Thoracic epidural anesthesia in patients with cytoreductive surgery and HIPEC

Peritoneal Cancers and Hyperthermic Intraperitoneal Chemotherapy

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.

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

Background

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

Main body

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

Conclusion

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

Epidural analgesia? A prospective analysis of perioperative coagulation in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is beneficial in peritoneal carcinomatosis. Epidurals provide excellent pain relief for laparotomies. Coagulopathy (platelet count <100 × 10⁹/L, INR>1.5 or PTT >45) occurs with CRS and HIPEC, increasing risk for bleeding complications with epidurals. This prospective study characterizes clot kinetics with thromboelastography (TEG) to determine suitability for epidural analgesia.

METHODS

After Research Ethics approval, thirty consented patients had blood collected. Primary data collected included TEG and conventional coagulation measures (platelets, PTT and INR). Secondary data collected included demographics, disease, surgical, intraoperative factors and complications from epidural placement.

RESULTS

Of 30 patients analyzed, two had incomplete data. Four developed abnormal coagulation between the second and fifth post-operative day. For all patients, TEG values remained normal. Postoperative INR was elevated until day 3 (all INR < 1.5). 17 patients received epidural analgesia, 3 demonstrated abnormal conventional coagulopathic criteria despite normal TEG.

CONCLUSIONS

In this study CRS and HIPEC do not contribute to the conventional definition of clinical coagulopathy. Clot kinetics indicate that epidural catheters may be recommended for post-operative analgesia.

Prolonged perioperative thoracic epidural analgesia may improve survival after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases: A comparative study

OBJECTIVE

To assess the effectiveness of prolonged perioperative thoracic epidural analgesia (PEA) on long term survival of patients who underwent a complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for colorectal peritoneal metastases (CPM).

BACKGROUND

Grade III-IV morbidity affects long term outcomes after CRS and HIPEC. As compared with opioid administered via patient-controlled analgesia (PCA), PEA reduces morbidity.

METHOD

From 2005 to 2016, 150 patients underwent CRS plus HIPEC with or without prolonged PEA. Clinical data and outcomes collected from prospective database were analyzed. Survival was assessed in terms of analgesic method using Kaplan-Meier plots and a propensity score.

RESULTS

Patients 'characteristics of 59 patients in PCA group were comparable to those of 91 patients in PEA group, except for age, ASA score and fluid requirements, significantly more important in PEA group. Grade III-IV morbidity was 62.7% in PCA group compared with 36.3% in PEA group (p = 0.0015). Median overall survival (OS) of PEA group was 54.7 months compared to 39.5 months in PCA group (p = 0.0078). When adjusted on the covariates, using the propensity score, the PEA significantly improves OS [HR 0.40 (95% CI: 0.28-0.56)] (p < 0.0001) and disease free survival (DFS) [HR 0.61 (95% CI: 0.45-0.81] (p < 0.0007) CONCLUSIONS: In this retrospective study of patients who underwent a complete CRS and HIPEC for colorectal peritoneal metastases, the perioperative thoracic epidural analgesia prolonged for over 72 h reduced significantly the grade III-IV morbidity and may improve OS and DFS.

Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines

Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.

Staged intraperitoneal brachytherapy and hyperthermic intraperitoneal chemotherapy in an adolescent: novel anesthetic challenges for pediatric anesthetists

Newer techniques that have found a place in cancer management in adults are offered far less commonly in pediatric patients. We present a case of a patient with recurrent Wilms' tumor managed with a novel combination of cytoreductive surgery, intraperitoneal brachytherapy, and subsequent hyperthermic intraperitoneal chemotherapy. Each stage presents challenges that the pediatric anesthetist is unlikely to have faced before. Such cases require flexibility and thorough planning to manage the combination of major surgery, remote anesthesia with brachytherapy and hyperthermic chemotherapy with its potential for metabolic derangement, significant fluid shifts, analgesic care, and potential exposure of staff to cytotoxic agents. Comprehensive care can be offered in pediatric centers.

Epidural analgesia for cytoreductive surgery with peritonectomy and heated intraperitoneal chemotherapy

PURPOSE

To evaluate epidural analgesia role after cytoreductive surgery with peritonectomy combined with heated intraperitoneal chemotherapy.

METHODS

101 patients were retrospectively studied (between 2008 and 2012) to evaluate epidural analgesia effectiveness, tolerability and safety in this surgical context through the assessment of pain, detection of adverse events (nausea, vomiting, itching), temporary motor block, respiratory failure and coagulation profile in the post-operative period.

