Hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment strategy for peritoneal metastases, offering improved oncological outcomes for select cancers. However, maintaining stable perfusion—defined by proper flow rate and target temperature—is critical for treatment efficacy. Perfusion instability (PI), characterized by the inability to sustain adequate flow without temperature compromise, is an underreported yet impactful complication. This study evaluates the incidence of PI in closed HIPEC procedures and assesses the effectiveness of a structured problem-solving approach in managing this issue.
The research involved a retrospective review of 208 HIPEC procedures performed between May 2018 and January 2023 at the Veneto Institute of Oncology. The study aimed to identify the frequency of PI and its impact on treatment efficacy. PI was defined as an outflow pressure failure preventing maintenance of target flow (≥1,100 ml/min) and temperature (41°C). To mitigate PI, a stepwise flowchart was developed, including checking drain positioning, ensuring proper muscle relaxation, modifying bed positioning, adjusting perfusion volume, and switching the drain flow switch. These interventions aimed to restore stable perfusion while minimizing the need for more invasive corrective actions.
Results indicated that PI occurred in 21 cases (10.1%). Patients experiencing PI had significantly lower mean outflow pressures and flow rates (p<0.001). However, despite these fluctuations, the target temperature was maintained throughout HIPEC. In cases where PI was detected, perfusion time was extended due to the time required to implement corrective steps. The median total perfusion time was longer in patients with PI (82 minutes) compared to those without (75 minutes, p=0.001). Notably, temporary cessation of perfusion was necessary in 16 patients, but only two cases required either conversion to an open technique or early HIPEC termination.
The study highlights that PI poses multiple risks, including suboptimal drug delivery, increased procedure duration, and potential tissue damage due to negative suction pressure. Additionally, conversion to an open procedure due to PI increases the risk of chemical contamination in the operating room, underscoring the importance of maintaining stability. While HIPEC is performed in a controlled environment, the complexity of intraperitoneal perfusion demands meticulous management to prevent these adverse events.
One major contributing factor to PI is an inadequate perfusion volume. Volume calculations are typically based on body surface area, but this may not accurately predict a patient’s intra-abdominal volume requirements. In six cases, adjustments to perfusion volume were required to restore stability, with an average addition of 400 ml of perfusate. Alternative methods, such as preoperative CT scan volumetry, could potentially improve volume prediction and minimize the risk of PI.
Another potential solution for improving flow stability is modifying patient positioning to encourage optimal fluid distribution around outflow catheters. In some cases, reversing the flow between inflow and outflow catheters helped resolve obstructions caused by tissue debris. These simple interventions effectively restored perfusion without requiring major modifications to the procedure.
The study concludes that while PI is a notable complication of HIPEC, it can be managed effectively with structured interventions. The problem-solving flowchart provided a standardized approach that significantly reduced the impact of PI, allowing most procedures to continue without major disruptions. However, further research is necessary to refine perfusion volume calculations and optimize catheter placement techniques. Additionally, developing new catheter and circuit designs could enhance stability and minimize the occurrence of PI in future HIPEC treatments.
This study is significant because it provides the first quantitative analysis of PI incidence in closed HIPEC and offers a practical solution for managing it. Given that CRS-HIPEC is a complex and resource-intensive procedure, optimizing perfusion parameters is essential for improving patient outcomes and procedural efficiency. Future investigations should explore alternative perfusion models and evaluate the long-term impact of PI on oncological outcomes.
Study Ranking: 4 (High-Quality Study) This study is a well-conducted retrospective analysis with a large sample size (208 cases). The methodology is robust, and the statistical analysis is comprehensive. However, as a retrospective study, it lacks the control and randomization of a prospective trial. Further validation in randomized controlled trials would strengthen its findings.
