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HIPEC stands for Hyperthermic Intra PEritoneal Chemotherapy. It is a specialised form of Chemotherapy delivered into the abdomen at high temperatures. It is never done in isolation as it is ineffective if there is gross disease in the abdomen. It has to be carried out after a Cytoreductive Surgery, in which all the visible peritoneal disease is removed . It is an innovative method for treatment of cancers which have spread to the peritoneum or originated in the peritoneum.
The prerequisite for HIPEC to work is cytroreductive surgery. Cytoreductive Surgery is a supramajor surgery which basically involves removing all visible tumour. This entails removing of the peritoneum which is the inner lining of the abdominal cavity, omentum which is the intra-abdominal fat curtain, appendicectomy and any other deposits of tumours. If the disease involves different organs like colon rectum and/or small bowel they are also resected. If the liver and diaphragm is involved, a procedure called “Glissonectomy”-Removal of Liver capsule and Diaphragmatic stripping -i.e., removal of the diaphragmatic peritoneum is also done. Once all the disease is removed, heated chemotherapy is then circulated throughout the abdominal cavity using a special device for one hour. The heat and circulation helps the chemotherapy reach places where conventional chemotherapy doesn’t reach, thus improving disease control and survival.
Certain cancers which are of peritoneal origin like Primary Peritoneal Carcinoma, Peritoneal Mesothelioma and Pseudomyxoma Peritonei benefit significantly from cytoreductive surgery and HIPEC. For conventional chemotherapy, the survival is hardly 30% for these cancers which increases to almost 70-90% with HIPEC. For other cancers like ovary, stomach and colon which have spread to peritoneum, traditional chemotherapy provides survival rate ranging from 0 - 19% depending on the type of cancer. In contrast, with HIPEC, the survival crosses 50%. Thus the patients suffering from following cancers benefit from HIPEC. At present, the following cancers are the only diseases where HIPEC has shown benefit. In all other cancers, the role is still experimental.
Primary Peritoneal Cancers
Recurrent Ovarian Cancer with peritoneal metastases
Colorectal Cancer with peritoneal metastases
Stomach Cancer with peritoneal metastases
Endometrial Cancers with Peritoneal metastases.
Cytoreductive Surgery is a supramajor surgery. The entire surgery can last any where between 8 to 16 hours. Typically a week before surgery we will start your prehabilitation programme. This entails use of high protein diet and immunonutrition. The physiotherapist will teach you exercise for strengthening your cardiopulmonary reserve. This prehabilitation reduces the post operative complications like pneumonia, Deep vein thrombosis, wound infections and labile sugar levels. For an uneventful post operative course ( without any complications), the patient typically spends 3 to 4 days in the ICU and around 10 - 15 days in the wards. Patients may get discharged earlier if they are highly motivated and actively incorporate post operative physiotherapy and rehabilitation planned out for them by our team.
If the disease is far advanced and/or if you a re medically unfit to undergo HIPEC surgery, then we also have the option of PIPAC. PIPAC stands for Pressurised Intra Peritoneal Aerosolised Chemotherapy. Dr. Ninad Katdare is pioneer of PIPAC in India. PIPAC can either be used as a standalone palliative chemotherapy which is repeated every 2 months till disease progression; or if the disease responds, the patient is assessed after 3 cycles for feasibility of HIPEC surgery. For more details on PIPAC, read below.
PIPAC stands for Pressurised Intra Peritoneal Aerosolised Chemotherapy. It is a specialised delivery system in which Aerosolised chemotherapy is delivered under pressure into the abdominal cavity. It is an innovative method for treatment of cancers which have spread to the peritoneum or originated in the peritoneum. PIPAC can either be used as a standalone palliative chemotherapy which is repeated every 2 months till disease progression; or if the disease responds, the patient is assessed after 3 cycles for feasibility of HIPEC surgery.
The procedure is carried out under general anaesthesia. Like in laparoscopic surgery two small openings are made in the abdomen. A scope is introduced and the abdominal cavity is examined. An objective measurement of the disease is done using an index called as the “Peritoneal Cacinomatosis Index”. (PCI). After this few biopsies are taken from various quadrant to confirm the diagnosis in the first sitting and to assess the response to PIPAC in subsequent sittings. After this, the PIPAC system is assembled and the procedure is carried out. An average PIPAC procedure will last around 2 hours. Patient can have normal food after 6 hours and if he/she is comfortable, he/she can go home the next day.
Cancers which are of peritoneal origin like Primary Peritoneal Carcinoma, Peritoneal Mesothelioma and Pseudomyxoma Peritonei benefit significantly from cytoreductive surgery and HIPEC. For conventional chemotherapy, the survival is hardly 30% for these cancers which increases to almost 70-90% with HIPEC.
However almost 30 to 40% patients are unfit for HIPEC either because of advanced disease or morbidites. For these patients and any patient who has peritoneal metastases from any site like ovary, colon, stomach, pancreas, liver, gall bladder, endometrium, breast PIPAC is effective. It is an evolving standard of care for patients who have already received multiple lines of chemotherapy. In experimental studies it has also been found to be as effective as standard intravenous chemotherapy, namely in ovarian cancers, colorectal and stomach cancers with peritoneal metastases. Any patient with peritoneal metastases with ascites is also a candidate for PIPAC. It has been found that the volume of ascites goes down significantly and the rates of intestinal obstruction also reduced. Thus even if in cases where the survival is not improved, PIPAC greatly improves the quality of life.
PIPAC is a simple but innovative procedure. It is done as a day care procedure or a one day stay in the hospital. No special investigations other than the routine pre-anaesthesia workup is required. A CT scan is done to assess the amount of disease and to plan the entry in the abdomen. The patient is admitted the night before the procedure. The PIPAC procedure is done the next day morning. The procedure takes around 2 hours after which patient is kept in the recovery ward for few hours and then shifted to the room. If the patient is comfortable, he/she can be discharged the same night or the next morning. As the dose of chemotherapy required in PIPAC is just 10% of the standard dose, there are no side effects of chemotherapy like hair loss, renal or haematological disturbances. The side effects seen in this procedure include occasional mild fever, malaise and occasional wound infection.
The only contraindication to this procedure is if the patient is in a very poor general condition or if the disease volume on the anterior abdominal wall is too large to preclude an entry into the abdomen.
The patient who is unfit for PIPAC is referred to the Palliative care department. If there is any surgically treatable problem like obstruction, it can be considered. Symptomatic treatment and supportive treatment for the symptoms is then instituted.