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Use of the Veress Needle for Instillation of Intraperitoneal Chemotherapy
GYNECOLOGIC ONCOLOGY
59, 249–250 (1995)
Use of the Veress Needle for Instillation of Intraperitoneal Chemotherapy J. MENCZER, M.D.1 Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel; and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Received January 18, 1995
The Veress needle was used for instillation of short-term cisplatin-based intraperitoneal chemotherapy in ovarian carcinoma patients who, after completion of systemic postoperative chemotherapy, were clinically in complete remission. A total of 87 instillations were done in 32 patients. Only two not severe complications were encountered. The Veress needle is a safe, convenient, and inexpensive access device especially for short-term intraperitoneal chemotherapy. q 1995 Academic Press, Inc.
Intraperitoneal chemotherapy is at present one of the treatment methods of ovarian carcinoma [1, 2] and a variety of access devices are being used for this purpose [3–7]. We have employed short-term intraperitoneal chemotherapy for the treatment of ovarian carcinoma patients who after postoperative chemotherapy were clinically in complete remission [8, 9]. Originally intraperitoneal chemotherapy was administered through a double cuff Tenckhoff catheter inserted at the time of second-look laparotomy. Subsequently, we used the Veress needle for intraperitoneal chemotherapy delivery. The following report summarized our experience with this intraperitoneal chemotherapy instillation device.
therapy prior to intraperitoneal chemotherapy; only 13 (40.6%) had £ 2 cm residual disease. Second-look laparotomy was done in 13 patients before intraperitoneal chemotherapy. This chemotherapy consisted of intraperitoneal cisplatin (200 mg/m2) with intraperitoneal etoposide (300 mg/ m2) or intraperitoneal cisplatin alone with or without systemic ifosfamide (1.2 g/m2). Intraperitoneal cisplatin was given with systemic thiosulfate kidney protection and systemic ifosfamide with mesna for uroprotection. The intraperitoneal chemotherapy agents, diluted in 2 liters of saline, were instilled through a Veress needle inserted prior to each treatment. The insertion was done under local anaesthesia in the left lower abdomen, at a point midway on the line between the left anterior superior ilial spine and the umbilicus. After insertion, aspiration, injection of 10 ml saline and reaspiration was done. If no blood or fluid was obtained during aspiration and reaspiration and the saline injection met with no resistance, needle placement was assumed to be correct. Thereafter, the needle was fixed and chemotherapy instillation commenced. The peritoneal cavity was not drained and the needle was removed after completion of instillation. The majority of the needle placements were done by senior physicians.
MATERIALS AND METHODS RESULTS
The study group consisted of 32 patients with histologically confirmed stage II–IV ovarian carcinoma of epithelial origin diagnosed from 1988 to 1993. All of these patients were clinically in complete remission after completion of six courses of postoperative cisplatin-based chemotherapy and were designated to received three courses of intraperitoneal chemotherapy at 3- to 4-week intervals. None of the patients underwent bowel resection during the initial operation, had postoperative septic morbidity, or received radio1 Current address: Gynecologic Oncology Service, Department of Obstetrics and Gynecology, Sackler Faculty of Medicine, Tel Aviv University, E. Wolfson Medical Center, Holon, Israel.
Six patients refused to complete the preplanned three courses of therapy. Each of the 32 patients ultimately received 1–3 (median 3) courses of intraperitoneal chemotherapy courses, totaling 87 instillations. Veress needle insertion complications occurred during two (2.3%) instillations. In one patient, part of the chemotherapy, which consisted of cisplatin with etoposide, was injected subcutaneously instead of intraperitoneally. Local edema, induration, and redness developed, which spontaneously gradually subsided within 5 weeks. An additional very slim patient complained of severe pain in the left flank shortly after beginning the instillation, probably due to retroperitoneal injection. The pain sub-
249
/ m3799$4084
09-26-95 07:03:14
goa
0090-8258/95 $12.00 Copyright q 1995 by Academic Press, Inc. All rights of reproduction in any form reserved.
AP: Gyn Onc
250
J. MENCZER
sided after reinsertion of the Veress needle. No other complications were observed.
