Cytoreductive Surgery – What Is Intraperitoneal Hyperthermic Chemotherapy?

Cytoreductive surgery, literally meaning cell-reducing surgery, is a general term summarizing all surgical procedures applied to tumors that have spread to the abdominal cavity and settled in the peritoneum. Although it implies tumor-reducing surgery, it can be considered an insufficient term from the perspective of oncological surgical principles. According to numerous scientific findings, the goal in tumors that have metastasized to the peritoneum is not just to reduce but to completely clear the tumor. In this context, for patients undergoing cytoreductive surgery, the peritoneum, stomach, small intestine, spleen, gallbladder, colon, uterus, ovaries, and other affected organs may need to be completely or partially removed.

In which cancers is Cytoreductive Surgery – Intraperitoneal Hyperthermic Chemotherapy applied?

Cytoreductive surgery is currently applied in various cancer cases, including colon cancer, rectum cancer, appendix tumors (pseudomyxoma peritonei), ovarian cancer, endometrial cancer, malignant mesothelioma, and rarely sarcoma, stomach cancer, and pancreatic cancer. The decision on whether cytoreductive surgery is appropriate in a cancer case spreading to the peritoneum should be made in multidisciplinary cancer councils. During the decision-making process, parameters such as the extent of tumor spread radiologically, the presence of metastasis outside the peritoneum, the patient’s overall health, the biology of the tumor, and the response to oncological treatments should be taken into consideration.

Who is not eligible for Cytoreductive Surgery – Intraperitoneal Hyperthermic Chemotherapy?

While the boundaries are not clearly defined, cytoreductive surgery – intraperitoneal hyperthermic chemotherapy is not recommended for patients with the following clinical and radiological characteristics:

Patients aged 70 and above
Serious additional diseases increasing the surgical risk
Disease progressing under chemotherapy
Presence of metastasis in organs outside the abdomen
Inoperable liver metastasis
Intensive disease in the retroperitoneal region or retroperitoneal lymph node metastasis.

Preparation for Cytoreductive Surgery – Intraperitoneal Hyperthermic Chemotherapy

In patients evaluated in a multidisciplinary council, where the decision for surgery has been made, there is a substantial preparation process similar to any specialized surgery. Since multiple organs are intervened simultaneously in such cases, strict adherence to nutritional status, replacement therapies, and all necessary precautions is crucial. Detailed information about patient preparation can be found here.

Stages of Cytoreductive Surgery – Intraperitoneal Hyperthermic Chemotherapy

The feasibility of the operation in patients undergoing cytoreductive surgery depends on several criteria. One of the most crucial factors is the peritoneal carcinomatosis index and whether the tumor involves critical regions. To evaluate these criteria, starting the operation laparoscopically may be appropriate. If a condition that could hinder the surgery is detected, the abdomen is examined with a few millimeters of incision, and the surgery is terminated. Starting the surgery laparoscopically, if possible, allows the patient to return to oncological treatment shortly. However, if the patient has undergone previous surgery or if there is an intense tumor presence, starting laparoscopically may not be feasible.

What does Peritoneal Carcinomatosis Index mean?

When entering the abdomen laparoscopically or through the classical open method, the surgeon calculates the tumor burden. The peritoneal carcinomatosis index (PCI) is used as a measurement method for this purpose. The imaginary abdomen is divided into 9 regions, and the imaginary small intestine is divided into 4 regions. The size of each tumor implant in each region corresponds to a score. For example, there may be dozens of tumor foci in the upper right region, but the scoring is based on the size of the largest focus. If there is no tumor in the relevant region, 0 points are given. If the size of the largest tumor is less than 0.5 cm, 1 point is given; if it is between 0.5 cm and 5 cm, 2 points are given, and if it is above 5 cm, 3 points are given. The scores obtained from the 13 imaginary regions in the abdomen are summed up to reach the total score. The maximum total score can be 39. Studies conducted so far have shown an association between the PCI score and the recurrence of the disease, disease-related deaths, and similar conditions. As expected, the lower the score, the better the outcome. Therefore, a rough PCI threshold value has been determined for each cancer type to decide whether to continue the surgery based on this score. For colon cancer, this score is set at 20. Studies have shown that results are even better when the score is below 16. For gastric cancer, the threshold value is found to be 12, but results are better if it is below 6. For appendix tumors, even if the PCI score is very high, good results are observed, so no threshold value is sought.

Cytoreductive Surgery – When is the Surgery Terminated in Intraperitoneal Hyperthermic Chemotherapy?

