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Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: A single institution experience
The American Journal of Surgery xxx (xxxx) xxx
Contents lists available at ScienceDirect
The American Journal of Surgery journal homepage: www.americanjournalofsurgery.com
Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: A single institution experience Ragavan Siddharthan*, Elizabeth Dewey, Kevin Billingsley, Erin Gilbert, Vassiliki Liana Tsikitis Oregon Health and Science Universtiy, Department of Surgery, United States
a r t i c l e i n f o
a b s t r a c t
Article history: Received 28 April 2019 Received in revised form 16 June 2019 Accepted 19 June 2019
Background: Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is reported to have a prolonged length of stay (LOS). We incorporated an enhanced recovery after surgery (ERAS) protocol to examine whether we could reduce our LOS. Methods: Patients were identified who underwent CRS/HIPEC from 2015 to 2018 before and after initiation of ERAS protocol. The protocol included pre-operative, peri-operative and post-operative interventions. Primary end point was LOS. Secondary endpoints were morbidity and mortality. Results: Forty patients were identified, thirty-one of which underwent CRS/HIPEC: 16 before and 15 after ERAS. The median LOS prior to ERAS was 11 days (5e20) and 7 days (5e27) after ERAS (P < 0.05). There was no significant difference in 30-day morbidity (Clavien-Dindo 3) or mortality between the groups. Conclusions: An ERAS protocol can safely be implemented in patients undergoing CRS/HIPEC with earlier return of bowel function and decrease in LOS without increasing morbidity or mortality. © 2019 Elsevier Inc. All rights reserved.
Keywords: CRS HIPEC ERAS
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are the mainstay of treatment for appendiceal mucinous neoplasms and pseudomyxoma peritonei.1 Together, these treatment modalities are important aspects of the therapeutic options provided to the patients diagnosed with tumors arising from the appendix, colon, rectum, mesothelium, and ovary2. CRS is performed with the goal to remove all visible macroscopic disease and/or to debulk to a level of minimal residual disease. The addition of HIPEC is based on the theoretical benefit that it will treat any residual microscopic disease. Usually used in combination, recent data from a large clinical trial in France demonstrates some survival benefit of CRS without HIPEC for the treatment of colorectal carcinomatosis.3 Despite the benefits of the CRS/HIPEC procedure, significant morbidities and mortalities have been reported, due to the extent of surgery and the addition of chemotherapy, which is a potential deteriment to wound healing. The result of this is a high incidence of post-operative ileus with associated prolonged length of stay (LOS).4
* Corresponding author. Oregon Health and Science University, Department of Surgery, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, United States. E-mail address: [email protected] (R. Siddharthan).
Enhanced recovery after surgery (ERAS) protocols are a multimodal, evidence-based approach to patient care that have become the standard of care for a variety of gastrointestinal surgeries. ERAS protocols promote goal-directed therapies throughout the preoperative, operative, and post-operative phases of care. In particular, early mobilization and feeding have allowed patients to start tolerating a diet earlier without adverse outcomes. ERAS protocols were initially implemented in the 1990s, and their success can be seen with the improvement in quality of patient care, leading to decreased LOS, morbity, cost and better resource utilization.5 At our hospital, after establishing a CRS/HIPEC program, we incorporated an ERAS protocol to examine if we could decrease LOS without increasing morbidity and mortality in CRS/HIPEC patients. A retrospective review was performed on patients taken for CRS/HIPEC from 2015 to 2018 at our single institution after institutional review board approval. All patients were evaluated in the clinic by one of the primary surgeons, and discussion was held at our formal multi-displinary tumor board prior to indication for surgery. Prior to CRS, the primary surgeon evaluated peritoneal carcinoma index (PCI). If the PCI was deemed too high, or another reason was indicated, HIPEC was deferred. The intraoperative chemotherapy used was mitomycin C over 90 min at a target
https://doi.org/10.1016/j.amjsurg.2019.06.019 0002-9610/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Siddharthan R et al., Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: A single institution experience, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.06.019
2
R. Siddharthan et al. / The American Journal of Surgery xxx (xxxx) xxx
Table 1 Eras protocol. Preoperative
Intraoperative
Postoperative
Prehabilitation High protein diet for 30 days Carbohydrate loading Mechanical bowel preparation with antibiotics
Epidural Placement Goal directed fluid resuscitation Limit intravenous narcotics
Removal of nasogastric tube on postoperative day 1 Removal of Foley catheter on postoperative day 2 Diet on postoperative day 1 Early mobilization Multimodal pain control Alvimopan
