International Journal of Surgery 19 (2015) 103
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Letter to the Editor
The best anesthesia regimen for patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy
We read with interest the recent article by Piccioni F et al. [1] stating that epidural analgesia ensures adequate pain relief and is well tolerated by patients after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). In their study, a total of 101 consecutive patients received intra- and post-operative thoracic epidural anesthesia (TEA); intraoperative anesthesia was maintained with general anesthesia (GA) plus TEA; 9.9% of patients had hypotensive episodes and 77.2% (78/ 101) of patients received intra-operative red blood cells (RBCs) transfusion. But we do not think GA plus TEA is the best anesthesia regimen for patients undergoing CRS and HIPEC procedures. On the one hand, hypotension is more likely to happen under epidural anesthesia because the epidural administration of local anesthetics leads to functional sympatholysis and TEA has an inherent risk of cardiovascular depression and arterial vasodilation [2]. Furthermore, mean arterial pressure and systemic vascular resistance showed a reduction in patients undergoing CRS and HIPEC which is a very demanding surgery [3]. Those increase the risk of severe intraoperative hypotension, especially in the patients under TEA plus GA. While patient controlled thoracic epidural analgesia (PCTEA) is probably the best option to control pain postoperatively for those patients [4]. So we think GA, instead of TEA combined with GA, followed by PCTEA is the best anesthesiae analgesia regimen in patients undergoing CRS and HIPEC procedures. On the other hand, the main reason for hypotension during epidural anesthesia may be arterial vasodilation, but not pre-load absolute deficiency. It is certainly reasonable to treat hypotension with a vasopressor (such as phenylephrine). Excessive fluid or fresh frozen plasma (FFP) infusion is inappropriate, or even harmful for those patients undergoing CRS þ HIPEC procedures. Because excess fluid or FFP would dilute the blood and reduce the hemoglobin concentration, thereby increase the possibility of iatrogenic RBCs transfusion which is associated with a higher risk of mortality and morbidity in surgical patients [5].
Conflicts of interest
Funding None. Ethical approval None. Author contribution Yongxin Liang and Shiduan Wang all for writing. Guarantor Yongxin Liang, MD; Shiduan Wang, MD. References [1] F. Piccioni, C. Casiraghi, L. Fumagalli, S. Kusamura, D. Baratti, M. Deraco, F. Arienti, M. Langer, Epidural analgesia for cytoreductive surgery with peritonectomy and heated intraperitoneal chemotherapy, Int. J. Surg. 16 (Pt A) (2015) 99e106. [2] N. Rolf, T.P. Weber, H.V. Aken, Hypotension during thoracic surgery under combined general and high thoracic epidural anesthesia, Tech. Reg. Anesth. Pain Manag. 4 (2000) 161e166. [3] F. Coccolini, D. Corbella, P. Finazzi, F. Catena, C. Germandi, M.R. Melotti, V. Sonzogni, L. Ansaloni, Perioperative Management of patients Undergonig cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, Cancer Oncol. Res. 2 (3) (2014) 29e34. [4] M. Ali, D.C. Winter, A.M. Hanly, C. O'Hagan, J. Keaveny, P. Broe, Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life, Br. J. Anaesth. 104 (2010) 292e297. [5] L.G. Glance, A.W. Dick, D.B. Mukamel, F.J. Fleming, R.A. Zollo, R. Wissler, R. Salloum, U.W. Meredith, T.M. Osler, Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery, Anesthesiology 114 (2) (2011 Feb) 283e292.
Yongxin Liang, Shiduan Wang* Department of Anesthesiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 276000, China * Corresponding author. E-mail address: [email protected] (S. Wang).
None. 21 March 2015 Available online 21 May 2015 http://dx.doi.org/10.1016/j.ijsu.2015.05.022 1743-9191/© 2015 Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Letter to the Editor
The best anesthesia regimen for patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy
We read with interest the recent article by Piccioni F et al. [1] stating that epidural analgesia ensures adequate pain relief and is well tolerated by patients after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). In their study, a total of 101 consecutive patients received intra- and post-operative thoracic epidural anesthesia (TEA); intraoperative anesthesia was maintained with general anesthesia (GA) plus TEA; 9.9% of patients had hypotensive episodes and 77.2% (78/ 101) of patients received intra-operative red blood cells (RBCs) transfusion. But we do not think GA plus TEA is the best anesthesia regimen for patients undergoing CRS and HIPEC procedures. On the one hand, hypotension is more likely to happen under epidural anesthesia because the epidural administration of local anesthetics leads to functional sympatholysis and TEA has an inherent risk of cardiovascular depression and arterial vasodilation [2]. Furthermore, mean arterial pressure and systemic vascular resistance showed a reduction in patients undergoing CRS and HIPEC which is a very demanding surgery [3]. Those increase the risk of severe intraoperative hypotension, especially in the patients under TEA plus GA. While patient controlled thoracic epidural analgesia (PCTEA) is probably the best option to control pain postoperatively for those patients [4]. So we think GA, instead of TEA combined with GA, followed by PCTEA is the best anesthesiae analgesia regimen in patients undergoing CRS and HIPEC procedures. On the other hand, the main reason for hypotension during epidural anesthesia may be arterial vasodilation, but not pre-load absolute deficiency. It is certainly reasonable to treat hypotension with a vasopressor (such as phenylephrine). Excessive fluid or fresh frozen plasma (FFP) infusion is inappropriate, or even harmful for those patients undergoing CRS þ HIPEC procedures. Because excess fluid or FFP would dilute the blood and reduce the hemoglobin concentration, thereby increase the possibility of iatrogenic RBCs transfusion which is associated with a higher risk of mortality and morbidity in surgical patients [5].
Conflicts of interest
Funding None. Ethical approval None. Author contribution Yongxin Liang and Shiduan Wang all for writing. Guarantor Yongxin Liang, MD; Shiduan Wang, MD. References [1] F. Piccioni, C. Casiraghi, L. Fumagalli, S. Kusamura, D. Baratti, M. Deraco, F. Arienti, M. Langer, Epidural analgesia for cytoreductive surgery with peritonectomy and heated intraperitoneal chemotherapy, Int. J. Surg. 16 (Pt A) (2015) 99e106. [2] N. Rolf, T.P. Weber, H.V. Aken, Hypotension during thoracic surgery under combined general and high thoracic epidural anesthesia, Tech. Reg. Anesth. Pain Manag. 4 (2000) 161e166. [3] F. Coccolini, D. Corbella, P. Finazzi, F. Catena, C. Germandi, M.R. Melotti, V. Sonzogni, L. Ansaloni, Perioperative Management of patients Undergonig cytoreductive surgery and hyperthermic intraperitoneal chemotherapy, Cancer Oncol. Res. 2 (3) (2014) 29e34. [4] M. Ali, D.C. Winter, A.M. Hanly, C. O'Hagan, J. Keaveny, P. Broe, Prospective, randomized, controlled trial of thoracic epidural or patient-controlled opiate analgesia on perioperative quality of life, Br. J. Anaesth. 104 (2010) 292e297. [5] L.G. Glance, A.W. Dick, D.B. Mukamel, F.J. Fleming, R.A. Zollo, R. Wissler, R. Salloum, U.W. Meredith, T.M. Osler, Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery, Anesthesiology 114 (2) (2011 Feb) 283e292.
Yongxin Liang, Shiduan Wang* Department of Anesthesiology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 276000, China * Corresponding author. E-mail address: [email protected] (S. Wang).
None. 21 March 2015 Available online 21 May 2015 http://dx.doi.org/10.1016/j.ijsu.2015.05.022 1743-9191/© 2015 Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
