Morbidity and Mortality Analysis of 200 Treatments With Cytoreductive Surgery and Hyperthermic Intraoperative Intraperitoneal Chemotherapy Using the Coliseum Technique
Background: Peritoneal carcinomatosis from gastrointestinal cancers is a fatal diagnosis without special combined surgical and chemotherapy interventions. Guidelines for cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) by using the Coliseum technique have been developed to treat patients with peritoneal carcinomatosis and other peritoneal surface malignancies. The purpose of this study was to analyze the morbidity and mortality of patients undergoing cytoreductive surgery and HIIC by using mitomycin C.
Methods: Data were prospectively recorded on 183 patients who underwent 200 cytoreductive surgeries with HIIC between November 1994 and June 1998. Seventeen of the 183 patients returned for a second-look surgery plus HIIC. All HIIC administrations occurred after cytoreduction and used continuous manual separation of intra-abdominal structures to optimize drug and heat distribution. Origins of the tumors were as follows: appendix (150 patients), colon (20 patients), stomach (7 patients), pancreas (2 patients), small bowel (1 patient), rectum (1 patient), gallbladder (1 patient), and peritoneal papillary serous carcinoma (1 patient). Morbidity was organized into 20 categories that were graded 0 to IV by the National Cancer Institute’s Common Toxicity Criteria. In an attempt to identify patient characteristics that may predispose to complications, each morbidity variable was analyzed for an association with the 25 clinical variables recorded.
Results: Combined grade III/IV morbidity was 27.0%. Complications observed included the following: peripancreatitis (6.0%), fistula (4.5%), postoperative bleeding (4.5%), and hematological toxicity (4.0%). Morbidity was statistically linked with the following clinical variables: duration of surgery (P < .0001), the number of peritonectomy procedures and resections (P < .0001), and the number of suture lines (P = .0078). No HIIC variables were statistically associated with the presence of grade III or grade IV morbidity. Treatment-related mortality was 1.5%.
Conclusions: HIIC may be applied to select patients with peritoneal carcinomatosis from gastrointestinal malignancies with 27.0% major morbidity and 1.5% treatment-related mortality. The frequency of complications was associated with the extent of the surgical procedure and not with variables associated with the delivery of heated intraoperative intraperitoneal chemotherapy. The technique has shown an acceptable frequency of adverse events to be tested in phase III adjuvant trials.
Key WordsMorbidity Mortality Cytoreductive surgery Hyperthermia Intraperitoneal chemotherapy Mitomycin C 5-Fluorouracil Pseudomyxoma peritonei Colon cancer
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- 1.Sugarbaker PH. Management of Peritoneal Surface Malignancy Using Intraperitoneal Chemotherapy and Cytoreductive Surgery: A Manual for Physicians and Nurses. 3rd ed. Grand Rapids, MI: Ludann, 1999.Google Scholar
- 2.Sugarbaker PH, Jacquet P, Stephens AD, Stuart OA, Averbach AM. Comparison of covered versus closed technique for heated intraoperative intraperitoneal chemotherapy for peritoneal carcinomatosis from gastrointestinal cancer. In: Abe O, Inokuchi K, Takasaki K, eds. XXX World Congress of the International College of Surgeons. Bologna, Italy: Monduzzi Editore, 1996:389–393.Google Scholar
- 3.Fernandez-Trigo V, Stuart OA, Stephens AD, Hoover LD, Sugarbaker PH. Surgically directed chemotherapy: heated intraperitoneal lavage with mitomycin C. In: Sugarbaker PH, ed. Peritoneal Carcinomatosis: Drugs and Diseases. Boston: Kluwer, 1996:51–61.Google Scholar
- 5.White SK, Stephens AD, Sugarbaker PH. Hyperthermic intraoperative intraperitoneal chemotherapy safety considerations. AORN 1996;63:716–724.Google Scholar
- 7.Sugarbaker PH, Averbach AM, Jacquet P, Stephens AD, Stuart OA. A simplified approach to hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) using a self retaining retractor. In: Sugarbaker PH, ed. Peritoneal Carcinomatosis: Principles of Management. Boston: Kluwer, 1996:415–421.Google Scholar
- 8.Stephens AD, White SK, Belliveau JF, et al. Hyperthermic Intraoperative Intraperitoneal Chemotherapy: A Manual for Perioperative Staff. Washington, DC: Washington Hospital Center, 1998.Google Scholar
- 10.Sugarbaker PH. Laser-mode electrosurgery. In: Sugarbaker PH, ed. Peritoneal Carcinomatosis: Principles of Management. Boston: Kluwer, 1996:375–385.Google Scholar
- 11.Sugarbaker PH, Ronnett BM, Archer A, et al. Pseudomyxoma peritonei syndrome. Adv Surg 1997;30:233–279.Google Scholar
- 12.Jacquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis. In: Sugarbaker PH, ed. Peritoneal Carcinomatosis: Principles of Management. Boston: Kluwer, 1996:359–374.Google Scholar
- 13.Esquivel J, Sugarbaker PH. Elective surgery in recurrent colon cancer with peritoneal seeding: when to and when not to proceed. Cancer Ther 1998;1:321–325.Google Scholar
- 14.Sugarbaker PH, Chang D, Koslowe P. Prognostic features for peritoneal carcinomatosis in colorectal and appendiceal cancer patients when treated by cytoreductive surgery and intraperitoneal chemotherapy. In: Sugarbaker PH, ed. Peritoneal Carcinomatosis: Drugs and Diseases. Boston: Kluwer, 1996:89–104.Google Scholar
- 15.Tansung T, Sugarbaker PH. Management of pancreatitis due to pancreatic injury in cytoreductive surgery. Reg Cancer Treat 1995;8:180–184.Google Scholar