temperature of 41 C (40 or 30 mg, dependent on patient BMI). The ERAS protocol was initiated in 2017, and patients were grouped into before and after protocol initiation. The protocol included prehabiliation with physical therapy, high protein diet for 30 days, carbohydrate loading the day before the operation, mechanical bowel preparation, peri-operative epidural placement, alvimopan (Entereg®) administration, intraoperative goal-directed fluid adminstration, and avoidance of drains. Post-operatively, the nasogastric tube (if present) was removed on post-operative day (POD) one, a clear liquid diet was started, patients were mobilized with physical therapy and Foley catheter was removed on POD 2 (Table 1). After implementation of the protocol, compliance of the measurable components of the protocol were assessed. Primary endpoints were day of return of bowel function and LOS. Secondary endpoints included morbidity and mortality. Nonparametric statistical testing was performed, and statistical significance was set at p < 0.05. Forty patients were identified, 31 of which underwent CRS/ HIPEC: 16 before and 15 after ERAS. The median age was 57 years (19e73). The patients that did not undergo CRS/HIPEC had either extensive tumor burden or no evidence of carcinomatosis. The median peritoneal cancer index (PCI) of patients who underwent CRS/HIPEC was four (0e26). Eighteen patients had low-grade appendiceal neoplasm (LAMN), fourteen had mucinous adenocarcinoma, and eight had colorectal adenocarcinoma (CRC). When evaluating the implementation of our ERAS protocol, the median LOS prior to ERAS protocol was 11 days (5e20), and seven days (5e27) after ERAS protocol (P < 0.05). The median time to return of bowel function was 5.5 days (4e8) prior to ERAS protocol, and four days (3e10) after ERAS protocol (P < 0.05). The 30-day morbidity (Clavien-Dindo 3) for patients prior to ERAS protocol was 25% compared to 20% (P ¼ 0.74) after ERAS protocol. The inhospital and 30-day mortality was zero for both groups. There was no statistical difference between the PCI prior to ERAS protocol at six (0e18), compared to three (0e26) after protocol (P ¼ 0.401, Table 2). Compliance with the ERAS protocol varied by component and often due to patient preference or clinical status. For the measurable components, compliance was as follows: bowel preparation 100%, epidural placement 66.7%, alvimopan administration 93.3%, goal-directed fluid resuscitation 73.3%, diet initiation on POD 1 53.3%, mobilization with ambulation 86.7%, multimodal pain control 100%, and foley removal on POD 2 73.3%. Despite the well-documented benefits of ERAS protocols in a
wide range of abdominal surgeries,6 many have been hesitant to use these protocols in CRS/HIPEC, due to surgeon's concerns of significant morbidity. Our results show that an ERAS protocol can be safely implemented with earlier return of bowel function and corresponding decrease in LOS without increasing morbidity or mortality. The benefits of the ERAS protocol were seen across patients independent of operative time, age, or PCI. To our knowledge, no other studies have examined implementation of an ERAS protocol in CRS/HIPEC patients. The literature reports a wide range of LOS for CRS/HIPEC patients from 13 to 29 days.7,8 This LOS is substantially higher than our median of seven days in the ERAS protocol group. The success of the ERAS program after CRS/HIPEC procedures in our institution is multifactorial. First, there was considerable involvement of the operating surgeons in the protocol's development, dissemination, and implementation. After its development, the primary operating surgeons continued with educational multidisplinary meetings addressed to all providers involved in the care of these patients (anesthesiologists, pharmacists, nurses, and dieticians) prior to the program's execution. Second, a standardized electronic health record (EHR) order set was developed that nursing staff and house officers could follow. The ERAS protocol has been welcomed as a safe intervention with known benefits. It is a bundled regimen of prehabilition efforts, intraoperative interventions, and postoperative surgical management. At this juncture, it is difficult to delineate which of its features play the most significant role in the reduction of LOS. A key component to the success of implementation of this program was that all of the patients who undergo this procedure are cared for on specialty surgical oncology floors, where physicians and staff have a strong familiarity of priorly implemented colorectal ERAS protocols. The direct involvement from the primary surgeons to the house staff and the nursing teams has allowed for adaptability and continued education to all care givers involved during the patients' hospital stay. Despite all the above efforts, lack of complicance to all the parts of the protocol still occurred. The primary reason for the lack of compliance was a change in the clinical status of a particular patient that prevented advancement of care. Even without 100% compliance across all components, the ERAS protocol implementation contributed to a decreased LOS. Limitations of this study include the limited number of patients examined and a lack of the generizability of the results, since the procedure is performed at a single institution. This point is
Table 2 Results before and after implementation of ERAS protocol for CRS/HIPEC patients: Data reported as medians and range as appropriate. Non-parametric testing was performed to determine significance.
