Laparoscopic HIPEC: A bridge between open and closed-techniques

An Asian Tertiary Centre's Early Experience with Laparoscopic Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis

The use of open cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has shown improved oncological survival in terms of treating peritoneal surface malignancies (PSM). However, this procedure often comes with associated morbidity. The move towards use of laparoscopic surgery in this field is postulated to lead to a reduction in morbidity and earlier return to function, but literature on its use for CRS and HIPEC has been scarce. We performed a retrospective review of 6 patients with PSM who underwent laparoscopic CRS and HIPEC in our institution and analysed the patient characteristics, oncological history, perioperative and postoperative outcomes. Median peritoneal cancer index (PCI) score was 0 (IQR 0-1.25). All 6 patients had appendiceal primaries. Median operative time was 285 min (IQR 228.8-300); median length of stay was 7.5 days (IQR 5-8.8). All patients achieved complete cytoreduction, and there was no conversion to open surgery. One patient developed port site infection and another 2 patients subsequently developed adhesions. Median follow-up time was 35 (IQR 17.5-41) months. No patients had developed recurrence at the time of data collection. We conclude that in patients with limited PCI sore (< 2), laparoscopic CRS and HIPEC are safe and feasible. With increasing experience, a select group of patients with limited PSM may be treated via minimally invasive surgery, minimising the morbidity of a traditional laparotomy.

A Review of the Use of Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Malignancy in Pediatric Patients

Hyperthermic intraperitoneal chemotherapy (HIPEC) can directly target microscopic peritoneal disease, has achieved regular consideration in the treatment of several adult cancer types, and is more recently being studied in pediatrics. This review paper provides an overview of the use of this modality in pediatrics in order to identify medication choice, discuss post-operative morbidity and mortality, and evaluate impact on overall survival. Four databases were searched including Scopus, PubMed, Embase, and CINAHL and ultimately 37 papers documenting the use of this modality comprising 264 pediatric patients were included. Malignancies treated include desmoplastic small round cell tumor, rhabdomyosarcoma, angiosarcoma, colorectal carcinoma, and mesothelioma, with several rarer tumor types. Cisplatin was the most commonly used drug for HIPEC at varying concentrations for 30-90 min in duration at temperatures of approximately 41-42 °C. Reported toxicities were generally self-limited and there was no post-operative mortality. The impact on overall survival versus systemic chemotherapy and debulking surgery is uncertain due to lack of clinical trials and very small sample size across tumor subsets and the overall pediatric population. The relationship between degree of tumor burden and extent of surgical debulking needs to be further clarified. Future directions include prospective clinical trials, establishment of patient databases to facilitate standardization of HIPEC in pediatric patients, and additional approaches to optimize HIPEC.

Side-effects of hyperthermic intraperitoneal chemotherapy in patients with gastrointestinal cancers

Background

Hyperthermic intraperitoneal chemotherapy (HIPEC) produces unwanted side-effects that are mainly caused by chemotherapeutic drugs in the treatment of gastrointestinal (GI) cancers, and these effects have not been systematically summarized. The aim of this article was to provide a comprehensive overview of the side-effects of HIPEC for GI cancers and propose practical strategies for adverse event management.

Methodology

PubMed, Web of Science, and the Cochrane Library were systematically searched for side-effects of HIPEC in GI cancers prior to October 20, 2022. A total of 79 articles were included in this review.

Results

Adverse events, such as enterocutaneous digestive fistulas, GI tract perforation, neutropenia, postoperative bleeding, ventricular tachycardia, hyperglycemia, hypocalcemia, renal impairment, encapsulating peritoneal sclerosis, scrotal ulceration, and sarcopenia were described, and their clinical management was discussed. These side-effects involve the digestive, hematopoietic, circulatory, metabolic, and urinary systems. Effective methods for adverse event management included an expert multidisciplinary team, replacing chemotherapy drugs, using Chinese medicine, and careful preoperative assessments.

Conclusion

The side-effects of HIPEC are frequent and can be minimized by several effective methods. This study proposes practical strategies for adverse event management of HIPEC to assist physicians in choosing the optimal treatment method.

Effect of HIPEC on Peritoneal Recurrence in Peritoneal Metastasis Treated With Cytoreductive Surgery: A Systematic Review

BACKGROUND

Peritoneal metastasis (PM) is a late-stage manifestation of intra-abdominal malignancies. The current standard of care indicates that cure can only be achieved with cytoreductive surgery (CRS) which is often indicated with concurrent adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC). However, the utility of HIPEC within subsets of PM is not fully understood. We seek to compare the effectiveness of HIPEC in improving peritoneal recurrence rates in PM of different origins.

