Perioperative fast track program in intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery in advanced ovarian cancer

TL;DR: Surgery with peritonectomy procedures and HIPEC in advanced ovarian carcinoma is possible under fast track surgery programs in patients with low volume peritoneal carcinomatosis under the fast track program.

Abstract: Introduction Diffuse peritoneal dissemination in advanced ovarian cancer can be treated using optimal effort surgery involving peritonectomy procedures and the administration of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC). Objective To report on our experience in the treatment of advanced ovarian cancer using peritonectomy procedures and HIPEC through the fast track program. Patients and method From September 2008 until May 2010, forty-six patients with primary advanced (stage III-C) or recurrent ovarian cancer have been included in the fast track protocol if they had optimal cytoreduction CC-0 or CC-1 accompanied by HIPEC and there had no more than one digestive anastomosis. Results The mean peritoneal cancer index (PCI) was 12.35 (3–21). The median operation time was 380 min (200–540). Optimal surgery CC-0 was achieved in 38 of the 46 patients and CC-1 in the remaining 8. Mean postoperative hospital stay was 6.94 ± 1.56 days (3–11). Major morbidity rates were 15.3%. Paralytic ileus was the most frequent of these. There was no mortality related to the procedure. Conclusion Surgery with peritonectomy procedures and HIPEC in advanced ovarian carcinoma is possible under fast track surgery programs in patients with low volume peritoneal carcinomatosis. Prospective and randomized studies are needed.

Summary

INTRODUCTION

• Among factors related to morbidity and mortality, the learning curve is a crucial factor (30).
• Fast-track surgery is a comprehensive approach, designed to accelerate recovery, reduce morbidity and shorten convalescence to ultimately improve outcomes and reduce costs (32).
• Nephrectomy (42); radical prostatectomy (43); knee and hip prosthesis (44); abdominal aortic aneurysm (36); bariatric surgery (45,46) and lung resections (47) can all be carried out with a mean hospital admittance of less than 4 days and others such as antireflux surgery; suprarenalectomy; cholecystectomy; thyroidectomy; etc, are already carried out in many hospitals in ambulatory care (48,49).
• This study evaluated fast-track protocol in patients with advanced ovarian carcinoma who underwent peritonectomy procedures and HIPEC.

SURGICAL PROTOCOL

• A xiphopubic laparotomy was performed, evaluating the overall resectability of the peritoneal disease.
• Abdominal drainage was systematically left in the pelvis.
• The authors group uses a 60 miligrams/m² dose of the intraperitoneal cytostatic paclitaxel (32 patients) according with the excellent results reported previously by Rufian et al (19) and BAE et al (20).
• After cytoreduction the peritoneal cavity was positioned according to the “Coliseum” technique.
• Two intracavity thermometers monitored the temperature within the peritoneal cavity during perfusion, which was kept constant between 42-43 ºC.

FAST-TRACK PROGRAM.

• All patients received a low-residue diet one week before surgery and were admitted 1 day before surgery.
• After the intervention, a nasogastric tube was not used.
• Postoperative treatment included prokinetics (10-20 mgrs intravenous metoclopramide every 8 hours).
• MORBIDITY AND MORTALITY M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT Morbidity and mortality data were collected.
• Mild complications required medical or no treatment for resolution (grade I/II respectively).

RESULTS

• Forty-six patients (80.7%) were enrolled and 11 patients were excluded from the protocol, (6 because they required at least 2 digestive anastomoses and 5 because they could not carry out optimal surgery for their peritoneal disease).
• Right diaphragmatic peritonectomy (8 patients), splenectomy (2 patients), ureter resection (1 patient) and left diaphragmatic peritonectomy (1 patient) were needed to achieve complete cytoreduction.
• Paralytic ileus (6 patients) was the most common complication.

DISCUSSION

• The publication of the study by Kehlet in Lancet (33) has raised controversy about the classical attitude toward the postoperative management of surgically treated patients.
• Some authors opt for the non-use of abdominal drainage after surgery.
• The need for positioning the nasogastric tube due to vomiting when introducing orally administered food has been calculated to occur in at least 10% of cases (in their series 2 out of the 46 patients).
• This is one of the points the surgeon has to inform the patient about in the preoperative visit, given that otherwise the speed of events could be shocking.
• The authors preliminary data support the idea that in surgery for peritoneal carcinomatosis of ovarian origin with cytoreduction followed by HIPEC, the introduction of multimodal rehabilitation is reasonable in a group of selected patients with a low volume of carcinomatosis.

Figures

Table 1. Patient characteristics

Table 4. PCI, Morbidity, mortality, type of drug used in HIPEC and hospital stay in some of the main studies published of patients with cytoreduction and HIPEC in advanced overian carcinoma and the present series.

Table 3. Morbidity after surgical cytoreduction and HIPEC in advanced ovarian cancer.

Table 2. PCI, surgical procedure, Completeness Cytoreductive Score (CCS), surgery time and hospital stay until discharge.

