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Quality of Life Study following Cytoreductive Surgery and Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei including Redo Procedures

Quality of Life Study following Cytoreductive Surgery and Intraperitoneal Chemotherapy for... Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2013, Article ID 461041, 5 pages http://dx.doi.org/10.1155/2013/461041 Research Article Quality of Life Study following Cytoreductive Surgery and Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei including Redo Procedures 1 2 3 4 Rachel Kirby, Winston Liauw, Jing Zhao, and David Morris Hepatobiliary and Surgical Oncology Unit, UNSW Department of Surgery, St. George Hospital, Sydney, NSW 2217, Australia Cancer Care Centre, St. George Hospital, Sydney, NSW 2217, Australia UNSW Department of Surgery, St. George Hospital, Sydney, NSW 2217, Australia The University of New South Wales, Department of Surgery, St. George Hospital, Kogarah, Sydney, NSW 2217, Australia Correspondence should be addressed to David Morris; david.morris@unsw.edu.au Received 17 February 2013; Revised 14 April 2013; Accepted 24 June 2013 Academic Editor: Perry Shen Copyright © 2013 Rachel Kirby et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Our aim was to evaluate the quality of life following cytoreductive surgery and intraperitoneal chemotherapy for pseudomyxoma peritonei. We also conducted an analysis of all patients who underwent CRS and HIPEC for pseudomyxoma peritonei from 1997 to 2012. Methods. We contacted 87 patients using the FACT C (version 4) quality of life questionnaire, and FACIT-TS-G (version 1) was also used. Results. A total of 63 patients (response rate 72%) were available for quality of life interview and analysis. The median time from surgery to questionnaire evaluation was 31 months (range 6–161 months). 62% were females with an average age of 54 years. 22% of the patients had over one cytoreductive surgical procedure. We analysed our patients postoperatively based on physical, functional, social, and emotional well being who reported favourable outcomes in all sections. Patients who had a single procedure had a significantly higher score ( 𝑃 = 0.016 ) in the additional concerns section of the questionnaire. The patients who had a single procedure had better gastrointestinal digestion in terms of bowel control, appetite, and food digestion and also body appearance scoring. Conclusions. 79% of the patients stated that they would undergo further cytoreductive surgery and that redo procedures do not result in a significantly worse quality of life. 1. Introduction recurrence and death secondary to bowel obstruction, sur- gical complications, or terminal starvation [3]. As a result of pioneering work by Sugarbaker, cytoreductive The macroscopic disease of PMP is targeted by surgical surgery (CRS) and heated intraperitoneal chemotherapy cytoreduction and the microscopic by intraperitoneal chem- (HIPEC) have become the mainstay of treatment for pseu- otherapy. It is a curative treatment option with many centres domyxoma peritonei (PMP) [1]. publishing successful data [4–9]. Appendiceal neoplasms are uncommon making up 1% A major past criticism of cytoreductive surgery has been of colorectal malignancies [2]. Epithelial appendiceal neo- theassociatedmorbidity andmortality.Theonlyeeff ctive plasms frequently present with mucinous ascites and tumour treatment of PMP is CRS and HIPEC with achievable survival implants throughout the abdomen. andagood qualityoflife[10–12]. Our aim in this study was Most cases of PMP result from rupture of a low grade to evaluate the quality of life in patients undergoing CRS and appendiceal tumour with mucin accumulating in the abdom- HIPEC for PMP at our institution. inal cavity due to its production by epithelial cells. PMP results in death via obliteration of the peritoneal cavity even 2. Method though there are little haematogenous or lymph node metas- tases. In the past, PMP was attempted to be treated with An analysis of all patients who underwent CRS and HIPEC repeated debulking procedures; however, this resulted in for pseudomyxoma peritonei from 1997 to 2012 was carried 2 International Journal of Surgical Oncology out from a