Hyperthermic Intraperitoneal Chemotherapy In Patients Research Articles

Survival outcomes in patients aged 75years and over with peritoneal colorectal carcinomatosis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC): multicenter study of the Spanish Group of Peritoneal Cancer Surgery (GECOP).

The attitude toward cytoreductive surgery with HIPEC in peritoneal carcinomatosis from colorectal cancer is unclear. The aim of this study is to report the perioperative outcomes after cytoreductive surgery with HIPEC in patients ≥ 75years. This retrospective multicenter study collected the data the Spanish Group of Peritoneal Cancer Surgery. Thirty-six patients with peritoneal carcinomatosis from colorectal cancer met the selection criteria for the study. Morbidity, mortality, disease-free and overall survival were analyzed. Morbidity (grade III-IV) was 17% and 2 patients died of complications related to the procedure (5.4%). Median disease-free survival (DFS) was 16months. DFS at 1 and 3years was 81% and 42%, respectively. Overall survival at 1 and 3years was 96% and 75%. In the univariate analysis, preoperative comorbidities (p = 0.01), liver metastases (p = 0.02), blood transfusion (p = 0.001) and postoperative complications (p = 0.001); and in the multivariate analysis, perioperative blood transfusion (OR 2.56, 95% CI 1.95-6.24, p = 0.03) and postoperative complications (OR 3.25, 95% CI 2.35-7.56, p = 0.02) were associated with a lower overall survival. Age is not an absolute contraindication to perform cytoreduction surgery with HIPEC in highly selected elderly patients with colorectal peritoneal carcinomatosis.

137 – Outcomes for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in Patients 65 Years of Age Or Older At a High Volume Center in the United States

137 – Outcomes for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in Patients 65 Years of Age Or Older At a High Volume Center in the United States

Increased Incidence of Central Venous Catheter-Related Infection in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intra-Peritoneal Chemotherapy.

Background: Cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) is a complex surgical intervention with associated risks. Central venous catheter (CVC) line sepsis is one of a number of potential morbidities. The aim of this study was to calculate the incidence of catheter-related infection (CRI) in a CRS and HIPEC patient population and to assess its influence on length of hospital stay. Methods: Data were collected on consecutive patients who underwent CRS HIPEC between August 2013 and October 2017. Data included patient demographics, timing of CVC insertion/removal, time spent in critical care, and CVC tip/blood culture results. Charts were reviewed for patients with both positive CVC culture and positive blood cultures to assess for evidence of catheter related infection and systemic inflammatory response syndrome (SIRS). Results: Data on 100 consecutive CRS HIPEC operations performed between August 2013 and October 2017 was analyzed. There were 11 CRIs in 100 CVCs, resulting in a CRI rate of 16.2 per 1,000 CVC days. Patients within the CRI group had a longer high-dependency unit (HDU) stay compared with the non-septic group (6 days vs. 4.07 days, p < 0.05). The CVC duration for the CRI and non-CRI group was 8.4 and 7.6 days, respectively (p = 0.12). The CRI group also had an increased total hospital length of stay (LOS; 20.8 days vs. 15.4 days, p < 0.05). On average, CRIs occurred eight days post-operative and four days post-HDU discharge. There was no association identified with longer CVC duration (p = 0.34). There has been an annual decline in CRI rates in CRS and HIPEC patients over the duration of the study period from 19.1 per 1,000 CVC days in 2016 to 8.2 per 1,000 CVC days in 2017. Conclusion: This is the first study to report on CRI rates in patients undergoing CRS and HIPEC. The CRI rate of 16.2 per 1,000 CVC days is higher than the overall national figure of 5.2 per 1,000 for CVC lines inserted in the operating room. Patients who developed line sepsis had longer HDU and longer overall hospital stay. Catheter-related infection was noted post-HDU discharge in all cases. Implementation of a CVC care bundle in the later years of the study period coincided with a reduction in CRI rates.

