Morbidity of the abdominal wall resection and reconstruction after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC)

Our plain-English summary of Morbidity of the abdominal wall resection and reconstruction after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), by M.F. Nunez, A. Sardi, C. Nieroda, et al (Annals of Surgical Oncology, 2015).

The study

• Authors: M.F. Nunez, A. Sardi, C. Nieroda, W. Jimenez, M. Sittig, R. MacDonald, N. Aydin, V. Milovanov, V. Gushchin
• Journal: Annals of Surgical Oncology
• Published: 2015;22(5):1658-63
• Cited by: 12 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: CRS/HIPEC has evolved as a therapeutic option for selected patients with peritoneal surface malignancies. To achieve complete cytoreduction (CC), some patients require extensive abdominal-wall resection (AWR) and subsequent complex reconstructions, which may be associated with wound complications (WC) and delay of postoperative cancer therapy.

Methods: Review of a prospective database of 350 patients revealed 213 patients with peritoneal carcinomatosis who underwent AWR due to suspected or proven wound/port site metastases during CRS/HIPEC. Tumor origin included: appendix, colon, ovarian, peritoneal mesothelioma, primary peritoneal, and others. WC were related to peritoneal carcinomatosis index (PCI), CC score, length of surgery, type of AWR and closure, blood transfusion, and albumin levels using binary logistic regression (odds ratios (OR) and 95 % CIs) analysis.

Results: PCI ≥ 20 was found in 151 (71 %), CC was achieved in 178 (84 %). Mean length of surgery was 613 min. Postoperative WC were detected in 49 of 213 (23 %) patients, 13 (6 %) had Grade III (according to Clavien-Dindo's classification) WC, and led to delay of postoperative chemotherapy. WC occurred in 21 of 64 (32.8 %) patients with excision of port sites (odds ratio [OR] = 2.11, confidence interval [CI] = 1.09-4.10, p = 0.026). Primary fascial closure was performed in 191 of 213 (89.7 %) patients, 40 (21 %) of whom had WC. Mesh-assisted abdominal wall reconstruction was required in 22 of 213 (10.3 %) patients, of whom 9 (40.9 %) had WC (OR = 2.61, CI = 1.04-6.55, p = 0.035).

Conclusions: Port-site excision and mesh-assisted abdominal wall reconstruction were associated with higher incidence of postoperative WC following CRS/HIPEC. The implications of these preliminary findings may need to be considered during surgical planning for these patients.

In plain English

This study, from the Institute for Cancer Care at Mercy Medical Center in Baltimore, reviewed a prospectively kept database of 350 patients with peritoneal carcinomatosis who had cytoreductive surgery with heated chemotherapy inside the abdomen (CRS/HIPEC) between April 2003 and July 2013. It focused on the 213 patients who also had full-thickness abdominal wall resection, mostly to remove scars from earlier operations. Most tumors began in the appendix (143 patients), and 13 patients (6%) had mesothelioma. The article did not discuss asbestos. Wound complications occurred in 49 of the 213 patients (23%), and 13 (6%) had Grade III complications. Of the 64 patients whose laparoscopic port sites were cut out, 21 (32.8%) had wound complications (odds ratio 2.11, CI 1.09 to 4.10). Of the 22 patients whose abdominal wall was closed with mesh, 9 (40.9%) had wound complications (odds ratio 2.61, CI 1.04 to 6.55). In the multivariate analysis, port site excision remained statistically associated (odds ratio 3.36, CI 1.02 to 11.03). The authors concluded that port site excision and mesh-assisted reconstruction were associated with more wound complications. They noted the limits of a retrospective, single-institution analysis.

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 review of a prospectively maintained single-institution surgical database (univariate and multivariate logistic regression)
• Who was studied: 213 of 350 patients with peritoneal carcinomatosis who had full-thickness abdominal wall resection during CRS/HIPEC at one center in Baltimore, April 2003 to July 2013. Most had tumors of appendiceal origin (143, 67%), and 13 (6%) had mesothelioma.
• Exposure: Not an asbestos exposure study. The factors studied were surgical: type of abdominal wall resection (midline scar excision in 149, port site excision in 64) and type of closure (primary fascial closure in 191, mesh-assisted closure in 22), plus PCI, CC score, transfusion, albumin and others.
• Main results:
  • Wound complications occurred in 49 of 213 patients (23%).
  • Grade III complications (Clavien–Dindo) occurred in 13 patients (6%).
  • Among the 64 patients with port site excision, 21 (32.8%) had wound complications (OR = 2.11, CI = 1.09 to 4.10, p = 0.026).
  • Among the 22 patients with mesh-assisted reconstruction, 9 (40.9%) had wound complications (OR = 2.61, CI = 1.04 to 6.55, p = 0.035).
  • On multivariate analysis, port site excision remained associated with wound complications (OR = 3.36, CI = 1.02 to 11.03).
  • All 4 Grade IIIb complications occurred in patients with port site excision.
  • PCI and CC scores, previous hernia, tumor appearance, extensive procedures, blood transfusion and preoperative albumin were not statistically associated with wound outcomes.
  • 75 of the 213 patients (35%) had confirmed metastatic disease in the resected scars.
• The authors' conclusion: The authors concluded that off-midline port site excision and mesh-assisted abdominal wall reconstruction were associated with a higher incidence of postoperative wound complications after CRS/HIPEC. They called these findings preliminary and believed the benefits of scar resection outweigh the short-term risks.
• Limitations the authors state:
  • The limits of any retrospective analysis, including selection and information bias from inaccurate medical-record documentation.
  • Most tumors were of appendiceal origin, so tumor type could confound the effect of the perfusion drugs used.
  • The choice of mesh type was left to each surgeon, and complications by mesh type were not studied.
  • Results from a single institution may not apply to other treatment centers.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Peritoneal Mesothelioma, Odds Ratio, Chemotherapy, confidence interval.

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)
• Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality — K.I. Votanopoulos, N.A. Newman, et al. (2013)
• Abdominal Wall Morbidity Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy — F. Struller, I. Koenigsrainer, et al. (2017)
• Cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for children, adolescents, and young adults: the first 50 cases — A. Hayes-Jordan, H. Green, et al. (2015)
• The Role of Ki-67 and Pre-cytoreduction Parameters in Selecting Diffuse Malignant Peritoneal Mesothelioma (DMPM) Patients for Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — S. Kusamura, P.A. Torres Mesa, et al. (2016)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)

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