Abstract
Purpose
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) treatment has classically presented a percentage of associated complications that have limited its expansion. The aim of this study is to describe the morbimortality results obtained from a referral center implemented with the support of a governmental health agency and directed by a surgical team experienced in CRS for Peritoneal Surface Malignancies (PSM).
Methods
Data from the Peritoneal Carcinomatosis Program of Catalonia (PCPC) prospective database, including patients who underwent CRS + HIPEC between September 2006 and January 2021, were analyzed.
Results
A total of 1151 consecutive patients underwent 1321 CRS + HIPEC procedures. Colonic origin of peritoneal metastasis was the most frequent (47.3%). Median PCI was 7 and most patients had CC0-1 (96.1%). Multivisceral resection was performed in 44% of all patients, 57% required digestive anastomosis. Median hospital stay was 11 days (range 6–144 days). High-grade complications occurred in 20% of all patient, most of them surgical complications. Anastomotic leak occurred in 0.6% of all cases. The overall in-stay and 30-day mortality rate was 0.4%. The low-rate of complications and the high rate of complete CRS were achieved from the beginning of the PCPC. Median overall survival was 54.7 months, with a 5-year survival rate of 47.5%.
Conclusions
Implementation of a CRS + HIPEC referral program for the treatment of PSM with preferably an experienced surgical team enables acceptable rates of severe morbidity (20%) and mortality (< 1%).
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Data availability
The data that support the findings of this study are available from the corresponding author upon reasonable request.
References
Spratt JD, Adcock RA, Muskovin M, Sherrill W, McKeown J. Clinical delivery system for intraperitoneal hyperthermic chemotherapy. Cancer Res. 1980;40(2):256–60.
Baratti D, Kusamura S, Pietrantonio F, Guaglio M, Niger M, Deraco M. Progress in treatments for colorectal cancer peritoneal metastases during the years 2010–2015. A systematic review. Crit Rev Oncol Hematol. 2016;100:209–22. https://doi.org/10.1016/j.critrevonc.2016.01.017.
Glehen O, Gilly FN, Boutitie F, Bereder JM, Quenet F, Sideris L, on behalf of the French Surgical Association, et al. Toward curative treatment of peritoneal carcinomatosis from nonovarian origin by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy: a multi-institutional study of 1290 patients. Cancer. 2010;116:5608–18. https://doi.org/10.1002/cncr.25356.
Chua TC, Yan TD, Saxena A, Morris DL. Should the treatment of peritoneal carcinomatosis by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy still be regarded as a highly morbid procedure? A systematic review of morbidity and mortality. Ann Surg. 2009;249:900–7. https://doi.org/10.1097/sla.0b013e3181a45d86.
Piso P, Nedelcut SD, Rau B, Königsrainer A, Glockzin G, Ströhlein MA, et al. Morbidity and mortality following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: data from the DGAV StuDoQ registry with 2149 consecutive patients. Ann Surg Oncol. 2019;26(1):148–54. https://doi.org/10.1245/s10434-018-6992-6.
Bartlett EK, Meise C, Roses RE, Fraker DL, Kelz RR, Karakousis GC. Morbidity and mortality of cytoreduction with intraperitoneal chemotherapy: outcomes from the ACS NSQIP database. Ann Surg Oncol. 2014;21(5):1494–500. https://doi.org/10.1245/s10434-013-3223-z.
Noiret B, Clement G, Lenne X, Bruandet A, Glehen O, Voron T, et al. Centralization and oncologic training reduce postoperative morbidity and failure-to-rescue rates after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies: Study on a 10-year National French Practice. Ann Surg. 2020;272(5):847–54. https://doi.org/10.1097/SLA.0000000000004326.
Carboni F, Valle M, Vaira M, Sammartino P, Federici O, Robella M, et al. Complications and mortality rate of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: Italian peritoneal surface malignancies oncoteam results analysis. Cancers (Basel). 2022;14(23):5824. https://doi.org/10.3390/cancers14235824.
