Cytoreductive Surgery With HIPEC

Surgery for peritoneal mesothelioma includes HIPEC, a heated type of chemotherapy delivered during the operation. The procedure, often called the HIPEC surgery, removes and kills tumors in the abdominal cavity through cytoreduction and chemotherapy.

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Written by Karen Ritter, RN BSN

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Important Facts About Cytoreductive Surgery With HIPEC

  • Cytoreductive surgery is the resection portion of the procedure. It is a debulking surgery for peritoneal mesothelioma. During debulking, doctors look for and remove all visible tumors one by one. Cytoreductive surgery usually involves a peritonectomy. This is the surgical removal of the peritoneum, which lines the abdominal cavity.
  • HIPEC is an acronym for “hyperthermic intraperitoneal chemotherapy.” The therapy involves delivering hyperthermic, or hot, liquid chemotherapy drugs into the abdominal cavity.
  • Cytoreduction and 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 average survival of 3-5 years following the procedure. Eligible patients have much better life expectancy.

How to Get Cytoreducton and HIPEC for Mesothelioma

If you’re wondering how to get mesothelioma cytoreductive surgery and 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:

1

Following your official diagnosis, contact a cancer center for a second opinion. We can help you find a cancer center close to where you live.

2

Look up all information about surgery for peritoneal mesothelioma. This includes survival rates, side effects, recovery time and patient recommendations.

3

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.

Overview of Cytoreduction With HIPEC

Cytoreduction with HIPEC is a multi-part surgical procedure for malignant peritoneal mesothelioma. The goal is to remove all or most tumors and prevent recurrence in the abdominal cavity.

Doctors use cytoreductive surgery to remove all visible tumors. HIPEC kills any remaining cancer cells hidden from plain sight.

Where Was Cytoreductive Surgery/HIPEC Developed?

Cytoreductive surgery with HIPEC is sometimes shortened to cytoreduction/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 ovarian cancer in 1934. However, the procedure wasn’t widely used until the 1970s. Doctors began introducing intraoperative chemotherapy to abdominal cancer treatment in the 1970s and 1980s.

The development of cytoreduction with HIPEC for peritoneal mesothelioma materialized in the 1990s. During this decade, Dr. Sugarbaker and colleagues introduced the Peritoneal Cancer Index (PCI) to stage the disease 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

Cytoreductive surgery intends to manually remove tumors from the body. It’s the only radical surgery for peritoneal mesothelioma.

Doctors focus on visible tumors and extract them one by one. This process is called “debulking.” The goal of cytoreduction is to leave only microscopic cancer cells behind.

Aside from the debulking, cytoreductive surgery for peritoneal mesothelioma involves removing the omentum. This is a large, flat tissue layer resting on the surface of peritoneal organs. Doctors may also remove the peritoneum, the lining of the abdominal cavity.

Depending on the severity of the disease, doctors may have to remove part or all of an organ in the abdominal cavity. The organs are only removed if the tumors cannot be separated from the organ’s surface.

According to the Tufts Medical Center website, the organs able to be safely removed are the:

  • Gallbladder
  • Spleen
  • 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

HIPEC, or hyperthermic intraperitoneal chemotherapy, is an intraoperative therapy to kill peritoneal mesothelioma tumors. Another name for it is “hot chemotherapy.”

HIPEC sends chemotherapy drugs directly into the abdominal cavity. This avoids some side effects associated with systemic (intravenous) chemotherapy.

Doctors create a liquid chemotherapy cocktail, usually with cisplatin or carboplatin included. Other drugs sometimes in HIPEC are doxorubicin and mitomycin. Doctors heat the chemotherapy drugs to a specific temperature for delivery.

Doctors rock the patient back and forth to “bathe” the entire abdominal cavity in the chemotherapy. This is a tedious process but ensures the therapy reaches every corner of the cavity and small creases between organs.

What Is the Peritoneum?

The peritoneum is a mesothelial tissue lining around your 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 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 includes fluid, which allows the linings to slide against one another with little resistance. This fluid also enables the peritoneum to allow for abdominal organ movement.

