What Your Surgeon Should Cover at Your CRS/HIPEC Consultation

A CRS/HIPEC consultation is often the first time a patient hears words like PCI, CC-0 and peritonectomy. CRS, or cytoreductive surgery, aims to remove all the disease the surgeon can see in the abdomen. HIPEC, hyperthermic intraperitoneal chemotherapy, washes heated chemotherapy through the abdomen at the end of the same operation. It’s a major operation, and recovery can be prolonged.

The new paper is a narrative review. It combines published evidence with the authors’ ethical analysis and reports no new patient data. Its 13 authors are surgeons, medical oncologists, a palliative care doctor and medical ethicists, most of them at the University of Chicago. One of them is Dr. Ardaman Shergill, a medical oncologist who treats appendix cancer. The paper was written for surgeons, especially younger ones, but most of it translates directly into questions a patient or caregiver can bring to the appointment.

What the surgeon says and what you hear

The paper gives two hypothetical examples. A patient told “the PCI is 12, and we can likely achieve a CC-0” may hear a promise of cure, when the surgeon means a chance that depends on what they find. A patient told “the complication rate is 30%” may not realize that a number like that can lump together a wound infection and a permanent fistula.

Numbers on their own don’t give patients enough to decide, according to the authors. They want surgeons to explain what recovery looks like over the long term, what limits a patient might live with afterward, and which symptoms may not go away. If your surgeon gives you a PCI or a complication rate, it’s fair to ask what that number means for your daily life. I explained PCI and CC scores in more detail in my post on reading your HIPEC operative report.

Best case and worst case

Two tools named in the paper can make these conversations clearer. The first is called Best Case/Worst Case, developed by surgeons at the University of Wisconsin. The surgeon draws a simple picture of each option, including no surgery, and describes the best realistic outcome, the worst, and the most likely one. In a small study at one Wisconsin hospital, surgeons trained in the tool did a better job of laying out real choices and describing how patients’ lives might change after surgery, rather than reading off a list of risks. Those patients were older adults in the hospital with acute, nonemergent surgical problems, not CRS/HIPEC patients.

The second tool is REMAP, built for cancer doctors. It’s a way of asking about a patient’s goals and values before making a recommendation. You don’t need your surgeon to know either name. You can simply ask for the best realistic outcome, the worst and the most likely, and then ask the same about not having surgery.

Regret after CRS/HIPEC

The authors believe that when surgeons don’t set realistic expectations before surgery, more patients end up regretting it. That’s their interpretation, and the study they lean on wasn’t designed to prove it. That study was a 2024 University of New Mexico survey of 122 people with appendix cancer who’d had CRS/HIPEC, recruited through ACPMP. About 15% of respondents met the study’s threshold for decision regret. Regret was more common in people who spent more than 30 days in the hospital, came home with a new ostomy, or had worse digestive symptoms afterward. I wrote about that study and two others on regret, including Yale’s DECISIVE study, in my post on caregivers and the CRS/HIPEC decision.

How completely can the disease be removed

The chance of meaningful survival benefit from CRS/HIPEC depends heavily on how completely the disease can be removed and on the tumor type. CC-0 means no visible disease remains. CC-1 means only tiny leftover nodules remain. Ask which result your surgeon considers adequate for your tumor type. When complete removal isn’t possible, the authors write that the operation is unlikely to add meaningful survival time and can still cause real harm.

Some patients have surgery started and then stopped because the disease can’t be removed. Surgeons call this an open-and-close. Careful planning before surgery is meant to keep this from happening. The paper gives an estimate of how often it happens, but that figure comes from studies of other peritoneal cancers, not appendix cancer alone, so I haven’t included it here.

The paper lists things that can make complete removal less likely. They include a bowel blockage, very high tumor markers, disease that kept growing or fluid that kept building up during chemotherapy, and certain findings on imaging, such as disease spread widely over the small bowel or around the liver. For these imaging features, the authors caution against using one finding alone to rule out surgery. Two or more together raise the chance the disease can’t be fully removed.

The subtype changes the conversation

The case for CRS/HIPEC differs a lot by tumor type. The review describes low-grade appendiceal mucinous neoplasms as mainly a surgical disease, because these tumors don’t respond well to chemotherapy. It also discusses mucinous and non-mucinous appendiceal adenocarcinoma, and it gives signet ring cell carcinoma its own section. Signet ring cell histology shouldn’t automatically rule out surgery, in the authors’ view, but the benefit depends heavily on the surgeon being able to remove everything.

If you’re facing a second surgery

Repeat CRS/HIPEC has the most support in low-grade mucinous tumors, according to the review. The authors suggest basing the decision on slow-growing tumor biology and a long gap before recurrence, generally at least a year. That year is their rough guide, not a cutoff. They also note that the first surgery offers the best chance, and if the surgeon couldn’t remove everything the first time, the odds of doing it on a second try are low. A 2022 Wake Forest study of 143 people with recurrent LAMN, one of the papers they cite, found that a longer time before recurrence was linked to better outcomes.

