The relationship between baseline nutritional status with subsequent parenteral nutrition and clinical outcomes in cancer patients undergoing hyperthermic intraperitoneal chemotherapy

The relationship between baseline nutritional status with subsequent parenteral nutrition and clinical outcomes in cancer patients undergoing cytoreductive surgery: a retrospective study

Introduction

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) with Cytoreductive Surgery (CRS) is the preferred treatment for peritoneal malignancies. This highly complex operation is associated with a high incidence of complications, particularly due to malnutrition. This study aimed to investigate the potential association between preoperative nutritional status and postoperative clinical outcomes in adult cancer patients who underwent CRS/HIPEC for peritoneal malignancy.

Methods

A retrospective study with 140 adult cancer patients, on parenteral nutrition (PN) (n = 40) and not on PN (n = 100) who underwent CRS with or without HIPEC, was conducted.

Results

Patients who received PN had significantly longer post-operative, hospital, and ICU LOS than those who did not (p = 0.001). ICU admission was significantly higher in the non-PN receiving group compared to the PN receiving group. When compared to the PN group, the majority of patients not receiving PN were at low risk of malnutrition (91% vs. 75%, p = 0.020), whereas 17.5% of PN patients were at risk of malnutrition during hospitalization. Multiple regression analyses revealed a strong positive relationship between patients with increased risk of malnutrition and ICU LOS (p = 0.047).

Discussion

Routine preoperative nutrition assessment is essential to identify patients who are at higher nutritional risk, and nutrition support should be provided preoperatively.

Nutrition Care for the Patient Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

The treatment for peritoneal malignancies has evolved over the years with the growing success of cytoreductive surgery combined with the use of hyperthermic intraperitoneal chemotherapy. Patients receiving this treatment are at risk for developing malnutrition not only due to the areas of tumor involvement but also due to the risk of undernutrition if nutritional interventions are not timely or fall short of their goal. Malnutrition leads to a gamut of health consequences. Understanding peritoneal malignancies, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, as well as the latest nutrition research may lead to a focus on the prevention or attenuation of the procedure's associated malnutrition risk. Reducing the effects of malnutrition in these patients is the goal of the nutrition support practitioner.

A global analysis of nutrition support practices in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignancy

BACKGROUND

Perioperative nutritional care has been identified as an important factor in the management of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Nevertheless, there is no published consensus on best practice for nutritional management specific to this patient group. The purpose of this study was to identify the current nutrition care practices among international centres performing CRS and HIPEC for patients with peritoneal malignancy.

METHODS

An online survey was developed and sent to experienced CRS and HIPEC centres. The survey questions covered clinician and institution demographics, formal nutrition care pathways, pre-operative nutrition care, post-operative nutrition support and post-discharge nutritional follow-up.

RESULTS

Eighty-two centres were contacted, and 42 responses were received. Respondents were from 20 different countries and were mostly dietitians (71%). Nutrition assessments were frequently completed (52% pre-operatively and 86% post-operatively) and most centres used a validated nutrition screening or assessment tool (79%). Perioperative nutrition support with respect to the use of enteral nutrition, parenteral nutrition and enhanced recovery after surgery varied widely between centres. The use of routine parenteral and enteral nutrition was significantly higher in Europe compared with other locations (p = 0.028).

CONCLUSIONS

Nutrition care is pivotal and has been positively integrated into the complex management of patients undergoing CRS and HIPEC globally, however variation in practice is evident. The findings highlight a unique opportunity to collaboratively investigate the role nutrition plays in determining outcomes and to identify the most appropriate nutrition support methods to achieve improved clinical outcomes for these high-risk patients.

Parenteral nutrition after cytoreductive surgery for peritoneal malignancy: Should it be administered routinely?

PURPOSE/BACKGROUND

Cytoreductive surgery (CRS) is complex abdominal surgery that is used to treat peritoneal malignancy. CRS is associated with major morbidity and efforts to address this include optimisation of perioperative care. There is variation in international protocols on the nutritional management after CRS, in particular whether parenteral nutrition (PN) should be routinely or selectively administered.

HYPOTHESIS/AIM

This study assessed parenteral nutrition use, factors associated with PN requirement and nutritional outcomes in a centre that selectively uses PN after CRS.

METHODS/INTERVENTIONS

A retrospective analysis was undertaken on patients who underwent cytoreductive surgery ± hyperthermic intraperitoneal chemotherapy (HIPEC) at Peter MacCallum Cancer Centre between 1st January 2015 and 31st December 2020 using data entered into a prospectively maintained database. Patient characteristics, nutritional status, oncological parameters, operative details and postoperative outcome data were retrieved. Categorical variables were compared using the chi-squared test and continuous data was compared using a non-parametric Mann-Whitney U-test. A p-value <0.05 was considered statistically significant. Cox regression analysis was performed to identify independent predictors of requiring PN and postoperative weight change over admission.

RESULTS

A total of 222 patients who had CRS between were included (mean age 56 years; female 61.3%). Preoperative nutritional characteristics of participants included a mean body mass index (BMI) of 27.6 kg/m2 and the majority (77.9%) were not at nutritional risk pre-operatively with a Patient Generated Subjective Global Assessment (PG-SGA) score of category A. A high proportion of patients had surgery for colonic adenocarcinoma (58.1%), received HIPEC (87.4%) and achieved complete cytoreduction (82%). Postoperative parenteral nutrition was required for 65 patients (29.3%). The most frequent indication for PN was postoperative ileus (63.1%) with the mean (SD) time to commencing PN being postoperative day 5. Factors associated with the requirement for postoperative PN included preoperative albumin (OR 0.89; p = 0.015), weight loss >5% of body weight in the 6 months prior to admission (OR 2.2; p = 0.05), higher PCI score (OR 1.048; p = 0.005), number of anastomoses completed (OR 1.766; p = 0.017) and development of any postoperative complication (OR 2.71; p = 0.009). PN use was not associated with postoperative weight change.

