Gastrointestinal complications in 147 consecutive patients with peritoneal surface malignancy treated by cytoreductive surgery and perioperative intraperitoneal chemotherapy.

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly used in the treatment of peritoneal carcinomatosis from gastrointestinal malignancies. The purpose of this study is to reevaluate the incidence of gastrointestinal events and identify risk factors associated with this treatment approach. Between January 1, 2006 and December 31, 2009, 147 patients with appendiceal and colorectal carcinomatosis were treated. Gastrointestinal events were analyzed. The overall incidence of grade I-IV gastrointestinal events was 17%. There were 4 grade III gastrointestinal events that occurred in 4 patients and 11 grade IV gastrointestinal events that occurred in 8 patients. On univariate analysis of grade I-IV events a statistically significant association was observed with the following variables: histological grade, peritoneal cancer index (PCI), small bowel resection, colorectal anastomosis, and the number of anastomoses performed per patient. By multivariate analysis, PCI was identified as the only independent risk factor for gastrointestinal complications. CRS combined with a uniform HIPEC regimen is associated with a 17% gastrointestinal morbidity rate (grade I-IV). The frequency of gastrointestinal complications was associated with a large extent of disease measured by PCI (>30).

Perioperative outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy for non-appendiceal peritoneal carcinomatosis from a prospective database.

BACKGROUND: Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy has expanded its application in the management of peritoneal carcinomatosis from gastrointestinal and ovarian malignancies. An accurate assessment of perioperative outcomes is crucial for integration of this combined procedure into clinical practice. METHODS: A prospective study of 80 patients undergoing the combined treatment for non-appendiceal peritoneal carcinomatosis was conducted. Forty-seven adverse events by eight organ-systems were rated from Grade I to IV with increasing severity. RESULTS: One patient (1.3%) died postoperatively. Postoperative adverse events affected genitourinary system (38%), hematological system (31%), gastrointestinal system (25%), infection (20%), intravenous catheters status (15%), pulmonary system (14%), cardiovascular system (11%) and neurological system (4%). Thirty-six patients (45%) experienced 49 Grade III adverse events. Six patients (8%) experienced eight Grade IV adverse events. More than four peritonectomy procedures (P = 0.010), and length of hospital stay of more than 21 days (P = 0.007) were strongly associated with Grade III and/or Grade IV morbidity. CONCLUSION: The morbidity and mortality rates after the combined treatment for non-appendiceal peritoneal carcinomatosis were within the acceptable range of surgical treatments for other gastrointestinal cancers. A standardized prospective database is required for an accurate assessment of perioperative outcomes.

Morbidity and mortality assessment of cytoreductive surgery and perioperative intraperitoneal chemotherapy for diffuse malignant peritoneal mesothelioma--a prospective study of 70 consecutive cases.

BACKGROUND: Although many reports regarding morbidity and mortality of cytoreductive surgery plus perioperative intraperitoneal chemotherapy are available, there are no prospective data on morbidity and mortality limited to patients with diffuse malignant peritoneal mesothelioma (DMPM). METHODS: This prospective morbidity and mortality assessment was performed on 70 consecutive cytoreductive procedures with perioperative intraperitoneal chemotherapy for DMPM. Forty-seven adverse events by eight categories were rated from grades I to IV with increasing severity. Grade I morbidity was self-limiting; grade II required medical treatments; grade III required an invasive intervention; grade IV required returning to the operating room or intensive care management. Risk factors for grades III and IV morbidity were determined. RESULTS: The perioperative mortality rate was 3%. The grades III and IV morbidity rates were 27 and 14%, respectively. Primary colonic anastomosis (P = 0.028), more than four peritonectomy procedures (P = 0.015), duration of the operation of more than 7 h (P = 0.027) were the risk factors for grade IV morbidity. Survival analysis of these 70 patients was provided. CONCLUSIONS: The morbidity and mortality results for cytoreductive surgery and perioperative intraperitoneal chemotherapy for patients with DMPM were within the acceptable range for major gastrointestinal surgery. Grade IV morbidity was associated with more extensive cytoreduction.

Prospective morbidity and mortality assessment of cytoreductive surgery plus perioperative intraperitoneal chemotherapy to treat peritoneal dissemination of appendiceal mucinous malignancy.

BACKGROUND: Appendiceal mucinous neoplasms present, in most patients, with peritoneal dissemination at the time of initial diagnosis. Patients may have a borderline tumor showing disseminated peritoneal adenomucinosis or an aggressive malignancy identified as peritoneal mucinous adenocarcinoma. Patients with these diagnoses were treated by cytoreductive surgery and perioperative intraperitoneal chemotherapy. METHODS: A database was established in 1998 that prospectively evaluated the morbidity and mortality of this group of patients. By using common toxicity grading criteria, 8 categories were scored on a grade of I to V. Grade IV indicated that the adverse event required urgent and definitive intervention: often a return to the operating room or to the surgical intensive care unit. Grade V indicated that the adverse events resulted in the patient's death. Adverse events were tabulated for each cytoreduction performed in these appendiceal malignancy patients. RESULTS: There were 356 procedures in patients taken to the operating room who received cytoreductive surgery with peritonectomy procedures plus heated intraoperative intraperitoneal chemotherapy. Only patients who had this combined treatment at our institution were included in the analysis. The total 30-day or in-hospital mortality was 2.0%. Nineteen percent of procedures were accompanied by at least one grade IV adverse event, and 11.1% of patients returned to the operating room. The most common category of grade IV complications was hematological (28%), followed by gastrointestinal (26%). CONCLUSIONS: The mortality of 2.0% and the overall grade IV morbidity of 19% in these patients may be acceptable in light of modern standards for the management of gastrointestinal cancer.

Prospective nonrandomized trial of silver impregnated cuff central lines.

Central venous lines were used to administer total parenteral nutrition at our institution. In an attempt to reduce line sepsis, silver impregnated cuff central lines (Hohn catheter) were adopted as standard of practice. Using a comprehensive morbidity and mortality database, 134 patients with Hohn catheters were compared to 252 patients who had polypropylene central line. The incidence of central line sepsis was increased with Hohn catheters to 23 of 134 (17.2%). This compared to 8 of 252 (3.2%) patients with polypropylene catheters (P < 0.0001). Also, an increased incidence of pulmonary embolism of 15 of 134 (11.2%) in patients with Hohn catheters was observed as compared to 2 of 252 (0.8%) with a polypropylene catheter (P < 0.0001). Insertion of Hohn catheters through the intrajugular vein was judged to be more difficult than polypropylene catheters. This may cause increased trauma to the vein resulting in a higher incidence of line infection and pulmonary embolism.