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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Wang JY, Gross M, Urban RR, Jorge S. Intraperitoneal and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Ovarian Cancer. Curr Treat Options Oncol 2024; 25:313-329. [PMID: 38270801 DOI: 10.1007/s11864-023-01171-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/26/2024]
Abstract
OPINION STATEMENT In our clinical practice, we have shifted away from the use of adjuvant normothermic intraperitoneal (IP) chemotherapy, particularly following the publication of GOG 252. Our decision is rooted in the accumulating evidence indicating a lack of demonstrable superiority, alongside the recognized toxicities and logistical challenges associated with its administration. This strategic departure is also influenced by the rising utilization of maintenance therapies such as bevacizumab and PARP inhibitors, which present viable alternatives for improving patient outcomes. Our utilization of hyperthermic IP chemotherapy (HIPEC) is currently reserved for a specific cohort of patients, mirroring the patient population studied in the OVHIPEC-1 trial. Specifically, our HIPEC protocol applies to patients presenting with newly diagnosed stage IIIC high-grade epithelial ovarian cancer who are deemed ineligible for primary debulking surgery. Patients must exhibit at least stable disease with neoadjuvant platinum-based chemotherapy, maintain a favorable performance status (ECOG score 0-1), possess good nutritional reserves (with no evidence of protein-calorie malnutrition and an albumin level exceeding 3.5), and not have chronic kidney disease. When HIPEC is planned, it is administered at the time of interval debulking surgery, contingent upon the attainment of optimal surgical outcomes (< 1 cm of residual disease). Our HIPEC protocol adheres to the original OVHIPEC-1 trial guidelines, employing cisplatin at a dosage of 100 mg/m2. We administer at least two antiemetics, antihistamines, and sodium thiosulfate to mitigate known side effects. Postoperatively, patients are admitted to the general surgical floor, reserving the intensive care unit for those in critical condition. We follow Enhanced Recovery After Surgery principles, incorporating early ambulation and feeding into our postoperative care strategy. We have encountered encouraging results with this approach, with most patients having largely uncomplicated postoperative courses and resuming adjuvant chemotherapy within 3 to 4 weeks of surgery.
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Affiliation(s)
- Joyce Y Wang
- Department of Obstetrics & Gynecology, University of Washington, 1959 NE Pacific St, Box 356460, Seattle, WA, 98195, USA
| | - Maya Gross
- Department of Obstetrics & Gynecology, University of Washington, 1959 NE Pacific St, Box 356460, Seattle, WA, 98195, USA
| | - Renata R Urban
- Department of Obstetrics & Gynecology, University of Washington, 1959 NE Pacific St, Box 356460, Seattle, WA, 98195, USA
| | - Soledad Jorge
- Department of Obstetrics & Gynecology, University of Washington, 1959 NE Pacific St, Box 356460, Seattle, WA, 98195, USA.
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Bhatt A, Glehen O, Zivanovic O, Brennan D, Nadeau C, Van Driel W, Bakrin N. The 2022 PSOGI International Consensus on HIPEC Regimens for Peritoneal Malignancies: Epithelial Ovarian Cancer. Ann Surg Oncol 2023; 30:8115-8137. [PMID: 37561343 DOI: 10.1245/s10434-023-13932-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/27/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND AND AIM We report the results of an international consensus on hyperthermic intraperitoneal chemotherapy (HIPEC) regimens for epithelial ovarian cancer (EOC) performed with the following goals: To define the indications for HIPEC To identify the most suitable HIPEC regimens for each indication in EOC To identify areas of future research on HIPEC To provide recommendations for some aspects of perioperative care for HIPEC METHODS: The Delphi technique was used with two rounds of voting. There were three categories of questions: evidence-based recommendations [using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system with the patient, intervention, comparator, and outcome (PICO) method], an opinion survey, and research recommendations. RESULTS Seventy-three (67.5%) of 108 invited experts responded in round I, and 68 (62.9%) in round II. Consensus was achieved for 34/38 (94.7%) questions. However, a strong positive consensus that would lead to inclusion in routine care was reached for only 6/38 (15.7%) questions. HIPEC in addition to interval cytoreductive surgery (CRS) received a strong positive recommendation that merits inclusion in routine care. Single-agent cisplatin was the only drug recommended for routine care, and OVHIPEC-1 was the most preferred regimen. The panel recommended performing HIPEC for a minimum of 60 min with a recommended minimum intraabdominal temperature of 41°C. Nephroprotection with sodium thiosulfate should be used for cisplatin HIPEC. CONCLUSIONS The results of this consensus should guide clinical decisions on indications of HIPEC and the choice and various parameters of HIPEC regimens and could fill current knowledge gaps. These outcomes should be the basis for designing future clinical trials on HIPEC in EOC.
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Affiliation(s)
- Aditi Bhatt
- Department of Surgical Oncology, KD Hospital, Ahmedabad, India.
| | - Olivier Glehen
- Department of Surgical Oncology, Centre Hospitalier, Lyon-sud, Lyon, France
| | - Oliver Zivanovic
- Department of Gynecological Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Donal Brennan
- UCD Gynaecological Oncology Group, UCD School of Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Cedric Nadeau
- Department of Gynecological Oncology, CHU de Poitiers, Poitiers, Cedex, France
| | - Willemien Van Driel
- Department of Gynecological Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Naoual Bakrin
- Department of Surgical Oncology, Centre Hospitalier, Lyon-sud, Lyon, France
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Reece L, Moran B, Ferrie S, Ansari N, Koh C, Allman-Farinelli M, Carey S. A global analysis of nutrition support practices in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignancy. Clin Nutr ESPEN 2023; 57:297-304. [PMID: 37739672 DOI: 10.1016/j.clnesp.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/10/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Perioperative nutritional care has been identified as an important factor in the management of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Nevertheless, there is no published consensus on best practice for nutritional management specific to this patient group. The purpose of this study was to identify the current nutrition care practices among international centres performing CRS and HIPEC for patients with peritoneal malignancy. METHODS An online survey was developed and sent to experienced CRS and HIPEC centres. The survey questions covered clinician and institution demographics, formal nutrition care pathways, pre-operative nutrition care, post-operative nutrition support and post-discharge nutritional follow-up. RESULTS Eighty-two centres were contacted, and 42 responses were received. Respondents were from 20 different countries and were mostly dietitians (71%). Nutrition assessments were frequently completed (52% pre-operatively and 86% post-operatively) and most centres used a validated nutrition screening or assessment tool (79%). Perioperative nutrition support with respect to the use of enteral nutrition, parenteral nutrition and enhanced recovery after surgery varied widely between centres. The use of routine parenteral and enteral nutrition was significantly higher in Europe compared with other locations (p = 0.028). CONCLUSIONS Nutrition care is pivotal and has been positively integrated into the complex management of patients undergoing CRS and HIPEC globally, however variation in practice is evident. The findings highlight a unique opportunity to collaboratively investigate the role nutrition plays in determining outcomes and to identify the most appropriate nutrition support methods to achieve improved clinical outcomes for these high-risk patients.
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Affiliation(s)
- Lauren Reece
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia.
| | - Brendan Moran
- Peritoneal Malignancy Institute, Hampshire Hospital Foundation Trust, Basingstoke, United Kingdom
| | - Suzie Ferrie
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia
| | - Nabila Ansari
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and the University of Sydney, Sydney, NSW, Australia
| | - Cherry Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia; RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and the University of Sydney, Sydney, NSW, Australia
| | - Margaret Allman-Farinelli
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; Charles Perkins Centre, The University of Sydney, Camperdown, NSW, Australia
| | - Sharon Carey
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Camperdown, NSW, Australia; RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and the University of Sydney, Sydney, NSW, Australia
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Khan A, Beaumont A, Laing E, Guerra G, Jain A, Warrier S, Heriot A. Parenteral nutrition after cytoreductive surgery for peritoneal malignancy: Should it be administered routinely? Clin Nutr ESPEN 2023; 57:487-493. [PMID: 37739696 DOI: 10.1016/j.clnesp.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/14/2023] [Accepted: 06/18/2023] [Indexed: 09/24/2023]
Abstract
PURPOSE/BACKGROUND Cytoreductive surgery (CRS) is complex abdominal surgery that is used to treat peritoneal malignancy. CRS is associated with major morbidity and efforts to address this include optimisation of perioperative care. There is variation in international protocols on the nutritional management after CRS, in particular whether parenteral nutrition (PN) should be routinely or selectively administered. HYPOTHESIS/AIM This study assessed parenteral nutrition use, factors associated with PN requirement and nutritional outcomes in a centre that selectively uses PN after CRS. METHODS/INTERVENTIONS A retrospective analysis was undertaken on patients who underwent cytoreductive surgery ± hyperthermic intraperitoneal chemotherapy (HIPEC) at Peter MacCallum Cancer Centre between 1st January 2015 and 31st December 2020 using data entered into a prospectively maintained database. Patient characteristics, nutritional status, oncological parameters, operative details and postoperative outcome data were retrieved. Categorical variables were compared using the chi-squared test and continuous data was compared using a non-parametric Mann-Whitney U-test. A p-value <0.05 was considered statistically significant. Cox regression analysis was performed to identify independent predictors of requiring PN and postoperative weight change over admission. RESULTS A total of 222 patients who had CRS between were included (mean age 56 years; female 61.3%). Preoperative nutritional characteristics of participants included a mean body mass index (BMI) of 27.6 kg/m2 and the majority (77.9%) were not at nutritional risk pre-operatively with a Patient Generated Subjective Global Assessment (PG-SGA) score of category A. A high proportion of patients had surgery for colonic adenocarcinoma (58.1%), received HIPEC (87.4%) and achieved complete cytoreduction (82%). Postoperative parenteral nutrition was required for 65 patients (29.3%). The most frequent indication for PN was postoperative ileus (63.1%) with the mean (SD) time to commencing PN being postoperative day 5. Factors associated with the requirement for postoperative PN included preoperative albumin (OR 0.89; p = 0.015), weight loss >5% of body weight in the 6 months prior to admission (OR 2.2; p = 0.05), higher PCI score (OR 1.048; p = 0.005), number of anastomoses completed (OR 1.766; p = 0.017) and development of any postoperative complication (OR 2.71; p = 0.009). PN use was not associated with postoperative weight change. CONCLUSION Most patients undergoing CRS did not require post-operative PN. Nutritional and operative factors may identify patients who are likely to need PN after surgery. Selective use of PN did not impact on postoperative weight change.
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Affiliation(s)
- Ayman Khan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Australia.
| | - Anna Beaumont
- Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Erin Laing
- Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Glen Guerra
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Australia
| | - Anshini Jain
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Australia
| | - Satish Warrier
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Australia
| | - Alexander Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, 305 Grattan Street, Australia
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Howbora N, Sonowal SJ, Borah TJ, Kakati SD, Das A, Ninu M, Chintey D. Anesthetic management of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: A case report. Saudi J Anaesth 2023; 17:272-274. [PMID: 37260654 PMCID: PMC10228853 DOI: 10.4103/sja.sja_682_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/01/2022] [Accepted: 10/03/2022] [Indexed: 03/11/2023] Open
Abstract
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) can significantly influence overall and disease-free survival in selected patients suffering from peritoneal surface malignancies (PSMs). We report here the anaesthetic management of a 52 year old patient of Ca Colon with secondary ovarian and peritoneal deposits. She underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) with curative intent. The advent of CRS/HIPEC gives a promising alternative to conventional treatment modalities but comes with numerous challenges to the anesthesiologist-in view of the metabolic and hemodynamic adjustments-and demands training.
