Surgery, then heated chemotherapy in the abdomen

What happens, step by step

1. 1
   Deciding whether this operation is for you.

   Not everyone with disease in the lining of the abdomen is offered this. Your case goes to the tumour board with the scans and the pathology report. The board weighs how widely the lining is involved, which organs are affected, whether there is disease outside the abdomen, how the cancer has behaved on treatment so far, and whether your heart, lungs, kidneys and nutrition would carry an operation of this size. Sometimes a short keyhole look inside under anaesthetic comes first, because the extent of disease on the lining is what a scan reports least reliably. If this is not the right operation for you, you are told so, and told what is offered instead.

2. 2
   The preparation, which is longer than for other operations.

   The work before the day is substantial and none of it is padding. You see the anaesthetist, and heart and lung tests are done. Blood is arranged and kept ready. Your nutrition is assessed — going into this operation underweight makes everything after it harder, so you may be asked to build up first. Blood thinners and some diabetes medicines are stopped or changed on instruction. A physiotherapist teaches you the breathing exercises beforehand, so you are not learning them in pain afterwards. A critical-care bed is booked as part of the plan, a night or two in intensive care immediately afterwards, and the consent conversation covers all of it, including the possibility of a stoma.

3. 3
   The day of the operation.

   You are admitted at least a day before, and asked not to eat or drink after stated times. In theatre you are put to sleep as for any major operation, and several lines are placed while you are asleep: a drip in the neck or arm, a fine tube in the wrist to watch the blood pressure continuously, a catheter, and usually an epidural for pain afterwards. Your family should be told the expected length, given a number to ring, and told where to sit — and told not to read anything into a long wait. This operation is long by design.

4. 4
   The first part: removing everything that can be seen.

   This is done as an open operation, through one long cut down the middle of the abdomen, because every surface has to be inspected by hand and eye. Your surgeon works systematically through the whole abdomen and scores how much of the lining is involved. The affected lining is stripped away region by region — from under the diaphragm, from the pelvis, from around the liver and the bowel — and any organ, or part of one, that the disease has grown into is removed with it. Where bowel is removed the ends are joined, and in some cases a stoma is made. This is the longest part of the operation and the part that decides everything after it. The aim is to leave nothing visible behind.

5. 5
   If cytoreduction is not achievable.

   Sometimes what the surgeon finds on opening the abdomen is more extensive than the scans showed, and removing all the visible disease is not possible. The heated chemotherapy is then not given, because it only makes sense once nothing visible remains. The operation is closed, sometimes after doing what was useful and possible that day — relieving a blockage, taking a fresh biopsy, forming a stoma. This is not the operation failing. It is information that could only be obtained by looking, and it moves you to a different plan rather than to none. You and your family are told afterwards what was found, why the decision was made, and what is offered next.

6. 6
   The heated chemotherapy.

   Once nothing visible remains the second part begins, and you are asleep for all of it. A chemotherapy solution is warmed to a little above body temperature and circulated through the abdomen by a machine that keeps it moving and holds the temperature steady,. It runs for a set period, and the abdomen may be gently rocked so the fluid reaches every surface. The warmth is part of the treatment, not a side effect of it. Very little of the drug passes into the rest of the body, which is why it can be given here at a strength that would not be given into a vein. The fluid is then drained out, the abdomen washed and the cut closed.

7. 7
   Critical care, and the first days.

   You go from theatre to the critical-care unit, and that is the plan, not a complication. The breathing tube often stays in for some hours while you warm up and settle, so your family should be prepared to see you on a ventilator. You will have several drains, a tube through the nose into the stomach, a catheter, and lines in the neck and arm. You will not eat for some days, and nourishment is given through a vein until the bowel wakes up. Blood counts, kidney function and fluid balance are checked repeatedly. Being muddled, or losing track of day and night, is common here, and it passes.

8. 8
   The ward, then home.

   You move to the ward when the critical-care team is satisfied, and progress from there is measured in small daily steps: one tube out, then another, sitting, standing, walking the corridor. Food restarts slowly, and appetite lags well behind permission to eat. If a stoma has been made you are taught to manage it before you go home. seven to ten days is what is planned for. Everything removed goes to the laboratory, and that report — 24 to 48 hours — is discussed with you at follow-up, along with whether further chemotherapy is advised. Recovery at home continues for weeks after discharge, and that is the ordinary shape of this operation.

Side effects, and the support that comes with them

This section is long because the operation is, and it is easier read before than after. Expect pain from a long wound, held by an epidural or a pain pump at first and by tablets later; say when it is not held, because pain that stops you breathing deeply or walking is what leads to a chest infection. Expect a tiredness different in kind from ordinary tiredness, lasting weeks. The bowel is slow to wake, so days of no appetite, of feeling full, of nausea and of a tube through the nose are usual. Weight is lost and takes months to come back, which is why the dietitian is part of the treatment and not an extra. The chemotherapy can lower the blood counts for a period, which is why they are checked, and it can affect the kidneys, which is why fluids are watched so closely. Some people need a blood transfusion. If a stoma has been made, you are taught to look after it before you go home. If the ovaries or uterus were removed, periods stop and the menopause follows, arriving all at once rather than gradually — there are treatments for that and it is worth asking. Later on, a hernia at the long wound, numbness around the scar, and adhesions inside that cause episodes of colic are all possible. In hospital the team watches for bleeding, infection, a leak where the bowel was joined, clots in the legs and lungs, and chest infection; the early sitting up, the breathing exercises, the stockings and the blood-thinning injections all exist because of those. And the part that is rarely written down: weeks of depending on other people is hard on the mind as well as the body, and low mood during this recovery is common. Say so rather than treating it as weakness.

Questions we hear every week