High-grade postoperative complications affect survival outcomes of patients with colorectal Cancer peritoneal metastases treated with Cytoreductive surgery and Hyperthermic Intraperitoneal chemotherapy

Factors Affecting the Prognosis after Primary Tumor Resection for Patients with Metastatic Colorectal Cancer with Synchronous Peritoneal Metastasis: A Multi-center, Prospective, Observational Study

Objectives

To clarify the risk factors affecting prognosis after primary tumor resection (PTR) in patients with metastatic colorectal cancer with synchronous peritoneal metastasis (mCRC-SPM).

Methods

Patients were enrolled prospectively in the JSCCR project "Grading of Peritoneal Seeding in Colorectal Cancer." Factors that may influence overall survival-age, sex, location of the primary tumor, lymph node metastasis, presence of liver metastasis, degree of peritoneal metastasis, peritoneal cancer index (PCI), cancer cure, and postoperative chemotherapy-in the PTR group were examined using multivariate analysis.

Results

Of the 133 enrolled patients with mCRC-SPM, 112 patients underwent PTR. Among them, 26 (23.2%) had mCRC-SPM of grade P1, 47 (42.0%) of P2, and 39 (34.8%) of P3. The median PCI was 4 (range, 1-28); no surgery-related deaths occurred. Postoperative complications of Clavien-Dindo classification ≥grade 2 were observed in 20 (17.9%) patients. R0 surgery became more difficult as the degree of dissemination increased, and the PTR group had a significantly better prognosis than the non-PTR group. In the multivariate analysis, age ≥75 years, rectal cancer, presence of liver metastasis, higher PCI, non-curative resection, and non-treatment with systemic chemotherapy were associated with poor prognosis in patients after PTR.

Conclusions

In patients with mCRC-SPM, postoperative complications are infrequent for P1 with localized peritoneal dissemination, and PTR may be considered as aggressive treatment. Factors including age ≥75 years, rectal cancer, presence of liver metastasis, increased PCI, non-curative resection, and non-treatment with systemic chemotherapy are associated with a reduced survival benefit from PTR.

Respiratory Complications in the Immediate Postoperative Period after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Nowadays: An Observational Study

Background and objectives

Several respiratory complications have been described after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

Materials and methods

Patients admitted to intensive care unit (ICU) after CRS and HIPEC during 10 years.

Data recorded were

Demographic characteristics; severity of illness; complete blood sample; chest radiographs; type of cancer and extension; HIPEC drug and temperature; ICU and hospital stay; and mortality.

Results

Of the 124 patients included, 67 patients (54.0%) presented respiratory complications: 56 (83.6%) acute respiratory failure, 25 (37.3%) pleural effusion, 13 (19.4%) atelectasis, and 3 (4.5%) other; only 1 (3.0%) developed pneumonia. They had higher severity scores at ICU admission. 1 patient required initiation of invasive mechanical ventilation during ICU admission due to pneumonia, and 1 patient needed placement of a pleural chest tube due to symptomatic pleural effusion.Only the need for a high fluid balance during surgery was correlated to the development of respiratory complications on multivariate analysis.Median ICU stay was 5 (4.0-5.0) days. ICU mortality was 0.8.0%.

Conclusion

In our study, 54% of patients treated with CRS and HIPEC developed respiratory complications during the postoperative period. However, the majority of these complications were not severe and did not significantly impact mortality rates or hospital stays.

How to cite this article

Pintado MC, Oñoro A, Beltran D, Nevado E. Respiratory Complications in the Immediate Postoperative Period after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Nowadays: An Observational Study. Indian J Crit Care Med 2024;28(10):952-957.

Is Hyperthermic Intraperitoneal Chemotherapy Appropriate for Colon Cancer?

Colorectal cancer (CRC) with peritoneal metastases is a complex disease and its management presents significant clinical challenges. In well-selected patients at experienced centers, CRS/hyperthermic intraperitoneal chemotherapy (HIPEC) can be performed with acceptable morbidity and is associated with prolonged survival. Based on the results of recent randomized controlled trials, HIPEC using oxaliplatin after CRS with shortened perfusion periods (30 minutes) is no longer recommended. There is a movement toward utilizing mitomycin C as a first-line intraperitoneal agent with extended perfusion times (90-120 minutes); however, there is currently little prospective evidence to support its widespread use.

