JOCS
Journal of Comprehensive Surgery

The aim of the Comprehensive Surgery is to publish original research articles of the highest scientific and clinical value at the international level in all surgical fields.

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Evaluation of cytoreductive surgery and the HIPEC approach in peritoneal metastases from Sugarbaker to the present day with current evidence
Abstract
Peritoneal metastases (PM) are a common clinical entity in gastrointestinal and gynecological malignancies, often characterized by advanced stages and a poor prognosis. The presence of PM, particularly in colorectal and gastric cancers, has historically been associated with short survival and limited treatment options. The inherent peritoneal-plasma barrier and limited drug diffusion to tumor nodules have historically limited the effectiveness of systemic chemotherapy at peritoneal surfaces. This process has been radically altered since the 1980s by the locoregional treatment approach pioneered by Paul H. Sugarbaker. Sugarbaker conceptualized peritoneal surface malignancies as a potentially "local-regional" disease site, exhibiting a different biology than systemic metastases; He defined a treatment paradigm consisting of the removal of macroscopic tumor burden with cytoreductive surgery (CRS) and targeting residual microscopic disease with hyperthermic intraperitoneal chemotherapy (HIPEC). Most reviews in the existing literature address CRS+HIPEC treatment solely from a surgical and chemotherapeutic perspective. This study offers a multidisciplinary perspective by examining the historical framework from Sugarbaker to the present, biomarker-based selection, artificial intelligence-supported patient assessment models, and data standardization initiatives. The idea that peritoneal surface malignancies have a disease biology distinct from systemic metastasis emerged in the 1980s with a conceptual revolution pioneered by Paul H. Sugarbaker. Sugarbaker redefined the peritoneal cavity as a "treatable anatomical compartment." Thus, a locoregional approach has been developed that aims to overcome the limitations of systemic therapy. The combination of CRS (cytoreductive surgery) and HIPEC is an approach that aims to achieve loco-regional control in peritoneal metastases. However, its effectiveness is sensitive to the primary tumor type, tumor burden (PCI), degree of surgical completeness (CC score), the HIPEC protocol used, and center experience. This section summarizes current evidence for peritoneal metastases from colorectal, ovarian, and gastric cancer (CRC-PM, EOC-PM, GC-PM). Current evidence suggests that cytoreductive surgery (CRS) is the strongest prognostic factor in the management of peritoneal metastases, while HIPEC may provide an additional survival advantage in carefully selected cases with appropriate agent, temperature, and duration parameters. However, current data are still limited due to protocol heterogeneity, agent differences, and variability in patient selection criteria. In the future, thanks to the integration of molecular biomarker-based selection strategies, AI-assisted imaging analyses, and international data-sharing networks (e.g., PSOGI, RENAPE), the CRS+HIPEC approach will become much more individualized, predictable, and standardized. This multifaceted advancement holds the potential to optimize not only survival but also treatment safety and quality of life in the treatment of peritoneal metastases.

Keywords : Cytoreductive surgery, HIPEC, peritoneal carcinomatosis

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Article available in :
Volume 3, Issue 4, 2025
Page : 72-77
https://doi.org/10.51271/JOCS-0064
Article Information
Received : 01 Kas 2025
Accepted : 22 Kas 2025
Published : 29 Kas 2025
Corresponding Author :

Turan Eray Seven: Department of Surgical Oncology, Sincan Training and Research Hospital, Ankara, Türkiye

[email protected]
Citation : Seven TE. Cytoreductive surgery and HIPEC in peritoneal metastases: from Sugarbaker’s concept to modern evidence. J Compr Surg. 2025;3(4):72-77.

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