Cytoreduction surgery with hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis

Evidence-based recommendations on cytoreduction surgery with hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis. This involves surgically removing visible cancer and bathing the abdominal cavity with heated chemotherapy fluid to reach any remaining cancer cells.

# Recommendations
Evidence on the safety of cytoreduction surgery with hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis shows frequent and serious but well-recognised complications. Evidence on its efficacy is limited in quality. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE website.
Clinicians wishing to do cytoreduction surgery with hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis should:
Inform the clinical governance leads in their healthcare organisation.
Give patients (and their families and carers as appropriate) clear written information to support shared decision making, including NICE's information for the public.
Ensure that patients (and their families and carers as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Audit and review clinical outcomes of all patients having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for every patient having this procedure.
Regularly review data on outcomes and safety for this procedure.
Patient selection should be done by an experienced multidisciplinary team.
The procedure should only be done in highly specialised centres by clinicians with specialist expertise and specific training in cytoreduction surgery and hyperthermic intraoperative peritoneal chemotherapy.
NICE encourages further research in the form of randomised controlled trials. These should clearly describe the patient selection criteria, the types of cancer being treated and the chemotherapy regimens used. Outcomes should include survival, reduction in tumour burden and quality of life.
NICE may update the guidance on publication of further evidence.# The condition, current treatments and procedure

# The condition
Peritoneal carcinomatosis is an advanced form of cancer resulting from the regional spread of gastrointestinal, gynaecological and other malignancies. It is associated with short survival and poor quality of life. It may lead to bowel obstruction, ascites and pain.

# Current treatments
Current standard management includes treating complications such as bowel obstruction using systemic chemotherapy (alone or with surgery), closed peritoneal instillation of chemotherapy or surgery alone.

# The procedure
Cytoreduction surgery is done to remove all macroscopic tumours within the abdominal cavity. Hyperthermic intraoperative peritoneal chemotherapy is then used to distribute a chemotherapeutic drug uniformly to all surfaces within the abdominal cavity and to increase drug penetration. This is done to treat any remaining microscopic traces of the cancer. The aim is to reduce symptoms, extend survival and improve quality of life.
Using general anaesthesia, a laparotomy is done and all macroscopic tumour is removed, with resection of involved organs and stripping of the tumour from the surface of some organs and peritoneum. The surgery is extensive and complex. It is followed by perfusion of the abdominal cavity with a heated (between 40 and 48degrees Celsius) chemotherapy solution for 30 to 120 minutes, with the abdomen open or closed. The fluid is drained from the abdominal cavity before closure. A further course of systemic or early postoperative intraperitoneal chemotherapy may be administered.