Number of patients Age Operation length Peritoneal Carcinoma Index (PCI) Return of bowel function Length of stay (LOS) Complication (Clavien Dindo 3)
Before ERAS
After ERAS
16 57 (31e72) years 452 (278e780) min 6 (0e18) 5.5 (4e8) days 11 (5e20) days 25%
15 60 (36e73) years 418 (270e590) min 3 (0e26) 4 (3e10) days 7 (5e27) days 20%
NS NS NS P < 0.05 P < 0.05 NS
Please cite this article as: Siddharthan R et al., Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: A single institution experience, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.06.019
R. Siddharthan et al. / The American Journal of Surgery xxx (xxxx) xxx
endorsed by the fact that despite the many benefits of ERAS protocols, they have not been universally adapted. Barriers to implementation include lack of standardization and lack of resources. For implementation to be successful, we have shown that coordination between multiple caregivers, including surgeons, anethesiolgists, nurses, physical therapists, pharmacists, dieticians, and social workers is required. Standardization of the protocol recorded in the EHR, starting at the pre-operative evaluation visit, continuing to the operating room, and then to surgical floor is a key factor for success. These logistics are often difficult and require significant buy-in from multiple teams. In conclusion, this study provides feasibility for the implementation of an ERAS protocol in patients undergoing CRS/HIPEC with improvement in LOS, but no increase in morbitiy or mortality. We hope we can initiate future multi-institutional efforts implementing ERAS after CRS/HIPEC that would allow for validation of these results. Conflicts of interest There are no conflicts of interest and no grant funding was used for this study. Disclosures The authors have nothing to disclose.
3
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.amjsurg.2019.06.019.
References 1. Choudry HA, Pai RK. Management of mucinous appendiceal tumors. Ann Surg Oncol. 2018;25(8):2135e2144. 2. Foster JM, et al. Morbidity and mortality rates following cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy compared with other high-risk surgical oncology procedures. JAMA Netw Open. 2019;2(1), e186847. 3. Quenet F, et al. A UNICANCER phase III trial of hyperthermic intra-peritoneal chemotherapy (HIPEC) for colorectal peritoneal carcinomatosis (PC): PRODIGE 7. J Clin Oncol. 2018;36(18_suppl). LBA3503-LBA3503. 4. Kapoor S, et al. Critical care management and intensive care unit outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. World J Crit Care Med. 2017;6(2):116e123. 5. Gotlib Conn L, et al. Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions' experiences. Implement Sci. 2015;10(1):99. 6. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292e298. 7. Cooksley TJ, Haji-Michael P. Post-operative critical care management of patients undergoing cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC). World J Surg Oncol. 2011;9:169. 8. Yan TD, et al. Cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei from appendiceal mucinous neoplasms. Br J Surg. 2006;93(10):1270e1276.
