Multidisciplinary Approach to Surgical Oncology Patients

Description

Foreword Foreword Preface Suggestions for Success Basic Tips for VIVA Acknowledgements Contents Editor and Contributors About the Editor Contributors 1: Concept of Surgery and Basic Principles of Onco Surgery 1.1 What is Surgery? 1.2 Basic Principle of Surgery 1.3 Outcome of a Surgical Patient 1.4 Start Prehabilitation 1.5 Post-Operative Period 1.6 Basic Principles of Oncosurgical 1.7 Diagnosis of Cancer 1.8 Different Types of Biopsies Are 1.9 Staging Work Up 1.10 General Work Up 1.11 Principles of Operative Oncosurgical 1.11.1 Curative Surgery 1.12 Lymph Nodes Dissection 1.13 Rehabilitation 1.14 Follow up 1.15 Overall Complications 2: Basics Principles of Radiation Oncology 2.1 Introduction 2.2 Mechanism of Action 2.3 Radiobiology of Radiation Treatment 2.4 Altered Fractionation Schedules [4] 2.4.1 Hyperfractionation 2.4.2 Hypofractionation 2.4.3 Accelerated Radiation Therapy 2.5 Types of Radiotherapy 2.5.1 Teletherapy 2.5.2 Brachytherapy 2.5.3 Unsealed Source Radiation Therapy 2.5.4 Intra-Operative Radiotherapy (IORT) 2.6 Intent of Radiotherapy 2.6.1 Definitive/Radical Radiotherapy 2.6.2 Adjuvant Radiotherapy 2.6.3 Neoadjuvant Radiotherapy 2.6.4 Extra-corporeal irradiation 2.6.5 Palliative Radiotherapy 2.7 Radiotherapy Volumes Definition 2.8 External Beam Radiotherapy Techniques (Table 2.1) [1, 8, 9] 2.8.1 Conventional 2D Technique 2.8.2 Conformal Radiotherapy 2.8.3 Stereotactic Radio Surgery (SRS) and Stereotactic Body Radiotherapy (SBRT) 2.8.4 Hadron Therapy (Particle Therapy) [1, 8, 9] 2.9 External Beam Radiotherapy Machines [1, 8, 9] 2.9.1 Cobalt-60 Unit 2.9.2 Linear Accelerator (Linac) 2.9.3 Machines to Deliver SRS and SBRT 2.10 Reirradiation 2.11 Common Toxicities of Radiation Treatment References 3: Basic Principles of Medical Oncology 3.1 Introduction 3.2 History of Medical Oncology 3.3 Mechanism of Action of Chemotherapy 3.4 Basic Principles of Chemotherapy 3.5 Commonly Used Terms and Definition in Medical Oncology 3.6 Chemo-Radiation 3.7 Organ Toxicities 4: Pre-Operative Surgical Assessment of Cancer Patients 4.1 Introduction 4.2 General Principles 4.3 Preoperative Judgement and Final Decision 4.4 Identifying High Risk Factors 4.5 Peri Operative Medications 4.6 Pre op Advice to the Patients 4.7 Pre op Optimization 5: Pre op Evaluation of Cancer Patients Undergoing Surgeries 5.1 Introduction 5.2 Risk Assessment 5.3 Cardiovascular Issues 5.4 Pulmonary Issues 5.4.1 Preoperative Preparation for Thoracic Surgeries 5.5 DLCO Good Predictor of Mortality and Morbidity 5.6 Coagulopathies 5.7 Preoperative Optimisation 5.7.1 Preoperative Evaluation for Endocrinal Disorders 5.7.2 Diabetes Mellitus 5.7.3 Implications for Perioperative and Anaesthetic Management Further Reading 6: Perioperative Management of co-Morbid Conditions in Cancer Patients 6.1 Introduction 6.2 Cardiac Diseases 6.2.1 Preoperative Evaluation 6.2.2 Recent Myocardial Ischaemia or Unstable Angina 6.2.3 Recent Percutaneous Coronary Intervention (PCI) 6.2.4 Perioperative Medication Management 6.2.5 Perioperative Myocardial Injury 6.2.6 Perioperative Management 6.3 Hypertension 6.3.1 Pathophysiology: [3] 6.3.2 Perioperative Considerations [4] 6.3.2.1 Target Blood Pressure 6.3.3 Diabetes Mellitus (DM) 6.3.4 Preoperative Evaluation 6.3.5 Effects of the Surgical Stress Response 6.3.6 Perioperative Glycaemic Management [6] 6.4 Thyroid Disease 6.4.1 Hypothyroidism 6.4.2 Perioperative Management 6.4.3 Hyperthyroidism 6.4.4 Perioperative Management 6.5 Chronic Obstructive Pulmonary Disease (COPD) 6.5.1 Preoperative Assessment 6.5.2 Perioperative Management 6.5.3 Surgical Factors 6.5.4 Chronic Renal Disease 6.5.5 Pathophysiology 6.5.6 Preoperative Evaluation 6.5.6.1 History 6.5.6.2 Examination 6.5.6.3 Investigations 6.5.7 Renal Risk Assessment and Prevention 6.5.7.1 Patients on Renal Replacement Therapy References 7: Proper Counselling and Consent of Patient for Medicolegal Aspects and Importance of Documentation 7.1 Introduction 7.2 Counselling 7.2.1 When to Start Counselling? 