METHODS

We conducted a systematic review of trials on the PubMed, EMBASE, and Cochrane databases, last searched in August 2021. Biases were assessed using the Cochrane Collaboration's tool for assessing the risk of bias in randomized trials as well as the Methodological Index for Non-Randomized Studies (MINORS) framework.

RESULTS

7 gastric PM studies, 3 ovarian PM studies, and 3 colorectal PM studies were included. Recurrence-free survival was improved in the HIPEC + CRS cohort in 5 gastric trials but only 1 ovarian trial and none of colorectal origin.

DISCUSSION

Our findings indicate decent effectiveness of HIPEC in gastric PM, but limited utility in ovarian and colorectal PM. Limitations in the current literature are attributed to the paucity of data available, a lack of homogeneity and consideration of novel and personalised treatment regimens. We implore for further studies to be conducted with a focus on patient selection and stratification, and suggest a reframing of approach towards modern molecular and targeted therapeutic options in future studies of HIPEC.

SYSTEMATIC REVIEW REGISTRATION

https://www.researchregistry.com/browse-the-registry#registryofsystematicreviewsmeta-analyses/registryofsystematicreviewsmeta-analysesdetails/60c1ffff0c1b78001e8efbe3/, identifier reviewregistry1166.

Case Report: Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy Application in Intraperitoneally Disseminated Inflammatory Myofibroblastic Tumor and in the Youngest Patient in the World: New Indication and Modification of Technique

Introduction: Peritoneal metastases occur in cancers that spread to the peritoneal cavity and indicate the advanced stage of the disease. In children they are mainly seen in sarcomas, Gastrointestinal Stromal Tumors and primary disseminated ovarian tumors. Inflammatory Myofibroblastic Tumor (IMT) is a very rare lesion, characterized by an unpredictable clinical course. The absorption of chemotherapeutic agents through the peritoneal-plasma barrier (PPB) is minimized, thus HIPEC procedure limits the systemic exposure to chemotherapy and permits the administration of its higher doses. The main purpose of HIPEC is to remove the visible macroscopic disease in order to achieve complete cytoreduction (CRS).

HIPEC Procedure in Children: Several papers deal with the CRS and HIPEC in children and adolescents, however pediatric experience is still limited. Thus far, the HIPEC procedure has been carried out on patients over 2 years old. The most common indication for the surgery and the best outcome was experienced by patients with desmoplastic small round cell tumor (DSRCT). Most patients received intraperitoneal cisplatin.

HIPEC Modification: A 5-month-old infant was admitted to the Department of Pediatric Oncology due to the abdominal distention and blood in the stool. The Computed Tomography (CT) revealed a solid-cystic mass in the right abdominal area. The primary tumor and numerous peritoneal metastasis were removed and the Inflammatory Myofibroblastic Tumor (IMT) was diagnosed. The patient underwent subsequently CRS and modified HIPEC procedure. To avoid overheating of the infant, the intraperitoneal normothermic chemoperfusion was performed. Due to the low body weight a modified dosage of intraperitoneal doxorubicin was used. The child underwent standard postoperative chemotherapy and received crizotinib therapy. At 12 months follow-up since treatment completion the patient remains in complete remission. To our knowledge this is the youngest patient, the only infant and the first pediatric patient with IMT who underwent the modified HIPEC procedure in the world.

Conclusions: CRS and HIPEC is technically possible also in infants. For its safe course patients selection and technique modification are necessary. Use of HIPEC should be also considered in intraperitoneally disseminated IMT. A complete cytoreductive surgery as the first HIPEC step seems to be the key factor in survival.

How do we perform hyperthermic intraperitoneal chemotherapy in ovarian cancer? -a narrative review

Ovarian malignancy is a leading cause of death caused by gynecologic cancer worldwide because it is mainly found in the advanced stage and recurs in most patients even after cytoreductive surgery and intravenous (IV) chemotherapy. Prevention of recurrence of primary disease and treatment of recurrent ovarian cancer are still remained as major interest and lots of researchers investigate novel treatment to find optimal method. Even though intraperitoneal (IP) chemotherapy turns out to increase the overall survival, it is not widely used because of adverse event. As an alternative treatment for IP chemotherapy, hyperthermic intraperitoneal chemotherapy (HIPEC) is emerging a new way. Thanks to much research and use in other cancer species, such as the colorectal cancer cytoreductive surgery followed by HIPEC is becoming a promising treatment. However, randomized controlled trials and unbiased data in ovarian cancer patients are still needed for the establishment of therapy. Moreover, among the current situation in which treatments such as bevacizumab or PARP inhibitor have been found to be effective and have been widely used, it may be necessary to establish the role in the combination of HIPEC. This article is a comprehensive review of the HIPEC in ovarian cancer to introduce techniques, treatment results, and clinical trials of HIPEC.

