Postoperative peritonitis without an underlying digestive fistula after complete cytoreductive surgery plus HIPEC

Abstract

Background/Aim:Peritoneal carcinomatosis (PC) is a pernicious event associated with a dismal prognosis. Complete cytoreductive surgery (CCRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is able to yield an important survival benefit but at the price of a risky procedure inducing potentially severe complications. Postoperative peritonitis after abdominal surgery occurs mostly when the digestive lumen and the peritoneum communicate but in rare situation, no underlying digestive fistula can be found. The aim of this study was to report this situation after CCRS plus HIPEC, which has not been described yet and for which the treatment is not yet well defined.Patients and Methods:Between 1994 and 2012, 607 patients underwent CCRS plus HIPEC in our tertiary care center and were retrospectively analyzed.Results:Among 52 patients (9%) reoperated for postoperative peritonitis, no digestive fistula was found in seven (1%). All had a malignant peritoneal pseudomyxoma with an extensive disease (median Peritoneal Cancer Index: 27). The median interval between surgery and reoperation was 8 days [range: 3-25]. Postoperative mortality was 14%. Five different bacteriological species were identified in intraoperative samples, most frequently Escherichia coli (71%). The infection was monobacterial in 71%, with multidrug resistant germs in 78%.Conclusions:Postoperative peritonitis without underlying fistula after CCRS plus HIPEC is a rare entity probably related to bacterial translocation, which occurs in patients with extensive peritoneal disease requiring aggressive surgeries. The principles of treatment do not differ from that of other types of postoperative peritonitis.

Systemic inflammatory response after hyperthermic intraperitoneal chemotherapy (HIPEC): The perfusion protocol matters!

“…However, the ratio of deep organ space (CDC definition) infections was higher after HIPEC with mitomycinC/doxorucicin compared to oxaliplatin (30% vs 11%, p=0.028), and two patients in this protocol group had postoperative peritonitis without an underlying digestive fistula, and observation also made by others [25]. This may indicate that, although a rare event, bacterial translocation may contribute to adverse postoperative outcomes.…”

“…Overall, in the majority of patients, this effect did not result in a more complicated course. However, it indicates a critical mechanistic step in the pathophysiology of HIPEC and may explain the rare finding of peritonitis without a cause, sometimes observed in patients after HIPEC [25].…”

Antibiotic Prophylaxis for Surgical Site Infection in General Surgery: Oncological Treatments and HIPEC

“…Interestingly, in case of reoperation after CRS and HIPEC, bacterial cultures from intra-operative samples are often positive—regardless of the reason for surgery (infectious or no infectious complication). Moreover Honore’ et al have reported that 13% of postoperative peritonitis after CRS and HIPEC happens without an underlying digestive perforation [ 23 ]. Therefore, some authors have hypothesized a bacterial translocation during HIPEC as the reason for these postoperative septic complications, assuming that traditional antibiotic prophylaxis may be not enough in this complex procedure.…”

Besonderheiten der postoperativen Peritonitis

“…[15]. Die Diagnose der nicht vorhandenen Perforation ist letztlich nur intraoperativ zu stellen, womit sich die Therapie nicht von den zuvor beschriebenen Krankheitsbildern unterscheidet.…”