prospective database from the Peritoneal Surface Table 1: Results of patients following a single cytoreductive proce- dure versus multiple procedures. Malignancy Program in St. George Hospital, Sydney, NSW, Australia. Currently, this is the main centre for CRS/HIPEC 1 CRS/HIPEC >1 CRS/HIPEC in the southern hemisphere. P value Mean (𝑛=115 patients/ (𝑛=38 patients/ CRS and HIPEC were carried out as per the Sugarbaker 153 cases) 56 cases) technique [13] with eighty percent of patients who responded 0.3 Age (ys) 54 52 to the questionnaire receiving EPIC (early postoperative 0.001 PCI (0–39) 24 18 intraperitoneal chemotherapy) in our high dependency or Operative time intensivecareunit. 0.02 10 9 (hours) Preoperative patients are assessed at St. George Hospital Transfusion 1.6 and discussed at a multidisciplinary meeting prior to surgery 93.9 (units ) with referrals received internationally and from across Aus- ICU LOS (days) 6 3 tralia. HDU LOS 0.02 We analysed demographics from this database (one 6 4.5 (days) hundred and y three patients) including operative time, 0.1 Total LOS (days) 36 29 peritoneal carcinomatosis index (PCI), transfusion require- ments, length of stay, and postoperative complications. Also included were thirty-eight patients who had undergone a Table 2: Complications in patients following single versus multiple required repeat procedure. cytoreductive procedures. In 2010, we attempted to contact eighty-seven patients— number of patients alive at that time following CRS and 1 CRS/HIPEC >1 CRS/HIPEC Complications HIPEC for PMP. We had a seventy-two percent response rate. (153 cases) (𝑛=38 patients/56 cases) Fifty-one patients responded via telephone and twelve via Infection 61 (40) 15 (27) postal questionnaire. Bleeding 10 (6.5) 3 (5) A subset of data was analysed from those who responded DIC 1 (0.7) 0 (0) to the questionnaire looking at those who had repeated pro- Sepsis 23 (15) 5 (11) cedures carried out. We compared length of stay, operative Pneumonia 11 (7) 3 (5) times, PCI, transfusion requirements, and postoperative Pleural effusion 66 (43) 16 (29) complications between the groups. Pneumothorax 28 (18) 1 (2) The FACT C (version 4) quality of life questionnaire that Pulmonaryembolus 8(5) 2(4) included PWB (physical well being), SFWB (social/family Cardiac 11 (7) 7 (12.5) well being), EWB (emotional well being), FWB (functional Renal impairment 1 (0.7) 1 (2) well being), and AC (additional concerns) was utilized with the addition of FACIT-TS-G (version 1). Small bowel obstruction 4 (3) 3 (5) Ileus 24 (16) 2 (4) Statistical analysis was carried out comparing two groups using a𝑡 -test two-tailed distribution with paired/two sample Pancreatic leak 12 (8) 1 (2) equal variance/unequal variance where appropriate. Statisti- Chemotherapy leak 11 (7) 2 (4) cal significance was a 𝑃 value<0.05. Perforated viscus 7 (5) 4 (7) The QOL scores were described using means and stan- Fistula 23 (15) 12 (21) dard deviations. Collection 59 (39) 19 (34) Return to OT 23 (15) 11 (20) 3. Results eTh re were 209 procedures (153 patients) who underwent 3.1. Postoperative Complications 1997–2012. Postoperative CRSand HIPECfrom1997to2012. 38%ofthe patients were complications are outlined in Table 2.Thereisnosignicfi ant males and 62% females. difference between groups 𝑃=0.08 . Since 1997, there have been twenty-three deaths (15% There was a higher percentage of patients who had grades mortality over ftefi en years) in total following CRS and 0(21%versus10%), 2(41% versus 39%),and 4(23%versus HIPEC for PMP. With regard to our mortality cases, the mean 22%) morbidities following a redo procedure versus a single age was fifty-five years and the mean time since surgery and procedure. mortality was twenty-three months. In this group, there were eight patients that had undergone repeated procedures. 3.2. Quality of Life Questionnaire Responders 1997–2010. All The median time from surgery to questionnaire evalua- eighty-seven patients alive at the time of the study who had tion was 31 months (range 6–161 months). undergone CRS and HIPEC for PMP from 1997 to 2010 were There was a significant difference in PCI, operative time, contacted. Fifty-one were contacted via telephone, and those and HDU stay between the patients following a single who could not be contacted received a postal questionnaire. procedure and redo cases demonstrated in Table 1. In total, we had a 72% response rate—sixty-three patients in fift International Journal of Surgical Oncology 3 total. 