General Surgery

HIPEC
by Prof. Koray Topgül, M.D.

Hyperthermic Intraperitoneal Chemotherapy HIPEC is a per-operative chemotherapy technique applied during a surgical oncology procedure. By this cytoreductive surgery, tumor on the wall of peritoneum is removed, sometimes including organ resections of colon, partial stomach, gall bladder, uterus or ovaries

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Prof. Koray Topgül, M.D.

General Surgery

Why?

Standard chemotherapy or post-operative intravenous chemotherapy may not sufficiently reach and affect peritoneum because of anatomical and physiologic structure of this tissue. So HIPEC provides a direct reach to the tissue and helps to reach the ultimate goal of the procedure which is to reach R0 resection where no tumor is left behind.

Who can benefit ?

The selection of patients to consider HIPEC depends on a few factors. The first one is there shouldn’t be metastasis to other organ systems other than abdomen. Another factor is the patient’s physical capacity to tolerate this intra-operative procedure. Lastly the Peritoneal Cancer Index that calculates the spread of cancer in peritoneum is taken into consideration by the surgeon before deciding on HIPEC.

Advantages

Although known since 30-35 years, HIPEC became more popular in the recent years. It has proven to be effective compared to regular chemotherapy in specific kinds of cancers. This advantage arises from three main areas:

  • The first issue is that patients are irritated by the toxicity of standard chemotherapeutic treatments. However with HIPEC treatment, the agents are delivered directly into the abdominal cavity and doesn’t enter the whole body’s circulation system, thus minimizing the risks of toxicity.
  • Another concern for many patients is the time span of the therapeutic process which usually takes several sessions over weeks, sometimes months. HIPEC on the other hand is usually administrated during a single treatment which explicitly implies less expenses, less visits to the doctor and less time off the normal course of life.
  • Statistical records and rates can also rise worries when it comes to alternative treatments. But not in the case of HIPEC, since recent reports show that patients diagnosed with mesothelioma at the early stages of cancer development, have higher life expectancy after treatment that even can double.

Points to Consider

Cytoreductive surgery itself is generally a long time consuming procedure. The additional extension of surgery time because of HIPEC has some indication on the patients such as increasing hospital stay for a few days more. But this disadvantage is balanced with being able to use lower doses of chemotherapy in HIPEC. Nevertheless a patient who underwent HIPEC treatment should stay in Turkey for at least 2 weeks after the surgery.  

Prof. Koray Topgül, M.D.

General Surgery
  • Medical School, Akdeniz University – Turkey
  • General Surgery, Ankara Training and Research Hospital – Turkey
  • Professor title from Altınbaş University – Turkey
  • Sub-specialty on Surgical Oncology
  • Works in İstanbul
  • ASM Anadolu Sağlık Merkezi Hospital

He focuses on oncology surgery for the last 20 years of his professional life, especially on gastrointestinal system cancers. Since he focuses on Peritoneal Carcinomatosis (late stage manifestation of several gastrointestinal malignancies including appendiceal, colorectal, and gastric cancer), he has wide experience with HIPEC that directly targets this diagnosis.

Thus there is no specific certification that authorize surgeons to perform HIPEC, Prof. Topgül regrets this negligence and states that only experienced oncology surgeons should perform this method taking difficulty of post-operative follow up and possible complication management processes into consideration.

“Surgeon has to be experienced and sincere about HIPEC”.

When Prof. Koray Topgül compares conventional treatment method (surgery and chemotherphy at post-operative period) and HIPEC ( surgery+HIPEC followed by chemotherphy at post-operative period), he highlights researches that showed life expectancy in 5 years after the surgery is 15 to 20% in the conventional method whereas around 50% in the HIPEC procedure in colorectal cancers.

 

After the discharge international patients are welcomed to receive therir systemic checmotheraphy in their home country. Prof. Topgül contineues to provide his services for his patients via mail and whatsapp and encourages them to share their foloow up test results with Turkey and consult in case they have a problem.

In addition to HIPEC, Prof. Koray Topgül calls attention to PIPAC which is a variation of HIPEC that emerged in the last 10 years. PIPAC means Pressurized Intraperitoneal Aerosol Chemotherapy and applied laparoscopically. This method can mainly be classified as palliative and preferred in cases where HIPEC couldn’t be performed. He explains that patients with spread tumors in the intestines and at which resection is not promising are main candidates of PIPAC.

In this procedure there is no extensive surgery but only a laparoscopy at which liquid chemotherapy solution is turned into aerosol form with a special PIPAC device. The procedure lasts around 30 minutes. Chemotherapy agents in gaseous form disperse homogeneously and because of the pressure related to laparoscopy technique, penetration into tissues is enhanced.

Generally PIPAC procedure is repeated several times in 6 weeks periods, while systemic chemotherapy continues in between sessions.

 

He mentions 2 topics for the success in surgical oncology:

  • Experience of the surgeon in the field of surgical oncology
  • The infrastructure and available resources that the hospital provides

Teamwork is an inseparable component of surgical oncology for Prof. Topgül and he mentions Medical Oncologists, Radiation Oncologists, Radiologists, sometimes Interventional Radiologists as his close counterparts.

Prof. Koray Topgül underlines the experience of the physician pointing at issues other than technical surgery skills. For him a good surgeon is not only a good technician to perform the procedure but also should be sufficiently experienced to deal with decisions, timing, management of possible complications, creating solutions and communicating these to the patients.

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