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Critical Assessment of Risk Factors for Complications After Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei

  • Gastrointestinal Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with pseudomyxoma peritonei (PMP). However, this aggressive treatment modality has been consistently associated with variable rates of perioperative mortality between 0% and 18% and morbidity between 30% and 70%.

This study evaluates the clinical and treatment-related risk factors for perioperative morbidity and mortality in PMP patients who underwent CRS and PIC.

Materials and Methods

A total of 145 consecutive CRS and PIC procedures for PMP performed between January 1996 and March 2009 were evaluated. The association of 12 clinical and 20 treatment-related risk factors with grades III and IV/V morbidity were assessed by univariable and multivariable analysis.

Results

The mortality (grade V) rate was 3%. The morbidity rates of grades III and IV were 23% and 22%, respectively. Eight factors were associated with grade IV/V morbidity on univariable analysis: peritoneal cancer index ≥21 (P = .034), ASA score ≥3 (P = .003), operation duration ≥10 h (P < .001), left upper quadrant peritonectomy procedure (P = .037), colonic resection (P = .012), ostomy (P = .005), ileostomy (P = .012), and transfusion ≥6 units (p = 0.011). Multivariable analysis showed 2 significant risk factors for grade IV/V morbidity: ASA ≥ 3 (P = .006) and an operation length ≥10 h (P < .001).

Conclusions

CRS and PIC has an acceptable rate of perioperative mortality and morbidity in selected patients with PMP. Patients with bulky disease who undergo a long operation are at a particularly high risk of a severe adverse event.

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References

  1. Sugarbaker PH. Pseudomyxoma peritonei. A cancer whose biology is characterized by a redistribution phenomenon. Ann Surg. 1994;219:109–11.

    Article  CAS  PubMed  Google Scholar 

  2. Deraco M, Baratti D, Inglese M, Allaria B, Andreola S, Gavazzi C, et al. Peritonectomy and intraperitoneal hyperthermic perfusion (IPHP): a strategy that has confirmed its efficacy in patients with pseudomyxoma peritonei. Ann Surg Oncol. 2004;11:393–8.

    Article  PubMed  Google Scholar 

  3. Piso P, Bektas H, Werner U, Schlitt HJ, Kubicka S, Bornscheuer A, et al. Improved prognosis following peritonectomy procedures and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis from appendiceal carcinoma. Eur J Surg Oncol. 2001;27:286–90.

    Article  CAS  PubMed  Google Scholar 

  4. Smeenk RM, Verwaal VJ, Antonini N, Zoetmulder FA. Survival analysis of pseudomyxoma peritonei patients treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg. 2007;245:104–9.

    Article  PubMed  Google Scholar 

  5. Elias D, Honore C, Ciuchendea R, Billard V, Raynard B, Lo Dico R, et al. Peritoneal pseudomyxoma: results of a systematic policy of complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Br J Surg. 2008;95:1164–71.

    Article  CAS  PubMed  Google Scholar 

  6. Gonzalez-Moreno S, Sugarbaker PH. Right hemicolectomy does not confer a survival advantage in patients with mucinous carcinoma of the appendix and peritoneal seeding. Br J Surg. 2004;91:304–11.

    Article  CAS  PubMed  Google Scholar 

  7. Yan TD, Black D, Savady R, Sugarbaker PH. A systematic review on the efficacy of cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei. Ann Surg Oncol. 2007;14:484–92.

    Google Scholar 

  8. Glehen O, Kwiatkowski F, Sugarbaker PH, Elias D, Levine EA, De Simone M, et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study. J Clin Oncol. 2004;22:3284–92.

    Article  CAS  PubMed  Google Scholar 

  9. Hansson J, Graf W, Pahlman L, Nygren P, Mahteme H. Postoperative adverse events and long-term survival after cytoreductive surgery and intraperitoneal chemotherapy. Eur J Surg Oncol. 2009;35:202–8.

    CAS  PubMed  Google Scholar 

  10. Verwaal VJ, van Tinteren H, Ruth SV, Zoetmulder FA. Toxicity of cytoreductive surgery and hyperthermic intra-peritoneal chemotherapy. J Surg Oncol. 2004;85:61–7.

