Cytoreduction Surgery With HIPEC

Cytoreductive surgery is the only surgery known to effectively treat peritoneal mesothelioma. It involves an invasive procedure to remove abdominal tumors. In the 1980s, world-renowned oncologist Dr. Paul Sugarbaker developed an idea to combine cytoreduction with hyperthermic intraperitoneal chemotherapy (HIPEC) to decrease the mortality rate in his patients. Today, cytoreduction surgery with HIPEC is considered the gold-standard treatment for peritoneal mesothelioma.

Fact-Checked and Medically Reviewed By: Dr. Mark Levin

What Is Cytoreduction Surgery With HIPEC?

Doctors often recommend a mesothelioma surgery called cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) to their peritoneal mesothelioma patients.

Cytoreductive surgery with HIPEC is the only curative (meant to extend a patient’s life) surgical option available to patients with peritoneal mesothelioma.

The two steps of cytoreduction surgery with HIPEC are shown in an illustration.
Illustration showing the two-part cytoreduction surgery with HIPEC procedure.

Cytoreduction surgery with HIPEC is a two-part procedure:

  1. The first part involves invasive surgery to remove visible tumors from the abdomen through a process called debulking.
  2. The second part involves hyperthermic intraperitoneal chemotherapy (HIPEC), which is a process that flushes the abdominal cavity with a warm chemotherapy agent.

HIPEC cytoreductive surgery was developed in the 1980s by oncologist (cancer doctor) Dr. Paul Sugarbaker. The now-retired Dr. Sugarbaker has had success in using this two-part procedure in cancer patients over 1,500 times.

Learn more about cytoreduction with HIPEC and other treatments in our Free Mesothelioma Guide.

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Cytoreduction With HIPEC for Peritoneal Mesothelioma

In 25% to 30% of cases, cytoreduction surgery with HIPEC can send peritoneal mesothelioma into full remission.

Studies have also shown that the median survival time for patients who have undergone cytoreduction with HIPEC is 53 months. This is about four times longer than the average life expectancy of patients who do not undergo cytoreduction with HIPEC.

New research indicates that immediate referral for cytoreduction with HIPEC is key to long-term patient survival.

Increased Survival After Cytoreductive Surgery With HIPEC

In peritoneal mesothelioma patients, cytoreductive surgery with HIPEC has substantially improved 5-year survival from less than 10% to 50-90%, according to a 2019 study of more than 1,800 patients who received the treatment.

Did You Know?

A study published in November 2022 in the Journal of Gastrointestinal Surgery found that delayed referral for HIPEC cytoreductive surgery resulted in reduced long-term patient survival.

Patients who underwent immediate treatment gained 3.2 added mean years of life compared to patients who did not have surgery.

The researchers noted that such delays are common, especially in rural areas where health care choices are limited. They concluded that referral to a medical center that performs cytoreduction with HIPEC should be done quickly so that patients can make informed decisions about surgical treatment options.

The Sugarbaker Technique

Today, many mesothelioma doctors refer to the method of using cytoreduction with HIPEC as the Sugarbaker Technique to honor the inventor of this procedure.

The procedure is considered the gold standard in treatment for patients with peritoneal mesothelioma.

Cytoreductive Surgery With HIPEC Procedure

Cytoreductive surgery with HIPEC is a complex process that is made up of two surgical procedures performed by a mesothelioma doctor who specializes in surgical oncology. The full procedure typically takes 10-12 hours.

Patients may require intravenous or oral mesothelioma chemotherapy treatments before or after surgery. The process of applying the chemotherapy solution directly to the abdomen reduces the chance of negative side effects associated with chemotherapy that is given intravenously (through a vein).

Currently, cytoreductive surgery with HIPEC is the most effective treatment for peritoneal mesothelioma.

Phase 1: Mesothelioma Cytoreductive Surgery

The first phase of HIPEC cytoreductive surgery involves surgically removing all visible tumors from the abdomen using cytoreductive surgery, otherwise known as tumor debulking.

This mesothelioma surgery happens through an open incision that extends from the bottom of the sternum to the top of the pubic bone.