80% of the cases studied also had postoperative EPIC Table 3: Results of patients who responded to the questionnaire. (early postoperative intraperitoneal chemotherapy). 1 CRS/HIPEC >1 CRS/HIPEC There was a significant difference between patients (55% Mean P value 𝑛=63 𝑛=17 males) following a single procedure and those who had a Age (ys) 53 51 0.5 repeat procedure in terms of PCI, high dependency unit PCI (0–39) 22.5 15 0.016 length of stay, and transfusion requirements. Table 3 outlines patients’ details who responded to the Operative time (hours) 9.3 8.5 0.25 questionnaire. Transfusion (units) 8.8 3.4 0.04 Complications are outlined in Table 4.Theinfection rate ICU LOS (days) 5.7 3 0.33 andpneumothoraxratewerethe only signicfi ant dieff rence HDU LOS (days) 6.5 3.7 0.04 in terms of postoperative complications found between those Total LOS (days) 33 24 0.17 patients who had a single versus a repeat procedure. There was a higher percentage of patients who had grades Table 4: Complications in patients following cytoreductive surgery. 0 (29% versus 16%) and grade 2 (53% versus 38%) morbidities following a redo procedure versus a single procedure. 1 CRS/HIPEC >1 CRS/HIPEC Complications P value Single procedures had higher grades 3 (27 versus 12%) and 𝑛=63 𝑛=17 4 (17 versus 6%) morbidities. Infection 28 (44) 3 (18) 0.045 Patients reported a favourable quality of life following Sepsis 10 (16) 1 (6) 0.3 CRS and HIPEC even after a redo procedure as outlined in Bleeding 1 (1.6) 0 0.6 Table 5(a). Pneumonia 4 (6) 0 0.3 3.3. Quality of Life Questionnaire: Results. There is no signif- Pleural effusion 29 (46) 6 (35) 0.4 icant difference in quality of life scores between patients who Pneumothorax 15 (24) 0 0.026 had a single versus redo procedure. Pulmonary embolus 2 (3) 0 0.46 Cardiac 3 (5) 2 (12) 0.3 4. Discussion Fistula 7 (11) 2 (12) 0.9 Small bowel obstruction 1 (1.6) 0 0.6 QOL assessment is essential in patients undergoing CRS and HIPEC as the procedure carries an associated degree of Ileus 8 (13) 0 0.12 morbidity and mortality. Long-term disease-free survival is Pancreatic leak 5 (8) 0 0.2 achievable, and if redo procedures are necessary, they can be Chemotherapy leak 5 (8) 1 (6) 0.8 undertaken successfully. Perforated viscus 2 (3) 0 0.5 We now have a curative approach in our management Collection 25 (40) 4 (24) 0.22 with modern treatment achieving survival rates of 59 to 96% at vfi e years [ 11]and 70%attwentyyears;however,withthis Return to OT 5 (8) 1 (6) 0.8 treatment, a signicfi ant morbidity has to be acknowledged [2]. Oursurvivalratewas85%atfieft enyears.Inourstudy,the due to pathology of colonic origin [19]. Similar patterns were mean time from surgery to responding to the questionnaire observed in patients following surgery for pseudomyxoma was thirty-one months. peritonei [20]. Previous studies have demonstrated postoperative mor- The overall grade III/IV morbidity rates for this proce- bidity, with low scores from a physical and functional well dure have been shown to be between 7% and 66% [19, 21–25]. being postoperatively increasing to baseline at 3, 6, and A UK study demonstrated grade III/IV morbidity in 9% 12 months [14]. Long-term followup of these patients was of patients [26]. analysed three to eight years after treatment illustrating a 28% 44% of our responders who had a single procedure and survival rate with 63% responding with a good quality of life 18% who had a repeat procedure carried out had a morbidity [15]. In the past, repeated debulking procedures were the only grade of III/IV. option necessary for symptomatic relief of PMP and had a Debulking procedures have a recognised risk of bowel median survival of two years [15]. injury and sfi tula formation due to progressive thickening of The European Organization for Research and Treatment intra-abdominal adhesions [2, 3]. of Cancer QOLquestionnaire collectedfouryears (range 1– Some patients have been shown having debulking proce- 8 years) following surgery suggested impaired