TOPIC: Respiratory Care
      TYPE: Fellow Case Reports
      INTRODUCTION: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are effective treatment modalities for selected patients with peritoneal carcinomatosis. Common pulmonary complications reported in the literature related to CRS and HIPEC are post-operative pneumonia, pleural effusion, and respiratory distress requiring intubation. We present a case of diaphragmatic weakness resulting as a complication of CRS and HIPEC.
      CASE PRESENTATION: A 76-year-old Caucasian male was seen in the clinic for evaluation of dyspnea on exertion. He reported symptoms for 1 year which worsened in the last 4 months. He had a history of recurrent esophageal adenocarcinoma with peritoneal carcinomatosis and underwent CRS (laparoscopic bilateral diaphragm stripping, omentectomy, and debulking of intraabdominal tumor) and HIPEC with cisplatin and mitomycin 4 months ago. Vital signs were normal. The physical exam was unremarkable. Bedside lung ultrasound showed decreased movement of the diaphragm. Recent CT chest from 2 months ago had shown bilateral rounded atelectasis and mild chronic effusions which were stable and were not significant enough to explain his symptoms. He did not have any cardiac dysfunction on the echocardiogram. There was suspicion of diaphragmatic weakness given the history of multiple procedures for his recurrent metastatic esophageal cancer.Further workup included pulmonary function tests which showed FEV1/FVC 0.9, FVC 51% predicted (N: 80-120%) and TLC 59% of predicted (N: 80-120%) suggesting restrictive disease. Also, maximum inspiratory (MIP) and expiratory pressures (MEP) were decreased at 42% and 27% of the predicted respectively suggesting diaphragmatic weakness. The patient was prescribed nocturnal bi-level pressure support to help the weakened diaphragm. His pulmonary function continues to decline slowly.
      DISCUSSION: Pulmonary complications are common after abdominal surgery. Combining CRS with HIPEC confers additional risk. Diaphragmatic weakness is not a well-reported complication. It can result either from diaphragmatic stripping or as a side effect of the chemotherapeutic agents normally used in the protocol, particularly cisplatin. Treatment includes ventilatory support with noninvasive ventilation (NIV) and tracheostomy in patients with contraindications to NIV.
      CONCLUSIONS: Diaphragmatic weakness should be in the differential diagnosis of dyspnea in patients who had a history of CRS and HIPEC. Early recognition and treatment can result in symptomatic improvement.
      REFERENCE #1: Guinard S, Olland A, Ohana M, Falcoz PE, Kessler R, Massard G. Paralysie diaphragmatique progressive consécutive à une chimiothérapie intra-abdominale [Progressive paralysis of the diaphragm following intra-abdominal chemotherapy]. Rev Mal Respir. 2017 Mar;34(3):244-248. French. doi: 10.1016/j.rmr.2016.05.013. Epub 2016 Sep 14. PMID: 27639949.
      REFERENCE #2: Vinicius Preti, David Chang, Paul H. Sugarbaker, "Pulmonary Complications following Cytoreductive Surgery and Perioperative Chemotherapy in 147 Consecutive Patients", Gastroenterology Research and Practice, vol. 2012, Article ID 635314, 8 pages, 2012
      DISCLOSURES: No relevant relationships by Mirza Ali, source=Web Response
      No relevant relationships by Shujaa Faryad, source=Web Response
      No relevant relationships by Pallavi Pradeep, source=Web Response