Updates in Surgical Oncology

Oncology Nursing Society 44th Annual CongressApril 11–14, 2019 • Anaheim, CA 1Advanced Practice

Lisa Parks, MS, APRN-CNP, ANP-BC The Ohio State University James Cancer Hospital Columbus, OH [email protected]

Key Session Takeaways1. Robotic surgery allows greater visualization with magnification

and ability to manipulate in close areas. There is a learning curve to perform robotic surgery. Robotic surgery does not reduce operating room time.

2. ERAS is a multidisciplinary clinical pathway that promotes qual-ity of patient care throughout the perioperative pathway. Each component of the pathway is based on current evidence-based practices. Education in the preoperative phase is key for success-ful implementation of the protocol.

3. One of the purposes of HIPEC is to bathe the peritoneal cells in chemotherapy to eradicate micro-metastatic disease. HIPEC should not be performed in patients who have not undergone CRS. Some of the most common complications include anasto-motic leaks and intestinal perforations.

Updates in Surgical OncologyThursday, April 11 • 9:45–11 am

Note one action you’ll take after attending this session: ____________________________________________________

________________________________________________________________________________

ONS 44th Annual Congress

Advanced Practice 1

Updates In Surgical Oncology

Lisa Parks, MS, APRN‐CNP, ANP‐BCSurgical Oncology

James Cancer Hospital and Solove Research Institute Columbus, Ohio

I, Lisa Parks, DO NOT have a financial interest or arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

Disclosures

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Advanced Practice 2

1. Discuss the pros and cons of robotic surgery

2. Explain the use of heated intraperitoneal chemotherapy (HIPEC) in surgical oncology

3. Review the use of Enhanced Recovery After Surgery (ERAS) in caring for surgical oncology patients

Robotic Surgery History

• Represents the most significant advancement in minimally invasive surgery

• First surgical robot designed in 1983 for orthopedic procedures

• 1998 da Vinci surgical system developed with central control panel and robotic arms• Used in robot‐assisted heart bypass in Germany

• First robot‐assisted radical prostatectomy in Paris In 2000 FDA approval for da Vinci in general surgery laparoscopic procedures

(Ng & Tam, 2014)

Da Vinci Surgical System

• Three components:• The surgeon’s console

• Patient‐side robotic cart with 4 robotic arms (1 to control the camera and 3 to manipulate instruments

• High definition three‐dimensional (3D) vision system

(Ng & Tam, 2014)

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Advanced Practice 3

PROS CONSAllows for precise dissection in a confined space No evidence showing superiority of robotic surgery

over laparoscopic surgery

3D magnified view 10‐12x High cost of purchasing the robotic system

Articulating instruments with more degrees of freedom

Increased cost of operating room time due to longer length of procedure

Tremor filtration Surgeon needs to perform approximately 60‐80 procedures to become proficient

Improved ergonomic benefit

Carbon dioxide insufflation reduces venous ooze and reduces blood loss

Robotic Surgery

(Gastrich, 2011; Ishihara, 2015)

Current Indications for Robotic Surgery

Head and Neck Cancers• TORS‐Transoral Robotic Surgery, Robotic Supraglottic laryngectomy

• FDA approved in 2009 for early stage oropharyngeal and supraglottic cancers

• Access to anatomical locations previously available by open procedure

• Associated with shorter LOS, decreased use of gastrostomy tubes, tracheostomy placement and hospital costs

(Sun & Fong, 2017)

Esophageal Cancer

• Robotic‐assisted esophagectomy• All data has been retrospective

• Decreased postoperative complications

• Decreased pulmonary complications

• Shorter LOS

• Lower blood transfusion rates and less blood loss

• Faster initial oral intake

• Reported higher fatigue, pain, and dyspnea

( Sun & Fong, 2017)

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Advanced Practice 4

Lung Cancer

• Robotic –assisted thoracoscopic lobectomy• Shorter hospital stays

• Lower morbidity

• Lower over all complications

(Sun & Fong, 2017)

Gastric Cancer

• Robotic‐assisted laparoscopic gastrectomy• Decreased in blood loss

• Decreased hospital length of stay

• Better short‐term postoperative outcomes

(Alhossaini, 2017; Sun & Fong, 2017)

Colorectal Cancer

• Robotic‐assisted hemicolectomy, Robotic‐assisted low anterior resection, robotic –assisted total mesorectal excision• Lower conversion rate to open vs laparoscopic

• Intracorporeal bowel anastomosis leads to less visceral trauma or tissue stretching‐Faster return of bowel function and shorter LOS, longer operative time

• Reduced autonomic nerve injury

(Lujan, 2018)

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Advanced Practice 5

Hepatobiliary Cancers

• Robotic‐assisted distal pancreatectomy, Robotic –assisted pancreatoduodenectomy, Robotic –assisted hepatectomy• Shorter hospital stay, decreased blood loss, and decreased complication rate

• Decreased conversion rate vs laparoscopic

• More R0 resections

• Splenic preservation with distal pancreatectomy

• Longer operative time

(Sun & Fong, 2017; Wang, 2018)

Pancreatic CAGallbladder CA

Liver CA

Gynecologic Cancers

• Robotic‐assisted radical hysterectomy• Longer operative time and increased cost

• Lower complication rate

• Less opioid use and lower postoperative pain

• Shorter hospital stay

• Less blood loss

• Better visualization in the morbidly obese

( Best, 2014; Sun & Fong, 2017)

Ovarian CA

Cervical CA

Uterine CA

Urologic Cancers

• Robotic‐assisted radical prostatectomy‐75%, Robotic‐assisted radical cystectomy, Robotic partial nephrectomy• Shorter operative time

• Lower blood loss and transfusion rate

• Shorter hospital length of stay

• Earlier removal of foley catheter

(Sun & Fong, 2017)

Prostate CA

Bladder CA

Kidney CA

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Advanced Practice 6

Implications for Nursing• Need for extensive preoperative teaching for the patient and family regarding post‐operative recovery due to shorter length of stay in the hospital.

