Feasibility and Outcomes of Cytoreductive Surgery & HIPEC for Peritoneal Surface Malignancies in Low and Middle Income Countries: A Single centre Experience of 232 Cases

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has recently emerged as a viable management option for peritoneal surface malignancy (PSM). CRS and HIPEC is a complex, multidisciplinary and resource intensive surgical option with a steep learning curve and significant morbidity and mortality. Most of experience is limited to few dedicated high volume centres from developed countries. We present a single institutional experience of 155 cases of CRS and HIPEC performed at a tertiary care cancer centre in a low & middle-income country (LMIC). Methods: : A multidisciplinary PSM program was initiated in 2015 at a high volume tertiary care cancer centre in north India catering largely to patients belonging to low and middle income groups. Perioperative protocols applicable to practice setting were developed and a prospective structured PSM data base was created for capturing the data. All patients undergoing CRS & HIPEC between January 2015 to December 2020 were identified and the data was analysed for clinical spectrum, surgical details, peri-operative morbidity and mortality. Results: : A total of 232 cases of PSM underwent CRS and HIPEC during the study period. Epithelial ovarian carcinoma (56.5%) was the most common clinical entity treated, followed by pseudomyxoma peritonei (18.5%), colorectal carcinoma (13.4%) and malignant mesothelioma (5.6%). Optimal CRS could be achieved in 94.4% of patients. Cisplatin and mitomycin were the most common drugs used for HIPEC. A total of 28.0% of patients had morbidity including deep vein thrombosis, sub-acute intestinal obstruction, sepsis, burst abdomen, lymphocele, ureteric injury, acute renal failure, entero-cutaneous fistula. The overall treatment related mortality was 3.5%. Conclusions: : Results of the current study indicate that it is feasible to establish a successful CRS and HIPEC program for PSM in LMIC facing resource constraints. The most common indication for CRS and HIPEC were carcinoma ovary followed by pseudomyxoma peritonei and colorectal carcinoma. Overall morbidity and mortality of the current series are comparable to global rates reported from high income countries. A protocol based multidisciplinary team approach, optimal patient selection and surgical expertise plays a crucial role for optimal outcomes.