Abstract
Background
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with increased postoperative complications and a prolonged length of stay (LOS). We report on our experience following implementation of an Enhanced Recovery After Surgery (ERAS) program for CRS and HIPEC.
Methods
Patients were divided into pre- and post-ERAS groups. Modifications in the ERAS group included routine use of transversus abdominis plane blocks, intra- and postoperative fluid restriction, and minimizing the use of narcotics, drains, and nasogastric tubes.
Results
Of a total of 130 procedures, 49 (38%) were in the pre-ERAS group and 81 (62%) were in the ERAS group. Mean LOS was reduced from 10.3 ± 8.9 days to 6.9 ± 5.0 days (p = 0.007) and the rate of grade III/IV complications was reduced from 24 to 15% (p = 0.243) following ERAS implementation. The ERAS group received less intravenous fluid during hospitalization (19.2 ± 18.7 L vs. 32.8 ± 32.5 L, p = 0.003) and used less opioids than the pre-ERAS group (median of 159.7 mg of oral morphine equivalents vs. 272.6 mg). There were no significant changes in the rates of 30-day readmission or acute kidney injury between the two groups (p = non-significant). On multivariable analyses, ERAS was significantly associated with a reduction in LOS (− 2.89 days, 95% CI − 4.84 to − 0.94) and complication rates (odds ratio 0.22, 95% CI 0.08–0.57).
Conclusions
Implementation of an ERAS program for CRS and HIPEC is associated with a reduction in overall intravenous fluids, postoperative narcotic use, complication rates, and LOS.
Similar content being viewed by others
References
O’Dwyer S, Verwaal V, Sugarbaker PH. Evolution of treatments for peritoneal metastases from colorectal cancer. J Clin Oncol. 2015;33(18):2122–3.
van Driel WJ, Koole SN, Sikorska K, et al. Hyperthermic intraperitoneal chemotherapy in ovarian cancer. N Engl J Med. 2018;378(3):230–40.
Dehal A, Smith JJ, Nash GM. Cytoreductive surgery and intraperitoneal chemotherapy: an evidence-based review-past, present and future. J Gastrointest Oncol. 2016;7(1):143–57.
Webb CA, Weyker PD, Moitra VK, Raker RK. An overview of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for the anesthesiologist. Anesth Analg. 2013;116(4):924–31.
Sheshadri DB, Chakravarthy MR. Anaesthetic considerations in the perioperative management of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Indian J Surg Oncol. 2016;7(2):236–43.
Votanopoulos KI, Russell G, Randle RW, Shen P, Stewart JH, Levine EA. Peritoneal surface disease (PSD) from appendiceal cancer treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): overview of 481 cases. Ann Surg Oncol. 2015;22(4):1274–9.
Chua TC, Yan TD, Smigielski ME, et al. Long-term survival in patients with pseudomyxoma peritonei treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy: 10 years of experience from a single institution. Ann Surg Oncol. 2009;16(7):1903–11.
Sugarbaker PH. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in the management of gastrointestinal cancers with peritoneal metastases: progress toward a new standard of care. Cancer Treat Rev. 2016;48:42–9.
Colantonio L, Claroni C, Fabrizi L, et al. A randomized trial of goal directed vs. standard fluid therapy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. J Gastrointest Surg. 2015;19(4):722–9.
Dineen SP, Robinson KA, Roland CL, et al. Feeding tube placement during cytoreductive surgery and heated intraperitoneal chemotherapy does not improve postoperative nutrition and is associated with longer length of stay and higher readmission rates. J Surg Res. 2016;200(1):158–63.
Cooksley TJ, Haji-Michael P. Post-operative critical care management of patients undergoing cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC). World J Surg Oncol. 2011;9:169.
Bell JC, Rylah BG, Chambers RW, Peet H, Mohamed F, Moran BJ. Perioperative management of patients undergoing cytoreductive surgery combined with heated intraperitoneal chemotherapy for peritoneal surface malignancy: a multi-institutional experience. Ann Surg Oncol. 2012;19(13):4244–51.
Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292–8.
Feldheiser A, Aziz O, Baldini G, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand. 2016;60(3):289–334.
Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg. 2013;37(2):259–84.
Nelson G, Altman AD, Nick A, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations—part I. Gynecol Oncol. 2016;140(2):313–22.
Nelson G, Altman AD, Nick A, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations—part II. Gynecol Oncol. 2016;140(2):323–32.
Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations. World J Surg. 2013;37(2):285–305.
Scott MJ, Baldini G, Fearon KC, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand. 2015;59(10):1212–31.
Schmidt U, Dahlke MH, Klempnauer J, Schlitt HJ, Piso P. Perioperative morbidity and quality of life in long-term survivors following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Eur J Surg Oncol. 2005;31(1):53–8.
Newton AD, Bartlett EK, Karakousis GC. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a review of factors contributing to morbidity and mortality. J Gastrointest Oncol. 2016;7(1):99–111.
Foster JM, Sleightholm R, Patel A, et al. Morbidity and mortality rates following cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy compared with other high-risk surgical oncology procedures. JAMA Netw Open. 2019;2(1):e186847.
Kusamura S, Moran BJ, Sugarbaker PH, et al. Multicentre study of the learning curve and surgical performance of cytoreductive surgery with intraperitoneal chemotherapy for pseudomyxoma peritonei. Br J Surg. 2014;101(13):1758–65.
Moradi BN 3rd, Esquivel J. Learning curve in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Surg Oncol. 2009;100(4):293–6.
Chua TC, Yan TD, Saxena A, Morris DL. Should the treatment of peritoneal carcinomatosis by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy still be regarded as a highly morbid procedure? A systematic review of morbidity and mortality. Ann Surg. 2009;249(6):900–7.
Kuijpers AM, Mirck B, Aalbers AG, et al. Cytoreduction and HIPEC in the Netherlands: nationwide long-term outcome following the Dutch protocol. Ann Surg Oncol. 2013;20(13):4224–30.
Jafari MD, Halabi WJ, Stamos MJ, et al. Surgical outcomes of hyperthermic intraperitoneal chemotherapy: analysis of the American college of surgeons national surgical quality improvement program. JAMA Surg. 2014;149(2):170–5.
Rahbari NN, Zimmermann JB, Schmidt T, Koch M, Weigand MA, Weitz J. Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery. Br J Surg. 2009;96(4):331–41.
Schol PB, Terink IM, Lance MD, Scheepers HC. Liberal or restrictive fluid management during elective surgery: a systematic review and meta-analysis. J Clin Anesth. 2016;35:26–39.
Ma N, Duncan JK, Scarfe AJ, Schuhmann S, Cameron AL. Clinical safety and effectiveness of transversus abdominis plane (TAP) block in post-operative analgesia: a systematic review and meta-analysis. J Anesth. 2017;31(3):432–52.
Funding
No dedicated funding was received for this study.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
The authors have no financial disclosures or conflicts of interest to declare.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Webb, C., Day, R., Velazco, C.S. et al. Implementation of an Enhanced Recovery After Surgery (ERAS) Program is Associated with Improved Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 27, 303–312 (2020). https://doi.org/10.1245/s10434-019-07900-z
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-019-07900-z