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Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC)

General Surgery

Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a minimally invasive surgery to treat intra-abdominal tumours. It aims to treat peritoneal metastases, especially those affecting the peritoneal surface, such as ovarian, colorectal, and bladder cancers. PIPAC involves introducing a pressurized system into the patient's abdominal cavity, delivering aerosolized chemotherapy directly onto the tumours on the peritoneal surface to enhance the therapeutic effect.

Introduction

Pressurized IntraPeritoneal Aerosol Chemotherapy (PIPAC) is a minimally invasive surgical procedure for treating intra-abdominal tumours. Its primary purpose is to address peritoneal metastases, especially those spreading to the peritoneal surface, such as ovarian, colorectal, and bladder cancers.

Here are the main features of PIPAC:

  • Minimally Invasive Surgery: PIPAC is a minimally invasive procedure that involves introducing a pressurized system into the patient's abdominal cavity to ensure the peritoneum is opened, providing a better view for subsequent treatment.
  • Aerosolized Chemotherapy: Chemotherapy drugs are introduced into the abdominal cavity in aerosolized form and sprayed onto the tumours on the peritoneal surface. It enhances the concentration of drugs in the tumour tissue, increasing the effectiveness of the treatment.
  • Pressure Control: The pressurized system in PIPAC helps control the pressure in the abdominal cavity, ensuring even distribution of chemotherapy drugs while minimizing damage to surrounding tissues.
  • Frequency: PIPAC is typically performed at intervals depending on the specific condition of the patient and the doctor's recommendations. The frequency and number of treatments may vary based on each patient's circumstances.
  • Treatment Efficacy: The application of PIPAC is still under continuous research and evaluation, but some studies suggest that, for certain patients with peritoneal metastases, this treatment modality may offer a practical therapeutic approach.

Procedure

PIPAC is a minimally invasive surgical procedure that takes about one hour, and patients can typically be discharged on the same day. This repeatable treatment protocol needs to be performed every six to eight weeks and is generally used as an adjunct to systemic chemotherapy.

  1. Surgery Preparation: The patient is scheduled in the operating room and receives general anaesthesia.
  2. Elevation of Intra-abdominal Pressure: Before the surgery begins, the doctor introduces carbon dioxide gas into the abdominal cavity to raise the intra-abdominal pressure. This ensures the abdominal membrane is opened, providing a better view for the surgeon.
  3. Creation of Access Ports: The doctor creates access through small incisions or uses a laparoscope for the necessary surgical procedures. Typically, two access ports are established, one for introducing the laparoscope and another for introducing the chemotherapy drug nebulizer.
  4. Administration of Atomized Chemotherapy Drugs: The doctor introduces chemotherapy drugs into the abdominal cavity through a nebulizer. The atomized chemotherapy drugs directly contact the tumour tissues on the surface of the abdominal membrane, increasing the drug concentration in that area to enhance treatment effectiveness.
  5. Pressure Control: Throughout the procedure, the pressure control system ensures that the intra-abdominal pressure remains within a safe range. It helps evenly distribute chemotherapy drugs while minimizing damage to surrounding tissues.
  6. Conclusion of the Surgery and Recovery: After completing atomized chemotherapy, the doctor extracts the remaining gas containing chemotherapy drugs from the abdominal cavity and closes the access ports. Following the surgery, the patient is transferred to the recovery room for observation and recuperation.

Indications

PIPAC is specifically used to treat complex peritoneal tumours and malignant ascites. The types of cancers treated with this procedure include:

  • Colorectal Cancer
  • Stomach Cancer
  • Mesothelioma
  • Ovarian Cancer
  • Pancreatic Cancer
  • Peritoneal Cancer

Not Eligible for PIPAC

If a patient has the following conditions, they are not suitable for PIPAC:

  • Expected life span of less than 3 months
  • Presence of intestinal obstruction
  • Decompensated ascites
  • Need for simultaneous tumour resection or gastrointestinal resection
  • Sole reliance on total parenteral nutrition for nutrient absorption
  • Previous allergic reactions to chemotherapy
  • Presence of extraperitoneal metastasis
  • ECOG performance status >2 (need to be in bed more than 50% of normal daytime)
  • Portal vein thrombosis

According to foreign medical research, PIPAC has been shown to improve patient symptoms, including: Pain Reduction (63.3%), Decreased Abdominal Fluid (60%), Relief of Intestinal Obstruction Symptoms (45.5%).
PIPAC is a repeatable, minimally invasive surgery primarily used to treat complex peritoneal tumours and malignant ascites. It is suitable for specific types of cancers such as ovarian, colorectal, gastric, etc. HIPAC, on the other hand, is a one-time surgery involving tumour resection combined with the infusion of heated chemotherapy. Its application may be more extensive, covering various types of intraperitoneal cancers.
As PIPAC typically needs to be performed every six to eight weeks and may require multiple treatments, patients need to consider the potential physical or financial burden caused by this relatively frequent treatment schedule.

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