Peritoneal Cancer Surgery - HIPEC
A scan cannot see most of this disease. Most people who search for peritoneal cancer surgery will turn out not to be candidates for the large operation.
About This Department
A scan cannot see most of this disease.
Cancer that has settled on the lining of the abdomen grows as a film and as scattered nodules a few millimetres across, spread over a surface with roughly the area of a bedsheet, and computed tomography resolves almost none of that. So people are told their scan is clear when it is not. Told the disease is limited when it is extensive. Occasionally taken to theatre for an operation abandoned once the abdomen is open. Every one of those is avoidable, and avoiding them is what the first half of this page is about. The second half is about something the marketing rarely covers. Most people who search for peritoneal cancer surgery will turn out not to be candidates for the large operation, and a page describing only that operation has abandoned the majority of its readers at precisely the point where they most needed somebody to tell them what else exists.
Free consultation
Tell us what the symptom is, and send the raw images
Describe what is actually happening to you day to day, meaning whether the abdomen is swelling, whether food comes back up, whether the bowels have changed, how much weight has gone and over what period, since those answers frequently carry more information than the scan does. Send the most recent CT as raw images on a disc, and any earlier one for comparison, because change over time is readable where a single study is not. Include every operation note, particularly any laparoscopy or laparotomy, and say whether anything was found unexpectedly. Send the pathology with the exact tumour type. List all chemotherapy with dates and how each line ended, and tell us whether any fluid has been drained and what the cytology showed.
What a scan cannot see
Imaging is good at masses. It is poor at films. Peritoneal disease is mostly film.
One deposit two millimetres across, sitting on the surface of the small bowel, is below the resolution of any scanner in routine use, and a hundred of them scattered across the mesentery still add up to nothing a radiologist can report with confidence. Certain patterns do show. Thickening of the omentum, nodules on the diaphragm, fluid in the abdomen and a mass at the umbilicus are all visible once they are large enough to be seen at all. What imaging consistently fails to do is measure how much disease is present and where, which is exactly the information any decision about surgery depends on.
The consequence appears in every study that has looked for it. One prospective study of incidentally discovered gallbladder cancer illustrates both halves of the problem neatly. Patients whose disease looked resectable on standard CT went on to have PET-CT, and additional findings appeared in 46 of 118, changing the management plan in just over a quarter. Diagnostic accuracy for peritoneal spread specifically reached 93 percent. Even so, the authors ended with a caution worth repeating, which is that PET must not be treated as a standalone gateway and should be followed by mandatory staging laparoscopy to rule out occult peritoneal dissemination. A better scan improves the picture. It does not close the question.
How it announces itself
Rarely with a lump anybody can feel. Far more often with something that sounds, at first, like an entirely different problem.
This table scrolls sideways on a narrow screen. Swipe or drag to see every column.
| What you notice | What is happening, and what it changes |
|---|---|
| The abdomen swells | Fluid accumulating because tumour on the lining both produces it and blocks its drainage. Trousers stop fastening, breathing shortens when lying flat, and the swelling is often mistaken for weight gain until it becomes obvious that weight is being lost everywhere else, and a sample of that fluid can establish the diagnosis without any operation at all. |
| Food stops going through | Cramping pain after eating, feeling full after a few mouthfuls, vomiting hours after a meal. Deposits on the outside of the bowel tether and kink it, so this is a mechanical problem and not a digestive one, and it tends to come and go for weeks before it settles into being constant. |
| Weight falls without trying | Partly the disease and partly the eating. Losing more than a twentieth of body weight over a few months is a finding and not a side note, since nutritional state predicts whether treatment of any kind will be tolerated. |
| Found during another operation | A surgeon opens the abdomen for something else and finds deposits nobody expected. What matters enormously here is what was written down at the time, since a description of where the disease sat and how much of it there was cannot be reconstructed afterwards from any scan. |
| A rising marker, a clear scan | Blood markers climbing while imaging shows nothing is a classic pattern for peritoneal recurrence, and it is the situation in which a camera earns its place most clearly, since repeating the scan in three months answers considerably less than looking once would. |
| A lump at the navel | Uncommon. Easily dismissed as a hernia, and almost always significant. Any firm new nodule at the umbilicus in somebody with a cancer history is biopsied rather than watched. |
None of those is specific, which is why this disease is typically found late. What follows from that is a low threshold for looking properly in anybody with a cancer that spreads this way, rather than waiting for a picture clear enough to be certain about.
