Dextrose-Containing Carrier Solution for Hyperthermic Intraperitoneal Chemotherapy: Increased Intraoperative Hyperglycemia and Postoperative Complications

Our plain-English summary of Dextrose-Containing Carrier Solution for Hyperthermic Intraperitoneal Chemotherapy: Increased Intraoperative Hyperglycemia and Postoperative Complications, by R.J. Torphy, C. Stewart, P. Sharma, et al (Annals of Surgical Oncology, 2020).

The study

• Authors: R.J. Torphy, C. Stewart, P. Sharma, A.L. Halpern, K. Oase, W. Herter, C. Bartsch, C. Friedman, M. Del Chiaro, R.D. Schulick, A. Gleisner, M.D. McCarter, S.A. Ahrendt
• Journal: Annals of Surgical Oncology
• Published: 2020;27(13):4874-4882
• Cited by: 8 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Purpose: Intraoperative hyperglycemia is associated with infectious complications in general surgery patients. This study aimed to determine if the use of lactated Ringer's (LR) carrier solution during hyperthermic intraperitoneal chemotherapy (HIPEC) would lower the incidence of intraoperative hyperglycemia and improve postoperative outcomes when compared with a standard 1.5% dextrose peritoneal dialysate carrier solution.

Patients And Methods: This is a retrospective cohort study of 134 patients who underwent HIPEC at the University of Colorado. Perioperative glucose levels and outcomes were compared between patients who were perfused with 1.5% dextrose peritoneal dialysate carrier solution (n = 68) versus LR carrier solution (n = 66).

Results: The study population consisted of patients undergoing HIPEC for appendiceal (50%), colorectal (34%), mesothelioma (8%), and ovarian cancer (5%). Intraoperative severe hyperglycemia (glucose ≥ 180 mg/dL) was significantly more common among patients perfused with a dextrose-containing carrier solution versus those perfused with LR (88% vs. 21%; p < 0.001). Patients in the dextrose cohort had significantly more severe complications (39% vs. 12%; p = 0.034), infectious complications (35% vs. 15%; p = 0.011), and organ space infections (18% vs. 5%: p = 0.026) than the LR cohort. On multivariable analysis, dextrose-containing carrier solution was significantly associated with an increased risk of postoperative infectious complications (HR 5.16; p = 0.006).

Conclusions: Intraoperative hyperglycemia is common when dextrose-containing carrier solution is used during HIPEC, and severe intraoperative hyperglycemia is strongly associated with an increased risk for infectious of complications following HIPEC. LR carrier solution should be routinely used to reduce intraoperative hyperglycemia and its associated risks.

