Impact of diaphragmatic intervention in cytoreductive surgery with heated intraperitoneal chemotherapy for colorectal carcinoma

Abstract

Objectives: To evaluate the impact of diaphragmatic intervention for patients with colorectal carcinoma undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) on overall survival and morbidity. Peritoneal Carcinomatosis Index (PCI) was used to stratify patients by low and high-volume.

Methods: Analysis was performed on a prospectively maintained database, from September 1996 to November 2021. Patient demographics, operative information such as PCI, as per the Jacquet and Sugarbaker description, CC score and HIPEC agent was recorded. Postoperative complications were recorded. Patients were assessed by histological subtype, colorectal carcinoma, and then separated into low and high-volume PCI (PCI<15). Patient cohort was divided into CRS with diaphragm intervention (DI) and CRS with no diaphragm intervention (NDI).

Results: Four-hundred and thirty-five patients over this time course were diagnosed with colorectal carcinoma, and 140 (29.9 %) patients had diaphragm involvement at time of surgery. Overall survival for patients with diaphragm involvement was a median of 26.1 months, compared to NDI at 42.4 months (p < 0.001). Post-operative complications were greater in the patients with diaphragmatic intervention, particularly intra-abdominal collections (DI 30.0 % (n = 42) vs NDI 22.0 % (n = 65); p < 0.001), and pleural effusions (DI 16.4 % (n = 23) vs NDI 13.2 % (n = 39); p < 0.001). When considering PCI, for low volume cohort, DI patients' median overall survival was 32.7 months compared to NDI patients with a median overall survival of 45.7 months (p = 0.015). For the high-volume cohort, PCI >15, DI involvement median overall survival was 18.5 months, compared to NDI patients median overall survival of 20.7 months (p = 0.282).

Conclusion: CRS/HIPEC should be utilised in patients who have colorectal carcinoma and diaphragmatic disease, as overall survival is improved for patients. Greater rates of post operative complications are noted in this cohort and thus should be considered early in the post-operative period. CA19.9 should be considered an important, however not essential, aspect of pre-operative workup, with further investigation required.