CONCLUSION

Most patients undergoing CRS did not require post-operative PN. Nutritional and operative factors may identify patients who are likely to need PN after surgery. Selective use of PN did not impact on postoperative weight change.

Clinical significance of the advanced lung cancer inflammation index in gastrointestinal cancer patients: a systematic review and meta-analysis

Background

The advanced lung cancer inflammation index (ALI) has been identified as a scientific and clinical priority in multiple malignancies. The aim of this study is to investigate the value of the ALI before treatment in evaluating postoperative complications (POCs) and survival outcomes in patients with gastrointestinal (GI) cancer.

Methods

Electronic databases including PubMed, Embase and Web of Science were comprehensively reviewed up to June 2022. The endpoints were POCs and survival outcomes. Subgroup analyses and sensitivity analyses were also performed.

Results

Eleven studies including 4417 participants were included. A significant heterogeneity in the ALI cut-off value among studies was observed. Patients in the low ALI group showed increased incidence of POCs (OR=2.02; 95%CI:1.60-2.57; P<0.001; I² = 0%). In addition, a low ALI was also significantly associated with worse overall survival (HR=1.96; 95%CI: 1.58-2.43; P<0.001; I² = 64%), which remained consistent in all subgroups based on country, sample size, tumor site, tumor stage, selection method and Newcastle Ottawa Scale score. Moreover, patients in the low ALI group had an obviously decreased disease-free survival compared to these in the high ALI group (HR=1.47; 95%CI: 1.28-1.68; P<0.001; I² = 0%).

Conclusion

Based on existing evidence, the ALI could act as a valuable predictor of POCs and long-term outcomes in patients with GI cancer. However, the heterogeneity in the ALI cut-off value among studies should be considered when interpreting these findings.

Perioperative nutritional assessment and interventions in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC): A systematic review

BACKGROUND

Peritoneal carcinomatosis is a catabolic state and cytoreductive surgery (CRS) is a high morbidity operation. Optimising perioperative nutrition is crucial to improve outcomes. This systematic review sought to examine literature describing clinical outcomes related to preoperative nutrition status and nutrition interventions in patients undergoing CRS with hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

A systematic review was registered with PROSPERO (300326). A search of eight electronic databases was undertaken on 8th May 2022 and reported according to the PRISMA statement. Studies reporting nutrition status through use of screening and assessment tools, nutrition interventions or nutrition-related clinical outcomes for patients undergoing CRS with HIPEC were included.

RESULTS

Of 276 screened studies, 25 studies were included for review. Commonly used nutrition assessment tools for CRS-HIPEC patients included Subjective Global Assessment (SGA), sarcopenia assessment with computed tomography, preoperative albumin, and body mass index (BMI). Three retrospective studies compared SGA with postoperative outcomes. Malnourished patients were more likely to have postoperative infectious complications (p = 0.042 SGA-B, p = 0.025 SGA-C). Malnutrition was significantly associated with increased hospital length of stay (LOS) in two studies (p = 0.006, p = 0.02), and with overall survival in another study (p = 0.006). Eight studies analysing preoperative albumin levels reported conflicting associations with postoperative outcomes. BMI in five studies was not associated with morbidity. One study did not support routine nasogastric tube (NGT) feeding.

CONCLUSIONS

Preoperative nutritional assessment tools, including SGA and objective sarcopaenia measures, have a role in predicting nutritional status for CRS-HIPEC patients. Optimisation of nutrition is important for preventing complications.

The Clinical Importance of Preoperative Rectal Swabs in Patients after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Background

Surgical site infections are among the most common healthcare-associated infections, especially in patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this retrospective study was to examine postoperative infectious complications according to preoperative screening findings of nasal and rectal swabs.

Methods

Two hundred four consecutive patients received nasal and rectal swab examination for multidrug-resistant (MDR) bacteria within 30 days before the operation in patients where CRS and HIPEC were planned. Inclusion criteria were as follows: confirmed peritoneal metastases (histologically and/or cytologically); age under 85 years; adequate renal, liver, and bone marrow function; no sign of infection preoperatively; resectable disease; and CRS and HIPEC procedure. If surgical site infection occurred, the microbial spectrum of the site was assessed. One hundred twenty-one patients (63 female [52.1%] and 58 male [47.9%]) met the criteria and were further analyzed retrospectively. Statistical correlations between postoperative complications and risk factors were investigated by univariate and multivariate analysis.

Results

Postoperative complications in total were observed in 57 patients (47.1%) with major complications (Clavien-Dindo grades 3-4) in 15 patients (12.4%) and infectious complications in 37 (30.6%) patients. The overall prevalence of nasal MRSA carriage was 3.28%, and the overall prevalence of rectal MDR bacteria carriage was 10.7%. In propensity score analysis, colonized patients compared to noncolonized patients showed increased total complications (CD1-5, p = 0.025), infectious complications (p = 0.028), surgical site infections (p = 0.022) as well as pneumonia (p = 0.016). Multivariate analysis showed that in addition to preoperative rectal colonization, American Society of Anesthesiologists score was a risk factor for postoperative complications.

Conclusions

Preoperative 3-MRGN and vancomycin-resistant enterococcus colonization were associated with increased complications and surgical site infections. Special antimicrobial treatment pathways are necessary for these patients to reduce postoperative complications due to colonization.

