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Keywords:

  • Intraperitoneal chemotherapy;
  • intraperitoneal catheter;
  • ovarian cancer

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Please cite this paper as: Helm C. Ports and complications for intraperitoneal chemotherapy delivery. BJOG 2012;119:150–159.

Intraperitoneal access ports are essential to the delivery of chemotherapy agents into the peritoneal cavity of women with ovarian cancer, but their malfunction and adverse effects are frequently responsible for the failure to complete planned therapy. Complications, such as obstruction of the catheter, infection, leakage, rotation, retraction, and pain, together with bowel and vaginal perforation, cause delays in treatment, patient suffering and the expenditure of medical resources. A wide variety of ports have been used, including vascular access devices and intraperitoneal access devices. This paper reviews the development and use of ports for intraperitoneal chemotherapy, their complications and reported methods of prevention.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Intraperitoneal (IP) chemotherapy in gynaecologic oncology has been targeted primarily at epithelial ovarian cancer (EOC), a true ‘peritoneal surface malignancy’ with a predilection for spreading widely within the peritoneal cavity (PC), implanting on all peritoneal surfaces, but remaining confined by the peritoneal lining for much of its natural history.

The theory and principles behind the delivery of IP chemotherapy for peritoneal malignancies were developed by Robert Dedrick et al., and were published in 1978.1 Clinical research into IP chemotherapy for EOC in the following three decades included two large randomised studies by the Gynecologic Oncology Group (GOG),2,3 but interest was stimulated by the publication of GOG-172 in January 2006,4 a study in which patients randomised to receive combined IP and intravenous (IV) chemotherapy had a median survival of 65.6 months compared with 49.7 months for patients receiving only IV chemotherapy. In a clinical announcement the National Cancer Institute advised that all women with small-volume disease remaining at the completion of front-line surgery should at least be offered IP chemotherapy.5

The delivery of IP chemotherapy requires the use of access devices (ports), the placement, malfunction and adverse effects of which can cause additional suffering to patients, and can introduce delay, prevent the completion of IP therapy, raise the cost of care and jeopardise a patient’s life. This paper will review the history of the development of ports for IP chemotherapy delivery, the experience of their use, reported complications and methods of prevention.

Methods of review

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Reports of the use of fully implantable ports for the repeated delivery of IP chemotherapy to patients with ovarian cancer in the English language were identified through Medline and PubMed. Relevant papers cited in these reports were also reviewed. For a historical perspective, publications reporting the use of the transcutaneous Tenckhoff catheters were also included. Data extracted included details of the type and manufacturer of the port, the method and timing of placement, complications, rates of complications and associated factors, and their contribution to the discontinuation of IP therapy.

Reports consisted of heterogeneous case series and subanalysis of data from patients treated primarily on clinical trials of IP chemotherapy. Terminology and descriptive terms varied. Data was not always specifically given, and no attempt was made to make ‘estimates’ of the information if it was not clearly stated. In many instances the specific types of ports used were not detailed in the papers.

Port development and characteristics

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

When Speyer and Myers6 first experimented with IP chemotherapy delivery, they used a catheter developed for chronic peritoneal dialysis by Tenckhoff and Schechter.7 This type of peritoneal access device suffered from the fact that the proximal end of the catheter lay outside of the body, and was thought to be associated with high rates of intraperitoneal infection. In addition, the catheters needed daily maintenance by patients in an attempt to reduce the risk of infection, and were poorly accepted.8 The overall rates of infection 7.7–25%,9–12 and of peritonitis 3.8–25%,9–13 motivated the development of fully implanted peritoneal access devices (FIPADs). The basic components and variables of FIPADs relate to the portal (access reservoir) and the catheter: for the portal they include size and composition (titanium or plastic), and for the catheter they include, length, size of lumen, external diameter (F size), composition (silastic or polyurethane), fenestrated or unfenestrated, and the presence or absence of cuff(s) to secure to the fascia.

The first FIPAD consisted of a ‘Porta-A-Cath’ peritoneal stainless steel portal (Pharmacia Nu Tech, then of Piscataway, NJ, USA) that was connected to a fenestrated catheter (Cobe Laboratories Inc., Lakewood, CO, USA), which was secured by a stainless steel slip lock.8 Soon afterwards the Pharmacia Company developed a FIPAD consisting of a stainless steel (subsequently titanium) portal attached to a fenestrated 14.7-F catheter, with a Dacron cuff to secure the catheter to the fascia, which gained Food and Drug Administration (FDA) approval for IP delivery in 1984 (21-2000-24; Smith Medical ASD Inc., St Paul, MN, USA; Figure S1; Table 1).

Table 1.   Examples of ports with FDA approval for IP delivery of chemotherapy and other ports with experience reported
CompanyNumberUsed in ref.FDA approvedPortCatheter
AttachedSize (F)*MaterialFenestratedCuffed
  1. *F, French refers to the external diameter of the catheter: 1 Fr = 0.33 mm.

  2. **Federal Drug Administration-approved for intraperitoneal chemotherapy delivery.

  3. ***Port-A-Cath® Peritoneal Implantable Access System; Smith Medical ASD Inc., St Paul, MN, USA.

