CRS (Cytoreductive Surgery) and HIPEC (Hyperthermic Intraperitoneal Chemotherapy) is an advanced two-part treatment used to manage certain cancers that have spread to the peritoneum, the thin layer of tissue lining the inside of the abdomen. This treatment is especially effective for selected patients with colorectal cancer, appendiceal cancer, ovarian cancer. The goal of CRS and HIPEC is to improve survival and quality of life by removing and destroying visible cancer cells within the abdomen.
Cytoreductive surgery, or CRS, is the first step of this treatment. It involves an extensive operation to remove all visible tumours from the abdominal cavity. Surgeons may need to remove affected parts of organs such as the bowel, spleen, uterus, or ovaries, depending on how far the cancer has spread. The aim is to leave behind no visible cancer, as this allows the next phase—HIPEC—to be most effective.
Immediately following CRS, while the patient is still in the operating theatre, HIPEC is performed. This involves delivering heated chemotherapy directly into the abdominal cavity. The chemotherapy solution is warmed to about 42°C and circulated through the abdomen for 60 to 90 minutes using a specialised machine. The heat improves the effectiveness of the chemotherapy, helping it penetrate tissues more deeply and kill any remaining microscopic cancer cells that could not be seen or removed during surgery. Unlike standard chemotherapy, HIPEC acts locally in the abdomen, which means it has fewer side effects on the rest of the body.
CRS and HIPEC is not suitable for everyone. Patients are carefully selected based on factors such as the type and spread of their cancer, their general health, and how well they may tolerate a major operation. In Wales, these evaluations are done by a dedicated team at the All-Wales Colorectal Peritoneal Metastasis Service, based in Cardiff. Since its launch in May 2022, over 40 patients in Wales have received CRS and HIPEC through this service, and over 312 cases have been reviewed. For suitable patients, the outcomes can be very positive, with some studies showing five-year survival rates above 50%.
This approach offers new hope to patients with Colorectal peritoneal malignancy in Wales, with the support of a highly experienced multidisciplinary team.
The journey for a patient being considered for CRS (Cytoreductive Surgery) and HIPEC (Hyperthermic Intraperitoneal Chemotherapy) at the Peritoneal Malignancy Institute Wales (PMIW) begins with a referral to the specialist team. Once referred, the case is reviewed by a Multidisciplinary Team (MDT) at PMIW, which includes surgeons, oncologists, radiologists, and nurses who collectively assess the patient's suitability for the treatment. If the MDT believes the patient may benefit from CRS and HIPEC, further investigations and preparations begin.
The patient is scheduled for an outpatient appointment where initial assessments are made, and information about the treatment is shared. The patient also attends a Pre-Operative Assessment Clinic (POAC) after the clinic appointment to ensure they are ready for surgery. A detailed evaluation then follows, including a Cardio-Pulmonary Exercise Test (CPET) to assess fitness for major surgery, and other tests like G+S (Group and Save) to prepare for potential blood transfusions.
Surgery takes place at the University Hospital of Wales (UHW) in Cardiff. Most patients are admitted on the morning of surgery but are able to come in the day before if needed. On the day of the procedure, the patient undergoes CRS to remove all visible cancer from the abdominal cavity. HIPEC is delivered directly into the abdomen during the same operation. After surgery, the patient is closely monitored in the Post-Anesthesia Care Unit (PACU) for 48 hours before being transferred to a surgical ward (ward C6) for recovery.
Post-operative recovery involves a hospital stay that can range from 7–14 days, depending on the extent of the surgery and the patient’s condition. Follow-up care is provided to monitor recovery, manage any complications, and once medically fit, the patient is discharged home. The PMI team will support the discharge process, but we also advise patients to see their GP if needed. Further oncology follow-up and long-term monitoring are arranged through the patient’s local cancer care team, in coordination with the PMIW. Cardiff and Vale patients will continue under the care of the PMI team.
This structured pathway ensures that patients in Wales receive expert, coordinated care throughout their CRS and HIPEC journey, improving outcomes and offering support every step of the way.
What is the peritoneum?
The peritoneum is a thin, protective layer of tissue that lines the inside of your abdominal cavity (the area of your body below the chest) and covers many of the organs inside it, including the intestines, liver, and stomach. It produces a small amount of fluid to help these organs move smoothly against each other as they work.
For Welsh patients needing advanced treatment for Colorectal Peritoneal Malignancy like HIPEC (Hyperthermic Intraperitoneal Chemotherapy) the All-Wales Colorectal Peritoneal Metastasis Service established in 2022 in Cardiff has made it possible for patients to receive this care. Over 43 patients have been treated locally with this method, and the service has reviewed over 300 cases. For the right patients, five-year survival rates after HIPEC are more than 50%, which is a significant improvement compared to standard care.
Treatment depends on the type of peritoneal malignancy (primary or secondary), where the cancer came from, your overall health, and how far the cancer has spread. In Wales, treatments are provided at University Hospital of Wales, Cardiff.
The goal is to remove as much of the cancer as possible—this is called cytoreductive surgery. This may involve:
For suitable patients, this is often the first and most important step. In some cases, cytoreductive surgery is followed by a procedure called HIPEC (Hyperthermic Intraperitoneal Chemotherapy), where heated chemotherapy is delivered directly into the abdominal cavity to kill any remaining cancer cells and reduce the risk of recurrence.
Chemotherapy uses drugs to kill cancer cells. It may be given:
It is usually delivered through a vein (intravenously), often in cycles over a few months. Patients will be referred to their local cancer treatment centre, where the care team will provide more detailed information about the treatment plan and expected outcomes.