Adult respiratory distress syndrome occurring in two patients undergoing cytoreductive surgery plus perioperative intraperitoneal chemotherapy: case reports and a review of the literature.

Cytoreductive surgery and perioperative intraperitoneal chemotherapy with mitomycin C and 5-fluorouracil may be considered as an accepted treatment for appendiceal malignancy with mucinous peritoneal carcinomatosis or for pseudomyxoma peritonei. This aggressive approach has been successfully utilized in approximately 500 patients with an acceptable mortality (1.5%) and morbidity (27%). Although pulmonary complications are frequently recorded, life-endangering acute respiratory failure in the absence of pulmonary infection or an obvious source of systemic sepsis has not been previously described. An extensive clinical review of two patients who had a clinical course compatible with acute respiratory distress syndrome without obvious cause except for the cytoreductive surgery and perioperative intraperitoneal chemotherapy itself was undertaken. These two patients developed gradually increasing respiratory distress in the postoperative period. No bacterial or fungal infections of lungs or intra-abdominal sites or sepsis were discovered. These two patients were unusual in that they had extensive cytoreduction, maximal heat with the mitomycin C chemotherapy, and perfusion of both the abdominal cavity and the right pleural space. Reoperation in both patients failed to show a septic source within the abdomen for progressive adult respiratory distress syndrome. We conclude that aggressive cytoreductive surgery plus perioperative intraperitoneal and intrapleural chemotherapy was associated with life-endangering respiratory failure in two patients. No other cause for this condition was evident from an exhaustive review of the clinical course of these two patients. It is possible that this aggressive approach to appendix malignancy with carcinomatosis is sufficiently traumatic to be considered a cause of adult respiratory distress syndrome.