The extent of the surgery is dependent on the disease stage and the location of the tumors.

Before the procedure, surgeons will discuss the possibility of having to remove organs or parts of organs to effectively rid the area of tumors.

Phase 2: Mesothelioma Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

When the cytoreduction surgery is complete and all visible mesothelioma tumors have been removed, part two of the procedure, hyperthermic intraperitoneal chemotherapy or HIPEC, will begin.

The HIPEC procedure involves the following steps:

  1. Doctors add a saline solution to the abdominal area through the closed or partially closed incision.
  2. The abdomen is flushed out with the solution.
  3. A chemotherapy solution is heated to 108 degrees Fahrenheit and added to the saline already flushing the area.
  4. The surgeon massages the abdomen to ensure even coverage of the heated chemotherapy.

Doctors use a heated mesothelioma chemotherapy agent to improve the effect of the drugs, allowing for better penetration in the cancer cells. HIPEC is also called “hot chemotherapy.”

The main goal of HIPEC is to rid the affected area of any remaining mesothelioma cancer cells. This minimizes the chance of new tumors growing from these individual cells that are not visible to the naked eye.

This heated chemotherapy treatment is believed to be more successful in treating peritoneal mesothelioma than intravenous chemotherapy.

This process also minimizes the amount of chemotherapy reaching the bloodstream, which decreases the side effects typically associated with intravenous chemotherapy treatments.

HIPEC Treatment Times

This process takes approximately 60-90 minutes to complete but can vary depending on the patient.

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Benefits of HIPEC Cytoreductive Surgery

Medical data analyzed by the Annals of Translational Medicine shows that cytoreductive surgery and HIPEC treatment has increased overall survival rates in peritoneal mesothelioma patients by 50%. A 2019 study found an increase in survival of as much as 90%.

The benefits of HIPEC cytoreductive surgery can be seen in a clear trend toward survival among patients with peritoneal cancer, along with well-tolerated side effects.

This success had led to medical centers using the procedure to treat other types of cancer, including various gastrointestinal cancers.

For example, HIPEC cytoreductive surgery has been used to treat:

  • Appendiceal cancer
  • Colorectal cancer
  • Gastric cancer (stomach cancer)
  • Ovarian cancer
  • Pseudomyxoma peritonei

Due to the nature of the concentrated one-time dose of chemotherapy drugs, patients get the survival benefit of chemotherapy without adverse side effects such as nausea, vomiting, and hair loss.

HIPEC Cytoreductive Surgery Risks and Side Effects

Because of the invasiveness and length of this surgery, complications are relevant factors in the success and recovery of patients during and after cytoreductive surgery and HIPEC treatment.

Complications may include:

  • Blood clots
  • Digestive problems
  • Heart failure
  • Infection
  • Internal bleeding
  • Death

Although only a small fraction of patients report some form of surgery-related illness, it is important to be aware of potential complications associated with the procedure.

Potential side effects of cytoreductive surgery and HIPEC include:

  • Bleeding and bruising easily
  • Blood pressure/heart rate change
  • Constipation
  • Diarrhea
  • Feeling sick and tired
  • Hair loss
  • Loss of appetite and weight
  • Lower resistance to infections

The most common side effects from the high-temperature dose of chemotherapy within the HIPEC procedure are the slowing of bowels and increases in white blood cell and platelet counts.

Even though these side effects can be serious in nature, they tend to decrease within hours after the procedure.

To learn more about treatment side effects and how to manage them, request your Free Mesothelioma Guide.

Handling Cytoreduction and HIPEC Side Effects

The side effects of cytoreduction with HIPEC can be uncomfortable, even when not as extreme as the effects of systemic chemotherapy (a chemotherapeutic drug injected into a vein or given orally).

Learn about common side effects and how to manage them below.

  • Fatigue
    Overall, following surgery, patients can expect to feel tired because their body is recovering from complex surgery. Patients will gradually improve based on levels of daily activity and needed rest.
  • Hair loss
    Hair loss is another common side effect, but it is temporary and can be managed with time and good nutrition.
  • Loss of Appetite
    One of the most common side effects is loss of appetite, which can be managed through eating small, more frequent meals.
  • Nausea and Pain
    Nausea and pain are also side effects of the procedure, but these can be managed through the use of prescribed medications.