Please cite this article as: Siddharthan R et al., Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: A single institution experience, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.06.019
Contents lists available at ScienceDirect
The American Journal of Surgery journal homepage: www.americanjournalofsurgery.com
Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: A single institution experience Ragavan Siddharthan*, Elizabeth Dewey, Kevin Billingsley, Erin Gilbert, Vassiliki Liana Tsikitis Oregon Health and Science Universtiy, Department of Surgery, United States
a r t i c l e i n f o
a b s t r a c t
Article history: Received 28 April 2019 Received in revised form 16 June 2019 Accepted 19 June 2019
Background: Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is reported to have a prolonged length of stay (LOS). We incorporated an enhanced recovery after surgery (ERAS) protocol to examine whether we could reduce our LOS. Methods: Patients were identified who underwent CRS/HIPEC from 2015 to 2018 before and after initiation of ERAS protocol. The protocol included pre-operative, peri-operative and post-operative interventions. Primary end point was LOS. Secondary endpoints were morbidity and mortality. Results: Forty patients were identified, thirty-one of which underwent CRS/HIPEC: 16 before and 15 after ERAS. The median LOS prior to ERAS was 11 days (5e20) and 7 days (5e27) after ERAS (P < 0.05). There was no significant difference in 30-day morbidity (Clavien-Dindo 3) or mortality between the groups. Conclusions: An ERAS protocol can safely be implemented in patients undergoing CRS/HIPEC with earlier return of bowel function and decrease in LOS without increasing morbidity or mortality. © 2019 Elsevier Inc. All rights reserved.
Keywords: CRS HIPEC ERAS
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are the mainstay of treatment for appendiceal mucinous neoplasms and pseudomyxoma peritonei.1 Together, these treatment modalities are important aspects of the therapeutic options provided to the patients diagnosed with tumors arising from the appendix, colon, rectum, mesothelium, and ovary2. CRS is performed with the goal to remove all visible macroscopic disease and/or to debulk to a level of minimal residual disease. The addition of HIPEC is based on the theoretical benefit that it will treat any residual microscopic disease. Usually used in combination, recent data from a large clinical trial in France demonstrates some survival benefit of CRS without HIPEC for the treatment of colorectal carcinomatosis.3 Despite the benefits of the CRS/HIPEC procedure, significant morbidities and mortalities have been reported, due to the extent of surgery and the addition of chemotherapy, which is a potential deteriment to wound healing. The result of this is a high incidence of post-operative ileus with associated prolonged length of stay (LOS).4
* Corresponding author. Oregon Health and Science University, Department of Surgery, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, United States. E-mail address: [email protected] (R. Siddharthan).
Enhanced recovery after surgery (ERAS) protocols are a multimodal, evidence-based approach to patient care that have become the standard of care for a variety of gastrointestinal surgeries. ERAS protocols promote goal-directed therapies throughout the preoperative, operative, and post-operative phases of care. In particular, early mobilization and feeding have allowed patients to start tolerating a diet earlier without adverse outcomes. ERAS protocols were initially implemented in the 1990s, and their success can be seen with the improvement in quality of patient care, leading to decreased LOS, morbity, cost and better resource utilization.5 At our hospital, after establishing a CRS/HIPEC program, we incorporated an ERAS protocol to examine if we could decrease LOS without increasing morbidity and mortality in CRS/HIPEC patients. A retrospective review was performed on patients taken for CRS/HIPEC from 2015 to 2018 at our single institution after institutional review board approval. All patients were evaluated in the clinic by one of the primary surgeons, and discussion was held at our formal multi-displinary tumor board prior to indication for surgery. Prior to CRS, the primary surgeon evaluated peritoneal carcinoma index (PCI). If the PCI was deemed too high, or another reason was indicated, HIPEC was deferred. The intraoperative chemotherapy used was mitomycin C over 90 min at a target
https://doi.org/10.1016/j.amjsurg.2019.06.019 0002-9610/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: Siddharthan R et al., Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: A single institution experience, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.06.019
2
R. Siddharthan et al. / The American Journal of Surgery xxx (xxxx) xxx
Table 1 Eras protocol. Preoperative
Intraoperative
Postoperative
Prehabilitation High protein diet for 30 days Carbohydrate loading Mechanical bowel preparation with antibiotics
Epidural Placement Goal directed fluid resuscitation Limit intravenous narcotics
Removal of nasogastric tube on postoperative day 1 Removal of Foley catheter on postoperative day 2 Diet on postoperative day 1 Early mobilization Multimodal pain control Alvimopan