The camera that settles it
Staging laparoscopy is a short operation under general anaesthetic. A camera is passed into the abdomen through a small incision, the surfaces are inspected directly, fluid is sampled and anything suspicious is biopsied on the spot. It usually takes under an hour, and most people go home the same day or the next.
It answers what no scanner can.
What looking found in 301 people whose scans were clear
A high-volume centre in Ankara reviewed every staging laparoscopy performed for biopsy-proven stomach cancer between March 2019 and April 2025. All 301 had been assessed as free of distant spread on preoperative imaging. Looking directly found occult metastatic disease in 65 of them, an upstaging rate of 21.6 percent, with malignant cells in the fluid in 13.9 percent and visible deposits in 17.3 percent. Treatment was changed in every single patient in whom disease was found, which in practice meant avoiding a major operation that would have delivered no benefit. The procedure itself caused complications in 0.66 percent and death in 0.33 percent. One finding is worth carrying into the consenting conversation, which is that the frozen sample read during the operation had a specificity of 95 percent but a sensitivity of only 67 percent, so a negative result on the day is less reliable than the final answer that follows a few days later.
One patient in five, sent for a major operation they did not need, spared it by an hour with a camera.
That is the argument. It holds in both directions. The same operation that rules a large procedure out is the operation that measures disease accurately enough to rule one in, and the extent recorded during it is what any subsequent decision rests on. Where a previous laparoscopy exists, its note is worth more than any imaging you can send us.
The order treatment comes in
Almost never surgery first, which surprises people who arrive having researched only the operation.
Establish what the tumour actually is
Tissue instead of fluid where possible, since cytology confirms cancer but often cannot type it precisely, and appendiceal, colorectal, ovarian, gastric and mesothelial disease behave so differently from one another that treating them alike is a category error rather than a simplification. Existing slides are re-read here before anything else happens.
Systemic treatment, in most cases before anything else
Chemotherapy and, where the tumour profile supports it, targeted or immune treatment. Beyond shrinking disease, this answers a question no scan can. Whether the cancer responds at all. A tumour that progresses through treatment will progress after an operation too.
Look again, with a camera
Reassessment after treatment shows what actually changed, and it is far more informative than a repeat scan. Some abdomens are transformed. Some look identical. That difference decides whether the conversation moves towards a large operation or away from one, and it is a real decision point rather than a formality.
A meeting that decides the route
Surgery, medical oncology, radiology, pathology, nutrition and palliative care together, weighing tumour type, response, disease extent, and how well you are. Several routes are legitimate, and the point of the meeting is to name which one and why, in writing.
Symptoms treated throughout, and never only at the end
Fluid, blockage, pain, appetite and nutrition are all managed from the first appointment onwards, whichever route is chosen. Palliative care running alongside active treatment is standard practice here and is not a signal that treatment has stopped.
Where the large operation fits
For a minority. The size of that minority is the honest starting point.
Cytoreductive surgery with heated chemotherapy means removing every visible deposit over eight to twelve hours and then washing the abdomen with warmed drug. It offers genuine long-term survival in carefully chosen people, particularly in appendiceal tumours, pseudomyxoma and peritoneal mesothelioma, and rather less certainly in the common cancers, while also being a very large undertaking with weeks in hospital and a real mortality attached to it. Our page on that operation sets out the evidence for each disease, the two scoring systems that predict outcome, the complication list and the trials that shaped current practice, so this page does not repeat any of it.
What belongs here instead is the boundary. Three things usually rule the operation out. Disease too extensive to remove completely, most often because it coats the small bowel and its mesentery. Cancer elsewhere in the body that will determine the outcome whatever happens in the abdomen. And a person too unwell to survive twelve hours of anaesthesia and the weeks that follow.
Being outside those boundaries is not the end of treatment. It changes which treatment.
The aerosol option
A middle route exists between a twelve-hour operation and drugs given into a vein. It deserves describing accurately and never enthusiastically.
