Cytoreductive Surgery and Continuous Hyperthermic Peritoneal Perfusion in Patients with Mesothelioma and Peritoneal Carcinomatosis: Hemodynamic, Metabolic, and Anesthetic Considerations

Abstract

Cytoreductive surgery and continuous hyperthermic peritoneal perfusion (CHPP) involve the conduct of a complex surgical procedure and delivery of high-dose hyperthermic chemotherapy to the peritoneum. This therapeutic modality has been shown to benefit patients with peritoneal carcinomatosis resulting from gastrointestinal and ovarian tumors and mesothelioma. However, it is unknown whether the primary disease (mesothelioma versus peritoneal carcinomatosis) affects hemodynamic and metabolic perturbations during the course of CHPP with cisplatin. We examined the perioperative course of patients undergoing CHPP with cisplatin and evaluated the effect of primary diagnosis (mesothelioma versus peritoneal carcinomatosis) on hemodynamic and metabolic parameters in response to peritoneal perfusion. Sixty-nine mesothelioma and 100 peritoneal carcinomatosis patients underwent 169 consecutive cytoreduction and CHPP procedures with general anesthesia. During CHPP, patients from both groups developed significant increases in central venous pressure, and heart rate, decreases in mean arterial pressure (all P < 0.0001), metabolic acidosis with significant decreases in pH and bicarbonate (P < 0.0001), deterioration of gas exchange with significant increases in PaCO 2 and oxygen alveolar-arterial gradient (P < 0.0001), and significant increases in activated partial thromboplastin time (aPTT) and prothrombin time (PT) and decreases in hematocrit and platelet counts (all P < 0.0001). However, patients with mesothelioma had lesser increases in temperature (P < 0.01) and heart rate (P < 0.0001) and lesser decreases in hematocrit (P = 0.0013) during CHPP and greater decreases in sodium bicarbonate (P = 0.0082) after completion of CHPP compared with patients with peritoneal carcinomatosis. We conclude that the transient hemodynamic and metabolic perturbations associated with cytoreductive surgery and CHPP with cisplatin can vary according to the primary diagnosis (mesothelioma versus peritoneal carcinomatosis) warranting this therapy.Z. M. N. Quezado, MD, e-mail: zquezado@nih.gov. NIH Public Access Author ManuscriptAnn Surg Oncol. Author manuscript; available in PMC 2009 February 9. Published in final edited form as:Ann Surg Oncol. 2009 February ; 16(2): 334-344. doi:10.1245/s10434-008-0253-z. NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author ManuscriptMesothelioma and peritoneal carcinomatosis resulting from gastrointestinal and gynecological malignancies are associated with decreased quality of life, significant morbidity, and poor survival with currently available systemic chemotherapies. 1,2 Often in patients with mesothelioma and peritoneal carcinomatosis the peritoneal surface is the only site of disease progression, and distant metastases are absent. For these reasons, regional treatment of mesothelioma and peritoneal carcinomatosis resulting from various primary malignancies may offer significant advantages over systemic therapy. 1 In order to treat patients with peritoneal carcinomatosis and mesothelioma,...

Impact of Intraoperative Anesthetic and Fluid Management on 30-day Postoperative Outcomes in a Newly Established Surgical Peritoneal Surface Malignancy Program

“…The operative time in this series was similar to reports in the literature [5]. Operative time and estimated blood loss were both increased in patients who developed complications, but this difference was not statistically different compared to uncomplicated patients.…”

“…The mean patient age in Capone's study was 57 years, which is closer to the age of our patients that had complications [10]. Remarkably, the mean age in our study closely resembled that found in larger investigations of patient population with peritoneal carcinomatosis, likely reflecting the preponderance for this disease in this age group [1,4,5,11].…”

“…Some authors in this specific area of oncologic surgery have begun to explore a goal directed approach to intra-and perioperative fluid administration following flow derived perfusion parameters to facilitate perioperative patient management and improve outcomes [2]. In our cohort, fluid replacement was extensive with a mean cumulative amount of 12866 ml, very similar to that described by Miao et al [5]. We also determined a large variability of fluid replacement between cases, ranging from 4,350 ml to 25,200 ml.…”

“…The complexity of intraoperative fluid management and their components for major surgeries has recently been described, and an individual demand oriented strategy has been suggested in the general surgical adult population [13,14]. However, most reports on intraoperative fluid management for peritoneal surface malignancy surgery emphasize the importance of liberal fluid administration to maintain adequate organ perfusion [1,2,4,5]. Some authors in this specific area of oncologic surgery have begun to explore a goal directed approach to intra-and perioperative fluid administration following flow derived perfusion parameters to facilitate perioperative patient management and improve outcomes [2].…”

“…The physiologic demands on patients undergoing these often prolonged procedures, and subsequently the intra-and postoperative management challenges to the perioperative care team have been well described [1][2][3]. Appropriate and liberal fluid management to maintain adequate organ perfusion has been advocated for CRS and HIPEC, but poorly defined [2,4,5]. However, intraoperative fluid replacement up to 12 ml/kg/hr or more has been reported [1].…”