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Society for Surgery of the Alimentary Tract

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Tiffany C. Lee*1, Koffi Wima1, Jeffrey Sussman1, Syed Ahmad1, Jordan Cloyd2, Ahmed Ahmed2, Keith Fournier3, Andrew Lee3, Sean Dineen4, Benjamin Powers4, Jula Veerapong5, Joel Baumgartner5, Callisia N. Clarke6, Harveshp Mogal6, Charles A. Staley7, Shishir K. Maithel7, Jennifer Leiting8, Travis e. Grotz8, Laura Lambert9, Ryan J. Hendrix9, Sharon M. Weber10, Courtney Pokrzywa10, Byrne Lee11, Fabian M. Johnston12, Jonathan B. Greer12, Sameer Patel1
1University of Cincinnati, Cincinnati, OH; 2The Ohio State University, Columbus, OH; 3University of Texas MD Anderson, Houston, TX; 4Moffitt Cancer Center, Tampa, FL; 5University of California, San Diego, La Jolla, CA; 6Medical College of Wisconsin, Milwaukee, WI; 7Emory University, Atlanta, GA; 8Mayo Clinic, Rochester, MN; 9University of Massachusetts, Worcester, MA; 10University of Wisconsin, Madison, WI; 11City of Hope National Medical Center, Duarte, CA; 12Johns Hopkins University, Baltimore, MD

Objective: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is indicated in the treatment of select patients with peritoneal carcinomatosis. The surgery is associated with significant postoperative morbidity and need for hospital readmission. Previous studies of risk factors for readmission have produced inconsistent results and been limited by their single institution design. We therefore sought to evaluate indications for and factors associated with readmission using the largest multi-institutional CRS-HIPEC database.

Methods: The US HIPEC Collaborative, a multi-institutional database from 12 academic institutions, was queried to include all patients undergoing CRS-HIPEC from 1999-2017. Exclusion criteria included patients who underwent CRS but not HIPEC or did not have readmission data. Patient and tumor factors, perioperative details, and postoperative outcomes were characterized and analyzed for associations with hospital readmission within 30 days of discharge.

Results: Out of 2372 cases in the database, 1327 were included in the analysis. The overall readmission rate was 19.3%, with 13.7% readmitted within 30 days of discharge (n=182). 87.3% were readmitted to the index hospital. Tumor origin in the entire cohort included appendiceal (93.1%), colorectal (4.2%), gastric (0.8%), mesothelioma (0.3%), small bowel (0.2%), and other (1.4%), with similar distributions within the readmission and non-readmission groups. Common indications for readmission included failure to thrive (FTT, 30.4%), infection (23.2%) and ileus/bowel obstruction (16.0%).

On multivariate analysis, factors during index admission not associated with readmission included ASA class, operative time, peritoneal cancer index, completeness of cytoreduction score, individual procedures during cytoreduction, open vs closed HIPEC technique, infectious complications, enteric fistula, or need for postoperative nutritional supplementation. Factors associated with readmission during the index hospitalization (p<0.05) included stoma creation (OR 1.95), ileus (OR 2.06), intraoperative need for red blood cell transfusion (OR 2.24), venous thromboembolism (OR 7.92), and anastomotic leak (OR 19.89).

Conclusions: In the largest study to date, approximately 20% of patients undergoing CRS-HIPEC experienced a hospital readmission. Indications for readmission included failure to thrive, ileus/bowel obstruction, or infectious complications. Demographic and tumor factors failed to predict the need for readmission. Postoperative complications, including venous thromboembolism, ileus, and anastomotic leaks, were strongly associated with hospital readmission. Patients who experience postoperative complications following CRS-HIPEC may benefit from closer post-discharge monitoring.

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