Perioperative anaesthetic management of patients undergoing thoracic cytoreductive surgery and HITHOC

Our plain-English summary of Perioperative anaesthetic management of patients undergoing thoracic cytoreductive surgery and HITHOC, by F. Unigarro-Londoño, R. Navarro-Ripoll, D. Sánchez-Lorente, et al (Annals of Translational Medicine, 2021).

The study

• Authors: F. Unigarro-Londoño, R. Navarro-Ripoll, D. Sánchez-Lorente, L. Molins
• Journal: Annals of Translational Medicine
• Published: 2021;9(11):956
• Type of article: Review
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Historically, patients with pleural malignant mesothelioma have had a poor prognosis and survival rate. Recently, new surgical approaches and chemotherapy delivery techniques have been developed. One of this treatment options is thoracic cytoreductive surgery and HITHOC (hyperthermic intrathoracic chemotherapy perfusion), a promising strategy in selected patients, offering significantly longer median survival length and tumour-free survival rate. However, there is little experience and little is known regarding the optimal perioperative management of this patients. Given that they usually present with poor preoperative status and the surgery is aggressive, prolonged and associated with significant hemodynamic repercussions, this procedure poses a true challenge to the anaesthesiologist. We will discuss optimal patient selection and optimization, as well as premedication, recommended monitoring aspects on top of the usual for any anaesthetic procedure, induction and anaesthetic agents, blood management and one lung ventilation. Also, we expose the importance of adequate pain control during the surgery and postoperatively, the hemodynamic disturbances that occur during the procedure and the potential complications that could occur afterwards. In a few words, this review intends to offer recommendations for the management of patients undergoing cytoreductive surgery and HITHOC for the perioperative care, based on the scarce evidence and our clinical experience.

2021 Annals of Translational Medicine. All rights reserved.

In plain English

This was a review article by anaesthesia and thoracic surgery staff at Hospital Clinic Barcelona. It offered recommendations for anaesthetic care of patients with pleural malignant mesothelioma undergoing cytoreductive surgery with HITHOC, which is heated chemotherapy washed through the chest cavity. The authors said the recommendations rested on scarce evidence and their own clinical experience. It did not study asbestos exposure. The authors described their own practice: wide monitoring of temperature, brain oxygen levels, heart output and haemoglobin, and a propofol-remifentanil infusion combined with ketamine. They found no evidence that any one anaesthetic agent was superior. During perfusion, using cisplatinum and pemetrexed at 41 degrees Celsius for 60 minutes, central venous pressure usually rose, and norepinephrine was their first-line drug for supporting blood pressure. In an earlier series of their own, they used a mean of 4.5 units of red blood cells per patient. Complication rates quoted in the article, such as atrial fibrillation in 24 to 32 percent, came from a separately cited meta-analysis. The authors noted that anaesthetic experience with this surgery is limited.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Narrative review with practice recommendations (commissioned review article), drawing on published evidence and the authors' clinical experience
• Who was studied: Selected patients with pleural malignant mesothelioma undergoing cytoreductive surgery and HITHOC. The authors describe practice at Hospital Clinic Barcelona. No new patient series or patient numbers are reported.
• Exposure: Not addressed. The article concerns anaesthetic management of a cancer treatment, not asbestos or any other exposure.
• Main results:
  • The authors stated there is no evidence that any anaesthetic agent is superior; the choice between intravenous and inhaled anaesthesia remains unsolved.
  • At the authors' institution, anaesthesia used a propofol-remifentanil target-controlled infusion combined with a ketamine infusion for pain control.
  • Both oesophageal and nasopharyngeal temperature were monitored. Brain depth-of-anaesthesia monitoring and cerebral oximetry were also used at their institution.
  • For extended pleurectomy/decortication, the authors stated that a continuous paravertebral infusion is not an option for pain relief, because the pleura bounding that space is removed.
  • In the authors' earlier experience (their cited reference 18), a mean of 4.5 units of packed red blood cells was used per patient. Plasma and platelets were given case by case.
  • Perfusion at their institution lasted 60 minutes at 41 degrees Celsius, using cisplatinum and pemetrexed in normal saline.
  • During hyperthermic perfusion, central venous pressure usually rose. Norepinephrine was the authors' first-line vasoactive drug, with epinephrine used as inotropic support if needed.
  • Postoperative complications quoted from a separately cited meta-analysis (reference 23), not from this article's own data: atrial fibrillation (24–32%), thrombosis/embolism (9–13%), laryngeal nerve dysfunction (11%), respiratory failure/ARDS (6–11%) and empyema (15%).
  • In the authors' experience, some patients developed neutropenia from systemic effects of the therapy. In all cases it was self-limited and caused no complications.
• The authors' conclusion: The authors presented their article as recommendations for perioperative anaesthetic management of cytoreductive surgery and HITHOC, based on scarce evidence and clinical experience.
• Limitations the authors state:
  • Because this surgery is relatively uncommon, anaesthetic experience with it is limited and the optimal management is not entirely clear.
  • Evidence for preoperative interventions in this population is lacking; some recommendations reflect the authors' belief.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, Mesothelioma, Prognosis, Chemotherapy, Intrathoracic, Median Overall Survival.

Related studies

• Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion for malignant pleural tumours: perioperative management and clinical experience — M. Ried, T. Potzger, et al. (2013)
• Management of Malignant Peritoneal Mesothelioma Using Cytoreductive Surgery and Perioperative Chemotherapy — P.H. Sugarbaker, K.K. Turaga, et al. (2016)
• Thoracic complications in patients undergoing intraperitoneal heated chemotherapy with mitomycin following cytoreductive surgery — M.Y. Chen, C. Chiles, et al. (1997)
• Anesthetic management and renal function in pediatric patients undergoing cytoreductive surgery with continuous hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin — P. Owusu-Agyemang, R. Arunkumar, et al. (2012)
• Peritoneal carcinomatosis: patients selection, perioperative complications and quality of life related to cytoreductive surgery and hyperthermic intraperitoneal chemotherapy — G. Glockzin, H.J. Schlitt, et al. (2009)
• Long-term survival outcomes of cytoreductive surgery and perioperative intraperitoneal chemotherapy: Single-institutional experience with 1225 cases — L.S. Kyang, N.A. Alzahrani, et al. (2019)

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