Surgery / HIPEC Safer Than Other High-Risk Cancer Procedures
Lower infection , 30-day mortality rates than with Whipple , esophagectomy
by Ian Ingram , Deputy Managing Editor , MedPage TodayJanuary 15 , 2019
Compared with other high-risk procedures in cancer , cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy ( HIPEC ) for patients with peritoneal metastasis was associated with lower 30-day mortality rates and either similar or lower infection rates , a retrospective database study found .
The 30-day mortality rate was 1 . 1 % for patients undergoing cytoreductive surgery / HIPEC , compared with rates ranging from 2 . 5 % to 3 . 9 % for pancreaticoduodenectomy ( Whipple ) , esophagectomy , and right lobe or trisegmental hepatectomies , reported Jason M . Foster , MD , of the University of Nebraska Medical Center in Omaha , and colleagues .
" Cytoreductive surgery / HIPEC is not only safe when compared with procedures of similar risk , but is often associated with less morbidity , " the authors wrote in JAMA Network Open . " Cytoreductive surgery / HIPEC had the lowest mortality risk , almost 50%to 75% lower than other advanced oncology surgical procedures . "
Compared with Whipple , lower infection rates with cytoreductive surgery plus HIPEC were seen for both superficial ( 5 . 4 % with HIPEC vs 9 . 7 % , P< ; 0 . 001 ) and deep incisional infections ( 1 . 7 % with HIPEC vs 2 . 7 % , P< ; 0 . 01 ) . Compared with esophagectomy , fewer HIPEC patients needed to return to surgery ( 6 . 8 % with HIPEC vs 14 . 4 % , P< ; 0 . 001 ) and there were lower rates of superficial incisional infection ( 5 . 4 % with HIPEC vs 7 . 2 % , P< ; 0 . 001 ) .
Time in hospital was shorter in the HIPEC group , at 8 days compared with 10 days each for both esophagectomy and Whipple ( P< ; 0 .001 ) .
For organ space infections , rates with cytoreductive surgery plus HIPEC ( 7 . 2 % ) were significantly lower than those seen with Whipple ( 12 . 9 % , P< ; 0 . 001 ) , and trisegmental ( 12 . 4 % , P< ; 0 . 001 ) or right lobe hepatectomies ( 9 . 0 % , P = 0 . 02 ) .
" Cytoreductive surgery / HIPEC was performed with a high level of safety , providing evidence to dispel misperceptions rooted in the historic data , " Foster ' s group wrote . " Safety concerns should no longer be a deterrent to routine referral to high-volume centers . "
The researchers noted that roughly 60 , 000 new cases of peritoneal metastasis are diagnosed each year ( most commonly stemming from mesothelioma and cancers of the colon , ovaries , and appendix ) , yet in 2015 , for example , cytoreductive surgery plus HIPEC was performed on fewer than 1 , 000 patients . They said that safety concerns , partly owing to a lack of available modern data , have played a part in the lack of referrals for this procedure , among other factors .
In an invited commentary that accompanied the study , Margaret E . Smith , MD , MS , and Hari Nathan , MD , PhD , both of the University of Michigan in Ann Arbor , wrote that comparing HIPEC with other high-risk surgeries for cancer constructs a " straw man . "
" A patient with pancreatic cancer has no other curative option besides a Whipple procedure , " they explained . " A patient with peritoneal carcinomatosis , on the other hand , could be offered continued palliative systemic therapy or cytoreductive surgery without HIPEC . "
They said that a more " salient concern " with HIPEC in patients with peritoneal carcinomatosis may be its effectiveness .
" The results of this study need to be interpreted in the context of emerging evidence questioning previously held assumptions regarding HIPEC and its survival benefit , " wrote Smith and Nathan , pointing to recent results from PRODIGE 7 in 265 patients with peritoneal carcinomatosis associated with colorectal cancer .
In that trial , results of which were presented at the 2018 American Society of Clinical Oncology meeting , the median overall survival was 41 . 7 months for cytoreductive surgery / HIPEC patients and 41 . 2 months for those treated with surgery alone , with 1-year survival rates of 86 . 9 % and 88 . 3 % , respectively . The rate of 30-day mortality was roughly 1 . 5 % in each arm of the trial .
In the current study , Foster ' s group examined 34 , 114 patients from the American College of Surgeons National Surgical Quality Improvement Project ( NSQIP ) database who underwent cytoreductive surgery plus HIPEC ( n = 1 , 822 ) , trisegmental hepatectomy ( n = 2 , 449 ) , right lobe hepatectomy ( n = 5 , 109 ) , esophagectomy ( n = 7 , 941 ) , or pancreaticoduodenectomy ( n = 16 , 793 ) from 2005 to 2015 .
The authors noted an extensive number of limitations to their findings , including younger age in the HIPEC group , higher American Society of Anesthesiologists classification in the esophagectomy group , and higher comorbidity rates in the esophagectomy and Whipple groups .
Smith and Nathan also pointed out that not all cytoreductive surgeries are created equally , as some may call for removal of a single peritoneal nodule while more complex operations might require multivisceral resection with peritoneal stripping , but this level of information is not captured by the NSQIP database .
Further , the authors noted that cytoreductive surgery plus HIPEC is only performed at high-volume centers , while the other procedures examined in the study included those performed at both high-and low-volume centers .
The study was funded in part by the Hill Foundation and Platon Foundation .
Foster and co-authors reported no conflicts of interest .
Smith disclosed a grant from the National Institute of Health . Nathan disclosed grants from the Agency for Healthcare Research and Quality and the National Institute on Aging .
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