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Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) represents a multimodal treatment approach for peritoneal surface malignancies arising from colorectal, appendiceal, ovarian, gastric, and primary peritoneal cancers. This procedure involves maximal surgical debulking of visible tumor deposits followed by intraoperative delivery of heated chemotherapy directly to the peritoneal cavity. Patient selection requires careful evaluation of tumor biology, disease burden, as assessed by the peritoneal carcinomatosis index, and functional status to identify candidates most likely to benefit from this intensive intervention. Successful outcomes depend on achieving complete macroscopic cytoreduction, as residual disease significantly diminishes the therapeutic benefit of intraperitoneal chemotherapy. This activity reviews the indications, contraindications, surgical technique, and complications of CRS-HIPEC and highlights the interprofessional team's role in optimizing patient selection, perioperative management, and long-term surveillance. Objectives: Describe the technique of cytoreduction and hyperthermic intraperitoneal chemotherapy. Identify the indications for cytoreduction and hyperthermic intraperitoneal chemotherapy. Evaluate the risks and benefits associated with cytoreduction and hyperthermic intraperitoneal chemotherapy. Strategize interprofessional teams to ensure optimal outcomes for patients who are candidates for cytoreduction and hyperthermic intraperitoneal chemotherapy. Access free multiple choice questions on this topic.

Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has transformed the management of peritoneal surface malignancies, offering select patients with these historically devastating diseases the potential for long-term survival and durable disease control.[1] Peritoneal surface malignancies arise either primarily from the peritoneum or through direct spread from gastrointestinal and gynecologic malignancies, typically presenting with diffuse nodular or mucinous involvement across multiple sites within the peritoneal cavity.[2] Patients with untreated peritoneal disease often experience progressive complications, including bowel obstruction, fistula formation, intractable pain, and cachexia.[1] The concept of combining aggressive surgical cytoreduction with regional chemotherapy delivery was first described by Spratt in 1980 through animal experiments using a thermal transfusion infiltration system.[3] This technique was subsequently refined and popularized by Sugarbaker in the 1990s.[4] The procedure involves the systematic removal of all visible tumor implants, followed by the intraoperative administration of heated cytotoxic agents directly into the peritoneal cavity, where elevated temperatures enhance drug penetration and cytotoxicity against residual microscopic disease.[5][6][7] Optimal outcomes depend on careful patient selection, accurate assessment of peritoneal tumor burden using the peritoneal cancer index, and achieving complete macroscopic cytoreduction. Each tumor histology has specific peritoneal cancer index thresholds beyond which surgical intervention is unlikely to confer meaningful survival benefit.[8] HIPEC protocols vary by tumor type and institutional practice, with cisplatin commonly used for ovarian cancer and mitomycin C or oxaliplatin for colorectal primaries, administered at 40 °C to 43 °C for 60 to 90 minutes.[9] This article reviews the principles, techniques, and clinical applications of CRS-HIPEC in the multidisciplinary treatment of peritoneal surface malignancies.

CRS-HIPEC carries substantial perioperative risk, with contemporary series reporting major morbidity rates of 19% to 44% and mortality rates of 0% to 2.3%. The most frequent complications involve the gastrointestinal, infectious, renal, and hematologic systems. Serious (grade ≥3) complications occur in 9% to 40% of patients, with 32% to 42% experiencing severe events within 30 days.[22][49][50][51] Gastrointestinal Digestive fistulas: 7% to 11%, among the most severe complications Anastomotic leaks: 5% to 10.5% Abscesses: 3%to 5% Bowel perforation and ileus Surgical site infections: ~7% Broader infectious complications include wound infections, sepsis, pneumonia, central line infections, and intra-abdominal abscesses Renal Particularly associated with cisplatin-based HIPEC: Elevated creatinine: ~15% (median onset 5 days postop) Renal insufficiency/failure requiring intervention Age ≥58 is an independent risk factor Hematologic These are more common with HIPEC, especially oxaliplatin-based regimens. Other Major Complications Hemorrhage requiring transfusion Venous thromboembolism Myocardial infarction Pleural effusion, pneumothorax Pulmonary complications Wound dehiscence

Interprofessional collaboration in CRS-HIPEC relies on structured multidisciplinary tumor board decision-making, coordinated preoperative planning, standardized perioperative protocols, and continuous communication to optimize patient selection, surgical outcomes, and complication management. Surgical oncologists, medical oncologists, radiologists, pathologists, anesthesiologists, intensivists, pharmacists, and specialized nursing staff collectively assess disease biology, resectability, peritoneal cancer index, imaging, and patient fitness to determine candidacy and guide preparation. Radiologists refine staging and operative planning, anesthesia teams manage complex physiologic demands with goal-directed therapy and advanced monitoring, and all personnel require dedicated HIPEC training to ensure safe chemotherapy delivery. Centers benefit from standardized pathways, including prehabilitation, nephrotoxicity prevention, antiemetic strategies, and multimodal pain control, to reduce variability and improve safety. Intraoperatively, real-time communication supports perfusion management and confirmation of complete cytoreduction before HIPEC administration. Postoperatively, experienced intensive care unit teams manage high-risk complications and implement early recovery measures. At the same time, long-term surveillance and decisions on systemic therapy or repeat CRS-HIPEC are coordinated through ongoing multidisciplinary review. High-volume centers with established multidisciplinary team models consistently demonstrate higher rates of complete cytoreduction, fewer complications, and shorter learning curves, underscoring the critical role of institutional experience and sustained team-based collaboration.

To perform a HIPEC safely, a qualified nursing team for the operating room and postoperative recovery is needed. Nurses must be trained in intensive care units and the operating room to manage intraoperative and postoperative complications without difficulty.

HIPEC must be carried out in university centers equipped with invasive vital signs monitoring and management of complications related to both surgery and the toxicity of cytotoxic drugs. This involves invasive monitoring of arterial pressure, central venous pressure, cardiac output, and peripheral vascular resistance.