Nephrotoxicity Associated with Cytoreductive Surgery Combined with Cisplatin-Based Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Malignant Disease: A Systematic Review and Meta-Analysis

Background: Cisplatin is employed in hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery (CRS) for peritoneal surface malignancies (PSMs). The main concern regarding intraperitoneal cisplatin administration is nephrotoxicity. Numerous reports in this context are available. Our objective was to conduct a systematic review and meta-analysis to assess cisplatin-based HIPEC-related nephrotoxicity (CHRN). Methods: A systematic literature review on CHRN after CRS for the treatment of PSMs was performed. The literature search was carried out using Medline, Cochrane, and Embase. The last day of the search was 23 October 2023. PRISMA guidelines were used. A meta-analysis was then conducted. The main endpoint was the incidence of acute and chronic renal impairment after CHRN. Secondary endpoints included the potential impact of several clinical variables on the primary endpoint and a critical appraisal of the different renal impairment scales employed. Results: Our study included 26 articles with a total sample of 1473 patients. The incidence of acute kidney injury (AKI) was 18.6% (95% CI: 13.6-25%, range of true effects 3-59%). For chronic kidney disease, it was 7% (95% CI: 3-15.3%, range of true effects 1-53%). The variables that statistically influenced these results were the scale used to measure renal insufficiency, the use of nephroprotective agents, and the presence of pre-existing renal disease. Conclusions: The reported incidence of renal impairment following cisplatin-based HIPEC is highly variable. The incidence of renal failure obtained in this meta-analysis should be used as a reference for subsequent reports on this topic. Further prospective studies are warranted to establish optimal and standardized management.

Safety and Efficacy Analysis of Radical Surgery for 403 Patients with Colon Cancer over 80 Years Old

Aim: To investigate the safety and efficacy of radical surgery in colon cancer patients over 80 years old. Methods: Data from colon cancer patients aged ≥80 years who underwent radical surgery at the Cancer Hospital of the Chinese Academy of Medical Sciences and affiliated Heji Hospital of Changzhi Medical College from January 2011 to December 2022 were retrospectively analysed. Data on clinical characteristics, pathological features, perioperative data, and long-term prognosis were collected. Severe complications were classified as grade III-V. Logistic regression models were used to identify the risk factors for severe postoperative complications, and a Cox regression model was used to determine prognostic variables. Results: A total of 403 eligible patients were included in the study. A total of 118 (29.3%) patients developed postoperative complications, of which 51 (12.7%) experienced grade 3-5 severe complications. Two (0.5%) patients died of pulmonary embolism and myocardial infarction during the perioperative period. The multivariate logistic regression analysis showed that preoperative albumin levels <35 g/L and right colon cancer were independent risk factors for grade 3-5 postoperative complications. In terms of prognosis, multivariate analysis revealed that overall survival was significantly affected by TNM stage III and grade 3-4 postoperative complications. In addition, TNM stage III and perineural invasion were the independent prognostic factors for disease-free survival. Conclusion: Radical surgery can be performed safely in elderly colon cancer patients aged over 80 years, with an acceptable morbidity and mortality. Patients with preoperative albumin levels <35 g/L or tumors in the right colon should be alerted to the development of severe postoperative complications. In addition, the occurrence of severe complications can significantly affect the prognosis of elderly colon cancer patients.

