Figure 37

Essential components of the coliseum technique for heated intraoperative intraperitoneal chemotherapy. A running suture on the self-retaining retractor suspends the skin of the abdominal wall. A sheet of plastic is incorporated into the running suture so that the abdomen is covered. This helps to hold the heat in the abdomen and prevents splashing as the viscera are vigorously manipulated. Temperature probes are placed at the inflow site for the heated chemotherapy and at a distant site within the abdomen or pelvis. Three or four closed suction drains are placed through the abdominal wall and positioned beneath the hemidiaphragms and within the pelvis. These drains return chemotherapy solution to the reservoir. A smoke evacuator is placed beneath the plastic sheet so that airflow is always from the operating theater, into the abdomen, and then out into a charcoal filter. The surgeon's double-gloved hand is placed through a cut in the plastic sheet. Vigorous scrubbing of all surfaces within the abdomen and pelvis is a crucial part of the dislodgment of fibrin and the entrapped tumor cells. Without chemotherapy, pseudomyxoma peritonei cells or mucinous adenocarcinoma cells will recur widely throughout the abdominopelvic surfaces.

Figure 38

Perfusion circuit for heated intraoperative intraperitoneal chemotherapy. The essential components are catheters, two roller pumps, a chemotherapy reservoir, a heat exchanger, a digital thermometer and a smoke evacuator.

Mitomycin C Orders

1. For adenocarcinoma from appendiceal, colonic, rectal, gastric and pancreatic cancer;
   add _____ mg mitomycin C to 2 liters of 1.5% peritoneal dialysis solution.
2. Dose of mitomycin C for males 12.5 mg/m², for females 10 mg/m².
3. Use a 33% dose reduction for heavy prior chemotherapy, marginal renal function,
   age > 60, extensive intraoperative trauma to small bowel surfaces, or prior radiotherapy.
4. Send 1 liter of 1.5% peritoneal dialysis solution to test the perfusion circuit.
5. Send 1 liter of 1.5% peritoneal dialysis solution for immediate postoperative lavage.
   Send the above to operating room at _____ o’clock

Figure 39

Temperature graph. Temperatures measured while treated with heated intraoperative intraperitoneal chemotherapy using the coliseum technique.

Figure 40 Top and Bottom.

Non-uniform distribution of chemotherapy solution noted when heated chemotherapy is given with the abdomen closed. At numerous institutions, the chemotherapy solution is placed into the abdomen and the abdomen closed for the duration of the heated intraoperative intraperitoneal chemotherapy treatments. If blue dye is placed in the abdomen using the closed technique, inconsistent staining of serosal surfaces will be observed. The areas that fail to stain with blue dye closely correspond to the areas of treatment failure used with early postoperative intraperitoneal chemotherapy. These areas of treatment failure are the anterior surface of the stomach, surfaces of the small bowel mesentery and anastomotic sites, especially the gastrojejunostomy.

Day of Operation:

1. Run in 1000 ml of 1.5% dextrose peritoneal dialysis solution as rapidly as possible.
   Warm to body temperature prior to instillation. Clamp all abdominal drains during infusion.
2. No dwell time.
3. Drain as rapidly as possible through the Tenckhoff catheter and abdominal drains.
4. Repeat irrigations every 1 hour for 4 hours, then every 4 hours until returns are clear;
   then every 8 hours until chemotherapy begins. Change dressing covering Tenckhoff catheter and abdominal drain sites using sterile technique once daily and prn.

Table 12

Immediate postoperative abdominal lavage is used in those patients who will receive early postoperative intraperitoneal chemotherapy with 5-fluorouracil.

Postoperative Days 1-5

1. Add to _____ ml 1.5% dextrose peritoneal dialysis solution:
   (a) _____ mg 5-fluorouracil (650 mg/m², maximum dose 1300 mg)
   (b) 50 mEq sodium bicarbonate.
2. Intraperitoneal fluid volume: 1 liter for patients < 2.0m², 1.5 liter for > 2.0 m².
3. Drain all fluid from the abdominal cavity prior to instillation; then clamp all drains.
4. Run the chemotherapy solution into the abdominal cavity through the Tenckhoff
   catheter as rapidly as possible.
   Dwell for 23 hours and drain for 1 hour prior to next instillation.
5. Use gravity to maximize intraperitoneal distribution of the 5-fluorouracil.
   Instill the chemotherapy with the patient in a full right lateral position.
   After 1/2 hour, direct the patient to turn to the full left lateral position.
   Change position right to left every 1/2 hour. If tolerated, use 10 degrees
   of Trendelenburg position. Continue turning for the first 6 hours after
   instillation of chemotherapy solution.
   
   Continue to drain abdominal cavity after final dwell until Tenckhoff catheter is removed.
   
   Use 33% dose reduction for heavy prior chemotherapy, age greater than 60, or prior radiotherapy.

Table 13

Early postoperative intraperitoneal chemotherapy with 5-fluorouracil.

Cycle # _______

1. CBC, Platelets, Profile A, and appropriate tumor marker prior to treatment; and CBC, platelets 10 days after initiation of treatments.
2. 5-Fluorouracil _____ mg (750 mg/m²)(maximum dose 1500 mg) and 50 mEq sodium bicarbonate in 1000 cc 1.5% dextrose dialysis solution via intraperitoneal catheter q day x 5 days. Last dose _______. Dwell for 23 hours, drain for one hour. Continue with next administration even if no drainage is obtained.
3. On Day 3 (Date _______): 1000 cc lactated Ringer's solution intravenously over 2 hours prior to mitomycin infusion. Mitomycin C _____ mg (10 mg/m² x _______ m2)(maximum dose 20 mg) in 200 cc 5% dextrose and water intravenously over 2 hours.
4. Follow routine procedure for peripheral extravasation of a vesicant if extravasation should occur.
5. Compazine 25 mg per rectum every 4 hours as necessary for nausea. OUTPATIENT ONLY: May dose x 4 for use at home.
6. Percocet 1 tablet by mouth every 3 hours as necessary for pain. OUTPATIENT ONLY: May dose x 4 for use at home.
7. Routine vital signs.

Table 14

Adjuvant or induction intraperitoneal 5-fluorouracil and intravenous mitomycin C chemotherapy.

Figure 41

Approach to the treatment of peritoneal carcinomatosis from appendix cancer. This more aggressive protocol is used in patients with intermediate grade mucinous adenocarcinoma and mucinous adenocarcinoma. It is not used for pseudomyxoma peritonei patients unless they have an incomplete cytoreduction. From Sugarbaker PH: Cancer of the appendix and pseudomyxoma (In) Current Therapy in Colon and Rectal Surgery. Fazio VW, Church J. Decker: Toronto, 1997.

Figure 42 A

CT scan showing uniform distribution of intraperitoneal fluid. This CT scan with intraperitoneal contrast is obtained on each cycle prior to the instillation of chemotherapy solution.

Figure 42 B

CT through the mid-abdomen in a patient given intraperitoneal contrast. Many of the small bowel loops are separated by the intraperitoneal chemotherapy. Small bowel loops on the right side of the abdomen are adherent to the right colon and to themselves. Incomplete drug distribution would be predicted, and cancer progression likely in the matted loops of small bowel.