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Cuenca Apolo D, Puppo Moreno A, Muñoz Casares C, Padillo Ruíz J, Noval Padillo JÁ, Rodríguez Martorell J, Leal Noval SR. Profile of haemostasis and coagulation in patients with peritoneal carcinomatosis undergoing cytoreductive surgery with hyperthermal chemotherapy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2025; 51:109497. [PMID: 39724721 DOI: 10.1016/j.ejso.2024.109497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Revised: 11/15/2024] [Accepted: 11/23/2024] [Indexed: 12/28/2024]
Abstract
BACKGROUND One-third of patients with peritoneal carcinomatosis undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) present alterations in conventional coagulation test results. However, perioperative coagulation has not been systematically investigated in these patients. This study aimed to investigate hemostatic changes in such patients. METHODS This prospective observational study included patients with peritoneal carcinomatosis who underwent CRS-HIPEC. Variables of conventional coagulation and rotational thromboelastometry (ROTEM) parameters of patients who underwent CRS-HIPEC at baseline (time 0, T0: before surgery) were compared with those of healthy blood donors (HBD). Blood samples were collected at baseline (T0), 2-h (T2), and 72-h (T72) after surgery. RESULTS 44 patients who underwent CRS-HIPEC and 40 HBDs were included. At T0, patients who underwent CRS-HIPEC presented with lower hemoglobin levels and elevated C-reactive protein, fibrinogen, factor XIII (FXIII), and D-dimer levels than HBDs. At T2, significant decreases in hemoglobin, platelet count, fibrinogen, and FXIII levels were observed. In contrast, D-dimer and von Willebrand factor levels increased. Regarding ROTEM parameters, in the postoperative period, increased clotting time in thromboelastometry with extrinsic activation, and maximum clot firmness in thromboelastometry with fibrin contribution, along with a significant decrease in maximum clot firmness in thromboelastometry with extrinsic activation without a hyperfibrinolysis pattern, were observed. Platelet function, as assessed using the platelet function assay, was normal. CONCLUSIONS CRS-HIPEC causes coagulopathy secondary to a pronounced platelet drop, worsening of fibrinogen and FXIII levels, and impaired clot firmness as evidenced by ROTEM. A proinflammatory status was ubiquitously observed.
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Affiliation(s)
- Diego Cuenca Apolo
- Neurocritical Care Division, University Hospital 'Virgen Del Rocío', Avda Manuel Siurot S/n, 41013, Seville, Spain.
| | - Antonio Puppo Moreno
- Critical Care Division, University Hospital 'Virgen Del Rocío', Avda Manuel Siurot S/n, 41013, Seville, Spain.
| | - Cristóbal Muñoz Casares
- General Surgery Department, Oncological Surgery Unit University Hospital 'Virgen Del Rocío', Avda Manuel Siurot S/n, 41013, Seville, Spain.
| | - Javier Padillo Ruíz
- General Surgery Department, University Hospital 'Virgen Del Rocío', Avda Manuel Siurot S/n, 41013, Seville, Spain.
| | - José Ángel Noval Padillo
- Department of Clinical Biochemistry, University Hospital 'Virgen Del Rocío', Avda Manuel Siurot S/n, 41013, Seville, Spain.
| | - Javier Rodríguez Martorell
- Coagulation Department, University Hospital 'Virgen Del Rocío', Avda Manuel Siurot S/n, 41013, Seville, Spain.
| | - Santiago R Leal Noval
- Critical Care Division, University Hospital 'Virgen Del Rocío', Avda Manuel Siurot S/n, 41013, Seville, Spain.
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Branco A, Weston FCL, Soares GDR, Linch GFDC, Caregnato RCA. Nursing care for cytoreduction and hyperthermic intraoperative chemotherapy in an Intensive Care Unit: a scoping review. Rev Esc Enferm USP 2024; 58:e20240176. [PMID: 39607881 PMCID: PMC11593163 DOI: 10.1590/1980-220x-reeusp-2024-0176en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 09/24/2024] [Indexed: 11/30/2024] Open
Abstract
OBJECTIVE To map postoperative nursing care for critically ill adult and older patients admitted to the Intensive Care Unit after cytoreduction surgery with hyperthermic intraoperative intraperitoneal chemotherapy. METHOD TScoping review according to the JBI methodology, with articles extracted from databases and gray literature, with no language or publica-tion date delimitation. The studies selection and results extraction process was carried out by two independent reviewers, using the soft-ware EndNote® and Rayyan®. PRISMA Extension for Scoping Review was used for the writing, with registration on the Open Science Framework. RESULTS Forty-two studies were selected. The analysis revealed 72 types of care grouped into 14 care areas. The use of an epidural catheter for anal-gesia, optimization of individualized hemodynamic status, and strict control of fluid balance were the most cited care measures. CONCLUSION The mapping identified post-operative nursing care similar to those for major surgeries for patients recovering in the Intensive Care Unit, with an indication of the use of personal protective equipment by professionals when handling tubes in the first 48 hours of admission.
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Affiliation(s)
- Aline Branco
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto
Alegre, RS, Brazil
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Ray M, Pathak B, Venugopal R, Sonvane S. Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Mesothelioma: Outcomes From a Tertiary Cancer Care Center in India. Cureus 2024; 16:e73658. [PMID: 39677167 PMCID: PMC11645539 DOI: 10.7759/cureus.73658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2024] [Indexed: 12/17/2024] Open
Abstract
BACKGROUND Malignant peritoneal mesothelioma (MPM) is a rare and aggressive form of cancer arising from the peritoneum. The prognosis for MPM has historically been poor, and treatment options are limited. This study evaluated the impact of cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) as a treatment modality for MPM. MATERIALS AND METHODS This retrospective analysis included 15 patients diagnosed with MPM between 2012 and 2023 at a tertiary referral cancer care center in North India. Patients underwent CRS followed by HIPEC. The study assessed outcomes based on overall survival (OS) and postoperative morbidity rates. RESULTS Demographic analysis revealed a female preponderance (n = 9, 60%) and a majority of younger patients, 80% (n = 12) of whom were younger than the age of 50. The mean peritoneal cancer index (PCI) was 14.0, with 60% (n = 9) of patients having a PCI above the mean. The completeness of cytoreduction (CC) varied, with 40% (n = 6) achieving CC0, 33.33% (n = 5) CC1, and 26.67% (n = 4) CC2. Adjuvant chemotherapy was administered to 60% (n = 9) of the patients. The median follow-up period was 25 months, revealing an overall median survival of 27.0 months, with one- and three-year survival rates of 86.7% and 33.3%, respectively. CONCLUSION CRS combined with HIPEC is a viable and effective treatment option for patients with MPM and offers improved survival rates and an acceptable safety profile. These findings support the integration of this treatment modality into the management plan for select patients with MPM, although optimal management is still evolving.
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Affiliation(s)
- Mukurdipi Ray
- Surgical Oncology, All India Institute of Medical Sciences, New Delhi, Delhi, IND
| | - Bhawani Pathak
- Surgical Oncology, All India Institute of Medical Sciences, New Delhi, Delhi, IND
| | - Ravi Venugopal
- Surgical Oncology, All India Institute of Medical Sciences, New Delhi, Delhi, IND
| | - Shwetal Sonvane
- Surgical Oncology, All India Institute of Medical Sciences, New Delhi, Delhi, IND
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Lundbech M, Damsbo M, Krag AE, Hvas AM. Changes in Coagulation in Cancer Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Treatment (HIPEC)-A Systematic Review. Semin Thromb Hemost 2024; 50:474-488. [PMID: 36828005 DOI: 10.1055/s-0043-1764125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
Venous thromboembolism and postoperative bleeding are complications of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this systematic review was to summarize current knowledge on the effect of cytoreductive surgery with HIPEC on coagulation and fibrinolysis within 10 days after surgery. Studies were identified in PubMed, Embase, and Web of Science on December 12, 2022. Data on biomarkers of coagulation and fibrinolysis measured preoperatively up to the 10th postoperative day were extracted. Among 15 included studies, 13 studies reported markers of primary hemostasis. Eleven studies found reduced platelet count following cytoreductive surgery with HIPEC and two studies reported reduced platelet function. Twelve studies reported impaired secondary hemostasis until postoperative day 10 indicated by prolonged international normalized ratio, prothrombin time, and activated partial thromboplastin time. Fibrinogen was decreased in three studies from preoperative to postoperative day 3 switching to increased levels until postoperative day 10. In accordance, three studies found reduced maximum amplitude and maximum clot firmness by thromboelastography/thromboelastometry (ROTEM/TEG) on the first postoperative day indicating impaired clot strength. Four studies demonstrated increased d-dimer, factor (F) VIII, and thrombin generation during the 10 postoperative days. Four studies investigated fibrinolysis by ROTEM/TEG and plasminogen activator inhibitor-1 (PAI-1) after cytoreductive surgery with HIPEC reporting contradictive results. In conclusion, a decrease in platelet count and subtle changes in secondary hemostasis were found following cytoreductive surgery with HIPEC. Data on the effect of cytoreductive surgery with HIPEC on fibrinolysis are sparse and this needs to be further investigated.
