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Introduction: The impact of concomitant urologic procedures (UPs) on perioperative and long-term outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is uncertain., Methods: In total, 935 consecutive CRS/HIPEC procedures were performed between 1996 and 2016 in Sydney, Australia. Among these, 73 (7.8%) involved concomitant UP. The association of concomitant UP with 21 perioperative outcomes and overall survival was assessed using univariate and multivariate analyses., Results: In-hospital mortality was 1.8%. Patients requiring UP were more likely to require transfusion of ≥5 units of red blood cells (P=0.031) and have a complete cytoreduction (79% vs. 60%, P<0.001). On multivariate analysis, UP was not associated with in-hospital mortality (2.7% vs. 1.7%, P=0.407) or grade III/IV morbidity (52% vs. 41%, P=0.376). The incidence of ureteric fistula (4% vs. 1%, P=0.004), return to theater (26% vs. 14%, P=0.005) and digestive fistula (22% vs. 11%, P=0.005) was higher in the UP group. The addition of a UP did not significantly impact overall survival for appendiceal cancer (P=0.162), colorectal cancer (P=0.315), or pseudomyxoma peritonei (P=0.120)., Conclusions: Addition of a UP was not associated with an increased risk of grade III/IV morbidity or poorer long-term survival after CRS/HIPEC.

Background: Peritoneal dissemination of small bowel adenocarcinoma (SBA) is rare but is associated with a dismal prognosis. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is a promising treatment option. We evaluated our experience of CRS-HIPEC for the treatment of SBA., Patients and Methods: Sixteen consecutive patients underwent CRS-HIPEC for small bowel malignancy between 2003 and 2016. Clinopathological and treatment-related factors were obtained from a prospective database. The study's endpoints of disease-free (DFS) and overall (OS) survival were evaluated using the Kaplan-Meier method. Prognostic variables were identified through univariate and multivariate analyses., Results: Follow-up was complete in all patients. The median follow-up was 20.6 (range=0.2-62) months. The was no in-hospital mortality and grade III/IV morbidity was 25%. The median OS after CRS-HIPEC was 24.7 months, with a 36-month survival of 34%. The median DFS was 11.3 months, with a 36-month DFS of 8%. Two factors were associated with a poorer OS on univariate analysis; only peritoneal cancer index >10 was associated with a poorer OS on multivariate analysis (p=0.032)., Conclusion: CRS-HIPEC in selected patients with peritoneal dissemination of SBA is associated with reasonable mid-term survival outcomes but treatment failure is common. High disease burden, quantified by the PCI is associated with poor outcomes. A large, prospective, multi-institutional study is needed to further evaluate the outcomes of CRS-HIPEC for SBA., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objective: To review the effect of cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) on health-related quality of life (HRQOL) in patients with peritoneal carcinomatosis., Background: CRS and HIPEC is increasingly performed with curative intent for peritoneal carcinomatosis. Significant morbidity rates are reported in the context of limited life-expectancy, necessitating accurate post-operative HRQOL outcome data., Methods: A systematic review of clinical studies published after January 2000 was performed using strict eligibility criteria. Key outcomes measures were post-operative HRQOL compared to pre-operative levels and reference populations. Quality appraisal and data tabulation were performed using pre-determined forms. Data were synthesised by narrative review and random-effects meta-analysis. Tau2 and I2 values and Funnel plots were analysed for consistency and bias., Results: 15 studies (1583 patients) were included. HRQOL declines at the 3-4 month time-point before becoming similar or better compared to pre-operative levels at 1 year. The pooled-effects of combined post-operative functional assessment of cancer therapy and European organisation for research and treatment quality of life questionnaire scores were significantly improved from baseline on overall health status (p=0.001) and emotional health (p=0.001). Physical health (p=0.83), social health (p=0.48) and functional health (p=0.24) remain similar. HRQOL after 1 year is less clear, but benefits may persist up to 5 years especially on overall and physical health domains. Evidence is conflicted and inconclusive on HRQOL compared to reference populations. Levels of consistency and bias were acceptable., Conclusions: CRS and HIPEC for peritoneal carcinomatosis can confer small to medium benefits for HRQOL. These results should be interpreted with in caution due to the small studies and absence of more randomised controlled trials., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: This study evaluates the accuracy of computed tomography (CT) scoring of the peritoneal cancer index (PCI) and examines its association with surgical morbidity and outcomes in pseudomyxoma peritonei., Methods: Forty-seven patients with pseudomyxoma peritonei had preoperative evaluation of CT scans and were treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy. Their radiological PCI and intraoperative PCI were scored for determination of accuracy and for correlation with morbidity and outcomes., Results: Accuracy in detecting peritoneal lesions regardless of size ranged from 51% to 85% in the abdominopelvic regions and 21% to 25% in the small intestinal regions. The sensitivity of CT detection of peritoneal implants ranged from 67% to 84% in the abdominopelvic regions and from 56% to 57% in the small intestinal regions. The specificity of CT detection of peritoneal lesions was 100% in all regions. Preoperative CT identification of larger peritoneal lesions in the right upper quadrant (P = 0.016), epigastrium (P = 0.003), left upper quadrant (P = 0.019), proximal jejunum (P = 0.022), distal jejunum (P = 0.022), and proximal ileum (P = 0.022) predicted development of severe complications. Similarly, larger peritoneal lesions in the right upper quadrant (P = 0.039), epigastrium (P = 0.024), right flank (P = 0.005), and right lower quadrant (P = 0.034) were negatively associated with disease-free survival, and the right upper quadrant (P = 0.037) was negatively associated with overall survival., Conclusions: Preoperative CT scan depicting extensive upper abdominal and small bowel disease predicts the presence of severe complications after cytoreduction. Extensive disease in the right upper quadrant seems to be associated with a poorer survival outcome.

