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Sugarbaker PH, Chang D. Critical appraisal of total gastrectomy plus total colectomy with hyperthermic intraperitoneal chemotherapy as a treatment for advanced pseudomyxoma peritonei. J Surg Oncol 2024. [PMID: 38935844 DOI: 10.1002/jso.27742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/06/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The absolute requirement for a long-term favorable result with cytoreductive surgery for pseudomyxoma peritonei is a complete resection of all visible disease. A combination of parietal peritonectomy procedures and visceral resections is required for this to occur. The cytoreductive surgery is supplemented by hyperthermic intraperitoneal chemotherapy. METHODS We searched our database and secured files for patients who required a total gastrectomy and a total colectomy to achieve a complete cytoreductive surgery. Survival of low-grade mucinous neoplasm (LAMN) and mucinous appendiceal adenocarcinoma (MACA) histologies were determined. Clinical and histologic variables were assessed for their impact on survival. RESULTS Thirteen of 450 patients (2.9%) with LAMN histology and 14 of 186 patients (7.5%) with MACA histology had these visceral resections. Median survival of these 27 patients was 10 years. LAMN and MACA patients showed the same survival. For LAMN histology, this requirement for extensive visceral resection markedly reduced survival (p < 0.0001). For MACA, there was no adverse impact on survival (p = 0.4359). Class 4 adverse events caused reduced survival (p = 0.0014). CONCLUSIONS A 10-year median survival accompanies total gastrectomy plus total colectomy for advanced pseudomyxoma peritonei. Systemic chemotherapy and class 4 adverse events reduced survival.
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Affiliation(s)
- Paul H Sugarbaker
- Program in Peritoneal Surface Malignancy, Washington Cancer Institute, Washington, District of Columbia, USA
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2
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Garrett C, Steffens D, Solomon M, Koh C. Surgical and survival outcomes of early-onset colorectal cancer patients: a single-centre descriptive Australian study. ANZ J Surg 2024. [PMID: 38475933 DOI: 10.1111/ans.18938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 02/09/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Early-onset colorectal cancer (EOCRC) incidence is increasing in Australia. However, no Australian studies have reported on EOCRC patients' surgical management and survival patterns. METHODS A retrospective study of 111 EOCRC patients treated at the Royal Prince Alfred Hospital (RPAH), Sydney, Australia between January 2013 and December 2021 was performed. RPAH is a quaternary referral centre for pelvic exenteration (PE) and cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). RESULTS Most patients had left-sided tumours (76.58%) and stage IV disease at the time of presentation (37.85%). 27.93% of patients underwent either CRS/HIPEC and PE and 72.07% of patients underwent other colorectal resections of which the most common was low anterior resection (19.82%). A stoma was fashioned in 50.54% of patients. Complications occurred in 54.95% of patients of which most were Clavien-Dindo grade II (47.54%). Absolute 1-, 3- and 5-year time intervals were 93.69%, 87.39% and 85.48%. Disease-free and overall survival were poorer in stage IV patients who had PE, followed by CRS/HIPEC then other colorectal resections (P < 0.001 and P = 0.003). CONCLUSIONS Stoma formation, PE and CRS/HIPEC and minor postoperative complications were common in our EOCRC cohort. Despite this, the 5-year absolute survival rate was acceptable. Thus, an aggressive surgical approach in EOCRC patients at a quaternary referral centre may be feasible at the cost of greater postoperative morbidity. This information is imperative in the surgical consent and preoperative counselling of EOCRC patients and highlights the need for further research to assess the postoperative functional outcomes and quality of life of EOCRC patients.
