Online Health Chat with Dr. Sricharan Chalikonda
November 8, 2011
Cleveland_Clinic_Host: Hyperthermic (or Heated) Intraoperative Peritoneal Chemotherapy (HIPEC) is used to treat cancers that have spread to the lining of the abdominal cavity, such as those of the appendix, colon, stomach, and ovaries. HIPEC is an alternative, innovative method of delivering chemotherapy. Unlike traditional chemotherapy that is delivered intravenously, HIPEC delivers chemotherapy directly into the abdomen, making it a good option for cancers that originated in or have spread to the abdominal cavity.
Typical HIPEC patients are seeking an alternative to traditional chemotherapy or radiation therapy, as these options offer limited success treating advanced abdominal cancers. Patients also may have been told that no other treatment will work, but are still hoping to find a solution.
Sricharan Chalikonda, MD, is a general surgeon and Director of Robotic Surgery in Cleveland Clinic’s Digestive Disease Institute. He received his medical training at Cleveland Clinic and University of Pittsburgh Medical Center and Children’s Hospital of Pittsburgh. His specialty interests include surgical oncology, hepatobiliary and pancreatic surgery, laparoscopic liver surgery, and robotic surgery.
Cleveland Clinic Digestive Disease Institute (DDI) is the first of its kind to unite all specialists within one unique, fully integrated model of care – aimed at optimizing the patient experience. At DDI, we offer patients the most advanced, safest, and proven medical and surgical treatments primarily focused on the gastrointestinal tract. Our Institute includes:
- Colorectal Surgery
- Gastroenterology and Hepatology
- General Surgery (including Hepato-pancreato-biliary & Transplant Surgery)
To learn more about the Digestive Disease Institute at Cleveland Clinic, you can visit us online at www.clevelandclinic.org/digestive.
Cleveland_Clinic_Host: To make an appointment please call 866.791.0994.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Sricharan Chalikonda. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.
god_bless: Can you please discuss what is involved with the HIPEC procedure?
Dr__Sricharan_Chalikonda: First, your surgeon removes any visible tumors from the abdomen. Next, HIPEC delivers heated chemotherapy directly inside the abdomen to help destroy any remaining cancer cells and very small tumors that cannot be seen by the surgeon. This occurs because the chemotherapy circulates inside the abdomen, allowing it to reach more places.
Dr__Sricharan_Chalikonda: The goal of HIPEC is to prevent these cells from growing into new tumors and causing the cancer to return.
NoreneVHB: During the HIPEC surgery, can a cancer be removed from the liver where it metastasized from my appendix? Thank you!
Dr__Sricharan_Chalikonda: If the disease can be optimally debulked by performing a liver resection, then we often combine cytoreductive surgery with a partial liver resection in those patients who we feel would benefit.
NoreneVHB: If a lymph node is active with appendiceal cancer cells, can you remove more lymph nodes where activity is noted in a PET or CAT?
Dr__Sricharan_Chalikonda: In certain situations, if I feel that removal of the lymph nodes would render the patient with no active disease, then we will excise those lymph nodes as part of the procedure.
NoreneVHB: How safe, dependable is the medical machine used to heat the chemo wash at an optimal temp., 108 degrees?
Dr__Sricharan_Chalikonda: The device currently used is FDA-approved and is very reliable at maintaining optimal temperatures. In addition, the patient’s core body temperature is monitored continuously for fluctuations.
Bunga: Is HIPEC used for bladder cancer?
Dr__Sricharan_Chalikonda: Currently, we are not utilizing HIPEC for bladder cancer. I would defer to your medical oncologist to see if the bladder cancer patient would be a candidate for intraperitoneal chemotherapy.
jennie: How is HIPEC used for colon cancer? How long a surgery is it?
Dr__Sricharan_Chalikonda: Yes, we are currently utilizing it for colon cancer that has spread to other areas in the abdominal cavity. The length of the surgery depends on the extent of disease and is highly variable.
no_trouble: What cancers is HIPEC an appropriate treatment for?
Dr__Sricharan_Chalikonda: The most commonly treated diseases are pseudomyxoma peritonei, mesothelioma, colon cancer, appendiceal cancer, gastric cancer, ovarian cancer, and primary peritoneal cancer.
jewynn_1: How about use in appendiceal cancer?
Dr__Sricharan_Chalikonda: HIPEC is often used in the treatment of appendiceal cancer.
garth342: What are the benefits of HIPEC procedures?
- HIPEC allows for a higher concentration of chemotherapy to be delivered into the abdomen more effectively and safely than standard chemotherapy, which is delivered intravenously.
- This type of chemotherapy is best at killing cancer cells that are too small to be seen with the naked eye.