Background: To evaluate the role of modern systemic therapies and its role as palliative or curative therapy for patients with colorectal peritoneal carcinomatosis with an emphasis on patient selection with the colorectal Peritoneal Surface Disease Severity Score (PSDSS)., Methods: From three specialized treatment centers, patients with colorectal peritoneal carcinomatosis were identified between December 1988 to December 2009 to receive best supportive care, standard, or modern systemic therapies. Intent was classified as palliative or curative (if treated by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy). Patients were stratified according to the PSDSS. Survival was estimated by the Kaplan-Meier method., Results: Palliative and curative treatment achieved a median survival of 9 (95% confidence interval [95% CI] 5.9-12.8) and 38 (95% CI 30.2-45.2) months, respectively (P < 0.001). The type of chemotherapy in the palliative and curative group influenced outcome (P < 0.001, P = 0.011, respectively). In the palliative group, PSDSS I/II had a median survival of 24 (95% CI 15.6-32.6) and PSDSS III/IV had a median survival of 6 (95% CI 4.9-8.0) months (P < 0.001). In the curative group, PSDSS I/II had a median survival of 49 (95% CI 40.0-58.3) and PSDSS III/IV had a median survival of 31 (95% CI 20.4-40.9) months (P = 0.002)., Conclusions: Modern systemic therapies were associated with improved outcome in patients with colorectal peritoneal carcinomatosis treated systemically alone or with cytoreductive surgery combined with perioperative intraperitoneal chemotherapy. Preoperative evaluation with the PSDSS may improve patient selection and optimize outcomes.

Background: Surgical cytoreduction and intraperitoneal chemotherapy is increasingly accepted as an effective treatment modality for mucinous appendiceal neoplasm. For the majority of patients with low-grade histology, outcomes have been encouraging. The survival of patients with neoplasms of malignant character is protracted and this study was designed to evaluate the effectiveness of this surgical strategy on outcomes., Methods: Forty-six consecutive patients with mucinous and nonmucinous appendiceal cancer with peritoneal dissemination were studied. Clinicopathological and treatment related factors were obtained from a prospective database. The study's end points of disease-free survival (DFS) and overall survival (OS) were analyzed using the Kaplan-Meier method., Results: The median DFS and OS after cytoreduction were 20.5 and 56.4 months respectively. Five-year overall survival rate was 45%. Five independent factors associated with DFS and OS were identified through a multivariate analysis: age (DFS p = 0.001, OS p = 0.002), completeness of cytoreduction (DFS p = 0.001, OS p = 0.003), previous chemotherapy treatment (DFS p = 0.021), CA 199 levels (DFS p = 0.013), and tumor grade (OS p = 0.005)., Conclusions: Cytoreductive surgery and intraperitoneal chemotherapy may achieve long-term survival in appendiceal malignancies with peritoneal dissemination for which the predictors of outcomes identified through this study may tailor the disease management to commit patients early toward this successful surgical strategy.

