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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00973-8
10.1016/j.ijscr.2024.110192
110192
Case Report
Abdominal compartment syndrome during intraoperative hyperthermic intraperitoneal chemotherapy following debulking surgery for colorectal cancer: A case report
Chiu Chen-Hsi a
Lu Cheng-Wei ab
Lin Tzu-Yu ab
Chen Pei-Fu femh96949@femh.org.tw
ac⁎
a Department of Anesthesiology, Far Eastern Memorial Hospital, New Taipei City 220, Taiwan
b Department of Mechanical Engineering, Yuan Ze University, Taoyuan 320, Taiwan
c Department of Electrical Engineering, Yuan Ze University, Taoyuan 320, Taiwan
⁎ Corresponding author at: No. 21, Section 2, Nanya S. Road, Banqiao District, New Taipei City 220, Taiwan. femh96949@femh.org.tw
03 9 2024
10 2024
03 9 2024
123 11019224 6 2024
13 8 2024
15 8 2024
© 2024 Published by Elsevier Ltd on behalf of IJS Publishing Group Limited.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction

Colorectal cancer leads to peritoneal metastasis in 8–15 % of cases and necessitates treatments, such as hyperthermic intraperitoneal chemotherapy (HIPEC). However, HIPEC may result in perioperative complications, some often overlooked, such as abdominal compartment syndrome.

Case presentation

A 52-year-old female with colorectal cancer and peritoneal metastasis underwent debulking surgery followed by HIPEC. During HIPEC, a sudden increase in airway pressure and severe hypotension were noted. Pneumothorax with abdominal compartment syndrome (ACS) was suspected and HIPEC was terminated. Despite intravenous fluids and vasopressors, she experienced circulatory and respiratory collapse. Laparotomy sutures were promptly removed, which effectively alleviated the intra-abdominal hypertension and immediately restored the vital signs. An inadequately repaired diaphragm defect was identified and repaired. A chest tube was inserted for pleural effusion.

Discussion

ACS is characterized by an increase in abdominal cavity pressure above 20 mmHg, leading to end-organ damage. It can mimic physiological effects of HIPEC and result in adverse outcomes. Early detection of ACS is essential, especially when complicated by pneumothorax from diaphragmatic tumor dissection. The closed technique for HIPEC, while efficient, can increase the risk of ACS and requires careful management.

Conclusions

This case underscores the complexity of HIPEC and the importance of promptly identifying and managing ACS during the procedure. Monitoring intra-abdominal pressure during HIPEC is essential. Thoroughly check for iatrogenic injuries, including the diaphragm, is crucial before starting before HIPEC.

Highlights

• ACS during HIPEC can mimic normal physiology, making early detection challenging.

• Timely intervention to release the intra-abdominal pressure is critical.

• Thoroughly check for iatrogenic injuries, including the diaphragm, before HIPEC

• Intra-abdominal pressure monitoring during HIPEC is crucial for ACS.

Keywords

Abdominal compartment syndrome
Colorectal neoplasms
Cytoreduction surgery
Hyperthermic intraperitoneal chemotherapy
Tension pneumothorax
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pmc1 Introduction

Colorectal neoplasms progress to peritoneal carcinomatosis in 8–15 % cases and include an unfavorable prognosis [1]. While there is no established optimal treatment for this terminal condition, cytoreductive surgery has the potential to prolong survival [2]. Additionally, intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as a promising treatment option because of the relatively low efficacy of systemic chemotherapy [3]. The median survival is significantly longer for cases receiving cytoreductive surgery with HIPEC compared to those without (34.7 months vs. 16.8 months) [3].

HIPEC involves administering heated cytotoxic chemotherapy that remains in the peritoneal cavity for 30 to 90 min [2], which provides better drug penetration into the peritoneal organs and improves the prognosis. However, HIPEC is associated with postoperative complications, such as metabolic acidosis, reintubation, pneumonia, intra-abdominal collection, reoperation, and readmission to the intensive care unit [4]. Despite these known complications, additional concerns including life-threatening tension pneumothorax and abdominal compartment syndrome (ACS) may arise as well. Herein, we present a case report of a patient who developed tension pneumothorax with ACS during HIPEC following debulking surgery. This is the first published case. This work has been reported in line with the SCARE criteria [5].

2 Case presentation

A 52-year-old female diagnosed with peritoneal carcinomatosis from colorectal cancer underwent a laparotomy under general anesthesia for debulking surgery, which including colon resection and salpingo-oophorectomy followed by HIPEC. Her chief complaints were abdominal distension and dyschezia for 2 weeks, accompanied by anorexia and general weakness. She had diabetes mellitus and hypertension, which were managed with oral medications. Two years prior, she was diagnosed with sigmoid colon cancer and underwent a lower anterior resection. Pathological analysis of the resected tissue revealed a T4aN2bM0 tumor, escalating the disease to IIIC. Following the surgery, she received 12 cycles of FOLFOX chemotherapy as adjuvant chemotherapy followed by 6 cycles of Avastin-FOLFIRI and 3 cycles of Erbitux-FOLFIRI as palliative chemotherapy. Preoperative electrocardiogram, complete blood count, and biochemical examination were within normal ranges, except for mild anemia (hemoglobin: 11.4 g/dL) and leukocytosis (11,740/μL).