Advances in the management of peritoneal malignancies

Peritoneal surface malignancies (PSMs) are usually associated with a poor prognosis. Nonetheless, in line with advances in the management of most abdominopelvic metastatic diseases, considerable progress has been made over the past decade. An improved understanding of disease biology has led to the more accurate prediction of neoplasia aggressiveness and the treatment response and has been reflected in the proposal of new classification systems. Achieving complete cytoreductive surgery remains the cornerstone of curative-intent treatment of PSMs. Alongside centralization in expert centres, enabling the delivery of multimodal and multidisciplinary strategies, preoperative management is a crucial step in order to select patients who are most likely to benefit from surgery. Depending on the specific PSM, the role of intraperitoneal chemotherapy and of perioperative systemic chemotherapy, in particular, in the neoadjuvant setting, is established in certain scenarios but questioned in several others, although more prospective data are required. In this Review, we describe advances in all aspects of the management of PSMs including disease biology, assessment and improvement of disease resectability, perioperative management, systemic therapy and pre-emptive management, and we speculate on future research directions.

The prognostic value of skeletal muscle index on clinical and survival outcomes after cytoreduction and HIPEC for peritoneal metastases from colorectal cancer: A systematic review and meta-analysis

BACKGROUND

Cytoreductive surgery (CRS) and hypertermic intraperitoneal chemotherapy (HIPEC) represent the most effective strategy to manage peritoneal metastases (PM). This systematic review and meta-analysis aimed to assess the impact of body composition on clinical outcomes in patients with PM.

METHODS

A systematic literature search was performed using Medline, Web of Science and EMBASE databases from inception to the 20^st August 2020. Data were independently extracted by 3 authors. Newcastle-Ottawa Scale was used to assess quality and risk of bias of studies. Pooled analyses were performed using Mantel-Haenszel method to estimate overall effect size with mean differences or odd ratios (ORs) and 95% confidence interval (CI). The primary outcome was postoperative complication (POC) rate, while secondary outcomes were severe POC and postoperative mortality.

RESULTS

A total of 4 studies were included in the systematic review and meta-analysis, including 582 patients. A significant association between low skeletal muscle mass and POC was found (OR 1.45, 95% CI 1.04 to 2.03; p = 0.03), while no differences were found in terms operative time, estimated blood loss, length of hospital stay, and postoperative mortality (p > 0.05).

CONCLUSIONS

Low skeletal muscle mass at diagnosis is a valid prognostic factor for POC development in colorectal and PM patients undergoing CRS. Prospective and larger studies are needed to better investigate the role of CT scan derived body composition and to understand how to implement this tool in clinical practice.

The Role of Total Parenteral Nutrition in Patients with Peritoneal Carcinomatosis: A Systematic Review and Meta-Analysis

Peritoneal carcinomatosis (PC) is often associated with malnutrition and an inability to tolerate enteral feeding. Although total parenteral nutrition (TPN) can be lifesaving for patients with no other means of nutritional support, its use in the management of PC patients remains controversial. Therefore, a systematic review and meta-analysis was performed to evaluate the benefit of TPN on the overall survival of PC patients, in accordance with PRISMA guidelines. A total of 187 articles were screened; 10 were included in this review and eight were included in the meta-analysis. The pooled median overall survival of patients who received TPN was significantly higher than patients who did not receive TPN (p = 0.040). When only high-quality studies were included, a significant survival advantage was observed in PC patients receiving TPN (p < 0.001). Subgroup analysis of patients receiving chemotherapy demonstrated a significant survival benefit (p = 0.008) associated with the use of TPN. In conclusion, TPN may improve survival outcomes in PC patients. However, further studies are needed to conclude more definitively on the effect of TPN.

Perioperative factors predicting delayed enteral resumption and hospital length of stay in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: Retrospective cohort analysis from a single centre in India

Background and Aims:

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an extensive procedure associated with significant morbidity, delay in return of gastrointestinal function and discharge from hospital. Our aim was to assess perioperative factors influencing enteral resumption (ER) and length of stay in the hospital (LOS) in CRS-HIPEC.

Methods:

A retrospective analysis was conducted in a major tertiary cancer centre. Sixty-five patients who underwent CRS-HIPEC between July 2014 and March 2019 were included in the study. The perioperative data were collected from patient records. The primary outcome measure was day of oral resumption of 500 ml of clear fluids and secondary outcome was the LOS. Univariate and multivariate logistic regression analysis was done for the various continuous and categorical perioperative variables for both ER and LOS to elicit the magnitude of risk for both outcomes.

Results:

Univariate logistic regression revealed that peritoneal carcinomatosis index score (PCI), duration of surgery, blood loss and postoperative ventilation influenced both ER and LOS. Serum albumin, plasma usage and total peritonectomy affected only the LOS but not ER. Multivariate analysis showed that duration of surgery (P = 0.006) and quantum of intravenous fluid infused (P = 0.043) were statistically associated with ER, while serum albumin level (P = 0.025) and postoperative ventilation (P = 0.045) were independently predictive of LOS.

Conclusion:

CRS-HIPEC is an extensive surgery and multiple factors are associated with ER; of these, duration of surgery and intraoperative fluid therapy are significant factors. Low serum albumin and prolonged postoperative ventilation are associated with increased LOS.

Physical, psychological and nutritional outcomes in a cohort of Irish patients with metastatic peritoneal malignancy scheduled for cytoreductive surgery (CRS) and heated intrapertioneal chemotherapy (HIPEC): An exploratory pilot study

Background

Treatment for peritoneal malignancy (PM) can include cytoreductive surgery (CRS) and heated intrapertioneal chemotherapy (HIPEC) and is associated with morbidity and mortality. Physical, psychological and nutritional outcomes are important pre-operatively. The aim of this pilot study was to investigate these outcomes in patients with PM before and after CRS-HIPEC.

