Safety courses are required for all staff participating in a heated chemotherapy procedure. A special method has been designed for drug delivery and disposal in the OR, as outlined below.
The initial preparation and positioning of the patient have been described in the surgical technique chapters on P/D (Chapter 121) and EPP (Chapter 122). After surgical resection is completed, our current protocol requires administration of amifostine at a dose of 910 mg/m2 for renal protection 30 to 45 minutes prior to the initiation of the lavage. After completing the lavage, the anesthesia team administers an intravenous bolus of sodium thiosulfate (4 g/m2), followed by a 6-hour infusion of 12 g/m2 sodium thiosulfate. This protects against intravascular volume depletion and helps to maintain a urine output of 100 mL/h during the lavage and afterwards.
Removing the diaphragm during surgical resection allows entry in the abdominal cavity. Once the tumor and specimen have been removed along with the lymph nodes, the chest is washed with 3 L of normal saline solution and 1 L of sterile water. Next, the chest is packed with Mikulicz's pads and the argon beam cautery is used for hemostasis of both the chest wall and lung surface (the latter for cases involving P/D). Once hemostasis is adequate, the chest is then irrigated with 3 L of warm normal saline solution to remove fibrin and debris before HIOC is initiated.
Special attention should be drawn to areas once laden with dense tumor, such as the costophrenic sulcus or areas that may have been contaminated during the procedure, such as the subscapular region, skin, and soft tissues bordering the incision.
Hemostasis is again ensured before setting up the chemotherapy delivery apparatus (Fig. 123-1). The thoracotomy incision is approximated at both ends by using a no. 2 nylon running locking suture, leaving a small aperture in the center of the wound (Fig. 123-2). This permits access for the surgeon to place a double-gloved hand into the thorax and evenly distribute the perfusate. The Omni retractor (Omni-Tract, Minneapolis, MN) is secured to the surgeon's side of the table. Interrupted no. 2 nylon sutures then are placed at selected points along the wound aperture, and the edges of the wound are lifted onto the Omni wishbone arms so as to create a funnel that prevents spillover of the intracavitary chemotherapy.
Cannula placement for delivery of hyperthermic intraoperative chemotherapy lavage in a patient undergoing resection for malignant pleural mesothelioma. The intake cannula (for delivery of the chemotherapy) is placed in the pelvis or over the diaphragm posteriorly in cases where the diaphragm is spared. The outflow cannula (for removal of the chemotherapy) is placed in the apex of the chest and the patient is placed in slight Trendelenburg position.
The wound is closed with no. 2 running locking nylon sutures from both ends. A thoracic well is created by lifting the edges of the wound over the wishbone arms of the Omni retractor for administration of the lavage.
Two cannulae are placed—the inflow cannula (straight) and the outflow cannula (L-shaped). For right-sided resections, the surgeon places the straight-inflow cannula in the pelvis by holding it in his left hand and pushing it through the wide open thoracoabdominal cavity. For left-sided resections, the surgeon holds the cannula in the right hand and pushes it above the stomach into the pelvis. Special attention is taken not to injure the capsule of the spleen during this maneuver. The L-shaped outflow cannula is placed at the apex of the pleural space to collect the perfusate and return it to the pump. Both drains are then connected to the perfusion pump. Adhesive tapes are used to cover the entire field creating a well. This prevents the lavage fluid from escaping the operative field. A slit is made in the plastic shield, which permits the surgeon to monitor the perfusate level (Fig. 123-3). Once HIOC is initiated, the inflow and outflow perfusate temperatures are monitored constantly and maintained at 42°C. The entire field should be submerged in the solution. The edges of the wound not bathed by the perfusate should be constantly irrigated by the surgeon with a properly labeled bulb syringe that is discarded at the end of the lavage. Constant communication between the surgeon and the perfusionist ensures that the level of the lavage fluid in the chest cavity is appropriate. A smoke evacuator is used to pull air from beneath the plastic cover and pass it through an activated charcoal filter to prevent any possible contamination of air in the OR by chemotherapy aerosols.
The edges of the wound, drains, and retractor are covered with a clear sheet of plastic adhesive.
After 1 hour of thoracoabdominal lavage, the patient is placed in steep Trendelenburg position, and the perfusate is drained out of the field back into the perfusion circuit. The volume of perfusate returned to the circuit is scrutinized, and different maneuvers are performed to maximize the return of perfusate. These include displacing the omentum or gently sweeping any perfusate retained in the pelvis or in between bowel loops into the field. Leaving behind a significant amount of perfusate will increase the systemic absorption of cisplatin and toxicity and cause prolonged postoperative ileus. At this point, an omental fat pad is fashioned with endovascular staples. It is of paramount importance that the pad reaches the bronchial stump without tension. In the absence of an adequate omental fat pad, one could use pericardial remnant or parathymic fat to buttress the bronchial stump. The chest cavity is once again irrigated with normal saline solution, hemostasis is completed, and the chest is packed with five or six Mikulicz pads.
Next, the diaphragm and pericardium are reconstructed with Gore-Tex patches (W.L. Gore and Associates, Flagstaff, AZ) (Fig. 123-4). For the diaphragm, we routinely use two 2-mm thick patches stapled together. Pericardial reconstruction is carried out with a 0.1-mm fenestrated pericardial patch. An omental flap is constructed most easily by stapling endo-GIA vascular loads (2.9 mm) across parts of the omentum while the abdomen is fully exposed (after the lavage but before the diaphragm patch is undertaken).
Reconstruction of the diaphragm with 2 GORE® DUALMESH® PLUS patches, joined in the middle by two staple lines using a Reloadable Linear Stapler with two staggered rows of titanium staples (60 mm staple line length). The patch is then sewn to the chest wall with 9 ETHIBOND EXCEL™ Polyester Suture 1.
Before the incision is closed, a final check for hemostasis is performed. We often use an aerosol 9F fibrin sealant across the thoracic cavity (Evicel, Ethicon, Inc., Somerville, NJ) to assist with firm hemostasis. A 12F Rob-Nel (Dover, Rob-Nel, Kendall, Inc., Mansfield, MA) catheter is left in the thoracic cavity to permit access to the space postoperatively. Once the wound is completely closed, air is withdrawn through the Rob-Nel catheter for medialization of the mediastinum. Current guidelines call for the withdrawal of 750 mL from the right thoracic space in a female and 1000 mL in a male, and 500 mL from the left thoracic space in a female and 750 mL in a male. The preceding serves as a guideline only, however, because the evacuation of air should be aborted early if any suggestion of hemodynamic instability develops as a consequence of excessively negative intrathoracic pressure. Beyond the immediate evacuation of fluid in the OR, the Rob-Nel catheter is used in the ensuing day(s) to withdraw postoperative fluid and correct for mediastinal shift, as well as to reduce intrathoracic pressures. The trend of intrathoracic pressures is monitored, and any sudden rise in pressure should be managed by urgent withdrawal of intrathoracic fluid to avoid potential compression on the mediastinum and vena cava.23
Once the patient is turned supine and the double-lumen endotracheal tube is exchanged for a single-lumen tube, bronchoscopy is repeated at the end of the procedure to visualize the bronchial stump and to clear secretions from the remaining dependent lung.