Cytoreductive Surgery

What Is Cytoreductive Surgery?

The combination of CRS and HIPEC has been an effective method of treating various cancers, including mesothelioma. CRS is a challenging surgery that involves a team of experienced doctors and often requires hours of time in the operating room.

Peritoneal mesothelioma affects the lining of the abdominal cavity, called the peritoneum. It develops as a result of asbestos exposure and is the second most common site of mesothelioma. A combination of surgery and chemotherapy is commonly used to treat this cancer.

CRS has been shown to increase life expectancy and may reduce the chance of the cancer recurring. The combination of CRS and HIPEC can result in a better overall mesothelioma prognosis, as well as reducing common symptoms and pain.

The goal of CRS is to remove all cancerous tumors and any nearby tissue that may be affected. The procedure is rigorous and can take up to 12 hours due to the complexity of the surgery.

There are two types of lining within the abdominal cavity, or peritoneum: the visceral (inner) and parietal (outer). The space between the two linings is called the peritoneal cavity, which contains a lubricating fluid that helps the abdominal cavity expand normally.

Patients develop peritoneal mesothelioma as a result of fluid buildup in the peritoneal cavity. The accumulation of fluid restricts the peritoneum from expanding, causing pain and swelling from the disease.

Special parts of the peritoneum, called the omentum, line the lymphatic system, blood vessels, and connective tissue. Surgeons may need to remove parts of the omentum if it has spread to that area of the body.

Cytoreductive Surgery Procedure

Before the procedure, surgeons examine each organ and the lining within the

abdominal cavity. The abdomen consists of 10 primary organs, each lined by the peritoneum. All abdominal organs can host malignant mesothelioma tumors:

• Appendix
• Colon
• Gallbladder
• Kidneys
• Large Intestine
• Liver
• Pancreas
• Small Intestine
• Spleen
• Stomach

Patients typically arrive at the hospital one day before the surgery to undergo specific tests that will ensure the success of the procedure. Nurses may conduct a combination of imaging, blood, and cardiac tests before the surgery.

Because the intestines make up a large portion of the abdomen, patients are required to prepare their bowels for the procedure. Similar to the preparation for a colonoscopy, patients drink a gallon of an electrolyte solution, which helps clear the digestive system.

After the patient is prepared for operation, the surgery can begin:

1. Patients are started on an IV and placed under anesthesia
2. Surgeons make an incision down the center of the abdomen
3. Cancerous parts of the abdominal lining are removed
4. Tumors in the abdomen are removed
5. The abdomen is closed

During the procedure, the surgeon opens the abdomen to remove any present tumors. In most cases, the surgeon applies heated chemotherapy (HIPEC) to the abdomen.

The most tedious part of the procedure involves surgeons searching through the various abdominal organs to find additional tumors. Parts of some organs may be removed to eliminate as much of the cancer as possible.

Cytoreductive Surgery With HIPEC

Hyperthermic (heated) intraperitoneal chemotherapy, known as HIPEC, involves the application of heated chemotherapy solution into the abdominal cavity of patients.

Doctors use HIPEC to treat gastric cancer, colorectal cancer, appendiceal cancer, intra-abdominal sarcoma, gynecologic cancers, and peritoneal mesothelioma. HIPEC is an option for patients who have difficulties with chemotherapy due to poor or limited blood supply. The heated chemotherapy allows direct contact between the drug and cancerous cells in the peritoneal cavity.

During CRS surgeons remove all visible cancer cells, then treat the remaining microscopic (invisible) cells with HIPEC. The combination of CRS and HIPEC ensures all cancerous cells are eliminated.

Cytoreductive Surgery Recovery

Recovery from CRS can be extensive due to the amount of displaced organs within the abdomen. Patients recovering from CRS may stay in the hospital for approximately 7-14 days before returning to normal activity.

After surgery, patients are moved from the operating room to the post-anesthesia care unit. Patients remain on a respirator until they can breathe without assistance. Once their respirator comes off, they are fitted with an oxygen mask.

During recovery time at the hospital, patients have their vital functions, like blood pressure, pulse, temperature, and oxygen level monitored and checked frequently. IV lines deliver pain medication and fluids to the patient.

At home recovery time is typically two to three weeks, depending on each patient. An IV may still be needed for nutritional supplements. Patients may gain functions like eating, drinking, bowel functions, and mobilization within two weeks post-surgery.

Complications of Cytoreductive Surgery

Complications have decreased in recent years, and researchers have reported a reduction of both mesothelioma and mortality over time. Some oncologists remain skeptical about the procedure due to certain complications.

Pulmonary Complications

Pulmonary complications, or complications related to the lungs, are common after any standard abdominal surgery. Patients risk the chance of developing postoperative infections or pneumonia.

Hematological Complications

Hematological complications related to blood toxicity has been reported in some post-CRS patients who also received HIPEC. Some patients may have a higher chance of developing hematological complications after CRS and HIPEC if they are anemic or obese.

Risks

Typical risks include internal bleeding, cardiac failure, blood clots, infection, and mortality. Overall, post-CRS risks are minimal compared to other radical procedures.

While there are certain risks involved while undergoing CRS, the surgery is a life-extending treatment that has been successful for many patients. To learn more about peritoneal mesothelioma and treatment options, download our free mesothelioma guide.