Background: Peritoneal carcinomatosis imposes an enormous clinical burden to the oncologic community. This study reports the patterns of care of the locoregional approach of cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy as a curative procedure for peritoneal carcinomatosis from the experience of a single tertiary center in Australia., Methods: We performed a review of clinical records from a prospective database of patients who were treated at the St George Hospital Peritoneal Surface Malignancy Program according to a standard protocol., Results: A total of 308 CRS were performed in 249 patients with peritoneal surface malignancy; the mean age was 53 years and 55% were women. Over the years, we expanded the age limit for treatment (P = .03), reduced intensive care unit stays (P = .04), reduced amount of blood transfusion (P = .03), treated patients with a higher peritoneal cancer index (P < .001), achieved higher rates of complete cytoreduction (P = .003), increased use of PIC (P < .001), and improved complication rate (P = .02) and mortality rate (P = .01). The median survival of patients treated over the years also improved (P = .001)., Conclusions: We show the maturity of the treatment of peritoneal carcinomatosis with CRS and perioperative intraperitoneal chemotherapy in our institution after an initial learning curve with expansion of the selection criteria, improved perioperative outcomes, improved surgical results, and long-term survival outcomes., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Cytoreductive surgery and perioperative intraperitoneal chemotherapy (PIC) is recognized as an effective treatment modality for patients with pseudomyxoma peritonei. This study investigates its role as a secondary definitive treatment procedure after earlier primary treatments., Study Design: Patients with pseudomyxoma peritonei undergoing secondary cytoreduction combined with PIC were identified from a prospective database. Retrospective analysis investigated the outcomes, prognostic factors, critical time points, and impact of malignant dedifferentiation. Survival analysis was performed via the Kaplan-Meier method and compared via the log-rank test., Results: The median time to progression after secondary cytoreduction was 28 months (95% CI 14 to 41 months), median survival was 97 months (95% CI 82 to 113 months), and 10-year survival was 25%. Median overall survival from initial diagnosis was 17 years and 10-year survival rate was 75%. Forty-five patients remained disease free (63%). Requiring an urgent treatment (waiting time < 60 days) after disease progression (p = 0.045) and having moderate or severe symptoms (p = 0.033) were associated with a shorter time to progression. Improved survival was associated with patients who had low-grade tumors (p = 0.029), and those who required less urgent treatment (wait > 30 days) after disease progression (waiting up to 15 days, p = 0.010; waiting up to 30 days, p = 0.005). Malignant dedifferentiation appeared to affect survival from initial diagnosis (p = 0.062) and after secondary cytoreduction (p = 0.006)., Conclusions: Secondary cytoreduction with PIC achieves long-term survival. Tumors that undergo malignant dedifferentiation appear to adversely affect survival, and this may support the rationale for early definitive treatment with cytoreduction and PIC., (Copyright © 2010 American College of Surgeons. All rights reserved.)

Background: Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with pseudomyxoma peritonei (PMP). However, this aggressive treatment modality has been consistently associated with variable rates of perioperative mortality between 0% and 18% and morbidity between 30% and 70%. This study evaluates the clinical and treatment-related risk factors for perioperative morbidity and mortality in PMP patients who underwent CRS and PIC., Materials and Methods: A total of 145 consecutive CRS and PIC procedures for PMP performed between January 1996 and March 2009 were evaluated. The association of 12 clinical and 20 treatment-related risk factors with grades III and IV/V morbidity were assessed by univariable and multivariable analysis., Results: The mortality (grade V) rate was 3%. The morbidity rates of grades III and IV were 23% and 22%, respectively. Eight factors were associated with grade IV/V morbidity on univariable analysis: peritoneal cancer index >or=21 (P = .034), ASA score >or=3 (P = .003), operation duration >or=10 h (P < .001), left upper quadrant peritonectomy procedure (P = .037), colonic resection (P = .012), ostomy (P = .005), ileostomy (P = .012), and transfusion >or=6 units (p = 0.011). Multivariable analysis showed 2 significant risk factors for grade IV/V morbidity: ASA >or= 3 (P = .006) and an operation length >or=10 h (P < .001)., Conclusions: CRS and PIC has an acceptable rate of perioperative mortality and morbidity in selected patients with PMP. Patients with bulky disease who undergo a long operation are at a particularly high risk of a severe adverse event.

