CRS AND HIPEC

1. DR. YAJNADATTA SARANGI
GUIDED BY-DR. SUNIL KUMAR
ASST. PROFESSOR
DEPT. OF GENERAL SURGERY
HYPERTHERMIC INTRAPERITONEAL
CHEMOTHERAPY

2. BASICS
 Principle of giving intraperitoneal chemotherapy
in presence of high temperature for peritoneal
metastasis.
 Almost always given combined with Cyto
reductive surgery

3. PERITONEAL CARCINOMATOSIS
 Shedding, implantation and dissemination of a
tumor, either localized or widespread to
peritoneum and serosal surface of intra peritoneal
viscera as well as adjacent structure of abdominal
cavity
 Traditionally considered as end stage disease
 With palliative chemo median survival was 6
month

4. DR. Paul Sugarbaker
Pioneer in CRS AND HIPEC
IN HIS EXTENSIVE STUDY IN PERITONEAL CARCINOMATOSIS HE SHOWED A
ASTONISHING RESULT OF MEDIAN SURVIVAL OF 17 YR

7.  3 route by which a malignancy spread
1.hematogenous
2.lymphatics
2.transcoelemic(peritoneal carcinomatosis)
 Transcoelemic route is responsible for peritoneal carcinomatosis
 Peritoneal carcinomatosis occurs due to exfoliation or breach of
serosa
 Thus peritoneal carcinomatosis should not be equated with
generalized disease instead local disease.
 PC respond poorly to systemic chemo due to PLASMA
PEROTONEAL BARRIER
 So concept of HIPEC is to give intra peritoneal chemotherapy
after clearing all macroscopic disease(CRS)

8. TUMOR

9. Rationale
 Synergistic cytotoxic effect of heat (42 to 43
degree) and chemotherapy
 Hyperthermia itself has anticancer activity
 This temperature causes protein denaturation,
impairs DNA repair and inhibit oxidative
metabolism
 Vasodilatation improving tumor oxygenation
which improves effect of chemotherapeutic agent
 Heat increases optimal diffusion of chemotherapy
 Heat increases concentration of chemo drugs in
peritoneum

10.  HIPEC almost always given in association with
cyto reductive surgery
 CRS take care of macroscopic disease in
peritoneal cavity
 HIPEC takes care of microscopic disease in
peritoneal cavity
 Chemotherapeutic drugs like mitomycin C have a
high intra peritoneal concentration than plasma
concentration

11.  CT drugs have limited penetration through nodule
 So for HIPEC to be effective only when residual
tumor size after CRS not more than 2mm(2.5mm)
 Completeness of cytoreduction is one of the
significant factor affecting survival after HIPEC
 Staging laparoscopy

12. CYTOREDUCTIVE SURGERY
 Removal of all visible peritoneal deposits,
peritoneum,omentum and involved other organs.

13. CRS Maximum
score13*3=39

14. CRS
 Midline incision
 All 13 region evaluated
 Peritoneum from right and left hemidiphgram,
right and left paracolic gutter and pelvic
peritoneum excised(peritonectomy)
 Adjacent organ removed if necessary
 Greater omentum , lesser omentum removed
 Glissonian capsule if required

15. Target of CRS CC-0 OR CC-1

16. HIPEC TECHNIQUES
3 methods to administer intraperitoneal
chemotherapy
 OPEN(COLLOSIUM)
 CLOSED
 SEMICLOSED

17. Open Technique
 Hyperthermic solution administered and manually
stirred
 Uniformly distribute hyperthermia solution to
all quadrant of abdomen
ADVANTAGE-uniformly distributed in all quadrant
DISADVANTGE-difficult to maintain temperature
theoretical exposure to team

19. Semiclosed HIPEC
 Abdomen covered with plastic sheet and small
opening given through which surgeon
manipulates
Disadv-Non uniform distribution
Adv-temperature better controlled

21. Closed HIPEC
Abdomen closed completely and through multiple catheter
chemo administered.
Advantages-earlier achievement of required
temperature
Safer for care givers
Disadvantage-
non uniform distribution

22. BELMONT Technique(closed)
 First 2 L of isotonic fluid administered at 43 to
44 degree
 At 40 degree CT agent added
 Also given IV chemo
simultaneously(BIDIRECTIONAL
CHEMOTHERAPY)
 Drain inserted in all five peritonectomy region