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Affiliation(s)
- Mikkel Lundbech
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Matilde Damsbo
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Engel Krag
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Plastic Surgery Research Unit, Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
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Elgendy H, Iqbal M, Youssef T, Alzahrani A, Rugaan A. Optimizing risk factors influence Intensive Care stay after Hyperthermic Intraperitoneal Chemotherapy? An observational cohort study. Cancer Treat Res Commun 2022; 33:100653. [PMID: 36327575 DOI: 10.1016/j.ctarc.2022.100653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/20/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND It may be necessary to admit patients receiving Hyperthermic Intraperitoneal Chemotherapy (HIPEC) to the intensive care unit (ICU). They were required to evaluate the length of ICU stay (LOS) following HIPEC, as well as their survival rates and risk factors that influence LOS. METHODS 74 HIPEC patients were observed after being admitted to the ICU. Their assignments were made based on their LOS at the ICU. Short stay group, patients who stayed in the ICU for three days or less (S-group) and patients who stayed for three days or longer (L-group). RESULTS Survival rates for both groups were comparable. After HIPEC, they exhibited intraoperative hypotension (P = 0.015), hyopthermia (P = 0.014), and hyperglycemia (P = 0.010). Additionally, patients in group L underwent longer surgeries (P = 0.013), lost more blood (P = 0.043), and required more transfusions (P = 0.001). Subjects in group-L had higher SOFA, fentanyl, and vasopressor requirements (all P 0.001), higher ALT and AST levels, disrupted K, lower Na, and higher INR levels (all P 0.001), as well as a higher APACHE II score (P = 0.007). Preoperative BUN had an independent risk factor for LOS of 0.861; (95% CI), (0.742- 0.999); P = 0.048; and crystalloid transfusion had an independent risk factor of 1.000; (95% CI), (0.999- 1.000); P = 0.003. CONCLUSIONS Transfusions of crystalloids and BUN were independent risk factors for extended LOS. ICU LOS had no impact on survival. All measures should be taken to control hemostasis in vulnerable HIPEC participants.
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Affiliation(s)
- Hamed Elgendy
- Department of Anaesthesia, Assiut University Hospitals, Egypt; Department of Anaesthesia, Al Wakrah Hospital, Hamad Medical Corporation, Doha, Qatar.
| | - Masood Iqbal
- Dept. Critical Care Medicine, King Abdullah Medical City, Makkah, Saudi Arabia
| | - Talha Youssef
- Department of Internal Medicine, Nephrology, king Abdul-Aziz Medical City - Ministry of National Guard, Riyadh, Saudi Arabia
| | | | - Asia Rugaan
- Dept. Critical Care Medicine, King Abdullah Medical City, Makkah, Saudi Arabia
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YILDIZ GÖ, SERTCAKACİLAR G, AKYOL D, KARAKAŞ S, HERGÜNSEL GO. Malign asitli over kanserinde sitoredüktif cerrahide perioperatif hemodinamik optimizasyon. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1097476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Purpose: In this study, we aimed to evaluate the effects of norepinephrine and albumin use in patients with epithelial ovarian cancer with malignant ascite in order to maintain plasma oncotic pressure and intravascular volume, to provide perioperative hemodynamic stabilization and tissue perfusion. In addition, it was aimed to compare in terms of postoperative intensive care admission, hospital stay and complications.
Materials and Methods: A total of 66 patients, 38 with ascites and 28 without ascites, who underwent cytoreductive surgery for ovarian cancer were included in this study. PVI and invasive arterial monitoring of the patients were performed after hemodynamic stabilization (after the start of surgery) (T0). T0, 1st hour (T1) and 2nd hour (T2) and postoperative (Tpostop.) Ascites patients were composed of 3 subgroups which the ones received norepinephrine (NE) infusion, norepinephrine + albumin (NEA) infusion or only fluid therapy (FT). From the perioperative hemodynamic and laboratory data of the patients, tissue perfusion was evaluated with lactate, and hemodynamic status was evaluated with pleth variability index (PVI), perfusion index (PI) and mean arterial pressure (MAP).
Results: Demographic and clinical findings did not differ significantly between patients with and without ascites. Lactate level in NEA / NE group in Tpostop, PVI level in T1h, T2h and Tpostop time frames were determined higher than the FT group. PI was found to be significantly lower in the T2 time frame. The postoperative ICU admission rate was higher in the NEA and NE groups. The duration of ICU stay in group NEA was shorter than in group NE.
Conclusion: We recommend the use of low-dose NE with albumin to provide perioperative hemodynamic optimization, tissue perfusion and plasma oncotic pressure in surgery of ovarian cancer with malignant ascites. Despite high fluid replacement in these patients, the use of norepinephrine and albumin together may have an important role in preventing / reducing major complications in the perioperative period.
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Affiliation(s)
- Güneş Özlem YILDIZ
- Department of Anesthesiology and Intensive Care, University of Health Sciences Istanbul, Bakirkoy Dr. Sadi Konuk Training and Research Hospital
| | - Gokhan SERTCAKACİLAR
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL BAKIRKÖY DR. SADİ KONUK TRAINING RESEARCH CENTER
| | - Duygu AKYOL
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL BAŞAKŞEHİR ÇAM VE SAKURA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ
| | - Sema KARAKAŞ
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL BAKIRKÖY DR. SADİ KONUK TRAINING RESEARCH CENTER
| | - Gülsüm Oya HERGÜNSEL
- UNIVERSITY OF HEALTH SCIENCES, İSTANBUL BAKIRKÖY DR. SADİ KONUK TRAINING RESEARCH CENTER
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Hübner M, Kusamura S, Villeneuve L, Al-Niaimi A, Alyami M, Balonov K, Bell J, Bristow R, Guiral DC, Fagotti A, Falcão LFR, Glehen O, Lambert L, Mack L, Muenster T, Piso P, Pocard M, Rau B, Sgarbura O, Somashekhar SP, Wadhwa A, Altman A, Fawcett W, Veerapong J, Nelson G. Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management. Eur J Surg Oncol 2020; 46:2292-2310. [PMID: 32873454 DOI: 10.1016/j.ejso.2020.07.041] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/14/2020] [Accepted: 07/28/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management. METHODS The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations. RESULTS Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma. CONCLUSION The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.
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Affiliation(s)
- Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland.
| | - Shigeki Kusamura
- Peritoneal Surface Malignancy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laurent Villeneuve
- Clinical Research and Epidemiological Unit, Department of Public Health, Lyon University Hospital, EA 3738, University of Lyon, Lyon, France
| | - Ahmed Al-Niaimi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Mohammad Alyami
- Department of General Surgery and Surgical Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Konstantin Balonov
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, USA
| | - John Bell
- Department of Anesthesiology, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Robert Bristow
- Department of Obstetrics and Gynecologic Oncology, University of California, Irvine School of Medicine, Orange, USA
| | - Delia Cortés Guiral
- Department of General Surgery (Peritoneal Surface Surgical Oncology). University Hospital Principe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Anna Fagotti
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Catholic University of the Sacred Heart, 00168, Rome, Italy
| | - Luiz Fernando R Falcão
- Discipline of Anesthesiology, Pain and Critical Care Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Olivier Glehen
- Department of Digestive Surgery, Lyon University Hospital, EA 3738, University of Lyon, Lyon, France
| | - Laura Lambert
- Peritoneal Surface Malignancy Program, Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Lloyd Mack
- Department of Surgical Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Tino Muenster
- Department of Anaesthesiology and Intensive Care Medicine. Hospital Barmherzige Brüder, Regensburg, Germany
| | - Pompiliu Piso
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Marc Pocard
- Department of Digestive Surgery, Lariboisière University Hospital, Paris, France
| | - Beate Rau
- Department of Surgery, Campus Virchow-Klinikum and Charité Campus Mitte, Charité-Universitätsmedizin Berlin, Germany
| | - Olivia Sgarbura
- Department of Surgical Oncology, Cancer Institute Montpellier (ICM), University of Montpellier, Montpellier, France
| | - S P Somashekhar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, Bengaluru, India
| | - Anupama Wadhwa
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Canada
| | - William Fawcett
- Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Jula Veerapong
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, La Jolla, CA, USA
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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Bezu L, Raineau M, Deloménie M, Cholley B, Pirracchio R. Haemodynamic management during hyperthermic intraperitoneal chemotherapy: A systematic review. Anaesth Crit Care Pain Med 2020; 39:531-542. [PMID: 32320757 DOI: 10.1016/j.accpm.2020.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 02/23/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Hyperthermic intraperitoneal chemotherapy (HIPEC) is a surgical technique for peritoneal carcinomatosis combining cytoreduction surgery and peritoneal irrigation of cytotoxic agents responsible for haemodynamics and fluid homeostasis alterations. To this day, no guidelines exist concerning intraoperative management. OBJECTIVES To review data on haemodynamic monitoring and management of patients undergoing HIPEC and to help design a standardised anaesthetic protocol. DATA SOURCES MEDLINE, EMBASE and Cochrane library were searched using the following. STUDY SELECTION Original articles and case-reports. Letters to editors and reviews were excluded. DATA EXTRACTION Data on haemodynamic management, morbidity and mortality. DATA SYNTHESIS Haemodynamic management during HIPEC is highly variable and depends on local protocols. Only one randomised controlled trial evaluated the benefit of goal-directed fluid administration (GDFA). GDFA guided by advanced haemodynamic monitoring resulted in significantly less complication, shorter length of stay and less mortality compared to standard fluid administration. Renal protection protocol did not decrease the risk of acute kidney injury (AKI). CONCLUSION Our review reveals that fluid administration guided by advanced monitoring seems to be associated with less postoperative morbidity and mortality after HIPEC. Nevertheless, the literature review shows that intraoperative haemodynamic management is highly variable for this surgery. The use of renal protection strategy does not decrease the prevalence of AKI. Further prospective trials comparing different fluid management and haemodynamic monitoring strategies are urgently needed (PROSPERO registration CRD42018115720).