In plain English

This retrospective cohort study looked at 134 adults who had cancer surgery plus heated abdominal chemotherapy (HIPEC) at the University of Colorado, 2005 to 2018. Most had appendiceal or colorectal cancer; 8.2% had mesothelioma. Asbestos exposure was not studied. Until 2017 the chemotherapy was mixed in a 1.5% dextrose (sugar) dialysis solution, then in lactated Ringer's (LR) solution. Severe high blood sugar during surgery (180 mg/dL or more) occurred in 60 of 68 dextrose patients (88.2%) and 16 of 66 LR patients (printed as 21.1%; 16 of 66 is about 24%). The dextrose group had more serious (grade 3–5) complications (29.4% vs. 12.1%), infections (24 of 68, about 35%, printed as 34.8%, vs. 10 of 66, 15.2%) and deep organ-space infections (17.6% vs. 4.6%). After adjustment, the dextrose solution was associated with infections (odds ratio 5.16; 95% CI 1.60–16.7). The authors reported that high blood sugar accounted for this link. They concluded severe high blood sugar during surgery is strongly associated with infectious complications. They noted the study was non-randomized, compared groups from different time periods and lacked insulin data.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective cohort study using a prospectively maintained database at a single institution, comparing two carrier-solution cohorts from different time periods
• Who was studied: 134 adults who had cytoreductive surgery and HIPEC at the University of Colorado, 2005 through 2018, with documented carrier solution (36 of 170 were excluded for lack of documentation). The cancers were appendiceal (50.0%), colorectal (33.5%), mesothelioma (8.2%, 11 patients) and ovarian (4.5%). The dextrose cohort had 68 patients and the LR cohort 66.
• Exposure: The type of HIPEC carrier solution. Before 2017 patients received a hypertonic dialysis solution with 1.5% dextrose (Dianeal low-calcium). From 2017 patients received lactated Ringer's solution. No asbestos or fiber exposure was studied.
• Main results:
  • Median peak blood glucose during surgery was 250 mg/dL (IQR 207–309) in the dextrose cohort and 155 mg/dL (IQR 142–179) in the LR cohort.
  • Severe hyperglycemia during surgery (blood glucose 180 mg/dL or more) occurred in 60 of 68 patients in the dextrose cohort (88.2%) and in 16 of 66 patients in the LR cohort. The article prints the LR figure as 21.1%, but 16 of 66 is about 24.2%.
  • There were no differences in blood glucose levels between the two cohorts on postoperative day 1.
  • Grade 3–5 (Clavien–Dindo) complications occurred in 29.4% of the dextrose cohort and 12.1% of the LR cohort (p = 0.034).
  • Overall infectious complications occurred in 24 of 68 patients in the dextrose cohort and 10 of 66 patients in the LR cohort (15.2%; p = 0.010). The dextrose figure is printed as 34.8%, but 24 of 68 is about 35.3%.
  • Organ space infections occurred in 17.6% of the dextrose cohort and 4.6% of the LR cohort (p = 0.026).
  • There were no statistically significant differences between the cohorts in urinary tract infections, wound infections or anastomotic leaks.
  • Patients who had severe hyperglycemia during surgery, compared with those who did not, had higher rates of overall infectious complications (36.8% vs. 10.4%; p = 0.001) and organ space infections (17.1% vs. 3.5%; p = 0.013).
  • In the multivariable analysis, which controlled for multivisceral resection score, operative time and estimated blood loss, dextrose-containing carrier solution was associated with postoperative infectious complications (OR 5.16; 95% CI 1.60–16.7; p = 0.006).
  • When carrier solution type and hyperglycemia during surgery were analyzed together, hyperglycemia remained associated with infectious complications (OR 4.27; 95% CI 1.29–13.5; p = 0.017).
  • In that same combined analysis, dextrose-containing carrier solution was no longer a significant risk factor (OR 1.35; 95% CI 0.48–3.83; p = 0.573). The authors interpreted this as hyperglycemia mediating the effect of the carrier solution.
• The authors' conclusion: The authors concluded that hyperglycemia during surgery is common when a dextrose-containing carrier solution is used during HIPEC. They also concluded that severe hyperglycemia during surgery is strongly associated with an increased risk of infectious complications after HIPEC.
• Limitations the authors state:
  • The study was non-randomized and retrospective. There was temporal bias because the two cohorts were treated in different time periods.
  • The surgeons differed somewhat between the earlier and later time periods.
  • The LR cohort was collected over an 18-month period, which reflected greater institutional and individual surgeon experience. The dextrose cohort was collected over 11 years.
  • The authors lacked data on insulin given during surgery to patients with diabetes, which may confound the results.

Topics

Medical terms in this study, explained in our Lexicon: HIPEC, Cohort Study, Mesothelioma, Ovarian Cancer.

Related studies

• A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy — J.M. Baumgartner, T.G. Kwong, et al. (2016)
• Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications — M.H. Squires, C.A. Staley, et al. (2015)
• Impact of Major Complications on Patients' Quality of Life After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy — T.D. Hamilton, E.L. Taylor, et al. (2016)
• Postoperative outcomes of laparoscopic vs open cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for treatment of peritoneal surface malignancies — G. Passot, N. Bakrin, et al. (2014)
• Urological approach for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a clinical care center — C.G. Trujillo, C. Domínguez, et al. (2018)
• Body surface area predicts plasma oxaliplatin and pharmacokinetic advantage in hyperthermic intraoperative intraperitoneal chemotherapy — J.C. Leinwand, G.E. Bates, et al. (2013)

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