Prognostic factors of early recurrence after complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Although cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) offer the potential for long-term survival in peritoneal carcinomatosis, outcomes following CRS/HIPEC vary significantly.

AIM

To identify the clinical factors associated with progression-free survival (PFS) after complete CRS/HIPEC in patients with colorectal/high-grade appendiceal, ovarian, and gastric cancers.

METHODS

We retrospectively evaluated the risk of recurrence within 1 year after CRS/HIPEC and its impact on overall survival (OS) in patients recruited between 2015 and 2020. Logistic regression models were used to assess the prognostic factors for the risk of recurrence within 1 year. Kaplan–Meier survival curves and Cox proportional hazards models were used to evaluate the association between recurrence and OS.

RESULTS

Of the 80 enrolled patients, 39 had an unfavorable PFS (< 1 year) and 41 had a favorable PFS (≥ 1 year). Simple logistic models revealed that the patients with a completeness of cytoreduction score of 0 (CC-0) or length of CRS ≤ 6 h had a favorable PFS [odds ratio (OR) = 0.141, P = 0.004; and OR = 0.361, P = 0.027, respectively]. In multiple logistic regression, achieving CC-0 was the strongest prognostic factor for a favorable PFS (OR = 0.131, P = 0.005). A peritoneal cancer index score > 12 was associated with a lower rate of achieving CC-0 (P = 0.027). The favorable PFS group had a significantly longer OS (median 81.7 mo vs 17.0 mo, P < 0.001).

CONCLUSION

Achieving CC-0 was associated with a lower early recurrence rate and improved long-term survival. This study underscores the importance of selecting appropriate candidates for CRS/HIPEC to manage peritoneal carcinomatosis.

Is Hyperthermic Intraperitoneal Chemotherapy Appropriate for Colon Cancer?

Colorectal cancer (CRC) with peritoneal metastases is a complex disease and its management presents significant clinical challenges. In well-selected patients at experienced centers, CRS/hyperthermic intraperitoneal chemotherapy (HIPEC) can be performed with acceptable morbidity and is associated with prolonged survival. Based on the results of recent randomized controlled trials, HIPEC using oxaliplatin after CRS with shortened perfusion periods (30 minutes) is no longer recommended. There is a movement toward utilizing mitomycin C as a first-line intraperitoneal agent with extended perfusion times (90-120 minutes); however, there is currently little prospective evidence to support its widespread use.

The immunomodulatory role of paracrine signalling factor VSIG4 in peritoneal metastases

Peritoneal metastasis (PM), the regional progression of intra-abdominal malignancies, is a common sequelae of colorectal cancer (CRC). Immunotherapy is slated to be effective in generating long-lasting anti-tumour response as it utilizes the specificity and memory of the immune system. In the tumour microenvironment, tumour associated macrophages (TAMs) are posited to create an anti-inflammatory pro-tumorigenic environment. In this paper, we aimed to identify immunomodulatory factors associated with colorectal PM (CPM). A publicly available colorectal single cell database (GSE183916) was analysed to identify possible immunological markers that are associated with the activation of macrophages in cancers. Immunohistochemical analysis for V-set and immunoglobin containing domain 4 (VSIG4) expression was performed on tumour microarrays (TMAs) of tumours of colorectal origin (n = 211). Expression of VSIG4 in cell-free ascites obtained from CPM patients (n = 39) was determined using enzyme-linked immunosorbent assay (ELISA). CD163-positive TAMs cluster expression was extracted from a publicly available single cell database and evaluated for the top 100 genes. From these macrophage-expressed genes, VSIG4, a membrane protein produced by the M2 macrophages, mediates the up-regulation of anti-inflammatory and down-regulation of pro-inflammatory macrophages, contributing to an overall anti-inflammatory state. CRC TMA IHC staining showed that low expression of VSIG4 in stromal tissues of primary CRC are associated with poor prognosis (p = 0.0226). CPM ascites also contained varying concentrations of VSIG4, which points to a possible role of VSIG4 in the ascites. The contribution of VSIG4 to CPM development can be further evaluated for its potential as an immunotherapeutic agent.

Predictors of Financial Toxicity Risk Among Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC)

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the preferred treatment for select patients with peritoneal malignancies. However, the procedure is resource intensive and costly. This study aimed to determine the risk of financial toxicity for patients undergoing CRS-HIPEC.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients undergoing CRS-HIPEC at a single institution from 2016 to 2022. We utilized insurance status, out-of-pocket expenditures, and estimated post-subsistence income to determine risk of financial toxicity. A multivariable logistic regression was used to determine risk factors for financial toxicity.

RESULTS

Our final study cohort consisted of 163 patients. Average age was 58 [standard deviation 10] years, and 52.8% (n = 86) were male. A total of 52 patients (31.9%) were at risk of financial toxicity. A total of 36 patients (22.1%) were from the lower income quartiles (first or second) and 127 patients (77.9%) were from the higher income quartiles (third or fourth). A total of 47 patients (29%) were insured by Medicare, and 116 patients (71%) had private insurance. The median out-of-pocket expenditure across the study cohort was $3500, with a median of $5000 ($3341-$7350) for the at-risk group and $3341 ($2500-$4022) for the not at-risk group (p < 0.001). Risk factors for financial toxicity included high out-of-pocket expenditures and a lower income quartile.

CONCLUSIONS

An estimated one-third of patients undergoing CRS-HIPEC at our institution were at risk for financial toxicity. Several preoperative factors were associated with an increased risk and could be utilized to identify patients who might benefit from interventions.

Cost Analysis and Financial Implications of a Peritoneal Surface Malignancy Program in the USA

BACKGROUND

We aimed to describe the financial implications of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in the USA.

MATERIALS AND METHODS

We conducted a retrospective cost analysis of 100 CRS/HIPEC procedures to examine the impact of patient and procedural factors on hospital costs and reimbursement. A comparison of surgeons' work relative value units (wRVUs) between CRS/HIPEC and a representative sample of complex surgical oncology procedures was made to assess the physicians' compensation rate. Univariable and multivariable backward logistic regression was used to analyze the association between perioperative variables and high direct cost (HDCs).

RESULTS

The median direct cost per CRS/HIPEC procedure was US $44,770. The median hospital reimbursement was US $43,066, while professional reimbursement was US $8608, resulting in a positive contribution margin of US $7493/procedure. However, the contribution margin significantly varied with the payer mix. Privately insured patients had a positive median contribution margin of US $23,033, whereas Medicare-insured patients had a negative contribution margin of US $13,034. Length of stay (LOS) had the most significant association with HDC, and major complications had the most significant association with LOS. Finally, CRS/HIPEC procedures generated a median of 13 wRVU/h, which is significantly lower than the wRVU/h generated by open pancreatoduodenectomies, open gastrectomies, and hepatectomies. However, higher operation complexity and multiple visceral resections help compensate for the relatively low wRVU/h.

CONCLUSIONS

CRS/HIPEC is an expensive operation, and prolonged LOS has the most significant impact on the total cost of the procedure. High-quality care is essential to improve patient outcomes and maintain the economic sustainability of the procedure.

Developing a hyperthermic intraperitoneal chemotherapy (HIPEC) gynecologic oncology program: a Canadian experience

Hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment option for epithelial ovarian cancer following cytoreductive surgery. The intraperitoneal spread of the disease makes the peritoneal cavity an ideal target for drug delivery. HIPEC has shown promising results in improving overall survival in epithelial ovarian cancer patients when performed during interval cytoreductive surgery. Recent studies have provided level 1 evidence supporting increased overall survival in stage III ovarian cancer patients treated with HIPEC during interval cytoreduction. Meta-analyses have further confirmed the survival improvement in women receiving HIPEC. Despite its inclusion in guidelines, many centers have been hesitant to implement HIPEC programs due to perceived obstacles, such as increased morbidity, cost, and resource requirements. Studies have shown that morbidity rates are acceptable in selected patients, and the addition of HIPEC to cytoreductive surgery is cost effective. Therefore, the main barrier to implementing HIPEC programs is related to resource requirements and logistics, but with proper preparation, these challenges can be overcome. Establishing a successful HIPEC program requires institutional support, a knowledgeable and dedicated team, adequate resources and equipment, and proper training and audit. This review aims to provide evidence based information to guide the development of successful HIPEC programs, including preoperative, anesthetic, and surgical considerations. It also reviews the different equipment and protocols for the perfusion and common postoperative events.