• Address stress and anxiety preoperatively and involve patient’s support system.

• Pain management will be multi‐modal. Will use intrathecal morphine or an epidural in combination with: scheduled Tylenol (650 mg) and Ibuprofen (600 mg) every 6 hours. Minimal use of oxycodone 5 mg PRN.

• Early ambulation – consult PT/OT

• Pulmonary toileting ‐ Use of incentive spirometer post‐op. Consider respiratory therapy options.

• Smoking cessation ‐ Order nicotine patches and counseling

• Nutritional needs ‐ early initiation of diet. Order clear liquids POD 0 or 1. Based on pre‐albumin; may add oral supplements

Key Points

1) Robotic surgery allows greater visualization with magnification and ability to manipulate in close areas

2) There is a learning curve to perform robotic surgery

3) Robotic surgery does not reduce operating room time

Enhanced Recovery After Surgery (ERAS)

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Advanced Practice 7

Enhanced Recovery After Surgery (ERAS)

• Pathways that are multidisciplinary standardized plans of care using evidence‐based interventions throughout the perioperative process

• Goal: To improve the quality of patient care and accelerate the recovery process

(Feldheiser, 2015)

ERAS

• Concept was developed by a group of European academic surgeons in 2001 (ERAS Society).

• Emphasis is that the key end point is quality patient care (not speed of recovery)

• Optimize outcomes based on published evidence

• Multidisciplinary guidelines

(Gustafsson, 2013; Feldheiser, 2015; Lassen, 2012; Nelson, 2016)

How To Create An ERAS Protocol

• Develop a multidisciplinary team• Define the patient population• Review the literature• Design pathways and process maps using evidence based practice and standards of care• Develop order sets• Audit and monitor outcomes. • Revise the process as needed

(Elias, 2019)

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Advanced Practice 8

Preoperative ERAS

• Optimization of pre‐existing health conditions• Alcohol Prehabilitation‐Alcohol Causes:

• Increased risk of perioperative bleeding

• Increased risk of wound infection

• Impairs the metabolic stress response, cardiac, and immune function

• Minimum of 4 weeks abstinence needed to reduce risks

• Can take 8‐12 weeks for patients to return to normal state

• Counseling

(Gustafsson, 2013; Feldheiser, 2016; Nelson, 2016)

Smoking and AnemiaPrehabilitation• Smoking:

• Impairs wound and tissue healing• Cessation for 4 weeks prior to surgery improves wound healing• Use of nicotine replacement therapy• Counseling

• Preoperative Anemia• Predictor of mortality and postoperative complications• Correct 3‐4 weeks prior to surgery• Blood transfusion• Supplemental iron, folate, and vitamin B12


Optimization of Medical Conditions

• Cardiovascular diseases

• Anemia

• COPD

• Diabetes

• Nutritional status

Requires provider to refer to specialists for optimization prior to surgery


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Advanced Practice 9

Preoperative Fasting and Carbohydrate Loading

• Solid food up to 6 hours prior to surgery

• Clear liquids up to 2 hours prior to surgery

• Fasting from midnight increases insulin resistance, patient discomfort, and decreases intravascular volume

• Preoperative treatment with complex carbohydrate drink the night before surgery and 2‐3 hours prior to surgery decreases insulin resistance


Carbohydrate Loading

• Reduces catabolic state induced by overnight fasting and surgery

• Fasting inhibits insulin secretion and promotes the release of catabolic hormones, such as glucagon and cortisol

• Carbohydrate loading increases insulin levels reducing postoperative insulin resistance, maintains glycogen reserves, decreases protein breakdown, and improves muscle strength


Perioperative Glycemic Control

• Blood glucose levels increase during and after surgery. Hyperglycemia depends on patient’s metabolic state (Fasting, diabetes, etc.), type of anesthesia, and the severity of surgical tissue trauma

• Even moderate increases in blood glucose are associated with adverse outcomes.

• Goal is to reduce insulin resistance


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Advanced Practice 10

Use of Nasogastric (NG) Tubes

• Routine use of NG tubes should be avoided

• Should be removed at the end of surgery

• Fever, oropharyngeal and pulmonary complications more frequent with ng tubes

• Avoidance of NG associated with earlier return to bowel function


Intraoperative Hypothermia

• Several meta‐analyses and randomized controlled trials have shown that preventing hypothermia during major abdominal surgery reduces wound infections, cardiac complications, bleeding, and improves immune function

• Active warming devices should be used in cases lasting more than 30 minutes


Anesthesia

• Bispectral Index (BIS)• Allows titration to the minimal amount of anesthesia to avoid complications, especially in the elderly

• Reduces the amount of anesthesia

• Minimizes anesthesia side effects

• Facilitates rapid awakening and recovery


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Use of Inspired Oxygen

• High inspired oxygen concentration protects against the risk of surgical site infection

• Short term use of high inspired oxygen is used to overcome hypoxic episodes and to pre‐oxygenate/de‐nitrogenate the lungs postoperatively


Intraoperative Fluid Requirements

• Avoidance of prolonged preoperative fasting and administration of preoperative carbohydrate drinks have reduced intraoperative fluid requirements.

