ONCOLOGICAL PROCEDURE WHERE NEITHER ONCOSURGEON, NEITHER ONCOANESTHETIST AND NOT EVEN SCRUB NURSE INSIDE THE OPERATING ROOM PIPAC

PIPAC: PRESSURISED  INTRAPERITONEAL AEROSOL CHEMOTHERAPY  

OVERVIEW: 

                                Pressurized intraperitoneal chemotherapy (PIPAC) is a surgical technique of administering aerosolized chemotherapy in the abdominal cavity for peritoneal metastasis. Systemic Chemotherapy may not be as effective as PIPAC in peritoneal metastasis due to poor peritoneal spread in systemic chemotherapy. A higher drug concentration is made available for tumor cells in PIPAC due to pressurized vapourisation. 

PIPAC may be a short and well tolerated procedure but this can happen if a well knowledgeable, well equipped, well experienced team performs this procedure. The major concerns while performing the procedure are operation room(OR) personnel hazardous risks, remote monitoring of patients, anaphylactic reactions to chemotherapeutic agents and minor cardiopulmonary complications in higher risk patients.

ONCO ANESTHESIA CONSIDERATIONS:

1. Pre - operative procedure: Routine preoperative assessment and routine workup investigations are sufficient for this procedure. Additionally, patients undergoing PIPAC have a high grade of peritoneal metastasis, always looking up for ascites and planning for anesthesia is mandatory.

1. Location For PIPAC Procedures: PIPAC procedure should be performed remote at remote OR. Airtight system in the OR, Zero CO2 leak and the OR should be well equipped with Laminar flow. Chemotherapy aerosol should be exhausted from the hospital waste scavenging system at the end of the procedure.  

1. Exposure Prevention For The OR Team: Double gloving, disposable glasses, disposable gowns and N- 95 masks are necessary for prevention of any accidental leaks and aerosolized chemotherapeutic exposure. 

1. Remote Monitoring: Since none of the OR team are present inside the OR, remote monitoring with monitors through which we can see clearly and can hear alarms must be available. Safest method is having monitors outside instead of constantly peeping through the window of OR. Routine electrocardiogram(ECG), Pulse oximetry, capnography and a non-invasive blood pressure monitoring may be sufficient for the procedure.

1. Perioperative Anesthesia: TIVA mode of anesthesia is usually preferred, because of the aerosolized chemotherapeutic drug interference with our inhalational agents. Shorter acting analgesics are sufficient for the procedure. No requirement of postoperative analgesia in these patients. Infiltration at the port sites with local anesthetics with minimal perioperative opioids and a good muscle relaxation may be more than sufficient.

1. Perioperative Emergencies:  The most common emergency encountered during this procedure is Anaphylactic reaction especially encountered with platinum chemotherapeutic agent. Emergency carts, steroids, intravenous fluids and mentally ready for potentially life threatening emergencies are essential. In case of emergencies aerosolized chemotherapy must be evacuated through closed Aerosol Waste System (CAWS) and only one anesthetist and one surgeon enters the OR. 

1. Day Care Discharge: Usually patients are admitted on a day care basis. So, General Anesthesia with shorter acting agents are sufficient. Patients are counseled similarly to laparoscopic surgeries. Postoperatively patients can be discharged if they have a good discharge score.

CONCLUSION:

                          PIPAC procedures have shown improved outcomes in peritoneal cancer patients who are not ideal for cytoreductive surgery and HIPEC procedures. Location, Equipment, monitoring, good muscle relaxation during general anesthesia can make PIPAC more safer to patients. Equally, well equiped OR with good scavenging system and good occupational care against hazards can make PIPAC a best tolerated procedure not only to patient but also to Professionals.