Gastric perforation following cytoreductive surgery with perioperative intraperitoneal chemotherapy.

OBJECTIVE: Gastrointestinal tract perforation after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has an incidence of 6%. The most common site is the small bowel. The trauma of CRS and delay in wound healing due to HIPEC has been thought to cause this complication. METHODS: From our database of 1,251 patients we recorded the treatments that resulted in a stomach perforation, the clinical manifestations, and the final outcome. We formulated a pathophysiology for the development of this postoperative complication. RESULTS: Four patients had postoperative gastrointestinal perforation limited to the wall of the stomach (incidence 0.3%). All patients underwent greater omentectomy with ligation of the gastroepiploic vessels on the surface of the greater curvature, received HIPEC and early perioperative intraperitoneal chemotherapy. All perforations occurred along the greater curvature of the stomach. Successful management of the perforation was by suture plication of the gastric defect. CONCLUSION: Perforation of the stomach following CRS and HIPEC likely results from vascular compromise, delay in wound healing from chemotherapy, seromuscular tears related to traction on the stomach wall and point pressure on the greater curvature from a long-term indwelling nasogastric tube. Reperitonealization of the greater curvature, if seromuscular tears occur, may help prevent this complication.

Interstitial pneumonitis following intrapleural chemotherapy.

BACKGROUND: Mucinous neoplasms within the abdomen may disseminate by direct extension through the diaphragm to involve the pleural space. Treatment of this condition is by parietal and visceral pleurectomy followed by hyperthermic intrapleural chemotherapy. CASE PRESENTATION: In this case report a patient developed persistent right upper lobe interstitial pneumonitis and progressive parenchymal fibrosis following intrapleural chemotherapy treatment with mitomycin C and doxrubicin. The condition persisted until death 28 months later. Death was from progressive intraabdominal disease with intestinal obstruction and sepsis associated with progressive pulmonary parenchymal disease. The right pleural space disease did not recur. CONCLUSION: This manuscript is the first case report describing interstitial pneumonitis and lung fibrosis following intrapleural chemotherapy. Since pulmonary toxicity from chemotherapy is a dose-dependent phenomenon, dose reduction of intrapleural as compared to intraperitoneal hyperthermic chemotherapy may be necessary.

A systematic review on the efficacy of cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei.

BACKGROUND: The efficacy of cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) for patients with pseudomyxoma peritonei (PMP) remains to be established. METHODS: Searches for all relevant studies prior to March 2006 were performed on six databases. Two reviewers independently appraised each study using a predetermined protocol. The quality of each study was assessed. Clinical effectiveness was synthesized through a narrative review with full tabulation of results of all included studies. RESULTS: Ten most recent updates from each institution were included for appraisal and data extraction. There were no randomized controlled trials or comparative studies. All included articles were observational studies without control groups. Five studies were relatively large series (n>or=100). Two studies had relatively long-term follow-up (48 months and 52 months). The median follow-up in the remaining eight studies was shorter than 3 years (range 19-35 months). The median survival ranged from 51 to 156 months. The 1-, 2-, 3- and 5-year survival rates varied from 80 to 100%, 76 to 96%, 59 to 96% and 52 to 96%, respectively. The overall morbidity rate varied from 33 to 56%. The overall mortality rates ranged from 0 to 18%. CONCLUSIONS: This study reviewed current evidence on CRS and PIC for PMP. Only observational studies were available for evaluation, which demonstrated some promising long-term results, as compared to historical controls. Due to the rarity of this disease, a well-designed prospective multi-institutional study would be meaningful.

Systematic review on the efficacy of cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal carcinoma.

PURPOSE: The efficacy of cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for patients with peritoneal carcinomatosis from colorectal carcinoma remains to be established. METHODS: A systematic review of relevant studies before March 2006 was performed. Two reviewers independently appraised each study using a predetermined protocol. The quality of studies was assessed. Clinical effectiveness was synthesized through a narrative review with full tabulation of results of all included studies. RESULTS: Two randomized controlled trials, one comparative study, one multi-institutional registry study, and 10 most recent case-series studies were evaluated. The level of evidence was low in 13 of the 14 eligible studies. The median survival varied from 13 to 29 months, and 5-year survival rates ranged from 11% to 19%. Patients who received complete cytoreduction benefited most, with median survival varying from 28 to 60 months and 5-year survival ranging from 22% to 49%. The overall morbidity rate varied from 23% to 44%, and the mortality rate ranged from 0% to 12%. CONCLUSION: The current evidence suggests that cytoreductive surgery combined with perioperative intraperitoneal chemotherapy is associated with an improved survival, as compared with systemic chemotherapy for peritoneal carcinomatosis from colorectal carcinoma.