• Maintain a near zero fluid balance

• Crystalloid excess increases the risk of pulmonary complications and prolonged ileus

• Early oral intake should be encouraged (1.5 liters/d) and postoperative IV fluid should be minimized


Pain Management

• Thoracic epidural analgesia (TEA) is the gold standard for abdominal surgery. May also see intrathecal morphine used.

• Works better with dedicated pain service

• Associated with 40% reduction of mortality• Accelerates return of bowel function

• Reduces insulin resistance

• Decreases cardiovascular and respiratory complications


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Multi-modal Analgesia

• Routine use of NSAIDS, COX‐2, and acetaminophen

as scheduled medications• Reduces opioid use and their side effects

• Should be utilized with TEA or intrathecal morphine

• Nursing interventions like heat packs, splint pillows, etc.


Early Mobilization

• Begin on the day of surgery and increase each day

• Preparation for this begins in the preoperative setting with instructions both verbally and written for daily postoperative mobility goals• Should be encouraged to increase activity preoperatively to improve physical fitness. This may include physical or occupational therapy

(Gustafsson, 2013; Feldheiser, 2016; Nelson, 2016

Key Points

1) ERAS is a multidisciplinary clinical pathway that promotes quality of patient care throughout the perioperative pathway

2) Each component of the pathway is based on current evidence based practices

3) Education is the preoperative phase is key for successful implementation of the protocol

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Cytoreduction and HIPEC

Peritoneal Space

• Peritoneal Space is a large intersecting space extending from the retroperitoneum to the peritoneal cavity • It is a serous membrane composed of mesothelial cells containing a rich blood and lymphatic system

• Covers most of the abdominal organs and pelvic walls in males

• In females, not a closed sac since the free end of the uterus open directly into the peritoneal cavity

(Dunn, 2010)

Routes of Metastasis

• Hematogenous metastasis

• Lymphatic metastasis

• Local extension through the peritoneal spaces and onto abdominopelvic surfaces. Progress rapidly along mesenteric and ligamentous attachments

(Dunn, 2010)

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Peritoneal Surface Malignancy

• New tumors form on peritoneal surface with intraperitoneal seeding from cancer tumor cells. This seeding causes nodular tumors to form throughout the abdominal cavity

• Peritoneal seeding occurs in 3‐28% of patients undergoing surgical resection

(Dunn, 2010)

Peritoneal Carcinomatosis

• Intraperitoneal dissemination is the most common means for metastasis to develop in the peritoneum

• Metastatic cells may implant anywhere in the peritoneal cavity

(Dunn, 2010)

Symptoms

• Increase in abdominal girth

• Early satiety

• Enlarging hernia (males) and ovarian mass (females)

• Acute pelvic pain

• Nausea, vomiting

• Bowel and bladder changes

(Dunn, 2010)

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History of Cytoreduction Surgery (CRS)

• In 1934, Dr. Meigs described tumor debulking surgery for ovarian cancer

• Did not become mainstay of operative management in ovarian carcinomatosis and pseudomyxoma peritoneii (PMP) with improved survival until late 1960’s and early 1970’s

• Cytoreduction was optimized with Dr. Sugarbaker who developed 7 peritonectomy procedures

(Morano, 2017)

Possible Surgical Resection

• Parietal peritoneal stripping of the anterior abdominal wall

• Visceral peritoneal stripping of the bladder

• Parietal peritoneal dissection of both paracolic gutters

• Left subphrenic (diaphragmatic) peritonectomy

• Peritoneal dissection at the falciform ligament, at the round ligament of the liver

• Cholecystectomy with resection of the lesser omentum and dissection at the hepatoduodenal ligament

• Multivisceral resection of the stomach, small bowel, colon, rectum, spleen, uterus, ovary, and vagina

(Brucher, 2011)

CRS

• Absolute Contraindications• Massive involvement of retroperitoneum

• Invasion of the mesenteric pedicle

• Massive small‐bowel involvement (short bowel syndrome)

• Unresectable intra‐abdominal and/or extra‐abdominal metastases

• Incurable second malignancy

(Brucher, 2011)

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CRS

• Relative contraindications• High body mass index

• Cardiac contraindication

• Hepatic contraindication

• Renal contraindication

• Florid infection

• Acute ileus

(Brucher, 2011)

PCI

• Extent of tumor involvement in each region is assessed using the lesion size score from 0‐3

• Main limitation is a reliable pre‐therapeutic prediction of tumor in the small bowel

• Recognized as the standard for describing peritoneal disease during the Fifth International Workshop on Peritoneal Surface Malignancy in 2006

• Score ranges from 1 to 39

(Brucher, 2011; Cianos, 2013;Lansom, 2016)

PCI• PCI score in colorectal cancer (CRC) is associated with good outcomes when <16

• Sugarbaker in CRC reported 50% 5 year survival for PCI <10 and 20% for PCI between 11 and20.

