Anesthesia and Pain Management for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Desmoplastic Small Round Cell Tumors in Children, Adolescents, and Young Adults

Enhanced recovery for cytoreductive surgery and hyperthermic intraperitoneal Chemotherapy: An international survey to assess acceptance and feasibility

BACKGROUND

Enhanced Recovery After Surgery (ERAS) protocols have markedly improved outcomes after colorectal and other major surgery, suggesting benefits also for complex surgeries like Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC). This study investigates the adoption and acceptance of the recent ERAS recommendations for CRS-HIPEC within expert centers.

METHODS

Clinicians from 16 expert centers across 9 countries were invited to answer an online survey inquiring about current clinical practice. Adoption of the 72 ERAS items from the recent dedicated guidelines were evaluated using a Likert-type scale with focus on preoperative, perioperative, and postoperative phases.

RESULTS

Overall, 27 clinicians (11 female, 21 surgeons, 2 gynecologists and 4 anesthesiologists/intensivists) participated, with high adoption of ERAS protocols at baseline (67 %). More than half of the guideline items (54 %) were widely adopted. However, despite nearly 18 % intending to change their practices, there remains substantial resistance to further adoption, such as for measures like alcohol cessation programs, mechanical bowel preparation, and oral antibiotic decontamination. Barriers identified include resource limitations(20 %), perceived irrelevance (17 %) for specific patient groups, unclear benefits (59 %), and restrictive policies (5 %).

CONCLUSION

The study shows that most ERAS principles are routinely implemented in CRS-HIPEC surgeries, despite significant challenges with specific components and complex processes. Future research will focus on generating additional evidence and streamlining ERAS guidelines to prioritize essential elements.

A Narrative Review of Pain in Pediatric Oncology: The Opioid Option for Procedural and Surgical Pain

This narrative review examines the evolving role of opioids in managing procedural and surgical pain in pediatric oncology patients. The review evaluates studies on opioid use across various oncological surgeries including thoracic, abdominal, orthopedic, and neurosurgical procedures, as well as for common painful procedures such as bone marrow aspirations and lumbar punctures. While opioids remain important for acute procedural and postoperative pain management in pediatric oncology patients, there is an increasing emphasis on multimodal, opioid-sparing approaches. The evidence presented within this review highlights the growing focus on judicious postoperative opioid prescribing to mitigate risks of adverse effects and persistent use or potential misuse. The review synthesizes findings from studies investigating various analgesic regimens, including the use of regional anesthesia techniques like epidural analgesia and peripheral nerve blocks, which have shown promise in reducing opioid requirements. For procedural pain, the review explores the efficacy of combining opioids with sedatives like midazolam or propofol, as well as the potential of ketamine as an opioid-sparing alternative. Key findings indicate that opioid-sparing techniques can effectively reduce overall opioid consumption without compromising pain control or patient satisfaction. Several studies demonstrated that regional anesthesia techniques and non-opioid adjuncts can significantly lower postoperative opioid requirements across various surgical procedures. For procedural pain, ketamine-based regimens often showed comparable or superior pain control to opioid-based approaches, with some studies reporting better patient satisfaction. This review also addresses the importance of tailored postoperative opioid prescribing, with some studies presenting algorithms to predict outpatient opioid needs more accurately. These approaches aim to ensure adequate pain control while minimizing excess opioid dispensing.

Acute kidney injury after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy - A systematic review

The use of nephrotoxic chemotherapeutic agents during hyperthermic intraperitoneal chemotherapy (HIPEC), carries the risk of postoperative acute kidney injury (AKI). The available evidence on this subject is sparse with variability in the reported incidence of AKI. In this systematic review, the aim was to analyse the incidence, risk factors, and preventive measures for AKI after cytoreductive surgery and HIPEC. A systematic literature search was conducted using the terms 'Acute kidney injury', 'Acute kidney failure', 'Acute renal failure', 'Acute renal impairment', 'HIPEC Surgery', 'Cytoreductive Surgery', 'Heated Chemotherapy' on PubMed, Scopus, clinical trial.gov, POPLINE and Google Scholar. Randomized controlled trials, cohort studies and observational studies published from January 2000-December 2020 were included. The systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021247781). Data from 16 articles, which included 1622 patients, was included. The incidence AKI by any definition, was 23.36 %. The highest incidence of AKI (45.45 %) was reported after paclitaxel-HIPEC. The incidence of AKI after cisplatin-HIPEC was 34.7 %. Cisplatin HIPEC was the most common factor associated with AKI in 7/16 studies followed by pre-existing comorbidities and low intraoperative diuresis in 4 and 3 studies respectively. The perioperative use of sodium thiosulfate and amifostine led to a significant reduction in the incidence of AKI. The reported incidence of AKI after CRS-HIPEC is high. Identifying preoperative risk factors, optimising comorbidities, maintaining perioperative haemodynamic stability, perioperative use of sodium thiosulfate, maintaining adequate diuresis could reduce the incidence of AKI.

