Skip to main content

What Drives High Costs of Cytoreductive Surgery and HIPEC: Patient, Provider or Tumor?



Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is utilized for peritoneal malignancies and is associated with significant resource use. To address potentially modifiable factors contributing to excessive cost, we sought to determine predictors of high cost of care for patients undergoing CRS/HIPEC.


An institutional CRS/HIPEC database was queried for adult patients from 2014 to 2018. Cost was defined as cost for the index hospitalization, and high-cost cases were defined as > 75th percentile for cost. Bivariate analyses for cost were performed, and all significant tumor, patient, and surgeon-specific variables were entered in a linear regression for cost. A separate linear regression was performed for length of stay (LOS).


In total, 59 patients underwent 61 CRS/HIPEC procedures. The median direct variable cost was $20,509 (16,395–25,240). Median length of stay (LOS) was 8 (7–11.5) days and ICU stay was 1 (1–1.5) day. LOS, length of ICU stay and operative time were predictive of cost. Factors associated with increased LOS were Clavien-Dindo grade II complications and ostomy creation. Patient-related factors, including age and BMI, tumor-related factors, such as PCI and CCR, and surgeon were not predictive of cost nor LOS.


Our results, the first to identify predictors of high cost of CRS/HIPEC-related care in the US, reveal cost was largely related to length and intensity of care. In turn, these drivers were influenced by complications and operative factors. Future work will focus on identifying an appropriate ERAS protocol following CRS/HIPEC and selection of those patients that may avoid routine ICU admission.

This is a preview of subscription content, access via your institution.

Fig. 1


  1. Bushati M, Rovers KP, Sommariva A, et al. The current practice of cytoreductive surgery and HIPEC for colorectal peritoneal metastases: results of a worldwide web-based survey of the Peritoneal Surface Oncology Group International (PSOGI). Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2018;44(12):1942–1948.

    Article  CAS  Google Scholar 

  2. Eveno C, Pocard M. Randomized controlled trials evaluating cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in prevention and therapy of peritoneal metastasis: a systematic review. Pleura Peritoneum. 2016;1(4):169–182.

    Article  PubMed  Google Scholar 

  3. Beal EW, Ahmed A, Grotz T, et al. Trends in the indications for and short-term outcomes of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. Am J Surg. 2019.

    Article  PubMed  Google Scholar 

  4. Sugarbaker PH, Ronnett BM, Archer A, et al. Pseudomyxoma peritonei syndrome. Adv Surg. 1996;30:233–280.

    CAS  PubMed  Google Scholar 

  5. Naffouje SA, O’Donoghue C, Salti GI. Evaluation of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a community setting: a cost-utility analysis of a hospital’s initial experience and reflections on the health care system. J Surg Oncol. 2016;113(5):544–547.

    Article  PubMed  Google Scholar 

  6. Squires MH, Staley CA, Knechtle W, et al. Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications. Ann Surg Oncol. 2015;22(5):1739–1745.

    Article  PubMed  Google Scholar 

  7. Hinkle NM, MacDonald J, Sharpe JP, Dickson P, Deneve J, Munene G. Cytoreduction with hyperthermic intraperitoneal chemotherapy: an appraisal of outcomes and cost at a newly established peritoneal malignancy program. Am J Surg. 2016;212(3):413–418.

    Article  PubMed  Google Scholar 

  8. Roudsari B, McWilliams J, Bresnahan B, Padia SA. Introduction to Cost Analysis in IR: Challenges and Opportunities. J Vasc Interv Radiol JVIR. 2016;27(4):539–545.e1.

    Article  PubMed  Google Scholar 

  9. Taheri PA, Butz D, Griffes LC, Morlock DR, Greenfield LJ. Physician Impact on the Total Cost of Care. Ann Surg. 2000;231(3):432–435.

    Article  CAS  Google Scholar 

  10. Dunn A, Grosse SD, Zuvekas SH. Adjusting Health Expenditures for Inflation: A Review of Measures for Health Services Research in the United States. Health Serv Res. 2018;53(1):175–196.

