Urgent re-laparotomies in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

The objective of the study was to evaluate the morbidity-mortality results in terms of immunscore factors and to predict the outcomes of urgent re-laparotomized patients treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

Prospectively maintained database of 661 patients treated with potentially curative intent of CRS and HIPEC through the years of 2007 and 2020 was evaluated. URL was done for 28 (4.2%) patients as unplanned re-explorative surgery; 22 (78.6%) of them was female. The median age was 57 year (ranging, 24-76 years). There were 22 (78.6%) elderly patients over 65 years old. All standard clini-co-pathological characteristics, re-operative findings, and the morbidity-mortality results were analyzed. The well-known immunoscores such as neutrophil-lymphocyte ratio (NLR), neutrophil-thrombocyte ratio (NTR), and CRP-albumin ratio (CAR) were determined.

The main indication for URL was small bowel anastomotic leak (n=13, 46.4%). The abdominal wall disruption (n=5, 17.9%) was the second indication. The frequent localization of injured organ was again small bowel. The 28.6% of patients (n=8) were re-op-erated in early postoperative period (in 7 days), while as the rest of them (n=20, 71.4%) in 90 days. There was only one repeat-URL patient in this series. Many of the URL patients (n=16, 57.1%) had more than one co-morbidities. Delving into the overall group, there were Clavien-Dindo (C-D) Grade I-II complications in 104 (16.4%) patients and C-D Grade III-IV in 88 (13.9%) patients, whereas in URL patient group, C-D Grade III-IV complications were seen in 22 (78.6%). In this prospective cohort, the overall mortality rate was 3.2% (n=20) in patients who were not re-explored. Six (21.4%) patients were lost in URL patients, which the main reason for fail-ure-to-rescue was sepsis due to entero-enteral anastomotic leak. In four of them, multiple co-morbidities were affected the post-URL period of complex cancer care. Pre-URL median NLR, NTR, and CAR values were 9.12 (ranging, 1.72-37.5), 0.03 (ranging, 0.01-0.12), and 41.4 (ranging, 4.2-181.3), respectively. NLR and CAR values (4.71 and 28.8) estimated before pre-CRS were also significantly high (p=0.01 and p<0.01) in patients who were going to be operated for URL. These immunoscores values did not show any association in between pre-CRS and pre-URL mortal patients.

The crucial decision-making factors at work were complex and complicated in 'unplanned' URL. The overall mor-bidity-mortality results seemingly depends on the severity and extent of peritoneal metastatic disease. Medically-unfit URL patients with high-risk factors should be selected to a vigilant monitoring and clinical care. Timely surgical intervention and intense management strategy are utmost important issues to lower morbi-mortality results in patients treated with URL.