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Affiliation(s)
- Nilanjana Howbora
- Department of Anaesthesiology, Critical Care and Pain, Dr. Bhubaneswar Barooah Cancer Institute, Guwahati, Assam, India
| | - Swaraj J. Sonowal
- Department of Anaesthesiology, Critical Care and Pain, Dr. Bhubaneswar Barooah Cancer Institute, Guwahati, Assam, India
| | - Tridip J. Borah
- Department of Anaesthesiology, Critical Care and Pain, Dr. Bhubaneswar Barooah Cancer Institute, Guwahati, Assam, India
| | - Sonai D. Kakati
- Department of Anaesthesiology, Critical Care and Pain, Dr. Bhubaneswar Barooah Cancer Institute, Guwahati, Assam, India
| | - Anupam Das
- Department of Anaesthesiology, Critical Care and Pain, Dr. Bhubaneswar Barooah Cancer Institute, Guwahati, Assam, India
| | - Marie Ninu
- Department of Anaesthesiology, Critical Care and Pain, Dr. Bhubaneswar Barooah Cancer Institute, Guwahati, Assam, India
| | - Dokne Chintey
- Department of Anaesthesiology, Critical Care and Pain, Dr. Bhubaneswar Barooah Cancer Institute, Guwahati, Assam, India
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Gearing PF, Hawke JA, Mohan H, Heriot AG, Khan A, Beaumont A, Laing E, Waters PS. Perioperative nutritional assessment and interventions in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC): A systematic review. Eur J Surg Oncol 2023; 49:902-917. [PMID: 36872111 DOI: 10.1016/j.ejso.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 02/13/2023] [Accepted: 02/23/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Peritoneal carcinomatosis is a catabolic state and cytoreductive surgery (CRS) is a high morbidity operation. Optimising perioperative nutrition is crucial to improve outcomes. This systematic review sought to examine literature describing clinical outcomes related to preoperative nutrition status and nutrition interventions in patients undergoing CRS with hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS A systematic review was registered with PROSPERO (300326). A search of eight electronic databases was undertaken on 8th May 2022 and reported according to the PRISMA statement. Studies reporting nutrition status through use of screening and assessment tools, nutrition interventions or nutrition-related clinical outcomes for patients undergoing CRS with HIPEC were included. RESULTS Of 276 screened studies, 25 studies were included for review. Commonly used nutrition assessment tools for CRS-HIPEC patients included Subjective Global Assessment (SGA), sarcopenia assessment with computed tomography, preoperative albumin, and body mass index (BMI). Three retrospective studies compared SGA with postoperative outcomes. Malnourished patients were more likely to have postoperative infectious complications (p = 0.042 SGA-B, p = 0.025 SGA-C). Malnutrition was significantly associated with increased hospital length of stay (LOS) in two studies (p = 0.006, p = 0.02), and with overall survival in another study (p = 0.006). Eight studies analysing preoperative albumin levels reported conflicting associations with postoperative outcomes. BMI in five studies was not associated with morbidity. One study did not support routine nasogastric tube (NGT) feeding. CONCLUSIONS Preoperative nutritional assessment tools, including SGA and objective sarcopaenia measures, have a role in predicting nutritional status for CRS-HIPEC patients. Optimisation of nutrition is important for preventing complications.
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Affiliation(s)
- Peter F Gearing
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia.
| | - Justin A Hawke
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Helen Mohan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Ayman Khan
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Anna Beaumont
- Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Erin Laing
- Nutrition and Speech Pathology Department, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia
| | - Peadar S Waters
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Australia; Department of Surgery, Cork University Hospital, Wilton Road, Cork, Ireland
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Tan GHC, Chia CS, Wong JSM, Ong WS, Zhu HY, Ong CAJ, Teo MCC. Randomized Controlled Trial Investigating Perioperative Immunonutrition for Patients Undergoing Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Ann Surg Oncol 2023; 30:777-789. [PMID: 36180619 DOI: 10.1245/s10434-022-12509-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 08/15/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Immunonutrition has been shown to reduce hospital stay and postoperative morbidity in patients undergoing gastrointestinal, and head and neck surgery. However, its use has not been demonstrated in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). This study aims to determine the effectiveness of perioperative immunonutrition on patients undergoing CRS-HIPEC in reducing length of hospitalization and postoperative complications. PATIENTS AND METHODS From April 2017 to December 2018, patients undergoing CRS-HIPEC for peritoneal metastases in a single center were enrolled in a randomized controlled trial. Patients with evidence of intestinal obstruction or with diabetes mellitus were excluded. Patients were randomly assigned in a 1:1 fashion to receive perioperative oral immunonutrition or standard nutritional feeds. Length of hospital stay and rates of wound infection and complications were recorded and compared between the two groups in an intention-to-treat manner. RESULTS A total of 62 patients were recruited and randomized into two groups. Compliance to nutritional feeds in the preoperative period was significantly higher in the standard nutrition group (95.2% versus 75.4%, p = 0.004). There was no difference in postoperative compliance rates. Length of hospital stay and rates of wound infection and postoperative complications were higher in the standard nutrition group when compared with patients on immunonutrition (15.5 versus 11.1 days, p = 0.186; 19% versus 9.7%, p = 0.473; 16% versus 9.7%, p = 0.653; respectively). CONCLUSIONS Patients undergoing CRS-HIPEC who received perioperative immunonutrition had shorter hospitalization and less wound infections and postoperative complications, although the differences with the standard nutrition group were not statistically significant. Potential benefits of perioperative immunonutrition need to be further evaluated in larger studies.
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Affiliation(s)
- Grace Hwei Ching Tan
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore. .,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.
| | - Claramae Shulyn Chia
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, SingHealth Duke-NUS Oncology Academic Clinical Program, Singapore, Singapore.,Division of Clinical Trials & Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore
| | - Jolene Si Min Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, SingHealth Duke-NUS Oncology Academic Clinical Program, Singapore, Singapore.,Division of Clinical Trials & Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore
| | - Whee Sze Ong
- Division of Clinical Trials & Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore
| | - Hong-Yuan Zhu
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.,Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore, Singapore
| | - Chin-Ann Johnny Ong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, SingHealth Duke-NUS Oncology Academic Clinical Program, Singapore, Singapore.,Division of Clinical Trials & Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore.,Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore, Singapore.,Institute of Molecular and Cell Biology, A*STAR Research Entities, Singapore, Singapore
| | - Melissa Ching Ching Teo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre, Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, SingHealth Duke-NUS Oncology Academic Clinical Program, Singapore, Singapore.,Division of Clinical Trials & Epidemiological Sciences, National Cancer Centre Singapore, Singapore, Singapore
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Charleux-Muller D, Fabacher T, Romain B, Meyer N, Brigand C, Delhorme JB. Implementation of an enhanced recovery program for complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a referral center: a case control prospective study. Pleura Peritoneum 2023; 8:11-18. [PMID: 37020473 PMCID: PMC10067553 DOI: 10.1515/pp-2022-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 12/09/2022] [Indexed: 01/13/2023] Open
Abstract
Abstract
Objectives
Current recommendations regarding enhanced recovery programs (ERPs) after complete cytoreductive surgery (CCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are based on a low level of evidence. The aim of this study is to evaluate the effect of implementing an adapted ERP for CCRS and HIPEC in a referral center.
Methods
We conducted a study with a prospective group of 44 patients (post-ERP group) who underwent CCRS with HIPEC between July 2016 and June 2018, the period during which ERP was implemented. This group was compared to a second retrospective group of 21 patients who underwent CCRS with HIPEC between June 2015 and June 2016, during which ERP was not yet implemented (pre-ERP group).
Results
The ERP compliance rate was 65% in the post-ERP group. The hospital length of stay (HLS) was shorter in the post-ERP group: 24.9 days (IQR 11–68, pre-ERP group) vs. 16.1 days (IQR 6–45, post-ERP group), as was the major morbidity rate (pre-ERP group=33.3% vs. post-ERP group=20.5%). The nasogastric tube, urinary catheter and abdominal drains were all retrieved faster in the post-ERP group.
Conclusions
The implementation of an adapted ERP after CCRS with HIPEC procedures reduces morbidity and shortens the HLS.
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Affiliation(s)
- Diane Charleux-Muller
- Department of General and Digestive Surgery , Hautepierre Hospital, Strasbourg University Hospital , Strasbourg , France
| | - Thibaut Fabacher
- Department of Public Health, Biostatistic laboratory , Strasbourg University Hospital , Strasbourg , France
| | - Benoit Romain
- Department of General and Digestive Surgery , Hautepierre Hospital, Strasbourg University Hospital , Strasbourg , France
- INSERM Unit 1113 , IRFAC , Strasbourg , France
| | - Nicolas Meyer
- Department of Public Health, Biostatistic laboratory , Strasbourg University Hospital , Strasbourg , France
| | - Cécile Brigand
- Department of General and Digestive Surgery , Hautepierre Hospital, Strasbourg University Hospital , Strasbourg , France
| | - Jean-Baptiste Delhorme
- Department of General and Digestive Surgery , Hautepierre Hospital, Strasbourg University Hospital , Strasbourg , France
- INSERM Unit 1113 , IRFAC , Strasbourg , France
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Mishra N, Kumar M, Singh S, Rani K. Re-do cytoreductive surgery with hyperthermic intra-peritoneal chemotherapy (HIPEC): Risk factors and complications. J Cancer Res Ther 2023; 19:S921-S924. [PMID: 38384080 DOI: 10.4103/jcrt.jcrt_354_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/20/2022] [Indexed: 02/23/2024]
Abstract
ABSTRACT An effective multi-modal treatment option for patients with peritoneal surface metastatic malignancies has progressed and developed over the decades as cytoreductive surgery (CRS), and hyperthermic intra-peritoneal chemotherapy (HIPEC) delivers highly concentrated, heated chemotherapy drugs directly to the abdomen during surgery. Peritoneal metastasis and high staging abdominal malignancies were considered incurable and end up with the palliation only; the CRS+HIPEC combination approach increases the median survival rate and gives a better quality of life to these patients. It is a complicated surgery which poses a high rate of complications and challenges which are difficult to manage and requires a multi-disciplinary approach. The aim of this study is to elaborate the perioperative possible physiological changes, risk factors, and related complications after re-do HIPEC.
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Affiliation(s)
- Namita Mishra
- Department of Anesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Madhav Kumar
- Department of Cardiothoracic Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Soumya Singh
- Department of Anesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Khushbu Rani
- Department of Anesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
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11
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Kang HX, Ma JY, Su YY, Kang S, Feng BJ, Feng XB, Wang XS, Lu YY. Risk factors of temperature increase after cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy. Front Oncol 2023; 13:1120499. [PMID: 37035204 PMCID: PMC10073652 DOI: 10.3389/fonc.2023.1120499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/28/2023] [Indexed: 04/11/2023] Open
Abstract
Background Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the standard treatment for patients with peritoneal cancer (PC). Following CRS-HIPEC, patients may also face risks caused by whole body hyperthermia. This study analyzed the incidence of temperature increases following CRS-HIPEC and identified the attendant risk factors. Methods A retrospective analysis was carried out among 458 patients who received CRS-HIPEC at the Fourth Hospital of Hebei Medical University between August 2018 and January 2021. The patients were divided into two groups according to post-HIPEC axillary temperature (≥38°C), with the demographics and the laboratory test results subsequently analyzed and compared, and the risk factors pertaining to temperature increases analyzed using univariate and multivariate logistic regression. Results During CRS-HIPEC, 32.5% (149/458) of the patients with a temperature increase had an axillary temperature of not lower than 38°C, and 8.5% (39/458) of the patients with hyperpyrexia had an axillary temperature of not lower than 39°C. Female gender, gynecological malignancies, type of chemotherapy drug, increased postoperative neutrophil percentage, and a sharp drop in postoperative prealbumin were associated with the incidence of a temperature increase and axillary temperatures of >38°C. Among these factors, the type of chemotherapy drug was identified as an independent risk factor for a temperature increase during CRS-HIPEC. Conclusion By determining the risk factors pertaining to temperature increases during CRS-HIPEC, medical staff can identify the attendant risks among the patients and thus take preventive measures in a timely manner to maintain the patient's body temperature at a stable level. This suggests that further clinical research should be conducted to build a risk-prediction model for temperature increases following CRS-HIPEC.
