Comprehensive Surgical Treatment for Advanced Abdominal Cancers
Introduction
Cytoreductive Surgery (CRS), with or without Hyperthermic Intraperitoneal Chemotherapy
(HIPEC), is a specialised treatment designed for cancers that have spread within the abdominal
cavity. Unlike traditional systemic therapy, CRS + HIPEC directly targets tumour deposits inside
the peritoneum, allowing for aggressive local control and improved long-term outcomes in
selected patients. The combined approach has transformed the management of peritoneal
surface malignancies, offering hope even in complex and advanced cases.
At our clinic, CRS and HIPEC procedures are performed by surgeons trained in peritoneal
oncology, supported by experienced anaesthesia, critical care, oncology, and rehabilitation
teams. Every case is evaluated meticulously to ensure that treatment aligns with global
guidelines and our philosophy of Cure, Precision, and Compassion.
1. What Is Cytoreductive Surgery (CRS)?
Cytoreductive Surgery is an extensive surgical procedure aimed at removing all visible tumour
deposits from the abdominal cavity. Because peritoneal cancers can cover multiple organs and
surfaces, CRS involves detailed inspection and removal of tumour-bearing tissues.
Objectives of CRS
● Achieve complete or near-complete tumour removal (CC-0 or CC-1)
● Reduce tumour burden to microscopic levels
● Improve effectiveness of intraperitoneal chemotherapy
● Prevent further disease progression
What CRS May Involve
Depending on tumour extent, CRS may include:
● Peritonectomy procedures
● Omentectomy
● Resection of involved bowel segments
● Removal of tumour from diaphragm, pelvis, and other peritoneal surfaces
● Organ removal only if involved (e.g., spleen, gallbladder, parts of stomach or colon)
The aim is to leave no visible cancer behind.
2. What Is HIPEC?
HIPEC stands for Hyperthermic Intraperitoneal Chemotherapy. It is administered
immediately after CRS, while the patient is still in the operating room.
Key Features
● Heated chemotherapy (41–43°C) enhances drug penetration
● Delivered directly into the peritoneal cavity
● Circulated for 60–90 minutes
● High local concentration with reduced systemic toxicity
HIPEC is designed to kill microscopic cancer cells that remain after CRS.
3. Cancers Treated With CRS ± HIPEC
CRS and HIPEC are most beneficial for cancers confined to the peritoneum.
1. Primary Peritoneal Cancers
● Peritoneal mesothelioma
● Pseudomyxoma peritonei (PMP)
● Primary peritoneal carcinoma
2. Metastatic Cancers With Peritoneal Spread
● Colorectal cancer
● Ovarian cancer
● Gastric cancer (highly selected cases)
● Appendiceal tumours
● Small bowel and some rare cancers
3. Recurrent Peritoneal Malignancy
In patients where disease is limited and surgically approachable.
Not all patients with peritoneal metastases are candidates; selection is crucial.
4. Patient Selection: A Critical Step
CRS and HIPEC are complex procedures, and outcomes heavily depend on careful patient
selection.
Ideal Candidates
● Good performance status (fit for major surgery)
● Disease limited to the peritoneum
● No or limited disease outside the abdomen
● Tumour that responds to chemotherapy
● Adequate organ function
Evaluation Process
● CT or MRI abdomen/pelvis
● PET-CT (in select cases)
● Tumour markers
● Diagnostic laparoscopy to assess Peritoneal Cancer Index (PCI)
A low to moderate PCI score and the possibility of complete cytoreduction (CC-0/1) predict
better outcomes.
5. Peritoneal Cancer Index (PCI)
PCI is a scoring system that quantifies the extent of peritoneal cancer.
Abdomen is divided into 13 regions; each scored 0–3 based on tumour size.
PCI Score Importance
● Guides operability
● Predicts prognosis
● Helps plan surgical extent
● Determines need for HIPEC
A lower PCI generally correlates with better surgical outcomes.
6. How CRS + HIPEC Are Performed
The procedure is typically performed in several key steps:
Step 1: Exploration and Mapping
Surgeons evaluate all abdominal regions and confirm PCI.
