SummaryCytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) is a long and complex procedure with significant blood and fluid loss during debulking and important pathophysiological alterations during the HIPEC phase. We performed a retrospective analysis of 78 consecutive patients undergoing cytoreductive surgery with HIPEC at a university hospital. Our data demonstrate large intra-operative fluid turnover, with 51% of patients requiring a blood transfusion. During HIPEC, airway pressure and central venous pressure increased with a lower oxygenation ratio as a result of increased intra-abdominal pressure with the closed abdomen technique. As a consequence of the raised body temperature, heart rate, end tidal carbon dioxide and arterial lactate levels increased with a slight metabolic acidosis. Peri-operative analysis of routine clotting parameters revealed disturbances of the coagulation status. For pain management, 72% of patients received supplementary thoracic epidural analgesia with consequential perioperative opioid sparing and a reduced duration of postoperative ventilation.

Conversion to an open procedure during laparoscopic rectal resection correlates with an increased postoperative morbidity, however, without impairment of the short-term oncological outcome. The conversion rate is minimized by the growing experience of the operating surgeon and, therefore, is a marker of the learning curve.

Anesthetic management importantly contributes to the containment of the perioperative complications of HIPEC. An appreciation of the technical aspects and physiologic disruptions associated with intra-abdominal HIPEC is critical to ensure effective anesthetic management. Although data on this specialized surgical procedure are scarce, some referral centers have accumulated extensive experience. This article reviews the current knowledge about the anesthesiological and intensive care management of patients undergoing HIPEC. It pinpoints strategies for perioperative monitoring as well as illustrates alterations in hemodynamic, hematopoetic, and fluid hemostasis.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) has become an important tool in the management of patients with peritoneal malignancies. It is a complex surgical procedure with significant fluid loss during debulking leading to relevant pathophysiological alterations and therefore a challenge for anesthesiologists and critical care physicians. This review summarizes perioperative changes in hemodynamics, oxygen supply, coagulation, hematopoetic parameters and fluid status during cytoreductive surgery and HIPEC and how to deal with these pathophysiological alterations.

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Background Various techniques for laparoscopic proctocolectomy have been reported worldwide. We evaluated the technical aspects and early postoperative results of hand-assisted laparoscopic proctocolectomy (HALP) with construction of an ileal pouch-anal anastomosis through a Pfannenstiel incision. Patients and methods Between June 2004 and May 2006, 20 patients (median age 28 years) underwent combined HALP at our institution. Preoperative diagnosis included ulcerative colitis (n = 16), indeterminate colitis (n = 1), familial adenomatous polyposis (n = 2), and carcinoma of the rectum associated with ulcerative colitis (n = 1). All patients were under immunosuppressive therapy. Laparoscopic mobilisation of rectum, sigmoid and descending colon was performed first. Subsequently, hand-assisted laparoscopic mobilization of the transverse and ascending colon as well as creation of an ileal J-pouch were performed through a Pfannenstiel incision. Ileal pouch-anal anastomosis was completed by transrectal stapling device and protected by a loop ileostomy. Results The ileal pouch-anal anastomosis could be achieved in 19 cases (95%). There was one conversion (5%) to open surgery with construction of an end-ileostomy. No intraoperative blood transfusions were necessary. The median operating time was 210 minutes (range 180 min to 330 min). It was longer for the first five procedures but then remained constant. Two patients (10%) developed anastomotic leakage, which could be treated conservatively. Mean length of hospital stay was 11 days (range 7-32 days). Conclusions Combined HALP with construction of an ileal J-pouch-anal anastomosis can be performed safely and effectively. The Pfannenstiel incision proved to be advantageous for hand-assisted mobilisation of the transverse colon. Additionally, it was useful for the specimen removal and the J-pouch construction. Our new technique not only proved to be safe, but also resulted in a shortened total operation-time after a learning curve of about five procedures.

Aim: Evaluation of high resolution linear ultrasound and intra-operative linear contrast enhanced ultrasound (CEUS) and its benefit for the detection and characterization of tumor lesions.Material and methods: Twenty patients were investigated preoperatively regarding tumor detection using CT (n = 8) or MRI (n = 12) and image fusion (VNav) (n = 3). All patients had surgery for their hepatic tumor (hepatocellular carcinoma (HCC), cholangiocellular carcinoma (CCC), metastasis, and adenoma).Ultrasound was performed intra-operatively first with B-scan using a convex probe. Than multifrequency linear transmitters (6-9 MHz, 6-15 MHz, LOGIQ E9, GE) were applied for B-scan, coulor coded Doppler sonography (CCDS) and Power Doppler followed by dynamic CEUS with Contrast Harmonic Imaging (CHI) after bolus injection of a maximum of 15 mL SonoVue ® .Results: In 9 cases with the use of intra-operative CEUS additional tumor lesions (diameter 4-15 mm) could be detected and were histologically confirmed after surgical resection (7 cases) or intra-operative biopsy (2 cases). Using intraoperative CEUS 64 tumor lesions could be detected compared to 51 tumor lesions detected by preoperative CT or MRI (p < 0.05). Using the 6-15 MHz multifrequency linear transducer with CHI, arterial perfusion of adenomas, neuroendocrine metastases and HCC lesions was detectable. In 3 cases a resection was not achievable. Two of these cases were treated with radio frequency ablation (RFA). The other case had no curable option due to multifocal tumor manifestation.Conclusion: The intra-operative use of high-resolution linear transducer techniques with CEUS offers new diagnostic perspectives for an effective liver surgery.

The use of cryopreserved homografts is a valuable alternative to in situ repair with prosthetic vascular grafts or extra-anatomic reconstructions in the surgical treatment of AEF. Endovascular stentgraft placement plays a role as a bridging procedure in emergency situations.