• PCI is commonly assessed preoperatively and intraoperatively

• CT can be used to calculate PCI and to assign a baseline peritoneal surface disease systemic score (PSDSS)

• Underestimates the extent of patient’s disease burden and limits preop PSDSS

• Involvement of the small bowel reflects biologic aggressiveness, even more when the disease targets the lower ileum

(Brucher, 2011; Cianos, 2013; Lansom, 2016)

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Completeness of Cytoreduction(CCR)

CCR grade 0 ‐ no macroscopic residual cancer

CCR grade 1 ‐ that the diameter of any residual nodule was less than 5 cm

CCR grade 2 – diameter of any residual nodule was more than 5 cm

(Brucher, 2011; Cianos, 2013)

History of Intraperitoneal Chemotherapy

• Phase 1 and 2 trials started in mid 1980’s in ovarian cancer• Early reports of survival benefits from Dr. Sugarbaker at the Washington Cancer Institute in gastrointestinal malignancies (gastric and colon)

• 2006 National Cancer Institute issued statement that HIPEC is regarded as standard adjuvant therapy for stage III epithelial ovarian cancer

David Sugarbaker, MD

(Ahmed, 2014; Morano, 2017; Neuwirth, 2016)

Tumor Cell Entrapment Hypothesis

• Proposed by Dr. Sugarbaker and associates

• Intraperitoneal free cancer cells are spontaneously disseminated and adhere to raw tissue area created during surgery.

• This is facilitated by fibrin entrapment and cytokines released for wound healing

• Cancer cells trapped in this hypoxic environment are immune to systemic chemotherapy

(Seshadri, 2016)

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Heated Intraoperative Chemotherapy (HIPEC)

• Purpose is to eradicate micro‐metastatic disease by bathing the peritoneal cavity with chemotherapy

• Damage from heating the chemotherapy is greater to malignant cells than normal cells

• Heat causes greater penetration of chemotherapy by increasing membrane permeability and improving membrane transport

• Heat increases cytotoxicity of the chemotherapy

(Cianos, 2013)

HIPEC

• Reduced systemic toxicity at higher concentrations

• Direct treatment of free intraperitoneal tumor cells

• Homogeneous distribution of chemotherapeutic agents as a result of intraperitoneal administration

• HIPEC should not be performed in patients with incomplete CRS

(Cianos, 2013; Loggie, 2015; McRee, 2015)

Cancers Treated with CRS and HIPEC

• Gastric‐Palliative use to control ascites and reduce need for frequent paracentesis

• Appendiceal Colon• Pseudomyxoma Peritonei (PMP)

• Diffuse Malignant Peritoneal Mesothelioma

• Colorectal • Synchronous Peritoneal and Liver Metastasis

• Epithelial Ovarian Cancer(Ahmed, 2014; Huo, 2015; Lansom, 2016; Morano, 2017; Seshadri, 2016; Sun, 2013)

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Chemotherapy Drugs For HIPEC

• Oxaliplatin and Mitomycin C are the most commonly used drugs

• The use of one drug versus the other is based on surgeon and institutional preference

(Ahmed, 2014)

HIPEC

• Can be performed with open (Coliseum) or closed abdomen• Open involves a silicon plastic sheet placed over a retractor and secured to the skin. Incision is made to expose the abdominal contents and form an elevated cavity or coliseum

• Open procedures allow for direct access by the surgeon to the cavity to manipulate the fluid and the bowel. All peritoneal surfaces can be exposed

( Neuwirth, 2016)

HIPEC

• Open procedure negatives:• Rapid dissipation of heat requiring more effort to maintain ideal temperature

• Potential exposure of surgeon/operating room staff to chemotherapy by direct contact and aerolization

(Neuwirth, 2016)

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HIPEC

• Closed procedure involves the closure of the abdominal wall prior to the use of chemotherapy• Provides a space in which flow rates can be maintained for hyperthermia and exposure for drug penetration

• Major disadvantage is uneven distribution of chemotherapy leading to pooling of fluids. Can be alleviated with manual external agitation but may be impaired by adhesions due to fact that chemotherapy can not reach all surfaces

(Neuwirth, 2016)

HIPEC

• Carrier solution initially fills abdomen

• Carrier solution is then passed through HIPEC machine to heat it

• Once a temperature of 42 C is reached the chemotherapy is added

• Intra‐abdominal temperature is measured every minute and temperatures of the bladder and head are assessed by anesthesia

• After 30‐120 minutes, the abdomen is drained and is lavaged with 8‐10 liters of solutions. Both solutions are disposed as hazardous waste

(Neuwirth, 2016)

Implications for Nursing

• Monitor intake and output• Significant intravascular volume loses from the peritoneal surface due to open abdomen and surgical inflammatory response‐May require IV fluid boluses to replace intravascular volume losses

• Monitor the output of the intra‐abdominal drains to detect bleeding or ascites

• Monitor hemodynamic status• Sinus tachycardia in the 100‐140 range and hypotension may be related to intravascular depletion. Fluid challenges may help to resolve

• May be due to systemic vasodilation and hyperdynamic state postoperatively. In this situation patient may not respond to fluid challenges but will resolve over 24‐72 hours

(Ahmed, 2010)

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• Monitor CBC (Complete Blood Count)• Monitor hemoglobin ‐High risk for intra‐abdominal bleeding.Transfuse blood for hemoglobin <7

• Monitor platelets and WBC (White Blood Count)‐Mitomycin C can cause mild to moderate thrombocytopenia and leukopenia. Neutrophil counts can decrease 5‐10 days after HIPEC

Monitor for VTE(Venous Thromboembolic Events)‐PE(Pulmonary Embolus) after CRS and HIPEC reported in 5% of patients.

