Complications of Cytoreduction Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
Cytoreduction surgery combined with intraperitoneal chemotherapy is a treatment for appendiceal cancer that has been associated with prolonged survival from this cancer, but also with a high risk of complications. Recovery form this surgery can be lengthy. The average hospital stay is at least 2 weeks, but often extends to an entire month.
Cytoreduction Surgery: The extent of metastatic disease into the peritoneal cavity determines the extent of the cytoreduction surgery, but in many cases appendiceal cancer has spread widely into the abdomen by the time it is discovered. The goal of cytoreduction surgery is to remove all visible tumors within the abdomen. Every major surgery, such as a colectomy or hysterectomy, has an associated risk for complications. In many cases, cytoreduction surgery is equivalent to having several major surgeries done at once as often affected organs are removed in addition to the tumors.
Intraoperative peritoneal hyperthermic chemotherapy is infused directly into the abdomen while the patient is still in surgery after the cancerous tumors and/or organs have been removed. The intraoperative peritoneal hyperthermic chemotherapy used at the time of surgery destroys cancer cells that may have been released into the abdomen when the tumors were removed. This prevents the cancerous cells from forming new tumors at a later date, but it can also interfere with the normal surgical wound healing. The chemotherapy may also interfere with the body's ability to produce white blood cells, therefore increasing the risk of post-operative infection. It may interfere with red blood cell production causing anemia, and platelet count production, causing an increased risk of bleeding.
General anesthesia (being "put to sleep" during surgery) can also be a cause of some complications. Complications can occur in any surgery related to the use of general anesthesia, but cytoreduction surgery often lasts 10-12 hours, so complications related to general anesthesia may also be more common than with other major surgeries.
For all of these reasons, the risk of complications with cytoreduction surgery is much greater than would be with a single major surgery. It must be remembered, though, that cure for this disease is not possible if there are tumors remaining in the abdomen. In many cases, this extensive surgery is the only hope for long term survival. Tumors left in the abdomen (peritoneal surface malignancies) do not respond well to IV chemotherapy. As a rule, IV chemotherapy for larger tumors remaining in the abdomen may prolong life, but will not cure the disease. Life expectancy when high-grade cancerous tumors are left in the abdomen with no treatment at all is very short, approximately 3-6 months.
Occurrence Rates for Complications
Some studies into the complication rate for cytoreduction surgery and peritoneal chemotherapy state overall complication rates of approximately 40%. This percentage includes minor complications such as nausea, vomiting and diarrhea. Major complications (Grade 3 or 4) are stated to be 20-25%. Complications that are severe enough to require a return to surgery are fewer, they are generally stated to be approximately 10%. Death rates vary from 2-4% in studies. Almost all complications, though, can be medically managed. Complication rates may also vary for different surgeons and facilities related to:
the experience of the surgeon
the particular technique used- i.e. open vs. closed technique for the peritoneal hyperthermic chemotherapy
the use of peritoneal chemotherapy after surgery in addition to hyperthermic chemotherapy used during surgery (some surgeons and facilities follow the initial surgery and hyperthermic chemotherapy with several days of peritoneal chemotherapy beginning the day after surgery)
extent of surgery and time under anesthesia
National Cancer Institute definitions of grades of adverse events:
Grade 1 Mild adverse event
Grade 2 Moderate adverse event
Grade 3 Severe adverse event
Grade 4 Life-threatening or disabling adverse events
If you want to know what questions to ask your surgeon, the US Department of Health and Human Services offers a suggested list of questions in a brochure entitled:
Making Sure Your Surgery is Safe
Complication rates are also greatly affected by the health and age of the patient prior to surgery. For example person who is younger and healthier will likely have fewer complications and recover faster than a person who is older with other health conditions. Diabetics will be at higher risk for delayed wound healing and infection. A smoker or person with asthma or respiratory illness will be at greater risk for breathing related complications. It is best to attain the best health you are able to achieve prior to having this surgery.
