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Original Contribution  |   January 2017
Physiologic Response to HIPEC: Sifting Through Perturbation to Identify Markers of Complications
Author Notes
  • From the Department of Surgery at Loyola University Medical Center in Maywood, Illinois. Presented as a poster on June 25, 2015, at the 2015 Annual Meeting of the Midwest Surgical Association in Lake Geneva, Wisconsin. 
  •  *Address correspondence to Timothy P. Plackett, DO, MPH, Department of Surgery, Womack Army Medical Center, 2160 S Reilly Rd, Fort Bragg, NC 28310-7301. E-mail: tplacke78@gmail.com
     
Article Information
Cardiovascular Disorders / Gastroenterology / Hypertension/Kidney Disease
Original Contribution   |   January 2017
Physiologic Response to HIPEC: Sifting Through Perturbation to Identify Markers of Complications
The Journal of the American Osteopathic Association, January 2017, Vol. 117, 16-23. doi:10.7556/jaoa.2017.003
The Journal of the American Osteopathic Association, January 2017, Vol. 117, 16-23. doi:10.7556/jaoa.2017.003
Abstract

Context: The postoperative physiologic response to hyperthermic intraperitoneal chemotherapy (HIPEC) has been poorly studied outside of the immediate perioperative time.

Objective: To characterize the physiologic response during the first 5 days after HIPEC and identify variables associated with major complications.

Methods: Patients undergoing HIPEC and cytoreductive surgery during a 14-month interval were retrospectively identified and their records reviewed for demographics, physiologic response, and major complications. Vital signs and laboratory results were recorded before the operation, immediately after the procedure, and for the first 5 postoperative days.

Results: Thirty-three patients were included. The mean body temperature and heart rate were elevated on postoperative day 1 compared with baseline (preoperative) status (37.1°C vs 36.6°C and 103 vs 78 beats/min, respectively) and remained elevated through postoperative day 5. The mean arterial pressure was lower on postoperative day 1 (73 mm Hg) but returned to baseline on postoperative day 3 (93 mm Hg). Mean creatinine level increased on postoperative day 1 (0.96 mg/dL) but returned to baseline on postoperative day 2 (0.87 mg/dL). Fourteen patients (42%) had major complications. The strongest predictors of major complications were a prolonged operative time (519 vs 403 minutes) and extreme changes in body temperature and renal function.

Conclusions: Hyperthermic intraperitoneal chemotherapy results in a hypermetabolic response that partially returns to baseline around postoperative day 3. Elevated body temperature and impaired renal function are the best predictors of major complications.

Keywords: chemotherapy, cytoreductive surgery, hyperthermic intraperitoneal chemotherapy, peritoneal carcinomatosis

