Research Article|Articles in Press

Open versus Closed technique for administration of heated intraperitoneal chemotherapy (HIPEC): Morbidity and Mortality outcomes from a high-volume centre

Published:April 28, 2023DOI:


      Background and aims

      Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is an established treatment in selected patients with peritoneal metastases, delivered in the UK in specialist centres. HIPEC can be administered via the open coliseum technique as first described by Sugarbaker (O-HIPEC) or using a closed technique (C-HIPEC). Data comparing the safety and outcomes of these different approaches is limited. This study aims to compare morbidity and mortality rates of O-HIPEC and C-HIPEC following CRS for peritoneal metastases from colorectal cancer and appendiceal tumours.


      Consecutive patients undergoing CRS with open (05/2019–04/2020) and closed (05/2020–04/2021) HIPEC were identified from a prospectively maintained database. Baseline data including primary pathology, HIPEC agent and major operative procedures were analysed using Chi-squared and Fishers exact tests to ensure comparability of groups. Primary outcomes were 30- and 60-day postoperative mortality and morbidity (Common Terminology Criteria for Adverse Events, CTCAE). Secondary outcomes were length of critical care and overall hospital stay. In addition, morbidity and mortality were compared between HIPEC agents (mitomycin and oxaliplatin/5-fluorouracil).


      99 patients (39.3%) and 153 patients (60.7%) underwent O-HIPEC, C-HIPEC respectively. Groups were well matched for baseline demographics, pathology, and HIPEC agent. In the O-HIPEC and C-HIPEC groups respectively, the incidence of 60-day complications (CTCAE 1–4) was 40.4% vs 39.3% (chi squared 0.94) and severe complications (CTCAE 3–4) 14% vs 13% (Fisher's exact p = 1) There was no perioperative mortality but one death in each group within the follow up period. There was no difference in morbidity or mortality between those receiving mitomycin or oxaliplatin.


      Closed administration of HIPEC is safe with no difference in post-operative morbidity or mortality compared to open HIPEC administration. Differences in longer term oncological outcomes including overall survival and disease-free survival between open and closed HIPEC techniques are yet to be determined.


