Anaesthesia in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: retrospective analysis of a single centre three-year experience

Abstract

Background: Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment option for selected patients with peritoneal carcinomatosis. There are limited data available on anaesthesia management and its impact on patients' outcome. Our aim was to retrospectively analyze and evaluate perioperative management and the clinical course of patients undergoing CRS/HIPEC within a three-year period.

Methods: After ethic committee approval, patient charts were retrospectively reviewed for patient characteristics, interventions, perioperative management, postoperative course, and complications. Analysis was intervention based. Data are presented as median (range).

Results: Between 2009 and 2011, 54 consecutive patients underwent 57 interventions; median anaesthesia time was 715 (range 370 to 1135) minutes. HIPEC induced hyperthermia with an overall median peak temperature of 38.1 (35.7-40.2)°C with active cooling. Bleeding, expressed as median blood loss was 0.8 (0 to 6) litre and large fluid shifts occurred, requiring a total fluid input of 8.4 (4.2 to 29.4) litres per patient. Postoperative renal function was dependent on preoperative function and the type of fluids used. Administration of hydroxyethyl starch colloid solution had a significant negative impact on renal function, especially in younger patients. Major complications occurred after 12 procedures leading to death in 2 patients. Procedure time and need for blood transfusion were associated with a significantly higher risk for major complications.

Conclusions: Cytoreductive surgery with HIPEC is a high-risk surgical procedure associated with major hemodynamic and metabolic changes. As well as primary disease and complexity of surgery, we have shown that anaesthesia management, the type and amount of fluids used, and blood transfusions may also have a significant effect on patients' outcome.

Figure 1

Time course of procedure. baseline = after induction of anaesthesia but 5 minutes before start of the operation, H0 = 30 minutes before HIPEC, H1 and H2 = 30 and 60 minutes after start of HIPEC, H3 = end of HIPEC, End = 5 minutes before end of the operation. CRS, cytoreductive surgery; HIPEC, hyperthermic intraperitoneal chemotherapy.

Figure 2

Intraoperative course of temperature and lactate. A. Change in temperature compared to baseline: the horizontal line set at 0 is representing baseline. If the 95% confidence interval presented for each time point does not overlap with baseline, temperature differs significantly from baseline (P <0.05). A mixed-effect model describing the effect of phase was used. B. Boxplot describing arterial lactate levels throughout the intervention. Baseline = after induction of anaesthesia but before start of the operation, H0 = 30 minutes before HIPEC, H1 and H2 = 30 and 60 minutes after start of HIPEC, H3 = end of HIPEC, End = 5 minutes before end of the operation. HIPEC, hyperthermic intraperitoneal chemotherapy.

Figure 3

Operation time, blood loss, and anaesthesia time and their effects on the need for postoperative ventilation and major surgical complications. A and B. The multiple logistic regression model describes the need for postoperative respiratory assistance (vertical axis: 0 = no assistance, 1 = assistance needed) depending on operation time (minutes) and blood loss (ml). The longer the operation (P <0.01) and the higher the blood loss (P <0.05), the higher the need was for postoperative ventilation. C and D. Major complications (≥3b according to the Clavien-Dindo classification) on the vertical axis (0 for complications <3b, 1 for ≥3b) are plotted against operation time (minutes) or anaesthesia time (minutes) on the horizontal axis. The longer the operation (P <0.01) and the longer anaesthesia time (P <0.01), the higher the incidence of major complication was. Data are corrected for BMI and age.