Pressurised intraperitoneal aerosol chemotherapy delivers drug into the abdomen as a fine spray under pressure through two small keyhole ports, taking around half an hour, repeated every few weeks. Nothing is removed. The aim is control of the disease and of its symptoms, not cure, the distribution through the abdomen is better than a liquid instillation achieves, and the doses used are small fractions of what a vein would receive.
What a registry of 156 patients shows, including the limit
An international registry study published in 2026 collected every patient with peritoneal spread from pancreatic cancer treated with aerosol chemotherapy across six centres, giving 156 patients and 350 procedures. Safety was good. No major surgical complications occurred, severe adverse events were recorded in 2.9 percent of procedures, and thirty-day mortality of 3.8 percent was in every case attributable to the cancer progressing rather than to the treatment. Median survival was 19 months from the diagnosis of peritoneal spread and 9 months from the first procedure, and a higher disease burden at the outset predicted worse survival. Then the limitation the authors put front and centre. Only 55 patients, 35.2 percent, completed three or more procedures. Disease progression was the reason in about half the cohort. Completing three or more remained independently associated with survival even after adjusting for the bias that favours people who live long enough to receive them. The conclusion was that the approach is safe, that a survival signal exists and is hypothesis-generating rather than proven, and that prospective trials are needed.
Reviewers examining the same technique across liver, bile duct and pancreatic cancers reached a compatible conclusion from ten studies and 332 patients. Access to the abdomen failed in between none and 11.8 percent of attempts, patients completed on average between one and three cycles, no severe systemic toxicity was reported anywhere, and median survival ranged so widely, from 85 days to just over 15 months, that the figure mostly tells you how differently selected these cohorts were. The reviewers described the evidence as heterogeneous and called for standardised prospective trials before the clinical role can be defined. So the honest position is narrow. This is a reasonable option for controlling peritoneal disease and its symptoms in somebody who cannot have cytoreductive surgery, offered with the evidence described as it actually is, and it does not replace systemic treatment that is still working.
Fluid, and how it is managed
Abdominal fluid wrecks daily life more reliably than anything else in this disease. It is also the most fixable. Draining it with a needle under ultrasound takes half an hour and the relief is immediate, with breathing, eating and sleeping all improving within the same afternoon. The difficulty is that it comes back, often within two or three weeks, so somebody accumulating fluid quickly ends up living between hospital visits and organising their month around them. That is where a tunnelled drain changes things. A soft catheter is placed under the skin and left in permanently, and the patient or a family member drains a set volume at home whenever it is needed, which removes the hospital from the equation entirely and hands back a great deal of ordinary life along with it, which is the whole point of doing it.
What the evidence on long-term drains actually says
A 2025 systematic review examined sixteen studies of long-term abdominal drains, including three randomised trials. Its stated subject was refractory fluid in end-stage liver disease, and its opening observation is directly relevant here, which is that these drains are already commonly used for malignant fluid and were being assessed for the liver population precisely because that use is established. Technical success was 100 percent, and while the drain stayed in, no repeat needle drainage was required. Catheters remained in place for periods ranging from 3 to 436 days. Kidney injury occurred in 17 to 50 percent of patients, and the authors specify that this happened only where more than 1.5 litres a day was drained, which makes the daily volume the single most important instruction a patient goes home with. Infection, including skin infection and peritonitis, occurred in 7 to 58 percent and generally resolved with antibiotics or removal of the device. The drains did not appear to worsen mortality. Quality of life data were contradictory, with most studies reporting a neutral effect, and the reviewers judged the overall quality of the literature low.
Which is a useful corrective. A drain reliably removes the journeys to hospital. It reliably carries an infection risk, and the honest way to offer one is with both halves stated and with the daily volume limit written down instead of mentioned. Two other things help and are frequently forgotten. Diuretic tablets work poorly for fluid caused by tumour, quite unlike the fluid caused by liver disease, so persisting with them for weeks on end wastes a quantity of time that somebody in this situation does not have to spare. And where systemic treatment is working the fluid often settles on its own, which is an argument for treating the cancer and not only the symptom.
Blockage, and the decisions around it
Bowel obstruction turns a manageable illness into a crisis faster than anything else here, and the decisions taken in the first days shape everything that follows them.