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Affiliation(s)
- Lucillia Bezu
- Service d'anesthésie, hôpitaux universitaires Paris Ouest, hôpital européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
| | - Mégane Raineau
- Service d'anesthésie, hôpitaux universitaires Paris Ouest, hôpital européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75015 Paris, France
| | - Myriam Deloménie
- Service de chirurgie cancérologique gynécologique et du sein, hôpitaux universitaires Paris Ouest, hôpital européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Bernard Cholley
- Service d'anesthésie, hôpitaux universitaires Paris Ouest, hôpital européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Inserm UMR S1140, Paris, France
| | - Romain Pirracchio
- Service d'anesthésie, hôpitaux universitaires Paris Ouest, hôpital européen Georges Pompidou, Assistance publique-Hôpitaux de Paris, 20, rue Leblanc, 75015 Paris, France; Université Paris Descartes, Sorbonne Paris Cité, Paris, France
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Pletcher E, Gleeson E, Labow D. Peritoneal Cancers and Hyperthermic Intraperitoneal Chemotherapy. Surg Clin North Am 2020; 100:589-613. [PMID: 32402303 DOI: 10.1016/j.suc.2020.02.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy is an aggressive, potentially curative approach used to treat locoregional disease associated with primary and secondary malignancies of the peritoneum. It involves resection of all macroscopic disease larger than 2.5 mm, followed by instillation of hyperthermic chemotherapy directly into the peritoneum for higher drug exposure to microscopic disease. In select patients with primary peritoneal mesothelioma, pseudomyxoma peritonei, colorectal adenocarcinoma, appendiceal adenocarcinoma, or ovarian cancer, with no extra-abdominal metastasis and limited involvement of the peritoneum, the procedure can be performed to increase overall survival.
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Affiliation(s)
- Eric Pletcher
- Surgery Department, Mount Sinai West and Morningside, 425 West 59th Street, 7th Floor, New York, NY 10019, USA
| | - Elizabeth Gleeson
- Division of Surgical Oncology, Mount Sinai Hospital, 19 East 98th Street, Suite 7A, New York, NY 10029, USA
| | - Daniel Labow
- Surgery Department, Mount Sinai Hospital, Mount Sinai West and Morningside, 425 West 59th Street, 7th Floor, New York, NY 10019, USA.
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10
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Solanki SL, Mukherjee S, Agarwal V, Thota RS, Balakrishnan K, Shah SB, Desai N, Garg R, Ambulkar RP, Bhorkar NM, Patro V, Sinukumar S, Venketeswaran MV, Joshi MP, Chikkalingegowda RH, Gottumukkala V, Owusu-Agyemang P, Saklani AP, Mehta SS, Seshadri RA, Bell JC, Bhatnagar S, Divatia JV. Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). Indian J Anaesth 2019; 63:972-987. [PMID: 31879421 PMCID: PMC6921319 DOI: 10.4103/ija.ija_765_19] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 10/28/2019] [Accepted: 11/18/2019] [Indexed: 02/07/2023] Open
Abstract
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.
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Affiliation(s)
- Sohan Lal Solanki
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
- Address for correspondence: Dr. Sohan Lal Solanki, Department of Anaesthesiology, Critical Care and Pain, 2nd Floor, Main Building, Tata Memorial Hospital, Mumbai - 400 012, Maharashtra, India. E-mail:
| | - Sudipta Mukherjee
- Department of Anaesthesiology, Critical Care Medicine and Pain, Tata Medical Center, Kolkata, West Bengal, India
| | - Vandana Agarwal
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Raghu S Thota
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kalpana Balakrishnan
- Department of Anaesthesia, Pain and Palliative Care, Cancer Institute, Chennai, Tamil Nadu, India
| | - Shagun Bhatia Shah
- Department of Anaesthesiology and Critical Care, Rajiv Gandhi Cancer Institute and Research Centre, Delhi, India
| | - Neha Desai
- Department of Anaesthesiology, Critical Care Medicine and Pain, Tata Medical Center, Kolkata, West Bengal, India
| | - Rakesh Garg
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Reshma P Ambulkar
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - Viplab Patro
- Department of Anaesthesiology, Critical Care Medicine and Pain, Tata Medical Center, Kolkata, West Bengal, India
| | - Snita Sinukumar
- Surgical Oncology, Jehangir Hospital, Pune, Maharashtra, India
| | | | - Malini P Joshi
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pascal Owusu-Agyemang
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Avanish P Saklani
- Gastro-Intestinal Services, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sanket Sharad Mehta
- Department of Surgical Oncology, Saifee Hospital, Mumbai, Maharashtra, India
| | | | - John C Bell
- Anaesthetics and Intensive Care Medicine, Peritoneal Malignancy Institute, Hampshire Hospitals NHS FT, Basingstoke, United Kingdom
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Jigeeshu V Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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11
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The perioperative course and anesthetic challenge for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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12
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Shamavonian R, McLachlan R, Fisher OM, Valle SJ, Alzahrani NA, Liauw W, Morris DL. The effect of intraoperative fluid administration on outcomes of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. J Gastrointest Oncol 2019; 10:235-243. [PMID: 31032090 DOI: 10.21037/jgo.2018.12.11] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Determine the effect of intraoperative fluids (IOFs) administered during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) on postoperative patient outcomes. Methods Retrospective cohort study of patients that underwent CRS/HIPEC from February 2010 to June 2017. Results A total of 335 patients formed the cohort study. Patients who received higher IOFs had longer hospital length of stay (LOS) (34 vs. 22.5 days; P<0.001), extended intensive care unit (ICU) admission (5.3 vs. 3.2 days; P<0.001) and a 12% increase in grade 3/4 complications (P<0.001). Greater amounts of blood product transfusion were associated with longer hospital LOS (33.7 vs. 23 days; P<0.001), and ICU admission (5 vs. 3.4 days; P<0.001) and 12% increase in grade 3/4 complications (P<0.001). When corrected for weight and peritoneal cancer index (PCI), increased transfusion of blood products still resulted in longer hospital LOS (31.2 vs. 25.2 days; P=0.04) and longer ICU admission (4.7 vs. 3.6 days; P=0.03). On multivariable analysis, less blood product transfusions demonstrated a decreased LOS in hospital by 4.8 days (P=0.01) and fewer grade 3/4 complications (OR 0.59; 95% CI, 0.35-0.99; P=0.05). Conclusions Greater IOF administration is associated with an increase in postoperative morbidity, including hospital LOS, ICU admission and grade 3/4 complications, in patients undergoing CRS/HIPEC.