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Affiliation(s)
- Celine Garrett
- Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine & Health, Central Clinical School, The University of Sydney, Camperdown, New South Wales, Australia
- Faculty of Medicine & Health, St George and Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine & Health, Central Clinical School, The University of Sydney, Camperdown, New South Wales, Australia
| | - Michael Solomon
- Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine & Health, Central Clinical School, The University of Sydney, Camperdown, New South Wales, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine & Health, Central Clinical School, The University of Sydney, Camperdown, New South Wales, Australia
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Feenstra TM, Verberne CJ, Kok NF, Aalbers AGJ. Anastomotic leakage after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal cancer. Eur J Surg Oncol 2022; 48:2460-2466. [PMID: 36096855 DOI: 10.1016/j.ejso.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 04/29/2022] [Accepted: 05/18/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Anastomotic leakage (AL) after colorectal surgery is well-researched, yet the effect of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) after Cytoreductive Surgery (CRS) is unclear. Assessment of risk factors in these patients may assist surgeons during perioperative decision making. METHODS This was a single-center, retrospective study of patients who underwent CRS-HIPEC for colorectal peritoneal metastases. Main outcome measures were anastomotic leakage and associated morbidity. RESULTS AL was observed in 17 of the 234 (7.3%) anastomoses in 17 of the total of 165 (10.3%) of patients. No association was observed between the number and location of anastomoses and AL, although only one in 87 small bowel anastomoses showed leakage. The only factor associated with AL was administration of bevacizumab within 60 days prior to surgery with an odds ratio (OR) of 6.13 (1.32-28.39), P = 0.03. Deviating stomata were not statistically protective of increased morbidity, although more AL occurred in the patients with colocolic and colorectal anastomoses when no concomitant deviating stoma was created. Deviation stomata were reversed in 52.6%, and no AL was observed after stoma reversal. CONCLUSION The overall AL rate of CRS-HIPEC is comparable to colorectal surgery, and there is no cumulative risk of multiple anastomoses - especially in the case of small bowel anastomoses. Deviating stomata should be considered in patients with colocolic or colorectal anastomosis, although there is a significant chance that the stoma will not be reversed in these patients. Due to increased AL-risk surgeons should be aware of previous bevacizumab treatment, and plan the CRS-HIPEC at least 60 days after the treatment-day.
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Affiliation(s)
| | | | - Niels Fm Kok
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
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Geropoulos G, Psarras K, Giannis D, Martzivanou EC, Papaioannou M, Kakos CD, Pavlidis ET, Symeonidis N, Koliakos G, Pavlidis TE. Platelet rich plasma effectiveness in bowel anastomoses: A systematic review. World J Gastrointest Surg 2021; 13:1736-1753. [PMID: 35070077 PMCID: PMC8727194 DOI: 10.4240/wjgs.v13.i12.1736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/11/2021] [Accepted: 11/18/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anastomotic leak constitutes a major problem in abdominal surgery. Technical insufficiency, topical or systemic factors contribute to disrupted healing of the performed bowel anastomosis and result in anastomosis leakage, with detrimental effects on patient postoperative outcomes. Despite the investigation of several factors and the invention of protective materials, the ideal agent to prevent anastomotic leaks is yet to be determined.
AIM To study the effect of platelet rich plasma (PRP) on the healing of bowel anastomoses.
METHODS A systematic literature search was performed in PubMed, EMBASE, and Scopus databases to identify studies investigating the effect of PRP application on bowel anastomosis.
RESULTS Eighteen studies were eligible with a total population of 712 animals including rats (14 studies), rabbits (2 studies) and pigs (2 studies). No postoperative complications were reported following PRP application. Fourteen out of 18 studies reported a statistically significant higher anastomosis bursting pressure in PRP groups compared to control either in healthy animals or animal models with underlying condition or intervention, such as intraperitoneal chemotherapy or peritonitis. Similar results were reported by ten studies in terms of tissue hydroxyproline levels. One study reported significant increase in collagen deposition in PRP groups. PRP application resulted in significantly decreased inflammatory cell infiltration in the presence of peritonitis or intraperitoneal chemotherapy (6 studies).
CONCLUSION The application of PRP is associated with improved bowel anastomosis outcomes, especially in animal models having an underlying condition affecting the normal healing process. PRP application seems to augment the normal healing process under these circumstances. However, further studies are needed to investigate the potential role of PRP on bowel anastomosis healing, especially in clinical settings.
