THE INTEGRATED OPERATING ROOM

The “integrated operating room” is a response to the new challenges in health and medical practice.

The increasing number of image-based non-invasive procedures (operative microscopy, endoscopy column…) has led to the development of a new-generation operating room, which also takes into account the extension of telecommunications in health care establishments.

The “integrated operating room” is aimed at facilitating the implementation of the new modalities of treatment.  It enables operating teams to enhance technical effectiveness and better ensure patient safety.

The “integrated operating room” concept involves several levels of integration: :

– The first level corresponds to the “communicating operating room”. The system imports information from the patient’s electronic records, whatever the source. It also renders possible the capture and display in the operating theater of intraoperative information. Finally, it  exports information to a classroom, a staff meeting area, a work station or a  surgery programming room.

– The second level of integration, which may be termed “blocotics” (a French operating area is a bloc opératoire…), draws inspiration from domotics. This module monitors medical and on-medical equipment from a single user interface. In the Poitiers CHU, a surgeon controls an interface while an operating room nurse pilots another interface in the non-sterile zone.  And recording tools can be integrated prior to the operation so as to prepare, install or program the surgical act.

– The third – and most elaborated – level considers the integrated operating room as “a new architectural concept”.  This module emphasizes optimization of the surgical team’s environment. It brings together experts from the fields of architecture, logistics, technology and medical equipment… The object is to create a space as ergonomic as possible through reappropriation of existing concepts, and creation of new ones.

Interviews :
Interview du professeur Jean-Pierre Faure, PU-PH – general, digestive and obesity surgery
Interview du professeur Bertrand Debaene, PU-PH – anesthesiologist
Interview d’Aurélie Supiot, biomedical engineer

INTRAPERITONEAL CHEMOTHERAPY (IP Chemo): A NEW THERAPEUTIC RESPONSE TO DIGESTIVE CANCER

Since May 2008, patients with peritoneal carcinomatosis from digestive cancer dispose in the Poitiers CHU of a therapeutic response to their disease: Intraperitoneal chemotherapy (IP Chemo, CHIP in French). Applied in the visceral surgery unit, this new procedure guarantees several years of survival to patients who would otherwise be condemned after a few months. Poitiers is the only establishment in the region to practice IP Chemo.

Cancers of the digestive tract constitute one of the main causes of death due to cancer. They evolve by three different routes: visceral metastases (liver and lungs), ganglionic metastases and peritoneal carcinomatosis. While the first can be treated by surgery and/or chemotherapy and the second by chemotherapy, the third was considered as constituting a therapeutic impasse up until a dozen years ago, when hyperthermic intraperitoneal chemotherapy (HIPEC, in English) first appeared.

It was Doctor Sugarbaker, an American surgeon, who had the idea of associating maximal surgical resection of tumors with intraperitoneal chemotherapy. Prior to this procedure, surgery was limited to removal of nodules and possible palliative treatment of an existing or potential occlusion. Intravenous chemotherapy could only temporarily slow the evolution of peritoneal carcinomatosis. A patient could only survive for a few months.

Operating as a regional recourse

Since May 2008, in its visceral surgery department the Poitiers CHU has been offering this new response to peritoneal carcinomatosis and thereby fulfilling its role as regional recourse in the cancerology center of the CHU.

As of today, only twenty establishments in France apply this procedure..

The particularity of this technique consists in a combination of complete removal of tumoral tissues and direct application of chemotherapy in the patient’s abdomen.  Administration of chemotherapy in the peritoneal cavity is maximally effective, and without toxicity, on account of a concentration twenty times greater than that achieved intravenously. This degree of concentration cannot be reached through systemic administration, without provoking severe disorders such as aplasia.

The techniques also owes its effectiveness to heat: Different experimental studies have demonstrated that on the one hand, heat had a cytotoxic effect on the tumoral celles, while on the other hand, it increased the intracellular penetration of chemotherapy.

Unfortunately, not all peritoneal carcinomatoses can be treated by applying this method. As of now it has been validated only for some pathologies, such as colorectal peritoneal carcinomatosis. Given that colon cancer is the second cancer in France, this development is encouraging, and the advantages for a patient are far from negligible:  Without IP Chemo, patient survival is estimated at 7 to at most 18 months; with IP Chemo, in 40 to 45% of cases it reaches 5 years. The method has also been validated, with substantially similar results, for other pathologies such as diffuse malignant peritoneal mesothelioma, a rare disease (2 to 5 cases per a million inhabitants), which is nonetheless more frequent today due to asbestos or to peritoneal pseudomyxoma (1 was per a million inhabitants).

Studies are presently being conducted so as to assess the advantages of IP Chemo in cases of stomach and ovary cancer, but up until now the preliminary results have not been conclusive.

Extremely rigorous patient selection

IP Chemo represents major surgery: According to the gravity of the pathology, an operation goes on from 5 to 12 hours. Concretely speaking, treatment initially consists in removing tumoral lesions visible to the naked eye.

Following that, the patient’s abdominal wall is suspended to a frame so as to form a bowl or basin, which is filled with a liquid containing the chemotherapy, heated to a temperature of 42°. Using a pump, for more than an hour the liquid is made to circulate in the patient’s abdomen. The combined action of the heat and chemotherapy destroys the remaining microscopic cells.

The toxicity of the products employed necessitates specific protection (Seveso-type mask, glasses, gloves…) to be worn by the medical and paramedical staff in the operating room and during the 48 hours following surgery. Stays in surgical intensive care can last from one to three weeks, while overall hospital stay will range from 15 days to three weeks.

The complex and cumbersome protocol necessitates exceedingly rigorous selection and patient age lower than 60 years. Each case is discussed during a multidisciplinary oncology unit meeting bringing together several specialists: medical oncologists, gastroenterologists, digestive surgeons, radiologists and anatamopathologists. Pharmacists may also be consulted by medical oncologists specialized in chemotherapy so as to validate the doses to be employed.

That much said, the final preoperative decision is made by the visceral surgeon who judges according to the development of the cancer the necessity or the non-necessity of IP Chemo.