Hyperthermic Intraperitoneal Chemotherapy (HIPEC) Surgery

Hyperthermic intraperitoneal chemotherapy (HIPEC) is a type of advanced regional perfusion cancer therapy. HIPEC occurs during abdominal surgery when the surgeon has access to the entire abdomen.

Typically, the surgeon will first perform cytoreductive surgery (CRS), where the goal is to surgically remove all visible cancer nodules. HIPEC is then performed by filling the open abdomen with heated chemotherapy solution. The HIPEC fluid is allowed to bathe the peritoneal surfaces for one to two hours.

CRS aims to surgically remove all visible cancer nodules. HIPEC then treats small cancer nodules or microscopic (invisible) cancer cells that may be left behind after CRS.

Malignant peritoneal tumors in children are rare but commonly associated with disease progression and poor outcomes. HIPEC procedures have been used for years to treat adult peritoneal carcinomatosis; it has recently been modified for pediatric use to treat children and teens with abdominal cancers.

We treat the following cancers with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy:

• Desmoplastic small round cell tumor (DSRCT) — A rare but aggressive malignant tumor occurring primarily in the abdomen.
• Sarcomas that are spread along the peritoneal surfaces of the abdomen — Alveolar type rhabdomyosarcoma is an example of a sarcoma that may act this way.
• Late-stage and advanced cancers of the peritoneal cavity or inner-abdominal lining — These are more typical in adults, but if present in children, HIPEC can treat advanced cancers of the abdomen, including cancers of the colon, stomach, appendix, and ovaries. It may be an option for children whose abdominal cancers have been resistant to other treatments.
• Metastases — Sometimes called secondary cancers, metastases are cancers that have spread from the original tumor to other parts of the body. Some are too advanced to be removed with surgery. But when peritoneal metastases are confined to the abdomen, HIPEC may be an option.

Is HIPEC right for my child?

When used in combination with cytoreductive surgery, HIPEC works best for children whose cancers are confined or have only spread to the abdomen's inner lining.

Your child’s care team will talk with you about HIPEC if they believe the surgery could benefit their cancer recovery journey.

Outcomes depend on your child’s:

• Cancer stage.
• Cancer type.
• Extent of cancer spread before surgery.
• Overall health.

In cytoreduction surgery (CRS), the surgeon tries to remove all visible nodules or tumors. This may involve removing part of the colon, omentum (a fatty tissue covering the abdominal organs), or other affected tissues.

Surgeons may use an open or closed procedure, depending on the location of the tumor and the extent of cancer spread.

After CRS, surgeons apply a potent dose of heated chemotherapy directly to the abdominal cavity.

Benefits of HIPEC may include:

• It can effectively treat early-stage cancers with little spread.
• It may have fewer side effects than chemotherapy given intravenously.
• It takes advantage of the access to the open abdomen that occurs during surgery, allowing the doctors to directly apply chemotherapy to the cancerous areas.

For more aggressive or advanced cancers, HIPEC can be combined with other therapies, such as standard IV chemo, and may provide benefit in treating remaining cancer cells.

Before surgery

Your child may receive intravenous chemotherapy to reduce the size of the tumor. Your child may be admitted to the hospital the day before surgery to receive intravenous fluids and make sure they are well-hydrated before surgery. In the operating room, CRS will occur first to remove all visible cancer nodules or as much of the tumor as possible, followed by HIPEC to treat any remaining cancer cells before completing the procedure.

Depending on the number of tumors present, the CRS and HIPEC surgery can last at least several hours. Your child will be under general anesthesia and completely asleep through the entire treatment.

A pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will meet with you before the surgery to ask questions about your child’s health and about when your child last ate. Because your child may have eaten more recently than is usually advised for surgery, the anesthesiologist may make adjustments to your child’s anesthesia. Once admitted, your child will not be able to have anything to eat or drink until after the operation.

During surgery

For the HIPEC procedure, the surgeon inserts small tubes and temperature probes into the abdomen:

• One tube delivers the heated chemotherapy solution into your child’s abdomen.
• The other tube circulates the fluid back to a heating element, maintaining a temperature in the abdomen between 105° F and 107.6° F (40.6° C and 42° C).
• The HIPEC surgeon will gently tilt your child's abdomen back and forth for about two hours to ensure the chemotherapeutic drug washes over all the cancer cells. This process aims to kill any remaining cancer within the abdomen.

At the end of the procedure, the surgeon:

• Turns off the pump and allows your child’s body to return to a normal temperature.
• Flushes the abdomen with a saline solution to ensure all the chemotherapy is cleared out.
• Removes the tubes and temperature probes, then closes all incisions.

During the surgery, your child will be given numbing medication directly into the incision to relieve discomfort after the surgery. Your child will continue to receive pain medication while they are in the hospital.

After surgery

After HIPEC surgery:

• Your child will stay in the hospital for about 10 to 14 days. This time will allow their body to heal and their bowel function to return. During their stay, your child will need an IV for fluids and possibly nutrition.
• Your child’s digestive system will need time to recover, so you may meet with a dietitian who can help you learn how to ensure your child gets the nutrients they need.
• Your child’s doctor or care team will provide details on how to care for your child at home.
• Your child may feel tired for a few weeks to months after surgery. Try to keep them active as they recover by taking slow daily walks and building up over time, but stay within their doctor's recommendations.
• The doctor will design a follow-up care plan for your child. They’ll need routine scans or blood tests in the coming years to watch for cancer recurrence.

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery.

One business day before your child’s surgery, you will receive a phone call from a nurse between the hours of 1 and 9 p.m. (Nurses do not make these calls on weekends or holidays.) Please have paper and a pen ready to write down these important instructions.

The nurse will give you specific eating and drinking instructions for your child based on your child’s age.

