Do patients undergoing cytoreductive surgery and HIPEC for peritoneal malignancy need parenteral nutrition?

Our plain-English summary of Do patients undergoing cytoreductive surgery and HIPEC for peritoneal malignancy need parenteral nutrition?, by D.R. Swain, A.L. Yates, F. Mohamed, et al (Pleura and Peritoneum, 2018).

The study

• Authors: D.R. Swain, A.L. Yates, F. Mohamed, S.P. Dayal, A. Tzivanakis, T.D. Cecil, B.J. Moran
• Journal: Pleura and Peritoneum
• Published: 2018;3(4):20180123
• Cited by: 10 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: To analyse the duration of parenteral nutrition (PN) in patients treated for peritoneal malignancy with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) over a 2 year period at a single UK National referral centre.

Methods: A retrospective analysis of prospective data for all patients (n=321) who underwent CRS and HIPEC for peritoneal malignancy at the Peritoneal Malignancy Institute Basingstoke between April 1, 2013 and March 31, 2015.Duration of PN was compared between primary tumour site (appendix, colorectal, mesothelioma and other); completeness of CRS (complete CRS vs. major tumour debulking) and pre-operative nutritional assessment measures (including Mid Upper Arm Circumference).

Results: The median duration of PN was 9 days (range 2-87 days). A total of 13 % of patients had PN for less than 7 days and 6 % for 5 days or less. There was no significant difference in duration of PN between the different tumour sites. Two factors that may increase the duration of PN include having major tumour debulking (MTD) and a baseline MUAC<23.5 cm.

Conclusions: Most patients who underwent CRS and HIPEC for peritoneal malignancy required PN for more than 7 days with poor pre-operative nutritional status and inability to achieve complete cytoreduction predictors of prolonged PN requirements.

In plain English

This study reviewed records, collected as patients were treated, of people with cancer in the lining of the abdomen (peritoneal malignancy). All had extensive tumour-removal surgery (cytoreductive surgery, CRS) plus heated chemotherapy washed through the abdomen (HIPEC) at the Peritoneal Malignancy Institute Basingstoke, UK, between April 2013 and March 2015. The authors called it a quality assurance report. Of 321 patients, 314 were analysed. In 77% the cancer started in the appendix, in 13% it was colorectal, 5% had peritoneal mesothelioma and 5% had other types. The study did not look at asbestos exposure. Patients were given intravenous feeding (parenteral nutrition, PN) starting the day after surgery. The median time on PN was 9 days (range 1 to 87 days). 19 patients (6%) needed it for 5 days or less. Patients whose tumour could not be fully removed had a median of 11 days, against 9 days after complete removal. Patients with a mid upper arm circumference under 23.5 cm had a median of 11.5 days, against 9 days. Neither difference was statistically significant. PN duration did not differ significantly by tumour site. The authors concluded that patients having CRS and HIPEC should routinely receive PN after surgery.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective review of prospectively collected data at a single centre; the authors describe it as a Quality Assurance report
• Who was studied: 321 patients who had CRS and HIPEC for peritoneal malignancy at the Peritoneal Malignancy Institute Basingstoke, UK, from April 1, 2013 to March 31, 2015. 7 were excluded, leaving 314. Primary tumour site: appendix 77%, colorectal 13%, peritoneal mesothelioma 5% (16 patients in Figure 2), other 5% (ovarian, sarcoma, unknown/other).
• Exposure: Not an asbestos exposure study. Patients had cytoreductive surgery with HIPEC, either complete CRS (262 patients, 83%) or major tumour debulking (52, 17%). They were given routine postoperative parenteral nutrition starting the day after surgery.
• Main results:
  • Among the 314 patients, the median duration of postoperative PN was 9 days (range 1–87 days).
  • 19 patients (6%) needed PN for 5 days or less, and 42 patients (13%) for less than 7 days.
  • Patients with complete CRS received PN for a median of 9 days (range 1–87). Patients with major tumour debulking received it for a median of 11 days (range 5–51). The difference was not statistically significant (p = 0.078).
  • PN duration showed no statistically significant difference between primary tumour sites (appendix, colorectal, peritoneal mesothelioma, other) (p greater than 0.05).
  • PN duration was not significantly longer for patients with a mid upper arm circumference under 23.5 cm (median 11.5 days) than for those at 23.5 cm or above (median 9 days) (p = 0.076).
  • Complications: 275 patients (87.6%) had Clavien-Dindo grade 2 or less, 29 (9%) had a grade 3 complication and 10 (3.18%) a grade 4 complication. Median hospital stay was 21 days (range 9–109 days).
• The authors' conclusion: The authors concluded that patients undergoing CRS and HIPEC should have routine postoperative PN, because the operations are long and complex with a high risk of complications and post-operative ileus (a stall in bowel function). They also wrote that no clear group of patients seemed to need PN for a shorter time or not at all.
• Limitations the authors state:
  • The study was retrospective.
  • Small numbers in the subgroups (major tumour debulking 17%, mid upper arm circumference under 23.5 cm 6%) may explain the lack of significant differences.
  • The relatively small number of colorectal patients may explain why no difference by tumour site was seen.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Mesothelioma.

Related studies

• Repeat Cytoreductive Surgery and HIPEC for Peritoneal Surface Malignancy and Peritoneal Carcinomatosis — J.F. Wong, G.H. Tan, et al. (2015)
• Genomic sequencing of multicystic mesothelioma finds cohesin complex mutations associated with disease recurrence in patients referred for cytoreductive surgery and HIPEC — J. Gibson, N.J. Carr, et al. (2026)
• Risk of definitive stoma after surgery for peritoneal malignancy in 958 patients: comparative study between complete cytoreductive surgery and maximal tumor debulking — S. Riss, K. Chandrakumaran, et al. (2015)
• Anesthetic management and renal function in pediatric patients undergoing cytoreductive surgery with continuous hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin — P. Owusu-Agyemang, R. Arunkumar, et al. (2012)
• The results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1200 patients with peritoneal malignancy — B. Moran, T. Cecil, et al. (2015)
• Long-term outcomes and survival analysis of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy in patients with pseudomyxoma peritonei at a newly established peritoneal malignancy centre in Japan — H. Yano, Y. Gohda, et al. (2024)

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