  4. ****Plastic ports are completely compatible with magnetic resonance imaging, whereas titanium ports manufactured by Bard are compatible up to 3 Tesla.

  5. Bard: Bard Access Systems Inc., Salt Lake City, UT, USA.

  6. Smith Medical: Smith Medical ASD Inc., St Paul, MN, USA.

Bard** (Figure S2)060300622,23,27YesTitaniumNo14.3SiliconeYesNo
Bard**0603000 YesTitaniumNo14.3SiliconeYesYes
Smith Medical** (Figure S1)21-2000-24***15,38YesTitaniumNo14.7PolyurethaneYesYes
Bard060530023NoTitaniumNo8.0PolyurethaneNoNo
Bard060266021,25–27NoPlastic****Yes9.6SiliconeNoNo
Bard (Figure S3)060268021,25–27NoPlasticNo9.6SiliconeNoNo
Bard060287021,25–27NoTitaniumNo9.6SiliconeNoNo
Bard060227021,25–27NoTitaniumYes9.6SiliconeNoNo

Also in the 1980s Bard developed a FIPAD consisting of a Tenckhoff IP fenestrated catheter attached to a subcutaneous portal that had been developed for venous access. Two Bard ports were given FDA approval for IP use, one with Dacron cuffs and one without (0603006 and 0603000; Bard Access Systems Inc., Salt Lake City, UT, USA; Figures S2 and S3; Table 1).

Prior to publication of GOG-172, the literature on FIPADs was mainly on those manufactured by Pharmacia,8,11,14–17 or modifications,18 or on ports referred to as simply ‘Port-A-Cath’, without identifying details.19,20 Port-A-Cath is the current trademark of Smith Medical ASD Inc., St Paul, MN, USA (originally Pharmacia), but has become a byword for literally any venous or peritoneal access device. Of the publications in this review a minority specifically identify the port used with a manufacturer’s identification number.8,18,21–23 For analysis of port experience this is probably not of any consequence, except with regard to the identification of the effect of fenestrations and cuffs.

The protocol for GOG-172 did not include specific directions for the exact type of FIPAD to be used or guidelines for management. In the analysis of port experience it was concluded that catheters with multiple fenestrations were prone to obstruction, and that Dacron cuffs lead to infection, as did insertion of the port at the time of left colon resection.24 The initial recommendation was to use venous access catheters with no cuff or fenestrations as FIPADs. Placement should be avoided during contaminated surgery, and ports should be removed after treatment has been completed. This led to reports of a variety of unfenestrated venous access catheters being used for the delivery of IP chemotherapy (Figure S3; Table 1).21,25,26 Some centres used only FDA-approved fenestrated devices,22 or a mix with unfenestrated vascular access devices.23,27 For clarity, any fully implantable port used for IP chemotherapy delivery, including vascular access devices, will be called a FIPAD.

Methods of port placement and removal

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

If IP therapy is to follow major surgery via laparotomy, a port can be placed at that time, or it can be inserted later using a small incision ‘open’ technique, or via a minimally invasive, laparoscopic approach. Techniques for placement during laparotomy and with the open technique,28 during laparoscopy,29–31 and with all three,26 have been described. The advantage of placement at initial surgery is that no further procedure is required prior to starting IP chemotherapy. With the laparoscopic approach there is an opportunity for the division of adhesions that may have developed since the initial surgery. These ranges of techniques are available when IP chemotherapy is delivered for consolidation or for recurrent disease.

The FIPADs without a cuff can be removed easily with local anaesthetic and mild sedation at the completion of treatment, whereas cuffed FIPADs are more difficult and have to be released from the fascia.

Port complications

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Complications involving FIPADs used for peritoneal access occur at overall rates of 6.8–40.5% (Table 2),15,16,19,21,25,27,28,32 and are responsible for the failure to complete planned IP chemotherapy in 1.9–26.2% (mean 12.6%) of patients, and represent between 9.6 and 71.1% of the reasons for discontinuation in those that fail to complete IP chemotherapy (Tables 3 and 4).

Table 2.   Reported complications of ports used for IP access
AuthorYearYears of accrualPortTypeNOverall **%Infection***%Peritonitis %Obstruction %Access %Leak %Bowel %Retraction %Pain or other %
  1. Studies where information was not given or was not clear have not been included.

  2. Ports: Bard, Bard Access Systems Inc., Salt Lake City, UT, USA; C, Celsite, B. Braun, Chasseneuil, France; I, Infusaid, Pharmacia Nu Tech, Piscataway, NJ, USA; P, Pharmacia, Piscataway, NJ, USA; PD, Pharmacia Deltec, St Paul, MN, USA; PU, Pharmacia, Uppsala, Sweden, probably now Smith Medical (21-2000-24 + three ports from Norport, Norfolk Medical Products, Skokie, IL, USA); SM, Smith Medical ASD Inc., St Paul, MN, USA.

  3. IAP, Infusa-A-Port; PAC, Port-A-Cath; PHAC, intraperitoneal access port (Porth-A-Cath).

  4. *Not mentioned or not clear.

  5. **excluding pain if not mentioned.

  6. ***infection overall, including peritonitis.

  7. ****Five (6%) patients had either inability to infuse OR displacement of port.

