The Importance of the Learning Curve and Surveillance of Surgical Performance in Peritoneal Surface Malignancy Programs

Morbidity and mortality of patients with peritoneal malignancy following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

The purpose of this study was to record the incidence, and identify the prognostic variables of morbidity and mortality in patients with peritoneal malignancy undergoing cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

The files of patients with peritoneal malignancy who underwent CRS + HIPEC from 2015-2022 were retrieved. Morbidity and hospital mortality were recorded and correlated to a variety of clinical variables.

RESULTS

A total of 44/192 (22.9%) patients were recorded with postoperative complications. Grade 3 and 4 complications were 12.5%. The possible prognostic variables of morbidity were the extent of peritoneal malignancy and the number of suture lines. The mortality rate was 2.5% (5 patients). The number of FFP units, and peritonectomy procedures were identified as possible prognostic variables of hospital mortality.

CONCLUSIONS

The morbidity rate in patients undergoing CRS + HIPEC is acceptable compared to morbidity of previous publications or major gastrointestinal surgical operations. The possible prognostic variables of morbidity are the extent of peritoneal malignancy, and the number of suture lines. The mortality rate is low. The possible prognostic variables of mortality are the number of FFP units, and the number of peritonectomy procedures.

The effect of the learning curve of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in treating colorectal peritoneal metastasis

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) are increasingly utilised in the management of colorectal peritoneal metastases (CPM). This combined modality is associated with a significant learning curve (LC) and is often criticised for its associated morbidity. This study aims to inspect the LC of this procedure in our institute.

METHODS

A retrospective review of the institution's prospectively maintained database of CRS-HIPEC cases was performed. Patients treated for CPM were stratified into two groups: Group 1 consists of patients in our initial 100 cases of CRS-HIPEC and Group 2 comprises patients treated subsequently. Perioperative prognostic factors and oncological outcomes were analysed.

RESULTS

Between 2001 and 2016, 77 patients with CPM underwent CRS-HIPEC, of which 31 patients (40.3%) were in Group 1 and 46 patients (59.7%) in Group 2. Median follow-up duration was 96 months in Group 1 and 25 months in Group 2. There were no differences in OS (35 months vs 46 months, p = 0.054) and DFS (13 months vs 14 months, p = 0.676) between the groups. There were more patients with higher PCI (≥12) (57.1% vs 22.2%, p = 0.006) and high-grade complications (25.8% vs 8.7%, p = 0.045) in Group 1. Group 2 patients had a shorter hospitalisation (14 days vs 11 days, p = 0.015) and SICU stay (1 day vs 0 days, p < 0.001).

CONCLUSION

An improvement in the perioperative outcomes after CRS-HIPEC for CPM may be partly attributed to overcoming the LC and incorporation of better patient selection methods.

Surgical and oncological outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy at a nonacademic center: 25-year experience

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is predominantly performed and studied in academic centers. While developing CRS/HIPEC programs in nonacademic hospitals can increase accessibility, its safety and oncological efficacy remains unclear. We evaluated CRS/HIPEC outcomes in a nonacademic setting.

METHODS

A single-center descriptive study was conducted using a prospective database. Data of all CRS/HIPEC attempts in peritoneal surface malignancies (PSM) patients from October 1994 to November 2019 were extracted. Surgical and survival outcomes were measured. Center experience was assessed by quartiles of cases.

RESULTS

Overall, 856 patients underwent 948 CRS/HIPEC attempts: 788 (83%) completed CRS/HIPECs, 144 (15%) aborted HIPECs, and 16 (2%) complete cytoreductions (CC-0/1) without chemoperfusion. For completed CRS/HIPECs, median peritoneal cancer index was 24 (interquartile range: 10-33) and CC-0/1 rate was 88%. Major complications occurred in 23.5% with 30- and 100-day mortality of 1.0% and 2.3%, respectively. Median overall survival was 68 months (95% confidence interval [CI]: 50-86). Median progression-free survival was 37 months (95%CI: 28-46). Incomplete cytoreduction and major complication rates decreased over time, while mortality remained low and constant.

CONCLUSIONS

CRS/HIPEC at a nonacademic center with advanced surgical and auxiliary services is a safe option to treat PSM with favorable surgical and oncological outcomes.

Cost analysis of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy and the risk factors for their increased cost in a public insurance health care system - Single centre study

INTRODUCTION

This study aimed to evaluate the costs of CRS and HIPEC and treatment of the related postoperative complications in the public healthcare system. We also aimed to identify the risk factors that increase the cost of CRS and HIPEC.

