Enhanced recovery for cytoreductive surgery and hyperthermic intraperitoneal Chemotherapy: An international survey to assess acceptance and feasibility

Abstract

Background: Enhanced Recovery After Surgery (ERAS) protocols have markedly improved outcomes after colorectal and other major surgery, suggesting benefits also for complex surgeries like Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC). This study investigates the adoption and acceptance of the recent ERAS recommendations for CRS-HIPEC within expert centers.

Methods: Clinicians from 16 expert centers across 9 countries were invited to answer an online survey inquiring about current clinical practice. Adoption of the 72 ERAS items from the recent dedicated guidelines were evaluated using a Likert-type scale with focus on preoperative, perioperative, and postoperative phases.

Results: Overall, 27 clinicians (11 female, 21 surgeons, 2 gynecologists and 4 anesthesiologists/intensivists) participated, with high adoption of ERAS protocols at baseline (67 %). More than half of the guideline items (54 %) were widely adopted. However, despite nearly 18 % intending to change their practices, there remains substantial resistance to further adoption, such as for measures like alcohol cessation programs, mechanical bowel preparation, and oral antibiotic decontamination. Barriers identified include resource limitations(20 %), perceived irrelevance (17 %) for specific patient groups, unclear benefits (59 %), and restrictive policies (5 %).

Conclusion: The study shows that most ERAS principles are routinely implemented in CRS-HIPEC surgeries, despite significant challenges with specific components and complex processes. Future research will focus on generating additional evidence and streamlining ERAS guidelines to prioritize essential elements.

Keywords: Cytoreductive surgery (CRS); Enhanced recovery after surgery (ERAS); Hyperthermic intraperitoneal chemotherapy (HIPEC); Perioperative care; Survey.