Like any major surgery, there are other risks such as bleeding, infection, and poor reactions to general anesthesia. These side effects are usually often minor and can be managed in the hospital on a case-by-case basis.

Who Is Eligible for Cytoreduction with HIPEC?

Even though cytoreduction surgery with HIPEC is the leading treatment for peritoneal mesothelioma, not everyone is eligible.

There are factors that must be taken into consideration before someone is selected to participate in the treatment.

  • The main eligibility factor is the patient’s baseline health. Due to the surgery’s length of 10-12 hours, the patient must be in overall good health.
  • Another factor that must be considered is the patient’s peritoneal mesothelioma stage. Only patients with early-stage peritoneal mesothelioma will be considered eligible for the treatment.

Limited spread is confirmed by seeing if the cancer has reached vital organs. If it has, it can have a significant impact on the success of HIPEC cytoreductive surgery and the patient’s ability to recover.

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HIPEC Cytoreductive Surgery Recovery

Patients recovering from cytoreduction surgery with HIPEC can expect to spend 2-3 months recovering from the treatment.

HIPEC Cytoreductive Hospital Stay Recovery

The first part of recovery is a short hospital stay at a mesothelioma cancer center or another health care facility.

Most patients are released from the hospital around day 8 or 9.

The next stage of recovery for patients is discharge from the hospital where they will return home and continue the recovery process.

HIPEC Cytoreductive Recovery at Home

Patients will continue to recuperate at home with moderate activity and lots of rest for at least the next 2-3 weeks.

Due to the area of the surgery, there is a considerable strain on the digestive system, and in some cases, patients will require an IV in order to get the required nutrients for a successful recovery.

Surgery Recovery Times

Research has shown that patients should feel relatively back to normal after roughly 4 months. The same research shows that a patient’s quality of life is significantly increased in the 8-12-month range.

To best aid in recovery, patients should:

  • Maintain good nutrition: Good nutrition aids in the body’s natural healing and plays a major role in recovery post-procedure. Doctors should discuss a nutritional regimen with patients following HIPEC cytoreductive surgery.
  • Stay active: Walking and doing non-strenuous activities around the house are often good ways to get moving. Getting up and walking will open your lungs and get the blood flowing from your legs to your heart, which can help avoid post-surgery infections and complications.

Patients can get advice about recovering from home by talking to their doctors.

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Learn More About Cytoreduction Surgery With HIPEC

You may have a lot of questions if you or someone you love has been diagnosed with peritoneal mesothelioma.

Get your Free Mesothelioma Guide to learn more about cytoreductive surgery with HIPEC and other treatment options.

Cytoreduction Surgery With HIPEC FAQs

What is cytoreduction with HIPEC surgery?

Cytoreduction surgery with HIPEC (hyperthermic intraperitoneal chemotherapy) is a two-part treatment for patients with peritoneal mesothelioma and some other types of cancer:

  1. First, surgeons remove visible tumors using a process known as debulking.
  2. Next, doctors flush the abdomen with a heated chemotherapy agent.

Dr. Paul Sugarbaker developed HIPEC cytoreductive surgery in the 1980s. The procedure, known as the “Sugarbaker technique,” is still considered the most effective treatment for peritoneal mesothelioma.

How long does it take to recover from cytoreductive surgery?

On average, patients can expect to spend 2-3 months recovering from HIPEC cytoreductive surgery.

This includes a hospital stay of up to 2 weeks and then the rest of the time spent healing at home.

Studies show that most patients feel back to normal after about 4 months.

Of course, every patient is different and may face unique health challenges. For this reason, patients should consult with their doctors about recovery times.

How successful is cytoreductive surgery?

Medical data indicates that HIPEC cytoreductive surgery increases overall survival rates in patients with peritoneal mesothelioma by 50-90%.

The median survival time for patients who have undergone the procedure is 53 months.

A study published in November 2022 shows that prompt treatment is key to long-term survival. 