Cytoreductive surgery paired with hyperthermic intraperitoneal chemotherapy (HIPEC) has been found to be effective for a variety of malignant neoplasms with peritoneal dissemination.1,2 Improved survival has been demonstrated for patients with colorectal cancer,3 gastric cancer,4 pseudomyxoma peritonei,3 ovarian cancer,5 and malignant peritoneal mesothelioma6 compared with standard treatment alone. As a result, HIPEC is increasingly used as an oncologic treatment strategy.3 
Although most studies of HIPEC have focused on the oncologic outcomes for patients and risk factors for postoperative complications, less is known about the early perioperative physiologic responses to these procedures. Intraoperatively, during the administration of HIPEC, patients have notable increases in both their core temperature7-9 and circulating inflammatory cytokines.10 The immediate effect of these changes is a decrease in the systemic vascular resistance and mean arterial pressure, which leads to compensatory tachycardia and increased cardiac output.8 Despite compensatory mechanisms, there is an ineffective intravascular volume and resultant evidence of hypoperfusion.7,8,11,12 These intraoperative findings have been well described, as have treatment strategies aimed at limiting the intraoperative physiologic stress of HIPEC.9,13 
Less well characterized are the postoperative physiologic effects of HIPEC. The present study attempts to address this gap in understanding by characterizing the usual physiologic changes that occur after HIPEC administration. Furthermore, it provides a comparison of the responses of patients with major postoperative complications vs those with an uncomplicated recovery. 
Methods
After obtaining approval from the Loyola University Medical Center Institutional Review Board, all patients who underwent a HIPEC procedure from April 1, 2013, through May 30, 2015, were retrospectively identified. No additional inclusion or exclusion criteria were applied. The decision to perform HIPEC was at the discretion of the treating physicians, as was any decision to perform a concomitant cytoreductive surgery. Inpatient and outpatient medical records were reviewed for patient demographics, cancer characteristics, hospital course, vital signs, complications, discharge status, and 30-day mortality. Vital signs were abstracted from those recorded immediately on arrival to the intensive care unit after the surgery and then at 6 am and 6 pm for the first 5 postoperative days. Laboratory values abstracted were the first set of results obtained on arrival to the intensive care unit after surgery (baseline) and then from the morning laboratory results for the first 5 postoperative days. Complications were stratified based on the Clavien-Dindo classification,14-16 and classes III through V were considered major complications. 
The surgical management generally consisted of cytoreductive surgery paired with HIPEC. The HIPEC regimen consisted of 30 mg/m2 of mitomycin C instilled at time 0, followed by an additional 10 mg/m2 of mitomycin C instilled at 60 minutes. The entire cycle ran for 90 minutes at a temperature of 42°C. Postoperatively, all patients were admitted to the surgical intensive care unit. Postoperative management was at the discretion of the treating physicians and not protocolized. 
Data were analyzed using SPSS Statistics version 23 (IBM). Continuous variables are reported as mean (SD). For nonrepeating measures, comparisons between patients with and without major complications were made with a t test for continuous variables and a χ2 analysis for categorical variables. Repeating categorical variables were compared using a 1-way analysis of variance with least significant different post hoc test or mixed-design analysis of variance with the Leven test. A P value of <.05 was considered statistically significant. For categorical variables whose differences were statistically significant, a receiver operating characteristic curve was performed and the area under the curve (AUC) calculated. 
Results
Thirty-three patients underwent HIPEC during the 16 months studied. The mean (SD) patient age was 54.0 (15.1) years and the majority (70%) were women (Table 1). The mean (SD) body mass index was 27.5 (7.8). The most common sites for the primary tumor were the colon (42%) and appendix (39%). Other malignant neoplasms were ovarian, gastric, mesothelial, and small bowel tumors. The mean (SD) peritoneal carcinomatosis index was 15.2 (9.2). 
Table 1.
Demographics, Tumor Characteristics, and Operative Variables in Patients Who Received HIPEC (N=33)a
Complications
Characteristic Total No (n=19) Yes (n=14) P Value
Age, y 54.0 (15.1) 53.3 (13.2) 55.0 (18.4) .754
Sex, No. (%) .178
 Male 10 (30) 4 (21) 6 (43)
 Female 23 (70) 15 (79) 8 (57)
BMI 27.4 (7.8) 28.5 (7.9) 25.8 (8.1) .938
Tumor Origin, No. (%) .272
 Colon 14 (42) 8 (42) 6 (43)
 Appendix 13 (39) 5 (26) 8 (57)
 Ovarian 2 (6) 2 (11) 0
 Gastric 2 (6) 2 (11) 0
 Mesothelioma 1 (3) 1 (5) 0
 Small bowel 1 (3) 1 (5) 0
PCI 15.2 (9.2) 16.4 (9.8) 13.6 (8.7) .865
Operative Time, min 452 (138) 403 (125) 519 (130) .014
Estimated Blood Loss, mL 695 (759) 580 (608.5) 850 (927) .32
Extubated at End of Case, No. (%) 21 (64) 16 (76) 5 (36) .004
Intraoperative Volume Resuscitation, mL/kg/h 17.4 (8.0) 18.2 (8.2) 16.4 (7.7) .515
Anastomosis, No. (%) 11 (33) 4 (21) 7 (50) .081

a Data are given as mean (SD) unless otherwise indicated.

Abbreviations: BMI, body mass index; HIPEC, hyperthermic intraperitoneal chemotherapy; PCI, peritoneal carcinomatosis index.

