Cytoreductive Surgery Associated with Intraperitoneal Chemotherapy: A Nine-Year Retrospective Study of a Single-Center Moroccan Experience

Cytoreductive Surgery Associated with Intraperitoneal Chemotherapy: A Nine-Year Retrospective Study of a Single-Center Moroccan Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cytoreductive Surgery Associated with Intraperitoneal Chemotherapy: A Nine-Year Retrospective Study of a Single-Center Moroccan Experience Anas Bakka, Kamal Belkadi, Najlaa Assaid, Hamza Samlali, Redouane Samlali This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6495552/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective This study aimed to retrospectively evaluate the intraoperative management and postoperative outcomes of patients who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) over a nine-year period. Additionally, it provides an overview of morbidity and mortality rates. Methods Data from patients who underwent CRS/HIPEC between January 2014 and December 2022 were retrospectively analyzed. Patient demographics, clinical and pathological profiles, postoperative complications, and mortality outcomes were analyzed. Results A total of 32 patients were included in the study, with the majority being women (81.25%), with a mean age of 54.4 years. The most common comorbidities were diabetes (53.13%) and hypertension (50%). The primary indications for CRS/HIPEC were ovarian cancer (54%) and pseudomyxoma peritonei (23%). Intraoperative complications, mainly bleeding with hemodynamic collapse and hyperthermia, occurred in 20% of the patients. Postoperative complications, including hematological, metabolic, and infectious complications, were observed in 38% of the patients. The three-year mortality rate was 9.4%, corresponding to three patients. Conclusion These findings highlight the importance of thorough assessment and management of complications, as well as long-term outcomes, in patients undergoing CRS/HIPEC. peritoneal carcinomatosis hyperthermic intraperitoneal chemotherapy cytoreductive surgery mortality morbidity Background Peritoneal carcinomatosis (PC) was first described by Sampson in 1931 and refers to the progression of gastrointestinal and gynecological cancer ( 1 ). It is characterized by the metastatic spread of the primary disease to the peritoneum and is often associated with a poor prognosis, with survival durations as short as three months ( 2 , 3 ). Historically, PC was perceived as having limited therapeutic options, primarily managed with palliative care. However, advancements in surgical techniques and systemic cancer treatments have significantly transformed its management ( 4 ). The current focus is on prolonging survival and, in selected cases, achieving a curative intent if the disease is not too advanced. Despite these advances, many patients with initially resectable disease are referred for surgery only after progression following multiple lines of chemotherapy, limiting the potential benefits of surgical intervention ( 5 ). Hyperthermic intraperitoneal chemotherapy (HIPEC) is an aggressive adjunctive therapy for peritoneal carcinomatosis. The first reported use of HIPEC was by Spratt and colleagues in 1980 ( 6 ). This technique involves the intraoperative administration of heated chemotherapy, which selectively destroys malignant cells, enhances drug penetration into tissues, and increases cancer sensitivity to chemotherapy by interfering with DNA repair mechanisms ( 7 ). HIPEC is typically combined with complete tumor cytoreduction surgery (CRS) and, in some cases, intravenous chemotherapy, offering a comprehensive treatment strategy ( 8 ). Indications for HIPEC can be categorized into two groups: (i) cancers for which its efficacy has been well established, such as peritoneal carcinomatosis of colorectal or appendicular origin, as well as primary peritoneal malignancies such as pseudomyxoma peritonei and peritoneal mesothelioma ( 9 ); and (ii) cancers where HIPEC remains a more recent and/or less universally accepted treatment, including peritoneal carcinomatosis of ovarian or gastric origin ( 10 , 11 ). Although HIPEC is associated with a high rate of medical and surgical complications, it has significantly improved survival in patients with malignancies where peritoneal dissemination was previously considered rapidly fatal. A recent multicenter Italian study of 276 patients reported an overall morbidity rate of 71.4% and a 60-day mortality rate of 4.3% ( 12 ). Currently, CRS combined with HIPEC has revolutionized the management of peritoneal malignancies, improving prognoses for appendiceal, colorectal, and ovarian cancers, as well as peritoneal mesothelioma. However, many patients worldwide lack access to these advanced therapies, leading to suboptimal outcomes ( 13 ). This disparity is particularly pronounced in low- and middle-income countries, where limited access is attributed to factors such as a shortage of trained surgeons and restricted opportunities for specialized training abroad. Several Moroccan surgeons have received training in CRS and HIPEC in centers in France ( 14 ). The first CRS/HIPEC procedure in Morocco’s private sector was performed at the Littoral Clinic in 2014. Despite its potential to significantly prolong survival or achieve a cure in selected patients with peritoneal carcinomatosis, data on HIPEC usage in Morocco remain scarce. The objective of this study was to retrospectively evaluate the intraoperative management and postoperative outcomes of patients undergoing CRS/HIPEC over a nine-year period and to provide insights into the morbidity and mortality associated with the procedure. Methods This retrospective study included 32 patients admitted to the Oncology institution, Littoral Clinic in Casablanca, between January 2014 and December 2022. All patients who were diagnosed with gynecological cancer and who underwent CRS combined with hyperthermic intraperitoneal chemotherapy (HIPEC) were included. Peritonectomy procedures followed the technique described by Sugarbaker. An ethical approval waiver was obtained from the Ethics Committee of the Faculty of Medicine of the University of Rabat, given the retrospective nature of the study and the use of fully anonymized medical records, in accordance with applicable local regulations. The study was conducted in accordance with the principles of the Declaration of Helsinki. Patients provided informed consent after