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Karen Ritter, RN BSN
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Important Facts About Cytoreductive Surgery and HIPEC
- Cytoreductive surgery is the resection portion of the procedure. It is a debulking surgery. During debulking, doctors look for and remove all visible tumors from the peritoneal surface and in the abdominal cavity. A peritonectomy is typically performed, which is the removal of the lining of the abdominal cavity.
- HIPEC is an acronym for “hyperthermic intraperitoneal chemotherapy.” The therapy involves delivering hyperthermic, or hot, liquid chemotherapy drugs directly into the abdominal cavity.
- Cytoreductive surgery combined with HIPEC is a time-consuming surgery due to debulking. The entire process can take up to 14 hours.
- Survival rates for this surgery vary. Some cancer centers report an average survival of 3 to 5-year survival rate following the procedure. Eligible patients have much better life expectancy.
How to Get Cytoreductive Surgery With HIPEC for Your Mesothelioma
If you’re wondering how to get mesothelioma cytoreductive surgery with HIPEC, you should contact our patient advocates for assistance. They’ll help you through these steps to get highly-rated medical care from a specialist:
Learn more about cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal mesothelioma. This includes survival rates, side effects, recovery time and patient recommendations.
Contact a peritoneal mesothelioma surgeon to schedule a consultation. This is the most important step, as you don’t want an inexperienced doctor performing your surgery. Let us help you find the best surgeon for your specific needs.
Overview of Cytoreductive Surgery With HIPEC
Cytoreductive surgery plus HIPEC is a multi-part surgical procedure and comprehensive treatment for malignant peritoneal mesothelioma. The goal is to remove all or most of the mesothelioma tumors and prevent recurrence in the abdominal cavity.
Removal of all visible tumors is how doctors achieve a complete cytoreduction of the cancer. HIPEC is used to kill any remaining cancer cells or peritoneal malignancies.
Some patients receive cytoreduction/HIPEC for palliative purposes, which can extend survival by a few months and decrease discomfort from symptoms, such as abdominal fluid excess or tumors pressing against the stomach.
At the Medical College of Wisconsin, 17 cancer patients underwent 20 HIPEC surgeries for palliative intent. While the survival average was less than one year, symptom management improved as patients experienced symptom reduction 90% of the time. Symptoms remained reduced or non-existent after HIPEC surgery for an average of 5.1 months.
Where Was Cytoreductive Surgery/HIPEC Developed?
Cytoreductive surgery with HIPEC is sometimes shortened to CRS plus HIPEC. It was developed at the end of the 20th century, thanks in large part to mesothelioma specialist Dr. Paul Sugarbaker of the Washington Cancer Institute. Dr. Sugarbaker’s influence on the development of this surgery is why it’s often called the “Sugarbaker Technique.”
Cytoreduction surgeries have existed since the middle of the 20th century. Dr. Joe Meigs, of Massachusetts General Hospital in Boston, first reported using tumor debulking surgery for the treatment of patients with ovarian cancer in 1934. However, the procedure did not become widely used until the 1970s. Doctors began introducing intraoperative chemotherapy to abdominal cancer treatment in the 1970s and 1980s.
The development of cytoreductive surgery and heated intraperitoneal chemotherapy for peritoneal mesothelioma began in the 1990s. During this decade, Dr. Sugarbaker and colleagues introduced the Peritoneal Cancer Index (PCI) to stage new cases of malignant peritoneal mesothelioma and determine patient eligibility for safe surgery.
In 1995, Dr. Sugarbaker introduced the peritonectomy to the cytoreduction portion. He also improved upon earlier approaches to heated chemotherapy by using an open abdominal technique, which provided direct access to tumors.
Cytoreductive surgery intends to manually remove tumors from the abdominal cavity. It’s the only radical surgery for patients with peritoneal mesothelioma.
Finding and removing all visible tumors becomes the goal of surgery. This “debulking” procedure removes tumors and any diseased tissue in the abdomen, although microscopic cancer cells may remain after the surgery.