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Affiliation(s)
- Georgios Geropoulos
- Department of General Surgery, University College London Hospitals, London NW1 2BU, United Kingdom
- Laboratory of Scientific Research and Experimental Surgery, 2nd Propedeutic Department of Surgery, School of Medicine, Aristotle University, Thessaloniki 54642, Greece
- Surgery Working Group, Society of Junior Doctors, Athens 15123, Greece
| | - Kyriakos Psarras
- Laboratory of Scientific Research and Experimental Surgery, 2nd Propedeutic Department of Surgery, School of Medicine, Aristotle University, Thessaloniki 54642, Greece
| | - Dimitrios Giannis
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Manhasset, NY 11030, United States
| | - Eirini Chrysovalantou Martzivanou
- Laboratory of Scientific Research and Experimental Surgery, 2nd Propedeutic Department of Surgery, School of Medicine, Aristotle University, Thessaloniki 54642, Greece
| | - Maria Papaioannou
- Laboratory of Biological Chemistry, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | | | - Efstathios Theodoros Pavlidis
- Laboratory of Scientific Research and Experimental Surgery, 2nd Propedeutic Department of Surgery, School of Medicine, Aristotle University, Thessaloniki 54642, Greece
| | - Nikolaos Symeonidis
- Laboratory of Scientific Research and Experimental Surgery, 2nd Propedeutic Department of Surgery, School of Medicine, Aristotle University, Thessaloniki 54642, Greece
| | - Georgios Koliakos
- Laboratory of Biological Chemistry, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Theodoros Efstathios Pavlidis
- Laboratory of Scientific Research and Experimental Surgery, 2nd Propedeutic Department of Surgery, School of Medicine, Aristotle University, Thessaloniki 54642, Greece
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The impact of gastrointestinal anastomotic leaks on survival of patients undergoing cytoreductive surgery and heated intraperitoneal chemotherapy. Am J Surg 2021; 223:331-338. [PMID: 33832737 DOI: 10.1016/j.amjsurg.2021.03.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/15/2021] [Accepted: 03/28/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Gastrointestinal (GI) leaks after cytoreductive surgery and hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) is a known life-threatening complication that may alter patients' outcomes. Our aim is to investigate risk factors associated with GI leaks and evaluate the impact of GI leaks on patient's oncological outcomes. METHODS A retrospective analysis of perioperative and oncological outcomes of patients with and without GI leaks after CRS/HIPEC. RESULTS Out of 191 patients included in this study, GI leaks were identified in 17.8% (34/191) of patients. Small bowel anastomoses were the most common site (44%). Most of the GI leaks were managed conservatively and re-operation was needed in 44.1% of cases. Univariate analysis identified higher PCI (p = 0.03), higher number of packed cells transfused (p = 0.036), pelvic peritonectomy (p = 0.013), high number of anastomoses (p = 0.003) and colonic resection (p = 0.042) as factors associated with GI leaks. Multivariate analysis identified stapled anastomoses (OR 2.59, p = 0.001) and pelvic peritonectomy (OR 2.33, p = 0.044) as independent factors associated with GI leaks. Disease-free survival tended to be worse in the leak group but did not reach statistical significance (p = 0.235). The 3- and 5-year OS was 73.2% and 52.9% in the leak group compared to 75.8% and 73.2% in the non-leak group (p = 0.236). CONCLUSIONS GI leak showed no impact on overall and disease free survival after CRS/HIPEC.Avoidance of stapled reconstruction in high risk patients with high tumor burden and large number of anastomoses may yield improved outcomes.
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Brind'Amour A, Pravong V, Sidéris L, Dubé P, De Guerke L, Fortin S, Auclair MH, Trilling B, Tremblay JF. Rectal anastomosis and hyperthermic intraperitoneal chemotherapy: Should we avoid diverting loop ileostomy? Eur J Surg Oncol 2021; 47:2346-2351. [PMID: 33637373 DOI: 10.1016/j.ejso.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/18/2021] [Accepted: 02/08/2021] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Literature on rectal anastomosis and diverting ileostomy in patients treated with hyperthermic intraperitoneal chemotherapy (HIPEC) is limited. This study assesses the safety of rectal anastomoses during cytoreductive surgery (CRS) and HIPEC, with and without fecal diversion, and its morbidity when performed. MATERIALS AND METHODS From January 2012 to January 2020, patients with peritoneal metastases who underwent CRS and HIPEC that required a rectal anastomosis were included in this single-hospital retrospective chart review. RESULTS 84 patients were included, of which 29 had a diverting loop ileostomy. The rectal anastomotic leak (AL) rate for the series was 8.3%. Factors associated with AL were male gender (p = 0.031) and increased BMI (p < 0.0005). Diverting loop ileostomy was associated with a significant decrease of clinically significant rectal AL (0% vs 12.7%, p = 0.045). However, the 90-day readmission rate was higher in this group (37.9% vs 10.9%, p = 0.003). Stoma reversal surgery was performed for all patients, but 3 patients experienced AL (10.7%). CONCLUSIONS This study suggests that creation of a diverting loop ileostomy may be an effective strategy to prevent symptomatic rectal AL following CRS with HIPEC. However, it is also associated with an increased readmission rate and increased risk of AL following reversal surgery.