Cytoreductive Surgery and Hyperthermic Peritoneal Chemotherapy in Appendiceal and Colorectal Cancer: Outcomes and Survival

BACKGROUND

We reviewed outcomes following cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (HIPEC) for patients with appendiceal or colorectal neoplasms and evaluated key prognostic indicators for treatment.

METHODS

All patients who underwent cytoreductive surgery/HIPEC for appendiceal and colorectal neoplasms were identified from an IRB-approved database. Patient demographics, operative reports, and postoperative outcomes were reviewed.

RESULTS

110 patients [median age 54.5 (18-79) years, 55% male] were included. Primary tumor location was colorectal (58; 52.7%) and appendiceal (52; 47.3%). 28.2%, .9%, and 12.7% had right, left, and sigmoid tumors, respectively; 11.8% had rectal tumors. 12/13 rectal cancer patients underwent preoperative radiotherapy. Mean Peritoneal Cancer Index was 9.6 ± 7.7; complete cytoreduction was achieved in 90.9%. 53.6% developed postoperative complications. Reoperation, perioperative mortality, and 30-day readmission rates were 1.8%, .09%, and 13.6%, respectively. Recurrence at a median of 11.1 months was 48.2%; overall survival at 1 and 2 years was 84% and 56.8%, respectively; disease-free survival was 60.8% and 33.7%, respectively, at a median follow-up of 16.8 (0-86.8) months. Univariate analysis of preoperative chemotherapy, primary malignancy location, primary tumor perforated or obstructive, postoperative bleeding complication, and pathology of adenocarcinoma, mucinous adenocarcinoma and negative lymph nodes were identified as possible predictive factors of survival. Multivariate logistic regression analysis showed that preoperative chemotherapy (P < .001), perforated tumor (P = .003), and postoperative intra-abdominal bleeding (P < .001) were independent prognostic indicators for survival.

CONCLUSIONS

Cytoreductive surgery/HIPEC for colorectal and appendiceal neoplasms has low mortality and high completeness of cytoreduction score. Preoperative chemotherapy, primary tumor perforation, and postoperative bleeding are adverse risk factors for survival.

Morbimortality after 1321 consecutive CRS + HIPEC procedures: seeking excellence in surgery for peritoneal surface malignancy

PURPOSE

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) treatment has classically presented a percentage of associated complications that have limited its expansion. The aim of this study is to describe the morbimortality results obtained from a referral center implemented with the support of a governmental health agency and directed by a surgical team experienced in CRS for Peritoneal Surface Malignancies (PSM).

METHODS

Data from the Peritoneal Carcinomatosis Program of Catalonia (PCPC) prospective database, including patients who underwent CRS + HIPEC between September 2006 and January 2021, were analyzed.

RESULTS

A total of 1151 consecutive patients underwent 1321 CRS + HIPEC procedures. Colonic origin of peritoneal metastasis was the most frequent (47.3%). Median PCI was 7 and most patients had CC0-1 (96.1%). Multivisceral resection was performed in 44% of all patients, 57% required digestive anastomosis. Median hospital stay was 11 days (range 6-144 days). High-grade complications occurred in 20% of all patient, most of them surgical complications. Anastomotic leak occurred in 0.6% of all cases. The overall in-stay and 30-day mortality rate was 0.4%. The low-rate of complications and the high rate of complete CRS were achieved from the beginning of the PCPC. Median overall survival was 54.7 months, with a 5-year survival rate of 47.5%.

CONCLUSIONS

Implementation of a CRS + HIPEC referral program for the treatment of PSM with preferably an experienced surgical team enables acceptable rates of severe morbidity (20%) and mortality (< 1%).

Risk factors for gastrointestinal perforation and anastomotic leak in patients submitted to cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)

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.

Predicting Severe Complications from Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: A Data-Driven, Machine Learning Approach to Augment Clinical Judgment

BACKGROUND

CRS-HIPEC provides oncologic benefit in well-selected patients with peritoneal carcinomatosis; however, it is a morbid procedure. Decision tools for preoperative patient selection are limited. We developed a risk score to predict severity of 90 day complications for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).

PATIENTS AND METHODS

Adults who underwent CRS-HIPEC at the University of Pittsburgh Medical Center (March 2001-April 2020) were analyzed as part of this study. Primary endpoint was severe complications within 90 days following CRS-HIPEC, defined using Comprehensive Complication Index (CCI) scores as a dichotomous (determined using restricted cubic splines) and continuous variable. Data were divided into training and test sets. Several machine learning and traditional algorithms were considered.

RESULTS

For the 1959 CRS-HIPEC procedures included, CCI ranged from 0 to 100 (median 32.0). Adjusted restricted cubic splines model defined severe complications as CCI > 61. A minimum of 20 variables achieved optimal performance of any of the models. Linear regression achieved the highest area under the receiving operator characteristic curve (AUC, 0.74) and outperformed the NSQIP Surgical Risk calculator (AUC 0.80 vs. 0.66). Factors most positively associated with severe complications included peritoneal carcinomatosis index score, symptomatic status, and undergoing pancreatectomy, while American Society of Anesthesiologists 2 class, appendiceal diagnosis, and preoperative albumin were most negatively associated with severe complications.

CONCLUSIONS

This study refines our ability to predict severe complications within 90 days of discharge from a hospitalization in which CRS-HIPEC was performed. This advancement is timely and relevant given the growing interest in this procedure and may have implications for patient selection, patient and referring provider comfort, and survival.

Early postoperative CRP predicts major complications following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)

Objectives

Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is associated with significant postoperative complications. Early detection of at-risk patients may lead to improved outcomes. The role of C-reactive protein (CRP) in predicting postoperative complications has only been recently investigated.

Methods

Postoperative complications were categorized according to Clavien-Dindo classification and further divided into minor (Grade <3) and major complications (Grade ≥3A). Absolute CRP counts (mg/L) on postoperative days (POD) 1-7, and proportional change in CRP was compared and the area under (AUC) receiver operating characteristics (ROC) curve was calculated. Univariate and multivariate analysis was performed. Significant findings were externally validated.

Results

Twenty-five percent of patients experienced one or more major complications. A CRP level of ≥106 mg/L on POD 2 and 65.5 mg/L on POD 4 were significantly associated with an increased risk of major complications with an AUC of 0.658 and 0.672, respectively. The proportional increase in CRP between POD 1 and 4 (ΔCRP POD 1/4) at a cut-off of 30 % had the best AUC of 0.744 and was the only independent risk factor for major complications (p<0.0001) on multivariate analysis. ∆CRP had an AUC of 0.716 (p=0.002) when validated in an independent database.

Conclusions

CRP can be used in a variety of ways to predict major complications after CRS and HIPEC. However, the ∆CRP POD 1/4>30 % is the best indicator of major complications. Serial CRP measurements in the early postoperative period may lead to early detection of patients at risk of major complications allowing for alternative management strategies to improve outcomes.

Preoperative systemic chemotherapy does not benefit for appendiceal pseudomyxoma peritonei

BACKGROUND

Pseudomyxoma peritonei (PMP) is a clinically malignant tumour syndrome mainly derived from mucin-producing appendiceal tumours. This study aimed to explore the effect of preoperative systemic chemotherapy (PSC) before cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) on the safety and postoperative survival in patients with appendiceal PMP.

