Long term survival and perioperative propensity score matched outcomes of diaphragmatic resections compared to stripping in cytoreductive surgery + intra-peritoneal chemotherapy

Our plain-English summary of Long term survival and perioperative propensity score matched outcomes of diaphragmatic resections compared to stripping in cytoreductive surgery + intra-peritoneal chemotherapy, by B. Singh, G. Singh, N. Alzahrani, et al (American Journal of Surgery, 2020).

The study

• Authors: B. Singh, G. Singh, N. Alzahrani, D.L. Morris
• Journal: American Journal of Surgery
• Published: 2020;219(4):673-680
• Cited by: 8 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: To assess the impact of short and long term outcomes of diaphragm resection and repair in cyto-reductive surgery (CRS) and intra-peritoneal chemotherapy (IPC).

Methods: 1230 consecutive CRS/IPC procedures were performed between 1996 and 2018 in Sydney, Australia. Among these, 652 underwent diaphragmatic intervention. The analysis was preformed according to histological subtype. First diaphragm interventions were compared to non-diaphragmatic CRS. Secondly, diaphragm resection was compared to diaphragm stripping. Overall survival and recurrence free survival was assessed based on histological diagnosis.

Results: There were no differences between the resection and stripping groups for the colorectal cohort. For mesothelioma, increased incidences of pleural effusions in the resection group were noted (63% vs.28%, p = 0.017). In HAMNs, the resection group was associated with increased reoperations (42% vs. 15%, p = 0.03) and in hospital death (16.7% vs. 0.6%, p = 0.012). Resection in LAMNs were linked with increased transfusion requirements (9 vs. 6, p = 0.01), reoperation (39% vs. 23%, p = 0.05) and prolonged length of stay (34 days vs. 25 days, p = 0.02). There were no differences in overall survival and recurrence free survival in colorectal cancer. Median overall survival was decreased in mesothelioma by 20 months. In LAMNs the median survival was significantly decreased for the resection group. Similarly, the resection group had a 4-month earlier recurrence.

Conclusion: We conclude that diaphragm interventions are an essential part of CRS. They are associated with increased perioperative morbidity. This morbidity is not attributable to whether the patient underwent diaphragm stripping or resection. However in mesothelioma and LAMNs, requiring diaphragm resection is likely to be an indicator for tumor aggression.

Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.

In plain English

This retrospective study from one surgical unit at St George Hospital in Sydney, Australia, covered patients treated from 1996 to 2018 with cytoreductive surgery (removing visible tumor in the abdomen) plus chemotherapy delivered into the abdomen. It did not study asbestos exposure. Of 1230 patients, 652 (53.0%) also had diaphragm surgery: either stripping the diaphragm's lining or cutting out (resecting) part of the muscle. Results were reported separately for colorectal cancer, peritoneal mesothelioma, and high-grade and low-grade appendiceal mucinous neoplasms. In peritoneal mesothelioma, resection was linked to more fluid around the lungs (pleural effusion) than stripping (63% versus 28.2%). Median overall survival was 32 months after resection and 52 months after stripping. Time to recurrence did not differ significantly. The authors concluded that diaphragm surgery is associated with more complications, that this is not explained by which technique was used, and that needing resection in mesothelioma and low-grade appendiceal tumors is likely a sign of more aggressive tumors. They noted the study was retrospective and from a single institution.