The omentum, a layer of fatty tissue that covers the organs in the abdomen, is often removed. along with the peritoneum may be removed during during surgery. Doctors may also remove the peritoneum, the lining of the peritoneal cavity.
Depending on the severity of the disease, doctors may have to partially or completely remove other organs in the abdominal cavity. The organs are only removed if the tumors cannot be separated from the organ’s surface and removal will not cause an increased health risk.
According to the Tufts Medical Center website, the organs able to be safely removed are the:
- Part of the small or large intestine
An article in the Annals of Surgical Oncology said surgeons may remove the pancreas, kidney, ureter, bladder and uterus without increasing severe complications or mortality rate.
HIPEC, or hyperthermic intraperitoneal chemotherapy, is an intraoperative therapy to kill peritoneal mesothelioma cancer cells. Another name for it is “hot chemotherapy.” HIPEC has led to improved outcomes.
HIPEC sends chemotherapy drugs directly into the abdominal cavity. This can help prevent some side effects associated with systemic (intravenous) chemotherapy.
Doctors create a liquid chemotherapy cocktail, usually containing cisplatin or carboplatin. Other drugs sometimes used in HIPEC are doxorubicin and mitomycin. Doctors heat the chemotherapy drugs to a specific temperature for delivery.
The heated chemotherapy solution is circulated throughout the abdominal cavity for about an hour. The chemotherapy drugs are then drained and the abdomen is flushed with a sterile saline solution. This is a complex procedure but HIPEC is a necessary part for patients with malignant peritoneal mesothelioma.
What Is the Peritoneum?
The peritoneum is a mesothelial tissue lining that lines your entire abdominal cavity. It is made up of fluid and mesothelial cells. The lining acts as a protective layer for the abdominal cavity and its many organs.
The peritoneum has two cell linings: the parietal peritoneum and the visceral peritoneum. The parietal peritoneum is the outer layer, next to the abdominal and pelvic walls. The visceral peritoneum is the inner layer of tissue covering the abdominal organs.
The peritoneal cavity is the space between the parietal and visceral tissue linings. This space is filled with fluid, which allows the linings to slide against one another with little resistance or friction. This fluid also enables the ability for abdominal organs to move freely within the cavity.
When tumors form in either of these linings, they take up space in the cavity, disrupting normal peritoneum functions. This causes peritoneal mesothelioma symptoms, such as abdominal pain and loss of appetite.
Multimodal Therapies With Cytoreductive Surgery and HIPEC
Systemic (intravenous) chemotherapy for malignant peritoneal mesothelioma is the primary treatment option and is often a combined treatment with cytoreductive surgery and HIPEC. Doctors can use mesothelioma chemotherapy either before or after cytoreductive surgery.
Doctors may use an alternative type of intraperitoneal chemotherapy treatment for malignant peritoneal mesothelioma. Dwell chemotherapy involves leaving the ports in the abdomen after surgery. Doctors can then deliver chemotherapy drugs into the abdominal cavity multiple times in the weeks following surgery.
An alternative to chemotherapy is immunotherapy. Doctors are becoming more supportive of this treatment option for peritoneal mesothelioma cases. Immunotherapy for patients with diffuse malignant peritoneal mesothelioma is available through clinical trials.
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What Happens During a Cytoreductive Surgery/HIPEC?
Cytoreductive surgery and intraperitoneal hyperthermic chemotherapy is a lengthy surgery due to the debulking process. Prior to incision, the patient is given anesthesia and closely monitored throughout the surgical procedures. The patient is properly positioned for surgery to ensure a safe surgical experience.
CRS and HIPEC for malignant peritoneal mesothelioma can take up to 14 hours. The extent of the cancer determines how long the surgery takes.
8 Steps of Cytoreductive Surgery and HIPEC
Here are the steps of cytoreductive surgery with HIPEC:
Incision — The surgeon creates a laparotomy incision from just below the xiphoid (small bone just below the sternum) down the middle of the abdomen.