  8. *****Percentage (%) in which complication led to discontinuation of IP therapy.

Pfeifle 81984*PCF54*5.55.5*11.1**1.8*
Piccart et al.1119851982–1985IF145*8.38.32.1*1.31.3**
Rubin et al.1719898/1985–4/1987PF130*5.42.35.4000**
Almadrones and Yerys1419908/1985–7/1987PDF106*10.34.78**3.5*48 pain (11.3 severe)
Davidson et al.1519914/1985–6/1989PDF22717.68.828.8**3.5*32 pain
Nanninga et al.191992*PHACF539.4003.8******0**3.8 pain
Malmstrom et al.1619945/1985–11/1991PUF12537.65.6*4.83.28**12.3 pain 1.2 other
Sakuragi et al.2020001987–1996PAC IAP*78*20.5*3.8**1.3*7.7 (3.8 pain, 3.8 other)
Topuz et al.1820001/1992–1/1996CF56*7.11.810.7**1.8*85.7 pain (23.2 g3-4)
Makijha et al.32200112/1989–5/1997BardF301103.7*6.3**0**
Landrum et al.2520081993–2006BardS8333.710.8*********4.83.6*8.4 pain g3-4
Helm et al.2620086/2005–4/2007BardS3839.45.307.97.9*2.65.310.5 pain
Berry et al.2120091/2006–12/2007BardS4240.516.60*4.711.92.3*2.3 pain g2
Lesnock et al.27201011/1999–8/2008BardFS1036.8**5.8**1**
Robinson and Beyer38201010/1999–9/2009SM BardF S177*2.2******22******2.8********
Table 3.   Percentage of cases where IP chemotherapy was discontinued because of the port
AuthorYearPortCatheterTotal n patients (A)Failing to complete IP (n) (B)Port
% of A% of B
  1. Bard, Bard Access Systems Inc., Salt Lake City, UT, USA; C, Celsite; B. Braun, Chasseneuil, France; F, fenestrated catheter; PU, Pharmacia, Uppsala, Sweden; S, single lumen (unfenestrated) catheter; SM, Smith Medical ASD Inc., St Paul, MN, USA.

Malmstrom et al.161994PUF125247.237.5
Topuz et al.182000CF561412.550
Makhija et al.322001BardF301216.9100
Fujiwara et al.392003**165249.766.6
Walker et al.242006**20511919.533.6
Landrum et al.252008BardS833313.233.3
Helm et al.262008BardS381615.837.5
Black et al.222008BardF342942.69.6
Ivy et al.232009BardF S815913.618.6
Berry et al.212009BardS423026.237
Lesnock et al.272010BardF S103161.912.5
Robinson and Beyer382010SM BardF S1404522.871.1
Table 4.   Port complications causing the discontinuation of IP chemotherapy*
AuthorYearnDiscontinued because of portInfection Obstruction Malfunction Leakage Access Pain Vaginal Bowel
nnnnnnnnn
  1. cvf, colovaginal fistula; perf, bowel perforation; pvf, peritoneovaginal fistula; sbo, small bowel obstruction.

  2. *Where detailed in publications.

  3. **Described as extravasation.

  4. ***Described as rupture of catheter tubing.

Davidson et al.15199122719127      
Malmstrom et al.1619941259        
Topuz et al.18200056734      
Makhija et al.322001301217 14     
Fujiwara et al.3920031651648   3 1 ileus
Walker et al.242006205402110 35 1 leak 
Black et al.222008342935  1   
Landrum et al.25200883114  1311 leak 
Helm et al.26200838611   31 cvf 
Ivy et al.232009811113 2**3  1 sbo
Berry et al.21200942116  3  1 pvf1 perf
Lesnock et al.2720101032 2      
Robinson and Beyer38201017748439 5***    
Total1945 2106679141412743
 31.4%37.6%6.7%6.7%5.7%3.3%1.9%1.4%
   14.8%        

Infection

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

The reporting of infections includes both superficial (skin cellulitis, portal pocket and catheter tunnel) and deep (intra-abdominal abscess and peritonitis). The overall rates remain high at 0–20.5%.8,11,14–21,25–27,32 The rate of peritonitis reported for ports manufactured by Pharmacia is 0.9–8.3%,8,11,14,15,17 but peritonitis has not been reported in series using Bard ports. The difference is unexpected and the reasons unknown, but possibly related to Dacron cuffs.

Infection associated with the FIPAD was the cause for discontinuation of IP therapy in 31.4% (66/210) of cases (Table 4). The numbers are skewed by a higher rate in one report.24 It has been suggested that to reduce the risk of infection, ports should not be placed in a contaminated surgical field,24 but even in a centre that avoids placing FIPADs at the time of bowel resection the infection rate was 10.8%,25 and where IP chemotherapy was totally avoided when bowel resection and reanastomosis was performed, the rate was 20.5%.20

Once a FIPAD has been inserted it should, of course, only be accessed using a fully aseptic technique to reduce the risk of external contamination.