METHODS

We performed a retrospective analysis including consecutive patients with PMP undergoing primary surgery between January, 2008 and December, 2019 in Aerospace Center Hospital. The clinical data and postoperative survival were compared between PSC group and non-PSC group.

RESULTS

Seven hundred and fifty patients were included in the study. Significant differences were found between PSC group and non-PSC group on clinicopathological data and perioperative outcomes and the independent risk factor of serious complications was blood loss >1000 mL (P = 0.026). Shorter median overall survival (OS) was found (42 months, 95% CI 31.9-52.1) in PSC group than that (67 months 95% CI 44.5-89.5) in non-PSC group. In the stratified study with PCI < 20, CC 0/1 and low-grade pathological subtype, the OS from non-PSC group was significantly better than that in PSC group (log rank P-values are <0.001, 0.006 and <0.001, respectively). Multivariate survival analysis showed that CC 0/1, HIPEC, PCI < 20 and low-grade pathological subtype were the independent prognostic factors for better OS.

CONCLUSIONS

PSC does not increase the risk of major perioperative complications in patients with appendiceal PMP, but it also does not bring postoperative survival benefits to patients either.

Complications and Mortality Rate of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: Italian Peritoneal Surface Malignancies Oncoteam Results Analysis

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy may significantly improve survival for selected patients with peritoneal surface malignancies, but it has always been criticized due to the high incidence of postoperative morbidity and mortality.

METHODS

Data were collected from nine Italian centers with peritoneal surface malignancies expertise within a collaborative group of the Italian Society of Surgical Oncology. Complications and mortality rates were recorded, and multivariate Cox analysis was used to identify risk factors.

RESULTS

The study included 2576 patients. The procedure was mostly performed for ovarian (27.4%) and colon cancer (22.4%). The median peritoneal cancer index was 13. Overall postoperative morbidity and mortality rates were 34% and 1.6%. A total of 232 (9%) patients required surgical reoperation. Multivariate regression logistic analysis identified the type of perfusion (p ≤ 0.0001), body mass index (p ≤ 0.0001), number of resections (p ≤ 0.0001) and colorectal resections (p ≤ 0.0001) as the strongest predictors of complications, whereas the number of resections (p ≤ 0.0001) and age (p = 0.01) were the strongest predictors of mortality.

CONCLUSIONS

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is a valuable option of treatment for selected patients with peritoneal carcinomatosis providing low postoperative morbidity and mortality rates, if performed in high-volume specialized centers.

Optimizing risk factors influence Intensive Care stay after Hyperthermic Intraperitoneal Chemotherapy? An observational cohort study

BACKGROUND

It may be necessary to admit patients receiving Hyperthermic Intraperitoneal Chemotherapy (HIPEC) to the intensive care unit (ICU). They were required to evaluate the length of ICU stay (LOS) following HIPEC, as well as their survival rates and risk factors that influence LOS.

METHODS

74 HIPEC patients were observed after being admitted to the ICU. Their assignments were made based on their LOS at the ICU. Short stay group, patients who stayed in the ICU for three days or less (S-group) and patients who stayed for three days or longer (L-group).

RESULTS

Survival rates for both groups were comparable. After HIPEC, they exhibited intraoperative hypotension (P = 0.015), hyopthermia (P = 0.014), and hyperglycemia (P = 0.010). Additionally, patients in group L underwent longer surgeries (P = 0.013), lost more blood (P = 0.043), and required more transfusions (P = 0.001). Subjects in group-L had higher SOFA, fentanyl, and vasopressor requirements (all P 0.001), higher ALT and AST levels, disrupted K, lower Na, and higher INR levels (all P 0.001), as well as a higher APACHE II score (P = 0.007). Preoperative BUN had an independent risk factor for LOS of 0.861; (95% CI), (0.742- 0.999); P = 0.048; and crystalloid transfusion had an independent risk factor of 1.000; (95% CI), (0.999- 1.000); P = 0.003.

CONCLUSIONS

Transfusions of crystalloids and BUN were independent risk factors for extended LOS. ICU LOS had no impact on survival. All measures should be taken to control hemostasis in vulnerable HIPEC participants.

The Impact of Low Skeletal Muscle Mass on Short- and Long-Term Outcomes After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a potentially curative treatment for peritoneal metastases from colorectal cancer (CRC) or pseudomyxoma peritonei (PMP). Because of the considerable morbidity of this treatment, optimal patient selection is key. This study aimed to assess the impact of low skeletal muscle mass (SMM) on outcomes after CRS-HIPEC.

METHODS

Patients who underwent CRS-HIPEC between 2014 and 2020 at a tertiary center were included. SMM was measured on computed tomography by means of the L3 muscle index. Postoperative complications and survival outcomes were compared between groups by use of logistic regression and Kaplan-Meier survival analyses.

RESULTS

Of 284 included patients, 149 had low SMM. Occurrence of severe postoperative complications did not differ between groups (28.9% for patients with low vs. 34.1% for patients with normal SMM). Low SMM was not associated with postoperative complications (p = 0.344). For CRC patients, no significant differences were observed in disease-free (DFS) or overall survival (OS) between patients with low (median DFS 7 months [IQR 4-14], median OS 33 months [IQR 14-NR]) and patients with normal SMM (median DFS 8 months [IQR 5-20], median OS 35 months [IQR 18-NR]). Regarding PMP, survival outcomes did not significantly differ between groups (3-year DFS 47.3% for patients with low SMM vs. 54.5% for patients with normal SMM, p = 0.676; 3-year OS 70.8% vs. 90.9% respectively, p = 0.172).

CONCLUSIONS

Low SMM could not be identified as a predictor of severe complications or survival outcomes after CRS-HIPEC.

Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy: Analysis of Perioperative Risk Factors and Impact on Outcome

Background

Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is an effective treatment option for appropriately selected patients with peritoneal carcinomatosis. Our aim was to analyze a multidisciplinary approach and to study the perioperative risk factors associated with morbidity and mortality.

Methods

We reviewed all patients who underwent CRS + HIPEC from January 2019 till December 2020 at our oncologic center. Patient demographics, risk scores, intraoperative variables, postoperative care, analgesia protocol, and adverse events (AE) within 30 days after treatment were collected and statistically analyzed.

Results

Of the 98 patients evaluated preoperatively by a multidisciplinary team, 39 patients required active optimization. The median age was 61 years, and 67 were women. Most tumors were appendiceal in origin. The median peritoneal cancer index (PCI) score was 12, and the median operative time length (OTL) was 400 minutes. Body mass index, Physiological and Operative Severity Score for the enUmeration of morbidity, PCI score, crystalloid volume, cell concentrates, and OTL were associated with postoperative intensive care unit admission (p <0.05). Epidural analgesia was given to 74 patients. AEs occurred in 39 patients, and 25 of the AEs were classified as mild or moderate. The intraoperative variables associated with development of AEs were anesthesia technique, estimated blood loss, crystalloid volume, cell concentrates, OTL, and analgesia protocol (p <0.05). On multivariate analysis, crystalloid volume >6 L, intravenous sufentanil analgesic protocol, and OTL were associated with 67%, 38%, and 15% increased risk of AE, respectively.

Conclusion

Our study highlighted the importance of a perioperative protocol with a standardized multidisciplinary approach in order to decrease the incidence of postoperative AE.

Antibiotic Prophylaxis for Surgical Site Infection in General Surgery: Oncological Treatments and HIPEC

The procedure of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a combined surgical and oncological treatment for peritoneal carcinomatosis of various origins. Antibiotic prophylaxis is usually center-related and should be discussed together with the infectious disease specialist, taking into account the advanced oncologic condition of the patient, the complexity of surgery—often requiring multiorgan resections—and the risk of post-HIPEC neutropenia. The incidence of surgical site infection (SSI) after CRS and HIPEC ranges between 11 and 46%. These patients are also at high risk of postoperative abdominal infections and septic complications, and a bacterial translocation during HIPEC has been hypothesized. Many authors have proposed aggressive screening protocols and a high intra and postoperative alert, in order to minimize and promptly identify all possible infectious complications following CRS and HIPEC.