receiving a detailed explanation of the potential postoperative complications associated with CRS and HIPEC. The extent of the disease at the start of surgery was assessed via the Peritoneal Cancer Index (PCI) scoring system. The completeness of the cytoreduction score (CCS) was recorded at the end of the CRS according to Sugarbaker's classification. A successful CRS was defined as the complete resection of all visible disease, with optimal cytoreduction defined as residual disease measuring less than 10 mm in diameter. HIPEC was administered immediately post-CRS via a closed-technique heat-exchange perfusion machine. Before abdominal closure, chemotherapeutic agents (oxaliplatin at 13 mg/m² and cisplatin at 100 mg/m²) were delivered through four separate surgical drains at a flow rate of 1,000 cc/min. The intraperitoneal temperature was raised to 42°C before initiating the procedure and was maintained between 42°C and 43°C for 60 minutes. Complications were documented via the Clavien‒Dindo classification, ranging from grade 1 (mild complications) to grade 5 (death). Surgical mortality was defined as any death occurring within 30 days postoperatively. Statistical analyses were performed via SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). Categorical data are presented as numbers (n) and percentages (%). Results Population Description Between 2014 and 2022, a total of 32 patients underwent CRS combined with HIPEC. The study population comprised 81.25% women, with a mean age of 54.4 years (range: 40–65 years) (Table 1 ). Among them, 14 patients (43.75%) had an ASA score of 2. Diabetes (53.13%) and hypertension (50%) were the most prevalent comorbidities (Table 1 ). The mean preoperative weight was 69 kg (range: 62–81 kg). A comparison of demographic characteristics between men and women (Table 2 ) revealed that men had a slightly greater average age (56 years vs. 53 years) and a slightly greater average weight (70 kg vs. 68 kg). However, both groups had similar average BMIs of approximately 27 kg/m². Table 1 Sociodemographic and clinical data of the patients included in the study Year Number of patients (%) 2014 2 (6.25) 2015 1 (3.12) 2016 2 (6.25) 2017 0 2018 1 (3.12) 2019 3 (9.38) 2020 6 (18.75) 2021 6 (18.75) 2022 11 (34.38) Table 2 Average demographic profile by sex: Comparison of age, weight, and BMI Gender Mean age (years) Mean weight (kg) Mean bmi (kg/m²) Male 56 ± 7.8 70 ± 13.1 27 ± 3.9 Female 53 ± 6.8 68 ± 9.4 27 ± 3.1 Ovarian cancer and pseudomyxoma were the most common indications, accounting for 54% and 23% of cases, respectively. Each patient received an epidural arterial catheter for invasive blood pressure monitoring, central venous access, and a thermal probe. The average PCI score was 9.45 [range: 7–18], with cytoreductive surgery lasting an average of 6 hours and 5 minutes (+/- 54 minutes) and a duration of general anesthesia averaging 7 hours and 50 minutes (+/- 1 hour and 23 minutes). All patients were extubated on the operating table (Table 3 ). Table 3 Description of intraoperative data Data Average Average PCI score 9.45 ± 6 Average ga duration 7 h 50 min ± 1 h 23 min Average duration of cytoreduction 6 h 05 min ± 0 h 54 min Hipec protocol duration 90–120 min Extubation 100% on table Cisplatin was the chemotherapy agent most commonly administered, accounting for 53.8% of the cases. Hyperthermia was assessed in both the inlet and outlet drains, with mean temperatures recorded as 43.9°C and 41.1°C, respectively. All patients were admitted to the intensive care unit (ICU) immediately after surgery, with an average ICU stay of 6.65 days (+/- 2.8 days) and an average inpatient stay of 4.1 days (+/- 3.2 days). All patients received a multimodal analgesia protocol. Thromboembolic prophylaxis based on low-molecular-weight heparin (LMWH) was administered, with early ambulation initiated in 80.8% of patients. Postoperative transfusion was necessary for 50% of the patient population. Postoperative nutrition consisted of parenteral and/or enteral methods (Table 4 ). Table 4 Utilization of Parenteral and Enteral Nutrition in Postoperative Care Postoperative day Parenteral nutrition (%) Enteral feeding (%) J0 6 (18.75) J1 26 (81.25) J4 16 (50.0) J5 14 (43.75) J6 2 (6.25) Our study examined both intraoperative and postoperative complications, as well as mortality rates, among patients undergoing this specific surgical intervention (Table 5 ). Intraoperative complications, which occur in 20% of patients, primarily include bleeding, collapse, and hyperthermia. Postoperative complications, including hematological issues such as anemia and thrombocytopenia, metabolic problems such as renal failure and hypoalbuminemia, and infections such as infectious pneumonitis and wall infection, occurred in 38% of the patients (Table 5 ). Additionally, a three-year follow-up revealed a distant mortality rate of 9.4%, representing 3 patients (Table 5 ). Table 5 Complications and mortality rates in patients undergoing HIPEC Complications Percentage Types of complications Intraoperative 20% Bleeding, collapse, and hyperthermia Postoperative 38% Hematological (30.7%): anemia, thrombocytopenia, wall hematoma. Metabolic (19.2%): renal failure, hypoalbuminemia. Infectious (15.3%): infectious pneumonitis, wall infection. Mortality Immediate mortality: 0% distant mortality (3-year follow-up): 9.4% (3 patients) Discussion Between 2014 and 2022, we performed 32 HIPEC procedures. The mean age of our patients was 54.4 years, with a predominance of females (81.25%). Ovarian cancer was the main indication for HIPEC (54%). The mean PCI score was 9.45 ± 6, with an average hospital stay of 10–11 days. Intraoperative complications were noted in 20% of the patients, whereas postoperative complications occurred in 38% of the patients. The immediate mortality rate was 0%, and the distant mortality rate at 3 years was 9.4%. Peritoneal carcinosis has long been regarded as a terminal stage of cancer, often necessitating palliative treatments aimed at symptom management, such as ascites or intestinal obstruction, primarily to improve quality of life in the final stages ( 15 ). However, since the early 2000s, cytoreductive surgery combined with HIPEC has been widely studied and validated as a curative treatment for peritoneal carcinosis, particularly for colorectal or primary peritoneal cancers (e.g., pseudomyxomas and mesotheliomas)( 16 ). However, its role in ovarian and gastric