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PIPAC vs HIPEC: how the two actually differ | CION Cancer Clinics
HIPEC is a single heated chemotherapy wash given at the end of a long operation that removes all visible cancer from the lining of the abdomen. PIPAC is a short keyhole procedure, repeated every few weeks, that sprays a small dose of chemotherapy onto cancer that cannot be removed. They are chosen for different situations, not as alternatives. This page sets the two side by side and explains how a team decides. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
MI
Medically reviewed by Dr. Mohammed ImaduddinConsultant Surgical Oncologist · MBBS, MS (General Surgery), MCh (Surgical Oncology) · last reviewed September 2026, next review due September 2027
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The short answer
What is the difference between PIPAC and HIPEC?
HIPEC is a single heated chemotherapy wash given at the end of a long open operation that removes all visible cancer from the lining of the abdomen. PIPAC is a repeated keyhole procedure that sprays a small dose of chemotherapy as a mist onto cancer that cannot be removed. They are used for different situations, not as alternatives to each other.
Different aims
The operation with HIPEC is done with the intent of clearing every deposit the surgeon can see, then using the heated wash to deal with cells too small to see. PIPAC does not remove anything. Its aim is to slow the disease on the lining, ease symptoms such as fluid build-up, and occasionally shrink deposits enough for surgery to be reconsidered later.
Different scale
Cytoreductive surgery with HIPEC is one of the largest operations in cancer care, with a long theatre time, a stay in intensive care and weeks of recovery. PIPAC is a short procedure through two small cuts, with most people home within a day or two, and it is repeated every few weeks. The first is done once, if at all. The second is a course.
Neither is offered everywhere. Ask your centre which of the two it actually does, and how often.Side by side
HIPEC and PIPAC, compared
Cytoreductive surgery with HIPEC
PIPAC
HIPEC: one long open operation, then a heated chemotherapy wash
PIPAC: a short keyhole procedure with a chemotherapy spray
HIPEC: aims to remove all visible cancer
PIPAC: aims to control cancer that cannot be removed
HIPEC: done once, with a stay in intensive care
PIPAC: repeated as a course, usually home the next day
HIPEC: for people fit for major surgery whose disease can be cleared
PIPAC: for people whose disease is too widespread or who are not fit for the operation
HIPEC: longer track record, guidance from bodies such as NICE
PIPAC: newer, with evidence from smaller studies and trials still running
How the team chooses
When does a team lean towards one or the other?
These are the patterns. The choice for you belongs to your treating team.
Towards cytoreduction and HIPEC
When the cancer on the lining is limited enough that the surgeon believes every visible deposit can be removed, and you are fit enough for a very long anaesthetic and a hard recovery.
Cancers where it is most established
- Pseudomyxoma peritonei and appendix tumours
- Selected bowel cancer spread
- Peritoneal mesothelioma
- Some ovarian cancer
Towards PIPAC
When the spread is too wide to clear, when earlier operations have left too much scarring, when fluid keeps building up, or when a person is not fit enough for the big operation but could manage a short keyhole procedure.
Most often used in
- Stomach cancer spread
- Widespread ovarian or bowel cancer spread
- Recurrent fluid in the belly
Sometimes one, then the other
In a minority of people, PIPAC shrinks the disease enough for the team to look again at whether the full operation has become possible. This cannot be promised in advance.
Sometimes neither
Where the cancer has spread beyond the abdomen, where the bowel is blocked in several places, or where a person is too unwell for any anaesthetic, the team will usually recommend drip chemotherapy or symptom control alone.
Not sure whether this applies to you?
Ask an oncologistThe decision
How the team decides which is possible
Scans
A CT, and sometimes a PET-CT or MRI, to see how much of the lining is affected and whether the cancer has spread anywhere else. Scans tend to under-count small deposits, so they are only the start.
A keyhole look
Many teams do a short laparoscopy to inspect the lining directly and score how much is involved. This is the peritoneal cancer index, or PCI, and it is the single biggest factor in the choice.
Fitness checks
Heart, lung, kidney and nutrition tests, because the HIPEC operation asks a great deal of the body. Someone who would not cope with it may still be a candidate for PIPAC.
Tumour board
Surgical, medical and radiation oncologists discuss the case together, with the cancer type and any earlier treatment in view, and agree a recommendation.
The conversation with you
What is being recommended, what the alternative was, and why. Bring the family member who will help you decide, and ask for the reasons in writing if that helps.
Commonly believed
What families mix up between the two, and what is true
"PIPAC is just a gentler version of HIPEC."
It is a different treatment with a different aim. HIPEC follows an operation that removes the cancer. PIPAC treats cancer that stays where it is. Calling one gentler than the other misses the point: they are chosen for different situations.
"If HIPEC is not possible, PIPAC gives the same result."
It does not. Being told the big operation is not possible is a statement about how far the disease has spread. PIPAC may help control it, but it is not a substitute that delivers what the operation would have.
