Hyperthermic Intraperitoneal Chemotherapy with Cytoreductive Surgery in a High-risk Patient: A Case Report

Abstract

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an important treatment option for patients with abdominal neoplasms and peritoneal dissemination of disease. However, there are considerable anesthetic risks to the procedure due to the significant temperature fluctuations and fluid shifts. We present a case of a patient with newly diagnosed severe mitral regurgitation who successfully underwent CRS/ HIPEC. A 64 year old male patient presented to our hospital for evaluation for CRS/HIPEC due to mucinous appendiceal neoplasm with peritoneal dissemination. The preoperative assessment found a severe mitral regurgitation with preserved left ventricular systolic function. The patient was asymptomatic and it was decided to proceed with CRS/ HIPEC. However, the hyperthermia and significant intraoperative fluid shifts associated with a HIPEC procedure were concerning for potential cardiac decompensation and pulmonary edema. The intraoperative goals were to maintain heart rate, reduce afterload, and avoid volume overload. A preoperative thoracic epidural catheter was placed for pain management. Additional monitoring included the post-induction placement of a pulmonary artery catheter and transesophageal echocardiography probe. Anesthesia was maintained on isoflurane and an epidural lidocaine infusion with intermittent epidural fentanyl boluses. Fluid management was guided by cardiac filling pressures, urine output, serial arterial blood gases, and transesophageal echocardiography. Nitroglycerin boluses and infusion were used to decrease afterload. The patient tolerated the surgery well without any cardiac decompensation; he was extubated in the operating room and taken to recovery. No immediate postoperative complications were observed. The case report documents that patients with significant cardiac co-morbidities can successfully undergo CRS with HIPEC. Pre-HIPEC systemic hypothermia can be utilized in these patients with advanced hemodynamic monitoring. It appeared advantageous to involve the complete anesthesia team early to allow multi-disciplinary planning of the perioperative course.