The first question is whether the blockage is at one point or many. A single narrowing in the large bowel is a mechanical problem. It has mechanical solutions. Multiple points of tethering along the small bowel, which is what widespread peritoneal disease produces, is a different situation in which an operation frequently fails to relieve anything and carries a high risk of leaving somebody worse. That distinction is made with a scan, a careful examination and sometimes a camera, and getting it right is the whole art of this part of the disease. Where a single large bowel narrowing is the problem, a stent placed through an endoscope is often the better route than an emergency operation. A 2025 cohort study of 112 patients with malignant colonic obstruction reports what to expect. Technical success reached 95 percent, with failures caused by complete blockage in one case and by perforation in another. Early complications occurred in 8 percent, chiefly perforation, blockage with stool and kinking of the stent. Used as a bridge to later planned surgery it did not compromise a keyhole approach or increase stoma formation, though it did lengthen hospital stay. Used purely to relieve symptoms, half the patients needed a second stent because the first re-blocked, and mean patency was 7 months. That last figure is the one to plan around.
Where obstruction is diffuse and operating would not help, the aim shifts to comfort and to eating what can be enjoyed. A fine tube through the nose relieves vomiting in the short term and is miserable in the long term, so a venting gastrostomy, meaning a tube placed directly into the stomach through the abdominal wall, is offered instead where the situation is not going to reverse. It allows somebody to drink and taste food without vomiting. Alongside it, medications that reduce secretions and settle cramping work well. Intravenous nutrition is considered case by case, with an honest conversation about what it does and does not achieve.
What we do not offer
People reach this diagnosis frightened and frequently after being told elsewhere that nothing more can be done, which makes them the most vulnerable audience any hospital website has.
We do not operate where complete removal of visible disease is unachievable. An abdomen opened and closed again, or cleared incompletely, delivers the full risk of a major operation and very little of its benefit, and where the assessment says so the answer is no and never an attempt.
Nor do we offer aerosol chemotherapy as a replacement for systemic treatment that is still working, or present it as anything other than what the registries show, which is a safe technique with a survival signal that remains unproven and a completion rate around one patient in three.
We do not offer unproven intraperitoneal infusions, ozone, high-dose intravenous vitamins or any other treatment sold specifically to people with peritoneal spread. This diagnosis attracts that market heavily. The harm is rarely the treatment itself. It is the weeks spent on it while something that works is available.
And we do not accept a patient for surgery on a scan report alone. Raw images are reviewed here, every operation note is read, and where extent cannot be established the honest next step is to look with a camera and accept whatever that shows.
A last thing, addressed to families. Asking for everything possible is understandable and it is not always the same as asking for what will help. A service willing to say that plainly is worth more than one agreeing to everything, and being told no here comes with the reasoning written down, so that you can take it elsewhere and test it against a second opinion.
Coming to Istanbul
How long you need depends entirely on which route the assessment lands on, and the range is wide.
Assessment itself is remote, takes one to two weeks and needs no travel, being a matter of raw images, operation notes, pathology and a meeting. A staging laparoscopy means three to four nights here. A course of aerosol chemotherapy means two to three days per cycle, repeated every few weeks, which for somebody living abroad is a serious commitment worth thinking through before the first one rather than after the second. A tunnelled drain or a stent is a two to three day visit. And cytoreductive surgery is four to six weeks, as our page on that operation sets out. Most nationalities enter Turkey visa-free or on an electronic visa completed online, with a letter of invitation issued where a longer stay needs supporting. Interpreters cover Turkish, English, Arabic, Russian and German as standard with other languages arranged, and a companion is strongly advised for anybody having a procedure rather than a consultation. Airport transfer and accommodation near the hospital are arranged alongside appointments.
Something is worth saying plainly to anybody considering a long journey while unwell. Somebody vomiting, unable to eat, or accumulating fluid quickly should have those things treated before flying instead of after landing, and where that is possible at home it is better done at home. We will advise on it by video, write to the team treating you, and see you when travelling is a reasonable thing to be doing.
What moves the cost
Quotations for this diagnosis vary more than for almost anything else in the hospital, because they describe entirely different routes rather than variations of one.
