Question 1 - DNB Obstetrics & Gynaecology Paper 4

a) Define HIPEC [2 marks]

• Temperature used: 41-43°C (106-109°F)
• The combined procedure is called CRS-HIPEC
• Chemotherapy is circulated for 60-90 minutes intraoperatively

b) Indications and Contraindications [3 marks]

Indications

• Epithelial ovarian cancer (EOC) - both upfront CRS + HIPEC (cisplatin) with adjuvant systemic chemotherapy, and interval debulking surgery (IDS) + HIPEC with perioperative systemic chemotherapy (treatment of choice in interval surgery scenario)
• Primary peritoneal carcinoma
• Fallopian tube cancer with peritoneal spread

• Pseudomyxoma peritonei (gold standard treatment regardless of PCI)
• Peritoneal mesothelioma (gold standard)
• Peritoneal metastases from colorectal cancer (PCI < 20)
• Appendiceal neoplasms (resectable disease, any PCI)
• Gastric cancer with peritoneal metastases (selected cases, PCI < 6)

Contraindications

1. Inability to achieve complete cytoreduction (incomplete CRS/CC2-CC3)
2. PCI above the acceptable limits for the specific tumour type (e.g., PCI >20 for colorectal)
3. Unresectable extra-peritoneal (systemic) metastases
4. Serious medical comorbidities, especially significant renal impairment (creatinine clearance <30 mL/min or serum creatinine >1 mg/dL)
5. Severe malnutrition / cachexia
6. Invasion of critical structures: root of mesentery, porta hepatis, retroperitoneal structures

1. WHO/ECOG performance status >2
2. Creatinine clearance 30-60 mL/min
3. ASA score ≥ 3
4. Poor nutritional status / hypoalbuminemia
5. High-risk histology (e.g., sarcomatoid/biphasic mesothelioma)
6. Haemodynamic instability at time of surgery (clinically tenuous status post-CRS)

c) Methodology and Post-operative Care [5 marks]

Pre-operative Planning

• Full staging (CT chest/abdomen/pelvis, PET-CT if needed) to assess PCI and exclude extra-abdominal disease
• Baseline CBC, renal function (critical before cisplatin-based HIPEC), hepatic function - ideally within 1 week of surgery
• Nutritional optimization (prehabilitation: nutritional, respiratory, physical, haematologic)
• Multidisciplinary tumour board decision
• Bowel preparation as required

Methodology (Step-by-step)

• Complete exploration of the entire abdomen for disease mapping and PCI scoring
• Peritonectomy procedures (parietal, diaphragmatic, pelvic) as described by Paul Sugarbaker
• Omentectomy, multi-visceral resections as needed to achieve CC-0 (complete cytoreduction - no residual disease) or CC-1 (residual nodules <2.5 mm, acceptable for PMP)
• Laparoscopic approach is feasible in selected patients at specialized centres

• After confirmation of adequate haemostasis and haemodynamic stability
• Techniques:
  • Open technique (Coliseum/Sugarbaker technique): Abdomen is kept open, inflow and outflow catheters are placed, surgeon manually distributes the perfusate
  • Closed technique: Abdomen is temporarily closed/skin sutured, perfusate circulates through catheters
• 3-6 litres of isotonic crystalloid carrier solution loaded with chemotherapy is heated and circulated via a heating perfusion pump/apparatus
• Temperature maintained at 41-43°C
• Duration: typically 60-90 minutes

• At completion, chemotherapy solution is evacuated from the abdomen
• Bowel anastomoses and abdominal closure performed after HIPEC

Post-operative Care

• Patients are transferred to ICU/HDU post-operatively given the intensive nature of the procedure
• Close monitoring of vital signs, urine output (target >0.5 mL/kg/hr), temperature

• Aggressive IV fluid resuscitation to maintain renal perfusion, especially with cisplatin-based HIPEC (nephrotoxic)
• Forced diuresis if cisplatin used

• Monitor creatinine, electrolytes daily
• Avoid nephrotoxic drugs
• Hyper-hydration protocol if cisplatin used

• CBC regularly - watch for myelosuppression (nadir typically at 7-14 days)

• Early post-operative enteral nutrition preferred
• Parenteral nutrition if enteral not feasible

• Abdominal drains monitored for output, colour, and volume

• Compression stockings + LMWH (high VTE risk given major pelvic-abdominal surgery + malignancy)

• Epidural or IV PCA for adequate pain control

• Anastomotic leak
• Sepsis/intra-abdominal infection
• Pleural effusion / respiratory complications
• Renal failure (especially with cisplatin)
• Prolonged ileus
• Haemorrhage

• Systemic chemotherapy resumed after adequate recovery (usually 4-6 weeks post-surgery)
• Serial imaging and tumour markers for surveillance