Ann Surg Treat Res.  2025 Jan;108(1):12-19. 10.4174/astr.2025.108.1.12.

Current status of postoperative morbidity following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal cancer with peritoneal metastasis: a prospective single-center observational study

• Jo JW
• Suh JW
• Lee SC
• Namgung H
• Park DG

• KMID: 2564238
• DOI: http://doi.org/10.4174/astr.2025.108.1.12

Abstract

Purpose
This study aimed to evaluate current morbidity rates following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with colorectal cancer and peritoneal metastasis.
Methods
A total of 42 patients who underwent CRS and HIPEC for colorectal cancer with peritoneal metastasis at a single tertiary referral center between January 2022 and December 2022 were included. Perioperative outcomes and postoperative complications were prospectively assessed.
Results
The mean peritoneal cancer index (PCI) was 16.0. The distribution of PCI scores was as follows: <10, 33.3%; 10– 19, 26.2%; and ≥ 20, 40.5%. Completeness of the cytoreduction (CCR) scores were as follows: 57.1% of patients achieved CCR-0, 16.7% achieved CCR-1, 7.1% achieved CCR-2, and 19.0% achieved CCR-3. The mean operation time was 9.1 hours, and the median hospital stay was 17.0 days. Postoperative complications occurred within 30 days in 47.6% of cases and between 30 and 60 days in 11.9% of cases. Reoperation within 30 days was required in 5 cases, and 1 patient died within 30 days. The most common complications were pleural effusion (5 patients), anastomosis site leakage (3 patients), and pneumonia (3 patients). Patients with higher PCI scores were more likely to experience complications (P = 0.038).
Conclusion
Although CRS and HIPEC are still associated with high morbidity and mortality compared to other colorectal surgeries, outcomes have improved with increased experience. These results suggest that the procedure is becoming a more acceptable treatment option over time.

Keyword

Colorectal neoplasms; Cytoreduction surgical procedures; Hyperthermic intraperitoneal chemotherapy; Peritoneal neoplasms; Postoperative complications

Reference

1. Quénet F, Elias D, Roca L, Goéré D, Ghouti L, Pocard M, et al. Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy versus cytoreductive surgery alone for colorectal peritoneal metastases (PRODIGE 7): a multicentre, randomised, open-label, phase 3 trial. Lancet Oncol. 2021; 22:256–266. PMID: 33476595.

2. Sadeghi B, Arvieux C, Glehen O, Beaujard AC, Rivoire M, Baulieux J, et al. Peritoneal carcinomatosis from non-gynecologic malignancies: results of the EVOCAPE 1 multicentric prospective study. Cancer. 2000; 88:358–363. PMID: 10640968.

3. Siebenhüner AR, Güller U, Warschkow R. Population-based SEER analysis of survival in colorectal cancer patients with or without resection of lung and liver metastases. BMC Cancer. 2020; 20:246. PMID: 32293337.

4. Benson AB, Venook AP, Adam M, Chang G, Chen YJ, Ciombor KK, et al. Colon cancer, version 3.2024, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2024; 22(2D):e240029. PMID: 38862008.

5. Piso P, Nedelcut SD, Rau B, Königsrainer A, Glockzin G, Ströhlein MA, et al. Morbidity and mortality following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: data from the DGAV StuDoQ registry with 2149 consecutive patients. Ann Surg Oncol. 2019; 26:148–154. PMID: 30456672.

6. Elias D, Gilly F, Quenet F, Bereder JM, Sidéris L, Mansvelt B, et al. Pseudomyxoma peritonei: a French multicentric study of 301 patients treated with cytoreductive surgery and intraperitoneal chemotherapy. Eur J Surg Oncol. 2010; 36:456–462. PMID: 20227231.

7. Sugarbaker PH. Peritoneal surface oncology: review of a personal experience with colorectal and appendiceal malignancy. Tech Coloproctol. 2005; 9:95–103. PMID: 16007367.