Apart from the PCI score, there are criteria previously mentioned to decide whether to proceed with the surgery. Many of these can be radiologically evaluated parameters before deciding on surgery. A reassessment should be done at the beginning of the surgery in case these conditions cannot be determined before the surgery. Although not strictly defined, conditions that could prevent continuing the surgery include retroperitoneal metastasis, intense involvement in the hepatoduodenal ligament, intense involvement in the mesentery of the small intestine, more than 3 obstructions in the small intestine, more than 3 metastases in the liver, and a higher-than-expected PCI score.

Which Organs are Removed in Cytoreductive Surgery – Intraperitoneal Hyperthermic Chemotherapy?

In patients where the decision to continue with cytoreductive surgery has been made, the goal is to eliminate all visually observed disease. For appendix tumors and peritoneal tumors, even if they are seen without tumors, the removal of the entire peritoneum is recommended. However, for colon cancer, ovarian cancer, gastric cancer, or other cancer types, cleaning the diseased peritoneum is sufficient. Since the peritoneum covers the surfaces of internal organs such as the stomach, spleen, intestines, and bladder, tumors in the membranes of these organs also need to be cleaned. However, in cases where the tumor has advanced deeply or has intense involvement, the affected organ may also need to be removed. In cytoreductive surgery, gallbladder, spleen, omentum, ovaries, and uterus are often removed. Depending on the situation, the stomach, pancreas, liver, and kidneys can be partially or completely removed. Similarly, the small intestine or large intestine may need to be removed. Except for two of the mentioned organs, all others can be completely removed, but the liver and small intestines are organs that cannot be completely removed. Complete removal of these organs is not possible for the patient to survive. Although many organs can be removed, preserving the organs to enable the cleaning of the tumor is essential to reduce the risks of the surgery.

How Long Does Cytoreductive Surgery – Intraperitoneal Hyperthermic Chemotherapy Last?

Cytoreductive surgery duration varies between 4-12 hours, or even longer, depending on the tumor burden in the abdominal cavity. This duration should include the application of hyperthermic chemotherapy for about 60-120 minutes.

How is the Success of Cytoreductive Surgery – Intraperitoneal Hyperthermic Chemotherapy Determined?

The surgeon should calculate the remaining tumor burden at the end of the surgery, as they did at the beginning. The completeness of cytoreduction score, abbreviated as CC score, is used to calculate the remaining tumor burden. If there is no visible tumor remaining after cytoreduction, it is labeled as CC0. If the remaining tumor is below 2.5mm after cytoreduction, it is CC1. If it is between 2.5mm and 2.5cm, it is CC2, and if it is above 2.5cm, it is CC3. The goal in cytoreductive surgery is to achieve cleanliness in CC0 or CC1. Because the application of hyperthermic chemotherapy is beneficial in patients with CC0-CC1, and success is considered achieved only when this is accomplished.

HIPEC (Intraperitoneal Hyperthermic Chemotherapy)

In many cases where cytoreductive surgery has been performed, the final stage of the operation aims to completely eliminate unseen, shed tumor cells by applying intraperitoneal hyperthermic chemotherapy (HIPEC). Special drains and a dedicated device are used for the HIPEC procedure. Depending on the tumor type, the drug to be applied to the abdominal cavity is determined. The dosage of this drug is calculated based on the patient’s body surface area. Subsequently, the liquid (serum) to be mixed with the drug and sent into the body is prepared.

The HIPEC procedure is predominantly applied using a closed technique today, but it can also be performed openly depending on the surgeon’s preference. In the closed technique, after placing small tubes called drains into the abdominal cavities, the abdomen is closed. If the surgeon intends to re-enter the abdomen after the HIPEC procedure, closing only the skin may be sufficient. If re-entry is not planned, both the fascia, a layer beneath the skin, and the skin are closed. In both cases, the skin should be tightly closed to prevent the chemotherapy drug from leaking out.

In the open method, also known as the Colosseum technique, the abdominal cavity is shaped like a bowl using special retractors, resembling the famous Colosseum architecture of the Italians. This technique has been almost abandoned in modern times.

Once the abdominal closure process is completed and the anesthesia team gives approval, the HIPEC device begins to pump and withdraw a serum without the chemotherapy drug into the abdomen through drains. During this process, the temperature of the serum is gradually increased to the level of 42 degrees Celsius. When the temperature of the circulating fluid between the abdominal cavity and the device reaches the desired level, an appropriate dose of the chemotherapy drug is added. The chemotherapy drug circulates at a constant temperature between the abdominal cavity and the device for a duration specific to each chemotherapy drug, calculated through scientific studies. This duration can range between 30 to 120 minutes. When the targeted time is reached, the fluid with chemotherapy is drawn from the abdominal cavity back into the device. The sets and fluids used during the procedure, being chemical waste, are disposed of in special containers for destruction.

