Challenges in setting up the first cyto-reductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC) service in Malaysia.

Abstract

Introduction: Cyto-Reductive Surgery (CRS) with Hyperthermic Intra-Peritoneal Chemotherapy (HIPeC) improves survival in selected patients with peritoneal surface malignancies (PSM) of various tumour entities. This treatment was not available in the Malaysian public health sector prior to 2018, due to lack of expertise, funding and accessibility. We report our challenges in establishing the first such service.

Materials and methods: Patients referred for CRS-HIPeC between February 2018 and November 2023 were discussed in a multidisciplinary team meeting. Prospectively collected data, including patient demographics, extent of disease (radiological stage, peritoneal carcinomatosis index - PCI), pre-operative workup, completeness of cytoreduction (CCR) score and surgical outcomes, were analysed.

Results: Of 162 patients referred, 47 (30.0%) underwent CRS-HIPeC. The median age was 59 years (range 20-76 years). Median PCI was 11 (range 1-39). CCR distribution was as follows: CCR 0 - 40 (85.1%), CCR 1 - 2 (4.3%), CCR 2 - 2 (4.3%) and CCR 3 - 3 (6.3%). Median operative time was 645 minutes (range 360 -1575 minutes) with a median length of in-hospital stay of 11 days (range 6-146 days). All patients were initially managed in the intensive care unit. Sixteen (34.0%) patients developed complications of Clavien-Dindo Class 3 and above, with three operative mortalities (6.3%).

Conclusion: CRS-HIPeC requires adequate clinical expertise, facilities and volume. Its labour and resourceintensive nature mean that centralization of services is necessary for sustainability. Further evaluation of its costbenefit in our setting will be required.