Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS and HIPEC)
What is Staging Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS and HIPEC)?
This is a major operation that aims at removing all abnormal tissue (tumour cells), a term called complete cytoreduction (CRS). It is combined with a warm chemotherapy wash of the abdomen by infusing a chemotherapy solution into the abdominal cavity during the operation called Hyperthermic Intraperitoneal Chemotherapy (HIPEC).
Complete cytoreduction
CRS and HIPEC is a technique developed and popularised by Professor Paul Sugarbaker at the Washington Cancer Centre which during complex abdominal surgery is combined with hyperthermic intraperitoneal chemotherapy (HIPEC). The average operating time for what is called a ‘major peritonectomy’ is ten hours. The operation comprises a number of different procedures namely:
- Right hemicolectomy: removing the right half of the large bowel which is where the appendix is attached
- Greater omentectomy: removing the fat apron that hangs off the stomach and large bowel
- Splenectomy: removing the Spleen
- Cholecystectomy: removing the gall bladder
- Lesser omentectomy: removing the fatty membrane between the stomach and liver
- Pelvic peritonectomy: removing the lining in the pelvis which sometimes includes the rectum by anterior resection and in the female includes removal of the ovaries and/or uterus
- Stripping of the peritoneum (lining) from the left hemidiaphragm
- Stripping of the peritoneum from the right hemidiaphragm
- Stripping of disease from the surface of the liver. This involves removing disease from the surface of the liver not the liver tissue itself.
An important factor at surgery is the involvement of the small bowel. In general the small bowel is not grossly involved due to small bowel peristalsis (normal movement of the bowel) being relatively protective against tumour implantation and growth. One of the ways of determining involvement of the small bowel prior to surgery is a CT scan with oral contrast to outline the small bowel. On CT scan sometimes it is possible to see tumour displacing the small bowel and involving it surface and mesentery and this is usually a poor prognostic factor. Sometimes we choose to perform a staging laparoscopy prior to CRS+HIPEC.
In selected cases we use a chemotherapy wash during the first few days following surgery called EPIC.
Major Tumour Debulking
If we are unable to achieve complete cytoreduction we tend to perform a debulking operation to remove as much of the tumour as possible. This generally includes removal of the uterus and ovaries in the female and often all of the large bowel including the most of the back passage and the omentum in men and women, leaving them with a permanent bag on the tummy called a stoma. We will also give HIPEC for patients that have a major tumour debulking.
Disease recurrence is almost inevitable due to residual disease (not all the disease has been removed) around the peritoneal cavity. Repeat debulking surgery may be possible, but each attempt becomes more difficult and dangerous and therefore repeat surgery is only used in carefully selected patients. The small bowel becomes increasingly involved due to disease and adhesions following previous surgery and eventually surgery becomes impossible and fraught with severe complications such as small bowel fistulae and intestinal failure.
Post-operative Mortality and Morbidity
Complete cytoreduction (CRS and HIPEC) carries a mortality risk of 3-5%, which means one in thirty to one in twenty patients die as a direct result of surgical complications.
Basingstoke currently has a 1-2% mortality rate. Surgery also has significant morbidity of around 30%. Approximately 10% (one in ten) patients will experience a significant complication such as further surgery to deal with the complications of the primary operation during the same admission, clots in the veins of the lungs or limbs, heart attack or stroke, severe chest infections, readmission to intensive care or drainage of fluid collections under radiological guidance.
Approximately 20% of patients require a stoma and in half of those the stoma will be permanent. A permanent stoma is required if all or most of the colon has to be removed. A temporary stoma is usually needed when the rectum has to be removed and the join in the bowel although appearing intact at the time of surgery, has a very high risk of leakage due to the particular position of the anastomosis (join of two parts of bowel) and the fact that intraperitoneal chemotherapy is used. The temporary stoma is usually closed between three to six months after the primary operation.
Most patients spend about three days in intensive care, and the average hospital stay is 21 days. All patients require feeding by intravenous or total parenteral nutrition (TPN) for an average of seven to ten days. Patients can take three to six months until they are fully active and able to return to work. Symptoms can affect the ability to undertake all usual activities whilst recovering from what is very major surgery.
For more information download our patient leaflet
Contact Us
Contact us today to schedule your consultation and take the first step towards better health.
Basingstoke Colorectal & Peritoneal
The Hampshire Clinic
Basing Road
Basingstoke RG24 7AL
Call us
01256 354747