The best anesthesia regimen for patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Abstract

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].