carcinomatosis remains controversial. Despite this, the technique has proven effective in improving survival outcomes for patients with peritoneal metastases ( 17 ). A study conducted at the National Institute of Oncology in Rabat, Morocco, in 2010 by Allam and Errihani reported that approximately two-thirds of peritoneal carcinoses originated from digestive cancers, with 50% being colorectal and 20% from gastric cancers. The remaining cancers were mainly ovarian cancers, which is consistent with our study ( 18 ). In 2016, Passot et al. published a 25-year experience from the Lyon hospital center, where 1125 HIPEC procedures were performed ( 19 ). The primary indications were colorectal (342; 30%), ovarian (271; 24%), pseudomyxoma (189; 17%), gastric (127; 11%), mesothelioma (84; 8%), and others (112; 10%). In our series, ovarian cancer was the most common indication for HIPEC (54%), followed by pseudomyxoma (23%) and colorectal cancer (15%) ( 19 ). A recent study involving 152 patients at the Singapore National Cancer Center reported a median PCI score of 9, with a range of 0–25. The highest PCI scores were observed in primary peritoneal tumors (median 13), whereas ovarian and colorectal cancers had median PCI scores of 7 and 9, respectively. The mean PCI score in our cohort was 9.45 ± 6 ( 20 ). Chua et al. conducted a systematic review published in 2009 to assess the morbidity and mortality associated with CRS combined with hyperthermic intraperitoneal chemotherapy (HIPEC). This review, encompassing 70 studies, reported morbidity rates ranging from 12–52% and mortality rates between 0% and 11% ( 21 ). Similarly, another systematic review from 2007 focused on CRS combined with heated intraperitoneal chemotherapy for ovarian cancer. This study revealed morbidity rates ranging from 5–36%, with a median mortality rate of 3% (ranging from 0–10%) ( 22 ). A study by Glehen et al. of 1290 patients with peritoneal carcinosis treated with HIPEC reported a morbidity rate of 33.6% and a 30-day mortality rate of 4.1%. The survival rates at 1, 3, and 5 years were 77%, 49%, and 37%, respectively ( 23 ). Another study at the Centre Hospitalier de Lyon in 2016 involved 122 patients, with a postoperative mortality rate of 5.7% on day 15, largely due to severe complications such as sepsis, hemorrhagic shock, and acute renal failure ( 24 ). Our study revealed no immediate postoperative mortality and a relatively low 3-year mortality of 9.4%. A prospective study conducted at the Centre Hospitalo-Universitaire de Rouen in 2016 reported a major complication rate of 12.3% at 7 days postsurgery, with no deaths observed within the first 28 days postsurgery ( 25 ). Foster et al. (2019) reported a 30-day mortality rate of 1.1% for CRS/HIPEC, which was lower than that reported for other major surgical procedures, such as pancreaticoduodenectomy (2.5%) and esophagectomy (3.0%) ( 26 ). Kelly et al. (2019) analyzed 2,017 patients who underwent CRS/HIPEC and reported a 30-day readmission rate of 15.9%. The most common causes of readmission included malnutrition (29.9%), infections (23.6%), and ileus or intestinal obstruction (15.1%) ( 27 ). In our study, the immediate mortality rate was 0%, the 3-year mortality rate was 9.4%, and the postoperative morbidity rate was 38%. These favorable outcomes may be attributed to the careful selection of patients who were generally young, in good preoperative condition, and had relatively low PCI scores. Limitations of our study include the small sample size, retrospective nature, and incomplete data in patient files. Conclusion In conclusion, CRS combined with HIPEC offers a curative or survival-extending option for patients with peritoneal carcinosis. However, it is associated with significant morbidity and mortality, highlighting the importance of careful patient selection. Future studies could focus on incorporating additional factors for patient selection, such as the use of PARP inhibitors for ovarian cancer, and on integrating HIPEC with enhanced recovery after surgery (ERAS) protocols to optimize patient recovery. Abbreviations CRS cytoreductive surgery HIPEC Hyperthermic intraperitoneal chemotherapy PC Peritoneal carcinomatosis DNA Deoxyribonucleic acid CCS Cytoreduction score PCI Peritoneal cancer Index ERAS- enhanced recovery after surgery Declarations Acknowledgments Not applicable. Author contributions Conceptualization – AB, KB Data curation – AB, KB, NA, HS; Formal Analysis – AB, KB, NA; Investigation – AB, KB, RS; Methodology – AB, KB, HS; Supervision – AB, KB; Validation – AB, NA, HS; Visualization – AB, KB, NA, HS, RS; Writing – original draft - AB, NA; Writing – review & editing AB, NA. All the authors read and approved the final version of the manuscript. Funding This research was conducted without external funding, and the authors did not receive any financial support or remuneration from either commercial or noncommercial entities. Data availability The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author upon reasonable request. Declarations Ethics approval and consent to participate Ethical approval was not required for this retrospective study, which was based on fully anonymized medical records, as per the applicable local regulations. The study was carried out in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References Sampson JA. Implantation peritoneal carcinomatosis of ovarian origin. Am J Pathol. 1931;7(5):423. Dehal A, Smith JJ, Nash GM. Cytoreductive surgery and intraperitoneal chemotherapy: an evidence-based review—past, present and future. J Gastrointest Oncol. 2016;7(1):143. López-Basave HN, Morales-Vásquez F, Ruiz Molina JM, González-Enciso A, Ñamendys-Silva SA, Medina Castro JM et al. Morbidity and mortality of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: national cancer institute, Mexico City, Mexico. International Scholarly Research Notices [Internet]. 2011 [cité 4 avr 2024];2011. Disponible sur: https://www.hindawi.com/journals/archive/2011/526384/ Neuwirth MG, Alexander HR, Karakousis GC. 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Treatment of peritoneal carcinomatosis with surgery and hyperthermic peroperative intraperitoneal chemotherapy (HIPEC): new aspects and validated indications. Bull Cancer. 2008;95(1):141–5. Bakrin N, Bereder JM, Decullier E, Classe JM, Msika S, Lorimier G, et al. Peritoneal carcinomatosis treated with cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for advanced ovarian carcinoma: a French multicenter retrospective cohort study of 566 patients. Eur J Surg Oncol (EJSO). 