The impact of BMI extremes on disease-free survival and overall survival following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are increasingly being offered to patients with peritoneal carcinomatosis (PC). On the other hand, the prevalence of obesity is also increasing and expected to reach unprecedented rates in the upcoming decades. Therefore, managing patients on either extreme of the body mass index (BMI) range is anticipated to become a routine challenge and it becomes imperative to understand the impact of BMI, as a spectrum, on the long-term outcomes of CRS and HIPEC. We aim to study the short and long-term outcomes of CRS and HIPEC in patients on both extremes of the BMI spectrum. Patients with PC who underwent CRS and HIPEC over 10 years for ovarian, colorectal, and pseudomyxoma peritonei (PMP), and whose BMI was recorded were retrospectively included. Patients were divided based on their weight strata. The primary outcomes were disease-free survival (DFS) and overall survival (OS). A total of 126 patients were included. Fifty-seven point one percent were females and mean age was 59.31±1.57 years. No difference was noted between the groups in regards to demographics, perioperative characteristics, and immediate postoperative outcomes. Underweight group had a trend toward a higher peritoneal cancer index and lower rates of complete cytoreduction. Optimum BMI for OS and DFS was in the obesity range in colorectal PC, in the overweight range in ovarian PC, and in borderline obesity in PMP. Regression analysis identified underweight as an independent risk factor for shorter DFS, whereas underweight and morbid obesity were risk factors for shorter OS, after adjustment for other factors such as incomplete cytoreduction, tumor histology, and grade. OS and DFS vary across the BMI strata. Ovarian PC demonstrates earlier recurrence and shorter survival, whereas colorectal PC demonstrates the "obesity paradox" as patients move into the realm of obesity. BMI extremes, low or high, generally carry a poor prognosis for OS.

Peritonectomy and hyperthermic intraperitoneal chemotherapy for advanced epithelial ovarian cancer: What gynaecological oncologists really think.

Peritonectomy and hyperthermic intraperitoneal chemotherapy (HIPEC) is used in specialised units outside of gynaecological cancer centres in Australia and New Zealand to treat advanced epithelial ovarian cancer (AEOC). There is significant equipoise toward this treatment by gynaecological oncologists (CGOs). To determine the attitudes and preferences of CGOs toward peritonectomy and HIPEC for the treatment of AEOC. A questionnaire was sent to all 53 CGOs in Australia and New Zealand asking their opinions about peritonectomy and HIPEC for the treatment of AEOC. Data collected included surgeon demographics, individual surgical practices, and willingness of CGOs to refer patients for peritonectomy or HIPEC. Potential factors influencing this decision were investigated using χ2 tests and logistic regression analysis. Response rate was 89%. While 68% of CGOs would refer a patient for peritonectomy, most cases would be recurrent tumour of borderline or mucinous histology. Only 13% would refer a case of primary stage 3 EOC, even if predicting they cannot completely resect the tumour. This was due to concerns around morbidity and mortality, and a preference for neoadjuvant chemotherapy. In regard to HIPEC, 61% of CGOs were unsure about its use, due to reported lack of evidence, and potential morbidity. CGOs of female gender were more likely to recommend peritonectomy and HIPEC. CGOs would refer only selected cases of AEOC for peritonectomy or HIPEC, due to concerns around insufficient evidence, and potential morbidity. The results of large well-conducted clinical trials will help determine the future of peritonectomy and HIPEC for the treatment of AEOC.

Adjuvant HIPEC in patients with colon cancer at high risk of peritoneal metastases: Primary outcome of the COLOPEC multicenter randomized trial.

