HIPEC & PIPAC Surgery: Procedure to treat Abdominal Cancer

The HIPEC and PIPAC are two innovative techniques used in chemotherapy, mainly in peritoneal carcinomatosis. Peritoneal carcinomatosis is a rare form of cancer affecting the peritoneum, the thin membrane surrounding your abdominal organ.

Surgery Name	HIPEC and PIPAC
Alternative Name	Cytoreduction
Disease Treated	Abdominal Cancer, End-Stage Peritoneal Carcinomatosis, Peritoneal Pseudomyxoma, Mesothelioma, Ovarian Cancer, Carcinoma of Gastric origin, and Colon Cancer
Benefits of the Surgery	Prolonged Survival Time, Fewer Side Effects and more safety, Successful in destroying cancer cells, Preventing the resistance to chemotherapy, Minimally Invasive
Treated By	Surgical Oncologists

HIPEC (Hyperthermic intraperitoneal chemotherapy)

1. HIPEC surgery is a two-step procedure used to treat cancer in the abdomen, including peritoneal cancer. It stands for heated intraperitoneal chemotherapy.
2. Cancerous tumours are surgically removed, and heated chemotherapy drugs are applied to the abdomen. It results in eliminating any remaining cancerous cells.

PIPAC (Pressurized intraperitoneal aerosol chemotherapy)

1. PIPAC is a novel therapeutic method that provides chemotherapy through pressurised spray or aerosol. This technique allows direct treatment of cancer in the peritoneum.
2. It also enables achieving a high concentration of chemotherapy without systemic side effects.
3. A special cannula is used to distribute the chemotherapy drug as an aerosol. PIPAC is delivered every six weeks for up to 6 cycles. 

Anatomy and Physiology of Abdomen

The abdomen is a complex structure made of many layers in human anatomy. The layers of the abdominal wall are:

1. Skin: Outermost layer made of soft tissue which helps in protection. 
2. Subcutaneous Tissue: It is also called the Hypodermis. It is the primary site of fat storage in the body and works as insulation. It is made of fibroblast, adipose tissue, and macrophages.
3. Fascia (Camper’s fascia, Scarpa’s fascia, and superficial Abdominal fascia): It is a sheet of connective tissue, mainly collagen fibres. It stabilizes and separates muscles and other organs.
4. Muscles: Mainly made of skeleton muscles and helps in contraction
5. Transversalis Fascia: It is a thin aponeurotic membrane of the abdomen. It lies between the inner surface of the abdominal muscle and the parietal peritoneum.
6. Extraperitoneal Fat: Between the inner surfaces of the fascia, there lies a considerable amount of connective tissue called extraperitoneal fat. 
7. Peritoneum: It forms the lining of the abdominal wall. It supports the abdominal organs and serves as a conduit for their blood vessels, nerves, and lymphatic vessels.

1. The HIPEC and PIPAC Surgery is used to treat Abdominal Cancer, which is hard to treat.
2. It is often used in end-stage Peritoneal Carcinomatosis (cancer in the thin layer of tissue that lines the abdomen).
3. In addition, it is used for Peritoneal Pseudomyxoma, Mesothelioma, Ovarian cancer, Carcinoma of gastric origin, and Colon cancer. It is also used to treat platinum-resistant ovarian cancer that comes back after six months (after being treated with platinum-based chemotherapy), and surgery is not an option for you.
4. HIPEC and PIPAC are also used to treat cancer in the pancreas, liver, appendix, female reproductive system, and colorectal cancer.

The HIPEC surgery is performed in two stages:

1. The First stage is called the Cytoreductive Stage of the HIPEC surgery. In this, the surgeon will administer the anaesthesia.
2. Then, the surgeon will incise the skin of your abdomen.
3. It allows the doctor to view all the cancerous tumours and diseases tissue. Finally, the surgeon removes all the cancerous tumours and tissue from the abdomen.
4. The second stage is called the HIPEC procedure.
5. After removing all the cancerous tissue, the surgeon will insert a catheter into the abdominal cavity. Through this catheter, the chemotherapy drugs are pumped into your abdominal cavity.
6. Next, the catheters are connected to a perfusion machine. It heats the chemotherapy drugs and allows them to flow into the abdominal cavity for 1 to 2 hours.
7. Once done, the surgeon will drain out the remaining chemotherapy drugs and rinse the abdomen with the salt solution. Finally, the surgeon closes the incision with the help of sutures or surgical tapes.