Foster JM, Sleightholm R, Patel A, Shostrom V, Hall B, Neilsen B, et al. Morbidity and mortality rates following cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy compared with other high-risk surgical oncology procedures. JAMA Netw Open. 2019;2(1): e186847. https://doi.org/10.1001/jamanetworkopen.2018.6847.
Kuijpers AM, Aalbers AG, Nienhuijs SW, de Hingh IH, Wiezer MJ, van Ramshorst B, et al. Implementation of a standardized HIPEC protocol improves outcome for peritoneal malignancy. World J Surg. 2015;39(2):453–60. https://doi.org/10.1007/s00268-014-2801-y.
Esquivel J, Sticca R, Sugarbaker P, Levine E, Yan TD, Alexander R, et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of peritoneal surface malignancies of colonic origin: a consensus statement. Ann Surg Oncol. 2007;14(1):128–33. https://doi.org/10.1245/s10434-006-9185-7. (Erratum in: Ann Surg Oncol. 2011 Dec;18 Suppl 3:S334-5).
Barrios P, Roqué M, Lozano JM, Ramos I, Bianchi A, Bonfill X. Revisión sistemática del tratamiento combinado multidisciplinar en las enfermedades malignas del peritoneo. Citorreducción quirúrgica radical + quimioterapia intraperitoneal +/- hipertermia (técnica de Sugarbaker). Informes de Evaluación de Tecnologías Sanitarias, AATRM núm. 2007/19.
Barrios P, Ramos I, Escayola C, Martin M. Implementación y desarrollo de un programa de tratamiento de la carcinomatosis peritoneal en Cataluña. Indicaciones y resultados clínicos con la técnica de Sugarbaker. Barcelona: Agència d’Avaluació de Tecnologia i Recerca Mèdiques. Servei Català de la Salut. Departament de Salut. Generalitat de Catalunya; 2009.
Sugarbaker PH. Peritonectomy procedures. Ann Surg. 1995;221:29–42. https://doi.org/10.1097/00000658-199501000-00004.
Jacquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis. Cancer Treat Res. 1996;82:359–74. https://doi.org/10.1007/978-1-4613-1247-5_23.
Barrios P, Ramos I, Crusellas O, Sabia D, Mompart S, Bijelic L. Safe anastomoses without ostomies in cytoreductive surgery with heated intraperitoneal chemotherapy: technical considerations and modifications. Ann Surg Oncol. 2021;28(12):7784–92. https://doi.org/10.1245/s10434-021-09842-x.
Kusamura S, González-Moreno S, Nizri E, Baratti D, Guadagni S, Guaglio M, et al. Learning curve, training program, and monitorization of surgical performance of peritoneal surface malignancies centers. Surg Oncol Clin N Am. 2018;27(3):507–17. https://doi.org/10.1016/j.soc.2018.02.009.
Bartlett EK, Choudhury RA, Roses RE, Fraker DL, Kelz RR, Karakousis GC. Intraperitoneal chemotherapy at the time of surgery is not associated with increased 30-day morbidity and mortality following colorectal resection. Ann Surg Oncol. 2015;22:1664–72. https://doi.org/10.1245/s10434-014-3975-0.
Überrück L, Nadiradze G, Yurttas C, Königsrainer A, Königsrainer I, Horvath P. In-hospital mortality and complication rates according to health insurance data in patients undergoing hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies in Germany. Ann Surg Oncol. 2021;28(7):3823–30. https://doi.org/10.1245/s10434-020-09301-z.
Nikiforchin A, Gushchin V, King MC, Baron E, Nieroda C, Sittig M, et al. Surgical and oncological outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy at a nonacademic center: 25-year experience. J Surg Oncol. 2021;123(4):1030–44. https://doi.org/10.1002/jso.26371.
