Over the last several years, surgeons trained in the use of complex surgical procedures have been applying their expertise to a procedure that significantly extends the survival of patients diagnosed with malignant peritoneal mesothelioma. These skilled experts in diagnosis, treatment, and rehabilitation undertake a combination of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy/chemoperfusion called HIPEC.[1]
What is the HIPEC Procedure?
Hyperthermic intraperitoneal chemotherapy/chemoperfusion is a multimodality therapy that combines complete macroscopic cytoreduction surgery with intra-abdominal hyperthermia and intraoperative chemotherapy. While it is increasingly used to manage peritoneal mesothelioma and has been shown to significantly extend survival, it is an extremely complex procedure that should only be performed by qualified physicians who have received sufficient training in surgical oncology. In addition to the significant experience the complexity of the procedure requires, most general surgeons lack familiarity with the intricacies of peritoneal cancers.[1]
Cytoreductive surgery with HIPEC is used to treat a range of conditions, including
- Advanced colon cancer
- Rectal cancer
- Appendiceal cancer
- Ovarian cancer
- Gastric cancer
- Pseudomyxoma peritonei
- Peritoneal mesothelioma
- Peritoneal carcinomatosis
What Kind of Doctor Performs the HIPEC Procedure?
Because cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is such a complex and multifaceted procedure, there are only about 150 surgeons in the United States who perform it. Those who do are generally board certified in both general surgery and complex general oncologic surgery, a distinction which acknowledges their specific knowledge and skills related to the diagnosis, multidisciplinary treatment, and rehabilitation required by patients with complex presentations or requiring complex general surgical oncology procedures, or with rare or unusual cancers.
How Does a Surgeon Become Qualified to Perform HIPEC?
Though there is no specific certification for a surgeon to perform the HIPEC procedure, its complexity and the highly technical environment and equipment required for the operation indicated that it is best performed by surgeons who have earned the American Board of Surgery certification process for complex general surgical oncology. Board certification follows the completion of an accredited complex general surgical oncology training program and after obtaining initial certification in general surgery.
It can take more than 13 years to become a surgeon. Following four years of undergraduate education and another four years to graduate from an accredited medical school, candidates match into a surgical residency that generally takes five years to complete. During the first year of the internship, residents work under the supervision of an attending surgeon, then gradually take on more responsibility as they gain more experience.[2]
Only after completing the five-year residency program can a surgeon apply for acceptance into a fellowship program for complex general surgical oncology. These highly competitive programs generally take at least two years to complete, with an option to extend for additional years in research.[3]
In addition to learning the advanced techniques for performing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, candidates for board certification in complex general surgical oncology also learn to perform procedures like isolated limb infusions, hepatic arterial infusion pump placement, liver ablation, minimally invasive nodal dissections, and robotic surgical approaches.[3]
How Do HIPEC Surgeons Treat Peritoneal Mesothelioma?
After a patient with malignant peritoneal mesothelioma is diagnosed, they may be told that there are no surgical options available for this highly aggressive, asbestos-related cancer. However, seeking care at a university-based center specializing in medico-surgical oncology and equipped with the appropriate medical infrastructure may lead them to hyperthermic intraperitoneal chemotherapy as an option: It has been the treatment of choice for treating peritoneal mesothelioma for decades. Studies have shown that combining the procedure with surgical cytoreduction has been a game-changer, improving patient survival by up to four years with repeated procedures.[1]
The first step that a complex general surgical oncologist will take is to assess the extent of invasion to determine whether the patient’s tumor is operable. This preoperative evaluation will include the patient’s medical-surgical history, assessment of the tumor, the history of preoperative or neoadjuvant chemotherapy, and the analysis of cardiopulmonary examinations. Once a patient is approved for the procedure, the surgeon will conduct cytoreductive surgery followed by either an open or closed abdomen technique for the infusion of the chemotherapy drugs, with the closed technique allowing faster attainment of the hyperthermia that helps to kill any mesothelioma cells that are left behind.[1]
Surgeons who are skilled in performing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy rely on collaboration with a multidisciplinary team that includes medical oncologists, anesthesiologists, nurses, and other allied health professionals.
