S. Aronson1, A. M. Blakely1, T. J. Miner1 1Brown University School Of Medicine,Department Of Surgery,Providence, RI, USA
Introduction: The combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with improved overall survival in patients with certain advanced peritoneal surface malignancies. Given often extensive debulking paired with intraperitoneal chemotherapy, nutritional recovery may be impaired postoperatively.
Methods: Retrospective review of a prospectively-maintained HIPEC database was performed. Patient demographics, primary tumor diagnosis, preoperative lab work (C-reactive protein [CRP]), intraoperative factors (extent of surgery score [ESS]), and patient outcomes (return to oral intake, utilization of parenteral nutrition [PN], complications, length of stay [LOS], and overall-survival) were measured.
Results: Seventy-four patients underwent 83 CRS/HIPEC operations (10 for recurrence) between March 1, 2008 to April 30, 2015. Primary tumor diagnoses included 39 pseudomyxoma peritonei, 14 colorectal, 5 mesothelioma, 5 ovarian, and 11 other. PN was delivered following 17 operations (20.5%); 3 patients required PN at discharge (2.4%). BMI was available for 75 operations; 31 were normal weight (BMI <25), 44 were overweight (BMI ≥25). PN administration was not associated with preoperative BMI (BMI ≥25: 24.4% vs. BMI <25: 29.2%; p=0.75), intra-abdominal complications (35.3% vs. 18.8%; p=0.15), overall complications (64.7% vs. 43.8%; p=0.12), or 30-day mortality (0% vs. 10.3%; p=0.10). BMI ≥25 was not associated with increased risk of complications (42.9% vs. 51.6%; p=0.46) but was associated with increased overall survival (median 1082 vs. 861 days; p=0.064) compared to BMI <25. ESS score of 3 was associated with delay to oral intake (median 7 vs. 4 days; p=0.0001), more PN utilization (29.1% vs. 3.8%; p=0.005), increased complications (60.0% vs. 24.0%; p=0.006), greater 30-day mortality (24.0% vs. 0%; p<0.0001), and decreased overall survival (median 959 vs. 1096 days; p=0.037) compared to ESS of 1-2. Patients who underwent bowel resection as part of tumor debulking had no difference in return to oral intake (both median 7 days, p=0.84), PN utilization (20.8% vs. 20.7%, p=0.78), or complications (46.3% vs. 48.3%; p=0.86) versus those who did not undergo bowel resection. Patients with elevated preoperative CRP had no difference in return to oral intake (both median 7 days; p=0.78) or PN utilization (58.3% vs 41.5%; p=0.30) compared to those with normal CRP.
Conclusions: Cytoreductive surgery and HIPEC places patients at risk of postoperative ileus and delay to resumption of oral intake. While performance of bowel resection itself did not further increase delay to oral intake, greater extent of surgery was associated with slower return of bowel function. Postoperative parenteral nutrition, was utilized in a minority of patients, with only three requiring home temporary PN. The combination of CRS and HIPEC was not associated with impaired long-term nutritional recovery.