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Invited Critique
May 1999

Invited Critique: Peritoneal Expansion by Artificially Produced Ascites During Perfusion Chemotherapy

Arch Surg. 1999;134(5):550. doi:10.1001/archsurg.134.5.550

The authors provide a modification in technique of hyperthermic peritoneal perfusion for peritoneal adenocarcinomatosis that builds on earlier studies. However, there are technical and cytokinetic limitations to their approach. From the technical standpoint, their perfusion system would not avoid streaming of flow. Like the authors, my approach would be to resect the primary cancer, omentum, and as much of the peritoneal implants as possible. Afterward, I would copiously irrigate the peritoneal cavity with 5% dextrose in water heated on last wash to 55°C and leave it in for only 3 to 5 minutes before removing. This temperature for short exposure is as thermolethal as the lower temperature used by the authors for longer periods. There is some evidence that the mucopolysaccharides forming the viscous ascites in pseudomyxoma are miscible in 5% dextrose in water. Also, 5% dextrose in water has an osmolytic effect on cells. The solution is not removed, but will be absorbed into the circulation. From this point on, my chemotherapy technique, developed with Thomas Woodcock, MD (unpublished data, 1998) is influenced by the fact that many cases of peritoneal carcinomatosis are composed of cancer cells with very low proliferative indexes. With antiproliferative drugs only, cells that are in cycle will be affected by the drugs. This requires a more protracted course of chemotherapy, which is obtained by inserting a titanium peritoneal port (PORT-A-CATH [catalog No. 21-2000]; Pharmacia Deltech Inc, St Paul, Minn) before abdominal closure. Drugs are administered via the PORT-A-CATH at weekly intervals for 6 weeks, followed by a 2-week rest. The drugs are diluted in 2000 mL 5% dextrose in water. The solution is not removed but will be absorbed. This volume is necessary for diffusion to occur throughout the peritoneal cavity. The course continues for 1 year. In the case of bowel cancer, the weekly course consists of 750 mg of fluorouracil and 1000 mg of leucovorin calcium. This is very well tolerated. Lorazepam (Ativan) can be given before each treatment for the prevention of nausea.

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