Table 1.
Demographics, Tumor Characteristics, and Operative Variables in Patients Who Received HIPEC (N=33)a
Complications
Characteristic Total No (n=19) Yes (n=14) P Value
Age, y 54.0 (15.1) 53.3 (13.2) 55.0 (18.4) .754
Sex, No. (%) .178
 Male 10 (30) 4 (21) 6 (43)
 Female 23 (70) 15 (79) 8 (57)
BMI 27.4 (7.8) 28.5 (7.9) 25.8 (8.1) .938
Tumor Origin, No. (%) .272
 Colon 14 (42) 8 (42) 6 (43)
 Appendix 13 (39) 5 (26) 8 (57)
 Ovarian 2 (6) 2 (11) 0
 Gastric 2 (6) 2 (11) 0
 Mesothelioma 1 (3) 1 (5) 0
 Small bowel 1 (3) 1 (5) 0
PCI 15.2 (9.2) 16.4 (9.8) 13.6 (8.7) .865
Operative Time, min 452 (138) 403 (125) 519 (130) .014
Estimated Blood Loss, mL 695 (759) 580 (608.5) 850 (927) .32
Extubated at End of Case, No. (%) 21 (64) 16 (76) 5 (36) .004
Intraoperative Volume Resuscitation, mL/kg/h 17.4 (8.0) 18.2 (8.2) 16.4 (7.7) .515
Anastomosis, No. (%) 11 (33) 4 (21) 7 (50) .081

a Data are given as mean (SD) unless otherwise indicated.

Abbreviations: BMI, body mass index; HIPEC, hyperthermic intraperitoneal chemotherapy; PCI, peritoneal carcinomatosis index.

