📍 Whitefield, Bengaluru
HOD & Senior Consultant · Surgical Oncology
Consultation by Appointment
Two treatments for cancer that has spread to the lining of the abdomen
The two treatments generally serve different patients, and many uses of PIPAC are still being studied.
If you or a loved one has been diagnosed with cancer that has spread to the lining of the abdomen, you may have heard of PIPAC (Pressurized Intraperitoneal Aerosol Chemotherapy). This minimally invasive, laparoscopic treatment delivers chemotherapy as a fine aerosol directly into the abdominal cavity, and it has been used for peritoneal metastases from ovarian, gastric, colorectal, appendiceal and other cancers. Patients often ask how PIPAC works, whether it is an alternative to HIPEC, how effective and safe it is, and what it costs.
This guide answers the 42 most common questions in plain language, organized by topic and ordered from the highest-interest questions to the most detailed. Each answer opens with a clear statement of the current evidence, followed by supporting detail, tables and checklists. Because PIPAC is a newer treatment and much of the evidence comes from small studies, statements are worded to reflect what is known, what is still being studied and what varies between hospitals.
In this guide: Understanding PIPAC: The Basics | Who Can Have PIPAC? | Success Rate, Effectiveness and Monitoring | The Procedure, Hospital Stay and Recovery | Side Effects, Risks and Safety | Availability, Cost and Making Your Decision. For topic-by-topic pages, see the PIPAC Patient Guide.
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.
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.
PIPAC differs from traditional intraperitoneal (IP) chemotherapy because it delivers a low-dose pressurized aerosol during laparoscopy, rather than a liquid infused through a catheter, and it allows the surgeon to see and biopsy the tumor at each session.
The main differences between PIPAC and traditional IP chemotherapy are:
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.
ePIPAC (electrostatic precipitation PIPAC) is an experimental variation of PIPAC in which the aerosol is electrically charged in an effort to improve drug deposition on the peritoneal surface.
The aim is better drug deposition and less wasted aerosol. ePIPAC is being studied at a small number of centers and has not replaced standard PIPAC.
PIPAC was developed by German surgeon Marc Reymond and colleagues and first used in patients in 2011, making it a relatively recent treatment with a growing research base.
Since then, centers across Europe, Asia and Australia have adopted the technique, and international registries and trials are gathering safety and outcome data.
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 |
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 not part of standard first-line ovarian cancer treatment; it is being investigated in clinical trials for newly diagnosed advanced ovarian cancer with peritoneal spread, alongside surgery and platinum-based chemotherapy.
To place PIPAC in context, the points below contrast standard first-line care with where PIPAC may fit:
Ask your gynecologic oncology team whether a first-line PIPAC study is open near you.
Recurrent and platinum-resistant ovarian cancer with peritoneal metastases is the setting in which PIPAC has been most studied, with reports of tumor regression, ascites control and symptom improvement in some patients.
Because these patients have limited treatment options, PIPAC is often offered at specialist centers or within trials, sometimes combined with intravenous chemotherapy. Benefit varies between patients, and randomized evidence is still developing.
PIPAC has been used for gastric cancer with peritoneal metastases, usually combined with systemic chemotherapy, and in a minority of patients it has been followed by surgery, although its benefit remains under investigation.
Peritoneal spread is common and difficult to treat in stomach cancer, so PIPAC is a frequent focus of research. Outcomes depend on disease extent and how well the cancer responded to earlier treatment.
PIPAC with oxaliplatin may be considered for colorectal and appendiceal peritoneal metastases, particularly when disease has progressed on chemotherapy or is not suitable for cytoreductive surgery with HIPEC.
When peritoneal disease is limited and can be removed completely, cytoreductive surgery with HIPEC generally remains the established option at expert centers. PIPAC is usually considered for wider or recurrent disease.
Previous abdominal surgery does not necessarily rule out PIPAC, but scar tissue (adhesions) can make safe laparoscopic entry difficult and is a recognized reason a procedure may not be completed.
Surgeons plan the entry point carefully, sometimes using an open technique at the first port. If the abdomen cannot be entered safely, the procedure is usually stopped and other options are discussed.
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 |
The Peritoneal Cancer Index (PCI) is a score from 0 to 39 that estimates how much peritoneal tumor is present, and the Peritoneal Regression Grading Score (PRGS) grades from 1 to 4 how tumor cells have responded to treatment.
