Cytoreductive Surgery and HIPEC Chemotherapy

HIPEC chemotherapy, which is the short form of hyperthermic intraperitoneal chemotherapy, is a special surgical oncology treatment that might provide hope to those who have complex and advanced abdominal cancers and usual chemotherapy drugs are not effective to them anymore. Using heated, sterilized chemotherapy solution, this cancer treatment procedure is performed after the cytoreductive surgery to kill the microscopic cancer cells that might have not been found and destroyed during the surgery. 

The combination of HIPEC and CRS (cytoreductive surgery) makes an effective solution for many cancer patients. However, the procedure has its own risks and is not suitable for all patients. This article explains the benefits of this treatment, how it is done, what its risks are, and who it’s for. 

Which Types of Cancer Are Treated with This Procedure?

Cytoreductive surgery and HIPEC are performed to treat several types of gastric cancer:

• Colorectal cancer
• Appendiceal cancer
• Ovarian cancer
• Colon cancer
• Stomach cancer
• Primary peritoneal cancer
• Pseudomyxoma Peritonei (PMP)
• All cancers in the peritoneal cavity

Cytoreductive Surgery

Cytoreductive surgery is the first step of this procedure. As chemotherapy treatments are less effective for treating cancers in the abdominal cavity, when the spread of disease in the abdomen is limited and patients have the qualifications, a major operation is performed by a team of surgeons.

A typical operation may involve a combination of removing some of the peritoneum and the abdominal areas affected by cancer spread. This operation lasts an average of 8-10 hours depending on the extent of the disease.

A typical operation may involve the removal of part of the colon or rectum, organs such as the gallbladder or spleen. In women, the uterus or the womb and ovaries are removed. 

The momentum, a fatty apron that lives inside the abdomen, is removed. And again the peritoneum, the lining of the abdominal organs or abdominal wall is removed. Also, a toma needs to be formed, either temporary or permanent.

The steps of the surgery:

• An incision is made into the abdominal wall
• Doctors assess the extent disease involvement and organs affected
• Using various surgical techniques, they remove as many tumors as possible.
• After the tumors have been removed, the HIPEC procedure begins.

HIPEC Procedure

After the surgery, there is a possibility the microscopic cancer cells remain. That’s why hyperthermic intraperitoneal chemoperfusion must be done right after the surgical process. During this procedure, high doses of heated chemotherapy can penetrate and destroy cancer cells that are left out in the abdomen after surgery.

Immediately following the cytoreductive surgery the surgical team performs the HIPEC treatment. As mentioned before, HIPEC is essentially a chemotherapy bath or wash that delivers chemotherapy directly to the abdominal cavity usually for an hour with the intention of killing any remaining cancer cells that were not a visible tumor and hence not seen with the naked eye.

The tubes are connected to a machine that both heats and pumps the solution allowing continuous circulation of the chemotherapy solution.

The temperature probes allow the temperature of the solution to be measured constantly.

The steps of HIPEC are as follows:

• Temperature probes are placed on each side of the abdominal wall
• Then, two inflow catheters are placed in the lower abdomen.
• And two outflow catheters are placed in the upper abdomen.
• The catheters are attached to tubes connected to the profusion machine, which warms, administers, and controls the temperature and flow of the chemotherapy solution.
• The temperature probes allow the surgical team to monitor the temperature of the solution within the abdomen.
• The abdomen is then temporarily sutured close for the procedure
• Sailing solution through the inflow catheters.
• The solution is warmed to the necessary temperature.
• Chemotherapy is added to the solution in 2 doses over a 90-minute period.
• The pump of the profusion machine delivers the solution into the abdomen.
• The solution flows back to the machine where it’s warmed and redelivered into the abdomen.
• This cycle continues.
• At the end, the chemotherapy solution is drained from the abdomen.
• The surgeon reopens the abdomen and the probes and catheters are removed.
• The whole procedure takes 6-12 hours to complete.

