Why CRS-HIPEC Surgeon Volume Is Only Part of the Story

CRS-HIPEC surgeon volume has long been the metric patients are told to focus on when picking a treatment center. That advice is correct, and it is incomplete. A new study from Johns Hopkins, published in Annals of Surgical Oncology in 2026, shows that the anesthesiologist’s experience matters too. When both the surgeon and the anesthesiologist were high-volume, patients had shorter hospital stays, lower operating room charges, and fewer delayed extubations.

The deeper reason any of this matters comes back to something most appendix cancer patients already know. Appendix cancer is rare. The full operation, and the recovery that follows it, calls for a trained eye at every position on the team. CRS-HIPEC is not an operation most surgical centers see often, and the patients who do best are usually the ones who reach a program that does see it often.

What the Study Looked At

The research team reviewed 237 patients who underwent CRS-HIPEC at a single quaternary academic center between 2016 and 2023. They sorted patients into four groups based on whether the surgeon and the anesthesiologist were high-volume or low-volume. High-volume was defined as the top quartile of cases for each role.

The thresholds tell you a lot on their own. A high-volume surgeon in this study had performed 87 or more CRS-HIPEC cases. A high-volume anesthesiologist had performed 10 or more. That gap is not a flaw in the study. It reflects how rarely most anesthesiologists encounter this operation, even at major academic centers.

What They Found About CRS-HIPEC Surgeon Volume and the Anesthesia Team

After adjusting for patient complexity, the group with both a high-volume surgeon and a high-volume anesthesiologist had measurable advantages over the group with neither:

• Operating room charges were about 5,784 dollars lower
• Hospital stays were about 4.77 days shorter
• Odds of delayed extubation were 21 percent lower

Total hospital charges trended lower for the experienced-team group, but that finding did not reach statistical significance. The operational and recovery metrics did.

Why Appendix Cancer Patients Need a Trained Eye

This is the part of the conversation that does not always make it into research papers. Appendix cancer is rare. Most general surgeons will see only a handful of cases across an entire career. Most pathologists outside specialty centers do not regularly grade LAMN, HAMN, goblet cell adenocarcinoma, or signet ring cell carcinoma. Most anesthesiologists have never managed a patient through eight to twelve hours of cytoreduction followed by heated chemotherapy in the abdomen.

The expertise patients need is not just one surgeon. It is a system. A specialty CRS-HIPEC program has seen the unusual presentations. It has pathologists who can distinguish G1 from G2 disease accurately. It has surgeons who recognize subtle peritoneal spread. It has anesthesiologists who know that body temperature, fluid balance, and electrolytes will swing dramatically during the HIPEC phase. It has ICU staff who have managed CRS-HIPEC recoveries before.

This study adds quantitative weight to something the community has understood for years. The reason to travel to a high-volume center is not credentialing on paper. It is the cumulative experience of everyone in the room.

What This Means for CRS-HIPEC Patients

For patients evaluating where to have surgery, the standard guidance still applies. Choose a high-volume specialty center. What this study adds is that the surgeon’s case count is one signal among several. The depth of the supporting team matters too.

Some questions worth asking your surgical program:

• Does this center have a dedicated anesthesia team for CRS-HIPEC?
• How many of these cases does the anesthesiologist on my case typically handle each year?
• Is the same anesthesia group involved across most of your CRS-HIPEC cases, or does it rotate?
• Are the pathologists who will read my specimens specialty-trained in peritoneal surface malignancies?

The clinical benefits are real, not just financial. Staying on a ventilator longer after surgery raises the risk of pneumonia and other complications. Extra hospital days raise the risk of infection and physical deconditioning. A team that has done this operation hundreds of times is making decisions faster and more accurately than a team encountering it for the third time that year.

Important Limitations to Keep in Mind

This study has real limitations that patients and families should weigh.

It was conducted at one center. The findings may not transfer directly to other hospitals with different staffing models, patient populations, or pathways. The study did not separate appendiceal cancer patients from the broader CRS-HIPEC population, which includes peritoneal mesothelioma, colorectal peritoneal metastases, and other diagnoses. Outcomes for PMP, LAMN, goblet cell adenocarcinoma, and high-grade appendiceal adenocarcinoma may differ from the pooled cohort.

The study looked at hospital charges, not actual costs or what patients paid out of pocket. Charges are the sticker price hospitals set, not what insurance reimburses or what the hospital actually spends to deliver care. The financial findings are informative for health systems and policymakers. They do not directly predict what any individual patient’s bill will look like.

The study also did not measure survival, recurrence, or quality of life. It measured operational and financial outcomes. A shorter hospital stay is good. It is not the same as a longer life. Other published research has linked surgeon volume to survival in CRS-HIPEC, but this particular paper did not.

The Bigger Picture on CRS-HIPEC Surgeon Volume

This adds to a growing body of evidence that high-volume centers do CRS-HIPEC better, and that the reason is structural rather than individual. The volume question is not just about one surgeon. It is about every position on the team. Operating room nurses, ICU staff, perfusionists running the HIPEC circuit, pathologists reading the tumor specimens, and anesthesiologists managing the patient through hours of physiologic stress all contribute to outcomes.

For appendix cancer patients, the practical advice has not changed. Seek out a high-volume specialty center. What this study reinforces is that when you evaluate a program, the surgeon’s case count is one signal among several. The depth of the surrounding team matters too.

Questions to Ask Your Doctor

• How many CRS-HIPEC cases does your center perform each year?
• How many of those does my specific surgeon perform?
• Do you have a dedicated anesthesia team for these cases?
• What is your center’s typical length of stay after CRS-HIPEC?
• What is your rate of complications like delayed extubation, return to the ICU, or readmission?
• Are pathology specimens read by specialists experienced with appendiceal histology?

Glossary

CRS-HIPEC: Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy. Surgery to remove visible tumor in the abdomen, followed by heated chemotherapy delivered directly into the abdominal cavity.

Quaternary center: A specialized academic medical center that handles the most complex cases, typically referred from other hospitals.

Delayed extubation: Remaining on a ventilator longer than expected after surgery.

Length of stay: The number of days a patient spends in the hospital for a given admission.

Charges: The amount a hospital bills for services. Different from actual costs to the hospital and different from what insurance reimburses.

Continue Reading: “Did They Get It All?” What a New Study Tells Us About CRS and the Limits of Human Vision

Source

Ciftci Y, Radomski SN, Yang VB, Winicki NM, Al-Ali S, Love S, Nicolson NG, Johnston FM, Greer JB. High-Volume Anesthesiologist and Surgeon Teams are Associated with Lower Operating Room Charges for Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. Annals of Surgical Oncology. 2026. PMID: 42135542. DOI: 10.1245/s10434-026-19341-6