Assessment of postoperative pain after pressurized intraperitoneal aerosol chemotherapy (PIPAC) in the treatment of peritoneal metastasis

Pressurised intraperitoneal aerosol chemotherapy (PIPAC): the first Australian experience

Objectives

Pressurised intraperitoneal aerosol chemotherapy (PIPAC) is a novel surgical technique for patients with peritoneal metastases not amenable to curative treatment. PIPAC delivers pressurised aerosolised chemotherapy using a hyperbaric capnoperitonem established laparoscopically. This study sought to investigate the feasibility and safety of PIPAC in an Australian population.

Methods

We undertook a cohort analysis of prospectively-collected data on patients undergoing PIPAC across two Australian hospitals. Participants were planned to have three PIPAC procedures, each 6 weeks apart. Study outcomes included post-operative complications including 30-day mortality, length of stay (LOS) and patient quality of life (EORTC QLQ-C30 scores).

Results

18 patients underwent 50 completed procedures. 13 patients had two or more PIPACs. The most common primary malignancy was colorectal cancer (n=8), followed by gastric cancer (n=4), appendiceal cancer (n=4) and mesothelioma (n=2). One grade four but no grade five complications occurred, with zero 30-day mortality. Median LOS was 1 day. Mean EORTC QLQ-C30 score increased from 47.8 at baseline to 53 post second PIPAC. Due to the heterogeneity of our cohort, survival analysis and statistical comparisons were unable to be made.

Conclusion

PIPAC is feasible, safe and well tolerated in an Australian population with a lack of severe complications and zero 30 day mortality. Due to the small number of patients and the heterogeneity of our study's sample, it was not possible to perform survival analysis. The study is nonetheless valuable as the first investigation of implementation of PIPAC in Australia.

Impact of Body Mass Index on Postoperative Pain and Opioid Administration After Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC)

PURPOSE

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new surgical technique, developed for the treatment of peritoneal carcinomatosis (PC). In this retrospective observational study we assessed the impact of body mass index (BMI) on postoperative pain and opioid consumption.

METHODS

We analyzed pain scores after 100 PIPAC procedures using either oxaliplatin or doxorubicin-cisplatin performed in 49 patients with PC between July 2016 and September 2020. The patients were divided into 3 groups (BMI <18.5, 18.5 ≥ BMI < 25, BMI≥25). Pain was self-rated on a visual analogue scale (VAS) from 0 to 10.

RESULTS

Univariate logistic regression analysis identified oxaliplatin and PCI score to be associated with moderate to severe pain (VAS 4-10 at 8 am D1) after adjustment on BMI (OR [95% CI]; 3.26[1.00 - 10.65] p=0.050) and (OR [95% CI]; 1.09[1.01 - 1.17] p=0.019). The level of pain appeared significantly different between the treatment groups (median 2.5[0; 5] vs 0[0; 2.5] p=0.0017) irrespective of BMI (p =0.705 and p=0.118). Multivariate logistic regression analysis identified moderate to severe pain and synchronous PC to be associated with greater use of opioids (OR [95% CI]: 3.91 [1.24 - 12.32]) and (OR [95% CI]: 5.16 [1.71 - 15.58]; respectively. Opioids were administered after 45 procedures (45%) and was comparable between the treatment groups. Opioid administration and length-of-stay were similar among BMI bands.

CONCLUSION

BMI is not related to postoperative pain or opioid use, howevermoderate to severe pain and synchronous PC are factors associated with requiring opioids.

PIPAC for Gastrointestinal Malignancies

The peritoneum is a common site of metastases for gastrointestinal tumors that predicts a poor outcome. In addition to decreased survival, peritoneal metastases (PMs) can significantly impact quality of life from the resulting ascites and bowel obstructions. The peritoneum has been a target for regional therapies due to the unique properties of the blood-peritoneum barrier. Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) have become accepted treatments for limited-volume peritoneal disease in appendiceal, ovarian, and colorectal malignancies, but there are limitations. Pressurized intraperitoneal aerosolized chemotherapy (PIPAC) improves drug distribution and tissue penetration, allowing for a minimally invasive application for patients who are not CRS/HIPEC candidates based on high disease burden. PIPAC is an emerging treatment that may convert the patient to resectable disease, and may increase survival without major morbidity, as indicated by many small studies. In this review, we discuss the rationale and benefits of PIPAC, as well as sentinel papers describing its application for gastric, colorectal, appendiceal, and pancreatobiliary PMs. While no PIPAC device has yet met FDA approval, we discuss next steps needed to incorporate PIPAC into neoadjuvant/adjuvant treatment paradigms, as well as palliative settings. Data on active clinical trials using PIPAC are provided.

Nurses' Assessments Versus Patients' Self-Assessments of Postoperative Pain: Knowledge and Skills of Nurses for Effective Pain Management

Postoperative pain is the most common form of acute pain. Nurses contribute to effective pain management with their knowledge and skills. The aims of this research were to examine differences between nurses' assessments and patients' self-assessments of postoperative pain, differences in the mentioned (self) assessments with respect to characteristics of both groups of respondents, and the correlation between the NRS and the VRS scale. The study included 103 nurses employed at a hospital and 103 patients treated in the surgical departments after the surgical procedures. Data were collected using the standardized Numerical rating scale (NRS) and Verbal rating score (VRS). The median of patients' self-assessments of pain intensity on the NRS scale was 4, while the nursing assessment of patients' pain was 3, with no significant difference (p = 0.083). No significant differences were found on the VRS scale between nurse assessments and patient self-assessments of current pain intensity. The pain was described as moderate by 35% of participants, including 35.9% nurses and 35% patients. Significant positive correlations were recorded between values on the VRS and NRS scales for nurses (Rho = 0.812; p < 0.001) and patients (Rho = 0.830; p < 0.001). The results of this study may have implications for the improvement of postoperative pain management protocols, with regular use of pain assessment scales and individualization of analgesic prescriptions.

Hospitalization cost of Pressurized Intraperitoneal Aerosol chemotherapy (PIPAC)

INTRODUCTION

Pressurized Intraperitoneal Aerosol chemotherapy (PIPAC) is a new surgical technique for the treatment of unresectable peritoneal carcinomatosis. Very little data is available on the costs of this treatment in France as there is currently no code for PIPAC in the French Common Classification of Medical Acts (CCAM). Our objective was to estimate the mean cost of hospitalization for PIPAC in two French public teaching hospitals.

METHODS

The mean cost of hospitalization was estimated from the mean fixed-rate remuneration paid to the hospital and the mean additional costs of treatment paid by the hospital. At discharge a patient's hospitalization is classified into a diagnosis related group, which determines the fixed-rate remuneration paid to the hospital (obtained from the national hospitals database - PMSI). Costs of medical devices and drug treatments specific to PIPAC, not covered by the fixed-rate remuneration, were obtained from the hospital pharmacies.

RESULTS

Between July 2016 and November 2021, 205 PIPAC procedures were performed on 79 patients (mean procedures per patient = 2.6). Mean operating room occupancy was 165 min. The mean fixed-rate remuneration received by the hospitals per PIPAC hospitalization was €4031. The actual mean cost per hospitalization was €6562 for a mean length-of-stay of 3.3 days. Thus, each PIPAC hospitalization cost the hospital €2531 on average.

CONCLUSION

The current reimbursement of PIPAC treatment by the national health system is insufficient and represents only 61% of the real cost. The creation of a new fixed-rate remuneration for PIPAC taking into account this cost differential is necessary.