23.  Duration of HIPEC depends on drugs
MITOMYCIN C-90MINS
OXALIPLATIN -30MINS

24. BELMONT

25. Types of intraperitoneal chemotherapy regimen
1.Neoadjuvant intraperitoneal plus
intravenous chemotherapy
 Pt in whom PC diagnose at staging laparoscopy
 both IV and IP chemotherapy given to downgrade
PC
 prevent dissemination
 Definitive surgery done after 3-4 cycles
 Disadvantage-extensive adhesion occurs

26. 2.Intraoperative HIPEC plus intravenous
chemotherapy
 Most widely used
 IP chemo at time of CRS and IV Chemo after CRS
2.EPIC(Early postoperative intraperitoneal
chemotherapy)
 IP chemo given through drains on POD 1 to 5
 Drugs given over 1 hour and drains are clamped for next 23
hour

27. 4.Adjuvant intraperitoneal and systemic
chemotherapy
through drain place through index CRS
adjuvant chemo given

28. Indications of CRS and HIPEC
 Psedomyxoma peritoni
 Peritoneal mesothelioma
 Primary colon and rectal cancer with
peritoneal seeding(M1C)
 Colorectal carcinoma with peritoneal cytology
positive
 Ovarian carcinoma with PC
 Primary gastric cancer

29. Contraindications to CRs+HIPEC
 Poor performance status(ECOG <2)
 Presence of extrabdominal metastasis
 Diffuse widespread PC
 Presence of unresectable liver metastasis
 Presence of more than 3 or more resectable
metastasis in liver
 Evidence of ureteric or billiary obstruction
 More than one site of small bowel involvement or
gross involvement of small bowel
 Even small volume disease in hepatodudenal
ligament
 PCI MORE THAN 17 (20)

30. complication
 Morbidity(22-34%)
 Mortality(.8-1.4%)
 Hematological toxicity
 Entero cutaneous fistula
 Sepsis
 Intrabodminal sepsis
 Wound morbidity

31.  Higher the PCI higher the morbidity
 Hematological toxicity more after mitomycin C
 Pulmonary complications due to subdiphgramtic
peritoneal stripping
 Oxaliplatin associated with higher intraabdominal
bleeding

32.  M1C
 STAGE 4 DISEASE
 Previously palliation preferred

33.  Verwal et al-
 Palliation and chemo vs CRS and HIPEC
 Better survival with hipec
 PRODIGE 7TRIAL
 Oxaliplatin HIPEC and CRS better survival
 NCCN-good PS, limited PC(PCI LESSTHAN
17),R0 OR CC-0/1
 Consider neoadjuvant FOLFIRIWith
Bevacizumab before CRS and HIPEC
 Mitomycin C vs oxaliplatin in HIPEC

35. Prophylactic HIPEC in colorectal
carcinoma
 T4a
 N2
 Mucinous histology
 Incomplete resection in emergency setting

36. Psedomyxoma peritonei
 Gelatinous ascitis and multifocal peritoneal
epithelial implants secreting copious globules of
extra cellular mucin
 Most commonly associated with appendicular
adenocarcinoma
 3 types
 Disseminated peritoneal carcinomatosis(DPAM)
 Peritoneal mucinous carcinomatosis(PMCA)
 PMCA with intermediate prognosis
 Excellent survival after CRS and HIPEC
 Sugarbaker et al- median survival of 17 year

37. GASTRIC CANCER
3 scenario
 Prophylactic HIPEC in advanced gastric cancer to
prevent PC
 In established case of PC
 Palliative for intractable ascitis
Mitomycin c and cisplatin used

38. Ovarian cancer
 Majority are stage 3(spread through PT cavity) at
diagnosis
 CRS+HIPEC preferred for patient with stage 3
and 4 Epithelial ovarian carcinoma with no
residual disease more than 1cm
 Paclitaxel and cisplatin are standard
 NCCN – CISPLATIN

39. PERITONEAL MESOTHELIOMA
 Patient with PCI score less than 20 ideal
candidate
 Epitheloid variant showed better response than
sarcomatoid and biphasic variant
 IP cisplatin standard

40. Conclusion
 Patients of CRS, PMP,Ovarian carcinoma with
peritoneal carcinomatosis should offered HIPEC
and CRS
 HIPEC preferred if only CC0 OR CC1 achieved
by CRS i.e less than 2.5mm
 Best results are with appendicular
adenocarcinoma with PC(PMP)

41.  https://www.youtube.com/watch?v=UYhdq8AlkTg

42. THANK YOU