RESULTS

The median duration of epidural analgesia was 5 [range 1-10] days. As regards pain relief, the median verbal numerical scale scores at rest and on movement were below 2 and 5 until the fifth post-operative day, respectively. 13% of patients suffered nausea, 4% vomit, and 1% itching. No bradycardia or respiratory failure event was reported. 9.9% of patients had hypotension episodes. Coagulation reached normality only 3-4 days after surgery. 5 risky accidental dislodgments of epidural catheter occurred (prothrombine time INR > 1.5) without neurological complications.

CONCLUSIONS

Epidural analgesia ensures adequate pain relief and is well tolerated by patients after cytoreductive surgery with peritonectomy combined with heated intraperitoneal chemotherapy. Hypotension is common in this context and careful monitoring of coagulation parameters, especially in the first 3 days after surgery, is advisable to reduce the risk of neuraxial complications.

Anesthetic management of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedures

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy procedure are performed with increasing frequency to treat patients with diffused peritoneal carcinomatosis. These procedures have showed to increase life expectancy in what was previously considered a “terminal condition”. Anyway patients face major and life threatening derangements of their hemodynamic, respiratory and metabolic physiologic balance during the surgery and in the immediate postoperative period. Despite the need of an advanced organ monitoring and support all these derangements seem to be mild and short-lived when timely addressed, at least in the majority of patients. Intensive care physicians are involved in providing surveillance and organ support till the patient is effectively weaned after the operation. Moreover, the anesthesiologist as perioperative physician is involved in pain control, metabolic and nutritional support of this cohort of patients. This task can be challenging considering that part of the patients are already on a long list of pain control medication after previous surgery or chemotherapy. A malnourished state is common too and it is secondary to difficult feeding, wasting syndrome from the tumor and massive ascites. The last issue the anesthesiologists need to be aware of is the impact over the quality of life (QoL) of this procedure. The patient’s underlying pathology is unlikely to be definitively cured so no treatment is an acceptable choice. The possibility to withhold the treatments must be part of the consultation process like the discussion about the QoL in the immediate, as well as in the long-term, after the operation. Careful monitoring and treatment of every aspect that can impact the QoL must be taken and the efforts to be poured into an effective preservation of the QoL must be doubled when compared with a patient scheduled for major abdominal surgery.

An overview of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for the anesthesiologist

Anesthesiologists face several perioperative challenges when patients need cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion. To adequately care for these patients, anesthesiologists must understand the goals and objectives of the operation in addition to having a basic knowledge of the chemotherapeutic drugs that are frequently used. Optimal anesthetic management of patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion requires control of a complex interplay of physiologic mechanisms, including hyperthermia, abdominal hypertension, electrolyte abnormalities, coagulopathies, increased cardiac index, oxygen consumption, and decreased systemic vascular resistance. As this surgery continues to gain popularity among oncologic surgeons, further studies that clearly define the chemistry, pharmacokinetics, pharmacodynamics, and end points of efficacy need to be performed to elucidate optimal perioperative management.

Anesthesia considerations during cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

This article outlines the anesthetic management of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. This includes a discussion of preoperative evaluation, hemodynamic monitoring, fluid and electrolyte therapy, and temperature management. An understanding of the unique physiologic consequences of this procedure is essential to ensure good outcomes and avoid patient injuries.

Perioperative management of patients undergoing cytoreductive surgery combined with heated intraperitoneal chemotherapy for peritoneal surface malignancy: a multi-institutional experience

BACKGROUND

Cytoreductive surgery (CRS) combined with heated intraperitoneal chemotherapy (HIPEC) is an established treatment for patients with pseudomyxoma peritonei. There is now increasing evidence for the use of CRS and HIPEC in the treatment of other peritoneal surface malignancies. There is currently no consensus on the perioperative management of this patient group.

METHODS

An international survey of practice was conducted using an online survey tool. Centers were identified from the list of delegates attending the Seventh International Workshop on Peritoneal Surface malignancy held in Uppsala, Sweden, in September 2010.

RESULTS

Fully completed surveys were received from 29 of 41 identified centers (71 %). The survey covers the combined experience amassed by anesthesiologists caring for 8,467 patients undergoing cytoreductive surgery. Intraoperative fluid management, management of coagulopathy, management of the HIPEC phase of the operation, and postoperative analgesia caused the greatest difficulties for the anesthesia team with variation in management identified between different institutions. The incidence of epidural abscess in this patient group was found to be 1:2,139.

CONCLUSIONS

Optimal preoperative, intraoperative, and postoperative care is crucial to diminish the complications in this complex treatment strategy. Multicenter collaboration is suggested to gain evidence on the best strategies for perioperative management. Further data collection needs to be undertaken to assess the safety of epidural anesthesia in this patient group.