Cytoreduction — The surgeon removes as many visible tumors as possible in the abdominal cavity. The omentum is also removed during this step.
Peritonectomy (sometimes) — Part or all of the peritoneum, where peritoneal mesothelioma forms, is removed. It’s a membrane lining the abdominal cavity. The peritoneum includes two linings: parietal peritoneum (outer lining next to the abdominal wall) and visceral peritoneum (inner lining covering the abdominal organs). Not all surgeons and cancer centers perform a peritonectomy for peritoneal mesothelioma.
Removal of other organs — If necessary and safe, the surgeon removes any diseased tissue and organs. They may also remove part or all of the diaphragm (respiratory muscle).
HIPEC preparation — The surgical team inserts catheters/ports into the patient’s abdomen. These catheters deliver and drain the chemotherapy solution.
Reconstruction — Closing the incision during HIPEC is called the closed-abdominal technique. Reconstruction could happen after HIPEC, which is called the open-abdominal technique.
HIPEC — The surgical team heats chemotherapy to around 107 degrees and delivers it into the abdomen through one of the catheters. The chemotherapy is circulated through the abdominal cavity for 60-90 minutes. The team rocks the patient to wash the area.
HIPEC drainage — The chemotherapy is drained from the body and then flushed out of the abdominal cavity with sterile saline. Doctors will then remove the catheters/ports and close any remaining open incisions.
If the patient is scheduled to receive dwell chemotherapy as an adjuvant (post-surgical) treatment, doctors will leave the catheters in the abdomen at the end of the surgery. These catheters will provide direct access to the disease location and a path to administer chemotherapy into the abdominal cavity.
Closed-Abdominal HIPEC Versus Open-Abdominal HIPEC
There are two main techniques for HIPEC:
- Closed-abdominal HIPEC prevents heat from escaping the abdominal cavity and decreases the effectiveness of the drugs. It also prevents drug spillage or leakage from the abdominal cavity since the incision is closed. This aids in drug penetration into the tumors.
- Open-abdominal HIPEC offers good chemotherapy drug distribution. This washes the abdominal cavity with the liquid and reaches hidden crevices. However, drug leakage and heat loss are concerns.
Recovery Time After Cytoreductive Surgery With HIPEC
According to the Johns Hopkins Medicine website, complete cytoreductive surgery with HIPEC requires 2-3 months of recovery. Patients should expect to spend 10-14 days in the hospital following surgery. Recovery continues for 6-10 weeks after discharge from the hospital.
Following surgery, most patients go to the intensive care unit (ICU). They will be monitored carefully and receive IV fluids and pain medication to help with recovery. Patients may experience bowel issues due to the length of the surgery.
The postoperative team will monitor bowel function, fluid and food intake, as well as progress with mobility (getting up to a chair and walking). This helps determine when a patient can transition from inpatient recovery to outpatient recovery.
Outpatient recovery can happen either at the patient’s home, the home of a loved one, or a medical rehabilitation facility. The outpatient recovery time varies.
Patients may remain on IV fluid treatments to ensure they receive nutrition. This also helps the digestive system recover.
Patients undergoing CRS and HIPEC will be required to have regular follow-up appointments with the surgical specialist and oncologist. These check-ins are to monitor imaging scans for success of the surgery and evaluate for signs of recurrence. The patient will often have their first follow-up within a couple of weeks after hospital discharge. They will continue every few months initially, then transition to every six months and eventually advance to annual check-ins.
Who Can Get Cytoreduction/HIPEC for Peritoneal Mesothelioma?
Patient eligibility for cytoreduction followed by hyperthermic intraperitoneal chemotherapy depends on a few factors. The first is the PCI score, as this summarizes how far the tumors have spread and infiltrated into organs.