When tumors form in either of these linings, they take up space in the cavity, disrupting the peritoneum’s normal functioning. This causes peritoneal mesothelioma symptoms, such as abdominal pain and loss of appetite.

Multimodal Therapies With Cytoreductive Surgery and HIPEC

Systemic (intravenous) chemotherapy is the primary treatment option paired with cytoreductive surgery and HIPEC. Doctors can use mesothelioma chemotherapy either before or after cytoreductive surgery.

Doctors may use other types of chemotherapy after surgery. Dwell chemotherapy involves leaving the ports for HIPEC in the abdomen. Doctors then deliver chemotherapy 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.

What Happens During a Cytoreductive Surgery/HIPEC?

Cytoreduction/HIPEC is a lengthy surgery due to the debulking process. Prior to incision, the patient is sedated with anesthesia and properly positioned for surgery. Doctors insert tubes to assist with breathing and fluid intake.

The procedure isn’t painful due to the anesthesia. However, dwell chemotherapy can be uncomfortable for patients since it is performed when the patient is awake.

HIPEC surgery 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:

1

Incision — The surgeon creates a laparotomy incision from just below the xiphoid (small bone just below the sternum) down the middle of the abdomen.

2

Cytoreduction — The surgeon removes as many visible tumors as possible in the abdominal cavity. The omentum is also removed during this step.

3

Peritonectomy (sometimes) — Part or all of the peritoneum, where peritoneal mesothelioma forms, is removed. It’s a thin lining around 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.

4

Removal of other organs — If necessary and safe, the surgeon removes any diseased organs. They may remove part or all of the diaphragm (respiratory muscle).

5

HIPEC preparation — The surgical team inserts two catheters/ports into the patient’s abdomen. These catheters deliver and drain the chemotherapy.

6

Reconstruction — Closing the incision during HIPEC is called the closed‑abdominal technique. Reconstruction could happen after HIPEC, which is called the open‑abdominal technique.

7

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.

8

HIPEC drainage — The chemotherapy is drained from the body and doctors remove the catheters/ports.

If the patient receives dwell chemotherapy as an adjuvant treatment, doctors leave the ports in the abdomen at the end of the surgery. This provides direct access to the disease location and a path to administer chemotherapy.

Closed‑Abdominal HIPEC Versus Open‑Abdominal HIPEC

There are two main techniques for HIPEC: closed‑abdominal technique and open-abdominal technique:

  • Closed‑abdominal HIPEC prevents heat from escaping the abdominal cavity and diminishing 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. However, this technique makes distributing the drugs evenly in the cavity more difficult.
  • Open‑abdominal HIPEC leads to ideal chemotherapy drug distribution. This washes the abdominal cavity with the liquid and reaches hidden crevices. However, drug leakage and heat loss are bigger concerns.

Recovery Time After Cytoreductive Surgery With HIPEC

According to the Johns Hopkins Medicine website, cytoreduction with HIPEC requires 2-3 months of recovery. Patients should expect to spend 10-14 days in the hospital following surgery. HIPEC recovery continues for 6-10 weeks after discharge from the hospital.

Inpatient Recovery

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 movements, food intake and fluid intake, as well as  progress with exercise (such as walking). This helps determine when a patient can transition from inpatient recovery to outpatient recovery.

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.

This surgery requires regular follow‑up appointments with the primary specialist. These check‑ins are to monitor imaging scans for signs of recurrence. Doctors often ask for the first follow‑up within a few weeks after hospital discharge. They’ll continue every few months initially, then transition to every six months and eventually an annual check‑in.

Who Can Get Cytoreduction/HIPEC for Peritoneal Mesothelioma?

Patient eligibility for cytoreduction/HIPEC depends on a few factors. The first is 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
  • Age
  • Cell type

Cytoreduction With HIPEC Eligibility: PCI Score

A patient’s PCI score is a significant factor in qualifying for cytoreduction/HIPEC. 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.