Where is the HIPEC Device Located?

There are several HIPEC devices available in the market. Both private and public institutions prefer to rent HIPEC devices due to their high cost. To ensure the supplier company is present at the desired time on the day of the operation, the operation can be organized according to the availability of the device, as these companies may participate in operations in various cities.

What is the Cost of Cytoreductive Surgery – Intraperitoneal Hyperthermic Chemotherapy (HIPEC)?

When calculating the cost of cytoreductive surgery and hyperthermic chemotherapy procedures, various parameters are taken into consideration. These surgeries are specialized procedures that require a certain level of experience and can last for extended hours, resulting in higher fees for medical professionals and staff. Supportive treatments such as blood products and nutritional supplements during and after the surgery also contribute to increased costs. Furthermore, the increased risk of complications during postoperative care and the extended recovery time for the patient result in longer hospital stays, affecting the overall cost. Lastly, the rental fee for the HIPEC device paid to the company is added to the total cost.

Cytoreductive Surgery – Intraperitoneal Hyperthermic Chemotherapy: Is it risky?

During the removal of cancer cells in surgery, injuries to several organs can occur. The most feared among these are the urinary tract, small intestine, and blood vessels. Additionally, injuries may occur in organs such as the diaphragm muscle, liver, spleen, stomach, bladder, colon, and pancreas. If we address the injured structures and their treatments separately:

In case of urinary tract injury, applying a stent or sewing the injured urinary tract to its continuation or bladder may be necessary.
Small intestine injuries can be repaired by suturing the affected area. However, depending on the characteristics of the tissue, in some patients, repair may not be possible, and a stoma may need to be opened.
In case of vascular injury, the damaged area is repaired with non-absorbable fine stitches to control bleeding. In some cases, special stapler systems may be preferred instead of stitches. If the vessel is expendable, it may be completely tied off.
In case of diaphragm injury, the opening is closed with non-absorbable suture material. In patients where the diaphragm is extensively removed, patch repair may be necessary. Depending on the patient’s characteristics and the size of the injury, some patients may require the placement of a tube, called a chest tube, into the lung cavity.
Superficial liver injuries can be controlled by applying a compress. In the case of deep injuries, the exposed blood vessels or bile ducts are either tied off or repaired to attempt to rectify the issue.
In the case of spleen injuries, bleeding can be controlled by using hemostatic materials or by suturing with high heat. If bleeding persists, the complete removal of the spleen may be necessary.
The stomach, being thick-walled, generally does not experience injuries. If the tumor deeply penetrates the stomach wall, injury is possible. Repair is possible by suturing. While removing tumors on and around the stomach, branches of the vagus nerve, which control the movements of the digestive system, can also be injured. Consequently, patients may experience difficulty in stomach emptying and vomiting. No specific repair is available for this.
In case of colon injuries, a similar approach to that of the small intestine is applied.
Pancreatic injuries are usually superficial and do not require repair. However, if the tumor extends deep into the pancreas, causing canal injury, partial removal of the pancreas may be necessary.
Bladder injuries are generally avoidable but can become inevitable in the presence of tumors entering the large and deep tissues in the pelvic region. Repair, often done in two or three layers using absorbable sutures, yields good results.

Complications After Cytoreductive Surgery – Intraperitoneal Hyperthermic Chemotherapy

Complications frequently occur after cytoreductive surgery and intraperitoneal chemotherapy applications, similar to during the surgery. Due to the simultaneous performance of many major surgeries, more complications are often observed compared to other major surgeries. These complications can be categorized as follows:

Gastrointestinal
Small intestine fistula
Anastomotic leakage
Intra-abdominal abscess
Pancreatic fistula
Biliary fistula
Chylous ascites (lymphatic leakage)
Prolonged ileus
Delayed gastric emptying (gastric stasis)
Respiratory
Pleural effusion (accumulation of fluid in the lung membrane)
Pneumonia
Hematologic and Other Complications
Neutropenia
Thrombocytopenia
Leukopenia
Other Complications
Renal failure
Urinary tract infection
Catheter infection
Venous thromboembolism

Cytoreductive Surgery – Intraperitoneal Hyperthermic Chemotherapy: What is the life expectancy after the surgery?

