Hepatic resection and blood transfusion increase morbidity after cytoreductive surgery and HIPEC for colorectal carcinomatosis.

BACKGROUND AND OBJECTIVES: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective but complex treatment for peritoneal metastasis (PM). Our objective was to identify risk factors for postoperative morbidity and mortality following CRS-HIPEC. METHODS: Retrospective study of prospectively collected data of patients undergoing CRS-HIPEC for PM arises from colorectal cancer between January 2008 and December 2017. Perioperative variables were correlated with morbidity outcomes using a logistic regression model. RESULTS: Sixty-seven patients underwent CRS-HIPEC, and overall morbidity and mortality were 31.3% and 4.5% respectively. Major morbidity rate was 19.4%; 7.5% of patients were re-operated. Intraoperative blood transfusion (p = 0.01), liver resection (p < 0.01), and intestinal anastomosis (p < 0.01) were associated with a higher morbidity in univariate analysis. A multivariate analysis identified blood transfusion and liver resection as independent risk factors (OR 3.66, IC 1.13-16.54; OR 4.33, IC 1.17-11.46, respectively). Extension of visceral resection did not correlate with morbidity. Patients with lymph-node infiltration had a higher major complication rate (p = 0.01). CONCLUSIONS: CRS-HIPEC is a feasible treatment for colorectal PM with an acceptable morbi-mortality rate in experienced centers. In our study, digestive anastomosis, perioperative blood transfusion, hepatic resection, and lymph-node infiltration were associated with higher morbidity rates.

Goal-directed therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a prospective observational study.

BACKGROUND: Cytoreductive surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in peritoneal carcinomatosis treatment causes significant hemodynamic, metabolic, and hematological alterations. Studies on the anesthetic intraoperative management are heterogeneous and scarce. There is a great heterogeneity in the anesthetic management of CRS and HIPEC. The aim of this study is to analyze perioperative hemodynamic goal-directed management and to evaluate the complications arisen until the seventh postoperative day. METHODS: Prospective, observational study of all CRS and HIPEC patients from March 2014 to May 2017. Hemodynamic and clinical parameters were registered during surgery and the first 3 postoperative days. We correlated intraoperative data with the postoperative course until the seventh day. RESULTS: A total of 92 patients were included in the study (age 58.5 ± 10.9 years, 47% colorectal carcinoma, and 38% ovarian carcinoma). Peritoneal Carcinomatosis Index (PCI) (median and ranges) was 10 [0-39]. Cardiac Index (CI) 3.15 l/min-1/m-2 [1.79-5.60]) and Systolic Volume Variation (SVV) (10% [3%-17%]) remained within the values of normality in all surgery phases. A large difference was observed between the minimum and maximum ranges of fluid therapy administered (median 9.8 ml/kg/h [5.3-24.3]), showing a great interindividual variation in the fluids requirement. A direct relationship was observed between PCI and surgery duration, fluid therapy, and intraoperative transfusion percentage (p < 0.02). CONCLUSIONS: There is a great variability in the intraoperative fluid therapy needs of the patients. SVV monitoring makes it possible to adjust the fluid therapy needs in each surgery phase. The use of a hemodynamic goal-directed anesthetic protocol in CRS and HIPEC enables to individually adjust the fluid therapy, avoiding over-hydration and ensuring hemodynamic stability in all surgery phases.

Resección hepática por metástasis de cáncer colorrectal: una visión multidisciplinar / Liver resection in metastatic colorectal cancer: a multidisciplinary approach

Objetivo: valorar los resultados cualitativos a corto y medio plazo de un programa de reciente implantación de evaluación hepática multidisciplinar de casos complejos de metástasis hepáticas de cáncer colorrectal.Pacientes y métodos: cuarenta evaluaciones clínicas consecutivas de pacientes con metástasis hepáticas de cáncer colorrectal valorados para resección hepática mayor, realizadas por un comité multidisciplinar de especialistas. Las exploraciones complementarias practicadas fueron TAC trifásica y ecografía intraoperatoria, junto a RMN y/o PET en casos de dudas. La resección hepática se podía realizar como gesto único o bien en dos tiempos y combinada a otras técnicas.Resultados: la mortalidad postoperatoria a los 30 días fue del 4%. Presentaron complicaciones el 28%, siendo la complicación más frecuente la infección de la herida quirúrgica (20%). Se transfundieron el 16,6% de los pacientes, con una necesidad transfusional media de 1000 cc. Dos casos precisaron reintervención (8%), en un caso precoz por absceso intraabdominal, y en otro caso tardía, por estenosis de la vía biliar principal. El porcentajede recaídas global es del 36%, siendo más frecuente la extrahepática (26%). La supervivencia actuarial al año de seguimiento es del 90 y del 82% a los dos años. Se hallaban libres de enfermedad a los dos años el 64% de los pacientes. Conclusiones: los programas de resección hepática de metástasis de cáncer colorrectal pueden ser implantados por equipos multidisciplinares de reciente creación, si bien existe la necesidad de auditarse y situarse dentro de los parámetros de calidad

Aim: to analyze qualitative short-time results of a new program for multidisciplinary liver evaluation in complex cases of liver metastasis from colorectal cancer. Patients and methods: 40 clinical consecutive evaluations with liver metastasis assessed for major liver resection by a multidisplinary specialist committee. Complementary explorations performed included CT and ultrasounds, and MRI or PET for doubtful cases. Liver resection was made in a single operation or two-stage hepatectomy, or combined with other techniques. Results: postoperative mortality at 30 days was 4%. Complications occurred in 28%, with surgical wound infection being most frequent (20%); 16.6% of resections were transfused, with a mean volume of 1000 ml. Two patients needed reoperation –one for an intraperitoneal abscess and one for bile-duct stenosis. Percentage of global relapse was 36%, with 26% of relapses out of the liver. Actuarial survival at one year follow-up was 90%, and 82% at two years; 64% of patients remain free of disease two years after the operation. Conclusions: programs for liver resection for colorectal cancer metastasis may be implemented by multidisciplinary teams of recent setup. There is a need to evaluate own results and then compare them with a standard of quality previously reported

Liver resection in metastatic colorectal cancer: a multidisciplinary approach.

AIM: To analyze qualitative short-time results of a new program for multidisciplinary liver evaluation in complex cases of liver metastasis from colorectal cancer. PATIENTS AND METHODS: 40 clinical consecutive evaluations with liver metastasis assessed for major liver resection by a multidisciplinary specialist committee. Complementary explorations performed included CT and ultrasounds, and MRI or PET for doubtful cases. Liver resection was made in a single operation or two-stage hepatectomy, or combined with other techniques. RESULTS: Postoperative mortality at 30 days was 4%. Complications occurred in 28%, with surgical wound infection being most frequent (20%); 16.6% of resections were transfused, with a mean volume of 1000 ml. Two patients needed reoperation -one for an intraperitoneal abscess and one for bile-duct stenosis. Percentage of global relapse was 36%, with 26% of relapses out of the liver. Actuarial survival at one year follow-up was 90%, and 82% at two years; 64% of patients remain free of disease two years after the operation. CONCLUSIONS: Programs for liver resection for colorectal cancer metastasis may be implemented by multidisciplinary teams of recent setup. There is a need to evaluate own results and then compare them with a standard of quality previously reported.

[Emphysematous pyelonephritis]. / Pielonefritis enfisematosa.

Presentation of one case of emphysematous pyelonephritis, an unusual entity usually affecting diabetic women with obstruction of the upper urinary pathways, all of which are conditions present in our patient. Death rate of this disease is high, requiring emergency surgical/endourological approach with appropriate antibiotic coverage.