Human tissue-resident peritoneal macrophages reveal resistance towards oxidative cell stress induced by non-invasive physical plasma

In the context of multimodal treatments for abdominal cancer, including procedures such as cytoreductive surgery and intraperitoneal chemotherapy, recurrence rates remain high, and long-term survival benefits are uncertain due to post-operative complications. Notably, treatment-limiting side effects often arise from an uncontrolled activation of the immune system, particularly peritoneally localized macrophages, leading to massive cytokine secretion and phenotype changes. Exploring alternatives, an increasing number of studies investigated the potential of plasma-activated liquids (PAL) for adjuvant peritoneal cancer treatment, aiming to mitigate side effects, preserve healthy tissue, and reduce cytotoxicity towards non-cancer cells. To assess the non-toxicity of PAL, we isolated primary human macrophages from the peritoneum and subjected them to PAL exposure. Employing an extensive methodological spectrum, including flow cytometry, Raman microspectroscopy, and DigiWest protein analysis, we observed a pronounced resistance of macrophages towards PAL. This resistance was characterized by an upregulation of proliferation and anti-oxidative pathways, countering PAL-derived oxidative stress-induced cell death. The observed cellular effects of PAL treatment on human tissue-resident peritoneal macrophages unveil a potential avenue for PAL-derived immunomodulatory effects within the human peritoneal cavity. Our findings contribute to understanding the intricate interplay between PAL and macrophages, shedding light on the promising prospects for PAL in the adjuvant treatment of peritoneal cancer.

Cytoreductive surgery for synchronous and metachronous colorectal peritoneal dissemination: Japanese P classification and peritoneal cancer index

Aim

The outcomes of cytoreductive surgery (CRS) for synchronous and metachronous colorectal peritoneal dissemination were investigated using the Japanese P classification and peritoneal cancer index (PCI).

Methods

CRS was performed in 111 cases of synchronous peritoneal dissemination and 115 cases of metachronous peritoneal dissemination. The P classification and PCI were determined at the time of laparotomy.

Results

In the synchronous dissemination group, the 5-year overall survival rates after CRS in P1/P2 and P3 cases were 51% and 13%, respectively. Even for P3, 51% of the patients achieved macroscopic cytoreductive complete resection (CC-0), with a 5-year survival rate of 40%. When P3 cases were classified into PCI 0-9, 10-19, 20-29, and 30-39, CC-0 was achieved in 93%, 70%, 6%, and 0% of the cases, respectively, and the 5-year survival rate of PCI 0-9 was 41%. In the metachronous dissemination group, the 5-year survival rates were 62% for PCI 0-9 and 22% for PCI 10-19; 5-year survival was not observed in patients with a PCI ≥ 20. CC-0 was significantly associated with the postoperative prognosis in both synchronous and metachronous peritoneal dissemination.

Conclusion

In cases of synchronous dissemination, CRS must be performed for P1 and P2 cases or those with a PCI < 10, while detailed examination using PCI is required for P3 cases. In cases of metachronous dissemination, CRS should be considered when the PCI score is <20.

Peritoneal Metastasis: A Dilemma and Challenge in the Treatment of Metastatic Colorectal Cancer

Peritoneal metastasis (PM) is a common mode of distant metastasis in colorectal cancer (CRC) and has a poorer prognosis compared to other metastatic sites. The formation of PM foci depends on the synergistic effect of multiple molecules and the modulation of various components of the tumor microenvironment. The current treatment of CRC-PM is based on systemic chemotherapy. However, recent developments in local therapeutic modalities, such as cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC), have improved the survival of these patients. This article reviews the research progress on the mechanism, characteristics, diagnosis, and treatment strategies of CRC-PM, and discusses the current challenges, so as to deepen the understanding of CRC-PM among clinicians.

Prognostic role of body composition in peritoneal carcinomatosis patients undergoing cytoreduction and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Bioelectric impedance analysis (BIA)-measured body composition and nutritional status have been used as prognostic indicators in various cancer cohorts. This study investigated whether BIA could provide information on prognosis in peritoneal carcinomatosis patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

We retrospectively analyzed the data of 99 patients with preoperative BIA data among those who underwent CRS and HIPEC. The association between BIA-derived parameters and intraoperative peritoneal cancer index (PCI) score was assessed. Predictive analysis for the occurrence of postoperative morbidities including major complications (Clavien-Dindo classification 3-4) and re-admission within 30 days after surgery as well as 1 year mortality was also performed.