8. Glehen O, Kwiatkowski F, Sugarbaker PH, Elias D, Levine EA, De Simone M, et al. Cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for the management of peritoneal carcinomatosis from colorectal cancer: a multi-institutional study. J Clin Oncol. 2004; 22:3284–3292. PMID: 15310771.

9. Elias D, Gilly F, Boutitie F, Quenet F, Bereder JM, Mansvelt B, et al. Peritoneal colorectal carcinomatosis treated with surgery and perioperative intraperitoneal chemotherapy: retrospective analysis of 523 patients from a multicentric French study. J Clin Oncol. 2010; 28:63–68. PMID: 19917863.

10. Noiret B, Clement G, Lenne X, Bruandet A, Glehen O, Voron T, et al. Centralization and oncologic training reduce postoperative morbidity and failure-to-rescue rates after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies: study on a 10-year national French practice. Ann Surg. 2020; 272:847–854. PMID: 32833761.

11. Glockzin G, Schlitt HJ, Piso P. Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. World J Surg Oncol. 2009; 7:5. PMID: 19133112.

12. Chua TC, Yan TD, Saxena A, Morris DL. Should the treatment of peritoneal carcinomatosis by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy still be regarded as a highly morbid procedure?: a systematic review of morbidity and mortality. Ann Surg. 2009; 249:900–907. PMID: 19474692.

13. Passot G, Vaudoyer D, Villeneuve L, Kepenekian V, Beaujard AC, Bakrin N, et al. What made hyperthermic intraperitoneal chemotherapy an effective curative treatment for peritoneal surface malignancy: a 25-year experience with 1,125 procedures. J Surg Oncol. 2016; 113:796–803. PMID: 27110915.

14. Chicago Consensus Working Group. The Chicago consensus on peritoneal surface malignancies: management of colorectal metastases. Ann Surg Oncol. 2020; 27:1761–1767. PMID: 32285270.

15. Sugarbaker PH. Peritonectomy procedures. Ann Surg. 1995; 221:29–42. PMID: 7826158.

16. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009; 361:1368–1375. PMID: 19797283.

17. Kozower BD. Failure-to-rescue: an evolving quality metric. J Thorac Cardiovasc Surg. 2015; 149:1247–1248. PMID: 25749141.

18. Sheetz KH, Dimick JB, Ghaferi AA. Impact of hospital characteristics on failure to rescue following major surgery. Ann Surg. 2016; 263:692–697. PMID: 26501706.

19. van Putten M, Nelen SD, Lemmens VE, Stoot JH, Hartgrink HH, Gisbertz SS, et al. Overall survival before and after centralization of gastric cancer surgery in the Netherlands. Br J Surg. 2018; 105:1807–1815. PMID: 30132789.

20. Schlottmann F, Strassle PD, Charles AG, Patti MG. Esophageal cancer surgery: spontaneous centralization in the US contributed to reduce mortality without causing health disparities. Ann Surg Oncol. 2018; 25:1580–1587. PMID: 29349529.

21. Vonlanthen R, Lodge P, Barkun JS, Farges O, Rogiers X, Soreide K, et al. Toward a consensus on centralization in surgery. Ann Surg. 2018; 268:712–724. PMID: 30169394.

22. Schneider MA, Eshmuminov D, Lehmann K. Major postoperative complications are a risk factor for impaired survival after CRS/HIPEC. Ann Surg Oncol. 2017; 24:2224–2232. PMID: 28265776.

23. Huang Y, Alzahrani NA, Chua TC, Huo YR, Liauw W, Morris DL. Impacts of preoperative serum albumin level on outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy. Ann Surg Oncol. 2016; 23:2411–2418. PMID: 26957502.

24. Chouliaras K, Levine EA, Fino N, Shen P, Votanopoulos KI. Prognostic factors and significance of gastrointestinal leak after Cytoreductive Surgery (CRS) with Heated Intraperitoneal Chemotherapy (HIPEC). Ann Surg Oncol. 2017; 24:890–897. PMID: 27995450.