    Article  PubMed  Google Scholar 

  11. Elias D, Goere D, Blot F, Billard V, Pocard M, Kohneh-Shahri N, et al. Optimization of hyperthermic intraperitoneal chemotherapy with oxaliplatin plus irinotecan at 43°C after compete cytoreductive surgery: mortality and morbidity in 106 consecutive patients. Ann Surg Oncol. 2007;14:1818–24.

    Article  PubMed  Google Scholar 

  12. Smeenk RM, Verwaal VJ, Zoetmulder FA. Toxicity and mortality of cytoreduction and intraoperative hyperthermic intraperitoneal chemotherapy in pseudomyxoma peritonei—a report of 103 procedures. Eur J Surg Oncol. 2006;32:186–90.

    Article  CAS  PubMed  Google Scholar 

  13. Kusamura S, Younan R, Baratti D, Costanzo P, Favaro M, Gavazzi C, et al. Cytoreductive surgery followed by intraperitoneal hyperthermic perfusion: analysis of morbidity and mortality in 209 peritoneal surface malignancies treated with closed abdomen technique. Cancer. 2006;106:1144–53.

    Article  PubMed  Google Scholar 

  14. Stephens AD, Alderman R, Chang D, Edwards GD, Esquivel J, Sebbag G, et al. Morbidity and mortality analysis of 200 treatments with cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy using the Coliseum technique. Ann Surg Oncol. 1999;6:790–6.

    Article  CAS  PubMed  Google Scholar 

  15. Glehen O, Osinsky D, Cotte E, Kwiatkowski F, Freyer G, Isaac S, et al. Intraperitoneal chemohyperthermia using a closed abdominal procedure and cytoreductive surgery for the treatment of peritoneal carcinomatosis: Morbidity and mortality analysis of 216 consecutive procedures. Ann Surg Oncol. 2003;10:863–9.

    Article  CAS  PubMed  Google Scholar 

  16. Yan TD, Links M, Fransi S, Jacques T, Black D, Saunders V, et al. Learning curve for cytoreductive surgery and perioperative intraperitoneal chemotherapy for peritoneal surface malignancy—a journey to becoming a Nationally Funded Peritonectomy Center. Ann Surg Oncol. 2007;14:2270—80.

    Article  PubMed  Google Scholar 

  17. Yan TD, Edwards G, Alderman R, Marquardt CE, Sugarbaker PH. Morbidity and mortality assessment of cytoreductive surgery and perioperative intraperitoneal chemotherapy for diffuse malignant peritoneal mesothelioma—a prospective study of 70 consecutive cases. Ann Surg Oncol. 2007;14:515–25.

    Article  PubMed  Google Scholar 

  18. Jacquet P, Stephens AD, Averbach AM, Chang D, Ettinghausen SE, Dalton RR, et al. Analysis of morbidity and mortality in 60 patients with peritoneal carcinomatosis treated by cytoreductive surgery and heated intraoperative intraperitoneal chemotherapy. Cancer. 1996;77:2622–9.

    Article  CAS  PubMed  Google Scholar 

  19. Guner Z, Schmidt U, Dahlke MH, Schlitt HJ, Klempnauer J, Piso P. Cytoreductive surgery and intraperitoneal chemotherapy for pseudomyxoma peritonei. Int J Colorectal Dis. 2005;20:155–60.

    Article  CAS  PubMed  Google Scholar 

  20. Gusani N, Cho S, Colovos C, Seo S, Franko J, Richard S, et al. Aggressive surgical management of peritoneal carcinomatosis with low mortality in a high-volume tertiary cancer center. Ann Surg Oncol. 2008;15:754–63.

    Article  PubMed  Google Scholar 

  21. Jacquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis. Cancer Treat Res. 1996;82:359–74.

    CAS  PubMed  Google Scholar 

  22. ASA. New classification of physical status. Anesthesiology. 1963;24:111–4.

    Google Scholar 

  23. Sugarbaker PH. Peritonectomy procedures. Ann Surg. 1995;221:29–42.

    Article  CAS  PubMed  Google Scholar 

  24. Ronnett BM, Yan H, Kurman RJ, Shmookler BM, Wu L, Sugarbaker PH. Patients with pseudomyxoma peritonei associated with disseminated peritoneal adenomucinosis have a significantly more favorable prognosis than patients with peritoneal mucinous carcinomatosis. Cancer. 2001;92:85–91.

