HIPEC surgery, step by step

The cytoreduction: what is happening during those hours

Spread out, the peritoneum covers around two square metres. The disease is rarely a lump: it is many small deposits scattered across a very large surface, more like a spatter than a stain.

Removing that means working across that surface millimetre by millimetre, stripping the affected peritoneum — the peritonectomy — and resecting the organs or segments that cannot be cleared any other way. That is all that is happening, and that is why it takes so long.

Every resection means a reconstruction, and every reconstruction is one more anastomosis that can fail. That is the price of the operation and the reason behind nearly all of its complications.

The heated bath: what it adds, and what it does not

Once the cytoreduction is finished, heated chemotherapy is instilled into the cavity and circulated for a set time, between thirty and ninety minutes depending on the protocol.

The logic is twofold. The peritoneal membrane is poor at letting things out, so a drug placed inside takes a very long time to reach the bloodstream: that allows concentrations far above what is tolerated intravenously, with fewer systemic effects. And heat increases the drug's effect on the tumour.

The limitation is physical too: intraperitoneal chemotherapy penetrates only a few millimetres into tissue. A two-centimetre nodule has a centre no bath will ever reach, and it has to come out by hand. Which is why the bath only makes sense after a complete cytoreduction.

How long it takes

It is a long operation. In published trials, mean operating times run from six to eight hours, and in practice it depends on how many resections are needed: an abdomen with localised disease is not the same as one requiring several bowel resections and a reconstruction.

For the family waiting, that is the useful figure: a long day, with news only at the end.

Mean operating times published in PRODIGE 7 (Lancet Oncology, 2021) and in the reference multicentre series.

The days afterwards

One or two days in intensive care. A nasogastric tube until the bowel wakes up, which takes three to five days. Discharge, if there are no complications, usually falls between day eight and day fourteen; published mean hospital stays in the trials run from thirteen to eighteen days.

The complication watched most closely is a leak from a bowel anastomosis, between the fourth and the seventh day, which often means a second operation. After that, in order of frequency: wound infection, intra-abdominal collections, bleeding, pancreatic fistula, respiratory complications, renal toxicity and thrombosis.

The risk figures, for the record: in the published series of this surgery, serious complications occur in roughly a quarter to a third of patients, and perioperative mortality runs between 1% and 4%.

Some of these operations end with a stoma, sometimes temporary and sometimes permanent. It is one of the things worth asking about explicitly beforehand, rather than discovering afterwards.

Hospital stay and toxicity: PRODIGE 7 (Lancet Oncol 2021). Perioperative mortality: 4.0% in Glehen 2004, 2.7% in Sugarbaker 1999, 2% in Yan 2009. Grade 3-4 complications in 31% of patients in Yan 2009. Postoperative course: the author's practice.

The recovery, which lasts longer than anyone says

Getting back to normal life takes three to six months, and probably never quite the same.

Fatigue is the dominant complaint, and it is not like being short of sleep: it is a background tiredness that lifts over weeks. You eat little and often, you lose weight, and putting it back on takes months. By the third or fourth month the energy returns.

Of everything that can be done at home, walking every day is the intervention with the best effort-to-result ratio of the whole recovery.

Two more things depend on the centre's protocol and are worth knowing: thromboprophylaxis with low-molecular-weight heparin continues for around four weeks after discharge, and if the spleen has been removed, specific vaccinations are needed, typically two weeks after surgery.

Extended thromboprophylaxis and post-splenectomy vaccination: recommendations recorded in the author's monograph. Enhanced recovery pathways specific to CRS+HIPEC: Hübner M, et al. European Journal of Surgical Oncology, 2020.

What can be done before going in

The weeks beforehand are not dead time. Loss of muscle mass and malnutrition consistently predict more complications, longer stays and a worse recovery, and they are among the few modifiable variables in this whole story.

Eating enough protein, moving every day and stopping smoking change the starting point. They do not change the tumour, but they change how well you withstand it.

Sarcopenia and hypoalbuminaemia as modifiable predictors of major morbidity: the author's monograph.

What this page does not do

This operation is not offered to everyone, and it should not be. It makes sense when all visible disease can be removed and the patient can withstand it; in other cases the balance does not work out.

Nothing here replaces the consultation in which candidacy is decided. And the figures describe groups of patients, not any one person.