Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment for certain tumors that have spread inside the abdominal cavity—known as peritoneal disease. The combination of surgery and regional chemotherapy has advantages for treating certain types of cancers. Unlike standard chemotherapy, which is given intravenously according to a predetermined schedule of alternating treatments and rest periods, HIPEC is administered in a single session that takes place during the surgical procedure after the tumors are removed. This allows for a higher concentration of the drug to reach the tumor.
How does CRS work?
During the CRS portion of this procedure, all visible cancer is removed from the patient’s abdominal cavity. First, the patient is placed under general anesthesia, meaning that they will be unconscious for the duration of the procedure. Once the patient has been put under anesthesia, the surgeon will make an incision on the patient’s abdomen and remove as much of the tumor as possible, along with any diseased tissue or organ. The goal of the cytoreduction portion of the operation is to remove all of the visible tumor or to leave only a small amount on vital structures.
In some instances, removing a tumor may require also removing nearby organs. For example, if the surgeon is tasked with removing a tumor on the surface of the intestine, it may be necessary to remove a portion of the intestines. This can include the large or small bowel. Because CRS is considered to be a technically challenging surgery to perform, it’s important that the surgeon be highly experienced with this type of procedure.
"The treatment of patients with peritoneal disease involves complex decision making. We think all such patients should be evaluated at a specialized center with a dedicated team to help patients achieve the best results."- Dr. Sean Dineen
How does HIPEC work?
While the goal of CRS surgery is to remove visible disease, the goal of the HIPEC portion of the procedure is to treat microscopic disease. After all visible tumors are surgically removed, the surgeon will insert a catheter that’s connected to a perfusion machine. Then, a highly concentrated, heated chemotherapy solution will be pumped directly into the abdominal cavity, where it will circulate and target any remaining cancer cells. This ‘hot chemotherapy bath’ continues for approximately 90 minutes while the patient lies on a special cooling pad. Afterward, the 108-degree chemo bath will be washed out, the surgical incisions will be closed, and the patient will begin the recovery process. Surgery times will vary from one patient to another, but the combined total of both procedures (CRS and HIPEC) is often between eight and 10 hours.
What to expect during recovery
Recovery from CRS/HIPEC surgery takes at least three months. Patients are typically in the hospital for about 10 days prior to being discharged home. While a patient is recovering from surgery, it’s important that they continue moving around as much as possible in order to prevent blood clots and other complications (of course, rest is certainly important, too). Surgeons will provide personalized instructions to their patients on what to do and not do during recovery.
Who is a candidate for CRS/HIPEC?
CRS/HIPEC is a procedure that may benefit patients with peritoneal spread of their cancer. Candidates for the surgery should have a good medical history since the surgery is invasive. HIPEC can be the primary approach for therapy or can be used in conjunction with other treatments.
HIPEC is most commonly used to treat patients with the following cancers:
HIPEC can also be effective when used as supportive therapy for patients who have a malignant ascites (an accumulation of fluid in the stomach cavity), which is a common side effect of peritoneal tumors.
Benefits of CRS/HIPEC
As compared to traditional chemotherapy, HIPEC has several potential advantages, including:
- Fewer side effects – Rather than entering the bloodstream and circulating throughout the entire body, the cancer-fighting medication is delivered directly into the stomach cavity, increasing the concentration of drug where the cancer was located. As a result, the chemo is less likely to be absorbed and affect healthy tissues and organs.
- Greater effectiveness – The heated chemotherapy solution causes blood vessels in the peritoneum to expand, allowing the medication to penetrate more deeply for better absorption. Also, because the chemo drugs are concentrated in the peritoneal cavity, a higher dose can be administered without causing adverse effects.
- A single treatment – Unlike standard chemo, which is delivered intravenously in multiple sessions over several weeks or months, HIPEC is one treatment given in the operating room after cytoreductive surgery.
For some patients, especially those who have an aggressive or difficult-to-treat type of cancer, HIPEC may lead to a better outcome and enhanced quality of life.
Potential risks of CRS/HIPEC
As was noted above, intraperitoneal chemotherapy produces fewer side effects than traditional chemotherapy. With that being said, patients may still experience side effects from HIPEC chemo, such as:
- Nausea and vomiting
- Constipation or diarrhea
- Weight loss
- Difficulty sleeping
As with any surgical procedure, there is always a risk of complications occurring with CRS/HIPEC. The most common of these is the development of bleeding and infection. Other potential complications include:
- Blood clots forming in the legs and then traveling to another area of the body, such as the lungs
- Developing an enterocutaneous fistula (an abnormal opening between the intestines and the skin)
- Experiencing an anastomotic leak (a leak that occurs when two sections of the intestines fail to join together properly after being reconnected)
- Not being able to consume a sufficient number of calories following the procedure
CRS/HIPEC at Moffitt
At Moffitt Cancer Center, a multispecialty team assesses each patient’s needs to determine the best strategy for treating peritoneal metastasis. Because we believe that informed patients make better treatment decisions, we fully educate each patient about the role of surgery, chemotherapy and radiation, including their purposes and potential side effects as well as any possible alternatives.
Moffitt’s renowned research team is continually investigating the effectiveness of new treatments. Through our robust clinical trials program, our patients have opportunities to benefit from promising new surgeries, drug combinations and chemotherapy delivery methods before those options are available in other settings. This is just one way that Moffitt is consistently challenging the odds by improving both patient outcomes and quality of life.
Medically reviewed by Dr. Sean Dineen, Gastrointestinal Oncology Program
If you’d like to learn more about hyperthermic intraperitoneal chemotherapy, you are encouraged to talk with a member of the Gastrointestinal Oncology Program at Moffitt Cancer Center. To request an appointment, call 1-888-663-3488 or complete our new patient registration form online. We’ve made it our goal to connect each new patient to a cancer expert within a day, so you can look forward to receiving a prompt response to your inquiry.