×
The mean (SD) operative time was 452 (138) minutes; estimated blood loss, 695 (759) mL; and intraoperative fluid resuscitation, 17.4 (8.0) mL/kg/h. Eleven patients had an enteric anastomosis performed during the index surgical procedure. 
Fourteen patients (42%) had a Dindo-Clavien class III-V complication.14-16 The most common complications were an anastomotic leak (5 patients) and surgical site infections (4 patients). Other complications, which all occurred in 1 patient, were fascial dehiscence, Clostridium difficile colitis, supraventricular tachycardia requiring cardioversion, rectovaginal fistula, and respiratory failure requiring tracheostomy. 
None of the patient demographics or tumor characteristics analyzed were found to be associated with complications (Table 1). Among the operative characteristics, the occurrence of a major complication was associated with a longer mean (SD) operative time (519 [130] minutes vs 403 [125] minutes). Although it was not statistically significant, an association was found between enteric anastomosis at the index surgical procedure and major complication. 
The mean (SD) baseline vital signs were obtained in the preoperative holding area on the day of the operation. The mean (SD) postoperative physiologic response was examined during the early postoperative period. The baseline body temperature was 36.6°C (0.3°C) and had decreased postoperatively to 36.5°C (0.5°C) (P=.221). The body temperature increased to 37.1°C (0.6°C) by the morning of postoperative day 1 (P<.001) and remained statistically significantly elevated above baseline through postoperative day 5. The baseline pulse rate was 78 (15) beats/min and was significantly higher immediately after the operation at 96 (22) beats/min (P<.001). The pulse rate peaked the morning of postoperative day 1 (103 [20] beats/min) and slowly decreased back toward baseline. However, it remained severely elevated through postoperative day 5. The baseline arterial pressure was 93 (12) mm Hg and was not significantly different immediately after the operation (91 [18] mm Hg, P=.461). However, the arterial pressure was significantly decreased the morning of postoperative day 1 (73 [7] mm Hg, P<.001) and remained significantly decreased through the morning of postoperative day 2. The baseline respiratory rate was 17 breaths/min and did not significantly change (P=.108) during the first 5 postoperative days. 
Mean (SD) vital signs were compared between patients with and without major complications. During the course of the first 5 postoperative days, a higher body temperature was noted in patients with complications (Figure 1A), but this finding was not statistically significant (P=.055). However, the temperature was significantly higher in patients with complications in the afternoon of postoperative day 1 (37.2°C [0.64°C] vs 37.1°C [0.33°C]; P=.003), afternoon of postoperative day 2 (37.3°C [0.77°C] vs 37.0°C [0.33°C]; P=.007), and the morning of postoperative day 3 (37.4°C [0.59°C] vs 37.0°C [0.29°C]; P=.002). The overall trend in pulse rate changes during the course of the first 5 postoperative days was not different between patients with and without complications (P=.65), nor were there differences between any of the specific times examined (Figure 1B). The overall trend in arterial blood pressure during the course of the first 5 postoperative days was not different between patients with and without complications (P=.661), nor were there differences between any of the times examined (Figure 1C). The overall trend in the respiratory rate was not different between patients with and without complications (P=.139). However, during the immediate postoperative period, patients with complications had a significantly lower respiratory rate (14.4 [2.5] vs 18.6 [5.7] breaths/min; P=.005). 
Figure 1.
Vital signs in patients with and without major complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (N=33). A, temperature; B pulse; and C, arterial pressure.
Figure 1.
Vital signs in patients with and without major complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (N=33). A, temperature; B pulse; and C, arterial pressure.
Postoperative laboratory values for complete blood cell count and basic metabolic panel were examined for the early postoperative period (Table 2). The baseline laboratory values were obtained within 7 days preceding the operation or the morning of the operation. All patients had severe anemia during the postoperative period (P<.001). Similarly, the platelet count had significantly decreased by the immediate postoperative period and remained decreased throughout the first 5 postoperative days (P=.001). Serum potassium, bicarbonate, and blood urea nitrogen levels significantly changed over time (P=.001, P<.001, and P=.002, respectively). However, these changes predominantly occurred during the first postoperative day. In contrast, the serum creatinine level also changed significantly over time (P=.002), but these changes occurred predominantly during postoperative days 4 and 5. 
Table 2.
Mean Laboratory Values During Initial Postoperative Period in Patients Who Received HIPEC (N=33)a
Postoperative Day
Analyte Baseline 0 1 2 3 4 5 P Valuea
Hemoglobin, g/dL 11.98 10.05 9.4 8.31 8.17 8.38 8.46 <.001
Platelets, ×103/μL 283.4 195.0 188.3 175.7 175.6 198.2 204.2 .001
Sodium, mEq/L 138.2 137.1 137.1 137.4 137.7 137.6 137.3 .49
Potassium, mEq/L 3.93 4.08 4.16 3.84 3.66 3.7 3.6 .001
Chloride, mEq/L 105.5 106.1 107.5 107.0 105.79 105.2 105.0 .062
Bicarbonate, mEq/L 26.1 21.7 23.76 26.07 27 27.0 26.3 <.001
BUN, mg/dL 30.08 21.06 24.73 29.21 24.11 24.22 25.82 .002
Creatinine, mg/dL 0.85 0.88 0.96 0.87 0.75 0.73 0.71 .002
Ionized calcium, mg/dL 4.44 4.24 4.48 4.64 4.56 4.52 4.40 .376

a P value applies to overall trend over time.

Abbreviations: BUN, blood urea nitrogen; HIPEC, hyperthermic intraperitoneal chemotherapy.

Table 2.
Mean Laboratory Values During Initial Postoperative Period in Patients Who Received HIPEC (N=33)a
Postoperative Day
Analyte Baseline 0 1 2 3 4 5 P Valuea
Hemoglobin, g/dL 11.98 10.05 9.4 8.31 8.17 8.38 8.46 <.001
Platelets, ×103/μL 283.4 195.0 188.3 175.7 175.6 198.2 204.2 .001
Sodium, mEq/L 138.2 137.1 137.1 137.4 137.7 137.6 137.3 .49
Potassium, mEq/L 3.93 4.08 4.16 3.84 3.66 3.7 3.6 .001
Chloride, mEq/L 105.5 106.1 107.5 107.0 105.79 105.2 105.0 .062
Bicarbonate, mEq/L 26.1 21.7 23.76 26.07 27 27.0 26.3 <.001
BUN, mg/dL 30.08 21.06 24.73 29.21 24.11 24.22 25.82 .002
Creatinine, mg/dL 0.85 0.88 0.96 0.87 0.75 0.73 0.71 .002
Ionized calcium, mg/dL 4.44 4.24 4.48 4.64 4.56 4.52 4.40 .376

a P value applies to overall trend over time.