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Affiliation(s)
| | - Vera Pravong
- Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Lucas Sidéris
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Pierre Dubé
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Lara De Guerke
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Gynecology & Obstetrics, University of Montreal, Montreal, QC, Canada
| | - Suzanne Fortin
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Gynecology & Obstetrics, University of Montreal, Montreal, QC, Canada
| | - Marie-Hélène Auclair
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Gynecology & Obstetrics, University of Montreal, Montreal, QC, Canada
| | - Bertrand Trilling
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Jean-François Tremblay
- Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada; Department of Surgery, University of Montreal, Montreal, QC, Canada.
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Gorur M, Sozutek A, Irkorucu O, Karakaya B. The influence of platelet-rich plasma (PRP) on colonic anastomosis healing impaired by intraperitoneal 5-flourouracil application. An experimental study. Acta Cir Bras 2020; 35:e202000504. [PMID: 32638844 PMCID: PMC7341987 DOI: 10.1590/s0102-865020200050000004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 04/22/2020] [Indexed: 12/18/2022] Open
Abstract
Purpose 5-flourourasil (5-FU) is commonly used for early intraperitoneal chemotherapy in colorectal or appendiceal cancer patients with peritoneal carcinomatosis. Due to its effect, anastomosis healing can be impaired and leads to anastomotic leakage. In this study, we aimed to investigate the potential healing effect of platelet-rich plasma (PRP) on colonic anastomosis impaired by intraperitoneal 5-flourouracil application. Methods After ten rats were sacrificed for preparing PRP, forty Wistar-albino rats were subjected to colonic anastomosis, and randomly allocated into four groups including 10 rats each. According to receiving PRP and/or 5-FU application, the groups were formed as control (C), 5-FU without PRP (CT), anastomosis with PRP (C-PRP), and 5-FU with PRP (CT-PRP). CT and CT-PRP groups also received 5-FU intraperitoneally on postoperative day 1 (POD 1). All animals were euthanized on pod 7. The body weight change, anastomotic bursting pressure (ABP), tissue hydroxiprolin (TH) and histopathological examination of each group were analyzed. Results 5-FU application significantly reduced ABP levels when compared with group C, C-PRP and CT-PRP (for each comparison, p<0,01). PRP application in CT-PRP group raised the measure of ABP up to the levels of C group. Although tissue hydroxyproline levels (THL) levels of CT-PRP group were found higher than CT group, it was not significant (p=0.112). Microscopically, comparing with CT group, PRP application significantly promoted the healing of colonic anastomosis subjected to 5-FU application by improving tissue edema, necrosis, submucosal bridging and collagen formation (p<0.05). Tissue healing in CT-PRP group was observed as good as the control groups. (C, C-PRP, p=0.181, p=0.134; respectively). Conclusion PRP administration on colonic anastomosis significantly promotes the healing process of anastomosis in rats receiving 5-FU. This result encourages further clinical use of PRP to reduce the frequency of AL in patients receiving EPIC.
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Liver metastasectomy-cytoreductive surgery- hyperthermic intraperitoneal chemotherapy and ileal pouch-anal anastomosis: A case report. Int J Surg Case Rep 2020; 72:397-401. [PMID: 32563829 PMCID: PMC7306530 DOI: 10.1016/j.ijscr.2020.06.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 02/07/2023] Open
Abstract
Peritoneal carcinomatosis with concurrent liver metastases should not be treated as end stage disease. IPAA anastomosis can be applied simultaneously with HIPEC, improving quality of life especially for Familial Adenomatosis Polyposis patients. HIPEC as a prognostic factor of anastomotic healing; ileorectal anastomosis. Liver metastasectomy with cytoreductive surgery and HIPEC may prolong survival.