2. Markman, M. Intraperitoneal cisplatin chemotherapy in the management of ovarian carcinoma, Semin. Oncol. 16, 79–82 (1989).
DISCUSSION
3. Tenckhoff, H., and Schechter, H. A bacteriologically safe peritoneal access device, Trans. Am. Soc. Artif. Intern. Organs 14, 181–187 (1968).
The complications associated with the different devices used for intraperitoneal chemotherapy administration include infection, bowel perforation, and device malfunction [5–7, 10–14]. We have not encountered serious complications with the double cuff Tenckhoff catheter [8, 9]. However, we were dissatisfied with the need for a separate surgical intervention for its removal and the occasional technical difficulties and patient inconvenience associated with this procedure. The use of an implantable port for short-term intraperitoneal chemotherapy seemed unreasonable and expensive. The Veress needle was therefore employed. Granted, its placement is blind and must be repeated with each course of therapy instillation, but the insertion technique is simple and the device is inexpensive and reusable. We were further encouraged to continue its use by the preliminary report of Pfeiffer et al. [15] who, on the basis of 22 instillations in 7 patients, found its use safe and reliable. It is noteworthy that serious complications including bowel perforation have also been reported with Veress needle insertion [16]. However, the types of complications we encountered were not severe and the complication rate was very low (2.3%). It should also be mentioned that, while in our case of inadvertent subcutaneous injection, no serious sequellae occurred, others reported severe local tissue damage and skin necrosis after cisplatin extravasation [17–19]. A device that measures fluid flow rate or pressure could aid in determining correct intraperitoneal placement. In contrast to Pfeiffer et al. [15], we inserted the Veress needle in the left lower abdominal quadrant and not at the umbilicus. This site was chosen in attempt to avoid the adhesions possibly present in the midline area, the region of scars from previous laparotomies. Childers et al. [20] recently proposed placement of the needle in the left upper quadrant in the 9th intercostal space in patients at high risk for adhesions. Permanent devices may be preferable when long-term intraperitoneal chemotherapy is contemplated. We suggest that the Veress needle is a safe, convenient, and inexpensive access device option, especially when short-term intraperitoneal chemotherapy is planned. REFERENCES 1. Howel, S. G. Intraperitoneal chemotherapy for ovarian carcinoma, J. Clin. Oncol. 6, 1673–1675 (1988).
/ m3799$4084
09-26-95 07:03:14
goa
4. Pfeifle, C. E., Howell, S. B., Markman, M., and Lucas, W. E. Totally implantable system for peritoneal access, J. Clin. Oncol. 2, 1277–1280 (1984). 5. Runowicz, C. D., Dottino, P. R., Shafir, M. K., Mark, M. A., and Cohen, C. J. Catheter complications associated with intraperitoneal chemotherapy, Gynecol. Oncol. 24, 41–50 (1986). 6. Waggoner, S. E., Johnson, J., Barter, J., and Barnes, W. Intraperitoneal therapy administered through a Gorshong catheter, Gynecol. Oncol. 53, 320–325 (1994). 7. Malmstrom, H., Carstensen, J., and Simonsen, E. Experience with implanted subcutaneous ports for intraperitoneal chemotherapy in ovarian cancer, Gynecol. Oncol. 54, 27–34 (1994). 8. Menczer, J., Ben-Baruch, G., Rizel, S., and Brenner, H. Intraperitoneal cisplatin chemotherapy in ovarian carcinoma patients who are clinically in complete remission, Gynecol. Oncol. 46, 222–225 (1992). 9. Menczer, J., Ben-Baruch, G., Rizel, S., and Brenner, H. Intraperitoneal chemotherapy with cisplatin and etoposide in ovarian carcinoma patients who are clinically in complete remission, Eur. J. Gynecol. Oncol. 16, 12–17 (1995). 10. Myers, C. E., and Collins, J. M. Pharmacology of intraperitoneal chemotherapy, Cancer Invest. 1, 395–407 (1983). 11. Wakefield, T., Eckhauser, F., Strodel, W., and Knol, J. Colocutaneous fistula complicating Tenckhoff catheter placement for intraperitoneal chemotherapy, J. Surg. Oncol. 27, 205–207 (1984). 12. Kouris, T. B., and Botha, J. R. Erosion of the caecum by a Tenckhoff catheter: A case report, S. Afr. J. Surg. 23, 117–118 (1985). 