Other factors affecting who can have this surgery are:
- Physical health
- Cell type
Cytoreduction With HIPEC Eligibility: PCI Score
A patient’s PCI score is a significant factor in determining if a patient can be treated with cytoreductive surgery. This score determines how far the tumors have spread in the abdominal cavity. If the cancer is too advanced, surgery won’t remove enough of the disease to improve the patient’s life expectancy.
Peritoneal mesothelioma specialists have different opinions on what PCI score is too high to operate. Dr. Shanel Bhagwandin, from Jupiter Medical Center, said scores higher than 20 often don’t qualify for surgery.
Cytoreduction With HIPEC Eligibility: Physical Health
Physical health is an important factor in eligibility for invasive surgery. Since cytoreduction with HIPEC involves an open abdominal surgery, removal of tissue and organs, and the use of heated chemotherapy, patients must be strong enough to withstand anesthesia, postoperative recovery and postoperative pain.
If the patient has a concerning medical history or lingering health issues, surgeons may avoid aggressive treatment. Operating on patients in poor health can cause severe complications.
Cytoreduction With HIPEC Eligibility: Age
Cytoreductive surgery and perioperative intraperitoneal chemotherapy is an aggressive treatment for peritoneal mesothelioma. This procedure would be difficult for most patients but especially challenging for older patients. Younger patients with this rare cancer are more likely to be in better overall health and able to tolerate the procedure and recover from this surgery.
Alexis Kidd, a peritoneal mesothelioma survivor of more than 13 years, received cytoreductive surgery with HIPEC in her late thirties. The average age for peritoneal mesothelioma patients is between 50 and 60.
Older patients — those in their sixties, seventies or eighties — may still qualify for the HIPEC procedure, but the selection process would need to determine if cytoreduction plus HIPEC was possible. It is important to discuss all treatment options with a mesothelioma specialist.
Cytoreduction With HIPEC Eligibility: Cell Type
Mesothelioma cell type is another important aspect in determining eligibility for surgery. Epithelioid mesothelioma cells are easier to treat, due to being the easiest to identify and remove. Sarcomatoid cells grow and spread faster than other cell types, which makes it more difficult to identify and treat.
Some surgeons may choose to be more aggressive and only accept patients with the epithelioid cell type. Sarcomatoid and biphasic mesothelioma types are still considered for surgery but present a more challenging surgical candidate. Specialists may choose other treatment alternatives in the management of their disease.
Epithelioid cells account for 75% of peritoneal mesothelioma cases. This is good news for patients seeking to be treated with CRS plus HIPEC.
Survival After Cytoreductive Surgery
Fortunately, there has been a steep improvement in the life expectancy for people with peritoneal mesothelioma. Credit goes to the development and advancement of cytoreductive surgery and HIPEC treatment.
The National Cancer Database includes 700 cases of peritoneal mesothelioma treated with cytoreduction and HIPEC. The average survival was 38 months (3 years, 2 months). If patients did not receive surgery, their survival was 7.1 months on average.
Wake Forest Baptist Cancer Center reported a median survival of 40 months (3 years, 4 months). The five-year survival rate was around 30%. Other centers report five-year survival rates of around 50%.
Importance of Getting HIPEC Surgery Soon After Diagnosis
Medical experts suggest cancer patients begin treatment right after diagnosis. The longer patients wait, the more likely the cancer will spread and become untreatable with surgery or immunotherapy.
Many studies support this theory, showing how patients getting treatment immediately will improve their survival and life expectancy. For peritoneal mesothelioma patients, the main option is HIPEC surgery and there’s scientific data supporting surgery as soon as possible.
The Journal of Gastrointestinal Surgery published a report comparing the wait times for peritoneal mesothelioma patients — and the effect on survival. When patients get HIPEC/cytoreductive surgery within four weeks of their diagnosis, their life expectancy is more than 5 years.