482 Background: Patients with T4 or perforated colon cancer are at high risk (~25%) of peritoneal metastases (PM). Sensitivity of imaging modalities for PM is limited and the majority of patients is diagnosed in a palliative setting. This provides a rationale for adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC). In this study, the effectiveness of adjuvant HIPEC in reducing the risk of PM was determined. Methods: In this multicenter trial, patients with T4 (either cT4 or pT4, N0-2, M0) or perforated colon cancer, who underwent curative resection were randomized to adjuvant HIPEC followed by routine adjuvant systemic chemotherapy or to adjuvant systemic chemotherapy alone (1:1). Adjuvant HIPEC with oxaliplatin was performed simultaneously (9%) or within five-eight weeks (91%) after the primary tumor resection. Patients without evidence of recurrent disease at 18 months based on CT imaging underwent diagnostic laparoscopy in both arms. The primary endpoint was PM free survival (PMFS) at 18 months using Kaplan Meier analysis. Results: Between April 2015 and January 2017, 204 patients were randomized: 102 in the control arm (0 drop-outs), 102 in the experimental arm (two drop-outs). Surgical exploration at the start of the HIPEC procedure at five-eight weeks postoperatively revealed metastases in 11 patients (PM in 9/11) in the experimental arm, and adjuvant HIPEC was not applied. Adjuvant systemic chemotherapy was administered in 89/100 eligible patients after median 6 weeks (IQR 5-7) in the control arm and in 84/89 after 10 weeks (IQR 9-12) in the experimental arm. PM rate after completion of 18 months follow-up was 22/102 and 18/100, respectively. In the ITT analysis no difference in 18 months PMFS was observed: 77% (control) versus 81% (experimental), HR 0.836 (0.489-1.428)). Also, no differences were observed in 18 months DFS (HR 1.016 (0.646-1.598)) and OS (HR 1.139 (0.532-2.439)). One patient developed encapsulating peritoneal sclerosis after HIPEC. Conclusions: Adjuvant HIPEC with oxaliplatin for patients with T4 or perforated colon cancer does not result in improved 18 months PMFS. Long-term results have to be awaited to assess the role of HIPEC in the adjuvant setting. Clinical trial information: NCT02231086.

Incorporation of paclitaxel-based hyperthermic intraperitoneal chemotherapy in patients with advanced-stage ovarian cancer treated with neoadjuvant chemotherapy followed by interval debulking surgery: a protocol-based pilot study.

ObjectivesWe conducted a protocol-based cohort study to evaluate the outcomes of interval debulking surgery (IDS) followed by paclitaxel-based hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of advanced-stage ovarian cancer.MethodsFrom October 2015 to May 2018, 65 patients with stages IIIC–IV ovarian cancer were treated according to the study protocol. HIPEC was performed with paclitaxel (175 mg/m2) for 90 minutes, only in cases of optimal cytoreduction.ResultsOf 65 patients, 40 (61.5%) patients underwent neoadjuvant chemotherapy (NAC), 34 (52.3%) patients had a high tumor burden with a Fagotti score ≥8 at diagnostic laparoscopy, and 6 (9.2%) had definite stage IV metastasis and/or poor performance status before NAC. Twenty-seven (41.5%) patients underwent IDS followed by HIPEC. The mean duration of IDS with HIPEC was 543.8 (range, 277.0–915.0) minutes. Grade III/IV perioperative complications occurred in 7.4% (n=2)/3.7% (n=1) of patients and no cases of mortality were reported within 30 days postoperatively. The median progression-free survival was 21.3 months, and the median overall survival was not reached for those who received HIPEC.ConclusionsAccording to our study protocol, IDS followed by paclitaxel-based HIPEC as a first-line treatment appears to be feasible and safe for the treatment of advanced-stage ovarian cancer. Further evaluations of this procedure are required to assess its survival benefits.