7.3 Consent 7.3.1 What Is Legally Valid Consent? 7.3.2 Who Can Give Consent? 7.3.3 What Is Loco Parentis? 7.3.4 What Is Proxy Consent or Substitute Consent? 7.3.5 What Is Informed Refusal? 7.3.6 What Is Paternalism? 7.4 Documentation References 8: Surgical Safety Checklist: Relevance and Importance References 9: Post op Fluid, Electrolytes, and Nutritional Management: Present Perspective 9.1 Effects of Aging on Renal Function, Fluids, and Electrolytes 9.2 Role of Medications in Fluid and Electrolyte Balance 9.3 Choice of Fluids in the Perioperative Period 9.4 Restrictive or Liberal Fluid Therapy 9.5 Summary of British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients 9.6 Conclusion 10: Acute Pain management in Onco Surgical Patient: Overview 10.1 Introduction 10.2 Pathophysiology of Acute Postoperative Pain 10.3 Assessment and Documentation of Pain 10.3.1 Management of Nausea and Vomiting 10.4 Review of Drugs 10.4.1 NSAIDs 10.5 Local Anaesthetics 10.6 Antineuropathics 10.7 Management of Acute Pain 10.7.1 Managing a Loco-regional Analgesia Patient in the Ward 10.7.2 Removal of Epidural Catheters 10.8 Planning a Strategy for Pain Relief 10.9 Some Special Problems 10.9.1 Analgesia Following Amputation 10.9.2 Analgesia for a Patient Dependent on a High Dose of Opioid 10.9.3 Analgesia for a Patient with Opioid Addiction 10.9.4 Principles of Managing Addicted Patients in Acute Pain Include 10.9.5 Analgesia for An Elderly Patient 10.9.6 Management of Patients with Acute Neuropathic Pain 10.9.7 Analgesia for Patients with Renal Impairments 10.10 Delivery of Care References 11: Multimodal Analgesic Plans for Cancer Surgeries 11.1 Introduction 11.2 Importance of Pain Management: Systemic Effects of Inadequate Pain Relief 11.3 Pain Pathways 11.4 Assessment of Pain 11.5 Modalities of Preoperative Analgesia 11.6 Regional Techniques 11.7 Systemic Agents 11.8 Role of Ultrasound 11.9 Patient Controlled Analgesia 11.10 Plan of Analgesic Techniques for Different Surgical Interventions 11.10.1 Analgesia for Head and Neck Surgical Interventions 11.10.2 Analgesia for Thoracic Surgical Interventions 11.10.3 Analgesia for Abdominal Surgical Interventions 11.10.4 Analgesia for Inguinal and Lower Limb Surgical Interventions 11.10.5 Analgesia for Upper Limb Surgical Interventions 11.11 Recent Advances 11.12 Conclusions References 12: Antiseptic Policy: What Could be Relevant Surgical Site Infection (SSI) and Abdominal Sepsis 13: Nosocomial Infections and Hospital-Acquired Illnesses: Overview 13.1 Surgical Site Infections (SSIs) 13.2 Risk Factors for Surgical Site Infections 13.2.1 Patient Factors 13.2.2 Procedural Factors 13.3 Species and Sources of Wound Bacteria 13.4 Prevention of Surgical Site Infection 13.5 Perioperative Antimicrobial Prophylaxis 13.6 Surgical Site Infection Surveillance 13.7 Nosocomial Urinary Tract Infection 13.8 Epidemiology 13.9 Risk Factors 13.10 Pathogenesis 13.11 Etiology 13.12 Signs and Symptoms 13.13 Diagnosis 13.14 Prevention 13.15 Management of Nosocomial Urinary Tract Infection 13.16 Summary 13.17 Nosocomial Pneumonia 13.18 