Due to hypercoagopathy of cancer patients

Prolonged immobility with long operative times

(Ajmed, 2010)

Surgical ComplicationsThe most common surgical complications resulting from CRS and HIPEC are:

• Anastomotic Leaks

• Intestinal Perforation • Abscesses• Intra‐abdominal Bleeding

Reported in 26% of patients with 11.1% returning to the operating room

(Loggie, 2015)

Surgical Complications

Prolonged Ileus

Bile leak

Pancreatitis

Abdominal wall dehiscence

Mesenteric ischemia

Mesenteric vein thrombosis

Mechanical intestinal obstruction

Impact of Surgical Complications

• Severe complications account for over 55% of total hospital admission costs

• In patients with severe complications, mean hospital admission costs were 320% higher than patients with uncomplicated hospital admission

• Mainly due to prolonged ICU and floor stays and diagnostic and therapeutic treatments

(Simkens, 2018)

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Nutrition

• Patients are usually malnourished before surgery due to the catabolic effect of the tumor and complications of bowel obstruction

• CRS and state of ‘no oral intake’ for 7‐10 days can lead to catabolism and loss of lean body mass

• Enteral route is preferred to preserve gut integrity and simplify glycemic management

• Most critically ill patients require 20‐30 kcal/kg for meet their daily expenditure

• If delays in enteral feeding of 2‐3 days, may start TPN (which helps with electrolyte and acid‐base balance)

(Dunn, 2010)


• Order oral supplements as soon as patient is able to take oral fluids with meals and at bedtime

• Educate patient to continue oral supplements after discharge throughout recovery period

• Patient is followed with serial CT scans every 6 months for 3 years, then annually for 2 years. CEA, CA‐125, CA‐19‐9 every 3 months for the first 3 years and then annually for the next 2 years

(Cianos, 2013)

Key Points

1) One of the purposes of HIPEC is to bathe the peritoneal cells in chemotherapy to eradicate micro‐metastatic disease

2) HIPEC should not be performed in patients who have not undergone CRS

3) Some of the most common complications include anastomotic leaks and intestinal perforations

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Thank You!

Any Questions..?

• References Robotic Surgery

• Best, J., Day, L., Ingram, L., Musgrave, B., Rushing, H., & Schooley, B. (2014). Comparison of robotic vs standard surgical procedure on postoperative nursing care of women undergoing total abdominal hysterectomy. MedSurg Nursing 23(6) 414‐421

• Brenner, A., Salathiel, M., Macey, B., & Krenzer, M. (2011). Postoperative care for the robotic surgery bowel resection patient. Gastroenterology Nursing 34(4) 217‐275 doi: 10.1097/SGA.0b013e31822486d0

• Doyle‐Lindrud, S. (2015). Use of robotics in oncology surgery. Clinical Journal of Oncology Nursing 19(3) 265‐266 doi: 10.1188/15.CJON.265‐266

• Gastrich, M., Barone, J., Bachmann, G., Anderson, M., & Balica, A., (2011). Robotic surgery: review of the latest advances, risks, and outcomes. Journal of Robotic Surgery 5 79‐97 doi: 10.1007/s11701‐011‐0246‐y

• Ishihara, S., Otani, K., Yasuda, K., Nishikawa, T., Tanaka, J., …Watanbe, T. (2015). Recent advances in robotic surgery for rectal cancer. International Journal of Clinical Oncology 20 633‐640 doi: 10.1007/s10147‐015‐0854‐z

References

• Kurt, G., Loerzel, V., Hines, Tavasci, K., Galura, S., Ahmad, S., & Holloway, R. (2018). Learning needs of women who undergo robotic versus open gynecologic surgery. Journal of Obstetric, Gynecologic, and Neonatal Surgery 47(4) 490‐497 doi: 10.1016/j.jogn.2018.04.133

• Ng, A & Tam, P. (2014). Current status of robot‐assisted surgery. Hong Kong Medical Journal 20(3) 241‐250 doi: 10.12809/hkmj134167

• Pappou,E. & Weiser, M. (2015). Robotic colonic resection. Journal of Surgical Oncology 112 315‐320 doi: 10.1002/jso.23953

• Stafford, A. & Walsh, R. (2015). Robotic surgery of the pancreas: the current state of the art. Journal of Surgical Oncology 112 289‐294 doi: 10.1002/jso.23952

• Sun, V. & Fong, Y. (2017). Minimally invasive cancer surgery; indications and outcomes. Seminars in Oncology Nursing 33(1) 23‐36 doi: 10.1016/j.sonen.2016.11.003

• Wang, W., Kuo, K., Wang, S., & Lee, K. (2018). Oncological and surgical result of hepatoma after robot surgery. Surgical Endoscopy doi: 10.1007/s00464‐018‐6131‐2

References

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• References Enhanced Recovery After Surgery