Obstruction to infusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Intraperitoneal ports are prone to obstruction directly, from kinking of the catheter, blockage of the fenestrations or catheter tip, by fibrous adhesions, or functionally, by restriction of flow resulting from the compartmentalisation of fluid by adhesions in the vicinity of the catheter tip. The rate of obstruction varies between 2.1 and 22% (Table 2). The formation of a fibrous sheath around the catheter that leads to a ‘one-way valve’ effect impeding drainage of IP fluid was recognised early on,8 but actual obstruction of the inflow was first reported by Piccart et al.11 with a rate of 2.1% (3/145).

Kinking of the catheter is rarely reported,8,26 but it is virtually the only form of obstruction that may be remediated laparoscopically without the removal and replacement of FIPAD. It is one of the reasons why a port dye study should be considered when obstruction to inflow occurs.

In the reviewed papers obstruction from all causes was the most common reason for discontinuation of IP therapy, being responsible for 79/210 (37.6%) of the cases, but there was a wide range across the series (Table 4). It was suggested that peritoneal dialysis catheters with fenestrations on the sides are associated with increased complications, and should be avoided.24 Only two papers have compared the experience of both fenestrated and non-fenestrated catheters in the same centre (albeit in non-randomised studies), and there was no significant difference in the overall complications or the percentage of patients in whom IP chemotherapy was discontinued because of the port (Table 5).23,27

Table 5.   Rate of overall complications and discontinuation of IP chemotherapy: comparison of Bard fenestrated and single lumen catheters
AuthorYearPortCatheternPort complications overall %Discontinuation because of port %P
  1. *Information not given.

  2. F, fenestrated catheter, (0603006; Bard Access Systems Inc., Salt Lake City, UT, USA); S, single lumen (unfenestrated) catheter; S1 (0605300; Bard Access Systems Inc., Salt Lake City, UT, USA); S2 (0602660; Bard Access Systems Inc., Salt Lake City, UT, USA).

Ivy et al.232009BardF29*17ns
S152*12
Lesnock et al.272010BardF488.317ns
S2555.514.5

Unfortunately, there is no proven way to prevent the obstruction of catheters occurring. The placement of an anti-adhesion barrier seems logical, but an initial report suggested no impact on completion rates.27 The above studies did not compare cuffed versus cuff-less ports, and so the issue of morbidity caused by cuffs is still open.

Access

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Access problems include difficulty inserting the needle into the portal and detachment of the port from fixation to the underlying fascia (rotation, dislocation and dislodgement). Pfeifle reported initial difficulty in accessing subcutaneous ports that was resolved by positioning the portal at or above the costal margin.7 A minority have also reported problems with access in between 3 and 7.9% of patients.16,21,26 Landrum et al.25 reported that five (6%) patients had either an inability to infuse or a displacement of the port.

The majority of such access problems can be prevented by placing the portal above the costal margin and securely fixing the portal to the deep fascia. In patients with considerable subcutaneous fat, a longer Huber needle should be used for accessing the port to reduce the chance of the needle backing out of the portal.

Retraction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Retraction, occurring when the catheter withdraws itself back out of the peritoneum and up towards the portal, was reported by Pendergrass et al.33 Malmstrom et al.16 had previously reported the ‘dislocation’ of the catheter in three of 122 FIPAD placements, but it is unclear whether this referred to retraction out of the peritoneal cavity or not.

With the objective of determining the incidence of, and factors related to, retraction of FIPAD catheters out of the peritoneal cavity, a questionnaire survey was made of members of the Society of Gynecologic Oncologists in Spring 2007 (L. Bazette, pers. comm.). Amongst the 119 respondents inserting FIPADs and delivering IP chemotherapy, 1428 ports were placed from January 2006 until April 2007 (average 13.6, range 1–90, per respondent). Fifteen instances of retraction were reported, which is an overall rate of 1% (15/1428). Retraction occurred with a variety of FIPAD makes and types, including single lumen (n = 14), double lumen (n = 1), cuffed (n = 4), cuff-less (= 10), fenestrated (n = 2) and unfenestrated (n = 13). Ports were inserted during initial surgery (n = 6), interval laparoscopy (n = 3) and interval mini-laparotomy (n = 6). The catheter was tunnelled straight through the abdominal wall (n = 6) or was angled diagonally (n = 9). In three cases additional sutures had been placed to secure the IP portion of the catheter to the peritoneum and posterior rectus sheath. The shortest length of catheter left within the peritoneal cavity was 9 cm, and the portals were secured with between one and five sutures.

Retraction will inevitably cause a delay in treatment and require the placement of an alternative FIPAD for IP therapy to be continued. It is possible that retraction can be reduced by leaving a sufficient catheter length in the peritoneal cavity (12 cm or more), securing the portal with additional sutures and ‘hitching’ the catheter to the peritoneum close to its peritoneal entry point with absorbable sutures, as suggested by some respondents to the questionnaire.

Bowel perforation

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Small and large bowel perforation can occur during the actual placement of the peritoneal access device, during IP treatment or can be delayed (or the detection delayed) until after treatment. Such complications have been reported for both transcutaneous Tenckhoff catheters and FIPADs.