Health Care Associated Pneumonia 13.19 Epidemiology 13.20 Ventilator-associated Pneumonia: The Risk Factors 13.21 Diagnosis 13.22 Microbiologic Evaluation 13.23 Treatment and Prevention References 14: DVT: Prophylaxis and Management 14.1 Introduction 14.2 Review of Literature 14.3 Pathophysiology of DVT 14.4 Pathophysiology of VTE and Cancer 14.5 Cell–Cell Interactions and Procoagulants 14.6 Fibrinolysis 14.7 Cytokines and Angiogenesis 14.8 Incidence of VTE in Malignancy 14.9 Diagnosis of DVT 14.9.1 Symptoms 14.9.2 Signs 14.10 Diagnostic Value of Clinical Features of VTE 14.11 Wells Clinical Probability Score (Table 14.1) 14.12 Biomarkers for the Diagnosis of Deep Vein Thrombosis 14.13 Risk Factors for DVT 14.14 Caprini Risk Scoring Method for the Risk Assessment (Table 14.3) 14.15 Preventive Measures of VTE 14.16 Primary Prophylaxis 14.17 Comparison among all Type of Heparins (Table 14.3) 14.18 Summary and Recommendations 14.19 Timing of Regional Anaesthesia/Analgesia: (Cork University Hospital, Version 1 Guideline 2015) References 15: Research and Publication: Importance in the 21st Century 15.1 Introduction 15.2 Definition of Research [4] 15.3 Requirements to Conduct Research [4] 15.4 Research and Publication in Indian Academic Curriculum 15.5 Process of Getting Research Grant, Medical Writing, and Publications 15.6 Relevance of Research and Publication in Today’s World 15.7 Relevance in Medical Field 15.8 Scenario in India 15.9 Importance of Research and Publication 15.10 Research Methodology 15.11 How to Improve Scientific Research and Publication Quality? 15.12 Conclusion References 16: Critical Care of Postoperative Patient after Major Onco-Surgery: Overview 16.1 Introduction 16.2 Need of Surgical ICU 16.3 Taking Care of Lines, Tubes, and Catheters 16.4 Clinical and Biochemical Monitoring and Other Specific Monitoring as per Need Based on Assessment like Cardiac Output Monitor 16.5 Systemic Examination: Head to Toe and also Include Other System Examination 16.6 Abdominal Examination in Abdominal Surgery 16.7 Temperature 16.8 Nursing Care 16.9 Glucose Control 16.10 Antibiotics in ICU 16.11 Ventilator Settings and Parameters 16.12 Weaning from Mechanical Ventilation 16.13 Preventing Ventilator-Associated Pneumonia (VAP) 16.14 Sedation 16.15 Analgesia 16.16 Prevention of Venous Thromboembolism and Deep Venous Thrombosis 16.17 Stress Ulcer Prophylaxis 16.18 Dealing with ICU Agitation and Delirium Suggested Reading 17: ICU Care of Surgical Oncology Patients 17.1 Introduction 17.2 Physiological Response to Surgical Stress 17.2.1 Endocrine Response 17.2.2 Third Space Fluid Sequestration and Altered Fluid Homeostasis 17.2.3 Hypercoagulable State 17.2.4 Respiratory Changes 17.3 Indications for Post-Operative ICU Admission 17.4 Triage and Predictors of Post-Operative ICU Admission 17.4.1 Predictors of Post-Operative Outcomes 17.5 Management of Post-Operative Patient in ICU 17.5.1 General Care 17.5.2 Acute Post-Operative Pain Management 17.5.3 General Recommendations 17.5.4 Post-Operative Elective Ventilation and Extubation 17.5.5 Post-Operative Fever and Sepsis 17.5.6 Management of Post-Operative Sepsis 17.5.6.1 Discharge from the ICU 17.6 Conclusion References 18: Blood and Blood Transfusion in Surgical Oncology Patients: Importance and Relevance 18.1 Blood Grouping 18.2 Why Blood Is Important in Surgical Oncology Patients 18.3 Measurement of Blood Loss 18.4 Maximum Surgical Blood Ordering Schedule (MSBOS) 18.4.1 Acute Complications 18.4.2 Delayed Complications 18.5 Preoperative Assessment for Blood Replacement Related Issues 