Annals of Surgical Oncology

, Volume 24, Issue 4, pp 890–897 | Cite as

Prognostic Factors and Significance of Gastrointestinal Leak After Cytoreductive Surgery (CRS) with Heated Intraperitoneal Chemotherapy (HIPEC)

  • Konstantinos Chouliaras
  • Edward A. Levine
  • Nora Fino
  • Perry Shen
  • Konstantinos I. Votanopoulos
Gastrointestinal Oncology

Abstract

Background

Gastrointestinal leak (GIL) after cytoreductive surgery with heated intraperitoneal chemotherapy (CRS/HIPEC) is associated with significant morbidity and mortality. This study aimed to identify GIL prognostic factors and its impact on overall survival.

Methods

A retrospective analysis of a prospectively maintained database comprising 1270 CRS/HIPEC procedures was performed. Type of GIL, functional and resection status, morbidity, mortality, and survival were reviewed.

Results

Gastrointestinal leaks were identified in 8.7% (110/1270) of CRS/HIPEC procedures, including 53 anastomotic leaks (4.2%), 53 hollow viscus perforations (4.2%), and four leaks at unknown sites. The multivariate predictors of leak were Eastern Cooperative Oncology Group (ECOG) functional status (ECOG 1 vs. 0: odds ratio [OR] 2.12, p = 0.009; ECOG 2 vs. 0: OR 2.90, p = 0.004), and number of anastomoses (OR 5.34; p < 0.0001). The in-hospital mortality rate for the GIL cohort was 21.8% (24/110), with a 72% (80/110) reoperation rate. The leak cohort had a higher major morbidity rate (88.3 vs. 23.3%; p < 0.0001), a longer hospital stay (39.0 vs. 9.9 days; p < 0.0001), and a longer intensive care unit (ICU) stay (7.7 vs. 1.7 days; p = 0.0003). After surgical mortality was excluded, the overall survival periods for the leak and no-leak patients with complete cytoreduction were respectively 1.5 and 4.98 years (p = 0.0001). Clinically significant decreases in survival were observed for all primary malignancies.

Conclusions

Gastrointestinal leak after CRS/HIPEC is a source of significant mortality, with a decrease in overall survival even after complete CRS. Preoperative functional status and number of anastomoses are predictors of leak for CRS/HIPEC patients.

References

  1. 1.
    Levine EA, Stewart JH, Shen P, Russell GB, Loggie BL, Votanopoulos KI. Intraperitoneal chemotherapy for peritoneal surface malignancy: experience with 1000 patients. J Am Coll Surg. 2014;218:573–85.CrossRefPubMedGoogle Scholar
  2. 2.
    Glockzin G, Schlitt HJ, Piso P. Peritoneal carcinomatosis: patients selection, perioperative complications, and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. World J Surg Oncol. 2009;8:1–8.Google Scholar
  3. 3.
    Ihemelandu CU, Mcquellon R, Shen P, Stewart JH, Votanopoulos K, Levine EA. Predicting postoperative morbidity following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CS + HIPEC) with preoperative FACT-C (Functional Assessment of Cancer Therapy) and patient-rated performance status. Ann Surg Oncol. 2013;20:3519–26.CrossRefPubMedGoogle Scholar
  4. 4.
    Jacquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis. Cancer Treat Res. 1996;82:359–74.CrossRefPubMedGoogle Scholar
  5. 5.
    Sugarbaker PH. Technical Handbook for the Integration of Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy Into the Surgical Management of Gastrointestinal and Gynecologic Malignancy. 4th ed. Grand Rapids: The Ludann Company; 2005.Google Scholar
  6. 6.
    Levine EA, Iv JHS, Russell GB, Geisinger KR, Loggie BL, Shen P. Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal surface malignancy: experience with 501 procedures. J Am Coll Surg. 2007;204:943–53.CrossRefPubMedGoogle Scholar
  7. 7.
    Dindo D, Demartines N, Clavien P. Classification of surgical complications. Ann Surg. 2004;240:205–13.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Younan R, Kusamura S, Baratti D, et al. Bowel complications in 203 cases of peritoneal surface malignancies treated with peritonectomy and closed-technique intraperitoneal hyperthermic perfusion. Ann Surg Oncol. 2005;12:910–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Sugarbaker PH. Cytoreduction including total gastrectomy for pseudomyxoma peritonei. Br J Surg. 2002;89:208–12.CrossRefPubMedGoogle Scholar
  10. 10.
    Elias D, Gilly F, Boutitie F, et al. Peritoneal colorectal carcinomatosis treated with surgery and perioperative intraperitoneal chemotherapy: retrospective analysis of 523 patients from a multicentric French study. J Clin Oncol. 2009;28: 63–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Glehen O, Gilly FN, Boutitie F, et al. Toward curative treatment of peritoneal carcinomatosis from nonovarian origin by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy. Cancer. 2010;116:5608–18.CrossRefPubMedGoogle Scholar
  12. 12.
    Damrauer SM, Bordeianou L, Berger D. Contained anastomotic leaks after colorectal surgery: are we too slow to act? Arch Surg. 2009;144:333–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Desantis M, Bernard JL, Casanova V, et al. Morbidity, mortality, and oncological outcomes of 401 consecutive cytoreductive procedures with hyperthermic intraperitoneal chemotherapy (HIPEC). Langenbecks Arch Surg. 2015;400:37–48.CrossRefPubMedGoogle Scholar
  14. 14.
    Saxena A, Yan TD, Morris DL. Critical assessment of preoperative and operative risk factors for complications after iterative peritonectomy procedures. Eur J Surg Oncol. 2010;36:309–14.CrossRefPubMedGoogle Scholar
  15. 15.
    Thornton M, Joshi H, Vimalachandran C, Heath R, Carter P, Gur U, Rooney P. Management and outcome of colorectal anastomotic leaks. Int J Colorectal Dis. 2011;26:313–20.CrossRefPubMedGoogle Scholar
  16. 16.
    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;21:1494–500.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2016

Authors and Affiliations

  • Konstantinos Chouliaras
    • 1
  • Edward A. Levine
    • 1
  • Nora Fino
    • 2
  • Perry Shen
    • 1
  • Konstantinos I. Votanopoulos
    • 1
  1. 1.Surgical Oncology Service, Department of General SurgeryWake Forest Baptist HealthWinston-SalemUSA
  2. 2.Department of Biostatistical SciencesWake Forest School of MedicineWinston-SalemUSA

Personalised recommendations