Indian Journal of Surgical Oncology

, Volume 10, Supplement 1, pp 71–79 | Cite as

Failure-to-Rescue Following Cytoreductive Surgery with or Without HIPEC is Determined by the Type of Complication—a Retrospective Study by INDEPSO

  • Snita Sinukumar
  • Sanket Mehta
  • Dileep Damodaran
  • Firoz Rajan
  • Shabber Zaveri
  • Mukurdipi Ray
  • Ninad Katdare
  • Kayomarz Sethna
  • Mahesh D. Patel
  • Praveen Kammer
  • Abraham Peedicayil
  • Aditi BhattEmail author
Original Article


To determine factors influencing failure-to-rescue in patients with complications following cytoreductive surgery and HIPEC. A retrospective analysis of patients enrolled in the Indian HIPEC registry was performed. Complications were graded according to the CTCAE classification version 4.3. The 30- and 90-day morbidity were both recorded. Three hundred seventy-eight patients undergoing CRS with/without HIPEC for peritoneal metastases from various primary sites, between January 2013 and December 2017 were included. The median PCI was 11 [range 0–39] and a CC-0/1 resection was achieved in 353 (93.5%). Grade 3–4 morbidity was seen 95 (25.1%) at 30 days and 122 (32.5%) at 90 days. The most common complications were pulmonary complications (6.8%), neutropenia (3.7%), systemic sepsis (3.4%), anastomotic leaks (1.5%), and spontaneous bowel perforations (1.3%). Twenty-five (6.6%) patients died within 90 days of surgery due to complications. The failure-to-rescue rate was 20.4%. Pulmonary complications (p = 0.03), systemic sepsis (p < 0.001), spontaneous bowel perforations (p < 0.001) and PCI > 20 (p = 0.002) increased the risk of failure-to-rescue. The independent predictors were spontaneous bowel perforation (p = 0.05) and systemic sepsis (p = 0.001) and PCI > 20 (p = 0.02). The primary tumor site did not have an impact on the FTR rate (p = 0.09) or on the grade 3–4 morbidity (p = 0.08). Nearly one-fifth of the patients who developed complications succumbed to them. Systemic sepsis, spontaneous bowel perforations, and pulmonary complications increased the risk of FTR and multidisciplinary teams should develop protocols to prevent, identify, and effectively treat such complications. All surgeons pursuing this specialty should perform a regular audit of their results, irrespective of their experience.


Failure-to-rescue Hyperthermic intraperitoneal chemotherapy Peritoneal metastases Cytoreductive surgery 



The authors thank Professor Ramakrishnan Seshadri for giving his views on the subject and suggestions on this manuscript.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Supplementary material

13193_2019_877_MOESM1_ESM.docx (63 kb)
ESM 1 (DOCX 63 kb)


