Urgent re-laparotomies in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND: The objective of the study was to evaluate the morbidity-mortality results in terms of immunscore factors and to predict the outcomes of urgent re-laparotomized patients treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).
METHODS: Prospectively maintained database of 661 patients treated with potentially curative intent of CRS and HIPEC through the years of 2007 and 2020 was evaluated. URL was done for 28 (4.2%) patients as unplanned re-explorative surgery; 22 (78.6%) of them was female. The median age was 57 year (ranging, 24–76 years). There were 22 (78.6%) elderly patients over 65 years old. All standard clini-co-pathological characteristics, re-operative findings, and the morbidity-mortality results were analyzed. The well-known immunoscores such as neutrophil-lymphocyte ratio (NLR), neutrophil-thrombocyte ratio (NTR), and CRP-albumin ratio (CAR) were determined.
RESULTS: The main indication for URL was small bowel anastomotic leak (n=13, 46.4%). The abdominal wall disruption (n=5, 17.9%) was the second indication. The frequent localization of injured organ was again small bowel. The 28.6% of patients (n=8) were re-op-erated in early postoperative period (in 7 days), while as the rest of them (n=20, 71.4%) in 90 days. There was only one repeat-URL patient in this series. Many of the URL patients (n=16, 57.1%) had more than one co-morbidities. Delving into the overall group, there were Clavien-Dindo (C-D) Grade I-II complications in 104 (16.4%) patients and C-D Grade III-IV in 88 (13.9%) patients, whereas in URL patient group, C-D Grade III-IV complications were seen in 22 (78.6%). In this prospective cohort, the overall mortality rate was 3.2% (n=20) in patients who were not re-explored. Six (21.4%) patients were lost in URL patients, which the main reason for fail-ure-to-rescue was sepsis due to entero-enteral anastomotic leak. In four of them, multiple co-morbidities were affected the post-URL period of complex cancer care. Pre-URL median NLR, NTR, and CAR values were 9.12 (ranging, 1.72–37.5), 0.03 (ranging, 0.01–0.12), and 41.4 (ranging, 4.2–181.3), respectively. NLR and CAR values (4.71 and 28.8) estimated before pre-CRS were also significantly high (p=0.01 and p<0.01) in patients who were going to be operated for URL. These immunoscores values did not show any association in between pre-CRS and pre-URL mortal patients.
CONCLUSION: The crucial decision-making factors at work were complex and complicated in “unplanned” URL. The overall mor-bidity-mortality results seemingly depends on the severity and extent of peritoneal metastatic disease. Medically-unfit URL patients with high-risk factors should be selected to a vigilant monitoring and clinical care. Timely surgical intervention and intense management strategy are utmost important issues to lower morbi-mortality results in patients treated with URL.

Sitoredüktif cerrahi ve hipertermik intraperitoneal kemoterapi sonrasý acil relaparatomiler

AMAÇ: Sitoredüktif cerrahi (SRC) ve hipertermik intraperitoneal kemoterapi (HÝPEK) sonrasý komplikasyonlara baðlý acil relaparotomi yapýlan hastalarýn immün skorlamalarla tahmin edilip, edilemeyeceðinin deðerlendirilmesi amaçlanmýþtýr.
GEREÇ VE YÖNTEM: Kliniðimizde 2007–2020 yýllarý arasýnda SRC&HÝPEK prosedürü uygulanan 661 hasta analiz edildi. Bu hastalarýn 28’ine (%4.2) acil relaparotomi (URL) yapýlmasý gerekmiþtir. Hastalarýn 22’si (%78.6) kadýn, median yaþ 57 (76–24) idi. Hastalarýn 22’si (%78.6) 65 yaþ altýndaydý. Tüm standart klinikopatolojik özellikler, ameliyat bulgularý ve morbid-mortalite sonuçlarý analiz edildi. Nötrofil-lenfosit oraný (NLR), nötrofil-trombosit oraný (NTR) ve CRP (C-reaktif protein)-albümin oraný (CAR) gibi iyi bilinen immünoskorlar belirlendi.
BULGULAR: URL için ana endikasyon ince baðýrsak anastomoz kaçaðýydý (n=13, %46.4). Ýkinci en sýk endikasyon ise karýn duvarý defektleriydi (evise-rasyon-evantrasyon) (n=5, %17.9). Hastalarda patoloji en sýk ince baðýrsak kaynaklýydý. Hastalarýn %28.6’sýna (n=8) erken ameliyat sonrasý dönemde (ilk 7 gün), geri kalanýna (n=20, %71.4) 7–90 gün aralýðýnda URL yapýldý. URL hastalarýnýn çoðu (n=16, %57.1) birden fazla komorbiditeye sahipti. Genel gruba bakýldýðýnda, 104 (%16.4) hastada Clavien-Dindo (C-D) evre I-II ve 88 (%13.9) hastada C-D evre III-IV komplikasyon görülürken, URL hasta grubunda 22 (%78.6) hastada C-D evre III-IV komplikasyon görüldü. Bu ileriye yönelik kohortta, URL yapýlmayan hastalarda genel mortalite oraný %3.2 (n=20) idi. URL hastalarýnda altý (%21.4) hasta ameliyat sonrasý dönemde kaybedildi ve kurtarýlamamanýn ana nedeni entero-enteral anastomoz kaçaðýna baðlý sepsisti. Bu hastalarýn dördünde çok sayýda komorbidite vardý. URL öncesi medyan NLR, NTR ve CAR deðerleri sýrasýyla 9.12 (1.72–37.5), 0.03 (0.01–0.12) ve 41.4 (4.2–181.3) idi. SRC öncesi tahmin edilen NLR ve CAR deðerleri (4.71 ve 28.8), ameliyat sonrasý dö-nemde çeþitli komplikasyonlara baðlý URL yapýlan hastalarda anlamlý olarak yüksekti (p=.01 ve p<.01). Bu immün skor deðerleri, SRC ve URL sonrasý kaybedilen hastalar arasýnda herhangi bir iliþki göstermedi.
TARTIÞMA: SRC sonrasý URL gerektiren ciddi komplikasyonlar genellikle artan mortalite oraný, kýsa saðkalým, primer tümörün erken rekürrensi, merkezin kaynaklarýnýn tükenmesi ve yüksek maliyetlerle iliþkilidir. URL, SRC&HÝPEK prosedürü için önemli bir kalite göstergesi olarak kabul edilebilir. URL ile tedavi edilen hastalarda morbi-mortalite sonuçlarýný azaltmak için zamanýnda cerrahi müdahale ve yoðun yönetim stratejisi son derece önemli konulardýr.