MATERIALS AND METHODS

We retrospectively evaluated 80 patients who underwent CRS and HIPEC between February 2016 and November 2018 in the Department of Surgery, University Hospital of Olomouc, Czech Republic. Intraoperative factors and postoperative complications were assessed. The treatment cost included the surgery, hospital stay, intensive care unit (ICU) admission, pharmaceutical charges including medication, hospital supplies, pathology, imaging, and allied healthcare services.

RESULTS

The postoperative morbidity rate was 50%, and the mortality rate was 2.5%. The mean length of hospitalisation and ICU admission was 15.44 ± 8.43 and 6.15 ± 4.12 for all 80 patients and 10.73 ± 2.93 and 3.73 ± 1.32, respectively, for 40 patients without complications, and 20.15 ± 13.93 and 8.58 ± 6.92, respectively, for 40 patients with complications. The total treatment cost reached €606,358, but the total reimbursement was €262,931; thus, the CRS and HIPEC profit margin was €-343,427. Multivariate analysis showed that blood loss ≥1.000 ml (p = 0.03) and grade I-V Clavien-Dindo complications (p < 0.001) were independently associated with increased costs.

CONCLUSION

The Czech public health insurance system does not fully compensate for the costs of CRS and HIPEC. Hospital losses remain the main limiting factor for further improving these procedures. Furthermore, treatment costs increase with increasing severity of postoperative complications.

Learning Curve, Training Program, and Monitorization of Surgical Performance of Peritoneal Surface Malignancies Centers

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy is a complex procedure with high cost and significant morbidity and mortality. The associated learning curve is steep and could reliably be evaluated using specific statistics. Risk-adjusted sequential probability ratio test is an effective and robust method to monitor surgical performance in the learning and audit phase of a peritoneal surface malignancies center development. The most critical factor associated with surgical performance is mentoring of the trainee by an expert. A well-structured tutor-based training program has been implemented in Europe. This initiative will improve the standardization of the combined procedure and improve quality of services across the continent.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in gastrointestinal cancers: fad or standard of care?

Peritoneal metastases (PM) are the common endpoint for patients with advanced gastrointestinal cancers. PM from these cancers are often managed in a similar fashion to other sites of systemic metastases, but the following must be taken into consideration. (a) PM do not respond to systemic chemotherapy in the same fashion as liver and lung metastases. (b) PM cause local problems, resulting in disruption of chemotherapy. (c) Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) actually work for PM. (d) PM are not easily detected on imaging modalities. There has been mounting evidence of the effectiveness of CRS-HIPEC at prolonging survival in selected patients with colorectal and gastric PM, but there remains a reluctance to explore this treatment modality. This is likely because of the perceived morbidity and mortality. An effective management strategy employing CRS-HIPEC for selected patients with gastrointestinal PM can only be achieved if a concerted effort is made to understand this disease and address the concerns regarding this treatment.

Outcome and factors associated with aborted cytoreduction for peritoneal carcinomatosis

Background

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) offers a potential cure for peritoneal carcinomatosis (PC), whereas aborted cytoreduction is associated with a poor outcome. We evaluate factors associated with aborted CRS procedures.

Methods

An IRB approved retrospective review was performed from 12/2011 to 2/2016. Clinicopathologic variables and outcomes are described.

Results

Seventy-four patients underwent attempted CRS/HIPEC which was completed in 51 (69%) and aborted in 23 (31%). There was no difference in age, race, gender or prior treatment between groups. Patients who underwent aborted procedures had a higher peritoneal cancer index (PCI, 26.1±9.9 vs. 16.2±10.5, P=0.001). Overall survival (OS) was significantly improved for patients who underwent completed CRS/HIPEC (41.0±10.4 vs. 6.0±2.3 months, P<0.0001). Patients with an appendiceal and colorectal primary who underwent CRS/HIPEC had a significantly better outcome (median not reached vs. 6±5.4 months, P<0.0001, and 28.0±7.5 vs. 8.0±4.0 months, P<0.0001, respectively). Colorectal pathology (P=0.014) and PCI score (<0.0001) were independent predictors of aborted CRS procedures.

Conclusions

One-third of patients with PC had significant disease which prevented successful completion of CRS/HIPEC. PCI and colorectal primary tumor pathology were associated with a greater likelihood of aborted CRS procedures.