QOL during dures that with repeated procedures there can be a transition the rfi st 6–12 months following surgery and a return to from a less to a more aggressive histopathologic type [12]. satisfactory QOL thereaer ft . Hill et al. concluded that, aer ft We had an 11% fistula rate in responding patients fol- 3 to 6 months, patients with colorectal carcinomatosis had a lowing a single CRS/HIPEC and 12% in those following return to preoperative function [16–18]. redo procedures with no significant difference between the Quality of life returns to baseline at four months and groups. eTh procedure carries an acceptable gastrointestinal improves greatly at eight and twelve months as illustrated in a morbidity compared to pancreatic duodenectomy, gastrec- study by Tuttle et al.; however, this was following CRS/HIPEC tomy for cancer, or other multiorgan resections, with PCI 4 International Journal of Surgical Oncology Table 5: (a) Quality of life questionnaire results for all patients w ho responded. (b) Comparison of QOL questionnaire responders who underwent a single versus redo procedure. (a) SWB PWB EWB FWB Concerns Stoma patients + FACIT-TS-G Range 9 to 24 0 to 11 2 to 21 12 to 28 6 to 20 0 to 4 9 to 25 Mean 19.8 2.84 7.14 21.7 12.6 1.75 20.4 Median 21 2 6 23 13 2 21 Standard dev. 4.4 2.7 3.6 4.9 3.1 1.4 3.8 (b) 1 procedure = 50 patients P value Mean Median Standard deviation >1 procedure = 13 patients SWB = 1 procedure 20 21 3.4 0.55 SWB> 1 procedure 19 22 6 PWB = 1 procedure 2.7 2 2.8 0.56 PWB> 1 procedure 3.2 3 2.2 EWB = 1 procedure 7.2 6.5 3.8 0.7 EWB> 1 procedure 6.7 6 2.9 FWB = 1 procedure 22 22.5 4.8 0.8 FWB> 1 procedure 21.4 23 3.3 Concerns = 1 procedure 13 13 2.7 0.016 Concerns> 1 procedure 11 10 4 FACIT-TS-G = 1 procedure 20.3 21 4 0.5 FACIT-TS-G> 1 procedure 21 21 2.7 being the only independent risk factor for gastrointestinal stay, or operative time. Overall, patients reported a favourable complications [27, 28]. QOL. Postoperative gastrointestinal complaints were analysed When we compared quality of life scores in those who had in our study—77% had no abdominal pain or cramps, 89% a single versus a redo procedure, the patients who had a single reported a good appetite (score 2–4), and, of the 25% of procedure had a significantly higher score ( 𝑃=0.016 )inthe patients with a stoma, 63% did not have any problems catering additional concerns section of the questionnaire. The patients for it. 27% reported experiencing a lack of energy (score 2– who had a single procedure had better gastrointestinal diges- 4), 4.7% experienced some pain, and 89% had no nausea on tion in terms of bowel control, appetite, and food digestion followup. andalsobodyappearancescoring. Overall, 62% of the patients were happy with the appear- In conclusion, 79% of our patients stated that they would ance of their body. undergo further CRS/HIPEC if required, including patients 92% had good family support and 90% good emotional who had experienced such a requirement previously, and 13% supportfromfriends.100%ofthe patients were happywith were undecided at the time of the study. how they were coping with their illness. 41% worried about Our limitations in this study are that we have not carried dying to some degree and 60% worried that their condition out a premorbid assessment and that there is a nonprogressive would worsen. When questioned regarding depression, 48% followup at three to six monthly intervals. Further research stated that they did not feel sad, 33% a little bit, and 18% possibly a multicentre trial with a systematic evaluation at somewhat. several time intervals is required postoperatively to improve 90% of the patients feel that they can work including at our ability to enhance our patient’s QOL in the future. home with a score of 1 to 4 and 84% found good job satis- faction. 100% of the patients could enjoy life to some degree Conflict of Interests score [1–4]. 98% of the patients have accepted their illness with 100% There is no conflict of interests to declare. content with their quality of life with a score of 1 to 4.98% felt that the treatment was right for them and were satisfied with References the results. 95% would recommend the treatment to others and 98% [1] P. H. 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Quality of Life Study following Cytoreductive Surgery and Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei including Redo Procedures

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Copyright © 2013 Rachel Kirby et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2013, Article ID 461041, 5 pages http://dx.doi.org/10.1155/2013/461041 Research Article Quality of Life Study following Cytoreductive Surgery and Intraperitoneal Chemotherapy for Pseudomyxoma Peritonei including Redo Procedures 1 2 3 4 Rachel Kirby, Winston Liauw, Jing Zhao, and David Morris Hepatobiliary and Surgical Oncology Unit, UNSW Department of Surgery, St. George Hospital, Sydney, NSW 2217, Australia Cancer Care Centre, St. George Hospital, Sydney, NSW 2217, Australia UNSW Department of Surgery, St. George Hospital, Sydney, NSW 2217, Australia The University of New South Wales, Department of Surgery, St. George Hospital, Kogarah, Sydney, NSW 2217, Australia Correspondence should be addressed to David Morris; david.morris@unsw.edu.au Received 17 February 2013; Revised 14 April 2013; Accepted 24 June 2013 Academic Editor: Perry Shen Copyright © 2013 Rachel Kirby et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Our aim was to evaluate the quality of life following cytoreductive surgery and intraperitoneal chemotherapy for pseudomyxoma peritonei. We also conducted an analysis of all patients who underwent CRS and HIPEC for pseudomyxoma peritonei from 1997 to 2012. Methods. We contacted 87 patients using the FACT C (version 4) quality of life questionnaire, and FACIT-TS-G (version 1) was also used. Results. A total of 63 patients (response rate 72%) were available for quality of life interview and analysis. The median time from surgery to questionnaire evaluation was 31 months (range 6–161 months). 62% were females with an average age of 54 years. 22% of the patients had over one cytoreductive surgical procedure. We analysed our patients postoperatively based on physical, functional, social, and emotional well being who reported favourable outcomes in all sections. Patients who had a single procedure had a significantly higher score ( 𝑃 = 0.016 ) in the additional concerns section of the questionnaire. The patients who had a single procedure had better gastrointestinal digestion in terms of bowel control, appetite, and food digestion and also body appearance scoring. Conclusions. 79% of the patients stated that they would undergo further cytoreductive surgery and that redo procedures do not result in a significantly worse quality of life. 1. Introduction recurrence and death secondary to bowel obstruction, sur- gical complications, or terminal starvation [3]. As a result of pioneering work by Sugarbaker, cytoreductive The macroscopic disease of PMP is targeted by surgical surgery (CRS) and heated intraperitoneal chemotherapy cytoreduction and the microscopic by intraperitoneal chem- (HIPEC) have become the mainstay of treatment for pseu- otherapy. It is a curative treatment option with many centres domyxoma peritonei (PMP) [1]. publishing successful data [4–9]. Appendiceal neoplasms are uncommon making up 1% A major past criticism of cytoreductive surgery has been of colorectal malignancies [2]. Epithelial appendiceal neo- theassociatedmorbidity andmortality.Theonlyeeff ctive plasms frequently present with mucinous ascites and tumour treatment of PMP is CRS and HIPEC with achievable survival implants throughout the abdomen. andagood qualityoflife[10–12]. Our aim in this study was Most cases of PMP result from rupture of a low grade to evaluate the quality of life in patients undergoing CRS and appendiceal tumour with mucin accumulating in the abdom- HIPEC for PMP at our institution. inal cavity due to its production by epithelial cells. PMP results in death via obliteration of the peritoneal cavity even 2. Method though there are little haematogenous or lymph node metas- tases. In the past, PMP was attempted to be treated with An analysis of all patients who underwent CRS and HIPEC repeated debulking procedures; however, this resulted in for pseudomyxoma peritonei from 1997 to 2012 was carried 2 International Journal of Surgical Oncology out from a prospective database from the Peritoneal Surface Table 1: Results of patients following a single cytoreductive proce- dure versus multiple procedures. Malignancy Program in St. George Hospital, Sydney, NSW, Australia. Currently, this is the main centre for CRS/HIPEC 1 CRS/HIPEC >1 CRS/HIPEC in the southern hemisphere. P value Mean (𝑛=115 patients/ (𝑛=38 patients/ CRS and HIPEC were carried out as per the Sugarbaker 153 cases) 56 cases) technique [13] with eighty percent of patients who responded 0.3 Age (ys) 54 52 to the questionnaire receiving EPIC (early postoperative 0.001 PCI (0–39) 24 18 intraperitoneal chemotherapy) in our high dependency or Operative time intensivecareunit. 0.02 10 9 (hours) Preoperative patients are assessed at St. George Hospital Transfusion 1.6 and discussed at a multidisciplinary meeting prior to surgery 93.9 (units ) with referrals received internationally and from across Aus- ICU LOS (days) 6 3 tralia. HDU LOS 0.02 We analysed demographics from this database (one 6 4.5 (days) hundred and y three patients) including operative time, 0.1 Total LOS (days) 36 29 peritoneal carcinomatosis index (PCI), transfusion require- ments, length of stay, and postoperative complications. Also included were thirty-eight patients who had undergone a Table 2: Complications in patients following single versus multiple required repeat procedure. cytoreductive procedures. In 2010, we attempted to contact eighty-seven patients— number of patients alive at that time following CRS and 1 CRS/HIPEC >1 CRS/HIPEC Complications HIPEC for PMP. We had a seventy-two percent response rate. (153 cases) (𝑛=38 patients/56 cases) Fifty-one patients responded via telephone and twelve via Infection 61 (40) 15 (27) postal questionnaire. Bleeding 10 (6.5) 3 (5) A subset of data was analysed from those who responded DIC 1 (0.7) 0 (0) to the questionnaire looking at those who had repeated pro- Sepsis 23 (15) 5 (11) cedures carried out. We compared length of stay, operative Pneumonia 11 (7) 3 (5) times, PCI, transfusion requirements, and postoperative Pleural effusion 66 (43) 16 (29) complications between the groups. Pneumothorax 28 (18) 1 (2) The FACT C (version 4) quality of life questionnaire that Pulmonaryembolus 8(5) 2(4) included PWB (physical well being), SFWB (social/family Cardiac 11 (7) 7 (12.5) well being), EWB (emotional well being), FWB (functional Renal impairment 1 (0.7) 1 (2) well being), and AC (additional concerns) was utilized with the addition of FACIT-TS-G (version 1). Small bowel obstruction 4 (3) 3 (5) Ileus 24 (16) 2 (4) Statistical analysis was carried out comparing two groups using a𝑡 -test two-tailed distribution with paired/two sample Pancreatic leak 12 (8) 1 (2) equal variance/unequal variance where appropriate. Statisti- Chemotherapy leak 11 (7) 2 (4) cal significance was a 𝑃 value<0.05. Perforated viscus 7 (5) 4 (7) The QOL scores were described using means and stan- Fistula 23 (15) 12 (21) dard deviations. Collection 59 (39) 19 (34) Return to OT 23 (15) 11 (20) 3. Results eTh re were 209 procedures (153 patients) who underwent 3.1. Postoperative Complications 1997–2012. Postoperative CRSand HIPECfrom1997to2012. 38%ofthe patients were complications are outlined in Table 2.Thereisnosignicfi ant males and 62% females. difference between groups 𝑃=0.08 . Since 1997, there have been twenty-three deaths (15% There was a higher percentage of patients who had grades mortality over ftefi en years) in total following CRS and 0(21%versus10%), 2(41% versus 39%),and 4(23%versus HIPEC for PMP. With regard to our mortality cases, the mean 22%) morbidities following a redo procedure versus a single age was fifty-five years and the mean time since surgery and procedure. mortality was twenty-three months. In this group, there were eight patients that had undergone repeated procedures. 3.2. Quality of Life Questionnaire Responders 1997–2010. All The median time from surgery to questionnaire evalua- eighty-seven patients alive at the time of the study who had tion was 31 months (range 6–161 months). undergone CRS and HIPEC for PMP from 1997 to 2010 were There was a significant difference in PCI, operative time, contacted. Fifty-one were contacted via telephone, and those and HDU stay between the patients following a single who could not be contacted received a postal questionnaire. procedure and redo cases demonstrated in Table 1. In total, we had a 72% response rate—sixty-three patients in fift International Journal of Surgical Oncology 3 total. 