RESULTS

BIA-derived mineral (r = 0.224, p = 0.027), fat (r =  - 0.202, p = 0.048), and total body water (TBW)/fat-free mass (FFM) (r =  - 0.280, p = 0.005) showed significant associations with intraoperative PCI score. Lower TBW/FFM was an independent predictor of major postoperative complications (OR 0.047, 95% CI 0.003-0.749, p = 0.031) and re-admission (OR 0.094, 95% CI 0.014-0.657, p = 0.017) within 30 days after surgery. Higher fat mass was also independently associated with a higher risk of major postoperative complications (OR 1.120, 95% CI 1.006-1.248, p = 0.039) and re-admission (OR 1.123, 95% CI 1.024-1.230, p = 0.013). Intraoperative PCI score > 20 (OR 4.489, 95% CI 1.191-16.917, p = 0.027) and re-admission within 30 days after surgery (OR 5.269, 95% CI 1.288-21.547, p = 0.021) independently predicted postoperative 1-year mortality.

CONCLUSIONS

We demonstrate that preoperative BIA-derived TBW/FFM and fat mass were significantly correlated with metastatic extent, assessed by PCI score, in patients with peritoneal carcinomatosis. In addition, BIA-derived TBW/FFM and fat mass showed independent predictability for postoperative 30-day major complications and re-admission in patients undergoing CRS and HIPEC. Our findings suggest that assessment of BIA may improve discrete risk stratification in patients who are planned to receive CRS and HIPEC.

A rare case of pseudomyxoma peritonei with Morgagni hernia

Both pseudomyxoma peritonei and Morgagni hernias in adults are rare clinical conditions. A 70-year-old woman who was diagnosed with pseudomyxoma peritonei with Morgagni hernia underwent cytoreductive surgery and primary repair. Pseudomyxoma peritonei causes increased intra-abdominal pressure that may lead to acquired congenital diaphragmatic hernia when there is a local fragility in the diaphragmatic musculature. Parietal peritonectomy of the right diaphragmatic peritoneum can safely remove the hernia sac. The high rate of infections associated with cytoreductive surgery causes hesitation for concurrent mesh repair for Morgagni hernia. This is the first report of pseudomyxoma peritonei with Morgagni hernia. Cytoreductive surgery including parietal peritonectomy of the right diaphragmatic peritoneum plus primary repair of hernial defect was performed safely and successfully, which achieved positive short-term results for patients with pseudomyxoma peritonei-associated Morgagni hernia.

Triple-Therapy of Peritoneal Metastasis-Partial-Dehydration under Hyperthermic Condition Combined with Chemotherapy: The First Preliminary In-Vitro Results

A newly introduced combination of intraperitoneal dehydration and hyperthermia has recently been shown to be feasible and cytotoxic for colon cancer cells in vivo. For the first time, our study now aims to evaluate dehydration under hyperthermic conditions combined with chemotherapy for potential use in the clinical setting. In this study, in vitro colon cancer cells (HT-29) were subjected to single or several cycles of partial dehydration under hyperthermic conditions (45 °C), followed by chemotherapy (triple exposure) with oxaliplatin or doxorubicin in various configurations. The viability, cytotoxicity, and proliferation of cells after the proposed protocols were assessed. Intracellular doxorubicin uptake was measured via flow cytometry. After one cycle of triple exposure, the viability of HT-29 cells was significantly reduced versus the untreated control (65.11 ± 5%, p < 0.0001) and versus only chemotherapy (61.2 ± 7%, p < 0.0001). An increased chemotherapeutic inflow into the cells after triple exposure was detected (53.4 ± 11%) when compared to cells treated with chemotherapy alone (34.23 ± 10%) (p < 0.001). Partial dehydration in a hyperthermic condition combined with chemotherapy increases the overall cytotoxicity of colon cancer cells significantly compared to chemotherapy alone. This could possibly be related to enhanced intracellular uptake of chemotherapeutic agents after partial dehydration. Further studies are required for the further evaluation of this new concept.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in Young Patients With Peritoneal Metastasis of Colorectal Cancer-An Asian Experience

INTRODUCTION

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are accepted treatment options for patients with cancers associated with the abdominal region. Currently, there are insufficient data that evaluate the effectiveness of these therapeutic options in young patients who have peritoneal metastasis (PM) originating from colorectal cancer.