  1. 1.
    Glehen O, Gilly FN, Boutitie F, Bereder JM, Quenet F, Sideris L, Mansvelt B, Lorimier G, Msika S, Elias D, French Surgical Association (2010) Toward curative treatment of peritoneal carcinomatosis from non-ovarian origin by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy: a multi-institutional study of 1,290 patients. Cancer 116:5608–5618CrossRefPubMedGoogle Scholar
  2. 2.
    Chua TC, Moran BJ, Sugarbaker PH, Levine EA, Glehen O, Gilly FN, Baratti D, Deraco M, Elias D, Sardi A, Liauw W, Yan TD, Barrios P, Gómez Portilla A, de Hingh IHJT, Ceelen WP, Pelz JO, Piso P, González-Moreno S, van der Speeten K, Morris DL (2012) Early and long-term outcome data of patients with pseudomyxoma peritonei from appendiceal origin treated by a strategy of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Clin Oncol 30:2449–2456CrossRefPubMedGoogle Scholar
  3. 3.
    Bakrin N, Bereder JM, Decullier E, Classe JM, Msika S, Lorimier G, Abboud K, Meeus P, Ferron G, Quenet F, Marchal F, Gouy S, Morice P, Pomel C, Pocard M, Guyon F, Porcheron J, Glehen O, FROGHI (FRench Oncologic and Gynecologic HIPEC) Group (2013) Peritoneal carcinomatosis treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for advanced ovarian carcinoma: a French multicentre retrospective cohort study of 566 patients. Eur J Surg Oncol 39:1435–1443CrossRefGoogle Scholar
  4. 4.
    Silber J, Romano P, Rosen A, Wang Y, Even-Shoshan O, Volpp K (2007) Failure-to-rescue: comparing definitions to measure quality of care. Med Care 45:918e925CrossRefGoogle Scholar
  5. 5.
    Silber JH, Williams SV, Krakauer H, Schwartz JS (1992) Hospital and patient characteristics associated with death after surgery: a study of adverse occurrence and failure to rescue. Med Care 30:615–629CrossRefPubMedGoogle Scholar
  6. 6.
    Mercier F, Cotte E, Glehen O, Passot G (2017) Why morbidity is not an adequate metric for evaluation of surgical quality. Ann Surg.
  7. 7.
    Passot G, Vaudoyer D, Villeneuve L, Kepenekian V, Beaujard AC, Bakrin N, Cotte E, Gilly FN, Glehen O (2016) What made hyperthermic intraperitoneal chemotherapy an effective curative treatment for peritoneal surface malignancy: a 25-year experience with 1,125 procedures. J Surg Oncol 113(7):796–803. CrossRefPubMedGoogle Scholar
  8. 8.
    Bhatt A, Mehta S, Zaveri S, Rajan F, Ray M, Sethna K, Katdare N et al (2018) Treading the beaten path with old and new obstacles: a report from the Indian HIPEC registry. Int J Hyperth:1–9.
  9. 9.
    Van der Speeten K, Lemoine L (2018) HIPEC methodology, comparison of techniques, and drug regimens: is there a need for standardization? In: Management of Peritoneal Metastases- Cytoreductive Surgery, HIPEC and Beyond. Springer, pp 298–391Google Scholar
  10. 10.
    Douchy T, Lemoine L, Van der Speeten K (2018) Early postoperative intraperitoneal chemotherapy: current role and future perspectives. In: Management of Peritoneal Metastases- Cytoreductive Surgery, HIPEC and Beyond. Springer, pp 392–511Google Scholar
  11. 11.
    United States Department of Public Health and Human Services, NIH, NCI: Common Toxicity Criteria for Adverse Events (CTCAE). National Cancer Institute, June 2010. 14;_QuickReference_5x7.pdf
  12. 12.
    Baumgartner JM, Kwong TG, Ma GL, Messer K, Kelly KJ, Lowy AM (2016) A novel tool for predicting major complications after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol 23(5):1609–1617. CrossRefGoogle Scholar
  13. 13.
    Moran B, Cecil T, Chandrakumaran K, Arnold S, Mohamed F, Venkatasubramaniam A (2015) The results of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in 1200 patients with peritoneal malignancy. Color Dis 17:772–778CrossRefGoogle Scholar
  14. 14.
    Passot G, Vaudoyer D, Villeneuve L, Wallet F, Beaujard AC, Boschetti G, Rousset P, Bakrin N, Cotte E, Glehen O (2017) A perioperative clinical pathway can dramatically reduce failure-to-rescue rates after cytoreductive surgery for peritoneal carcinomatosis: a retrospective study of 666 consecutive cytoreductions. Ann Surg 265(4):806–813CrossRefPubMedGoogle Scholar
  15. 15.
    Li KY, Mokdad AA, Minter RM, Mansour JC, Choti MA, Augustine MM, Polanco PM (2017) Failure to rescue following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Surg Res 214:209–215. CrossRefPubMedGoogle Scholar
  16. 16.
    Kim B, Alzharani N, Valle S, Liauw W, Morris D (2017) Treatment-related post-operative mortality after cytoreductive surgery and perioperative intraperitoneal chemotherapy. J Peritoneum (and other serosal surfaces) 2:65CrossRefGoogle Scholar
  17. 17.
    Gupta V, Singla N, Gombar S, Palta S, Chander J (2018) Prevalence of multidrug-resistant pathogens and their antibiotic susceptibility pattern from late-onset ventilator-associated pneumonia patients from a tertiary-care hospital in North India. J Assoc Chest Phys 6:4–11CrossRefGoogle Scholar
  18. 18.
    Laxminarayan R, Chaudhury RR (2016) Antibiotic resistance in India: drivers and opportunities for action. PLoS Med 13(3):e1001974.
  19. 19.
    Chéreau E, Ballester M, Selle F, Cortez A, Pomel C, Darai E, Rouzier R (2009) Pulmonary morbidity of diaphragmatic surgery for stage III/IV ovarian cancer. Int J Obstet Gynaecol 116(8):1062–1068CrossRefGoogle Scholar
  20. 20.
    Franssen B, Tabrizian P, Weinberg A, Romanoff A, Tuvin D, Labow D, Sarpel U (2015) Outcome of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy on patients with diaphragmatic involvement. Ann Surg Oncol 22:1639–1644CrossRefPubMedGoogle Scholar
  21. 21.
    Gouda J, Prusty RK (2014) Overweight and obesity among women by economic stratum in urban India. J Health Popul Nutr 32(1):79–88PubMedPubMedCentralGoogle Scholar
  22. 22.
    Pradeepa R, Anjana RM, Joshi SR, Bhansali A, Deepa M, Joshi PP, Dhandania VK, Madhu SV, Rao PV, Geetha L, Subashini R, Unnikrishnan R, Shukla DK, Kaur T, Mohan V, Das AK, ICMR-INDIAB Collaborative Study Group (2015) Prevalence of generalized & abdominal obesity in urban & rural India--the ICMR-INDIAB study (phase-I) [ICMR- NDIAB-3]. Indian J Med Res 142(2):139–150CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Alyami M, Lundberg P, Kepenekian V, Goéré D, Bereder JM, Msika S, Lorimier G et al (2016) Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis in the elderly: a case-controlled, multicenter study. Ann Surg Oncol 23(Suppl 5):737–745CrossRefPubMedGoogle Scholar
  24. 24.
    Kammar P, Waghoo S, Anam J, Agarwal A, Borkar N, Mehta S, et al (2018) Utility of bipap (biphasic positive airway pressure) ventilation in crs+hipec (cytoreductive surgery+ hyperthermic intraperiotneal chemotherapy). Pleura and Peritoneum; 1, Special Suppl, pp sA6–sA463, September 2018 (page sA123)Google Scholar
  25. 25.
    McPartland SJ, Goodman MD (2014) The effect of elevated body mass index on outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol 21:1463–1467CrossRefPubMedGoogle Scholar
  26. 26.
    Votanopoulos KI, Swords DS, Swett KR, Randle RW, Shen P, Stewart JH, Levine EA (2013) Obesity and peritoneal surface disease: outcomes after cytoreductive surgery with hyperthermic intra- peritoneal chemotherapy for appendiceal and colon primary tumours. Ann Surg Oncol 20:3899–3904CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Baratti D, Kusamura S, Mingrone E, Balestra MR, Laterza B, Deraco M (2012) Identification of a subgroup of patients at highest risk for complications after surgical cytoreduction and hyperthermic intraperitoneal chemotherapy. Ann Surg 256:334–341CrossRefPubMedGoogle Scholar
  28. 28.
    Franko J, Gusani NJ, Holtzman MP, Ahrendt SA, Jones HL, Zeh HJ, Bartlett DL (2008) Multivisceral resection does not affect morbidity and survival after cytoreductive surgery and chemoperfusion for carcinomatosis from colorectal cancer. Ann Surg Oncol 15(11):3065–3072CrossRefPubMedGoogle Scholar
  29. 29.
    Johnston M, Arora S, Anderson O, King D, Behar N, Darzi A (2015) Escalation of care in surgery: a systematic risk assessment to prevent avoidable harm in hospitalized patients. Ann Surg 261:831–838CrossRefPubMedGoogle Scholar
  30. 30.
    Johnston MJ, Arora S, King D, Bouras G, Almoudaris AM, Davis R, Darzi A (2015) A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery 157:752–763CrossRefPubMedGoogle Scholar
  31. 31.
    Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213. CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Youkan R, Kamara S, Buratti D et al (2008) Morbidity, toxicity, and mortality classification systems in the local regional treatment of peritoneal surface malignancy. J Surg Oncol 98:253–257CrossRefGoogle Scholar
  33. 33.
    Alyami M, Kim BJ, Villeneuve L, Vaudoyer D, Képénékian V, Bakrin N, Gilly FN, Cotte E, Glehen O, Passot G (2018) Ninety-day post-operative morbidity and mortality using the National Cancer Institute’s common terminology criteria for adverse events better describe post-operative outcome after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Int J Hyperth 34(5):532–537. CrossRefGoogle Scholar
  34. 34.
    Kusamura S, Baratti D, Deraco M (2012) Multidimensional analysis of the learning curve for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in peritoneal surface malignancies. Ann Surg 255(2):348–356. CrossRefPubMedGoogle Scholar

