Cytoreductive surgery (CRS) aims to remove all of the visible tumour in the abdomen. Intra-abdominal organs that are invaded by tumour and can be safely removed will be resected to ensure that no disease remains. Removal of the involved peritoneum will then be performed. Peritoneum that is commonly removed includes the peritoneum in the pelvis, under the diaphragm and the paracolic gutters (the right and left flanks of the abdominal cavity where the colon lies).
Once the surgical procedures are completed, hyperthermic intraperitoneal chemotherapy (HIPEC) is administered in the operating room. The chemotherapy drug is heated and maintained at a temperature of 42 degrees Celsius. HIPEC addresses the microscopic disease (tumour that is invisible to the eye) after CRS.
Heat is used to increase the effect of the chemotherapy by increasing the penetration of chemotherapy drug into the tissues and the efficacy of the chemotherapy drug in terms of toxicity.
Giving the chemotherapy during surgery has other benefits. It allows manual distribution of the drug and heat uniformly to all surfaces of the abdominal cavity. The majority of these patients will have had prior abdominal surgery to remove their primary cancers. During surgery, adhesions caused by previous surgery (scarring between peritoneal surfaces) are taken down and this ensures that the drug is uniformly distributed.
The chemotherapy is pumped in using a specialised pump that moves the heated chemotherapy solution into the abdominal cavity and then out for a constant flow. This is done over 60 minutes after which the abdominal cavity is washed and the surgery is completed.
Patients with extensive peritoneal disease that cannot be completely removed are not candidates for CRS and HIPEC. These patients may be identified pre-operatively on imaging or may only be identified during surgery. Disease on the peritoneum may be very small (millimeters) and can be difficult to detect on imaging. During surgery, if the surgeon decides that not all the tumour can be removed as the surgery may be too extensive or if too much bowel may need to be removed, the surgery may not proceed. However, debulking surgery may be an option for some patients. In these instances, we remove as much tumour as possible to lessen the symptoms.
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