Feasibility and outcomes of cytoreductive surgery and HIPEC for peritoneal surface malignancies in low- and middle-income countries: a single-center experience of 232 cases

Our plain-English summary of Feasibility and outcomes of cytoreductive surgery and HIPEC for peritoneal surface malignancies in low- and middle-income countries: a single-center experience of 232 cases, by S. Deo, M. Ray, B. Bansal, et al (World Journal of Surgical Oncology, 2021).

The study

• Authors: S. Deo, M. Ray, B. Bansal, S. Bhoriwal, S. Bhatnagar, R. Garg, N. Gupta, A. Sharma, L. Kumar, S. Thulkar, E. Dhamija, S. Mathur, P. Das
• Journal: World Journal of Surgical Oncology
• Published: 2021;19(1):164
• Cited by: 19 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has recently emerged as a viable management option for peritoneal surface malignancy (PSM). CRS and HIPEC is a complex, multidisciplinary and resource-intensive surgical procedure. It has a steep learning curve and is associated with significant morbidity and mortality. The expertise is mostly limited to few dedicated high-volume centers located in developed countries. We present a single institutional experience of 232 cases of CRS and HIPEC performed at a tertiary care cancer center in a low- and middle-income country (LMIC).

Methods: A multidisciplinary PSM program was initiated in 2015 at a high-volume public-sector tertiary care cancer center in North India catering largely to patients belonging to low- and middle-income groups. Perioperative protocols were developed, and a prospective structured database was created to capture data. All patients undergoing CRS and HIPEC between January 2015 and December 2020 were identified, and the data was retrospectively analyzed for clinical spectrum, surgical details, and perioperative morbidity and mortality.

Results: Two hundred and thirty-two patients underwent CRS and HIPEC during the study period. Epithelial ovarian carcinoma (56.5%) was the most common malignancy treated, followed by pseudomyxoma peritonei (18.5%), colorectal carcinoma (13.4%), and malignant mesothelioma (5.6%). Optimal CRS could be achieved in 94.4% of patients. Cisplatin and mitomycin were the most common drugs used for HIPEC. A total of 28.0% of patients had morbidity including deep vein thrombosis, subacute intestinal obstruction, sepsis, burst abdomen, lymphocele, urinoma, acute renal failure, and enterocutaneous fistula. The overall treatment-related mortality was 3.5%.

Conclusions: Results of the current study indicate that it is feasible to establish a successful CRS and HIPEC program for PSM in government-funded hospitals in LMIC facing resource constraints. The most common indication for CRS and HIPEC were carcinoma of the ovary followed by pseudomyxoma peritonei and colorectal carcinoma. Overall morbidity and mortality in the current series are comparable to global standards, reported from high-income countries. A protocol-based multidisciplinary team approach, optimal patient selection, and surgical expertise can help achieve optimal outcomes in government-funded hospitals in LMIC.

In plain English

This study reviewed the records of 232 patients who had cytoreductive surgery, which removes visible tumor in the abdomen, followed by heated chemotherapy washed through the abdomen (HIPEC). All were treated between January 2015 and December 2020 at a government-funded cancer center in northern India. Most patients were women (196, 84.5%). The most common cancers treated were carcinoma of the ovary (131 patients, 56.5%), pseudomyxoma peritonei (43, 18.5%) and colorectal cancer (31, 13.4%). Thirteen patients (5.6%) had malignant mesothelioma. The article did not report results separately for the mesothelioma patients and did not discuss asbestos. Surgeons judged the tumor removal optimal in 219 patients (94.4%). Cisplatin was the most common HIPEC drug, used in 191 patients (82.3%). Within 30 days of surgery, 65 patients (28.0%) had serious complications, most often deep venous thrombosis (15 patients, 6.5%). Eight patients (3.5%) died in the perioperative period, which the study defined as up to 30 days after surgery. The authors concluded that such a program is feasible in resource-constrained hospitals in low- and middle-income countries, with complication and death rates comparable to those reported from high-income countries.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective analysis of a prospectively maintained database at a single center (case series of surgical outcomes)
• Who was studied: 232 patients with peritoneal surface malignancies treated with cytoreductive surgery and HIPEC between January 2015 and December 2020 at a government-funded tertiary care cancer center in northern India (AIIMS, New Delhi). Mean age was 47.3 years and 196 (84.5%) were female.
• Exposure: This is a treatment study, not a study of asbestos exposure; asbestos is not discussed. Patients received cytoreductive surgery followed by HIPEC for 45 to 60 minutes at 41 to 42°C, given mostly with cisplatin or mitomycin-C.
• Main results:
  • Malignant mesothelioma accounted for 13 of the 232 patients (5.6%). The other diagnoses were ovarian carcinoma 131 (56.5%), pseudomyxoma peritonei 43 (18.5%) and colorectal cancer 31 (13.4%).
  • Optimal cytoreduction (CC-0/CC-1) was achieved in 219 of 232 patients (94.4%). Suboptimal cytoreduction occurred in 13 (5.6%).
  • Cisplatin was the most common HIPEC drug, used in 191 patients (82.3%).
  • Grade 3 to 4 perioperative complications (within 30 days of surgery) occurred in 65 of 232 patients (28.0%).
  • The most common complication was deep venous thrombosis, in 15 patients (6.5%).
  • Perioperative death occurred in 8 of 232 patients (3.5%). The study defined the perioperative period as up to 30 days after surgery; no longer-term survival was reported.
  • The study's outcome window was the perioperative period, defined as up to 30 days after surgery.
  • Patients spent an average of 1.3 days in intensive care and 8.1 days in hospital after surgery.
• The authors' conclusion: The authors concluded that it is feasible to implement CRS and HIPEC in resource-constrained hospitals in low- and middle-income countries. They also concluded that overall complication and death rates in their series were comparable to those reported from high-income countries.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, High-Volume Center, Carcinoma, Mesothelioma, Cisplatin, Multidisciplinary Team.

Related studies

• Postoperative outcomes of laparoscopic vs open cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for treatment of peritoneal surface malignancies — G. Passot, N. Bakrin, et al. (2014)
• A Canadian single-centre experience with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for abdominal malignancies — R. Nassabein, R. Younan, et al. (2022)
• Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin in pediatric patients with peritoneal mesothelioma: a single institution experience and long term follow up — P. Malekzadeh, M. Good, et al. (2021)
• Dose-Dependent Effect of Red Blood Cells Transfusion on Perioperative and Long-Term Outcomes in Peritoneal Surface Malignancies Treated with Cytoreduction and HIPEC — E. Nizri, S. Kusamura, et al. (2018)
• Advancing Treatment Outcomes for Peritoneal Surface Malignancies in Low- and Middle-Income Countries: Insights from the First Multicenter Study in North Africa — A. Souadka, H. Habbat, et al. (2025)
• Adjuvant dendritic cell based immunotherapy (DCBI) after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal mesothelioma, a phase II single centre open-label clinical trial: rationale and design of the MESOPEC trial — N.L. de Boer, J.P. van Kooten, et al. (2019)

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