outlooks to infectious diseases, re...

outlooks to infectious diseases, residual ethylene oxide, radiation, and inadvertent inhalation of anesthetics are familiar occupational risks to perioperative staff members. As more surgeon use hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) to treat patients with abdominopelvic cavity malignancies, perioperative staff members face increasing risks of in all senses to cytotoxic agents. The cumulative events of long-term, low-dose occupational exposing to cytotoxic agents are unknown. Clinical research terminates offer few answers to questions about cumulative tenors because research protocols are designed to consideration the toxicities of cytotoxic agents administered in therapeutic dosages.(1) Institutional policies and acts that guide the use of cytotoxic agents must house patients and their health care providers. At the Washington (DC) Hospital Center we have adopted conservative policies to defend perioperative personnel from occupational in all senses to HIIC agents.

recently made known CANCER TREATMENT REGIMENS

Patients with abdominopelvic cavity malignancies (eg appendiceal, ovarian, colorectal, gastric cancers; mesotheliomas; retroperitoneal and visceral sarcomas) oftentimes have progressive involvement of their peritoneal surfaces, which is attributed partly to preoperative and intraoperative tumor dissemination.(2) When malignant solitary abode; squalids gain access to the peritoneal cavity, they implant and swell as peritoneal carcinomatosis. To decrease these patients' morbidity and mortality rates, surgeon are combining multiple treatment modalities, single in kind of which is HIIC. Figure 1 illustrates the succession of treatments in the HIIC protocol that we use at the Washington Hospital Center for patients with peritoneal carcinomatosis.

Chemotherapy. Chemotherapy (Table 1) can be administered intraoperatively using cell-cycle independent medications (eg mitomycin C) that posses a pharmacokinetic advantage when delivered directly into the peritoneal cavity. Mitomycin C a chemotherapeutic agent that commonly is used to treat colorectal malignancies, acts through inhibiting DNA synthesis through alkylation of DNA strands, generation of exempt radicals, cross-linking of DNA strands, and creation of single-strand breaks in DNA.(3) Heating can enhance the cytotoxicity of many chemotherapy agents that may be administered intraoperatively.(4) Table 1 GLOSSARY OF TERMS(1)

* Chemotherapy: The prevention or treatment of disease with chemical agents.

* Cytoreduction: A series of peritonectomies and resections that strip the peritoneum from the abdominal cavity.

* Cytotoxicity: The kind or amount of poisonous efficiency on cells caused by a chemical substance not of biologic origin.

* 5-Fluorouracil: An antimetabolite that is used widely to treat breast and gostrointestinal malignancies.

* Hyperthermic crisis: A potentially fatal situation in which the dead body cannot dissipate heat as quickly as it is generated. A hyperthermic crisis may proceed from excessive heat production, diminished heat dissipation, or disorders of hypothalamic function.

* Mitomycin C: An antibiotic that is derived from Streptomyces caesitosis and is used to treat gastrointestinal cancers, breast cancer, sarcomas, mesotheliomas, and genitourinary cancers.

* Pharmacokinetics: The characteristic interactions of a medication and the material substance in terms of its absorption, distribution, metabolism, and excretion.

NOTE

(1) Blakiston's Gould Medical Dictionary, fourth ed (New York: McGraw-Hill Book Co 1979); Physician's Desk respect 49th ed (Montvale, NJ: Medical Economics Data Production Company, 1995)

Cytoreductive surgery Patients who have isolated cancer spread to peritoneal surfaces in the absence of bloodborne or lymphatic metastasis are ideal candidates for cytoreductive surgery Cytoreductive surgery is a combination of peritoneal stripping proceedings and resections that remove all macroscopic tumor tissue from the abdominal cavities of patients with peritoneal carcinomatoses.(5) Cytoreductive surgery is designed to achieve local direct of peritoneal cavity disease and is compos of six separate procedures:

* omentectomy/splenectomy,

* left subdiaphragmatic peritonectomy,

* right subdiaphragmatic peritonectomy,

* pelvic peritonectomy/sigmoidectomy,

* cholecystectomy/lesser omentectomy, and

* antrectomy.

Each practice is a discrete en bloc resection that requires an orderly succession of surgical maneuvers to create an optimum cytoreduction. Using precise procedural techniques, surgeon can favorably resect peritoneal carcinomatoses caused at lesions of low-grade malignancy (eg grade I mucous adenocarcinoma, malignant pseudomyxoma peritonei).(6) Cytoreductive surgery acts may last 10 to 14 hours and require well-trained, informed perioperative staff members.

Chemotherapy with cytoreductive surgery Cytoreductive surgery involves extensive surgical dissection. To obstruct the surgical dissemination of cancer enclosed spaces within these patients' abdominal cavities, many facilities are beginning to combine cytoreductive surgery and HIIC. The rationale for this combined therapeutic approach is