Estudio de los factores asociados con la morbi-mortalidad postoperatoria y la supervivencia tras citorreducción quirúrgica y quimioterapia intraperitoneal hipertérmica (hipec), en pacientes con carcinomatosis peritoneal por cáncer de colon

Résumé

Work Summary INTRODUCTION. The objectives of this study are to analyze and define the predictive factors of postoperative morbidity and mortality, as well as the survival of patients with peritoneal carcinomatosis due to colon cancer, after radical cytoreductive surgery and intraperitoneal hyperthermic intraoperative chemotherapy (HIPEC) in our setting. WORK HYPOTHESIS: Is it possible to propose a radical cytoreductive surgery with HIPEC safely and with postoperative morbidity and mortality within the current standards?. Can radical cytoreductive surgery with HIPEC influence in survival of selected patients with peritoneal metastatic disease due to colon cancer?. OBJECTIVES: 1. Analyze postoperative morbidity and mortality and its predictive factors. 2. Analyze global survival, disease-free survival and prognostic factors. 3. To determine the incidence of local and distant recurrence of the operated patients. 4. Compare our results with accepted standards in the literature. 5. Study the quality of postoperative life. MATERIAL AND METHOD Design and Selection of patients This is a study from a prospective database of 67 patients operated consecutively, between January 2008 and December 2017. Intraoperative phase HIPEC was performed with open technique, using oxaliplatin (450 mg/m2) for 30 minutes in the first 55 patients. In the following 12 patients Mitomycin C (30 mg / m2) was used for 60 minutes, due to hemorrhagic complications by oxaliplatin. The two cytostatics were diluted in 3L of 1.5% glucose solution, at an average temperature of 42ºC. Statistic Analysis The categorical variables were described as percentages and compared with the Pearson Chi-square test. The continuous variables were expressed with the mean and the standard deviation; they were compared with the Mann-Whitney U test. A univariate and multivariate analysis was performed. A p value <0.05 was considered statistically significant RESULTS Morbidity and mortality Overall morbidity was 38.8% and severe morbidity was 19.4%. The postoperative mortality was 4.4% (3 patients). The univariate analysis showed greater morbidity in the patients transfused intraoperatively (p 0.01), in those subjected to simultaneous hepatic resection (p 0.009) and in those who required a digestive anastomosis (p 0.006). The multivariate analysis confirmed an increased risk of complications with transfusion (OR 3.66) and liver resection (OR 4.33). Overall Survival The mean overall survival was 51.4 ± 7.45 months, with a median of 34 months (23.7-42.2). Survival at one, three and five years was 92%, 40% and 34% respectively. The variables with significant difference were the PCI (p = 0.001), the lateral resection of the colon (p = 0.039), the number of peritonectomies (p = 0.035), the duration of the intervention (p = 0.01) and a second CCR-HIPEC due to peritoneal recurrence (p = 0.031). PCI (HR: 2.61, 95% CI 1.073-6.351) (p = 0.034) and a second CCR-HIPEC (HR: 0.102, 95% CI 0.013-0.780) (p = 0.028), were shown as independent prognostic factors. Disease Free Survival The mean disease-free survival was 34.8 ± 6.27 months, with a median of 15 months (1-21.7). The disease-free survival at one, three and five years was 50%, 26% and 26% respectively. The variables with statistical significance were the PCI (0.014), the number of peritonectomies (p = 0.034) and the duration of the intervention (p = 0.019). Of these, only the PCI was shown as an independent prognostic factor (HR: 2.46, 95% CI 1.17-5.15) (P = 0.017). CONCLUSIONS 1. In our setting, morbidity, reintervention rate and postoperative mortality are within the recommended standards. 2. Simultaneous hepatic resection and perioperative transfusion have been shown to be independent predictors of overall morbidity. 3. Simultaneous liver resection, perioperative transfusion and lymph node infiltration presented a greater number of serious complications. Of these factors, perioperative transfusion was shown as an independent factor of severe morbidity. 4. It has not been possible to determine any predictive factor for postoperative mortality. 5. The survival results achieved in our series are within current standards. 6. The rate of peritoneal carcinomatosis and the duration of the intervention have been shown as independent prognostic factors for overall survival. 7. The Peritoneal Carcinomatosis Index was shown as an independent prognostic factor for disease-free survival. 8. The quality of life indicators after the CCR with HIPEC show a good quality of postoperative life in our patients.