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Page 6 of 9 Ray et al. J Cancer Metastasis Treat 2020;6:9 I http://dx.doi.org/10.20517/2394-4722.2020.16

approximate volume of the peritoneal cavity in litres. Dosage was calculated at 50 mg of cisplatin per litre.
The chemotherapeutic solution was prepared by a resident doctor/specialized staff nurse using aseptic
technique and full body personal protective equipment in a separate room adjacent to the surgical suite.
The desired temperature from the inflow tube was kept in the range between 42 °C to 44 °C and out-flow
was maintained at 41 °C to 43 °C. Per the literature, microscopic as well as tumour deposits up to 2.5 mm
[5]
are destroyed by the synergistic effects of hyperthermia (42 °C) and chemotherapy . To achieve the desired
temperature in the abdominal cavity, the temperature in the heat exchanger of the machine was regularly
titrated depending on the recorded temperature. During combined HIPEC and HITAC for 60 min with
close intra-operative monitoring of core body temperature, hemostasis was ensured before starting. We
also constantly monitored the flow rate and nature of fluid content in the tubings. The inflow tube was
kept in the pelvis away from critical areas and the great vessels. The average perfusate volume was 2.30 L,
depending upon the capacity of the abdominal cavity. We used a triple-layered filtration mask, tightly fit to
the face. It was also desirable to have a surgical smoke evacuator work continuously under the plastic sheet
during perfusion and we used this in a number of cases. After completion of the procedure, the perfusate
was aspirated, hemostasis ensured, and lung expansion confirmed before closure of the pleural defect. We
did not perform peritoneal saline irrigation after completion of HITAC although some surgeons prefer
to do so after clearing out the chemotherapeutic solution at the end of the procedure. Ipsilateral single
intercostal drainage tube would then be placed. Two soft abdominal drains, one each in the sub-hepatic
region and pelvis, were routinely placed in all cases. Additionally, we also placed a suction drain in the
subcutaneous cavity after mobilizing the rectus sheath as mentioned earlier and this was removed on day 3
routinely unless drainage was more than 100 mL in the last 24 h.

Intraoperative monitoring
The role of the anesthesiologist is crucial during CRS with HITAC because of the extensive resection and
long duration of procedures. The addition of hyperthermia in HITAC presents further challenges for
the clinicians so a team approach is paramount. The main concern is related to the various physiological
changes that can occur during CRS with HITACe, where hyperthermia and the use of chemotherapeutic
agents concurrently may affect body systems. These concerns relate mainly to major fluid shifts, respiratory,
hemodynamic, renal, hepatic, hematological and metabolic changes along with electrolyte, fluid and
thermal imbalances. The maintenance of normal physiology remains the main goal. Ventilatory strategies
are also of a major concern, not only because of abdominal surgery but also from exposure of the thorax to
chemotherapy drugs and hence, the need for single lung ventilation.

Preoperative assessment and optimization are thus required for optimal outcomes. A thorough history and
examination is key and includes routine assessment along with evaluation of prior drug therapy including
chemotherapy, analgesics or drugs for associated comorbidities. Preoperative rehabilitation is also emerging
as an important management tool because of its various beneficial aspects in enhanced recovery after
surgery.

Appropriate monitoring is essential for patients undergoing CRS and HITAC. Apart from routine
conventional intra-operative monitoring (electrocardiogram, non-invasive blood pressure monitoring,
pulse oximeter, capnography, temperature), certain additional monitoring strategies are required for
such interventions. For airway management, the conventional endotracheal tube is used routinely with
oropharyngeal core body temperature probe monitoring. However, single lung ventilation is desirable
in cases of pleural deposit excision. Anesthesia induction is usually done using propofol, fentanyl and
atracurium and maintained with atracurium, fentanyl and inhalational agents like sevoflurane or desflurane
in oxygen and air mixture. Based on the extent of the abdominal mass and the patient’s clinical condition,
ventilator strategies may require further planning.