Methods

Between June 2018 and November 2019, participants were recruited to a single-centre study. Primary outcome was cardiopulmonary exercise testing (CPET) variables oxygen uptake (VO₂) at anaerobic threshold (AT) and at peak. Secondary outcome measures were upper and lower body strength, health related quality of life (HRQoL) and the surgical fear questionnaire. Exploratory outcomes included body mass index, nutrient intake and post-operative outcome. All participants were asked to undertake assessments pre CRS-HIPEC and 12 weeks following the procedure.

Results

Thirty-nine patients were screened, 38 were eligible and 16 were recruited. Ten female and 6 male, median (IQR) age 53 (42–63) years. Of the 16 patients recruited, 14 proceeded with CRS-HIPEC and 10 competed the follow up assessment at week 12. Pre-operative VO₂ at AT and peak was 16.8 (13.7–18) ml.kg^-1.min^-1 and 22.2 (19.3–25.3) ml.kg^-1.min^-1, upper body strength was 25.9 (20.3–41.5) kg, lower body strength was 14 (10.4–20.3) sec, HRQoL (overall health status) was 72.5 (46.3–80) % whilst overall surgical fear was 39 (30.5–51). The VO₂ at AT decreased significantly (p = 0.05) and HRQoL improved (p = 0.04) between pre and post- CRS-HIPEC. There were no significant differences for any of the other outcome measures.

Conclusion

This pilot study showed a significant decrease in VO₂ at AT and an improvement in overall HRQoL at the 12 week follow up. The findings will inform a larger study design to investigate a prehabilitation and rehabilitation cancer survivorship programme.

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced Recovery After Surgery (ERAS®) Society Recommendations - Part II: Postoperative management and special considerations

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part II of the guidelines highlights postoperative management and special considerations.

METHODS

The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.

RESULTS

Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items. No consensus could be reached regarding the preemptive use of fresh frozen plasma.

CONCLUSION

The present ERAS recommendations for CRS ± HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS ± HIPEC and to prospectively evaluate recommendations in clinical practice.

Appendiceal Mucinous Neoplasm: Nurse Education About a Rare and Complex Disease

BACKGROUND

Appendiceal mucinous neoplasms (AMNs) are a rare and complex spectrum of disease involving a mucinous tumor within the appendix, which can range from benign to malignant. If not limited to the appendix, the mucinous tumor can spread diffusely throughout the peritoneum.

OBJECTIVES

Because of the low incidence of AMN, this study describes the diagnosis and treatment process for this disease, which is not well known to most care providers.

METHODS

An extensive analysis of the current literature, including incidence, diagnosis, and surgical treatment, was performed. A review of the pre- and postoperative needs for patients undergoing surgery was also conducted.

FINDINGS

There is minimal information in the nursing literature about AMN and the complexity of surgical management. Nurses play an important role in caring for these patients and their unique needs both before and after surgery.

The Chicago Consensus on peritoneal surface malignancies: Palliative care considerations

The Chicago Consensus Working Group provides multidisciplinary recommendations for palliative care specifically related to peritoneal surface malignancies. These guidelines are developed with input from leading experts including surgical oncologists, medical oncologists, gynecologic oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

Peritoneal Cancers and Hyperthermic Intraperitoneal Chemotherapy

Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy is an aggressive, potentially curative approach used to treat locoregional disease associated with primary and secondary malignancies of the peritoneum. It involves resection of all macroscopic disease larger than 2.5 mm, followed by instillation of hyperthermic chemotherapy directly into the peritoneum for higher drug exposure to microscopic disease. In select patients with primary peritoneal mesothelioma, pseudomyxoma peritonei, colorectal adenocarcinoma, appendiceal adenocarcinoma, or ovarian cancer, with no extra-abdominal metastasis and limited involvement of the peritoneum, the procedure can be performed to increase overall survival.

The Chicago Consensus on Peritoneal Surface Malignancies: Palliative Care Considerations

The Chicago Consensus Working Group provides multidisciplinary recommendations for palliative care specifically related to peritoneal surface malignancies. These guidelines are developed with input from leading experts including surgical oncologists, medical oncologists, gynecologic oncologists, pathologists, radiologists, palliative care physicians, and pharmacists. These guidelines recognize and address the emerging need for increased awareness in the appropriate management of peritoneal surface disease. They are not intended to replace the quest for higher levels of evidence.

The Association of Tumor Laterality and Survival After Cytoreduction for Colorectal Carcinomatosis

BACKGROUND

Primary tumor location has emerged as an important surrogate for tumor biology in metastatic colorectal cancer treated with systemic chemotherapy. It is unclear if primary tumor location is associated with survival after cytoreductive surgery (CRS) with or without heated intraperitoneal chemotherapy (HIPEC) for colorectal carcinomatosis.

METHODS

Study of a contemporary cohort merged data from the California Cancer Registry, 2004-2012, and the Office of Statewide Health Planning and Development inpatient database. For patients undergoing CRS/HIPEC, clinicopathologic variables, treatment characteristics, and survival were compared by right versus left colon primary site. Survival was analyzed by Cox proportional hazards.

RESULTS

Of 272 patients identified, 128 (47.1%) had right-sided tumors. Left- and right-sided cohorts had similar patient, tumor, and treatment factors. Patients with left-sided primary tumors had significantly prolonged overall survival (mean 34 versus 15.5 mo, P = 0.0010). Factors independently associated with decreased overall survival included age >80 (HR 7.0, P < 0.0001), advanced T4 stage (HR 3.6, P = 0.0031), and positive lymph nodes (HR 2.2, P = 0.0004). Metachronous peritoneal involvement (HR 0.38, P < 0.0001) and left-sided primary tumors (HR 0.72, P = 0.041) were independently associated with improved overall survival.