Quo Vadis Oncological Hyperthermia (2020)?

Heating as a medical intervention in cancer treatment is an ancient approach, but effective deep heating techniques are lacking in modern practice. The use of electromagnetic interactions has enabled the development of more reliable local-regional hyperthermia (LRHT) techniques whole-body hyperthermia (WBH) techniques. Contrary to the relatively simple physical-physiological concepts behind hyperthermia, its development was not steady, and it has gone through periods of failures and renewals with mixed views on the benefits of heating seen in the medical community over the decades. In this review we study in detail the various techniques currently available and describe challenges and trends of oncological hyperthermia from a new perspective. Our aim is to describe what we believe to be a new and effective approach to oncologic hyperthermia, and a change in the paradigm of dosing. Physiological limits restrict the application of WBH which has moved toward the mild temperature range, targeting immune support. LRHT does not have a temperature limit in the tumor (which can be burned out in extreme conditions) but a trend has started toward milder temperatures with immune-oriented goals, developing toward immune modulation, and especially toward tumor-specific immune reactions by which LRHT seeks to target the malignancy systemically. The emerging research of bystander and abscopal effects, in both laboratory investigations and clinical applications, has been intensified. Our present review summarizes the methods and results, and discusses the trends of hyperthermia in oncology.

Colorectal Peritoneal Metastases: A Systematic Review of Current and Emerging Trends in Clinical and Translational Research. Gastroenterol Res Pract. 2019;2019:5180895. [PMID: 31065262 PMCID: PMC6466888 DOI: 10.1155/2019/5180895]

Colorectal peritoneal metastases (CPM) are associated with abbreviated survival and significantly impaired quality of life. In patients with CPM, radical multimodality treatment consisting of cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) has demonstrated oncological superiority over systemic chemotherapy alone. In highly selected patients undergoing CRS + HIPEC, overall survival of over 60% has been reported in some series. These are patients in whom the disease burden is limited and where the diagnosis is made at an early stage in the disease course. Early diagnosis and a deeper understanding of the biological mechanisms that regulate CPM are critical to refining patient selection for radical treatment, personalising therapeutic approaches, enhancing prognostication, and ultimately improving long-term survivorship. In the present study, we outline three broad themes which represent critical future research targets in CPM: (1) enhanced radiological strategies for early detection and staging; (2) identification and validation of translational biomarkers for diagnostic, prognostic, and therapeutic deployment; and (3) development of optimized approaches for surgical cytoreduction as well as more precise strategies for intraperitoneal drug selection and delivery. Herein, we provide a contemporary narrative review of the state of the art in these three areas. A systematic review in accordance with PRISMA guidelines was undertaken on all English language studies published between 2007 and 2017. In vitro and animal model studies were deemed eligible for inclusion in the sections pertaining to biomarkers and therapeutic optimisation, as these areas of research currently remain in the early stages of development. Acquired data were then divided into hierarchical thematic categories (imaging modalities, translational biomarkers (diagnostic/prognostic/therapeutic), and delivery techniques) and subcategories. An interactive sunburst figure is provided for intuitive interrogation of the CPM research landscape.

Laparoscopic cytoreductive surgery and HIPEC is effective regarding peritoneum tissue paclitaxel distribution

BACKGROUND

In some patients with peritoneal carcinomatosis, we could perform the cytoreductive surgery and the HIPEC procedure by a complete laparoscopic approach to avoid morbidity. We consider that using laparoscopic approach for performing peritoneal carcinomatosis cytoreductive surgery and HIPEC with closed CO₂ recirculation technique is possible and safe, with equal efficacy to conventional methods and hemodynamic complications.

OBJECTIVE

Monitoring the effectiveness of the drug distribution in a laparoscopic ctoreductive and HIPEC surgery group with CO₂ recirculation respect to a closed and open HIPEC group METHODS: Porcine model that included fifteen mini-pigs. Five pigs were operated with laparoscopic approach performing a pelvic and retroperitoneal lymphadenectomy. They later received a total laparoscopic closed HIPEC with CO₂ recirculation (G1). Group 2 (G2): five pigs operated by an open cytoreductive surgery and closed HIPEC technique. Group 3 (G3): five animals in which an open cytoreductive surgery and an open HIPEC technique was performed. Blood and peritoneal determinations were realized after recirculation of the drug, at 60 min using chromatographic analysis.

RESULTS

G1-G2: phrenic right peritoneum, p: 0.46. Phrenic left peritoneum, p: 0.46. Pelvic peritoneum, p: 0.17. Serum paclitaxel: p: 0.01. G1-G3: phrenic right peritoneum, p: 0.34. Phrenic left peritoneum, p: 0.34. Pelvic peritoneum, p: 0.17. Serum paclitaxel G1-G3, p: 0.02.

CONCLUSIONS

A total laparoscopic approach for ctoreductive surgery and closed HIPEC with CO₂ recirculation may be safe and feasible. In our experimental model there was no significant difference in tissue drug distribution respect the conventional techniques and there was a less toxicity because the serum drug concentration was significantly lower with laparoscopic approach respect the other groups.

Comparison of open and closed abdomen techniques for the delivery of intraperitoneal pemetrexed using a murine model

BACKGROUND AND OBJECTIVES

Pemetrexed is an appealing agent to use for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC). However, the optimal method of pemetrexed delivery still remains undefined. Using a murine model, we compared the use of open and closed abdomen techniques on the absorption of intraperitoneal (IP) pemetrexed in different compartments.

METHODS

Eleven Sprague-Dawley rats were submitted to a fixed dose of IP pemetrexed (1000 mg/m² ) at a perfusion temperature of 40°C during 25 min according to two techniques: open and closed. At the end of perfusion, samples in different compartments were harvested and the concentrations of pemetrexed were measured by high performance liquid chromatography.

RESULTS

Absorption of IP pemetrexed in portal and systemic blood was significantly higher using the open compared to the closed abdomen technique (93.17 vs 52.50 µg/mL, P < 0.001) and (76.26 vs 51.65 µg/mL, P < 0.001), respectively. No difference was found between the two techniques on the peritoneal tissue concentration of pemetrexed (18.07 vs 19.17 µg/g, P = 0.51).

CONCLUSION

Peritoneal absorption of pemetrexed is not modified by the use of either technique. However, systemic concentrations of pemetrexed increased using the open technique, suggesting it could increase systemic toxicity.

Clinical studies in CRS and HIPEC: Trials, tribulations, and future directions-A systematic review

BACKGROUND

The field of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has suffered from a lack of clinical trials to validate its expanding use.

OBJECTIVE

To evaluate published and ongoing clinical trials seeking to better define role of CRS/HIPEC in the treatment of peritoneal surface malignancies.

METHODS

Systematic review by PubMed search was performed using terms "Clinical trial," "intraperitoneal chemotherapy," and "HIPEC." ClinicalTrials.gov and EudraCT registries were searched for active clinical trials. Eligibility included CRS/HIPEC trials investigating adult patient populations from published clinical reports and/or trials currently accruing or at completion.

RESULTS

Thirteen published trials and 57 active clinical trials were included for review.

CONCLUSIONS

Published and ongoing U.S. and international clinical trials for CRS and HIPEC are defining important parameters that include improving patient selection, strategic sequences of treatment, cytoreductive strategies, chemotherapeutics, optimal hyperthermic temperature and timing, and toxicity profiles. Main barriers or limitations to trial development remain patient enrollment, trial design, and oncologic community collaboration. Overall progress is positive with increasing number of clinical trials throughout the world. Collaboration between surgeons and the wider oncologic community will be crucial to validate this important treatment strategy.

Are there intra-operative hemodynamic differences between the Coliseum and closed HIPEC techniques in the treatment of peritoneal metastasis? A retrospective cohort study

BACKGROUND

Although two main methods of intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) are currently accepted, the superiority of one over the other has not yet been demonstrated. The purpose of this study was to determine whether there are hemodynamic and temperature differences between patients who received HIPEC in two different techniques, open versus closed abdomen.

METHODS

This retrospective study was conducted in our center between 2011-2015 in 30 patients who underwent surgery for peritoneal carcinomatosis secondary to colorectal cancer, in whom cytoreduction and HIPEC were performed by the Coliseum (15) or closed techniques (15). The main end points were morbidity, mortality, hemodynamic changes, and abdominal temperature. The comparative analysis of quantitative variables at different times was done with the parametric repeated measure ANOVA for those variables that fulfilled the suppositions of normality and independence and the Friedman non-parametric test for the variables that did not fulfill either of these suppositions.