temperature of 41 C (40 or 30 mg, dependent on patient BMI). The ERAS protocol was initiated in 2017, and patients were grouped into before and after protocol initiation. The protocol included prehabiliation with physical therapy, high protein diet for 30 days, carbohydrate loading the day before the operation, mechanical bowel preparation, peri-operative epidural placement, alvimopan (Entereg®) administration, intraoperative goal-directed fluid adminstration, and avoidance of drains. Post-operatively, the nasogastric tube (if present) was removed on post-operative day (POD) one, a clear liquid diet was started, patients were mobilized with physical therapy and Foley catheter was removed on POD 2 (Table 1). After implementation of the protocol, compliance of the measurable components of the protocol were assessed. Primary endpoints were day of return of bowel function and LOS. Secondary endpoints included morbidity and mortality. Nonparametric statistical testing was performed, and statistical significance was set at p < 0.05. Forty patients were identified, 31 of which underwent CRS/ HIPEC: 16 before and 15 after ERAS. The median age was 57 years (19e73). The patients that did not undergo CRS/HIPEC had either extensive tumor burden or no evidence of carcinomatosis. The median peritoneal cancer index (PCI) of patients who underwent CRS/HIPEC was four (0e26). Eighteen patients had low-grade appendiceal neoplasm (LAMN), fourteen had mucinous adenocarcinoma, and eight had colorectal adenocarcinoma (CRC). When evaluating the implementation of our ERAS protocol, the median LOS prior to ERAS protocol was 11 days (5e20), and seven days (5e27) after ERAS protocol (P < 0.05). The median time to return of bowel function was 5.5 days (4e8) prior to ERAS protocol, and four days (3e10) after ERAS protocol (P < 0.05). The 30-day morbidity (Clavien-Dindo 3) for patients prior to ERAS protocol was 25% compared to 20% (P ¼ 0.74) after ERAS protocol. The inhospital and 30-day mortality was zero for both groups. There was no statistical difference between the PCI prior to ERAS protocol at six (0e18), compared to three (0e26) after protocol (P ¼ 0.401, Table 2). Compliance with the ERAS protocol varied by component and often due to patient preference or clinical status. For the measurable components, compliance was as follows: bowel preparation 100%, epidural placement 66.7%, alvimopan administration 93.3%, goal-directed fluid resuscitation 73.3%, diet initiation on POD 1 53.3%, mobilization with ambulation 86.7%, multimodal pain control 100%, and foley removal on POD 2 73.3%. Despite the well-documented benefits of ERAS protocols in a
wide range of abdominal surgeries,6 many have been hesitant to use these protocols in CRS/HIPEC, due to surgeon's concerns of significant morbidity. Our results show that an ERAS protocol can be safely implemented with earlier return of bowel function and corresponding decrease in LOS without increasing morbidity or mortality. The benefits of the ERAS protocol were seen across patients independent of operative time, age, or PCI. To our knowledge, no other studies have examined implementation of an ERAS protocol in CRS/HIPEC patients. The literature reports a wide range of LOS for CRS/HIPEC patients from 13 to 29 days.7,8 This LOS is substantially higher than our median of seven days in the ERAS protocol group. The success of the ERAS program after CRS/HIPEC procedures in our institution is multifactorial. First, there was considerable involvement of the operating surgeons in the protocol's development, dissemination, and implementation. After its development, the primary operating surgeons continued with educational multidisplinary meetings addressed to all providers involved in the care of these patients (anesthesiologists, pharmacists, nurses, and dieticians) prior to the program's execution. Second, a standardized electronic health record (EHR) order set was developed that nursing staff and house officers could follow. The ERAS protocol has been welcomed as a safe intervention with known benefits. It is a bundled regimen of prehabilition efforts, intraoperative interventions, and postoperative surgical management. At this juncture, it is difficult to delineate which of its features play the most significant role in the reduction of LOS. A key component to the success of implementation of this program was that all of the patients who undergo this procedure are cared for on specialty surgical oncology floors, where physicians and staff have a strong familiarity of priorly implemented colorectal ERAS protocols. The direct involvement from the primary surgeons to the house staff and the nursing teams has allowed for adaptability and continued education to all care givers involved during the patients' hospital stay. Despite all the above efforts, lack of complicance to all the parts of the protocol still occurred. The primary reason for the lack of compliance was a change in the clinical status of a particular patient that prevented advancement of care. Even without 100% compliance across all components, the ERAS protocol implementation contributed to a decreased LOS. Limitations of this study include the limited number of patients examined and a lack of the generizability of the results, since the procedure is performed at a single institution. This point is
Table 2 Results before and after implementation of ERAS protocol for CRS/HIPEC patients: Data reported as medians and range as appropriate. Non-parametric testing was performed to determine significance.
