Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC)

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment for certain tumors that have spread inside the abdominal cavity—known as peritoneal surface malignancies (PSM). The combination of surgery and regional chemotherapy has significant advantages for treating certain patients with PSM. 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 within the abdomen that takes place during the surgical procedure after the visible tumors are removed. This allows for a higher concentration of the drug to reach any microscopic tumors and partially prevents the chemotherapy from causing as many toxicities in the rest of the body.

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 that would otherwise be unable to be removed by surgery.

In some instances, removing a tumor may also require 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 bowel and put it back together. 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. Additionally, these surgeries are complex and lengthy (sometimes over 14 hours) and require weeks of recovery before returning to normal function. Patients should be prepared for a long recovery.  

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 catheters that are 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 average 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 before being discharged home. Recovery most often involves a significant amount of fatigue while the body heals and general gastrointestinal upset (feelings of being full or food not sitting right), both of which are temporary in the weeks after the procedure. 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. Receiving help from family members and friends, such as grocery shopping or house cleaning, during this time period is critical. 

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 and carries risk. CRS/HIPEC can be the primary approach for therapy or can be used in conjunction with other treatments.

CRS/HIPEC is most commonly used to treat patients with the following cancers:

• Appendix cancer
• Colorectal cancer
• Stomach cancer
• Peritoneal mesothelioma

CCRS/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.

Patients who get the most benefit from this procedure have a low to moderate volume of disease that can be completely removed with surgery (a complete cytoreduction or CC0).

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, CRS/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:

• Pain
• Nausea and vomiting
• Constipation or diarrhea
• Bloating
• Weight loss
• Difficulty sleeping
• Fatigue
• Depression

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
• Infections after surgery, such as pneumonia or a UTI
• 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. Our experts see a high volume of patients with PSM each day, a critical benefit of having an experienced and centralized team.  

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. Their tumor tissue also has the potential to foster research and benefit both themselves and future patients for years to come with new discoveries. CRS/HIPEC and the research involving PSM are just a few ways that Moffitt is consistently challenging the odds by improving both patient outcomes and quality of life.

If you’d like to learn more about cytoreductive surgery and 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 as quickly as possible, so you can look forward to receiving a prompt response to your inquiry.