“In terms of the research out there and advances that we’ve made looking at patients who benefit from this procedure, traditionally, if you have a score that’s higher than 20, usually the patient won’t respond well to surgery,” he said. “It usually means they have more disease than can be affected by surgery without all the associated risks.”

Cytoreduction With HIPEC Eligibility: Physical Health

Physical health is an important factor in eligibility for invasive surgery. Since cytoreduction/HIPEC involves removing areas of the body and washing organs in hot 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

Age is not the only determining factor in eligibility for the HIPEC surgery. However, younger peritoneal mesothelioma patients are more likely to be in good health and tolerate the procedure.

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.

“Because I was younger and healthier, they were able to be aggressive when treating me,” she said.

Older patients — those in their sixties or seventies — may still qualify for the HIPEC procedure. Before assuming anything, talk to a specialist.

Cytoreduction With HIPEC Eligibility: Cell Type

Mesothelioma cell type

is one of the most important aspects in determining eligibility. Epithelioid mesothelioma cells are easiest to treat, mostly due to being easiest to identify and remove. Sarcomatoid cells are tougher to identify and remove. They also grow quicker than other cell types.

Some surgeons may operate only on patients with the epithelioid type. Others may consider operating on biphasic mesothelioma cases if the diagnosis is mostly epithelioid cells.

Epithelioid cells account for 75% of peritoneal mesothelioma cases. This is good news for patients seeking cytoreductive surgery with HIPEC.

Life Expectancy and Survival Rates for Cytoreduction With HIPEC

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 cytoreduction with HIPEC for peritoneal mesothelioma. The average survival was 38 months (3 years, 2 months). Patients who didn’t have surgery survived for 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%.

Survival After Surgery and Multimodal Treatment

Adding systemic chemotherapy after cytoreduction/HIPEC can assist with lengthening survival. This is the primary option for multimodal treatment with the HIPEC procedure. Another is immunotherapy.

The same National Cancer Database research showed a median survival of 41.2 months (3 years, 5 months) when chemotherapy was used after surgery. This is called “adjuvant chemotherapy.”

Other options are dwell chemotherapy, which involves leaving ports in the abdomen and continuing to deliver liquid chemotherapy multiple times after surgery. For peritoneal mesothelioma, the dwell chemotherapy used is “NIPEC” (normothermic intraperitoneal chemotherapy).

Dr. Paul Sugarbaker reported a 75% five‑year survival rate for select patients undergoing cytoreduction, HIPEC and NIPEC. This protocol also included “EPIC” (early postoperative intraperitoneal chemotherapy), which is the first session of dwell chemotherapy. Paclitaxel is one chemotherapy drug option for NIPEC.

Alexis Kidd received NIPEC following her HIPEC surgery. She’s one of the longest survivors of peritoneal mesothelioma, largely thanks to cytoreductive surgery with HIPEC and NIPEC.

“I remember they left two ports in my lower abdomen after surgery. That’s how we did the chemo after,” she said. “They put cisplatin in one port and laid me on my side. Then they switched sides to lay me on the other side.”

Possible Complications From Cytoreductive Surgery With HIPEC

Patients may experience complications from cytoreductive surgery and HIPEC. Many are related to the digestive system:

  • Gastrointestinal problems (bowel blockage, nausea and vomiting)
  • Gastrointestinal perforations (a hole in the stomach, colon, bowel or small intestine)
  • Pancreatic fistulas (leakage of pancreatic fluid into the abdominal cavity)
  • Intraperitoneal abscesses (collections of pus)
  • Gastric stasis (paralysis of the stomach)
  • Pleural effusions (fluid surrounding the lungs)
  • Pneumonia
  • Infections

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 occurs because peritoneal mesothelioma tumors hide within crevices of the abdominal cavity. The number of organs and small, hidden spaces allow tumors to escape the surgical team’s sight.

Fortunately, select patients can have repeat cytoreduction/HIPEC. A second surgery can improve the already-stellar survival times for this operation:

  • A 2014 study of 65 patients reported a median survival of nearly four years.
  • A study one year later, of 44 patients, reported a median survival of 4.5 years.