Introduction Cytoreductive surgery (CRS) with hyperthermal intraperitoneal chemotherapy (HIPEC) are established treatments for peritoneal carcinomatosis that prolong survival in carefully selected patients. At the time of diagnosis, 4–7% of patients with colorectal cancer (CRC) have metastasis to the peritoneum. There is a lack of evidence in the literature if J-pouch can be applied simultaneously with HIPEC to improve quality of life in patients with familial adenomatous polyposis syndrome (FAP) and peritoneal carcinomatosis. Case presentation We describe a case of a 41-year-old Caucasian male with Familial Adenomatous Polyposis which was diagnosed as metastatic colorectal cancer in the liver and peritoneum. He was treated with systemic chemotherapy followed by total proctocolectomy with a J-shaped IPAA, liver metastasectomy, right hemidiaphragm resection, CRS and HIPEC. Discussion CRS and HIPEC have been implicated with high morbidity and mortality rates. A major independent risk factor correlated with high morbidity is anastomotic failure. J-Pouch formation although considered a technique with high complication rates, improves the quality of life of patients after total proctocolectomy and is related to high patient satisfaction. There are inconclusive data on whether anastomotic failure rates are higher when performing J-Pouch and HIPEC together. Conclusions J-Pouch after CRS and HIPEC can be offered as a treatment as long as the patient is carefully selected, in high volume centers with experienced surgeons.
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Baron E, Gushchin V, King MC, Nikiforchin A, Sardi A. Pelvic Anastomosis Without Protective Ileostomy is Safe in Patients Treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2020; 27:4931-4940. [PMID: 32506191 DOI: 10.1245/s10434-020-08479-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND During cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), surgeons are reluctant to perform unprotected pelvic anastomosis despite lack of supporting data. We analyzed pelvic anastomosis outcomes and factors that influence ostomy creation in CRS/HIPEC patients. METHODS A single-center, descriptive study of patients with rectal resection during CRS/HIPEC was conducted using a prospective database. Surgical variables were reviewed. Multinomial logistic regression of outcomes (end or protective ostomy) was performed with pre- and intraoperative factors as predictors. RESULTS Overall, 274 of 789 CRS/HIPEC patients underwent rectal resection, including 243 (89%) with pelvic anastomosis [232 (85%) without ostomy, 11 (4%) with protective ileostomy] and 31 (11%) with no anastomosis [16 (6%) with end colostomy, 15 (5%) with end ileostomy]. The median age was 57 and 29% (79) were male. Of 243 pelvic anastomosis patients, 3 (1.2%) had rectal anastomotic leaks, including 1 with a protective ileostomy. Other anastomotic leaks occurred in 3.6%. Overall, 13% had Clavien-Dindo complications ≥ IIIB and the readmission rate was 30%. Mortality at 30 days and 100 days was 0.4% and 2.2%, respectively. Male gender and primary rectal cancer were associated with protective ileostomy [odds ratio (OR) = 7.01, 95% CI: 1.6-31.5, p = 0.011, and OR = 16.4, 95% CI: 3-88.4, p = 0.001, respectively). Male gender and prior pelvic surgery were associated with end colostomy (OR = 13.9, 95% CI: 3.7-53, p < 0.0001, and OR = 17.2, 95% CI: 3.8-78.6, p < 0.0001). CONCLUSIONS Pelvic bowel reconstruction without protective or end ostomy during CRS/HIPEC is safe. Protective ileostomy is associated with male gender and primary rectal cancer. End colostomy is associated with male gender and prior pelvic surgery.
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Affiliation(s)
- Ekaterina Baron
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care at Mercy, Baltimore, MD, USA
| | - Vadim Gushchin
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care at Mercy, Baltimore, MD, USA
| | - Mary Caitlin King
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care at Mercy, Baltimore, MD, USA
| | - Andrei Nikiforchin
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care at Mercy, Baltimore, MD, USA
| | - Armando Sardi
- Department of Surgical Oncology, Mercy Medical Center, The Institute for Cancer Care at Mercy, Baltimore, MD, USA.