2013;39(12):1435–43. Montori G, Coccolini F, Ceresoli M, Catena F, Colaianni N, Poletti E et al. The treatment of peritoneal carcinomatosis in advanced gastric cancer: state of the art. Int J Surg Oncol [Internet]. 2014 [cité 4 avr 2024];2014. Disponible sur: https://www.hindawi.com/journals/ijso/2014/912418/abs/ Macrì A, Accarpio F, Arcoraci V, Casella F, De Cian F, De Iaco P et al. 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Half of Postoperative Deaths After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Could be Preventable: A French Root Cause Analysis on 5562 Patients. Ann Surg 1 nov. 2021;274(5):797–804. Blampied L. Morbi-mortalité précoce après chimiothérapie hyperthermique intrapéritonéale au Centre Hospitalo-Universitaire de Rouen‎: étude prospective. 2016. Foster JM, Sleightholm R, Patel A, Shostrom V, Hall B, Neilsen B, et al. Morbidity and Mortality Rates Following Cytoreductive Surgery Combined With Hyperthermic Intraperitoneal Chemotherapy Compared With Other High-Risk Surgical Oncology Procedures. JAMA Netw Open 4 janv. 2019;2(1):e186847. Lee TC, Wima K, Sussman JJ, Ahmad SA, Cloyd JM, Ahmed A, et al. Readmissions After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: a US HIPEC Collaborative Study. J Gastrointest Surg janv. 2020;24(1):165–76. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6495552","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":467690773,"identity":"d984ae3a-d0b2-4c12-a9ab-ecf98d075d65","order_by":0,"name":"Anas Bakka","email":"","orcid":"","institution":"Littoral Clinic","correspondingAuthor":false,"prefix":"","firstName":"Anas","middleName":"","lastName":"Bakka","suffix":""},{"id":467690777,"identity":"77a808e7-d94b-4f7b-882c-ec0c4a1196df","order_by":1,"name":"Kamal Belkadi","email":"","orcid":"","institution":"Littoral Clinic","correspondingAuthor":false,"prefix":"","firstName":"Kamal","middleName":"","lastName":"Belkadi","suffix":""},{"id":467690778,"identity":"44c987bf-1724-4374-857a-40992366266a","order_by":2,"name":"Najlaa Assaid","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYPACCcZ+KIuxgWgtMxtI1MLAuOEAsVrMGZgff/xRYyG7+XjvwQ8f99jJzo8+fEy6gGGbPC4tlg1sZtI8xySMt505lyw541my8cZzaWnSMxhuG+KyzuAAgxkzA5tE4rYbOWbMPAeYEzf28AANYbiN04UGB9g/f/zxTyJx8wywlnq4FnvcWngMJHjbJBI3SIC1HE6czwPRkohTy2GeMmnePgnjGWfOGEvOOHDceAMPW7L1DIPbyTi1HG/f/PHHtzrZ/vYeww8fDlTLzu9hPni7oOK2LS4tDMxYAgQoaIBLPTYg34DFnFEwCkbBKBjRAAD4LFeC7uIq3AAAAABJRU5ErkJggg==","orcid":"","institution":"Littoral Clinic","correspondingAuthor":true,"prefix":"","firstName":"Najlaa","middleName":"","lastName":"Assaid","suffix":""},{"id":467690779,"identity":"c35e960c-6f6f-42a2-9ca3-2d799423e610","order_by":3,"name":"Hamza Samlali","email":"","orcid":"","institution":"Littoral Clinic","correspondingAuthor":false,"prefix":"","firstName":"Hamza","middleName":"","lastName":"Samlali","suffix":""},{"id":467690780,"identity":"e3db2811-0348-41ce-ad7e-f305fb3bfbf8","order_by":4,"name":"Redouane Samlali","email":"","orcid":"","institution":"Littoral Clinic","correspondingAuthor":false,"prefix":"","firstName":"Redouane","middleName":"","lastName":"Samlali","suffix":""}],"badges":[],"createdAt":"2025-04-21 11:23:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6495552/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6495552/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106797071,"identity":"383f2db9-ba7c-4a0b-a52b-bbe371d4c3e7","added_by":"auto","created_at":"2026-04-13 14:13:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":558918,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6495552/v1/e6c992ff-1021-453b-b0ff-9cab94a1d0b6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cytoreductive Surgery Associated with Intraperitoneal Chemotherapy: A Nine-Year Retrospective Study of a Single-Center Moroccan Experience","fulltext":[{"header":"Background","content":"\u003cp\u003ePeritoneal carcinomatosis (PC) was first described by Sampson in 1931 and refers to the progression of gastrointestinal and gynecological cancer (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It is characterized by the metastatic spread of the primary disease to the peritoneum and is often associated with a poor prognosis, with survival durations as short as three months (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Historically, PC was perceived as having limited therapeutic options, primarily managed with palliative care. However, advancements in surgical techniques and systemic cancer treatments have significantly transformed its management (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The current focus is on prolonging survival and, in selected cases, achieving a curative intent if the disease is not too advanced. Despite these advances, many patients with initially resectable disease are referred for surgery only after progression following multiple lines of chemotherapy, limiting the potential benefits of surgical intervention (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHyperthermic intraperitoneal chemotherapy (HIPEC) is an aggressive adjunctive therapy for peritoneal carcinomatosis. The first reported use of HIPEC was by Spratt and colleagues in 1980 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This technique involves the intraoperative administration of heated chemotherapy, which selectively destroys malignant cells, enhances drug penetration into tissues, and increases cancer sensitivity to chemotherapy by interfering with DNA repair mechanisms (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). HIPEC is typically combined with complete tumor cytoreduction surgery (CRS) and, in some cases, intravenous chemotherapy, offering a comprehensive treatment strategy (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIndications for HIPEC can be categorized into two groups: (i) cancers for which its efficacy has been well established, such as peritoneal carcinomatosis of colorectal or appendicular origin, as well as primary peritoneal malignancies such as pseudomyxoma peritonei and peritoneal mesothelioma (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e); and (ii) cancers where HIPEC remains a more recent and/or less universally accepted treatment, including peritoneal carcinomatosis of ovarian or gastric origin (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough HIPEC is associated