Peritoneal Cancer Guidelines

Updated: Feb 05, 2021
  • Author: Wissam Bleibel, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Guidelines

Guidelines Summary

The Enhanced Recovery After Surgery Society (ERAS) has published clinical practice guidelines on perioperative care in cytoreductive surgery for peritoneal malignancy. [28]  ERAS notes that cytoreductive surgery, with or without the addition of hyperthermic intraperitoneal chemotherapy, (CRS ± HIPEC) has become a treatment standard for peritoneal surface malignancies. However, these extended procedures may cause excessive tissue trauma with subsequent inflammation that ultimately lead to potentially life-threatening adverse effects. Major complication rates have been reported to be as high as 51%. ERAS recommendations include the following:

  • Advanced resuscitation and dedicated care protocols are warranted. Early reversal of this pathophysiologic cascade by improvements of perioperative care forms the basis of ERAS interventions.
  • Prophylactic nasogastric drainage for CRS ± HIPEC, in the absence of risk factors for delayed gastric emptying (resection of lesser omentum), should not be done because nasogastric decompression has been associated with undesired effects of delayed resumption of gastrointestinal motility and increased postoperative complications.
  • Removal of a urinary catheter as early as the morning of postoperative day 3 is recommended.
  • Thoracic epidural analgesia (TEA: T5-11) containing local anesthetics and short-acting opiates is recommended for 72 hr after CRS ± HIPEC to prevent postoperative ileus, and for at least 72 h afterward as an alternative to intravenous opiates for postoperative analgesia.
  • After TEA removal, analgesia with paracetamol (acetaminophen), nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids is recommended.
  • Early oral intake resumption after CRS ± HIPEC, aiming for clear liquids on the day of surgery and solid food from postoperative day 1, in the absence of risk factors for delayed gastric emptying (resection of lesser omentum), is recommended to improve mortality, anastomotic dehiscence, resumption of bowel function, and hospital length of stay.
  • Daily recording of nutritional intake after CRS ± HIPEC to identify patients with insufficient intake is recommended routinely.
  • Preemptive parenteral nutrition after CRS ± HIPEC (in addition to oral and/or enteral nutrition), for 7 postoperative days is recommended in selected patients (expected insufficient oral/enteral intake).
  • Monitoring of blood glucose in critically ill patients after CRS ± HIPEC and correction of glycemia using short-acting insulin to keep blood glucose levels at 140–180 mg/dL (7.8–10 mmol/L) are recommended routinely to reduce postoperative mortality.
  • Mechanical thromboprophylaxis (intermittent pneumatic compression) until complete mobilization, in association with pharmacologic thromboprophylaxis as an alternative to pharmacologic thromboprophylaxis alone, should be performed routinely.
  • Pharmacologic thromboprophylaxis (low molecular weight heparin, unfractionated heparin or fondaparinux) started 12 hr before CRS ± HIPEC should be performed routinely.
  • Extended pharmacologic thromboprophylaxis until 4 weeks after CRS ± HIPEC, as an option in addition to in-hospital thromboprophylaxis, should be performed routinely to reduce the risk of asymptomatic deep vein thrombosis (not pulmonary embolism).
  • Bevacizumab or other anti-angiogenic treatment should be routinely discontinued at least 5 weeks before CRS ± HIPEC to reduce intraoperative bleeding complications.
  • Placement of ureteral stents to reduce the risk of ureteral complications in patients with a high probability of pelvic peritonectomy should not be done routinely
  • Intraoperative administration of loop diuretics and dopamine for renal protection should not be performed routinely in patients undergoing CRS and HIPEC.
  • Mobilization and physiotherapy as early as the day of surgery (out of bed) with goals of > 2 hr of physical exercises for postoperative day 2 and > 6 hr thereafter should be performed routinely after CRS ± HIPEC to improve capacity to perform out-of-bed activities, facilitate resumption of gastrointestinal function, and decrease postoperative complications.