Available online 9 May 2025, 102229

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For the CRS/HIPEC treatment, 3.4% of patients had evisceration by day 30.

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A BPCO/respiratory pathology and the OPEN_HIPEC technique were identified as independent risk factors linked to evisceration.

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There were no eviscerations after change to polydioxanone suture.

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These insights advocate for standardized closure techniques and preoperative planning, especially in patients with respiratory comorbidities, to improve surgical outcomes.

ABSTRACTBackground

Standard treatment for resectable peritoneal metastasis (PM) includes the combination of cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Postoperative evisceration is a rare but major complication after CRS and HIPEC. This study aimed to identify the risk factors associated with evisceration after HIPEC, comparing outcomes between open and closed abdominal HIPEC.

Methods

We conducted a retrospective multi-center study analyzing data of 233 patients with PM who underwent CRS/HIPEC between 2014 and 2023. Patients were categorized based on the HIPEC technique: Open (OPEN_HIPEC), n=110; Closed abdominal technique (CLOSED_HIPEC), n=123). We aimed to identify patient factors associated with evisceration within 30 days of CRS/HIPEC, using multivariate analysis.

Results

Among 233 patients included, 129 (55.4%) were women. The median age was 60 [51; 67] years. The OPEN_HIPEC group was significantly younger than the CLOSED_HIPEC group (median 57 [47; 62] vs 63 [54; 70] years; p ≤0.001) with a higher PCI score (median 9.5 [5; 17] vs 6 [2; 11]; p≤0.001). Severe complications were similar between OPEN and CLOSED_HIPEC: 17 (15.5%) vs 15 (12.2%); p=0.471 with no mortality. Eight (3.4%) patients had postoperative evisceration with significantly more occurrences in the OPEN_HIPEC than in the CLOSED_HIPEC group (7/110 (6.4%) vs 1/123 (0.8%); p=0.028). Univariate analysis identified chronic obstructive pulmonary disease (COPD) / respiratory pathology (HR = 7.02 [1.76-28.1]) and PCI score category of 11-15 (HR = 5.09 [1.03-25.2] as risk factors. Multivariate analysis identified a history of COPD/respiratory pathology (HR=7.39 [1.85-29.6], p=0.005) and OPEN_HIPEC (HR=8.37 [1.03-68.1], p=0.047) as risk factors of postoperative evisceration. Although suture material was not identified as a significant factor by the analysis, all eviscerations in the OPEN_HIPEC group were observed following musculoaponeurotic closures using Vicryl 1 sutures.

Conclusions

Following CRS/HIPEC treatment, 3.4% patients had evisceration by day 30. A history of COPD/respiratory pathology and OPEN_HIPEC technique were identified as independent risk factors associated with evisceration, necessitating reintervention. It should also be noted that in the OPEN_HIPEC group there were no eviscerations after the change to PDS sutures.

Section snippetsINTRODUCTION:

Peritoneal metastases (PM) are due to peritoneal pseudomyxoma, peritoneal mesothelioma metastasis of digestive cancer (mostly colorectal or gastric cancer), metastasis of ovarian cancer or occasionally to other types of cancer (breast, bladder, renal cancer etc.).1 The diffusion of systemic cytotoxic agents to the peritoneum is poor, resulting in efficacy which could be improved.2 Consequently, hyperthermic intraperitoneal chemotherapy (HIPEC) associated with complete cytoreductive surgery

Patients and study design

This was a retrospective study of procedures performed at Begin Military Teaching Hospital (HIA-B), La Pitié Salpêtrière Hospital, Paris (LPS) and Grenoble-Alpes University Hospital (CHU-GA), expert centers for HIPEC, between January 2014 and December 2023. OPEN abdomen HIPEC at two centers and closed HIPEC at one center during the same period. All consecutive patients who had received HIPEC treatment at one of the participating hospitals during the study period and who had been evaluated by an

Patient characteristics

Demographic and medical data of the 233 patients included in the study (OPEN_HIPEC, n = 110 or CLOSED_HIPEC, n = 123) are presented in Table 1. Their median age was 60 [51; 67] years; 129 (55.4%) were female. In the OPEN_HIPEC group, patients were significantly younger (median 57 [47; 62] vs 63 years [54; 70]; p ≤0.001 and had a higher PCI score (median 9.5 [5; 17] vs 6 [2; 11]; p≤0.001). There were more patients with previous CRS (5 (4.6%) vs 0 (0%); p = 0.022), adjuvant chemotherapy (79

DISCUSSION

In this study that included selected patients undergoing CRS with HIPEC, we sought associations between potential predictive factors and postoperative evisceration and the need for reintervention in the first 30 days after the CRS/HIPEC. Our results show that 3.4% of patients had evisceration and required reintervention. The overall evisceration rate (3.4%) is identical to that found in major surgical series. 18, 19 We previously reported complications at D30 as being similar following open and

CONCLUSION

For CRS/HIPEC treatment, our study shows that 3.4% of patients had evisceration by day 30. A COPD/respiratory pathology and the OPEN_HIPEC technique were identified as independent risk factors linked to evisceration. It should also be noted that in the OPEN_HIPEC group there were no eviscerations after the change to PDS sutures. These insights advocate for standardized closure techniques and preoperative planning, especially in patients with respiratory comorbidities, to improve surgical

Uncited reference

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Conflicts of interest/Competing interests:

Fatah Tidadini, Jade Fawaz, Jean-Louis Quesada, Julio Abba, Brice Malgras, Bertrand Trilling, Pierre-Yves Sage, Juliette Fischer, Marc Pocard, Catherine Arvieux and Anne-Cécile Ezanno have no conflict of interest to declare.

Ethical Approval

The study was registered in the CHU Grenoble Alpes register of studies respecting the reference methodology MR004 of the National Commission for Informatics and Liberties (CNIL). All procedures performed in this study were in accordance with the ethical standards in research committee and with the Helsinki declaration.

Funding

No funding was received to conduct this study.

ACKNOWLEDGEMENTS

We thank Manasterski Meryl for her contribution to the illustration of the 2 HIPEC techniques.

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