Infectious Complications after Cytoreductive Surgery and Hyperthermic Intra-Peritoneal Chemotherapy

BACKGROUND

The aim of this study was to review the post-operative and infectious complications and determine the risk factors associated with infections in cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC).

PATIENTS AND METHODS

Between October 2007 and December 2013, patients who underwent CRS and HIPEC with a curative intent were included in the study. The Centers for Disease Control and Prevention's National Nosocomial Infections Surveillance System definitions were used to identify post-operative nosocomial infections.

RESULTS

One hundred and sixty-nine CRS and HIPEC procedures were performed. Overall, 155 complications were observed in 82 (48.5%) patients. Grade 3-4 morbidity rate was 25.5% (n = 43). Seventy infections occurred in 47 patients. Surgical site infection was the most common infectious complication. The most common micro-organism isolated from the cultures was Escherichia coli. Age (odds ratio [OR]1.039, confidence interval [CI] 1.006-1.073), the mean total number of staff scrubbing in the operation(OR 2.241, CI 1.415-3.548), and intensive care unit stay (OR 1.325, CI 0.953-1.842) were independent risk factors for infectious complications.

CONCLUSIONS

Infectious complications are the most important cause of peri-operative morbidity and death in CRS and HIPEC. As well as patient and tumor characteristics, surgeon/center-related factors play an important role in infectious morbidity. Patients with peritoneal carcinomatosis should be considered as a complex oncologic group at high risk of infectious complications.

Cytoreductive surgery and intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal cancer: 2-year follow-up results at a single institution in Korea

Purpose

The purpose of this study was to examine 2-year follow-up results of cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) for peritoneal carcinomatosis (PC) of colorectal cancer.

Methods

We performed 54 cases of CRS and IPC in 53 patients with PC of colorectal cancer from December 2011 to December 2013. We collected data prospectively and analyzed the grade of PC, morbidity and mortality, and short-term follow-up (median, 10 months; range, 2–47 months) results.

Results

Mean peritoneal cancer index (PCI) was 15 (range, 1–35), and complete cytoreduction was possible in 35 patients (64.8%). Complications occurred in 25 patients (46.3%) and mortality occurred in 4 patients (7.4%). Excluding the 4 mortalities, 17 patients out of 49 patients (31.5%) were alive at the time of the last follow-up and the overall median survival was 10.3 months. Patients with complete cytoreduction had a median survival of 22.6 months, which was significantly longer than the median survival of 3.5 months for patients without complete cytoreduction (P < 0.001). PCI grade, CCR grade, cell type, and postoperative chemotherapy were significant prognostic factors by univariate analysis. Positive independent prognostic factors by multivariate analysis included PCI grade and postoperative chemotherapy.

Conclusion

CRS and IPC increased the survival of patients with low PCI and postoperative systemic chemotherapy was mandatory. However, this combined therapeutic approach showed high rate of complications and mortality. Therefore, this aggressive treatment should be performed in only selected patients by considering the general condition of the patient and the extent of PC.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a review of factors contributing to morbidity and mortality

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with prolonged survival for appropriately selected patients with peritoneal dissemination of abdominal malignancies. CRS and HIPEC has been criticized for perceived high rates of morbidity and mortality. Morbidity and mortality rates of CRS and HIPEC, however, do not appear dissimilar to those of other large abdominal surgeries, particularly when relevant patient and operative factors are accounted for. The risk of morbidity and mortality following this surgery for a given individual can be predicted in part by a variety of patient and operative factors. While strong data are lacking, the limited data that exists on the matter suggests that the independent contribution of the heated intraperitoneal chemotherapy to CRS and HIPEC morbidity is relatively small. A more thorough understanding of the patient and operative factors associated with CRS and HIPEC morbidity and mortality, as well as the specific complications related to the intraperitoneal chemotherapy, can better inform clinicians in multidisciplinary teams and patients alike in the decision-making for this surgery.

Preliminary Experience and Morbidity Analysis of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) from a Tertiary Cancer Center in India

BACKGROUND

Peritoneal carcinomatosis (PC) can arise directly from peritoneum (primary) or from regional spread of gastrointestinal and gynecological malignancies. It is often considered a terminal event. CRS/HIPEC procedure provides encouraging outcomes in select sub-set of patients with PC. In this study we present our initial experience of this combined procedure from a tertiary cancer care center in India.

MATERIALS AND METHODS

Between January 2014 to January 2015, 13 patients underwent CRS + HIPEC procedure at our center. Preoperative assessment for cytoreduction was done using contrast CT-scan of the abdomen and staging laparoscopy. All procedures were performed by the same surgical team. After cytoreduction, HIPEC was performed by closed method.

