Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has been shown to improve clinical outcomes and prognosis in patients with peritoneal metastasis. However, it is associated with a significant complication rate and a long postsurgical recovery in the hospital.
Brigham and Women’s Hospital’s Nelya Melnitchouk, MD, MSc, is one of the few surgeons in New England with expertise in CRS with HIPEC. Over the past several years, she and Matthias F. Stopfkuchen-Evans, MD, a general and gastrointestinal anesthesiologist at the Brigham, have developed an Enhanced Recovery After Surgery (ERAS) protocol to better quality of life for patients with peritoneal metastasis.
“Quoted in literature, the complication rate for CRS with HIPEC is about 30 to 40%,” says Dr. Melnitchouk, director of the Program in Peritoneal Surface Malignancy within the Division of General and Gastrointestinal Surgery and program director of the Colorectal Surgery Fellowship. “With the enhanced recovery pathway, we’re seeing a much lower complication rate—about 10 to 15%—and a faster return home.”
ERAS Protocol Is Changing the Game
According to Dr. Melnitchouk, the traditional approach to patient care following CRS with HIPEC included elements like these:
- Placing nasogastric tube to suction the stomach
- Waiting for flatus before feeding
- Flooding the patient with intravenous fluids
“We used to think we had to give patients lots of fluids to protect the kidneys,” Dr. Melnitchouk says. “But that led to patients becoming very swollen, needing to be intubated, and having lots of electrolyte abnormalities.”
The ERAS protocol represents a major shift. A nasogastric tube is not used, which increases patient comfort. There is an emphasis on carbohydrate loading before surgery to prevent starvation and stress response during surgery, and patients are fed immediately after surgery.
In addition, the ERAS guidelines call for goal-directed fluid therapy, which substantially reduces the volume of intravenous fluids administered. An anesthesiologist is closely involved to ensure the patient receives enough fluids to protect the kidneys, but nothing more.
“We have been using the enhanced recovery pathway for about three years and have seen very good results,” Dr. Melnitchouk says. “Patients don’t need to go to the ICU anymore after surgery, and they’re having fewer complications and regaining their bowel functions faster. Postsurgical hospital stay, which used to be seven to 10 days, is now four to seven days.”
High-Volume Expertise in Performing CRS With HIPEC
Dr. Melnitchouk has been conducting CRS with HIPEC for nearly eight years. She is presently the only surgeon at the Brigham performing the procedure and estimates completing about 20 annually. Given the specialized knowledge and decision-making skills required, she says, high-volume expertise is critical to optimizing patient outcomes.
Also critical is having the right personnel in place. Besides Dr. Melnitchouk, the peritoneal malignancy program includes anesthesiologist Dr. Stopfkuchen-Evans, a medical oncologist, radiation oncologist, radiologist, nutritionist, perfusionist, and physician assistants on the floor and in the clinic. The entire team contributes in managing patients before, during, and after surgery.
In recent years, the program has made impressive strides in patient selection, an area in which Dr. Melnitchouk receives input from medical oncology, radiation oncology, and radiology.
“Not every patient is a candidate for this surgery,” Dr. Melnitchouk notes. “You have to make sure that the patient will benefit and that you will not reduce survival or decrease their options for further treatments like systemic chemotherapy.
“As a surgeon, you see what it looks like in the OR and then how the patient does after. You know what you did intraoperatively, and then you modify your selection for the next time. You might not offer surgery to patients with very faster-growing disease and might be more aggressive in offering surgery to patients with slower-growing disease and not that many nodules.”