Background: Cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC) has improved survival in selected patients with peritoneal carcinomatosis. This study evaluates the morbidity of postoperative pancreatic fistula (PF) within the context of CRS and PIC., Methods: Two hundred seventy-one consecutive CRS and PIC procedures were evaluated. Diagnosis and classification of postoperative PF were performed according to the international study group on PF criteria. The associations between 8 clinical and 20 treatment-related factors with postoperative PF were determined by univariate and multivariate analysis. The management and clinical sequelae of postoperative PF were discussed., Results: Seventeen patients (6.3%) developed postoperative PF. None of these patients died during their in-hospital stay. Multivariate analysis identified three independent risk factors for PF: transfusion of >or=6 units of blood (P = 0.029), operation duration of >or=9 h (P = 0.035), and splenectomy (P = 0.020). Conservative management of PF was instituted in all 17 patients and was successful in 16 (94%). The overall time to PF closure was 26 (standard deviation 16) days after diagnosis. Although PF did not contribute to procedure-related mortality, it was associated with increased length of hospital stay (P < 0.001)., Conclusions: CRS and PIC presented an acceptable rate of PF that did not increase the procedure-related mortality. However, PF was associated with longer hospital stay. Most patients with PF were treated conservatively and did not require surgical intervention.

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are treatment approaches for peritoneal carcinomatosis that has demonstrated improved survival outcomes with acceptable complication rates. This report aims to measure and describe the survival outcomes and health care cost associated with CRS and HIPEC for peritoneal surface malignancies at a centralized tertiary institution in Australia., Methods: The expenditure of treatment for 136 consecutive patients who underwent 159 CRS and HIPEC from June 2002 to June 2008 were obtained. Together with their survival outcomes from treatment, a cost-effectiveness analysis was performed., Results: The average cost of CRS and HIPEC per patient and per life year for appendix cancer is AUD $88,423 (range, AUD $23,933-AUD $299,145) and AUD $37,737/LY; for colorectal cancer is AUD $66,148 (range, AUD $26,079-AUD $409,666) and AUD $29,757/LY; for pseudomyxoma peritonei is AUD $92,308 (range, AUD $11,562-AUD $501,144) and AUD $29,559/LY; for peritoneal mesothelioma is AUD $55,062 (range, AUD $23,261-AUD $94,104) and AUD $20,521/LY; and for other peritoneal surface malignancies is AUD $44,668 (range, AUD $31,592-AUD $70,026) and AUD $22,091/LY., Conclusions: This complex surgical treatment results in significant increases in medical costs with a parallel increase in survival for a disease that has been poorly treated, and hence may be considered as cost-effective given the observed life years gained.

Introduction: Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) is a treatment option for peritoneal surface malignancy. Despite the survival benefits, this treatment was previously associated with a high morbidity and mortality rates and the perception of the poor perioperative outcomes associated with this regimen remains. The aim of this study was to report the perioperative outcomes of CRS and PIC from a single institution to review factors that are associated with a poor perioperative outcome., Methods: The clinical- and treatment-related data of 243 consecutive procedures performed were prospectively collected and retrospectively reviewed. Adverse events were rated according to the National Cancer Institute's Common Toxicity Criteria (grade I-V). Univariate and multivariate analyses were performed to identify significant clinical and treatment-related factors for a poor perioperative outcome (grades III/IV/V morbidity)., Results: The perioperative mortality rate was 3%. The rate of severe morbidity was 43%. Multivariate analysis demonstrated that left upper quadrant peritonectomy (P < 0.001) and small bowel resection (P < 0.01) were factors that predicted for a poor perioperative outcome., Conclusions: The morbidity and mortality rates of CRS and PIC are within an acceptable range for a major gastrointestinal surgery which is performed with a curative intent. Patient selection is important in ensuring that suitable patients receive this treatment. A new perspective of this treatment needs to be sought.