The table below explains how each score is generally read:
| Score | What it measures | How to read it |
|---|---|---|
| PCI (0–39) | Tumor size across 13 abdominal regions | Higher score suggests more extensive disease |
| PRGS 1 | Complete response | No tumor cells; fibrosis only |
| PRGS 2 | Major response | Few tumor cells remain |
| PRGS 3 | Minor response | Tumor cells with some regression |
| PRGS 4 | No response | Tumor cells with no regression |
PIPAC may reduce malignant ascites (abdominal fluid), abdominal pain and bloating in some patients, which can contribute to better quality of life.
Reduced need for fluid drainage (paracentesis) has been reported after repeated sessions. Symptom benefit does not occur in everyone, and improvement often builds over several cycles.
A PIPAC procedure is typically a laparoscopic operation under general anesthesia lasting roughly one to two hours, during which chemotherapy aerosol is delivered into the abdomen for about 30 minutes.
From the patient’s point of view, the day of treatment usually follows this order:
| Order | Stage | What you can expect |
|---|---|---|
| 1 | Admission | Check-in, final questions and consent review |
| 2 | Anesthesia | General anesthesia is given so you are asleep during the procedure |
| 3 | Procedure | Small incisions, inspection, biopsies and aerosol delivery (about 30 minutes of exposure) |
| 4 | Closure | Aerosol is removed, ports are taken out and incisions are closed |
| 5 | Recovery room | Monitoring as you wake up, with pain and nausea control |
| 6 | Ward | Gradual eating and walking before discharge, often within 1–3 days |
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.
Preparation for PIPAC usually includes pre-treatment tests, review of your medications, fasting before anesthesia, and arranging support for the days after treatment.
The checklist below groups preparation tasks by timing; your hospital will give you exact instructions:
| When | Action |
|---|---|
| Weeks before | Complete blood tests, imaging and an anesthesia assessment |
| Weeks before | Review blood thinners, diabetes drugs and supplements with your team |
| Day before | Follow any bowel preparation advice you are given |
| Day of treatment | Follow fasting instructions (often no food for about 6 hours before anesthesia) |
| Day of treatment | Pack for a short stay and arrange transport home |
| After discharge | Plan for help at home for the first few days |
Many patients resume light eating within a day and usual activities within one to two weeks, though fatigue and appetite changes can last longer depending on other treatment.
General guidance for returning to daily life is summarized below; follow your own team’s advice:
| Activity | General guidance |
|---|---|
| Eating | Small, frequent meals at first; increase as tolerated |
| Work | Often possible within one to two weeks for desk-based roles |
| Exercise | Gentle walking is usually encouraged; avoid heavy lifting until cleared |
| Driving | Only when pain-free and off strong pain relief |
Follow-up after PIPAC generally includes symptom checks, blood tests and scheduled reassessment, with repeat laparoscopy at each cycle and imaging after a course of treatment.
Ask for a written plan at discharge covering who to call, day and night.
Contact your care team urgently, or seek emergency care, if you develop any of the following warning signs:
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.
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 performed as a closed-system procedure with remote injection and filtered evacuation, and workplace studies have reported minimal contamination when safety protocols are followed.
Typical safety measures at specialist centers include:
Hair loss is generally uncommon with PIPAC because drug doses are low and little enters the bloodstream, although some patients notice thinning, particularly when PIPAC is combined with systemic chemotherapy.
Whether you lose hair depends on the drugs used and any other treatment you receive. Your oncologist can tell you what to expect for your regimen.
A PIPAC procedure may be stopped if the surgeon cannot enter the abdomen safely because of adhesions, or if unexpected findings such as bowel obstruction or extensive disease make treatment unsafe.
Common reasons a procedure may be cancelled or not completed include:
Even then, biopsies and information gained may still guide other options.
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.
Patients who meet eligibility criteria may be able to join a PIPAC clinical trial, which can provide access to treatment and contributes to the evidence needed to assess its value.
The usual route into a clinical trial follows the steps below:
| Step | Action |
|---|---|
| 1 | Ask your oncologist whether a suitable trial exists |
| 2 | Search registries such as ClinicalTrials.gov |
| 3 | Review eligibility, visit schedule, costs and risks |
| 4 | Discuss with the trial team and give informed consent |
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 |
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:
