Short bowel syndrome after cytoreductive surgery and HIPEC: nutritional considerations

The aim of this study was to present a group of patients with <150 cm of small intestine after cytoreductive surgery (CRS)+hyperthermic intraperitoneal chemotherapy (HIPEC) and the special problems arising from this condition.

From November 2005 to November 2013, 130 patients were treated for peritoneal carcinomatosis (PC) with CRS+HIPEC. Ten patients (7.7%) were left with a short bowel due to anatomical and surgical reasons. All these patients were subjected to ileostomy. Four patients (40%) were treated for ovarian carcinoma, 4 (40%) for colon and appendiceal carcinoma, 1 for peritoneal mesothelioma and 1 patient for primary peritoneal carcinoma. The completeness of cytoreduction (CC) score was CC-0 in 4 patients (40%), CC-1 in 3 (30%) and CC-2 in 3 (30%).

The mean length of the remaining small bowel was 105 cm (range 80-150). Mean hospitalization was 42 days vs 24 days in other patients with CRS+HIPEC (p<0.002). The daily ileostomy output increased between the 3rd to 4th week as a result of oral feeding and decreased at the 4th week due to somatostatin analogue administration and possible intestinal adaptation. The mean ileostomy output at 6 months was 810±100 ml vs 1590±210 ml the first month after CRS+HIPEC (p<0.001). The overall morbidity and mortality rate was the same as in patients without extensive resection. The impact of small bowel syndrome (SBS) on overall survival was very important, as the mean overall survival in the SBS group was 28.6 months vs 41 months in other CRS+HIPEC patients (p<0.001).

SBS is sometimes inevitable in order to perform optimal cytoreduction. Special management is required for these patients, including special nutritional efforts and home total parenteral nutrition (TPN). Extensive small bowel resection may constitute a contraindication in the management of peritoneal carcinomatosis.