Hyperthermic intraperitoneal chemotherapy surgery
| Anesthesia type |
General |
|---|---|
| Airway |
ETT |
| Lines and access |
Large bore PIV X2 Central venous access Nasogastric tube |
| Monitors |
Standard ASA monitors Arterial Line (consider cardiac output monitoring) Central venous pressure |
| Primary anesthetic considerations | |
| Preoperative |
Baseline renal function Electrolyte status Anemia Prehabilitation Nutrition optimization |
| Intraoperative |
Hemodynamic monitoring Active fluid resuscitation Normothermia or mild hypothermia Pre-HIPEC electrolytes HIPEC-phase electrolytes |
| Postoperative |
Maintain urine output Consider ICU admission Prolonged vasoplegia Sodium thiosulfate infusion (12 hrs) |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Cytoreductive surgery and Hyperthermic Intraperitoneal Chemoperfusion (HIPEC) is a combined procedure utilized to treat peritoneal surface cancers.[1] These cancers include secondary peritoneal carcinomatosis, pseudomyxoma peritonei and primary peritoneal tumors.[1][2] Cytoreductive surgery involves debulking the majority of tumors until the remainder are small enough to ensure adequate efficacy with HIPEC.
HIPEC involves infusing heated cytotoxic chemotherapeutic drugs directly into the surgical site in order to effectively penetrate involved cancer while limiting exposure to normal tissue and decrease systemic uptake.[1][3][4] This may be performed in a closed abdomen via perfusion circuit or an open abdomen +/- cavity expanders.[5] An open abdomen technique may reduce increased intraabdominal pressures and prevent reuse of the cytotoxic solution. However, the closed abdomen technique reduces risk of exposure of the medications to the OR staff.
Important perioperative considerations include temperature management, cardiovascular management, intra-abdominal pressures, metabolic derangements (depending on carrier solution of chemotherapeutic agent), potential toxicities (see table below), coagulopathy, fluid/renal management and pain management.[1][3]
Intraoperatively, OR staff may be exposed to cytotoxic agents due to high concentrations of chemotherapeutic medications, long case duration, and smoke and or mechanical exposure. Pregnant or those actively planning for pregnancy, those with a history of congenital malformations or abortions should carefully consider participation in HIPEC cases. Safety precautions including high-power filtration masks, eye protection, gloves, and standard universal precautions should always be heeded.[6]
Preoperative management
Cytotoxic Agents
| Chemotherapeutic
agent |
End-organ toxicity |
|---|---|
| Platinum
(cisplatin/oxaliplatin) |
Nephrotoxicity (hypomagnesemia/hypocalemia)
Nausea/Vomiting Neurotoxicity (Peripheral neuropathy, seizure, ototoxcity, blindness) Myelosupression Anaphylaxis |
| Mitomycin C | Myelosupression
Pulmonary/interstitial pneumonitis nausea/vomiting/diarrhea cardiomyopathy hemolytic uremic syndrome |
| 5-Fluropyrimidines | GI ulcers
myelosuppression rashes, keratitis, ataxia, cognitive dysfunction coronary spasm biliary sclerosis |
| Anthracyclines
(doxorubicin) |
Myelosuppression
GI mucositis Cardiomyopathy |
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | |
| Cardiovascular | |
| Respiratory | |
| Gastrointestinal | |
| Hematologic | |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
Operating room setup
Patient preparation and premedication
Regional and neuraxial techniques
Intraoperative management
Monitoring and access
Induction and airway management
Positioning
Maintenance and surgical considerations
Emergence
Postoperative management
Disposition
Pain management
Potential complications
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ 1.0 1.1 1.2 1.3 Webb, Christopher Allen-John; Weyker, Paul David; Moitra, Vivek K.; Raker, Richard K. (2013-04). "An overview of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for the anesthesiologist". Anesthesia and Analgesia. 116 (4): 924–931. doi:10.1213/ANE.0b013e3182860fff. ISSN 1526-7598. PMID 23460568. Check date values in:
|date=(help) - ↑ Macrì, Antonio (2010-01-15). "New approach to peritoneal surface malignancies". World Journal of Gastrointestinal Oncology. 2 (1): 9–11. doi:10.4251/wjgo.v2.i1.9. ISSN 1948-5204. PMC 2999159. PMID 21160811.
- ↑ 3.0 3.1 Schmidt, C.; Moritz, S.; Rath, S.; Grossmann, E.; Wiesenack, C.; Piso, P.; Graf, B. M.; Bucher, M. (2009-09-15). "Perioperative management of patients with cytoreductive surgery for peritoneal carcinomatosis". Journal of Surgical Oncology. 100 (4): 297–301. doi:10.1002/jso.21322. ISSN 1096-9098. PMID 19697426.
- ↑ Al-Shammaa, Hassan-Alaa-Hammed; Li, Yan; Yonemura, Yutaka (2008-02-28). "Current status and future strategies of cytoreductive surgery plus intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis". World Journal of Gastroenterology. 14 (8): 1159–1166. doi:10.3748/wjg.14.1159. ISSN 1007-9327. PMC 2690662. PMID 18300340.
- ↑ Witkamp, A. J.; de Bree, E.; Van Goethem, R.; Zoetmulder, F. A. (2001-12). "Rationale and techniques of intra-operative hyperthermic intraperitoneal chemotherapy". Cancer Treatment Reviews. 27 (6): 365–374. doi:10.1053/ctrv.2001.0232. ISSN 0305-7372. PMID 11908929. Check date values in:
|date=(help) - ↑ González-Moreno, Santiago; González-Bayón, Luis; Ortega-Pérez, Gloria (2012-10). "Hyperthermic intraperitoneal chemotherapy: methodology and safety considerations". Surgical Oncology Clinics of North America. 21 (4): 543–557. doi:10.1016/j.soc.2012.07.001. ISSN 1558-5042. PMID 23021715. Check date values in:
|date=(help)