Predicting Early and Late Readmissions Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Background

Postoperative readmissions not only burden the healthcare system but may also affect clinical outcomes of cancer patients. Despite this, little is known about readmissions after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), or their impact on survival outcomes.

Patients and Methods

A single-institution retrospective cohort study of CRS-HIPEC procedures from April 2001 and September 2019 was performed. Early readmission (ERA) was defined as hospitalization within 30 days of discharge post-CRS/HIPEC, while late readmission (LRA) was defined as hospitalization between day 31 and 90 after discharge. Patient demographic, oncological, and perioperative factors were analyzed to identify predictors of readmission, and comparison of survival outcomes was performed.

Results

Overall, 342 patients who underwent CRS-HIPEC were included in the study. The incidence of ERA and LRA was 18.5% and 7.4%, respectively. High-grade postoperative complication was the only independent predictor of ERA (HR 3.64, 95% CI 1.47–9.02), while comorbid hypertension (HR 2.71, 95% CI 1.17–6.28) and stoma creation (HR 2.83, 95% CI 1.23–6.50) were independent predictors for LRA. Patients with readmission had significantly worse disease-free survival than patients who had no readmission (NRA) (LRA 1.1 years, ERA 1.2 years, NRA 1.8 years, p = 0.002), and patients with LRA had worse median overall survival (2.1 years) than ERA patients (3.3 years) or patients without readmission (4.4 years) (p < 0.001).

Conclusions

Readmission following CRS-HIPEC is associated with adverse survival outcomes. In particular, LRA may portend worse prognosis than ERA.

Comparison of the outcomes of cytoreductive surgery versus surgery plus hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis: a propensity score matching analysis

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are effective treatment options for selected patients with peritoneal carcinomatosis (PC). We compared the short-term outcomes of surgery plus HIPEC and CRS alone for PC.

METHODS

We retrospectively examined patients who underwent CRS-HIPEC for PC at a single center from 2014 to 2019 using the Chinese CRS-HIPEC patient database at our institution. Patients were divided into two groups: surgery plus HIPEC (450) and surgery alone (200). A 1:1 propensity score matching (PSM) analysis was performed. The postoperative outcomes, mortality, and length of hospital stay were compared between the surgery plus HIPEC and CRS alone groups.

RESULTS

Propensity scoring generated 162 pairs. There was no statistically significant difference in the 30-day mortality rate between the groups (0% vs 0%, P = 1.000), and the morbidity rates were similar in both groups (7.4% vs 8.0%, P = 0.835). The surgery plus HIPEC group had a longer operative time (247.81 ± 64.70 vs 184.55 ± 29.56, P ≤ 0.001) and a slightly longer postoperative hospital stay (14.64 ± 5.24 vs 12.59 ± 3.76, P ≤ 0.001). No other baseline characteristics were significantly different.

CONCLUSIONS

Surgery plus HIPEC is feasible for select patients and is associated with prolonged surgery times and prolonged hospital stays, and there is no significant difference in mortality rates or postoperative outcomes.

Complete Cytoreductive Surgery vs. Debulking Surgery for pseudomyxoma peritonei of appendiceal origin: A propensity score-matched study based on a single-center experience

OBJECTIVE

This study aimed to report the prognostic predictors and compare the long-term outcomes of complete cytoreductive surgery (CCRS) vs. debulking surgery (DS) in patients with pseudomyxoma peritonei (PMP) of appendiceal origin.

METHODS

A retrospective analysis of 1008 consecutive patients with PMP undergoing primary surgery from January 2008 to December 2019 was performed. A propensity score-matched (PSM) analysis (1:1) was performed, and oncologic outcomes were compared between the CCRS and DS groups.

RESULTS

Out of 1008 patients, 258 patients were excluded. Baseline characteristics differed significantly between the CCRS and DS groups (total n = 750). After PSM, 106 patients were selected from each group and the baseline characteristics were matched between groups. There were significant differences between groups in operative time, the incidence of major complications (P = 0.017), and the numbers of organs removed. The median follow-up was 28 (1-131) months. Median overall survival (OS) for the 212 patients was 52.0 months (95% CI 40.2-63.8), and 10-year OS was 39.0%. Median OS could not be calculated for the CCRS group; in the DS group, this value was 41 months (P = 0.010). The 10-year OS rate was 54.2% in the CCRS group and 31.2% in the DS group. Multivariate analyses identified CCRS (P = 0.012) and histopathologic subtype (P < 0.001) as independent prognostic factors for OS.

CONCLUSIONS

In this matched-pair analysis of patients with appendiceal PMP, CCRS was safe and associated with better prognosis than DS. The completeness of cytoreduction and histopathologic subtype were two independent prognostic factors for OS.

Coagulopathy and Venous Thromboembolic Events Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Background

Coagulopathy after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is recognized but few details have been studied.

Objectives

The aim of this study was to investigate changes in coagulation biomarkers and their predictive ability for venous thromboembolism (VTE).

Methods

Patients undergoing CRS and HIPEC at Uppsala University Hospital, Sweden, from 2004 to 2014 were included in a prospective study of coagulation biomarkers. Prothrombin time international normalized ratio (PT-INR), activated partial thromboplastin time (APTT), fibrinogen, antithrombin, D-dimer, and platelets were sampled on postoperative days 1, 2, 5, and 10. Logistic regression analysis was used to evaluate predictive capacity for coagulation-related complications.

Results

Overall, 380 patients were included (214 females, mean age 56 years); 38 patients had a history of thromboembolism and 57 were active smokers. Mean perioperative blood loss was 1228 mL and 231 (61%) received perioperative blood transfusions. PT-INR and APTT were elevated directly after surgery but returned to normal levels on postoperative day 5. Conversely, fibrinogen, platelet count, D-dimer, and antithrombin increased by postoperative day 5 and continued to increase up to day 10. There were 23 radiologically verified cases of VTE within 6 months. The multivariate analysis identified a completeness of cytoreduction score of 2–3 (p = 0.047) and day 2 D-dimer (p = 0.0082) as independent risk factors for postoperative VTE.

Conclusion

Significant postoperative changes in coagulation biomarkers occur with dynamic changes over 10 days postoperatively. The incidence of symptomatic VTE was low. Residual tumor at completion of surgery and elevated D-dimer on day 2 were independent risk factors for postoperative VTE.

A multi-institutional analysis of Textbook Outcomes among patients undergoing cytoreductive surgery for peritoneal surface malignancies

BACKGROUND

While recent studies have introduced the composite measure of a textbook outcome (TO) for measuring postoperative outcomes, the incidence of a TO has not been characterized among patients undergoing cytoreductive surgery (CRS) for peritoneal surface malignancies (PSM).

STUDY DESIGN

All patients who underwent CRS ± hyperthermic intraperitoneal chemotherapy (HIPEC) between 1999 and 2017 from 12 institutions were included. A TO was defined as the absence of any of the following criteria: completeness of cytoreduction >1, reoperation within 90-days, readmission within 90-days, mortality within 90-days, any grade ≥2 complication, hospital stay >75th percentile, and non-home discharge.

RESULTS

Among 1904 patients who underwent CRS, only 30.9% achieved a TO while 69.1% failed to achieve a TO most commonly because of postoperative complications. On multivariable analysis, factors associated with achieving a TO were age <65 years (OR: 1.5), albumin ≥3.5 g/dl (OR: 5.7), receipt of HIPEC (OR: 4.5), PCI ≤14 (OR: 2.2), intravenous fluid volume ≤10,000 ml (OR: 2.1), blood loss ≤1000 ml (OR: 4.2) and operative time <7 h (OR: 1.9); while receipt of neoadjuvant therapy (OR: 0.7) and liver resection (OR: 0.4) were associated with not achieving a TO (all p < 0.05). TO was associated with improved overall survival (median 159 months vs 56 months, p < 0.01) even after controlling for confounders on Cox regression (hazard ratio: 2.5, p < 0.01).