CONCLUSIONS

This study identifies location of primary tumor as an important determinant of long-term survival after CRS/HIPEC. Patients with left-sided tumors have a more favorable prognosis.

Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.

Preoperative Nutrition Status and Postoperative Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex surgery to treat peritoneal surface malignancy (PSM). PSM and gastrointestinal (GI) resection from CRS can lead to significant GI symptoms and malnutrition. There is limited research into the nutrition status of this patient group and the impact of malnutrition on morbidity.

OBJECTIVE

This study aims to determine if preoperative malnutrition, assessed using the Subjective Global Assessment (SGA), is associated with postoperative morbidity and increased length of stay (LOS) in patients undergoing CRS/HIPEC for PSM.

METHODS

This study prospectively assessed the nutritional status of patients undergoing CRS/HIPEC using a validated nutrition assessment tool. Preoperative clinical symptoms, Peritoneal Cancer Index (PCI), intraoperative blood transfusions, operative time, GI resections, postoperative morbidity, and LOS, as well as pre- and postoperative nutritional interventions, were recorded. The impact of preoperative nutritional status was assessed in relation to postoperative complications and hospital LOS.

RESULTS

The study included 102 participants; 34 patients (33%) were classified as malnourished (SGA = B or C). Preoperative weight loss (15% vs. 74%; p ≤ 0.001) and the presence of clinical symptoms (18% vs. 47%; p = 0.002) were significantly higher in malnourished patients. While PCI, intraoperative blood transfusions, and GI resections were independent predictors of morbidity, malnutrition was significantly associated with infectious complications and LOS. For each grade of worsening malnutrition, LOS increased by an average of 7.65 days.

CONCLUSIONS

Preoperative malnutrition is prevalent in patients undergoing CRS/HIPEC and postoperative morbidity is common. Malnutrition is linked to LOS and plays a role in postoperative outcomes such as infection. Clear pre- and postoperative nutrition pathways are needed to optimize nutrition support and postoperative recovery.

Prognostic Factors Influencing Infectious Complications after Cytoreductive Surgery and HIPEC: Results from a Tertiary Referral Center

Background

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) showed promising results in selected patients. High morbidity restrains its wide application. The aim of this study was to report postoperative infectious complications and investigate possible correlations with the preoperative nutritional status and other prognostic factors in patients with peritoneal metastases treated with CRS and HIPEC.

Methods

For the study, we reviewed the clinical records of all patients with peritoneal metastases from different primary cancers treated with CRS and HIPEC in our Institution from November 2000 to December 2017. Patients were divided according to their nutritional status (SGA) into groups A (well-nourished) and B/C (mild or severely malnourished, respectively). Possible statistical correlations between risk factors and postoperative complication rates have been investigated by univariate and multivariate analysis.

Results

Two hundred patients were selected and underwent CRS and HIPEC during the study period. Postoperative complications occurred in 44% of the patients, 35.3% in SGA-A patients, and 53% in SGA-B/C patients. Cause of complications was infective in 42, noninfective in 37, and HIPEC related in 9 patients. Infectious complications occurred more frequently in SGA-B/C patients (32.6% vs. 9.8% of SGA-A patients). The most frequent sites of infection were surgical site infections (SSI, 35.7%) and central line-associated bloodstream infections (CLABSI, 26.2%). The most frequent isolated species was Candida (22.8%). ASA score, blood loss, performance status, PCI, large bowel resection, postoperative serum albumin levels, and nutritional status correlated with higher risk for postoperative infectious complications.

Conclusions

Malnourished patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are more prone to postoperative infectious complications, and adequate perioperative nutritional support should be considered, including immune-enhancing nutrition. Sequential monitoring of common sites of infection, antifungal prevention of candidiasis, and careful patient selection should be implemented to reduce the complication rate.

Do patients undergoing cytoreductive surgery and HIPEC for peritoneal malignancy need parenteral nutrition?

BACKGROUND

To analyse the duration of parenteral nutrition (PN) in patients treated for peritoneal malignancy with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) over a 2 year period at a single UK National referral centre.

METHODS

A retrospective analysis of prospective data for all patients (n=321) who underwent CRS and HIPEC for peritoneal malignancy at the Peritoneal Malignancy Institute Basingstoke between April 1, 2013 and March 31, 2015.Duration of PN was compared between primary tumour site (appendix, colorectal, mesothelioma and other); completeness of CRS (complete CRS vs. major tumour debulking) and pre-operative nutritional assessment measures (including Mid Upper Arm Circumference).

RESULTS

The median duration of PN was 9 days (range 2-87 days). A total of 13 % of patients had PN for less than 7 days and 6 % for 5 days or less. There was no significant difference in duration of PN between the different tumour sites. Two factors that may increase the duration of PN include having major tumour debulking (MTD) and a baseline MUAC<23.5 cm.

CONCLUSIONS

Most patients who underwent CRS and HIPEC for peritoneal malignancy required PN for more than 7 days with poor pre-operative nutritional status and inability to achieve complete cytoreduction predictors of prolonged PN requirements.

Knowledge, attitudes and practice of surgeons regarding nutritional support in CRS and HIPEC patients: Are we missing something?

Nutrition's impact on the surgical outcome has been established in various surgical specialties. However, data addressing the nutritional aspect following surgery for peritoneal surface malignancies are considered scarce. We aim to evaluate the knowledge, attitudes, and practice of surgeons regarding their nutritional support for patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS and HIPEC) via a survey directed to self-evaluate nutritional knowledge, screening, and practice toward patients. The survey was submitted to the attendees of the International Regional Cancer Therapies Symposium. The response rate was 37% (56/151). Most surgeons estimated their knowledge and malnutrition screening skills in CRS and HIPEC to be 'adequate' or better. Only 35.19% reported the availability of nutritional screening and assessment tools for CRS and HIPEC patients. 86.5% of participants stated that their CRS and HIPEC patients have access to a dietitian on inpatient and outpatient basis. However, only 32.69% reported to 'always' consult a dietitian. Otherwise, the involvement of a nutrition specialist is considered on variable basis. Despite the consensus on the importance of nutrition in HIPEC patients, there appears to be a profound underutilization of nutrition specialists in the patients' management, which may have had in impact on their surgical outcome.

