1. 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

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

3. 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:

4. 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.

5. 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.

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

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

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

9. 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

10. 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

11. HIPEC Tenckhoff catheter suction drains temperature probes
roller pumps
chemotherapeutic agents

12. HIPEC

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

14. 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

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

16. 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)

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

18. Preoperative management
physical examination
hematological laboratory data
cardiopulmonary function testing

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

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

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

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

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

24. 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

25. Thank you