CONCLUSION

Among patients undergoing CRS ± HIPEC for PSM, failure to achieve a TO is common and independently associated with worse overall survival.

The association between surgical duration and venous thromboembolism in outpatient surgery: A propensity score adjusted prospective cohort study

Background

Outpatient surgeries account for 60–70% of all procedures. Increased surgical duration has been demonstrated to be an independent risk factor for the development of venous thromboembolism (VTEs) after inpatient surgeries. In contrast, it is currently unknown if surgical duration increases the risk of VTEs for outpatient surgeries.

Materials and methods

The 2005 through 2016 NSQIP Participant Use Data Files were queried to extract all patients scheduled for outpatient surgery. A z-score for surgical duration was calculated for each procedure to allow for standardization across surgeries of expected shorter or longer duration. The primary outcome measured was incidence of VTEs within 30 days of surgery.

Results

A total of 3474 patients out of 1,863,523 (0.19%) had a VTE. After adjusting for confounding factors, the first and fifth quintiles compared to the middle quintile had odds ratios (ORs) of 0.75 (95% CI 0.68, 0.80) and 1.43 (95% CI, 1.35%–1.52%), respectively, P < 0.001. Patients who developed VTEs were more likely to be readmitted to the hospital, OR (95%CI) of 51.9 (48.0–56.2), C statistic = 0.67.

Conclusion

Surgical duration is associated with the development of VTEs after outpatient surgery. While the overall incidence of VTE is low and does not require generalized prophylaxis, clinical practitioners should consider prophylaxis for patients undergoing outpatient surgery performed with excessive time compared to the average surgical procedure duration.

•

Surgical duration is related with VTE development 30 days within outpatient surgery.

•

Long outpatient surgeries resulted in a 1.43-fold increase in developing a VTE.

•

Short outpatient surgeries resulted in a 25% reduction in developing a VTE.

•

ENT surgery had the lowest VTE incidence while vascular surgery had the highest.

•

Patients who developed VTEs were 52 times more likely to be readmitted.

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management

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 I of the guidelines highlights preoperative and intraoperative management.

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.

Predictive Ability of C-Reactive Protein in Detecting Short-Term Complications After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Retrospective Cross-Sectional Study

Background

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is a potentially curative treatment for peritoneal carcinomatosis.

Objective

The aim of this study was to determine the predictive value of postoperative inflammatory biomarkers in assessing complications after CRS and HIPEC.

Methods

A prospective database of 181 patients, who underwent CRS-HIPEC between March 2014 through April 2018 in the Erasmus MC, was retrospectively analyzed. Postoperative complications were defined according to the serious adverse event (SAE) grading system. Levels of C-reactive protein (CRP) and white blood cell (WBC) count were compared between patients with SAE grade < 3 and SAE grade ≥ 3. The area under the receiver operating characteristic curve (AUC) was calculated for CRP and WBC against SAE ≥ 3 and various intra-abdominal complications.

Results

SAE ≥ 3 postoperative complications occurred in 50 patients. From the second until the fifth postoperative day (POD), CRP levels were significantly higher (p = 0.023, p < 0.001, p = 0.002, and p = 0.002, respectively) in these patients. CRP concentrations above 166 mg/L on POD3 (AUC 0.75) and 116 mg/L on POD4 (AUC 0.70) were associated with the highest risk of an SAE ≥ 3. Postoperative WBC levels were not significantly different between patients with SAE < 3 and SAE ≥ 3 complications.

Conclusion

Data from our hospital suggest that CRP levels that continue to rise after POD2 or that are ≥ 166 mg/L at POD3 or ≥ 116 mg/L at POD4, indicate a considerable risk for developing high-grade SAEs. The cut-off values we found can potentially be used as a threshold for additional diagnostic interventions, after they have been validated in external data.

Hepatic resection and blood transfusion increase morbidity after cytoreductive surgery and HIPEC for colorectal carcinomatosis

BACKGROUND AND OBJECTIVES

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective but complex treatment for peritoneal metastasis (PM). Our objective was to identify risk factors for postoperative morbidity and mortality following CRS-HIPEC.

METHODS

Retrospective study of prospectively collected data of patients undergoing CRS-HIPEC for PM arises from colorectal cancer between January 2008 and December 2017. Perioperative variables were correlated with morbidity outcomes using a logistic regression model.

RESULTS

Sixty-seven patients underwent CRS-HIPEC, and overall morbidity and mortality were 31.3% and 4.5% respectively. Major morbidity rate was 19.4%; 7.5% of patients were re-operated. Intraoperative blood transfusion (p = 0.01), liver resection (p < 0.01), and intestinal anastomosis (p < 0.01) were associated with a higher morbidity in univariate analysis. A multivariate analysis identified blood transfusion and liver resection as independent risk factors (OR 3.66, IC 1.13-16.54; OR 4.33, IC 1.17-11.46, respectively). Extension of visceral resection did not correlate with morbidity. Patients with lymph-node infiltration had a higher major complication rate (p = 0.01).

CONCLUSIONS

CRS-HIPEC is a feasible treatment for colorectal PM with an acceptable morbi-mortality rate in experienced centers. In our study, digestive anastomosis, perioperative blood transfusion, hepatic resection, and lymph-node infiltration were associated with higher morbidity rates.

Surgeons' Ability to Predict the Extent of Surgery Prior to Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

Background

The extent of surgery (ES) during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is a well-known risk factor for major postoperative morbidity. Interestingly, the reliability of surgeons to predict the ES prior to CRS + HIPEC is unknown.

Methods

In this prospective, observational cohort study, five surgeons predicted the ES prior to surgery in all consecutive patients with peritoneal metastases (PM) who were scheduled for CRS + HIPEC between March 2018 and May 2019. After the preoperative work-up for CRS + HIPEC was completed, all surgeons independently predicted, for each individual patient, the resection or preservation of 22 different anatomical structures and the presence of a stoma post-HIPEC according to a standardized ES form. The actual ES during CRS + HIPEC was extracted from the surgical procedure report and compared with the predicted ES. Overall and individual positive (PPV) and negative predictive values (NPV) for each anatomical structure were calculated.

Results

One hundred and thirty-one ES forms were collected from 32 patients who successfully underwent CRS + HIPEC. The number of resections was predicted correctly 24 times (18.3%), overestimated 57 times (43.5%), and underestimated 50 times (38.2%). Overall PPVs for the different anatomical structures ranged between 33.3 and 87.8%. Overall, NPVs ranged between 54.9 and 100%, and an NPV > 90% was observed for 12 anatomical structures.

Conclusions

Experienced surgeons seem to be able to better predict the anatomical structures that remain in situ after CRS + HIPEC, rather than predict the resections that were necessary to achieve a complete cytoreduction.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-08237-8) contains supplementary material, which is available to authorized users.

High-grade complication is associated with poor overall survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly used in peritoneal carcinomatosis (PC) management. This modality is criticized for its high morbidity and mortality. We evaluate the morbidity and mortality of patients undergoing this procedure in our institution.

METHODS

A review of our institution's database was performed. All patients who underwent CRS/HIPEC between July 2011 and March 2018 were divided into three groups: no, low-grade, and high-grade complications. Prognostic factors were determined with Cox regression, while morbidity risk factors were analyzed using multinomial logistic regression.

