Thromboprophylaxis, pain and organization: How do expert centers manage PIPAC's perioperative care? An international survey

Abstract Introduction: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is an emerging therapeutic option for peritoneal carcinomatosis, offering improved drug distribution and tissue penetration. Although clinical outcomes have been encouraging, international guidelines for perioperative management - including pain control and thromboprophylaxis - are still lacking. Materials and methods: A global online survey was distributed to PIPAC practitioners to corresponding authors of published PIPAC studies and members of the International Society for the Study of Pleura and Peritoneum (ISSPP). The questionnaire consisted of 24 closed-ended questions covering five domains: institutional experience, perioperative organization, thromboprophylaxis, biological monitoring, and postoperative pain management. Consensus was defined as ≥70% agreement among respondents. Results: Out of 300 contacted experts, 125 responded (42% overall response rate), representing 68 centers across 27 countries (71.2% from Europe). Consensus was reached for four items: performing a surgical or oncological consultation before each PIPAC procedure (74.59%), conducting pre and postoperative laboratory tests (89.43% and 70.73% respectively) and the non-use of non-medicated thromboprophylaxis (70.97%). Pharmacological thromboprophylaxis was prescribed in 63.71% of centers, mainly low-molecular-weight heparin, up to 7 days in 33% of centers, up to 21 days in 33%, and limited to the in-hospital stay in 22%. Otherwise, anesthetic consultations were systematically performed in 57.26% of centers. Outpatient procedures (<24 h) were performed in 11.29%, while 41.94% and 34.68% of patients were hospitalized for one and two days respectively. Paracetamol was the first-line analgesic and was used in more than 80% of cases on postoperative day 1. A significant difference was observed regarding the use of morphine PCA, which was more frequently prescribed after oxaliplatin-based PIPAC (p = 0.013). Discussion: This international survey highlights substantial heterogeneity in perioperative care practices. Although PIPAC and cytoreductive surgery are performed for peritoneal metastases, pharmacological thromboprophylaxis appears to be less frequently prescribed in the PIPAC settings. Pre-PIPAC consultation and perioperative biological monitoring are more standardized, although noteworthy variations persist. These findings underscore the need for evidence-based international guidelines to harmonize perioperative management and improve patient outcomes in PIPAC.