METHODS

In this investigation, we evaluated perioperative data, clinicopathological manifestations, and survival consequences in 46 younger (≤50 y) patients who underwent CRS and HIPEC therapy between 2017 June and 2019 June and then compared these data with 94 older patients (aged >50 y).

RESULTS

Compared with older patients, younger patients had a higher synchronous PM incidence (78.3% versus 51.1%, P < 0.001) and were more likely to exhibit signet ring histology and mucinous (29.8% versus 60.9%; P < 0.001). The cancer-specific survival rates after CRS and HIPEC treatment were similar in both age sets. Multivariate Cox regression revealed that mucinous/signet adenocarcinoma (hazard ratio 2.20, 95% confidence interval 1.02-4.74; P = 0.044) and rectal origin (hazard ratio 2.51, 95% confidence interval 1.11-5.67; P = 0.027) were independent risk factors for a lower cancer-specific survival rate.

CONCLUSIONS

Younger (age ≤50 y) patients who have PM of colorectal cancer origin often present synchronous PM, which is less commonly observed in older patients. Tumors in younger patients are more aggressive; however, post-CRS and HIPEC treatment, the benefits are similar to those observed in older cohorts.

Risk factors and prognostic significance of postoperative complications following lateral pelvic lymph node dissection for rectal cancer: results of the multicenter lateral node study in China

OBJECTIVE

Total mesorectal excision (TME) plus lateral pelvic lymph node (LPN) dissection (LPND) is a technically complex and challenging procedure with higher morbidity than TME alone. We aimed to investigate the risk factors for postoperative complications after TME + LPND, and the impact of complications on patient prognosis.

METHODS

A total of 387 rectal cancer patients with clinical LPN metastasis (LPNM) who underwent TME + LPND at three institutions affiliated with the Chinese Lateral Node Collaborative Group were included. Logistic regression models were used to identify the risk factors for post-surgical complications, and the log-rank test was used to compare the prognosis. Severe complications were described as grade III-V.

RESULTS

The incidence rates of overall complications and severe complications after TME + LPND were 15.2% (59/387) and 7.8% (30/387), respectively. Multivariate analysis showed that a duration of operation ≥260 min was an independent risk factor for both overall (odds ratio [OR] = 3.03, 95% confidence interval [CI] = 1.57-5.85, P = 0.001) and severe postoperative complications (OR = 2.67, 95% CI = 1.06-6.73, P = 0.037). The development of overall postoperative complications (P = 0.114) and severe postoperative complications (P = 0.298) had no significant impact on the overall survival. However, patients with overall complications (P = 0.015) or severe complications (P = 0.031) with a postoperative hospital stay >30 days had significantly an overall worse survival.

CONCLUSION

A surgical duration of ≥260 min is a significant risk factor for both overall and severe postoperative complications after TME + LPND for middle-low rectal cancer. Furthermore, the development of overall complications or severe complications that require a postoperative hospital stay >30 days significantly worsens the prognosis.

The impact of hyperthermic intraperitoneal chemotherapy and cytoreductive surgery on clinical outcomes and quality of life of patients with peritoneal carcinomatosis

AIM OF THE STUDY

To investigate the impact of hyperthermic intraperitoneal chemotherapy (HIPEC) on the clinical and oncological outcomes and quality of life (QOL) of patients with peritoneal carcinomatosis (PC).

MATERIAL AND METHODS

The study involved 304 patients with PC of different origin, who were divided into 2 groups: Group I - cytoreductive surgery (CRS) + adjuvant chemotherapy (ACT) - 247 patients; Group II - CRS + HIPEC + ACT - 57 patients. Intraoperative characteristics and postoperative complications were compared. Patients' QOL was assessed at all phases of treatment using the international scales the Short Form-36 Health Survey (SF-36) and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for Breast Cancer Core 30 (EORTC QLQ-C30).

