Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Preoperative Considerations

The use of hyperthermic intraperitoneal chemotherapy (HIPEC) has been evaluated in a number of malignancies, and although each of these differs in fundamental ways, there is one overarching similarity—the benefit of HIPEC is only realized following an optimal cytoreductive surgery (CRS), preferably with no gross residual disease.
- Low-grade appendiceal
- Pseudomyxoma
- Mesothelioma
- Ovarian cancer
  - Primary, following neoadjuvant chemotherapy
  - Recurrent
- Certain recurrent gastrointestinal cancers
Recognizing this, successful surgical cytoreduction often involves multivisceral resection prior to instilling HIPEC (Fig. 25-1).

FIGURE 25-1 ▪ Multivisceral resection from peritoneal carcinomatosis.
- Pelvic exenteration
- Multiple bowel resections
- Peritonectomy
- Splenectomy +/− distal pancreatectomy
- Partial liver resection
- Diaphragm stripping or resection
Preoperative planning and assessment of the tumor distribution are essential to determine how extensive the disease may be and what surgical procedures would be necessary to render an R0 (complete) resection.
- Calculating a peritoneal carcinomatosis/cancer index (PCI) will have a predictive capability preoperatively to determine who is an appropriate candidate (Fig. 25-2).
  
  FIGURE 25-2 ▪ Peritoneal carcinomatosis/cancer index.
Careful preoperative assessment will often identify the need for a multidisciplinary team of surgical specialists, such as surgical oncology, gynecologic oncology, urology, plastics, hepatobiliary, or vascular surgery.

Intraoperative Assessment

Prior to committing to a radical surgery, determine whether the disease can be completely resected.
- Careful exploration: complete and thorough assessment of the abdomen and pelvis (Fig. 25-3).
  
  FIGURE 25-3 ▪ Carcinomatosis in the abdominal cavity.
- Our preference is for laparotomy to ascertain the extent of disease.
- Hand-assisted laparoscopy is preferred, especially if there are concerns for unresectable carcinomatosis.
  - Complete lysis of adhesions and mobilization of the colon are generally preformed.
  - Identification of major vessels and tagging ureters to facilitate radical resection.
  - Ureteral stents are an alternative commonly used.

It is useful to have a complete understanding of the disease burden early in the case to coordinate the efforts of your surgical team.

Using a completeness of cytoreduction score will help determine prognosis and ability to undergo HIPEC (need to have CC 0/1; Table 25-1).

TABLE 25-1 ▪ CC score: completeness of cytoreduction score

CC 0	No residual tumor (= R0 resection) (en bloc resection)
CC 1	<0.25 cm residual tumor tissue (complete cytoreduction)
CC 2	0.25-2.5 cm residual tumor tissue (incomplete cytoreduction with moderate residual tumor proportion)
CC 3	>2.5 cm residual tumor tissue (incomplete cytoreduction with high residual tumor proportion)

Generally, we proceed quadrant by quadrant until the disease is completely removed. Care is taken to evaluate the retroperitoneum and identify urinary and vascular structures (Figs. 25-4, 25-5, 25-6 and 25-7).

FIGURE 25-4 ▪ View of the retroperitoneum.

FIGURE 25-5 ▪ View of the right pelvis with the iliac artery.

FIGURE 25-6 ▪ Gonadal vessels and ureter dissected free.

FIGURE 25-7 ▪ Closer view of the ureter and exposed retroperitoneum.
Once complete cytoreduction is accomplished, and prior to any bowel anastomotic procedures, HIPEC tubing is placed, the abdomen is closed, and the chemotherapy infusion is performed.

Program Requirements

Infusing chemotherapy in the operating room (OR), at first glance, appears to be a simple process. What many fail to realize is that in order to successfully infuse chemotherapy in an OR, numerous obstacles need to be addressed well ahead of time.

Recommend identifying a team of health care professionals who are committed to safely and efficiently administering HIPEC (Fig. 25-8).