Number of patients Age Operation length Peritoneal Carcinoma Index (PCI) Return of bowel function Length of stay (LOS) Complication (Clavien Dindo 3)
Before ERAS
After ERAS
16 57 (31e72) years 452 (278e780) min 6 (0e18) 5.5 (4e8) days 11 (5e20) days 25%
15 60 (36e73) years 418 (270e590) min 3 (0e26) 4 (3e10) days 7 (5e27) days 20%
NS NS NS P < 0.05 P < 0.05 NS
Please cite this article as: Siddharthan R et al., Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: A single institution experience, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.06.019
R. Siddharthan et al. / The American Journal of Surgery xxx (xxxx) xxx
endorsed by the fact that despite the many benefits of ERAS protocols, they have not been universally adapted. Barriers to implementation include lack of standardization and lack of resources. For implementation to be successful, we have shown that coordination between multiple caregivers, including surgeons, anethesiolgists, nurses, physical therapists, pharmacists, dieticians, and social workers is required. Standardization of the protocol recorded in the EHR, starting at the pre-operative evaluation visit, continuing to the operating room, and then to surgical floor is a key factor for success. These logistics are often difficult and require significant buy-in from multiple teams. In conclusion, this study provides feasibility for the implementation of an ERAS protocol in patients undergoing CRS/HIPEC with improvement in LOS, but no increase in morbitiy or mortality. We hope we can initiate future multi-institutional efforts implementing ERAS after CRS/HIPEC that would allow for validation of these results. Conflicts of interest There are no conflicts of interest and no grant funding was used for this study. Disclosures The authors have nothing to disclose.
3
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.amjsurg.2019.06.019.
References 1. Choudry HA, Pai RK. Management of mucinous appendiceal tumors. Ann Surg Oncol. 2018;25(8):2135e2144. 2. Foster JM, et al. Morbidity and mortality rates following cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy compared with other high-risk surgical oncology procedures. JAMA Netw Open. 2019;2(1), e186847. 3. Quenet F, et al. A UNICANCER phase III trial of hyperthermic intra-peritoneal chemotherapy (HIPEC) for colorectal peritoneal carcinomatosis (PC): PRODIGE 7. J Clin Oncol. 2018;36(18_suppl). LBA3503-LBA3503. 4. Kapoor S, et al. Critical care management and intensive care unit outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. World J Crit Care Med. 2017;6(2):116e123. 5. Gotlib Conn L, et al. Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions' experiences. Implement Sci. 2015;10(1):99. 6. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292e298. 7. Cooksley TJ, Haji-Michael P. Post-operative critical care management of patients undergoing cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC). World J Surg Oncol. 2011;9:169. 8. Yan TD, et al. Cytoreductive surgery and perioperative intraperitoneal chemotherapy for pseudomyxoma peritonei from appendiceal mucinous neoplasms. Br J Surg. 2006;93(10):1270e1276.
Please cite this article as: Siddharthan R et al., Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: A single institution experience, The American Journal of Surgery, https:// doi.org/10.1016/j.amjsurg.2019.06.019