Step 2: Cytoreductive Surgery
Tumour deposits are meticulously removed from:
● Peritoneum
● Omentum
● Pelvis
● Abdominal surfaces
● Organs involved (if necessary)
● Bowel segments (when affected)
Step 3: HIPEC Delivery
Once cytoreduction is complete:
● Catheters are placed inside the abdomen
● Chemotherapy solution is heated and circulated
● Temperature, flow rates, and drug levels are monitored
● Duration typically 60–90 minutes
Step 4: Reconstruction
After HIPEC:
● Bowel anastomosis
● Organ reconstruction
● Drain placement
Step 5: Closure & Transfer to ICU
Patients are usually monitored in the ICU for 24–48 hours.
7. Benefits of CRS ± HIPEC
1. Localised, High-Dose Therapy
HIPEC delivers chemotherapy directly where the tumour is located.
2. Reduced Systemic Side Effects
Lower blood levels mean fewer systemic toxicities.
3. Improved Survival
Significant survival benefits have been shown in:
● Colorectal peritoneal metastases
● Pseudomyxoma peritonei
● Ovarian cancer (in selected cases)
4. Potential for Long-Term Remission
When cytoreduction is complete, long disease-free intervals are possible
5. Quality of Life Benefits
Many patients regain normal routine within months of surgery.
8. Risks and Challenges
CRS ± HIPEC is a major surgical procedure requiring expertise.
Potential Risks
● Infection
● Prolonged ileus
● Bleeding
● Anastomotic leak
● Organ dysfunction
● Blood transfusion requirement
● Fluid and electrolyte disturbances
● ICU stay
Long-Term Risks
● Adhesions
● Hernias
● Nutritional issues (rare)
Factors Increasing Risk
● High PCI score
● Poor performance status
● Involvement of multiple organs
● Poor nutritional status
Robust pre-, intra-, and postoperative protocols minimise complications.
9. Postoperative Care and Recovery
ICU Care (First 24–48 Hours)
● Fluid management
● Organ monitoring
● Pain control
● Respiratory support
Ward Care
● Early mobilisation
● Gradual diet advancement
● Physiotherapy
● Electrolyte monitoring
● Blood tests
Hospital Stay
Typically 10–14 days, depending on operative extent.
Full Recovery
Most patients resume routine activities in 6–8 weeks
Long-Term Follow-Up
● Surveillance scans
● Tumour markers
● Nutritional counselling
● Psychological support
This comprehensive approach ensures safe recovery.
10. Our Clinic’s Approach to CRS ± HIPEC
1. Multidisciplinary Evaluation
Cases are reviewed by:
● Surgical oncologists
● Medical oncologists
● Radiologists
● Pathologists
● Anaesthesiologists
● Critical care specialists
2. Precision in Patient Selection
Only patients who will truly benefit are recommended for CRS ± HIPEC
3. Experienced Peritoneal Oncology Team
CRS requires technical expertise; our surgeons have specialised training in:
● Peritonectomy procedures
● Radical cytoreduction
● HIPEC protocols
4. Advanced Intraoperative Technology
● Temperature-monitored perfusion machines
● Real-time flow monitoring
● High-definition surgical imaging
5. Comprehensive Critical Care Support
Dedicated ICU teams ensure safe postoperative recovery.
6. Supportive & Survivorship Care
We provide:
● Pain relief
● Nutrition guidance
● Physiotherapy
● Emotional counselling
7. Compassionate Communication
Patients and families are guided through every step of the process.
Conclusion
Cytoreductive Surgery and HIPEC have revolutionised the management of peritoneal surface
malignancies. When performed in carefully selected patients by experienced teams, CRS ±
HIPEC offers improved survival, symptom relief, and the potential for long-term control of
disease. Although it is a major surgical undertaking, the benefits can be substantial—especially
when delivered with meticulous surgical technique and comprehensive postoperative care.
At our clinic, we provide CRS ± HIPEC with a strong focus on scientific precision,
multidisciplinary planning, and deeply compassionate care—reflecting our ethos of Cure,
Precision, and Compassion.