An Immune-Enhancing Injectable Hydrogel Loaded with Esketamine and DDP Promotes Painless Immunochemotherapy to Inhibit Breast Cancer Growth

Chemotherapy is the cornerstone of triple-negative breast cancer. The poor effectiveness and severe neuropathic pain caused by it have a significant impact on the immune system. Studies confirmed that immune cells in the tumor microenvironment (TME), have critical roles in tumor immune regulation and prognosis. In this study, it is revealed that the painless administration of Esketamine, combined with Cisplatin (DDP), can exert an anti-tumor effect, which is further boosted by the hydrogel delivery system. It is also discovered that Esketamine combined with DDP co-loaded in Poloxamer Hydrogel (PDEH) induces local immunity by increasing mature Dendritic Cells (mDCs) and activated T cells in PDEH group while the regulatory T cells (Tregs) known as CD4+CD25+FoxP3+decreased significantly. Finally, , CD8+ and CD4+ T cells in the spleen exhibited a significant increase, suggesting a lasting immune impact of PDEH. This study proposes that Esketamine can serve as a painless immune modulator, enhancing an anti-tumor effect while co-loaded in poloxamer hydrogel with DDP. Along with improving immune cells in the microenvironment, it can potentially alleviate anxiety and depression. With its outstanding bio-safety profile, it offers promising new possibilities for painless clinical therapy.

Impact of warm saline irrigation, hyperthermic intraperitoneal chemotherapy on postoperative pain in primary ovarian cancer from the KOV-HIPEC-01 randomized trial

BACKGROUND

Hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as a treatment option at the time of cytoreductive surgery after neoadjuvant chemotherapy. The effect of active warming of HIPEC on postoperative pain needs to be investigated. This study aimed to investigate whether HIPEC reduces postoperative pain.

METHODS

From the KOV-HIPEC-01 trial, a randomized controlled trial of HIPEC for advanced primary ovarian cancer, 184 patients with a residual tumor size <1 cm were randomly assigned to the HIPEC and control groups at a 1:1 ratio. The consumption of analgesics and pain scales were analyzed. Hyperthermic intraperitoneal chemotherapy was administered after cytoreductive surgery. The primary objective was to compare the consumption of opioids measured in morphine milligram equivalents and non-opioids measured as the maximum daily dose between the HIPEC and control groups. The secondary objective was to compare the minimum and maximum pain intensities on numeric rating scales between the two groups using a linear mixed model.

RESULTS

Lesser consumption of non-opioids, with a lower mean maximum daily dose on postoperative days 1 and 2, was observed. The HIPEC group also experienced lower maximum pain intensities on postoperative day 1. No overall differences in the minimum or maximum pain intensities were observed on postoperative day 7.

CONCLUSION

The addition of HIPEC to cytoreductive surgery did not lead to increased postoperative pain, as demonstrated by a reduction in the use of analgesics and lower scores on postoperative pain scales during the early postoperative period.

Anesthesia and pain management of pediatric cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has shown to improve survival in patients with extensive or refractory abdominal tumors of many different histologies. Postoperative pain control can be challenging as the surgical procedure is performed through a midline laparotomy incision from xiphoid to symphysis pubis, and patients are usually nothing by mouth for the first 8-10 postoperative days.

AIMS

We present the anesthetic management and postoperative pain control strategies for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy using a multimodal, opioid-sparing, and total intravenous anesthetic technique with a tunneled thoracic epidural.

METHODS

A single institution retrospective review of anesthetic management, intraoperative fluid and blood administration, and postoperative pain control for pediatric patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy between July 2018 and December 2020 was conducted. We employed a novel anesthetic and analgesia protocol consisting of premedication with gabapentin followed by intraoperative infusions of propofol, dexmedetomidine, ketamine, and cisatracurium. A tunneled thoracic epidural catheter was placed for management of pain.

RESULTS

We reviewed and analyzed the first 25 patient records. The most common diagnosis was desmoplastic small round cell tumor (n = 12). Median age of patients was 14 years (range 21 months-22 years). All patients were extubated in the operating room and no patients required reintubation. There were no incidences of acute kidney injury. Epidural infusions were used for a median of 8 days (range 2-14 days). Median postoperative intravenous opioid use (morphine equivalent) through postoperative day 10 was 0.02 mg/kg/day (range 0-0.86 mg/kg/day) administered for a median of 2 days (range 0-17 days). Nine patients (36%) did not require any intravenous opioids in the postoperative period.

