📍 Whitefield, Bengaluru
HOD & Senior Consultant · Surgical Oncology
Consultation by Appointment
Looking for more detail? Read our complete guide with 42 patient FAQs: PIPAC: Pressurized Intraperitoneal Aerosol Chemotherapy.
PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy) is a minimally invasive, laparoscopic chemotherapy treatment that delivers a pressurized aerosol directly into the abdominal cavity, and it is used mainly for peritoneal metastases (peritoneal carcinomatosis) in selected patients.
PIPAC was developed for cancers that have spread to the peritoneum, the thin membrane lining the abdomen, where conventional intravenous chemotherapy often reaches tumors poorly. During keyhole surgery, a small dose of chemotherapy is turned into a fine mist so the drug contacts the tumor surface directly.
The key features of PIPAC chemotherapy can be summarized as follows:
PIPAC generally works by using pressure and a high-pressure nebulizer to spread a low dose of chemotherapy as a fine aerosol across the peritoneal surface, which is intended to improve drug distribution and tissue penetration while limiting systemic (whole-body) exposure.
A typical PIPAC procedure follows the ordered sequence below, although details differ between centers:
| Step | Stage | What happens |
|---|---|---|
| 1 | Inspection | A laparoscopic camera examines the abdomen; tumor extent is recorded and biopsies are taken. |
| 2 | Access and gas | Two ports are placed and the abdomen is inflated with gas (capnoperitoneum) to a set pressure. |
| 3 | Nebulizer placement | A nebulizer connected to a high-pressure injector is inserted through a port. |
| 4 | Aerosol delivery | The injector is operated remotely from outside the operating room. |
| 5 | Exposure | The aerosol remains in the abdomen for about 30 minutes. |
| 6 | Evacuation | The aerosol is removed through a closed filter system and the ports are taken out. |
Regimens vary by center and tumor type. Commonly reported drug choices are shown below:
| Primary cancer | Commonly used PIPAC drugs |
|---|---|
| Ovarian, gastric, pancreatic, biliary | Cisplatin with doxorubicin (low-dose) |
| Colorectal, appendiceal | Oxaliplatin |
| Peritoneal mesothelioma | Cisplatin-based regimens (varies) |
PIPAC is generally considered a minimally invasive laparoscopic (keyhole) procedure rather than major surgery, although it still requires general anesthesia and carries the risks of abdominal surgery.
The table below shows what patients can typically expect from a PIPAC procedure compared with open surgery:
| Feature | Typical PIPAC procedure |
|---|---|
| Incisions | Usually two small ports of about 5–12 mm |
| Operating time | Roughly one to two hours in total |
| Hospital stay | Often one to three days |
| Recovery | Usually quicker than open cytoreductive surgery, which may require weeks in hospital |
Because it is less invasive, PIPAC may be offered to some patients who are too frail, or whose disease is too extensive, for major surgery.
PIPAC is generally a repeatable, minimally invasive aerosol treatment given without heating, whereas HIPEC (Hyperthermic Intraperitoneal Chemotherapy) is usually a single heated chemotherapy wash given during major cytoreductive surgery.
The table below compares PIPAC and HIPEC on the points patients ask about most:
| Feature | PIPAC | HIPEC |
|---|---|---|
| Surgery type | Laparoscopic (keyhole) | Open major surgery (cytoreduction) |
| Drug form | Pressurized aerosol | Heated liquid perfusion |
| Temperature | Normal body temperature | Heated (about 41–43 °C) |
| Repeatable | Usually yes, often every 4–6 weeks | Typically once |
| Typical patient | Extensive disease, not suitable for major surgery | Limited disease suitable for complete surgical removal |
| Hospital stay | Often 1–3 days | Often 1–3 weeks |
The two treatments generally serve different patient groups rather than competing directly. Your multidisciplinary team can advise which, if either, fits your situation.
See also: HIPEC patient guide
PIPAC is generally not used as a replacement for intravenous (IV) chemotherapy; it delivers a low dose of drug directly to peritoneal tumors and is usually given alongside, between or after systemic treatment.
The table below sets out how PIPAC and IV chemotherapy differ:
| Aspect | PIPAC | Intravenous chemotherapy |
|---|---|---|
| Delivery | Directly into the abdomen as an aerosol | Through the bloodstream |
| Drug dose | Low | Standard systemic doses |
| Peritoneal drug exposure | High local concentration | Limited |
| Whole-body side effects | Generally milder | Can be significant |
| Treats spread outside abdomen | No | Yes |
PIPAC has not been shown to be superior to standard chemotherapy. It is an added option for peritoneal disease, whereas IV therapy usually remains the backbone of treatment for cancer elsewhere in the body.
See also: How PIPAC differs from traditional IP chemotherapy
PIPAC is not established as a cure for peritoneal metastases; it is a locoregional treatment aimed at disease control, symptom relief and, in selected patients, access to further treatment.
Peritoneal metastases are difficult to eradicate. Studies report tumor regression on repeat biopsies in a proportion of patients, but long-term cure has not been demonstrated, and most evidence comes from small and phase II studies.
