Colobronchial fistula: an unusual complication after peritonectomy and hyperthermic intra-peritoneal chemotherapy (HIPEC).

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is an innovative approach to peritoneal carcinomatosis. Due to the complexity of the combined procedure, high rates of potentially life-threatening complications have been reported. This is the first report of colobronchial fistula following CRS and HIPEC. CASE REPORT: A 70-year-old woman underwent CRS and HIPEC for papillary well-differentiated peritoneal mesothelioma. During the postoperative course, recurrent pneumonia occurred and bacteria of intestinal origin were isolated from expectorated sputum. Water-soluble contrast studies revealed direct communication between the left colon flexure and the bronchial tree. After appropriate medical and supportive therapies, the patient underwent resection of the splenic flexure and immediate anastomosis with complete recovery. CONCLUSION: Colobronchial fistula is a rare and potentially lethal complication of CRS and HIPEC. A suggestive clinical picture and contrast studies allow conclusive diagnosis to be made. Surgery is a safe and effective therapeutic option.

Role of explorative laparoscopy to evaluate optimal candidates for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with peritoneal mesothelioma.

BACKGROUND: Prognosis of peritoneal mesothelioma (PM) treated by cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is closely related to the completeness of the surgical cytoreduction. The reliability of explorative laparoscopy (EL) in selecting patients with PM amenable to optimal combined treatment has never been specifically assessed. PATIENTS AND METHODS: Thirty-three patients with PM underwent EL before CRS and closed-abdomen HIPEC with cisplatin and doxorubicin. EL effectiveness in predicting complete cytoreduction (residual tumour nodules < or = 2.5 mm) was analyzed. RESULTS: At EL, peritoneal involvement was considered amenable to complete CRS in 30 out of 33 patients (91%). In this group, cytoreduction was complete in 29 patients and incomplete in one. Three patients were judged not amenable to complete CRS and subsequently were not able to undergo complete cytoreduction. CONCLUSION: EL findings can integrate clinical and radiological information in the selection process of patients with PM for combined treatment.

Incidence of postoperative pancreatic fistula and hyperamylasemia after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

INTRODUCTION: The purpose of this study was to analyze the postoperative pancreatic morbidity of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal surface malignancies (PSM). PATIENTS AND METHODS: Two hundred and sixty five patients (87M/178F) with PSM underwent 270 consecutive procedures. The mean age was 52 years (range: 22-79 years). CRS was performed using peritonectomy procedures. HIPEC through the closed abdomen technique was conducted using cisplatin (CDDP 25 mg/m2/L of perfusate)+mitomycin C (MMC 3.3 mg/m2/L of perfusate) or CDDP (43 mg/L of perfusate)+doxorubicin (Dx 15.25 mg/L of perfusate), at 42.5 degrees C. Diagnosis and classification of postoperative pancreatic fistula (POPF) were performed according to the international study group on pancreatic fistula criteria. Serum amylase alterations were graded according to the National Cancer Institute (NCI) common terminology criteria for adverse events (CTCAE) v3. RESULTS: POPF was observed in 13 (4.8%) cases. Three cases were classified as major (grade C). Two cases presented postoperative pancreatitis. G3-4 alteration of amylase was observed in 12.3% of the cases. Performing splenectomy and CDDP dosage for HIPEC >240 mg were proven to be independent risk factors for both G3-4 hyperamylasemia and POPF. CONCLUSIONS: CRS+HIPEC presented an acceptable rate of pancreatic morbidity which did not contribute to the mortality related to the procedure. Most of the POPF were mild and/or easily controlled by conservative measures. Although not specific a normal amylasemia could be a useful marker of pancreatic integrity after CRS+HIPEC.

Impact of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy on systemic toxicity.

INTRODUCTION: The purpose of this study was to analyze the postoperative systemic toxicity and procedure-related mortality (PRM) of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal surface malignancies (PSMs). PATIENTS AND METHODS: A total of 242 (84 males/158 females) patients with PSM underwent 247 consecutive procedures. The mean age was 52 years (range 22-79). CRS was performed using peritonectomy procedures. The HIPEC technique through the closed abdomen was conducted with cisplatin (CDDP 25 mg/m(2)/l of perfusate)+mitomycin C (MMC 3.3 mg/m(2)/l perfusate) or CDDP (43 mg/l perfusate)+doxorubicin (Dx 15.25 mg/l perfusate) at 42.5 degrees C. These dosages were reduced by 30% when the patient had received systemic chemotherapy before the CRS+HIPEC. Systemic toxicities were graded according to the NCI CTCAE v3 criteria. RESULTS: G3-5 systemic toxicity rate was 11.7 % and adverse events were bone marrow suppression, 13; nephrotoxicity, 14; neutropenic infection, 2 and pulmonary toxicity, 1. Independent risk factors for G3-5 systemic toxicity after multivariate analysis were a dose of CDDP for HIPEC of 240 mg or more (OR 2.78, CI 95% 1.20-6.45) and CDDP+Dx schedule for HIPEC (OR 2.36, CI 95% 1.02-5.45). PRM was 1.2%. CONCLUSIONS: CRS+HIPEC presented acceptable systemic toxicity and PRM rates. Independent risk factors for systemic toxicity were the CDDP+Dx schedule and CDDP dose for HIPEC.

Bowel complications in 203 cases of peritoneal surface malignancies treated with peritonectomy and closed-technique intraperitoneal hyperthermic perfusion.

BACKGROUND: Peritonectomy and intraperitoneal hyperthermic perfusion (IPHP) are increasingly used in the management of carcinomatosis of various sites of origin. We analyzed the risk factors for bowel complications with primary anastomoses and the closed technique for IPHP. METHODS: From 1995 to 2004, 203 consecutive procedures were performed at the National Cancer Institute of Milan. We retrospectively analyzed this series of patients. Treated pathologies included peritoneal mesothelioma; pseudomyxoma peritonei; colorectal, ovarian, or gastric carcinomatosis; and abdominal sarcomatosis. All digestive anastomoses were performed before the IPHP. Only one defunctioning stoma was used. RESULTS: We found a bowel complication rate of 10.8%. The bowel complications:anastomoses ratio was 11.3%. On univariate analysis we found a statistically significant association between bowel complications and the following variables: sex, previous systemic chemotherapy status, number of anastomoses ( fewer than two vs. two or more), duration of the procedure (<8.7 vs. >or=8.7 hours), and extent of cytoreduction. After multivariate analysis, male sex (odds ratio [OR], 4.2), no previous systemic chemotherapy (OR, 3.5), and duration of the procedure >or=8.7 hours (OR, 6.3) were considered independent risk factors for bowel complications. CONCLUSIONS: Bowel complications are not increased when primary unprotected anastomoses are performed during peritonectomy and IPHP when the closed technique is used. Male sex, duration of the procedure, and no previous systemic chemotherapy are independent unfavorable risk factors.