Abbreviations: BUN, blood urea nitrogen; HIPEC, hyperthermic intraperitoneal chemotherapy.

×
Laboratory values were compared between patients with and without major complications. No significant difference in the mean hemoglobin levels or platelet counts were found between patients with and without complications during the first 5 postoperative days (P=.179 and P=.850, respectively). Similarly, no significant differences were found in the mean serum sodium (P= 0.283), chloride (P=.159), bicarbonate (P=.267), or ionized calcium (P=.874) levels between patients with and without complications during the first 5 postoperative days. Mean serum potassium (P=.002), blood urea nitrogen (P=.017), and creatinine (P=.005) levels were higher in patients with complications (Figure 2). On posthoc analysis, the difference in serum potassium level was statistically significant during the immediate postoperative period, the difference in blood urea nitrogen was statistically significant on postoperative day 1, and the difference in creatinine was statistically significant on postoperative days 3 and 5. 
Figure 2.
Laboratory values during the initial postoperative period for patients with and without clinically significant complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (N=33). A, potassium; B, blood urea nitrogen; and C, creatinine.
Figure 2.
Laboratory values during the initial postoperative period for patients with and without clinically significant complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (N=33). A, potassium; B, blood urea nitrogen; and C, creatinine.
To determine the predictive value of the changes in vital signs and laboratory values found to be statistically significant between patients with and without complications, receiver operating characteristic curves were created and the AUC was calculated. The AUC for temperature on the afternoon of postoperative day 1 was 0.534, on the afternoon of postoperative day 2 was 0.633, and in the morning of postoperative day 3 was 0.712. Immediately after the operation, the AUC for respiratory rate was 0.729 and for serum potassium level was 0.799. On postoperative day 1, the AUC for the blood urea nitrogen level was 0.749. The AUC for serum creatinine level was 0.686 on postoperative day 3 and 0.756 on postoperative day 5. 
Discussion
Intraoperatively, HIPEC produces a physiologic response that often mimics that of sepsis, with a rise in the inflammatory cytokine interleukin 6 within the peritoneum,10 decrease in systemic vascular resistance,11,12 and decreased effective circulatory volume.11,12 This inflammatory response persists in the immediate postoperative period and can take several days to become quiescent. In a study17 of patients with ovarian peritoneal carcinomatosis who underwent cytoreductive surgery and HIPEC, C-reactive protein levels did not peak until postoperative day 2 and did not reach a nadir until postoperative day 7. In addition, the white blood cell count was at the high end of normal during the immediate postoperative period and then decreased, although not statistically significant, during the next 4 days.17 The present study builds on this research by characterizing additional physiologic changes. 
Hyperthermic intraperitoneal chemotherapy produces a hyperdynamic metabolic response that persists beyond the immediate operative period. Congruent with the work of Medina Fernandez et al,17 the present study demonstrates that the response persists for 2 to 3 days after the operation. The body temperature and pulse rate increased and the arterial pressure decreased during this time. All 3 of these changes are markers traditionally used to gauge a patient’s clinical status and provide insight into whether the patient is having a complicated postoperative course. However, with the hyperdynamic response being normal in the patients studied, the utility of these physiologic changes as a marker of a patient’s clinical status is somewhat limited. Only a persistent increase in body temperature into postoperative day 3 was indicative of a major complication. This finding may reflect the multifactorial nature of the changes in both the pulse rate and mean arterial pressure, which can be affected by resuscitation; however, resuscitation is less likely to affect body temperature. 