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Affiliation(s)
- Raphael Shamavonian
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW, Australia.,School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Rohan McLachlan
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW, Australia.,St George Hospital Clinical School, University of New South Wales, Sydney, NSW, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Oliver M Fisher
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW, Australia.,School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Sarah J Valle
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW, Australia
| | - Nayef A Alzahrani
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW, Australia.,St George Hospital Clinical School, University of New South Wales, Sydney, NSW, Australia.,College of Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Winston Liauw
- St George Hospital Clinical School, University of New South Wales, Sydney, NSW, Australia.,Cancer Care Centre, St George Hospital, Kogarah, NSW, Australia
| | - David L Morris
- Hepatobilliary and Surgical Oncology Unit, Department of Surgery, St George Hospital, Kogarah, NSW, Australia.,St George Hospital Clinical School, University of New South Wales, Sydney, NSW, Australia
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13
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Li D, Henker R, Zhang F. Perianesthesia Measurement During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Procedure: A Case Report and Review of the Literature. J Perianesth Nurs 2019; 34:198-205. [DOI: 10.1016/j.jopan.2017.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/15/2017] [Accepted: 09/22/2017] [Indexed: 01/19/2023]
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14
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Angeles MA, Quenet F, Vieille P, Gladieff L, Ruiz J, Picard M, Migliorelli F, Chaltiel L, Martínez-Gómez C, Martinez A, Ferron G. Predictive risk factors of acute kidney injury after cytoreductive surgery and cisplatin-based hyperthermic intra-peritoneal chemotherapy for ovarian peritoneal carcinomatosis. Int J Gynecol Cancer 2019; 29:382-391. [PMID: 30674567 DOI: 10.1136/ijgc-2018-000099] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/10/2018] [Accepted: 12/11/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The aim of our study was to assess the incidence and identify the predictive risk factors of acute kidney injury after cytoreductive surgery and cisplatin-based hyperthermic intra-peritoneal chemotherapy. METHODS This is a retrospective study from two centers evaluating patients with advanced or recurrent ovarian cancer who underwent cytoreductive surgery followed by cisplatin-based hyperthermic intra-peritoneal chemotherapy from January 2007 to December 2013. Patients were classified into two groups according to the occurrence of acute kidney injury, defined as a glomerular filtration rate at post-operative day 7 25% lower than at day 0. We also evaluated acute kidney injury following Risk, Injury, Failure, Lost and End-stage kidney function criteria. Univariate and multivariate analyses were conducted in order to assess the association between different variables and the occurrence of acute kidney injury. RESULTS Sixty-six patients were included: 29 (44%) underwent first-line treatment and 37 (56%) were treated for recurrent disease. The incidence of post-operative acute kidney injury was 48%. After multivariate analysis, hypertension (OR 18.6; 95% CI 1.9 to 182.3; p=0.012) and low intra-operative diuresis (OR 0.5; 95% CI 0.4 to 0.8; p=0.001) were associated with acute kidney injury. CONCLUSION The incidence of acute kidney injury after cytoreductive surgery and cisplatin-based hyperthermic intra-peritoneal chemotherapy was high. Hypertension and low intra-operative diuresis were independent risk factors for this complication. Adequate peri-operative hydration, in order to maintain correct diuresis, could decrease the occurrence of acute kidney injury in patients undergoing cytoreductive surgery plus hyperthermic intra-peritoneal chemotherapy.
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Affiliation(s)
- Martina Aida Angeles
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - François Quenet
- Department of Surgical Oncology, Institut du Cancer de Montpellier (ICM), Montpellier, France
| | - Pierre Vieille
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France.,Department of Gynecology, CHR, Perpignan, France
| | - Laurence Gladieff
- Department of Medical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Jean Ruiz
- Intensive Care Unit, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Muriel Picard
- Intensive Care Unit, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Federico Migliorelli
- Institute Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Leonor Chaltiel
- Biostatistics Unit, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Carlos Martínez-Gómez
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France.,INSERM CRCT 1, Toulouse, France
| | - Alejandra Martinez
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France.,INSERM CRCT 1, Toulouse, France
| | - Gwénaël Ferron
- Department of Surgical Oncology, Institut Claudius Regaud - Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France .,INSERM CRCT 19, Toulouse, France
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15
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Hendrix RJ, Damle A, Williams C, Harris A, Spanakis S, Lambert DH, Lambert LA. Restrictive Intraoperative Fluid Therapy is Associated with Decreased Morbidity and Length of Stay Following Hyperthermic Intraperitoneal Chemoperfusion. Ann Surg Oncol 2018; 26:490-496. [PMID: 30515670 DOI: 10.1245/s10434-018-07092-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recent data have demonstrated multiple benefits of intra- and postoperative fluid restriction in major abdominal surgery; however, data regarding the outcomes of fluid restriction in cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion (CRS/HIPEC) are limited. This study evaluates the safety and short-term clinical outcomes of restricted intraoperative fluid therapy in CRS/HIPEC. METHODS This was a single-institution, retrospective review of all CRS/HIPEC procedures performed at the University of Massachusetts Medical School between January 2009 and July 2017. Recorded variables included demographics, intraoperative factors, 60-day postoperative complications, and length of stay (LOS). Outcomes based on the use of intraoperative permissive fluid therapy (PFT) versus restrictive fluid therapy (RFT) were compared. RESULTS Overall, 169 CRS/HIPEC cases were performed during the study period; 84 were managed with PFT and 85 were managed with RFT. No significant differences were identified in patient demographics. There was a decrease in intraoperative administration of crystalloid (8.0 vs. 4.4 L, p < 0.01), colloid (900 vs. 300 mL, p < 0.01), and blood transfusion (0.26 vs. 0.04 units, p < 0.01) in the RFT cohort. LOS was reduced from 11.5 to 9.7 days (p < 0.01) and the incidence of any 60-day complication decreased from 45 to 28% (p = 0.02) in the RFT group. The overall 90-day mortality rate was 0.6% (n = 1). Adjusted logistic regression demonstrated the odds of having a Clavien-Dindo grade III or higher complication was 0.31 (95% confidence interval 0.10-0.95) with RFT. CONCLUSION Intraoperative RFT with standard anesthesia monitoring devices can be safely used in CRS/HIPEC and is associated with a decreased LOS and decreased rate of postoperative complications.
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Affiliation(s)
- Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Aneel Damle
- Section of Colon and Rectal Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Chloe Williams
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ariana Harris
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Spiro Spanakis
- Division of Perioperative Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Donald H Lambert
- Department of Anesthesiology, Boston University School of Medicine, Boston, MA, USA
| | - Laura A Lambert
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA. .,Peritoneal Surface Malignancy Program, Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
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16
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Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Kapoor S, Bassily-Marcus A, Alba Yunen R, Tabrizian P, Semoin S, Blankush J, Labow D, Oropello J, Manasia A, Kohli-Seth R. Critical care management and intensive care unit outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. World J Crit Care Med 2017; 6:116-123. [PMID: 28529913 PMCID: PMC5415851 DOI: 10.5492/wjccm.v6.i2.116] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/14/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To study the early postoperative intensive care unit (ICU) management and complications in the first 2 wk of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).
METHODS Our study is a retrospective, observational study performed at Icahn School of Medicine at Mount Sinai, quaternary care hospital in New York City. All adult patients who underwent CRS and HIPEC between January 1, 2007 and December 31, 2012 and admitted to ICU postoperatively were studied. Fifty-one patients came to the ICU postoperatively out of 170 who underwent CRS and HIPEC therapy during the study period. Data analysis was performed using descriptive statistics.
RESULTS Of the 170 patients who underwent CRS and HIPEC therapy, 51 (30%) came to the ICU postoperatively. Mean ICU length of stay was 4 d (range 1-60 d) and mean APACHE II score was 15 (range 7-23). Thirty-one/fifty-one (62%) patients developed postoperative complications. Aggressive intraoperative and postoperative fluid resuscitation is required in most patients. Hypovolemia was seen in all patients and median amount of fluids required in the first 48 h was 6 L (range 1-14 L). Thirteen patients (25%) developed postoperative hypotension with seven requiring vasopressor support. The major cause of sepsis was intraabdominal, with 8 (15%) developing anastomotic leaks and 5 (10%) developing intraabdominal abscess. The median survival was 14 mo with 30 d mortality of 4% (2/51) and 90 d mortality of 16% (8/51). One year survival was 56.4% (28/51). Preoperative medical co morbidities, extent of surgical debulking, intraoperative blood losses, amount of intra op blood products required and total operative time are the factors to be considered while deciding ICU vs non ICU admission.
CONCLUSION Overall, ICU outcomes of this study population are excellent. Triage of these patients should consider preoperative and intraoperative factors. Intensivists should be vigilant to aggressive postop fluid resuscitation, pain control and early detection and management of surgical complications.
