CRS is short for cytoreductive surgery, which is removal of all sites of cancer within the abdominal cavity. The peritoneum is an organ which, when affected with cancer, can respond to resection. However, surgical excision is complex and involves removal of some of its surface area and destruction of the tumor cells in other areas to achieve a complete cytoreduction (a decrease of the cancer cell load) and prepare the field for the intra-peritoneal heated chemotherapy. With CRS, now treatment of few advanced cancers are possible, which were previously considered inoperable and were offered palliative care only.

CRS has been shown to be effective in carefully selected patients with peritoneal metastases from various cancers. Not all patients benefit from extensive CRS. Quantitative prognostic indicators used in selecting patients are histopathology to assess the invasive character of the malignancy, radiological findings of thorax, abdomen & pelvis, peritoneal cancer index (PCI) and the completeness of cytoreduction score (CCR).

A multidisciplinary team comprising of oncosurgeon, medical oncologist, anesthesiologist, intensivist, radiologist and pathologist will evaluate the patient. Pretreatment records will be checked carefully with histological confirmation by an experienced histopathologist. Pathology review and an assessment of the invasive or non-aggressive nature of a malignancy will be done for planning treatment. Imaging studies will be done to rule out extra-abdominal disease.

Patient and relatives will be counseled initially regarding therapy, expected response with same, prognosis and expected cost of treatment. Risks involved and quality of life issues will be explained by Dr. Monika. Need for systemic chemotherapy if required will be explained beforehand.

Patient will be given nutritional assessment and support and will be asked to abstain from smoking/alcohol and other addictions. The patient might be asked to discontinue NSAIDS, anticoagulants and systemic chemotherapy at least 6 weeks prior to surgery. Preoperative exercise like stoma counseling & marking will be done in an upright position.

The entire procedure can be subdivided in three main parts: exploration, cytoreductive surgery and HIPEC. The whole procedure time varies from 4-14 hours depending on extend of disease. CRS comprises of peritonectomy procedures and visceral resections. The goal is to remove all macroscopic disease leaving no residual disease or for some pathologies like pseudomyxoma peritonei or peritoneal mesothelioma, disease that is not greater than 2.5 mm in size. Generally, the procedure is performed through a long abdominal midline incision and a complete and meticulous exploration looking for peritoneal deposits. Metastases in the region of the ileocaecal valve may necessitate a removal of the terminal ileum and limited part of the right colon to achieve a complete resection. Sometimes, a distal or total gastrectomy is required to achieve a complete cytoreduction in cancer in subpyloric space. After peritoneal and organ resection is done, and finally the hyperthermic chemotherapy is administered.

The average length of stay in the hospital is 7-10 days. By the time the patient is discharged from the hospital, all patients should be able to tolerate an oral diet, ambulate and have their postoperative pain controlled with regular oral pain medication. Most patients return to their work activity one month after the procedure, provided that lifting of heavy objects is avoided for a total of at least six weeks after the procedure.