There is a low risk of perforation at the time of placement of catheters, ranging from 3.5 to 4.2% for Tenckhoff catheters,9–11 and 1.2–3.6% for FIPADs.11,18,25 Several series reported the occurrence (or identification) of perforation during, or soon after, treatment. A Tenckhoff catheter perforated the right colon 3 weeks after placement for the treatment of colon cancer,34 and two cases of small bowel perforation by an FIPAD also occurred, one discovered during treatment and one discovered a month after, during a reassessment laparotomy following the completion of IP chemotherapy.35 Davidson et al.15 reported a 3.5% incidence of bowel perforation (8/227), with most cases being detected during treatment; however, in two cases the perforations were occult, being discovered at reassessment laparotomy following the completion of chemotherapy. Landrum et al.25 reported an incidence of 3.6% (3/83) overall, with one perforation noticed at the time of placement, one during treatment (near the ileocecal junction) and one at the time of port removal. One FIPAD catheter eroded the small bowel during treatment (incidence 2%),21 and another was involved in a colovaginal fistula (2.6%).26 Lesnock et al.27 reported the erosion of a fenestrated catheter into the bowel (1%) at an unknown time after placement.

Although concern has been expressed about the development of delayed complications of FIPADs a long time after the completion of IP chemotherapy, there are only a few reports in the literature. Braly et al.13 reported a perforation of the sigmoid colon 8 months after placement, and Sakuragi20 reported a case of small bowel perforation discovered 36 months following placement and a vaginal perforation at 18 months following placement. Sakuragi advised removing the FIPADs within 1 year of treatment to avoid major complications. Others supported this view.24

Pain and discomfort

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Some pain and discomfort is expected with infusion of up to 2 l of fluid into the abdominal cavity at each IP treatment, and patients should be informed of feelings of bloating, abdominal pressure and abdominal discomfort that should dissipate within 24–48 hours.36 It is thought that this type of discomfort may be helped by warming the infusate prior to infusion, reducing the rate of flow and reducing the volume of the second litre infused after the chemotherapy infusion.37

Patients may experience pain and discomfort specifically associated with the portal and catheter, although the reporting of this is inconsistent. When portals are placed over the costal margin, patient discomfort may be exacerbated by bra straps and sleeping on that side. Patients may experience discomfort in the area in which the IP catheter is situated within the peritoneal cavity, whether resulting from the catheter itself or local adhesions.

In the minority of studies that report pain associated with FIPADs and IP chemotherapy,14,16,18–20,25,26 the frequency varies widely between 2.3 and 85.7%. None of the documentation of pain was prospective, and in no cases was a pain score used. Almadrones reported occurrences of varying degrees of pain during the treatment of 51 out of 106 women (48%): 24.5% reported mild pain, expressed as a sensation of discomfort caused by the large volume of fluid in the abdomen; 12% reported moderate pain, relieved by narcotic, and which did not cause the patient any limitation in daily activity; and 11% reported severe pain during infusion, requiring narcotics and the discontinuation of IP therapy. Pain and discomfort specifically related to the FIPADs are not mentioned. Infusions became painful during the treatment of three out of 53 women (5.7%) in one study,19 and in 32% of women in another study.15 Portal site pain was reduced by placing the portal in the xiphoid region rather than at the costal margin.18 Grades 1–2 and grades 3–4 (WHO scoring system) of pain were experienced in 23.2% (13/56) and 62.5% (35/56) of women overall, and for the costal margin and xiphoid sites 54% (20/37), 35% (13/37), 79% (15/19) and 0%, respectively. Malmstrom et al.16 reported portal-related pain in three of 125 women (3.8%), and catheter-related pain in 12 of 125 women (9.6%). Landrum et al.25 reported that seven of 83 women (8.4%) experienced abdominal pain of grades 3–4, with one woman experiencing grade-4 pain, leading to the discontinuation of treatment. Others reported rates of 10.5 and 16.7%, excluding pain related to infection.20,26

To the author’s knowledge placing the portal in the region of the xiphoid is not common practice. In slim patients it is possible to place the port just below the costal margin, and to use a smaller and thus less prominent portal whilst not compromising accessibility.

Leakage

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Excluding leakage into the vagina or bowel, the rate of leakage (around the access site, portal or in the subcutaneous track of the catheter) is reported as 1.3,11 4.8,25 and 11.9%.21 In the analysis of GOG-172, leakage was considered to have contributed to discontinuation in 12.5% (5/40) of cases with discontinued IP therapy.

The cause of leakage may include a faulty needle connection to the portal, the needle falling out, a faulty portal, failure in the portal–catheter connection, catheter or back-flow up the tunnel from the peritoneal cavity.

Malmstrom et al.16 reported 8% of patients experiencing a disconnection of the catheter from the portal, which was presumably associated with leakage prior to a new type of connector being introduced.