with a high rate of medical and surgical complications, it has significantly improved survival in patients with malignancies where peritoneal dissemination was previously considered rapidly fatal. A recent multicenter Italian study of 276 patients reported an overall morbidity rate of 71.4% and a 60-day mortality rate of 4.3% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCurrently, CRS combined with HIPEC has revolutionized the management of peritoneal malignancies, improving prognoses for appendiceal, colorectal, and ovarian cancers, as well as peritoneal mesothelioma. However, many patients worldwide lack access to these advanced therapies, leading to suboptimal outcomes (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This disparity is particularly pronounced in low- and middle-income countries, where limited access is attributed to factors such as a shortage of trained surgeons and restricted opportunities for specialized training abroad. Several Moroccan surgeons have received training in CRS and HIPEC in centers in France (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The first CRS/HIPEC procedure in Morocco\u0026rsquo;s private sector was performed at the Littoral Clinic in 2014. Despite its potential to significantly prolong survival or achieve a cure in selected patients with peritoneal carcinomatosis, data on HIPEC usage in Morocco remain scarce.\u003c/p\u003e \u003cp\u003eThe objective of this study was to retrospectively evaluate the intraoperative management and postoperative outcomes of patients undergoing CRS/HIPEC over a nine-year period and to provide insights into the morbidity and mortality associated with the procedure.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis retrospective study included 32 patients admitted to the Oncology institution, Littoral Clinic in Casablanca, between January 2014 and December 2022. All patients who were diagnosed with gynecological cancer and who underwent CRS combined with hyperthermic intraperitoneal chemotherapy (HIPEC) were included. Peritonectomy procedures followed the technique described by Sugarbaker.\u003c/p\u003e \u003cp\u003e An ethical approval waiver was obtained from the Ethics Committee of the Faculty of Medicine of the University of Rabat, given the retrospective nature of the study and the use of fully anonymized medical records, in accordance with applicable local regulations. The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e \u003cp\u003ePatients provided informed consent after receiving a detailed explanation of the potential postoperative complications associated with CRS and HIPEC. The extent of the disease at the start of surgery was assessed via the Peritoneal Cancer Index (PCI) scoring system. The completeness of the cytoreduction score (CCS) was recorded at the end of the CRS according to Sugarbaker's classification. A successful CRS was defined as the complete resection of all visible disease, with optimal cytoreduction defined as residual disease measuring less than 10 mm in diameter.\u003c/p\u003e \u003cp\u003eHIPEC was administered immediately post-CRS via a closed-technique heat-exchange perfusion machine. Before abdominal closure, chemotherapeutic agents (oxaliplatin at 13 mg/m\u0026sup2; and cisplatin at 100 mg/m\u0026sup2;) were delivered through four separate surgical drains at a flow rate of 1,000 cc/min. The intraperitoneal temperature was raised to 42\u0026deg;C before initiating the procedure and was maintained between 42\u0026deg;C and 43\u0026deg;C for 60 minutes.\u003c/p\u003e \u003cp\u003eComplications were documented via the Clavien‒Dindo classification, ranging from grade 1 (mild complications) to grade 5 (death). Surgical mortality was defined as any death occurring within 30 days postoperatively.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed via SPSS version 20.0 (SPSS Inc., Chicago, IL, USA). Categorical data are presented as numbers (n) and percentages (%).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePopulation Description\u003c/h2\u003e \u003cp\u003eBetween 2014 and 2022, a total of 32 patients underwent CRS combined with HIPEC. The study population comprised 81.25% women, with a mean age of 54.4 years (range: 40\u0026ndash;65 years) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among them, 14 patients (43.75%) had an ASA score of 2.\u003c/p\u003e \u003cp\u003eDiabetes (53.13%) and hypertension (50%) were the most prevalent comorbidities (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The mean preoperative weight was 69 kg (range: 62\u0026ndash;81 kg).\u003c/p\u003e \u003cp\u003eA comparison of demographic characteristics between men and women (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) revealed that men had a slightly greater average age (56 years vs. 53 years) and a slightly greater average weight (70 kg vs. 68 kg). However, both groups had similar average BMIs of approximately 27 kg/m\u0026sup2;.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic and clinical data of the patients included in the study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of patients (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (9.38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (18.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (18.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (34.38)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAverage demographic profile by sex: Comparison of age, weight, and BMI\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean age (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean weight (kg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean bmi (kg/m\u0026sup2;)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e56\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e70\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e27\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e53\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e68\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e27\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOvarian cancer and pseudomyxoma were the most common indications, accounting for 54% and 23% of cases, respectively. Each patient received an epidural arterial catheter for invasive blood pressure monitoring, central venous access, and a thermal probe. The average PCI score was 9.45 [range: 7\u0026ndash;18], with cytoreductive surgery lasting an average of 6 hours and 5 