Staging laparoscopy is a short day case with an anaesthetic and a pathology bill attached. Aerosol chemotherapy is priced per cycle, and since the evidence describes courses of three or more, a single-cycle figure describes a fraction of the treatment. A tunnelled drain is a modest procedure carrying an ongoing supply cost for the drainage bottles that most quotations omit entirely. A stent is a day case plus an endoscopy. The real variable there is whether a second one will be needed, which in the published series happened to half of palliative patients. And cytoreductive surgery sits in an entirely different bracket, driven by theatre hours and intensive care days.
Your own circumstances change all of them. Somebody malnourished, with low albumin and recent weight loss, needs preparation before any procedure and recovers more slowly afterwards. Pretending otherwise produces a quotation wrong by a wide margin. Four questions make a figure comparable. Ask which route it is quoting for and what happens to the figure if the assessment recommends a different one. Ask whether the laparoscopy is charged separately when it ends with a decision not to proceed. Ask what a full course costs rather than a single cycle. And ask what the ongoing consumable and follow-up costs are once you are home. All four are answered in writing before anything is booked.
Living with it
Peritoneal disease is frequently something people live with for a long period instead of something resolved once. The practical business of that deserves more attention than it gets.
Eating is the daily problem. Small frequent meals, low residue where the bowel is narrowed, and food that is soft and calorie-dense will beat any amount of encouragement to eat more of what is already difficult to get down. A dietitian is part of this from the start rather than called when weight loss has become alarming, and written guidance goes home with clear instructions about what to do when things tighten up. Where a drain is in place, the daily volume limit is written down. So is what an infected drain looks like, and who to telephone at what hour. Pain is usually manageable with the right combination, and it is frequently undertreated because people wait to be asked. Cramping responds to different drugs from constant aching. Saying which kind you have gets you the right one faster.
Video review runs at intervals set by the route taken, with your own oncologist copied into everything, and the correspondence states plainly which symptoms mean telephone today and which mean mention it at the next appointment, because that distinction is the one families most often get wrong. Where treatment is continuing at home, we write the protocol so another clinician can act on it without contacting us first.
And the conversation about what happens if treatment stops working is had early, calmly, and while there is time to make choices, rather than in an emergency department at three in the morning. That conversation is part of good care in this disease. Postponing it helps nobody.
Frequently asked questions
My scan looks clear. Could I still have peritoneal disease?
Why do I need a laparoscopy if I have already had a PET scan?
I was told I cannot have the big operation. What is left?
Does aerosol chemotherapy work?
The fluid keeps coming back. Is a permanent drain a good idea?
My bowel is blocked. Do I need an operation?
Should I have surgery before chemotherapy?
How long would I need to be in Istanbul?
Written by the Biruni Hospital medical editorial team.
Reviewed by Dr Yunus Emre Yavuz, Surgical Oncology and Peritoneal Surface Malignancy.
References
- Colakoglu MK, Piskin E, Oter V, et al. Role of staging laparoscopy in gastric cancer management, evaluation of occult disease and its influence on clinical decision making. European Journal of Surgical Oncology. 2026;52(6):111847.
- Kohli M, Goel S, Iqbal A, et al. Impact of 18-FDG PET-CT on the preoperative staging and management of incidental gall bladder cancer, a prospective study. European Journal of Surgical Oncology. 2026;52(9):111982.
- Di Giorgio A, Catania P, Ferracci F, et al. Pressurized intraperitoneal aerosol chemotherapy for pancreatic cancer peritoneal metastases, a retrospective multicentric study from the ISSPP PIPAC Database. European Journal of Surgical Oncology. 2026;52(11):112078.
- Martins HS, Rebelo P, Nogueiro J, et al. Feasibility, efficacy and safety of pressurized intraperitoneal aerosol chemotherapy for hepatobiliary and pancreatic cancers with peritoneal metastases, a systematic review. European Journal of Surgical Oncology. 2026;52(9):111992.
- Simas D, Goncalves A, Gomes P, et al. Long-term abdominal drains as a therapeutic option in refractory ascites, a systematic review. GE Portuguese Journal of Gastroenterology. 2025;32(4):227-241.
- Alhassan N, Helmi H, Alzamil A, et al. Clinical outcomes of endoscopic stent in curative and palliative management of malignant colonic obstruction, a retrospective cohort study. BMC Gastroenterology. 2025;25(1):628.
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