    Article  CAS  PubMed  Google Scholar 

  25. Miner TJ, Shia J, Jaques DP, Klimstra DS, Brennan MF, Coit DG. Long-term survival following treatment of pseudomyxoma peritonei: an analysis of surgical therapy. Ann Surg. 2005;241:300–8.

    Article  PubMed  Google Scholar 

  26. Gough DB, Donohue JH, Schutt AJ, Gonchoroff N, Goellner JR, Wilson TO, et al. Pseudomyxoma peritonei. Long-term patient survival with an aggressive regional approach. Ann Surg. 1994;219:112–9.

    Article  CAS  PubMed  Google Scholar 

  27. Al-Homoud S, Purkayastha S, Aziz O, Smith JJ, Thompson MD, Darzi AW, et al. Evaluating operative risk in colorectal cancer surgery: ASA and POSSUM-based predictive models. Surg Oncol. 2004;13:83–92.

    Article  PubMed  Google Scholar 

  28. McCulloch P, Ward J, Tekkis PP. Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study. BMJ. 2003;327:1192–7.

    Article  PubMed  Google Scholar 

  29. Schroeder RA, Marroquin CE, Bute BP, Khuri S, Henderson WG, Kuo PC. Predictive indices of morbidity and mortality after liver resection. Ann Surg. 2006;243:373–9.

    Article  PubMed  Google Scholar 

  30. Vamvakas EC. Possible mechanisms of allogeneic blood transfusion-associated postoperative infection. Transfus Med Rev. 2002;16:144–60.

    Article  PubMed  Google Scholar 

  31. Hill GE, Frawley WH, Griffith KE, Forestner JE, Minei JP. Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis. J Trauma. 2003;54:908–14.

    Article  PubMed  Google Scholar 

  32. Saxena A, Yan TD, Morris DL. Critical assessment of preoperative and operative risk factors for complications after iterative peritonectomy procedures. Eur J Surg Oncol. 2009 [Epub ahead of print].

  33. Loungnarath R, Causeret S, Bossard N, Faheez M, Sayag-Beaujard AC, et al. Cytoreductive surgery with intraperitoneal chemohyperthermia for the treatment of pseudomyxoma peritonei: a prospective study. Dis Colon Rectum. 2005;48:1372–9.

    Article  PubMed  Google Scholar 

  34. Smeenk RM, Verwaal VJ, Zoetmulder FA. Learning curve of combined modality treatment in peritoneal surface disease. Br J Surg. 2007;94:1408–14.

    Article  CAS  PubMed  Google Scholar 

  35. Chua TC, Yan TD, Smigielski ME, Zhu KJ, Ng KM, Zhao J, et al. Long-term survival in patients with pseudomyxoma peritonei treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy: 10 years of experience from a single institution. Ann Surg Oncol. 2009;16:1903–11.

    Article  PubMed  Google Scholar 

  36. Kusamura S, Baratti D, Younan R, Laterza B, Oliva G, Costanzo P, et al. Impact of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy on systemic toxicity. Ann Surg Oncol. 2007;14:2550–8.

    Article  PubMed  Google Scholar 

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Acknowledgment

The authors thank Dr. Jing Zhao, MD, for her maintenance of the peritoneal surface malignancy database.

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Authors and Affiliations

  1. Department of Surgery, St. George Hospital, University of New South Wales, Sydney, Australia

    Akshat Saxena BMedSc, Tristan D. Yan BSc (Med), MBBS, PhD, Terence C. Chua BSc (Med) (Hons), MBBS & David L. Morris MB, ChB, MD, PhD

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  1. Akshat Saxena BMedSc
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  2. Tristan D. Yan BSc (Med), MBBS, PhD
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  3. Terence C. Chua BSc (Med) (Hons), MBBS
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  4. David L. Morris MB, ChB, MD, PhD
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Correspondence to Akshat Saxena BMedSc.

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Saxena, A., Yan, T.D., Chua, T.C. et al. Critical Assessment of Risk Factors for Complications After Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei. Ann Surg Oncol 17, 1291–1301 (2010). https://doi.org/10.1245/s10434-009-0875-9

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  • DOI: https://doi.org/10.1245/s10434-009-0875-9

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