Pancreatic Surgical Diseases and Cancer
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HIPEK (Hyperthermic intra-abdominal chemotherapy - Intra-abdominal hot chemotherapy) is a form of treatment called "Hyperthermic Intraperitoneal Chemotherapy" and has been widely mentioned in cancer treatment in recent years.
Today, many different methods are used in the fight against cancer and significant successes are achieved. Intra-abdominal hot chemotherapy application, which we call HIPEK, is one of the important steps taken in terms of both extending the patient's life expectancy and ensuring the comfort of life. In some cancers originating from intra-abdominal organs and in advanced stages of these cancers, chemotherapy given intravenously (systemic) before (neoadjuvant treatment) or after (adjuvant treatment) or both before and after surgical treatment (adjuvant treatment) or cancer drugs may not show the expected effect.
In this case, the desired response to the treatments applied cannot be obtained. Despite all these efforts, the disease progresses gradually and eventually the patient's life comfort deteriorates and eventually the patient is lost. At this point where the desired response cannot be obtained from the treatment, "intra-abdominal hot chemotherapy-hipec", which is a method that will both prolong the patient's life expectancy and improve the comfort of life, appears as a treatment option.
The abdominal organs and the abdominal wall are covered by a layer called the peritoneum. This structure covers both the surface of the abdominal organs (visceral peritoneum) and the inner surface of the abdominal wall (parietal peritoneum). This thin layer covering the abdomen provides lubrication of the organs with the small amount of fluid it secretes.
While cancer disease continues to develop in the organ where it originates, it tends to spread to other organs and areas with the progression of the disease. Spread can occur through blood, lymphatic neighbourhood and spillage into the abdominal cavity. In advanced stages of intra-abdominal cancers, tumour cells can spread to the peritoneum through neighbourhood and spillage into the abdomen. This is a condition seen in the last stage of cancer. Since the peritoneal membrane does not have its own vessels, cancer-killing drugs administered intravenously cannot reach the peritoneum at the desired levels and the treatment may be ineffective.
In this case, the peritoneum invaded by the tumour should be philosophically considered as an organ, and the organ or organs involved with the peritoneum should be removed and the intra-abdominal cavity should be macroscopically made as tumour-free as possible. This procedure is called "cytoreductive surgery+peritonectomy". Following these procedures, tumour-killing drugs (chemotherapeutic drugs or drugs) heated to 42-43 degrees are administered into the abdomen with a special apparatus and system. This washing process is continued between 60-90 minutes depending on the situation, so that it is aimed to destroy tumour cells at the microscopic level.
There are some reasons why anticancer drugs are given into the abdomen by heating. To list; Heat facilitates the penetration of the drug into the tissue and increases the effect of the selected chemotherapeutic agent to kill the cancer cell.
In addition, heat itself has an anti-tumour effect and heat contributes to the even distribution of the drug to all surfaces in the abdomen. During HIPEK, tumour cells are mechanically removed from the surfaces of the small intestine and from the clot-fibrin layers.
When there is peritoneal involvement, fluid starts to collect in the abdomen of the patient (ascites). This fluid may cause the patient's abdomen to swell gradually and the respiration and circulation may become problematic with the pressure and tension it creates. Sometimes it becomes so common that the patient does not allow the patient to lie down. In addition, it causes the spread of cancer cells to the diaphragm and other intra-abdominal areas. From time to time, this fluid is drained out with cannula etc... to relieve the patient, but since the pathology continues, the fluid collection returns to the same level as soon as possible.
These patients are the ones with advanced cancer that nothing can be done anymore. Cytoreductive surgery and HIPEK are performed to improve the comfort of life and prolong life in this patient group.
The best results are obtained in diseases such as pseudomyxoma peritonei, appendix cancer, ovarian cancer in women. In addition, it has started to be applied in large intestine (colorectal tm. ), stomach and recently pancreatic cancers. Some components should not be ignored while performing this kind of treatment. It makes sense when all stages of treatment are carried out together.