13. Piccart, M. J., Speyer, J. L., Markman, M., ten Bokkel Huinink, W. W., Alberts, D., Jenkins, J., and Muggia, F. Intraperitoneal chemotherapy: Technical experience at five institutions, Semin. Oncol. 12, 90–96 (1985). 14. Varney, R. R., Goel, R., van Sonnenberg, E., Lucas, W. E., and Casola, G. Delayed erosion of intraperitoneal chemotherapy catheters into the bowel, Cancer 64, 762–764 (1989). 15. Pfeiffer, P., Asmussen, L., Kuist-Pulsen, H., and Bertelsen, K. Intraperitoneal chemotherapy: Introduction of a new ‘‘single use’’ delivery system—A preliminary report, Gynecol. Oncol. 35, 47–49 (1989). 16. Frenkel, Y., Oelsner, G., Ben-Baruch, G., and Menczer, J. Major surgical complications of laparoscopy, Eur. J. Obstet. Gynecol. Reprod. Biol. 12, 107–111 (1981). 17. Algarra, S. M. Cutaneous necrosis after intraarterial treatment with cisplatin, Cancer Treat. Rep. 70, 687–688 (1986). 18. Leyden, M., and Sullivan, J. Full-thickness skin necrosis due to inadvertent interstitial infusion of cisplatin, Cancer Treat. Rep. 67, 199 (1983). 19. Fields, S., Koeller, J., Topper, R. L., and Guritz, G., Von Noff D. Local soft tissue toxicity following cisplatin extravasation, J. Natl. Cancer Inst. 82, 1649–1650 (1990). 20. Childers, J. M., Brzechffa, P. R., and Surwit, E. A. Laparoscopy using the left upper quadrant as the primary trocar site, Gynecol. Oncol. 50, 221–225 (1993).
AP: Gyn Onc
59, 249–250 (1995)
Use of the Veress Needle for Instillation of Intraperitoneal Chemotherapy J. MENCZER, M.D.1 Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel; and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Received January 18, 1995
The Veress needle was used for instillation of short-term cisplatin-based intraperitoneal chemotherapy in ovarian carcinoma patients who, after completion of systemic postoperative chemotherapy, were clinically in complete remission. A total of 87 instillations were done in 32 patients. Only two not severe complications were encountered. The Veress needle is a safe, convenient, and inexpensive access device especially for short-term intraperitoneal chemotherapy. q 1995 Academic Press, Inc.
Intraperitoneal chemotherapy is at present one of the treatment methods of ovarian carcinoma [1, 2] and a variety of access devices are being used for this purpose [3–7]. We have employed short-term intraperitoneal chemotherapy for the treatment of ovarian carcinoma patients who after postoperative chemotherapy were clinically in complete remission [8, 9]. Originally intraperitoneal chemotherapy was administered through a double cuff Tenckhoff catheter inserted at the time of second-look laparotomy. Subsequently, we used the Veress needle for intraperitoneal chemotherapy delivery. The following report summarized our experience with this intraperitoneal chemotherapy instillation device.
therapy prior to intraperitoneal chemotherapy; only 13 (40.6%) had £ 2 cm residual disease. Second-look laparotomy was done in 13 patients before intraperitoneal chemotherapy. This chemotherapy consisted of intraperitoneal cisplatin (200 mg/m2) with intraperitoneal etoposide (300 mg/ m2) or intraperitoneal cisplatin alone with or without systemic ifosfamide (1.2 g/m2). Intraperitoneal cisplatin was given with systemic thiosulfate kidney protection and systemic ifosfamide with mesna for uroprotection. The intraperitoneal chemotherapy agents, diluted in 2 liters of saline, were instilled through a Veress needle inserted prior to each treatment. The insertion was done under local anaesthesia in the left lower abdomen, at a point midway on the line between the left anterior superior ilial spine and the umbilicus. After insertion, aspiration, injection of 10 ml saline and reaspiration was done. If no blood or fluid was obtained during aspiration and reaspiration and the saline injection met with no resistance, needle placement was assumed to be correct. Thereafter, the needle was fixed and chemotherapy instillation commenced. The peritoneal cavity was not drained and the needle was removed after completion of instillation. The majority of the needle placements were done by senior physicians.