RESULTS

There were no deaths in either group. The incidence of postoperative complications in the Coliseum group was 53% (8 patients), grade II-III. The incidence of complications in the closed group was 13% (2 patients), grade II-III. The intra-operative conditions regarding the systolic and diastolic pressures were more stable using the closed abdomen technique (but not significantly so). We found statistically significant differences in abdominal temperature in favor of the closed technique (p = 0.009).

CONCLUSIONS

Both HIPEC procedures are similar. In our series, the closed technique resulted in a more stable intra-abdominal temperature.

Pharmacokinetic problems in peritoneal drug administration: an update after 20 years

Intraperitoneal chemotherapy has demonstrated significant pharmacologic and clinical advantage over traditional intravenous administration for cancers that are restricted to the peritoneal cavity. The combination of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) has become the standard technique used to fight ovarian and gastrointestinal cancers in many centers. However, challenges remain for HIPEC to contact the entire peritoneal surface, penetrate the tumor tissue, and transport to the lymphatics and other metastatic sites. New innovations in delivery technique, such as heated aerosol, and in delivery molecules, such as microparticles, nanoparticles, nanogels, and tumor-penetrating peptides are being tested in animal models and will likely soon be in human trials. Improvements in overall care, such as the recent clinical trial of an oral agent for maintenance therapy in ovarian carcinoma, will continue in this field for the next 20 years.

The Onset of Intra-Abdominal Adhesions During Closed-Abdomen Hyperthermic Intraperitoneal Chemotherapy

INTRODUCTION

Hyperthermic intraperitoneal chemotherapy (HIPEC) is delivered after cytoreductive surgery (CRS) in selected patients with peritoneal carcinomatosis. The closed-abdomen technique, preferred by many centers, prevents heat loss and drug spillage, but does not warrant homogeneous distribution of the perfusion fluid (PF). The hypothesized formation of intra-abdominal adhesions during the closed-abdomen perfusion period has never been described.

MATERIALS AND METHODS

From March 2014 to April 2016, 10 consecutive patients with peritoneal carcinomatosis, selected for CRS, underwent the Laparoscopy-Enhanced HIPEC technique to explore the abdominal cavity during the perfusion. The aim of the study was to investigate the incidence and the extent of intra-abdominal adhesions that are formed after CRS during the perfusion period of closed-abdomen HIPEC.

RESULTS

During the perfusion, adhesions developed in 70% of the patients. Adhesions developed mainly in the period between the closure of the abdomen and the subsequent filling of the abdomen with the PF. After their first division, during the following perfusion period, adhesions between the bowel and the abdominal wall reformed in 3 patients (30%).

CONCLUSIONS

Intra-abdominal adhesions are frequently formed during closed-abdomen HIPEC and can hamper the adequate circulation of the PF. The Laparoscopy-Enhanced technique enables the early detection and the division of any intra-abdominal adhesions.

Distribution pattern and penetration depth of doxorubicin after pressurized intraperitoneal aerosol chemotherapy (PIPAC) in a postmortem swine model

BACKGROUND

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel approach delivering intraperitoneal chemotherapy by means of a pressurized aerosol. This study was conducted to evaluate the distribution pattern of doxorubicin in the abdominal cavity after PIPAC in a postmortem swine model.

METHODS

Doxorubicin was aerosolized through a Micropump© (MIP) into the peritoneal cavity of two swines at a pressure of 12 mm Hg CO2 and 32 °C. To measure the distribution of the drug, 9 different positions within the abdominal cavity were sampled. In-tissue doxorubicin penetration was evaluated using fluorescence microscopy on frozen thin sections.

RESULTS

A maximum of drug penetration was observed in the area around the MIP. The penetration in the small intestine reached a depth of 349 ± 65 µm. Penetration depth in the right upper abdomen and left upper abdomen were 349 ± 65 and 140 µm ± 26 µm, respectively. Distant areas to the MIP showed variable penetration rates between 50 and 150 µm.

CONCLUSIONS

Doxorubicin reached all areas within the peritoneum. Highest penetration rates were measured in the area around the Micropump. Further studies are warranted to evaluate and optimize the distribution and penetration of cytotoxic agent into the tissue after PIPAC.