Full text

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Perioperative fast track program in intraoperative
hyperthermic intraperitoneal chemotherapy (hipec) after
cytoreductive surgery in advanced ovarian cancer
Pedro Antonio Cascales Campos, José Gil Martinez, Pedro J. Galindo
Fernandez, Elena Gil Gomez, Isabel María Martínez Frutos, Pascual Parrilla
Paricio
To cite this version:
Pedro Antonio Cascales Campos, José Gil Martinez, Pedro J. Galindo Fernandez, Elena Gil Gomez,
Isabel María Martínez Frutos, et al.. Perioperative fast track program in intraoperative hy-
perthermic intraperitoneal chemotherapy (hipec) after cytoreductive surgery in advanced ovarian
cancer. EJSO - European Journal of Surgical Oncology, WB Saunders, 2011, 37 (6), pp.543.
�10.1016/j.ejso.2011.03.134�. �hal-00696628�

Accepted Manuscript
Title: Perioperative fast track program in intraoperative hyperthermic intraperitoneal
chemotherapy (hipec) after cytoreductive surgery in advanced ovarian cancer
Authors: Pedro Antonio Cascales Campos, José Gil Martinez, Pedro J. Galindo
Fernandez, Elena Gil Gomez, Isabel María Martínez Frutos, Pascual Parrilla Paricio
PII: S0748-7983(11)00218-6
DOI: 10.1016/j.ejso.2011.03.134
Reference: YEJSO 3142
To appear in:
European Journal of Surgical Oncology
Accepted Date: 17 March 2011
Please cite this article as: Cascales Campos PA, Martinez G, Galindo Fernandez PJ, Gomez EG,
Martínez Frutos IM, Paricio PP. Perioperative fast track program in intraoperative hyperthermic
intraperitoneal chemotherapy (hipec) after cytoreductive surgery in advanced ovarian cancer, European
Journal of Surgical Oncology (2011), doi: 10.1016/j.ejso.2011.03.134
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MANUS CRIP T
ACCEP TED
ACCEPTED MANUSCRIPT
PERIOPERATIVE FAST TRACK PROGRAM IN
INTRAOPERATIVE HYPERTHERMIC INTRAPERITONEAL
CHEMOTHERAPY (HIPEC) AFTER CYTOREDUCTIVE SURGERY
IN ADVANCED OVARIAN CANCER.
Pedro Antonio Cascales Campos*, José Gil Martinez*, Pedro J. Galindo Fernandez*,
Elena Gil Gomez*, Isabel María Martínez Frutos*, Pascual Parrilla Paricio*
*Department of Surgery.
Virgen de la Arrixaca University Hospital (Murcia-Spain)
Contact Author
Pedro Antonio Cascales Campos
Calle Dr Fleming Nº 12 3º E
La Alberca, Murcia (Spain)
CP: 30150
e-mail: cascalex@yahoo.es

MANUS CRIP T
ACCEP TED
ACCEPTED MANUSCRIPT
ABSTRACT
INTRODUCTION: Diffuse peritoneal dissemination in advanced ovarian cancer can be
treated using optimal effort surgery involving peritonectomy procedures and the
administration of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC).
OBJECTIVE: To report on our experience in the treatment of advanced ovarian cancer
using peritonectomy procedures and HIPEC through the fast track program. PATIENTS
AND METHOD: From September 2008 until May 2010, forty-six patients with primary
advanced (stage III-C) or recurrent ovarian cancer have been included in the fast track
protocol if they had optimal cytoreduction CC-0 or CC-1 accompanied by HIPEC and
there had no more than one digestive anastomosis. RESULTS: The mean peritoneal
cancer index (PCI) was 12.35 (3-21). The median operation time was 380 minutes (200-
540). Optimal surgery CC-0 was achieved in 38 of the 46 patients and CC-1 in the
remaining 8. Mean postoperative hospital stay was 6.94±1.56 days (3-11). Major
morbidity rates were 15.3%. Paralytic ileus was the most frequent of these. There was no
mortality related to the procedure. CONCLUSION: Surgery with peritonectomy
procedures and HIPEC in advanced ovarian carcinoma is possible under fast track surgery
programs in patients with low volume peritoneal carcinomatosis. Prospective and
randomized studies are needed.

MANUS CRIP T
ACCEP TED
ACCEPTED MANUSCRIPT
INTRODUCTION
Since Sugarbaker’s publication in 1995 about the surgical treatment of peritoneal
carcinomatosis (1), the approach for the peritoneal dissemination of pathologies such as
colorectal carcinoma, peritoneal pseudomixoma, peritoneal mesotelioma and advanced
ovarian carcinoma has undergone serious remodelling. The approach changed from non-
committal attitude toward the diagnosis of peritoneal carcinomatosis to a much more
active attitude leading to more aggressive surgery being carried out including
peritonectomy procedures and intraoperative hyperthermic intraperitoneal chemotherapy
(HIPEC) (2-21). The overall rate of severe perioperative morbidity ranged from 0 to 40%
and the mortality rate varied from 0 to 10% (22-29), with a mean hospital stay of over two
weeks (21, 23, 26, 31, 33). Among factors related to morbidity and mortality, the learning
curve is a crucial factor (30).
Fast-track surgery is a comprehensive approach, designed to
accelerate recovery,
reduce morbidity and shorten convalescence
to ultimately improve outcomes and reduce
costs (32). The introduction of Fast-track programs achieves good results in postoperative
outcomes in many surgical pathologies (34-41). For instance, nephrectomy (42); radical
prostatectomy (43); knee and hip prosthesis (44); abdominal aortic aneurysm (36);
bariatric surgery (45,46) and lung resections (47) can all be carried out with a mean
hospital admittance of less than 4 days and others such as antireflux surgery;
suprarenalectomy; cholecystectomy; thyroidectomy; etc, are already carried out in many
hospitals in ambulatory care (48,49). In the literature no experience has been reported of
fast-track programs in surgery with peritonectomy procedures and HIPEC for peritoneal
surface malignancies such advanced ovarian cancer.
This study evaluated fast-track protocol in patients with advanced ovarian
carcinoma who underwent peritonectomy procedures and HIPEC.
PATIENTS AND METHOD

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Q1. What are the contributions mentioned in the paper "Perioperative fast track program in intraoperative hyperthermic intraperitoneal chemotherapy (hipec) after cytoreductive surgery in advanced ovarian cancer" ?

In this paper, the authors report on their experience in the treatment of advanced ovarian cancer using peritonectomy procedures and HIPEC through the fast track program.