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12
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Fidkowski CW, Hussain A, Younger JD, Giska MA, McCurry C, Loyd GE. Erector Spinae Plane Catheters for Analgesia for Cytoreduction Surgery With Hyperthermic Intraperitoneal Chemotherapy: A Case Series. A A Pract 2022; 16:e01643. [PMID: 36599010 DOI: 10.1213/xaa.0000000000001643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Christina W Fidkowski
- From the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Hospital, Detroit, Michigan
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13
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Wong LCK, Wong JSM, Seo CJ, Soo KC, Ong CAJ, Chia CS. High intra-abdominal pressure during hyperthermic intraperitoneal chemotherapy (HIPEC) following cytoreductive surgery (CRS) for peritoneal surface malignancies. Int J Hyperthermia 2022; 39:1195-1201. [PMID: 36096487 DOI: 10.1080/02656736.2022.2121861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
OBJECTIVE Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) represent a mainstay of treatment for peritoneal malignancies. There is evidence that HIPEC using high intra-abdominal pressure (IAP) results in increased tissue penetration, although its safety profile remains relatively unknown. We thus aim to evaluate differences in intra- and post-operative outcomes in patients undergoing CRS-HIPEC with different levels of IAP. METHODS This pilot prospective cohort study was conducted from January 2020 to February 2021 with patients undergoing CRS-HIPEC. Low IAP during HIPEC was defined as <18 mmHg and high IAP as ≥18 mmHg. Data was collected on patient and tumor characteristics, intra-operative clinical and biochemical parameters, and immediate post-operative outcomes. RESULTS 40 patients underwent CRS-HIPEC (n low = 20, n high = 20). Median IAP in the low and high IAP groups were 12.0 and 19.0 mmHg respectively. During HIPEC, both groups experienced increase in heart rate, central venous pressure, end tidal CO2, temperature, and serum glucose, with decrease in mean arterial pressure and base excess. There were no significant differences in hemodynamics between the 2 groups. Mild electrolyte derangements and a decrease in hemoglobin were noted in the high IAP group but were of small magnitude. Post-operatively, high IAP did not result in increased rate of complications, time to full feeds, ICU or total hospital stay. CONCLUSIONS High IAP in HIPEC is well tolerated and did not result in additional adverse events.
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Affiliation(s)
- Louis Choon Kit Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore.,Duke-NUS Medical School, Singapore
| | - Jolene Si Min Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore.,SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore.,SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Chin Jin Seo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore
| | - Khee Chee Soo
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore.,SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore.,SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Chin-Ann Johnny Ong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore.,SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore.,SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore.,Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore.,Institute of Molecular and Cell Biology, A*STAR Research Entities, Singapore
| | - Claramae Shulyn Chia
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore.,Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore.,SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore.,SingHealth Duke-NUS Surgery Academic Clinical Program, Duke-NUS Medical School, Singapore
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14
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Lim PQ, Han IH, Seow KM, Chen KH. Hyperthermic Intraperitoneal Chemotherapy (HIPEC): An Overview of the Molecular and Cellular Mechanisms of Actions and Effects on Epithelial Ovarian Cancers. Int J Mol Sci 2022; 23:10078. [PMID: 36077477 DOI: 10.3390/ijms231710078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/15/2022] [Accepted: 08/31/2022] [Indexed: 12/04/2022] Open
Abstract
Most patients with epithelial ovarian cancers (EOCs) are at advanced stages (stage III–IV), for which the recurrence rate is high and the 5-year survival rate is low. The most effective treatment for advanced diseases involves a debulking surgery followed by adjuvant intravenous chemotherapy with carboplatin and paclitaxel. Nevertheless, systemic treatment with intravenous chemotherapeutic agents for peritoneal metastasis appears to be less effective due to the poor blood supply to the peritoneal surface with low drug penetration into tumor nodules. Based on this reason, hyperthermic intraperitoneal chemotherapy (HIPEC) emerges as a new therapeutic alternative. By convection and diffusion, the hyperthermic chemotherapeutic agents can directly contact intraperitoneal tumors and produce cytotoxicity. In a two-compartment model, the peritoneal–plasma barrier blocks the leakage of chemotherapeutic agents from peritoneal cavity and tumor tissues to local vessels, thus maintaining a higher concentration of chemotherapeutic agents within the tumor tissues to facilitate tumor apoptosis and a lower concentration of chemotherapeutic agents within the local vessels to decrease systemic toxicity. In this review, we discuss the molecular and cellular mechanisms of HIPEC actions and the effects on EOCs, including the progression-free survival (PFS), disease-free survival (DFS) and overall survival (OS). For primary advanced ovarian cancers, more studies are agreeing that patients undergoing HIPEC have better surgical and clinical (PFS; OS) outcomes than those not, although one study reported no differences in the PFS and OS. For recurrent ovarian cancers, studies have revealed better DFS and OS in patients undergoing HIPEC than those in patients not undergoing HIPEC, although one study reported no differences in the PFS. HIPEC appears comparable to traditional intravenous chemotherapy in treating advanced EOCs. Overall, HIPEC has demonstrated some therapeutic benefits in many randomized phase III trials when combined with the standard cytoreductive surgeries for advanced EOCs. Nevertheless, many unknown aspects of HIPEC, including detailed mechanisms of actions, along with the effectiveness and safety for the treatment of EOCs, warrant further investigation.
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15
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Adamina M, Warlaumont M, Berger MD, Däster S, Delaloye R, Digklia A, Gloor B, Fritsch R, Koeberle D, Koessler T, Lehmann K, Müller P, Peterli R, Ris F, Steffen T, Weisshaupt CS, Hübner M. Comprehensive Treatment Algorithms of the Swiss Peritoneal Cancer Group for Peritoneal Cancer of Gastrointestinal Origin. Cancers (Basel) 2022; 14:4275. [PMID: 36077810 PMCID: PMC9454505 DOI: 10.3390/cancers14174275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Peritoneal cancer (PC) is a dire finding, yet in selected patients, long-term survival is possible. Complete cytoreductive surgery (CRS) together with combination immunochemotherapy is essential to achieve cure. Hyperthermic intraperitoneal chemotherapy (HIPEC) and pressurized intraperitoneal aerosol chemotherapy (PIPAC) are increasingly added to the multimodal treatment. The Swiss Peritoneal Cancer Group (SPCG) is an interdisciplinary group of expert clinicians. It has developed comprehensive treatment algorithms for patients with PC from pseudomyxoma peritonei, peritoneal mesothelioma, gastric, and colorectal origin. They include multimodal neoadjuvant treatment, surgical resection, and palliative care. The indication for and results of CRS HIPEC and PIPAC are discussed in light of the current literature. Institutional volume and clinical expertise required to achieve best outcomes are underlined, while inclusion of patients considered for CRS HIPEC and PIPAC in a clinical registry is strongly advised. The present recommendations are in line with current international guidelines and provide the first comprehensive treatment proposal for patients with PC including intraperitoneal chemotherapy. The SPCG comprehensive treatment algorithms provide evidence-based guidance for the multimodal care of patients with PC of gastrointestinal origin that were endorsed by all Swiss clinicians routinely involved in the multimodal care of these challenging patients.
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Sommariva A, Tonello M, Migliori E, Pizzolato E, Cenzi C, Mirabella M, Pilati P. HIPEC as a risk factor for postoperative coagulopathy after cytoreductive surgery for peritoneal metastases. Updates Surg 2022. [PMID: 35932406 DOI: 10.1007/s13304-022-01340-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/19/2022] [Indexed: 10/15/2022]
Abstract
AIM OF THE STUDY Postoperative coagulopathy is a poorly investigated condition after Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). This study aims to evaluate the occurrence and risk factors of coagulative disorders after surgery for peritoneal metastases. PATIENTS AND METHODS The records were extracted from a prospectively maintained database of consecutive patients who underwent CRS between January 2018 and September 2020. The study was approved by the local Ethics Committee. For each patient, the coagulation profile (CP), which included international normalized ratio (INR), partial thromboplastin time (aPTT), and platelets (PLTS) before surgery, intensive care unit admission,1st, 3rd, 5th postoperative day (POD) and the day before discharge was collected. Risk factors for postoperative coagulopathy were identified at multivariate analysis. RESULTS During the study period, 125 patients were included in the study. Among these, 48 (38.4%) underwent CRS only, and 77 (61.6%) CRS followed by HIPEC. Twenty-one patients (16.8%) developed severe coagulopathy, 5 (10.4%) after CRS and 16 (20.8%) after CRS-HIPEC. At multivariate analysis, HIPEC and blood loss ≥ 500 ml represented independent risk factors for severe alteration of INR > 1.5 (p = 0.05, OR 1.2) and PLTS < 75 109/L (p = 0.03, OR 1.3), respectively. CONCLUSION HIPEC is an independent risk factor for postoperative coagulopathy after CRS. Further studies are necessary to assess the usefulness of the point-of-care test in patients treated with CRS-HIPEC.
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17
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Bechtold ML, Brown PM, Escuro A, Grenda B, Johnston T, Kozeniecki M, Limketkai BN, Nelson KK, Powers J, Ronan A, Schober N, Strang BJ, Swartz C, Turner J, Tweel L, Walker R, Epp L, Malone A. When is enteral nutrition indicated? JPEN J Parenter Enteral Nutr 2022; 46:1470-1496. [PMID: 35838308 DOI: 10.1002/jpen.2364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/07/2022]
Abstract
Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.
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Affiliation(s)
| | | | | | - Brandee Grenda
- Morrison Healthcare at Atrium Health Navicant, Charlotte, North Carolina, USA
| | - Theresa Johnston
- Nutrition Support Team, Christiana Care Health System, Newark, Delaware, USA
| | | | | | | | - Jan Powers
- Nursing Research and Professional Practice, Parkview Health System, Fort Wayne, Indiana, USA
| | - Andrea Ronan
- Fanconi Anemia Research Fund, Eugene, Oregon, USA
| | - Nathan Schober
- Cancer Treatment Centers of America - Atlanta, Newnan, Georgia, USA
| | | | - Cristina Swartz
- Northwestern Medicine Delnor Cancer Center, Chicago, Illinois, USA
| | - Justine Turner
- Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | | | - Renee Walker
- Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA
| | - Lisa Epp
- Mayo Clinic, Rochester, Minnesota, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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18
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Angeles MA, Hernández A, Pérez-Benavente A, Cabarrou B, Spagnolo E, Rychlik A, Daboussi A, Migliorelli F, Bétrian S, Ferron G, Gil-Moreno A, Guyon F, Martinez A. The effect of major postoperative complications on recurrence and long-term survival after cytoreductive surgery for ovarian cancer. Gynecol Oncol 2022; 166:8-17. [PMID: 35568582 DOI: 10.1016/j.ygyno.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 04/28/2022] [Accepted: 05/01/2022] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To assess the impact on survival of major postoperative complications and to identify the factors associated with these complications in patients with advanced ovarian cancer after cytoreductive surgery. METHODS We designed a retrospective multicenter study collecting data from patients with IIIC-IV FIGO Stage ovarian cancer who had undergone either primary debulking surgery (PDS), early interval debulking surgery (IDS) after 3-4 cycles of neoadjuvant chemotherapy, or delayed debulking surgery (DDS) after 6 cycles, with minimal or no residual disease, from January 2008 to December 2015. Univariable and multivariable analyses were conducted to identify factors associated with major surgical complications (≥Grade 3). We assessed disease-free survival (DFS) and overall survival (OS) rates according to the occurrence of major postoperative complications. RESULTS 549 women were included. The overall rate of major surgical complications was 22.4%. Patients who underwent PDS had a higher rate of major complications (28.6%) than patients who underwent either early IDS (23.2%) or DDS (14.0%). Multivariable analysis revealed that extensive peritonectomy and surgical timing were associated with the occurrence of major complications. Median DFS and OS were 16.9 months (95%CI = [13.7-18.4]) and 48.0 months (95%CI = [37.2-73.1]) for the group of patients with major complications, and 20.1 months (95%CI = [18.6-22.4]) and 56.7 months (95%CI = [51.2-70.4]) for the group without major complications. Multivariable analysis revealed that major surgical complications were significantly associated with DFS, but not with OS. CONCLUSIONS Patients who experienced major surgical complications had reduced DFS, compared with patients without major morbidity. Extensive peritonectomy and surgical timing were predictive factors of postoperative morbidity.