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18
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Abramian A, Zivanovic O, Kuhn W, Weber S, Schaefer N, Keyver-Paik MD, Kiefer N. Introducing Hyperthermic Intraperitoneal Chemotherapy into Gynecological Oncology Practice - Feasibility and Safety Considerations: Single-Center Experience. Oncol Res Treat 2016; 39:178-84. [PMID: 27160457 DOI: 10.1159/000445180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 03/03/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Within the surgical oncology community interest is increasingly focusing on combining surgical cytoreduction and regional chemotherapeutic drug delivery to manage solid abdominal tumors. In particular, the role of hyperthermic intraperitoneal chemotherapy (HIPEC) is evolving for treating epithelial ovarian carcinomas (EOCs), as EOCs remain confined to the peritoneal cavity for most of their natural history. Currently there is no evidence from prospective trials to confirm an overall survival benefit associated with HIPEC. In addition, there are no generally accepted regimens, which results in heterogeneous clinical procedures. METHODS We have initiated a HIPEC program at our institution and completed a phase I study of HIPEC with cisplatin in patients with platinum-sensitive recurrent EOC. The data have been published and prove the feasibility of this approach. In the process of introducing HIPEC, several safety measures had to be taken into consideration. RESULTS We present the implications and requirements of introducing HIPEC in clinical practice and discuss our proposed procedure referring to the recent literature. CONCLUSION HIPEC is feasible and can be performed safely in daily gynecological oncology routine provided that certain considerations and precautions are taken into account during its introduction to guarantee a proper and safe operating sequence.
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Affiliation(s)
- Alina Abramian
- Department of Obstetrics and Gynecology, Center for Integrated Oncology, University Hospital Bonn, Bonn, Germany
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19
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Sheshadri DB, Chakravarthy MR. Anaesthetic Considerations in the Perioperative Management of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Indian J Surg Oncol 2016; 7:236-43. [PMID: 27065715 DOI: 10.1007/s13193-016-0508-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 02/11/2016] [Indexed: 02/06/2023] Open
Abstract
Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has emerged as one of the primary modalities of treatment of diffuse peritoneal malignancies. It is a complex surgical procedure with the patients facing major and potentially life threatening alterations of haemodynamic, respiratory, metabolic and thermal balance with significant fluid losses and the perioperative management is challenging for anaesthesiologists and intensive care physicians. Though the alterations are short lived, these patients require advanced organ function monitoring and support perioperatively. The anaesthesiologist is involved in the management of haemodynamics, respiratory function, coagulation, haematologic parameters, fluid balance, thermal variations, and metabolic and nutritional support perioperatively. The chemotherapy instillate used are known to cause nephrotoxicity, cardiotoxicity, dyselectrolytemia and lactic acidosis. The preoperative polypharmacy for pain control, previous surgery and/or chemotherapy, malnourished status secondary to feeding problems and tumour wasting syndrome make the task all the more challenging. The anaesthesiologist also needs to consider the perioperative care from a quality of life perspective and proper preoperative counselling is important. The present overview summarizes the challenges faced by the anaesthesiologist regarding the pathophysiological alterations during the Cytoreductive surgery and Hyperthermic intraperitoneal chemotherapy in the preoperative, intraoperative and postoperative periods.
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Affiliation(s)
- Deepak B Sheshadri
- Fortis Hospital, 154/9, Opp. IIM (B), Bannerghatta Road, Bangalore, India 560076
| | - Murali R Chakravarthy
- Department of Anaesthesia, Critical Care and Pain Relief, Fortis Hospital, 154/9, Opp. IIM (B), Bannerghatta Road, Bangalore, India 560076
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20
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Korakianitis O, Daskalou T, Alevizos L, Stamou K, Mavroudis C, Iatrou C, Vogiatzaki T, Eleftheriadis S, Tentes AA. Lack of significant intraoperative coagulopathy in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) indicates that epidural anaesthesia is a safe option. Int J Hyperthermia 2015; 31:857-62. [DOI: 10.3109/02656736.2015.1075606] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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21
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Colantonio L, Claroni C, Fabrizi L, Marcelli ME, Sofra M, Giannarelli D, Garofalo A, Forastiere E. A randomized trial of goal directed vs. standard fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. J Gastrointest Surg 2015; 19:722-9. [PMID: 25595308 DOI: 10.1007/s11605-015-2743-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 01/02/2015] [Indexed: 01/31/2023]
Abstract
The use of adequate fluid therapy during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains controversial. The aim of the study was to assess whether the use of fluid therapy protocol combined with goal-directed therapy (GDT) is associated with a significant change in morbidity, length of hospital stay, and mortality compared to standard fluid therapy. Patients American Society of Anesthesiologists (ASA) II-III undergoing CRS and HIPEC were randomized into two groups. The GDT group (N = 38) received fluid therapy according to a protocol guided by monitored hemodynamic parameters. The control group (N = 42) received standard fluid therapy. We evaluated incidence of major complications, total length of hospital stay, total amount of fluids administered, and mortality rate. The incidence of major abdominal complications was 10.5% in GDT group and 38.1% in the control group (P = 0.005). The median duration of hospitalization was 19 days in GDT group and 29 days in the control group (P < 0.0001). The mortality rate was zero in GDT group vs. 9.5% in the control group (P = 0.12). GDT group received a significantly (P < 0.0001) lower amount of fluid (5812 ± 1244 ml) than the control group (8269 ± 1452 ml), with a significantly (P < 0.0001) lower volume of crystalloids (3884 ± 1003 vs. 68,528 ± 1413 ml). In CRS and HIPEC, the use of a GDT improves outcome in terms of incidence of major abdominal and systemic postoperative complications and length of hospital stay, compared to standard fluid therapy protocol.
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Affiliation(s)
- Luca Colantonio
- Department of Anaesthesiology, Regina Elena National Cancer Institute, Rome, Italy
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22
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Piccioni F, Casiraghi C, Fumagalli L, Kusamura S, Baratti D, Deraco M, Arienti F, Langer M. Epidural analgesia for cytoreductive surgery with peritonectomy and heated intraperitoneal chemotherapy. Int J Surg 2015; 16:99-106. [PMID: 25771101 DOI: 10.1016/j.ijsu.2015.02.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 02/23/2015] [Indexed: 01/18/2023]
Abstract
PURPOSE To evaluate epidural analgesia role after cytoreductive surgery with peritonectomy combined with heated intraperitoneal chemotherapy. METHODS 101 patients were retrospectively studied (between 2008 and 2012) to evaluate epidural analgesia effectiveness, tolerability and safety in this surgical context through the assessment of pain, detection of adverse events (nausea, vomiting, itching), temporary motor block, respiratory failure and coagulation profile in the post-operative period. RESULTS The median duration of epidural analgesia was 5 [range 1-10] days. As regards pain relief, the median verbal numerical scale scores at rest and on movement were below 2 and 5 until the fifth post-operative day, respectively. 13% of patients suffered nausea, 4% vomit, and 1% itching. No bradycardia or respiratory failure event was reported. 9.9% of patients had hypotension episodes. Coagulation reached normality only 3-4 days after surgery. 5 risky accidental dislodgments of epidural catheter occurred (prothrombine time INR > 1.5) without neurological complications. CONCLUSIONS Epidural analgesia ensures adequate pain relief and is well tolerated by patients after cytoreductive surgery with peritonectomy combined with heated intraperitoneal chemotherapy. Hypotension is common in this context and careful monitoring of coagulation parameters, especially in the first 3 days after surgery, is advisable to reduce the risk of neuraxial complications.
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Affiliation(s)
- Federico Piccioni
- Department of Anesthesia, Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy.
| | - Claudia Casiraghi
- School of Anesthesia and Intensive Care, University of Milan, Via Festa del Perdono 7, Milan, 20122, Italy
| | - Luca Fumagalli
- Department of Anesthesia, Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy
| | - Shigeki Kusamura
- Colorectal Cancer Unit-Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy
| | - Dario Baratti
- Colorectal Cancer Unit-Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy
| | - Marcello Deraco
- Colorectal Cancer Unit-Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy
| | - Flavio Arienti
- Immunohematology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy
| | - Martin Langer
- Department of Anesthesia, Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, Milan, 20080, Italy; Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, Milan, 20122, Italy
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Ñamendys-Silva SA, Correa-García P, García-Guillén FJ, López-Basave HN, Montalvo-Esquivel G, Texcocano-Becerra J, Herrera-Gómez Á, Meneses-García A. Organ dysfunction in critically ill cancer patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Oncol Lett 2015; 9:1873-1876. [PMID: 25789059 PMCID: PMC4356393 DOI: 10.3892/ol.2015.2921] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 01/08/2015] [Indexed: 11/23/2022] Open
Abstract
The aim of the present study was to observe the incidence of organ dysfunction and the intensive care unit (ICU) outcomes of critically ill cancer patients during the cytoreductive surgery with hyperthermic intraperitoneal chemotherapy post-operative period. The present study included 25 critically ill cancer patients admitted to the ICU of the National Cancer Institute (Mexico City, Mexico) between January 2007 and February 2013. The incidence of organ dysfunction was 68% and patients exhibiting ≤1 organ system dysfunction during ICU admittance remained in hospital for a significantly shorter period compared with patients who exhibited ≥2 organ system dysfunctions (12.4±10.7 vs. 24.1±12.8 days; P=0.025). Therefore, the present study demonstrated that a high incidence of organ dysfunction was associated with a longer ICU hospital stay.