PIPAC has been used for peritoneal metastases from ovarian, gastric (stomach), colorectal, appendiceal, pancreatic and biliary cancers, and for primary peritoneal tumors such as peritoneal mesothelioma, although use varies by center and much of it remains investigational.
The table below lists the cancer types most often discussed in PIPAC studies; the order is approximate rather than a formal ranking:
| Order (approx.) | Cancer type | Typical use of PIPAC |
|---|---|---|
| 1 | Ovarian and primary peritoneal cancer | Recurrent or platinum-resistant peritoneal disease |
| 2 | Gastric cancer | Peritoneal metastases, sometimes as a bridge to surgery |
| 3 | Colorectal cancer | Peritoneal disease after standard chemotherapy |
| 4 | Appendiceal cancer | Selected patients, including some with pseudomyxoma |
| 5 | Pancreatic and biliary cancers | Investigational, mostly within studies |
| 6 | Peritoneal mesothelioma | Selected patients at specialist centers |
See also: PIPAC for ovarian cancer · PIPAC for gastric and colorectal cancer
Patients may be suitable for PIPAC if they have biopsy-proven peritoneal metastases, adequate general health and disease mainly confined to the abdomen, as assessed by a multidisciplinary cancer team.
Suitability criteria vary between hospitals and trials, but doctors commonly look for the following:
| Criterion | Typical requirement |
|---|---|
| Diagnosis | Confirmed peritoneal metastases from a suitable primary cancer |
| General fitness | Fit for general anesthesia and laparoscopy (often ECOG performance status 0–2) |
| Organ function | Acceptable kidney, liver and blood-count results |
| Bowel status | No complete obstruction and no severe uncontrolled symptoms |
| Treatment history | Progression on standard chemotherapy, or not suitable for major surgery |
| Surgical access | A safe laparoscopic entry route into the abdomen |
PIPAC may be unsuitable for patients with complete bowel obstruction, poor general health, extensive spread outside the abdomen or severe abdominal adhesions that prevent safe laparoscopic access.
Situations in which doctors commonly advise against PIPAC include:
Suitability is decided individually, and criteria differ between hospitals and trials.
PIPAC is often combined with intravenous (systemic) chemotherapy, and combinations with targeted therapy or immunotherapy are being studied in clinical trials.
Because PIPAC treats the abdominal lining while systemic therapy treats disease elsewhere in the body, the two approaches can complement each other. Sequencing, such as PIPAC alternating with systemic cycles, is set by your oncologist based on blood counts, recovery and drug interactions.
In some patients, particularly with gastric and ovarian cancer, repeated PIPAC has been followed by cytoreductive surgery after tumor burden decreased, although this outcome is not guaranteed and remains under study.
This “conversion” strategy is reported in case series and early trials. After each cycle, doctors reassess using repeat laparoscopy, imaging and tumor markers, and surgery is considered only when disease appears sufficiently reduced and controlled.
No single PIPAC success rate applies to all patients: published studies report tumor regression or disease control in a proportion of patients with peritoneal metastases, but results vary by cancer type, prior treatment and how success is defined, and large randomized trials are still limited.
Because “success” can be measured in several ways, doctors may look at the outcomes below:
| What “success” can mean | How it is measured |
|---|---|
| Tumor regression | Peritoneal Regression Grading Score (PRGS) on repeat biopsies |
| Disease control | Stable or reduced Peritoneal Cancer Index (PCI) |
| Symptom relief | Less pain, bloating and ascites |
| Surgical eligibility | Becoming suitable for cytoreductive surgery |
| Survival | Progression-free and overall survival |
In small published series, regression rates are often reported between roughly 50% and 80%, depending on cancer type and definitions. These figures come from selected patients and should be interpreted cautiously.
PIPAC has been associated with encouraging survival in selected patients in published series, but an overall survival benefit has not yet been confirmed in large randomized controlled trials.
Reported survival differs widely because patient groups differ in disease extent, prior chemotherapy and cancer type. Patients who complete several cycles tend to do better, partly because they were fit enough to complete them. Ask your team for figures that apply to your cancer type rather than relying on averages.
Many patients are offered a course of about three PIPAC treatments spaced roughly four to six weeks apart, and further cycles may be considered if the treatment appears to be working and is well tolerated.
A typical PIPAC treatment schedule is outlined below, although your team may adjust it:
| Stage | Approximate timing | Purpose |
|---|---|---|
| Session 1 | Week 0 | Staging laparoscopy, biopsies and first aerosol treatment |
| Session 2 | About 4–6 weeks later | Repeat treatment and reassessment of response |
| Session 3 | About 4–6 weeks after session 2 | Repeat treatment and reassessment of response |
| Review | After 3 cycles | Imaging, biopsy results and tumor markers reviewed |
| Next step | Depends on response | Continue, change treatment, or consider surgery |
Doctors usually judge PIPAC response by combining repeat laparoscopic findings, biopsy results (PRGS), the Peritoneal Cancer Index, imaging, tumor markers, ascites volume and symptoms.
