One of my patients with ovarian cancer is scheduled for hyperthermic intraperitoneal chemotherapy (HIPEC). What can you tell me about this therapy?—U.B., MASS.
Jeanne Held-Warmkessel, MSN, RN, AOCN, ACNS-BC, replies: HIPEC is used in combination with complete cytoreductive surgical resection (CRS) of certain intra-abdominal malignancies in carefully selected patients. The goal of CRS with HIPEC is to surgically resect as completely as possible the intra-abdominal malignancy and then employ intra-abdominal cytotoxic chemotherapy to destroy any residual disease. The heat and chemotherapy act synergistically to kill cancer cells.1 Candidates for CRS with HIPEC include patients with cancers that involve the peritoneal surface, such as ovarian cancer, colonic or colorectal peritoneal carcinomatosis, or primary peritoneal carcinomatosis.1-4,6,7 The procedure is limited to patients who have disease confined to the abdomen.
Because chemotherapy can penetrate only a short distance into tumors, surgical resection of all visible tumors is required so that the tumors remaining after resection are less than 2.5 mm in diameter.3 The patient must be able to tolerate chemotherapy, the cardiopulmonary stress of the procedure (because CRS is lengthy surgery), and prolonged immobility on the surgical table.4
HIPEC is used only after CRS is completed. The selected chemotherapy agent, such as mitomycin (off-label use), is warmed to 41° C (105.8° F) and infused into the abdominal cavity using equipment designed to both warm and infuse the drug. Other antineoplastic agents used off-label include doxorubicin, cisplatin, oxaliplatin, and taxanes.4 Hyperthermia helps the chemotherapy to kill malignant cells.1 After the allotted time for drug circulation in the abdomen, the drug is drained, anastomoses are performed, and the abdomen is closed.3
Postoperatively, the patient requires critical care nursing. Assessing for fluid and electrolyte imbalances is crucial along with ongoing assessments of cardiopulmonary function and monitoring for complications related to immobility and the surgical procedure. The nurse monitors the large incision, drains (if present), ostomy site and function (if present), central venous pressure, respiratory function, and renal function. Besides maintaining the nasogastric tube, the nurse administers antiemetics, hydration, electrolytes, and any needed blood products.5
Pain is managed with opioid analgesics administered via an epidural catheter. Venous thromboembolism (VTE) prophylaxis and pressure point reduction are required.5 The patient is assessed and monitored for a fever and other vital sign changes suggesting sepsis or bleeding.
Blood work results are monitored for neutropenia and other chemotherapy-related adverse reactions. Chemotherapy excretion precautions are maintained according to facility policy. Postoperative complications include anastomotic leaks, fistula development, abscess formation, wound dehiscence, bowel perforation, VTE, cardiac events, and death.1,6
When stable, the patient is moved to a general surgical oncology unit for continued monitoring and patient education while the discharge process is initiated. The patient and family need to know how to care for the wound and monitor for any new surgical complication. They also need to know to inform the surgeon about any postoperative issues right away.
Although complicated and extensive, HIPEC offers selected patients a better chance of survival than systemic chemotherapy alone.7
1. Witkamp AJ, de Bree E, Van Goethem R, Zoetmulder FA. Rationale and techniques of intra-operative hyperthermic intraperitoneal chemotherapy. Cancer Treat Rev
2. Cashin PH, Graf W, Nygren P, Mahteme H. Intraoperative hyperthermic versus postoperative normothermic intraperitoneal chemotherapy for colonic peritoneal carcinomatosis: a case-control study. Ann Oncol
3. González-Moreno S, González-Bayón LA, Ortega-Pérez G. Hyperthermic intraperitoneal chemotherapy: rationale and technique. World J Gastrointest Oncol
4. de Bree E, Helm CW. Hyperthermic intraperitoneal chemotherapy in ovarian cancer: rationale and clinical data. Expert Rev Anticancer Ther
5. Wooten L. Appendix B: nursing care of the HIPEC patient. Curr Probl Cancer
6. Elias D, Lefevre JH, Chevalier J, et al. Complete cytoreductive surgery plus intraperitoneal chemohyperthermia with oxaliplatin for peritoneal carcinomatosis of colorectal origin. J Clin Oncol
7. Yan TD, Black D, Savady R, Sugarbaker PH. Systematic review on the efficacy of cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis from colorectal carcinoma. J Clin Oncol