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Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Fluid and temperature remain the culprit!

R. Garg

Published 2018 in Indian Journal of Anaesthesia

ABSTRACT

Optimal cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are an acceptable management modality for primary peritoneal neoplasm and metastasis to peritoneum from gynaecologic or gastrointestinal malignancies.[1,2] This technique involves removal of the tumour load followed by instillation of HIPEC. Another alternative technique is pressurised intraperitoneal aerosolised chemotherapy (PIPAC) for patients with a high load of disease or HIPEC intolerable to patient. It involves delivering chemotherapeutic drugs into the peritoneal cavity as a pressurised normothermic aerosol after optimal cytoreduction.[3] These procedures require not only extensive surgical dissection associated with significant fluid shifts and blood loss but also have haemodynamic concerns related to instillation of chemotherapeutic agent in the peritoneal cavity at high temperature (41°C–43°C) or its pressurised aerosol. CRS and HIPEC require large amounts of fluids to replace ascites, longer duration, extensive surgery, blood loss and vasodilatory effects of hyperthermia.[1,2] Optimal fluid management strategy is required for a good patient outcome. The literature is scarce for a definite protocol for perioperative fluid management during CRS and HIPEC, and a consensus has yet to be reported. The initial phase of cytoreduction may lead to hypothermia due to major surgical exposure, extensive dissection and blood loss, and subsequently, HIPEC phase leads to hyperthermia. Unique concern relates to direct chemotherapeutic agent-associated nephrotoxicity in addition to haemodynamic alterations due to temperature fluctuations and its impact on renal and other vital organ functions in perioperative period.[4] These issues mandate meticulous fluid and temperature management apart from other anaesthetic management concerns for such surgical intervention.[5-9] This issue publishes two manuscripts related to the use of intraoperative intraperitoneal chemotherapy during oncosurgery.[10,11] In a retrospective analysis, the authors have assessed factors associated with morbidity and mortality after CRS and HIPEC.[10] The other manuscript describes a case undergoing CRS and PIPAC.[11]

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