80% of the cases studied also had postoperative EPIC Table 3: Results of patients who responded to the questionnaire. (early postoperative intraperitoneal chemotherapy). 1 CRS/HIPEC >1 CRS/HIPEC There was a significant difference between patients (55% Mean P value 𝑛=63 𝑛=17 males) following a single procedure and those who had a Age (ys) 53 51 0.5 repeat procedure in terms of PCI, high dependency unit PCI (0–39) 22.5 15 0.016 length of stay, and transfusion requirements. Table 3 outlines patients’ details who responded to the Operative time (hours) 9.3 8.5 0.25 questionnaire. Transfusion (units) 8.8 3.4 0.04 Complications are outlined in Table 4.Theinfection rate ICU LOS (days) 5.7 3 0.33 andpneumothoraxratewerethe only signicfi ant dieff rence HDU LOS (days) 6.5 3.7 0.04 in terms of postoperative complications found between those Total LOS (days) 33 24 0.17 patients who had a single versus a repeat procedure. There was a higher percentage of patients who had grades Table 4: Complications in patients following cytoreductive surgery. 0 (29% versus 16%) and grade 2 (53% versus 38%) morbidities following a redo procedure versus a single procedure. 1 CRS/HIPEC >1 CRS/HIPEC Complications P value Single procedures had higher grades 3 (27 versus 12%) and 𝑛=63 𝑛=17 4 (17 versus 6%) morbidities. Infection 28 (44) 3 (18) 0.045 Patients reported a favourable quality of life following Sepsis 10 (16) 1 (6) 0.3 CRS and HIPEC even after a redo procedure as outlined in Bleeding 1 (1.6) 0 0.6 Table 5(a). Pneumonia 4 (6) 0 0.3 3.3. Quality of Life Questionnaire: Results. There is no signif- Pleural effusion 29 (46) 6 (35) 0.4 icant difference in quality of life scores between patients who Pneumothorax 15 (24) 0 0.026 had a single versus redo procedure. Pulmonary embolus 2 (3) 0 0.46 Cardiac 3 (5) 2 (12) 0.3 4. Discussion Fistula 7 (11) 2 (12) 0.9 Small bowel obstruction 1 (1.6) 0 0.6 QOL assessment is essential in patients undergoing CRS and HIPEC as the procedure carries an associated degree of Ileus 8 (13) 0 0.12 morbidity and mortality. Long-term disease-free survival is Pancreatic leak 5 (8) 0 0.2 achievable, and if redo procedures are necessary, they can be Chemotherapy leak 5 (8) 1 (6) 0.8 undertaken successfully. Perforated viscus 2 (3) 0 0.5 We now have a curative approach in our management Collection 25 (40) 4 (24) 0.22 with modern treatment achieving survival rates of 59 to 96% at vfi e years [ 11]and 70%attwentyyears;however,withthis Return to OT 5 (8) 1 (6) 0.8 treatment, a signicfi ant morbidity has to be acknowledged [2]. Oursurvivalratewas85%atfieft enyears.Inourstudy,the due to pathology of colonic origin [19]. Similar patterns were mean time from surgery to responding to the questionnaire observed in patients following surgery for pseudomyxoma was thirty-one months. peritonei [20]. Previous studies have demonstrated postoperative mor- The overall grade III/IV morbidity rates for this proce- bidity, with low scores from a physical and functional well dure have been shown to be between 7% and 66% [19, 21–25]. being postoperatively increasing to baseline at 3, 6, and A UK study demonstrated grade III/IV morbidity in 9% 12 months [14]. Long-term followup of these patients was of patients [26]. analysed three to eight years after treatment illustrating a 28% 44% of our responders who had a single procedure and survival rate with 63% responding with a good quality of life 18% who had a repeat procedure carried out had a morbidity [15]. In the past, repeated debulking procedures were the only grade of III/IV. option necessary for symptomatic relief of PMP and had a Debulking procedures have a recognised risk of bowel median survival of two years [15]. injury and sfi tula formation due to progressive thickening of The European Organization for Research and Treatment intra-abdominal adhesions [2, 3]. of Cancer QOLquestionnaire collectedfouryears (range 1– Some patients have been shown having debulking proce- 8 years) following surgery suggested impaired QOL during dures that with repeated