A 44-year-old male patient was presented who consulted for a clinical picture of six months of evolution of abdominal pain in the epigastrium and colic that was postprandial and later generalized to the entire abdomen. He presented emesis of food content and involuntary weight loss (15 kg in three months). Endoscopic studies and gastric mucosa biopsy revealed the presence of mixed adenocarcinomas (intestinal and diffuse). Diagnostic laparoscopy revealed peritoneal carcinomatosis, which allowed the gastric adenocarcinoma to be staged as T4aN1-3M1.
The patient did not present with other concomitant diseases and was not functionally dependent (Karnofsky scale 90); additionally, his general physical condition was good, and his functional capacity, as assessed by the Duke Activity Status Index (DASI), was 58.2 (10 MET, CE: 87%). On physical examination, he had normal vital signs, a weight of 72 kg (ideal weight 75 kg), a height of 1.8 m, and a BMI of 22 kg/m2. Consequently, the patient was considered a candidate for treatment with five cycles of the FLOT protocol (fluorouracil with leucovorin, oxaliplatin and docetaxel) as neoadjuvant therapy, followed by surgical management with cytoreduction and hyperthermic intraperitoneal chemotherapy.
Within the extension studies, the stress echocardiogram was negative for myocardial ischemia, reaching 94% of the maximum hazard ratio (HR) estimated for age, with normal biventricular function (LVEF 64%) and adequate pressure and chronotropic responses. The pre- and postbronchodilator flow-volume curves were of good quality, with a mild restrictive pattern without postβ2 agonist changes (FEV1/FVC: 69%). The development of the paraclinical parameters during the perioperative period is summarized in Table 1.
On the day of surgery, under sedation, an epidural catheter was inserted for continuous postoperative analgesia, and balanced general anesthesia was administered with sevoflurane. Induction was performed with propofol at a dose of 1 mg/kg, infusion of dexmedetomidine (0.3-1 mcg/kg/h) or administration of remifentanil (0.08–1.2 mcg/kg/min). Basic and advanced monitoring was performed with five-lead electrocardiography, pulse oximetry, noninvasive blood pressure, depth of anesthesia (PSI, Patient State Index), esophageal temperature, invasive blood pressure, and minimally invasive cardiac output monitoring with index software prediction of hypotension, central venous pressure and measurement of urine output. Within the protocol, thermal protection was ensured with forced-air heating blankets, as well as prewarming in the surgical readiness unit, which was suspended 30 minutes before the onset of hyperthermia (HIPEC). Arterial and venous gas levels were measured every 2 hours, including before and after hyperthermia, as were electrolyte levels and renal function. Laparoscopic debridement (total gastrectomy and lymphadenectomy) was then performed, followed by HIPEC with mitomycin. The maximum body temperature reached during hyperthermia was 38.4°C. There were no critical hemodynamic or respiratory events during surgery. Gasometric analysis revealed mild metabolic acidosis without oxygenation disorders, which subsequently resolved. There were no significant changes in airway pressure, and no adjustments in tidal volume or respiratory rate were needed.
After eight hours of surgical and anesthetic treatment, the patient was successfully extubated and subsequently transferred to the intensive care unit (ICU) without the need for hemodynamic support; additionally, a multimodal analgesia scheme (NSAIDs, acetaminophen) and epidural infusion of 0.125% levobupivacaine and 1.5 mcg/mL fentanyl (institutional premix) were used. The patient remained in the ICU for 72 hours and underwent invasive hemodynamic monitoring without the need for vasopressors, inotropes, or ventilatory support. Total parenteral nutrition was indicated due to the initial impossibility of advancing the nasojejunal tube; however, 24 hours later, he successfully tolerated oral nutrition. The postoperative course was satisfactory, and the patient did not experience acute kidney injury or coagulopathy, two of the main expected outcomes after chemotherapy was administered. Leukocytosis with neutrophilia was detected in the first 48 hours, and there were no significant alterations in electrolyte levels (Table 1).
Table 1
Development of paraclinical parameters during the operative and anesthetic periods.
| Exam | Previous | End of surgery | Postoperative | |
| 6 hours | 24 hours | 48 hours |
| Leukocytes/mm3 (%) | 6340 (45.3%) | 4480 (61%) | 14270 (91%) | 13220 (78.6%) | 10260 (67%) |
| Hemoglobin (g/dL) | 15.6 | 12.5 | 14.3 | 14.1 | 14 |
| Hematocrit (%) | 45.5 | 37 | 41.3 | 40.3 | 40.3 |
| Platelets/mm3 | 216000 | 133000 | 144000 | 146000 | 144000 |
| Creatinine (mg/dL) | 0.98 | 0.86 | 0.91 | 1.0 | |
| Urea nitrogen (mg/dL) | 14.1 | | 14.7 | | |
| Sodium (mEq/L) | 138 | 136 | 133 | 136 | |
| Potassium (mEq/L) | 4.14 | 4.06 | 3.93 | 3.97 | |
| Chlorine (mEq/L) | 101.5 | 107.8 | 103 | | |
| Ionic calcium (mEq/L) | | 1 | 1.26 | | |
| Albumin (g/dL) | 4.37 | | 3.45 | | |
| Globulins (g/dL) | 2.38 | | | | |
| Albumin/globulins | 1.84 | | | | |
| PT (sec) | 11.1 | 12.8 | 13.5 | 13.5 | |
| INR | 0.99 | 1.14 | 1.21 | 1.21 | |
| PTT (sec) | 29.7 | 29.1 | 30.9 | 30.9 | |