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Schwartz PB, Stahl CC, Vande Walle KA, Pokrzywa CJ, Cherney Stafford LM, Aiken T, Barrett J, Acher AW, Leverson G, Ronnekleiv-Kelly S, Weber SM, Abbott DE. What Drives High Costs of Cytoreductive Surgery and HIPEC: Patient, Provider or Tumor? Ann Surg Oncol 2020; 27:4920-4928. [PMID: 32415351 DOI: 10.1245/s10434-020-08583-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is utilized for peritoneal malignancies and is associated with significant resource use. To address potentially modifiable factors contributing to excessive cost, we sought to determine predictors of high cost of care for patients undergoing CRS/HIPEC. METHODS An institutional CRS/HIPEC database was queried for adult patients from 2014 to 2018. Cost was defined as cost for the index hospitalization, and high-cost cases were defined as > 75th percentile for cost. Bivariate analyses for cost were performed, and all significant tumor, patient, and surgeon-specific variables were entered in a linear regression for cost. A separate linear regression was performed for length of stay (LOS). RESULTS In total, 59 patients underwent 61 CRS/HIPEC procedures. The median direct variable cost was $20,509 (16,395-25,240). Median length of stay (LOS) was 8 (7-11.5) days and ICU stay was 1 (1-1.5) day. LOS, length of ICU stay and operative time were predictive of cost. Factors associated with increased LOS were Clavien-Dindo grade II complications and ostomy creation. Patient-related factors, including age and BMI, tumor-related factors, such as PCI and CCR, and surgeon were not predictive of cost nor LOS. DISCUSSION Our results, the first to identify predictors of high cost of CRS/HIPEC-related care in the US, reveal cost was largely related to length and intensity of care. In turn, these drivers were influenced by complications and operative factors. Future work will focus on identifying an appropriate ERAS protocol following CRS/HIPEC and selection of those patients that may avoid routine ICU admission.
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Affiliation(s)
- Patrick B Schwartz
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christopher C Stahl
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kara A Vande Walle
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Courtney J Pokrzywa
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Linda M Cherney Stafford
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Taylor Aiken
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - James Barrett
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alexandra W Acher
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Glen Leverson
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sean Ronnekleiv-Kelly
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sharon M Weber
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Buk OF, Ocak S, Genc B, Avcı B, Uzuner HO. Is platelet-rich plasma improves the anastomotic healing in hyperthermic intraperitoneal chemotherapy with oxaliplatin: an experimental rat study. Ann Surg Treat Res 2020; 98:89-95. [PMID: 32051817 PMCID: PMC7002883 DOI: 10.4174/astr.2020.98.2.89] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 10/30/2019] [Accepted: 01/04/2020] [Indexed: 01/04/2023] Open
Abstract
Purpose Hyperthermic intraperitoneal chemotherapy (HIPEC) is a novel treatment option for peritoneal surface malignancies. Due to cytotoxic effects of chemotherapeutic agents, anastomosis healing can be impaired and lead to leakage rates higher than conventional intestinal surgery. In this experimental study, we aimed to investigate the effects of platelet-rich plasma (PRP) on colonic anastomosis in rats that received HIPEC with oxaliplatin. Methods Thirty rats were divided into 3 groups. Group 1 was determined as control group and hyperthermic saline perfusion was performed after colon anastomosis. In group 2, colon anastomosis then hyperthermic oxaliplatin perfusion was performed. In the last group, the colonic anastomosis was enhanced by PRP gel and then hyperthermic oxaliplatin perfusion was performed. All the rats were reoperated on postoperative day 7 and anastomotic bursting pressure values were recorded. Tissue samples were taken for hydroxyproline assay and histopathological examination. Results Control group had higher anastomotic bursting pressure value than group 2 and group 3 (P < 0.001). There were significant differences in anastomotic bursting pressure between groups 2 and 3 (P < 0.001). Group 2 had significantly lower hydroxyproline levels than group 3 and control group (P < 0.001). Histopathological examination revealed that PRP application reduced inflammatory response. Conclusion PRP application on colonic anastomosis improves anastomotic healing and can reduce anastomosis related complications and stoma creation; though further clinical studies are needed.