"We should push for HIPEC because it is the bigger treatment."
Bigger is not automatically better for you. The HIPEC operation carries real risk, and in someone whose disease cannot be fully cleared it offers the risk without the benefit. A careful team turns people down for it for exactly that reason.
"PIPAC is only offered when someone is dying."
It is usually given alongside standard drip chemotherapy in people who are still well enough to be treated actively. Being offered it does not mean other options have run out. Ask what the whole plan around it is.
Did you know
The same chemotherapy drugs are used in both. What changes is the amount, the way they are delivered and what they are meant to achieve. HIPEC uses a large heated volume once, after the cancer has been cut out. PIPAC uses a tiny dose as a spray, again and again, on cancer that stays.
Being straight with you
What this page cannot tell you
This page cannot tell you which of the two, if either, is right for you. That is a judgement made on your scans, a direct look inside the abdomen, your cancer type and your fitness, and it belongs to a team that has seen all of those.
It cannot tell you how either will turn out
Neither treatment comes with a promise. The evidence for HIPEC is stronger and older, but it applies to carefully chosen people. The evidence for PIPAC is newer and thinner, and trials are still running. Be wary of any centre that quotes you a figure for what either will achieve in your case.
What to ask your centre
Ask which of the two the centre does and how many it has done. Ask whether your case was discussed at a tumour board. Ask why one was recommended over the other, and what would change that. Ask what happens if you choose neither. Write the answers down, because you will be asked to repeat them at home.
If you have a report and want a surgical oncologist to say which conversations are worth having, call the helpline.Questions we are asked
Common questions about PIPAC and HIPEC
Can I have PIPAC and HIPEC both?
Sometimes, in that order. A few people whose disease shrinks after PIPAC sessions are reassessed for the full operation with HIPEC. It is not a planned combination for most people, and nobody can promise that the first will lead to the second. Ask your team whether it is a realistic path for you.
Which one is more expensive?
The HIPEC operation costs far more per treatment, because of the theatre time, intensive care and long stay. A single PIPAC session is much cheaper, but it is repeated, so the course adds up. Ask each centre for a written estimate, and check what your scheme or insurer covers for each before deciding.
Which has the stronger evidence?
HIPEC, after cytoreductive surgery, has been studied for longer and in more people, and is covered by guidance from bodies such as NICE for selected cancers. PIPAC is newer, with evidence from smaller studies. Neither is proven for every cancer, and your team should say where the evidence is thin.
Is PIPAC easier to recover from?
Yes, by a long way. It is a short keyhole procedure and most people are eating the same evening and home in a day or two. The HIPEC operation involves intensive care and weeks of recovery. But the two are not competing for the same job, so an easier recovery is not by itself a reason to choose PIPAC.
Why was I offered PIPAC and not HIPEC?
Usually because the surgeon judged that the cancer on the lining could not all be removed, or that your body would not cope with the big operation. Ask which of those it was. It is a fair question, and a careful team will answer it directly.
Is either done through keyhole surgery?
PIPAC always is. Cytoreductive surgery with HIPEC almost always needs a long open cut, because the surgeon has to reach and strip the whole lining. A keyhole HIPEC is occasionally described for very limited disease, but it is uncommon. Ask your surgeon what they are proposing for you.
Do both need chemotherapy through a vein as well?
Often, yes. Drip chemotherapy treats the whole body, while both HIPEC and PIPAC act only on the lining of the abdomen. PIPAC is usually given between cycles of drip chemotherapy. After a HIPEC operation, further chemotherapy depends on the cancer type and what the pathology shows.
Are both available in Hyderabad?
Cytoreductive surgery with HIPEC is offered at a small number of centres in Hyderabad. PIPAC is rarer, and you may be referred to a centre in another city. Ask any centre directly which it offers and how often, rather than assuming from a website. The helpline can help you find a surgical oncologist to ask.
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Sources
- NICE — Cytoreduction surgery with hyperthermic intraoperative peritoneal chemotherapy for peritoneal carcinomatosis (IPG688)
- Cancer Research UK — Pseudomyxoma peritonei
- National Cancer Institute — Chemotherapy to treat cancer
- American Cancer Society — Surgery for cancer
- Tata Memorial Centre — Tata Memorial Centre
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
PIPAC: Pressurised Aerosol ChemotherapyPIPAC on its own, step by stepHIPEC: What Heated Chemotherapy in the Abdomen Actually IsThe operation half of this comparisonWho Is Eligible for HIPEC?The factors that decide whether the big operation is possibleThe Peritoneal Cancer Index (PCI) ExplainedThe score that most shapes the choiceDeciding on Cancer SurgeryHow to weigh any operation with your team
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Been offered one of these and want a second view?
Tell us what has been found so far. We will help you reach a surgical oncologist who can look at your reports and explain the options. One helpline serves every CION centre.