Advanced abdominal cancer which is not considered curative by surgery or chemotherapy, may be treated with PIPAC. In Sydney, PIPAC surgery is commonly performed at St George Hospital by the St George Peritonectomy & Liver Cancer Unit.
What cancers are treated with PIPAC?
In our unit and other units performing peritonectomy and HIPEC the chances of living 5 years after surgery are 50%. The chemotherapy we use is HIPEC with oxaliplatin and intravenous injection of 5-fluorouracil.
How will PIPAC help me?
PIPAC has proven to be beneficial for different cancer types but it is not possible to predict how your cancer will respond. It is hoped PIPAC will slow down or stabilise your cancer growth. Our main aim is to relieve your symptoms including pain, fatigue and ascites (build-up of fluid in the abdomen) and ultimately improve your current quality of life. While the use of PIPAC is not for a cure, a very small number of people may experience enough tumour shrinkage to make them eligible for surgery with curative intent called Peritonectomy or cytoreductive surgery with Heated Intraperitoneal Chemotherapy (HIPEC).
What is PIAPC and how does it work?
While PIPAC is a new treatment process in Australia, it has been available in Europe since 2011 and is not considered as experimental. During a procedure called laparoscopy (keyhole surgery) which takes approximately 60 to 90 minutes and is performed under general anaesthetic, pressurized intraperitoneal aerosol chemotherapy is administered directly into the abdomen. A laparoscope (camera) is introduced through a small incision near the navel (belly button), a further one to three instruments called ports are also placed into the abdomen. Carbon Dioxide gas (CO2) is then used to inflate the abdomen, this separates the abdominal wall from the underlying organs, the space between these 2 surfaces is known as the peritoneal cavity.
A low volume of chemotherapy is then delivered as a vapour directly into this cavity for 5 to 10 minutes depending on your chosen drug treatment. The abdomen remains expanded by gas during this time and for up to 30 minutes from the time the chemo is dispersed. On completion, the gas and pressure in the abdomen is released and the small skin incisions are closed with stitches which dissolve or are removed a few days later.
The pressure created by the carbon dioxide in the abdomen has several benefits,
- its helps disperse the chemotherapy evenly throughout the cavity,
- it assists with the penetration of chemotherapy into the tissues
- it achieves high concentration of the drug into the tissue.
- because this treatment mode is so effective, much lower doses of chemotherapy can be effective, minimising the risk of drug side effects
How long will I be in hospital after PIPAC?
It is anticipated you will be in hospital for 1 to 2 days following the procedure.
What are the possible side effects?
Side effects typically associated with laparoscopy which may last a couple of days may include
- local tenderness at the incision site which may require some short-term pain relief
- abdominal bloating or cramps
- shoulder tip pain caused by diaphragm irritation from the carbon dioxide gas
What are the possible complications of PIPAC/laparoscopy?
- Reaction to the chemotherapy drug (rare)
- Perforation of the bowel
- Not being able to access the peritoneal cavity due to adhesions/scar tissue or tumour
How will I know if PIPAC is working?
At the start of the procedure, the surgical team will assess the Peritoneal Cancer Index (PCI), being the volume of cancer seen in the peritoneal cavity and take biopsies, the results of both will be compared with any follow-up procedures. It is usual to plan for 3 PIPAC procedures 6 weeks apart.
You may simply notice an improvement in symptoms e.g. a reduction in the volume of ascites, less pain or generally feeling better. Some people due to the presence of adhesions (scar tissue), cancer progression or bowel obstruction may not be able to have the initial or follow-up PIPAC treatment.
Do I still need to have intravenous (systemic) chemotherapy?
It is likely you have already had 1 to 2 lines of chemotherapy to treat your cancer and you may currently be receiving intravenous chemotherapy. PIPAC can safely be included in your treatment plan with systemic chemotherapy, the combination may achieve a better result. Your treating oncology doctor or surgeon will discuss this with you.
What happens after PIPAC treatment?
You will be given an outpatient appointment to see the surgeon in the clinic approximately 2 weeks after the PIPAC treatment for a physical assessment and removal of stitches if still present. Your surgeon will discuss what was seen during the laparoscopy and explain the biopsy results i.e. is your cancer responding to treatment or not. Plans for repeat PIPAC will then be discussed if appropriate to continue. It is a good idea to bring a support person to all appointments and please feel free to ask as many questions as you wish.