Chemical/technical risk analysis of a new multi-directional nebulizer (MDN) and its clinical implementation for the safe administration of Pressurized Intraperitoneal Aerosol Chemotherapy (MDN-PIPAC)

ABSTRACT Background/Aim To test the chemoresistance of a multi-directional nebulizer (MDN) and to establish and implement a perioperative clinical safety concept for its clinical use to deliver pressurised intraperitoneal aerosol chemotherapy (MDN-PIPAC). Study design Ex-vivo nebulization of cytostatic drugs with the MDN device to assess chemoresistance/toxicological risks. Establishment of a perioperative safety concept for the clinical administration of MDN-PIPAC by ex- and in-vivo porcine simulation studies. Unicentric case series of 30 MDN-PIPACs in 21 patients with peritoneal surface malignancies (PSM). Endpoints were intraoperative adverse events and perioperative complications (Clavien-Dindo). Results Toxicological studies/risk assessment confirm the safety of administering PIPAC with the MDN. The horizontal nozzles must protrude at least 7 mm beyond the most distal end of the trocar tip and lateral tilting should be prevented by fixation of the device in a single-arm holder. A total of 21 patients (male/female ratio: 2:1) with a mean age of 62 (range: 38-86) years underwent 30 consecutive MDN-PIPACs for peritoneal surface malignancies of different origin. ECOG 0 and 1 were seen in five and 16 patients, respectively. Thirteen, seven, and one patient underwent one, two, and three MDN-PIPACs, respectively. Two patients received only one cycle of MDN-PIPAC because they were considered candidates for cytoreductive surgery and heated intraperitoneal chemotherapy. There were no intraoperative technical/medical problems observed. Four patients suffered from postoperative grade I complications. Conclusions Compounds leached during chemotherapy nebulization with the MDN are toxicologically safe. MDN-PIPAC administrations are safe and the postoperative course is comparable to that of the conventional PIPAC nebulizer. MINI ABSTRACT Toxicological analyses confirm that doxorubicin, cisplatin, and oxaliplatin nebulized with the MDN do not release leachables that pose a toxicological risk to patients. Through technical risk analysis and PIPAC simulations, a safety concept for the administration of MDN-PIPAC was established. No technical/medical intraoperative adverse events were observed. The perioperative course was comparable to that of the conventional axial single-direction nebulizer (SDN) PIPAC.