Risk factors for postoperative evisceration after cytoreductive surgery and HIPEC. A comparative study of open and closed abdominal techniques.

BACKGROUND

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.