The longer the wait time for surgery, the worse the life expectancy:
- Delayed surgery (4-12 weeks after diagnosis) — 4.8 years of life expectancy
- Delayed surgery (13-24 weeks after diagnosis) — 4.37 years of life expectancy
- No surgery — 2.1 years of life expectancy
Survival After Surgery and Multimodal Treatment
Adding systemic chemotherapy after cytoreduction and HIPEC can improve the life expectancy for malignant mesothelioma of the peritoneum. This is a common multimodal treatment used with the HIPEC procedure.
Giving chemotherapy for diffuse malignant peritoneal mesothelioma before surgery is called “adjuvant chemotherapy.” The National Cancer Database research showed a median survival of 41.2 months (3 years, 5 months) when chemotherapy was used after surgery. Another is immunotherapy through clinical trials, this treatment is currently the only FDA-approved treatment for pleural mesothelioma.
Dwell chemotherapy is another intraperitoneal chemotherapy for malignant peritoneal mesothelioma. The ports used with HIPEC during surgery are left in the abdomen when surgery ends. This allows doctors to deliver liquid chemotherapy directly into the abdominal cavity multiple times in the weeks following surgery. For peritoneal mesothelioma, the dwell chemotherapy used is “NIPEC” (normothermic intraperitoneal chemotherapy).
Alexis Kidd received NIPEC following her cytoreductive surgery with HIPEC. She’s one of the longest survivors of peritoneal mesothelioma, largely thanks to cytoreductive surgery with HIPEC and NIPEC.
Possible Complications From Cytoreductive Surgery With HIPEC for Peritoneal Mesothelioma
Patients may experience complications from cytoreductive surgery and HIPEC. Many are related to the digestive tract:
- Gastrointestinal problems (bowel blockage, nausea and vomiting)
- Small perforations of the bowel (a hole in the stomach, small intestines or colon)
- Intraperitoneal abscesses (infection with collections of pus in the abdominal cavity)
- Pancreatic fistulas (leakage of pancreatic fluid into the abdominal cavity)
- Gastroparesis (paralysis of the stomach – food not being pushed down into small intestines)
- Pleural effusions (fluid surrounding the lungs)
Mesothelioma Recurrence After Cytoreduction With HIPEC
A report in the Journal of Gastrointestinal Oncology assessed that most mesothelioma patients will have recurrence after HIPEC surgery. It occurs within the abdominal cavity in up to 57% of patients.
Recurrence often occurs because peritoneal mesothelioma cancer cells hide in the small crevices between the organs in the abdominal cavity. This is an aggressive form of cancer and the small spaces in the abdomen allow tumors and cancer cells to escape the diligence of the surgeon.
Fortunately, select patients can sometimes have repeat cytoreduction with HIPEC. A second surgery can improve the already elevated survival times for this operation:
- A 2014 study of 65 patients reported a median survival of nearly 4 years
- In 2015 a study of 44 patients, reported a median survival of 4.5 years.
Mortality Assessment of Cytoreductive Surgery With HIPEC
Researchers from the University of Nebraska-Omaha Cancer Center reported a 30-day mortality rate of 1.1% for cytoreduction with HIPEC. This was much lower than the mortality rates for these other major surgeries:
- Tri-segmental hepatectomy (surgery that removes all or part of the liver)
- Right lobe hepatectomy (surgery that removes one lobe of the liver)
- Pancreaticoduodenectomy, also known as a Whipple procedure (surgery that removes cancer of the head of the pancreas – removing the head of the pancreas, the first part of the small intestine, the gallbladder and the bile duct)
- Esophagectomy (surgery to remove all or part of the esophagus)
Quality of Life After Cytoreduction With HIPEC
Quality of life is a significant concern for patients considering peritoneal mesothelioma surgery. Increased discomfort and additional health concerns are always possible following any major operation.
Researchers at Wake Forest Baptist Cancer Center reported improvement in quality of life following the HIPEC procedure. Their physical functioning initially worsened but then reached preoperative normalcy at the one-year mark.
Other findings were:
- General health improved by the six-month mark after surgery
- Emotional well-being and social functioning improved after surgery
- Physical pain decreased after surgery
The researchers wrote that patients “may tolerate HIPEC well and have good overall quality of life postoperatively.” Alexis Kidd herself vouches for cytoreduction with HIPEC for her own quality of life.