RESULTS

No statistically significant differences were observed between the 2 groups comparing the average blood loss and the total rate of postoperative complications, although the rates of hyperthermia and acute renal failure in the early postoperative period were higher in the HIPEC group. The use of HIPEC significantly contributed to the worse restoration of intestinal function in the postoperative period and to prolonged hospital stay. Assessment of the QOL of patients in Group II using SF-36 showed no significant difference between the physical and psychological components of health compared with the control group. The analysis of EORTC data showed a significant deterioration in the QOL of patients in Group II due to increased scales of pain, nausea and vomiting, and constipation in the early postoperative period. No difference in QOL was observed in the subsequent phases of treatment and after its completion. Overall survival and disease-free survival of patients with ovarian cancer who underwent HIPEC were significantly better compared with CRS + ACT alone.

CONCLUSIONS

The proposed HIPEC technique has demonstrated its clinical safety in the treatment of PC, no long-term negative impact on the QOL of patients, and better oncological results for ovarian cancer.

Does the primary tumour location affect the prognosis of patients with colorectal cancer peritoneal metastases treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy?

Background

The impact of primary tumour location on the prognosis of patients with peritoneal metastasis (PM) arising from colorectal cancer (CRC) after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is rarely discussed, and the evidence is still limited.

Methods

Patients with PM arising from CRC treated with CRS and HIPEC at the China National Cancer Center and Huanxing Cancer Hospital between June 2017 and June 2019 were systematically reviewed. Clinical characteristics, pathological features, perioperative parameters, and prognostic data were collected and analysed.

Results

A total of 70 patients were divided into two groups according to either colonic or rectal origin (18 patients in the rectum group and 52 patients in the colon group). Patients with PM of a colonic origin were more likely to develop grade 3–4 postoperative complications after CRS+HIPEC (38.9% vs 19.2%, P = 0.094), but this difference was not statistically significant. Patients with colon cancer had a longer median overall survival (OS) than patients with rectal cancer (27.0 vs 15.0 months, P = 0.011). In the multivariate analysis, the independent prognostic factors of reduced OS were a rectal origin (HR 2.15, 95% CI 1.15–4.93, P = 0.035) and incomplete cytoreduction (HR 1.99, 95% CI 1.06–4.17, P = 0.047).

Conclusion

CRS is a complex and potentially life-threatening procedure, and we suggest that the indications for CRS+HIPEC in patients with PM of rectal origin be more restrictive and that clinicians approach these cases with caution.

Predicting Early and Late Readmissions Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Background

Postoperative readmissions not only burden the healthcare system but may also affect clinical outcomes of cancer patients. Despite this, little is known about readmissions after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), or their impact on survival outcomes.

Patients and Methods

A single-institution retrospective cohort study of CRS-HIPEC procedures from April 2001 and September 2019 was performed. Early readmission (ERA) was defined as hospitalization within 30 days of discharge post-CRS/HIPEC, while late readmission (LRA) was defined as hospitalization between day 31 and 90 after discharge. Patient demographic, oncological, and perioperative factors were analyzed to identify predictors of readmission, and comparison of survival outcomes was performed.

Results

Overall, 342 patients who underwent CRS-HIPEC were included in the study. The incidence of ERA and LRA was 18.5% and 7.4%, respectively. High-grade postoperative complication was the only independent predictor of ERA (HR 3.64, 95% CI 1.47–9.02), while comorbid hypertension (HR 2.71, 95% CI 1.17–6.28) and stoma creation (HR 2.83, 95% CI 1.23–6.50) were independent predictors for LRA. Patients with readmission had significantly worse disease-free survival than patients who had no readmission (NRA) (LRA 1.1 years, ERA 1.2 years, NRA 1.8 years, p = 0.002), and patients with LRA had worse median overall survival (2.1 years) than ERA patients (3.3 years) or patients without readmission (4.4 years) (p < 0.001).

Conclusions

Readmission following CRS-HIPEC is associated with adverse survival outcomes. In particular, LRA may portend worse prognosis than ERA.