Systematic review and meta-analysis of the evidence for oral nutritional intervention on nutritional and clinical outcomes during chemo(radio)therapy: current evidence and guidance for design of future trials

Background

Driven by reduced nutritional intakes and metabolic alterations, malnutrition in cancer patients adversely affects quality of life, treatment tolerance and survival. We examined evidence for oral nutritional interventions during chemo(radio)therapy.

Design

We carried out a systematic review of randomized controlled trials (RCT) with either dietary counseling (DC), high-energy oral nutritional supplements (ONS) aiming at improving intakes or ONS enriched with protein and n-3 polyunsaturated fatty acids (PUFA) additionally aiming for modulation of cancer-related metabolic alterations. Meta-analyses were carried out on body weight (BW) response to nutritional interventions, with subgroup analyses for DC and/or high-energy ONS or high-protein n-3 PUFA-enriched ONS.

Results

Eleven studies were identified. Meta-analysis showed overall benefit of interventions on BW during chemo(radio)therapy (+1.31 kg, 95% CI 0.24-2.38, P = 0.02, heterogeneity Q = 21.1, P = 0.007). Subgroup analysis showed no effect of DC and/or high-energy ONS (+0.80 kg, 95% CI -1.14 to 2.74, P = 0.32; Q = 10.5, P = 0.03), possibly due to limited compliance and intakes falling short of intake goals. A significant effect was observed for high-protein n-3 PUFA-enriched intervention compared with isocaloric controls (+1.89 kg, 95% CI 0.51-3.27, P = 0.02; Q = 3.1 P = 0.37). High-protein, n-3 PUFA-enriched ONS studies showed attenuation of lean body mass loss (N = 2 studies) and improvement of some quality of life domains (N = 3 studies). Overall, studies were limited in number, heterogeneous, and inadequately powered to show effects on treatment toxicity or survival.

Conclusion

This systematic review suggests an overall positive effect of nutritional interventions during chemo(radio)therapy on BW. Subgroup analyses showed effects were driven by high-protein n-3 PUFA-enriched ONS, suggesting the benefit of targeting metabolic alterations. DC and/or high-energy ONS were less effective, likely due to cumulative caloric deficits despite interventions. We highlight the need and provide recommendations for well-designed RCT to determine the effect of nutritional interventions on clinical outcomes, with specific focus on reaching nutritional goals and providing the right nutrients, as part of an integral supportive care approach.

Does having a gastrectomy delay time to feeding and prolong hospital stay in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy?

AIM

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is routinely used to treat selected patients with peritoneal carcinomatosis, but can be associated with prolonged hospital stay, significant morbidity and mortality. Our objective was to assess whether patients undergoing gastrectomy as part of CRS/HIPEC were at increased risk of delayed feeding time and prolonged hospital stay.

METHODS

Two hundred and fourteen consecutive patients with peritoneal carcinomatosis treated with CRS/HIPEC between 2001 and 2016 were stratified by whether CRS included gastrectomy (n = 19, 9%) and compared. Primary outcomes were time to full feeds and rate of serious morbidity (Clavien-Dindo grades III-V). Secondary outcomes were durations of ICU and hospital stays.

RESULTS

Of 214 patients undergoing CRS/HIPEC, those undergoing gastrectomy (19, 8.9%) had increased time to full feeds (8 vs. 5 days, p < 0.01), and duration of ICU (2 vs. 1 days, p < 0.01) and total hospital stays (16 vs. 14 days, p = 0.013). There was no significant increase in serious complications, although increased risk of pneumonia was noted (21% vs. 4.1%, p = 0.011). Undergoing gastrectomy was not independently prognostic in multivariable analysis including high peritoneal tumour load (PCI >12), multiple CRS procedures (number >2) and operation duration (>480 min) in which operative duration remained independently prognostic (p < 0.01).

CONCLUSIONS

After surgery, early oral refeeding may be beneficial in the majority of patients undergoing CRS/HIPEC. However, patients found to have high peritoneal tumour load with extended surgery and those who underwent gastrectomy should be considered for early post-operative TPN due to the significant risk of delayed time to full feeds.

Cytoreduction and hyperthermic intraperitoneal chemotherapy (CS/HIPEC) in colorectal cancer: Evidence-based review of patient selection and treatment algorithms

Cytoreduction and heated intraperitoneal chemotherapy (CS/HIPEC) is increasingly utilized as a treatment strategy for patients with peritoneal metastases from various primary tumor sites. For this heterogenous procedure, related to patient characteristics, patient selection, and the extent of surgical completeness of cytoreduction, high level evidence (ex: multiple randomized controlled trials) is not available to support efficacy. This review of the available literature supporting application of the procedure, focusing on colorectal cancer, provides a summary of current evidence for patient selection and treatment algorithms based on patient presentation.

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 with intraperitoneal chemotherapy in the management of peritoneal surface malignancy: a pharmacist's perspective

Objectives

To explore the use of intraperitoneal chemotherapy in conjunction with cytoreductive surgery for the treatment of peritoneal surface malignancy and highlight the challenges this provides for the hospital pharmacist.