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Affiliation(s)
- Omer Faruk Buk
- Department of General Surgery, University of Healthy Sciences, Samsun Research and Training Hospital, Samsun, Turkey
| | - Sonmez Ocak
- Department of General Surgery, University of Healthy Sciences, Samsun Research and Training Hospital, Samsun, Turkey
| | - Bugra Genc
- Department of Animal Nutrition and Nutritional Diseases, Faculty of Veterinary Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Bahattin Avcı
- Department of Biochemistry, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Hatice Olger Uzuner
- Department of Pathology, University of Healthy Sciences, Samsun Research and Training Hospital, Samsun, Turkey
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Duzgun O, Kalin M. Safety of coloanal/ileoanal anastomosis during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis: results of 20 consecutive patients. J Int Med Res 2019; 47:4911-4919. [PMID: 31502496 PMCID: PMC6833411 DOI: 10.1177/0300060519872618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Objective No studies to date have focused on the safety of coloanal/ileoanal anastomosis (CAIAA) in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC), which is associated with severe morbidity and mortality. We herein present the outcomes of patients with peritoneal carcinomatosis (PC) who underwent CAIAA. Methods We evaluated the prospectively collected data from 20 patients with PC who underwent CRS + HIPEC with respect to the primary disease, synchronous resections, intraoperative chemotherapy regimen, timing of protective ileostomy closure, and overall postoperative complications. Results Most patients underwent CRS + HIPEC and CAIAA for PC due to colorectal cancer. Coloanal anastomosis was performed in 15 (75%) patients, and J-pouch ileoanal anastomosis was performed in 5 (25%) patients. No anastomosis-related complications occurred in any patients who underwent CAIAA; however, one patient died of pulmonary embolism on postoperative day 7. Conclusions CAIAA is associated with serious complications even after performing benign colorectal surgery. However, it may be challenging for surgeons to simultaneously perform CAIAA in patients with PC who undergo CRS + HIPEC. We emphasize that this procedure can be safely performed with experienced surgical teams by using a multidisciplinary approach.
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Affiliation(s)
- Ozgul Duzgun
- Department of General Surgery, Health Sciences University, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Murat Kalin
- Department of General Surgery, Health Sciences University, Umraniye Training and Research Hospital, Istanbul, Turkey
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Ocak S, Buk OF, Genc B, Avcı B, Uzuner HO, Gundogdu SB. The effects of platelet-rich-plasma gel application to the colonic anastomosis in hyperthermic intraperitoneal chemotherapy: An experimental rat model. Int Wound J 2019; 16:1426-1432. [PMID: 31448554 DOI: 10.1111/iwj.13207] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/05/2019] [Accepted: 08/11/2019] [Indexed: 12/14/2022] Open
Abstract
Hyperthermic intraperitoneal chemotherapy (HIPEC) has cytotoxic effects on tumour cells but also negative impacts on anastomotic healing. Platelet-rich-plasma (PRP) is used for wound care but data about effects on gastrointestinal anastomosis are limited. In this experimental study, we aimed to investigate the effects of PRP application on colon anastomosis in rats those received HIPEC with cisplatin. Five rats were sacrificed to obtain PRP gel. Thirty rats were divided into three groups; Group 1: control group, Group 2: colon anastomosis and HIPEC with cisplatin, and Group 3: colon anastomosis enhanced by PRP and HIPEC with cisplatin. The rats were re-operated on postoperative day seven and anastomotic bursting pressure (ABP) was recorded. Also, tissue samples were taken for hydroxyproline assessment and histopathological examination. There were significant differences in ABP between Groups 2 and 3, and also those groups had lower ABP compared with the control group. Group 3 had significantly higher hydroxyproline levels and had better histopathological findings than group 2. According to our findings, we suggest that PRP application improves the anastomotic healing by increasing anastomotic bursting pressure, hydroxyproline levels, and decreasing inflammatory response. Further clinical studies are needed to prove our hypothesis.