 Benefits of HIPEC

HIPEC is not the solution for all cancer patients. However, for people who have advanced surface spread of cancer within the abdomen without disease involvement outside of the abdomen. Overall, HIPEC is an effective treatment for cancer because it:

• Allows for high doses of chemotherapy
• Enhances and concentrates chemotherapy within the abdomen
• Minimizes chemotherapy exposure and side effects
• Improves chemotherapy absorption and susceptibility of cancer cells

Am I Qualified for HIPEC?

Each individual’s case differs from another. Therefore, to assess a patient’s eligibility, a team of doctors, surgeons, radiologists, pathologists, and chemical nurse specialists of a specialized medical center consult and perform diagnostic studies to find out whether each patient needs this treatment or not.  But there are special circumstances that make patients unsuitable for this process. 

For instance, eligible patients should not have disease in multiple sites or disease in the abdomen which is too widespread, then they’re unlikely to benefit from this type of surgery. Each patient is assessed individually and treatment or a surveillance plan is put into treatment.

Life After HIPEC

The entire process is really invasive and it takes 3 to 4 months for patients to recover completely. You have to stay 7-10 days in the hospital, which is not a short time in comparison with many types of surgery. During this time, your digestive system needs to recover from the intense dose of chemotherapy it has received. Nutrition is given to patients via a feeding tube. 

During your recovery time at home, make sure to take a walk every day as it decreases the chance of post-surgery complications. 

If you feel tired most of the time, don’t worry. It’s totally normal and will continue for 2 or 3 months. Remember, your body has been through a lot. Give it time to heal. But try to stay active, even if it means brief, small, daily activities. 

Wait for at least 2 months before you restart your sexual activity. Listen to your body. Don’t be hard on yourself. 

If your job does not require heavy physical activities, you can go back to work within a month. 

Driving is not recommended sooner than 7 to 8 weeks after the surgery. 

If you have to travel after your surgery or you choose medical tourism for your treatment, ask your airline for a ‘curb to curb wheelchair’. Ask your surgical oncologist or your surgeon to evaluate your nutrition status because your calorie needs after surgery must be met. 

In general, you can eat well-cooked vegetables, white bread, plain pasta, white rice, etc. And please, don’t forget your follow-up sessions. Even 4 years after the surgery, you need follow-ups every 6 months. 

Side Effects

Serious complications are seen in between 10-15% of patients. The most common side effects are Bleeding and asthmatic leak which happens when the bowel ends that have been joined together do not heal. It most of the time needs antibiotics, sometimes a drain, and even a second operation.

Another common risk is fluid collections within the abdomen. This might require the insertion of a drain into the abdomen under x-ray guidance blood clots within the leg. This is called deep vein thrombosis.

Other complications are:

– Wound, chest, and urine infections

– Fistulas

– Kidney failure

– Abscesses

– Hemorrhages

– Bloating

– Constipations

– Diarrhea 

– Depression 

– Pain

– Vomiting

– Weight loss

– Fatigue

Even though the side effects are not limited, most of the time HIPEC does not have

the usual side effects of traditional chemotherapy.

Also, infections might be treated with antibiotics. Severe infections may require more aggressive treatment. The last point is that if a team of professional surgeons performs the process in a specialized center, the side effects won’t be more than the risks of other types of digestive surgery. 

Call your doctor when:

– Fever higher than 101 degrees Fahrenheit

– Uncontrollable pain 

– Redness beyond your incision

– Nausea or vomiting for more than one day

And basically any other circumstances you find intolerable. 

About the cost of cytoreductive surgery and HIPEC, we will talk more in the next article as we give you information about the cost of the procedure in different countries and what factors affect its cost. 

Death and Survival Rate of HIPEC

Safety concerns and analysis of morbidity matter a lot to cancer patients before making a decision. Even though the process is risky, in comparison with other treatments for cancer, the survival rate is higher. According to a review of morbidity, the 30-day mortality rate of HIPEC was 1.1%. Median improved survival is not fixed for all patients, but it varies from 22 to 47 months. Also, the 5-year survival rate is 27% to 54%.