Outcomes of cytoreductive surgery and HIPEC for pseudomyxoma peritonei of appendiceal origin from two Indian centers: A preliminary five-year experience.

PURPOSE: To evaluate the short-term outcomes of patients of pseudomyxoma peritonei (PMP) of appendiceal origin treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) at two tertiary Indian centers. METHODS: Data was prospectively collected from January 2011 to January 2016. Palliative procedures were excluded. HIPEC was performed by the coliseum technique using either a mitomycin or oxaliplatin-based regimen. RESULTS: 77 procedures were performed on 71 patients. The average time interval between diagnosis and CRS was 15.3 months. Of the tumors, 22.1% were high grade, 77.9% low grade and 24.6% intermediate grade. The median peritoneal carcinomatosis index (PCI) was 26 (<25 in 70.1% and >30 in 38.9%). Completeness of cytoreduction score (CCS)-1 was achieved in 75.3% (CC-0 in 42.9%). The mean number of bowel anastomoses was 1.1 and the mean number of organs resected per patient was 3.3. Of the 77 patients, 71% had resection of 3 or more organs and 50.6% had resection of 4 or more organs. Grade 3-4 complications occurred in 42.9% of the patients and the perioperative mortality was 5.2%. The projected 5-year overall survival (OS) was 62.3% and the 3-year disease-free survival (DFS) was 71% at a median follow up of 13 months. CONCLUSION: CRS and HIPEC can be used to treat PMP with an acceptable morbidity and mortality in Indian patients. Lack of early referrals leads to a large portion of patients presenting with extensive disease and an inferior survival which should improve with increasing awareness about the procedure and its results.

Anaesthetic Considerations in the Perioperative Management of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy has emerged as one of the primary modalities of treatment of diffuse peritoneal malignancies. It is a complex surgical procedure with the patients facing major and potentially life threatening alterations of haemodynamic, respiratory, metabolic and thermal balance with significant fluid losses and the perioperative management is challenging for anaesthesiologists and intensive care physicians. Though the alterations are short lived, these patients require advanced organ function monitoring and support perioperatively. The anaesthesiologist is involved in the management of haemodynamics, respiratory function, coagulation, haematologic parameters, fluid balance, thermal variations, and metabolic and nutritional support perioperatively. The chemotherapy instillate used are known to cause nephrotoxicity, cardiotoxicity, dyselectrolytemia and lactic acidosis. The preoperative polypharmacy for pain control, previous surgery and/or chemotherapy, malnourished status secondary to feeding problems and tumour wasting syndrome make the task all the more challenging. The anaesthesiologist also needs to consider the perioperative care from a quality of life perspective and proper preoperative counselling is important. The present overview summarizes the challenges faced by the anaesthesiologist regarding the pathophysiological alterations during the Cytoreductive surgery and Hyperthermic intraperitoneal chemotherapy in the preoperative, intraoperative and postoperative periods.