    Article  PubMed  Google Scholar 

  11. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–213.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Hair JF, Risher JJ, Sarstedt M, Ringle CM. When to use and how to report the results of PLS-SEM. Eur Bus Rev. 2019;31(1):2–24.

    Article  Google Scholar 

  13. Lee ZJ, Teo CCM. ASO Author Reflections: Cost Effectiveness of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Ann Surg Oncol. 2018;25(Suppl 3):757–758.

    Article  CAS  PubMed  Google Scholar 

  14. Tentes AA, Pallas N, Korakianitis O, et al. The cost of cytoreductive surgery and perioperative intraperitoneal chemotherapy in the treatment of peritoneal malignancy in one Greek institute. J BUON Off J Balk Union Oncol. 2012;17(4):776–780.

    CAS  Google Scholar 

  15. Chua TC, Martin S, Saxena A, et al. Evaluation of the cost-effectiveness of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (peritonectomy) at the St George Hospital peritoneal surface malignancy program. Ann Surg. 2010;251(2):323–329.

    Article  PubMed  Google Scholar 

  16. Stiles ZE, Hinkle NM, Munene G, Dickson PV, Davidoff AM, Deneve JL. The Impact of Ostomy Creation after Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy in a Newly Established Peritoneal Malignancy Program. Am Surg. 2018;84(6):776–782.

    Article  Google Scholar 

  17. Pakraftar S, Ramalingam L, Shuai Y, et al. Institutional Experience with Ostomies Created During Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion. Ann Surg Oncol. 2017;24(13):3811–3817.

    Article  PubMed  Google Scholar 

  18. Kelly KJ, Cajas L, Baumgartner JM, Lowy AM. Factors Associated with 60-Day Readmission Following Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol. 2018;25(1):91–97.

    Article  PubMed  Google Scholar 

  19. Lee TC, Wima K, Sussman JJ, et al. Readmissions After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: a US HIPEC Collaborative Study. J Gastrointest Surg Off J Soc Surg Aliment Tract. 2019.

    Article  Google Scholar 

  20. Whealon MD, Gahagan JV, Sujatha-Bhaskar S, et al. Is Fecal Diversion Needed in Pelvic Anastomoses During Hyperthermic Intraperitoneal Chemotherapy (HIPEC)? Ann Surg Oncol. 2017;24(8):2122–2128.

    Article  PubMed  Google Scholar 

  21. Lu PW, Fields AC, Shabat G, et al. Cytoreductive Surgery and HIPEC in an Enhanced Recovery After Surgery Program: A Feasibility Study. J Surg Res. 2019.

    Article  PubMed  Google Scholar 

  22. Webb C, Day R, Velazco CS, et al. Implementation of an Enhanced Recovery After Surgery (ERAS) Program is Associated with Improved Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol. 2020;27(1):303–312.

    Article  PubMed  Google Scholar 

  23. Siddharthan R, Dewey E, Billingsley K, Gilbert E, Tsikitis VL. Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: a single institution experience. Am J Surg. 2019.

    Article  PubMed  Google Scholar 

  24. Mogal HD, Levine EA, Fino NF, et al. Routine Admission to Intensive Care Unit After Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy: Not Always a Requirement. Ann Surg Oncol. 2016;23(5):1486–1495.

    Article  PubMed  Google Scholar 

Download references


The authors would like to thank Deborah Lemaster for her assistance with data abstraction.

Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number T32 CA090217 and Award Number T32 ES007015. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Daniel E. Abbott MD.

Ethics declarations


The authors declare no conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Schwartz, P.B., Stahl, C.C., Vande Walle, K.A. et al. What Drives High Costs of Cytoreductive Surgery and HIPEC: Patient, Provider or Tumor?. Ann Surg Oncol 27, 4920–4928 (2020).

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI:


  • Cytoreductive
  • Cost
  • Resource
  • Peritoneal