Upon entering the operating theatre, her vital signs were: blood pressure 138/75 mmHg, heart rate 84 beats per minute (regular), pulse oximetry 97 %, and body temperature was 36.1 °C. Under general anesthesia, tracheal intubation was performed, and mechanical ventilation was started with a tidal volume of 400 mL. After positioning her supine, the surgery began. A large omentum cake with multiple invasions was identified, requiring tumor debulking, including bilateral salpingo-oophorectomy, subtotal colectomy with lower anterior resection, small bowel segmental resection, radical proctectomy with pelvic lymph node dissection, and excision of intra-abdominal tumor at small bowel, colon, mesentery, gastrocolic ligaments and bilateral peritoneum, lesser sac, subhepatic region, and diaphragm. The cytoreductive procedure spanned 9 h with approximately 3200 mL blood loss, necessitating 10 units of packed red blood cells (about 150 mL per unit), raising hemoglobin from 9.7 to 12 g/dL. An incidental lung injury and a missed diaphragm defect went unnoticed, leading to unawareness of potential pneumothorax when the patient began closed HIPEC.

Post-debulking surgery, HIPEC with Oxaliplatin was initiated using a closed technique [6]. While in a supine position, the tidal volume was set at 400 mL. Initial measurements included a peak airway pressure of 19 cmH2O, an EtCO2 of 33 mmHg, an SpO2 of 100 %, a blood pressure of 88/68 mmHg, and a body temperature of 36.9 °C. Within 15 min, the body temperature increased to 37.6 °C. The patient experienced a rise in airway pressure to 36 cmH2O and a significant drop in blood pressure to 55/46 mmHg. The tidal volume dropped to 163 mL, bilateral breath sounds diminished, and the EtCO2 climbed to 44 mmHg. We ventilated with 100 % oxygen. The abdomen became distended and tensed. Suspecting increased intra-abdominal pressure leading to obstructive shock, the HIPEC was terminated, and the solution started to be drained out.

Despite intravenous vasopressors and fluid administration, mean blood pressure persistently declined to levels below 50 mmHg coupled with a narrowing pulse pressure. Ventilatory efforts, both mechanically and through manual bag-valve-mask maneuvers, were ineffective, even with peak airway pressures reaching 40 cmH2O. Pulse oximetry readings were notably compromised, demonstrating a flattened waveform with absent saturation values. Given the acute circulatory and respiratory collapse, intravenous epinephrine was promptly administered to counteract the profound bradycardia and hypotension. Suspecting ACS superimposed on a tension pneumothorax, emergent release of the laparotomy sutures was undertaken. This resulted in the expulsion of the intraperitoneal chemotherapy solution, accompanied by a notable release of air. Subsequent to the alleviation of intra-abdominal pressure, ventilation normalized, and both pulse oximetry readings and hemodynamic parameters stabilized. On examination, there was an absence of subcutaneous emphysema over the thorax and neck regions.

Exploratory findings unveiled that a defect in the left diaphragm had not been adequately repaired, which was addressed promptly. Arterial blood gas analysis indicated the presence of metabolic acidosis, prompting the administration of sodium bicarbonate. Lactate levels were elevated immediately after the incident and exhibited a decline upon reassessment in the intensive care unit (Table 1). Subsequent to the irrigation and drainage of the cytotoxic solution, the abdomen was closed. The tidal volume stabilized between 395 and 410 mL, with an airway pressure at 19 cmH2O, EtCO2 at 36 mmHg, SpO2 at 100 %, blood pressure measuring 85/65 mmHg, and a body temperature of 36.5 °C. Given the stability in airway pressures and maintained tidal volumes, the initial decision, after deliberative discussions among the surgical team, was to abstain from chest tube placement. Instead, vigilant monitoring for signs of pneumothorax was instituted as the patient was transitioned to the intensive care unit. Nevertheless, a routine post-operation plain film revealed extensive subcutaneous emphysema and a left pleural effusion when juxtaposed against the preoperative film (Fig. 1A and B). A chest tube was inserted to address the pleural effusion on postoperative day 1 (Fig. 1C).Table 1 Serial arterial blood gas (post-induction, pre-event, post-event, and in the intensive care unit).

Table 1	Post-induction	Pre-event	Post-event	ICU	
FiO2	60 %	60 %	100 %	40 %	
pH	7.47	7.42	7.23	7.49	
pO2	212.5	214.4	272.7	142.2	
pCO2	36.6	33.5	41.7	28.3	
HCO3	27.3	22.1	17.6	21.2	
Lactate	0.6	1.7	8.6	1.09	
Na	130.3	134.2	135.0	141	
K	3.30	3.89	4.20	3.1	
iCa	1.10	1.03	1.09	–	
Abbreviations: pO2, partial pressure oxygen; pCO2, partial pressure of carbon dioxide; HCO3, bicarbonate; Na, sodium; K, potassium; iCa, ionized calcium; ICU, intensive care unit.