Mortality From Cytoreductive Surgery With HIPEC

Researchers from the University of Nebraska-Omaha Cancer Center reported a 30-day mortality rate of 1.1% for cytoreduction/HIPEC. This was much lower than the mortality rates for the following surgeries:

  • Tri‑segmental hepatectomy (a type of surgery that removes all or part of the liver)
  • Right lobe hepatectomy (a type of surgery that removes all or part of the liver)
  • Pancreaticoduodenectomy (surgery to remove cancer from the pancreas)
  • 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 is 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.

“You get to live, you get to enjoy your life,” Alexis said in a podcast interview with Mesothelioma Guide. “There are challenges, lots of challenges, but you get more time to do whatever it is you want to do in your life.

“That’s miraculous to me.”

Doctors Who Perform Cytoreductive Surgery and HIPEC for Peritoneal Mesothelioma

There is a long list of doctors who perform cytoreductive surgery with 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 doctors who perform cytoreductive surgery with HIPEC are:

  • Dr. Richard Alexander, Rutgers Cancer Institute (New Brunswick, New Jersey)
  • Dr. Edward Levine, Wake Forest Baptist Cancer Center (Winston‑Salem, North Carolina)
  • Dr. Kiran Turaga, University of Chicago Medical Center (Illinois)
  • Dr. Joel Baumgartner, University of California‑San Diego Moores Cancer Center (California)
  • Dr. Daniel Labow, Mount Sinai Medical Center (New York, New York)
  • Dr. Mecker Moller, University of Miami Sylvester Comprehensive Cancer Center (Florida)
  • Dr. Kamran Idrees, Vanderbilt University‑Ingram Cancer Center (Nashville, Tennessee)
  • Dr. Eugene Choi, Baylor St. Luke’s Medical Center (Houston, Texas)

Finding Surgical Treatment in the VA Health Care System

The VA health care 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 signing up for VA health insurance or contacting a VA hospital, please reach out to LCDR Carl Jewett. As a veterans support advocate, he can help you receive treatment.

Common Questions About Mesothelioma Cytoreduction With HIPEC

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What is cytoreductive surgery with HIPEC?

Cytoreduction with HIPEC is a combination of surgery and heated chemotherapy used to treat peritoneal mesothelioma. Cytoreduction for mesothelioma involves removing the peritoneum (the thin lining surrounding the abdominal cavity) and manually resecting visible tumors. HIPEC stands for hyperthermic (heated) intraperitoneal chemotherapy. It involves bathing the abdominal cavity with liquid chemotherapy.

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What is the success rate of cytoreduction with HIPEC for mesothelioma?

One study shows a five‑year survival rate of 80% after completing cytoreduction with HIPEC. By comparison, peritoneal mesothelioma patients have an average one‑year survival rate of 50%. Cytoreduction with HIPEC has an extraordinary success rate for extending the lives of peritoneal mesothelioma patients.

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Is cytoreduction with HIPEC dangerous?

Any surgery has risks, with the severity ranging from minor infections to internal bleeding. Cytoreduction is no different, but safety has improved in recent years. Other potential complications include damage to any abdominal cavity organs or the body’s digestive system. In one study, 22% of patients experienced surgery‑related side effects.

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How long is recovery after cytoreduction/HIPEC?

Recovery from cytoreductive surgery with HIPEC is approximately 6‑8 weeks. Most patients spend two weeks at 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.

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How long does cytoreduction with HIPEC take?

Cytoreduction with HIPEC can last up to 14 hours. The cytoreduction part is a meticulous process where surgeons attempt to detect and remove as many tumors as they can. The extent of the disease determines how long cytoreduction takes. HIPEC has a fixed time of 60‑90 minutes.

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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

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About the Writer, Karen Ritter, RN BSN

Karen Ritter is a registered nurse and patient advocate for Mesothelioma Guide. She leads patients and families through their mesothelioma diagnosis, explaining treatments and support options. Karen joined Mesothelioma Guide in 2021.