Where Oncologic and Surgical Complication Scoring Systems Collide: Time for a New Consensus for CRS/HIPEC
- 460 Downloads
Morbidity and mortality rates after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are important quality parameters to compare peritoneal surface malignancy centers. A major problem to assess postoperative outcomes among centers is the inconsistent reporting due to two coexisting systems, the diagnose-based common terminology criteria for adverse events (CTCAE) classification and the therapy-oriented Clavien-Dindo classification. We therefore assessed and compared both reporting systems.
Patients and Methods
Complications after CRS/HIPEC were recorded in 147 consecutive patients and independently graded by an expert board using both systems. In a next step, a group of residents, experienced surgeons, and medical oncologists evaluated a set of twelve real complications, either with the Clavien-Dindo or CTCAE classification.
The postoperative complication rate after CRS/HIPEC was 37 % (54/147), 6.8 % (10/147) were reoperated, and three (2 %) patients died. The most frequent complications were intestinal fistula or abscess, pulmonary complications, and ileus. Grading of complications with the CTCAE classification resulted in a significantly higher major morbidity rate compared to the Clavien-Dindo classification (25 vs. 8 %, p = 0.001). Evaluating a set of complications, residents, surgeons, and oncologists correctly assessed significantly more complications with the Clavien-Dindo compared to the CTCEA classification (p < 0.001). In addition, all participants evaluated the Clavien-Dindo classification as more simple. Residents (p < 0.001) and surgeons (p < 0.01) required less time with the Clavien-Dindo classification; there was no difference for oncologist.
In conclusion, our data indicate that there is a different interpretation of severity grades of complications after CRS/HIPEC between the two classifications. There is a need for a common language in the field of CRS/HIPEC, which should be defined by a new consensus to compare surgical outcomes.
KeywordsPeritoneal Carcinomatosis Intraclass Correlation Coefficient Severity Grade Hyperthermic Intraperitoneal Chemotherapy Peritoneal Surface Malignancy
Common terminology criteria for adverse events
Hyperthermic intraperitoneal chemotherapy
Peritoneal Cancer Index
Completeness of cytoreduction scoring
- 2.Elias D, Lefevre JH, Chevalier J et al (2009) Complete cytoreductive surgery plus intraperitoneal chemohyperthermia with oxaliplatin for peritoneal carcinomatosis of colorectal origin. J Clin Oncol 27(681–68):5Google Scholar
- 5.Chua TC, Yan TD, Saxena A et al (2009) 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 249:900–907CrossRefPubMedGoogle Scholar
- 6.Pelz JO, Germer CT (2013) Morbidity and mortality of hyperthermic intraperitoneal chemoperfusion. Der Chir Z fur alle Geb der Oper Med 84:957–961Google Scholar
- 11.Sink EL, Leunig M, Zaltz I et al (2012) Reliability of a complication classification system for orthopaedic surgery. Clin Orthop Relat Res 470(2220–222):6Google Scholar
- 13.Clavien PA, Camargo CA Jr, Croxford R et al (1994) Definition and classification of negative outcomes in solid organ transplantation. Appl Liver Transpl Ann Surg 220:109–120Google Scholar
- 14.Jafari MD, Halabi WJ, Stamos MJ et al (2013) Surgical outcomes of hyperthermic intraperitoneal chemotherapy: analysis of the American College of Surgeons National Surgical Quality Improvement Program JAMA SurgeryGoogle Scholar
- 16.van Hagen P, Hulshof MC, van Lanschot JJ et al (2012) Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 366(2074–208):4Google Scholar
- 17.Nordlinger B, Sorbye H, Glimelius B et al (2013) Perioperative FOLFOX4 chemotherapy and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC 40983): long-term results of a randomised, controlled, phase 3 trial. Lancet Oncol 14:1208–1215CrossRefPubMedGoogle Scholar
- 18.Glehen O, Osinsky D, Cotte E et al (2003) 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 10:863–869CrossRefPubMedGoogle Scholar
- 19.CTCAE: Common Terminology Criteria for Adverse Events v3, Cancer Therapy Evaluation Program (CTEP), 2006Google Scholar
- 20.Clavien PA (2009) Strasberg SM severity grading of surgical complications. Ann Surg 250(197–19):8Google Scholar
- 21.Clavien PA, Barkun J, de Oliveira ML et al (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(187–19):6Google Scholar
- 22.Haynes AB, Weiser TG, Berry WR et al (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. New Engl J Med 360(491–49):9Google Scholar