minutes (+/- 54 minutes) and a duration of general anesthesia averaging 7 hours and 50 minutes (+/- 1 hour and 23 minutes). All patients were extubated on the operating table (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescription of intraoperative data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eData\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage PCI score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.45\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage ga duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 h 50 min\u0026thinsp;\u0026plusmn;\u0026thinsp;1 h 23 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAverage duration of cytoreduction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 h 05 min\u0026thinsp;\u0026plusmn;\u0026thinsp;0 h 54 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHipec protocol duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90\u0026ndash;120 min\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtubation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100% on table\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCisplatin was the chemotherapy agent most commonly administered, accounting for 53.8% of the cases. Hyperthermia was assessed in both the inlet and outlet drains, with mean temperatures recorded as 43.9\u0026deg;C and 41.1\u0026deg;C, respectively. All patients were admitted to the intensive care unit (ICU) immediately after surgery, with an average ICU stay of 6.65 days (+/- 2.8 days) and an average inpatient stay of 4.1 days (+/- 3.2 days). All patients received a multimodal analgesia protocol. Thromboembolic prophylaxis based on low-molecular-weight heparin (LMWH) was administered, with early ambulation initiated in 80.8% of patients. Postoperative transfusion was necessary for 50% of the patient population. Postoperative nutrition consisted of parenteral and/or enteral methods (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUtilization of Parenteral and Enteral Nutrition in Postoperative Care\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative day\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParenteral nutrition (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEnteral feeding (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJ0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (18.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJ1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (81.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJ4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJ5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (43.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJ6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (6.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOur study examined both intraoperative and postoperative complications, as well as mortality rates, among patients undergoing this specific surgical intervention (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Intraoperative complications, which occur in 20% of patients, primarily include bleeding, collapse, and hyperthermia. Postoperative complications, including hematological issues such as anemia and thrombocytopenia, metabolic problems such as renal failure and hypoalbuminemia, and infections such as infectious pneumonitis and wall infection, occurred in 38% of the patients (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Additionally, a three-year follow-up revealed a distant mortality rate of 9.4%, representing 3 patients (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComplications and mortality rates in patients undergoing HIPEC\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTypes of complications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBleeding, collapse, and hyperthermia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHematological (30.7%): anemia, thrombocytopenia, wall hematoma. \u003c/p\u003e \u003cp\u003eMetabolic (19.2%): renal failure, hypoalbuminemia. \u003c/p\u003e \u003cp\u003eInfectious (15.3%): infectious pneumonitis, wall infection.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMortality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImmediate mortality: 0% \u003c/p\u003e \u003cp\u003edistant mortality (3-year follow-up): 9.4% (3 patients)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eBetween 2014 and 2022, we performed 32 HIPEC procedures. The mean age of our patients was 54.4 years, with a predominance of females (81.25%). Ovarian cancer was the main indication for HIPEC (54%). The mean PCI score was 9.45\u0026thinsp;\u0026plusmn;\u0026thinsp;6, with an average hospital stay of 10\u0026ndash;11 days. Intraoperative complications were noted in 20% of the patients, whereas postoperative complications occurred in 38% of the patients. The immediate mortality rate was 0%, and the distant mortality rate at 3 years was 9.4%.\u003c/p\u003e \u003cp\u003ePeritoneal carcinosis has long been regarded as a terminal stage of cancer, often necessitating palliative treatments aimed at symptom management, such as ascites or intestinal obstruction, primarily to improve quality of life in the final stages (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). However, since the early 2000s, cytoreductive surgery combined with HIPEC has been widely studied and validated as a curative treatment for peritoneal carcinosis, particularly for colorectal or primary peritoneal cancers (e.g., pseudomyxomas and mesotheliomas)(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, its role in ovarian and gastric carcinomatosis remains controversial. Despite this, the technique has proven effective in improving survival outcomes for patients with peritoneal metastases (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA study conducted at the National Institute of Oncology in Rabat, Morocco, in 2010 by Allam and Errihani reported that approximately two-thirds of peritoneal carcinoses originated from digestive cancers, with 50% being colorectal and 20% from gastric cancers. The remaining cancers were mainly ovarian cancers, which is consistent with our study (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn 2016, Passot et al. published a 25-year experience from the Lyon hospital center, where 1125 HIPEC procedures were performed (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The primary indications were colorectal (342; 30%), ovarian (271; 24%), pseudomyxoma (189; 17%), gastric (127; 11%), mesothelioma (84; 8%), and others (112; 10%). In our series, ovarian cancer was the most common indication for HIPEC (54%), followed by pseudomyxoma (23%) and colorectal cancer (15%) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA recent study involving 152 patients at the Singapore National Cancer Center reported a median PCI score of 9, with a range of 0\u0026ndash;25. The highest PCI scores were observed in primary peritoneal tumors (median 13), whereas ovarian and colorectal cancers had median PCI scores of 7 and 9, respectively. The mean PCI score in our cohort was 9.45\u0026thinsp;\u0026plusmn;\u0026thinsp;6 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eChua et al. conducted a systematic review published in 2009 to assess the morbidity and mortality associated with CRS combined with hyperthermic intraperitoneal chemotherapy (HIPEC). This review, encompassing 70 studies, reported morbidity rates ranging from 12\u0026ndash;52% and mortality rates between 0% and 11% (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Similarly, another systematic review from 2007 focused on CRS combined with heated intraperitoneal chemotherapy for ovarian cancer. This study revealed morbidity rates ranging from 5\u0026ndash;36%, with a median mortality rate of 3% (ranging from 0\u0026ndash;10%) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA study by Glehen et al. of 1290 patients with peritoneal carcinosis treated with HIPEC reported a morbidity rate of 33.6% and a 30-day mortality rate of 4.1%. The survival rates at 1, 3, and 5 years were 77%, 49%, and 37%, respectively (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Another study at the Centre Hospitalier de Lyon in 2016 involved 122 patients, with a postoperative mortality rate of 5.7% on day 15, largely due to severe complications such as sepsis, hemorrhagic shock, and acute renal failure (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Our study revealed no immediate postoperative mortality and a relatively low 3-year mortality of 9.4%.\u003c/p\u003e \u003cp\u003eA prospective study conducted at the Centre Hospitalo-Universitaire de Rouen in 2016 reported a major complication rate of 12.3% at 7 days postsurgery, with no deaths observed within the first 28 days postsurgery (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Foster et al. (2019) reported a 30-day mortality rate of 1.1% for CRS/HIPEC, which was lower than that reported for other major surgical procedures, such as pancreaticoduodenectomy (2.5%) and esophagectomy (3.0%) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Kelly et al. (2019) analyzed 2,017 patients who underwent CRS/HIPEC and reported a 30-day readmission rate of 15.9%. The most common causes of readmission included malnutrition (29.9%), infections (23.6%), and ileus or intestinal obstruction (15.1%) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, the immediate mortality rate was 0%, the 3-year mortality rate was 9.4%, and the postoperative morbidity rate was 38%. These favorable outcomes may be attributed to the careful selection of patients who were generally young, in good preoperative condition, and had relatively low PCI scores. Limitations of our study include the small sample size, retrospective nature, and incomplete data in patient files.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, CRS combined with HIPEC offers a curative or survival-extending option for patients with peritoneal carcinosis. However, it is associated with significant morbidity and mortality, highlighting the importance of careful patient selection. Future studies could focus on incorporating additional factors for patient selection, such as the use of PARP inhibitors for ovarian cancer, and on integrating HIPEC with enhanced recovery after surgery (ERAS) protocols to optimize patient recovery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCRS\u0026nbsp;\u003c/strong\u003ecytoreductive surgery\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHIPEC\u0026nbsp;\u003c/strong\u003eHyperthermic intraperitoneal chemotherapy\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePC\u0026nbsp;\u003c/strong\u003ePeritoneal carcinomatosis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDNA\u0026nbsp;\u003c/strong\u003eDeoxyribonucleic acid\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCCS\u0026nbsp;\u003c/strong\u003eCytoreduction score\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePCI\u0026nbsp;\u003c/strong\u003ePeritoneal cancer Index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eERAS-\u003c/strong\u003eenhanced recovery after surgery\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization \u0026ndash; AB, KB Data curation \u0026ndash; AB, KB, NA, HS; Formal Analysis \u0026ndash; AB, KB, NA; Investigation \u0026ndash; AB, KB, RS; Methodology \u0026ndash; AB, KB, HS; Supervision \u0026ndash; AB, KB; Validation \u0026ndash; AB, NA, HS; Visualization \u0026ndash; AB, KB, NA, HS, RS; Writing \u0026ndash; original draft - AB, NA; Writing \u0026ndash; review \u0026amp; editing AB, NA. All the authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was conducted without external funding, and the authors did not receive any financial support or remuneration from either commercial or noncommercial entities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was not required for this retrospective study, which was based on fully anonymized medical records, as per the applicable local regulations. The study was carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSampson JA. Implantation peritoneal carcinomatosis of ovarian origin. Am J Pathol. 1931;7(5):423.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDehal A, Smith JJ, Nash GM. Cytoreductive surgery and intraperitoneal chemotherapy: an evidence-based review\u0026mdash;past, present and future. 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Pleura and Peritoneum. 26 f\u0026eacute;vr. 2021;6(1):21\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePocard M. Medical devices for treating peritoneal metastasis in low-income countries: is less more? Pleura Peritoneum 20 d\u0026eacute;c. 2017;2(4):149\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEssangri H, Bahaoui NE, Souadka A, Majbar MA, Benkabbou A, Mohsine R, et al. 854 The Establishment of a National Peritoneal Surface Malignancy Programme: The Success, Pitfalls and Difficulties of the Moroccan Experience. Br J Surg. 2022;109(Supplement6):znac268\u0026ndash;029.