Adjuvant Hyperthermic Intraperitoneal Chemotherapy in Patients with Locally Advanced Colon Cancer; the COLOPEC Randomized Trial

Background: Patients with locally advanced (T4) or perforated colon cancer are at high risk (~25%) of developing peritoneal metastases (PM), often without curative treatment options. In this study, the effectiveness of adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) in reducing the development of PM was determined. Methods: In this multicentre non-blinded superiority trial, patients with c/pT4N0-2M0 or perforated colon cancer were randomized to adjuvant HIPEC followed by routine adjuvant systemic chemotherapy or to adjuvant systemic chemotherapy alone. Adjuvant HIPEC with oxaliplatin (460mg/m2, 30 minutes, 42°C, concurrent 5-FU/LV iv) was performed simultaneously (9%) or within 5-8 weeks (91%) after primary tumour resection. In all patients without evidence of recurrent disease at 18 months, a diagnostic laparoscopy was performed. The primary endpoint was PM free survival (PMFS) at 18 months. Findings: Between April 2015 and January 2017, 204 patients were randomized, 102 in each arm. In the control arm, 23 patients were diagnosed with PM, of which 7 by 18 months laparoscopy. In the experimental arm, 19 patients were diagnosed with PM, of which 9 during surgical exploration preceding intentional adjuvant HIPEC, 8 during routine follow-up and 2 by 18 months laparoscopy. In the intention to treat analysis (n=202), no difference in 18 months PMFS was observed; 76% (control) vs. 81% (experimental), HR 0·86 (0·51-1·45). After adjuvant HIPEC, 14% of patients developed postoperative complications and encapsulating peritoneal sclerosis occurred in one. PM were treated with cytoreductive surgery and HIPEC in 15/23 and 13/19 patients in the control and experimental arm, respectively. Interpretation: No superiority of adjuvant HIPEC with oxaliplatin could be demonstrated regarding 18 months PMFS in patients with T4 or perforated colon cancer. Trial registration number: NCT02231086 (Clinicaltrials.gov). Funding Statement: Organization for Health Research and Development (ZonMw) and the Dutch Cancer Society (KWF). Declaration of Interest: The authors have nothing to declare. Ethical Approval Statement: The Amsterdam UMC was the coordinating centre and approval of the protocol was obtained from its institutional review board.

Efficacy of hyperthermic intraperitoneal chemotherapy in patients with epithelial ovarian cancer: a meta-analysis

Objective: The role of hyperthermic intraperitoneal chemotherapy (HIPEC) in epithelial ovarian cancer (EOC) is still controversial. Present analysis aims to evaluate the survival benefit of HIPEC in treatment of EOC patients.Methods: Articles related to ‘HIPEC’ and ‘ovarian cancer’ were comprehensively searched in four databases (PubMed, EMBASE, MEDLINE and Cochrane Library) up to 4 February 2018. Eligible studies were identified depending on the selection criteria. The survival outcome and adverse events were collected. The relationship between HIPEC and survival of EOC was assessed using random-effects models.Results: A total of 1464 patients from 17 trials were subjected to analysis. The pooled results showed that HIPEC significantly improved overall survival (OS, HR = 0.50, 95% CI 0.36–0.69; p = 0.000) and progression-free survival (PFS, HR = 0.57, 95% CI 0.47–0.69; p = 0.000) among EOC patients when compared with no HIPEC controls. Similar results were observed in each year rate of survival. Subgroup analysis didn’t lead to the opposite results, except no significant increased 1-year of OS in primary EOC and 1- and 2-year of PFS in recurrent EOC treated with HIPEC were observed. No significant difference existed in the adverse events and mortality between HIPEC and no HIPEC.Conclusions: HIPEC is associated with improved OS and PFS in both primary and recurrent EOC. However, no significant increased 1- and 2-year of PFS were reached in recurrent EOC treated with HIPEC. Further prospective randomized controlled trials are warranted.