• Aviles, C., Hockenberry, M., Vrochides, D., Iannitti, D., Cochran, A., Tezber, K., & Desamero, J. (2017). Perioperative care implementation. Clinical Journal of Oncology Nursing 21(4) 466‐472 doi: 10.1188/17.CJON.466‐472

• Bakker, N., Cakir, H., Doodeman, H., & Houdijk, A. (2015). Eight years of experience with enhanced recovery after surgery in patients with colon cancer: impact of measures to improve adherence. Surgery 157(6) 1130‐1136 doi: 10.1016/j.surg.2015.01.016

• Bohnenkamp, S., Pelton, N., Rishel, C., & Kurtin, S. (2014). Implementing evidence‐based practice using an interprofessional team approach. Oncology Nursing Forum 41(4) 434‐437 doi: 10.1188/14.ONF.434‐437

• Brady, K., Keller, D., & Delaney, C. (2015). Successful implementation of an enhanced recovery pathway: the nurses’s role. AORN Journal 102(5) 470‐478 doi: 10.1016/j.aorn.2015.08.015

• Chand, M., De’Ath, H., Rasheed, S., Mehta, C., Bromilow, J., & Qureshi, T. (2016). The influence of peri‐operative fators for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway. International Journal of Surgery 25 59‐63 doi: 10.1016/j.ijsu.2015.11.047

• Committee on Gynecologic Practice. (2018). Perioperative pathways: enhanced recovery after surgery. Obstetrics & Gynecology 132(3) e120‐e130

• Conchin, S., Muirhead, R., Ferrie, S., & Carey, S. (2013). Can’t we just let them eat? Defining and addressing under‐use of the oral route in a post‐surgical ward. Asia Pacific Journal of Clinical Nutrition 22(2) 200‐205 doi: 10.6133/apjcn.2013.22.2.12

References

• Dummigan, C. (2014). Early feeding protocol in elective colorectal surgery. Gastrointestinal Nursing 12(9) 15‐21

• Elias, K., Stone, A., McGinigle, K., Tankou, J., Scott, M., Fawcett, W., Demartines, N., Lobo, D., Ljungqvist, O., & Urman, R. (2019). The reporting of ERAS compliance, outcomes, and elements research (RECOvER) checklist: a joint statement by the ERAS and ERAS USA Societies. World Journal of Surgery 43 1‐8 doi: 1007/s00268‐018‐4753‐0

• Fujii, T., Morita, H., Sutoh, T., Yajima, R., Yamaguchi, S., Tsutsumi, S., Asao, T., & Kuwano, H. (2014). Benefit of oral feeding as easrly on one day after elective surgery for colorectal cancer: oral feeding on first versus second postoperative day. International Surgery 99 211‐215 doi: 10.9738/INTSURG‐D‐13‐00146.1

• Feldheiser, A., Aziz,O., Baldini, G., Cox, B., Fearon, K.,Feldman, L….Carli, R. (2016). Enhancedrecovery after surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. ActaAnaesthesiologica Scandinavica 60 289‐334 doi: 10.111/aas.12651

• Feldman, L., Lee, L., & Fiore, J. (2015). What outcomes are important in the assessment of enhanced recovery after surgery (ERAS) pathways? Canadian Journal of Anesthesia 62 120‐130 doi: 10.1007/s12630‐014‐0263‐1

• Foss,M. & Bernard, H. (2013). Enhanced recovery after surgery: implications for nurses. British Journal of Nursing 21(4) 221‐223

References

• Gemmill, E., Humes, D., & Catton, J. (2015). Systematic review of enhanced recovery after gastro‐oesophageal cancer surgery. Annuals of Royal College of Surgeons England 97 173‐179 doi: 10.1308/003588414X14055925061630

• Gerritsen Arja, Wennink, R., Besselink, M., Santvoort, H., Tseng, D., Steenhagen, E., Rinkes, I., & Molenaar, I. (2013). Early oral feeding after pancreatoduodenectomy enhances recovery without increasing morbidity. HPB 16 656‐664 doi: 10.1111/hpb.12197

• Gustafsson, U., Scott, M., Schwenk, W., Demartines, N., Roulin, D., Francis, N., …Ljungqvist, O. (2013). Guidelines for perioperative care in the elective dolonic surgery: enhances recovery after surgery (ERAS) society recommendations. World Journal of Surgery 37 259‐284 doi: 10.1007/s00268‐012‐1772‐0

• Hain, D. & Kear, T. Using evidence‐based practice to move beyond doing things the way we have always done them. Nephrology Nursing Journal 42(1) 11‐21

• Hwang, s., Jung, M., Cho, B,m & Yu, H. (2014). Clinical feasibility and nutritional effects of early oral feeding after pancreaticoduodenectomy. Korean Journal of Hepato‐Biliary‐Pancreatic Surgery 18 84‐89 doi: 10.14701/kjhbps.2014.18.3.84

• Joliat, G., Labagaa, Peterman, D., Hubner, M., Griesser, A., Demartines, N., & Schafter, M. (2015). Cost‐benefit analysis of an enhances recovery protocol for pancreaticoduodenectomy. British Journal of Surgery 102(13)1673‐1683 doi:10.1002/bjs.9957

• Kapritsou, M., Korkolis, D., Giannakopoulou, M., Kaklamanos, I., Elefsiniotis, I., Mariolis‐Sapsakos, T., Birbas, K., & Konstantinou, E. ( 2014). Fast‐track recovery after major liver and pancreatic resection from the nursing point of view. Gasroenterology Nursing 37(30) 228‐233 doi: 10.1097/SGA.0000000000000049

