Predictors of Anastomotic Failure After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Does Technique Matter?

BACKGROUND: Anastomotic failure (AF) after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) remains a dreaded complication. Whether specific factors, including anastomotic technique, are associated with AF is poorly understood. METHODS: Patients who underwent CRS-HIPEC including at least one bowel resection between 2000 and 2017 from 12 academic institutions were reviewed to determine factors associated with AF (anastomotic leak or enteric fistula). RESULTS: Among 1020 patients who met the inclusion criteria, the median age was 55 years, 43.9% were male, and the most common histology was appendiceal neoplasm (62.3%). The median Peritoneal Cancer Index was 14, and 93.2% of the patients underwent CC0/1 resection. Overall, 82 of the patients (8%) experienced an AF, whereas 938 (92.0%) did not. In the multivariable analysis, the factors associated with AF included male gender (odds ratio [OR], 2.2; p < 0.01), left-sided colorectal resection (OR 10.0; p = 0.03), and preoperative albumin (OR 1.8 per g/dL; p = 0.02).Technical factors such as method (stapled vs hand-sewn), timing of anastomosis, and chemotherapy regimen used were not associated with AF (all p > 0.05). Anastomotic failure was associated with longer hospital stay (23 vs 10 days; p < 0.01), higher complication rate (90% vs 59%; p < 0.01), higher reoperation rate (41% vs 9%; p < 0.01), more 30-day readmissions (59% vs 22%; p < 0.01), greater 30-day mortality (9% vs 1%; p < 0.01), and greater 90-day mortality (16% vs 8%; p = 0.02) as well as shorter median overall survival (25.6 vs 66.0 months; p < 0.01). CONCLUSIONS: Among patients undergoing CRS-HIPEC, AF is independently associated with postoperative morbidity and worse long-term outcomes. Because patient- and tumor-related, but not technical, factors are associated with AF, operative technique may be individualized based on patient considerations and surgeon preference.

Use of cholecystostomy tubes in the management of patients with primary diagnosis of acute cholecystitis.

BACKGROUND: Management of patients with severe acute cholecystitis (AC) remains controversial. In settings where laparoscopic cholecystectomy (LC) can be technically challenging or medical risks are exceedingly high, surgeons can choose between different options, including LC conversion to open cholecystectomy or surgical cholecystostomy tube (CCT) placement, or initial percutaneous CCT. We reviewed our experience treating complicated AC with CCT at a tertiary-care academic medical center. STUDY DESIGN: All adult patients (n = 185) admitted with a primary diagnosis of AC and who received CCT from 2002 to 2010 were identified retrospectively through billing and diagnosis codes. RESULTS: Mean patient age was 71 years and 80% had ≥1 comorbidity (mean 2.6). Seventy-eight percent of CCTs were percutaneous CCT placement and 22% were surgical CCT placement. Median length of stay from CCT insertion to discharge was 4 days. The majority (57%) of patients eventually underwent cholecystectomy performed by 20 different surgeons in a median of 63 days post-CCT (range 3 to 1,055 days); of these, 86% underwent LC and 13% underwent open conversion or open cholecystectomy. In the radiology and surgical group, 50% and 80% underwent subsequent cholecystectomy, respectively, at a median of 63 and 60 days post-CCT. Whether surgical or percutaneous CCT placement, approximately the same proportion of patients (85% to 86%) underwent LC as definitive treatment. CONCLUSIONS: This 9-year experience shows that use of CCT in complicated AC can be a desirable alternative to open cholecystectomy that allows most patients to subsequently undergo LC. Additional studies are underway to determine the differences in cost, training paradigms, and quality of life in this increasingly high-risk surgical population.