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Affiliation(s)
- Silvio A Ñamendys-Silva
- Department of Critical Care Medicine, National Cancer Institute, Mexico City 14080, Mexico ; Department of Critical Care Medicine, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City 14000, Mexico
| | | | | | | | | | | | - Ángel Herrera-Gómez
- Division of Surgical Oncology, National Cancer Institute, Mexico City 14080, Mexico
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Hemodynamic Monitoring During Heated Intraoperative Intraperitoneal Chemotherapy Using the FloTrac/Vigileo System. Int Surg 2015; 100:1033-9. [PMID: 25590363 DOI: 10.9738/intsurg-d-14-00138.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cytoreductive surgery with HIPEC has provided a chance for long-term survival in selected patients. However, perioperative management remains a challenge for the anesthesiology team. The aim of this study was to evaluate the changes in hemodynamic parameters during hyperthermic intraperitoneal chemotherapy (HIPEC) using the FloTrac/Vigileo system. Forty-one consecutive patients undergoing cytoreductive surgery and HIPEC were enrolled. Heart rate (HR), esophageal temperature, and cardiac output (CO) steadily increased until the end of HIPEC. In the first half of HIPEC, systolic blood pressure (SBP) and central venous pressure (CVP) increased whereas systemic vascular resistance (SVR) decreased; SVR stabilized in the second half. Diastolic blood pressure (DBP), mean arterial pressure (MAP), and stroke volume (SV) showed no significant variation. Male gender was related to increased CVP, CO, and SV, and decreased SVR; age >55 years was related to increased SBP, and peritoneal cancer index (PCI) was correlated with HR, DBP, and SV. PCI >14 was associated with increased HR and decreased DBP and MAP. American Society of Anesthesiologists score >1 was related to decreased CO and SV. Patients undergoing HIPEC develop a hyperdynamic circulatory state because of the increased temperature, characterized by a steady decrease in SVR and continuous increase in HR and CO. FloTrac/Vigileo system may provide an easy-to-handle, noninvasive monitoring tool.
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Kerscher C, Ried M, Hofmann HS, Graf BM, Zausig YA. Anaesthetic management of cytoreductive surgery followed by hyperthermic intrathoracic chemotherapy perfusion. J Cardiothorac Surg 2014; 9:125. [PMID: 25059994 PMCID: PMC4123496 DOI: 10.1186/1749-8090-9-125] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 07/08/2014] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Macroscopic cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion (HITHOC) is a new multimodal approach for selected patients with primary and secondary pleural tumors, which may provide the patient with better local tumor control and increased overall survival rate. METHODS We present a single-center study including 20 patients undergoing cytoreductive surgery and HITHOC between September 2008 and April 2013 at the University Medical Center Regensburg, Germany. Objective of the study was to describe the perioperative, anaesthetic management with special respect to pain and complication management. RESULTS Anaesthesia during this procedure is characterized by increased intrathoracic airway and central venous pressure, hemodynamic alterations and the risk of systemic hypo- and hyperthermia. Securing an adequate intravascular volume is one of the primary goals to prevent decreased cardiac output as well as pulmonary edema. Transfusion of packed red blood cells (PRBC) was necessary in seven of 20 (35%) patients. Only two patients (10%) showed an impairment of coagulation in postoperative laboratory analysis. Perioperative forced diuresis is recommended to prevent postoperative renal insufficiency. Supplementary thoracic epidural analgesia in 13 patients (65%) showed a significant reduction of post-operative pain compared with peroral administration of opioid and non-opioid analgesics. CONCLUSION This article summarizes important experiences of the anaesthesiological and intensive care management in patients undergoing HITHOC.
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Affiliation(s)
- Christoph Kerscher
- Department of Anaesthesiology, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, Germany
| | - Michael Ried
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg 93042, Germany
| | - Hans-Stefan Hofmann
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg 93042, Germany
| | - Bernhard M Graf
- Department of Anaesthesiology, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, Germany
| | - York A Zausig
- Department of Anaesthesiology, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg, Germany
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Teo MCC, Ching Tan GH, Lim C, Chia CS, Tham CK, Soo KC. Colorectal peritoneal carcinomatosis treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: the experience of a tertiary Asian center. Asian J Surg 2014; 38:65-73. [PMID: 25059814 DOI: 10.1016/j.asjsur.2014.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 04/01/2014] [Accepted: 05/12/2014] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Compared with intravenous chemotherapy, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been shown to improve survival in patients with recurrent colorectal disease confined to the peritoneum. We report our experience with CRS and HIPEC for colorectal cancer patients with peritoneal carcinomatosis, evaluating prognostic factors for disease-free survival (DFS), overall survival (OS), and perioperative morbidity and mortality. METHODS All patients who underwent CRS and HIPEC were included in our study. Clinical characteristics, operative data, and 30-day morbidity and mortality were collected and evaluated. RESULTS Between January 2001 and December 2012, there were 35 consecutive patients who underwent CRS and HIPEC at our institution. Thirty-three patients (94%) had optimal cytoreduction. No 30-day mortality was reported, but 14 patients had postoperative complications. The median DFS was 9.4 months (95% confidence interval 5.5-18.7 months), and DFS at 1 year, 3 years, and 5 years were 43.8%, 22.3%, and 22.3%, respectively. The median OS was calculated to be 27.1 months (95% confidence interval 15.3-39.1), and the OS at 1 year, 3 years, and 5 years were 83.7%, 38.2%, and 19.1%, respectively. CONCLUSION CRS and HIPEC can provide survival benefit, with reasonable morbidity and mortality for Asian patients with peritoneal carcinomatosis from colorectal cancer. Patient selection and perioperative management of the patients are key to the success of the procedure.
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Affiliation(s)
- Melissa Ching Ching Teo
- Department of Surgical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, 169610 Singapore; Department of General Surgery, Singapore General Hospital, 9 Hospital Drive, 169612 Singapore.
| | - Grace Hwei Ching Tan
- Department of General Surgery, Singapore General Hospital, 9 Hospital Drive, 169612 Singapore
| | - Cindy Lim
- Department of Surgical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, 169610 Singapore
| | - Claramae Shulyn Chia
- Department of Surgical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, 169610 Singapore
| | - Chee Kian Tham
- Department of Medical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, 169610 Singapore
| | - Khee-Chee Soo
- Department of Surgical Oncology, National Cancer Centre Singapore, 11 Hospital Drive, 169610 Singapore; Department of General Surgery, Singapore General Hospital, 9 Hospital Drive, 169612 Singapore
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Anaesthesia in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: retrospective analysis of a single centre three-year experience. World J Surg Oncol 2014; 12:136. [PMID: 24886171 PMCID: PMC4113247 DOI: 10.1186/1477-7819-12-136] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 04/15/2014] [Indexed: 12/11/2022] Open
Abstract
Background Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment option for selected patients with peritoneal carcinomatosis. There are limited data available on anaesthesia management and its impact on patients’ outcome. Our aim was to retrospectively analyze and evaluate perioperative management and the clinical course of patients undergoing CRS/HIPEC within a three-year period. Methods After ethic committee approval, patient charts were retrospectively reviewed for patient characteristics, interventions, perioperative management, postoperative course, and complications. Analysis was intervention based. Data are presented as median (range). Results Between 2009 and 2011, 54 consecutive patients underwent 57 interventions; median anaesthesia time was 715 (range 370 to 1135) minutes. HIPEC induced hyperthermia with an overall median peak temperature of 38.1 (35.7-40.2)°C with active cooling. Bleeding, expressed as median blood loss was 0.8 (0 to 6) litre and large fluid shifts occurred, requiring a total fluid input of 8.4 (4.2 to 29.4) litres per patient. Postoperative renal function was dependent on preoperative function and the type of fluids used. Administration of hydroxyethyl starch colloid solution had a significant negative impact on renal function, especially in younger patients. Major complications occurred after 12 procedures leading to death in 2 patients. Procedure time and need for blood transfusion were associated with a significantly higher risk for major complications. Conclusions Cytoreductive surgery with HIPEC is a high-risk surgical procedure associated with major hemodynamic and metabolic changes. As well as primary disease and complexity of surgery, we have shown that anaesthesia management, the type and amount of fluids used, and blood transfusions may also have a significant effect on patients’ outcome.
