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Surgical Complications And Bevacizumab

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Surgical Complications And Bevacizumab

  1. 1. SURGICAL COMPLICATIONS AND BEVACIZUMAB PETER HEWETT MBBS FRACS
  2. 2. AETIOLOGY <ul><li>Angiogenesis is a critical process in wound healing </li></ul><ul><li>VEGF is a potent angiogenic factor </li></ul><ul><li>Bevacizumab inhibits VEGF binding to its receptors </li></ul><ul><li>Wound healing is compromised </li></ul>
  3. 3. PATHOPHYSIOLOGY <ul><li>Animal Studies </li></ul><ul><li>Inhibition of VEGF was found to reduce vascular density in capillary beds by 70% </li></ul><ul><li>Fibrin clots and endothelial apoptosis leaving vessels as empty basement membrane sleeves. </li></ul>
  4. 4. Complications <ul><li>Grade 3 Proteinuria 1-5% </li></ul><ul><li>Grade 3 or 4 bleeding 1-6% </li></ul><ul><li>Delayed wound healing 1-6% </li></ul><ul><li>GI perforation 0%-3.3% </li></ul><ul><li>Arterial Thrombotic events 0-3% </li></ul>
  5. 6. Gordon M. Oncology 2005;69(suppl 3):25–33
  6. 7. RISK FACTORS <ul><li>In first 6 months of treatment </li></ul><ul><li>Peptic ulcer disease </li></ul><ul><li>Tumour necrosis </li></ul><ul><li>Diverticulitis </li></ul><ul><li>Colitis </li></ul><ul><li>Intraabdominal abscess </li></ul><ul><li>Abdominal Carcinomatosis </li></ul><ul><li>Pelvic Radiation </li></ul><ul><li>NSAID </li></ul><ul><li>Sugrue et al BRiTE study </li></ul>
  7. 8. TREATMENT <ul><li>Resuscitate </li></ul><ul><li>Operate </li></ul><ul><li>Do not anastomose. </li></ul>
  8. 10. Scappaticci FA. Surgical wound healing complications in metastatic colorectal cancer patients treated with bevacizumab. J Surg Oncol 2005;91:173– 180
  9. 11. Elective Surgery <ul><li>Wound complications have occurred up to 56 days after termination of bevacizumab. </li></ul><ul><li>Withhold for 2 to 3 half lives (40-60 days) but surgery 28 days after ceasing bevacizumab is probably safe </li></ul>
  10. 12. Minor surgery <ul><li>No difference in wound complications in venous access device complications implanted within 7 days of starting bevacizumab. </li></ul><ul><li>First BEATrial Berry et al </li></ul><ul><li>American Society of Clinical Oncology Gastrointestinal Symposium 2005 </li></ul>
  11. 13. Major Surgery <ul><li>Withhold bevacizumab. </li></ul><ul><li>Avoid anastomoses </li></ul><ul><li>Form stomas </li></ul><ul><li>Consider tension sutures to </li></ul><ul><li>close abdominal wall. </li></ul>
  12. 14. Surgical morbidity substudy <ul><li>GI perforations. Incidence and outcomes </li></ul><ul><li>Wound healing in patients undergoing major surgery less than 28 days prior to starting bevacizumab. </li></ul><ul><li>Wound healing in patients undergoing any surgery during the administration of bevacizumab. </li></ul><ul><li>Wound healing in patients undergoing any surgery during 28 days after the administration of bevacizumab. </li></ul>
  13. 15. Perforation <ul><li>Tumour at site of perforation </li></ul><ul><li>GI obstruction </li></ul><ul><li>Abdominal Carcinomatosis </li></ul><ul><li>Intraabdominal Abscess </li></ul><ul><li>Acute Diverticulitis </li></ul><ul><li>Other Findings </li></ul>
  14. 16. Grading of Perforation <ul><li>Grade 1: Asymptomatic X-Ray findings only. </li></ul><ul><li>Grade 2 : Medical intervention indicated, I/V fluids for< 24 hours. </li></ul><ul><li>Grade 3: IV fluids, tube feeding, TPN, operative intervention </li></ul><ul><li>Grade 4 : Life threatening Complications </li></ul><ul><li>Grade 5 : Death </li></ul>
  15. 17. Wound Healing <ul><li>Wound Infection </li></ul><ul><li>Wound Dehiscence </li></ul><ul><li>Abscess formation </li></ul><ul><li>Anastomotic leakage (Radiolgical/Clinical) </li></ul><ul><li>Return to Theatre </li></ul><ul><li>Length of Stay (ICU/Hospital) </li></ul><ul><li>Death </li></ul>

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