Intraperitoneal hyperthermic perfusion (IPHP)
After secondary CRS, 4 Tenckhoff catheters are placed in the abdominal cavity. Two inflow catheters are placed in the right subphrenic cavity and at deep pelvic level, respectively; and two further catheters in the left subphrenic cavity and in the superficial pelvic site.
Schema of Intra Peritoneal Hyperthermic Perfusion
The IPHP requires the employment of lung-heart machine, comprised by a roller pump, a thermostat, a heat exchanger and an extra corporeal circuit. The perfusate flow is controlled as well as the heat exchanger adjusts the temperature of perfusate, by circulating water at a desired temperature in the arterial phase of circuit. The extra corporeal circuit consists of interconnected tubes which has: a) an input section (inflow); b) an output section (outflow); c) an axis of rapid filling up; d) a central body connected with a filter; e) a deflow section; f) a series of multiperforated catheters in their extremities. The device should be approved by C.E accreditation. Several centers are using the Performer LRT®, RAND, Medolla (MO), Italy.
The perfusate, defined as the liquid filling the circuit could be of various type: a) peritoneal dialysis solution, physiologic solution or a composition of Normosol solution R pH 7.4 associated with Haemagel (in the proportion 2:1). The priming volume ought to be abundant enough to achieve homogeneity and constancy of heating, but not excessive, in order to avoid abdominal distension and bodily thermo-dilution. For an optimal working of circuit 2l/m2 of perfusate for opened technique and 6 l for closed technique is usually sufficient.
The drugs schedule
Modalities of execution: open, closed abdominal or semi-closed techniques
|Author / year
||Duration of the perfusion
|Rossi et al 2002
||43 mg/l of perfusate
||15.25 mg/l of perfusate
||Ovarian cancer and peritoneal mesothelioma
|Fujimoto et al. 1993
||25.0 mg/m2/l of perfusate
||3.3gm/m2/l of perfusate
||Pseudomyxoma peritonei Colorectal cancer
|Elias et al. 2002
||460 mg/m2 in 2l/m2 of perfusate
|De Bree et. al 2003
In the closed technique the skin of abdominal wall is temporary closed with a running suture and the Tenckhoff catheters connected to the circuit, in order to initiate the IPHP. In the open modality, also known as Coliseum technique, the abdomen is covered with a plastic sheet and drug vapor is evacuated to protect the operating room personnel.
The catheters are connected to the extra-corporeal circuit and the preheated polysaline perfusate containing Cisplatin and Adriamycin is instilled in the peritoneal cavity using the heart-lung pump at a mean flow of 600 - 1000 ml/min for 90 minutes. In order to achieve intrabdominal temperature of 42.5C, we will maintain the inflow temperature of approximately 44C. Throughout the perfusion, if the opened technique is adopted; the surgeon will continuously manipulate the viscera to distribute both heat and chemotherapy. Following perfusion, the perfusate is quickly drained and the abdomen closed after careful intraperitoneal inspection.