Scar tissue can make it harder to get into the abdomen safely on a second operation. The bowel can be nicked, a fistula can form, and removing more bowel can lead to short bowel syndrome, where the body can’t absorb enough food.

Chronic pain after HIPEC

Long-term pain after CRS/HIPEC gets its own section. The review recommends a pain team and palliative care, using a mix of medicines, nerve blocks, acupuncture, behavioral therapy and exercise. It also warns surgeons against offering another operation to fix the pain. The review it cites found little evidence that surgery to cut adhesions gives lasting relief for chronic pain, in patients who’d had gynecologic and general surgery. Those weren’t CRS/HIPEC patients specifically, and it doesn’t mean surgery can never help any one person. My post on abdominal pain after HIPEC goes into what the research shows for pain that comes and goes.

Palliative care isn’t the same as giving up

Palliative care is a team that treats symptoms and stress and helps with decisions, and you can have it while you’re getting treatment aimed at a cure. It isn’t hospice. The authors recommend bringing it in early, and they write that early palliative care helps patients understand their prognosis and keep treatment in line with what they want.

Questions to take to your CRS/HIPEC consultation

These are the questions the review points toward. You can print them or keep them on your phone.

• How likely is it you can remove all the visible disease in my case?
• What will you do if you find more disease than the scans showed?
• What’s the best realistic recovery, the worst, and the most likely?
• What happens if I don’t have surgery?
• What does my PCI score or complication rate mean for my daily life?
• If I have signet ring cell histology, how does that change my chances?
• Does your center have a palliative care team that works with surgical patients and caregivers?
• Would a second opinion at another peritoneal center make sense for me?

What this paper doesn’t do

The review does not test whether these recommendations improve outcomes. Its supporting evidence varies by topic and includes retrospective studies, randomized trials, systematic reviews and expert consensus. It covers several types of peritoneal malignancy, including ovarian, colorectal, stomach and mesothelioma, and it doesn’t address goblet cell adenocarcinoma or appendiceal neuroendocrine tumors separately.

The authors disclosed their industry ties. Dr. Shergill has been paid for advisory board work by several drug and diagnostics companies, including Natera, Pfizer, Amgen, AbbVie and Revolution Medicines. She’s also received travel support from groups including ASCO and ACPMP. Another author serves on an advisory board for Boston Scientific. The paper is free to read.

Did your surgeon walk you through a worst-case recovery before your CRS/HIPEC? Yes or no.

Frequently asked questions

What should I ask at a CRS/HIPEC consultation?

Ask how likely it is the surgeon can remove all the visible disease, what the best, worst and most likely recovery looks like, and what happens if you don’t have surgery. Ask what any number they give you, like a PCI score or complication rate, means for your daily life.

What is an open-and-close surgery?

It’s when a surgeon starts CRS/HIPEC, finds the disease can’t be removed, and closes without completing the operation. The patient still recovers from a major incision. Careful planning before surgery aims to make this less likely.

What is Best Case/Worst Case?

It’s a communication tool developed by surgeons at the University of Wisconsin. The surgeon draws a simple picture of each treatment option and describes the best realistic outcome, the worst and the most likely one, including for no surgery.

Can CRS/HIPEC be done a second time?

Sometimes. A 2026 review says repeat surgery has the most support in low-grade mucinous tumors that took a long time to come back, generally at least a year, though that’s a rough guide rather than a strict rule. Scar tissue makes a second operation riskier.

Will another surgery fix chronic pain after HIPEC?

Another operation only to treat suspected adhesion-related chronic pain needs careful thought. Evidence of lasting benefit is limited, and surgery carries risks. A pain team and palliative care are the usual first steps.

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Sources

Williams JK, et al. Primum Non Nocere: Ethical Considerations of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) in Peritoneal Malignancies. Annals of Surgical Oncology, 2026. Read the study
Graves A, et al. Decision Regret in Patients with Appendiceal Cancer Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Annals of Surgical Oncology, 2024. Read the study
Taylor LJ, et al. A Framework to Improve Surgeon Communication in High-Stakes Surgical Decisions: Best Case/Worst Case. JAMA Surgery, 2017. Read the study
Childers JW, et al. REMAP: A Framework for Goals of Care Conversations. Journal of Oncology Practice, 2017. Read the study
Valenzuela CD, et al. Timing of Repeat Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Recurrent Low-Grade Appendiceal Mucinous Neoplasms. Annals of Surgical Oncology, 2022. Read the study
van den Beukel BA, et al. Surgical Treatment of Adhesion-Related Chronic Abdominal and Pelvic Pain after Gynaecological and General Surgery. Human Reproduction Update, 2017. Read the study

Two details are described from the original studies rather than from the review. The Best Case/Worst Case study took place at one hospital, and the New Mexico regret study’s summary doesn’t list ICU stays among the factors linked to regret.

This post is for education and doesn’t replace advice from your own medical team.