©2026 Mayo Foundation for Medical Education and Research Naina Singh, MD1 , Matthew Colontonio, MD1 ,Ilana Logvinov, PhD, DNP, RN1 , Matheus Montano dos Santos, MD1 , Fatima Serhan, MD1 , Hari Kalagara, MD1 , Tri Dinh, MD1 1 Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida Epidural Versus Non-Epidural Analgesia in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy: A Case Series 1. Arakelian, E. et al. Factors influencing early postoperative recovery after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. European Journal of Surgical Oncology, Volume 37, Issue 10, 897 - 903 2. Gupta N, Kumar V, Garg R, Bharti SJ, Mishra S, Bhatnagar S. Anesthetic implications in hyperthermic intraperitoneal chemotherapy. J Anaesthesiol Clin Pharmacol. 2019 JanMar;35(1):3-11. doi: 10.4103/joacp.JOACP_93_18. PMID: 31057232; PMCID: 3. Lorimier, G. et al. Prolonged perioperative thoracic epidural analgesia may improve survival after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases: a comparative study. Eur J Surg Oncol, 44 (11) (2018), pp. 1824-1831 4. Martin H. et al. Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced Recovery After Surgery (ERAS®) Society Recommendations — Part II: Postoperative management and special considerations, European Journal of Surgical Oncology, Volume 46, Issue 12, 2020, 2311-2323. https://doi.org/10.1016/j.ejso.2020.08.006. 5. Yue TM, Sun BJ, Xu N, Ohkuma R, Fowler C, Lee B. Improved Postoperative Pain Management Outcomes After Implementation of Enhanced Recovery After Surgery (ERAS) Protocol for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC). Ann Surg Oncol. 2024 Jun;31(6):3769-3777. doi: 10.1245/s10434-024-15120-3. Epub 2024 Mar 11. PMID: 38466484. BACKGROUND METHODS RESULTS Thoracic epidural analgesia during CRS-HIPEC: Improves early postoperative pain control, reduces systemic opioid requirements and accelerates gastrointestinal recovery. Use of adjuvant analgesics were comparable between groups. These findings support the consideration of thoracic epidural analgesia as part of a multimodal analgesia pathway for CRSHIPEC. Larger prospective and multicenter studies are needed to validate these findings and define the role of epidural analgesia with enhanced recovery protocols for CRS-HIPEC. REFERENCES Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is associated with significant postoperative pain, prolonged opioid requirements, delayed gastrointestinal recovery, and increased length of stay. Epidural analgesia may enhance postoperative recovery, but its efficacy and implementation in enhanced recovery after surgery protocols for CRSHIPEC surgery are not fully defined. This case series compares effects of epidural versus non-epidural analgesia on systemic opioid consumption (MME). Secondary outcomes included hospital length of stay, postoperative pain scores, time to first ambulation, time to first flatus, placement of nasogastric tube and adjuvant analgesics. CONCLUSIONS Retrospective, single-center chart review of adults undergoing exploratory laparotomy for CRS-HIPEC. Patients ≥18 years with complete perioperative documentation. Categorical data: Pearson’s χ² test. Continuous data: mean ± SD (normally distributed) or median (IQR) (skewed) Group tests: t-tests or Mann–Whitney U tests, based on distribution. Characteristic Epidural (n =11) No Epidural (n=12) P-value PACU average pain score, mean (SD) 3.4 (3.1) 4.0 (3.6) 0.41 Pain score 24 hrs postop, mean (SD) 1.3 (1.7) 5.5 (2.7) <.001 * Pain score 48 hrs postop, mean (SD) 3.0 (3.2) 5.4 (2.2) 0.06 Pain score 72 hrs postop, mean (SD) 2.9 (2.3) 3.7 (2.0) a 0.47 First ambulation (hrs), mean (SD) 33.5 (15.7) 34.4 (20.1) 0.90 Intraoperative opioids, mean (SD) 51.4 (14.3) 61 (34.3) 0.65 Postoperative opioids, mean (SD) 45.3 (63.7) 272.4 (409.6) 0.04 * Total opioids during hospitalization, mean (SD) 96.7 (72.4) 333.4 (421.7) 0.06 Time to first flatus (hrs), mean (SD) 38.8 (31.9) 62.8 (29.0) b 0.05 Hospital length of stay (days), mean (SD) 5 (1.9) 5.8 (2.4) 0.29 TABLE 2: PATIENT OUTCOMES SD: standard deviation. Statistically significant at p 0.05. a Two patients discharged prior to 72hrs. bOne patient discharged prior to documented flatus. FIGURE 1: PATIENT DEMOGRAPHICS FIGURE 2: PAIN TRAJECTORY