RESULTS

225 consecutive patients underwent CRS/HIPEC. The most common primary cancer types were colorectal (35.1%), appendiceal (25.8%), and ovarian (22.2%). Median age was 55 years old (range 14-77), and patients were typically female (68.0%). 38.7% developed low-grade complications and 14.7% had high-grade complications. No 30-day mortality was observed. Different tumor origins are associated with significant differences in overall survival (p < 0.001). Patients without complications had significantly better survival than those with high-grade complications (HR 0.35, 95% CI 0.15-0.81, p < 0.001). Males were more likely to develop low-grade complications (OR 3.30, 95% CI 1.31-8.30, p = 0.011). Intra-operative blood loss was associated with greater odds of developing any post-operative complications (OR 1.001, 95% CI 1.0003-1.002, p = 0.007; and OR 1.002, 95% CI 1.001-1.002, p < 0.001, for low and high grade, respectively).

CONCLUSION

Presence of high-grade complication was associated with poorer survival in patients after CRS/HIPEC. Pre-operative careful assessment of patients is pivotal to ensure favorable patient outcome following this complex procedure.

Readmissions After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: a US HIPEC Collaborative Study

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) results in significant morbidity and readmissions. Previous studies have been limited by single-institution design or lack of tumor details in the database used.

METHODS

The 12-institution US HIPEC Collaborative Database was queried between 1999 and 2017. Preoperative and intraoperative patient and tumor details were analyzed for associations with readmissions.

RESULTS

A total of 2017 of 2372 cases were included in the analysis. The 30-day readmission rate was 15.9% (n = 321). Common indications for readmission included failure to thrive (29.9%), infection (23.6%), and ileus/bowel obstruction (15.1%). The readmitted cohort had more complications, including intra-abdominal abscess (21.2% vs 6.2%), ileus (28.0% vs 17.2%), anastomotic leak (11.2% vs 2.2%), enteric fistula (5.6% vs 1.5%), deep venous thrombosis (6.2% vs 2.5%), and pulmonary embolism (6.9% vs 2.5%). Factors independently associated with readmission (p < 0.05) included ECOG score ≥ 3 (OR 3.4), depression (OR 2.4), total parenteral nutrition (OR 3.6), low anterior resection or partial colectomy (OR 2.0), and stoma creation (OR 2.2). Factors not associated included neoadjuvant chemotherapy, peritoneal cancer index, and completeness of cytoreduction. Readmission rate between 31 and 90 days was 3.9% (n = 78). Independent predictors (p < 0.05) included operative time (OR 1.1), low anterior resection or partial colectomy (OR 1.7), and stoma creation (OR 2.2).

CONCLUSIONS

In the largest study to date examining readmissions after CRS-HIPEC, 30-day readmission rate was 15.9%. Tumor factors failed to predict readmission, whereas preoperative functional status and depression along with individual cytoreductive procedures predicted readmission. Patients with these risk factors or postoperative complications may benefit from closer post-discharge monitoring.

[Perioperative management for CRS and HIPEC : Anesthesiological aspects]

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are therapeutic options for the treatment of intra-abdominal neoplasms. Following the resection of all visible tumor areas by CRS, microscopic tumor areas are treated with HIPEC. This procedure increases the quality of life and survival. The CRS with HIPEC is a complex surgical procedure in which the mainly younger and often otherwise healthy patients undergo several pathophysiological changes during the operation. The main concern of the anesthesiologist is the massive volume loss, volume shift and metabolic alterations. Patients with a high comorbidity should undergo preoperative optimization to reduce the perioperative morbidity and mortality especially by protracted interventions.

Does Perceived Resident Operative Autonomy Impact Patient Outcomes?

OBJECTIVE

We investigated the association of perceived trainee autonomy with patient clinical outcomes following colorectal surgery.

DESIGN

This was a prospective multi-institutional study that consisted of surgery trainees completing a survey tool immediately after participating in colorectal resections to rate their self-perceived autonomy and case characteristics. Self-perception of autonomy was classified as observer, assistant, surgeon, or teacher. The completed trainee surveys were linked with patient information available through each hospital's internal NSQIP directory. The primary outcome was death and serious morbidity (DSM) and secondary outcome was 30-day readmissions. Separate mixed effects regression models were used to examine the association between perceived trainee autonomy and DSM or 30-day readmissions. Fixed effects were used to control for the effects of the training environment. The models were constructed to adjust for patient and trainee characteristics associated with each outcome independently.

SETTING

This study was conducted at 7 general surgery training programs (5 academic medical centers and 2 independent training programs) with general surgery or colorectal surgery services.

PARTICIPANTS

This study included a total of 63 residents and fellows rotating on surgery services that performed colorectal resections at the included 7 general surgery training programs from January until March 2016.

RESULTS

The 63 trainees that participated in this study completed 417 surveys with over a 95% response rate. National Surgical Quality Improvement Program (NSQIP) patient records were available for 67% (n = 273) of completed surveys. The clinical year of the trainees were 6.1% PGY 1/2, 36% Post graduate year (PGY) 3, 40.9% PGY 4/5, and 17% fellows. Residents perceived their participation in the case to be that of an observer in 9.2% of surveys, an assistant in 51.6% of surveys, and the surgeon/teacher in 39.3% of surveys. About 50% of patients were male, 80% were White, the majority had an American Society of Anesthesiologists classification of 3, almost half had prior abdominal surgery, and over 80% of surgeries were elective. The primary operation types performed were laparoscopic (40.3%) and open (35.9%) partial colectomies. The rate of DSM in patients was approximately 24% when trainees perceived their role as observers, 23% when trainees perceived their role as assistants, and 18% when trainees perceived their role as surgeons/teachers. After adjustment for patient, trainee, and training environment, we found that the perceived level of trainee autonomy of a surgeon/teacher was associated with a 4-fold lower rate of DSM (odds ratio: 0.23, confidence of interval: 0.05-0.97, p = 0.045) compared to observers. The rate of readmissions was approximately 20% when trainees perceived their role as observers, 14% when trainees perceived their role as assistants and 9% when trainees perceived their role as surgeons/teachers. After adjustment for patient, trainee, and training environment, we found that the perceived level of trainee autonomy of a surgeon/teacher was significantly associated with a 10-fold lower rate of 30-day readmissions (odds ratio: 0.09, confidence of interval: 0.01-0.70, p = 0.022) compared to observers.

CONCLUSIONS

There was an association between increased perceived trainee autonomy and improved patient outcomes, suggesting that when trainees identify with an increased role in the operation, patients may have improved care. Further research is needed to understand this association further.

Understanding the Clinical Implications of Resident Involvement in Uncommon Operations

OBJECTIVE

The objective of this study was to examine uncommon operations in greater detail given that the outcomes of uncommon operations are largely understudied. This study examines the incidence of postoperative events and the role of the resident following uncommon operations.

DESIGN

We identified uncommon general surgical operations using the ACS National Surgical Quality Improvement Program Participant Use file (2008-2011). Death or serious morbidity (DSM) within 30 days of the operation was the primary outcome of interest. Failure to rescue (FTR) and prolonged operative time (PRopt) were evaluated as secondary outcome measures. PRopt was defined as ≥90 percentile of operative time for each procedure type. Independent multivariate logistic regression models were generated to examine the impact of these descriptors on the outcomes of interest.

SETTING/PARTICIPANTS

The dataset utilized was the United States National Surgical Quality Improvement Program Participant Use File which leverages data points from over 700 hospitals that range from primary to quaternary care centers. Resident participation was defined as resident involved (RI) or no resident involved (NRI), and stratified by postgraduate year (PGY): 1-3, 4-5, and 6+.