“That’s miraculous to me.”
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Specialists Who Perform Cytoreductive Surgery With HIPEC for Peritoneal Mesothelioma
There is a long list of doctors who perform cytoreductive surgery followed by HIPEC. There are surgeons in each region of the country who specialize in peritoneal mesothelioma. They work at the top cancer centers in the world, with vast resources at their disposal.
Some of the top mesothelioma surgeons who perform cytoreductive surgery and HIPEC:
- Dr. James Pingpank, UPMC Hillman Cancer Center (Pittsburgh, PA)
- Dr. Eugene Choi, Baylor St. Luke’s Health Medical & Houston VA Medical Center (Houston, TX)
- Dr. Edward Levine, Wake Forest Baptist Cancer Center (Winston-Salem, NC)
- Dr. Richard Alexander, Rutgers Cancer Institute (New Brunswick, NJ)
- Dr. Joel Baumgartner, University of California-San Diego Moores Cancer Center (San Diego, CA)
- Dr. Mecker Moller, University of Miami Sylvester Comprehensive Cancer Center (Miami, FL)
- Dr. Kamran Idrees, Vanderbilt University-Ingram Cancer Center (Nashville, TN)
Finding Surgical Treatment in the VA Health Care System
The VA healthcare system provides veterans access to the top cancer doctors in the world. Three VA hospitals have mesothelioma treatment programs, staffed by experienced surgeons and oncologists from nearby cancer centers.
The Houston VA program is the only one known to treat peritoneal mesothelioma. Dr. Eugene Choi is the head peritoneal mesothelioma surgeon at the Houston VA Medical Center.
If you need help with your VA benefits and finding a VA hospital, please reach out to LCDR Carl Jewett. As a VA-accredited claims agent and patient advocate, he can help you find the specialized treatment strategies you need.
Frequently Asked Questions About Mesothelioma Cytoreduction With HIPEC
What is cytoreductive surgery with HIPEC?
Cytoreduction with HIPEC is a combination of resection surgery and heated chemotherapy used as a peritoneal mesothelioma treatment. Cytoreduction for mesothelioma involves removing the peritoneum (the thin lining of the abdominal cavity) and manually removing all visible tumors. HIPEC stands for hyperthermic (heated) intraperitoneal chemotherapy. It involves bathing the abdominal cavity with liquid chemotherapy.
What is the success rate of cytoreduction with HIPEC for mesothelioma?
One study shows that patients treated with cytoreductive surgery have a five-year survival rate of 80%. By comparison, peritoneal mesothelioma patients without surgery have an average one-year survival rate of 50%. Complete cytoreduction with HIPEC is an effective treatment with an extraordinary success rate for extending the lives of malignant peritoneal mesothelioma patients.
Is cytoreduction with HIPEC dangerous?
All surgeries have risks, the severity ranging from minor infections or side effects to internal bleeding. Cytoreduction is no different, but safety has improved in recent years. Potential complications related to this surgery include damage to the organs in the abdominal cavity or to the digestive system. In one study, 22% of patients undergoing cytoreductive surgery experienced surgery-related side effects.
How long is recovery after cytoreduction/HIPEC?
Recovery time from cytoreductive surgery with HIPEC is approximately 6-8 weeks. Most patients spend 1-2 weeks in the hospital following their surgery. Outpatient recovery — at their home or temporary residence — takes 4-6 weeks depending on how the patient responds to the operation. Patients return to a more normal routine 3-6 months after surgery.
How long does cytoreduction with HIPEC take?
The duration of cytoreduction surgery and HIPEC can last up to 14 hours. The cytoreduction part is a meticulous process where surgeons attempt to detect and remove all visible tumors. The extent of the disease determines how long cytoreduction takes. HIPEC is administered and circulated in the abdominal cavity for a period of 60-90 minutes - it is then drained and the abdomen flushed with saline.