Beal EW, Ahmed A, Grotz T, Leiting J, Fournier KF, Lee AJ, et al. Trends in the indications for and short-term outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Am J Surg. 2020;219(3):478–83. https://doi.org/10.1016/j.amjsurg.2019.09.017.
Doud AN, Levine EA, Fino NF, Stewart JH, Shen P, Votanopoulos KI. Stoma creation and reversal after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2016;23:503–10. https://doi.org/10.1245/s10434-015-4674-1.
Delhorme JB, Sattler L, Severac F, Triki E, Gross I, Romain B, et al. Prognostic factors of hemorrhagic complications after oxaliplatin-based hyperthermic intraperitoneal chemotherapy: toward routine preoperative dosage of Von Willebrand factor? Eur J Surg Oncol. 2017;43(6):1095–101. https://doi.org/10.1016/j.ejso.2017.01.015.
Sand O, Andersson M, Arakelian E, Cashin P, Semenas E, Graf W. Severe pulmonary complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy are common and contribute to decreased overall survival. PLoS ONE. 2021;16(12):e0261852. https://doi.org/10.1371/journal.pone.0261852.
Preti V, Chang D, Sugarbaker PH. Pulmonary complications following cytoreductive surgery and perioperative chemotherapy in 147 consecutive patients. Gastroenterol Res Pract. 2012;2012:635314. https://doi.org/10.1155/2012/635314.
Cascales Campos P, Martinez Insfran LA, Wallace D, Gil J, Gil E, Gonzalez Gil A, et al. Identifying the incidence of respiratory complications following diaphragmatic cytoreduction and hyperthermic intraoperative intraperitoneal chemotherapy. Clin Transl Oncol. 2020;22(6):852–9. https://doi.org/10.1007/s12094-019-02195-8.
Lee TC, Wima K, Sussman JJ, Ahmad SA, Cloyd JM, Ahmed A, et al. Readmissions after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a US HIPEC collaborative study. J Gastrointest Surg. 2020;24(1):165–76. https://doi.org/10.1007/s11605-019-04463-y.
García-Fadrique A, Estevan Estevan R, Sabater OL. Quality standards for surgery of colorectal peritoneal metastasis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2022;29(1):188–202. https://doi.org/10.1245/s10434-021-10642-6.
Acknowledgements
The authors are grateful to Jordi Colomer Mascaró MD, PhD (Former Director of Sant Pau Hospital) for his decisive commitment to a specialized approach in the treatment of peritoneal metastases and Domenico Sabia MD, for his participation as a member of the surgical team and data collection.
Funding
No funding was received for conducting this study.
Author information
Authors and Affiliations
Contributions
All authors contributed to the study conception and design. Formal analysis was performed by MMB. The first draft of the manuscript was written by MIRB and PBS and all authors commented on previous versions of the manuscript. All authors have read and agreed to the published version of the manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors have no relevant financial or non-financial interests to disclose.
Ethics approval
Our study has been performed in accordance with the ethical standards laid down in the Declaration of Helsinki and its later amendments. The study was approved by the local IRB at the beginning of the Program.
Consent to participate
Informed consent was obtained from all all participants.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Pedro Barrios Sánchez: Former Director of the Peritoneal Carcinomatosis Program of Catalonia. Former Head of the Peritoneal Surface Malignancies Unit, Department of Surgery Hospital Moisès Broggi, Consorci Sanitari Integral Barcelona, Spain
Dr Barrios: Retired from Department of Surgery, Hospital Moisès Broggi, Consorci Sanitari Integral, Barcelona, Spain.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Ramos Bernadó, M., Crusellas Maña, O., Martín-Baranera, M. et al. Morbimortality after 1321 consecutive CRS + HIPEC procedures: seeking excellence in surgery for peritoneal surface malignancy. Clin Transl Oncol 25, 2911–2921 (2023). https://doi.org/10.1007/s12094-023-03155-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12094-023-03155-z