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Peritoneal Surface Malignancies

E352: Implementation of a multidisciplinary Enhanced Recovery After Surgery program for Cytoreductive Surgery (CRS) with Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Introduction: Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) has been associated with high morbidity and prolonged hospital stay. We designed and implemented a novel Enhanced Recovery After Surgery (ERAS) program at our center based on ERAS Society guidelines and aimed to assess its impact on clinical outcomes.

Methods: A retrospective cohort study of patients who underwent CRS/HIPEC from January 1, 2018, to October 31, 2022, with ERAS implementation on July 1, 2022. The primary outcome was ERAS compliance, and secondary outcomes included length of stay (LOS), post-operative morbidity and mortality, and 30-day readmission rate. Statistical analysis included significance testing using t-test, Mann Whitney U test, chi-square, and Fisher exact. Patient characteristics were controlled for using binomial regression and logistic regression. Ethics approval was obtained from the regional Health Research Ethics Board.

Results: Eighty patients underwent CRS/HIPEC: 59 in the Historical Group, and 21 in the ERAS Group. In comparing the Historical and ERAS groups respectively, the mean (SD) ages were 55.7 (13.2) years and 53.3 (13.1) years, the majority were female, with 60% and 52% being ASA class III. The mean (SD) Peritoneal Carcinomatosis Index (PCI) was 14.4 (11.1) in the Historical Group and 10.6 (9.9) in the ERAS Group. On average, the percentage compliance to ERAS increased from 26.5% in the Historical Group to 51.5% in the ERAS group (p< 0.001).  The mean (SD) LOS decreased from 19 days (16) in the Historical Group to 10 days (5) in the ERAS Group (p< 0.001). In comparing the Historical and ERAS groups respectively, there was no significant difference in the major morbidity rate (13.6% vs 9.5%) or 30-day readmission rate (9.4% vs 4.8%). There were no deaths in either group within 90 days of surgery.

With adjustment for patient characteristics, the mean LOS decreased in the ERAS group by 6.32 days (95% CI, -9.33,-3.32, p< 0.001) with no significant differences in major morbidity or 30-day readmission.

Conclusions: Implementation of an ERAS CRS/HIPEC program is safe with no increased major morbidity or mortality, with associated improvement in outcomes including significantly increased compliance to ERAS protocols and a decrease in LOS. Compliance to protocols is necessary to see positive outcomes and should be regularly audited.

Learning Objectives:

  • Upon completion, participant will be able to list the key elements of a multidisciplinary Enhanced Recovery After Surgery (ERAS) program for Cytoreduction with Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC).
  • Upon completion, participant will be able to describe the clinical outcomes associated with the implementation of an ERAS program designed for patients undergoing CRS/HIPEC.
  • Upon completion, participant will be able to describe the importance of compliance to ERAS protocols to achieve positive clinical outcomes.