RESULTS

Resident participant data was available for 21,453 (84.5%) uncommon operations with NRI in 25.4% (5447). With regard to resident participation, PGY1-3 were found in 12.6% (2699), PGY4-5 in 50.4% (10,817), and PGY6+ in 11.6% (2490). The overall observed DSM rate was 28.6% and the observed FTR rate was 5.8%. Overall, there was no difference in DSM by RI status (NRI: 1528; 28.1% vs RI: 4602; 28.8%; p = 0.324); however, PGY level was associated with DSM (PGY1-3: 774, 28.7%, PGY4-5: 3210, 29.7%, PGY6+: 618, 24.8%; p < 0.001). Any RI was associated with a lower rate of FTR (5.1%) when compared to NRI (8.3%, p < 0.001) with decreasing FTR events by increasing PGY (PGY1-3: 6.4%, PGY4-5: 5.2%, PGY6+: 3.3%; p < 0.001). After adjustment for patient risk factors, any RI remained associated with a lower likelihood of FTR than NRI (odds ratio: 0.65, 95% confidence interval: 0.49-0.87) while only the PGY4-5 and PGY6+ groups were associated with lower likelihood of FTR in comparison to NRI. RI was associated with PRopt in univariate and multivariable analyses.

CONCLUSIONS

Uncommon operations were associated with substantial DSM. The involvement of PGY4-5 residents was associated with the greatest likelihood of DSM. With increasing PGY of the involved resident, cases with PGY > 5 demonstrated a lower likelihood of risk-adjusted FTR. The explanation for these findings is not clear; however, the involvement of more senior residents in the technical aspects of uncommon operations may lead to improved results.

Incidence and Long-term Outcomes of Patients Requiring Early Reoperation After HIPEC

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) remains a formidable operation associated with considerable morbidity. It is unclear how often these patients require reoperation for postoperative complications and if the need for reoperations leads to worse long-term outcomes.

METHODS

The Peritoneal Surface Malignancy Database at a single center was retrospectively queried. Out of 149 entries, 141 HIPECs performed between 2012 and 2018 met inclusion criteria. Patients were categorized based on early reoperation (<60 d after HIPEC), and demographic and tumor factors were compared using univariate analyses. Recurrence was calculated for patients with complete cytoreduction and overall survival analyzed using the Kaplan-Meier method.

RESULTS

There were 15 reoperations after 141 HIPECs (10.6%). Median duration between HIPEC and reoperation was 18 d. Indications for reoperation included intra-abdominal infection (n = 5), bowel obstruction (n = 4), wound infection (n = 3), bleeding (n = 2), and evisceration (n = 1). There were no identified patient- or tumor-related risk factors for reoperation. Reoperations were associated with longer hospital length of stay (19 versus 9 d, P = 0.005) and 30-d readmissions (46.7% versus 12.8%, P = 0.003). There was no significant difference in 3-year recurrence-free survival, but there was a significant association between reoperation and 3-year overall survival (38.0% versus 71.9%, P = 0.03).

CONCLUSIONS

Complications requiring reoperation after HIPEC lead to increased short-term morbidity, longer hospital length of stay, and most importantly, reduced overall survival. Further studies investigating interventions to decrease complications and reduce reoperation rates are needed to improve outcomes after HIPEC.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy combined with liver resection for concurrent peritoneal and hepatic metastases of gastrointestinal and gynecological primary tumors

AIM OF THE STUDY

Cytoreductive surgery including liver resection and hyperthermic intraperitoneal chemotherapy provide survival benefit to selected patients but is associated with relevant morbidity and mortality rates. We aimed to report morbidity and mortality rates and parameters linked to increased morbidity.

PATIENTS AND METHODS

Retrospective analysis of 37 patients who underwent liver resection and cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy between 2006 and 2016. From a prospectively collected database the morbidity and mortality rates and survival data were analyzed.

RESULTS

The mortality rate was 0% and grade III-IV morbidity was 42%. Re-operation rate was 27%. Patients with complications tended to have a higher peritoneal cancer index (16 vs. 13; P=0.23). The performance of rectal resections was statistically significantly associated with morbidity (P=0.02). Neither performance of other type of resections nor the hyperthermic intraperitoneal chemotherapy compound nor the completeness of cytoreduction score was associated with elevated morbidity. No complications related to liver resections were observed. Furthermore, origin of peritoneal metastases did not impact on occurrence of complications. Median overall survival for colorectal primaries was 22 months (range, 9-60 months) and 30 months (range, 12-58 months) for ovarian cancer.

CONCLUSION

Simultaneous resection of hepatic and peritoneal metastases seems to provide a survival benefit for selected patients and is associated with acceptable morbidity and mortality rates. Knowledge of patients and operative factors linked to morbidity will help to provide a strict selection process and a safer surgical procedure.

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.

Mucinous appendiceal neoplasms: classification, imaging, and HIPEC

Recent advances, specifically cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), offer advantages compared to the traditional therapeutic approach of systemic chemotherapy in the treatment of peritoneal carcinomatosis from mucinous appendiceal neoplasms (MAN). This review provides an up-to-date, comprehensive summary of the histologic classification of MAN, reviews common imaging findings of mucoceles and pseudomyxoma peritonei, and describes the radiologist's role in the multidisciplinary care team in quantifying disease and in helping select patients for definitive surgery.

Peritoneal Surface Oncology in Singapore

Peritoneal surface malignancy is now an established indication for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. The landscape of treatment in Singapore has evolved through the years, with expanded indications as the experience in the management of this disease improves.

More Synchronous Peritoneal Disease but Longer Survival in Younger Patients with Carcinomatosis from Colorectal Cancer Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Colonoscopy to detect colorectal cancer (CRC) is recommended starting at age 50 years; however, CRC rates are increasing in the prescreening population. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been proven effective in select patients with peritoneal carcinomatosis (PC) from CRC, although it has not been evaluated specifically in patients < 50 years.

METHODS

CRC patients aged < 50 years at diagnosis undergoing CRS/HIPEC 2007-2017 were compared with those aged ≥ 50 years. Age distribution was analyzed in patients undergoing colectomy alone versus CRS/HIPEC for CRC 1993-2013.

RESULTS

A total of 98 patients underwent CRS/HIPEC, of which 44% were < 50 years. Younger patients were more likely to present with synchronous peritoneal metastases (p = 0.050). Receipt of perioperative chemotherapy was comparable (p = not significant [NS]). Charlson Comorbidity Index and ECOG score were similar (p = NS). Tumor grade was similar (p = NS). Peritoneal Carcinomatosis Index, total organs resected, and anastomoses created were comparable (p = NS). Major Clavien-Dindo morbidity and LOS were similar (p = NS). Younger patients survived longer after CRS/HIPEC (p = 0.011). Demographic data from patients undergoing colectomy (n = 225) and CRS/HIPEC (n = 98) showed that age < 50 years was increasingly common with the more aggressive procedure (9% and 44% respectively, p < 0.001).

CONCLUSIONS

Younger patients with PC from CRC presented more often with peritoneal metastases at the time of diagnosis. Yet despite similar perioperative features at CRS/HIPEC, they survived longer than older patients. Patients undergoing CRS/HIPEC are overall younger than those undergoing index colectomy.

Morbidity and Mortality Rates Following Cytoreductive Surgery Combined With Hyperthermic Intraperitoneal Chemotherapy Compared With Other High-Risk Surgical Oncology Procedures

IMPORTANCE

Currently, rates of referral of patients with peritoneal metastasis in the United States who qualify for cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) are low, in part because of the misperception of high morbidity and mortality rates. However, patients requiring major gastrointestinal surgical procedures with similar complication rates are routinely referred.

OBJECTIVE

To evaluate the relative safety of CRS/HIPEC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 34 114 patients who underwent CRS/HIPEC, right lobe hepatectomy, trisegmental hepatectomy, pancreaticoduodenectomy, and esophagectomy between January 1, 2005, and December 31, 2015, included in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database. Data analysis was performed in 2018.

MAIN OUTCOMES AND MEASURES

Data from the NSQIP database were used to compare perioperative and 30-day postoperative morbidity and mortality rates of CRS/HIPEC (1822 patients) with other, well-accepted, high-risk surgical oncology procedures: right lobe hepatectomy (5109 patients), trisegmental hepatectomy (2449 patients), pancreaticoduodenectomy (Whipple) (16 793 patients), and esophagectomy (7941 patients).