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Affiliation(s)
- Martina Aida Angeles
- Department of Surgical Oncology, Institut Claudius Regaud, Toulouse University Cancer Institute (IUCT) - Oncopole, Toulouse, France.
| | - Alicia Hernández
- Gynecological Oncology Unit, La Paz Investigation Institute (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Asunción Pérez-Benavente
- Department of Gynecological Oncology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Bastien Cabarrou
- Biostatistics Unit, Institut Claudius Regaud, Toulouse University Cancer Institute (IUCT) - Oncopole, Toulouse, France
| | - Emanuela Spagnolo
- Gynecological Oncology Unit, La Paz Investigation Institute (IdiPAZ), La Paz University Hospital, Madrid, Spain
| | - Agnieszka Rychlik
- Department of Gynecological Oncology, Maria Skłodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Amel Daboussi
- Department of Anesthesiology, Institut Claudius Regaud, Toulouse University Cancer Institute (IUCT) - Oncopole, Toulouse, France
| | - Federico Migliorelli
- Department of Obstetrics and Gynecology, Paule de Viguier Hospital, Toulouse University Hospital, Toulouse, France
| | - Sarah Bétrian
- Department of Medical Oncology, Institut Claudius Regaud, Toulouse University Cancer Institute (IUCT) - Oncopole, Toulouse, France
| | - Gwénaël Ferron
- Department of Surgical Oncology, Institut Claudius Regaud, Toulouse University Cancer Institute (IUCT) - Oncopole, Toulouse, France; Oncogenesis of Sarcomas (ONCOSARC) team 19, Cancer Research Center of Toulouse (CRCT), INSERM, Toulouse, France
| | - Antonio Gil-Moreno
- Department of Gynecological Oncology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Frédéric Guyon
- Department of Surgical Oncology, Institut Bergonié, Bordeaux, France
| | - Alejandra Martinez
- Department of Surgical Oncology, Institut Claudius Regaud, Toulouse University Cancer Institute (IUCT) - Oncopole, Toulouse, France; Tumor Immunology and Immunotherapy team 1, Cancer Research Center of Toulouse (CRCT), INSERM, Toulouse, France
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19
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van Stein RM, Lok CA, Aalbers AG, H.J.T. de Hingh I, Houwink AP, Stoevelaar HJ, Sonke GS, van Driel WJ. Standardizing HIPEC and perioperative care for patients with ovarian cancer in the Netherlands using a Delphi-based consensus. Gynecol Oncol Rep 2022; 39:100945. [PMID: 35252523 PMCID: PMC8894234 DOI: 10.1016/j.gore.2022.100945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 12/29/2022] Open
Abstract
Implementation of HIPEC for ovarian cancer is ongoing, aiming to offer this treatment to all eligible patients in the Netherlands. Standardization reduces unwanted variation in clinical treatment. We intend to standardize patient selection, technical aspects, and perioperative care of CRS and HIPEC. This consensus study comprised a two-phase modified Delphi approach. Consensus was reached on 82% of items.
Objective Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is standard of care in the Netherlands in patients with stage III epithelial ovarian cancer following interval cytoreductive surgery (CRS). Differences in patient selection, technical aspects, and perioperative management exist between centers performing HIPEC. Standardization aims to reduce unwanted variation in clinical practice. As part of an implementation process, we aimed to standardize perioperative care for patients treated with CRS and HIPEC using a Delphi-based consensus approach. Methods We performed a two-phase modified Delphi method involving a multidisciplinary panel of 40 experts who completed a survey on CRS and HIPEC. During a consensus meeting, survey outcomes and available scientific evidence was discussed. Items without consensus (<75% agreement) were adjusted and evaluated in a second survey. Results Consensus was reached in the first round on 51% of items. After two rounds, consensus was reached on the majority of items (82%) including patient selection, preoperative workup, technical aspects of CRS and HIPEC, and postoperative care. No consensus was reached on the role of HIPEC in rare ovarian cancer types, preoperative bowel preparation, timing to create bowel anastomoses, and manipulation of the perfusate. Conclusions Dutch experts reached consensus on most items regarding interval CRS and HIPEC for ovarian cancer. This consensus study may help to align treatment protocols and to minimize practice variation. Topics without consensus may be put on the research agenda of HIPEC for ovarian cancer.
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20
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Peng JS, LaPiano J, Wang K, Attwood K, Skitzki JJ, Kane JM, Francescutti VA. Restrictive Intraoperative Fluid Rate is Associated with Improved Outcomes in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2022; 29:163-173. [PMID: 34383185 PMCID: PMC8715760 DOI: 10.1245/s10434-021-10556-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 07/18/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Management of patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CS/HIPEC) has historically favored liberal fluid administration owing to lengthy duration of surgery and hyperthermia. This practice has been challenged in recent years with studies demonstrating improved outcomes with restrictive fluid administration. METHODS Patients who underwent CS/HIPEC between March 2010 and September 2018 were included for analysis. Patients who received an above-median fluid rate (high-IVF) versus below-median fluid rate (low-IVF) were compared, and multivariate analyses were performed for length of stay, 90-day unplanned readmissions, and major complications. RESULTS The 167 patients had a mean age of 56.7 ± 11.4 years and body mass index of 29.5 ± 6.9 kg/m2. The median rate of total intraoperative crystalloid and colloid was 7.4 mL/kg/h. The low-IVF group had less blood loss (183 vs. 330 mL, p = 0.002), were less likely to need intraoperative vasopressor drip (2.4% vs. 11.9%, p = 0.018), and experienced fewer cardiac complications (2.4% vs. 10.7%, p = 0.031), pneumonias (0% vs. 6.0%, p = 0.024), and Clavien-Dindo grade 3-5 complications (14.5% vs. 33.3%, p = 0.004). Multivariate analyses identified bowel resection (HR 4.65, p = 0.0008) as a risk factor for 90-day unplanned readmission, while bowel resection, intraoperative fluid rate, and estimated blood loss were associated with increased length of stay. CONCLUSION Higher intraoperative fluid intake was associated with multiple postoperative complications and increased length of stay, and represents a potentially avoidable risk factor for morbidity in CS/HIPEC.
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Affiliation(s)
- June S. Peng
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA,Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA USA
| | - Jessica LaPiano
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Katy Wang
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Kristopher Attwood
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Joseph J. Skitzki
- Department of Biostatistics and Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - John M. Kane
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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21
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Lundbech M, Krag AE, Iversen LH, Hvas AM. Postoperative bleeding and venous thromboembolism in colorectal cancer patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:17-33. [PMID: 34626208 DOI: 10.1007/s00384-021-04021-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/25/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has improved survival for selected patients with peritoneal metastases from colorectal cancer. Previous studies report conflicting rates of postoperative bleeding and venous thromboembolism (VTE) after CRS + HIPEC. The aim of the present study was to systematically review the literature and to estimate the overall 30-day incidence of postoperative bleeding and the overall 90-day incidence of VTE after CRS + HIPEC. METHODS Studies were identified in PubMed, Embase, and Web of Science on 29 April 2021. Data were extracted for a qualitative synthesis and to estimate an overall mean incidence in the meta-analysis. RESULTS Fourteen studies with a total of 3268 patients were included in the systematic review. Postoperative bleeding incidence rates within 30 days ranged from 1.7 to 8.3% with an overall 30-day postoperative bleeding incidence with [95% CI] at 4.2 [2.6;6.2]%. VTE incidence rates within 90 days ranged from 0.2 to 13.6% with an overall 90-day VTE incidence with [95% CI] at 2.7 [1;5.2]% after CRS + HIPEC. CONCLUSION This systematic review and meta-analysis indicate a low risk for postoperative bleeding within 30 days and VTE within 90 days after CRS + HIPEC for peritoneal metastases from colorectal cancer.
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Affiliation(s)
- Mikkel Lundbech
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Andreas Engel Krag
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Lene Hjerrild Iversen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark. .,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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22
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Brydges N, Brydges GJ. Oncologic Emergencies. AACN Adv Crit Care 2021; 32:306-314. [PMID: 34490450 DOI: 10.4037/aacnacc2021832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A new cancer diagnosis is expected to affect approximately 1.9 million people in the United States in 2021. A small percentage of these patients will experience an emergent cancer-related complication. Oncologic emergencies may be encountered in emergency departments or require intensive care management. Patients newly diagnosed with cancer are more likely to present with emergencies related to the underlying malignancies. Oncologic emergencies can have various manifestations, ranging from mechanical obstruction due to tumor growth to metabolic derangements due to abnormal secretions from the tumor. Therefore, early identification and treatment of life-threatening oncologic events is critical. Although there are several different types of oncologic emergencies, this article focuses on metabolic emergencies (tumor lysis syndrome and cytoreductive hyperthermic intraperitoneal chemotherapy) and structural emergencies (increased intracranial pressure and vena cava thrombus). The purpose of this article is to provide acute care clinicians with an overview of selected oncologic emergencies and their evidence-based management.
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Affiliation(s)
- Ninotchka Brydges
- Ninotchka Brydges is Manager and Advanced Practice Provider, Department of Critical Care Medicine, Division of Anesthesia, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston TX 77030
| | - Garry J Brydges
- Garry J. Brydges is Director, Anesthesia Safety and Quality, Department of Anesthesiology, Division of Anesthesia, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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García-Fadrique A, Estevan Estevan R, Sabater Ortí L. Quality Standards for Surgery of Colorectal Peritoneal Metastasis After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2021; 29:188-202. [PMID: 34435297 DOI: 10.1245/s10434-021-10642-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/27/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The standardization of surgical outcomes throughout surgical procedures is mandatory. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) should provide proficient oncological and surgical outcomes. STUDY DESIGN The aim of this study was to identify clinically relevant quality indicators and their quality standard, and to determine their acceptable quality limit. A systematic review on cytoreductive results from 2000 to 2018 was performed focusing on clinical guidelines, consensus conferences, and publications. After the selection of quality indicators, a systematic review of indexed references was performed in order to calculate the quality standard for each indicator. STUDY SELECTION Unicentric/multicentric series, comparative studies, and clinical trials. Studies were to include outcomes after cytoreduction of colorectal origin and series with more than 50 patients. Quality indicators with at least 10 series were mandatory and objective measurements were also mandatory for inclusion. MAIN OUTCOME MEASUREMENTS Quality indicators selected were 1- to 5-year survival, overall disease-free survival, 1- to 5-year disease-free survival, complete surgical resection, duration of surgery, length of stay, overall morbimortality, major morbidity, re-intervention, postoperative hemorrhage, intestinal fistula, anastomotic leakage, wound infection, postoperative medical complications, overall recurrence, and failure to rescue. RESULTS The most relevant quality indicators and critical quality limits were overall disease-free survival and 5-year overall disease-free survival (14 months and <10 months, and 14% and <4%, respectively), completeness of surgical resection (89% and <80%, respectively), overall mortality (3% and >8%, respectively), overall morbidity (47% and >63%, respectively), failure to rescue (12% and <30%, respectively), reintervention (13 and <22%, respectively), anastomotic leakage (6% and <13%, respectively), and overall recurrence (60% and <74%, respectively). CONCLUSION This is the first study to assess quality standards in CRS + HIPEC for colorectal peritoneal metastases. The current data are of particular relevance for future studies to control the variability of this surgery.
