Ulus Travma Acil Cerrahi Derg. 2023; 29(3): 370-378 | DOI: 10.14744/tjtes.2023.52358

The risk factors for gastrointestinal anastomotic leak after cytoreduction with hyperthermic intraperitoneal chemotherapy

Tayfun Bisgin¹, Selman Sökmen¹, Naciye Cigdem Arslan², Sevda Ozkardesler³, Funda Barlik Obuz^4
1Department of General Surgery, Dokuz Eylül University Faculty of Medicine, Ýzmir-Türkiye
²Department of General Surgery, Medipol University Faculty of Medicine, Ýstanbul-Türkiye
³Department of Anesthesiology and Reanimation, Dokuz Eylül University Faculty of Medicine, Ýzmir-Türkiye
⁴Department of Radiology, Dokuz Eylül University Faculty of Medicine, Ýzmir-Türkiye

BACKGROUND: Gastrointestinal anastomotic leak (GAL) is a major cause of morbidity and mortality after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this study is to determine the risk factors associated with GAL in peritoneal metastases (PM) surgery.
METHODS: Patients who underwent CRS and HIPEC with gastrointestinal anastomosis were included. Charlson Comorbidity Index (CCI) and Eastern Cooperative Oncology Group (ECOG) performance status were used to assess preoperative condition of the patients. GAL was recorded as gastrointestinal extralumination diagnosed clinically, radiologicaly, or during reoperation.
RESULTS: Among 362 patients who were analyzed, the median age was 54 years, 72.6% were female, and the most common histopathologies were ovarian cancer (37.8%) and colorectal (36.2%) cancer. The median Peritoneal Cancer Index was 11 and 80.1% of the patients underwent complete cytoreduction. A single anastomosis was performed in 293 (80.9%) patients, two anastomoses in 51 (14.1%) and three anastomoses in 18 (5%) patients. Diverting stoma was performed in 43 (11.8%) patients. GAL was seen in 38 (10.5%) patients. Smoking (p<0.001), ECOG performance status (p=0.014), CCI score (p=0.009), pre-operative albumin level (p=0.010), and number of resected organs (p=0.006) were significantly associated factors with GAL. Independent risk factors for GAL were smoking (Odds Radio [OR]: 6.223, confidence interval [CI]: 2.814–13.760; p<0.001), CCI score ≥7 (OR: 4.252, CI: 1.590–11.366; p=0.004), and pre-operative albumin level ≤3.5 g/dl (OR: 3.942, CI: 1.534–10.130; p=0.004).
CONCLUSION: Patient-related factors such as smoking, comorbidity, and pre-operative nutritional status had an impact on anasto-motic complications. Proper patient selection and prediction of an index patient requiring a prehabilitation program with a high level of care are essential prerequisites to obtaining lower anastomotic leak rates and improving outcomes in PM surgery.

Keywords: Anastomotic leak, cytoreductive surgery; hyperthermic intraperitoneal chemotherapy; peritoneal metastasis.

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Hipertermik intraperitoneal kemoterapi ile sitoredüksiyon sonrasý gastrointestinal anastomoz kaçaðý için risk faktörleri

Tayfun Bisgin¹, Selman Sökmen¹, Naciye Cigdem Arslan², Sevda Ozkardesler³, Funda Barlik Obuz^4
1Dokuz Eylül Üniversitesi Týp Fakültesi, Genel Cerrahi Anabilim Dalý, Ýzmir
²Medipol Üniversitesi Týp Fakültesi, Genel Cerrahi Anabilim Dalý, Ýstanbul
³Dokuz Eylül Üniversitesi Týp Fakültesi, Anesteziyoloji ve Reanimasyon Anabilim Dalý, Ýzmir
⁴Dokuz Eylül Üniversitesi Týp Fakültesi, Radyoloji Anabilim Dalý, Ýzmir

AMAÇ: Gastrointestinal anastomoz kaçaðý (GAK), sitoredüktif cerrahi (SRC) ve hipertermik intraperitoneal kemoterapi (HÝPEC) sonrasý önemli bir morbidite ve mortalite nedenidir. Bu çalýþmanýn amacý peritoneal metastaz (PM) cerrahisinde GAK ile iliþkili risk faktörlerini belirlemektir. GEREÇ VE YÖNTEM: Çalýþmaya gastrointestinal anastomozlu SRC ve HÝPEK uygulanan hastalar dahil edildi. Hastalarýn ameliyat öncesi durumunu deðerlendirmek için Charlson Komorbidite Ýndeksi (CCI) ve Eastern Cooperative Oncology Group (ECOG) performans durumu kullanýldý. GAK klinik, radyolojik veya yeniden ameliyat sýrasýnda teþhis edilen gastrointestinal ekstralüminasyon olarak kaydedildi.
BULGULAR: Analiz edilen 362 hastanýn ortanca yaþý 54 idi. Hastalarýn %72.6’sý kadýn ve en sýk görülen histopatolojiler over kanseri (%37.8) ve kolorektal kanser (%36.2) idi. Medyan Periton Kanser Ýndeksi 11 idi ve hastalarýn %80.1’ine tam sitoredüksiyon uygulandý. Ýki yüz doksan üç (%80.9) hastada tek anastomoz, 51 (%14.1) hastada iki anastomoz ve 18 (%5) hastada üç anastomoz yapýldý. Kýrk üç (%11.8) hastaya saptýrýcý stoma uygulan-dý. Otuz sekiz (%10.5) hastada GAK görüldü. Sigara kullanýmý (p<0.001), ECOG performans durumu (p=0.014), CCI skoru (p=0.009), preoperatif albümin düzeyi (p=0.010) ve rezeke edilen organ sayýsý (p=0.006) GAK ile anlamlý iliþkili faktörlerdi. GAK için baðýmsýz risk faktörleri sigara (OR: 6.223, CI: 2.814–13.760; p<0.001), CCI skoru ≥7 (OR: 4.252, CI: 1.590–11.366; p=0.004) ve preoperatif albümin seviyesi ≤3.5 g/dl (OR: 3.942, CI: 1.534–10.130; p=0.004) idi.
TARTIÞMA: Sigara kullanýmý, komorbidite ve ameliyat öncesi beslenme durumu gibi hasta ile iliþkili faktörlerin anastomoz komplikasyonlarý üzerinde etkisi vardý. Uygun hasta seçimi ve yüksek düzeyde bakým gerektiren prehabilitasyon programý ihtiyacý olan indeks hastanýn tahmini, daha düþük anastomoz kaçak oranlarý elde etmek ve PM cerrahisinde sonuçlarý iyileþtirmek için temel ön koþullardýr.

Anahtar Kelimeler: Anastomoz kaçaðý, hipertermik intraperitoneal kemoterapi; peritoneal metastaz; sitoredüktif cerrahi.

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