The risk of leakage can be reduced with the use of an appropriate length Huber needle for access, care with securing the needle to the port and restriction of patient movement during infusion. A test run of saline should always be given prior to starting the chemotherapy infusion. Nursing staff should always be vigilant for evidence of leakage because of the risks of chemotherapy agent extravasation.36

If an open technique of port insertion is used, early leakage into the wound can be reduced by introducing the catheter into the peritoneum away from the peritoneal incision.28 The majority report starting the IP infusion a week or more following the insertion: 1 week;8 >1 week;18 1–4 weeks;32 and 2–4 weeks.27 Others report 0–60 days (median 11 days),16 and at least 1 day.25

Effect of the timing of placement

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

The timing of placement of the FIPAD during front-line cytoreductive surgery, or during a second surgical procedure, did not significantly affect complications of FIPADs,15,22 or the completion rates of IP chemotherapy.24,25,38 Two series have included large numbers of patients undergoing FIPAD placement laparoscopically for consolidation. Makhija et al.32 reported a series of 313 patients in which 218 of 313 women (70%) were placed during laparotomy, and 61 of 313 women (20%) were placed during laparoscopy. Whereas Black et al.22 reported on 342 patients, 111 (32%) of which were placed during laparotomy and 228 (67%) of which were placed during laparoscopy. Combining the data for these 655 patients, there was no significant difference between laparoscopy versus ‘laparotomy overall’ for port malfunction rates: 0/61, 18/218 (8.2%); infection, 2/61 (3.3%), 8/218 (4.4%); or catheter-related complications 15/228 (6.6%), 8/111(7.3%).

At the time of bowel resection

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

In the experience of over 1000 patients at the Memorial-Sloane Kettering Cancer Center,14,15,17,22,32 there was a clinical impression,14,17 or non-significant trend, towards increased infection with placement at the time of large bowel surgery and appendectomy (but only when data was combined from catheter insertions at front-line surgery, and subsequent surgeries where large bowel surgery was performed in the presence of a pre-existing FIPAD, which was left in place),15 or at the time of a major procedure or bowel surgery.32 If series from Makhija and Black above are combined,26,28 the port malfunction rates for ‘laparotomy overall’ and ‘laparotomy with a bowel procedure’ were 8.2% (8/218) and 9.1% (1/11), respectively, for infection were 4.4% (8/218) and 9.1% (1/11), respectively, and for catheter-related complications were 7.3% (8/111) and 6.8% (3/44), respectively.

Interestingly, the infection rates in series reporting that FIPAD insertion was avoided at the time of bowel resection were 20.5 and 10.8%.20,25 Others reported no effects of bowel surgery on completion of IP chemotherapy.22,27

In the analysis of GOG-172,24 there was no relationship between the performance of appendectomy, small bowel resection or ileocecal resection with completion of IP chemotherapy, although there was a significant problem initiating IP chemotherapy after left colon or rectosigmoid resection.

It seems sensible to avoid placing an FIPAD in the presence of gross contamination,37 but there appears to be little contraindication for placing an FIPAD when routine large or small bowel resections are performed.

Influence of surgeon and team experience

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

There is a lack of information in the literature with regard to the effect of the expertise of the surgeon placing the ports, and the experience of the support team (including doctors and nurses) in managing the ports and patients to reduce complications and improve completion rates.

Only two papers mention specifically the number of individuals inserting the ports.16,38 Malmstrom et al.16 reported that a single surgeon placed 38% (47/125) of ports, with the remainder split between 13 other surgeons. There was a lower rate of complications by the single surgeon versus all of the rest combined (= 0.009). The lowest rate of complications was 19% and the highest for a single surgeon was 50%, with the majority occurring within the first 15 months. Robinson and Beyer38 reported that all of the 177 ports were placed by one of two gynecologic oncologists trained in the technique. There is no specific mention of the relationship between complications and surgeon experience, but completion rates improved markedly after the first 4 years of experience.

Several reports allude to the idea that a dedicated and (experienced) team can improve completion rates.16,21,25,27,38 A trend to less severe overall complications during the last two years of study was reported,16 and completion rates for frontline treatment were much higher after the first 4 years: 2000–2003, 45% (23 of 51) versus 2004–2009, 81% (72 of 89).38

Experience at the Memorial-Sloane Kettering Cancer Center indicates a reduction in complications and increase in completion rates over successive reports, spanning over 20 years. Between April 1985 and June 1989, and during December 89–May 97, catheter complication rates dropped from 17.6 to 10%.15,32 This was thought to reflect factors such as a change in the type of FIPAD used, placement at laparoscopy and avoidance of placement at the time of bowel surgery. In a more recent series, from May 1997 to May 2006, using a different FIPAD again, only 2.6% of patients discontinued IP therapy because of the FIPAD, in comparison with 6.9% during the period December 1989–May 1997.22,32 These low rates overall might be expected to be related in part to the experienced team,14 and the better health and nutritional parameters of women receiving IP therapy for consolidation, as apposed to front-line or recurrent disease.22

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Port complications are significant, and overall, 15% (210/1945) of patients discontinued IP chemotherapy as a result of a port complication, with obstruction (37.6%) and infection (31.4%) being the most common reasons.

Complications such as leakage, retraction of the catheter, rotation of the portal, difficulties with access and perforation of the bowel can be kept to a minimum with careful technique, but they are still not completely avoidable. Although infection may theoretically be reduced by the avoidance of placement during grossly contaminated surgeries, hard data on the influence of associated bowel surgery at the time of placement are lacking, and there is no proven method of preventing the adhesions that cause obstruction to flow. There does not appear to be a difference in the rates of complications between fenestrated or unfenestrated ports, and the choice of port should be at the surgeon’s discretion.