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Affiliation(s)
- Sonmez Ocak
- Department of General Surgery, University of Health Sciences, Samsun Research and Training Hospital, Samsun, Turkey
| | - Omer F Buk
- Department of General Surgery, University of Health Sciences, Samsun Research and Training Hospital, Samsun, Turkey
| | - Bugra Genc
- Department of Animal Nutrition and Nutritional Diseases, Faculty of Veterinary Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Bahattin Avcı
- Department of Biochemistry, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Hatice O Uzuner
- Department of Pathology, University of Health Sciences, Samsun Research and Training Hospital, Samsun, Turkey
| | - Salih B Gundogdu
- Department of Gastroenterological Surgery, University of Health Sciences, Turkiye Yuksek Ihtisas Research and Training Hospital Ankara, Turkey
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Gremonprez F, Gossye H, Ceelen W. Use of hyperthermia versus normothermia during intraperitoneal chemoperfusion with oxaliplatin for colorectal peritoneal carcinomatosis: A propensity score matched analysis. Eur J Surg Oncol 2019; 45:366-370. [DOI: 10.1016/j.ejso.2018.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 07/25/2018] [Accepted: 08/17/2018] [Indexed: 12/20/2022] Open
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Implications of Stoma Formation as Part of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. World J Surg 2018; 42:2036-2042. [PMID: 29302727 DOI: 10.1007/s00268-017-4450-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Formation of protective stoma as part of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) may be an effective tool in reducing anastomotic leak incidence. Our aim was to evaluate the incidence and implications of stoma formation during CRS-HIPEC and to examine whether a creation of protective stoma reduces the postoperative morbidity. METHODS A cohort retrospective analysis of all CRS-HIPEC procedures performed between 2004 and 2016 was conducted. Predicting factors for stoma formation were assessed by comparing all patients who underwent stoma formation to those who did not; both groups were then restricted to cases with ≥2 bowel anastomoses and compared in terms of perioperative outcomes in order to determine whether protective stoma confers a morbidity benefit. RESULTS One hundred and ninety-nine CRS-HIPEC procedures were performed on 186 patients. Thirty-four patients (17%) underwent stoma formation, 24 of them as protective stoma. Formation of a stoma was correlated with higher peritoneal carcinomatosis index score (13.6 ± 8 vs. 9.5 ± 7.7, p = 0.007), larger number of organs resected (p < 0.001), greater number of anastomoses (p < 0.001), prolonged operative time (8.1 ± 2.7 vs. 6.6 ± 2.2 h, p = 0.002), and prolonged hospital stay (12 vs. 8.5 days, p = 0.001). In procedures requiring ≥2 anastomoses, formation of protective stoma reduced the anastomotic leak rate (6 vs. 37%, p = 0.025), the morbidity rate (6 vs. 41%, p = 0.017), and reoperation rate (0 vs. 28%, p = 0.03). Overall, 15 patients (44%) underwent stoma reversal, 3 of whom had a complication treated non-operatively. CONCLUSIONS Protective stoma should be considered in extensive CRS-HIPEC procedures requiring two or more bowel anastomoses in order to reduce the postoperative morbidity rate.
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Kelly KJ, Cajas L, Baumgartner JM, Lowy AM. Factors Associated with 60-Day Readmission Following Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2017; 25:91-97. [PMID: 29090402 DOI: 10.1245/s10434-017-6108-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Readmission rates following surgery are subject to scrutiny in efforts to control health care costs. This study was designed to define the 60-day readmission rate following cytoreduction and HIPEC at a high-volume center and to identify factors associated with readmission. METHODS Patients who underwent complete cytoreduction and HIPEC at a single institution from August 2007 through June 2014 were identified from a prospectively maintained database. Multiple preoperative and operative factors were analyzed for their ability to predict 60-day readmission following surgery. RESULTS A total of 250 patients were identified. Forty patients (17%) experienced readmission within 60 days of surgery. The most common reasons for readmission were ileus/dehydration (12, 31%), deep space infection (8, 21%), and DVT/PE (6, 15%). Initial postoperative length of stay was longer for patients readmitted within 60 days (median 12 vs. 9 days, p = 0.013). Of categorical variables analyzed, including gender, histology, HIPEC agent, intraoperative transfusion, and individual procedures performed during cytoreduction, adjuvant systemic therapy, and postoperative morbidity, only Charlson comorbidity index CCI (odds ratio (OR) = 3.80 [1.68-8.60]) and stoma creation (OR = 6.04 [1.56-12.14]) were associated with 60-day readmission. CONCLUSIONS Few measurable variables are associated with readmission following cytoreduction and HIPEC. Patients with high CCI and those with stomas created at the time of CRS/HIPEC may be at increased risk of readmission within 60 days. Earlier or more frequent follow-up for high-risk patients should be considered as a strategy to reduce readmissions.
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Affiliation(s)
- Kaitlyn J Kelly
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA. .,Moores Cancer Center, UCSD, San Diego, CA, USA.
| | - Luis Cajas
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Joel M Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Andrew M Lowy
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
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