Methods

A literature search for relevant articles was performed using MEDLINE, PubMed and Cochrane databases. The following keywords and phrases were used: 'hyperthermic intraperitoneal chemotherapy', 'early postoperative intraperitoneal chemotherapy', 'carrier solutions' and 'cytoreductive surgery'. Local experience was also shared, referencing national guidelines and published literature.

Results

The rationale behind intraperitoneal chemotherapy is to directly administer drugs into the peritoneal cavity and achieve exposure of higher concentrations of cytotoxic agents to tumour nodules within the abdomen and on peritoneal surfaces for a prolonged period of time, without significant systemic toxicity. This has been widely demonstrated in intraoperative and early postoperative settings. Hydrophilic chemotherapy drugs with high molecular weights and permeable to the peritoneum, but slow plasma clearance create high concentrations of the drug in the peritoneal cavity, with lower systemic circulation. Commonly used drugs include mitomycin C, oxaliplatin, cisplatin, doxorubicin and 5-fluorouracil. Newer drugs such as the taxanes and bevacizumab have also shown promise. Heat increases drug penetration into body tissues and destroys tumour cells directly by causing damage to cells that have inherently faulty heat regulation pathways and also increases the cytotoxic effect of selected chemotherapeutic agents. Optimal temperature for hyperthermic intraperitoneal drug administration is between 41 and 43°C in a carrier solution that is compatible with the drug chosen. For early postoperative intraperitoneal chemotherapy high molecular weight starch carrier solutions prolong intraperitoneal dwell time and exposure of drug to tumour cells. Drugs are administered intraoperatively with the abdomen open or closed for between 30 and 120 min depending on the drug chosen and local protocols. Drug doses are traditionally calculated using body surface area. Toxicity such as neutropenia is encountered far less than with systemic chemotherapy.

Conclusions

This paper discusses the rationale for intraperitoneal drug administration following cytoreductive surgery and describes appropriate drug selection, methods of drug delivery and potential challenges in the use of the intraperitoneal route. It provides evidence and practical guidance for hospital pharmacists who may be involved in the surgical management of peritoneal malignancy particularly in dose calculation, preparation and administration of intraperitoneal chemotherapy.

Preoperative Preparation and Patient Selection for Cytoreductive Surgery and HIPEC

Peritoneal dissemination is a significant variable affecting long term survival of abdominal cancer patients. A generally accepted clinical point of view is that peritoneal dissemination is tantamount to distant organ metastases. This implies it to be a terminal condition. Current practice dictates that if peritoneal dissemination is observed intraoperatively, the curative therapeutic options are deferred and comprehensive systemic chemotherapy remains the only option with a dismal prognosis. The past few years have generated lot of interest in management of peritoneal carcinomatosis. Prof Paul Sugarbaker has researched, validated and fine-tuned the concept of cytoreductive surgery with peritonectomy procedure (Sugarbaker technique) and perioperative chemotherapy as HIPEC & EPIC. Recognition of a HIPEC centre is based on an infrastructure equipped with basic knowledge of the tumor biology, oncosurgical techniques, technical knowhow for HIPEC administration, intensive care unit etc. There are some aspects which need to be accorded special consideration. Comprehensive therapy of Cytoreduction surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is initiated with exploration and cytoreductive surgery and includes visceral resections and peritonectomy procedure when achieved optimally results in complete, visible resection of all cancer within the abdomen and pelvis. Subsequent to CRS, HIPEC forms an integral part of the surgical procedure. This approach involves conceptual changes in both the route and timing of chemotherapy administration. Patient selection is of utmost importance. The greatest impediment to lasting benefits from intraperitoneal chemotherapy remains an improper patient selection. Currently, there are four important clinical assessments of peritoneal metastasis that need to be used to select patients ie; histopathological type of tumour, radiological distribution of disease, peritoneal cancer index and completeness of cytoreduction. Patients undergoing HIPEC surgery face the usual physiological insults of a major surgery in addition to the thermal stress secondary to intraperitoneal administration of heated chemotherapy agent. A team approach of everyone involved in care of these patients is known to improve patient outcomes. It has also been observed that with the necessary preoperative & perioperative steps, the morbidity and mortality for this treatment can be brought down as comparable to any other major abdominal surgeries.

Prognostication of Survival in Patients With Advanced Cancer: Predicting the Unpredictable?

BACKGROUND

Prognosis is a key driver of clinical decision-making. However, available prognostication tools have limited accuracy and variable levels of validation.

METHODS

Principles of survival prediction and literature on clinician prediction of survival, prognostic factors, and prognostic models were reviewed, with a focus on patients with advanced cancer and a survival rate of a few months or less.

RESULTS

The 4 principles of survival prediction are (a) prognostication is a process instead of an event, (b) prognostic factors may evolve over the course of the disease, (c) prognostic accuracy for a given prognostic factor/ tool varies by the definition of accuracy, the patient population, and the time frame of prediction, and (d) the exact timing of death cannot be predicted with certainty. Clinician prediction of survival is the most commonly used approach to formulate prognosis. However, clinicians often overestimate survival rates with the temporal question. Other clinician prediction of survival approaches, such as surprise and probabilistic questions, have higher rates of accuracy. Established prognostic factors in the advanced cancer setting include decreased performance status, delirium, dysphagia, cancer anorexia-cachexia, dyspnea, inflammation, and malnutrition. Novel prognostic factors, such as phase angle, may improve rates of accuracy. Many prognostic models are available, including the Palliative Prognostic Score, the Palliative Prognostic Index, and the Glasgow Prognostic Score.

CONCLUSIONS

Despite the uncertainty in survival prediction, existing prognostic tools can facilitate clinical decision-making by providing approximated time frames (months, weeks, or days). Future research should focus on clarifying and comparing the rates of accuracy for existing prognostic tools, identifying and validating novel prognostic factors, and linking prognostication to decision-making.

