New Enhanced Recovery Pathway After HIPEC Improves Outcomes

Concentrated female surgeon performing surgery with her team in hospital operating room. Medics during surgery in operation theater.A treatment option that has shown to improve clinical outcomes and prognosis in patients with peritoneal metastasis is cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). While HIPEC can improve disease-free survival in many patients, it’s a major operation.

Referred to as the “mother all surgeries” by some surgeons, the marathon cytoreductive surgery with HIPEC carries risks, involves many abdominal resections, and can sometimes last 16 hours. Complications are not uncommon, and patients usually recover in the hospital for many days.

“We wanted to improve the quality of life for patients with peritoneal disease, so we pioneered a new enhanced recovery pathway for patients who undergone HIPEC at the Brigham,” said Nelya Melnitchouk, MD, MSc, Director of the Program in Peritoneal Surface Malignancy within the Division of Gastrointestinal Surgery.

Dr. Melnitchouk has spent the last several years refining an Enhanced Recovery After Surgery (ERAS) in collaboration with Matthias F. Stopfkuchen-Evans, MD, a general and GI anesthesiologist, and pioneer in ERAS. As the two added steps to their evolving protocol, they observed lower risks of complications after HIPEC and improved quality of life in patients who underwent the operation.

“Following our protocol, we feed patients the day after their surgery, as opposed to placing nasogastric tube and waiting for flatus. We also emphasize preoperative carbohydrate loading to avoid starvation and stress response during the surgery,” said Dr. Melnitchouk.

The ERAS protocol also limits the amount of intravenous fluids given to patients (via “goal-directed fluid therapy”) following HIPEC. Importantly, this step did not increase the risk of kidney injury and decreased ileus (lack of movement in the intestines).

In fact, patients who were both fed a day after surgery and had their fluids limited after surgery regained their bowel functions faster, experienced fewer complications (e.g., less risk of anastomotic leak), and stayed in the hospital fewer days than patients who were not.

Dr. Melnitchouk will present clinical outcomes associated with this Enhanced Recovery After Surgery protocol at the 2019 ERAS USA Conference. An abstract has also been accepted for a meeting of the Society of Surgical Oncology.

“Peritoneal disease is often heterogeneous with no standard algorithms for care, so we manage and treat patients individually. Since each patients’ disease and risk tolerance is unique, we emphasize shared decision-making and carefully counsel each patient,” said Melnitchouk.

All patients in the Peritoneal Malignancy Program are reviewed by a multidisciplinary tumor board where Dr. Melnitchouk receives input from medical oncology, radiation oncology and radiology. An expert gastrointestinal pathologist also confirms each patients’ histology.

“Our unique enhanced recovery pathway improves quality of life for many of our patients, but it also gives many patients with peritoneal metastasis the gift of time. A large percentage of these patients have been off systemic chemotherapy for a significant period and some are several years out with no evidence of cancer,” said Dr. Melnitchouk.

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