- Chemotherapy delivered through HIPEC causes fewer side effects than intravenous chemotherapy. This is because the high concentrations of chemotherapy solution are unable to cross what is known as the peritoneal plasma barrier.
- Experts say that pairing surgery and HIPEC may be more beneficial than chemotherapy alone.
down_side: Does HIPEC ‘get everything out?” Does it get all the cancer cells? (colon cancer)
Dr__Sricharan_Chalikonda: The aim of surgery is to remove all visible disease. The HIPEC portion of the surgery helps to treat the microscopic disease that may remain in the abdominal cavity. The ultimate goal is to "get everything out." However, in many situations, there may be small areas of disease left behind.
please: What are the advantages and disadvantages (as you see them) of HIPEC?
Dr__Sricharan_Chalikonda: The advantages are related to the surgical resection of the tumor deposits. By removing them, the surgery can prevent consequences such as malignant bowel obstruction, as well as the formation of intra-abdominal fluid (ascites). The major disadvantage is that it is an invasive surgical procedure with associated complications.
challenger: Are the side effects of HIPEC the same as for other forms of chemotherapy?
Dr__Sricharan_Chalikonda: Because there is very little systemic infiltration of the chemotherapy, the conventional side effects are rarely seen. The majority of effects are related to the debulking (surgical removal of part of the tumor, also called cytoreduction) procedure itself.
Before and After
jano: What are the criteria that makes one a candidate for HIPEC?
Dr__Sricharan_Chalikonda: Typical HIPEC patients are those with certain stage IV abdominal cancers. Many are seeking an alternative to traditional chemotherapy or radiation therapy, as these options offer limited success treating advanced abdominal cancers. Patients also may have been told that no other treatment will work, but are still hoping to find a solution.
NoreneVHB: Which scan is most helpful to you, pre-surgery, to view active cancer peritoneal areas: PET or CT? Maybe both?
Dr__Sricharan_Chalikonda: A good quality CT scan is usually the initial first test. However, if a CT/PET scan has been obtained, any additional information would surely help.
Yogi: What is the average length of stay for a HIPEC patient?
Dr__Sricharan_Chalikonda: A typical length of stay is approximately 7 to 10 days.
gringo: I had HIPEC done for severe abdominal swelling. When inside, the doctors found many, many tumors (they said they were metastases). I had no symptoms and they did not show up on scans (the doctor said they were flat). In your experience, will the HIPEC also take (care) of these tumors? I was told by the doctor that we will know on my next visit. Just thought I would ask for your expert opinion. I am very scared right now.
Dr__Sricharan_Chalikonda: It is difficult to answer without reviewing your records in detail. I would be happy to review and get back to you, my contact information will be provided at the end of the chat.
marty: How often does the cancer reoccur after HIPEC surgery? What are the chances? Are they greater or less than for other treatments?
Dr__Sricharan_Chalikonda: That is highly dependent on the type of cancer and the extent of disease at the time of surgery. It is also related to the completeness of debulking surgery.
jumboj: What is the statistical success that has been seen with HIPEC?
Dr__Sricharan_Chalikonda: In appropriate patients, there is an increase in survival. However, it is highly dependent on the type of tumor and extent.
HIPEC and Other Treatments
Bostonian: What is your view of the balance between systemic chemotherapy and HIPEC? Is it an either/or choice? Can chemotherapy in advance of HIPEC lead to an improved prognosis?
Dr__Sricharan_Chalikonda: It depends on the type of disease we are treating. In those patients that have invasive cancers -- such as colon, gastric, or other adenocarcinomas -- there is definitely a role of combining systemic chemotherapy with HIPEC. For patients with pseudomyxoma peritonei, often HIPEC is used as the primary therapy.
yes_sir: How often is HIPEC done in conjunction with other necessary surgeries, such as removing parts of the liver or ileo reversal? I understand that the HIPEC itself is a grueling procedure. Would the recovery time be too great combining these procedures or is it a good idea to just go ahead and do them all at once, since the area is already open?
Dr__Sricharan_Chalikonda: HIPEC is often combined with other surgical resections as part of the debulking. The surgeon has to determine if the extent of resection will be tolerated by the patient.
willpharm: Does the HIPEC compensate for a surgeon with limited experience in cytoreduction?
Dr__Sricharan_Chalikonda: No. The benefit of HIPEC is only seen after optimal cytoreduction. Optimal cytoreduction refers to the surgical removal of part of the tumor or debulking. The cytoreductive component of the procedure and making sure that it is performed safely is just as and probably more important than the chemotherapy.
149trd: Is HIPEC done at all cancer treatment centers or is it only done at specialized centers?