In some cases where the cancer is in an early stage, the procedure can send peritoneal mesothelioma into remission.

Cytoreduction with HIPEC is considered the standard of care for treating patients with peritoneal mesothelioma.

Reviewed by:Dr. Mark Levin

Certified Oncologist and Hematologist

  • Fact-Checked
  • Editor

Mark Levin, MD has over 30 years of experience in academic and community hematology and oncology. In addition to serving as Chief or Director at four different teaching institutions throughout his life, he is also still a practicing clinician, has taught and designed formal education programs, and has authored numerous publications in various fields related to hematology and oncology.

Dr. Mark Levin is an independently paid medical reviewer.

  • Board Certified Oncologist
  • 30+ Years Experience
  • Published Medical Author
Written by:

Lead Editor

Laura Wright is a journalist and content strategist with more than 14 years of professional experience. She attended college at the University of Florida, graduating magna cum laude with a bachelor’s degree in journalism in 2008. Her writing has been featured in The Gainesville Sun and other regional publications throughout Florida.

10 References
  1. Mayo Clinic. “Cytoreductive surgery and HIPEC offers effective treatment for selected patients with peritoneal carcinomatosis.” Retrieved from: http://www.mayoclinic.org/medical-professionals/clinical-updates/cancer/cytoreductive-surgery-hipec-offers-effective-treatment-for-patients-with-peritoneal-carcinomatosis. Accessed on November 30, 2022.

  2. Johns Hopkins Medicine. “Peritoneal Surface Malignancy Program.” Retrieved from: http://www.hopkinsmedicine.org/surgery/about/innovations/hipec.html. Accessed on November 30, 2022.

  3. World Journal of Surgical Oncology. “Cytoreduction and HIPEC in the treatment of “unconventional” secondary peritoneal.” Retrieved from:  carcinomatosis”https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4618525/. Accessed on November 30, 2022.

  4. Springer. “Repeat Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy May Offer Survival Benefit for Intraperitoneal Mesothelioma: A Single Institution Experience.” Retrieved from: https://link.springer.com/article/10.1245/s10434-013-3341-7. Accessed on November 30, 2022.

  5. University of Maryland Medical System. “Cytoreductive Surgery and HIPEC – FAQs.” Retrieved from: https://www.umms.org/umgccc/cancer-services/cancer-types/gastrointestinal/diagnostic-treatment/peritoneal-surface-malignancies/cytoreductive-surgery-hipec. Accessed on November 30, 2022.

  6. Pleura Peritoneum. “Update of randomized controlled trials evaluating cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in prevention and therapy of peritoneal metastasis: a systematic review.” Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9166620/. Accessed on November 30, 2022.

  7. ClinicalTrials.gov. “Trial of Cytoreductive Surgery and HIPEC in Patients With Primary and Secondary Peritoneal Cancers.” Retrieved from: https://clinicaltrials.gov/ct2/show/NCT03604653. Accessed on November 30, 2022.

  8. JAMA Network. “Morbidity and Mortality Rates Following Cytoreductive Surgery Combined With Hyperthermic Intraperitoneal Chemotherapy Compared With Other High-Risk Surgical Oncology Procedures.” Retrieved from: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2720582. Accessed on November 30, 2022.

  9. Rouhi, A.D., Choudhury, R.A., Hoeltzel, G.D. et al. “Delayed CRS-HIPEC Is Associated with Decreased Survival in Patients with Malignant Peritoneal Mesothelioma: A Markov Decision Analysis.” Journal of Gastrointestinal Surgery (2022, November 28). Retrieved from: https://doi.org/10.1007/s11605-022-05540-5. Accessed on December 1, 2022.

  10. The Society for Surgery of the Alimentary Tract. “DELAYED REFERRAL TO CRS/HIPEC ASSOCIATED WITH DECREASED SURVIVAL FOLLOWING MALIGNANT PERITONEAL MESOTHELIOMA DIAGNOSIS: A MARKOV DECISION ANALYSIS.” Retrieved from: https://meetings.ssat.com/program/2022/3692265.cgi. Accessed on December 1, 2022.

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