Some of the specific complications that may occur:
Pleural Effusion- a collection of fluid between the membranes lining the lung and chest wall.
Nausea and Vomiting
Wound infection- infection of surgical wounds by bacteria
Atelectasis- collapse or partial collapse of the lung
Line-Related Complications- complications related to the use of central venous IV lines
Pancreatitis- inflammation of the pancreas
Ileus- bowel does not start moving again for a period of time after surgery
Arrhythmia- irregular or abnormal heart beat
Pulmonary embolus- a blood clot that travels to the lung
Diarrhea - liquid bowel movements
Intra-abdominal abscess- pocket of fluid and pus inside the abdomen
Deep Vein Thrombosis (DVT)- blood clots that develop in the deep veins of the legs
Things you can do to help prevent complications
While not all complications can be anticipated or prevented, there are things a patient can do to prevent some of the potential complications.
Blood clots developing in the deep veins of the legs (DVT-deep vein thrombosis) are most often a result of blood pooling and clotting when a person is inactive for a long period of time. Normal walking and movement of the muscles in the legs keeps blood circulating through the veins and prevents this pooling of blood and the formation of clots. While in bed, ankle exercises such as pointing your toes to your head and then to the foot of the bed over and over helps keep the blood moving though the veins of your legs. When you are awake you can do these exercises several times every 30 minutes or hour. Compression stockings and or pneumatic sequential compression devices may also be used to prevent this complication. In some cases a doctor may order injections of a medication that helps prevent clotting. Walking as soon as you are able will greatly help prevent this complication.
Preventing the formation of clots in the deep veins of the legs (DVT-deep vein thrombosis) helps prevent a second very serious and sometimes fatal complication, a pulmonary embolus. A pulmonary embolus is a clot (usually a deep vein thrombosis) that dislodges from the veins in the legs and then travels to the lungs.
Pneumonia and atelectasis- general anesthesia, prolonged bed rest and decreased movement, along with shallow breathing and underlying lung diseases are all risk factors for atelectasis, or a partial collapse of the lung. These same risk factors also prevent mucous and secretions from being expelled from the lungs and promote the development of pneumonia. Using an incentive spirometer, turning from side-to-side in bed, taking deep breaths and coughing several time an hour, and getting out of bed to walk or sit in a chair will all help keep your lungs expanded and clear. These activities will help prevent respiratory complications. Holding a pillow against your abdominal incision will help you feel more comfortable when you cough.
Ileus: as soon as you are able to get out of bed, start walking. Walk as much as you are able to tolerate. Not only will you expand your lungs and prevent deep vein thrombosis and pulmonary emboli, you will also help your bowels to become more active and to start moving sooner. The sooner your bowels and digestive tract start functioning, the sooner you will be able to be rid of the NG tube! Narcotics also can cause or aggravate an ileus, so as soon as you are able, decrease your use of narcotic pain medication.
Nausea and vomiting are common complications that can be treated with various medications. Nausea and vomiting are very uncomfortable in any circumstance, but they are even more uncomfortable when you have a very large incision in you abdomen. Talk to the staff until you are able to find a way to control nausea with medication, if you have that side effect. If you do need to vomit, hold a pillow against your abdominal incision for comfort.
*Please note, getting out of bed and walking is a great way to prevent numerous complications and to speed up recovery. You can walk slowly and it's okay if you can't stand up straight at first, but do your best to walk as soon as you can and as much as you can.
Morbidity and mortality analysis of 200 treatments with cytoreductive surgery and hyperthermic intraoperative intraperitoneal chemotherapy using the coliseum technique
Intraperitoneal chemohyperthermia using a closed abdominal procedure and cytoreductive surgery for the treatment of peritoneal carcinomatosis: morbidity and mortality analysis of 216 consecutive procedures.
Prospective Morbidity and Mortality Assessment of Cytoreductive Surgery Plus Perioperative Intraperitoneal Chemotherapy To Treat Peritoneal Dissemination of Appendiceal Mucinous Malignancy