procedures there can be a transition the rfi st 6–12 months following surgery and a return to from a less to a more aggressive histopathologic type [12]. satisfactory QOL thereaer ft . Hill et al. concluded that, aer ft We had an 11% fistula rate in responding patients fol- 3 to 6 months, patients with colorectal carcinomatosis had a lowing a single CRS/HIPEC and 12% in those following return to preoperative function [16–18]. redo procedures with no significant difference between the Quality of life returns to baseline at four months and groups. eTh procedure carries an acceptable gastrointestinal improves greatly at eight and twelve months as illustrated in a morbidity compared to pancreatic duodenectomy, gastrec- study by Tuttle et al.; however, this was following CRS/HIPEC tomy for cancer, or other multiorgan resections, with PCI 4 International Journal of Surgical Oncology Table 5: (a) Quality of life questionnaire results for all patients w ho responded. (b) Comparison of QOL questionnaire responders who underwent a single versus redo procedure. (a) SWB PWB EWB FWB Concerns Stoma patients + FACIT-TS-G Range 9 to 24 0 to 11 2 to 21 12 to 28 6 to 20 0 to 4 9 to 25 Mean 19.8 2.84 7.14 21.7 12.6 1.75 20.4 Median 21 2 6 23 13 2 21 Standard dev. 4.4 2.7 3.6 4.9 3.1 1.4 3.8 (b) 1 procedure = 50 patients P value Mean Median Standard deviation >1 procedure = 13 patients SWB = 1 procedure 20 21 3.4 0.55 SWB> 1 procedure 19 22 6 PWB = 1 procedure 2.7 2 2.8 0.56 PWB> 1 procedure 3.2 3 2.2 EWB = 1 procedure 7.2 6.5 3.8 0.7 EWB> 1 procedure 6.7 6 2.9 FWB = 1 procedure 22 22.5 4.8 0.8 FWB> 1 procedure 21.4 23 3.3 Concerns = 1 procedure 13 13 2.7 0.016 Concerns> 1 procedure 11 10 4 FACIT-TS-G = 1 procedure 20.3 21 4 0.5 FACIT-TS-G> 1 procedure 21 21 2.7 being the only independent risk factor for gastrointestinal stay, or operative time. Overall, patients reported a favourable complications [27, 28]. QOL. Postoperative gastrointestinal complaints were analysed When we compared quality of life scores in those who had in our study—77% had no abdominal pain or cramps, 89% a single versus a redo procedure, the patients who had a single reported a good appetite (score 2–4), and, of the 25% of procedure had a significantly higher score ( 𝑃=0.016 )inthe patients with a stoma, 63% did not have any problems catering additional concerns section of the questionnaire. The patients for it. 27% reported experiencing a lack of energy (score 2– who had a single procedure had better gastrointestinal diges- 4), 4.7% experienced some pain, and 89% had no nausea on tion in terms of bowel control, appetite, and food digestion followup. andalsobodyappearancescoring. Overall, 62% of the patients were happy with the appear- In conclusion, 79% of our patients stated that they would ance of their body. undergo further CRS/HIPEC if required, including patients 92% had good family support and 90% good emotional who had experienced such a requirement previously, and 13% supportfromfriends.100%ofthe patients were happywith were undecided at the time of the study. how they were coping with their illness. 41% worried about Our limitations in this study are that we have not carried dying to some degree and 60% worried that their condition out a premorbid assessment and that there is a nonprogressive would worsen. When questioned regarding depression, 48% followup at three to six monthly intervals. Further research stated that they did not feel sad, 33% a little bit, and 18% possibly a multicentre trial with a systematic evaluation at somewhat. several time intervals is required postoperatively to improve 90% of the patients feel that they can work including at our ability to enhance our patient’s QOL in the future. home with a score of 1 to 4 and 84% found good job satis- faction. 100% of the patients could enjoy life to some degree Conflict of Interests score [1–4]. 98% of the patients have accepted their illness with 100% There is no conflict of interests to declare. content with their quality of life with a score of 1 to 4.98% felt that the treatment was right for them and were satisfied with References the results. 95% would recommend the treatment to others and 98% [1] P. H. 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