Indications and surgical results of Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) for palliative therapy of peritoneal metastasis after 748 consecutive procedures

Marc A Reymond, MD, Cedric Demtroder, MD, Jurgen Zieren, MD, Urs Giger-Pabst, MD, Dirk Strumberg, MD, Clemens B Tempfer, MD. Ruhr-University Bochum

Objective of the Study: Peritoneal metastasis has a dismal prognosis and better therapies are urgently needed. Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a minimally-invasive therapy distributing chemotherapy as a pressurized aerosol into the abdominal cavity during laparoscopy. Superior drug delivery into peritoneal tissue has been demonstrated. Objective was to determine indications, patient characteristics, operating time, intraoperative and postoperative surgical complications and hospital mortality.

Methods and Procedures: Single center study. Prospective registry data, retrospective analysis. PIPAC includes following steps: 1) installation of a 12 mmHg capnoperitoneum; 2) staging laparoscopy with multiple biopsies; 3) aerosolization of low-dose chemotherapy (oxaliplatin 92 mg/m2 body surface for colorectal and appendiceal cancer; cisplatin 7.5 mg/m2 combined with doxorubicin 2.5 mg/m2 for all other indications) using a dedicated micropump driven by an industry-standard injector; 4) steady state for 30 min. application time at 37 °C; 5) exsufflation of the toxic aerosol over a closed aerosol waste system (CAWS). The operating room is equipped with laminar airflow. Chemotherapy application is remote controlled.

Results: Between 5/2013 and 9/2015 748 PIPAC were scheduled in 336 consecutive patients (219 females, 117 males) with peritoneal metastasis; mean age 60.2 ± 11.6 years; > 2.2 PIPAC/patient; max. 8 PIPAC/patient). Indications were ovarian (40%), gastric (19%) and colorectal cancer (15%), CUP ( 7%), HBP (6%) and appendiceal tumors (5%), mesothelioma (5%) and others (3%). 92.6% patients had received previous chemotherapy. No patient was eligible for CRS and HIPEC. No patient had extraperitoneal metastasis. PCI was 15 ± 11.6. Ascites volume was 582 ± 1273 ml. In 91 cases (12.2%) abdominal access was not possible due to adhesions. 655 PIPAC and 11 PITAC (intrathoracic application) were performed. Mean operating time was 84 min.There were 5 access lesions (bowel perforations), one of them remained undetected, 4 were immediately repaired. No further intraoperative complication was noted. There was no postoperative bowel perforation. In 4 cases, a parietal hematoma developed. Median postoperative hospital stay was 3 days. Hospital mortality was 2 (0.3%): peritonitis =1; tumor lysis syndrome = 1).

Conclusions: Most common indication for PIPAC is platin-resistant, recurrent ovarian cancer, followed by gastric and colorectal cancer. PIPAC can be performed in 9/10 cases in spite of peritoneal adhesions and can be repeated up to 8 times in the same patient. Abdominal access is the critical step of the procedure. PIPAC does not induce chemical bowel perforations. PIPAC is safe and surgical complications are rare.

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