CRS/HIPEC

See separate topic for 'pseudomyxoma peritonei' under 'peritoneal malignancy'

Rationale:

• Need both CRS and HIPEC to see a survival benefit
• Goal will be macroscopic resection with CRS then microscopic tumour elimination with HIPEC
• HIPEC penetrates to a depth of 2-5mm
• HIPEC doesn't penetrate into systemic circulation, allowing for higher local concentrations

Indications:

• Best results for mets from
  • Colorectal
  • Appendix
  • Ovarian
  • Mesothelial peritoneal carcinomatosis

Contraindications

• Invasion of mesoenteric pedicle
• Diffuse small bowel or retroperitoneal involvement
• Unresectable disease
• Extraperitoneal mets, with some exceptions

Process:

• Assess tumour burden - CT is good, MRI may be better, unclear
  • Staging - can use Peritoneal Carcinomatosis Index (9 quadrants, each one 0-3. If <20, favourable prognosis)
• CRS - can be a long procedure, ERAS principles apply
• Fill abdomen with carrier solution and heat to 41.5-43 degrees (saline, dextrose etc)
• Add CTX - commonly mitomycin or oxaliplatin
• Wait 2 hours
• Drain and lavage
• Can be done lap or open

Complications

• Morbidity 12-52%, mortality 1-5.8%
• Complications:
  • Anastomotic leak
  • Intra-abdominal abscess
  • Intra-abdominal bleeding
  • Pancreatic/ureteral leak
• Complications more likely with
  • Higher PCI score
  • Diffuse tumour burden
  • Intra-op blood loss
  • Multiple anastamoses
• Side effects:
  • Platinum agents: Nephrotoxicity, neurotoxicity, myelosuppression
  • MMC: Cardiomyopathy, pulmonary disease, myelosuppression
  • Myelosuppression/cardiomyopathy with doxorubicin