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.

The role of HIPEC in the treatment of peritoneal carcinomatosis from gastric cancer: between lights and shadows

Gastric cancer is one of the most dreadful neoplastic diseases and remains the second cause of cancer death worldwide. Patients who develop peritoneal metastasis have a poor prognosis, with a median survival of less than 6 months. Despite being the cause of 60% of deaths from gastric cancer, peritoneal metastasis can still be considered a local disease and a local multidisciplinary approach can improve the prognosis even in this end-stage disease. At present, hyperthermic intraperitoneal chemotherapy (HIPEC) is the most widely accepted treatment for peritoneal surface diseases and can be performed in patients with different stages of cancer and with various antitumoral drugs. We performed a systematic review of the current status of HIPEC in the treatment of gastric peritoneal metastasis in an attempt to obtain answers to the questions that still remain: do results differ with these different methods? Does HIPEC exert a significant effect on the intracavitary delivery of drugs? Which patients should be treated and which should not? What can we expect from this approach in terms of survival, morbidity, and mortality? On reviewing the literature, despite the lack of trials comparing the different methods, we found that HIPEC has been shown to be an effective tool whenever a complete or an almost complete resection of the peritoneal implants can be performed. Therefore, it is advisable to refer all at-risk patients to specialized centers to be enrolled in randomized trials to achieve truly reliable results.

The influence of preoperative nutritional status on the outcomes of an enhanced recovery after surgery (ERAS) programme for colorectal cancer surgery

BACKGROUND

The aim of the present study was to evaluate the effects of preoperative nutritional status on the short-term outcomes of an enhanced recovery after surgery (ERAS) programme for colorectal cancer surgery.

METHODS

This prospective observational study included 149 patients who underwent elective resection of colorectal cancer with ERAS from January 2011 to January 2014 in a university hospital. Subjective global assessment (SGA) was used to determine preoperative nutritional status. Primary outcomes included the length of postoperative stay, postoperative morbidity, gastrointestinal recovery, and 30-day readmission.

RESULTS

The patients were divided into 3 groups according to the SGA classification. There were 96 patients (64.4 %) in SGA-A (well-nourished), 48 (32.2 %) in SGA-B (mild to moderately malnourished), and 5 (3.4 %) in SGA-C (severely malnourished). Patients in SGA-A had the median length of postoperative stay of 4 days (range 2-23), which was significantly shorter compared to SGA-B (5 days; range 2-16; p < 0.01) and SGA-C (7 days; range 4-17; p < 0.01). The overall complication rates of SGA-A, SGA-B, and SGA-C patients were 11, 31 % (adjusted OR 3.76; 95 % CI 1.36-10.36; p < 0.01) and 40 % (adjusted OR 2.15; 95 % CI 0.07-63.64; p = 0.66). Mean time to resumption of normal diet and time to first defecation were 1.6 ± 1.3 and 2.2 ± 0.9 days in SGA-A, 2.6 ± 1.7 and 3.1 ± 1.6 days in SGA-B (p < 0.01 compared to SGA-A) and 3.2 ± 2.4 days and 2.6 ± 1.5 days in SGA-C (p = 0.07 and p = 0.1 compared to SGA-A, respectively). No 30-day mortality occurred in any group. One patient in SGA-A (1 %), and 3 patients in SGA-B (6 %) had unplanned 30-day re-admission; p = 0.11.

CONCLUSIONS

Within an ERAS programme for colorectal cancer surgery, malnourished patients were at risk for increased postoperative morbidity, delayed recovery of gastrointestinal function, and prolonged length of hospital stay.

Impact of BMI on postoperative outcomes in patients undergoing proctectomy for rectal cancer: a national surgical quality improvement program analysis

BACKGROUND

There is a mounting body of evidence that suggests worsened postoperative outcomes at the extremes of BMI, yet few studies investigate this relationship in patients undergoing proctectomy for rectal cancer.

OBJECTIVE

We aimed to examine the relationship between BMI and short-term outcomes after proctectomy for cancer.

DESIGN

This was a retrospective study comparing the outcomes of patients undergoing proctectomy for rectal cancer as they relate to BMI.

SETTINGS

The American College of Surgeons-National Surgical Quality Improvement Program database was queried for this study.

PATIENTS

Patients included were those who underwent proctectomy for rectal neoplasm between 2005 and 2011.

MAIN OUTCOME MEASURES

Study end points included 30-day mortality and overall morbidity, including the receipt of blood transfusion, venous thromboembolic disease, wound dehiscence, renal failure, reintubation, cardiac complications, readmission, reoperation, and infectious complications (surgical site infection, intra-abdominal abscess, pneumonia, and urinary tract infection). Univariate logistic regression was used to analyze differences among patients of varying BMI ranges (kg/m; ≤20, 20-24, 25-29, 30-34, and ≥35). When significant differences were found, multivariable logistic regression, adjusting for preoperative demographic and clinical variables, was performed.

RESULTS

A total of 11,995 patients were analyzed in this study. The incidences of overall morbidity, wound infection, urinary tract infection, venous thromboembolic event, and sepsis were highest in those patients with a BMI of ≥35 kg/m (OR, 1.63, 3.42, 1.47, 1.64, and 1.50). Wound dehiscence was also significantly more common in heavier patients. Patients with a BMI <20 kg/m had significantly increased rates of mortality (OR, 1.72) and sepsis (OR, 1.30).

LIMITATIONS

This study was limited by its retrospective design. Furthermore, it only includes patients from the American College of Surgeons-National Surgical Quality Improvement Program database, limiting its generalizability to nonparticipating hospitals.

CONCLUSIONS

Obese and underweight patients undergoing proctectomy for neoplasm are at a higher risk for postoperative complications and death.