Factors affecting the survival of patients with peritoneal carcinomatosis of colorectal origin

To determine the predictive factors of overall (OS) and disease-free survival (DFS) in CRC patients with PC after CS with HIPEC. From 2010 to 2018 years 102 patients with CRC and PC were included in the study. The cytoreduction was complete (CC0, according to Sugabaker scale) in 96 (94.2%) cases. The age median of patients was 65 years. There were 63 (62%) women. In 81 (79%) patients, the PC was synchronous. The median level of CEA was 8.5 ng/ml. The median peritoneal carcinomatous index (PCI) was 3 (1-23). The median of follow-up was 18 (11; 33) months. The median of DFS and OS were 13 (9;31) and 32 (17; n/d) months, respectively. Multifactorial Cox-regression analysis showed the localization of the primary tumor in the right colon (OR=1.66; 95% CI 1.1-2.5; p=0.013) and the level of the PCI (OR = 1.08; 95% CI 1.024-1.15; p=0.008) were independent negative factors of OS. The CS and HIPEC in patients with CRC with PC allowes to achieve five-year survival in a part of patients, especially with low PCI. Identifying adverse prognostic factors preoperatively can help in selecting patients for CS in the future.

Sites of Recurrence After Complete Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy for Patients with Peritoneal Carcinomatosis from Colorectal and Appendiceal Adenocarcinoma: A Tertiary Center Experience.

This report describes patterns of disease recurrence after optimal cytoreduction (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis (PC) of colorectal (CRC) and appendiceal adenocarcinoma (AC) origin. Patients undergoing optimal CRS/HIPEC (2007-2016) at the authors' institution were retrospectively reviewed from a prospectively maintained database. Data regarding disease recurrence were analyzed. Of 74 patients who underwent CRS/HIPEC for PC from CRC (n = 46) or AC (n = 28), 49 (66%) had recurrence during a median follow-up period of 39.5months. The sites of recurrence were peritoneal-only (n = 34, 69%), hematogenous-only (n = 6, 12%), and combined peritoneal and hematogenous (n = 9, 19%) sites. No patients with AC had hematogenous-only recurrence. The median disease-free survival (DFS) time for all the patients was 15months (95% confidence interval [CI] 12.5-17.5months). The recurrence rate after CRS/HIPEC was 41% at 1year, 73% at 3years, and 76% at 5years. All the patients with hematogenous-only metastases experienced recurrence within 12months after CRS/HIPEC. Mucinous or signet ring features predicted peritoneal recurrence (p = 0.041), whereas a complete cytoreduction of 1 was a predictor of early recurrence (p = 0.040). Patients who underwent repeat cytoreduction survived longer than those who received systemic chemotherapy alone. The median survival time after peritoneal-only recurrence was 33months (95% CI 27.8-38.9months). Recurrence for patients with PC is common, even after optimal CRS/HIPEC. Hematogenous-only recurrence occurs early after CRS/HIPEC, suggesting occult disease at the time of treatment and highlighting the need for methods to identify micro-metastases and improve patient selection. Patients experiencing peritoneal-only recurrence had long survival period after CRS/HIPEC, suggesting its effectiveness at controlling peritoneal disease for a time.

Goal-directed therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a prospective observational study.

Cytoreductive surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in peritoneal carcinomatosis treatment causes significant hemodynamic, metabolic, and hematological alterations. Studies on the anesthetic intraoperative management are heterogeneous and scarce. There is a great heterogeneity in the anesthetic management of CRS and HIPEC. The aim of this study is to analyze perioperative hemodynamic goal-directed management and to evaluate the complications arisen until the seventh postoperative day. Prospective, observational study of all CRS and HIPEC patients from March 2014 to May 2017. Hemodynamic and clinical parameters were registered during surgery and the first 3 postoperative days. We correlated intraoperative data with the postoperative course until the seventh day. A total of 92 patients were included in the study (age 58.5 ± 10.9years, 47% colorectal carcinoma, and 38% ovarian carcinoma). Peritoneal Carcinomatosis Index (PCI) (median and ranges) was 10 [0-39]. Cardiac Index (CI) 3.15l/min-1/m-2 [1.79-5.60]) and Systolic Volume Variation (SVV) (10% [3%-17%]) remained within the values of normality in all surgery phases. A large difference was observed between the minimum and maximum ranges of fluid therapy administered (median 9.8ml/kg/h [5.3-24.3]), showing a great interindividual variation in the fluids requirement. A direct relationship was observed between PCI and surgery duration, fluid therapy, and intraoperative transfusion percentage (p < 0.02). There is a great variability in the intraoperative fluid therapy needs of the patients. SVV monitoring makes it possible to adjust the fluid therapy needs in each surgery phase. The use of a hemodynamic goal-directed anesthetic protocol in CRS and HIPEC enables to individually adjust the fluid therapy, avoiding over-hydration and ensuring hemodynamic stability in all surgery phases.