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Corbella D, Piraccini E, Finazzi P, Brambillasca P, Prussiani V, Corso MR, Germandi C, Agnoletti V. Anesthetic management of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedures. World J Obstet Gynecol 2013; 2:129-136. [DOI: 10.5317/wjog.v2.i4.129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 04/07/2013] [Accepted: 05/19/2013] [Indexed: 02/05/2023] Open
Abstract
Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure are performed with increasing frequency to treat patients with diffused peritoneal carcinomatosis. These procedures have showed to increase life expectancy in what was previously considered a “terminal condition”. Anyway patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. Despite the need of an advanced organ monitoring and support all these derangements seem to be mild and short-lived when timely addressed, at least in the majority of patients. Intensive care physicians are involved in providing surveillance and organ support till the patient is effectively weaned after the operation. Moreover, the anesthesiologist as perioperative physician is involved in pain control, metabolic and nutritional support of this cohort of patients. This task can be challenging considering that part of the patients are already on a long list of pain control medication after previous surgery or chemotherapy. A malnourished state is common too and it is secondary to difficult feeding, wasting syndrome from the tumor and massive ascites. The last issue the anesthesiologists need to be aware of is the impact over the quality of life (QoL) of this procedure. The patient’s underlying pathology is unlikely to be definitively cured so no treatment is an acceptable choice. The possibility to withhold the treatments must be part of the consultation process like the discussion about the QoL in the immediate, as well as in the long-term, after the operation. Careful monitoring and treatment of every aspect that can impact the QoL must be taken and the efforts to be poured into an effective preservation of the QoL must be doubled when compared with a patient scheduled for major abdominal surgery.
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Owusu-Agyemang P, Soliz J, Hayes-Jordan A, Harun N, Gottumukkala V. Safety of epidural analgesia in the perioperative care of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol 2013; 21:1487-93. [PMID: 23982249 DOI: 10.1245/s10434-013-3221-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND The perioperative coagulopathy, hemodynamic instability, and infectious complications that may occur during cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has raised concerns about the safety of epidural analgesia in patients undergoing such procedures. METHODS We conducted a retrospective review of the perioperative anesthetic management of 215 adult patients who had undergone CRS with HIPEC with epidural analgesia. We reviewed epidural-related complications and analyzed the effect of early initiation of continuous epidural analgesia on estimated blood loss, intraoperative fluid administration, blood transfusion and vasopressor requirements, time to extubation, and length of stay. RESULTS No epidural hematomas or abscesses were reported. Two patients (0.9 %) had delays in epidural removal because of thrombocytopenia, and two had epidural-site erythema (0.9 %). The majority of postoperative epidural-related hypotensive episodes were successfully treated with fluid boluses. Early initiation of epidural analgesic infusions (before HIPEC) was associated with significantly less surgical blood loss and fluid requirements (P = 0.005 and 0.02, respectively). Pre-HIPEC initiation of epidural infusions was not associated with a statistically significant difference in the following: volume of blood transfused, intraoperative vasopressors use, time to extubation, and length of hospital stay. CONCLUSIONS With close hematologic monitoring and particular attention to sterility, epidural analgesia can be safely provided to patients undergoing CRS with HIPEC. Early initiation of continuous epidural infusions during surgery could lead to decreased blood loss and less intraoperative fluid administration. Prospective randomized studies are required to further investigate these potential benefits.
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Affiliation(s)
- Pascal Owusu-Agyemang
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA,
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Sarpel U, Melis M, Newman E, Pachter HL, Berman RS. The development of a peritoneal surface malignancy program: a tale of three hospitals. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2012; 27:670-675. [PMID: 22477235 DOI: 10.1007/s13187-012-0352-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
An increasing amount of evidence supports the use of cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC) for the treatment of select patients with carcinomatosis. The care of such patients is optimal at centers where physicians with expertise in the recognition, treatment, and follow-up of carcinomatosis collaborate to manage issues particular to patients undergoing HIPEC. New Peritoneal Surface Malignancy Programs should be introduced to meet the growing interest in this field; however, there are few guidelines available on how to propose, develop, and safely implement them across different hospital models. A new Peritoneal Surface Malignancy Program was initiated at a large academic medical center affiliated with three hospital systems serving distinct patient populations: a private hospital, a public hospital, and a Veterans Affairs hospital. Ten groups were identified as playing key roles in program implementation. Program approval was successfully obtained at all three hospitals. The initial two-year experience included a total of 20 cases across the three sites. Six of these cases were aborted due to high tumor volume, most of which (4/6) were at the public hospital. No 30-day mortalities occurred. Hospitals vary significantly in their approval process and timeline for new Peritoneal Surface Malignancy Program development. Patient populations differ in their awareness of HIPEC as a therapeutic modality. Public hospitals may serve patient populations with more advanced disease presentations. Careful coordination by the surgical oncologist with ten key groups allows for the safe introduction of a complex procedure within varied hospital models.
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Affiliation(s)
- Umut Sarpel
- Department of Surgery, New York University Langone Medical Center, New York, NY 10016, USA.
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Arakelian E, Torkzad MR, Bergman A, Rubertsson S, Mahteme H. Pulmonary influences on early post-operative recovery in patients after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy treatment: a retrospective study. World J Surg Oncol 2012; 10:258. [PMID: 23186148 PMCID: PMC3538602 DOI: 10.1186/1477-7819-10-258] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 10/31/2012] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The combination of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a curative treatment option for peritoneal carcinomatosis (PC). There have been few studies on the pulmonary adverse events (AEs) affecting patient recovery after this treatment, thus this study investigated these factors. METHODS Between January 2005 and December 2006, clinical data on all pulmonary AEs and the recovery progress were reviewed for 76 patients with after CRS and HIPEC. Patients with pulmonary interventions (thoracocenthesis and chest tubes) were compared with the non-intervention patients. Two senior radiologists, blinded to the post-operative clinical course, separately graded the occurrence of pulmonary AEs. RESULTS Of the 76 patients, 6 had needed thoracocentesis and another 6 needed chest tubes. There were no differences in post-operative recovery between the intervention and non-intervention groups. The total number of days on mechanical ventilation, the length of stay in the intensive care unit, total length of hospital stay, tumor burden, and an American Society of Anesthesiologists (ASA) grade of greater than 2 were correlated with the occurrence of atelectasis and pleural effusion. Extensive atelectasis (grade 3 or higher) was seen in six patients, major pleural effusion (grade 3) in seven patients, and signs of heart failure (grade 1-2) in nine patients. CONCLUSIONS Clinical and radiological post-operative pulmonary AEs are common after CRS and HIPEC. However, most of the pulmonary AEs did not affect post-operative recovery.
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Affiliation(s)
- Erebouni Arakelian
- Department of Surgical Sciences, Section of Surgery, Uppsala University, Uppsala, Sweden
| | - Michael R Torkzad
- Department of Radiology, Oncology and Radiation Science, Section of Radiology, Uppsala University, Uppsala, Sweden
| | - Antonina Bergman
- Department of Radiology, Oncology and Radiation Science, Section of Radiology, Uppsala University, Uppsala, Sweden
| | - Sten Rubertsson
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Haile Mahteme
- Department of Surgical Sciences, Section of Surgery, Uppsala University, Uppsala, Sweden
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Abstract
PURPOSE OF REVIEW Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an important therapeutic option for selected patients with peritoneal surface malignancies. This aggressive multimodality treatment is complex, not only regarding surgical technique, but also regarding anesthesia. The present review represents our experience in anesthetic care. RECENT FINDINGS Improved prognosis compared with systemic chemotherapy alone has recently been demonstrated for cytoreductive surgery when combined with intraoperative intracavitary hyperthermic chemotherapy. Anesthetic management of HIPEC is further impacted by these developments. In addition to the ambitious, long-lasting surgery, HIPEC causes significant fluid, blood and protein losses, increased intra-abdominal pressure, systemic hyperthermia, and increased metabolic rate, leading to relevant pathophysiological alterations, and therefore represents a challenge for anesthetist and critical care physicians. SUMMARY Anesthetic management importantly contributes to the containment of the perioperative complications of HIPEC. An appreciation of the technical aspects and physiologic disruptions associated with intra-abdominal HIPEC is critical to ensure effective anesthetic management. Although data on this specialized surgical procedure are scarce, some referral centers have accumulated extensive experience. This article reviews the current knowledge about the anesthesiological and intensive care management of patients undergoing HIPEC. It pinpoints strategies for perioperative monitoring as well as illustrates alterations in hemodynamic, hematopoetic, and fluid hemostasis.
