Annals of Surgical Oncology

, Volume 26, Issue 11, pp 3652–3662 | Cite as

Standard Operating Procedures for Anesthesia Management in Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Improve Patient Outcomes: A Patient Cohort Analysis

  • Dominique Fichmann
  • Lilian Roth
  • Dimitri A. Raptis
  • Marie-Elisabeth Kajdi
  • Philippe Gertsch
  • René Vonlanthen
  • Olivier de Rougemont
  • Julio Moral
  • Beatrice Beck-Schimmer
  • Kuno LehmannEmail author
Peritoneal Surface Malignancy



Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) offer survival benefits in well-selected patients with peritoneal tumors. The complexity of CRS/HIPEC requires surgical specialization. In contrast, limited data are available regarding the impact of anesthesia management. We assessed the role of standard operating procedures (SOPs) for anesthesia on perioperative patient outcomes after CRS/HIPEC.


Between 2009 and 2015, 112 CRS/HIPEC were performed at the University Hospital of Zurich. Procedures were grouped in an “early or late” group before (n = 57) and after (n = 55) the introduction of SOPs, which defined management of fluids, serum albumin, hemostasis, and body temperature.


Introduction of SOPs significantly changed patient management. Patients received in total less colloids (p = 0.03) and less diuretics (p = 0.007). We noticed an increased substitution of albumin (p = 0.001) and coagulation factors (p = 0.008). Body temperatures were higher at the end of the operation (p = 0.005), and more patients were extubated in the operating room (66% vs. 42%, p = 0.02). The rate of major complications (p = 0.003) and reoperations (p = 0.01) was reduced after the introduction of SOPs. On multivariate analysis, two independent prognostic factors were identified. The use of > 2000 mL of colloids [odds ratio (OR) 5.31 (1.06–26.56), p = 0.042] was associated with major morbidity. In contrast, substitution of albumin [OR 0.12 (0.01–0.96), p = 0.046] was associated with better outcomes.


SOPs for perioperative anesthesia management have a major impact on outcomes of patients after CRS/HIPEC. Management of colloid administration was an independent prognostic factor for perioperative outcomes. This highlights the role of the anesthesiologist and the need for specialization beyond the surgical team.



All authors declare no conflict of interest referring to this work. No third-party financial funds or materials were accepted or necessary for execution of this research project.