References

70

71

72



• Lassen, K., Coolsen, M., Slim, K., Carli, F., de Aguilar‐Nascimento, J., Schafer, M., Parks, R., Fearon, K., Lobo, D., Demartines, N., Braga, M., Ljungqvist, O., Dejong, C. on behalf of the ERAS society, The European Society for Clinical Nutrition and Metabolism and the International Association for Surgical Metabolism and Nutrition. (2012). Guidelines in perioperative care for pancreaticoduodenectomy: enhances recovery after surgery (ERAS) society recommendations. Clinical Nutrition 31 817‐830 doi: 10.1016/j.clnu.2012.08.011

• Lassen, K., Coolsen, M., Slim, K., Carli, F., de Aguilar‐Nascimento, J., Schafer, M., Parks, R., Fearon, K., Lobo, D., Demartines, N., Braga, M., Ljungqvist, O., & Dejong, C. (2013). Guidelines for perioperative care for pancreaticoduodenectomy: enhanced recovery after surgery (ERAS) society recommendations. World Journal of Surgery 37 240‐258 doi: 10.1007/s00268‐012‐1771‐1

• Ljungqvist, O., Scott, M., & Fearon, K. (2017). Enhanced recovery after surgery a review. JAMA Surgery 152(3) 292‐298 doi: 10.1001/jamasurg.2016.4952

• Mahmoodzadeh, H., Shoar, S., Sirati, F., & Khorgami, Z. (2015). Early initiation of oral feeding following upper gastrointestinal tumor surgery: a randomized controlled trial. Surgery Today 45 203‐208 doi: 10.1007/s00595‐014‐0937‐x

• Lui, X., Wand, D., Zheng, L., Mou, T., Lui, H., & LE, G. (2014). Is early oral feeding after gastric cancer surgery feasible? A systematic review and meta‐analysis of randomized controlled trials. PLOS 14(9) e112062

• Meyer, L., Lasala, J., Iniesta, M., Nick, A., Munsell, M., Shi, Q., Wang, S., Cain, K., Lu, K., & Ramirez, P. (2018). Effect of an enhanced recovery after surgery program on opioid use and patient‐reported outcomes. Obstetrics & Gynecology 132(2) 281‐290

• Montgomery, R., & McNamara, S. (2016). Multimodal pain management for enhanced recovery: reinforcing the shift from traditional pathways through nurse‐led interventions. AORN Journal 104(65) s9‐s16 doi: 10.106/j.aorn.2016.10.012

• Moya, P., Soriano‐Irigaray, L., Ramirez, J., Garcea, A., Blaasco, O., Blanco, F., Brugiotti, C., Miranda, E., & Arroyo, A. (2016). Perioperative stand oral nutrition supplements versus immunonutrition in patients undergoing colorectal resection in an enhanced recovery (ERAS) protocol. Medicine 95(21) 1‐11 doi: 10.1097/MD.0000000000003704

References

• Nikfarjam, M., Weinberg, L., Low, N., Fink, M., Muralidharan, V., Houli, N., Starkey, G., Jones, R., & Christophi, C. (2013). A fast track recovery program significantly reduces hospital length of stay following uncomplicated pancreaticoduodenectomy. Journal of the Pancreas 14(1) 63‐70 doi: 10.6092/1590‐8577/1223

• Nussbaum, D., Penne, K., Stinnett, S,m Speicher, P., Cocieru, A., Blazer, D., Zani, S., Clary, B., Tyler, D., & White, R. (2015). A standardized care plan is associated with shorter hospital length of stay in patients undergoing pancreaticoduodenectomy. Journal of Surgical Research 195 237‐245 doi: 10.106/j.jss.2014.06.036

• Pearsall, E., Meghji, Z., Pitzul, K., Aarts. M., McKenzie, M., McLeod, R., & Okrainec, A. (2015). A qualitative study for understand the barriers and enabler in implementing an enhanced recovery after surgery program. Annals of Surgery 261(1) 92‐96 doi: 10.1097/SLA.0000000000000604

• Pedziwiatr, M., Kisialeuski, M., Wierdak, M., Stanek, M., Natkaniec, M., Matlok, M., Major, P., Maizak, P., & Budzyriski, A. (2015). Early implementation of enhanced recovery after surgery (ERAS) protocol‐compliance improves outcomes: a prospective cohort study. International Journal of Surgery 21 75‐81 doi: 10.1016/j.ijsu.2015.06.087

• Rohatiner, T., Wend, J., Rhodes, A., Murrell, Z., Berel, D., & Fleshner, P. (2012). A prospective single‐institution evaluation of current practices of early postoperative feeding after elective intestinal surgery. The American Surgeon 78 1147‐1150

• Teeuwen, P., Bieichrodt, R., Strik, C., Groenewoud, J., Brinkert, W., van Laarhoven, C., van Goor, H., & Bremers, A. (2010). Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery. Journal of Gastrointestinal Surgery 14 88‐95 doi: 10.1007/s11605‐009‐1037‐x

• Varadhan, K., Neal, K., Dejong, C., Fearon, K., Ljungqvist, O., & Lobo, D. (2010). The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta‐analysis of randomized controlled trials. Clinical Nutrition 29 434‐440 doi: 10.106/j.clnu.2010.01.004

