Care of the Open Abdomen After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface Malignancies

Abstract

A patient with a mucinous appendiceal cancer presents to the surgeon complaining of abdominal discomfort and nausea. Having undergone a prior right hemicolectomy, the patient has been disease free and on surveillance with clinical and carcinogenic antigen (CEA) monitoring. The CEA was noted to be elevated and a computed tomography scan revealed peritoneal nodules throughout the abdomen with a presumptive diagnosis of pseudomyxoma peritonei (progressive peritoneal implants from a mucinous primary). Several therapeutic options were offered and the patient selected to undergo cytoreductive surgery (CRS) with the potential to receive hyperthermic interoperative chemotherapy (HIPEC). Extensive resection was performed, including removal of the entire greater omentum, partial gastrectomy, and total pelvic exenteration with end colostomy and ileal conduit. Reassessment of the peritoneal cavity after the resections revealed almost complete cytoreduction. HIPEC was performed with mitomycin C and, after drainage and abdominal washing, the intestinal segments were anastomosed and the abdominal wall closed. Seven days postoperatively, an acute abdomen with septic shock developed as a result of a leak from the ileocolonic anastomosis. The patient returned to the operating room and an exploratory laparotomy, a small bowel resection, a resection of the ileocolonic anastomosis, and an abdominal washout were performed. Edema of the bowel caused by peritonitis resulting from the anastomotic leak necessitated delayed closure of the abdominal wall. A temporary abdominal closure using the ABThera™ Open Abdomen Negative Pressure Therapy system was applied and the abdomen was eventually closed.

Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy, Part II: Implementation

“…Padding the patient's vulnerable sites at risk for injury is imperative to avoid nerve and muscle damage, pressure injury, and postoperative back pain . Repositioning the patient periodically may help prevent compartment syndrome and other injuries, especially because these patients may be under general anesthesia for 6 to 20 hours …”

“…Personnel turning over the room should pour solidifier powder into the canisters and perfusion pump reservoir container to render the contents gelatinous and prevent a spill during transport. This waste should never be flushed into the sewer system . Because fluid management systems are docked at a station to be flushed and cleaned before the fluid is released into the water sewage system, they are not an appropriate fluid collection device for HIPEC procedures.…”

“…Determining the unit into which the patient is admitted will depend on his or her acuity level and monitoring needs . Patients requiring hemodynamic surveillance, vasopressor support, and vigilant fluid and electrolyte balancing are admitted to the intensive care unit . Even if patients require an intensive care unit admission, a prolonged stay in tandem with their comorbidities usually has a minimal effect on their quality of life six months after surgery and on their long‐term survival .…”

“… age, body mass index, nutritional status, comorbidities, peritoneal cancer index score, length and complexity of CRS, estimated blood and other body fluid loss, pulmonary function, hemodynamic monitoring needs, chemotherapy agent used (ie, level of hematologic and renal toxicity), and intraoperative complications …”

“…35 Repositioning the patient periodically may help prevent compartment syndrome and other injuries, 35 especially because these patients may be under general anesthesia for 6 to 20 hours. 27,33 Thermal regulation Hypothermia is a concern during CRS because of its lengthy duration and the exposure of internal organs to room air. Hypothermia may impair the patient's platelet function, 36,37 decrease the enzymatic activity of clotting factors, and increase blood loss.…”