Despite almost 30 years of experience, it remains difficult to identify which patients are going to experience port complications that impact on the completion of IP therapy. More effective methods of preventing complications and improving tolerability, and thus reducing discontinuation rates, are needed.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information
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    Dedrick RI, Myers CE, Bungay PM, De Vita VT. Pharmacokinetic rationale for peritoneal drug administration in the treatment of ovarian cancer. Canc Treat Rep 1978;62:111.
  • 2
    Alberts DS, Liu PY, Hannigan EV, O’Toole R, Williams SD, Young JA, et al. Intraperitoneal cisplatin plus intravenous cyclophosphamide versus intravenous cisplatin plus intravenous cyclophosphamide for stage III ovarian cancer. [see comment] New Engl J Med 1996;335:19505.
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    Markman M, Bundy BN, Alberts DS, Fowler JM, Clark-Pearson DL, Carson LF, et al. Phase III trial of standard-dose intravenous cisplatin plus paclitaxel versus moderately high-dose carboplatin followed by intravenous paclitaxel and intraperitoneal cisplatin in small-volume stage III ovarian carcinoma: an intergroup study of the Gynecologic Oncology Group, Southwestern Oncology Group, and Eastern Cooperative Oncology Group.[see comment]. J Clin Oncol 2001;19:10017.
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    Armstrong DK, Bundy B, Wenzel L, Huang HQ, Baergen R, Lele S, et al. Intraperitoneal cisplatin and paclitaxel in ovarian cancer. New Engl J Med 2006;354:3443.
  • 5
    NCI Clinical Announcement. [www.cancer.gov/newscenter/pressreleases/2006/ipchemotherapyrelease]. Accessed 30 June 2011.
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    Speyer JL, Myers CE. The use of peritoneal dialysis for delivery of chemotherapy to intraperitoneal malignancies. Recent Results Cancer Res 1980;74:2649.
  • 7
    Tenckhoff H, Schechter H. A bacteriologically safe peritoneal access device. Trans Am Soc Artific Int Org 1968;14:1817.
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    Pfeifle E. Totally implantable system for peritoneal access. J Clin Oncol 1984;2:127780.
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    Jenkins J, Sugarbaker PH, Gianola FJ, Myers CE. Technical considerations in the use of intraperitoneal chemotherapy administered by Tenckhoff catheter. Surg, Gynecol & Obstet 1982;154:85862.
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    Myers CE, Collins JM. Pharmacology of intraperitoneal chemotherapy. Cancer Invest 1983;1:395407.
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    Piccart MJ, Speyer JL, Markman M, ten Bokkel Huinink WW, Alberts D, Jenkins J, et al. Intraperitoneal chemotherapy: technical experience at five institutions. Semin Oncol 1985;12 (3 Suppl 4):906.
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    Runowicz CD, Dottino PR, Shafir MK, Mark MA, Cohen CJ. Catheter complications associated with intraperitoneal chemotherapy. Gynecol Oncol 1986;24:4150.
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    Braly P, Doroshow J, Hoff S. Technical aspects of intraperitoneal chemotherapy in abdominal carcinomatosis. Gynecol Oncol 1986;25:31933.
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    Almadrones L, Yerys C. Problems associated with the administration of intraperitoneal therapy using the Port-A-Cath system. Oncol Nurs Forum 1990;17:7580.
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    Davidson SA, Rubin SC, Markman M, Jones WB, Hakes TB, Reichman B, et al. Intraperitoneal chemotherapy: analysis of complications with an implanted subcutaneous port and catheter system. Gynecol Oncol 1991;41:1016.
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    Malmstrom H, Carstensen J, Simonsen E. Experience with implanted subcutaneous ports for intraperitoneal chemotherapy in ovarian cancer. Gynecol Oncol 1994;54:2734.
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    Rubin SC, Hoskins WJ, Markman M, Hakes T, Lewis JL Jr. Long-term access to the peritoneal cavity in ovarian cancer patients. Gynecol Oncol 1989;33:468.
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    Topuz E, Salihoglu Y, Aydiner A, Saip P, Tas F, Sozen T, et al. Celsite port and catheter as an intraperitoneal access device in the treatment of ovarian cancer. J Surg Oncol 2000;74:2236.
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    Nanninga AG, Willemse PHB, Boonstra H, De Vries EGE. Low complication rate during intraperitoneal therapy through a totally implanted peritoneal access port in patients with ovarian cancer. Int J Gynaecol Cancer 1992;2:10710.
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    Sakuragi N, Nakajima A, Nomura E, Noro N, Yamada H, Yamamoto R, et al. Complications Relating to Intraperitoneal Administration of Cisplatin or Carboplatin for Ovarian Carcinoma. Gynecol Oncol 2000;79:4203.
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    Berry E, Matthews KS, Singh DK, Buttin BM, Lurain JR, Alvarez RD, et al. An outpatient intraperitoneal chemotherapy regimen for advanced ovarian cancer. Gynecol Oncol 2009;113:637.
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    Black D, Levine DA, Nicoll L, Chou JF, Iasonos A, Brown CL, et al. Low risk of complications associated with the fenestrated peritoneal catheter used for intraperitoneal chemotherapy in ovarian cancer. Gynecol Oncol 2008;109:3942.
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    Ivy JJ, Geller M, Pierson SM, Jonson AL, Argenta PA. Outcomes associated with different intraperitoneal chemotherapy delivery systems in advanced ovarian carcinoma: a single institution’s experience. Gynecol Oncol 2009;114:4203.
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    Walker JL, Armstrong DK, Huang HQ, Fowler J, Webster K, Burger RA, et al. Intraperitoneal catheter outcomes in a phase III trial of intravenous versus intraperitoneal chemotherapy in optimal stage III and primary peritoneal cancer: A Gynecologic Oncology Group study. Gynecol Oncol 2006;100:2732.
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    Landrum LM, Gold MA, Moore KN, Myers TKN, McMeekin DS, Walker JL. Intraperitoneal chemotherapy for patients with advanced epithelial ovarian cancer: a review of complications and completion rates. Gynecol Oncol 2008;108:3427.
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    Helm CW, Metzinger DS, Parker LP, Gordinier ME. Port complications associated with delivery of intraperitoneal chemotherapy for ovarian cancer. Gynecol Oncol [Abstract 294 Annual Meeting of the Society of Gynecologic Oncology, Tampa, FL March 2008]. 2008;108:S32155.
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    Walker JL. Intraperitoneal chemotherapy: technique and complications. In: Helm CW, Edwards RP, editors. Intraperitoneal Cancer Therapy. Totowa, NJ: Humana Press; 2007. pp. 5569.
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    Arts HJ, Willemse PH, Tinga DJ, de Vries EG, van der Zee AG. Laparoscopic placement of PAP catheters for intraperitoneal chemotherapy in ovarian carcinoma. Gynecol Oncol 1998;69:325.
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    Liou W-S, Teng NN, Chan JK. A modified technique for insertion of intraperitoneal port for chemotherapy. J Surg Oncol 2005;90:2478.
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    Anaf V, Gangji D, Simon P, Saylam K. Laparoscopical insertion of intraperitoneal catheters for intraperitoneal chemotherapy. Acta Obstet Gynecol Scand 2003;82:11405.
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    Makhija S, Leitao M, Sabbatini P, Bellin N, Almadrones L, Leon L, et al. Complications associated with intraperitoneal chemotherapy catheters. Gynecol Oncol 2001;81:7781.
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    Pendergrass M, Gordinier ME, Parker LP, Metzinger DS, Helm CW. Retraction of an intraperitoneal chemotherapy port: a case report and literature review. Int J Gynaecol Cancer 2007;17:113171.
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    Wakefield T, Eckhauser F, Strodel W, Knol J. Colocutaneous fistula complicating Tenckhoff catheter placement for intraperitoneal chemotherapy. J Surg Oncol 1984;27:2057.
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    Varney RR, Goel R, van Sonnenberg E, Lucas WE, Casola G. Delayed erosion of intraperitoneal chemotherapy catheters into the bowel. Report of two cases. Cancer 1989;64:7624.
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    Doane L. Administering intraperitoneal chemotherapy using a peritoneal port. Nurs Clin N Amer 1993;28:88597.
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    Markman M, Walker JL. Intraperitoneal Chemotherapy of Ovarian Cancer: a Review, With a Focus on Practical Aspects of Treatment. J Clin Oncol 2006;24:98894.
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    Robinson WR, Beyer J. Factors Affecting the Completion of Intraperitoneal Chemotherapy in Women With Ovarian Cancer. Int J Gynaecol Cancer 2010;20:704.
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    Fujiwara K, Sakuragi N, Suzuki S, Yoshida N, Maehata K, Nishiya M, et al. First-line intraperitoneal carboplatin-based chemotherapy for 165 patients with epithelial ovarian carcinoma: results of long-term follow-up. Gynecol Oncol 2003;90:63743.[Erratum appears in Gynecol Oncol 2003 Dec;91(3):662]

Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods of review
  5. Port development and characteristics
  6. Methods of port placement and removal
  7. Port complications
  8. Infection
  9. Obstruction to infusion
  10. Access
  11. Retraction
  12. Bowel perforation
  13. Pain and discomfort
  14. Leakage
  15. Effect of the timing of placement
  16. At the time of bowel resection
  17. Influence of surgeon and team experience
  18. Conclusion
  19. Disclosure of interests
  20. Contribution to authorship
  21. Details of ethics approval
  22. Funding
  23. Acknowledgement
  24. References
  25. Supporting Information

Figure S1. Port-A-Cath® intraperitoneal port with attachable, polyurethane, fenestrated catheter with cuff (21-2000-24; Smith Medical ASD Inc., St Paul, MN, USA).

Figure S2. Intraperitoneal access port with attachable, silastic, fenestrated catheter, cuff-less version (0603006; Bard Access Systems Inc., Salt Lake City, UT, USA).

Figure S3. Vascular access port with attachable, silastic, single lumen, cuff-less catheter (0602680; Bard Access Systems Inc., Salt Lake City, UT, USA).

FilenameFormatSizeDescription
BJO_3179_sm_FigS1.pdf224KSupporting info item
BJO_3179_sm_FigS2.pdf190KSupporting info item
BJO_3179_sm_FigS3.pdf417KSupporting info item

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