Fig. 1 Radiographic images preoperatively (A), before chest tube placement (B), and following chest tube insertion (C). (Grey scale) The white arrow in (B) indicates left pleural effusion.

Fig. 1

The chest tube was removed on postoperative day 8, and the patient was transferred to the wards on day 9. After completing antibiotics for a wound infection, she was discharged on day 35. Oral chemotherapy with regorafenib and immunotherapy with pembrolizumab were started. Five-month later, she was re-admitted due to right side massive pleural effusion, and ultimately died from pneumonia, malignant pleural effusion, and multiple organ failure.

3 Discussion

ACS is a life-threatening condition characterized by an increase in abdominal cavity pressure above 20 mmHg, leading to end-organ damage [7]. Intra-abdominal hypertension is a sustained elevation in pressure of 12 mmHg or higher [7]. However, the diagnosis is challenging due to non-specific signs like hypotension and elevated airway pressure, which reflect the increased intra-abdominal and intrathoracic pressures common in closed HIPEC procedures [8]. While cytoreductive surgery with HIPEC offers survival benefits for colorectal cancer patients with peritoneal carcinomatosis and is relatively safe [2,3,9,10], complications like pneumothorax and ACS are rarely discussed [9,10]. Common complication including small bowel perforations and anastomotic leaks (4.5–19 %), pulmonary complications (10–16 %), and hematological toxicity (4–39 %) [9]. In this case, a pneumothorax and diaphragm defect led to increased intra-abdominal pressure during chemotherapy administration, causing elevated airway pressure as the volume-controlled ventilator compensated to maintain tidal volume.

This case highlights the importance of early detection of ACS, exacerbated by a pneumothorax from diaphragmatic tumor dissection. This case had diaphragmatic resection as studies suggest it may improve survival without increasing the risk of morbidities [11,12]. However, the impairment of diaphragm and the possibility of pneumothorax were overlooked. In addition, thoroughly check for iatrogenic injuries, including the diaphragm, is crucial before starting HIPEC. If a diaphragm defect remains, the HIPEC fluid can flow into the pleural space, increasing pulmonary toxicity and airway pressure more than if it had stayed within the intra-abdominal space. In addition to repairing the diaphragm defect, we advocate for the immediate placement of thoracostomy tubes to treat pneumothorax [13].

Although the American Society of Peritoneal Surface Malignancies guidelines recommend the closed technique for HIPEC, both closed and open techniques are used [6,14]. The open technique offers better organ visualization and uniform heat distribution but increases heat loss and exposure to cytotoxic agents [6]. The closed technique limits the contamination and achieves hyperthermia more efficiently, with high intra-abdominal pressure enhancing drug concentration and safe [[15], [16], [17]]. However, the risk of ACS must be emphasized. This case was different due to concurrent pneumothorax and a diaphragm defect, which elevated intra-abdominal and intra-thoracic pressures.

Oxaliplatin used in HIPEC can cause side effects include hyperglycemia, lactic acidosis, hyponatremia, and laryngeal neurotoxicity [8]. Pulmonary toxicity has also been reported, which can lead to interstitial lung disease and pulmonary fibrosis [18]. Consequently, follow-up of pulmonary function is necessary following accidental intrathoracic chemotherapy [19]. In this case no clinical deterioration of pulmonary function was observed, and two-month postoperative plain films and computed tomography showed no lung fibrosis.

4 Conclusion

This case underscores the complexity of HIPEC and the importance of promptly identifying and managing ACS during the procedure. Monitoring intra-abdominal pressure during HIPEC is essential. Thoroughly check for iatrogenic injuries, including the diaphragm, is crucial before starting HIPEC.

Abbreviations

ACS abdominal compartment syndrome

HIPEC hyperthermic intraperitoneal chemotherapy

Ethical approval

This study was approved by the Institutional Review Board of Far Eastern Memorial Hospital (FEMH-112112-C). See the appendix on the last page.

Funding

This work was supported by the 10.13039/501100005866 Far Eastern Memorial Hospital (grant number FEMH-2023-C-074 ).

Author contribution

CC: First author, data collection, and writing up of the first draft of the paper and revising it.

PC: corresponding author, revising the article critically for important intellectual content, final approval of the version to be published, and agreement to be accountable for all aspects of the work thereby ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

CL and TL: Analysis and interpretation of data.

Guarantor

Pei-Fu Chen

Research registration number

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request

Conflict of interest statement

None declared.

Data availability

Data and material are available from the corresponding author on reasonable request.

Acknowledgements

This work was supported by the Far Eastern Memorial Hospital, Taiwan (Grant FEMH-2023-C-074). The sponsors had no role in the manuscript drafting. All authors have approved the final article.
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