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Affiliation(s)
| | | | - Luis Sabater Ortí
- Hospital Clínico Universitario, Department of Surgery, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
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24
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Ong XYS, Sultana R, Tan JWS, Tan QX, Wong JSM, Chia CS, Ong CAJ. The Role of Total Parenteral Nutrition in Patients with Peritoneal Carcinomatosis: A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:4156. [PMID: 34439309 PMCID: PMC8393754 DOI: 10.3390/cancers13164156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 01/23/2023] Open
Abstract
Peritoneal carcinomatosis (PC) is often associated with malnutrition and an inability to tolerate enteral feeding. Although total parenteral nutrition (TPN) can be lifesaving for patients with no other means of nutritional support, its use in the management of PC patients remains controversial. Therefore, a systematic review and meta-analysis was performed to evaluate the benefit of TPN on the overall survival of PC patients, in accordance with PRISMA guidelines. A total of 187 articles were screened; 10 were included in this review and eight were included in the meta-analysis. The pooled median overall survival of patients who received TPN was significantly higher than patients who did not receive TPN (p = 0.040). When only high-quality studies were included, a significant survival advantage was observed in PC patients receiving TPN (p < 0.001). Subgroup analysis of patients receiving chemotherapy demonstrated a significant survival benefit (p = 0.008) associated with the use of TPN. In conclusion, TPN may improve survival outcomes in PC patients. However, further studies are needed to conclude more definitively on the effect of TPN.
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Affiliation(s)
- Xing-Yi Sarah Ong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore; (X.-Y.S.O.); (J.W.-S.T.); (Q.X.T.); (J.S.M.W.); (C.S.C.)
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore 169608, Singapore
- Duke-NUS Medical School, Singapore 169857, Singapore;
- Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore 169610, Singapore
| | | | - Joey Wee-Shan Tan
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore; (X.-Y.S.O.); (J.W.-S.T.); (Q.X.T.); (J.S.M.W.); (C.S.C.)
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore 169608, Singapore
- Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore 169610, Singapore
| | - Qiu Xuan Tan
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore; (X.-Y.S.O.); (J.W.-S.T.); (Q.X.T.); (J.S.M.W.); (C.S.C.)
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore 169608, Singapore
- Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore 169610, Singapore
| | - Jolene Si Min Wong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore; (X.-Y.S.O.); (J.W.-S.T.); (Q.X.T.); (J.S.M.W.); (C.S.C.)
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore 169608, Singapore
| | - Claramae Shulyn Chia
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore; (X.-Y.S.O.); (J.W.-S.T.); (Q.X.T.); (J.S.M.W.); (C.S.C.)
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore 169608, Singapore
- SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore 169857, Singapore
| | - Chin-Ann Johnny Ong
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore; (X.-Y.S.O.); (J.W.-S.T.); (Q.X.T.); (J.S.M.W.); (C.S.C.)
- Department of Sarcoma, Peritoneal and Rare Tumours (SPRinT), Division of Surgery and Surgical Oncology, Singapore General Hospital, Singapore 169608, Singapore
- Laboratory of Applied Human Genetics, Division of Medical Sciences, National Cancer Centre Singapore, Singapore 169610, Singapore
- SingHealth Duke-NUS Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore 169857, Singapore
- Institute of Molecular and Cell Biology, A*STAR Research Entities, Singapore 138673, Singapore
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Castellanos Garijo ME, Sepúlveda Blanco A, Tinoco Gonzalez J, Merinero Casado A, Medina de Moya JI, Yanes Vidal G, Forastero Rodriguez A, Martín García CÁ, Muñoz-Casares FC, Padillo Ruiz J. Fluid administration in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: neither too much nor too little. Braz J Anesthesiol 2021; 72:695-701. [PMID: 34371057 DOI: 10.1016/j.bjane.2021.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 07/07/2021] [Accepted: 07/19/2021] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Intraoperative fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy plays an important role in postoperative morbidity. Studies have found an association between overload fluid therapy and increased postoperative complications, advising restrictive intraoperative fluid therapy. Our objective in this study was to compare the morbidity associated with restrictive versus non-restrictive intraoperative fluid therapy. METHODS Retrospective analysis of a database collected prospectively in the Anesthesiology Service of Virgen del Rocío Hospital, from December 2016 to April 2019. One hundred and six patients who underwent complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were divided into two cohorts according to Fluid Therapy received 1. Restrictive ≤ 9 mL.kg-1.h-1 (34 patients), 2. Non-restrictive ≥ 9 mL.kg-1.h-1 (72 patients). Percentage of major complications (Clavien-Dindo grade III-IV) and length hospital stay were the main outcomes variables. RESULTS Of the 106 enrolled patients, 68.9% were women; 46.2% had ovarian cancer, 35.84% colorectal cancer, and 7.5% peritoneal cancer. The average fluid administration rate was 11 ± 3.58 mL.kg-1.h-1. The restrictive group suffered a significantly higher percentage of Clavien-Dindo grade III-IV complications (35.29%) compared with the non-restrictive group (15.27%) (p = 0.02). The relative risk associated with restrictive therapy was 1.968 (95% confidence interval: 1.158-3.346). We also found a significant difference for hospital length of stay, 20.91 days in the restrictive group vs 16.19 days in the non-restrictive group (p = 0.038). CONCLUSIONS Intraoperative fluid therapy restriction below 9 mL.kg-1.h-1 in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy was associated with a higher percentage of major postoperative complications.
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Gajarawala S, Pelkowski J, Dorian R, Stanton A, Dinh T. Hyperthermic intraperitoneal chemotherapy for treating ovarian cancer. JAAPA 2021; 34:50-53. [PMID: 34320542 DOI: 10.1097/01.jaa.0000735800.98948.bb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Hyperthermic intraperitoneal chemotherapy (HIPEC) has been used for decades as a treatment for disseminated abdominal malignancies, including pseudomyxoma peritonei and peritoneal mesothelioma. HIPEC had been used to treat recurrent ovarian cancer only when curative options were lacking, but new data indicate that it may be suitable as a primary treatment for patients with late-stage epithelial ovarian cancer, increasing the recurrence-free time interval and improving quality of life. However, treatment can be challenging because of patient trauma from surgery, combined with the toxicity and high temperature of the chemotherapeutic agents. This article reviews HIPEC and its targeted intraoperative and postoperative management.
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Affiliation(s)
- Shilpa Gajarawala
- Shilpa Gajarawala is lead PA in the Department of Medical and Surgical Gynecology and an assistant professor of obstetrics and gynecology at Mayo Clinic Florida College of Medicine and Science in Jacksonville, Fla. She also is an adjunct faculty member in the doctor of medical science program at Rocky Mountain University of Health Science in Provo, Utah. Jessica Pelkowski practices in the Department of Orthopedic Surgery at the Mayo Clinic Florida. Rose Dorian practices in the Department of Blood and Marrow Transplantation and Cellular Immunotherapy at Moffitt Cancer Center in Tampa, Fla. Amanda Stanton practices in the Department of Medical and Surgical Gynecology and is an instructor in obstetrics and gynecology at the Mayo Clinic Florida. Tri Dinh is an assistant professor of obstetrics and gynecology at the Mayo Clinic Florida. The authors have disclosed no potential conflicts of interest, financial or otherwise
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27
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Li D, Huang S, Zhang F, Ball RD, Huang H. Perianesthesia Care of the Oncologic Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: A Retrospective Study. J Perianesth Nurs 2021:S1089-9472(20)30378-6. [PMID: 34303613 DOI: 10.1016/j.jopan.2020.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 10/23/2020] [Accepted: 10/23/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE This study was to understand the perianesthesia care for patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). METHOD This is a retrospective study. DESIGN The perioperative electronic medical records of 189 CRS + HIPEC surgical cases at a hospital of Western Pennsylvania from 2012 to 2018 were analyzed to study the characteristics of perianesthesia care for CRS + HIPEC surgery. FINDINGS The patients' median age was 57 (range 21-83) years, and 60% were men. The mean anesthesia time was 10.47 ± 2.54 hours. Most tumors were appendix or colorectal in origin, and the mean peritoneal cancer index score was 16.19 ± 8.76. The mean estimated blood loss was 623 ± 582 mL. The mean total intravenous crystalloid administered was 8,377 ± 4,100 mL. Fifty-two patients received packed red blood cells during surgery. Postoperatively, 100% of the patients were transferred to the intensive care unit. A majority (52%) of patients were extubated in the operating room. Median lengths of hospital and intensive care unit stays were 13 and 2 days, respectively. A majority (73%) of patients had 1 or more postoperative complications and 29% of patients experienced major postoperative complications (Clavien-Dindo grade III or higher) during the hospital stay. Prolonged hospitalization was owing to gastrointestinal dysfunctions and respiratory failure related to atelectasis and pleural effusion. CONCLUSIONS CRS + HIPEC is a major surgery with numerous challenges to the perianesthesia care team regarding hemodynamic adjustment, pain control, and postoperative complications, which demand training and future studies from the perianesthesia care team.
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28
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Gronau F, Jara M, Feldbrügge L, Wolf V, Oeff A, Rau B. [Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in gastric cancer]. Chirurg 2021; 92:522-527. [PMID: 33620502 DOI: 10.1007/s00104-021-01371-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Gastric cancer with peritoneal metastases is associated with an extremely poor prognosis. Developed multimodal treatment concepts, which include a combination of perioperative systemic treatment and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), show promising results with respect to improvement of the long-term survival. METHODS This article contains a review of the literature of published studies on the topic of gastric cancer and peritoneal metastasis. RESULTS The prognosis of patients with gastric cancer peritoneal carcinomatosis shows an extremely limited median survival of 7 months under palliative second-line systemic treatment. The median survival time increased to 12 months with cytoreductive surgery and in combination with HIPEC showed a positive effect on survival in individual studies. EXPERT OPINION Treatment recommendations for patients with peritoneal metastases of gastric cancer should be carried out by experts in surgical reference centers.
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Affiliation(s)
- Felix Gronau
- Chirurgische Klinik Campus Charité Mitte
- Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin, Deutschland
| | - Maximilian Jara
- Chirurgische Klinik Campus Charité Mitte
- Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin, Deutschland
| | - Linda Feldbrügge
- Chirurgische Klinik Campus Charité Mitte
- Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin, Deutschland
| | - Vincent Wolf
- Chirurgische Klinik Campus Charité Mitte
- Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin, Deutschland
| | - Alan Oeff
- Chirurgische Klinik Campus Charité Mitte
- Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin, Deutschland
| | - Beate Rau
- Chirurgische Klinik Campus Charité Mitte
- Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin, Deutschland. .,Klinik für Chirurgie, Universitätsmedizin Berlin, Charité Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Deutschland.
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29
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Cotogni P, Stragliotto S, Ossola M, Collo A, Riso S. The Role of Nutritional Support for Cancer Patients in Palliative Care. Nutrients 2021; 13:306. [PMID: 33498997 PMCID: PMC7911232 DOI: 10.3390/nu13020306] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/11/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023] Open
Abstract
The role of nutritional support for cancer patients in palliative care is still a controversial topic, in part because there is no consensus on the definition of a palliative care patient because of ambiguity in the common medical use of the adjective palliative. Nonetheless, guidelines recommend assessing nutritional deficiencies in all such patients because, regardless of whether they are still on anticancer treatments or not, malnutrition leads to low performance status, impaired quality of life (QoL), unplanned hospitalizations, and reduced survival. Because nutritional interventions tailored to individual needs may be beneficial, guidelines recommend that if oral food intake remains inadequate despite counseling and oral nutritional supplements, home enteral nutrition or, if this is not sufficient or feasible, home parenteral nutrition (supplemental or total) should be considered in suitable patients. The purpose of this narrative review is to identify in these cancer patients the area of overlapping between the two therapeutic approaches consisting of nutritional support and palliative care in light of the variables that determine its identification (guidelines, evidence, ethics, and law). However, nutritional support for cancer patients in palliative care may be more likely to contribute to improving their QoL when part of a comprehensive early palliative care approach.
