Evaluation of Enhanced Recovery After Following a Surgical Protocol for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis

Predictors of Financial Toxicity Risk Among Patients Undergoing Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC)

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the preferred treatment for select patients with peritoneal malignancies. However, the procedure is resource intensive and costly. This study aimed to determine the risk of financial toxicity for patients undergoing CRS-HIPEC.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients undergoing CRS-HIPEC at a single institution from 2016 to 2022. We utilized insurance status, out-of-pocket expenditures, and estimated post-subsistence income to determine risk of financial toxicity. A multivariable logistic regression was used to determine risk factors for financial toxicity.

RESULTS

Our final study cohort consisted of 163 patients. Average age was 58 [standard deviation 10] years, and 52.8% (n = 86) were male. A total of 52 patients (31.9%) were at risk of financial toxicity. A total of 36 patients (22.1%) were from the lower income quartiles (first or second) and 127 patients (77.9%) were from the higher income quartiles (third or fourth). A total of 47 patients (29%) were insured by Medicare, and 116 patients (71%) had private insurance. The median out-of-pocket expenditure across the study cohort was $3500, with a median of $5000 ($3341-$7350) for the at-risk group and $3341 ($2500-$4022) for the not at-risk group (p < 0.001). Risk factors for financial toxicity included high out-of-pocket expenditures and a lower income quartile.

CONCLUSIONS

An estimated one-third of patients undergoing CRS-HIPEC at our institution were at risk for financial toxicity. Several preoperative factors were associated with an increased risk and could be utilized to identify patients who might benefit from interventions.

Impact of Successful Implementation of an Enhanced Recovery After Surgery Protocol for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) are complex operations for the treatment of peritoneal metastases. Enhanced recovery after surgery (ERAS) protocols are intended to standardize preoperative, intraoperative, and postoperative pathways, with the goal of improving patient care. This study describes feasibility and outcomes after implementing an ERAS protocol for CRS/HIPEC at a tertiary academic center.

METHODS

A single-institution experience of CRS/HIPEC was reviewed from January 2020 to March 2023. Patients were categorized according to whether they underwent CRS/HIPEC before or after ERAS initiation. Outcomes and protocol adherence were evaluated.

RESULTS

A total of 115 CRS/HIPEC operations were included-74 before and 41 after ERAS implementation. Median age was younger in the post-ERAS group, whereas sex, comorbidities, peritoneal carcinomatosis index, operation performed, and operative time were similar between groups. The most common primary cancer sites were gynecologic (40%), appendiceal (24%), and colorectal (22%). Adherence to all postoperative ERAS components was 76%. More post-ERAS patients ambulated by postoperative day (POD) 1 (90% vs. 54%; p < 0.001), tolerated liquid diet by POD 2 (88% vs. 32%; p < 0.001), and had foley removed by POD 3 (86% vs. 43%; p < 0.001). There was a trend toward decreased length of stay in the post-ERAS cohort (7 vs. 8 days; p = 0.092), with no difference in major complications, intensive care unit admission, or 30-day readmission.

CONCLUSIONS

Despite the heterogeneity of CRS/HIPEC operations, implementing an ERAS protocol for our patients was feasible and resulted in postoperative outcomes and adherence comparable with that of other major abdominal surgeries. This supports the potential for success in ERAS programs for CRS/HIPEC patients.

The effects of enhanced recovery after surgery on wound infection, complications, and postoperative hospital stay in patients undergoing colorectal surgery: A systematic review and meta-analysis

This study aimed to systematically evaluate the effects of enhanced recovery after surgery (ERAS) on surgical site infections, postoperative complications, and length of hospital stay in patients undergoing colorectal surgery. A comprehensive search was conducted of PubMed, Web of Science, Ovid, EMBASE, The Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang Data from database inception to April 2023 to identify relevant studies on the application of ERAS in colorectal surgery. Studies were screened, and data were extracted based on predetermined inclusion and exclusion criteria. Meta-analysis was performed using RevMan 5.4 software. A total of 22 studies, including 3702 patients (ERAS group: 1906; control group: 1796), were included in the final analysis. ERAS significantly reduced the incidence of surgical site infection (odds ratio [OR]: 0.49, 95% confidence interval [CI]: 0.34-0.69, p < 0.001), postoperative complications (OR: 0.33, 95% CI: 0.27-0.41, p < 0.001), and length of hospital stay (standardised mean difference: -1.22 days, 95% CI: -1.66 to -0.77 days, p < 0.001). These findings suggest that ERAS reduces the incidence of surgical site infections and postoperative complications and shortens the length of hospital stay in patients undergoing colorectal surgery. Therefore, ERAS should be promoted and applied in clinical practice.

