PIPACs

PIPACs refer to the use of pressurized intraperitoneal aerosol chemotherapy, a minimally invasive technique designed to deliver chemotherapy as an aerosolized mist under positive pressure into the peritoneal cavity during laparoscopy. The goal is to treat peritoneal metastases by achieving better local distribution and tissue penetration of the drugs while limiting systemic exposure.

The procedure is performed under general anesthesia. The abdomen is accessed laparoscopically, and the peritoneal cavity is insufflated with CO2. A specialized aerosolization device disperses a chemotherapeutic solution as a fine aerosol, maintained at a controlled pressure to enhance tissue uptake. Treatments typically last about 30 minutes and are repeated in several cycles over weeks, often as part of a planned course.

Regimens used in PIPACs vary by center and country. Commonly employed combinations include cisplatin with doxorubicin and oxaliplatin-based regimens; the specific drugs, doses, and cycle frequency are adapted to tumor type, prior therapy, and patient condition.

Indications for PIPACs include peritoneal carcinomatosis from gastric, ovarian, colorectal cancers, appendiceal neoplasms, and mesothelioma. It is used for palliation, to downstage disease toward cytoreductive surgery, or within experimental settings and clinical trials. In some cases, it follows systemic chemotherapy when response is limited by toxicity.

Evidence supporting PIPACs comes primarily from small prospective studies and retrospective series. Reported benefits include local disease control and symptom relief with lower systemic toxicity, but robust randomized data on survival are limited. The procedure requires specialized equipment and trained teams and carries risks related to laparoscopy, chemotherapy exposure, and anesthesia, necessitating strict safety protocols.