic anastomoses in ischemic or septic conditions by Phd2+/--mediated M2 polarization of macrophages, conferring a favorable microenvironment for anastomotic healing. Patients with critically perfused colorectal anastomosis or abdominal sepsis could benefit from pharmacologic PHI.
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Affiliation(s)
- Moritz J Strowitzki
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany.,School of Medicine and Conway Institute of Biomolecular & Biomedical Research, University College Dublin, Dublin, Ireland
| | - Gwendolyn Kimmer
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Julian Wehrmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Alina S Ritter
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Praveen Radhakrishnan
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Vanessa M Opitz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Christopher Tuffs
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Marvin Biller
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Julia Kugler
- School of Medicine and Conway Institute of Biomolecular & Biomedical Research, University College Dublin, Dublin, Ireland
| | - Ulrich Keppler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany.,Department of Anaesthesiology, Heidelberg University, Heidelberg, Germany
| | - Jonathan M Harnoss
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Johannes Klose
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Alfonso Blanco
- Flow Cytometry Core Technology. Conway Institute of Biomolecular & Biomedical Research, University College Dublin, Dublin, Ireland
| | - Cormac T Taylor
- School of Medicine and Conway Institute of Biomolecular & Biomedical Research, University College Dublin, Dublin, Ireland
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
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