CONCLUSIONS

Utilizing a multimodal, opioid-sparing, total intravenous anesthetic technique in conjunction with a tunneled thoracic epidural catheter, we were able to avoid the need for postoperative mechanical ventilation and minimize both intraoperative and postoperative opioid requirements.

Erector Spinae Plane Catheters for Analgesia for Cytoreduction Surgery With Hyperthermic Intraperitoneal Chemotherapy: A Case Series

Cytoreduction surgery with hyperthermic intraperitoneal chemotherapy is a complex and painful procedure that can cause postoperative hypotension and coagulopathy. Epidural analgesia may worsen hypotension and is contraindicated in the setting of coagulopathy. While alternative regional techniques are being explored, the use of erector spinae plane blocks has not been reported. We present a case series of 6 patients who had erector spinae plane catheters for cytoreduction surgery with hyperthermic intraperitoneal chemotherapy. They remained stable intraoperatively and had adequate pain control postoperatively. Erector spinae plane catheters may be a suitable alternative for epidural analgesia for these patients.

Mediastinal desmoplastic small round cell tumor

RATIONALE

Desmoplastic small round cell tumor (DSRCT) is a rare distinct tumor with a high-grade malignancy.

PATIENT CONCERNS

A 51-year-old male visited a local hospital in April 2016 complaining of shortness of breath, chest tightness and pain, and exhibited significant swelling in both sides of the chest.

DIAGNOSES

CT demonstrated thoracic symmetry and no abnormalities were observed in the soft tissues of the ribs and the chest wall. A general observation of CT-guided puncture biopsy revealed 2 stripes of gray and grayish-white puncture tissues of 0.5 and 1 cm in length, respectively, and 0.1 cm in diameter. These results preliminarily suggested a (mediastinum) malignant small round cell tumor.

INTERVENTION

Given the progression of the disease, the chemotherapy regimen, consisting of ifosfamide and etoposide, was altered during the course and radiotherapy (total of 70 Gy of mediastinal Y field radiation) was conducted.

OUTCOMES

The patient and his family declined further treatment. Through follow-up, the total survival period was determined as 17 months.

LESSONS

DSRCT is a rare interstitial malignant tumor. Effective cytoreduction combined with comprehensive therapies could achieve partial remission or prolong the survival of patients.

Haemodynamic management during hyperthermic intraperitoneal chemotherapy: A systematic review

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).

Postoperative pain pathophysiology and treatment strategies after CRS + HIPEC for peritoneal cancer

Background

Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment choice for peritoneal cancer. However, patients commonly suffer from severe postoperative pain. The pathophysiology of postoperative pain is considered to be from both nociceptive and neuropathic origins.

Main body

The recent advances on the etiology of postoperative pain after CRS + HIPEC treatment were described, and the treatment strategy and outcomes were summarized.

Conclusion

Conventional analgesics could provide short-term symptomatic relief. Thoracic epidural analgesia combined with opioids administration could be an effective treatment choice. In addition, a transversus abdominis plane block could also be an alternative option, although further studies should be performed.

Impact of Anesthetics, Analgesics, and Perioperative Blood Transfusion in Pediatric Cancer Patients: A Comprehensive Review of the Literature

Cancer is the leading cause of death by disease in developed countries. Children and adolescents with cancer need surgical interventions (ie, biopsy or major surgery) to diagnose, treat, or palliate their malignancies. Surgery is a period of high vulnerability because it stimulates the release of inflammatory mediators, catecholamines, and angiogenesis activators, which coincides with a period of immunosuppression. Thus, during and after surgery, dormant tumors or micrometastasis (ie, minimal residual disease) can grow and become clinically relevant metastasis. Anesthetics (ie, volatile agents, dexmedetomidine, and ketamine) and analgesics (ie, opioids) may also contribute to the growth of minimal residual disease or disease progression. For instance, volatile anesthetics have been implicated in immunosuppression and direct stimulation of cancer cell survival and proliferation. Contrarily, propofol has shown in vitro anticancer effects. In addition, perioperative blood transfusions are not uncommon in children undergoing cancer surgery. In adults, an association between perioperative blood transfusions and cancer progression has been described for some malignancies. Transfusion-related immunomodulation is one of the mechanisms by which blood transfusions can promote cancer progression. Other mechanisms include inflammation and the infusion of growth factors. In the present review, we discuss different aspects of tumorigenesis, metastasis, angiogenesis, the immune system, and the current studies about the impact of anesthetics, analgesics, and perioperative blood transfusions on pediatric cancer progression.