Two-stage hepatectomy combined with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with synchronous bilobar colorectal cancer liver metastases and peritoneal metastases: initial experience

Two-stage hepatectomy combined with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with synchronous bilobar colorectal cancer liver metastases and peritoneal metastases: initial experience

Benefit of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy in patients with isolated peritoneal metastases from colorectal cancer.

Ever since Sugarbaker has established the cytoreductive surgery (CRS) in combination with intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC), there is a chance of cure for selected patients with peritoneal metastases from colorectal cancer. Objective of this study was to investigate the benefit of CRS and HIPEC compared to other therapy options in patients with isolated synchronous and metachronous peritoneal metastases of colorectal origin in terms of long-term overall survival. A retrospective population-based cohort study, including 370 patients diagnosed with isolated synchronous and metachronous peritoneal metastases of colorectal origin, was carried out. Therefore, data were acquired from the cancer registry at the Regensburg Tumor Center in Bavaria, Germany. Patients' overall survival (OAS) according to their therapy received was analyzed by means of Kaplan-Meier method and multivariable Cox regression. Overall median survival was 41.6months for patients treated with CRS and HIPEC, compared with surgery and chemotherapy (24.0months, log-rank p = 0.015), chemotherapy only (14.1months, p < 0.001), surgery only (11.4months, p < 0.001), and best supportive care (7.9months, p < 0.001). This benefit persisted after adjustment for further risk factors in multivariable analysis. The effect of CRS and HIPEC stands out significantly in comparison to all other therapies. The multimodality approach should be a regular option for patients with isolated peritoneal metastases.

Impact of Combination Chemotherapy in Peritoneal Mesothelioma Hyperthermic Intraperitoneal Chemotherapy (HIPEC): The RENAPE Study.

The introduction of cytoreductive surgery (CRS) in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) improved the prognosis of selected patients with peritoneal mesothelioma (PM). The objective of our study was to evaluate whether different HIPEC agents were associated with different outcomes in patients with PM. From the RENAPE database, we selected all patients with histology-proven PM who underwent CRS + HIPEC from 1989 to 2014. Inclusion criteria were age ≤ 80years, performance status ≤ 2, and no extraperitoneal metastases. Overall, 249 patients underwent CRS + HIPEC for PM. The HIPEC regimen included five chemotherapeutic agents (CAs), consisting of cisplatin, doxorubicin, mitomycin-C, oxaliplatin, and irinotecan. When considering all CAs (alone or in combination), there was no significant statistical difference in regard to postoperative overall survival (OS). However, OS was better when using two CAs (group 2 drugs) versus one CA (group1 drug) (p = 0.03). The different CA regimens were equally distributed between the two groups. This association between OS and HIPEC agent, as well as a trend for better progression-free survival, were both observed in the two-drug group versus the one-drug group (p = 0.009) for patients undergoing complete cytoreductive surgery (CC-0) with an epithelioid subtype. This large study seems to show improved OS when combined CAs, especially with platinum-based regimens, are used for HIPEC in patients with PM, but needs to be confirmed by a randomized controlled trial.

Results of a randomized phase 3 study evaluating the potential benefit of a second-look surgery plus HIPEC in patients at high risk of developing colorectal peritoneal metastases (PROPHYLOCHIP- NTC01226394).

3531Background: Complete cytoreductive surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) allow to prolong survival in patients with colorectal peritoneal metastases (CRPM)...

Clinical impact of nodal status on survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for patients with gastric peritoneal metastasis.

e16093Background: Lymph node status (LNS) drives prognosis of gastric cancer. Peritoneal carcinomatosis (PC) is a stage IV regardless of the LNS and associated with poor prognosis. For selected pat...

