Lulic I, Miric M, Tomicic M, Palian M, Tomasevic B, Peric M Intensive Care Unit mortality of patients with peritoneal surface malignancies after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy Lulic I, Miric M, Tomicic M, Palian M, Tomasevic B, Peric M Department of Anaesthesiology, Reanimatology and Intensive Care Medicine, Clinical Hospital Center Zagreb, Zagreb, Croatia

cancer dissemination within the abdomen and pelvis Peritoneal surface malignancies (PSMs) cancer dissemination within the abdomen and pelvis

past - > “incurable” condition today - > multimodality treatment PSMs past - > “incurable” condition today - > multimodality treatment Sugabaker PH. Peritonectomy procedures. Ann Surg 1995;221:29-42. Glehen O, Mohamed F, Gilly FN. Peritoneal carcinomatosis from digestive tract cancer: new management by cytoreductive surgery and intraperitoneal chemohyperthermia. Lancet Oncol 2004;5:219-228.

Selection criteria one of the crucial factors for the successful outcome preoperative exclusion criteria according to CT: - bowel segments obstructed by tumor - mesentery drown together by tumor - tumor > 5 cm located in small bowel mesentery Sugabaker PH. Peritonectomy procedures. Ann Surg 1995;221:29-42.

PCI ≤ 10 - > mild disease PCI > 10 - > severe disease Peritoneal cancer index (PCI) PCI ≤ 10 - > mild disease PCI > 10 - > severe disease Sugabaker PH. Peritonectomy procedures. Ann Surg 1995;221:29-42.

PCI clinical intergration of peritoneal implant size & distribution of of peritoneal surface malignancy Sugabaker PH. Peritonectomy procedures. Ann Surg 1995;221:29-42.

Multimodality treatment Two components: cytoreductive surgery (CRS) hyperthermic intraperitoneal chemotherapy (HIPEC)

CRS resection of visible implants within the abdomen and pelvis peritonectomy along with visceral resections

Peritonectomy procedures greater omentectomy with splenectomy left upper quadrant peritonectomy right upper quadrant peritonectomy lesser omentectomy with cholecystectomy pelvic & lower quadrants peritonectomy with resection of ectosigmoid colon (hysterectomy, bilateral salphingo-oophorectomy may be added in females) antrectomy

Completeness of cytoreduction score (CC score) - no peritoneal nodule was seen CC – 1 - tumor nodules persisting after CRS < 2.5 mm CC – 2 - tumor nodules persisting after CRS between 2.5 mm & 2.5 cm CC – 3 - tumor nodules persisting after CRS > 2.5 cm

HIPEC Tenckhoff catheter suction drains temperature probes roller pumps chemotherapeutic agents

HIPEC

high peritoneal concentrations with limited systemic absorption HIPEC high peritoneal concentrations with limited systemic absorption

CRS + HIPEC University Hospital Center Zagreb: started in January 2007 teams training in USA total of 94 procedures performed by the same team complex procedures long learning curves

Selection criteria inclusion criteria: exclusion criteria: - diagnosis of PSMs exclusion criteria: - extra-peritoneal malignant proliferation & ASA score 4 or ↑

81% ♀ 19% ♂ mean ± SD age 55±13 years (range from 27 to 85 years old) Patients 81% ♀ 19% ♂ mean ± SD age 55±13 years (range from 27 to 85 years old)

Diagnosis ovarian cancer colorectal adenocarcinoma adenocarcinoma of the appendix mesothelioma stomach cancer 1 patient PSMs of unknown origin

Preoperative management physical examination hematological laboratory data cardiopulmonary function testing

general balanced anaesthesia - sevoflurane - sufentanil - rocuronium Perioperative management general balanced anaesthesia - sevoflurane - sufentanil - rocuronium

Perioperative management monitoring - electrocardiogram - capnography - pulse oximetry - invasive radial arterial BP - CVP - oesophageal temperature - urinary output

Perioperative management arterial blood samples - FBC - blood gas analysis - coagulation parameters

all patients were trasferred to the ICU Postoperative management all patients were trasferred to the ICU

Results early postoperative ICU mortality 0.1% late postoperative death was observed in another patient

Conclusion CRS + HIPEC for PSMs treatment: lack of clinical evidence for alternative management strategies validated quantitative prognostic indicators power to gain life & safety in highly experienced centers

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