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, observational, single-center study of a surgical database. The title mentions propensity score matching, but the methods do not describe it.
• Who was studied: 1230 patients who had cytoreductive surgery with intraperitoneal chemotherapy at St George Hospital, Sydney, from 1996 to 2018, analysed by diagnosis: colorectal cancer (adenocarcinoma), peritoneal mesothelioma, high-grade (HAMNs) and low-grade (LAMNs) appendiceal mucinous neoplasms. Redo surgery, incomplete cytoreduction and other diagnoses were excluded. For mesothelioma, 16 had diaphragm resection and 39 had diaphragm stripping.
• Exposure: No asbestos or fiber exposure was studied. The comparison was surgical: diaphragm intervention versus none, and diaphragm muscle resection versus diaphragm stripping, during cytoreductive surgery with intraperitoneal chemotherapy.
• Main results:
  • Across all 1230 patients, 652 (53.0%) had diaphragm procedures during their surgery.
  • In the peritoneal mesothelioma group, 73% needed diaphragm interventions. Compared with mesothelioma patients without diaphragm surgery, they had more blood transfusions, pleural effusions, grade 3 or 4 complications, ICU days and longer hospital stays.
  • In mesothelioma, pleural effusion was more common after resection than after stripping: 10 of 16 (63%) versus 11 of 39 (28.2%), p = 0.017. The authors suggested this was probably a result of early drain removal.
  • In mesothelioma, median overall survival was 32 months in the resection group and 52 months in the stripping group (p = 0.042), based on 36 deaths.
  • In mesothelioma, median recurrence-free survival was 7 months after resection and 9 months after stripping (p = 0.417, not statistically significant).
  • In colorectal cancer, resection and stripping groups did not differ in complications or survival. Median overall survival was 30 months after resection and 24 months after stripping (p = 0.583).
  • In HAMNs, resection (12 patients) compared with stripping (169) was linked to more reoperations, 5 (42%) versus 25 (15%), p = 0.030, and more in-hospital deaths, 2 (16.7%) versus 1 (0.6%), p = 0.012. The authors cautioned that the resection group was small.
  • In LAMNs, median overall survival was 27 months after resection and 64 months after stripping (p = 0.014). Median recurrence-free survival was 10 versus 14 months (p = 0.051).
  • For pleural recurrences in all diagnoses combined (25 recurrences), median recurrence-free survival was 7 months after resection and 26 months after stripping (p = 0.003).
• The authors' conclusion: The authors concluded that diaphragm interventions are an essential part of cytoreductive surgery and are associated with increased perioperative complications. They found this was not attributable to stripping versus resection. They also concluded that in mesothelioma and LAMNs, needing diaphragm resection is likely an indicator of tumor aggression. For mesothelioma, they suggested this might reflect more biphasic or sarcomatoid subtypes.
• Limitations the authors state:
  • The study was retrospective and observational, and unidentified confounding factors could influence the results.
  • Extubation times were not available.
  • Types of diaphragm repair (closed primarily or with mesh) were not compared.
  • The sample size may be too small to detect rare complications.
  • It was a single-institution study, and results may not apply elsewhere.
  • The HAMN survival analysis had only 5 events in the resection group and was not reliable.
  • The pleural recurrence analysis pooled all diagnoses because of low event numbers.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Colon cancer.

Medical terms in this study, explained in our Lexicon: Diaphragmatic Resection, Cytoreductive Surgery, Chemotherapy, Diaphragm, Histological Subtype, Overall Survival, Mesothelioma, Pleural Effusion.

Related studies

• Long-term Survival and Propensity Score Matched Outcomes of Bilateral vs. Unilateral Diaphragm Interventions in Cytoreductive Surgery plus Intra-peritoneal Chemotherapy — B. Singh, G. Singh, et al. (2018)
• Long-term survival outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy: Single-institutional experience with 1225 cases — L.S. Kyang, N.A. Alzahrani, et al. (2019)
• Multicystic mesothelioma: Operative and long-term outcomes with cytoreductive surgery and hyperthermic intra peritoneal chemotherapy — E. Nizri, D. Baratti, et al. (2018)
• The results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1200 patients with peritoneal malignancy — B. Moran, T. Cecil, et al. (2015)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: long-term results at St George Hospital, Australia — N. Alzahrani, J.S. Ferguson, et al. (2016)
• Iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent or progressive diffuse malignant peritoneal mesothelioma: clinicopathologic characteristics and survival outcome — C. Ihemelandu, L. Bijelic, et al. (2015)

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