How much does cytoreduction with HIPEC cost?
According to a report in the Annals of Surgical Oncology, the median cost of cytoreduction with HIPEC was $20,509. A New York Times article says the cost ranges from $20,000 to $100,000. Health insurance usually covers some or all of the expenses after the deductible.
Sources & Author
- Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Tufts Medical Center. Retrieved from: https://www.tuftsmedicalcenter.org/-/media/Brochures/TuftsMC/Patient%20Care%20Services/Departments%20and%20Services/Cancer%20Center/HIPEC_Final.ashx. Accessed: 07/01/2021.
- Palliative Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis: Is It Safe and Effective? Journal of Surgical Research. Retrieved from: https://www.journalofsurgicalresearch.com/article/S0022-4804(22)00194-9/fulltext. Accessed: 07/03/2022.
- Hyperthermic Intraperitoneal Chemotherapy. MD Anderson Cancer Center. Retrieved from: https://www.mdanderson.org/treatment-options/hyperthermic-intraperitoneal-chemotherapy.html. Accessed: 07/01/2021.
- Value of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy to treat malignant peritoneal mesothelioma. American Journal of Translational Research. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/34650746/. Accessed: 10/18/2021.
- Then and now: cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC), a historical perspective. Journal of Gastrointestinal Oncology. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754315/. Accessed: 07/01/2021.
- Surgical Debulking of Ovarian Cancer: What Difference Does It Make? Reviews in Obstetrics and Gynecology. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3046749/. Accessed: 07/01/2021.
- Chemotherapy for intraperitoneal use: a review of hyperthermic intraperitoneal chemotherapy and early post-operative intraperitoneal chemotherapy. Journal of Gastrointestinal Oncology. Retrieved from: https://jgo.amegroups.com/article/view/5503/5760. Accessed: 07/01/2021.
- Peritoneal Surface Malignancy Program. Johns Hopkins Medicine. Retrieved from: https://www.hopkinsmedicine.org/surgery/specialty-areas/surgical-oncology/peritoneal-surface-malignancy-program.html. Accessed: 03/31/2021.
- HIPEC Surgery – What to Expect. Tufts Medical Center. Retrieved from: https://www.tuftsmedicalcenter.org/patient-care-services/Departments-and-Services/Cancer-Center/Clinical-Care-Services/Peritoneal-Surface-Malignancy-Program/What-to-Expect-After-HIPEC-Surgery. Accessed: 03/31/2021.
- Predictors and Outcomes of Surgery in Peritoneal Mesothelioma: An Analysis of 2000 Patients From the National Cancer Database. Annals of Surgical Oncology. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/32006127/. Accessed: 07/08/2020.
- CRS/HIPEC safety concerns may be outdated. Journal of the American Medical Association. Retrieved from: https://www.mdedge.com/hematology-oncology/article/192729/gynecologic-cancer/crs/hipec-safety-concerns-may-be-outdated. Accessed: 07/29/19.
- CRS/HIPEC with Major Organ Resection in Peritoneal Mesothelioma Does not Impact Major Complications or Overall Survival: A Retrospective Cohort Study of the US HIPEC Collaborative. Annals of Surgical Oncology. Retrieved from: https://link.springer.com/article/10.1245/s10434-020-09232-9. Accessed: 10/22/2020.
- Repeat cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: review of indications and outcomes. Journal of Gastrointestinal Oncology. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4754305/. Accessed: 07/08/2021.
- Laparoscopic HIPEC: A bridge between open and closed-techniques. Journal of Minimal Access Surgery. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4746985/. Accessed: 07/12/2021.
- Delayed CRS-HIPEC Is Associated with Decreased Survival in Patients with Malignant Peritoneal Mesothelioma: A Markov Decision Analysis. Journal of Gastrointestinal Surgery. Retrieved from: https://link.springer.com/article/10.1007/s11605-022-05540-5. Accessed: 12/07/2022.