Failure-to-Rescue Following Cytoreductive Surgery with or Without HIPEC is Determined by the Type of Complication—a Retrospective Study by INDEPSO

Abstract

To determine factors influencing failure-to-rescue in patients with complications following cytoreductive surgery and HIPEC. A retrospective analysis of patients enrolled in the Indian HIPEC registry was performed. Complications were graded according to the CTCAE classification version 4.3. The 30-and 90-day morbidity were both recorded. Three hundred seventy-eight patients undergoing CRS with/without HIPEC for peritoneal metastases from various primary sites, between January 2013 and December 2017 were included. The median PCI was 11 [range 0-39] and a CC-0/1 resection was achieved in 353 (93.5%). Grade 3-4 morbidity was seen 95 (25.1%) at 30 days and 122 (32.5%) at 90 days. The most common complications were pulmonary complications (6.8%), neutropenia (3.7%), systemic sepsis (3.4%), anastomotic leaks (1.5%), and spontaneous bowel perforations (1.3%). Twenty-five (6.6%) patients died within 90 days of surgery due to complications. The failure-to-rescue rate was 20.4%. Pulmonary complications (p = 0.03), systemic sepsis (p < 0.001), spontaneous bowel perforations (p < 0.001) and PCI > 20 (p = 0.002) increased the risk of failure-to-rescue. The independent predictors were spontaneous bowel perforation (p = 0.05) and systemic sepsis (p = 0.001) and PCI > 20 (p = 0.02). The primary tumor site did not have an impact on the FTR rate (p = 0.09) or on the grade 3-4 morbidity (p = 0.08). Nearly one-fifth of the patients who developed complications succumbed to them. Systemic sepsis, spontaneous bowel perforations, and pulmonary complications increased the risk of FTR and multidisciplinary teams should develop protocols to prevent, identify, and effectively treat such complications. All surgeons pursuing this specialty should perform a regular audit of their results, irrespective of their experience.

Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): a cross-sectional survey

“…Incentive spirometry was initiated by most (95%) when a decision of surgery was made [ 27 ]. Our previous report showed a reduction in respiratory complications in patients undergoing CRS-HIPEC with preoperative spirometry and non-invasive ventilation in the postoperative period [ 28 , 29 ].…”

“…In the international consensus, 65.2% recommended MBP for patients undergoing rectal resection, which is low considering that these patients have higher rates of bowel resections and multiple anastomoses. Most of our patients present with a high peritoneal cancer index, that merits multiple bowel resections, and most commonly, a rectal resection [ 28 , 31 ]. There are two theoretical benefits of bowel preparation – reduction in leak rates and wound infections.…”

Severe pulmonary complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are common and contribute to decreased overall survival

“…To date, our study is the largest one conducted on the incidence and risk factors for PPCs after CRS and HIPEC. Previous studies have presented a wide range of incidence numbers, 6.8%-69%, and have also used a variety of grading systems [ 10 – 13 ], which complicates comparison. Sinukumar et al [ 10 ], Arakalian et al [ 11 ], and Cascales Campos et al [ 12 ] all used different versions of the Common Terminology Criteria for Adverse Events (CTCAE) [ 23 ] whereas Preti et al [ 13 ] used a customized classification system for their study.…”

“…Previous studies have presented a wide range of incidence numbers, 6.8%-69%, and have also used a variety of grading systems [ 10 – 13 ], which complicates comparison. Sinukumar et al [ 10 ], Arakalian et al [ 11 ], and Cascales Campos et al [ 12 ] all used different versions of the Common Terminology Criteria for Adverse Events (CTCAE) [ 23 ] whereas Preti et al [ 13 ] used a customized classification system for their study. We found a higher incidence of PPCs than the majority of these studies and we believe that this could be partially explained by the use of a different grading system.…”

“…Postoperative pulmonary complications (PPCs), such as pneumonia and respiratory failure, are common in the period after abdominal surgery [ 9 ] and studies on PPCs after CRS and HIPEC quote an incidence between 6.8% and 69% [ 10 – 13 ]. Non-pulmonary complications such as hemorrhage and wound infection are also frequent after CRS and HIPEC: reports suggest that the overall severe morbidity rate is around 12% [ 8 ].…”