Enhanced recovery after surgery is safe for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

INTRODUCTION

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective, aggressive approach to treating intraperitoneal carcinomatosis. This study aimed to test the efficacy/safety of an enhanced recovery (ERAS) program after CRS-HIPEC surgery.

METHODS

Review of an IRB-approved prospectively maintained HIPEC database from 2003 to 2019. Adverse events and outcomes related to the primary operation were noted.

RESULTS

125 HIPEC procedures performed met inclusion criteria, with 20 treated through ERAS. There was an improvement in LOS (ERAS: 9, 6.0-28.0; non-ERAS: 11.0, 6.0-45.1, P = 0.5), a significant reduction in opioid use during hospitalization (ERAS Total Morphine Equivalents 156 vs Non-ERAS of 856, p < 0.001), and a significant reduction in discharge opioid requirements (ERAS 55% of patients, non-ERAS 97%, p < 0.02).

CONCLUSION

ERAS for CRS-HIPEC is safe, while maintaining quality outcomes, and leads to significant reductions in hospital opioid use and discharge narcotic usage. Our experience supports the full implementation of an ERAS protocol for HIPEC.

Impact of Perfusate Glucose Concentration on Perioperative Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a common treatment for peritoneal surface malignancies but no standard carrier solution currently exists for the procedure. This study compared a standard low-dextrose perfusate to a higher-dextrose dialysate that has previously shown favorable impact on perioperative patient outcomes in trauma settings.

MATERIALS AND METHODS

A single-center retrospective study identified patients undergoing CRS/HIPEC from 2008 to 2019 with recorded dextrose concentration of administered perfusate. An institutional shift to a higher-dextrose solution was made in late 2015. Comparisons of preoperative factors, intraoperative and postoperative glucose levels, and postoperative outcomes were made using the chi-square test, Fisher's exact test, Wilcoxon rank sum test, or repeated measures analysis of variance.

RESULTS

There were 97 patients in the study, 73 (75%) in the low-dextrose group and 24 (25%) in the high-dextrose group. There was no significant difference in peak intraoperative blood glucose levels between the 1.5% (mean 230 mg/dL) and the 2.5% group (mean 199 mg/dL, P = 0.15). Daily postoperative glucose values were also not statistically different (repeated measures analysis of variance, P = 0.18). Median length of stay was slightly lower for the high-dextrose group (10 d, interquartile range 8-15) than that for the low-dextrose group (12 d, interquartile range 9-17), but was not statistically significant (P = 0.29). Return of bowel function and resumption of diet were similar between the groups. The high-dextrose group had a lower rate of overall complications (20.8%) than the low-dextrose group (49.3%, P = 0.0143). Ninety-day mortality was equivalent between the two groups (2.7% low-dextrose, 4.2% high-dextrose, P = 1.0).

CONCLUSIONS

Use of 2.5% dextrose-containing perfusate appears safe for CRS/HIPEC operations, does not negatively impact intraoperative or postoperative glucose levels, and may be associated with a decreased risk of complications.

Tn5 Insertion Mutants of Pseudomonas fluorescens Defective in Adhesion to Soil and Seeds

Tn5 insertion mutants of a soil isolate, Pseudomonas fluorescens Pf0-1, were selected for decreased ability to adhere to quartz sand in a column assay. Three adhesion-deficient mutants that differed in the location of the Tn5 insertion in the chromosome were isolated and compared with the wild-type strain. One mutant, Pf0-5, was described previously as an adhesion-defective, nonmobile, flagellumless mutant (M. F. DeFlaun, A. S. Tanzer, A. L. McAteer, B. Marshall, and S. B. Levy, Appl. Environ. Microbiol. 56:112-119, 1990). Another insertion mutant, Pf0-10, was also missing flagella and the 34-kDa outer membrane protein that was absent in Pf0-5 but present in the wild-type strain. The third mutant (Pf0-15) had increased amounts of this 34-kDa outer membrane protein and more flagella than the wild-type strain. These mutants also displayed decreased ability to adhere to sterile and natural (live) soil and to a variety of plant seeds. In kinetics studies, the wild-type strain showed an initial rapid binding to seeds followed by a later slow phase of binding. The mutant strains were defective in the initial stages of attachment but did show the later slow binding. The findings indicate that the same mutations that affect binding to sand and soil also affect adhesion to plant seeds.

Release of bacteria during the purge cycles of steam-jacketed sterilizers

The design of the steam-jacketed sterilizer includes an exterior air-gap fixture through which purged chamber aerosols potentially could escape into the ambient environment. Studies of the purge cycle in two sterilizer models tested the potential release of a genetically marked Enterococcus faecalis, together with Bacillus stearothermophilus spores introduced as exposed cultures. Direct plate counts, broth enrichment and polymerase chain reaction analysis were used to confirm any released organisms trapped in an all-glass impinger. From the retrieval of both bacterial strains, an estimated 10(3) organisms can be released from uncontained bacterial loads of 10(11) E. faecalis and 10(7) B. stearothermophilus, even from properly functioning autoclaves. The release of an opportunistic pathogen from sterilizer purge exhausts emphasises the importance of proper sterilizer location, ventilation, containment of heavily contaminated loads, and adequate sterilizer maintenance.

Postpartum rupture of a subcapsular hematoma of the liver

We report a case of postpartum rupture of a subcapsular hematoma of the liver. The etiology, pathology, diagnosis and treatment of this condition are discussed. We emphasize the modern concepts in treatment of hepatic hemorrhage. This knowledge and an awareness of the possible diagnosis will help to decrease the high morbidity and mortality rates associated with this disorder.

Ethical issues in assisted reproduction

Since the birth of Louise Brown in 1978, no other area in clinical practice and medical research has held the public interest to the same extent as the assisted reproductive technologies. This has led to the formation of committees of enquiry, guidelines from professional bodies, the passage of legislation, and the formation of legislative bodies. The ethical issues which arise in the clinical practice of assisted reproduction, the donation of gametes and embryos, and their cryopreservation, surrogacy, and human embryo research are reviewed.

Catamenial pneumothorax and malignant hyperthermia

This paper presents a patient showing both the unusual syndrome of catamenial pneumothorax and a strong family history of malignant hyperthermia. The anaesthetic management is described and discussed.

Observations on the effects of intrathecal papaverine in experimental vasospasm

✓ Subarachnoid hemorrhage was produced in monkeys by injecting fresh arterial blood. Serial angiographic studies of the basilar artery then showed vasospasm, occurring as a biphasic response similar to that seen following subarachnoid hemorrhage in man. Papaverine had previously been found to be the most potent vasodilator for topical use to release spasm resulting from experimentally induced subarachnoid hemorrhage. This drug was therefore administered, in various dilutions, as a slow infusion into the subarachnoid space of these monkeys. In a concentration of 0.03%, papaverine proved to be effective in reducing the vasospasm without toxicity.

Common carotid to intracranial internal carotid bypass venous graft. Technical note

✓ A 54-year-old woman was admitted with a complete occlusion of the right internal carotid artery and a 25% stenosis of the left internal carotid artery. Intracranial circulation on the right side was restored by taking a vein from the leg and anastomosing the vein of the intracranial carotid artery just distal to the anterior clinoid process. Prior to insertion the vein was turned inside out, the valves removed and then reinverted allowing the distal end of the vein to be anastomosed to the intracranial internal carotid artery. The blood flow was therefore reversed in the vein. The proximal end of the vein was anastomosed to the common carotid artery. Upon completion there was excellent circulation in the bypass graft and internal carotid artery.