RESULTS

Median patient age was 52 and median PCI was 13.5 (5-21). Ovarian cancers were commonest origin of PC in our series. All patients had a complete cytoreduction with a median operative time of 8.3 hours. Postoperative ileus was the commonest adverse event. In the immediate postoperative period, major complications were observed in 23% (3/13) of our patients (1. intra-abdominal abscess 2. Septicemia and liver function derangement 3. Bowel obstruction which required a re-operation. Median hospital stay was 12 days (range 9-45 days) and there was no perioperative mortality.

CONCLUSION

Our initial results indicate that CRS + HIPEC procedure can be performed with acceptable morbidity and no mortality. Appropriate case selection by a multi-disciplinary team is vital to achieve complete cytoreduction and optimize outcomes.

Multicentre study of the learning curve and surgical performance of cytoreductive surgery with intraperitoneal chemotherapy for pseudomyxoma peritonei

Background

The learning curves for cytoreductive surgery with intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei (PMP) were explored between international centres/surgeons to identify institutional or other factors that might affect performance.

Methods

Data from patients with PMP treated with the combined procedure across 33 international centres between 1993 and 2012 were analysed retrospectively. A risk-adjusted sequential probability ratio test was conducted after defining the target outcome as early oncological failure (disease progression within 2 years of treatment), an acceptable risk for the target outcome (odds ratio) of 2, and type I/II error rates of 5 per cent. The risk prediction model was elaborated and patients were evaluated sequentially for each centre/surgeon. The learning curve was considered to be overcome and proficiency achieved when the odds ratio for early oncological failure became smaller than 2.

Results

Rates of optimal cytoreduction, severe postoperative morbidity and early oncological failure were 84·4, 25·7 and 29·0 per cent respectively. The median annual centre volume was 17 (range 6–66) peritoneal malignancies. Only eight of the 33 centres and six of 47 surgeons achieved proficiency after a median of 100 (range 78–284) and 96 (86–284) procedures respectively. The most important institutional factor affecting surgical performance was centre volume.

Conclusion

The learning curve is extremely long, so centralization and/or networking of centres is necessary to assure quality of services. One centre for every 10–15 million inhabitants would be ideal.

[Morbidity and mortality of hyperthermic intraperitoneal chemoperfusion]

Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) is a treatment option for peritoneal surface malignancy. Despite the survival benefits, this treatment was previously associated with a high morbidity and mortality rates, and the perception of the poor perioperative outcomes associated with this regimen remains. Careful patient selection with an optimal level of postoperative care must be advocated to avoid undesirable complications of this treatment.However, for this treatment to be accepted as standard of care, teams undertaking this treatment strategy must aim to minimize morbidity and mortality by learning from the experience of established centers and using the "global learning curve". The HIPEC Registry and accreditation of centers will improve the quality of the treatment.

Circulating tumor markers: predictors of incomplete cytoreduction and powerful determinants of outcome in pseudomyxoma peritonei

BACKGROUND

Incomplete cytoreduction (IC) is one of the main prognostic factor in pseudomyxoma peritonei (PMP). We evaluated the ability of preoperative Ca125, CEA, and Ca19-9 to predict IC and prognosis in PMP.

METHODS

One hundred fifty-six cases elected candidate to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy from 1996 to 2011 were included in the study. We assessed the: (1) optimal cut-off values for circulating Tumor markers (CTM) in predicting IC (residual disease >2.5 mm) using receiver-operating characteristics (ROC); (2) discriminant power of CTM and risk prediction models for IC by calculating the area under ROC curve (AUC-ROC); (3) prognostic factors using Cox proportional-hazard model.

RESULTS

Optimal cut-offs were 125 U/ml for Ca125, 18 ng/ml for CEA, and 89 U/ml for Ca19-9. The AUCs-ROC were 0.76, 0.68, and 0.69 for Ca125, CEA, and Ca19-9, respectively. The addition of CTM to risk prediction model that considered preoperative clinicopathological factors increased marginally the AUC-ROC (0.80-0.84). Ca125 > 125 U/ml, Ca19-9 > 89 U/ml independently affected overall survival.

CONCLUSIONS

Preoperative CTMs were reasonable but not perfect discriminators of IC. Moreover, Ca125 and Ca19-9, using new cut-off values, were proven to be new strong prognostic factors that overcome the value of disease extension and histological subtype.