18.6 Preoperative Optimization 18.7 Intraoperative Strategies 18.7.1 Surgical Technique 18.7.2 Anaesthesia Techniques 18.8 Postoperative Strategies 18.9 Indications of PRBC Transfusion 18.10 Restrictive vs. Liberal Strategy of Blood Transfusion 18.11 Blood Storage and its Effects 18.12 Platelet Transfusion 18.13 Plasma Component Transfusion 18.13.1 Fresh Frozen Plasma (FFP) 18.13.2 Cryoprecipitate 18.13.3 Transfusion Reaction 18.13.4 Summary 19: Principles of Blood Products Management in Onco-surgeries 19.1 Introduction 19.2 Why Blood in Onco-surgeries? 19.3 Concerns Related to Blood Transfusion 19.4 Preoperative Assessment for Blood Replacement Related Issues 19.4.1 Onco-surgeries and Hemoglobin 19.4.2 Onco-surgeries and Platelet 19.4.3 Onco-surgeries and Fresh-frozen Plasma (FFP)/Cryoprecipitate 19.5 Preoperative Optimization 19.5.1 Therapeutic Interventions for Anemia 19.5.2 Advice Regarding Ongoing Anticoagulants and Antiplatelet Agents 19.5.3 Autologous Blood Donation 19.6 Prophylactic Strategies to Reduce Blood Loss 19.6.1 Multimodal Protocols or Algorithms 19.6.2 Use of Antifibrinolytics 19.6.3 Acute Normovolemic Hemodilution (ANH) 19.7 Strategies for Management of Blood Loss 19.7.1 Transfusion of Allogeneic Blood 19.7.2 Perioperative Patient Monitoring 19.7.2.1 Blood Loss Assessment 19.7.2.2 Monitoring for Perfusion of Vital Organs 19.7.2.3 Monitoring for Coagulopathy 19.7.2.4 Monitoring Blood Transfusion-related Side Effects 19.7.3 Management of Massive Bleeding 19.7.3.1 Initial Resuscitation 19.7.3.2 Hemostatic Resuscitation 19.8 Biological and Clinical Consequences of Perioperative Blood Transfusion 19.9 Summary Further Reading 20: Management of Surgical Wounds, Wounds Healing and Burst Abdomen 20.1 Introduction 20.2 Basic Principles of Wound Management 20.3 Stages of Wound Healing: 5 Stages 20.4 Pneumonic ME Foreign Body 20.5 Different Types of Edges to Diagnose the Types of Ulcer 20.6 Types of Surgical Wounds 20.7 Features of Wound Healing 20.8 Management of Surgical Wounds 20.9 Wound Debridement 20.9.1 Topical Therapy 20.9.2 Wound Coverage 20.9.3 Commonly Use Agents for Different Stages 20.9.4 An Ideal Dressing 20.9.5 Common Dressings 20.10 EUSOL (Edinburg University Solution of Lime) 20.11 Mechanism of Action 20.12 Role of Wound Closure 20.13 Adjunctive Therapy: Hyperbaric Oxygen Therapy (HBOT) 20.14 Management of Very Specific Wounds 20.15 Pressure Sore/Ischemic Ulcer 20.16 Few Important Points to Remember 20.17 Management of Burst Abdomen Further Reading 21: Medical Negligence, Consumer Protection Act (CPA) and Surgeons 21.1 Introduction 21.2 Definition of a “Consumer” 21.3 Objectives of Consumer Protection Act (CPA) 21.4 Medical Negligence 21.5 Deficiency in Medical Service 21.6 Liability of Medical Services and Doctor 21.7 Judicial Approaches 21.8 Conclusion References 22: Classification of Surgical Complications: Clavien–Dindo and Review 22.1 Introduction 22.2 So why and What Is the Need of Such Classification 22.3 Daniel Dindo and Pierre A Clavien 22.4 Modified Clavien–Dindo Classification (Table 22.1) 22.4.1 Sub-grouping of Clavien–Dindo Classification 22.4.2 Limitations 22.5 The Clavien-Dindo Classification of Surgical Complications [4] 22.5.1 Aim 22.5.2 Material and Methods 22.5.3 Results 22.5.4 Conclusion 22.6 Applicability of the Clavien-Dindo Classification to Emergency Surgical Procedures [5] 22.6.1 Aim 22.6.2 Material and Methods 22.6.3 Results 22.6.4 Conclusion 22.7 Charlson Comorbidity Index (Table 22.1) 22.8 Clinical Examples 22.8.1 Summary 22.8.2 Conclusion References 23: Immediate Postoperative