Exploring the Limits of Perigastric Surgery in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei: A Functional Burden with Preserved Oncologic Outcomes.

INTRODUCTION

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is the standard treatment for pseudomyxoma peritonei (PMP), and complete cytoreduction remains essential for prognosis. While gastrectomy has traditionally represented a major threshold of surgical aggressiveness, the functional impact of increasingly extensive perigastric dissection is not well defined.

METHODS

We retrospectively analyzed 110 consecutive patients who underwent CRS and HIPEC for appendiceal PMP between 2016 and 2024. Perigastric procedures were categorized into five Gastric Cytoreductive Levels (GCLs) based on the extent of vascular sacrifice. Postoperative gastrointestinal recovery was compared among stomach-preserving procedures (GCL1-4), whereas morbidity and oncologic outcomes were evaluated across all five groups. Independent predictors of delayed oral refeeding were assessed through multivariable logistic regression, and a predictive nomogram was developed.

RESULTS

Gastrointestinal recovery worsened with increasing extent of stomach-preserving perigastric dissection. Patients in GCL4 experienced delayed oral intake, longer dependence on parenteral nutrition, and prolonged hospitalization compared with those undergoing less extensive procedures; nasogastric tube removal was also delayed. Major morbidity, 30 day mortality, and long-term survival were similar across all groups. Female sex, longer operative duration, and GCL4 independently predicted delayed oral refeeding. The nomogram demonstrated good discrimination and calibration.

CONCLUSIONS

Increasingly extensive perigastric cytoreduction is associated with impaired postoperative gastric recovery while maintaining acceptable morbidity and oncologic outcomes. The predictive nomogram-although exploratory-may help to anticipate postoperative nutritional needs and support tailored recovery strategies after extensive CRS and HIPEC for PMP.