Background: Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with colorectal peritoneal carcinomatosis (CRPC). This treatment modality is associated with relatively high rates of perioperative morbidity and mortality. This study evaluated the clinical and treatment-related risk factors for perioperative morbidity and mortality in patients with CRPC who underwent CRS and PIC., Methods: Sixty-three consecutive patients who underwent CRS and PIC for CRPC were evaluated. Adverse events were rated from grades I to V with increasing severity. Clinical and treatment-related risk factors for grades III and IV/V morbidity were determined., Results: There were no perioperative deaths (0%). The grades III and IV morbidity rates were 14 and 17%, respectively. A peritoneal cancer index >12 (p = 0.019), transfusion >4 units (p = 0.028), number of peritonectomy procedures >3 (p = 0.013), left upper quadrant peritonectomy procedure (p < 0.001), and number of primary colonic anastomosis >1 (p = 0.004) were associated with grade IV morbidity on univariate analysis. Only left upper quadrant procedure was associated with grade IV morbidity on multivariate analysis (p = 0.002). Only number of primary colonic anastomosis >1 (p = 0.037) was associated with grade III morbidity on univariate analysis. This also was associated with grade III morbidity on multivariate analysis (p = 0.028)., Conclusions: CRS and PIC has an acceptable risk of perioperative morbidity in carefully selected patients with CRPC. Patients who require extensive surgery have the highest risk for a severe adverse event. Preoperative evaluation of patients is essential to improve perioperative outcome.

Background: Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has demonstrated improved survival in selected patients with peritoneal carcinomatosis (PC). This treatment modality is associated with high blood loss and often requires massive allogenic red blood cell transfusion (MABT). Our study is the first of its kind to evaluate the risk factors for intraoperative MABT in peritonectomy procedures., Methods: Two hundred and forty-three consecutive CRS and PIC procedures were evaluated. The associations between 17 preoperative and intraoperative risk factors and intraoperative MABT (>or=6 units) were assessed by univariate and multivariate analysis., Results: One hundred and eighty-six (77%) procedures required intraoperative transfusion of packed red blood cells. Ninety-one procedures required MABT (37%). Multivariate analysis showed six significant risk factors for intraoperative MABT: operative length > 9 h (p < 0.001), preoperative hemoglobin < 125 g/l (p < 0.001), operation date prior to 2004 (p = 0.002), peritoneal cancer index >or= 16 (p = 0.006), preoperative international normalized ratio (INR) >or= 1.2 (p = 0.008), and number of peritonectomy procedures >or= 4 (p = 0.021). Statistical analysis also revealed that MABT was associated with increased intensive care unit (ICU) (p < 0.001), high-dependency unit (HDU) (p = 0.020), and total hospital stay (p < 0.001) and with severe morbidity (p < 0.001)., Conclusions: Patients with preoperative anemia, impaired coagulation profile or extensive tumor burden are at high risk of MABT. Appropriate blood conservation strategies should be adopted in these patients on the basis of their risk factors.

Background: : Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been offered in many institutions worldwide since the 1990s. Despite its existence of more than 10 years, this treatment has received heavy criticism for its morbidity and mortality rates. This consequentially resulted in a lack of randomized trials being conducted and translates into a lack of the most reliable form of scientific evidence in clinical research, hence limiting its general acceptance., Objective: : To report the morbidity and mortality outcomes of CRS and HIPEC from all institutions performing this treatment as a prelude toward establishing the safety of this treatment for peritoneal carcinomatosis., Methods: : A systematic review of relevant studies before August 2008 was performed. Each study was appraised using a predetermined protocol. The quality of studies was assessed. The morbidity and mortality of the treatment were synthesized through a narrative review with full tabulation of results of all included studies., Conclusions: : The morbidity and mortality outcomes of CRS and HIPEC are similar to a major gastrointestinal surgery, such as a Whipple's procedure. To derive the maximal benefit of this treatment, careful patient selection with an optimal level of postoperative care must be advocated to avoid undesirable complications of this treatment.