The table below summarizes the main ways response is assessed:
| Method | What it shows |
|---|---|
| Repeat laparoscopy | Surgeon inspects and scores the peritoneum at each session |
| Biopsies | Microscopic regression of tumor cells |
| CT or MRI | Overall disease, although peritoneal disease can be hard to see |
| Blood tests | Tumor markers such as CA-125 or CEA where relevant |
| Symptoms | Appetite, pain, bloating, energy and quality of life |
See also: PCI and PRGS scores explained
Most patients stay in hospital for about one to three days after PIPAC and return to usual daily activities within about one to two weeks, although this varies between individuals.
The table below shows a typical recovery timeline:
| Timeline | What to expect |
|---|---|
| Day 0 | Procedure and recovery-room monitoring |
| Days 1–2 | Pain and nausea control, gradual eating, mobilizing |
| Days 2–3 | Usually discharged home if eating and pain are controlled |
| Weeks 1–2 | Fatigue and mild abdominal discomfort settle |
| Weeks 4–6 | Next PIPAC cycle if planned |
PIPAC is performed under general anesthesia, so patients are asleep and should not feel pain during the procedure; afterwards, many report mild to moderate abdominal discomfort that is managed with routine pain relief.
Discomfort typically comes from the small incisions and residual gas. Some patients experience temporary shoulder-tip pain from the gas used to inflate the abdomen, and abdominal cramping in the first days.
The most commonly reported side effects of PIPAC are abdominal pain, nausea, vomiting, fatigue and temporary changes in bowel habit, and they are generally milder than those of full-dose systemic chemotherapy.
Reported side effects are grouped below by how often they occur:
Most effects settle within days; medicines to prevent nausea and pain are given routinely.
See also: PIPAC safety for staff and family · Hair loss
PIPAC carries the risks of laparoscopic abdominal surgery, including bowel injury, bleeding, infection, port-site hernia and postoperative bowel obstruction, and serious complications are reported in a minority of patients in published series.
The table below summarizes recognized complications and how they are generally described:
| Risk | Notes |
|---|---|
| Bowel injury or perforation | Uncommon but serious; may need further surgery |
| Bleeding | Usually minor |
| Infection | Wound or abdominal infection |
| Postoperative ileus or obstruction | Often temporary |
| Port-site hernia | Rare |
| Anesthesia risks | Depend on general health |
Rates vary by center and patient selection. Ask your surgeon about their own experience and outcomes.
PIPAC is offered at specialist centers in Europe, Asia and Australia and in some United States centers mainly within clinical trials, and its regulatory status varies by country and device.
The delivery device and drug use are regulated differently by region, and many drug uses are off-label or investigational. Check with your national health authority and treating hospital for the current position.
PIPAC is best performed at experienced cancer centers with a multidisciplinary peritoneal-surface-malignancy team and dedicated safety procedures.
When comparing hospitals, consider the following points:
| What to check | Why it matters |
|---|---|
| Outcome reporting | Centers that report results or join registries and trials add transparency |
| Team experience | Ask how many PIPAC procedures the team has performed |
| Multidisciplinary team | Surgeons, anesthetists and oncologists should work together |
| Second opinion | Helps confirm suitability and alternatives |
| Travel and stay | Repeat cycles every 4–6 weeks may require planning |
PIPAC costs vary widely by country and hospital, and coverage depends on your insurer or health system; many payers currently treat PIPAC as investigational.
The cost of each PIPAC cycle is usually made up of the components below:
| Component | What it usually covers |
|---|---|
| Surgery and anesthesia | Operating room, surgical team and anesthetic care |
| Hospital stay | Ward or day-unit care after the procedure |
| Chemotherapy drugs | Drugs used for the aerosol |
| Disposable devices | Nebulizer, injector line and related equipment |
| Diagnostics | Pathology of biopsies and imaging |
| Travel and accommodation | Costs for patients treated away from home |
Request a written estimate for each cycle and ask your insurer about pre-authorization, trial coverage and appeals.
See also: Joining a PIPAC clinical trial
Alternatives to PIPAC include systemic chemotherapy, targeted therapy, immunotherapy, cytoreductive surgery with HIPEC in suitable patients, ascites drainage, palliative care and other clinical trials.
The table below matches each option to the situation it is usually used for:
| Option | Best suited to |
|---|---|
| Systemic chemotherapy | Cancer spread inside and outside the abdomen |
| Targeted therapy or immunotherapy | Tumors with specific biomarkers |
| Cytoreductive surgery + HIPEC | Limited, completely removable peritoneal disease |
| Ascites drainage | Symptom relief for abdominal fluid |
| Palliative and supportive care | Comfort and quality of life at any stage |
See also: HIPEC patient guide · Getting a second opinion
Before deciding on PIPAC, it is reasonable to ask your doctor about expected benefits, risks, alternatives, the team’s experience and what will happen if the treatment does not work.
Consider bringing the following questions to your consultation:
See also: Getting a second opinion · Book an appointment