Dr__Sricharan_Chalikonda: The HIPEC procedure requires extensive resources and a surgeon specifically trained to do the procedure safely. Currently, it is not offered at all cancer centers and is only offered at specialized centers such as Cleveland Clinic.
NoreneVHB: How many procedures have you done, both at University of Pittsburgh with Dr. Bartlette, and then in Cleveland at your Clinic? Thanks.
Dr__Sricharan_Chalikonda: I have personally performed approximately 75 procedures.
ulla444: How do you best choose a surgeon/facility for HIPEC? My husband has stage IV metastatic colon cancer.
Dr__Sricharan_Chalikonda: There are many factors that can be evaluated in choosing a HIPEC center. The most important is feeling comfortable with the surgeon and the team taking care of your husband. It is also important that the center is experienced in preoperative, intraoperative, and postoperative care.
Here at the Cleveland Clinic we have a multidisciplinary team that sees the patient along with me. We ensure that all questions, both pre-and postoperatively are answered to the patient's satisfaction. We also take pride in the fact that we have some of the lowest rates of ICU admission of any center currently performing HIPEC.
happy_day: Why come to Cleveland Clinic?
Dr__Sricharan_Chalikonda: Cleveland Clinic’s DDI is one of few programs in the country that perform the HIPEC procedure. Our program was the first program in Ohio to receive FDA approval to perform the procedure, and we have completed the highest volume of HIPEC procedures in Ohio . Our DDI not only has experience with this complicated procedure, but it has a rich history of mastering innovative surgical techniques and offering cutting-edge treatment options.
Dr__Sricharan_Chalikonda: By choosing us, you also will benefit from being cared for by a multidisciplinary program that unites all of the physicians you need for your cancer care, including specialists from Cleveland Clinic’s Taussig Cancer Institute and OB/GYN and Women’s Health Institute.
Bostonian: What is the timeline/wait time for scheduling HIPEC at the Cleveland Clinic? (How soon can an eligible patient have the surgery?)
Dr__Sricharan_Chalikonda: The wait time to be seen in the office is often one to two weeks. As for scheduling surgery, there are multiple factors, including whether you are currently undergoing systemic chemotherapy, which would require a short break before surgery could be initiated, and if you've had recent surgery for your cancer. We prioritize patients based on the urgency with which surgery is needed.
jolly_well: If I wanted to come to the Clinic for this surgery/treatment from out of town, is there a procedure in place to accommodate me (including visits, surgery, family/caregiver, place to stay, etc.)?
Dr__Sricharan_Chalikonda: Many of the patients treated at Cleveland Clinic are outside the Cleveland Metropolitan area. We have numerous resources in place to help facilitate out-of-state patients.
Cleveland_Clinic_Host: Regarding our Medical Concierge...Just like the concierge at a fine hotel, your Cleveland Clinic Medical Concierge will help facilitate and coordinate your Cleveland Clinic experience and your visit to Cleveland, Ohio. Your Medical Concierge will provide the following complimentary services:
- Assistance with coordinating multiple appointments
- Scheduling or confirming airline reservations in cooperation with Cleveland Clinic's Travel Services
- Assistance with hotel and housing reservations and providing discounts when available
- Arranging taxi or car service between the airport and hotel
- Providing information about leisure activities for family members
Cleveland_Clinic_Host: A Medical Concierge will meet and accompany you to your appointments, upon request. If your visit includes a hospital stay, your Medical Concierge also can make arrangements for private nursing, if desired.
Cleveland_Clinic_Host: Your Medical Concierge is on hand for your convenience every weekday from 8 a.m. to 5 p.m. (EST). Contact your Medical Concierge at: 800.223.2273 ext. 5-5580 or via email at firstname.lastname@example.org.
open_up: Is HIPEC covered by insurance or are there issues?
Dr__Sricharan_Chalikonda: Generally, it is covered by many insurance companies, but each case is evaluated individually.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Sricharan Chalikonda is now over. Thank you again, Dr. Chalikonda, for taking the time to answer our questions today about HIPEC.
Dr__Sricharan_Chalikonda: Thank you for taking part in our online web chat today, we appreciate your interest in the HIPEC procedure and hope this information was helpful to you. Please feel free to contact us if you have additional questions.
Cleveland_Clinic_Host: To learn more about the HIPEC procedure, please visit us at www.clevelandclinic.org/HIPEC or to make an appointment please call 866.791.0994.
If you're interested in making an appointment with any of the specialists in the Digestive Disease Institute at Cleveland Clinic, please call 216.444.7000 or toll free at 1.800.223.2273, extension 47000. Cleveland Clinic has been ranked #2 in gastroenterology in the nation by U.S.News & World Report since 2003.
You may request a remote second opinion from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit eclevelandclinic.org/myConsult.