RESULTS

For 34 114 patients, median (interquartile range [IQR]) age was 63 (55-71) years and 42% were female. Patients undergoing CRS/HIPEC tended to be younger, with a median age of 57 years, and esophagectomy had the highest median (IQR) American Society of Anesthesiologists classification (3 [3-3]). When compared with CRS/HIPEC, higher complication rates were reported in the following categories: (1) superficial incisional infection in Whipple and esophagectomy (5.4% [95% CI, 4.4%-6.4%] vs 9.7% [95% CI, 9.3%-10.1%] and 7.2% [95% CI, 6.6%-7.8%], respectively; P < .001); (2) deep incisional infection in Whipple (1.7% [95% CI, 1.1%-2.3%] vs 2.7% [95% CI, 2.5%-2.9%]; P < .01); (3) organ space infection in right lobe hepatectomy (7.2% [95% CI, 6.0%-8.4%] vs 9.0% [95% CI, 8.2%-9.8%]; P = .02), trisegmental hepatectomy (12.4% [95% CI, 11.1%-13.7%]; P < .001), and Whipple (12.9% [95% CI, 12.4%-13.4%]; P < .001); and (4) return to the operating room for esophagectomy (6.8% [95% CI, 5.6%-8.0%] vs 14.4% [95% CI, 13.6%-15.2%]; P < .001). Median (IQR) length of hospital stay was lower in CRS/HIPEC (8 [5-11] days) than Whipple (10 [7-15] days) and esophagectomy (10 [8-16] days) (P < .001). Overall 30-day mortality was lower in CRS/HIPEC (1.1%; 95% CI, 0.6%-1.6%) compared with Whipple (2.5%; 95% CI, 2.3%-2.7%), right lobe hepatectomy (2.9%; 95% CI, 2.4%-3.4%), esophagectomy (3.0%; 95% CI, 2.6%-3.4%), and trisegmental hepatectomy (3.9%; 95% CI, 3.1%-4.7%) (P < .001).

CONCLUSIONS AND RELEVANCE

Comparative analysis revealed CRS/HIPEC to be safe, often safer across the spectrum of NSQIP safety metrics when compared with similar-risk oncologic procedures. Patient selection was important in achieving observed outcomes. High complication rates are a misperception from early CRS/HIPEC experience and should no longer deter referral of patients to experienced centers or impede clinical trial development in the United States.

Long term survival analysis after hyperthermic intraperitoneal chemotherapy with oxaliplatin as a treatment for appendiceal peritoneal carcinomatosis

BACKGROUND AND OBJECTIVES

Complete cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) have been proven to lengthen survival in appendiceal peritoneal carcinomatosis (PC-A). The aim of this study was to analyze survival results of this therapy in our institution over the last 10 years.

METHODS

Data was retrospectively reviewed and analyzed. Treatment consisted of CRS plus HIPEC with oxaliplatin. Ronnett's histologic classification was used (peritoneal mucinous carcinomatosis (PMCA), PMCA with intermediate features (PMCA-I) and disseminated peritoneal adenomucinosis (DPAM)). Overall survival (OS) and disease-free survival (DFS) estimates were calculated using Kaplan-Meier survival curves.

RESULTS

109 patients with PC-A underwent laparotomy with curative intent. Of those, 92 underwent CRS plus HIPEC. Median follow-up was 42 months. The 5 and 10-year OS rates for the HIPEC group were 82.2% and 76.5%. The 5 and 10-year OS estimates for DPAM and PMCA-I subgroups were 100% and 100%, 78.1% and 72.9%, respectively. For the PMCA subgroup, the 3 and 5-year OS were 61.4% and 40.1%, respectively. The 5 and 10-year DFS estimates were 71.9% and 42.7%.

CONCLUSION

CRS plus HIPEC with oxaliplatin represent an effective therapeutic approach for PC-A. Long term OS estimates for patients treated at our institution are encouraging.

Impact of Synchronous Liver Resection on the Perioperative Outcomes of Patients Undergoing CRS-HIPEC

BACKGROUND

While liver resection (LR) and cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) are commonly performed for hepatic and peritoneal metastases, respectively, the safety of synchronous LR and CRS-HIPEC has not been established.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) databases from 2005 to 2016 were used to identify patients who underwent CRS-HIPEC. Demographic, clinical, and perioperative outcomes were compared among patients who underwent CRS-HIPEC with and without synchronous LR.

RESULTS

Among 1168 patients who underwent CRS-HIPEC, 100 (8.6%) underwent synchronous LR and 1068 (91.4%) did not. The most common primary diagnosis was unspecified (65.3%) followed by appendix (16.0%) and colorectal (12.5%). Among patients who underwent CRS-HIPEC plus LR, the majority had a partial hepatectomy (96.0%), while a small subset underwent trisegmentectomy (2.0%) or hemihepatectomy (2.0%). Patients who underwent CRS-HIPEC plus LR underwent a greater number of operative procedures (8.3 ± 2.5 vs 6.7 ± 2.5, p < 0.001), had a longer operative time (520.7 ± 155.3 vs 454.6 ± 160.7 min, p = 0.001), had a longer hospital length of stay (16.7 ± 15.6 vs 11.1 ± 11.5 days, p < 0.001), were more likely to require reoperation (13.0 vs 6.9%, p = 0.03), and experienced greater 30-day morbidity (47.0 vs 27.4%, p < 0.001), but not mortality (3.0 vs 1.4%, p = 0.22). On multivariate logistic regression, LR was strongly associated with increased risk of postoperative morbidity even after controlling for potential confounders (OR 1.65, 95% CI 1.03-2.64).

CONCLUSIONS

Simultaneous LR and CRS-HIPEC was associated with increased operative time, length of hospital stay, reoperation, and postoperative morbidity compared to CRS-HIPEC alone. For patients with synchronous hepatic and peritoneal metastases, a staged operative approach should be considered.

The Malnourished Patient With Obesity: A Unique Paradox in Bariatric Surgery

BACKGROUND

Hypoalbuminemia is a known risk factor for poor outcomes following surgery. Obesity can be associated with modest to severe malnutrition. We evaluated the impact of hypoalbuminemia on surgical outcomes in patients with obesity undergoing elective bariatric surgical procedures.

MATERIALS AND METHODS

The 2015 metabolic and bariatric surgery accreditation and quality improvement program database was queried. Patients ≥ 18 y with body mass index ≥35 undergoing bariatric surgery were included. Revision procedures were excluded. Patients were classified by albumin level (albumin ≥3.5 g/dL [normal], 3.49-3.0 g/dL [mild], 2.99-2.5 g/dL [moderate], and <2.5 g/dL [severe]). Independent logistic regression models were developed to estimate the adjusted odds of (1) death or serious morbidity (DSM); (2) mild to moderate complications; (3) severe complications; and (4) 30-d readmissions by albumin level. In addition, effect modification by >10% weight loss was examined.

RESULTS

A total of 106,577 patients were included in the study. Over 6% of patients had hypoalbuminemia. Fifty-five percent of complications were severe as categorized by the Clavien-Dindo classification. Patients with mild hypoalbuminemia had 20% increased odds of DSM (95% confidence interval: 1.1-1.4). There was increasing likelihood of DSM with severe hypoalbuminemia. Patients with mild hypoalbuminemia had 20% increased odds of 30-d readmission (confidence interval: 1.1-1.3). A >10% weight loss modified the effect of moderate to severe hypoalbuminemia on DSM.

CONCLUSIONS

More than 6% of patients with obesity undergoing bariatric surgery are malnourished. Hypoalbuminemia is an important and modifiable risk factor for postoperative adverse outcomes following bariatric surgery. Preoperative weight loss >10% combined with moderate to severe hypoalbuminemia is synergistic for high rates of DSM and should be addressed before proceeding with bariatric surgery.