Cytoreductive Surgery And HIPEC

Dr Praveen performs Cytoreductive surgery and HIPEC for following cancers that have spread to peritoneum

  1. Ovarian cancer
  2. Appendicular cancers
  3. Pseudomyxoma peritonei
  4. Colorectal cancers
  5. Stomach cancer
  6. Primary peritoneal cancer
  7. Endometrial cancer
  8. Peritoneal mesothelioma

Cancer spreading to peritoneum was considered uniformly fatal. This was primarily due to lack of understanding of the pathogenesis of disease, perceived inability to remove the affected peritoneum and multiple organs and due to the lack of good quality chemotherapeutic agents.

Cytoreductive surgery and HIPEC has changed this perception. With this technique cure is possible in pseudomyxoma and appendicular malignancies and prolonged treatment free periods can be achieved in several types of cancers.

When is cytoreductive surgery- CRS needed?

When the disease from an abdominal organ spreads to the peritoneum a CRS is recommended.

Peritoneum: all the abdominal organs and inside of the abdomen is covered by a thin layer called peritoneum. The cancer cells once leaving the primary organ of origin get implanted onto this layer. Some of these cancer cells travel with the fluid generated in the peritoneum and thus reach distant sites where they get implanted. Technically it is possible to remove the entire peritoneum covering the inside of the abdomen while it is not possible to remove the peritoneum covering the organs this necessitates removal of those organs themselves to achieve tumour clearance.

Fig 01. Normal Peritoneum
Fig 01. Normal Peritoneum
Fig 02. Diaphragmatic Peritoneum With Peritoneal Metastasis
Fig 02. Diaphragmatic Peritoneum With Peritoneal Metastasis
Fig 03. Normal Pelvic Peritoneum
Fig 03. Normal Pelvic Peritoneum
Fig 04. Single Small Peritoneal Deposit In Pelvic Peritoneum From Gastric Cancer
Fig 04. Single Small Peritoneal Deposit In Pelvic Peritoneum From Gastric Cancer
Fig 05. Multiple Nodular Deposits In Peritoneum And Omentum From Colon Cancer
Fig 05. Multiple Nodular Deposits In Peritoneum And Omentum From Colon Cancer
Fig 06. Plaque Like Deposits From Colorectal Cancer
Fig 06. Plaque Like Deposits From Colorectal Cancer

How are patients selected for such a procedure?

Two driving factors are important as far as case selection for CRS HIPEC is considered. One is the extent of the disease spread. The modern day CT scans and MRI give a fair idea of disease extent. However sometime we do advise staging laparoscopy to visually confirm the disease spread before recommending CRS and HIPEC.

The extent of disease is mapped and calculated using an index called PCI. PCI allows us to map disease in different parts of the abdomen and depending on the size of the disease a score is given to each region. Thus a score is generated that is called PCI score. There are other indices also for the same purpose. The cut off PCI scores for selecting patients for CRS and HIPEC varies based on the site of the primary tumour. While for PMP and appendicular cancers there is no upper limit of PCI cutoff, for gastric cancer PCI score of more than 12 is considered a contraindication for CRS HIPEC.

Second is the patient’s general health to withstand such a challenging surgical procedure. Physical examination and several tests are required to confirm this.

What is cytoreductive surgery?

It’s a combination of multiple surgical procedures carried out in the abdomen. The aim of cytoreductive surgery is to remove all the visible tumour nodules. A cytoreductive surgery essentially involves removal of the peritoneum to various extents (called peritonectomy) along with removal of other affected viscera to achieve complete clearance of the tumour. These Other surgical procedures usually involve –anterior resection ( removal of part of rectum), colectomy ( removal of colon) , gastrectomy ( removal of part of stomach), splenectomy, small bowel resection.

Fig 07. Pelvic Peritonectomy
Fig 07. Pelvic Peritonectomy
Fig 08. Pelvic Peritonectomy Before
Fig 08. Pelvic Peritonectomy Before
Fig 09. Pelvic Peritonectomy After
Fig 09. Pelvic Peritonectomy After

What is HIPEC?

HIPEC is a procedure where chemotherapeutic drugs are circulated at high temperatures inside the abdominal cavity after the performance of cytoreductive surgery. The purpose of HIPEC is to kill the microscopic tumour residue that may be left behind after CRS. The high temperatures increase the efficacy of chemotherapeutic drugs. A specialized machine is required to perform HIPEC. It purifies the chemotherapeutic solution and reheats it and recirculates it for a time period of 60-90 minutes.

Fig 10. HIPEC
Fig 10. HIPEC
Fig 11. HIPEC Surgery
Fig 11. HIPEC Surgery

Can CRS HIPEC be performed at any center/hospital?

CRS + HIPEC is a major surgical undertaking. The procedure itself takes 6-10 hours and puts a huge physiological stress on the patient. The patient experiences significant hemodynamic change during and after the surgery and recovery is slow compared to other major surgeries. Hence a close collaboration between surgeon, anesthetist and intensivist is absolutely essential for good results. Studies have shown that surgeons and teams who do these procedures on a regular basis have better results compared to those who do them occasionally.

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