Enhanced Recovery after Surgery (ERAS) Program for Patients with Peritoneal Surface Malignancies Undergoing Cytoreductive Surgery with or without HIPEC: A Systematic Review and a Meta-Analysis

Enhanced recovery after surgery (ERAS) program refers to a multimodal intervention to reduce the length of stay and postoperative complications; it has been effective in different kinds of major surgery including colorectal, gynaecologic and gastric cancer surgery. Its impact in terms of safety and efficacy in the treatment of peritoneal surface malignancies is still unclear. A systematic review and a meta-analysis were conducted to evaluate the effect of ERAS after cytoreductive surgery with or without HIPEC for peritoneal metastases. MEDLINE, PubMed, EMBASE, Google Scholar and Cochrane Database were searched from January 2010 and December 2021. Single and double-cohort studies about ERAS application in the treatment of peritoneal cancer were considered. Outcomes included the postoperative length of stay (LOS), postoperative morbidity and mortality rates and the early readmission rate. Twenty-four studies involving 5131 patients were considered, 7 about ERAS in cytoreductive surgery (CRS) + HIPEC and 17 about cytoreductive alone; the case histories of two Italian referral centers in the management of peritoneal cancer were included. ERAS adoption reduced the LOS (-3.17, 95% CrI -4.68 to -1.69 in CRS + HIPEC and -1.65, 95% CrI -2.32 to -1.06 in CRS alone in the meta-analysis including 6 and 17 studies respectively. Non negligible lower postoperative morbidity was also in the meta-analysis including the case histories of two Italian referral centers. Implementation of an ERAS protocol may reduce LOS, postoperative complications after CRS with or without HIPEC compared to conventional recovery.

Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): a cross-sectional survey

OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols have been questioned in patients undergoing cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies. This survey was performed to study clinicians' practice about ERAS in patients undergoing CRS-HIPEC.

METHODS

An online survey, comprising 76 questions on elements of prehabilitation (n=11), preoperative (n=8), intraoperative (n=16) and postoperative (n=32) management, was conducted. The respondents included surgeons, anesthesiologists, and critical care specialists.

RESULTS

The response rate was 66% (136/206 clinicians contacted). Ninety-one percent of respondents reported implementing ERAS practices. There was encouraging adherence to implement the prehabilitation (76-95%), preoperative (50-94%), and intraoperative (55-90%) ERAS practices. Mechanical bowel preparation was being used by 84.5%. Intra-abdominal drains usage was 94.7%, intercostal drains by 77.9% respondents. Nasogastric drainage was used by 84% of practitioners. The average hospital stay was 10 days as reported by 50% of respondents. A working protocol and ERAS checklist have been designed, based on the results of our study, following recent ERAS-CRS-HIPEC guidelines. This protocol will be prospectively validated.

CONCLUSIONS

Most respondents were implementing ERAS practices for patients undergoing CRS-HIPEC, though as an extrapolation of colorectal and gynecological guidelines. The adoption of postoperative practices was relatively low compared to other perioperative practices.

Enhanced Recovery After Surgery for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: A Systematic Review and Meta-Analysis

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a promising approach for the management of peritoneal carcinomatosis, but is associated with significant morbidity and prolonged hospital stay. Herein, we review the impact of Enhanced recovery after surgery (ERAS) protocol on length of stay (LOS) and early complications in patients undergoing CRS and HIPEC for peritoneal carcinomatosis.

Methods: PubMed and Embase were searched for studies comparing ERAS protocol with control for CRS + HIPEC. Mean difference (MD) and risk ratios (RR) were calculated for LOS and complications respectively.

Results: Six retrospective studies were included. Meta-analysis indicated statistically significant reduction in LOS with ERAS (MD: −2.82 95% CI: −3.79, −1.85 I² = 29% p < 0.00001). Our results demonstrated significantly reduced risk of Calvien Dindo grade III/IV complications with the use of ERAS protocol as compared to the control group (RR: 0.60 95% CI: 0.41, 0.87 I² = 0% p = 0.007). Pooled analysis of limited studies demonstrated no statistically significant difference in the risk of reoperation (RR: 1.04 95% CI: 0.54, 2.03 I² = 50% p = 0.90) readmission (RR: 0.55 95% CI: 0.21, 1.49 I² = 0% p = 0.24), acute kidney injury (RR: 0.55 95% CI: 0.28, 1.10 I² = 0% p = 0.09) or mortality (RR: 0.62 95% CI: 0.17, 2.26 I² = 0% p = 0.46) between the study groups.