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Affiliation(s)
- Paolo Cotogni
- Department of Anesthesia, Pain Management and Palliative Care, Intensive Care and Emergency, Molinette Hospital, University of Turin, 10126 Turin, Italy
| | - Silvia Stragliotto
- Medical Oncology 1, Veneto Institute of Oncology-IRCCS, 35128 Padova, Italy;
| | - Marta Ossola
- Clinical Nutrition and Dietetics Unit, Department of Internal Medicine, Molinette Hospital, 10126 Turin, Italy;
| | - Alessandro Collo
- Clinical Nutrition and Dietetics Unit, Maggiore della Carità Hospital, University of Eastern Piedmont, 28100 Novara, Italy; (S.R.); (A.C.)
| | - Sergio Riso
- Clinical Nutrition and Dietetics Unit, Maggiore della Carità Hospital, University of Eastern Piedmont, 28100 Novara, Italy; (S.R.); (A.C.)
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Chichura A, Chambers LM, Costales AB, Yao M, Gruner M, Morton M, Rose PG, Vargas R, Michener CM, Debernardo R. Impact of intra-operative factors upon peri-operative outcomes in women undergoing hyperthermic intraperitoneal chemotherapy for gynecologic cancer. Gynecol Oncol 2021; 161:194-201. [PMID: 33468319 DOI: 10.1016/j.ygyno.2021.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/07/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To evaluate the incidence of intra-operative metabolic and electrolyte abnormalities and subsequent impact on peri-operative outcomes in women with gynecologic cancer undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). METHODS An IRB-approved single institution retrospective cohort study was performed in women with gynecologic cancer who underwent CRS + HIPEC. Patient demographics, intra-operative electrolyte and metabolic values and peri-operative outcomes were recorded. To assess the association of pH and lactate upon post-operative outcomes, patients were divided in four quartiles for both variables and univariate analysis was performed. RESULTS 100 consecutive women who underwent CRS + HIPEC from 2017 to 2020 were identified. Intra-operative blood transfusion and pressor support were required in 40% and 86%, respectively. The rate of ICU admission was 17%. Longer operative time (7.0 vs. 5.3 h, p = 0.002), increased blood loss (400.0 vs. 200.0 mL, p = 0.02) and transfusion (70.6% vs. 34.1%, p = 0.005) were associated with ICU admission. Compared to patients in the highest quartile of pH, lower median pH, (7.211 vs. 7.349, p < 0.001) was associated with increased rates of ICU admission, prolonged intubation (36.0% vs. 0.0%, p < 0.05, respectively) and any post-operative complication (72.0% vs. 28.0%, p = 0.01). Similarly, need for prolonged intubation (40% vs. 0%, p = 0.04) and VTE (13.0% vs. 0%, p = 0.01) were increased in women with the highest quartile of lactate levels compared to the lowest (4.7 vs 1.9, p < 0.001). CONCLUSIONS Intra-operative acidosis is associated with higher incidence of ICU admission and peri-operative complications following CRS + HIPEC in women with gynecologic cancer. These data support the importance of adequate intra-operative resuscitation and timely correction of hemodynamic and metabolic abnormalities.
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Affiliation(s)
- Anna Chichura
- Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States.
| | - Laura M Chambers
- Division of Gynecologic Oncology, Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Anthony B Costales
- Department of Gynecologic Oncology, Baylor College of Medicine, Houston, TX 77030, United States
| | - Meng Yao
- Department of Qualitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Morgan Gruner
- Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Molly Morton
- Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Peter G Rose
- Division of Gynecologic Oncology, Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Roberto Vargas
- Division of Gynecologic Oncology, Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Chad M Michener
- Division of Gynecologic Oncology, Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States
| | - Robert Debernardo
- Division of Gynecologic Oncology, Obstetrics, Gynecology, Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States
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31
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Koemans WJ, Houwink A, van der Kaaij RT, Wassenaar ECE, Boerma D, Hahn C, Imhof O, Brandt MG, Ariëns MP, Veenhof AAFA, Hartemink KJ, van Sandick JW. Perioperative Management of Gastric Cancer Patients Treated With (Sub)Total Gastrectomy, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy (HIPEC): Lessons Learned. Ann Surg Oncol 2021; 28:4647-4654. [PMID: 33389293 DOI: 10.1245/s10434-020-09465-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 11/25/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND The PERISCOPE I study was designed to assess the safety and feasibility of (sub)total gastrectomy, cytoreductive surgery (CRS), and hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin and docetaxel for gastric cancer patients who have limited peritoneal dissemination. The current analysis investigated changes in perioperative management together with their impact on postoperative outcomes. METHODS Patients with resectable gastric cancer and limited peritoneal dissemination were administered (sub)total gastrectomy, CRS, and HIPEC with oxaliplatin (460 mg/m2) and docetaxel (escalating scheme: 0, 50, 75 mg/m2). Of the 25 patients who completed the study protocol, 14 were treated in the dose-escalation cohort and 11 were treated in the expansion cohort (to optimize perioperative management). RESULTS A significant proportion of the patients in the dose-escalation cohort (n = 7, 50%) had ileus-related complications. In this cohort, enteral nutrition was started immediately after surgery at 20 ml/h, which was increased on day 1 to meet nutritional needs. In the expansion cohort, enteral nutrition was administered at 10 ml/h until day 3, then restricted to 20 ml/h until day 6, supplemented with total parenteral nutrition to meet nutritional needs. Ileus-related complications occurred for two patients (18%) of the expansion cohort. The intensive care unit (ICU) readmission rate decreased from 50 (n = 7) to 9% (n = 1; p = 0.04). CONCLUSION The implementation of a strict nutritional protocol during the PERISCOPE I study was associated with a decrease in postoperative complications. Based on these results, a perioperative care path was described for the gastric cancer HIPEC patients in the PERISCOPE II study.
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Affiliation(s)
- W J Koemans
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A Houwink
- Department of Anesthesiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - R T van der Kaaij
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - E C E Wassenaar
- Department of Dietetics, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - D Boerma
- Department of Dietetics, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - C Hahn
- Department of Anesthesiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - O Imhof
- Clinical Perfusion, Heartbeat, Eemnes, The Netherlands
| | - M G Brandt
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M P Ariëns
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - A A F A Veenhof
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - K J Hartemink
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - J W van Sandick
- Department of Surgical Oncology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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Balakrishnan K, Srinivasaraghavan N, Venketeswaran MV, Ramasamy T, Seshadri RA, Raj EH. Perioperative factors predicting delayed enteral resumption and hospital length of stay in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: Retrospective cohort analysis from a single centre in India. Indian J Anaesth 2020; 64:1025-1031. [PMID: 33542565 PMCID: PMC7852446 DOI: 10.4103/ija.ija_480_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/13/2020] [Accepted: 09/27/2020] [Indexed: 12/19/2022] Open
Abstract
Background and Aims: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an extensive procedure associated with significant morbidity, delay in return of gastrointestinal function and discharge from hospital. Our aim was to assess perioperative factors influencing enteral resumption (ER) and length of stay in the hospital (LOS) in CRS-HIPEC. Methods: A retrospective analysis was conducted in a major tertiary cancer centre. Sixty-five patients who underwent CRS-HIPEC between July 2014 and March 2019 were included in the study. The perioperative data were collected from patient records. The primary outcome measure was day of oral resumption of 500 ml of clear fluids and secondary outcome was the LOS. Univariate and multivariate logistic regression analysis was done for the various continuous and categorical perioperative variables for both ER and LOS to elicit the magnitude of risk for both outcomes. Results: Univariate logistic regression revealed that peritoneal carcinomatosis index score (PCI), duration of surgery, blood loss and postoperative ventilation influenced both ER and LOS. Serum albumin, plasma usage and total peritonectomy affected only the LOS but not ER. Multivariate analysis showed that duration of surgery (P = 0.006) and quantum of intravenous fluid infused (P = 0.043) were statistically associated with ER, while serum albumin level (P = 0.025) and postoperative ventilation (P = 0.045) were independently predictive of LOS. Conclusion: CRS-HIPEC is an extensive surgery and multiple factors are associated with ER; of these, duration of surgery and intraoperative fluid therapy are significant factors. Low serum albumin and prolonged postoperative ventilation are associated with increased LOS.
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Affiliation(s)
- Kalpana Balakrishnan
- Department of Anaesthesiology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | | | | | - Thendral Ramasamy
- Department of Anaesthesiology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | | | - E Hemanth Raj
- Department of Surgical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
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Lee RM, Gamboa AC, Turgeon MK, Zaidi MY, Kimbrough C, Leiting J, Grotz T, Lee AJ, Fournier K, Powers B, Dineen S, Baumgartner JM, Veerapong J, Mogal H, Clarke C, Wilson G, Patel S, Hendrix R, Lambert L, Pokrzywa C, Abbott DE, LaRocca CJ, Raoof M, Greer J, Johnston FM, Staley CA, Cloyd JM, Maithel SK, Russell MC. A novel preoperative risk score to optimize patient selection for performing concomitant liver resection with cytoreductive surgery/HIPEC. J Surg Oncol 2020; 123:187-195. [PMID: 33002202 DOI: 10.1002/jso.26239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 08/25/2020] [Accepted: 09/09/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND While parenchymal hepatic metastases were previously considered a contraindication to cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC), liver resection (LR) is increasingly performed with CRS/HIPEC. METHODS Patients from the US HIPEC Collaborative (2000-2017) with invasive appendiceal or colorectal adenocarcinoma undergoing primary, curative intent CRS/HIPEC with CC0-1 resection were included. LR was defined as a formal parenchymal resection. Primary endpoints were postoperative complications and overall survival (OS). RESULTS A total of 658 patients were included. About 83 (15%) underwent LR of colorectal (58%) or invasive appendiceal (42%) metastases. LR patients had more complications (81% vs. 60%; p = .001), greater number of complications (2.3 vs. 1.5; p < .001) per patient and required more reoperations (22% vs. 11%; p = .007) and readmissions (39% vs. 25%; p = .014) than non-LR patients. LR patients had decreased OS (2-year OS 62% vs. 79%, p < .001), even when accounting for peritoneal carcinomatosis index and histology type. Preoperative factors associated with decreased OS on multivariable analysis in LR patients included age < 60 years (HR, 3.61; 95% CI, 1.10-11.81), colorectal histology (HR, 3.84; 95% CI, 1.69-12.65), and multiple liver tumors (HR, 3.45; 95% CI, 1.21-9.85) (all p < .05). When assigning one point for each factor, there was an incremental decrease in 2-year survival as the risk score increased from 0 to 3 (0: 100%; 1: 91%; 2: 58%; 3: 0%). CONCLUSIONS As CRS/HIPEC + LR has become more common, we created a simple risk score to stratify patients considered for CRS/HIPEC + LR. These data aid in striking the balance between an increased perioperative complication profile with the potential for improvement in OS.