MATERIALS AND METHODS RESULTS
The study group consisted of 32 patients with histologically confirmed stage II–IV ovarian carcinoma of epithelial origin diagnosed from 1988 to 1993. All of these patients were clinically in complete remission after completion of six courses of postoperative cisplatin-based chemotherapy and were designated to received three courses of intraperitoneal chemotherapy at 3- to 4-week intervals. None of the patients underwent bowel resection during the initial operation, had postoperative septic morbidity, or received radio1 Current address: Gynecologic Oncology Service, Department of Obstetrics and Gynecology, Sackler Faculty of Medicine, Tel Aviv University, E. Wolfson Medical Center, Holon, Israel.
Six patients refused to complete the preplanned three courses of therapy. Each of the 32 patients ultimately received 1–3 (median 3) courses of intraperitoneal chemotherapy courses, totaling 87 instillations. Veress needle insertion complications occurred during two (2.3%) instillations. In one patient, part of the chemotherapy, which consisted of cisplatin with etoposide, was injected subcutaneously instead of intraperitoneally. Local edema, induration, and redness developed, which spontaneously gradually subsided within 5 weeks. An additional very slim patient complained of severe pain in the left flank shortly after beginning the instillation, probably due to retroperitoneal injection. The pain sub-
249
/ m3799$4084
09-26-95 07:03:14
goa
0090-8258/95 $12.00 Copyright q 1995 by Academic Press, Inc. All rights of reproduction in any form reserved.
AP: Gyn Onc
250
J. MENCZER
sided after reinsertion of the Veress needle. No other complications were observed.
2. Markman, M. Intraperitoneal cisplatin chemotherapy in the management of ovarian carcinoma, Semin. Oncol. 16, 79–82 (1989).
DISCUSSION
3. Tenckhoff, H., and Schechter, H. A bacteriologically safe peritoneal access device, Trans. Am. Soc. Artif. Intern. Organs 14, 181–187 (1968).
The complications associated with the different devices used for intraperitoneal chemotherapy administration include infection, bowel perforation, and device malfunction [5–7, 10–14]. We have not encountered serious complications with the double cuff Tenckhoff catheter [8, 9]. However, we were dissatisfied with the need for a separate surgical intervention for its removal and the occasional technical difficulties and patient inconvenience associated with this procedure. The use of an implantable port for short-term intraperitoneal chemotherapy seemed unreasonable and expensive. The Veress needle was therefore employed. Granted, its placement is blind and must be repeated with each course of therapy instillation, but the insertion technique is simple and the device is inexpensive and reusable. We were further encouraged to continue its use by the preliminary report of Pfeiffer et al. [15] who, on the basis of 22 instillations in 7 patients, found its use safe and reliable. It is noteworthy that serious complications including bowel perforation have also been reported with Veress needle insertion [16]. However, the types of complications we encountered were not severe and the complication rate was very low (2.3%). It should also be mentioned that, while in our case of inadvertent subcutaneous injection, no serious sequellae occurred, others reported severe local tissue damage and skin necrosis after cisplatin extravasation [17–19]. A device that measures fluid flow rate or pressure could aid in determining correct intraperitoneal placement. In contrast to Pfeiffer et al. [15], we inserted the Veress needle in the left lower abdominal quadrant and not at the umbilicus. This site was chosen in attempt to avoid the adhesions possibly present in the midline area, the region of scars from previous laparotomies. Childers et al. [20] recently proposed placement of the needle in the left upper quadrant in the 9th intercostal space in patients at high risk for adhesions. Permanent devices may be preferable when long-term intraperitoneal chemotherapy is contemplated. We suggest that the Veress needle is a safe, convenient, and inexpensive access device option, especially when short-term intraperitoneal chemotherapy is planned. REFERENCES 1. Howel, S. G. Intraperitoneal chemotherapy for ovarian carcinoma, J. Clin. Oncol. 6, 1673–1675 (1988).