For example, in gastric cancer patients, "Neoadjuvant intraperitoneal systemic chemotherapy - NIPS" should be started with gastric resection followed by cytoreductive surgery + peritonectomy + HIPEK
Then the treatment is completed with systemic chemotherapy. In patients with ascites who are not suitable for cytoreductive surgery due to their general condition and disease, HIPEK application alone can be applied only for palliation, that is, to reduce complaints to some extent. The procedure is performed laparoscopically by means of catheters inserted into the abdomen. It does not have much effect on survival time.
In such an operation, the abdomen is opened in the midline from the xiphoid process to the pubis, and the entire abdomen is evaluated. The peritoneum and other organs (ovary, large intestine, stomach, etc...) that are involved together with the diseased organ are removed and a macroscopic tumour cleaning and complete or near complete cytoreduction is performed. During these procedures, the small or large intestine may need to be temporarily moulded to the abdominal wall, and the intestine is taken back in after the treatment is finished. Without these procedures, HIPEK application alone does not make much sense. On the other hand, performing cytoreductive surgery + peritonectomy alone does not make much sense. These two components should complement each other. Cytoreductive surgery + peritonectomy + HIPEK must be supported by systemic chemotherapy.
HIPEK application is performed following intra-abdominal tumour cleansing. After tumour cleansing, a total of four drains, two in each upper and lower quadrants of the abdomen, are placed. The ends of the drains are mounted to the HIPEK device (a special device that heats the chemotherapy fluid). Two heat probes are placed one on the lower side of the abdomen and one on the upper side to monitor the temperature level. Thus, as long as chemotherapy is given, the desired constant level of temperature is monitored. The amount of chemotherapy fluid given should be 42-43 degrees centigrade. The amount of chemotherapy fluid given is 3.5 litres. The duration of washing with chemotherapy fluid is around 60-90 minutes. At the end of the procedure, the fluid in the abdomen is removed and the procedure is terminated. All these procedures and operation time require a very long time. In order to perform this operation, which can last between 6-10 hours, a good patient preparation and an experienced team-group unity are needed.
HIPEK application is not performed in cases of involvement outside the abdomen (brain, bones, lung metastases ...). If there are three or less metastatic foci in the liver, HIPEK can be applied by removing them. However, there is no indication for HIPEK in cases of extensive liver metastases.
Another important organ is the small intestine. Since the small intestines are the organs of nutrient absorption in the digestive system, extensive small bowel resections are incompatible with life. Therefore, it does not make much sense to perform HIPEK in patients with extensive small bowel involvement.
The majority of these patients have advanced cancer and their life expectancy is limited to months. This important detail should not be ignored and it should be taken into consideration that the disease cannot be completely cured and eliminated, but life comfort and life expectancy can be prolonged.
HIPEK application has different long-term results in different intra-abdominal organ cancers. In pseudomyxoma peritonei, which is the cancer of the peritoneum itself, the 5-year survival rate is around 66 - 97%. Ovarian cancers of the intra-abdominal organs are the cancers with the best benefit and 5-year survival is around 50%. In large bowel cancers, the 5-year survival rate is around 30% in favourable cases.
This situation is slightly different in stomach cancers, and it progresses worse than ovarian and colon cancers. While one-year survival is 43%, unfortunately, 5-year survival is around. While the life expectancy of patients with advanced-stage gastric cancer with peritoneal metastasis is normally around 6 months, talking about the 5-year survival of a certain proportion of patients is quite insightful about the success of the treatment applied.
The risk rate of cytoreductive surgery and HIPEC surgery, which is a complex form of treatment, is higher than other elective standard operations. However, as mentioned before, good results are obtained in patients who are well prepared before the surgery and who are well observed and followed up during the surgery. Bleeding, embolism (such as lung, brain) during surgery; Complications such as bone marrow failure, renal failure, anastomotic separation and leakage, wound infection and dehiscence, etc. due to chemotherapy may be encountered.
Such complications can be minimized by being organized by experienced teams in experienced centers. Post-operative mortality, that is, the risk of losing the patient, appears at different rates in the literature, but is between 0-7% on average. In such advanced stage and serious cancer cases, the possible complications and risk of death are at an acceptable level, considering the comfort of life and survival time achieved with this treatment method.