There are numerous scientific studies demonstrating the positive impact of cytoreductive surgery on the survival rates of well-selected patients. For instance, in patients with colon cancer that has spread to the peritoneum, the probability of surviving 5 years or more can reach up to around 60%. Survival rates can vary based on factors such as the origin of the tumor, tumor type, the extent of spread in the abdomen (PCI), whether the tumor is completely cleared (CC score), and the development of postoperative complications.

Patient Comments

Nuri Hocamızla, binbir doktor arayışındayken, daha önce de çalışmış olduğu bağcılar devlet hastanesi acilinde ki hemşirenin tavsiyesiyle tanıştık. İyiki de tanıştık. Tanıştıranlarda sağolsun. Annemdeki fıtığı düzeltmek amacıyla konulan yamanın, bir süre sonra enfekte olup, karın ön duvarında apse yapmasıyla, kocaman şişmiş bir karınla hastaneye başvurduk. İlk süreç korkunçtu, karında ki şişliğin kötü bir hastalığın habercisi olmasından korktuk. Bağcılar devlet hastanesi acilden, çam sakuraya sevk edildik. Orada apse boşaltıdı ama bir süre sonra tekrar apse oluştu. Bu arada 8 9 ay bu aşamalar sürdü. Bir türlü apsenin sebebi için net bir teşhis konulamadı. Burdaki doktorların tek dediği şey annenizin içini açıp bakıcaz. İyi de doktor bey bir sebep, tahmin ? Bize bir şey söyleyin. Her doktor farklı konuşuyor. En kötüsü de yaşı var her şey olabilir diyolarlar. Annem 60 yaşında ve ağır hastalığı ve ameliyatı yok. Birine bunları söylemek doktor olarak kolay, belki literatür, ama hasta iletişimi neden bir şey var. Ben bunun en güzel örneğini hocamda gördüm. Yaklaşımı, sevecenliği ve iyi niyeti olmasa bu süreci nasıl tamamlardık bilmiyorum. Her zaman sorularımıza sabırla cevap verdi. Sonunda da kapalı ameliyatla başarılı bir şekilde yamayı alarak tedavimizi sonuçlandırdı. Allah tüm şifa bekleyen hastalara şifa versin. Tüm doktorlarımıza Nuri hoca gibi işini aşkla yapmasını gönülden diler, örnek almalarını arz ederim. Her şey için teşekkürler.

21 January 2023 Saturday

Nuri Bey ile uzun ve zorlu geçen 1 yıllık araştırma sürecinin sonrası tanıştık. Başka bir sağlık kuruluşunda annemin rahim ve derin endometriozis ameliyatı sırasında ya da sonrasındaki enfeksiyondan kaynaklı oluştuğunu düşündüğümüz retrovajinal fistül için kendisine başvurduk.1 yıllık süreçte çoğu hekimin istisnasız ileostomi/kolostomi açılacak demesine rağmen Nuri Bey ile ilk görüşmemizde sabırla tüm geçmişimizi dinleyip , şartlar uygun olduğu takdirde stoma açılmadan ameliyatın yapılabileceğini söyledi, tüm avantaj ve dezavantajları detaylı bir şekilde anlattı. Daha önce yaşadığımız güvensizlik sebebiyle her ne kadar kararsız kalsak da gerek yüz yüze gerek telefon ile görüşmelerimizde Nuri Beyin aurası bizi kendisine yöneltti. Daha sonrasındaki araştırma sürecinde kolorektal cerrahi konusunda yurtiçi/yurtdışı üstün başarıları annemin ameliyatı için kendisine güvenmemize ön ayak oldu.Nitekim stoma torbası açılmadan yirmi gün arayla ilki 8 saat ikincisi 5 saat süren bir kalın bağırsak bir ince bağırsak olmak üzere yüksek riskli ve başarılı iki operasyon gerçekleştirdi. Annemin tip 1 diabet hastası olması,bir yıl önceki ameliyattan kaynaklanan psikolojik güvensizlik ve 1 yıllık süreçte vücüt direncinin düşmesi iyileşme sürecini yavaşlatsa da Nuri Beyin sabır ve kararlılıkla hiçbir zaman mental ve tıbbi desteğini bizden esirgememesi iyileşme sürecine artarak olumlu yön verdi.Yaşadığımız zorlu süreçler her aklımıza geldiğinde kendisiyle tanıştığımıza dua ediyoruz.Nuri Beye şifahen çok kez teşekkürlerimi sunduk fakat bu mecra vesilesiyle tüm hastalarının/yakınlarının önünde tekrar teşekkür ederiz.Emeğinin karşılığı hiçbir şekilde ödenmez.Kendisine meslek hayatında daha nice başarılar, annem gibi nice hastalara şifa olmasını diliyoruz.

