Early postoperative intraperitoneal chemotherapy for pseudomyxoma peritoneii: A state of the art review

Cytoreductive surgery (CRS) followed by heated intraperitoneal chemotherapy (HIPEC) remains the mainstay of treatment for patients with pseudomyxoma peritonei (PMP). CRS and intraperitoneal chemotherapy (IPC) was first proposed by Sugarbaker in the 1980s for peritoneal malignancies of various origins. This approach, as described by Sugarbaker, included CRS aiming for complete cytoreduction intraoperative intraperitoneal chemotherapy utilising heated Mitomycin C, and 5 consecutive days of intraperitoneal 5-fluorouracil (early postoperative intraperitoneal chemotherapy, EPIC)(1). Currently, the use of EPIC for PMP has fallen out of favour due to concerns regarding complications and uncertainty regarding its oncological benefit. This narrative review explores the history and rationale behind the conception of EPIC, describes past and current evidence for EPIC, and attempts to establish a future role and direction for its use in the treatment of PMP.

We conducted a systematic search in Pubmed and OVID according to the PRISMA guidelines and included all studies published before 25th April 2025 comparing EPIC to HIPEC. Our search found 102 studies and after excluding non-relevant studies, a total of 12 retrospective studies were identified. The literature suggests EPIC may improve survival without increasing major morbidity but can increase hospital length of stay.

The role of EPIC for PMP remains unanswered. However, the literature appears to support a survival benefit with EPIC for PMP without an increase in morbidity risk despite an increase in hospital length of stay.