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Affiliation(s)
- Rachel M Lee
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Adriana C Gamboa
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michael K Turgeon
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mohammad Y Zaidi
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Charles Kimbrough
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jennifer Leiting
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic , Rochester, Minnesota, USA
| | - Travis Grotz
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Gastrointestinal Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew J Lee
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Keith Fournier
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Gastrointestinal Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benjamin Powers
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA.,Department of Oncologic Sciences, Morsani College of Medicine, Tampa, Florida, USA
| | - Sean Dineen
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA.,Department of Oncologic Sciences, Morsani College of Medicine, Tampa, Florida, USA
| | - Joel M Baumgartner
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, University of California, San Diego, California, USA
| | - Jula Veerapong
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, University of California, San Diego, California, USA
| | - Harveshp Mogal
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Callisia Clarke
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Gregory Wilson
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sameer Patel
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ryan Hendrix
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgical Oncology, Health Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Laura Lambert
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Courtney Pokrzywa
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin, USA
| | - Daniel E Abbott
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, University of Wisconsin, Madison, Wisconsin, USA
| | - Christopher J LaRocca
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Mustafa Raoof
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Greer
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Fabian M Johnston
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Charles A Staley
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Shishir K Maithel
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maria C Russell
- Department of Surgery, Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, Minnesota, USA
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Chambers LM, Costales AB, Crean-Tate K, Kuznicki M, Morton M, Horowitz M, Jagielo T, Rose PG, Michener C, Vargas R, Debernardo R. A guide to establishing a hyperthermic intraperitoneal chemotherapy program in gynecologic oncology. Gynecol Oncol 2020; 158:794-802. [DOI: 10.1016/j.ygyno.2020.06.487] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/10/2020] [Indexed: 12/11/2022]
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35
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Somashekhar SP, Rohit KC, Deo SVS, Ashwin KR. Practice patterns, attitudes, and knowledge among clinicians regarding hyperthermic intraperitoneal chemotherapy and pressurized intraperitoneal aerosol chemotherapy: a national survey by Indian society of peritoneal surface malignancies (ISPSM). Pleura Peritoneum 2020; 5:20200120. [PMID: 33364340 PMCID: PMC7746887 DOI: 10.1515/pp-2020-0120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/29/2020] [Indexed: 11/15/2022] Open
Abstract
Objectives Perception of cytoreductive surgery (CRS), hyperthermic intraperitoneal chemotherapy (HIPEC), and pressurized intraperitoneal aerosol chemotherapy (PIPAC) for treating peritoneal surface malignancies (PSM) differ widely among physicians. Methods This on-site survey performed during a major oncology congress in 2019 evaluated the current opinion, perceptions, knowledge and practice of HIPEC and PIPAC among oncologists in India. Results There were 147 respondents (gynecologists (30%), surgical oncologists and gastrointestinal surgeons (64%), and medical oncologists (6%)). Whereas most respondents considered CRS and HIPEC an appropriate therapeutic option, 25% would not recommend CRS and HIPEC. The main barriers to referral to an expert center were inaccessibility to such a center (37.8%), non-inclusion of CRS and HIPEC in clinical practice guidelines (32.4%), and a high morbidity/mortality (21.6%). Variations were found in the various practice patterns of CRS/HIPEC like eligibility criteria, HIPEC protocols and safety measures. Although PIPAC awareness as a novel therapeutic option was high, only a limited number of centers offered PIPAC, mainly because of non-access to technology and missing training opportunities (76.2%). Conclusions Lack of widespread acceptance, poor accessibility and low utilization presents a significant challenge for HIPEC and PIPAC in India. There is a need to raise the awareness of curative and palliative therapeutic options for PSM. This might be achieved by the creation of expert centers, specialized training curricula and of a new sub-speciality in oncology.
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Affiliation(s)
| | - Kumar C Rohit
- Department of Surgical Oncology, Manipal Comprehensive Cancer Center, Manipal Hospital, Bangalore, India
| | - S V S Deo
- All India Institute of Medical Sciences, New Delhi, India
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Carboni F, Federici O, Zazza S, Sperduti I, Valle M. Feasibility of diaphragmatic interventions in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis: A 20-year experience. Eur J Surg Oncol 2021; 47:143-8. [PMID: 32888734 DOI: 10.1016/j.ejso.2020.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/28/2020] [Accepted: 08/20/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Complete cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is an effective treatment for improving prognosis of selected patients with peritoneal carcinomatosis. The addiction of diaphragmatic procedures may increase the incidence of postoperative respiratory complications. Our goal was to evaluate the early postoperative results following diaphragmatic surgery. METHODS Prospectively collected data of patients undergoing diaphragmatic surgery between January 2000 and January 2020 were retrospectively analyzed. Chest drains were routinely placed in all cases. Demographics, clinical and perioperative features were evaluated. RESULTS The study included 222 patients. Peritoneal stripping and full-thickness resections were performed in 165 and 57 cases, respectively. Women and ovarian tumours represented the vast majority of cases. Overall postoperative mortality and morbidity rates were 1.3% (3 patients) and 43.2% (96 patients), respectively. Specific diaphragmatic surgery-related complications was 9.4% (21 patients). No pleural effusion and pneumothotrax occurred. The incidence of pneumonia was 1.8% (4 patients), each due to systemic bacterial origin, 2 (0.9%) of which required Intensive Care Unit-readmission. Postoperative bleeding was observed in 15 (6.7%) cases, 12 (5.4%) of which required reoperation. A comparison with 105 patients who operated during the same period without diaphragmatic surgery was performed and by multivariate analysis, Peritoneal Cancer Index, histology and overall morbidity resulted significantly associated with diaphragmatic surgery. CONCLUSION Diaphragmatic surgery during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is often required in order to obtain complete resection. It may be associated with higher postoperative morbidity, especially bleeding, but routine placement of chest drains may reduce the incidence of adverse respiratory events.
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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: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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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 II: Postoperative management and special considerations. Eur J Surg Oncol 2020; 46:2311-23. [PMID: 32826114 DOI: 10.1016/j.ejso.2020.08.006] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] 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 II of the guidelines highlights postoperative management and special considerations. 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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Kamm AM, Turaga KK. Appendiceal Mucinous Neoplasm: Nurse Education About a Rare and Complex Disease. Clin J Oncol Nurs 2020; 24:409-414. [PMID: 32678367 DOI: 10.1188/20.cjon.409-414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Appendiceal mucinous neoplasms (AMNs) are a rare and complex spectrum of disease involving a mucinous tumor within the appendix, which can range from benign to malignant. If not limited to the appendix, the mucinous tumor can spread diffusely throughout the peritoneum. OBJECTIVES Because of the low incidence of AMN, this study describes the diagnosis and treatment process for this disease, which is not well known to most care providers. METHODS An extensive analysis of the current literature, including incidence, diagnosis, and surgical treatment, was performed. A review of the pre- and postoperative needs for patients undergoing surgery was also conducted. FINDINGS There is minimal information in the nursing literature about AMN and the complexity of surgical management. Nurses play an important role in caring for these patients and their unique needs both before and after surgery.
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Liu JB, Schuitevoerder D, Vining CC, Berger Y, Turaga KK, Eng OS. Benchmarking Perioperative Outcomes of Cytoreductive Surgery for Cancer: Implications for Quality Measurement. Ann Surg Oncol 2020; 27:5039-5046. [PMID: 32729047 DOI: 10.1245/s10434-020-08815-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/19/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Understanding variation and heterogeneity in practice patterns allows programs to develop effective strategies to improve patient outcomes. Cytoreductive surgery is a potentially highly morbid operation that could benefit from systematic assessments directed towards quality improvement. We describe the hospital-level variation and benchmarks for programs performing cytoreductive surgery. PATIENTS AND METHODS Cytoreductive and tumor debulking operations with or without hyperthermic intraperitoneal chemotherapy performed for cancer between January 1, 2013 and June 30, 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program registry. Risk-adjusted hospital-level variation in 30-day death, serious morbidity, reoperation, readmission, and a composite of death or serious morbidity (DSM) were evaluated using hierarchical models. National Cancer Institute (NCI)-designated cancer center (NCI-CC) status was also explored. RESULTS A total of 6203 operations across 589 hospitals were included, of which 56 were at NCI-CCs. Unadjusted rates of death, serious morbidity, reoperation, readmission, and DSM were 1.4%, 12.9%, 3.6%, 8.6%, and 13.4%, respectively. The coefficients of variation for hospital-level performance were 4.7%, 2.1%, 4.6%, 14.4%, and 1.0% for DSM, death, serious morbidity, unplanned reoperation, and unplanned readmissions, respectively. When compared with other hospitals, NCI-CCs had better risk-adjusted 30-day mortality (median odds ratio 0.984 versus 0.998, p < 0.001), but not for the other outcomes studied. CONCLUSIONS Hospital-level variation was modestly detected using the usual measures of perioperative outcomes. Given the increasing interest in cytoreductive surgery, we demonstrate a clear opportunity to not only improve the quality of our care but to also better improve the way quality is measured for these patients.
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Affiliation(s)
- Jason B Liu
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA.
| | | | - Charles C Vining
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Yaniv Berger
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Kiran K Turaga
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Oliver S Eng
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
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Gamboa AC, Lee RM, Turgeon MK, Zaidi MY, Kimbrough CW, Grotz TE, Leiting J, Fournier K, Lee AJ, Dineen SP, Powers BD, Veerapong J, Baumgartner JM, Clarke CN, Mogal H, Patel SH, Lee TC, Lambert LA, Hendrix RJ, Abbott DE, Pokrzywa C, Raoof M, Eng OS, Johnston FM, Greer J, Cloyd JM, Maithel SK, Staley CA. Implications of Postoperative Complications for Survival After Cytoreductive Surgery and HIPEC: A Multi-Institutional Analysis of the US HIPEC Collaborative. Ann Surg Oncol 2020; 27:4980-4995. [PMID: 32696303 DOI: 10.1245/s10434-020-08843-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/27/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Postoperative complications (POCs) are associated with worse oncologic outcomes in various cancer histologies. The impact of POCs on the survival of patients with appendiceal or colorectal cancer after cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is unknown. METHODS The US HIPEC Collaborative (2000-2017) was reviewed for patients who underwent CCR0/1 CRS/HIPEC for appendiceal/colorectal cancer. The analysis was stratified by noninvasive appendiceal neoplasm versus invasive appendiceal/colorectal adenocarcinoma. The POCs were grouped into infectious, cardiopulmonary, thromboembolic, and intestinal dysmotility. The primary outcomes were overall survival (OS) and recurrence-free survival (RFS). RESULTS Of the 1304 patients, 33% had noninvasive appendiceal neoplasm (n = 426), and 67% had invasive appendiceal/colorectal adenocarcinoma (n = 878). In the noninvasive appendiceal cohort, POCs were identified in 55% of the patients (n = 233). The 3-year OS and RFS did not differ between the patients who experienced a complication and those who did not (OS, 94% vs 94%, p = 0.26; RFS, 68% vs 60%, p = 0.15). In the invasive appendiceal/colorectal adenocarcinoma cohort, however, POCs (63%; n = 555) were associated with decreased 3-year OS (59% vs 74%; p < 0.001) and RFS (32% vs 42%; p < 0.001). Infectious POCs were the most common (35%; n = 196). In Multivariable analysis accounting for gender, peritoneal cancer index (PCI), and incomplete resection (CCR1), infectious POCs in particular were associated with decreased OS compared with no complication (hazard ratio [HR] 2.08; p < 0.01) or other types of complications (HR, 1.6; p < 0.01). Similarly, infectious POCs were independently associated with worse RFS (HR 1.61; p < 0.01). CONCLUSION Postoperative complications are associated with decreased OS and RFS after CRS/HIPEC for invasive histology, but not for an indolent disease such as noninvasive appendiceal neoplasm, and this association is largely driven by infectious complications. The exact mechanism is unknown, but may be immunologic. Efforts must target best practices and standardized prevention strategies to minimize infectious postoperative complications.
