Cytoreductive Surgery and HIPEC

What the outcome depends on

The peritoneum is most often involved by tumors of the colon, appendix, stomach and ovaries. Pseudomyxoma peritonei — a slow accumulation of mucus containing tumor cells, most often from a mucinous tumor of the appendix — and peritoneal mesothelioma are considered separately.

The tumor origin determines how effective cytoreduction is: the best results are in pseudomyxoma, ovarian cancer and limited disease from colorectal cancer; in gastric cancer it is not a standard and is possible only in a narrow group of patients, mainly within clinical trials. About the disease itself — on the page “Peritoneal Carcinomatosis”.

When surgery is possible

Cytoreduction is considered when:

• all visible tumor deposits can be removed;
• there are no metastases outside the abdominal cavity, or they are limited and resectable;
• small bowel involvement is not too extensive;
• the general condition allows a long operation.

The extent of disease is assessed with the peritoneal cancer index (PCI) — from 0 to 39 across 13 regions of the abdominal cavity. The acceptable PCI depends on the origin: in colorectal cancer results are best with a low index, while in pseudomyxoma surgery is performed even with a large tumor volume. Because CT often underestimates small deposits, diagnostic laparoscopy is sometimes performed before surgery.

If carcinomatosis is found unexpectedly during another operation, the extent of the urgent procedure is decided by the situation; if there is no urgent need, a biopsy is taken, the extent of spread is documented and treatment is planned after the tumor board: removing individual deposits “while we are there” without a plan makes subsequent complete cytoreduction harder.

HIPEC: when it is appropriate

HIPEC is washing of the abdominal cavity with a heated chemotherapy solution right after the tumor has been removed. Its effectiveness depends on the origin:

The indications for HIPEC are decided by the tumor board in each case.

If surgery is not possible right now

If complete cytoreduction is not possible, the basis of treatment is systemic chemotherapy according to the tumor origin, combined with targeted drugs or immunotherapy when indicated. After a response to treatment the question of surgery sometimes returns. Increasing ascites is drained by paracentesis; with bowel obstruction, a bypass anastomosis, stoma or stent is considered to relieve symptoms.

How the operation is performed

Cytoreduction is performed through a midline incision. All visible deposits are removed: affected areas of the peritoneum (peritonectomy), the greater omentum, the lesser omentum if involved and, if needed, part of the bowel, the spleen, the gallbladder, the uterus with adnexa. The goal is to leave no visible deposit: the completeness of cytoreduction is one of the most important factors in the outcome. Such an operation can last many hours.

For most tumors the operation is combined with systemic chemotherapy before and after it; in low-grade pseudomyxoma it is usually not needed. The sequence is decided by the tumor board.

Hospital stay, recovery and follow-up

Recovery follows the enhanced recovery (ERAS) protocol: early mobilization, early eating, controlled pain relief. After major cytoreduction the first days are usually spent in the intensive care unit, and the hospital stay is longer than after a standard operation; a temporary stoma is sometimes created.

A few weeks later, once the patient has recovered, systemic chemotherapy is continued when indicated. The schedule of CT or MRI and tumor markers depends on the primary tumor, its histology and the treatment given; in pseudomyxoma follow-up is long-term.

Risks and complications

Risks are what patients ask about least often, although they are the most important thing to discuss before surgery. The more extensive the cytoreduction, the higher they are. The main ones are:

• bowel complications — anastomotic leak, which is why a temporary stoma is sometimes created;
• bleeding during or after the operation;
• infection, including within the abdomen, and general surgical complications such as thrombosis;
• side effects of the chemotherapy drug — if HIPEC was performed.

The likelihood of each depends on the extent of the operation, previous treatment and your general condition. I will explain the risks in your particular case at the consultation.

What the cost depends on

The cost depends on the extent of cytoreduction, whether HIPEC is indicated, the number of days in the hospital, including intensive care, and the tests, such as diagnostic laparoscopy. The exact amount is named once the treatment plan has been defined. The payment can be split into parts — installments are available. The in-person consultation is free. More details are on the page “Cost of Surgery: What It Depends On”.

What documents are needed and how to book

• CT or MRI discs with reports — the discs themselves;
• operative reports of previous surgery and laparoscopy describing the peritoneal spread;
• the pathology report, tissue blocks and slides;
• tumor markers over time;
• chemotherapy summaries with regimens and number of cycles.

Book a consultation by phone or through the form. If you are from another city, send the documents in advance — how to do this is described on the page “Online Oncologist Consultation”.