Perioperative Care in Cytoreductive Surgery Clinical Practice Guidelines (ERAS,2020)

Enhanced Recovery after Surgery Society (ERAS)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

September 02, 2020

In August 2020, the Enhanced Recovery After Surgery Society (ERAS) published clinical practice guidelines on perioperative care in cytoreductive surgery (for peritoneal malignancy).[1]

Cytoreductive surgery with or without the addition of hyperthermic intraperitoneal chemotherapy (CRS ± HIPEC) has become a treatment standard for peritoneal surface malignancies.

These extended procedures may cause excessive tissue trauma with subsequent inflammation that ultimately lead to potentially life-threatening side effects. Major complication rates have been reported to be as high as 51%.

Advanced resuscitation and dedicated care protocols are warranted. Early reversal of this pathophysiologic cascade by improvements of perioperative care forms the basis of ERAS interventions.

Prophylactic nasogastric drainage for CRS ± HIPEC, in the absence of risk factors for delayed gastric emptying (resection of lesser omentum), should not be done because nasogastric decompression has been associated with undesired effects of delayed resumption of gastrointestinal motility and increased postoperative complications.

Removal of a urinary catheter as early as the morning of postoperative day 3 is recommended

Thoracic epidural analgesia (TEA: T5-11) containing local anesthetics and short-acting opiates for 72 hr after CRS ± HIPEC is recommended to prevent postoperative ileus.

Thoracic epidural analgesia (TEA: T5-11) containing local anesthetics and short-acting opiates for at least 72 hr after CRS ± HIPEC is recommended as an option to intravenous opiates for postoperative analgesia.

After TEA removal, analgesia with paracetamol (acetaminophen), NSAIDs, and opioids is recommended.

Early oral intake resumption after CRS ± HIPEC, aiming for clear liquids on the day of surgery and solid food from postoperative day 1, in the absence of risk factors for delayed gastric emptying (resection of lesser omentum), is recommended to improve mortality, anastomotic dehiscence, resumption of bowel function, and hospital length of stay.

Daily recording of nutritional intake after CRS ± HIPEC to identify patients with insufficient intake is recommended routinely.

Preemptive parenteral nutrition after CRS ± HIPEC (in addition to oral and/or enteral nutrition), for 7 postoperative days is recommended in selected patients (expected insufficient oral/enteral intake).

Monitoring of blood glucose in critically ill patients after CRS ± HIPEC and correction of glycemia using short-acting insulin to keep blood glucose levels at 140–180 mg/dL (7.8–10 mmol/L) are recommended routinely to reduce postoperative mortality.

Mechanical thromboprophylaxis (intermittent pneumatic compression) until complete mobilization in association with pharmacologic thromboprophylaxis as an option to pharmacologic thromboprophylaxis alone should be performed routinely.

Pharmacologic thromboprophylaxis (low molecular weight heparin, unfractionated heparin or fondaparinux) started 12 hr before CRS ± HIPEC should be performed routinely.

Extended pharmacologic thromboprophylaxis until 4 weeks after CRS ± HIPEC, as an option in addition to in-hospital thromboprophylaxis, should be performed routinely to reduce the risk of asymptomatic deep vein thrombosis (not pulmonary embolism).

Discontinuation of bevacizumab or other anti-angiogenic treatment should be done routinely at least 5 weeks before CRS ± HIPEC to reduce intraoperative bleeding complications.

Prophylactic positioning of ureteral stents in patients with a high probability of pelvic peritonectomy should not be done routinely to reduce the risk of ureteral complications.

Intraoperative loop diuretics and dopamine for renal protection should not be performed routinely in patients undergoing CRS and HIPEC.

Mobilization and physiotherapy as early as the day of surgery (out of bed) with goals of  >2 hr of physical exercises for postoperative day 2 and >6 hr thereafter should be performed routinely after CRS ± HIPEC to improve capacity to perform out-of-bed activities, facilitate resumption of gastrointestinal function, and decrease postoperative complications.

For more information, go to Peritoneal Cancer.

For more Clinical Practice Guidelines, go to Guidelines.

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