Copyright information

© Indian Association of Surgical Oncology 2019

Authors and Affiliations

  • Snita Sinukumar
    • 1
  • Sanket Mehta
    • 2
  • Dileep Damodaran
    • 3
  • Firoz Rajan
    • 4
  • Shabber Zaveri
    • 5
  • Mukurdipi Ray
    • 6
  • Ninad Katdare
    • 7
  • Kayomarz Sethna
    • 8
  • Mahesh D. Patel
    • 9
  • Praveen Kammer
    • 2
  • Abraham Peedicayil
    • 10
  • Aditi Bhatt
    • 9
    Email author
  1. 1.Department of Surgical OncologyJehangir HospitalPuneIndia
  2. 2.Department of Peritoneal surface oncologySaifee HospitalMumbaiIndia
  3. 3.Department of surgical oncologyMVR Cancer Center and Research InstituteCalicutIndia
  4. 4.Department of surgical oncologyKovai Medical CenterCoimbatoreIndia
  5. 5.Department of surgical oncologyManipal HospitalBangaloreIndia
  6. 6.Department of surgical oncologyAll India Institute of Medical SciencesNew DelhiIndia
  7. 7.Department of surgical oncologyRaheja HospitalMumbaiIndia
  8. 8.Department of general surgeryLokmanya Tilak Municipal Medical College and HospitalMumbaiIndia
  9. 9.Department of Surgical OncologyZydus HospitalAhmedabadIndia
  10. 10.Department of Gynecologic oncologyChristian Medical College and HospitalVelloreIndia

Personalised recommendations