  1. 1.
    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):219–28.CrossRefPubMedGoogle Scholar
  2. 2.
    Sugarbaker PH. New standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome? Lancet Oncol. 2006;7(1):69–76.CrossRefPubMedGoogle Scholar
  3. 3.
    Chua TC, Moran BJ, Sugarbaker PH, et al. Early- and long-term outcome data of patients with pseudomyxoma peritonei from appendiceal origin treated by a strategy of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Clin Oncol. 2012;30(20):2449–56.CrossRefPubMedGoogle Scholar
  4. 4.
    Elias D, Gilly F, Boutitie F, et al. Peritoneal colorectal carcinomatosis treated with surgery and perioperative intraperitoneal chemotherapy: retrospective analysis of 523 patients from a multicentric French study. J Clin Oncol. 2010;28(1):63–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Schneider MA, Eshmuminov D, Lehmann K. Major postoperative complications are a risk factor for impaired survival after CRS/HIPEC. Ann Surg Oncol. 2017;24(8):2224–32.CrossRefPubMedGoogle Scholar
  6. 6.
    Franko J, Shi Q, Goldman CD, et al. Treatment of colorectal peritoneal carcinomatosis with systemic chemotherapy: a pooled analysis of North Central Cancer Treatment Group Phase III Trials N9741 and N9841. J Clin Oncol. 2011;30(3):263–7.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Kuijpers AM, Mirck B, Aalbers AG, et al. Cytoreduction and HIPEC in the Netherlands: nationwide long-term outcome following the Dutch protocol. Ann Surg Oncol. 2013;20(13):4224–30.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Schneider MA, Eden J, Pache B, et al. Mutations of RAS/RAF proto-oncogenes impair survival after cytoreductive surgery and HIPEC for peritoneal metastasis of colorectal origin. Ann Surg. 2018;268(5):845–53.CrossRefPubMedGoogle Scholar
  9. 9.
    Loupakis F, Cremolini C, Masi G, et al. Initial therapy with FOLFOXIRI and bevacizumab for metastatic colorectal cancer. N Engl J Med. 2014;371(17):1609–18.CrossRefPubMedGoogle Scholar
  10. 10.
    Saltz LB, Clarke S, Diaz-Rubio E, et al. Bevacizumab in combination with oxaliplatin-based chemotherapy as first-line therapy in metastatic colorectal cancer: a randomized phase III study. J Clin Oncol. 2008;26(12):2013–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Van Cutsem E, Kohne CH, Hitre E, et al. Cetuximab and chemotherapy as initial treatment for metastatic colorectal cancer. N Engl J Med. 2009;360(14):1408–17.CrossRefPubMedGoogle Scholar
  12. 12.
    Verwaal VJ, Bruin S, Boot H, van Slooten G, van Tinteren H. 8-year follow-up of randomized trial: cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy in patients with peritoneal carcinomatosis of colorectal cancer. Ann Surg Oncol. 2008;15(9):2426–32.CrossRefPubMedGoogle Scholar
  13. 13.
    Elias D, Lefevre JH, Chevalier J, et al. Complete cytoreductive surgery plus intraperitoneal chemohyperthermia with oxaliplatin for peritoneal carcinomatosis of colorectal origin. J Clin Oncol. 2009;27(5):681–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Amblard I, Mercier F, Bartlett DL, et al. Cytoreductive surgery and HIPEC improve survival compared to palliative chemotherapy for biliary carcinoma with peritoneal metastasis: a multi-institutional cohort from PSOGI and BIG RENAPE groups. Eur J Surg Oncol. 2018;44(9):1378–83.CrossRefPubMedGoogle Scholar
  15. 15.
    Chua TC, Yan TD, Saxena A, Morris DL. Should the treatment of peritoneal carcinomatosis by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy still be regarded as a highly morbid procedure? A systematic review of morbidity and mortality. Ann Surg. 2009;249(6):900–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Kusamura S, Moran BJ, Sugarbaker PH, et al. Multicentre study of the learning curve and surgical performance of cytoreductive surgery with intraperitoneal chemotherapy for pseudomyxoma peritonei. Br J Surg. 2014;101(13):1758–65.CrossRefPubMedGoogle Scholar
  17. 17.
    Kuijpers AM, Hauptmann M, Aalbers AG, et al. Cytoreduction and hyperthermic intraperitoneal chemotherapy: the learning curve reassessed. Eur J Surg Oncol. 2016;42(2):244–50.CrossRefPubMedGoogle Scholar
  18. 18.
    Passot G, Vaudoyer D, Villeneuve L, et al. A Perioperative clinical pathway can dramatically reduce failure-to-rescue rates after cytoreductive surgery for peritoneal carcinomatosis: a retrospective study of 666 consecutive cytoreductions. Ann Surg. 2017;265(4):806–13.CrossRefPubMedGoogle Scholar
  19. 19.
    Kajdi ME, Beck-Schimmer B, Held U, Kofmehl R, Lehmann K, Ganter MT. Anaesthesia in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: retrospective analysis of a single centre three-year experience. World J Surg Oncol. 2014;12:136.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Schmidt C, Creutzenberg M, Piso P, Hobbhahn J, Bucher M. Peri-operative anaesthetic management of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Anaesthesia. 2008;63(4):389–95.CrossRefGoogle Scholar
  21. 21.
    von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–7.CrossRefGoogle Scholar
  22. 22.
    Holte K, Nielsen KG, Madsen JL, Kehlet H. Physiologic effects of bowel preparation. Dis Colon Rectum. 2004;47(8):1397–402.CrossRefPubMedGoogle Scholar
  23. 23.
    Lehmann K, Eshmuminov D, Slankamenac K, et al. Where oncologic and surgical complication scoring systems collide: time for a new consensus for CRS/HIPEC. World J Surg. 2016(40):1075–81.CrossRefPubMedGoogle Scholar
  24. 24.
    Eng OS, Dumitra S, O’Leary M, et al. Association of fluid administration with morbidity in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. JAMA Surg. 2017;152(12):1156–60.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Caironi P, Tognoni G, Masson S, et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014;370(15):1412–21.CrossRefPubMedGoogle Scholar
  26. 26.
    Arroyo V, Fernandez J. Pathophysiological basis of albumin use in cirrhosis. Ann Hepatol. 2011;10 Suppl 1:S6–14.CrossRefPubMedGoogle Scholar
  27. 27.
    Bulatao IG, Heckman MG, Rawal B, et al. Avoiding stay in the intensive care unit after liver transplantation: a score to assign location of care. Am J Transpl. 2014;14(9):2088–96.CrossRefGoogle Scholar
  28. 28.
    Serrano AB, Candela-Toha AM, Zamora J, et al. Preoperative hydration with 0.9% normal saline to prevent acute kidney injury after major elective open abdominal surgery: a randomised controlled trial. Eur J Anaesthesiol. 2016; 33(6):436–43.CrossRefPubMedGoogle Scholar
  29. 29.
    Leemann H, Lustenberger T, Talving P, et al. The role of rotation thromboelastometry in early prediction of massive transfusion. J Trauma. 2010;69(6):1403–8; discussion 1408–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Smart L, Mumtaz K, Scharpf D, et al. Rotational thromboelastometry or conventional coagulation tests in liver transplantation: comparing blood loss, transfusions, and cost. Ann Hepatol. 2017;16(6):916–23.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Dominique Fichmann
    • 1
  • Lilian Roth
    • 1
  • Dimitri A. Raptis
    • 1
  • Marie-Elisabeth Kajdi
    • 2
  • Philippe Gertsch
    • 1
  • René Vonlanthen
    • 1
  • Olivier de Rougemont
    • 1
  • Julio Moral
    • 2
  • Beatrice Beck-Schimmer
    • 2
  • Kuno Lehmann
    • 1
    Email author
  1. 1.Department of Visceral Surgery and TransplantationUniversity Hospital ZurichZurichSwitzerland
  2. 2.Institute of AnesthesiologyUniversity Hospital ZurichZurichSwitzerland

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