Complications: An Overview for Better Management 23.1 Introduction 23.2 Wound Complications 23.3 Postoperative Fever 23.4 Respiratory Complications 23.5 Paralytic Ileus 23.6 Hypotension 23.7 Renal Function Derangement 23.8 Stress Ulcer 23.9 Neurological Complications 24: Intestinal Obstruction in Cancer Patients: An Overview 24.1 Introduction 24.2 Summary References 25: An Overview of Post-operative Enterocutaneous Fistula and Vasicovaginal Fistula in Cancer Patients 25.1 Introduction 25.2 Definition and Classification 25.3 Prevention 25.4 Etiology and Risk Factors 25.5 Clinical Features 25.6 Diagnosis 25.7 Initial Management 25.8 Management of External Fistula Output 25.9 Entero-atmospheric Fistula 25.10 Vesico Vaginal Fistula References 26: Management of Chylous Ascites: A Short Review 26.1 Introduction 26.2 Anatomy of Lymphatic System 26.3 Composition of Chyle 26.4 Pathophysiology of Malignant Chylous Ascites 26.5 Interventional Procedures 26.6 Our Institutional Protocol 26.7 Conclusion References 27: Management of Anastomotic Leak 27.1 Introduction 27.2 Rate of Leaks 27.3 Causes 27.4 Investigation 27.5 Treatment 27.6 Suturing Devices 27.7 Few Words on Anastomotic Complication of Colorectal Surgery 27.8 Outcomes 27.9 Conclusion References 28: Palliative Care for Incurable Cancer Patient 28.1 Introduction 28.2 Different Dimensions of Palliative Care 28.3 The Different Way of Management 29: Palliative Care of Patients with Ovarian Cancer 29.1 Introduction 29.2 Pathophysiology 29.3 Clinical Signs and Symptoms (General Symptoms) 29.4 Role of Palliative Care in Ovarian Cancer Patients 29.4.1 When to Start Palliative Care? 29.4.2 Early Integration of Palliative Care 29.4.3 Different Dimensions of Palliative Care 29.5 The Different Way of Palliative Management 29.6 Ovarian Cancer Pain Management References 30: Comprehensive Surgical Training & Mentorship: Foundation of the Excellent Onco-surgical Services 30.1 Landmarks of Surgical Training Evolution 30.2 First Structural Model by Halsted 30.2.1 Halsted’s Surgical Training Principles 30.3 The Mall Model 30.4 The “Osler” Model 30.5 Is Simulation in Surgery Changing the Training Future? 30.6 Surgical Oncology Training: Global and Indian Perspective References 31: Role of MIS in Onco Surgery 31.1 Staging Laparoscopy 31.1.1 Oesophagus and GE Junction Tumours 31.1.2 Stomach 31.1.3 Pancreas 31.1.4 Biliary Tract Cancers 31.1.4.1 Gallbladder 31.1.4.2 Cholangiocarcinoma 31.1.5 Colon or Rectal Cancer 31.1.6 Lymphoma 31.2 Laparoscopic and Robotic Surgeries 31.2.1 Oesophagus and GE Junction 31.2.2 Stomach 31.2.3 Pancreas 31.2.4 Colorectal Cancer 31.2.5 NCCN Guidelines on Minimal Access Surgery on Carcinoma of the Colon and Rectum 31.2.6 NCCN Criteria on Transanal Excision 31.2.7 ESMO Guidelines 31.2.8 Japanese Guidelines: JSCCR 2016 31.2.9 MIS in Gynaecologic Oncology 31.2.10 CA Endometrium 31.2.11 CA Cervix References 32: Quality of Life Issue in Pelvic Cancer Surgery 32.1 Gynecological Cancer Care in India 32.2 Gynecological Cancer Related Morbidities 32.3 Cancer Treatment Related Morbidities 32.3.1 Ovarian Failure 32.3.2 Sexual Dysfunction 32.3.3 Fertility Impairment 32.3.4 Bowel and Bladder Dysfunction 32.4 Quality of Life for Gynecological Cancer Patients 32.4.1 Quality of Life: Assessment 32.4.2 QOL Consideration: Indian Scenario (Table 32.1) 32.4.3 QOL Improvement: Indian Contribution (Table 32.2) 32.5 Conclusion References 33: History and Evolution of Cytoreductive Surgery (CRS) and HIPEC for Peritoneal Surface Malignancies 33.1 Introduction 33.2 Timeline of Landmark Events in