In addition to the hypermetabolic response, patients have been described as having a relative intravascular hypovolemia during the operation,8 leading to poor end-organ perfusion.7,9 As a result, renal function undergoes subtle changes that persist for several days after the operation. The early elevation in blood urea nitrogen, creatinine, and potassium levels were subtle, but they were useful as predictors of complications. Whereas the potassium and blood urea nitrogen levels were predictive in the early period, creatinine level was more helpful in the later period. The relationship between renal dysfunction and complications after an intraabdominal surgical procedure has been described by others18; however, this research has largely focused on acute kidney injury. The present study demonstrates that even minor perturbations in postoperative renal and electrolyte function can be associated with major complications. In the case of HIPEC, these perturbations are more predictive of complications than the traditional markers of fever, tachycardia, and hypotension.19 
The current study is limited by its retrospective nature. Although the HIPEC procedure itself was standardized, the intraoperative resuscitation and postoperative care were not standardized. The intraoperative resuscitation was comparable to what others have described7 and is best characterized as an aggressive volume replacement strategy. Because the majority of factors predictive of complications related to renal dysfunction, it is possible that even minor variations in resuscitation may have influenced outcomes. For this reason, cardiac monitoring and goal-directed therapy have been advocated for intraoperative management9,20 and may be indicated in the postoperative period as well. However, the present study is unable to offer a more definitive statement on either of these points. 
The study is also limited by its small sample size. While comparable in size to many other studies,7-13 the limited number of cases falls within the intuitional learning curve. Wide estimates exist regarding the learning curve with this procedure; however, the most conservative estimate is that the highest complication rates occur in the first 40 cases.21-23 Given these constraints, not only are the results at risk for a type II error, but the results may be reflective of complications during the learning curve and not necessarily indicative of factors associated with complications after the learning curve. 
A further limitation is that we studied patients undergoing HIPEC with a cytoreductive surgery but without a control group of patients who underwent cytoreductive surgery alone. Although the findings presented herein are ascribed to HIPEC, it is plausible that they could be applicable to other intra-abdominal surgical procedures. An appropriate control group would be needed to determine whether these effects are solely the result of HIPEC. 
Conclusion
The hypermetabolic response to HIPEC and the renal dysfunction in patients with complications persisted for several days after the operation. Subtle exaggerations of these physiologic changes are early heralds of major postoperative complications. Failure of these changes to return to baseline at the expected rate or time should prompt surgeons to evaluate patients for major complications. 
References
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Figure 1.
Vital signs in patients with and without major complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (N=33). A, temperature; B pulse; and C, arterial pressure.
Figure 1.
Vital signs in patients with and without major complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (N=33). A, temperature; B pulse; and C, arterial pressure.
Figure 2.
Laboratory values during the initial postoperative period for patients with and without clinically significant complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (N=33). A, potassium; B, blood urea nitrogen; and C, creatinine.
Figure 2.
Laboratory values during the initial postoperative period for patients with and without clinically significant complications after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (N=33). A, potassium; B, blood urea nitrogen; and C, creatinine.
Table 1.
Demographics, Tumor Characteristics, and Operative Variables in Patients Who Received HIPEC (N=33)a
Complications
Characteristic Total No (n=19) Yes (n=14) P Value
Age, y 54.0 (15.1) 53.3 (13.2) 55.0 (18.4) .754
Sex, No. (%) .178
 Male 10 (30) 4 (21) 6 (43)
 Female 23 (70) 15 (79) 8 (57)
BMI 27.4 (7.8) 28.5 (7.9) 25.8 (8.1) .938
Tumor Origin, No. (%) .272
 Colon 14 (42) 8 (42) 6 (43)
 Appendix 13 (39) 5 (26) 8 (57)
 Ovarian 2 (6) 2 (11) 0
 Gastric 2 (6) 2 (11) 0
 Mesothelioma 1 (3) 1 (5) 0
 Small bowel 1 (3) 1 (5) 0
PCI 15.2 (9.2) 16.4 (9.8) 13.6 (8.7) .865
Operative Time, min 452 (138) 403 (125) 519 (130) .014
Estimated Blood Loss, mL 695 (759) 580 (608.5) 850 (927) .32
Extubated at End of Case, No. (%) 21 (64) 16 (76) 5 (36) .004
Intraoperative Volume Resuscitation, mL/kg/h 17.4 (8.0) 18.2 (8.2) 16.4 (7.7) .515
Anastomosis, No. (%) 11 (33) 4 (21) 7 (50) .081

