Hemodynamic and respiratory implications of high intra-abdominal pressure during HIPEC

BACKGROUND

cytoreduction surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is currently the standard of care for some peritoneal surface malignancies. There is experimental evidence supporting that high Intra Abdominal Pressure (IAP) during HIPEC could enhance the uptake of drugs by tumor tissues. However, few papers are describing the hemodynamic and respiratory effects of increased IAP during HIPEC.

AIMS

to evaluate the hemodynamic and respiratory association with different IAPs during HIPEC.

METHODS

This is part of an IRB board approved prospective randomized controlled trial conducted at The National Tumor Institute of Milan from 2014 to 2017 (NCT0294979). Patients diagnosed with Pseudomyxoma (PMP) or Peritoneal Metastasis of Colorectal Cancer (PM-CRC) were submitted to CRS and then randomized to receive low IAP (8-12 mmHg) or high IAP (18-22 mmHg) HIPEC. Hemodynamic and respiratory data were collected in eight different time-points during the whole procedure.

RESULTS

33 patients (n low = 15, n high = 18) with PM-CRC and PMP were analysed. The mean IAP in the low IAP HIPEC group was 11.4 mmHg (SD: 2.5) and 18.1 mmHg (SD: 2.5) in the high IAP HIPEC group (p«0.001). There was no difference in the hemodynamic parameters between both groups, except for the central venous pressure (CVP) that was significantly higher in the high IAP group (p = 0.006). High IAP was well tolerated in the experimental arm with no hemodynamic and ventilation instability observed during the intervention.

CONCLUSION

We conclude that high IAP at the level of 18-22 mmHg during HIPEC has no significant hemodynamic parameters difference, being feasible and safe in our study.

Phase II randomized study on tissue distribution and pharmacokinetics of cisplatin according to different levels of intra-abdominal pressure (IAP) during HIPEC (NCT02949791)

AIMS

To evaluate the effects of high intra-abdominal pressure (IAP) during hyperthermic intraperitoneal chemotherapy (HIPEC) on cisplatin uptake by residual tumor and normal tissues, pharmacokinetics, and short-term surgical outcomes.

PATIENTS & METHODS

Patients with peritoneal metastasis from colorectal cancer or pseudomyxoma peritonei were randomized to closed-abdomen HIPEC with low-IAP or high-IAP, after complete cytoreduction. High-IAP was obtained increasing the volume of perfusate maintaining constant the cisplatin concentration (42 mg/L). We determined the Platinum concentration using an Inductive Coupled Plasma Mass Spectrometry System. Randomization was stratified according to tumor type. To consider the multiple sampling in the three tissues types of interest, we performed linear mixed models to assess the differences of cisplatin concentration between study arms. We also compared AUC perfusate/plasma ratios (Wilcoxon-Mann-Whitney) and perioperative severe complication rates (chi-square) between study arms.

RESULTS

38 cases were randomly assigned to IAP arms (n = 19 each). Median IAPs were 19 mmHg and 11 mmHg in the high and low arms, respectively. Cisplatin concentrations did not differ in the tumor residual tissues and in the muscular fascia [22.8 ng/mg (SD: 25.5) vs. 15.9 ng/mg (SD: 13.3), p = 0.181] and [50.3 ng/mg (SD: 40.1) vs. 42.0 ng/mg (SD: 38.3), p = 0.426, respectively], whereas in the mesenteric peritoneum it did [5.4 ng/mg (SD: 7.82) vs. 2.7 ng/mg (SD: 2.9), p = 0.048]. Pharmacokinetic advantage did not differ between the two arms. High-IAP did not increase perioperative severe complications rate (NCI-CTCAE.v3).

CONCLUSIONS

high-IAP HIPEC increases cisplatin distribution in the mesenteric peritoneum, is safe, and could be considered to obtain microscopic cytoreduction.