Relieving Symptoms in Women Undergoing Intraperitoneal Chemotherapy with Cryoreductive Surgery

MAY 02, 2009
Christina T. Loguidice
Peritoneal carcinomatosis is the metastatic spread of cancer within the peritoneal cavity by seeding from a primary malignancy, such as colon, ovarian, gastric, or breast cancer; it may also occur as a primary disease, as in the case of peritoneal mesothelioma. In a session entitled “Intraperitoneal Chemotherapy Combined with Cryoreductive Surgery: Nursing Management Targeted Toward Aspects of Symptom Distress,” Pamela Esquivel, NP-C, Loma Linda University Medical Center, Loma Linda, California, noted that 10% to 15% of patients with gastrointestinal cancer are found to have peritoneal carcinomatosis at initial surgery and that prognosis is quite poor, with a median survival of 6 months in patients presenting with this cancer.

Managing Peritoneal Carciomatosis

A combination of cryoreductive surgery and hyperthermic intraperitoneal chemoperfusion (HIPEC) are used to manage peritoneal carcinomatosis. The purpose of cryoreductive surgery is to excise all gross tumor, relieving any bowel obstruction and removing macroscopic disease. HIPEC is used to palliate symptoms and improve survival. It is favored over systemic chemotherapy because it reaches more tissue in the abdominal cavity by being administered directly to the abdomen. HIPEC is typically performed concomitantly with cryoreductive surgery, during which cannulas and temperature probes are placed. The abdomen is temporarily closed and heat is applied for 90 to 120 minutes as the chemo is circulated through the tubes in the abdomen. Thereafter, reconstructive surgery is performed and the abdomen is closed.

Postoperative Nursing Care
Following treatment, patients are admitted to the surgery intensive care unit (SICU), where they remain for 5 to 7 days. Ventilatory support is provided for 2 to 3 days and patients often have a variety of chest tubes, drains, gastrostomy, and jejunostomy that must be managed. Chemotherapy precautions are taken for 48 hours. Patients may experience postoperative ileus, requiring bowel rest, and enteral feedings may also be needed in some cases. During their time in the SICU, patients are susceptible to systemic inflammatory response syndrome, abscess, bowel fistulas, short bowel syndrome, pneumonia, and hematological toxicity. Personal protective equipment must be worn by nurses at all times, including gloves, gowns, and eye/face protection to prevent against hospital acquired infections.

Morbidity and Mortality
Morbidity of cytoreductive surgery with HIPEC can result from surgical complications or from chemotherapy-related toxicity. Major morbidity rates after CRS and HIPEC range from 14% to 56% in the literature, with a reported mortality between 0% and 19%.

Using Symptom Experience to Guide Clinical Practice
Patients with ovarian cancer who are treated with surgical resection and intraperitoneal chemotherapy (IPC) often experience pain, decreased physical activity, bowel issues, fatigue, and, for those who are pre/peri-menopausal, symptoms of menopause, which include hot flashes, night sweats, sleep disturbances, mood swings, altered memory or concentration, and weight gain. Patients may also have to contend with IPC regional symptoms, include bloating, distention, cramping, abdominal pain, dyspnea, and gastric reflux. A combination of these symptoms is often experienced, which can add to the considerable amount of emotional and psychological distress that patients are already experiencing.

Robin Green, RN, MSN, Clinical Nurse Specialist, NYU Clinical Cancer Center, New York, defined symptom experience as “a patient’s perception and response to the frequency, intensity, and distress associated with symptom occurrence.” She also noted that the link between physical symptoms or behaviors and psychological distress is crucial to identifying symptom experience. Green noted three distinct symptom experiences in patients with ovarian cancer receiving IPC: (1) Nausea/Vomiting, Constipation, Abdominal Distention; (2) Numbness/Tingling, Constipation, Muscle Aches/Joint Pain; and (3) Insomnia, Cognitive Changes, Hot Flashes, Night Sweats.

Treating Nausea/Vomiting, Constipation, Abdominal Distention―The etiology of this symptom experience can be attributed to chemotherapy, mechanical pressure on the bowel, and use of 5HT3 antagonist/NK-1 antagonist, opioids, and nonsteroidal anti-inflammatory drugs. Interventions may include use of antiemetics, bowel agents (eg, stool softener and anti-flatulence drugs), ambulation, and dietary consultation.

Numbness/Tingling, Constipation, Muscle Aches/Joint Pain―This etiology of this symptom experience stems from neurotoxicities, electrolyte imbalances, and nephrotoxicity. Renal function should be examined, including creatinine and blood urea nitrogen levels. Electrolyte replacement (magnesium and potassium) is warranted.

Insomnia, Cognitive Changes, Hot Flashes, Night Sweats―Patients with this symptom experience can be helped with supportive therapy (listening to their concerns), pain control, comfort measures (using a fan), and nutritional counseling.

Identifying and Managing Infections
Infections of the port site can be identified by redness, pain, swelling, and discharge. Infections of the abdominal region can have a chemical or bacterial etiology and generally present with abdominal pain, diarrhea, and, in some cases, fever. A chemical etiology can result when the chemotherapeutic agent leaks around the needle insertion site or from the port after the needle is removed. If this complication is discovered, the chemotherapy infusion should be stopped immediately and the cause of leakage investigated. In the majority of cases, leakage results from incorrect needle placement or from the needle becoming displaced during treatment.

Concluding Remarks
Managing multidimensional symptoms in patients receiving IPC requires a multidisciplinary approach, often involving surgeons, medical oncologists, nursing staff, social services, and nutritionists. Patient education, symptom management, and psychosocial/emotional support are all crucial to reduce patient distress and improve a patient’s quality of life.

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