Hyperthermic intraperitoneal chemotherapy surgery

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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
Comprehensive
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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[1][7]

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 Neurologic dysfunction risk based upon chemotherapy agents used
Cardiovascular Cardiomyopathy risk based upon chemotherapy agents used
Respiratory Pneumonitis based upon chemotherapy agents used
Gastrointestinal Hypoalbuminemia associated with higher major mobidity[8]
Hematologic Risk of profound anemia
Renal Renal dysfunction based upon chemotherapy used.

Monitor creatinine and GFR

Abnormal electrolytes

Endocrine
Other Patients may need nutrition optimization prior to surgery

Patients can benefit from active prehabilitation prior to surgery

Labs and studies

  • CMP (particularly renal function and electrolytes)
  • CBC (identify and correct anemia)
  • Consider pre-albumin to evaluate nutrition status

Operating room setup

  • Fluid warmer
  • Arterial line setup
  • ± Central line
  • ± Cardiac output monitor (i.e. Flowtrack)
  • NG tube
  • Vasopressor drips
  • Blood products

Patient preparation and premedication

  • Preoperative nutrition consult
  • Preoperative prehabilitation plan

Regional and neuraxial techniques

  • Epidural or paravertebral blocks (if epidural is contraindicated)

Intraoperative management

Monitoring and access

  • Multiple large-bore PIVs (for active fluid resuscitation)
  • ± Rapid infusion catheter
  • Arterial line
  • ± Central venous catheter

Induction and airway management

  • General anesthesia with ETT

Surgical Timeout Communication

Operative goals are crucial to delineate with the surgical team prior to incision. Key discussion points include:

  1. Patient Risk Factors
  2. DVT prophylaxis
  3. Fluid Goals
  4. Body Temperature Management plus additional monitors (esophageal, nasopharyngeal, bladder, axillary, etc)
  5. Type of chemotherapy agent used, including dilution solution and its implications on electrolytes
  6. Consideration for further renal protection therapy
  7. Trigger for blood transfusion
  8. Preoperative antibiotic choice

Positioning

  • Supine

Maintenance and surgical considerations

Cytoreductive Phase
  • Fluid resuscitation to maintain euvolemia: consider to utilize arterial line and cardiac output monitoring to guide fluid resuscitation and avoid over-resuscitation
  • Check ABG and base deficit q1hour
  • Check coagulation status q4 hours
  • Resuscitate with lactated ringers or plasmalyte (Avoid normal saline)
  • Consider albumin administration for intravascular fluids
  • Maintain normothermia to mild hypothermia (target temp 35-36.5 c)
  • Monitor urine output and evaluate volume status. If UOP less than 0.5 mL/kg/hr - Consider vasopressin or norepinephrine to maintain MAP if patient is hypotensive but not hypovolemic
  • Obtain pre-HIPEC chemistries (Na+, K+, Mg2+, Ca2+)[9]
HIPEC Phase
  • Maintain good muscle relaxation
  • Intra-abdominal pressure may be elevated up to 26 mm Hg
    • Maintain abdominal perfusion pressure of >60 (MAP – IAP)
  • Manage ventilation to maintain normocarbia and normoxia
  • Avoid hypervolemia during high volume resuscitation
  • Maintain UOP according to discussed fluid goals (up to 100 cc/15 min)
  • Check ABG and base deficit q30min to q1hour
    • Treat hyperglycemia (>200) with insulin drip
    • Treat hyponatremia
      • Diuretics for hypervolemia
      • Volume resuscitate for hypovolemia; consider hypertonic saline if Na<130
  • Check electrolytes (Na+, K+, Mg2+_, Ca2+) during HIPEC phase
  • Continue to check coagulation factors q4 hour
  • Goal intraperitoneal tissue temperature: 41-43 degrees Celcius
  • Watch for core temperature >39.5 c
    • Consider passive cooling vs active cooling with ice
    • Consider cooling intraperitoneal fluids
  • Cisplatin Perfusion ONLY:
    • sodium thiosulfate bolus at start of chemoperfusion
    • Sodium thiosulfate drip starts immediately after bolus over 12 hrs
    • Crystalloid (avoid NS) to maintain urine output > 100mL/hr through the end of case and into PACU / ICU

Emergence

  • After fascia is closed, check twitches and reverse paralysis
  • Plan for extubation if hemodynamically stable, normothermic and normoxic

Postoperative management

Disposition

  • Admit to ICU (consider discussion with ICU team and surgeon beforehand)
  • UOP Goals: UOP 100 mL/hr (for Cisplatin)
  • May require pressors due to prolonged vasoplegia postoperatively
  • Continue Sodium thiosulfate drip over 12 hours from start of perfusion

Pain management

Potential complications

Procedure variants

Open Abdominal

Perfusion

Closed Abdominal

Perfusion

Unique considerations High intrabdominal pressures
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. 1.0 1.1 1.2 1.3 1.4 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)
  2. 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. 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.
  4. 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.
  5. 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)
  6. 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)
  7. Cancer chemotherapy and biotherapy : principles and practice. Bruce Chabner, Dan L. Longo (5th ed ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. 2011. ISBN 1605474312. OCLC 751669717. |edition= has extra text (help)CS1 maint: others (link)
  8. Seretis, Charalampos; Gill, Jagjit; Malik, Adnan; Elhassan, Ali Mohamed; Shariff, Umar; Youssef, Haney (2020-12). "Low Preoperative Serum Albumin Levels Are Associated With Impaired Outcome After Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Peritoneal Surface Malignancies". Journal of Clinical Medicine Research. 12 (12): 773–779. doi:10.14740/jocmr4362. ISSN 1918-3003. PMC 7781284. PMID 33447310. Check date values in: |date= (help)
  9. Rothfield, Kenneth P.; Crowley, Kathy (2012-10). "Anesthesia considerations during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy". Surgical Oncology Clinics of North America. 21 (4): 533–541. doi:10.1016/j.soc.2012.07.003. ISSN 1558-5042. PMID 23021714. Check date values in: |date= (help)