The following are the usual instructions given for eating and drinking. No matter what age your child is, you should follow the specific instructions given to you on the phone by the nurse.

For children older than 12 months

• After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, coffee, and chewing gum or candy.

For infants under 12 months

• Up to six hours before the scheduled arrival time, formula-fed babies may be given formula.
• Up to four hours before the scheduled arrival time, breastfed babies may nurse.

For all children

• Up to two hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid®, and juices you can see through, such as apple or white grape juice. Milk is not a clear liquid.
• In the 2 hours before the scheduled arrival time, give them nothing to eat or drink.

Once your child has been registered for the surgery, a member of the anesthesia staff will meet with you to take your child’s vital signs, weight, and medical history.

A pediatric anesthesiologist — a doctor who specializes in anesthesia for children — will meet with you before the surgery. They will ask questions about your child’s health and about when your child last ate.

Because your child may have eaten more recently than is usually advised for surgery, the anesthesiologist may make adjustments to your child’s anesthesia. Once admitted, your child will not be able to have anything to eat or drink until after the operation.

• As the parent or legal guardian, you will be asked to sign a consent form before the anesthesia is given.
• If your child is very scared or upset, the doctor may give a special medication to help them relax. This medication is flavored and takes effect in about 10 to 15 minutes.
• If you wish, you may be allowed to go with your child to the room where the surgery will be done and stay while the sleep medication is given.
• Younger children will get their sleep medication through a “space mask” that will carry air mixed with medication. Your child may choose a favorite scent to flavor the air flowing through the mask. There are no shots or needles used while your child is still awake.
• Older children may choose between getting their medication through a mask or directly into a vein through an intravenous (IV) line.
• When your child has fallen asleep, you will be taken to the waiting room. If it has not already been done, an IV will be started so that medication can be given to keep your child sleeping throughout the surgery.

While your child is asleep, their heart rate, blood pressure, temperature, and blood oxygen level will be checked continuously. Your child will have a breathing tube placed while they are asleep. Your child might have a sore throat after the surgery.

To keep your child asleep during the surgery, they might be given anesthetic medication by mask, through the IV tube, or both. When the surgery is over, the medications will be stopped, and your child will begin to wake up.

After surgery, your child will be moved to the recovery room to allow the anesthetic to wear off. You will be called so that you can be there as they wake up.

• Children coming out of anesthesia react in different ways. Your child might cry, be fussy or confused, feel sick to their stomach, or vomit. These reactions are normal and will go away as the anesthesia wears off.
• While your child is in recovery, your surgeon will talk to you about the surgery. This is a good time to ask questions about pain medications, diet, and activity.
• When your child is awake enough, they might be given a Popsicle® or “slushy” to drink in the recovery room.
• Once the anesthesiologist sees that your child is recovering and their pain is controlled, they will be moved to their hospital room. This usually takes about an hour, but every child is different, so times may vary.

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. The best way to help your child stay calm is for you to stay calm.

• You are encouraged to talk to your child or hold their hand before the surgery, while sleep medication is given, and while in recovery.
• You may bring along a “comfort” item — such as a favorite stuffed animal or “blankie” — for your child to hold before and after the surgery.

After your child is discharged and goes home, they should avoid strenuous activity for the next two to four weeks. You may be given additional precautions about your child’s activity when they are discharged.

Most children take up to 12 weeks to feel fully recovered from HIPEC surgery.

Bathing

Your child may take a shower one to three days after the surgery; baths are allowed five to seven days after surgery.

Activity

Following the surgery, activity needs to be somewhat restricted.

• Participation in contact sports and gym class is not permitted until cleared by the surgical team (typically two to four weeks after surgery).
• Swimming is usually permitted one to two weeks after surgery.
• Walking and stair climbing are encouraged.
• Your child may return to school when he or she feels up to it.
• Your surgeon will determine when your child may resume normal activities.

After the surgery, your child will most likely have abdominal pain. Your child may take Tylenol^® or Motrin^®. If your child is still having pain, your child’s doctor may prescribe a stronger medication or a narcotic.

Before you go home, your doctor will prescribe pain medication for your child.

If your child has a fever higher than 101.5 F, bleeding, or foul-smelling drainage from the area around the incisions, call your surgeon right away.

Also, call the doctor if your child has:

• Increased or unexplained pain.
• Increased swelling or redness at the incision site.
• Increased tenderness near the incision.
• Nausea, vomiting, diarrhea, or constipation that is not improving.

If you have any specific questions about your child’s surgery, you should discuss them with the surgeon before the surgery. After the surgery, you may call the Division of Pediatric General and Thoracic Surgery at UPMC Children’s and ask to speak with your child’s surgeon or speak with them during the follow-up visit, if needed.

If your child has any special needs or health issues you feel the doctor needs to know about, please call the Division of Pediatric General and Thoracic Surgery at UPMC Children's Hospital of Pittsburgh before the follow-up visit and ask to speak with a nurse. It is important to notify us in advance about any special needs your child might have.

• UPMC Children’s Hospital of Pittsburgh is one of only a handful of U.S. pediatric medical centers offering hyperthermic intraperitoneal chemotherapy (HIPEC) for treating late-stage abdominal tumors in children, teens, and young adults.
• UPMC surgeons have pioneered HIPEC surgery for the treatment of adults with a variety of advanced and complex abdominal cancers. Since 2001, surgeons with UPMC Hillman Cancer Center have performed more than 2,000 CRS-HIPEC procedures, demonstrating a significant survival benefit in select patients. Our pediatric surgical oncology team have worked with the adult teams to bring HIPEC surgery to UPMC Children's.
• When combined with cytoreductive surgery (CRS), HIPEC is now widely considered the standard of care for treating abdominal cancers, including appendiceal cancer, colorectal cancer, and peritoneal carcinomatosis.