LAUSR

To the Editor, In a recent issue of Supportive Care in Cancer, we read with great interest the article from Smibert OC et al. [1]. The paper is well written, and we must compliment the authors for their outstanding experience and the results. Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal perfusion (HIPEC) has been increasingly used for the treatment of selected primary and metastatic peritoneal malignancies with excellent postoperative results [2]. Due to the complex and prolonged surgical procedures associated with the local cytotoxic drugs administration, infections represent the majority of complications [3]. As properly stated by the authors, the implementation of effective prevention strategies in the perioperative period is essential in order to improve results and decrease healthcare costs. Having said that, we have some questions and comments. First, the median number of resected organ and PCI value were 1 and 5, respectively, and looking at the range, the lowest value was 0 in both groups. Apparently few extended procedures were performed, so it would be useful to know more details about these cases? Second, since infection may be associated with other complications, it would be interesting to know the overall postoperative morbidity rate, revealing also the other type of complications recorded. Third, did you find any improvement in outcomes with respect to the beginning of the experience, in accordance with the well-known required learning curve, as reported in the literature [4]. With respect to the microbiologic aspect, we disagree with the authors on the protocol of treatment. Surgical site infections constitute the majority of infectious complications [5, 6]. Empirical treatment with piperacillin/tazobactam does not cover Enterococcus pathogens, which are responsible for several cases, especially following bowel opening [3, 5]. This could represent one of the main causes for the extended prolonged mean days (23) of antibiotic therapy reported. Did you perform any culture of the drained fluid or tip to select a targeted therapy? We do agree that antifungal therapy should be avoided in first-line treatment without positive cultures. We congratulate with the authors again for the extremely interesting paper focusing on such a relevant and complex issue and we are grateful for the opportunity to discuss it.