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Rothfield KP, Crowley K. Anesthesia considerations during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Surg Oncol Clin N Am 2012; 21:533-41. [PMID: 23021714 DOI: 10.1016/j.soc.2012.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
This article outlines the anesthetic management of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. This includes a discussion of preoperative evaluation, hemodynamic monitoring, fluid and electrolyte therapy, and temperature management. An understanding of the unique physiologic consequences of this procedure is essential to ensure good outcomes and avoid patient injuries.
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Affiliation(s)
- Kenneth P Rothfield
- Department of Anesthesiology, Saint Agnes Hospital, Baltimore, MD 21229, USA.
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Bell JC, Rylah BG, Chambers RW, Peet H, Mohamed F, Moran BJ. Perioperative management of patients undergoing cytoreductive surgery combined with heated intraperitoneal chemotherapy for peritoneal surface malignancy: a multi-institutional experience. Ann Surg Oncol 2012; 19:4244-51. [PMID: 22805865 DOI: 10.1245/s10434-012-2496-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) combined with heated intraperitoneal chemotherapy (HIPEC) is an established treatment for patients with pseudomyxoma peritonei. There is now increasing evidence for the use of CRS and HIPEC in the treatment of other peritoneal surface malignancies. There is currently no consensus on the perioperative management of this patient group. METHODS An international survey of practice was conducted using an online survey tool. Centers were identified from the list of delegates attending the Seventh International Workshop on Peritoneal Surface malignancy held in Uppsala, Sweden, in September 2010. RESULTS Fully completed surveys were received from 29 of 41 identified centers (71 %). The survey covers the combined experience amassed by anesthesiologists caring for 8,467 patients undergoing cytoreductive surgery. Intraoperative fluid management, management of coagulopathy, management of the HIPEC phase of the operation, and postoperative analgesia caused the greatest difficulties for the anesthesia team with variation in management identified between different institutions. The incidence of epidural abscess in this patient group was found to be 1:2,139. CONCLUSIONS Optimal preoperative, intraoperative, and postoperative care is crucial to diminish the complications in this complex treatment strategy. Multicenter collaboration is suggested to gain evidence on the best strategies for perioperative management. Further data collection needs to be undertaken to assess the safety of epidural anesthesia in this patient group.
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Affiliation(s)
- John C Bell
- National Centre for Pseudomyxoma Surgery, Basingstoke and North Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK.
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Cooksley TJ, Haji-Michael P. Post-operative critical care management of patients undergoing cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC). World J Surg Oncol 2011; 9:169. [PMID: 22182345 PMCID: PMC3261105 DOI: 10.1186/1477-7819-9-169] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 12/19/2011] [Indexed: 12/15/2022] Open
Abstract
Background Cytoreductive surgery (CRS) and Heated Intraperitoneal Chemotherapy (HIPEC) results in a number of physiological changes with effects on the cardiovascular system, oxygen consumption and coagulation. The Critical Care interventions required by this cohort of patients have not yet been quantified. Methods This retrospective audit examines the experience of a Specialist Tertiary Centre in England over an 18 month period (January 2009-June 2010) during which 69 patients underwent CRS and HIPEC. All patients were extubated in the operating theatre and transferred to the Critical Care Unit (CCU) for initial post-operative management. Results Patients needed to remain on the CCU for 2.4 days (0.8-7.8). There were no 30 day mortalities. The majority of patients (70.1%) did not require post-operative organ support. 2 patients who developed pneumonia post-operatively required respiratory support. 18 (26.1%) patients required vasopressor support with norepinephrine with a mean duration of 13.94 hours (5-51 hours) and mean dose of 0.04 mcg/kg/min. Post-operative coagulopathy peaked at 24 hours. A significant drop in serum albumin was observed. Conclusion The degree of organ support required post-operatively is minimal. Early extubation is efficacious with the aid of epidural analgesia. Critical Care monitoring for 48 hours is desirable in view of the post-operative challenges.
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Desgranges FP, Steghens A, Rosay H, Méeus P, Stoian A, Daunizeau AL, Pouderoux-Martin S, Piriou V. [Epidural analgesia for surgical treatment of peritoneal carcinomatosis: a risky technique?]. ACTA ACUST UNITED AC 2011; 31:53-9. [PMID: 22154448 DOI: 10.1016/j.annfar.2011.08.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Accepted: 08/25/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND To study the risks of haemodynamic instability, and the possible occurrence of spinal haematoma, meningitis and epidural abscess when epidural analgesia is performed for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS We retrospectively analyzed the data of 35 patients treated by HIPEC with oxaliplatin or cisplatin. An epidural catheter was inserted before induction of general anaesthesia. Postoperatively, a continuous epidural infusion of ropivacain, then a patient-controlled epidural analgesia were started. RESULTS The epidural catheter was used peroperatively before HIPEC in 12 subjects (34%), and after HIPEC in 23 subjects (66%). The median dose of ropivacain given peroperatively in the epidural catheter was 40 mg (30-75). Norepinephrin was used in two subjects (6%) peroperatively (median infusion rate 0.325 μg/kg per minute [0.32-0.33]), and in four subjects (11%) in the postoperative 24 hours. No spinal haematoma, meningitis or epidural abscess were noted. Five subjects (14%) had a thrombopenia or a prothrombin time less than 60% before catheter removal. Two subjects (6%) had a leukopenia before catheter removal. No thrombopenia or blood coagulation disorders were recorded the day of catheter removal. CONCLUSION In this series of 35 patients, the use of epidural analgesia for HIPEC does not seem to be associated with a worse risk of haemodynamic instability, spinal haematoma, meningitis or epidural abscess. HIPEC with platinum salt is not incompatible with the safety of epidural analgesia, with an optimized fluid management peroperatively and the following of perimedullary anesthesia practice guidelines.
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Affiliation(s)
- F-P Desgranges
- Département d'anesthésie-réanimation, centre régional de lutte contre le cancer Léon-Bérard, Lyon, France.
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Schmidt C, Steinke T, Moritz S, Bucher M. Thoracic epidural anesthesia in patients with cytoreductive surgery and HIPEC. J Surg Oncol 2010; 102:545-6. [PMID: 20607760 DOI: 10.1002/jso.21660] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Demetri GD, von Mehren M, Antonescu CR, DeMatteo RP, Ganjoo KN, Maki RG, Pisters PWT, Raut CP, Riedel RF, Schuetze S, Sundar HM, Trent JC, Wayne JD. NCCN Task Force report: update on the management of patients with gastrointestinal stromal tumors. J Natl Compr Canc Netw 2010; 101:442. [PMID: 20457867 DOI: 10.1002/jso.21485] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The standard of care for managing patients with gastrointestinal stromal tumors (GISTs) rapidly changed after the introduction of effective molecularly targeted therapies involving tyrosine kinase inhibitors (TKIs), such as imatinib mesylate and sunitinib malate. A better understanding of the molecular characteristics of GISTs have improved the diagnostic accuracy and led to the discovery of novel immunomarkers and new mechanisms of resistance to TKI therapy, which in turn have resulted in the development of novel treatment strategies. To address these issues, the NCCN organized a task force consisting of a multidisciplinary panel of experts in the fields of medical oncology, surgical oncology, molecular diagnostics, and pathology to discuss the recent advances, identify areas of future research, and recommend an optimal approach to care for patients with GIST at all stages of disease. The task force met for the first time in October 2003 and again in December 2006 and October 2009. This supplement describes the recent developments in the field of GIST as discussed at the October 2009 meeting.
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Abstract
As life expectancy increases and advances in cancer treatment more often convert deadly conditions into more chronic diseases, the surgical intensivist can expect to be faced with greater numbers of oncology patients undergoing aggressive surgical treatments for curative intent, prolonging survival, or primarily palliation by alleviating obstruction, infection, bleeding, or pain. Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) are a paradigm for the emerging field of multimodal aggressive oncological surgery. This article describes the CRS/HIPEC technique, and discusses the most common postoperative complications and critical care issues in these patients, including anastomotic leaks, intestinal perforation, abscesses, and intra-abdominal bleeding. The leading cause of mortality is sepsis leading to multiple organ failure, and such patients are at particularly higher risk due to the extensive CRS and HIPEC. The intensivist must be vigilant to ensure that source control is not overlooked. This process is a very difficult one, made even more challenging by the blunting of physiologic responses and the frequent absence of the classic acute abdomen.
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Affiliation(s)
- Sanam Ahmed
- Division of Critical Care Medicine, Department of Surgery, The Mount Sinai School of Medicine, 1 Gustave L. Levy Place, New York, NY 10029, USA
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