CRS and HIPEC 33.3 Cytoreductive Surgery and Peritonectomy 33.4 Intraperitoneal Chemotherapy and Hyperthermia 33.5 Proof of Principle Animal Studies 33.6 Evolution of Intraperitoneal Heated Chemotherapy Delivery Techniques 33.7 Scoring Systems for Peritoneal Cancer Burden and Completeness of Resection 33.8 Conclusion 33.9 Patient Selection and Scoring Systems 33.9.1 Patients Related Criteria 33.9.2 Disease-Related criteria 33.10 Scoring Systems for CRS & HIPEC 33.11 Prognostic Scoring Systems 33.12 Peritoneal Surface Disease Severity Score (PSDSS) 33.13 Colon and Rectal Peritoneal Carcinomatosis (COREP) References 34: Management of Common Complications of CRS and HIPEC 34.1 Intraoperative Complications 34.2 Postoperative Complications 34.3 Factors Contributing to the Complications 34.4 Conclusion References 35: Surgical Safety for the Team Performing CRS and HIPEC 35.1 Excessive Surgical Smoke 35.2 Cytotoxic Drugs References 36: Role of HIPEC in Pseudomyxoma Peritonei and Appendicular Tumor 36.1 Introduction 36.2 Origin and Definition of Pseudomyxoma Peritonei 36.3 Clinical Features 36.4 Preoperative Workup 36.5 Treatment 36.5.1 Surgical Management of PMP 36.5.2 Peritonectomy Procedures for Complete Cytoreduction 36.5.3 Intraperitoneal Chemotherapy 36.5.4 Hyperthermic Intraperitoneal Chemotherapy 36.6 Summary References 37: CRS and HIPEC for Management of Malignant Mesothelioma 37.1 Conclusion References 38: The Role of CRS and HIPEC in Ovarian Cancer 38.1 What Is Optimal Cytoreduction in Stage III and IV Ovarian Cancer 38.2 The Rationale for CRS in Ovarian Carcinoma 38.3 Primary versus Interval CRS 38.4 Overall Completeness and Applicability of Evidence 38.5 CRS for Recurrent Ovarian Cancer 38.6 How Does HIPEC Act? Pharmacokinetic and Molecular Pathway 38.7 Conclusions References 39: CRS and HIPEC for Peritoneal Metastasis from Colorectal Cancer 39.1 Introduction 39.2 Clinical Presentation and Diagnosis 39.3 Treatment Options for CRC Peritoneal Metastasis 39.3.1 Systemic Chemotherapy 39.3.2 Role of CRS and HIPEC 39.4 Concerns with CRS and HIPEC in the Modern Era 39.5 Conclusions References 40: The Role of HIPEC in Gastric Cancer 40.1 The Burden and Presentation 40.2 The Pattern of Recurrence 40.3 Selection of Patients for Cytoreduction and HIPEC 40.4 The Strategies for Management of Peritoneal Disease 40.5 Randomized Studies 40.6 Meta-Analysis 40.7 The Ongoing Trials 40.8 Conclusions References 41: Rule of Six for CRS and HIPEC and Institutional Experience Institutional Experience References 42: HIPEC, HITHOC, and Technique: How we Do it? 42.1 Introduction 42.2 Materials and Methods 42.3 CRS Technical Aspects 42.4 The Technique of Diaphragmatic Resection 42.5 Reconstruction of the Diaphragm after HITAC Procedure 42.6 HITAC: Technical Aspects 42.7 Intra-Operative Monitoring 42.8 Results 42.9 Conclusion References 43: Bowled out Phenomena in CRS and HIPEC 43.1 Introduction 43.1.1 Prehyperthermic Intraperitoneal Chemotherapy and Hyperthermic Intraperitoneal Chemotherapy Era Results [6, 7] 43.2 Patients and Methods 43.3 Results 43.3.1 Cytoreductive SURGERY and Hyperthermic Intraperitoneal Chemotherapy 43.4 Discussion 43.5 Conclusion References 44: Where Does HIPEC Stand: An Evidence Based Review 44.1 Introduction 44.2 Rationale of HIPEC 44.3 Prerequisites 44.4 Tumor Biology and Patient Selection 44.5 Recent Clinical Data of CRS + HIPEC 44.6 Pseudomyxoma Peritonei (PMP) 44.7 Malignant Peritoneal Mesothelioma 44.8 Colorectal Cancer 44.9 Gastric Cancer 44.10 Ovarian Cancer 44.11 Peritoneal Sarcomatosis 44.12 Conclusion References