The second patient is a 37 year-old man of Mexican origin with an unremarkable past medical history. He had no history of asbestos exposure or any coagulopathy. In April 2006, he presented with diffuse abdominal pain and distension. Abdominal ultrasound showed an important mass in the left inferior quadrant and a diagnosis of epithelioid mesothelioma was confirmed by percutaneous biopsy. The patient was initially treated with systemic chemotherapy (cisplatin and gemcitabine) with some response. In October 2006, the patient suffered a thrombotic stroke attributed to gemcitabine. Chemotherapy was stopped and the patient was treated with low molecular weight heparin as well as anticonvulsant therapy for residual seizures. He completely recovered from this episode. Two months later, he underwent an incomplete cytoreduction of his mesothelioma (omentectomy and appendectomy) in Mexico. The post-operative course was uneventful. Few weeks later, he consulted our team for an opinion regarding treatment of his residual disease. At preoperative workup, the disease seemed to be resectable and hepatic and coagulation functions were completely normal. Cytoreductive surgery including left hemicolectomy, splenectomy, gastric wedge excision, and diverting loop ileostomy were performed in June 2007. The PCI score was 13. HIPEC-OX was then performed as previously described. Surgery was uneventful, and total blood losses were estimated at 500 ml. On postoperative day one, the patient developed hypotension with a hemoglobin count of 68 g/L. Fresh blood was emerging from the abdominal wound. He was transferred to the operating room, where an important hepatic laceration at the inferior border of segment V with ongoing bleeding was noticed. Hemostasis and damage control surgery were performed with extensive packing to control hemorrhage. The following day, the patient returned to the operating room for removal of packing material. At surgery, bleeding was under control but the gallbladder appeared necrotic. Cholecystectomy was performed and the V.A.C.® abdominal dressing system was used to close the abdomen. He later developed hepatic dysfunction with liver enzymes up to 5300 and alkaline phosphatase at 340. Coagulation values were mildly elevated. Five other abdominal explorations and V.A.C.® dressing changes were necessary. Twenty days following CS, he underwent a partial right hepatectomy for excision of infected hepatic necrosis. He slowly regained his hepatic function and his sepsis was successfully treated with antibiotics. He was discharged after 66 days of hospitalisation. He was later reoperated to repair his large ventral hernia and he recovered very well. He finally presented a recurrence of peritoneal mesothelioma in November 2010.

I n conclusion, hepatic necrosis is an unusual complication of HIPEC. Oxaliplatin entrapment within Glisson’s capsule or within hepatic lacerations could induce local or systemic toxicity with resultant parenchyma necrosis. Thermal injury may be contributory, and therefore extreme caution should be exerted to avoid it.