a Data are given as mean (SD) unless otherwise indicated.

Abbreviations: BMI, body mass index; HIPEC, hyperthermic intraperitoneal chemotherapy; PCI, peritoneal carcinomatosis index.

Table 1.
Demographics, Tumor Characteristics, and Operative Variables in Patients Who Received HIPEC (N=33)a
Complications
Characteristic Total No (n=19) Yes (n=14) P Value
Age, y 54.0 (15.1) 53.3 (13.2) 55.0 (18.4) .754
Sex, No. (%) .178
 Male 10 (30) 4 (21) 6 (43)
 Female 23 (70) 15 (79) 8 (57)
BMI 27.4 (7.8) 28.5 (7.9) 25.8 (8.1) .938
Tumor Origin, No. (%) .272
 Colon 14 (42) 8 (42) 6 (43)
 Appendix 13 (39) 5 (26) 8 (57)
 Ovarian 2 (6) 2 (11) 0
 Gastric 2 (6) 2 (11) 0
 Mesothelioma 1 (3) 1 (5) 0
 Small bowel 1 (3) 1 (5) 0
PCI 15.2 (9.2) 16.4 (9.8) 13.6 (8.7) .865
Operative Time, min 452 (138) 403 (125) 519 (130) .014
Estimated Blood Loss, mL 695 (759) 580 (608.5) 850 (927) .32
Extubated at End of Case, No. (%) 21 (64) 16 (76) 5 (36) .004
Intraoperative Volume Resuscitation, mL/kg/h 17.4 (8.0) 18.2 (8.2) 16.4 (7.7) .515
Anastomosis, No. (%) 11 (33) 4 (21) 7 (50) .081

a Data are given as mean (SD) unless otherwise indicated.

Abbreviations: BMI, body mass index; HIPEC, hyperthermic intraperitoneal chemotherapy; PCI, peritoneal carcinomatosis index.

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Table 2.
Mean Laboratory Values During Initial Postoperative Period in Patients Who Received HIPEC (N=33)a
Postoperative Day
Analyte Baseline 0 1 2 3 4 5 P Valuea
Hemoglobin, g/dL 11.98 10.05 9.4 8.31 8.17 8.38 8.46 <.001
Platelets, ×103/μL 283.4 195.0 188.3 175.7 175.6 198.2 204.2 .001
Sodium, mEq/L 138.2 137.1 137.1 137.4 137.7 137.6 137.3 .49
Potassium, mEq/L 3.93 4.08 4.16 3.84 3.66 3.7 3.6 .001
Chloride, mEq/L 105.5 106.1 107.5 107.0 105.79 105.2 105.0 .062
Bicarbonate, mEq/L 26.1 21.7 23.76 26.07 27 27.0 26.3 <.001
BUN, mg/dL 30.08 21.06 24.73 29.21 24.11 24.22 25.82 .002
Creatinine, mg/dL 0.85 0.88 0.96 0.87 0.75 0.73 0.71 .002
Ionized calcium, mg/dL 4.44 4.24 4.48 4.64 4.56 4.52 4.40 .376

a P value applies to overall trend over time.

Abbreviations: BUN, blood urea nitrogen; HIPEC, hyperthermic intraperitoneal chemotherapy.

Table 2.
Mean Laboratory Values During Initial Postoperative Period in Patients Who Received HIPEC (N=33)a
Postoperative Day
Analyte Baseline 0 1 2 3 4 5 P Valuea
Hemoglobin, g/dL 11.98 10.05 9.4 8.31 8.17 8.38 8.46 <.001
Platelets, ×103/μL 283.4 195.0 188.3 175.7 175.6 198.2 204.2 .001
Sodium, mEq/L 138.2 137.1 137.1 137.4 137.7 137.6 137.3 .49
Potassium, mEq/L 3.93 4.08 4.16 3.84 3.66 3.7 3.6 .001
Chloride, mEq/L 105.5 106.1 107.5 107.0 105.79 105.2 105.0 .062
Bicarbonate, mEq/L 26.1 21.7 23.76 26.07 27 27.0 26.3 <.001
BUN, mg/dL 30.08 21.06 24.73 29.21 24.11 24.22 25.82 .002
Creatinine, mg/dL 0.85 0.88 0.96 0.87 0.75 0.73 0.71 .002
Ionized calcium, mg/dL 4.44 4.24 4.48 4.64 4.56 4.52 4.40 .376

a P value applies to overall trend over time.

Abbreviations: BUN, blood urea nitrogen; HIPEC, hyperthermic intraperitoneal chemotherapy.

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