/ m3799$4084
09-26-95 07:03:14
goa
4. Pfeifle, C. E., Howell, S. B., Markman, M., and Lucas, W. E. Totally implantable system for peritoneal access, J. Clin. Oncol. 2, 1277–1280 (1984). 5. Runowicz, C. D., Dottino, P. R., Shafir, M. K., Mark, M. A., and Cohen, C. J. Catheter complications associated with intraperitoneal chemotherapy, Gynecol. Oncol. 24, 41–50 (1986). 6. Waggoner, S. E., Johnson, J., Barter, J., and Barnes, W. Intraperitoneal therapy administered through a Gorshong catheter, Gynecol. Oncol. 53, 320–325 (1994). 7. Malmstrom, H., Carstensen, J., and Simonsen, E. Experience with implanted subcutaneous ports for intraperitoneal chemotherapy in ovarian cancer, Gynecol. Oncol. 54, 27–34 (1994). 8. Menczer, J., Ben-Baruch, G., Rizel, S., and Brenner, H. Intraperitoneal cisplatin chemotherapy in ovarian carcinoma patients who are clinically in complete remission, Gynecol. Oncol. 46, 222–225 (1992). 9. Menczer, J., Ben-Baruch, G., Rizel, S., and Brenner, H. Intraperitoneal chemotherapy with cisplatin and etoposide in ovarian carcinoma patients who are clinically in complete remission, Eur. J. Gynecol. Oncol. 16, 12–17 (1995). 10. Myers, C. E., and Collins, J. M. Pharmacology of intraperitoneal chemotherapy, Cancer Invest. 1, 395–407 (1983). 11. Wakefield, T., Eckhauser, F., Strodel, W., and Knol, J. Colocutaneous fistula complicating Tenckhoff catheter placement for intraperitoneal chemotherapy, J. Surg. Oncol. 27, 205–207 (1984). 12. Kouris, T. B., and Botha, J. R. Erosion of the caecum by a Tenckhoff catheter: A case report, S. Afr. J. Surg. 23, 117–118 (1985). 13. Piccart, M. J., Speyer, J. L., Markman, M., ten Bokkel Huinink, W. W., Alberts, D., Jenkins, J., and Muggia, F. Intraperitoneal chemotherapy: Technical experience at five institutions, Semin. Oncol. 12, 90–96 (1985). 14. Varney, R. R., Goel, R., van Sonnenberg, E., Lucas, W. E., and Casola, G. Delayed erosion of intraperitoneal chemotherapy catheters into the bowel, Cancer 64, 762–764 (1989). 15. Pfeiffer, P., Asmussen, L., Kuist-Pulsen, H., and Bertelsen, K. Intraperitoneal chemotherapy: Introduction of a new ‘‘single use’’ delivery system—A preliminary report, Gynecol. Oncol. 35, 47–49 (1989). 16. Frenkel, Y., Oelsner, G., Ben-Baruch, G., and Menczer, J. Major surgical complications of laparoscopy, Eur. J. Obstet. Gynecol. Reprod. Biol. 12, 107–111 (1981). 17. Algarra, S. M. Cutaneous necrosis after intraarterial treatment with cisplatin, Cancer Treat. Rep. 70, 687–688 (1986). 18. Leyden, M., and Sullivan, J. Full-thickness skin necrosis due to inadvertent interstitial infusion of cisplatin, Cancer Treat. Rep. 67, 199 (1983). 19. Fields, S., Koeller, J., Topper, R. L., and Guritz, G., Von Noff D. Local soft tissue toxicity following cisplatin extravasation, J. Natl. Cancer Inst. 82, 1649–1650 (1990). 20. Childers, J. M., Brzechffa, P. R., and Surwit, E. A. Laparoscopy using the left upper quadrant as the primary trocar site, Gynecol. Oncol. 50, 221–225 (1993).
AP: Gyn Onc