BA.

26 October 2022 Wednesday

Nuri bey, konusunda bu ülkenin sahip olduğu en değerli hocalarımızdan biridir. Hastasına olan müthiş pozitif yaklaşımı, takibi, bilimsel donanımı üst düzey. Ben şahsen kendisinin çok daha iyi yerlere geleceğine, hatta Uluslararası platformlarda dahi isim yapacağına inanıyorum. Rabbim kendisini önce ailesine sonrada hastalarına bağışlasın. Saygılarımla.

18 July 2022 Monday

Babamın çift taraflı kapalı kasık fıtığı ameliyatını gerçekleştirdik. Doktorumuza tavsiye üzerine gitmiştik. Doktorumuz güler yüzlü ilgili, aklınıza ne soru gelirse gelsin cevaplayan, hasta yakınını merakta bırakmayan biri. Açıkçası zor bir hastamız vardı hastamızı psikolojik olarak rahatlattı ve zor geçeceğini düşündüğümüz ameliyat sonrası bizim için çok kolaydı. Kafamızdaki tereddütleri soru işaretlerini ortadan kaldırabilecek bir doktor kesinlikle öneriyorum.

U.K

5 April 2022 Tuesday

Merhaba ben pankreas kanseri hastasiyim Nuri hocamla hastalarımın basinda tanıştım ilk randevuda bana nelerle karsilasacagimi nelere dikkat etmem gerektigini samimi bir sekilde anlattı sonra agar kemoterapi sonrası cekilen pet sonucumu kendisiyle paylaştım bana ameliyat olmamı önerdi hipek amaliyatı nı bana anlattı neler olabilecegini soyledi ben kendisine guvendigimi söyledim bana bu güveni sağolsun verdi 8 şubatta ameliyatimi oldum sorunsuz ve iyi geçtiğini anlattı bir hafta sonra taburcu oldum şu anda tedbir amacli kemoterapi görmeye devam ediyorum kontrolle gittigimde hocamin ilgi ve alakası samimiyeti doktor hasta diyaloğu harika mutevazi ve alakalı davranışları taktire deger sağolsun allaha hep beni sevdiklerimi iyi insanlarla karsilastirsin diye dua ederdim beni Nuri hocamla karsilastirdi allahta onu sevdiklerine bağışlasın yolun acik olsun hocam benden yaşca küçük ama ellerinden öperim sağol varol iyiki varsin guzel insan saygılar

ER.İ

25 March 2022 Friday

Annemin 10 gün süren kabizlik problemi sonrasi Balıkesir’de tedavi olumsuz ilerledigi icin kendi çalıştığım yerdeki doktorlarla görüştüm ve Nuri beyi öyle tanıdık annemi hemen buraya getirdik ve Nuri bey tani aşamasından ameliyat sonrasına kadar o kadar ilgilendi ve bizi rahatlatacak acik sekilde konuştuki aklimda hic soru olmadan annemi ona emanet ettim ve iyikide etmişim hic bir sorun çıkmadan laparoskopik kolon tümörü cikarilmasi gibi büyük bi ameliyati başarılı bi sekilde atlattık sayesinde ve ameliyat sonrasida hic bir sorun cikmadi iyiki sizi tanımışız

EZ.

7 January 2022 Friday

Doktor Nuri Beyi annemin safra kesesi kanseri hastalığı için hipeci araştırırken tanıdım. Kendisi bize tedavinin tüm detayları ile anlattı, faydaları ve risklerini çok şeffaf bir şekilde bizimle paylaştı. Kararsızlığımızda bize çok güzel bir ışık oldu ve yön gösterdi. Çok dürüst ve özverili bir doktor, mesleğini severek yaptığı için çok başarılı olduğunu düşünüyorum. Hiç sıkılmadan tüm sorularımızı çok detaylı bir şekilde açıklıyor. Kendisi devamlı güncel gelişmeleri ve yenilikleri takip eden ve kendisini geliştiren bir doktor olduğu için yeniliklere çok açık olduğunu düşünüyorum. Artık ailemizin doktoru olarak gözümüz kapalı güvendiğimiz bir doktorumuz, başarılarının devamını diliyorum..

11 February 2021 Thursday