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        • Larentzakis A.
        • O'Dwyer S.T.
        • Becker J.
        • Shuweihdi F.
        • Aziz O.
        • Selvasekar C.R.
        • et al.
        Referral pathways and outcome of patients with colorectal peritoneal metastasis (CRPM).
        Eur J Surg Oncol. 2019 Dec 1; 45: 2310-2315
        • O'Dwyer S.
        • Verwaal V.J.
        • Sugarbaker P.H.
        Evolution of treatments for peritoneal metastases from colorectal cancer.
        J Clin Oncol. 2015 Jun 20; 33: 2122-2123
        • Sugarbaker P.H.
        Peritonectomy procedures.
        Ann Surg. 1995 Jan; 221: 29-42
        • Glehen O.
        • Cotte E.
        • Kusamura S.
        • Deraco M.
        • Baratti D.
        • Passot G.
        • et al.
        Hyperthermic intraperitoneal chemotherapy: nomenclature and modalities of perfusion.
        J Surg Oncol. 2008 Sep 15; 98: 242-246
        • Fish R.
        • Selvasekar C.
        • Crichton P.
        • Wilson M.
        • Fulford P.
        • Renehan A.
        • et al.
        Risk-reducing laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for low-grade appendiceal mucinous neoplasm: early outcomes and technique.
        Surg Endosc. 2014 Jan 6; 28: 341-345
        • Ferron G.
        • Simon L.
        • Guyon F.
        • Glehen O.
        • Goere D.
        • Elias D.
        • et al.
        Professional risks when carrying out cytoreductive surgery for peritoneal malignancy with hyperthermic intraperitoneal chemotherapy (HIPEC): a French multicentric survey.
        Eur J Surg Oncol. 2015 Oct; 41: 1361-1367
        • Elias D.
        • Antoun S.
        • Goharin A.
        • Otmany A.E.
        • Puizillout J.M.
        • Lasser P.
        Research on the best chemohyperthermia technique of treatment of peritoneal carcinomatosis after complete resection.
        Int J Surg Invest. 2000; 1: 431-439
        • Rodríguez Silva C.
        • Moreno Ruiz F.J.
        • Bellido Estévez I.
        • Carrasco Campos J.
        • Titos García A.
        • Ruiz López M.
        • et al.
        Are there intra-operative hemodynamic differences between the Coliseum and closed HIPEC techniques in the treatment of peritoneal metastasis? A retrospective cohort study.
        World J Surg Oncol. 2017 Dec 21; 15: 51
        • Facy O.
        • Combier C.
        • Poussier M.
        • Magnin G.
        • Ladoire S.
        • Ghiringhelli F.
        • et al.
        High pressure does not counterbalance the advantages of open techniques over closed techniques during heated intraperitoneal chemotherapy with oxaliplatin.
        Surgery. 2015 Jan; 157: 72-78
        • Halkia E.
        • Tsochrinis A.
        • Vassiliadou D.T.
        • Pavlakou A.
        • Vaxevanidou A.
        • Datsis A.
        • et al.
        Peritoneal carcinomatosis: intraoperative parameters in open (coliseum) versus closed abdomen HIPEC.
        Int J Surg Oncol. 2015; 2015610597
        • Shariff F.
        • Bischof D.
        • Govindarajan A.
        • Prince R.
        • Burkes R.
        • Haase E.
        • et al.
        Evidence-based strategies for the treatment of peritoneal malignancies during health care resource restriction: the COVID-19 pandemic.
        Curr Oncol. 2020 Dec 1; 28: 40-51
        • Näslund Andréasson S.
        • Anundi H.
        • Thorén S.B.
        • Ehrsson H.
        • Mahteme H.
        Is platinum present in blood and urine from treatment givers during hyperthermic intraperitoneal chemotherapy?.
        JAMA Oncol. 2010; 2010: 1-4
        • Benoit L.
        • Cheynel N.
        • Ortega-Deballon P.
        • Giacomo G di
        • Chauffert B.
        • Rat P.
        Closed hyperthermic intraperitoneal chemotherapy with open abdomen: a novel technique to reduce exposure of the surgical team to chemotherapy drugs.
        Ann Surg Oncol. 2008 Feb; 15: 542-546
        • Cao C.
        • Yan T.D.
        • Black D.
        • et al.
        A systematic review and meta-analysis of cytoreductive surgery with perioperative intraperitoneal chemotherapy for peritoneal carcinomatosis of colorectal origin.
        Ann Surg Oncol. 2009; 16: 2152-2165
        • Parkin E.
        • Selvasekar C.
        • Wilson M.
        • Renehan A.
        • O'Dwyer S.
        • Aziz O.
        Laparoscopic cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (L-CRS/HIPEC) for perforated low-grade appendiceal mucinous neoplasm (LAMN II).
        Ann Surg Oncol. 2019 Jul 15; 26 (2285–2285)
        • Abudeeb H.
        • Selvasekar C.R.
        • O'Dwyer S.T.
        • Chakrabarty B.
        • Malcolmson L.
        • Renehan A.G.
        • et al.
        Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for perforated low-grade appendiceal mucinous neoplasms.
        Surg Endosc. 2020 Dec 28; 34: 5516-5521
        • Younan R.
        • Kusamura S.
        • Baratti D.
        • Cloutier A.S.
        • Deraco M.
        Morbidity, toxicity, and mortality classification systems in the local regional treatment of peritoneal surface malignancy.
        J Surg Oncol. 2008 Sep 15; 98: 253-257
        • Ortega-Deballon P.
        • Facy O.
        • Jambet S.
        • Magnin G.
        • Cotte E.
        • Beltramo J.L.
        • et al.
        Which method to deliver hyperthermic intraperitoneal chemotherapy with oxaliplatin? An experimental comparison of open and closed techniques.
        Ann Surg Oncol. 2010; 17 ([PMID: 20143265): 1957-1963
        • Leiting J.L.
        • Cloyd J.M.
        • Ahmed A.
        • Fournier K.
        • Lee A.J.
        • Dessureault S.
        • et al.
        Comparison of open and closed hyperthermic intraperitoneal chemotherapy: results from the United States hyperthermic intraperitoneal chemotherapy collaborative.
        World J Gastrointest Oncol. 2020 Jul 15; 12: 756-767
        • Quénet F.
        • Elias D.
        • Roca L.
        • Goéré D.
        • Ghouti L.
        • Pocard M.
        • et al.
        Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy versus cytoreductive surgery alone for colorectal peritoneal metastases (PRODIGE 7): a multicentre, randomised, open-label, phase 3 trial.
        Lancet Oncol. 2021 Feb; 22: 256-266
        • Ortega-Deballon P.
        • Facy O.
        • Jambet S.
        • Magnin G.
        • Cotte E.
        • Beltramo J.L.
        • et al.
        Which method to deliver hyperthermic intraperitoneal chemotherapy with oxaliplatin? An experimental comparison of open and closed techniques.
        Ann Surg Oncol. 2010 Jul 9; 17: 1957-1963
        • Benzaquen E.
        • Wang Y.
        • Vanounou T.
        Morbidity associated with the use of oxaliplatin versus mitomycin C in hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis of colorectal or appendiceal origin: a multi-institutional comparative study.
        Can J Surg. 2021 Apr; 64