• Wallstrom, A. & Frisman, C. (2013). Facilitating early recovery of bowel motility after colorectal surgery: a systematic review. Journal of Clinical Nursing 23 24‐44 doi: 10.1111/jocn.12258

• Yeung, S., Hilkewich, L., Gillis, C., Heine, J., & Fenton, T. (2017). Protein intakes are associated with reduced length of stay: a comparison between enhanced recovery after surgery (ERAS) and conventional care after elective colorectal surgery. American Journal of Clinical Nutrition 106 44‐51 doi: 10.3945/ajcn.116.148619

References

• References For Cytoreduction and HIPEC

• Ahmed, S. & Oropello, J. (2010). Critical care issues in oncological surgery patients. Critical Care Clinics 26 93‐106 doi: 10.1016/j.cc.2009.10.004

• Ahmed, S., Stewart, J., Shen, P., Votanopoulos, K., and Levine, E. (2014). Outcomes with cytoreductive surgery and HIPEC for peritoneal metastasis. Journal of Surgical Oncology 110 575‐584 doi: 10.1002/jso.23749

• Brucher, B., Piso, P., Verwaal, V., Esquivel, J., Derraco, M., Yonemura, Y., Gonzalez‐Moreno, S., Pelz, J., Konigsrainer, A., Strohlein, M., Levine, E., Morris, D,m Bartlett, D., Glehen, O., Garofaol, A., & Nissan, A. (2011). Peritoneal carcinomatosis: cytoreductive surgery and HIPEC‐overview and basics. Cancer Investigation 30 209‐224 doi: 10.3109/07357907.2012.654871

• Cianos, R,, LaFever, S., & Mills, N. (2013). Heated intraperitoneal chemotherapy in appendiceal cancer treatment. Clinical Journal of Oncology Nursing 17(1) 84‐88 doi: 10.1188/13.CJON.84‐87

• Dunn, D. ( 2010). Surgical treatment of patients with peritoneal surface malignancy. Journal of Wound Ostomy and Continence Nurses 37(4) 379‐385

• Dell, D., Held‐Warmkessel, J., Jakubek, P., & O’Mara, T. (2014). Care of the open abdomen after cytoreduction surgery and hyperthermic intraperitoneal chemotherapy for peritoneal surface malignancies. Oncology Nursing Forum 41(4) 438‐441 doi: 10.1188/14.ONE.438‐441

• Elias, D., Marianai, A., Cloutier, A., Blot, F., Goere, D., Dumont, F., Honore, C., Billiar, V., Dartigues, P., & Decreux, M. (2014). Modified selection critieria for complete cytoreductive surgery plus HIPEC based on peritoneal cancer index and small bowel involvement for peritoneal carcinomatosis of colorectal origin. European Journal of Surgical Oncology 40 1467‐1473 doi: 10.1016./j.ejso.2014.06.006

• Giri, S., Shah, S., Modi, K., Rajappa, S., Shukla, H., Shrestha, E., Jain, V., Sekhon, R., & Rawal, S. (2017). Factors affecting perioperative outcomes after crs and HIPEC for advanced and recurrent ovarian cancer: a prospective single institutional study. Journal of Gynecologic Surgery 33(1) 4‐11 doi: 10.1089/gyn.2016.0077

References

73

74

75



References• Huo, Y., Richards, A., Liauw, W., & Morris, D. (2015). Hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive

surgery (CRS) in ovarian cancer: a systematic review and meta‐analysis. European Journal of Surgical Oncology 41 1578‐1589 doi: 10.1016/j.ejso.2015.08.172

• Lansom, J., Alzahrani, N., Liauw, W., & Morris, D. (2016). Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei and appendix tumours. Indian Journal of Surgical Oncololgy 7(2) 166‐176 doi: 10.1007/s13193‐015‐0478‐9

• Loggie, B. & Thomas, P. ( 2015). Gastrointestinal cancers with peritoneal carcinomatosis: surgery and hyperthermic intraperitoneal chemotherapy. Oncology 29(7) 515‐521

• McRee, A. & O’Neil, B. ( 2015). The role of HIPEC in gastrointestinal malignancies: controversies and conclusions. Oncology 29(7) 523‐4

• Morano, W., Khalili, M., Chi, D., Bowne, W., Esquivel, J. (2017). Clinical studies in crc and HIPEC: trials, tribulations, and future directions‐a systematic review. Journal of Surgical Oncology 117 245‐259 doi: 10.1002/jso.24813

• Neuwirth, M., Alexander, H., & Karakousis, G. (2016). Then and now: cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), a historical perspective. Journal of Gastrointestinal Oncology 7(1) 18‐28 doi: 10.3978/j.issn.2078‐6891.2015.106

• Seshadri, R. & Glehen, O. (2016). Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in gastric cancer. World Journal of Gastroenterology 33(3) 1114‐1130 doi: 10.3748/wjg.v22.i3.1114

• Simkens, G., Rovers, K., van Oudheusden, T., Nienhuijs, S., Rutten, H., & Hingh, I. (2018). Major influence of postoperative complications on costs of cytoreductive surgery and HIPEC in patients with colorectal peritoneal metastases. Medicine 97(10) 1‐5 doi: 10.1097/MD.0000000000010042

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