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLambert LA, Hendrix RJ. Palliative management of advanced peritoneal carcinomatosis. Surg Oncol Clin. 2018;27(3):585\u0026ndash;602.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCardi M, Sammartino P, Mingarelli V, Sibio S, Accarpio F, Biacchi D, et al. Cytoreduction and HIPEC in the treatment of unconventional secondary peritoneal carcinomatosis. World J Surg Oncol 22 oct. 2015;13(1):305.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMirnezami R, Mehta AM, Chandrakumaran K, Cecil T, Moran BJ, Carr N, et al. Cytoreductive surgery in combination with hyperthermic intraperitoneal chemotherapy improves survival in patients with colorectal peritoneal metastases compared with systemic chemotherapy alone. Br J Cancer oct. 2014;111(8):1500\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllam W, Errihani H. Carcinose p\u0026eacute;riton\u0026eacute;ale: diagnostic et prise en charge th\u0026eacute;rapeutique. La Presse M\u0026eacute;dicale. 2010;39(11):1150\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePassot G, Vaudoyer D, Villeneuve L, Kepenekian V, Beaujard A, Bakrin N, et al. What made hyperthermic intraperitoneal chemotherapy an effective curative treatment for peritoneal surface malignancy: A 25-year experience with 1,125 procedures. J Surg Oncol juin. 2016;113(7):796\u0026ndash;803.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen V, Jones M, Cohen L, Yang W, Bedi J, Mohan HM et al. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in small bowel adenocarcinoma with peritoneal metastasis: a systematic review. Pleura Peritoneum 7(4):159\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChua TC, Yan TD, Saxena A, Morris DL. Should the treatment of peritoneal carcinomatosis by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy still be regarded as a highly morbid procedure? a systematic review of morbidity and mortality. Ann Surg. 2009;249(6):900\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBijelic L, Jonson A, Sugarbaker PH. Systematic review of cytoreductive surgery and heated intraoperative intraperitoneal chemotherapy for treatment of peritoneal carcinomatosis in primary and recurrent ovarian cancer. Ann Oncol d\u0026eacute;c. 2007;18(12):1943\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlehen O, Gilly FN, Boutitie F, Bereder JM, Quenet F, Sideris L, et al. Toward curative treatment of peritoneal carcinomatosis from nonovarian origin by cytoreductive surgery combined with perioperative intraperitoneal chemotherapy: A multi-institutional study of 1290 patients. Cancer 15 d\u0026eacute;c. 2010;116(24):5608\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoulz\u0026eacute;-Laroye C, Glehen O, Sgarbura O, Gayat E, Sourrouille I, Tuech JJ, et al. Half of Postoperative Deaths After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Could be Preventable: A French Root Cause Analysis on 5562 Patients. Ann Surg 1 nov. 2021;274(5):797\u0026ndash;804.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlampied L. Morbi-mortalit\u0026eacute; pr\u0026eacute;coce apr\u0026egrave;s chimioth\u0026eacute;rapie hyperthermique intrap\u0026eacute;riton\u0026eacute;ale au Centre Hospitalo-Universitaire de Rouen\u0026lrm;: \u0026eacute;tude prospective. 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoster JM, Sleightholm R, Patel A, Shostrom V, Hall B, Neilsen B, et al. Morbidity and Mortality Rates Following Cytoreductive Surgery Combined With Hyperthermic Intraperitoneal Chemotherapy Compared With Other High-Risk Surgical Oncology Procedures. JAMA Netw Open 4 janv. 2019;2(1):e186847.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee TC, Wima K, Sussman JJ, Ahmad SA, Cloyd JM, Ahmed A, et al. Readmissions After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: a US HIPEC Collaborative Study. J Gastrointest Surg janv. 2020;24(1):165\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"peritoneal carcinomatosis, hyperthermic intraperitoneal chemotherapy, cytoreductive surgery, mortality, morbidity","lastPublishedDoi":"10.21203/rs.3.rs-6495552/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6495552/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to retrospectively evaluate the intraoperative management and postoperative outcomes of patients who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) over a nine-year period. Additionally, it provides an overview of morbidity and mortality rates.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eData from patients who underwent CRS/HIPEC between January 2014 and December 2022 were retrospectively analyzed. Patient demographics, clinical and pathological profiles, postoperative complications, and mortality outcomes were analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 32 patients were included in the study, with the majority being women (81.25%), with a mean age of 54.4 years. The most common comorbidities were diabetes (53.13%) and hypertension (50%). The primary indications for CRS/HIPEC were ovarian cancer (54%) and pseudomyxoma peritonei (23%). Intraoperative complications, mainly bleeding with hemodynamic collapse and hyperthermia, occurred in 20% of the patients. Postoperative complications, including hematological, metabolic, and infectious complications, were observed in 38% of the patients. The three-year mortality rate was 9.4%, corresponding to three patients.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThese findings highlight the importance of thorough assessment and management of complications, as well as long-term outcomes, in patients undergoing CRS/HIPEC.\u003c/p\u003e","manuscriptTitle":"Cytoreductive Surgery Associated with Intraperitoneal Chemotherapy: A Nine-Year Retrospective Study of a Single-Center Moroccan Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-09 03:35:57","doi":"10.21203/rs.3.rs-6495552/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"641c5004-2a61-4445-85ec-0cb0f023b801","owner":[],"postedDate":"June 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T14:11:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-09 03:35:57","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6495552","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6495552","identity":"rs-6495552","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}