Surgical treatment of peritoneal metastases of gastric cancer

Up to 17% of all patients with gastric cancer are diagnosed with the presence of peritoneal metastases, which is associated with apoor prognosis. The most promising results were shown with multimodal treatment regimens including systemic chemotherapy and cytoreductive surgery (CRS). A subsequent hyperthermic intraperitoneal chemotherapy (HIPEC).possibly has a positive effect and is currently being tested. This manuscript highlights the key role of CRS and HIPEC in patients with peritoneal metastases of gastric cancer and illustrates which patients benefit from this intensive therapy. We performed a comprehensive review of the literature to demonstrate relevant aspects in the treatment of peritoneal metastases in gastric cancer. The use of CRS and HIPEC improves the overall survival to 11months compared to best supportive care in selected patients. Patients who present with low volume peritoneal disease (peritoneal cancer index ≤6) have the best prognosis. This intensive treatment is associated with arelatively high morbidity (15-50%) and mortality (1-10%). Complete cytoreduction, i.e. acomplete macroscopic absence of tumor tissue after resection is the most important prognostic factor. The CRS and HIPEC procedures have a proven survival benefit in selected patients. Due to the relatively high morbidity and mortality, the evaluation should be performed by an experienced team including a surgical oncologist, medical oncologist and intensive care physician, to achieve the highest rate of complete cytoreduction in combination with low morbidity; however, the effect of HIPEC has to be proven and the results of the randomized GASTRIPEC trial are awaited.

Major influence of postoperative complications on costs of cytoreductive surgery and HIPEC in patients with colorectal peritoneal metastases.

Complications after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) result in impaired short- and long-term outcomes. However, financial consequences of complications after CRS and HIPEC in a European health care setting are unknown. This study aims to assess the consequences of complications on hospital costs after CRS and HIPEC.In this prospective observational cohort study, patients with colorectal peritoneal metastases treated with CRS and HIPEC were included. Financial information was collected according to the Dutch manual for costs analyses. Costs were compared between patients without complications (NC), minor complications (MC), or severe complications (SC), according to the Clavien–Dindo classification.One hundred and sixty-one patients were included, of whom 42% experienced NC, 27% MC and 31% SC. Mean hospital costs were €9.406 ± 2.235 in NC patients, €12.471 ± 3.893 in MC patients, and €29.409 ± 22.340 in SC patients. The 31% of patients with severe complications accounted for 56% of all hospital costs. Hospital admission costs in SC patients were 320% higher compared to NC patients. Costs of complications were estimated to be 43% of all admission costs.Severe postoperative complications have major influence on costs after CRS and HIPEC and result in a threefold increase of hospital costs in affected patients. This finding stresses the need for adequate risk assessment of developing severe complications after CRS and HIPEC.

Perioperative dialogue on postoperative recovery measured by the use of pain medication, psychopharmaceutical agents and length of hospital stay

The effects of perioperative dialogue have been studied using qualitative methods, describing patient satisfaction with their care. However, they have not been studied in patients with peritoneal carcinomatosis who undergo major surgery, nor with quantitative variables. The aim was to study the use of pain medication and length of hospital stay following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients who received, versus those who did not receive, perioperative dialogue. The study had a quantitative, retrospective and comparative design including 89 audits. Of these, 37 patients received perioperative dialogues, and 52 patients did not (the control group). The result showed that by postoperative day six, patients who received a perioperative dialogue experienced pain less frequently than patients in the control group. However, no differences between the groups were noted with regard to pain medication consumption and length of hospital stay. To ease their worries, all patients in both groups used benzodiazepines. The perioperative dialogue may be studied quantitatively, but it must involve the patient, who is an equal partner in the dialogue. Structured validated self-reporting measures may be used systematically before and after surgery in order to evaluate the perioperative dialogue using quantitative measures.