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Affiliation(s)
- Adriana C Gamboa
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Rachel M Lee
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Michael K Turgeon
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Mohammad Y Zaidi
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Charles W Kimbrough
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Travis E Grotz
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, NY, USA
| | - Jennifer Leiting
- Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, NY, USA
| | - Keith Fournier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J Lee
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sean P Dineen
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Benjamin D Powers
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Department of Oncologic Sciences, Morsani College of Medicine, Tampa, FL, USA
| | - Jula Veerapong
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Joel M Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of California, San Diego, CA, USA
| | - Callisia N Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Harveshp Mogal
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sameer H Patel
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tiffany C Lee
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Laura A Lambert
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ryan J Hendrix
- Division of Surgical Oncology, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Courtney Pokrzywa
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Mustafa Raoof
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Oliver S Eng
- Division of Surgical Oncology, Department of Surgery, University of Chicago, Chicago, IL, USA
| | | | - Jonathan Greer
- Department of Surgery, Johns Hopkins University, Baltimore, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA.
| | - Charles A Staley
- Division of Surgical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA, USA
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Hervás MS, Játiva-Porcar R, Robles-Hernández D, Rubert AS, Segarra B, Oliva C, Escrig J, Llueca JA. Evaluation of the relationship between lactacidemia and postoperative complications after surgery for peritoneal carcinomatosis. Korean J Anesthesiol 2020; 74:45-52. [PMID: 32434292 PMCID: PMC7862932 DOI: 10.4097/kja.20089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/14/2020] [Indexed: 12/12/2022] Open
Abstract
Background Cytoreductive surgery was developed as a treatment for peritoneal carcinomatosis. However, this surgery is associated with important complications. The present study aimed to assess the relationship between lactacidemia and the rate of associated complications during the immediate postoperative period in the intensive care unit (ICU) in patients undergoing cytoreductive surgery. Methods This was a retrospective observational study. A total of 57 patients underwent cytoreductive surgery. All patients were admitted to the ICU immediately after the surgery. Data on lactic acid levels at the time of admission and discharge from the ICU were collected. Postsurgical complications that occurred during the ICU stay were recorded according to failure-to-rescue analysis and their severity stratified according to the Clavien-Dindo classification. Results The lactic acid levels at admission to the ICU were significantly higher in patients who developed complications, with an almost tripled unadjusted relative risk (2.9, 95% CI: 1.6, 5.3), than in those who did not develop complications for the lactacidemia threshold established in the cumulative sum curve graphs. After adjustment for confounding effects, the relative risk became even higher (3.1, 95% CI: 1.8, 3.6). Lactic acid levels were still significantly higher in this group at the time of discharge from the ICU. Conclusions Serum lactate level is a risk factor for postoperative complications in patients undergoing cytoreductive surgery for peritoneal carcinomatosis. This study suggests that the risk of developing severe complications almost triples with a lactic acid level of 2.5 mmol/L or higher at the time of admission in the ICU.
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Affiliation(s)
- Marta Soriano Hervás
- Department of Anesthesiology, University General Hospital of Castellon, Castellón de La Plana, Spain
| | - Rosa Játiva-Porcar
- Department of Anesthesiology, University General Hospital of Castellon, Castellón de La Plana, Spain
| | - Daniel Robles-Hernández
- Department of Anesthesiology, University General Hospital of Castellon, Castellón de La Plana, Spain
| | - Anna Serra Rubert
- Department of Obstetrics and Gynecology, University General Hospital of Castellon, Castellón de La Plana, Spain
| | - Blanca Segarra
- Department of Obstetrics and Gynecology, University General Hospital of Castellon, Castellón de La Plana, Spain
| | - Cristina Oliva
- Department of Obstetrics and Gynecology, University General Hospital of Castellon, Castellón de La Plana, Spain
| | - Javier Escrig
- Department of General Surgery, University General Hospital of Castellon, Castellón de La Plana, Spain
| | - José Antonio Llueca
- Department of Obstetrics and Gynecology, University General Hospital of Castellon, Castellón de La Plana, Spain
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Duzgun O. Evaluation of Enhanced Recovery After Following a Surgical Protocol for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis. Med Arch 2020; 73:331-337. [PMID: 31819307 PMCID: PMC6885212 DOI: 10.5455/medarh.2019.73.331-337] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Introduction: Cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (CRS ± HIPEC) has positive effects on the survival of patients with peritoneal carcinomatosis (PC) due to intra-abdominal tumors. Currently, the available literature on the safety of the Enhanced Recovery After Surgery (ERAS) protocol for PC, which is associated with severe morbidity and mortality, is insufficient. Aim: This study aimed to present our results from treating patients using the ERAS protocol for PC that developed due to intra-abdominal tumors. Material and Methods: The data of 120 consecutive patients with PC due to different etiologies of abdominal origin and who underwent CRS ± HIPEC were analyzed. The patients were divided into two groups according to whether the ERAS protocol was applied. Information on demographics, length of hospital stay, cost, morbidity, and mortality was statistically compared between groups. Results: A total of 102 patients were included in the study. The first 40 patients did not undergo the ERAS protocol, whereas 62 patients did undergo the protocol. The mean length of hospital stay was 10 days in the non-ERAS group and 7 days in the ERAS group. The ERAS group was observed to have earlier mobilization, earlier gas and stool release, lower oral intake, and fewer respiratory problems than the non-ERAS group. Conclusion: CRS ± HIPEC has a positive effect on survival. The simultaneous application of the ERAS protocol with the aforementioned procedure has positive effects on intestinal motility and postoperative outcomes. In addition, this protocol may reduce costs by shortening the length of hospital stay.
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Affiliation(s)
- Ozgul Duzgun
- Department of Surgical Oncology, Health Sciences University, Umraniye Training and Research Hospital, Umraniye/Istanbul, Turkey
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Di Leo A, Corvasce A, Weindelmayer J, Mason EJ, Casella F, de Manzoni G. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in pseudomyxoma peritonei of appendiceal origin: result of a single centre study. Updates Surg 2020; 72:1207-1212. [PMID: 32410159 DOI: 10.1007/s13304-020-00788-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/02/2020] [Indexed: 12/25/2022]
Abstract
Pseudomyxoma peritonei (PMP) is a rare condition characterized by the intraperitoneal accumulation of mucus derived mostly by appendiceal mucinous neoplasm. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) can offer a favourable overall survival. In this study, we report a single-institute outcomes following CRS and HIPEC in patients with this condition. This is a review of prospectively collected data from 32 patients (11 men and 21 women) affected by PMP of appendiceal origin who underwent CRS and HIPEC from 2008 to 2016 in our Surgical Unit of General and Esophagogastric Surgery. The median age of the patients was 53 years (range 25-77 years). After CRS, all patients underwent HIPEC (mytomicin C 3.3 mg/m2/L and cisplatin 25 mg/m2/L at 41 °C for 60 min) with closed abdomen technique. The median (range) follow-up time for surviving patients was 43 (18-119) months. The median peritoneal cancer index (PCI) was 17. Complete cytoreductive surgery (CC0) was achieved in in 22 patients (69%). The majority of patients (88%) had grade I-II complications, 3 (9%) had grade III complications, and 1 (3%) patient had a grade IV complication. There were no perioperative mortalities. The median hospital stay was 9.5 (range 9-24) days. One year and 5-year overall survival (OS) were 90% and 58%, respectively. Regardless of histotype, disease-free survival was 95% at 1 year and 46% at 5 years. CRS in combination with HIPEC is a feasible treatment strategy and can achieve a satisfactory outcome in patients with PMP of appendiceal origin.
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Affiliation(s)
- Alberto Di Leo
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy.
| | - Arianna Corvasce
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy
| | - Jacopo Weindelmayer
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy
| | - Elena Jane Mason
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy
| | - Francesco Casella
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy
| | - Giovanni de Manzoni
- General and Upper GI Surgery Division, University of Verona, Piazzale Stefani, 1, 37124, Verona, Italy
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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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Wang X, Li T. Postoperative pain pathophysiology and treatment strategies after CRS + HIPEC for peritoneal cancer. World J Surg Oncol 2020; 18:62. [PMID: 32234062 PMCID: PMC7110707 DOI: 10.1186/s12957-020-01842-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/20/2020] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Xiao Wang
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, 100038, China
| | - Tianzuo Li
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, No. 10 Tieyi Road, Yangfangdian, Haidian District, Beijing, 100038, China.
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Fields AC, Lu PW, Li GZ, Welten V, Jolissaint JS, Vierra BM, Saadat LV, Larson AC, Atkinson RB, Melnitchouk N. Current practices and future steps for hyperthermic intraperitoneal chemotherapy. Curr Probl Surg 2020; 57:100727. [PMID: 32151327 DOI: 10.1016/j.cpsurg.2019.100727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/23/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Adam C Fields
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Pamela W Lu
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - George Z Li
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Vanessa Welten
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joshua S Jolissaint
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Lily V Saadat
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Abby C Larson
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Rachel B Atkinson
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nelya Melnitchouk
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Gehlen J, Klaschik S, Neumann C, Keyver-Paik MD, Mustea A, Soehle M, Frede S, Velten M, Hoeft A, Hilbert T. Dynamic changes of angiopoietins and endothelial nitric oxide supply during fluid resuscitation for major gyn-oncological surgery: a prospective observation. J Transl Med 2020; 18:48. [PMID: 32005259 DOI: 10.1186/s12967-020-02236-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 01/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite goal-directed hemodynamic therapy, vascular function may deteriorate during surgery for advanced abdominal tumor masses. Fluid administration has been shown to be associated with distinct changes in serum levels of functional proteins. We sought to determine how serum total protein and angiopoietin (ANG) levels change during major abdominal tumor surgery. In addition, ex vivo endothelial nitric oxide synthase (eNOS) activation as well as NO bioavailability in vivo were assessed. METHODS 30 patients scheduled for laparotomy for late-stage ovarian or uterine cancer were prospectively included. Advanced hemodynamic monitoring as well as protocol-driven goal-directed fluid optimization were performed. Total serum protein, ANG-1, -2, and soluble TIE2 were determined pre-, intra-, and postoperatively. Phosphorylation of eNOS was assessed in microvascular endothelial cells after incubation with patient serum, and microvascular reactivity was determined in vivo by near-infrared spectroscopy and arterial vascular occlusion. RESULTS Cardiac output as well as preload gradually decreased during surgery and were associated with a median total fluid intake of 12.8 (9.7-15.4) mL/kg*h and a postoperative fluid balance of 6710 (4113-9271) mL. Total serum protein decreased significantly from baseline (66.5 (56.4-73.3) mg/mL) by almost half intraoperatively (42.7 (36.8-51.5) mg/mL, p < 0.0001) and remained at low level. While ANG-1 showed no significant dilutional change (baseline: 12.7 (11.9-13.9) ng/mL, postop.: 11.6 (10.8 -13.5) ng/mL, p = 0.06), serum levels of ANG-2 were even increased postoperatively (baseline: 2.2 (1.6-2.6) ng/mL vs. postop.: 3.4 (2.3-3.8) ng/mL, p < 0.0001), resulting in a significant shift in ANG-2 to ANG-1 ratio. Ex vivo phosphorylation of eNOS was decreased depending on increased ANG-2 levels and ANG-2/1 ratio (Spearman r = - 0.37, p = 0.007). In vivo, increased ANG-2 levels were associated with impaired capillary recruitment and NO bioavailability (Spearman r = - 0.83, p = 0.01). CONCLUSIONS Fluid resuscitation-associated changes in serum vascular mediator profile during abdominal tumor surgery were accompanied by impaired eNOS activity ex vivo as well as reduced NO bioavailability in vivo. Our results may explain disturbed microvascular function in major surgery despite goal-directed hemodynamic optimization.
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Pameijer C, Lewcun J, Pauli E. Incisional hernia formation can be reduced following hyperthermic intraperitoneal chemotherapy with increased suture length to wound length ratio fascial closure. Int J Abdom Wall Hernia Surg 2020. [DOI: 10.4103/ijawhs.ijawhs_30_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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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: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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