Conclusion: For CRS + HIPEC, ERAS is associated with significantly reduced LOS along with lower incidence of complications. Limited data suggest that use of ERAS protocol is not associated with increased readmission, reoperation, and mortality rates in these patients. There is a need for randomized controlled trials to corroborate the current evidence.

Guide to Enhanced Recovery for Cancer Patients Undergoing Surgery: ERAS for Patients Undergoing Cytoreductive Surgery with or Without HIPEC

ERAS protocols may reduce length of stay and return to full functional recovery after cytoreductive surgery and HIPEC. Prehabilitation programs and post-operative goal directed pathways, along with other essential components of ERAS are discussed with supporting evidence.

The Impact of Thoracic Epidural Analgesia Versus Four Quadrant Transversus Abdominis Plane Block on Quality of Recovery After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy Surgery: A Single-Center, Noninferiority, Randomized, Controlled Trial

BACKGROUND

Recovery after CRS-HIPEC influenced by several factors, including pain and opioid consumption. We hypothesized that 4Q-TAP blocks provide not inferior quality of recovery compared with TEA after CRS-HIPEC. We conducted a randomized, controlled trial to determine whether 4-quadrant transversus abdominis plane (4Q-TAP) block analgesia was noninferior to thoracic epidural (TEA) among patients who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS HIPEC).

METHODS

Patients 18 years or older who underwent a CRS-HIPEC surgery were randomly assigned to have either TEA or 4Q-TAP blocks. The primary outcome of this study was the change in quality of recovery 2 days after surgery. Secondary outcomes included quality of recovery on Days 1, 3, 5, 7, 10, and 30 postoperatively, opioid consumption, pain intensity, length of stay, and postoperative complications. Analyses were performed on a per-protocol basis.

RESULTS

Sixty-eight patients were included in the analysis. The difference between 4Q-TAP and TEA in the mean QoR-15 change from surgery at postoperative Days 1, 2, and 3 was 0.80 (P = 0.004), -4.5 (P = 0.134), and 3.4 (P = 0.003), respectively. All differences through postoperative day 30 were significantly within the noninferiority boundary of -10 except at postoperative Day 2 (P = 0.134). Length of stay, opioid-related adverse events, and frequency and grade of complications were not significantly different between TEA and 4Q-TAP patients.

CONCLUSIONS

Despite the significantly higher use of opioids after CRS-HIPEC in patients with 4Q-TAP blocks, their short-term quality of recovery was not inferior to those treated with TEA. Patients undergoing CRS-HIPEC can be effectively managed with 4Q-TAP blocks.

Impact of Enhanced Recovery After Surgery on Postoperative Outcomes for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have been associated with significant morbidity and increased hospital length of stay (LOS). The authors report their experience after implementation of an enhanced recovery after surgery (ERAS) program for CRS-HIPEC.

METHODS

Outcomes were analyzed before and after ERAS implementation. The components of ERAS included preoperative carbohydrate loading, goal-directed fluid management, multimodal pain management, minimization of narcotic use, avoidance of nasogastric tubes, and early mobilization and feeding.

RESULTS

Of 168 procedures, 88 (52%) were in the pre-ERAS group and 80 (48%) were in the post-ERAS group. The two groups did not differ in terms of age, sex, comorbidities, peritoneal carcinomatosis index scores, completeness of cytoreduction, or operative time. The ERAS patients received fewer fluids intraoperatively (mean, 4.2 vs 6.4 L; p < 0.01). The mean LOS was 7.9 days post-ERAS compared with 10.0 days pre-ERAS (p = 0.015). Clavien-Dindo complications classified as grade ≥ 3 were lower after ERAS (23.7% vs 38.6%; p = 0.04). Moreover, the readmission rates remained the same (16.2% vs 13.6%; p = 0.635).

CONCLUSIONS

Implementation of an ERAS program for patients undergoing CRS-HIPEC is feasible and not associated with an increase in overall major complications or readmissions. These data support incorporation of ERAS protocols for CRS-HIPEC procedures.