Procedure for PIPAC: 

1. It is performed through the minimally invasive laparoscopic method.
2. First, the doctor will give you general anaesthesia. Then two small incisions of about 5 to 12mm are made in the abdomen. Through these incisions, tubes are inserted into the peritoneal cavity.
3. The surgeon then retrieves small tissue samples of the tumour knots (biopsy). Once done, the surgeon will disperse the chemotherapeutic agent as pressurized aerosol inside the abdominal cavity for 30 minutes.
4. Finally, the pressure is released, and the gas is aspirated. The incisions are closed later with the help of sutures or surgical tapes.

Before the Surgery

1. The night before the surgery, the surgeon will ask to take some precautionary steps to prevent infection and complications.
2. The surgeon will ask you to stop eating or drinking anything after midnight to clear the bowel of all the solid contents.
3. The surgeon will prescribe you antibiotics which are needed to be taken at the directed time to prevent infection.
4. The doctor may ask you to leave valuable items such as jewellery and watches at home.
5. You will need to carry a list of all your current medications and comfortable clothes on the day of surgery.

1. The time to complete the surgery varies from patient to patient and the stage of cancer, which has spread throughout the abdomen. Advanced Stage cancer takes longer to treat with surgery.
2. In HIPEC, after surgery, you will be shifted to the ICU for 24 to 48 hours.
3. Your average hospital stay will be for 10 to 15 days. In PIPAC, you will be shifted to ICU for 24 to 48 hours, and the length of the hospital stay is usually 3 to 4 days. 

First follow-up appointment

You will have your first follow-up one week after being discharged from the hospital. The doctor will assess your healing to ensure everything is right and adjust your care if needed. You will have frequent follow-ups with your surgeon after surgery at regular intervals. The doctor will instruct you to follow the following:

1. To eat a diet rich in calories and high in protein. It will boost energy and promote healing. Have a small frequent meal throughout the day.
2. Drink plenty of fluids throughout the day.
3. Keep your bowel moving, and do not go more than three days without a bowel movement. 
4. Stay active with light exercise but avoid movement that engages your core and abdominal.
5. You can return to work in about a month but avoid duties, including heavy li
6. You can take a shower but avoid using a hot tub bath until your incision heals. 
7. Take multiple walks throughout the day. It prevents blood clots and improves your sense of well-being. 

One should consult the doctor as soon as possible if they experience the following symptoms or side effects:

1. Extreme pain that is uncontrollable and getting worse
2. Having  a fever
3. Redness that extends beyond your incision  
4. Nausea and vomiting for over 24 hours
5. Swelling

Delaying the HIPEC and PIPAC surgery leads to disease progression and affects the outcomes. If not treated on time, cancer will spread to other body parts and start attacking significant organs. It will lead to the following:

1. Malnutrition (By blocking  or interfering with the absorption of essential nutrients)
2. Lack of oxygen 
3. Fatigue 
4. Liver damage
5. Too much calcium in the bloodstream (when it starts attacking the bones)
6. Problems with blood and blood vessels (when cancer reaches the advanced stage)
7. Prone to infections

It is essential to diagnose and treat cancer as early as possible. Once spread, it will become challenging to control it and lead to death.

The cost of HIPEC and PIPEC ranges from ₹4,10,000 to ₹6,30,000. The cost varies based on the following factors:

1. Type of HIPEC and PIPEC surgery
2. Age of the patient
3. The medical condition of the patient
4. The type of hospital facility availed - individual room or shared.

Procedure Name	Cost Value
HIPEC and PIPEC	₹4,10,000 to ₹6,30,000